From the microbiology laboratory perspective, determining the underlying cause of pneumonia based on respiratory culture specimen testing requires anywhere from one to three days to report actionable results. This turnaround time (TAT) in relaying clinically relevant information to the clinician often then results in presumptive treatment with antibiotics prior to establishing the probable source of infection.

Furthermore, elderly patients with comorbidity factors are at an increased risk of pneumonia-related complications, thereby rendering rapid identification and targeted treatment vital. Medical management associated with caring for inpatients diagnosed with pneumonia has cost our facility between $7,000 and $10,000, daily (per VHA Facility 534’s FY23 Simple Pneumonia and Pleurisy cost summary). As such, this was identified as a clear area for improvement.

Improve Speed to Care

In our efforts to reduce TAT for pneumonia-related specimen cultures, emerging applications of multiplex PCR technology became a viable solution, with the overall goal of reducing the time required to report actionable results to the physician. However, a lack of guidance due to limited research and publications on the specific application to pneumonia cases poses a risk of jeopardizing the appropriate use of the new technology alongside ongoing hospital-based antimicrobial stewardship initiatives.

Realizing the potential benefits of multiplex technology when used appropriately, the microbiology department began collaborating with stakeholders to establish an effective pneumonia diagnostic protocol. We began by conducting a retrospective review of results from the prior year to identify the average number of respiratory cultures performed, acknowledge common organisms detected, and establish benchmarks for the average time to report results. Retrospective data analysis demonstrated an average time of 52 hours for laboratory personnel to release final reports to the clinician. Following review, we created a visual current state map to track the entire process from the initial patient examination to the final release of respiratory culture results (see FIGURE 1). Developing a current state map enables identification of gaps in the process and their associated delays while allowing the process of remediation to begin.

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Establish a Target State

A target state map was established after identifying primary testing concerns from facility stakeholders; in our case, this comprises representatives from pulmonary care, infectious disease, antimicrobial stewardship, and intensive care unit clinicians (see FIGURE 2). Collaboratively, we can identify risks to determine a viable solutions approach. We initially created a test algorithm that allowed reflex multiplex tests using a pneumonia panel for all bronchoalveolar lavage (BAL) collections submitted for routine culture. The reflex testing criteria for BAL specimens incorporated the preanalytical time requirements for initial patient consult, scheduling, and specimen collection when the decision was made to test all incoming specimens. BAL collections were categorized as high-quality specimens where rapid results could serve as a critical diagnostic aid in establishing an appropriate approach to ongoing treatment.

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In contrast, the algorithm established for self-induced sputum and assisted aspirate collections via suction required an initial screening to ensure an appropriate sample was collected in conjunction with pre-defined qualifications for our reflex pneumonia panel (see FIGURE 3).

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Conclusion

The process improvement project led to the establishment of a reliable, quality-driven standard of reporting probable respiratory pathogens 94% faster compared to routine bacterial cultures. The microbiology team members work as gatekeepers, ensuring that only high-quality specimens are run on the multiplex system, thereby dramatically reducing the occurrence of inappropriate test performance. Of additional benefit, the use of the platform also allows us to differentiate bacterial, viral, and viral-bacterial co-infections. Given that antibiotics are not typically indicated for viral pneumonia, timely results help the clinician administer proper treatment and recognize when to discontinue unnecessary therapy. On several occasions, we have reported the presence of atypical bacteria that would ordinarily require specialized orders, resulting in an undiagnosed pathogen or an extended time to detection, significantly delaying care.

Creating procedural updates has been useful for our less experienced microbiology staff. The detection of significant, but commonly missed organisms—Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumonia—increased substantially following culture review. Notably, Haemophilus inlfuenzae growth has been identified almost ten times more frequently than prior years, while Moraxella catarrhalis and Streptococcus pneumoniae have been detected five times more frequently than before.

Our microbiology laboratory team continues to implement process improvements and safeguards now that the test method is routinely used throughout the facility. Future improvements will represent the result of a collaborative, facility-wide effort intended to reduce diagnostic time and increase the value of patient care. Recent initiatives include rapid reporting of common resistance mechanisms to further facilitate a targeted approach to treatment. We also evaluated the sensitivity of quantitative bacterial detection following a two-year retrospective review. Subsequent data indicated rare or no growth on cultures media when pathogens were detected at the lowest value via PCR.

Reporting alerts have been added to all low-level detections notifying clinicians that such detections may indicate a source of contaminant or normal flora, advising a review of culture results to determine significance of the initial detection. The department quickly identifies a probable respiratory source of infection, enabling the clinician to administer a targeted treatment plan, improving the process for both the physician and patient. These are just a few ways in which the microbiology laboratory can contribute meaningful value to both the general laboratory and the institutions and patients it serves.

Lolanya Rivers, MS, MLS(ASCP)^CM, SM^CM, is a microbiology technical specialist at Ralph H. Johnson VA Medical Center in Charleston, South Carolina. She works on microbiology-based process improvement projects directed toward addressing ongoing staffing shortages and implementing surveillance systems to limit contamination rates and unit-based outbreaks.