Microbiology laboratory consolidation at the National Reference Laboratory, United Arab Emirates: implementation, early outcomes, and lessons learned from a hub-and-spoke network redesign

Highlights

• •Selective hub-and-spoke consolidation centralized routine microbiology across the National Reference Laboratory.
• •Urgent and stability-sensitive testing was retained at peripheral laboratories.
• •Bacterial culture turnaround time decreased by 35.3%; methicillin-resistant Staphylococcus aureus screening decreased by 13.3%.
• •Urine culture contamination dropped from 0.99% to 0.80% after consolidation.
• •Estimated annual savings of United Arab Emirates dirham 180,500 with ∼1-2 full-time equivalent efficiency gain.

Abstract

Objectives

This case study examines the planning, design, and initial post-implementation outcomes of a phased microbiology laboratory consolidation project within the National Reference Laboratory (NRL) network. The project sought to enhance operational efficiency; minimize inter-site variability; safeguard urgent diagnostic pathways; expand access to advanced microbiology resources; and eliminate unnecessary duplication of space, instrumentation, quality activities, and labor.

Methods

The consolidation used a selective hub-and-spoke model, designating NRL Industrial City of Abu Dhabi as the reference center for routine, non–time-critical assays, whereas peripheral sites retained urgent and stability-dependent testing. The network comprises a central reference laboratory and two peripheral laboratories that serve our clients within the United Arab Emirates. The project encompassed service mapping, hub selection, workflow testing, risk assessment, laboratory information system validation, transport and readiness planning, phased implementation, and structured post-implementation refinement. Baseline workload and collection timing data informed staffing, courier scheduling, and the extent of centralization.

Results

Urgent diagnostic pathways were maintained at existing testing sites, and standardization and governance were enhanced at all locations. Turnaround times improved across several routine culture workflows: the aggregate bacterial culture category decreased by 35.3% (P = 0.01) and methicillin-resistant Staphylococcus aureus screening by 13.3% (P = 0.04). The aggregate bacterial culture figure is an unweighted summary of the routine culture menu and is not weighted by individual test volume; test-level changes are reported separately in Figure 4. Urine culture contamination rates declined from 0.99% to 0.80% (P ≈ 0.045), whereas the median blood culture turnaround time remained stable at approximately 5 days. The estimated annual savings amounted to United Arab Emirates dirham 180,500, with a projected operational efficiency gain of one to two full-time equivalents.

Conclusion

Phased, selective hub-and-spoke consolidation enables the centralization of routine microbiology while preserving time-critical diagnostics. Contingent upon reliable transport, it protects urgent workflows, harmonizes standard operating procedures, validates laboratory information system routing, enables active stakeholder communication, and sustains governance from the outset.

Introduction

Clinical microbiology laboratories play a central role in the diagnosis and management of infectious diseases. Their functions include organism detection and identification, antimicrobial susceptibility testing, antimicrobial stewardship, infection prevention and control, outbreak recognition, and public health surveillance [1]. Beyond analytical testing, laboratory staff interpret complex findings, escalate critical results, provide guidance on test selection and antimicrobial choices, and ensure timely communication when diagnostic decisions are urgent [2].

Microbiology is a resource-intensive discipline that requires experienced scientific and medical personnel; robust biosafety protocols; well-maintained instruments and infrastructure; and stringent governance of pre-analytical, analytical, and post-analytical processes. In health systems with multiple geographically dispersed laboratories, microbiology services are frequently duplicated across sites. This duplication leads to issues such as redundant equipment, low test volumes at individual locations, inconsistent standard operating procedures (SOPs), variable reporting formats, uneven access to specialist expertise, and fragmented quality oversight.

Motivated by the objectives of efficiency and clinical responsiveness, many health systems have adopted laboratory consolidation. Factors such as cost pressures, shortages of specialist staff, increased automation and molecular diagnostics, and the standardization requirements of quality and accreditation systems have promoted centralized models [[3], [4], [5], [6], [7]]. Centralizing routine, high-volume, non-urgent work optimizes staff and equipment utilization, reduces duplication, enhances methodological consistency [8,9], and supports investment in advanced platforms when properly designed. Evidence from consolidated services has clarified the productivity and cost gains achievable through balanced restructuring and robust operational controls [10], whereas workforce benchmarking informs necessary staffing adjustments [11].

Microbiology consolidation presents unique challenges due to the time-sensitive nature of certain services. Positive blood culture signals, cerebrospinal fluid specimens, urgent Gram stains, specific rapid molecular assays, and specimens with limited stability require immediate local intervention. Transport delays or unclear responsibilities in these pathways can impede clinical decisions, infection control measures, or patient movement. Previous analyses of centralized microbiology consistently emphasize the necessity of maintaining close communication between microbiologists and clinicians and ensuring that high-value specimens are not delayed [12,13].

