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Medical Laboratory Professionals Week Approaches

In light of Medical Laboratory Professionals Week 2017, I wanted to take this quarter’s post and thank all of you who work hard in so many ways to get patients the results they need. You truly are “All Stars.” I thought it would be interesting to have an interactive sort of post; feel free to write in the comments examples of how you and your lab go above and beyond to help patients.

Here is just one example of how the Molecular Diagnostics Lab here at Nebraska Medicine continues to do our part to serve our patient population. Our hospital (University of Nebraska Medical Center) has become a participating center for the TAPUR trial. This stands for “Targeted Agent and Profiling Utilization Registry” study; it is a non-randomized clinical trial that is essentially matching anticancer drugs to genomic variants in the patient’s tumor. Currently, most drugs are given based first on what type of tumor it is, then by the genomic variants. For example, if a patient has a gastrointestinal stromal tumor (GIST), and that tumor has a duplication in the KIT gene (p.A502_Y503dup), that tumor is sensitive to a drug called Imatinib, among others, and that drug has been shown to help fight the GIST. The TAPUR study’s goal is to see if any tumor that presents with that KIT variant is sensitive to Imatinib, whether the tumor is a GIST or some other type of cancer.

What does this have to do with our lab? Well, there are certain criteria necessary for a patient to be eligible for this trial. In addition to being 18 years or older, not currently pregnant or planning to become pregnant, the patient must have a solid tumor, multiple myeloma, or B cell non-Hodgkin lymphoma that is not responding to standard anti-cancer treatment and they must be able to be active for at least half the day, every day. Lastly, they need to have had a genomic or molecular test performed on their tumor. I and the technologists that I work with have seen an increase in our testing since our hospital has become a center for this trial because of that last point. We run an assay that tests areas of 50 genes that are known to contain “hotspot” regions that are commonly mutated in different types of cancers, and we run this by next generation sequencing (more to come regarding this type of technology–stay tuned for next quarter’s post!). We have been testing tumors of patients that have not been responding to treatment, and we all realize that each one of the tests that we perform has an impact on how that patient’s tumor will be treated. And here I have to commend the techs in our lab for thriving when faced with the challenge of this increase in testing–they have done an excellent job with the added workload and with keeping up with the changes that are made in this rapidly evolving area of the lab. I think we all appreciate this aspect of our careers–knowing that the hard work we put in every day to do our jobs to the best of our abilities can and does have an effect on people’s lives. Thank you all for everything you do!

For more information on the TAPUR trial, follow this link: http://www.tapur.org/.

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-Sharleen Rapp, BS, MB (ASCP)^CM is a Molecular Diagnostics Coordinator in the Molecular Diagnostics Laboratory at Nebraska Medicine.

Interference in Lab Assays

A 69 year old patient with cirrhosis presented to the ER with fever. Her bilirubin was markedly elevated at 7.4 g/dl and her hemoglobin and hematocrit were measured at 13.4 g/dl and 35.6% respectively with a MCV of 103.2 fl and MCH of 38.5 pg. The next day her H/H were 11.9 g/dl and 31.3 % respectively. While her hemoglobin one day later was 11.9 g/dl, the reported hematocrit was 39.3%. Patient had a bilirubin level of 8.7 g/dl at this time.

The fluctuating numbers together with the discrepancy between hemoglobin and hematocrit over a very short period of time was concerning. We realized that presence of markedly icteric plasma was responsible for these discordant values. Saline replacement and spun crit were performed in order to correct interference by bilirubin. Subsequent measurements of H/H revealed hemoglobin in the range of 12.9 g/dl with a hematocrit of 38% and a MCV of 113 fl. As the bilirubin levels started dropping (in the range of 6.5 g/dl) the hemoglobin level measured by the analyzer fell in the range of 10.3 to 11 g/dl. The instrument (XN-200) gave no error codes and therefore we were able to report out the analyzer results without correction. It was however very important to convey to the clinical team that the H/H values did not truly represent a fall from the previous values. As the two methodologies were different (spun crit and plasma replacement was being no longer performed) the numbers should be interpreted accordingly. Patient was not bleeding actively and did not require any blood transfusion.

