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Abstracts & Commentary
Synopsis: Placing clinical microbiology services and expertise further from their clients not only jeopardizes good patient care outcomes but may also waste rather than save money.
Sources: Guidos R. Clin Infect Dis. 2001;32:604; Peterson L, et al. Clin Infect Dis. 2001;32:605-611.
The policy statement written on behalf of the Infectious Diseases Society of America (IDSA) bases itself on an accompanying article of Peterson and colleagues and argues that locating clinical microbiology laboratories away from their clients, namely the patients and physicians who rely on them, threatens their unique function in the effective management of infectious diseases.
First, the laboratory generates information critical for accurate diagnosis and treatment of infectious diseases, which requires rapid and reliable transporting of specimens, proficient testing, direct and timely reporting, and personal interpretation of the results. Second, the laboratory is the backbone of infection control programs. It is hard to imagine how a laboratory at a distant site can gain and maintain the intimate knowledge of each and every hospital that infection control requires when relevant staff are working elsewhere. Third, the laboratory is the first line of defense against emerging microbial threats including antimicrobial resistance and bioterrorism. Although this aspect can be fulfilled at a distant site, the lack of seamless communication between those involved and the difficult logistics in getting the right specimens in a timely manner to the laboratory inevitably involve delay. Fourth, the laboratory provides critical training facilities for infectious disease specialists, which by its nature requires integration of both microbiological and clinical information in order to understand the ongoing process of infectious diseases.
The trend toward consolidating these functions in large institutions to contain costs and improve efficiency actually means that the local dimension is relegated to the dim and distant past while the notion that such a conglomerate can serve several better with fewer staff, at a greater distance, seems little more than a cruel deception. A survey of 35 members of a network of clinical microbiology laboratory directors directly involved in centralizing services showed the top 5 benefits and detriments of consolidating clinical microbiology services (see Table).
|Table-Benefits and Detriments of Consolidating Clinical Microbiology Services|
|Cost reduction||Poor communication between
clients and laboratory
|Improved accuracy of
|Recurrent problems with timely
|Expanded menu of tests
among different facilities
|Time-consuming customization of
reports for various clients
|Increased funding for education||Poor rapid Gram-stain testing done
at client hospitals
Compromised infection control in
Peterson et al are not convinced and argue that even if the consolidated laboratories were to have the necessary expertise and funding, their remoteness alone would hinder them from offering the high-quality necessary to achieve the highest standard of patient care for several reasons. Specimen handling and transport would be less than optimal because it would take more time and the delay would adversely affect microbial viability and, hence, recovery of pathogens. Even if specimens were to be processed at the bedside and inoculated on appropriate medium, this would require a degree of technical expertise usually only found among laboratory personnel. This need can only be met by having more personnel, thereby negating one of the putative cost savings. Other solutions would involve couriers who would have to contend with the ever stricter rules regarding transport of dangerous materials. Communication would be less frequent and, therefore, less effective. The vast improvements in the techniques for relaying messages would not overcome this because, simply put, people prefer face-to-face contact when discussing problems and engaging in dialogue. In an age of mobile messaging, internet highways, and instant contact there is still no substitute for corridor encounters to discuss immediate and sensitive issues and dropping in to see how things are going—both near impossible if the persons concerned are at 2 different locations. Advances in health care would be harder to achieve if the laboratories lost their direct and close contact with patients since the testing of new antimicrobial drug products and diagnostic tests effectively require the close cooperations of physicians and the laboratory. Last, but not least, future health care practitioners would be deterred if the laboratory was not in close proximity to the patients because there is only so much that can be done during working hours and travelling back and forth would be viewed as a waste of precious time. Thus, Peterson et al conclude that the management of infectious diseases is best accomplished by maintaining clinical microbiology laboratories on the same site as the health care institutions they serve.
Comment by J. Peter Donnelly, phd
I can vouch for the arguments advanced to keep laboratories on-site. My first laboratory was a stone’s throw from the wards, operating theatres, kitchens, and pharmacy, and we went back and forth providing each with the service they required. We did well in all proficiency tests and the working environment was fruitful, friendly, and fun. That was 20 years ago in another country and in another era. Be that as it may, it doesn’t take much imagination to see the sense in what Peterson et al are saying. Most would prefer a local store to a far off hypermarket, but they are a luxury we believe we can no longer afford.
Economic imperatives provide the driving force toward consolidation, and, I fear, the only way to reverse the trend is to show that local laboratories are cost-effective. The example set by the Northwestern Memorial Hospital in Chicago and referred to by Peterson et al must be followed by others. Briefly, instead of cutting the budget for microbiology, this hospital opted to staff and equip the laboratory to fully handle local patient care and infection control. It cost them $400,000 annually, but they measured a savings of $2 million, avoided 285 nosocomial infections, and spared possibly 10 lives. In reality, no one would actually expect otherwise. A proactive infection control program that ensures a clean environment, identifies potential infectious hazards ahead of time, provides for continuous education of staff on hygiene, and keeps its staff abreast of new developments in the field is surely worth having. Similarly, an intimate knowledge of the microbial pathogens causing infection and their resistance patterns, the antimicrobial agents used to treat them, and the true clinical and microbial outcome are essential for optimum drug use and adherence to formularies and would translate directly into cost savings. Both are self-evidently desirable but require investment. The return on this investment is almost bound to be several-fold greater than the outlay. So why isn’t it happening? The answer is simple. There is no willingness to pay for it because it seems less urgent than other programs—reducing waiting lists for operations or reversing the drift of nurses out of hospitals—both subjects understood by the public at large and, therefore, damaging to policy-maker’s images. The issue can also be readily ignored, even by the media, as it cannot be reduced to sound bites and seems too remote to matter. In Europe, the issue is further complicated by the fact that, in contrast to the United States, infectious disease physicians are a rarity and medical graduates who specialize in the area of infectious diseases are used by the laboratory and do not function in the same way. Such staff are incrementally more expensive than their laboratory counterparts in the United States and not always viewed favorably by their surgical and medical peers. While laudable, statements such as that made by the IDSA can be easily dismissed as self-serving. What is needed is for more institutions to follow the lead taken by the Northwestern Memorial Hospital in demonstrating measurable benefits from maintaining a fully funded clinical microbiology laboratory that translate easily into sparing added misery to patients, reducing antimicrobial resistance, and better husbanding of antimicrobial agents. Then, armed with these data, the ID physicians of America and their clinical microbiological counterparts on my side of the Atlantic and, indeed the rest of the world, should mount a forthright publicity campaign aimed at persuading their clients (ie, the public at large) that by taking care of the bugs, the dollars will take care of themselves.