Diary of the mad med-lab techs

July 1, 2011

“Garbage in” = “garbage out” (GIGO)

Cultures can be real problems for techs, physicians, and patients because it is so easy for “bad” specimens to lead to “bad” tests that lead to “bad” results, “bad” therapy, and “bad” outcomes. (Feel free to substitute “improper,” “inappropriate,” “incorrect,” or “dumb” for “bad” in any of the preceding.) I have tried to explain to clinicians on many occasions that GIGO results are misleading: Under the best circumstances, the patient will not be helped; under the worst circumstances, the patient can be harmed. Physicians know the lab will make them accept full responsibility by signing for anything less than a completed cross match as “uncross matched” — yet, they want the lab to release preliminary micro results with the assurance that they can treat the patient as if the testing was fully completed. If we let physicians get away with this, any repercussions are our fault.

—Chuck Millstein, MBA, MT(ASCP), CLDir(NCA), Retired

Unnecessary cultures

Since my retirement last year, I have decided that I am too young to hang it up, so I am doing temporary travel assignments in clinical microbiology labs around the country. These positions are usually for 13 weeks and are a great way to stay active and see how other labs are doing microbiology. I am finding out that I am never too old to learn, and I am getting a hefty supply of topics for this column.

I keep harping on a subject that comes up all the time: Receiving and working up unacceptable specimens for culture and reporting out worthless information to the provider with the assumption that he will know how to “sort it out.”

We are the microbiologists, and it is our legal responsibility to provide accurate, timely results that will have a positive impact on patient management.

I am amazed by what I am seeing! And I am appalled by the excuses I hear. A brutal fact: Directors and supervisors of microbiology departments are not involving themselves in the day-to-day running of the laboratory at the bench level. Instead, they are relying on senior techs who may have little or no background knowledge of normal vs. abnormal or pathogen versus commensal.

Directors and supervisors come in annually to sign the manuals, but do they really look at what is being reported? Do they really understand what is causing antimicrobial resistance? Do they realize that their techs are reporting out normal flora organisms with susceptibility results, and providers are making patient-management decisions based on that information?

Examples of misleading information?

  • Again with the normal throat flora! Reporting out Streptococcus pneumoniae, Moraxella catarrhalis, Haemophilus influenzae, or Staphylococcus aureus from a throat specimen will lead to unnecessary antibiotic usage and, ultimately, add to the problem of resistance.
  • Working up wound cultures without guidance from initial Gram stain to determine quality of specimen (e.g., presence of epithelial cells).
  • Processing and reporting sputum cultures without a screen for acceptability.
  • Non-representative sources for diagnosis of infection:

                •  nasal swab for sinus infection;

                •  external ear canal swab for middle-ear infection;

                •  vaginal culture for uterine infection;

                •  nasal secretions for sinus infection.
  • Identifying and performing susceptibilities on Pseudomonas aeruginosa from stool specimens!

The last temporary assignment I had was with a prestigious hospital in a large metropolitan area. There were four full-time techs in the microbiology department; the youngest was 50, and the oldest was 75. These people have years of valuable experience that will be lost when they retire. There are no prospects for replacements at that facility; they rely on temporaries to cover for them. Medical-technologist shortages are at a critical stage. I see new, minimally trained people filling in the gaps and that, in the end, will translate into substandard results.

—By Colleen K. Gannon, MT(AMT) HEW, un-retired,

the “Nancy Grace” for labs