Interference occurs when a substance or process falsely alters an assay result. Interferences are classified as endogenous or exogenous. Endogenous interference originates from substances present in the patient’s own specimen. Exogenous interferences are substances introduced into the patient’s specimen. Interference from hemolysis, icterus and lipemia are most frequently studied. Protein interferences are most often associated with paraproteins and predominantly with IgM or IgG and rarely with IgA. Drug interference may be due to the parent drug, metabolite(s) or additives in the drug preparation. Determining if interference is significant requires deviation limits from the original result. Once interferences are identified there is a need to establish procedures for handling affected results as part of the quality system.

Hemoglobin is quantified based on its absorption characteristics. Conditions such as hyperlipidemias, hyperbilirubinemia, a very high white blood cell count, and high serum protein can interfere with this measurement and result in falsely elevated hemoglobin values. When the values of hemoglobin, red cell count, and MCV are affected, MCH and MCHC also become abnormal, since these indices are calculated and are not directly measured. Sometimes a set of spurious values may be the first clue to an otherwise unsuspected clinical condition (e.g., the combination of low hematocrit, normal hemoglobin, and high MCV and MCHC is characteristic of cold agglutinins).

Although one must pay attention to very high amounts of bilirubin within the plasma, most hematology analyzers do not presently demonstrate any interference with bilirubin, at least for concentrations up to 250 mg/l. Above these values attention is however needed.

High serum or plasma bilirubin concentrations can cause spectral interference with assays near the bilirubin absorbance peak of ~ 456 nm. Chemical interference e.g. with peroxidase-catalysed reactions may also occur.

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-Neerja Vajpayee, MD, is the director of Clinical Pathology at Oneida Health Center in Oneida, New York and is actively involved in signing out surgical pathology and cytology cases in a community setting. Previously, she was on the faculty at SUNY Upstate for several years ( 2002-2016) where she was involved in diagnostic work and medical student/resident teaching.

Social Accountability Inside and Outside the Laboratory

Being a medical laboratory scientist is more profession than occupation. Those of us who are affiliated with ASCP through our certification or work know the value of being part of an organization that values education, certification, and advocacy for patients. Finding a place in this network has given me a strong foundation through years of understanding a “best practices” paradigm. If you’ve been following my posts these last few months, you’ll have heard all about my work with Zika virus prevention and detection initiatives on the island country of Sint Maarten. Being here at the right time and right place have provided ample opportunity to flourish as a medical student with a history of laboratory experience. Recently, my school honored me with the Social Accountability Award and Scholarship for outstanding service during my time as a student with respect for my colleagues and the surrounding community of Sint Maarten. Having authored proposals and leading initiatives coalesced into an ongoing functional public health initiative, partnered with local government and NGOs. My experience as a certified scientist allowed me to build on three major ASCP foundations:

Leadership. Receiving the award from the school validated my confidence in the work that I and my team have been doing this last year. Letters of recommendation came from my service-learning course director and Dean of Community Affairs, and the consultant advisor to the public health prevention office of the local Ministry of Health. The Dean of Medical Sciences even spoke about me with kind words and an inspired tone that really meant a lot to me, personally. This overall validation was not just for me—it was for the work, my team, and our efforts in local public health. The exercise in textbook-to-field informatics, education, and interventions could not have come to fruition without experiences I drew from in my lab years. Responding to CAP inspections, spearheading changes to SOPs or operations, and being a voice at the conference table taught me how to collaborate as well as lead.

Education. If there’s anything I would say has been paramount in my time (both here in medical school and back in the lab) it’s the value of education. I could not do the work or pursue the projects I do today without backgrounds in molecular science, lab informatics, or general pathology and disease. Through numerous degrees and opportunities to work in the field of laboratory medicine, there are countless venues for someone to continue to patient care. My journey included a foundation of molecular biology, a graduate degree in lab science, an ASCP certificate with continuing maintenance as an MLS—now in post graduate work; I continue to work and learn in a dynamic environment. I have created SOPs from scratch, researched literature on seroprevalence and epidemiological statistics, managed and interpreted specimen collection and ELISA testing, and contributed to public health awareness and education. If you want diverse and exciting, this field has it! Education doesn’t stop with the degrees and certificates on the wall behind my desk, however. A very important, and arguably mandatory part, of being a scientist/clinician is being able to engage in an educational conversation with a wide variety of audiences. Talking about Zika virus prevention, seroprevalence, and risk mitigation is a different conversation with children, or local adults, or medical colleagues.

