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.

 

 

 

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.

The ABCs of BSCs

Many labs have received notices this year that their Biological Safety Cabinet (BSC) certification company will no longer certify a certain type of BSC that those labs have had for years. NSF International (formerly the National Sanitation Foundation) is an organization that supplies product testing, inspection and certification. NSF is accredited by the American National Standards Institute (ANSI) to develop American National Standards, and in 2010 an updated version of the NSF/ANSI 49 was published. This is better known as the Biosafety Cabinetry: Design, Construction, Performance, and Field Certification standard.

The names can be confusing, but the important message is the revisions to the standard eliminated the option of direct-connected Type A cabinets (which had been previously allowed). Also, an alarm requirement was added for canopy connected Type A cabinets. There was time allowed for sites with these types of BSCs to make necessary adjustments, and in 2016 field certification agencies have been told they can no longer certify BSCs which do not meet the updated standards.

That means that some labs that have not updated their BSCs or purchased new ones, they are left with uncertified (and therefore unusable) cabinets.

There are three main classes of BSCs. Class I offers the least amount of protection, and it pulls air in and over the work area. The air is then exhausted via a HEPA filter. Class II BSCs are the most commonly-used cabinets in clinical laboratories. They offer a maintained inward airflow, a HEPA-filtered unidirectional airflow within the work area, and a HEPA-filtered exhaust into the room or to the facility exhaust system. Class III BSCs (or glove boxes) are for use with high risk biological agents, and they are typically sealed and gas-tight enclosures.

The commonly-used class II cabinets come in a variety of designs or types:

  • A1 – 70% of the air recirculates through the supply HEPA filter, the other 30% of air goes through the exhaust HEPA filter.
  • A2 – 70% of the air is recirculated through the supply HEPA filter, the other 30% of air goes through the exhaust HEPA filter. The air intake is faster than in a type A1 cabinet.
  • B1 – 40% of the air is recirculated, 60% of air is exhausted.
  • B2 –   No air is recirculated within, it is all exhausted into the facility system.

Some older Class II Type A cabinets had the exhaust directly connected to the facility exhaust system. This is no longer permitted since hard connections need to meet specific regulated criteria and is not considered the safest type of connection. If connected to an exhaust system, the cabinets must use a canopy (thimble or air-gap) connection which has an opening to the room. Because there is always the potential for equipment failure (and a possibility of air contamination to the room via the opening), an alarm system must also now be in place to alert the user of this possible danger. In 2016, all BSC field service workers were notified not to certify Type A cabinets with a hard connection or with a non-alarmed canopy connection. If you received a memo and had an issue with certification this year, that’s why!

No matter what Class II type of BSC you are using, there are some basic safety guidelines every user should know in order to keep protected while working. If the blower is not kept on all the time, turn it on about ten minutes before use. This will stabilize the protective air flow in the cabinet.  Adjust the seat height so that the user’s face is above the front opening. Set all specimens and materials that are needed inside the work space, and separate the clean from the dirty. Do not set anything on the front grille.  Objects too close to the front, side, and rear air grilles can disturb airflow and compromise the specimen and the worker’s safety.

When working in a BSC, avoid frequent and fast motions. When moving arms in and out of BSC, move them slowly and perpendicular to the sash. This will allow less interference with the air flow. Be sure to limit traffic in the area when working- people walking behind a BSC in use will disturb the air flow such that air will pass out of the cabinet into the breathing zone of the user. In general, fume hoods and BSCs should never be located in high traffic areas.

Once work is completed inside the BSC, properly dispose of all waste material. Disinfect the cabinet surfaces using an extension apparatus to reach the back wall. Never put your head inside the BSC. Use a bleach solution for disinfection. If damage to the surface is a concern, wipe down the surface with water after using the bleach. Let the BSC run for at least 10 minutes before turning off.

It is important to remember that a Biological Safety Cabinet is an engineering control designed to protect the worker, but it only does so if used properly. Make sure all users are properly trained to use a BSC safely. Have them certified annually, and let certified professionals perform the required maintenance. If you received a memo this year, it may be time to purchase a newer BSC in order to maintain safe work practices in your lab. Ask your field service representatives for the best option for your laboratory.

