Rakesh Patel
Antimicrobial pharmacist Shilpa Jethwa takes part in multidisciplinary bench rounds at Northwick Park hospital in London. The rounds were introduced to help identify any unusual cultures and improve teamworking.
What are multidisciplinary bench rounds about?
Before 2008, healthcare professionals at London North West Healthcare NHS Trust were working autonomously. Multidisciplinary bench rounds were introduced to build a team approach to help improve antimicrobial prescribing and reduce the rise and spread of resistant organisms.
Essentially, bench rounds involve a multidisciplinary approach from a microbiology perspective to managing a patient. The team includes a consultant microbiologist as the lead, an antimicrobial pharmacist, a junior doctor and an infection control nurse.
We conduct the round at approximately 11.30am daily. During the rounds we review all positive and unusual cultures and liaise with the relevant teams if necessary or assess the patient on an antimicrobial stewardship round.
The bench rounds take place each morning in the microbiology laboratory and are therefore not patient-facing. They have allowed increased collaboration with the microbiology and infection control departments and have also enabled me to increase my own knowledge in this area.
What are the benefits of this approach in the area of infection?
Benefits of the approach include improved teamworking, a more holistic approach to patient care, better information gathering and streamlining resources. If a patient requires isolation, this will be identified during the bench round and the information relayed to the ward in a timely manner. The rounds are also used as a teaching opportunity.
As the specialist pharmacist, I am expected to provide advice on the management of antimicrobial therapy for patients. I also act as a liaison between the microbiology and pharmacy departments, relaying specific issues to the relevant ward pharmacist and discussing particular cases with the relevant teams to advise on the most appropriate course of therapy.
How do the bench rounds feed into the antimicrobial stewardship agenda?
The antimicrobial stewardship agenda has a number of goals but the focus is around the prudent use of antimicrobials. The bench round helps identify patients who require an antimicrobial stewardship team review. The stewardship team evaluate diagnoses, patient notes and recent results, and discuss the patient with the team looking after him or her. A number of actions may be recommended following the review such as stopping therapy, de-escalating therapy, continuing therapy and reviewing within an agreed time frame, switching the patient to a more appropriate antimicrobial or
making a recommendation for outpatient antimicrobial therapy.
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At Northwick Park Hospital, all new pharmacists visit the laboratory during their induction programme
What advice would you give to another hospital team wishing to implement the bench rounds?
I would advise other pharmacists to spend some time shadowing a biomedical scientist to understand their role and processes. This will provide greater insight into what happens in the laboratory. At Northwick Park Hospital, we have incorporated a visit to the laboratory for all new pharmacists during their induction programme. Some of them have not visited a laboratory since they completed their university courses. In this way, all new starters are introduced to the bench rounds and see first-hand the role of the microbiology department in aiding diagnosis of infections.
At Northwick Park Hospital the bench rounds are led by the consultant microbiologist and therefore the introduction of this initiative was met with no barriers and was a fairly easy process.
What have you found interesting about working in antimicrobials?
The role has given me an understanding of what happens to samples in the laboratory. After cultures are taken, what happens to them? We know they go the laboratory and then the result appears on the system 24–48 hours later. However, the journey a sample takes and what happens to it is interesting.
For example, blood cultures are usually ordered in sets, which consists of two bottles. Some bacteria prefer oxygen (aerobes) while others prefer an oxygen deprived environment (anaerobes), so samples are taken for analysis when a patient is unwell and placed into both an aerobic and an anaerobic bottle. This increases the likelihood of identifying a pathogenic organism.
These samples are taken to the laboratory and booked in, then placed into a blood culture machine, which incubates the specimens at body temperature. The machine monitors the samples for any bacteria and they are flagged as positive if any are present. Samples are then removed from the machine so that a gram stain can be performed — this detects and identifies the general type of bacteria quickly before any susceptibility testing can be performed. After a gram stain is performed the blood is sub-cultured on to agar plates to isolate the pathogenic organism for culture and susceptibility testing, which is a slightly longer process. This latter type of test determines the most appropriate antimicrobial that may be used in treating an infection.
I now have a wider understanding of the way samples are processed, antimicrobial testing, how results are obtained and the high standards required.
