Labs solve price, space squeeze to welcome TLA

Kevin B. O’Reilly

May 2015—After several years of watching their European counterparts have all the fun, a handful of American microbiology laboratories are going live with systems touted as providing total automation of diagnostic bacteriology. The systems automate how specimens are barcoded, plated, and inoculated, then move the plates on a track to an incubator, photograph them at a preset incubation time, discard or keep the plates as appropriate, and offer up the digital images for interpretation by medical technologists viewing them on computer screens.

Leaders at American microbiology labs making the move to total automation say it marks a profound transition that dramatically improves turnaround times but also can be wrenching, hindered by technical and management challenges that come with adopting state-of-the-art technology.

For other laboratories, the journey toward total automation is progressing more fitfully, and may begin with adoption of standalone automated specimen processors. Even as microbiology labs argue the case that automation can offer a return on investment for their institutions, they must first solve a more basic problem: how to make the new equipment fit into their workspaces and workflows.

“I never thought microbiology could be this automated. It’s amazing,” says Irene K. Dusich, MT(ASCP)SM, microbiology manager at NorthShore University HealthSystem in Chicago’s northern suburbs. “Our positive cultures are turned around much quicker because we’re able to read them when they are ready to be read. We’ve got the images there at 12 hours and things that are floridly positive—you know it.”

The four-hospital system’s laboratory performs about 300,000 micro­biology tests annually, and in July 2014 brought in BD’s Kiestra TLA. After several months of setup, the system went live in December. Dusich tells CAP TODAY it’s already making an impact.

“Before, people would come in and there would be the shelf in the incubator with all the urine cultures, and they would bring out all 300. Now, they are sitting in the incubator until it’s time to actually read it. It’s not sitting out in room temperature in the ambient air,” she says.

“There’s a lot to be said for reading a plate when it’s ready to be read, rather than when it’s too early. In the proper atmosphere, colonies will be more robust, and you will be able to distinguish whether it is well isolated enough to do tests on,” Dusich adds. “The whole process is much improved, because of the Kiestra and because of MALDI.” NorthShore acquired the Bruker MALDI Biotyper in December 2013.

Data collection and analysis regarding the impact of the Kiestra TLA implementation on NorthShore’s turnaround times and patient care is still ongoing, Dusich says. Anecdotally, however, the outcomes are clear.

“We’re definitely getting positive results out much faster, maybe even a day faster,” she says. “Before, when sometimes things weren’t dropped off till midnight or 1 AM, we wouldn’t look at them today; we would look at them tomorrow. Now on Kiestra, if it’s set up at midnight last night, we’re looking at them at noon today. Because it’s taking the images at 12 hours, if the growth looks good enough, then we’re going ahead and doing the identification and the susceptibility testing today instead of tomorrow.”
The BD Kiestra TLA’s automated specimen processor, InoqulA, offers another big advantage by reducing the proportion of specimens that require subculturing. Because the machine performs the streaking the same each time—as customized by the laboratory—the human element of variation is lost, Dusich says.

“Some people are just good at [streaking], and some people are not,” she says. “What this has done for us, with its consistency and the way we get well-isolated colonies, is that we do very, very few subcultures anymore to gain a pure isolate to do identification or susceptibility testing.”

Poor streaking that necessitates subculturing means “more work and more media,” Dusich notes. “And it’s going to delay turnaround time and results. We have really seen a drastic decrease in the number of subcultures that we do.”

For Susan Kannady, BSMT(ASCP) SM, the promise of predictable streaking would be one of the big bonuses of bringing more automation into the microbiology and immunology laboratory she manages at Virginia Commonwealth University Health System.

“The greatest savings would be with the specimen processor,” Kannady says. “We’d have the instrument streaking all the plates and each plate would be uniform. It would be consistent, and you would get better isolation and you would improve workflow on the other end. Right now, you’ve got humans doing it on three different shifts. You have three different people, and not everybody streaks the same.”

Laboratory professionals report that the TLA systems available from BD, Copan Diagnostics, or BioMérieux cost $1.2 million or more depending on the number of incubators and workstations customers choose, as well as the capabilities of the conveyor system they opt for. Automated specimen processors, on the other hand, cost between $125,000 and $300,000 (Ledeboer NA, et al. J Clin Microbiol. 2014;52[9]:3140–3146).

That cost differential makes the hands-off specimen processor a more palatable first bite at the total automation apple, even for a high-volume lab like Kannady’s that performs 365,000 tests each year with the equivalent of 41 full-time staff.

“Total laboratory automation—we would love to have it,” she told the crowd at the American Society for Microbiology’s 2014 annual meeting during a presentation called “Squeezing Automation into the Laboratory.” TLA would help with a staffing shortage the laboratory has been struggling with and save a great deal of time for technologists who would no longer have to read negative cultures. But, she concluded, “We just don’t have the space.”

It is not just the cost of the equipment that makes moving to a TLA system such a pricey proposition. All the systems available require a major footprint and an open plan. A TLA system certainly changes the look and the layout of the laboratory. It’s goodbye to rows of workbenches and hello to a conveyor system straight out of a factory assembly line. And VCU’s microbiology laboratory has not been redesigned since the mid-1980s.

“We didn’t realize it,” Kannady said, “but just the cost for the architect ranged from $300,000 to $600,000, and that’s before you even begin renovating.”

For now, any renovation of Kannady’s laboratory is on hold pending a broader review of the entire pathology department’s workspaces.

“The question is whether to renovate where we’re standing or find somewhere else,” Kannady says. “In the meantime, we’re going to push to get the automated specimen inoculator part.” That would be either the BD Kiestra InoqulA or Copan’s Walk-Away Specimen Processor.

Despite the hurdles Kannady and her microbiology colleagues at VCU face in moving toward automation, they do have a head start on some others in one area that is essential to taking full advantage of automation. They have moved to a total liquid collection system.

“We’re ready as far as specimen collection goes,” Kannady says.

This is key because the TLA systems only work with liquid-based microbiology samples. This requires a different method of collecting throat, wound, stool, genital, and other samples using flocked swabs that release the entirety of the sample when it is mixed with reagents or placed in a buffer solution.

The switch to the flocked-swab method of specimen collection is one element that has delayed complete implementation of TLA in NorthShore’s microbiology laboratory. For now, they are using the BD Kiestra TLA for urine specimens only. They must verify the new swabs and train clinicians on how to use them properly.