As a former Professor and Director of the Infectious Disease Diagnostic Laboratory service for two multi-system hospitals in the U.S., I have experienced an evolutionary change in laboratory medicine, specifically Infectious Disease Diagnostic Laboratories. Over the course of several years, we have been faced with numerous threats including new or re-emerging illnesses, antimicrobial resistance, healthcare-acquired infections (HAIs), more administrative requirements, staffing shortages, and decreased reimbursement. In addition to these challenges, there has been greater emphasis on decreasing hospital length of stay, improving quality of care, patient safety and experience, and supporting antimicrobial stewardship programs (ASPs).
In 1999, the Institute of Medicine (renamed National Academy of Medicine) published To Err is Human, a real eye opener, not only for the medical community, but also for the public. The article stated most adverse events (AEs) are preventable and caused by poor communication, yet they cause thousands of lives lost and billions of dollars spent. They concluded that AEs are due to process problems. This publication really began the patient safety and team training movement that led to the development of the evidenced-based TeamSTEPPS programme in 2005 by the Department of Defense (DoD) and Agency for Healthcare, Research and Quality (AHRQ), initially used by the U.S. military and now used internationally.
TeamSTEPPS is based on the use of a 3-phase programme (i.e., Assessment, Action Plan/Training/ Implementation, and Sustainment), led by a multi-disciplinary change team (e.g., senior administrator who will have clout and resources to support and advocate for the programme, nurse/physician/lab leaders and other champions). They are responsible for mapping a process associated with AEs to identify when, where and who is involved, and then redesigning the process for a successful outcome.
A comprehensive tool-kit is provided that includes a multi-curricula of teaching materials based on the TeamSTEPPS framework, whereby change teams develop competencies in teachable-learnable skills (i.e., communication, leadership, situational awareness, and mutual support) and use communication tools to positively affect innate abilities of knowledge, attitudes, and performance. Some of the keys to a successful outcome include having an excellent team leader, team communication, and a shared mental model, i.e., all team members are on the same page. Although the TeamSTEPPS programme has commonly been used to correct problems related to direct patient care, it is amenable to being used successfully in other departments that affect patient care and quality, albeit indirectly.
Laboratory Utilization & Stewardship Team (LUST)
Laboratories are now playing an even greater role in addressing current challenges by using a value-based model and providing more timely results for improved patient care and treatment. Many laboratories have introduced automated equipment and molecular platforms for direct specimen plating and direct sample identification, respectively, MALDI-TOF for organism identification of an almost unlimited number of organisms, and next-generation sequencing of difficult to isolate or identify organisms.
Although an estimated 70 per cent of clinical decisions are based on laboratory results, close to 40 per cent of these tests are deemed unnecessary and are an over-utilisation of laboratory resources. Likewise, underutilisation of laboratory tests occurs leading to missed or delayed diagnosis, increased length of stay, and legal liability. To that point, some healthcare facilities are developing a LUST to ensure the right tests are offered, ordered and performed. This is where multi-disciplinary teams are essential. Various models for developing a LUST exist based on resources and commitments of stakeholders. For example, a stewardship team supported by the C-suite, may include a pathologist, laboratory administrator and technical staff, a cross-section of physicians and nurses, information technology representative, and ad hoc members as needed. Toolbox strategies for improved laboratory utilisation are available, e.g., discontinuing obsolete tests, improving physician order entry design by test harmonisation, and using an evidence-based approach to establish practice guidelines.
Diagnostic Management Team (DMT)
In May 2017, the World Health Organization (WHO), recognising the importance of diagnosis prior to treatment, released the first essential in vitro diagnostics list of > 100 tests to be expanded annually, to guide countries regarding appropriate test selection. Some hospitals have even developed multi-disciplinary DMTs comprised of experts covering each of the laboratory disciplines to provide guidance to physicians in selecting the appropriate tests, avoiding over- and underutilisation of tests, and interpreting complex test results.
Clinical role of multi-disciplinary teams in sepsis
Kumar et al. reported a 7.6 per cent increase in mortality with each hour of delay in providing an effective antibiotic for septic patients. One of the milestone publications on sepsis, 3rd International Consensus Definition for Sepsis and Septic Shock (Sepsis-3) – 2016 guidelines advocate for patients with hypotension and a lactate > 2 mmol/L to receive antibiotics and fluid resuscitation along with blood cultures (BCs) and rapid molecular testing within 3 hrs (the so-called 3 h bundle). In 2018, an update was published calling for a 1 h bundle. These recommendations are challenging to adhere to, especially a 1 h bundle in a busy emergency department (ED) with high patient acuity. That said, they may be achievable using a multi-disciplinary TeamSTEPP approach for immediate assessment of qSOFA criteria (altered mental status, elevated heart rate, low systolic blood pressure) and point-of-care lactate for patients presenting with signs and symptoms of sepsis.
Laboratory role of multi-disciplinary teams in sepsis
BCs are still considered the gold standard for sepsis, even with less than optimal sensitivity and turnaround to results. Many laboratories have turned to using a molecular platform for pathogen identification to speed up results once a BC turns positive, e.g., Biofire film array, Nanosphere, ePlex BCID, or Accelerate that includes susceptibilities. In contrast, the T2Biosystems has the capability of identifying the most common Candida spp. and sepsis-causing bacteria directly from whole blood in ~3-6 hrs. Circumventing the need for a positive BC provides even more timely decisions for optimal antibiotic therapy or discontinuation of therapy, supporting the goal of ASPs.
We developed a multi-disciplinary committee (D.C. Halstead, unpublished data), e.g., pharmacy, infectious disease (ID) physician, and microbiology, with the goal of decreasing time to effective or optimal therapy in septic patients using a rapid molecular platform and immediate 24/7 communication of results to a pharmD. We appreciated a statistically significant decrease in time to appropriate and optimal therapy between the pre- and post- intervention period and attributed our success to the use of a multi-disciplinary team and improved use of communication skills.
The TeamSTEPPS approach can also have a significant impact on decreasing BC contamination rates to <3 per cent per guidelines. False-positive results can have severe consequences, e.g., overuse of antibiotics, resistance and AEs and increased costs. Meta-analysis has shown team strategies to be effective, e.g., saturation training using a shared mental model, collecting blood from venipunctures, not catheters, and using sterile gloves. The next guideline from the American Society for Microbiology (ASM) in collaboration with the Centers for Disease Control and Prevention (CDC), i.e., The Laboratory Medicine Best Practice initiative, will focus on updating their 2012 BC contamination guideline.
BCs are still considered the gold standard for sepsis, even with less than optimal sensitivity and turnaround to results.
We will continue to see staff moving out of their safe silos into a multi-disciplinary workforce, greater reliance on developing basic skill competencies as advocated in the TeamSTEPPS programme for improved patient safety and quality of care, and implementation of Laboratory Stewardship and Diagnostic Management Teams for improved laboratory utilisation and test interpretations, respectively. Even though there have been many improvements in healthcare over the course of the last 10+ years, we need to be prepared for even more changes in ‘culture’ as we move into the third decade of the 21st century. Are you ready?
References available on request.