(59) Improving Mycobacterial sputum culture (MSCx) collection in adult patients during the highly effective modulator therapy (HEMT) era

Background: Annual Mycobacterial sputum cultures (MSCx) is a best practice standard for surveillance of nontuberculosis mycobacterium (NTM) infection. MSCx collection among sputum-producing people with CF (pwCF) is essential for early identification and management of NTM. Initiation of highly effective modulator therapy (HEMT), elexacaftor/tezacaftor/ivacaftor in 2019, resulted in a reduction in sputum production in pwCF. Concurrently, the emergence of the COVID-19 pandemic led to a shift from in-person to virtual clinic visits. These two events led to a dramatic decline in the rate of MSCx collection at our center from 52.7% (2019) to 26.5% (2020) based on our CF Patient Registry report. We utilized a multidisciplinary approach to evaluate and implement continuous quality improvement (CQI) measures with the specific aim to increase MSCx collection from 52.7% to 65% in 12 months. Eligibility defined as pwCF producing >1 mL of sputum and no MSCx within the past 12 months.

Methods: The MN CF Center care team consists of multidisciplinary specialties and approximately 450 pwCF. The CQI team generated the specific aim and developed a process map highlighting key stakeholders and barriers to MSCx collection. The team utilized Plan, Do, Study, Act (PDSA) to optimize key steps involved in MSCx collection. The first PDSA included microbiology lab leadership identifying optimal (5-10 ml) and acceptable (≥ 1 ml) sputum volumes to avoid rejected specimens. Next, providers approved a new protocol to prioritize first sputum for MSCx and subsequent for CF bacterial cultures among eligible pwCF. Development of a CMA flowchart guided determination of eligibility for MSCx collection (Figure 1). CMAs then completed a paper tool to document eligibility, specimen type, and lab orders placed for pwCF in clinic during 4-week PDSA cycle. The paper tool was adapted utilizing electronic health record (EHR) capabilities to generate date of last MSCx and allow electronic documentation of specimen collection type and orders placed.

Results: With the use of HEMT, the percentage of sputum-producing pwCF declined from 74% to 40%. Utilization of process mapping and paper tool identified barriers to collecting MSCx in our clinic. Workflows were established through recurrent PDSA cycles to identify actionable interventions (education of lab personnel, paper tool, EHR documentation) which have led to collection of 53% of eligible samples. This increased from 26.5% in 2020 and is on track for a goal of 65% MSCx collection for the year. The paper tool exposed the greatest barrier to obtaining MSCx was due to lab cancellation. By November, the team will complete another PDSA cycle after further lab education with an aim to decrease the number of erroneously rejected MSCx by lab.

Conclusions: Despite the reduction in sputum production following use of HEMT, approximately 40% of pwCF still produce sufficient sputum for MSCx monitoring. Applying effective CQI tools including process mapping, PDSA cycles, pareto charts, and run charts to implement an improved, standardized workflow can lead to improvement in the rate of MSCx. This will aid in detection and management of NTM infections and inform the epidemiology of NTM in the era of HEMT.

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