Who Moved My Lab?

Infection control impact of a changing laboratory environment

Daniel J. Diekema, MD, D(ABMM) Professor University of Iowa Carver College of Medicine Associate Hospital Epidemiologist Associate Micro Lab Director University of Iowa Hospitals
Disclosures: Research support from Pfizer, Merck, Astellas, Schering and bioMerieux

How common?
No recent reliable data on laboratory consolidation and off-site moves Managed care during 1990s was associated with widespread changes in lab services
Consolidation, downsizing, mergers, off-site moves

From 1990-1998, 23% reduction in CMLs

Simultaneous reduction in employment of technologists experienced in clinical microbiology
Marwick C. JAMA 1998;280:1213-14.

Is it a problem?
Key roles of the microbiology lab in infection prevention Surveillance Outbreak detection and management Antimicrobial stewardship Advisory Educational
How do offsite moves and laboratory consolidation affect these functions?

Absence of data seems to be a problem!

Very limited published literature Needed: data on outcomes following labs moving offsite, restructuring or consolidating My approach:
literature review e-mail and phone interviews with directors of large offsite labs

Microbiology Lab and Surveillance

Review of microbiology reports most common method for case finding Accurate identification and susceptibility testing is the cornerstone of good surveillance
Valid rates for benchmarking Detection of clusters & outbreaks

Top 5 limitations of consolidation or off-site laboratory moves

Poor communication between caregivers and laboratory personnel Problems with timely specimen transport* Difficulty with customized reporting* Poor quality Gram stain readings at onsite rapid response laboratories Compromised HAI surveillance, lack of personal interaction with IPs*
ClinMicroNet Survey, results summarized in: Peterson LR, et al. Clin Infect Dis 2001;32:605-610.

Does quality suffer after lab restructuring?

25 93-95 20 95-96 96-98

% ID Error Rate

15 10 5 0 Same Reclassified Classification of Laboratories

Church DL, et al. Arch Pathol Lab Med 2000;124:357-61.

Delays in specimen transport

Examples from interviews:
8 h from blood cx collection to loading in instrument >4 h from hospital to offsite lab receipt

Problems: delay in results reporting, falsely negative cultures, falsely positive cultures Solution? On-site lab for Gram stains, plating of samples, point-of-care testing
Can lead to quality issues if non-microbiology trained technologists, without appropriate oversight, staff onsite lab
Bekeris LG, et al. Arch Pathol Lab Med 2008;132:913-17. Brook I. J Clin Microbiol 1987;25:2020-2022.

Role of the Lab in Streamlining Surveillance

Time consuming, resource intensive
Traditionally occupies ~50% of time/resources We spend too much time gathering data!

Lab is an essential partner in using electronic data sources to reduce time and improve surveillance
Must be customized to each hospitals IC program, risk assessment, surveillance priorities
We cant custom-design protocols to fit each and every hospitals wishes

New Surveillance Challenges

New and emerging infectious agents
e.g. H1N1 (complex testing issues!)

New antimicrobial resistances

e.g. VISA/VRSA, carbapenemases

New mandates
Active surveillance for MDROs Public reporting of HAI rates

The need for speed.

Meeting these challenges requires close collaboration between the micro lab and infection prevention!

Laboratory capacity to detect antimicrobial resistance

CDC survey performed in 1998 (N=369 labs) 33% of labs didnt use an acceptable method for detection of VISA Most used inappropriate methods for ESBL detection and confirmation Onsite laboratories serving larger hospitals more likely to use recommended methods Managed care based labs significantly less likely to use recommended methods
MMWR 2000;48:1167-71.

Advantages of rapid results reporting.

Allows for rapid institution of infection control precautions, but only for those who need them Rapid availability of AST results allows for earlier intervention by antimicrobial management teams Allows for earlier investigation of outbreaks Provide results in a clinically relevant time frame LOS becoming shorter and shorter

Faster, faster!