Advocacy. Finally, I should say: if there’s one major thing professional organizations like the ASCP do for its members and our communities, it’s advocacy. Giving a concrete voice and substantial representation to the causes we care about as professionals yields positive returns for our overall shared goal of improved patient outcomes. My work here is first as a medical student, and second as a public health partner. Sharing and collaborating on how this community can best utilize its resources to address a local epidemic is at the forefront of my team’s work. When I started this project, I was inspired by the aims and goals of the Partners for Cancer Diagnosis and Treatment in Africa Initiative from the ASCP Foundation. I first heard about this at the annual meeting in Long Beach, and, as I prepared for my own stint overseas, I tried to keep that close to heart. Improving global health outcomes and increasing laboratory visibility were two of the major tenets of this project. Proudly, I would say I’ve been involved in both aims. Clear success has been documented (and continues to be seen!) in my Zika initiatives, and more and more people engage in conversations with me about translational medicine. With all my documents signed “C. Kanakis, MS, MLS (ASCP),” people have been surprised by all the things someone with “just a lab” background can really do! Breaking stereotypes and inspiring others to reach out for improving patient outcomes is all part of the same conversation I have with my community partners.

In short, my work with Zika virus prevention is an ongoing project, with new events and achievements tallied weekly. But before I get back to recounting the most successful events each month, I wanted to take a step back and say that I could not have been a Social Accountability Award recipient in this community without first learning the way to be a leader, educator, and advocate in our community.

Thanks for reading! Until next time…

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–Constantine E. Kanakis MSc, MLS (ASCP)^CM graduated from Loyola University Chicago with a BS in Molecular Biology and Bioethics and then Rush University with an MS in Medical Laboratory Science. He is currently a medical student at the American University of the Caribbean and actively involved with local public health.

The Learner Experience in a Blended Model of Curriculum Delivery

Key to successful delivery of an online course (or as in our case, a blended model of online and traditional), along with achievement of the learning objectives, is the learner experience. I’ll never forget the feelings of trepidation I had on our first day with our inaugural class, piloting this new model of curriculum delivery with our bacteriology course.

Our lesson plan requires that the students prepare for class by studying the online lecture material as homework, prior to the next day’s laboratory section. Our students were excited about starting our program and eager to learn, yet some were hesitant. I remember one student stating that they “might not be so sure about this new format.” After all, we hadn’t tried it before, and to be frank, it was scary. I remember thinking to myself, “What are we going to do if they do not study the online content? What if they do not prepare for class? What if they dislike this format? What will we do if they flunk their first exam?
Fortunately that was not the case, and our student’s performance in our program has been and continues to be highly successful.

Alex, a student in our current class put it this way:

“It is worth noting that this is not your typical college course. The program here really emphasizes the “reverse classroom” technique. For those unfamiliar, this term means that one will read about the lesson the night before and come to class the next day and perform a laboratory assignment based on that reading.

I came into the program experiencing nothing like this before, so I wasn’t sure how this learning strategy would work for me. After completing our didactic schedule, many of my peers would agree with me that this learning technique is fantastic and is very beneficial to the overall learning experience.

However, to maximize this benefit, time management is vital. Simply reading the lesson at the last minute does not cut it. Whether it helps you to take notes as you go, doing a re-read, or fill out a study guide, this style of learning is a classic example of getting out what you put into it.”

I loved hearing our student reflect that “you get out of it what you put into it.” To me, that is the ultimate goal of education, to prepare our students to be able to think critically and self-direct their learning. In this regard, our inaugural class was a success.

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-Susan M. Lehman, MA, MT(ASCP)SM graduated from the University of Wisconsin-Madison in 1983 with a BS in medical technology. She is program director for the Medical Laboratory Science Program and course director for Clinical Microbiology I and II; her areas of interest include distance education and education methodology.