This work was conducted at the National Reference Laboratory (NRL), a United Arab Emirates (UAE)–based diagnostic organization and M42 partner (https://m42.ae/) dedicated to enhancing the quality, breadth, coverage, and efficiency of laboratory testing across the UAE and the broader Gulf Cooperation Council (GCC) region. The NRL operates an extensive, internationally accredited network of owned and managed laboratories that serve hospitals and clinics nationwide, implementing international best practice processes to establish a regional benchmark for laboratory quality. Its services include referral and specialized testing, laboratory management, and point-of-care testing. Medical microbiology services are provided across multiple sites within this network, with the NRL hub at the Industrial City of Abu Dhabi (ICAD) functioning as the largest microbiology facility. The department's scope encompasses bacteriology and culture-based diagnostics, antimicrobial susceptibility testing, mycobacteriology with biosafety level 3 containment, mycology, parasitology, molecular and mass spectrometry–based identification (including Matrix-Assisted Laser Desorption/Ionization Time-of-Flight (MALDI-TOF)), and referral testing for the wider network. This combination of a multi-site presence and a comprehensive, specialized microbiology menu formed the rationale and the practical foundation for the consolidation project described herein. A detailed description of the participating laboratories and their accreditation status, staffing, and service hours is provided in setting and network description section.

In this context, the NRL network undertook microbiology consolidation as a systematic overhaul of its services. The objectives were to eliminate preventable duplication, harmonize testing and reporting, optimize staff deployment, expand access to advanced microbiology tools, and maintain local responsiveness for urgent pathways. Baseline workload analysis identified blood and urine cultures as the highest-volume activities during a 6-month review period (Figure 1). Specimen collection patterns by weekday and hour revealed demand that is concentrated in weekday daytime hours, with consistent but lower activity during evenings and weekends (Figure 2). These workload characteristics informed the operating model, determining which activities should remain local, which could be centralized, and how courier and staffing arrangements should be structured.

Figure 1.

Baseline distribution of high-volume microbiology tests over a 6-month period. The concentration of work in blood culture and urine culture supported the need to distinguish high-volume routine processing from time-critical local functions.

Figure 2.

Workload heatmap showing specimen collection activity by weekday and hour. The concentration of demand during weekday daytime hours informed staffing distribution, courier timing, and readiness planning for the hub-and-spoke model.

Methods

Setting and network description

The NRL network delivers medical microbiology services through a single central reference laboratory (NRL-ICAD) and two peripheral (spoke) laboratories. All three laboratories are located within the Abu Dhabi area. The typical courier drive time between the hub and the more distant spoke is about 30 minutes by car. The facilities served comprise one quaternary academic medical center, one secondary or general hospitals, two ambulatory and day-surgery clinics, and one outpatient collection center, with a combined total of more than 500 licensed inpatient beds, more than 30 intensive care beds, and a combined annual microbiology workload of approximately 250,000 specimens.

The central laboratory is accredited by the College of American Pathologists (CAP) and the ISO 15189 by the Emirates International Accreditation Centre and is licensed by the Department of Health – Abu Dhabi. The peripheral laboratories also hold CAP accreditation and ISO 15189 accreditation. All network laboratories participate in the same external quality assessment schemes and, since consolidation, have operated under a common set of SOPs.

At the time of consolidation, the hub microbiology department was staffed by two consultant clinical microbiologist, one supervisor, five senior medical technologists, and 11 medical technologists and provided a 24-hour, 7-day service. Each peripheral microbiology unit was staffed by six technologists and operated from 07:00 to 23:00 daily, with on-call cover overnight. Consultant clinical microbiology advice was available on call across the network at all times, before and after consolidation.

Consolidation planning

The future operating model was developed through a structured planning process. The planning team worked through the rationale for change, the criteria for selecting the hub laboratory, clinical and operational leadership responsibilities, transport frequency and route feasibility, the feasibility of the proof-of-concept workflow, and the implications for clinical and non-clinical functions. The intent was to look beyond physical specimen transfer and treat microbiology as a continuous service, so that every clinical, operational, and governance dependency was considered together. The main drivers were space constraints in peripheral laboratories, potential economies of scale, more effective use of specialist staff, harmonization of SOPs and reporting, broader access to advanced technologies, and higher throughput through workflow restructuring. This pointed to a selective model: routine work would move to the hub, whereas urgent or stability-sensitive activities would remain at peripheral sites, wherever clinical urgency or specimen stability was at stake.

