A multi-centre retrospective study of Nocardia speciation and antimicrobial susceptibility in Queensland, Australia.

The study aims to characterise the species identification and antimicrobial susceptibility testing (AST) results of Nocardial isolates from adult patients across major public hospitals in Queensland, Australia, over a 15-year period. A multi-centre retrospective observational study of Nocardia sp. isolates was conducted from 7 major public hospitals in Queensland, Australia, over a 15-year period. Clinical samples from patients aged ≥ 18 years that isolated Nocardia sp. were included. Demographic and clinical data were collected, along with species identification and AST results. Overall, 484 Nocardia sp. were isolated. Most patients were male (297, 61%) with a mean (IQR) age of 60 (51-75) and a median (IQR) Charlson Comorbidity Index of 4 (2-6). Of these, 239 (49%) patients were immunosuppressed. Organisms were most frequently isolated from sputum (174, 36%), and superficial swabs (102, 21%). Patients presented with pulmonary infections (165, 35%) and superficial skin and soft tissue infections (87, 18%) most commonly. One hundred (21%) isolates were deemed pulmonary colonisation and were not treated. Of the speciated organisms, N. nova complex was the most common (93, 19%), followed by N. farcinica complex (79, 16%). Organisms were reliably susceptible to linezolid (240/245, 98%), amikacin (455/470, 97%), and trimethoprim/sulfamethoxazole (459/476, 96%), but less so to imipenem (243/472, 51%) and ceftriaxone (261/448, 58%). This is the largest Australian description of Nocardia sp. to date. Given antimicrobials are often commenced prior to AST results and sometimes even speciation, characterisation of local species and antibiogram data is important to guide empiric choices and local guidelines.

Quality of warfarin control in atrial fibrillation patients in South East Queensland, Australia.

BACKGROUND: Warfarin is widely prescribed to decrease the risk of stroke in atrial fibrillation (AF) patients. Due to patient variability in response, regular monitoring is required, and time in therapeutic range (TTR) used to indicate quality of warfarin control with a TTR>60% is recommended. Recently, an Australian Government review of anticoagulants identified the need to establish current warfarin control and determine the potential place of the newer oral anticoagulants. AIM: To determine warfarin control by a pathology practice in Queensland, Australia and identify factors influencing TTR. METHODS: Retrospective data were collected from Sullivan Nicolaides Pathology, a major pathology practice offering a warfarin care programme in Australia. Patients enrolled in their programme as of September 2014 were included in the study. TTR was calculated using INR test results, and test dates using the Rosendaal method with mean patient TTR were used for analysis and comparison. Exclusions were target therapeutic range outside 2.0-3.0, less than two INR tests and programme treatment time of less than 30 days. RESULTS: The eligible 3692 AF patients had 73.6% of INR tests within the therapeutic range. The mean TTR was 81%, with 97% of patients above a TTR of 60%. TTR was not significantly influenced by age, gender or socioeconomic factors. CONCLUSIONS: The observed mean TTR of over 80% is superior to the minimum recommended threshold of 60%. The TTR achieved by the Queensland pathology practice demonstrates that dedicated warfarin programmes can produce high-quality warfarin care, ensuring the full benefit of warfarin for Australian patients.

Full Blood Count - Internal QC Protocol: a review by the Royal College of Pathologists of Australasia Quality Assurance Programs (RCPAQAP) Pty Ltd - Haematology.

INTRODUCTION: The RCPAQAP (Royal College of Pathologists of Australasia Quality Assurance Program) Haematology has undertaken an exercise to review the internal quality control protocol for full blood count (FBC) instrumentation as well as review the action taken by laboratories when nonconforming results are evident in the RCPAQAP proficiency testing reports. METHOD: A questionnaire was sent to laboratories enrolled in the RCPAQAP FBC module. Laboratories were asked to provide information with regard to the type of control measures used within their testing environment that would trigger alerts for nonconforming events. The questionnaire also reviewed the action taken by laboratories in response to nonconforming test results in their external QA reports. RESULTS: A total of 253 of the 850 laboratories enrolled in the FBC module returned a response to the questionnaire, which identified variation in the QC protocol used to identify nonconforming events on the FBC analyser, including the type of controls, control levels processed and the frequency of use. CONCLUSION: This questionnaire identified variation in the internal QC protocol used by laboratories, including the types of control measures used and the rules applied to identify nonconforming events. However, the majority of laboratories appear to follow the most favourable choice of actions supplied when reviewing results of external QA data.

A call for a value based approach to laboratory medicine funding.

All areas of healthcare, including pathology, are being challenged by the reality that the days of ever increasing budgets are over and the key debate is about how to provide value for money. As originally described by Porter and Tiesberg, value-based healthcare is defined as maximising outcomes over cost by moving away from fee for service models to ones that reward providers on the basis of outcomes (1). While production efficiencies will continue to evolve, the opportunities for future stepwise improvements in production costs are likely to have diminished. The focus now is on delivering improved testing outcomes in a relatively cost neutral or at least cost effective way. This brings pathology into line with other health services that focus on value for money for payers, and maximising health outcomes for consumers. This would signal a break from the existing pathology funding model, which does not directly recognise or reward the contribution of pathology towards improved health outcomes, or seek to decommission tests that offer little clinical value. Pathology has a direct impact on clinical and economic outcomes that extend from testing and it is important to garner support for a new approach to funding that incentivises improvements of the overall quality and contribution of the pathology service.

Heterophilic antibodies remain a problem for the immunoassay laboratory.

The prevalence of heterophilic antibody interference in a modern immunochemiluminometric assay containing blocking agents was determined using thyrotropin as an illustrative example. Serum samples were obtained from 295 consecutive patients who underwent routine thyroid function testing. The following versions of the thyrotropin assay were used: protocol A (zero blocker), protocol B (routine blocker concentration), and protocol C (extra blocker). Ten patients (prevalence 3.4%) had significant levels of heterophilic antibodies (protocol A value greater than 9 SD from the protocol B value). The observed thyrotropin levels for protocols B and C were the same for all patients, consistent with the reagent blockers in routine assays adequately eliminating heterophilic antibody interference. However, seven more patients (0.03%) in series of 21,000 assessed by routine thyroid function testing had discordant results because of a concentration of heterophilic antibodies so high as to overwhelm the added blocking agents.

Urgent ("stat") testing in chemical pathology--position paper.

Increasingly heavy use is made of the pathology laboratory in many hospitals. This can cause problems, particularly with regard to urgent ("stat") tests, where a result is required in a short time. Many small laboratories are forced to offer a wide battery of tests, many of which may not help greatly in the acute diagnosis and/or management of the patient, and are expensive and inconvenient to perform. This paper addresses the questions as to which (chemical pathology) analytes should be available as emergency ("stat") tests, and how long should it take for results to come back.

Influences on the implementation of TQM in health care organizations: professional bureaucracies, ownership and complexity.

TQM is introduced into many organisations in an attempt to improve productivity and quality. There are a number of organisational variables that have been recognised as influencing the success of TQM implementation including leadership, teamwork, and suppliers. This paper presents findings of a study of the implementation of TQM in Australian health care organisations. Structural factors were observed to affect the progress of TQM. Professional bureaucracies were less successful than machine bureaucracies. Private organisations were more successful than their public counterparts.