Zika Virus: The Struggle is Still Real

Well, even though the groundhog has predicted another 6 weeks of winter, it’s not too early to start thinking about those summer pests – mosquitos – and the diseases they bring with them. Zika virus, in particular. Even though the winter weather has dulled our sensitivity to this emerging threat, it remains a significant problem. The virus is now circulating in 65 countries, mostly in the Americas (1). Currently, the CDC has issued travel alerts to areas where Zika is spreading including Miami-Dade, Florida, Puerto Rico, American Samoa, and the US Virgin Islands (2). Laboratory professionals should be aware of Zika virus because the diagnosis of Zika Virus Disease (ZKD) relies on the laboratory, and many healthcare professionals require guidance from the laboratory on how to proceed with diagnostic testing.

Zika is a flavivirus borne by the Aedes mosquito. Symptoms of ZKD usually last 2-7 days and include mild fever, skin rash, conjunctivitis, muscle and joint pain, malaise or headache. There is scientific consensus that Zika virus infection during pregnancy is the cause of congenital brain abnormalities of the fetus, including microcephaly. This devastating effect of the virus sets it apart from the other Aedes-borne viruses dengue, chikungunya, and yellow fever.

Diagnosis of Zika virus relies on laboratory testing, and yet, there are no FDA approved assays for Zika virus currently available. There are however a number of assays that have been given approval for emergency use, including: Real-Time PCR, MAC-ELISA, and a plaque neutralization reduction test. In the United States, these tests are available from the CDC and some state health labs. An algorithm describing the appropriate use of these tests can be found here. Unfortunately, in developing countries where Zika is endemic, access to the appropriate diagnostic test can be very difficult.

Impediments to accurate diagnosis of ZKD in developing countries include lack of education and access to quality laboratories that offer the right test. Lack of education encompasses not only transmission and prevention of the virus, but also who should seek medical attention and when and who should be tested and when. In many countries where visiting a medical professional is a financial burden to a family, it is less likely that a family will seek medical attention for a disease that has such mild symptoms symptoms as ZKD. While most cases of ZKD don’t require medical attention beyond comfort care, if patients don’t report to clinics or health centers, it is difficult to track and confirm cases if no one presents with a suspected case! Also, there is a need for consensus about what should be called a suspected ZKD case and then how to proceed with confirmatory testing. Some countries, including Brazil, the respective Ministries of Health have issued definitions of a suspected Zika case. The Brazilian definition includes: “patients who present with pruriginous maculopapular exanthema accompanied by two or more of the following signs and symptoms: fever, conjunctival hyperemia without secretion and pruritus, polyathralgia, and periarticular edema” (3). Suspected cases can be confirmed with diagnostic testing, but this is another challenge. The easiest and least expensive test for a clinic in the developing world is a Ig-M based rapid diagnostic test. There are several of these available commercially, mostly from European markets. However, these demonstrate significant cross-reactivity with other flaviruses such as dengue and chikungunya, which are also endemic in areas where Zika is now circulating. The most appropriate tests – RT-PCR, MAC-ELISAs, and plaque reduction tests – are only available in national laboratories it at all. The combination of lack of patients reporting Zika-like symptoms, lack of consensus of what constitutes a suspected case, and limited availability of confirmatory testing means that there is a significant likelihood that the number of Zika cases in many developing countries are underreported.

In January 2016, the WHO presented the Strategic Response Framework and Joint Operations Plan in response to the growing Zika virus epidemic. In October 2016, a quarterly update was released that described the goals and scope of the plan through December 2017. The plan is Strategic Response Plan comprised of four areas: 1) Detection, 2) Prevention, 3) Care and Support, and 4) Research. $10.9 million are dedicated to the detection arm of the strategic plan, which in addition to laboratory testing and diagnosis includes assessment and implementation of preparedness measures, and surveillance and monitoring in it’s scope. $41.2 million are dedicated to the research arm of the plan, which includes the “fast track and scale up of research development and availability of diagnostic tests.”

Hopefully in the next year we will see not only new diagnostic testing, but also medical interventions such as vaccines. In the meantime, it is important that we as laboratory professionals continue to be apprised of available testing, to educate our healthcare partners on the use of lab testing for ZKD, and to support research and development of Zika diagnostics.