Selection of the central microbiology laboratory

The NRL-ICAD was chosen as the central microbiology laboratory because it met the core operational and technical requirements for a hub. It was the largest NRL-owned microbiology facility, with the largest physical footprint and strong backing from executive and medical leadership. It also offered the broadest diagnostic menu in the network—including biosafety level 3 mycobacteriology, MALDI-TOF mass spectrometry, broth microdilution, and mycology and parasitology services—alongside established staff experienced in specimen receipt and referral testing. Together, these features made the NRL-ICAD the most suitable site for consolidating routine operations while retaining capacity for higher-complexity work.

Proof-of-concept workflow model

A proof-of-concept workflow was developed to allocate activities based on clinical urgency, specimen stability, transport feasibility, analytical complexity, and operational benefit. Peripheral sites kept the urgent and stability-sensitive functions; these included immediate loading of blood culture bottles, urgent Gram staining for positive blood cultures and cerebrospinal fluid, rapid molecular testing after a positive blood culture, selected syndromic molecular panels, rapid screening assays for infection prevention and bed management, and semen analysis. All eligible routine specimens and post-urgent positive blood culture material were transferred to the central laboratory within a 2-hour target time (Table 1).

Table 1.

Urgent and stability-sensitive microbiology functions are retained at peripheral laboratories under the consolidation model.

Function retained locally	Operational rationale
Automated incubation of blood culture bottles	Preserves immediate local loading of critical blood cultures and reduces pre-incubation delay.
Urgent Gram stain for positive blood cultures and cerebrospinal fluid specimens	Supports rapid preliminary reporting for time-critical clinical decisions.
Rapid molecular testing triggered by positive blood cultures	Maintains prompt organism and resistance-marker assessment once a blood culture flags positive.
Rapid syndromic molecular testing for sepsis, meningitis, gastrointestinal, respiratory, and joint panels	Retains local access for selected high-impact urgent diagnostic pathways.
Rapid molecular screening for carbapenem-resistant Enterobacterales, methicillin-resistant Staphylococcus aureus, and Clostridioides difficile	Preserves infection prevention and urgent bed-management workflows.
Semen analysis	Remains decentralized because of specimen stability requirements.

Risk assessment

Before go-live, the team conducted a comprehensive risk assessment to identify clinical and operational weaknesses in the proposed hub-and-spoke model. The exercise weighed the likelihood and the potential impact of problems with specimen quality, turnaround time, workflow continuity, staff engagement, and stakeholder buy-in. This approach is consistent with broader laboratory system strengthening frameworks that identify and remedy operational shortcomings before launch [14]. Input came from microbiology operations, logistics, quality, laboratory information system (LIS), and clinical service teams. The key risks were staff turnover or disengagement, new pre-analytical errors arising from changed specimen pathways, loss of physician confidence, specimen loss or misrouting in transit, longer turnaround times, and delayed delivery of stability-limited specimens. Mitigations followed directly: retain vital local testing, standardize SOPs across the network, introduce courier confirmation, validate LIS routing, establish escalation and communication lines, and maintain active oversight through go-live.

Implementation phases

Implementation was organized into five linked phases: conception (May-October 2024), executive proposal preparation (October-December 2024), pre–go-live readiness (from December 2024), go-live (from January 2025), and ongoing optimization (from December 2025). This staged framework kept decisions, resource commitments, staff preparation, information system validation, transport readiness, and post-implementation follow-through in a planned and accountable sequence. The phases and their constituent activities are shown in Figure 3.

Figure 3.

Phased implementation roadmap for microbiology laboratory consolidation at NRL. The figure links planning, executive approval, pre–go-live readiness, go-live governance, and continuing optimization into a single implementation sequence. Conception (May-October 2024) established the rationale for consolidation, defined central laboratory selection criteria, identified clinical and operational leadership champions, confirmed logistics and transport requirements, delivered proof-of-concept workflow testing, and assessed clinical and non-clinical impact. Executive proposal preparation (October-December 2024) appointed a dedicated manager and developed the business plan, timeline, and human resources, LIS, procurement, facilities, and logistics requirements for executive review. Pre–go-live readiness (from December 2024) set and communicated go-live dates, tested LIS routing and reporting, established sending and receiving workflows through SOPs, confirmed courier pick-up and drop-off details, and defined key performance indicators and their measurement processes. Go-live (from January 2025) delivered a phased rollout with command center meetings; confirmed inter-laboratory and hospital communication plans; monitored courier performance against expectations; and evaluated clinical, operational, and cost outcomes. Ongoing optimization (from December 2025) established recurring clinical and operational meetings, streamlined workflows, and identified further opportunities for standardization, education, and continuous improvement.

Abbreviations: KPI, key performance indicator; LIS, laboratory information system; NRL, National Reference Laboratory; SOP, standard operating procedure.

