Transforming the microbiology laboratory to address the Triple Aim in healthcare
For several years, hospitals across the country have been striving to deliver the Institute for Healthcare Improvement “Triple Aim” by improving patient outcomes, improving the patient experience, and delivering care at a lower cost. However, successfully delivering on the goals of the Triple Aim must be achieved in a challenging environment resulting from a number of factors, including some provisions of The Patient Protection and Affordable Care Act, labor shortages, increasing rates of antimicrobial resistance, declining budgets, demands to increase quality measures, and an increasing number of patients with access to health insurance. All of these are occurring as the Centers for Medicare and Medicaid Services (CMS) has introduced the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) in an effort to gain an objective comparison of hospitals on topics important to consumers, provide public reporting of survey results to create new incentives for hospitals to improve quality of care, and enhance accountability by increasing transparency in the quality of hospital care provided.
Identifying the challenges
In the midst of our journey to achieve the Triple Aim, our microbiology laboratory here at NorthShore University HealthSystem, Evanston Hospital collaborated with senior management and other departments to determine how we could contribute as a solutions provider to address the challenges being faced in our hospital. We recognized that we had challenges within our own department that we needed to solve in order to support the hospital more broadly. We opted for an ambitious plan to implement an innovative new technology in our microbiology laboratory that would allow us to address an impending labor shortage at a time when our volume of microbiology testing was increasing. We also recognized a need to improve the turnaround time we provided for our bacteriology results and increase the quality by minimizing the variability that exists in our current process of inoculating, streaking, and incubating plates. For our needs, we decided to introduce a microbiology laboratory automation system that utilizes magnetic rolling beads to streak the plate and subsequently incubate the sample at optimal temperatures in incubators capable of storing 1,150 plates at a time.
Implementing an automation system
Although the system is well established in the European market, we embarked on a journey of becoming the first site in the U.S. to implement it. Because we wanted to increase the quality of our results by minimizing the variation in our labor-intensive processes and reduce the opportunity for errors, we leveraged the magnetic rolling bead technology to accomplish these tasks. During our implementation process, we noticed more colonies with greater isolation using the magnetic rolling bead compared to traditional streaking with a loop. This is important because it contributes to our organizational desire to provide the right patient with the right treatment at the right time. In addition, we needed to increase our productivity. We discovered from discussions with microbiology leaders in Europe that they were able to double their Laboratory Productivity Index (LPI), the number of samples processed per technologist per day, from 37.4 to 75.9. This level of productivity increase was exactly what we required in an era of anticipated reductions in staffing due to retirement and increasing volumes.
As we grew comfortable with the productivity gains and the high quality of the streaking of the magnetic rolling bead, we turned our attention to improvements in turnaround time for our bacteriology results. Improving the turnaround time is a function of earlier isolate availability and the selection of an identification technology. In our laboratory, we use matrix assisted laser desorption ionization-time of flight (MALDI-TOF) mass spectrometry for rapid identification of isolates. The microbiology automation system has provided earlier isolate availability due to more consistent incubation times and temperatures, imaging capabilities, and a reduction of subcultures. In a study we conducted, the MALDI-TOF technology and the microbiology laboratory automation system significantly improved turnaround time for identification and susceptibility compared to MALDI-TOF and traditional processing of urine cultures. This is in alignment with the Triple Aim because it allows us to inform clinicians and pharmacy up to a day earlier regarding the appropriate therapy for the patient.
The context of the literature
Earlier results have documented that automated systems have a positive impact clinically, operationally, and economically. As reported by Lodise et al,1 delayed antibiotic treatment in patients with hospital-acquired Staphylococcus aureus bacteremia was found to be an independent predictor of infection-related mortality and was associated with a length of stay increase of 41.2 percent. Huang et al2 found that rapid organism identification, combined with an antimicrobial stewardship team intervention, improved time to effective antibiotic therapy and optimal antibiotic therapy by 9.7 hours and 43 hours, respectively. In addition, mortality, length of ICU stay and recurrent bacteremia all declined. Finally, Perez et al3 found a reduction in length of stay of 2.6 days and a reduction in hospital costs of $19,583 per patient. This combination of improvements is exactly the desired impact of the Triple Aim.
Responding to new imperatives
Hospitals across the country are working in an environment of increased transparency relative to quality and patient experience metrics that have a financial impact tied to HCAHPS. As a result, this pay for performance allows for payment or potential penalties based on clinical data and the perception of the patient. In this era of increasing challenges in healthcare, the microbiology laboratory has an opportunity to play a significant role as a solution provider by collaborating with administrative staff, medical staff, and partners in pharmacy and infection control to drive successful antimicrobial stewardship programs, reduce healthcare-associated infections, reduce length of stay on the wards, increase bed capacity to meet patient demand, and ultimately reduce costs in the healthcare system. An effective microbiology laboratory automation system is allowing my organization to successfully pursue our organizational desires to deliver on the Triple Aim.
REFERENCES
- Lodise TP, McKinnon PS, Swiderski L, et al. Outcomes analysis of delayed antibiotic treatment for hospital-acquired Staphylococcus aureus bacteremia. Clin Infect Dis. 2003;36(1):1418-1423.
- Huang AM, Newton D, Kunapuli A, et al. Impact of rapid organism identification via Matrix-Assisted Laser Desorption/Ionization Time-of-Flight combined with antimicrobial stewardship team intervention in adult patients with bacteremia and candidemia. Clin Infect Dis. 2013; 57(9):1237-1245.
- Perez KK, Olsen RJ, Musick WL, et al. Integrating rapid pathogen identification and antimicrobial stewardship significantly decreases hospital costs. Arch Pathol Lab Med. 2013;137(1):1247-1254.