References

Falcao et al. Ann Clin Microbioal Antimicrob (2016) 15:57
MMWR, February 12, 2016: 65(05); 122-127
Zika Strategic Response Plan Quarterly Update. 25 October 2016.

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–Sarah Riley, PhD, DABCC, is passionate about bringing the lab out of the basement and into the forefront of global health.

ASCP Annual Meeting Call for Abstracts Now Open

The 2017 ASCP Annual Meeting is in Chicago, IL September 6-8. If you’d like to present your research at the meeting, the call for abstracts is now open. Summarize your work in 300 words or less and submit it through the online portal by March 20th, 2017.

Spread the word, and good luck!

Managing the Emergency in Your Lab

So far in 2017, the United States has seen blizzards, fires, tornadoes, floods, and other disasters. Have any of these disasters struck near you or affected your laboratory? If it did strike your area, would you be prepared? Would your lab staff know what to do and how to work to continue lab operations? A comprehensive emergency operations plan is not something that should be dusted off and considered when an emergency situation occurs. It should be reviewed and tested on a regular basis, and all lab staff should know how to put it into action easily.

The College of American Pathologists (CAP) requires laboratories to have “written policies and procedures defining the role and responsibilities of the laboratory in internal and external disaster preparedness.” A second related standard also requires that labs have a functional evacuation plan in case work can no longer be performed in the department because of unsafe conditions. These policies should be developed with input from lab leaders, medical directors, and other key hospital or facility emergency management personnel. The disaster plan for the lab must work for the department, but consideration must be given to other areas if the lab does not stand alone in the building.

As with many lab safety guidelines and rules, regulatory agencies often put forth changes or updates as they deem necessary. At the end of 2016, the U.S. Centers for Medicare & Medicaid Services (CMS) published an updated final rule for healthcare providers- and that includes labs- regarding Emergency Preparedness. The purpose of the rule was to establish national emergency preparedness requirements, to ensure adequate planning for both natural and man-made disasters, and to provide coordination with federal, state, tribal, regional and local emergency preparedness systems.

The CMS requirements can be broken down into four elements, Policies and Procedures, Risk Assessment and Emergency Planning, Communication Plans, and Training and Testing. First, all lab and hospital emergency management policies or procedures need to comply with federal and state laws. As stated earlier, these policies need to be easily understood so that any staff member can put them into motion. There may be disaster scenarios in which lab leadership may not be able to get to the site. Lab emergency operations plans should be reviewed or updated annually.

Hospitals and labs should review the hazards in the local areas and assess what disaster types are most likely. Consider situations like equipment or power failures, and even an interruption in communications, including cyber-attacks. CMS also wants facilities to plan for the loss of all or a portion of a facility, or even the loss of supplies.

Laboratories should have a plan to contact staff, including physicians or other necessary persons. This communication system should be well-coordinated within the facility and across health care providers. The state and local public health departments and emergency management agencies need to be included in the facility communication plan as well.

The final CMS-required core element for emergency response includes testing and training. All staff needs to be familiar with the contents of the response plan, and the plan should be well-maintained through regular training of staff and testing. That testing can include the use of table-top drills or even assessing how the plan worked in a real disaster scenario. While CAP allows many lab policies to be reviewed once every other year, CMS requires an annual review or update of these disaster policies and procedures.

Developing a comprehensive emergency management plan is no small undertaking, and if you don’t have one in place already, make sure you gather a team to help with that project since there is much to consider. If you belong to a system of laboratories, you also need to consider how the plan will connect the actions of multiple sites. If you have a plan in place, make sure you assess it regularly for ease of use and the ability to achieve its goals. Those goals should include the safety of staff, the continued delivery of services (if possible), and recovery to normal operation. We know that emergency situations aren’t all that rare, and following this pathway can help your lab be ready when the next disaster strikes.

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–Dan Scungio, MT(ASCP), SLS, CQA (ASQ) has over 25 years experience as a certified medical technologist. Today he is the Laboratory Safety Officer for Sentara Healthcare, a system of seven hospitals and over 20 laboratories and draw sites in the Tidewater area of Virginia. He is also known as Dan the Lab Safety Man, a lab safety consultant, educator, and trainer.