Communication and resource preparation before go-live

Pre–go-live work focused on communication with stakeholders, identifying practical resources, and operational and LIS validation. Go-live dates and operational changes were shared with laboratory leadership, frontline staff, clinical teams, and administrators. LIS routing and reporting were tested end to end, covering order worklists, specimen-transfer processes, and result-reporting pathways; central laboratory staff were granted remote access to the electronic patient record to read results in a clinical context. Specialist LIS and quality staff joined implementation meetings before any live activity began, so that technical and governance issues could be resolved in advance.

A full set of SOPs, job aids, specimen-handling instructions, packaging guidance, and transfer workflows was prepared and distributed to all network laboratories. A single online tracker mapped implementation tasks, logged unresolved issues, and recorded who owned each follow-up item, thus keeping the transition transparent and preventing site-specific assumptions from persisting after go-live.

Pre-analytical handling of urine specimens

Urine specimens for culture were collected as midstream clean-catch or catheter specimens into sterile containers. The operating model required specimens to reach the central laboratory within a 2-hour target from collection. Specimens that could not be dispatched within this window were refrigerated at 2-8°C at the collection site and transported under controlled temperatures. Contamination was defined as growth of more than two organism types at ≥10⁴ CFU/mL or the presence of mixed genital or skin flora without a predominant uropathogen, and this definition was applied identically in the pre- and post-consolidation periods.

Continuity of clinical and educational commitments

We also assessed the wider service commitments that consolidation might affect. Microbiology-related clinical calls continued to be routed through on-shift laboratory staff, directed to the central ICAD laboratory. Participation in infection control and antimicrobial stewardship programs continued without interruption. Allied health education, pharmacy and medical student teaching, and intern training were incorporated into the revised model, so that consolidation did not disrupt teaching or infection prevention and control, as well as antimicrobial stewardship commitments that are easy to overlook but matter for long-term capacity.

Outcome domains

The evaluation spanned service redesign, transport performance, workflow function, quality and standardization, communication and governance, continuity of clinical and educational activities, workforce optimization, turnaround time, selected quality indicators, and estimated financial impact. The dataset reflects early implementation experience and approximate savings rather than a mature, long-term performance dashboard, so the quantitative findings should be read as early signals that need continued monitoring. To address this, we will implement structured, ongoing monitoring of key operational and quality indicators. Data will be systematically collected through the laboratory information system and internal quality management tools at regular intervals. Reports summarizing specimen and assay turnaround times, transport exceptions, specimen rejection and contamination rates, clinician and staff satisfaction, and audited financial outcomes will be generated quarterly and shared with clinical, operational, and executive stakeholders. This continuous performance assessment will ensure that the impacts of consolidation are rigorously evaluated over time and support further refinement of the network model.

Statistical analysis

Turnaround time data were summarized as medians because of their skewed distribution, and pre- vs post-consolidation values were compared using the Mann–Whitney U test. Categorical outcomes, including urine culture contamination rate, were compared between the pre- and post-consolidation periods using the chi-square test. A two-sided P-value of less than 0.05 was considered statistically significant. Turnaround time was defined as the interval from specimen receipt in the laboratory information system to the release of the final report. Percentage change for each test was calculated as the difference between post- and pre-consolidation median turnaround times, expressed as a proportion of the pre-consolidation median; each test was, therefore, treated as an independent comparison, and changes were not weighted by test volume (turnaround times and quality indicators section). All statistical analyses were performed using GraphPad Prism (version 10.0; GraphPad Software, Boston, MA, USA).

Results

Service redesign and operating model

The hub-and-spoke service was established as planned, with NRL-ICAD handling routine and non-urgent work, and peripheral sites retaining urgent and stability-sensitive activities. Eligible routine culture processing moved to the central laboratory without removing local capacity for urgent action. The design balanced the operational advantages of centralization against the clinical risk attached to time-critical specimens: routine, non-urgent samples were routed to the hub, whereas positive blood culture bottles and other urgent materials followed a selective pathway that required immediate local action first and hub processing afterward. This allowed the model to combine standardization and efficiency with responsiveness for high-impact work.

Risk mitigation and implementation controls

Controls were matched to the vulnerabilities identified in the planning. Staff concerns were managed through leadership engagement, role clarification, and a phased rollout. Pre-analytical risks were reduced by standardizing specimen collection, packaging, dispatch, receipt, and transfer. Physician confidence was supported by maintaining urgent peripheral services, defining clear escalation pathways, and maintaining microbiology involvement in infection prevention and control and antimicrobial stewardship. The low-probability but high-impact scenario of specimen loss in transit was controlled through courier verification, documented chain-of-custody steps, and clear routing responsibilities.

Transport logistics and service continuity

Transport design was central to the operating model. Routine specimens and post-urgent positive blood culture material were expected to reach the central laboratory within 2 hours. Courier pick-up and drop-off arrangements were confirmed before go-live, and transport performance was tracked through the transition. Keeping urgent and stability-sensitive testing at peripheral laboratories insulated the specimen categories most exposed to transport delays from any early logistics problems.

