My Scope of Practice: A Specimen of a Lab Champion

 Do you ever wonder what happens to the specimens you send to the laboratory? This month we interviewed Leonard (Len) Levin, MS, MBA, RM(NRCM), M(ASCP), Microbiology Laboratory Supervisor, Robert Wood Johnson (RWJ) University Hospital – Hamilton, Hamilton, NJ, a 2004 Malcolm Baldrige National Quality Award-winning facility. A professional with 33 years’ clinical and administrative experience in the laboratory, Len shares the details of his multifaceted career, as well as some advice for wound care clinicians on ensuring accurate lab results.   After obtaining a Bachelors degree in Biochemistry at Albright College (Reading, PA) and a Masters degree in Microbiology and Immunology at Temple University School of Medicine (Philadelphia, PA), Len began working in hospital microbiology/serology laboratories, progressing to the level of Microbiology Section Chief at St. Francis Medical Center (Trenton, NJ). He subsequently obtained an MBA degree in finance from La Salle University (Philadelphia, PA) and shifted into laboratory administration, becoming an Assistant Laboratory Administrator at St. Francis, Laboratory Manager at Northeastern Hospital of Philadelphia, and Administrative Director of Laboratory Services at Capital Health (Mercer County, NJ). Len also has worked as a scientific writer; he was an Assistant Editor at Biosciences Information Service (Philadelphia, PA), Editor-in-Chief of AIDS Insurance Reports, and a freelance writer and reviewer of online laboratory continuing education modules for Gannett Education, a division of Gannett Healthcare Group (Falls Church, VA).

  As the Microbiology Supervisor at RWJ Hamilton, Len oversees bacteriology testing for all types of clinical specimens. His responsibilities include ensuring test quality, complying with regulatory requirements, recommending new technologies, working with the administrative and medical laboratory directors and technical supervisors to ensure all laboratory services fulfill the needs of the organization, managing the technical microbiology operations to produce the best quality of services in the most cost-effective manner, and serving on multidisciplinary hospital committees that strive to minimize spread of infection and promote appropriate utilization of antibiotics.

   “Our microbiology laboratory plays an instrumental role in the diagnosis and treatment of wound infections,” Len says. “It is an important resource for RWJ Hamilton’s Center for Wound Healing, which provides specialized care for all kinds of wounds including compromised surgical grafts, bone infections, diabetic wounds, and others using proven therapies such as hyperbaric oxygen therapy. The Center for Wound Healing provides an important component of care to persons with diabetes; RWJ Hamilton is one of only two hospitals in New Jersey to be accredited for outpatient diabetes care by the Joint Commission.”

  The Microbiology Laboratory at RWJ analyzes cultures from all kinds of wound specimens, including superficial wounds, deep wounds, abscesses, drainages and exudates, postoperative wounds, and body fluids. The first test performed on these specimens is the gram stain, which provides preliminary information about which microorganisms may be present in culture, and especially which of those microbes are clinically significant. The appearance of white blood cells on the gram stain further supports the clinical significance of potential pathogens that may be recovered in the wound culture. The specimens are inoculated using various types of culture media, incubated generally for 48 to 72 hours, and visually examined by clinical laboratory scientists for growth of significant pathogens. Clinically significant isolates are identified by a variety of biochemical tests and assessed for antibiotic susceptibility to guide clinicians as to the best course of treatment. As expected, the microbiology lab is heavily involved in helping prevent serious wound infections within the facility, including the screening of patients for methicillin-resistant Staphylococcus aureus (MRSA) colonization.

  When asked what wound clinicians can do to ensure expedient, accurate results, Len says, “The clinical laboratory is best able to provide accurate, useful results when the specimens it receives for testing are of suitable quality and are accompanied by complete information on test requisitions. For microbiology cultures, it is useful to know if the clinician is looking for a particular pathogen in the specimen and whether the patient is already being treated with antibiotics. It is best to collect culture specimens before commencing antibiotic treatment, because such specimens yield the best recovery of significant isolates on cultures.”

