Laboratory Laboratory ‘Network’ ‘Network’

UpdateUpdate

Laboratory Laboratory ‘Network’ ‘Network’

UpdateUpdateMax SalfingerMax Salfinger

New York State Department of New York State Department of HealthHealth

Princeton October 24, 2006Princeton October 24, 2006

‘‘It is healthIt is health

which is real wealthwhich is real wealth

not pieces of silver and not pieces of silver and gold’gold’

Mahatma Gandhi, 1869-1948Mahatma Gandhi, 1869-1948

•3 questions3 questions•SurveySurvey•Systems thinkingSystems thinking

History / physical examHistory / physical exam

33 Time to negativity? Time to negativity?

Chest x-rayChest x-ray

1 Tuberculosis?1 Tuberculosis?

2 RIF resistance?2 RIF resistance?

Adherence/Adherence/CureCure

seessees

aa

doctordoctor

Nucleic acid amplificationNucleic acid amplification

MicroscopyMicroscopy

Growth detectionGrowth detection

IdentificationIdentification

1.Tuberculos1.Tuberculosisis

yesyes

oror

no no ??

rpoBrpoB analysis (line probes) analysis (line probes)

Clinical courseClinical course

Radiometric / Non-Radiometric / Non-rad.rad.

Agar based ASTAgar based AST

Egg based ASTEgg based AST

2. RIF res.2. RIF res.

yesyes

oror

no no ??

DrugDrug 460TB460TB MGITMGIT 7H107H10 7H117H11

INHINH 0.1/0.40.1/0.4 0.1/0.40.1/0.4 0.2/1.00.2/1.0 0.2/1.00.2/1.0

RIFRIF 2.02.0 1.01.0 1.01.0 1.01.0

EMBEMB 2.5/7.52.5/7.5 5.05.0 5.0/105.0/10 7.57.5

SMSM 2/62/6 1/41/4 2/102/10 2/102/10

PZAPZA 100100 100100 N/AN/A N/AN/A

Testing Testing concentrations:concentrations:

What gets What gets captured in the TB captured in the TB database?database?•Result - susceptible; resistant?Result - susceptible; resistant?

•Method - BACTEC 460; MGIT, Method - BACTEC 460; MGIT, etc?etc?

•Concentration tested?Concentration tested?

•Percent resistant colonies?Percent resistant colonies?

•Mutation found, type?Mutation found, type?

3. Time to negativity3. Time to negativity•Follow up specimens until 2 Follow up specimens until 2 consecutive specimens are culture consecutive specimens are culture negative... negative...

•Initial cavitation & Initial cavitation & mo-2mo-2 culture culture pos: extend INH/Rif from 4 to 7 pos: extend INH/Rif from 4 to 7 monthsmonths

•Repeat susceptibility testing after Repeat susceptibility testing after 3 mo3 mo

•Pos culture @ Pos culture @ mo-4mo-4: Treatment : Treatment failurefailure

Survey [N=11]Survey [N=11]::CT, DE, IN, MA, CT, DE, IN, MA,

MI, NJ, NYC, MI, NJ, NYC, NYS, PA, VT, WVNYS, PA, VT, WV

NAANAA::

YES: 6YES: 6NO: 5NO: 5

DSTDST::

Bactec 7Bactec 7MGIT 2MGIT 27H10, ESP ea 17H10, ESP ea 1

DST - screeningDST - screening::

SIRE-PZA 5SIRE-PZA 54 drugs 44 drugs 43 drugs 13 drugs 1

DST - 2nd-lineDST - 2nd-line::

YES 6YES 6NO 5NO 5

QuantiferonQuantiferon::

YES 2YES 2NO 9NO 9

Work daysWork days::

7 days: 17 days: 16 days: 16 days: 15 days: 85 days: 8

Biggest concernsBiggest concerns::•Not enough resourcesNot enough resources•Federal TB grant reductionFederal TB grant reduction•Gamma Interferon assays: PHL or hospital-based labsGamma Interferon assays: PHL or hospital-based labs•Ability to keep high level of testingAbility to keep high level of testing•Delayed delivery of specimens and isolatesDelayed delivery of specimens and isolates•Loosing 40+ years of experience (retirement)Loosing 40+ years of experience (retirement)•Staff shortageStaff shortage•Time and moneyTime and money•Maintaining staff competencyMaintaining staff competency•Reduction of Federal $$$Reduction of Federal $$$

Success storiesSuccess stories::•FAST TRACK programFAST TRACK program•Being a member of the LIMS RFQBeing a member of the LIMS RFQ•Moving into better lab spaceMoving into better lab space•Implementation of NAA (homeless case)Implementation of NAA (homeless case)•NAA turnaround timeNAA turnaround time•Staff cross-trainingStaff cross-training•Surpassing CDC turnaround time guidelinesSurpassing CDC turnaround time guidelines•Improving TAT & client relationship with less staffImproving TAT & client relationship with less staff•Molecular identification and drug susceptibilityMolecular identification and drug susceptibility

Systems Systems ThinkingThinking ‘‘We tend to focus on We tend to focus on

snapshots of isolated parts of snapshots of isolated parts of the system, and wonder why the system, and wonder why our deepest problems never our deepest problems never seem to get solved.’seem to get solved.’

Peter Senge in The Fifth Discipline, 1990Peter Senge in The Fifth Discipline, 1990

Did you hear Claudia’s Did you hear Claudia’s husband?husband?

If you suspect If you suspect DRDR, , MDRMDR, or , or XDRXDR TBTB

you have a moral you have a moral responsibility to responsibility to get the results in get the results in the the shortestshortest TAT TAT

possible!possible!

$$$$$$

??

Laboratory Laboratory standardsstandardsNew YorkNew York: NAA : NAA mandatory for newly mandatory for newly diagnosed patients diagnosed patients whose sputum tested whose sputum tested AFB smear positive.AFB smear positive.

Reference Reference Laboratory Laboratory

SystemSystem

Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change Change

TT BBTThinkhink BigBig

BeBeBold !Bold !

Picasso: Peace DovePicasso: Peace Dove

WEWE can do it ! can do it !

Thank YOUThank YOU

forfor

Working Working TOGETHER!TOGETHER!

The Journey The Journey sets the sets the

DestinationDestination

see you ALL in see you ALL in Tallahassee, FL Tallahassee, FL

!!