 

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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.

Facing CJD and Prion Diseases in the Lab

According to the National Institute of Health (NIH), Creutzfeldt-Jakob disease (CJD) is a rare, degenerative, fatal brain disorder that affects about one person in every one million people per year worldwide. In the United States there are about 300 cases per year. Some of us know the ailment better as “Mad Cow disease,” but that is only one form of this illness which is not caused by a virus or bacteria. CJD is a prion disease. A prion is a protein that exists in both a normal form, which is a harmless, and in an infectious form. The infectious form of the protein takes on a different folded shape, and once these abnormal proteins appear, they aggregate or clump together. Investigators think these prion aggregates may lead to the neuron loss and other brain damage seen in CJD. However, they do not know exactly how this damage occurs.

Since laboratory professionals may deal with specimens from possible CJD patients, we need to know how to properly handle them should such a situation arise. If the Operating Room calls your labs to process a brain biopsy specimen from a patient who was suspected of having a prion disease, would you know what to do? Can your lab do that? Should your lab do that?

Prions are dangerous, but CJD cannot be transmitted through the air or through touching or most other forms of casual contact. Prion transmission can occur, however, from contact with highly-infectious specimens. Brain tissue, eye tissue, and pituitary tissue are considered high-risk specimens, and contact with these should be avoided. When asked to handle a brain biopsy, medical staff and safety experts should work out a plan. For instance, a lab tech who is trained in Category A packaging could go to the OR, dress in fully protective PPE (including a body suit, gloves, and hood), and receive the specimen in the OR and package it there. The specimen is then ready for transport to the reference laboratory. If another department asks you to handle tissue samples from a suspected CJD patient, stop everything and escalate the issue immediately. Contact your medical director, your manager, or the safety officer and await further instructions.

There are other specimen types a lab might receive from a prion patient. Blood, serum, urine, feces, and sputum are considered no-risk specimens. Prions are not found in these types of specimens, and they may be handled and processed as usual.

The last category of specimens from prion patients is known as “low-risk.” These specimens include CSF, kidney, liver, spleen, lung, lymph nodes, placenta, and olfactory epithelium tissues. Of course the most common specimen a lab would see from this group is a spinal fluid, and labs do need to make sure they do not handle it as a normal specimen.

Lab staff should be notified when a specimen is going to be sent from a prion patient, particularly when a low-risk specimen like a CSF is on the way. Procedures should be in place, and it is recommended that such specimens have special labels on them to alert those of the potential risks.

There is no record of lab employees becoming infected with prions from handling low-risk specimens, but they must still be handled with care. All testing of low-risk specimens should be performed inside a Biological Safety Cabinet (BSC). Use disposable equipment as much as possible. For example, use disposable cups for stains or reagents where possible. Perform manual testing only; do not run low-risk specimens on automated analyzers as disinfection is not easily accomplished.

While using standard bleach solutions to disinfect surfaces is recommended after processing low-risk specimens, a lab spill of such a specimen is an entirely different matter, and this is why lab specimens should have special labeling. When a low-risk specimen spills, the area should be flooded with 2N Sodium Hydroxide (NaOH) or undiluted sodium hypochlorite (bleach). Remember, never mix bleach with formaldehyde as it produces a dangerous gas, so if a pathology specimen is spilled, only use NaOH. Leave the solution on the spilled material for one hour, then rinse with water. Place the spill materials into a sharps container so that they will be incinerated. If a spill of a low-risk CJD or prion specimen occurs, contact a manager, a medical director, or the safety officer immediately.