Serotypes and Stereotypes: the Path to Pathology

Hello and welcome back! After a hiatus for the holidays, I’m now back at school and gearing up to write about more Arbovirus-related public health endeavors. But, with projects on hold until now, I’m going to briefly depart the world of mosquito source reduction and epidemiology to discuss something that relates to my experiences in medical school. If you read my Lablogatory bio, you’ll see I spent a number of years studying and working in some of Chicago’s great clinical laboratories. In the past decade, I’ve been very close to the field of pathology and laboratory medicine. As I reach the “half-way” mark in medical school now, I have become increasingly aware of the way people across healthcare professions and specialties view laboratory clinicians. One thing that stands out strikingly is, what I argue, a potential stereotype.

Let me tell you one of my pet peeves. As a medical student, I am fortunate enough to learn and work under the guiding hands of physicians, nurses, and other educators. I work my hardest to learn how to provide the best care possible as I learn the skills needed for my future practice. In debriefing from a simulation, a good performance might spark conversation which culminates to the paramount question: “Have you thought about a specialty?” My heart set on it for a while, I often remark “Pathology” before I correct myself to “Clinical Pathology” since I’ve learned to curtail jokes about autopsies. (Disclosure: autopsies are a very important part of medicine, and the number of autopsies have experienced an unfortunate downward trend.)

As a result of my AP/CP answer, many people are often surprised, citing that I’ve been “great with the patient(s).” So that begs the question: why does my current answer surprise people? And more importantly, what perpetuates the stereotype of an introverted, microscope jockey who doesn’t want to be near patients? Yes, hyperbole, but I’ll come back to this stereotype.

While I was stateside visiting family, I coordinated some clinical shadow time with a colleague and alumnus of my medical school in her pathology residency at University of Alabama at Birmingham (UAB). I spent time rounding with their teams in derm-path, watching sign-outs for endless cases, and getting up close and personal with autopsy training with another pathology resident. Each interaction with the faculty and staff were familiar and expected—full of enthusiasm and passion about their respective field of research or clinical work. What struck me as special, however, was that I was neither questioned for my motives in seeking pathology as a specialty, nor did I surprise anyone by being social and amicable. Everyone was quite sociable and proud of their work. My interactions were limited to the anatomic and clinical pathology departments so I suspect there may have been some bias. When I was a medical laboratory science student, I recall working with other disciplines, and, though I may have been in a nascent time in school to notice any stereotypes, they became clearer as I progressed through various jobs across the city. Large trauma centers, small community hospitals, even a shadow stint at the Cook County Medical Examiner’s Office, all taught me valuable lessons on varied scope and different professional perspectives. And all the while, people seemed surprised I would be interested in such a misunderstood specialty.

On Lablogatory, I’ve enjoyed just about every post and one of my favorites is a series by Dr. Lori Racsa, “Lonely Life of a Clinical Pathologist.” Dr. Racsa discussed things about laboratory medicine I had observed in my time as a medical laboratory scientist: the critical role of pathologists on committees, the value of built-in mentorships, the [aforementioned] mystery about the particularities of the job to clinicians and laypeople alike, and the value of technologists like myself! One of the most poignant posts she wrote addressed the potential for a clinical pathologist to round with other “floor” clinicians. That was something I thought I’d dreamed up in my ambition to go to medical school, blazing a trail in Path where I could put some cracks in that stereotype. Dr. Racsa cited a great article from Critical Values by Dr. H. Cliff Sullivan where he recommended pathologists become more actively involved with fellow clinicians to directly improve patient outcomes. Having freshly attended several events at the ASCP National Meeting in Long Beach just prior to his article, I rode a wave of his “rally call” for changing the face and accessibility of pathology as a specialty. I saw myself in both his and Dr. Racsa’s stories of interdisciplinary teams, rounds, and committees and I’ve been excited ever since.