Microbiology Laboratory and Outbreak Detection and Management

Early detection (surveillance, notification) Case finding
review of lab results/archived samples

Consultative role
Could it be a pseudo-outbreak? Inclusion of lab diagnosis in case definition

Generate hypotheses about reservoir, spread

Molecular typing: assess genetic relatedness Environmental cultures? Personnel cultures?
Diekema DJ, Pfaller MA. Manual of Clinical Microbiology, 9th ed. 2007.

Use of Molecular Typing

Study pathogenesis of infection
Colonizing versus infecting Contamination versus pathogen

Assess extent and mode of pathogen transmission

Effectiveness of IC efforts Outbreak investigation

Requires maintaining an organism bank!

Microbiology Lab and Antimicrobial Stewardship

Microbiology reports essential to all AM stewardship efforts Communication between lab, pharmacy and AM stewardship team is essential Unit specific and tailored antibiograms, updated regularly Information in real time is needed for concurrent review programs

Surveillance for Antimicrobial Resistance:

Antibiogram preparation
Important for empiric antimicrobial selection, 100 detection of resistance 90 trends 80 CLSI guidelines exist %S Hospital wide 70 antibiograms dont 60 always reflect unit specific resistance 50 rates
E. coli susceptibility to TMPSMX and levofloxacin

TMP-SMX Whole house

Levofloxacin MICU

Binkley et al. Infect Cont Hosp Epidemiol 2006;27:682-7.

Antibiogram Preparation: Room for Improvement

We surveyed 494 lab directors nationwide
Compilation of an antibiogram Yearly updating of antibiogram Yearly distribution of antibiogram to infection control and medical staff

Only 60% of hospitals met all three criteria Those meeting criteria more likely to:
provide onsite susceptibility testing have more micro lab FTEs per hospital bed
Ernst EJ, et al. Diagn Microbiol Infect Dis 2004;49:141-145.

Advisory role of the clinical microbiologist

Importance of participation on the IC committee
100 80
CML on IC committee CML not on IC committee

% of labs

60 40 20 0 Formulary decisions* Antibiogram* Antibiogram updates* Molecular typing

Percent of labs providing selected antimicrobial resistance control support, according to whether the micro lab has representation on the infection control committee. *p<0.05

Diekema DJ, et al. ICAAC 2001, abstract K-1213.

Practical challenges to attending each hospitals IC committee meetings

Five hospitals: monthly (3), quarterly (2) Forty-two meetings per year! Hundreds of miles on the road.. Several meetings may conflict Conference calling, webinars, etc.

Personal communications, offsite lab directors.

Location, location, location

...it is easy to get isolated there is not nearly as much interaction. The big difference for meis communication. Since Im not in their facility, it seems Im less aware of what their infection control priorities or issues are.
Personal communications, offsite lab directors.

Microbiology Laboratory and Education and Training

ACGME requirement for training in infectious diseases Important aspect of training for infection preventionists

Are there advantages to consolidation or offsite moves?

Provides smaller hospitals easier access to some higher complexity or automated testing One lab providing service to multiple hospitals in a system could improve inter-hospital coordination and MDRO tracking

Summary:
The many roles of the microbiology lab in infection control
Accurate detection of organisms/resistance Facilitate efficient and timely surveillance Assistance in detection and investigation of outbreaks and clusters of infection
Provision of typing, maintainance of an organism bank

Facilitate antimicrobial stewardship efforts

Antibiograms, real time AST data for regimen adjustment

Advisory to infection control committee Education and training

Practical recommendations for microbiology lab support of infection control

Onsite laboratory services Clinical microbiology representation on the infection control committee Regular infection control rounds with the microbiology laboratory director

Practical recommendations for programs with offsite labs:

Reach out to the laboratory director Establish open line(s) of communication Invite to infection control meetings Arrange regular meeting times or lab rounds Establish parameters of support, write into contract next time it is negotiated
Surveillance, MDRO control, outbreak assistance, organism banking, molecular typing

Special thanks to:

Gary Doern, PhD Alan Junkins, MD Erik Munson, MD Lance Peterson, MD Michael Pfaller, MD Susan Sharp, PhD