Laboratory professionals handle infectious specimens every day which is why it is so important that we utilize Standard Precautions. Wear PPE when working in the lab and treat all specimens as if they were infectious. It’s the only way to prevent a lab-acquired infection. If you see a co-worker not wearing gloves or a lab coat and working at a lab counter or computer, use coaching to remind them that those surfaces are potentially contaminated with pathogens, and they can be deadly. We can protect ourselves from low-risk prion disease (and other pathogens) with everyday PPE. If a specimen is processed in the lab and it is found later the patient was prion-positive, you do not want to be the one who wasn’t wearing PPE when you handled the specimens. The results will be potentially disastrous for you and your family.

Remember, if you receive a phone call that a CJD or prion specimen is being sent to the lab, escalate the situation immediately. Find out if your lab is able to receive and process that type of specimen. Protect yourself, and keep your lab safe from CJD and other infectious pathogens.

 

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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.

 

Waste Not, Want Not

In the year 1987 medical waste became a national issue when syringes, needles and other medical wastes began to wash up on the shores of New Jersey. There were multiple episodes that both posed danger to the general public and revealed a potential healthcare-created environmental disaster. It was obvious that many hospitals and laboratories were not properly handling and disposing of their wastes. In the ensuing years, many laws and regulations were put into place that affect how labs and hospitals should handle their many different types of wastes. How is waste segregated in your areas? Do you separate regular waste from biohazard trash? Do you store chemical wastes in a room or department away from the lab? Some of these practices are not safe, and others may harm the environment and break the law.

There are multiple waste streams generated in the lab. Staff should be aware of each, and they should handle each differently. While a few waste streams may be combined legally, it is important not to do so in order to reduce department expenses and in order to protect the environment. Regular (non-hazardous) waste includes paper items, specimen transport bags, and gauze pads used for disinfection. In many areas of the country, items that are not visibly dripping with blood or body fluids (saturated) can be placed into regular waste containers. These items might include disposable lab coats, plastic transfer pipettes, and gloves. Knowledge of proper disposal here is key- fines can be levied against the hospital or lab for disposing of bloody items into the local landfills. Also, in many states, any item with a biohazard symbol may not be disposed of into the regular waste stream, even if the item is clean. Be careful about tossing away biohazard-labeled specimen transport bags.

Another common lab waste includes Regulated Medical Waste (RMW) which encompasses biohazard waste and biohazard sharps. RMW should be placed into containers that are closable and constructed to contain all contents and to prevent fluids from leaking during handling, storage, transport, or shipping. If the lab is responsible for changing its own biohazard waste bags, they should be tied in such a way that the bags will not leak (i.e. the use of a gooseneck knot rather than a square knot). Then the bags need to be placed into a container with a tight-fitting lid for removal from the department. It is not a requirement that RMW trash containers in use in the lab have a lid (unless it is a sharps container). RMW removal is expensive, and it is typically charged by weight. Sharps container disposal is also charged by weight and is much more expensive than bag disposal since these containers are usually incinerated.

This is why trash segregation in the lab is critical, and teaching it to staff is not difficult. Some biohazard waste ends up in biohazard landfills. These landfills are more expensive to create and to maintain, and the potential for environmental contamination is greater than from standard municipal landfills. If environmental concerns aren’t a motivator on the lab, then cost may be. Throwing items into biohazard trash bags and sharps containers that do not belong there creates unnecessary spending. That money would be better utilized for product purchases, equipment, and salaries. Many labs decide it is easier to provide only biohazard trash containers and no waste education. That is not a good practice.

A third lab waste is Hazardous or Chemical waste. Often hazardous waste is removed from the lab via a contracted waste handler which may charge the lab by chemical weight, number of barrels, or even time spent in waste collection.  Final disposal of the chemical waste usually occurs via incineration, fuel blending, or even burial. Once hazardous waste is generated in the lab, the labeling, storage and tracking of it become vital processes that must be properly managed. A Satellite Accumulation Area (SAA) is a place in the lab where chemical waste may be temporarily stored before it is moved to a Central Accumulation Area or until it is picked up for final disposal. The SAA should be within view of the point of generation of the waste- you should not move the waste to another area unless that area is a CAA. A Central Accumulation Area (CAA) is where hazardous waste is stored until it is picked up for final disposal at an outside facility. These regulations about chemical waste may vary by facility depending on the facility’s EPA waste designation- bit that’s a topic for another time. If you aren’t aware of that designation, speak to your facility director to find out.