Back to that stereotype. Those articles about pathologists’ roles in medicine reflect a distinct lack of visibility to fellow colleagues. While we all recognize that nearly 100% of cancers are lab-dependent diagnoses and 70% of patient records are tied to diagnostic laboratory data, why are nearly half the residency spots for Pathology in the US National Resident Matching Program unfilled for the past few years? According to recent surveys by the American Medical Association, Pathology has one of the lowest relative rates of physician burn-out compared to other specialties. Pathologists are earning within 15% of the average physician income, with one of the highest relative satisfaction scores to match. So with lifestyle and career quality reporting positive values, I would argue that the seeming lack of interest stems from the possible lack of exposure of pathology as a dynamic field. The stereotype I’ve been talking about might also be one of attrition—“out of sight, out of mind.” Some great pieces of work on Lablogatory focus on promoting the value of laboratory medicine as an integral part of any patient’s care. Just recently, Dr. Sarah Riley discussed CO poisoning and public health, while her bio calls for “bringing the lab out of the basement and into the forefront of global health.” I feel close to that cause myself, hopefully made evident in my previous posts. Stay tuned for next month’s where I’ll be discussing the next steps in our public health project on Sint Maarten. After celebrating a successful 2016 effort presented by the Ministry to the Global Health Securities Agenda, our team has a number of projects lined up to demonstrate effective integration of lab medicine, epidemiology/public health, and social outreach.

A friend and mentor once told me to keep a completely open mind about my medical career and let whatever specialty fits best “find me,” so to speak. I couldn’t have asked for more sound advice. I’ll admit I have my biases and comfort zones, and for now that’s what they’ll remain. In this post, I had hoped to shine some light on the disparities in career reputation between pathology versus other disciplines. Is the stereotype founded in any truths I may have missed? Don’t pathologists have the social tact to work up and down the ladder, working with lab assistants to government health officials? Have you ever been challenged for your career choices in pathology? What reasons do you think contribute to the stereotypes I mentioned? What words can you offer students like me just starting to find a foothold in their newfound careers in medicine?

Leave your comments below! Thanks!

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Toilet Paper Safety

As the years have passed, I have noticed many changes in the toilet paper dispensers in the healthcare setting. First there was the standard rolling style. This was great- you could get as much paper as you wanted, and the only issue was whether or not the roll was installed properly (I prefer “over”). The next style to come along was the bumpy roller. As it rolled out, the lop-sided holder would cause tissue to rip off before the user was ready. Then came covered paper holders that forced the user to reach under a sharp edge for paper access. The latest version I have seen completely covers the roll leaving a tiny access port that allows one piece of paper to be ripped off at a time.

As each dispenser style was replaced by a newer, more insidious model, I began to wonder why hospitals were being so cheap with the paper. Was it being stolen often? Was there a black market for toilet paper? Did the hospitals understand that each newer model forced staff to remain in the rest rooms for longer periods of time in order to get an adequate tissue supply? Surely this was affecting productivity in the work place. Clearly I had given this too much thought, and I let it bother me. I learned this year, however, that I was wrong about the topic for many years. I found out that in hospital rooms with patients under contact precautions (such as patients who have contracted C. difficile) all of the open paper products must be discarded. In fact, it is a common practice to dispose of any open tissue when any patient room is cleaned. This latest dispenser designs prevents the wasting of paper and actually saves money. Once I received education about the issue, I had a better mindset about the tissue issue.

This is often true with laboratory safety, and providing the necessary education can truly improve safety compliance. There are many who have worked in the lab setting for years, and some have ignored safety regulations while others have followed them grudgingly. Often, the staff approach to lab safety can be improved with basic knowledge; information about the regulations, leadership expectations, and potential consequences of non-compliance.

I approached a lab manager about the need for his staff to utilize face protection when pouring chemicals. He said he was not aware of the need, and it would be an enormous change for the staff. We had a discussion about OSHA’s Chemical Hygiene standard and the Bloodborne Pathogen standard, both of which require face protection when handling open specimens and chemicals. Once he knew this and could also locate it in the safety policies, he immediately covered the information with his staff and compliance was improved. In this case, simple knowledge of the regulations was enough reason for the lab safety to be improved. Knowing the reason why is an important motivator for lab staff.

