Who Moved My Lab? Infection control impact of a changing laboratory environment

Daniel J. Diekema, MD, D(ABMM)ProfessorUniversity of Iowa Carver College of MedicineAssociate Hospital EpidemiologistAssociate Micro Lab DirectorUniversity 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 on-site 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?

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

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Classification of Laboratories

93-95 95-96 96-98

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 can’t custom-design protocols to fit each and every hospital’s 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 didn’t 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.

Faster, faster!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……

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, detection of resistance trends

• CLSI guidelines exist

• Hospital wide antibiograms don’t always reflect unit specific resistance rates

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% S

TMP-SMX Levofloxacin

Whole house MICU

E. coli susceptibility to TMP-SMX and levofloxacin

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.

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Antibiogram* Antibiogramupdates*

Moleculartyping

CML on IC committeeCML not on IC committee

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

Advisory role of the clinical microbiologistImportance of participation on the IC committee

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

Practical challenges to attending each hospital’s 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 me…is communication.”

“Since I’m not in their facility, it seems I’m 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