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A balanced approach to infection control

Mitchell Reed, a Microbiology Services Manager, discusses bringing previously outsourced microbiology tests back in-house.  

Hospital lab managers across the UK are constantly striving to balance clinical need and expectations with laboratory resources and efficient processing. Outsourcing has been a solution for some, with larger facilities providing an effective service for non-urgent tests covering all lab disciplines. However, some tests are more urgent than others; for example, results for norovirus and Clostridium difficile can dictate whether patients can be discharged, if they should be moved away from the main ward to reduce the risk of the spread of infection, or even if wards need to be shut down to halt contamination in its tracks. At the Royal United Hospitals Bath NHS Foundation Trust (RUH), a simple yet sophisticated analyser installed in a “hot” lab provides results for these and other tests in hours, having a dramatic effect on infection control, and consequently a knock-on effect on bed and side ward management. 

Historically, the RUH has outsourced all GP and hospital requests for microbiology testing to an external provider, complemented by an on-site team of three consultants and a microbiology services manager to provide clinical expertise and technical support. As part of a review of the current technology available, the trust looked at the feasibility and benefits of performing some microbiology tests in-house, including the potential for improved turnaround times and efficiency, as well as cost savings. 

While RUH has a small “hot” lab staffed by an external microbiology provider for acute testing, sample numbers are insufficient for the hospital to employ its own biomedical scientists. Molecular diagnostic testing using a GeneXpert system (Cepheid) had the potential to allow some microbiology tests to be carried out on-site; the system’s small footprint is ideal for the limited space available, and it can be interfaced with the hospital’s LIMS. An initial trial focusing on norovirus and C. difficile testing of inpatients was successful, and the system went live in November 2016. Although very sophisticated, the tests are straightforward to perform and are carried out by multidisciplinary staff who have received additional training on designated molecular diagnostic tests.

Improved turnaround times

A big advantage of on-site molecular testing is speed, helping to avoid a longer turnaround time to result. When testing is outsourced, samples are likely to be collected at set times and must then be transferred to the service provider. Also, many testing systems rely on batch testing, with the laboratory waiting until a sufficient number of samples has built up for cost-effective analysis. In contrast, the GeneXpert offers random-access, on demand testing, allowing individual samples to be analysed immediately on receipt by the laboratory. 

In many cases, the staff simply load the instrument and walk away, and the results are generated automatically. If a repeat test is necessary, it can be performed straight away. The RUH trial showed that the accuracy and sensitivity of the norovirus and C. difficile tests were comparable to off-site testing, while turnaround times were improved significantly, with most results available in less than four hours. Many C. difficile results were returned at earlier times during the day when more staff are available to make decisions.

Enhanced management

Rapid turnaround times for norovirus and C. difficile are key to managing the patient flow through the hospital, as the test result impacts on the decision to discharge or isolate a patient, and enables optimal use of side rooms. A conservative estimate of the cost of an average seven-day ward closure due to an outbreak of norovirus – including the suspension of patient admission and discharge and deep cleaning of the ward – approaches £16,000. On top of that, additional staffing costs will probably be incurred. During the short trial period, ward closures and occupancy of side rooms due to norovirus were pre-empted on two occasions. Without same-day reporting, a ward closure would have been implemented and the patients isolated in side rooms, pending test results, for longer than necessary. The consensus from the RUH infection control team, as well as divisional and site managers, is that implementation of on-site PCR for norovirus and C. difficile has transformed bed management across the hospital.

RUH performed a small-scale trial comparing rapid on-site PCR testing for influenza with off-site testing, to investigate whether processing times could be shortened to enable more accurate and timely antiviral prescribing, as well as better management of cohorting and isolation of patients. With on-site testing, same-day results were available in all but one case while most tests carried out off-site were reported the next day, an extension of one day before the results could be acted upon.


Implementation of on-site molecular diagnostic tests for norovirus and C. difficile has been very successful, enhancing infection control, and bed and side ward management in the hospital. The initial trial for influenza generated reliable results which were delivered faster than off-site testing, further demonstrating the potential benefits of on-site PCR testing.  

Mitchell Reed is Microbiology Services Manager at Royal United Hospitals Bath NHS Foundation Trust

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