Lab leaders can make a strong impact on PPE compliance both by voicing expectations with staff and by being a good role model. If you lead lab safety, talk to new employees about what is expected, and regularly remind current staff about the safety policies that are to be followed. Every successful leader also has to be a positive role model. If you expect certain safety practices to be followed, you need to make sure you follow them when you are in the lab as well. A safety professional that walks through the lab in mesh sneakers is going to have a (pardon the pun) paper-thin positive impact on the overall culture.

Some long-term lab employees who regularly comply with safety regulations do so because they have learned an unfortunate lesson. Lab staff that has been the victim of an exposure or injury knows the consequences, and sometimes the cost has been very high. Exposures from an unknown source, for example, can result in treatments that cause illness and that will interfere with personal lives. An exposure that results in contracting an illness or a career-altering injury can be devastating. Our goal as lab safety professionals should be to get staff to comply with regulations proactively, rather than as a response to an incident. Teaching about potential consequences often can have an impact on safety behaviors. You may be surprised at how little laboratorians (and lab leaders) may think of the effects of poor safety conduct. Use real life incidents to tell stories and discuss other possible bad outcomes of non-compliance.

As the average age of laboratory professionals in the country continues to rise, we may be working with some folks who have had the same weak safety mindset for quite some time. They remember the days of eating, drinking and smoking in the lab, and they don’t understand why all of these rules are now in place. They’re healthy today, aren’t they? It’s time to change that way of thinking. It’s time to explain that while they may have practiced unsafe behaviors without incident, it just means they were lucky, not smart. Getting staff to think about the regulations, the expectations, and the consequences will help them to have a new and positive mindset about the lab safety issue.

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-Dan Scungio, MT(ASCP), SLS, CQA (ASQ) has over 25 years experience as a certified medical technologist. Today he is the Laboratory Safety Officer for Sentara Healthcare, a system of seven hospitals and over 20 laboratories and draw sites in the Tidewater area of Virginia. He is also known as Dan the Lab Safety Man, a lab safety consultant, educator, and trainer.

Choosing Wisely

Having recently completed the 2016 survey regarding topics to be considered in the updated ASCP Choosing Wisely campaign, there were several thoughts that came to mind.

First, I applaud the ASCP for taking the initiative to participate early on with Choosing Wisely and now to review and update these elements. As we all know, as the evidence and needs of our patients change, so must we. We should always strive to maintain the “latest and greatest” particularly given the continued growth of laboratory medicine. Identifying appropriate and necessary laboratory utilization shows our concern as individual practitioners and as a professional society. Our involvement clearly influences patient outcomes and we must remain diligent about putting forth this message.

Secondly, I will admit that there were numerous tests and the questions regarding their usefulness listed in the Survey that were completely unfamiliar to me. This highlighted how lab menus are expanding and many of these were subspecialty oriented, pointing out how intricate and complicated our scope of laboratory practice has become. With the multitude of tests available and their complexity, is it any wonder our clinical colleagues suffer the same, and I venture to say even MORE, angst than we face given this array of testing options? Therefore it is even more important, then, that we as a Society continue to be about the forefront of laboratory initiatives, educating ourselves and helping those healthcare providers that live outside “our walls.”

Of course, the Choosing Wisely campaign is also focused on patients and the information needed for solid patient-centered decision-making. It is thus incumbent upon us to participate in this national campaign, for who better than laboratory professionals to help navigate these waters on the behalf of patients?

The onus is upon us, then, to pursue this initiative and provide guidance regarding laboratory utilization, appropriate testing, testing intervals, adequate test menus and laboratory interpretation. The ASCP participation in the Choosing Wisely campaign allows us to solidly insert our expertise in this arena. Each of us, as members, is responsible for our participation, not just in this Survey, but on an ongoing daily basis as part of the patient care team.

Burns

-Dr. Burns was a private practice pathologist, and Medical Director for the Jewish Hospital Healthcare System in Louisville, KY. for 20 years. She has practiced both surgical and clinical pathology and has been an Assistant Clinical Professor at the University of Louisville. She is currently available for consulting in Patient Blood Management and Transfusion Medicine. You can reach her at cburnspbm@gmail.com.