Some laboratories generate other types of waste that may need consideration. Radioactive waste, universal waste (batteries, light bulbs), and mixed wastes (hazardous and radioactive) all need to be managed and require proper disposal. Labs should also look at waste reduction methods such as solid and liquid recycling and replacement of hazardous chemicals.

Performing waste audits is the final step in the waste program management. Reviewing regulations, physically inspecting lab waste streams, and reviewing waste records will help you understand what your lab needs are. If you need help with training, contact your waste vendors, they may have the education materials you need. Management of the laboratory waste program is important, and it accomplishes multiple goals – money savings, regulatory compliance, and the safety of your staff.

 

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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.

 

Perspectives on Lab Safety

I attended a work shop where different people were allowed to express their views on life from their generation’s perspective. One group representative said that members of the “Millennials” generation often acted as if entitled to things in life and don’t feel as if they have to work for it. A Millennial representative spoke up. She said that she did not feel entitled, but felt a victim of broken promises. She watched the generation before her live the good life- go to school, get a job, get married, buy a house, etc. – and now she was done with school, full of debt and still living at home. The economy and the world had changed, and the life she hoped for was not the one she now faced. Listening to a different perspective was truly eye-opening, and it reminded me about an important aspect of lab safety coaching.

In conversations with long-term lab safety professionals (or those lab managers, POCT supervisors and others who share the lab safety role), I often hear about the constant frustrations with lab safety compliance. Staff does not wear PPE, they don’t follow safe work practices, or they don’t think about chemical or bloodborne pathogen safety. Some who oversee lab safety have become so frustrated that they have given up on coaching or talking to the people they are assigned to keep safe. That is most definitely an incorrect approach, and if you find yourself in that situation, it may be necessary to take a step back, look in the mirror, and notice that the problem could be you.

That’s not meant to sound accusatory, but if your lab is suffering from a poor safety culture, the best place to begin with a solution is in your head, and understanding that can be powerful. First, remember that each time you are in the laboratory and you see a safety issue that you ignore, you are seriously damaging the culture. Few are scrutinized more than those who manage the safety program in the lab, and if ignoring safety regulations is witnessed by staff, they will know how unimportant safety is in the department, and they will act accordingly. If you are burned out from years of battling the culture, it may be time for someone else to enter the safety role so that the culture is not damaged further.

Next, if you plan to remain the safety role, it may be time to examine your approach to staff. Instead of becoming frustrated with people when the need to coach arises, try to change your perspective. How a safety coaching episode will play out is largely determined by what you (the coach) are thinking as you approach the situation. It is important to remember that each time a staff member does not act in a way you wish or expect as it relates to safety, there are several possible reasons or influences on the situation, and all should be considered before acting.

Janet is in chemistry handling specimens without gloves. This alone could generate a range of negative feelings when you see this- anger, frustration, or even apathy. What are the possibilities? She was not trained properly, there are no gloves that fit her, she is having a reaction to gloves and is embarrassed to confess it, or gloves are kept in the store room and she doesn’t know the door combination. Any of these scenarios and more is possible. Your emotions about the situation are real, they can result from a broken promise (you’ve spoken to Janet before), judgement (she’s not a stellar tech anyway), or failed expectations (you recommended she be hired). However, you should not act on those emotions; there is little chance the coaching will go well. Approach Janet with a question that will start a reasonable, two-way conversation. “Hi, Janet. I notice you aren’t wearing gloves. What size can I get you?” Or “Janet, I see you are handling samples with no gloves and that is dangerous. Can you tell me why?” If this is a repeat situation, put the ball in Janet’s court. “Janet, we discussed glove use last week, but you are not wearing them. You told me you would. What’s going on?” Now the focus is on the important issue for you, Janet’s broken promise. The answer may help you understand her behavior, and help you to rectify the situation permanently. Remember to use a soft approach and a civil tone. Otherwise, the work of your thought-out coaching will be for naught.

