Last year, the Royal Devon and Exeter (RDE) NHS Foundation Trust ran a pilot scheme showing how adopting highly accurate, laboratory quality testing on admission can help to control the spread of influenza and mitigate the effect this can have on patient flow and bed management.
As the flu season draws to a close, patient numbers inevitably increased over the winter, leading many Trusts to take stock and keep a look out for solutions. Last year, the Royal Devon and Exeter (RDE) NHS Foundation Trust ran a pilot scheme showing how adopting highly accurate, laboratory quality testing on admission can help to control the spread of influenza and mitigate the effect this can have on patient flow and bed management.
The RDE NHS Foundation Trust is an 800bed acute Trust, employing more than 8000 staff. The hospital serves the population of Exeter, Mid and east Devon, with over 120,000 admissions every year. In common with most hospitals in the UK, the RDE has a robust infection control strategy developed in close association with the pathology team, which aims to tackle hospital acquired infections and seasonal epidemics such as influenza.
In the last few years, upwards of a thousand patients have been tested for flu every season. The hospital is very proactive with regard to flu screening, with all tests funnelled through the infection control team and requested only for patients who meet certain criteria; patients admitted with a temperature and cough will automatically be tested for flu. The protocol then continues for any contacts the patients have had, so people who are in the same bay also have to be isolated and followed up to make sure they themselves don’t develop symptoms.
The cascade builds, hopefully halting the spread of infection but also, unfortunately stopping the flow of patients; some are effectively ‘trapped’ in bays waiting to be cleared, and sometimes a bay or even a whole ward is closed.
The whole situation has a significant impact on the life and workings of the hospital – especially during seasons of high flu activity that result in increased numbers of admissions to hospital. And that’s why the infection control team relies so heavily on diagnostic results.
Negative results mean they can start freeing up beds or ease contact restrictions, and so it’s no surprise that the timetable of test runs provided in the winter season is very closely coordinated with bed meetings. In recent years this has formed an intensive service based on a fast molecular diagnostic assay [Cepheid GeneXpert Xpert Xpress Flu/RSV].
Results from the first run at 9am would be available for 11am; the second at lunchtime would have results for 2pm; and the final run at 3pm gave results at 5pm. However, the schedule only runs in normal laboratory hours, and there has been no service for anybody admitted outside of these times, testing has had to wait until the next day - hours where a patient could potentially infect fellow patients in a bay.
Making use of existing resources
In January of 2017, the team embarked on a three-month trial* to evaluate whether point-of-care flu testing using an accurate but easy-to-use laboratory analyser around the clock in the emergency department and the acute medical unit (AMU) could address this situation. For the AMU in particular, many patients are admitted with respiratory conditions, especially the elderly, and their symptoms could easily mask flu. The trial was based on a flexible system bought in 2008 for MRSA screening and used over time for confirmation of Clostridium difficile and Neisseria gonorrhoea, for norovirus testing at weekends and on-call, and for rapid tests towards the end of the working day.
The timing of the trial coincided with a roadshow from the system provider that gave colleagues from all over the hospital a good opportunity to see how the instrument could work in different areas and the impact it could potentially have. The idea was to base the equipment on the wards, screen patients as they came in, and minimise the waiting period for results.
The pathology team was tasked with introducing the nursing staff to the idea, and training the users, including competency assessments signed off by biomedical scientists. The analyser was manned by lab staff in the first instance to familiarise everyone who would eventually be carrying out the tests themselves. Everything was password controlled so that only authorised personnel could carry out testing, and very detailed methodologies were printed and laminated for the walls for additional support.
Double testing and quality control checks were regularly carried out to ensure consistent and correct results, but one of the major advantages of the analyser is that it is so easy to use. All reagents are included in a single-use cartridge, so no reagent storage is required, and it’s simply a case of taking a sample, placing it in the media, putting it into the machine and pressing a button. Timers were supplied to go off 20 minutes later, when the result came out of the printer.
The trial ran from late January until the end of March, and included 672 samples from AMU and 84 from the emergency department, alongside 811 that were performed in the lab from other wards and community hospitals. Patients were tested at any time of the day or night in the ward, even during normal lab hours, and members of the lab team kept a close eye on the tests performed, entering the results onto the main computer system so that they were available to anyone that might need them.
Positive impact on patient flow
The pilot only started halfway through the season but already there was a significant impact seen in AMU. The main aim at this stage of the process was to improve the rapidity of diagnosis, and introduce the idea of point-of-care microbiology testing to the wards. While many of the staff were already familiar with this approach for chemistry, microbiology is a whole new ball game. The trial served as an excellent demonstration of how it could work on the ground, the advantages it could bring, and the art of the possible. It is also important to open the gateway to point-of-care testing for microbiology in general, not only for flu, because there is a surge of new molecularbased technology constantly becoming available that lends itself well to this kind of analysis.
There is no doubt that faster testing bringing the mean time to result from five hours (90% same day) to 32 minutes (100% same day) - had an impact on patient treatment. While those with positive flu tests could start treatment more promptly, negative results also turned the doctors’ attention to other potential causes of a patient’s symptoms more quickly.
Rolled out to other areas
A second stage of the initiative was rolled out through the winter of 2017/18, covering the entire season and collecting data from the outset. This year, the laboratory has targeted AMU, the paediatric assessment unit and the oncology and haematology outpatients’ clinic.
On the paediatric side, the emphasis has been on RSV, which started much earlier in the season - the wards had already dealt with a high number of samples from November onwards. Choosing the outpatients’ clinics also made a lot of sense because of immunocompromised patients who come for IV chemotherapy; if one patient has flu that’s very bad news for the whole room. It is hoped that screening as patients come into the department could prevent this kind of transmission.
For now, flu and RSV are the obvious candidate organisms for a point-of-care approach of this kind, mainly because of the nature of the sample - they are very easy to process. Other specimens such as faeces, which could be used for tests like norovirus, present problems of contamination from sample to sample; the laboratory has special procedures in place for these samples but this is difficult to replicate in ward areas. Nevertheless, these are areas to explore in the future.
Overall, everybody - from senior managers to the nursing staff on the ward and the infection control team - was very impressed with last year’s project and the Trust management was in full support of extending it for the 2017/18 season
For them, it clearly demonstrated that highly accurate testing under the auspices of the laboratory but carried out at the point of admission significantly contributes to managing patients and beds in a far more efficient way. This approach was very popular with the pathology staff too, giving them much-appreciated interaction with their ward colleagues.
Other laboratories in the surrounding regions have already visited the site to learn more about the testing model, with some already trying out similar projects this season.
Authors
Julie King Microbiology Manager
Bupe Kambashi Lead Senior Biomedical Scientist
Stella Roberts Senior Biomedical Scientist
Gosia Poznalska Specialist Biomedical Scientist
Dr Cressida Auckland Consultant Microbiologist and Head of Department, Royal Devon and Exeter NHS Foundation Trust
To learn more about better managing winter outbreaks, please visit the Cepheid Stand #278 at the IPS Conference.
