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The consolidation of two microbiology labs.

The considation of two microbiology labs Once there were two microbiology labs serving our 935-bed university-affiliated hospital complex--one for adult patients, the other for children. Now there is one.

Dual services in microbiology and other clinical labortaory areas had existed for years because separate though adjoining insitutions, with 700 and 235 beds respectively, provided care for adult and pediatric patients. Each hospital had its own administration.

Then in the eraly 1980s, the adult and pediatric chemistry laboratories combined to provide more comprehensive and cohesive service. Hematology and some of the small specialty units followed, but adult and pediatric microbiology were less likely candidates for consolidation since they saw different organisms and furnished different services.

The outlook changed after a study determined that merger of the two micro labs would be more cost-effective than separate operations. Among the ways we could save money were reduced evening and weekend staffing and elimination of duplicate quality control procedures. The smaller pediatric lab (37,000 cultures a year, 9.6 FTEs) would also benefit from merger with the adult lab (91,000 cultures a year, 23.5 FTEs) where there were more extensive facilities, more personnel, and plans for computerization.

As assistant director of the adult microbiology lab, I served on the consolidation task force along with the director of clinical pathology, and directors, supervisors, and other management personnel from both labs. The adult laboratory was responsible for co-ordinating the consolidation, which included relocation of the pediatric lab to the site of the recently enlarged and renovated adult lab.

We identified three main areas of concern: first, how to satisfy the needs fo physicians and patietns in both facilities and at the same time practice clinically relevant and cost-effective microbiology; second, how to actually move the pediatric lab without interrupting service; and third but by no means least important, how to minimize the impact on personnel of both labs. Recollections of other consolidations, which resulted in loss of positions and transfers to other lab areas, were still in the minds of many of our technologists.

As already indicated, the two laboratories operated in many different ways, used different schemes and tests, and by and large saw a spectrum of different organisms. Each lab took pride in its work and felt, naturally, that its ways were preferable to those of the other lab. In moving t the adult lab with its staff of more than 20, the seven technologists from the pediatric lab faced a troubling loss of identity. They believed their operation would surely be swallowed up in the consolidation.

Concern about these feelings among the staffs ob both labs, as well as a need to resolve differences in protocols and methods before the physical relocation, led us to plan four phases for the merger:

1. Getting to know one another. We began in October 1983 by setting up a "personnel exchange program" that gave technologists at each laboratory an opportunity to visit the other lab for up to a week, getting acquainted and observing operations, protocols, and test procedures. Technologists were assigned to concentrate on a specific area--fox example, blood cultures or specimen processing or stool cultures--and encouraged to take notes and ask questions. By the end of the personnel exchange period, everyone was acquainted with everyone else and with a specific area of the visited lab. We could begin the second phase.

2. Comparing methods. For the areas they had investigated, technologists from each lab wrote up differences and similarities between the two operations in techniques, protocols, tests, and even philosophy. The reports covered specimen processing, respiratory cultures, genital cultures, stool cultures, blood cultures, urine cultures, miscellaneous cultures, antibiotic susceptibility testing, and organism identification/terminology.

Differences existed in every area--in media used for planting specimens, incubation atmospheres, length of incubation, extent of culture workup and organism identification, bioichemical and serological testing methods, antibiotic suceptibility techniques, and the antibiotics themselves.

3. Arriving at common protocols and policies. Directors of the two laboratories, supervisors, technologists who prepared the written comparions, and I met to decide on the methods and procedures we were going to use in the combined laboratory. Each lab's representatives underscored what they felt was important about their present operation, particularly special services or courtesies that physicians were accustomed to (hand-delivered reports, phone calls, etc.). We all recognized the necessity of continuing such service or making alternative arrangements.

At times the discussions heated up--each side feeling out the other, strenuously advocating its way of doing things. As a result, we learned a great deal about the special needs of the adult and pediatric patient populations and the distinctive operations of the two hospital divisions. We discussed a lot of microbiology from the standpoints of clinical relevance and cost-effectiveness. But mostly we got to know each other better. Once we experienced some give and take, the meetings began to run smoothly and decisions came more easily.

Table I compares the different protocols for respiratory cultures and indicates those adopted for the consolidated laboratory. The management of both labs wanted protocols, procedures, etc., to be chosen for documented reliability or clinical relevance, and not because one lab happened to be more comfortable with a particular procedure. Thus we selected the adult lab's method of incubating blood plates anaerobically because the literature reports this to be the most sensitive way to isolate beta strep.

Sometimes a method was choen or protocl formulated that neither laboratory had used. Sputum cultures were the best example: The pediatric lab worked up all organisms except obvious normal flora, but the adult lab worked up only predominant potential pathogens. Several meetings failed to produce an agreement on how these cultures should be handled. Finally, it was proposed that we adopt one of the sputum quality screening methods and proceed with a more extensive cultures workup on good quality speciments and/or special patient groups.

Technologists involved in the respiratory culture area went through the literature and presented information on various screening methods to the group for selection. Having technologists carry out the investigation made the resulting policy changes more acceptable to the rest of the staff; it was a joint effort rather than a policy dictated by management.

In some instances, two methods were used in the consolidated laboratory with the stipulation that by a certain date a choice had to be made. When the methods were deemed comparable in quality and reproducibility, the selection was made by a majority vote of the technologists. On respiratory cultures, however, we continue to use a strep ID method from each lab--Phadebact for confirmation of goup A streptococci from throat cultures and Steeptex for grouping strep from other sources.

