Leveraging the Lab: Four Ways to Boost Infection Prevention (and Quality of Care)

Implementing an effective infection prevention and control program that includes a strong antibiotic stewardship program isn’t the sole province of the nursing home’s infection preventionist (IP). In other words, it’s a team sport like football or baseball, not an individual sport like tennis or marathon running. Making the referral (i.e. consultant) laboratory a key partner in infection prevention instead of just a source of lab results can help the entire team achieve more consistent gains in infection prevention and control, as well as overall quality of care. Steps that the IP can take to build that partnership include the following:

1. Establish a relationship with lab personnel

“The IP needs have a collegial relationship with the lab, whether it’s a private lab or a hospital lab,” says Steven Schweon, RN, MPH, MSN, CIC, LTC-CIP, CPHQ, FSHEA, FAPIC, an infection preventionist based in Saylorsburg, PA, and a member of the Emerging Infectious Diseases task force at APIC. “A collegial, friendly, helpful relationship will go a long way.”

“The reason to work on developing a relationship is that the IP should have what amounts to a ‘phone a friend’ in the microbiology department of the lab,” points out Deb Patterson Burdsall, PhD, RN-BC, CIC, FAPIC, an infection prevention and control consultant and board member at the Association for Professionals in Infection Control and Epidemiology (APIC) in Arlington, VA. “Having an actual human who you can reach out and talk to is critical. You need access to someone who can answer your questions and questions from the nursing staff on the lab side. For example, you may have a question about the susceptibility of a pathogen or what certain lab values mean—or you may even need help translating an acronym.”

Two ways to begin fostering a relationship with the lab include the following:

Steven Schweon, RN, MPH, MSN, CIC, LTC-CIP, CPHQ, FSHEA, FAPIC, infection preventionist and member of the Emerging Infectious Diseases task force at APIC

Ask lab staff to participate on key committees. “You should invite lab personnel to sit on either your Antibiotic Stewardship Committee or your Infection Prevention and Control Committee, depending on your facility’s organizational structure,” suggests Schweon. “The key is to have that person from the lab attend the meeting on a consistent basis.”

Lab staff may push back and say, for example, “I don’t have the time to drive 30 minutes to attend this meeting,” notes Schweon. “The answer to that is to say, ‘I completely understand. Let’s have you call into the committee the old-fashioned way on the phone. We’ll have you first on the agenda to talk about lab issues and what we could be doing better.’ This will become a win-win. You can identify and address immediate lab issues more timely, and you will be developing a collegial relationship over time.”

Visit the lab. “If the lab is in a community hospital, the IP should visit the lab, including the person in the microbiology department, and the hospital’s IP,” says Schweon. “This will help you bolster those ties and find out if there are any problems or concerns on their end.”

If the facility’s referral lab is private, a visit probably will depend on where the lab is located, acknowledges Schweon. “However, if you can visit and see exactly what goes on in the lab as far as the different tests that are done, whether it’s a PCR (polymerase chain reaction), a Gram stain, or a culture, that will help you build up relationships as well.”

2. Set up a critical value alert system with the lab

Often, the lab will fax or e-mail test results, and those results may not be seen by the people who need to see them for hours, points out Schweon. “The IP should work with the interdisciplinary team and the lab to set up a critical value policy that requires the lab to provide prompt, targeted notifications when test results identify certain bacteria, certain conditions, or certain diseases.”

Schweon offers the example of a resident whose urine culture indicates that they have Methicillin-resistant Staphylococcus aureus (MRSA). “If a resident has MRSA in their urine, depending upon their clinical condition and facility policy, you will need to implement enhanced barrier or contact precautions, and the prescribing clinician may need to change their antibiotics,” he explains.

“In this situation with a critical value policy, you may require the lab to call the nursing supervisor at the nurse’s station and say, ‘Your resident Mrs. X, medical record number, date of birth, in room 14 has MRSA in her urine,’” continues Schweon. “Then, your nursing staff can take immediate action on that information because the lab has bumped up the importance of those test results. This is part of antibiotic stewardship. It’s also important to view the actual laboratory report as soon as possible for additional confirmation.”

Deb Patterson Burdsall, PhD, RN-BC, CIC, FAPIC, infection prevention and control consultant and board member at the Association for Professionals in Infection Control and Epidemiology

Alerts on critical lab values and cultures via secured text lines or e-mails also can work when they are done correctly, notes Burdsall. “Whatever communication method you use, the key points are (1) have the information go to specific people on the day, evening, and night shifts, and (2) have these communications formatted to generate alerts so that these people know to look at the information immediately. This allows you to do something quickly to help provide the best care for that resident and for the people around them when it comes to infection prevention and control.”

For example, if the lab is sending critical information at 8 p.m., their staff should know who to contact (e.g., the evening shift nursing supervisor Nurse Y) and how to reach them (e.g., secured e-mail), says Burdsall. “Or, on the day shift, the IP, the director of nursing services (DNS), or the assistant director of nursing services (ADNS) are all potential contacts for the lab.”

3. Ask IT for improved EHR coordination

The IP should find out if the information technology (IT) department can prioritize getting the facility’s electronic health record (EHR) to “talk” to both the lab and the pharmacy, says Burdsall. “If your EHR can pull in information from the lab and the pharmacy and automatically put it in the resident’s medical record so that you or the nursing staff can see, for example, the lab values, that can be a significant benefit to your antibiotic stewardship program.”

4. Obtain prescriber-focused data for the medical director to review

“If you have a prescriber who is always prescribing the ‘big guns’ like vancomycin rather than narrower-spectrum therapy that targets the specific organism—or who is not doing antibiotic time-outs and should be, prescriber-focused data is a great tool to help the medical director do their job of ensuring that antibiotics are prescribed appropriately in your facility,” says Burdsall.

Both the lab and the pharmacy can provide this data, suggests Burdsall. “For example, the lab can provide data on cultures and other lab orders. The appropriate order of cultures is another huge part of antibiotic stewardship. If a prescriber is overordering cultures, there may be a corollary with antibiotics being prescribed more than they really should be.”

Note: One of the actions that CDC recommends in the Checklist for Core Elements of Antibiotic Stewardship in Nursing Homes is for nursing homes to “Develop facility-specific algorithms for appropriate diagnostic testing (e.g., obtaining cultures) for specific infections.”

Lab data can then be tied into the antibiogram and pharmacy data on the types of antibiotics that the individual prescribers are prescribing, as well as pharmacy or EHR data on antibiotic timeout usage, says Burdsall. “It will give the medical director a more complete picture if you can say, for example, ‘This prescriber is a driver who is ordering a lot of cultures, and they are ordering these broad-spectrum antibiotics.’ That is a set-up for antibiotic resistance.”

Note: To learn how to conduct an antibiotic timeout, review the Antibiotic Time-out Checklist from Telligen. Many EHRs will now send out antibiotic timeout prompts to nursing home staff.

Caralyn Davis

Caralyn Davis is a freelance writer specializing in the post-acute care sector. Email her at: caralynd@outlook.com.