Everyone has their own perspective. That in no way excuses all behaviors, especially failing to follow lab safety guidelines, but understanding a perspective will go far in helping you succeed with coaching those bad behaviors when needed. Think first, always act, and be the safety role model you need to be for your department. Those are the powerful steps to a strong lab safety culture.

 

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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.

Special Safety Considerations in the Anatomic Pathology Laboratory

Margie had worked in the histology department for years. She never used the chemical fume hood when pouring formaldehyde, but lately she had been coughing quite a bit, so she decided it was time to use the hoods. Soon she would be diagnosed with lung cancer.

Steve was a cytotechnologist working in the radiology department for a fine needle aspirate procedure. The radiologist was in a hurry, and when he handed the uncapped sample needle to Steve, the needle pierced the skin in Steve’s hand. The patient had Hepatitis C.

Jane had finished her long day of assisting with frozen sections and had to clean the cryostat. It was the end of the day, and she wanted to go home. She reached into the cryostat to change the blade with her gloved hands. She received a nasty cut on her finger, and since the blade had been used for multiple patients, Jane had to be treated for an exposure from an unknown source.

Anatomic Pathology laboratories present unique safety concerns that can differ from clinical lab concerns. Formaldehyde and other hazardous chemicals are used to preserve tissue specimens, workers can be exposed to large amounts of blood and body fluid during autopsies, and the sharp blades in cryostats and microtomes create additional cause for concern. Histology and Cytology employees need to be ever-vigilant to protect themselves from these exceptional hazards.

Formaldehyde and xylene are two chemicals typically handled in the AP lab. Xylene is a strong-smelling flammable liquid, and formaldehyde is listed by OSHA as a known carcinogen. If using these chemicals in the lab, you should have specific safety procedures for them, and vapor concentration monitoring should be performed to determine employee exposure levels. It is important to review the monitoring results as soon as possible, and never more than 10 ten days after receiving them. Discuss the results with each monitored employee individually or post the results in the department. Because monitoring is performed for tasks as well as locations, it is considered representative monitoring. That means one result may represent several employees who perform the same tasks or work in the same area.

If vapor concentration levels are elevated, make sure to take measures (such as using engineering controls) to reduce or eliminate staff exposure. OSHA’s Formaldehyde Standard requires annual monitoring if results are above the STEL (short term exposure limit). To discontinue sampling, the lab needs to obtain results from two consecutive sampling periods taken at least 7 days apart show that employee exposure is below the action level and the STEL.

OSHA requires a specific safety formaldehyde training for all employees who are exposed to formaldehyde concentrations of 0.1 parts per million (ppm) or greater. This formaldehyde training must include specific elements including education of the contents of the Formaldehyde Standard, the contents of the formaldehyde Safety Data Sheet (SDS), the health hazards of formaldehyde exposure, the proper use of necessary PPE, and spill response and clean-up procedures. This training is required by OSHA annually, and it may need to be provided to some employees who work outside the laboratory (operating room staff, labor and delivery staff, etc.). Even though the laboratory may not be responsible to provide this training, it is a good idea to communicate with other department leaders to ensure they get the required training for their staff.

Blades and other sharps pose great risks in AP procedure areas. Most microtomes and cryostats are equipped with knife guards- insist that they be used. Remove used blades with magnetic-tipped implements and insert new blades using rubber-tipped tweezers. Place disposable knives in sharps containers after use.

Odd as it may seem, there are Cytology procedures where the hand-off of uncapped needles containing samples sometimes occurs. Unprotected needles should never be passed from one person’s hand to another. These needles should be placed on a counter or the technologist should only take them from the collector with an implement such as tweezers. Be sure there is ample space to safely perform the cytology tasks in the procedure area away from the lab.

Laboratory Safety is not a “one-size fits all” umbrella for all areas where laboratorians work. Risk assessments and task assessments are critical to determine the particular hazards in a specific lab. In the Anatomic Pathology laboratory, these assessments should guide safety leaders to those specific safety measures which can help your staff prevent injuries and exposures which can be career and life-changing.