  He continues, “The most valuable culture results are obtained from specimens collected from relatively clean sites — eg, anaerobic culture specimens should be collected from areas that are not normally populated with normal flora. Superficial swabs of pressure ulcers are not suitable for culture, because the presence of colonizing flora causes false-positive culture results. Transport of culture specimens also affects the quality of culture results; specimens should be submitted in sterile containers, and swabs must be submitted in transport media to preserve the specimen integrity. It is also best to avoid significant delays in transporting specimens to the laboratory, so growth of normal flora or contaminants can be prevented.”

  Len says the dynamic nature of clinical microbiology makes his job enjoyable and exciting. “Working in this field is a constant learning experience and is intellectually stimulating. New species of microorganisms frequently are discovered, and those that already exist develop new mechanisms of pathogenicity and antimicrobial resistance. In turn, these changes spur the development of new antimicrobial agents to treat the ‘superbugs’ that emerge. Over the years, we have seen the appearance of MRSA , vancomycin-resistant enterococci, and most recently, carbapenem-resistant enterobacteriaceae.”

  Len finds one important challenge for clinical microbiologists, as well as infection control practitioners and pharmacists, is to provide clinicians with guidance on the most appropriate antimicrobial agents for treatment of the various types of infections to avoid the emergence of resistant strains. “Clinical microbiology technology is becoming increasingly sophisticated, with new automated technologies enabling faster production of more accurate culture results,” Len says. “But these technological advances are a double-edged sword. It is exciting to see new molecular tests that employ DNA amplification and probes to provide excellent sensitivity and specificity in detection and identification of pathogens, as well as new mass spectrometry methods, such as matrix-assisted laser desorption ionization-time of flight (MALDI-TOF), that further improve the accuracy and speed of bacterial identification. But like other healthcare disciplines, the clinical microbiology laboratory faces economic challenges. With limited financial resources, it becomes a difficult balancing act to decide whether the higher cost of these new technologies is adequately justified by their ability to improve patient care.”

  In these situations, the clinical laboratory can cooperate with other members of the healthcare team. Such was the case when the laboratory wanted to acquire an analyzer for DNA amplification testing of stool specimens for Clostridium difficile toxin. “The cost per test of this molecular method is significantly higher than the previously used immunochromatography procedure,” Len says. “But that higher cost also yields superior accuracy of results. With the assistance of our infection control and pharmacy experts, we were able to demonstrate an overall reduction in the cost per patient’s episode of care to justify this more expensive test. We are now utilizing a similar approach to consider transitioning from conventional culture methods to molecular testing to screen for MRSA.”

  Over the next few years, Len hopes to further modernize the microbiology laboratory, instituting new procedures that will increase the accuracy of results while reducing turnaround times. He also will continue to promote formal laboratory education while serving on the Advisory Board of the Mercer County Community College Medical Laboratory Technology program — in part in response to the diminishing supply of clinical laboratory scientists due to the retirement of aging baby boomers. He intends to remain an active member of the Delaware Valley chapter of the Clinical Laboratory Management Association and the Eastern Branch of the American Society for Microbiology.

  Most importantly, Len will continue to advocate for the laboratory. He says, “Unfortunately, because the healthcare industry has become very business-oriented due to dwindling financial resources, hospitals must balance quality of care with cost. The most highly valued hospital services are those most visible to the patients; perceptions of healthcare are paramount to ensuring high patient satisfaction scores, which now impact reimbursement for services. The clinical laboratory historically has worked in the background; its services are not well recognized by patients. Consequently, while lab test results account for 70% of diagnosis and treatment decisions, the lab receives a disproportionately low share of financial resources — only 1.6% of Medicare spending. I therefore strive to heighten the public’s recognition of the clinical laboratory and the value it provides, while seeking new technology that will produce test results accurately, efficiently, and expediently to improve the patient’s health and reduce the length of stay.”

  Published data reveal that generally 70% of a patient’s medical record comprises laboratory test results that play a crucial role in diagnosis and treatment and no small part in wound management. It also is estimated that 10 billion laboratory tests are performed in the United States each year, involving 300,000 clinical laboratorians. For these reasons and more, Len is a champion for his scope of practice.

  For more information about the RWJ Wound Center, visit: www.rwjhamilton.org/Pages/Wound_Care.aspx

This article was not subject to the Ostomy Wound Management peer-review process.