Standardization and quality systems

Consolidation created a practical opportunity to align microbiology practices across the network. Test routing, specimen packaging and transport, receipt, and result reporting were brought under a shared set of SOPs. LIS routing and reporting were tested and validated before go-live to ensure consistent transfer and result management. Beyond improving procedural consistency, these steps were expected to reduce the quality overhead (e.g. proficiency testing enrollment) of running parallel site-level processes.

Governance and communication

Governance during implementation rested on command center sessions at go-live and formal communication plans between laboratories and hospitals. After go-live, regular operational and clinical review meetings were held to raise issues, examine workflows, and guide further refinements. These structured forums provided a rapid problem-solving mechanism during the transition and a foundation for continued oversight afterward.

Preserving clinical and educational roles

Consultative, infection prevention, stewardship, and educational duties all continued in the new format. Microbiology input into the relevant clinical committees was maintained, and training commitments to allied health workers, pharmacy personnel, medical students, and interns were preserved. Keeping these roles mattered for clinician confidence; consolidation changed where testing was performed, but it was never meant to diminish the specialist microbiology function.

Workforce productivity and optimization

A time-based review of bench work, workload distribution, and potential inefficiencies was conducted before and during consolidation planning. Its findings informed the redeployment of responsibilities across the network and the development of a staffing model that consolidates redundant, low-volume work from multiple sites into a single plan. Throughout the process, staff feedback was actively sought, with some initial concerns being raised regarding changes to roles, workload redistribution, and adjustment to new workflows. Resistance was most often expressed around the perceived impact on job security and adaptation to SOPs shared across sites. Ongoing communication, involvement of staff representatives in planning, and targeted training helped address these challenges and foster greater engagement. Productivity benchmarking suggested that the new model could raise output by restructuring work, cutting duplicated effort, and using specialist skills more effectively. The projected gain of roughly one to two full-time equivalents is an operational estimate rather than an independently audited figure and will be refined as the model matures.

Turnaround times and quality indicators

Early quantitative data showed improvements in several workflows, although performance varied across the broader test menu. Bacterial culture turnaround time decreased by 35.3% (P = 0.01), and methicillin-resistant Staphylococcus aureus (MRSA) culture screening turnaround time by 13.3% (P = 0.04); these reductions are shown in Figure 4, where negative values represent shorter post-consolidation turnaround times. Median blood culture turnaround time changed only marginally, from 5.03 to 5.00 days, consistent with the decision to maintain immediate local action for this time-bound pathway before any downstream processing.

Figure 4.

Change in turnaround time by test after consolidation. Negative values indicate shorter turnaround time after consolidation. Tests are ordered by magnitude of change, with the aggregate bacterial culture category shown last, below a dashed rule, so that it is not read as a member of the individual test series. “Miscellaneous bacterial culture” denotes low-volume culture types not separately itemized in the figure; it is distinct from the aggregate bacterial culture category, which encompasses the full routine culture menu. Candida auris screening is shown as a single test. Blood culture is included for completeness and was essentially unchanged, consistent with the deliberate retention of immediate local incubation and urgent preliminary work for this pathway. Percentage changes are unweighted by test volume(turnaround times and quality indicators section).

The derivation of the 35.3% figure warrants explanation. It refers to the aggregate “bacterial culture” order category as recorded in the LIS and was obtained by comparing the median specimen-to-final-report interval for all specimens in that category before and after consolidation. It is an unweighted summary: each constituent test contributes to the category median in proportion to its own volume, but the headline percentage change is not weighted by the relative clinical or operational importance of individual tests. Because the category pools workflows of very different scales, the aggregate is influenced disproportionately by lower-volume tests, notably, genital culture, which showed the largest proportional gain but represents a small share of network workload (Figure 1). To make the picture volume-aware, we separately examined the highest-volume routine tests in the network: urine culture turnaround time increased by 6%, whereas blood culture was essentially unchanged (−0.6%). The fact that the second highest-volume test in the network moved in the opposite direction to the aggregate reinforces this point. The aggregate figure should, therefore, be read as a volume-independent summary of the routine culture menu, not as a weighted measure of the network’s overall culture turnaround performance.

Urine culture contamination declined from 0.99% before consolidation to 0.80% afterward (chi-square ≈ 4.04, P ≈ 0.045). This is consistent with the expected effects of standardized specimen handling, harmonized workflow controls, and clearer accountability in the pre-analytical pathway. Chemical urine preservation was neither introduced nor altered as part of consolidation: boric acid tubes were already in routine use for clients outside Abu Dhabi, and plain sterile containers were used for clients within Abu Dhabi in the pre- and post-consolidation periods (pre-analytical handling of urine specimens section). The reduction, therefore, cannot be attributed to a change in preservative use. The pre-analytical controls that did change were the 2-hour transport target, refrigeration of specimens that could not be dispatched within that window, standardized collection instructions, and harmonized packaging and dispatch. Because the dataset is early, continued monitoring is needed to confirm whether the improvement persists across specimen types, clinical areas, and seasonal workload variation.