 

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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.

Anatomy of a Safety Stand Down

In March of 2016, the United States Government Accountability Office (an independent agency that works for Congress) produced a report stating that stronger oversight mechanisms are needed to improve safety in high-containment laboratories. The laboratories referred to are those which work with hazardous biological agents in order to protect public and animal health and the food supply against contamination of those agents. Because of several very public lab safety lapses in the past two years, the report makes 33 recommendations to improve lab safety. These recommendations include the development and update of policies that contain missing safety elements, the reporting of oversight activity to senior officials, and the development of plans with time frames to implement the safety recommendations. The report basically recommends a “Safety Stand Down.” Has your laboratory seen a similar situation? Have you encountered a series of like safety events that created the need to stop and review?

OSHA’s definition of a safety stand down is “an event for employers to talk directly to employees about safety.” Because of the danger to employees, a more specific definition means that all work stops until the issue is corrected and all affected (or potentially affected) staff has been educated to make sure the issue does not re-occur. However, in the real world, unless someone is in imminent danger, the work of the laboratory must go on for the sake of patient care. Still, a stand down can be important, and there are ways to run one successfully.

Once you have decided there is a need for the stand-down, develop the stand-down education. This can include a set of presentation slides, a hand-out, or talking points to use as the information is delivered. Make sure you stick to the topic(s) at hand, and do not include extraneous information, but be certain to include all items that are pertinent to the stand-down subject.

The next step is deciding on the stand-down delivery approach. Will you meet with staff one-on one, in small groups, or with everyone at the same time? Choose the meeting location(s) and schedule the meetings. Because this is a stand-down and a safety issue that must be dealt with, these steps should occur quickly. If you are facilitating the stand-down but not delivering it personally, be sure to give a short deadline for its completion and mandate that all involved personnel are included. Keep documentation of attendance and subject matter for future reference.

Once the stand-down is completed, gather the documentation of attendance and any other associated information and keep it for your records. This does not end the stand-down, however. Make a plan and a schedule to follow-up on the safety issue. The plan may include daily or weekly checks to ensure new processes are being followed or that staff has understood the information completely.

Conducting a laboratory safety stand-down can seem difficult and time-consuming. It may interrupt the work you planned to do, and it may change your schedule for the next couple of days or weeks. While that may be inconvenient, remember that this course of action was chosen to help prevent harm to employees or patients, and that is what laboratory professionals are here to do.

During the week of May 2, 2016, OSHA called for a construction fall prevention safety stand-down. This was in response to a high number of preventable worker deaths due to falls on the job. What safety issues have you seen in your lab? Have you seen multiple needle sticks? What about slips, trips, and falls? If you notice a group of similar safety events, it may be time to conduct a safety stand-down. If you deliver the information, provide the education, and document the attendance of all affected staff, you will prevent further injury and continue to raise awareness in the lab of vital safety issues.

 

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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.

The Final Countdown

As June 1 rapidly approaches, I hear many questions about OSHA’s final deadline in its implementation of the Globally Harmonized System (GHS) for the classification and labeling of chemicals. For laboratories in the United States, this journey began in 2013 when the first training deadline arose. All employees who work with chemicals were required to have training on the changing chemical label elements and the updated and standardized Safety Data Sheets (SDS).

Helpful Hint: Neither you nor your staff should be writing or saying “Material Safety Data Sheet” or “MSDS.” Those are outdated terms and should no longer be used. Unlike the old versions, the new SDS are standardized with 16 uniform sections that are the same no matter which chemical manufacturer provides the information.

The 2013 GHS training provided a good amount of information, and it raised many questions. Will manufacturers really be using pictograms and signal words to identify hazards? Would they truly be able to make those changes by the next deadline dates? How does that affect secondary chemical container labeling? What about changes to the lab’s chemical hygiene plan and signage? It was a great deal to absorb and digest.

