The Role of the Clinical Laboratory in the Future of Health Care: Lean Microbiology

This commentary will introduce lean concepts into the clinical microbiology laboratory. The practice of lean in the clinical microbiology laboratory can remove waste, increase efficiency, and reduce costs. Lean, Six Sigma, and other such management initiatives are useful tools and can provide dividends but must be accompanied by organizational leadership commitment to sustaining the lean culture in the laboratory setting and providing resources and time to work through the process.     

Outbreak of Transient Conversions of the QuantiFERON-TB Gold In-Tube Test in Laboratory Health Care Worker Screenings

Gamma interferon release assays were recently introduced in health care worker (HCWs) screenings for tuberculosis surveillance. In longitudinal surveys, conversions and reversions are seen, and yet whether these changes are unspecific or are an expression of new infections and microbial clearance remains unclear. In order to further elucidate these changes, we analyzed an outbreak of 15 transient conversions in 53 HCWs who operate in the same laboratory and handle specimens potentially containing Mycobacterium tuberculosis who underwent screening by the QuantiFERON-TB Gold In-Tube (QFT-GIT) test between 11 May and 30 June 2010: 15/46 (33%) negative HCWs showed a conversion and then reverted after 7 to 107 days. To validate these results, an evaluation of methodological procedures and test reliability, as well as an analysis of results obtained during the same period and processed by the same laboratory, was carried out. For the latter purpose, QFT-GIT results determined for 78 ward HCWs who underwent screening during the same period and were employed in departments with at least 3 infectious tuberculosis patients per year or had cared for an infectious patient without airborne precautions were analyzed with the following results: 6/63 (9%) HCWs with negative results in 3 different departments showed transient conversion (P = 0.002; odds ratio, 4.60; 95% confidence interval, 1.62 to 13.04). A retrospective survey of in-house biosafety practices led to determination of a single exposure factor within the laboratory. These data emphasize the validity of the hypothesis that a transient conversion demonstrates the presence of a real tubercular infection and could be an important indicator for occupational biosafety concerns. They also confirm that subjects with recent conversion should be retested before chest radiography and chemotherapy is offered.     

The Evolving Role of Clinical Psychology in Health Care Systems

An intriguing aspect of the meta-analysis by Chiles, Lambert, and Hatch (this issue) is the finding that medical cost offsets associated with psychological interventions vary across patient populations. Our commentary describes four types of patients: the worried well, the worried unwell, the chronically disabled, and the chronically ill. We suggest the kinds of behavioral medicine interventions most likely to lead to restored health and decreased medical utilization for each patient type, and the changes in research and practice necessary to maximize clinical psychology's impact on physical health intervention.