Early financial outcomes

The early cost review estimated annual savings in internal quality control materials, proficiency testing and external quality control, instrument maintenance, and accreditation-related work effort (Table 2). These savings are consistent with the expected benefits of reducing duplicated site-level processes and centralizing routine platforms to ensure clinical and analytical safety. Together, the quantified domains amount to an estimated United Arab Emirates dirham (AED) 180,500 in annual savings. Although these figures are based on internal analysis and early implementation data, plans are in place to enhance data validation through structured reviews and ongoing internal audits. In the future, possibilities for independent auditing or external validation of financial and operational outcomes will be explored to strengthen confidence in the reported results.

Table 2.

Early estimated operational and financial outcomes after microbiology consolidation at the NRL.

Outcome domain	Estimate	Interpretation
Internal quality control (IQC) materials	AED 17,000/year	Reduced duplication of quality control activities across sites
Proficiency testing (PT) /external quality control (EQA)	AED 15,000/year	Lower expenditure through consolidated participation and reduced duplication
Instrument maintenance	AED 141,000/year	Reduced maintenance burden after centralizing routine testing platforms
Accreditation-related work effort	AED 7500/year	Lower recurring effort from maintaining parallel site-level processes
Workforce optimization	∼1-2 FTE projected	Expected efficiency gain through workload redistribution rather than immediate staff reduction
Service model impact	Qualitative early improvement	Improved standardization, governance, communication, and operational streamlining

Abbreviations: AED, United Arab Emirates dirham; EQA, external quality assessment; FTE, full-time equivalent; IQC, internal quality control; NRL, National Reference Laboratory; PT, proficiency testing.

Discussion

This case study shows that microbiology consolidation is best managed as a whole-service redesign rather than as a transfer of test volumes between laboratories. Our project brought together infrastructure rationalization, workflow alignment, transport planning, LIS readiness, governance, and the selective retention of urgent local services. This combination matters, especially in microbiology, where efficiency gains must always be weighed against the costs of delayed diagnosis, delayed reporting, and reduced access to specialist advice.

One of the project’s main strengths was its selective centralization. Routine and non-urgent work were moved to NRL-ICAD, whereas urgent and stability-sensitive functions stayed at peripheral laboratories. This design directly addressed one of the principal hazards of microbiology consolidation: the risk of negatively impacting critical pathways. The stable median blood culture turnaround time after implementation validated the decision to keep immediate local incubation and urgent preliminary work before any downstream transfer. The larger reductions for bacterial culture and MRSA culture screening, by contrast, suggest that centralization can be more efficient for tests where routing rules and operational controls are clear.

Our experience also underlines the importance of functions beyond the analytical bench. The implementation plan covered call routing, committee and service participation, teaching responsibilities, LIS routing, courier logistics, and go-live governance—all of which determine whether clinicians and staff experience consolidation as a service improvement rather than a disruption. Similar concerns about communication, specimen transport, and service continuity have been raised in earlier reports of centralized microbiology services [15].

The phased roadmap was a further safeguard: separating conception, executive preparation, pre–go-live readiness, go-live, and ongoing optimization allowed the team to refine workflows and reduce risk before and during the transition. In a networked service, where small failures in routing, transport timing, or communication can erode turnaround time and stakeholder confidence, the roadmap became not just a timeline but also a governance tool.

The anticipated savings suggest that consolidation can lower costs by avoiding the duplication of quality control materials, proficiency testing, instrument maintenance, and accreditation-related efforts. Broader cost pressures and consolidation in health care markets are well documented [16], but our figures should be read as early estimates rather than audited long-term results. Importantly, the projected staffing benefit is better understood as a marker of improved operational productivity than as a confirmed reduction in headcount.

Comparison with other consolidation programs

Our findings can usefully be set alongside other microbiology consolidation programs, regional and international. The most directly comparable local experience is the 2024 consolidation of microbiology services across the Dubai Health network, which independently adopted an almost identical architecture: a single central hub for non-urgent testing, with rapid response laboratories retained at peripheral sites for urgent work, supported by unified protocols, optimized transport logistics, and a single laboratory information system [17]. That program reported on-time specimen delivery rates of 98.57% for routine and 97.90% for critical samples, alongside workforce optimization and cost reduction [17]. The convergence of two independently designed UAE networks on the same configuration—central processing of routine work, local retention of urgent and stability-limited testing, and a unified information system—suggests that this model suits the geography, transport infrastructure, and service structure of the region. Our project differs mainly in emphasis: Dubai Health reported transport reliability and revenue cycle optimization as primary end points, whereas our early evaluation centered on turnaround time and pre-analytical quality.