Antibiotic susceptibility test methods differed. The pediatric laboratory used a microtiter broth dilution method, and the adult lab used agar dilution, both with lab-prepared media. If we discarded one approach, what would we do with the expensive equipment--the dispenser and inoculator for microdilution or the replica plate reader system? The ideal answer lay in using both, but how? The solution came from other discussions between the laboratory directors and physicians in the cystic fibrosis center.

These physicians were interested in a computer program for collecting and monitoring all antibiotic susceptibility test data on isolates from their patients. It was decided that a separate susceptibility test system for organisms from cystic fibrosis patients would be ideal for several reasons: a different battery of antibiotics was used for testing CF isolates, a separate computer program would be needed to compile the epidemiological data, and the increased workload would not have to be handled by one system. So the microtitier method would be used, as it had been in the pediatric lab, for testing CF organisms, and the agar dilution method would be maintained for routine testing.

In fact, all of the major instruments and equipment owned by the pediatric lab--including a Bactec 460, a Dynatech MIC 2000, a microtiter-tray dispenser, refrigerators, and incubators--are used in the consolidated lab. There was not much to gain by selling off these items.

We kept records of all our meetings and distributed reports of changes to the staff. Protocols and procedures written for the new lab manual--a blend of the best from both labs--included a detailed speciment planting guide, specific guidelines for working up cultures, the extent to which organisms should be identified from various sources, test methods for bacterial identification, and reporting policies. The staff heard the new procedures explained at general lab meetings.

To meet our goal of providing clincially relevant and cost-effective service, we had to establish new policies dealing with how cultures are to be processed, what organisms will be sought and worked up fully, and when susceptibility tests will be done routinely. Having two physicians qualified in adult and pediatric infectious disease as laboratory directors was a great advantage. Their knowledge and experience helped us not only to formulate these policies but also to communicate them to clinicians.

Since the consolidation of other laboratories at our institution, technologists had become anxious about job security. Those in microbiology did not want to be transferred to chemistry, hematology, or some other lab. Microbiology supervisors were very concerned about these feelings, particularly because our initial consoldiation study had recommended a reduction in force for the evening shift.

Although such issues are often beyond an individual section's control, we were able to extract a promise from laboratory and hospital administration that any staff cutback would take place only when an employee resigned a position or gave up a block of hours. The promise was kept; attrition among the part-timers led to a net reduction of 1 FTE in evening and weekend coverage. There was no reduction in the full-time staff.

A committee of adult and pediatric micro technologists, reporting to the management team from both labs, met to discuss policies on starting times, weekend and holiday coverage, compensatory time, and other staffing/scheduling matters. Proposed policies had to conform with those mandated by hospital administration and could not conflict with our obligation to provide the best possible service.

The pediatric lab staff started at 7:30 a.m., the adult staff at 8:30. A compromise work schedule, which we termed "modified flextime," was developed by the technologist committee. At least one of the two technologists assigned to the blood culture bench and the one assigned to reading antiobiotic susceptibilities had to begin work at 7:30 a.m--all others could start anytime between 7:30 and 8:30, ending their shift accordingly.

In addition, a medical technologist experienced in interpreting culture results and making decisions about special requests would be assigned to ansewer physicians' phone calls. This person starts at 8:30 a.m. and is on duty until the evening crew takes over at 5 p.m.

4. Moving day. After four months of planning, the pediatric laboratory moved in January 1984 to the site of the consolidated laboratory, an expanded, renovated area that alreaday housed theadult lab. The relocation took one day. It went smoothly and did not interrupt service.

In the past, adult microbiology, including TB and mycology, media, and glassware, had occupied 2,800 square feet, and the pediatric lab,600 square feet. The new space, including an enlarged section for virology, added up to 4,334 square feet.

Our move was not made until all technologists were familiar with the new protocols for specimen processing, culture examination, and workups, as well as organism identification criteria, terminology, and personnel policies. We made sure that new or amended policies had been shared with the pediatric and adult infectious disease department heads and other physicians.

The technologists who had worked on protocols and policies for a specific lab area during Phase 3 were assigned to work in that area until procedures were well established. It took about a year for all technologists to rotate through the different lab areas.

After consolidation, only one major problem remained: Now that we had two micro supervisors--one from the adult lab, the should we organize their duties? For the pediatric lab supervisor, a further adjustment was required. She had reported to the pediatric lab's director, but in the adult lab, an assistant director was responsible for some activities.

We felt the job of running the lab should be shared. After the two supervisors worked together for the first few months, we split their duties into two groups, A and B. The supervisor assigned to A duties, with a desk in front of the lab, handles incoming orders and any problems with incoming specimens, specimen transport, or unsatisfactory speciments. She also monitors personnel attendance and is available for telephone consultations.

At the rear of the lab, the other supervisor assumes the B duties--responsibility for monitoring workload at the bench areas, consulting on problems, answering questions, and training new personnel. Usually the supervisor on B duty has fewer interrptions and more time for special assignments or projects. The supervisors rotate weekly between the two job areas, but each has remained in charge of some specialized areas, as they had been p rior to the merger.

The director of the adult micro lab has become director of the entire micro lab. The director of the pediatric lab serves as associate director of microbiology.

We owe the success of our consolidation to the participation and cooperation of all our personnel, who work with the confidence that their ideas are important and desired by management. The knowledge gained about working together, about microbiology, and about topics unique to pediatric and adult infectious diseases has enriched and motivated our staff.
COPYRIGHT 1987 Nelson Publishing
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Title Annotation:adult and pediatric labs
Author:Morrissey, Anne M.
Publication:Medical Laboratory Observer
Date:Feb 1, 1987
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