Rounding in the Clinical Microbiology Lab
Rounding, the process during which medical teams visit patients and discuss important elements of their individual cases, is a longstanding cornerstone of medical education and patient care. In the clinical microbiology laboratory, rounding can contribute to improved education of clinicians, as well as enhanced antimicrobial and diagnostic stewardship. Laboratory rounding also plays a critical role in infection prevention by promoting rapid communication, surveillance and outbreak management.
In the lab setting, rounding may include not only members of the microbiology team, but infectious disease clinicians, pharmacists, nurse practitioners or physician assistants, epidemiologists and a variety of trainees, including medical students, residents and fellows. Integrated care delivery through interprofessional rounding has been associated with improved communication, prevention of patient harm and improved outcomes. As we have seen during the COVID-19 pandemic, teamwork across disciplines is imperative to the successful diagnosis and management of infectious diseases, and rounding provides a unique and effective forum for this teamwork.
While new methods for improving clinical rounding have continued to evolve for inpatient units over the years, changes in payment models, space constraints and lack of time have led to a decrease in on-site laboratories that perform rounds. Yet with the increased need for interdisciplinary medicine and effective stewardship, the importance of laboratory rounding should be re-emphasized and reinstated.
Success Stories From Microbiology Rounds
When I started working in the microbiology laboratory at Children's Hospital Colorado (Children's Colorado) more than 12 years ago, I was intimidated and dazzled by the daily rounds that occur every day at 9:30 a.m. This diagnostic forum began 47 years ago with Drs. James Todd and Marti Roe, members of the then-new infectious diseases program. Every weekday since 1973, a multidisciplinary group of professionals from microbiology, virology, infection prevention, pharmacy, antimicrobial stewardship and infectious diseases has met to discuss all positive cultures from the previous day.
Rounds in Children's Colorado's microbiology lab not only provide valuable education and clinical pearls (small bits of free standing, clinically-relevant information), but have led to the discovery of several important outbreaks. In 2009, after noticing a significant increase in blood cultures positive for Bacillus cereus reported at rounds, the infection prevention team launched an investigation. They discovered that alcohol prep pads were the source of the B. cereus contamination, a finding that prompted an international recall of a dangerously contaminated product.
The open and collaborative discussion between experts facilitated by microbiology rounds can provide clinical insights that improve patient care. Lab rounds helped Children's Colorado clinicians discover and describe some of the earliest cases of acute flaccid paralysis and cranial nerve dysfunction associated with enterovirus-D68 respiratory illness in 2014.
Even in situations where formal rounds are not conducted regularly within the laboratory, collaboration and communication between clinical microbiologists and infectious disease clinicians has resulted in the discovery of unique outbreaks, such as severe Group B Streptococcus infection from the consumption of raw fish and Hepatitis E infection from pork in Singapore.
Other real-world examples of discussions that happen during rounds include the workup of organisms from mixed cultures, the appropriate reporting of antimicrobials from a bacterial culture and how to properly collect and send specimens. Rounding with the lab allows clinicians to see how testing is performed and better understand why certain tests can be performed, while others cannot. Last, but not least, this process establishes a relationship between clinicians and laboratorians that helps reinforce the qualifications and necessity of the medical laboratory and the people that work within it.
Benefits of Microbiology Rounding for Various Disciplines
The Laboratory Team
- Opportunity to interact with the clinical team.
- Opportunity to learn about the clinical picture of patients with cultures in the microbiology lab.
- Demonstrates knowledge base and expertise that may otherwise not be fully appreciated.
- Opportunity for the laboratory team to feel an intimate connection to the patient and their family, even if they never get to interact with them in person.
- Builds a climate of trust that allows the laboratory team to feel comfortable discouraging poor practices, like reporting out inappropriate antimicrobial susceptibilities or testing specimens of poor quality.
Infectious Disease Clinicians
- Rapid dissemination of information from lab to clinician.
- Opportunity to get to know the laboratory staff.
- Provides access to plates, Gram stains, all culture results, as well as behind-the-scenes information.
- Improves understanding of the laboratory process and workflow.
Trainees and Students
- Provides access to key clinical pearls that are valuable for training and exams.
- Gives students the opportunity to experience multidisciplinary patient care.
Pharmacists (PharmDs) and Nurses
- Rapid dissemination of information from the lab to PharmDs, which can be particularly important for antimicrobial stewardship efforts.
- Access to susceptibility results that may not be released to all providers.
- Opportunity to identify clusters or trends from daily culture reports.
- Ability to be closely involved with the laboratory with regards to surveillance and state health department reporting.
- Rapid dissemination of information from lab to infection preventionist that can help with precautionary measures. For example: the laboratory notifies the IP team that they have received a specimen on an inpatient for Measles testing. The IP team can be proactive in their isolation and precautionary measures.
The Future of Microbiology Rounds
While rounding in the microbiology laboratory is not a new concept, novel methods for this process could use more consideration. Rounding is not feasible for many labs due to time constraints, lack of resources or physical distance from the patients and clinicians. However, even when daily rounding is not possible, reviewing cases and concepts regularly with a microbiologist (or microbiology team) has positive impacts on clinical decision making and patient care. Additionally, the role of translational science should be considered an important component to bridging the gap between the microbiology laboratory and clinical practice.
Microbiologists that are trained at the doctoral level in either laboratory science or translational science work at the intersection of research and practice, and can help supplement the rounding infrastructure, as well as develop ways to continue this incredibly important clinical interaction. Advanced training for clinical laboratory scientists positions them to lead diagnostic management teams, which provide critical preanalytical, analytical and postanalytical interpretation of laboratory medicine to physicians and the healthcare team, particularly in hospitals where microbiology rounding is not feasible.
In terms of education, the use of online modules has shown to be effective for clinical learners who are unable to attend microbiology rounds where they might otherwise have access to infectious disease vignettes. With the world becoming rapidly accustomed to online meeting platforms, the sky may be the limit when it comes to future rounding possibilities, and this should be actively explored.
Finally, the utility of social media as a teaching tool cannot be ignored. Platforms like Twitter offer an amazing array of microbiology pearls that could potentially take the place of or supplement in-person sessions with the microbiology laboratory. For example, #MedLabTwitter and #MedLabChat have become real-time learning opportunities that can help save resources, lives and time.