Internationally, Carter et al. [15] described consolidation across a three-hospital system that produced net annual savings of approximately US$100,000 while maintaining turnaround time and clinician satisfaction. Our estimated AED 180,500 (approximately US$49,000) per year is of a broadly similar order once the difference in network scale is considered; as in their experience, the savings derive predominantly from avoided duplication of quality control materials, proficiency testing, instrument maintenance, and accreditation effort rather than from headcount reduction. In their point–counterpoint review of consolidated microbiology laboratories, Sautter and Thomson [18] concluded that financial pressure is the dominant driver of consolidation, with turnaround time and access to newer technology as important secondary drivers, while cautioning that centralized laboratories may be located hours from the point of care and that transport conditions must preserve organism viability. Vandenberg et al. [19] subsequently argued that consolidation across large geographical regions creates precisely the scale required for cost-effective adoption of advanced diagnostic technologies, but that this benefit is contingent on well-designed specimen logistics and information flow.

Our experience is consistent with both positions. The turnaround-time gains we observed were largest where routing rules were unambiguous and transport intervals were short, and the deliberate retention of urgent and stability-limited pathways at the spokes is the most plausible reason that the recognized hazards of centralization—delayed critical results, loss of clinician confidence, and compromised specimen viability—did not materialize in our early data. Two features distinguish our setting from most published series: transport distances within the network are short by international standards, which lowers the transport risk that Sautter and Thomson emphasize, and the hub already held the network’s specialized menu before consolidation, so centralization did not require new capability, only new routing.

Interpretation of the quality indicators

The fall in urine culture contamination is a meaningful early quality signal, but it requires careful interpretation. The absolute change was small, and the pre- and post-consolidation rates were already low according to international benchmarks. In a CAP Q-Probes study of 127 laboratories, the median institutional urine culture contamination rate was 15.0%, with the lowest-performing decile averaging 41.7% and the highest-performing decile averaging 0.8% [20]. Our baseline of 0.99% and post-consolidation rate of 0.80%, therefore, sit at or below the best-performing benchmark in that series, which leaves limited room for further improvement and should temper the weight placed on the change. The comparison is also not exact: the Q-Probes study defined contamination as more than two isolates at ≥10⁴ CFU/ml, and although our laboratory applies a closely similar definition, case mix differs. Notably, the same Q-Probes analysis found that post-collection processing—refrigeration in particular—had a substantial effect on contamination, whereas collection site did not [20]. That finding aligns with our own pre-analytical controls, which centered on a 2-hour transport target and refrigeration, with preservative practice unchanged across the two periods, and it supports the plausibility of the observed reduction. Continued monitoring will be needed to determine whether the reduction persists and whether similar gains appear in other pre-analytical quality indicators, such as rejection rates, labeling errors, or delayed specimen receipt.

Limitations and future evaluation

This study has limitations. The dataset is rich in operational design, early performance indicators, and estimated savings, but it does not yet constitute a mature, long-term key performance indicator dashboard. Follow-up will be needed to assess turnaround time across an expanded test menu, specimen rejection, transport deviations, clinician satisfaction, staff experience, patient outcomes, and the durability of savings. It is also a single-network case study, and its transferability will vary with geography, staffing, governance, transport infrastructure, baseline laboratory resources, and clinical involvement.

A further limitation concerns the aggregate turnaround-time figure. Because percentage changes were calculated per test and not weighted by test volume, the headline 35.3% reduction in the bacterial culture category reflects the routine culture menu as a set of workflows rather than the network’s throughput-weighted performance, and it is influenced disproportionately by lower-volume tests. We have made this explicit in the abstract, in statistical analysis section, and in turnaround times and quality indicators section; readers should not interpret the figure as a volume-weighted measure.

Two domains will be added to the monitoring set in the next evaluation cycle. First, critical result turnaround time—the interval from result availability to documented receipt by the responsible clinician for positive blood cultures, positive cerebrospinal fluid Gram stains, and alert-organism detections—will be tracked as an indicator in its own right. This is the measure most sensitive to the specific risks of a distributed model, and it is not captured by specimen-to-report turnaround time; it is also the indicator that would most directly demonstrate whether the selective retention of urgent testing at the spokes has achieved its clinical purpose. Second, formal productivity studies benchmarked against established workload standards [11] will quantify billable tests and worked hours per full-time equivalent at both hub-and-spoke sites, together with time-in-motion analysis of the redesigned bench workflows. This will convert the current operational estimate of one to two full-time equivalents into an auditable measure and allow the productivity effect of consolidation to be separated from the effect of concurrent workflow changes.

Even so, the underlying operational approach offers a useful reference for other health systems considering selective microbiology consolidation. To adapt or modify this model, other networks should consider their specific setting, including laboratory size, patient population, existing infrastructure, and staffing expertise. Elements such as the selective retention of urgent pathways, phased implementation, and early stakeholder communication can be tailored to fit different operational and clinical environments. An explicit assessment of local requirements and constraints is essential to successfully generalize or customize this consolidation framework in other health care systems.

Conclusion

The NRL microbiology consolidation project demonstrates that routine, non-urgent microbiology testing can be brought into a hub-and-spoke model, whereas urgent and stability-critical work remains at the periphery. Early during implementation, the project improved standardization and governance clarity, preserved urgent pathways, supported workforce efficiency and estimated annual savings, delivered marked improvements in several turnaround-time measures (reported per test rather than as a volume-weighted aggregate), and produced a small but significant decrease in urine contamination from an already low baseline. Blood culture turnaround time remained stable, justifying selective local retention for that time-critical workflow.

The central message is that microbiology consolidation must be treated as a clinically driven service transformation rather than mainly a logistical or financial exercise. Sound execution depends on explicit specimen routing, dependable transport with defined time targets, consistent SOPs, validated LIS routing and reporting, genuine communication with staff and stakeholders, and sustained post-implementation monitoring. Although the present analysis focused on operational and quality measures, no adverse patient care or safety outcomes were identified in the early post-implementation phase of the project. Direct metrics of patient safety and clinical outcomes, such as rates of diagnostic or treatment delays, infection control events, or patient adverse events, were not systematically tracked during the initial review. However, plans are in place to include these domains in future evaluations, ensuring that clinical impact and patient safety remain central to the ongoing assessment of the model. Future evaluations should also include mature post-implementation metrics, such as specimen and assay turnaround times, critical result turnaround time, formal productivity and workload-benchmarked studies, transport exceptions, specimen rejection and contamination, clinician satisfaction, staff experience, patient safety measures, and audited financial results, to test whether the early gains are sustained and to guide further optimization of the network model.

Funding

No specific external funding was received for this operational improvement initiative.

Ethical approval

The work reported here represents an operational improvement and service-redesign project carried out at the system level. Because it entailed no collection of patient-level data and no human subjects research, the NRL Institutional Review Board confirmed that it qualified for exemption from review.

Submission declaration

The present work is original, has not been published in any form previously, and is not currently under review by another journal. Formal submission will proceed once all authors and the relevant responsible parties have granted their approval.

Data availability

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

Declaration of generative AI and AI-assisted technologies in the writing process

Generative artificial intelligence tools were used for language editing and formatting during manuscript preparation. All content, analysis, and interpretation were developed by the authors who reviewed and revised all text; verified the accuracy of the data, references, and interpretations; approved the final manuscript; and take full responsibility for its content.

CRediT authorship contribution statement

Mubarak Alfarsi: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Laila AbdelWareth: Supervision, Resources, Project administration, Methodology, Conceptualization. Arun Kumar Jha: Methodology, Investigation, Conceptualization. Imran Mirza: Writing – review & editing, Supervision, Project administration, Methodology, Investigation, Conceptualization. Mohammed Ahmed Nagi: Validation, Supervision, Project administration, Methodology, Investigation, Conceptualization. Shweta Narang: Supervision, Project administration, Methodology, Investigation, Conceptualization. Andrew Turner: Supervision, Project administration, Methodology, Conceptualization.

Declaration of competing interest

The authors have no competing interests to declare.

Appendix A. Members of the NRL Microbiology department group

The following members of the Microbiology Department, NRL, contributed to the consolidation program and are represented collectively in the byline as “The NRL Microbiology department group.”

No.	Name	Email address
1	Saly Hassan	shassan@nrl.ae
2	Rafeeque Arakkakattil	rarakkakattil@nrl.ae
3	Shafeer Subair	Shafeer@nrl.ae
4	Betsy Kayyalackal Zacharia	bzachariah@nrl.ae
5	David Anti	antid@nrl.ae
6	Fatima Alkarbi	falkarbi@nrl.ae
7	Hashim Elsayed	elsayeh@nrl.ae
8	Laila Hasan Abdulkabeer Baqais	lbaqais@nrl.ae
9	Maria Teresa Balaing Real	Maria@nrl.ae
10	Martin Ricbenson Del Rosario De Castro	mcastro@nrl.ae
11	Mohamed Hasbelnabee	mhasbelnabee@nrl.ae
12	Mohamed Mostafa Mohamed Elfadil	melfadil@nrl.ae
13	Mohammed Ahmed Mohammed Al-Maeati	malmaeati@nrl.ae
14	Muntasir Ibrahim	Mibrahim1@nrl.ae
15	Nasna Rasulin	nrasulin@nrl.ae