The year 2015 held within it two more deadlines that would affect all laboratories. First, chemical manufacturers would have to create only products which contained GHS-compliant labels, and they would have to produce only GHS-compliant SDS. OSHA realized that these manufacturers would have a substantial amount of non-compliant inventory at this point, so there was a six month period before the next requirement would be enforced. That meant these companies would have six months to continue delivering non-compliant chemicals and SDS to laboratories. The second deadline in 2015 was the cut-off period for these manufacturers. They would no longer be permitted to ship chemicals with non-compliant labels or SDS. The last deadline would also provide a six month gap. OSHA has given laboratories time to accept and use these chemicals with non-compliant labels.

Helpful Hint: Walk around your laboratory and look at all of your primary chemical container labels. If you find any that are not GHS-compliant, you need to remove them from your lab before June 1 of this year. OSHA does NOT allow the re-labeling of primary chemical containers.

The final GHS implementation deadline, June 1, 2016, requires that labs complete the updates of all workplace labels, Safety Data Sheets, and any hazard communication policies and procedures. The lab Chemical Hygiene Plan should be updated to include newer terminology and labeling instructions. The chemical inventory may need updating as well to include signal words or pictograms if used on that form. While this last deadline has an impact on primary chemical container labels, it does not need to affect secondary container labeling. OSHA does allow the continued use of NFPA or HMIS labels for secondary containers in the lab provided staff is trained on those hazard warning systems as well.

Helpful Hint: For consistency and better staff understanding, choose one labeling convention for secondary chemical containers in the lab. Using GHS and NFPA/HMIS may be confusing. Labeling is an important piece of hazard communication, and staff needs to be clear on what hazards they may be handling.

Some signs in the lab may need updating in certain areas. Buried in OSHA’s Formaldehyde Standard (1910.1048) is a GHS reference that points to a required wording change. If the formaldehyde warning sign is posted in your lab, the GHS implementation requires updated wording. The sign is required in labs where the formaldehyde concentration exceeds OSHA’s limits as detected via vapor badge monitoring. The updated signage must read as follows:

DANGER

FORMALDEHYDE

MAY CAUSE CANCER

CAUSES SKIN, EYE, AND RESPIRATORY IRRITATION

AUTHORIZED PERSONNEL ONLY

The full implementation of the Globally Harmonized System is here, and it is a modern system designed to adequately communicate hazards to those who work with chemicals. Many countries around the world have been or are in the process of adopting GHS, a system which provides standardized warnings and information. Once fully implemented in your laboratory, these updated chemical hygiene practices will assist in providing an environment for working with chemicals that is both comprehensible and safe.

 

Scungio 1

-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.

The “Safety Eyes” Epiphany

The manager walked into the lab to talk to Joan about the schedule. Joan was working with Mike, an older technologist who never seemed to follow the safety regulations of the laboratory. Joan was glad her manager was coming, because today Mike was wearing mesh sneakers and he was chewing gum! She couldn’t wait to see the manager chewing him out about that. However, the manager walked quickly to Joan, asked her a question and went immediately back to the office. She never said a word to Mike.

There are several things to be said about a scenario like this. First, why doesn’t Joan say something to Mike herself? Why doesn’t she feel empowered to speak up for safety? Has anyone ever taught her how to coach her peers for safety? Second, does the manager realize how much damage was just done to the lab’s safety culture? Intended or not, her ignoring Mike’s behavior is tantamount to permitting it, and therefore promoting it.

I was a laboratory manager before I became a Lab Safety Officer. When I moved to the safety role, I was lucky to have the previous safety officer still on site to provide orientation. As we walked through the labs, my predecessor noticed several safety issues and corrected them. I was very disheartened since I didn’t notice any of them myself. I wondered if I could do the job. Not long after that, I had a “safety epiphany.” I realized I could not see those safety issues because I had not trained myself to see them. I had not yet learned how to use my “Safety Eyes.”

Since then, I have been training lab people that “Safety Eyes” is a super-power that all laboratorians have. It is a latent ability and it must be honed in order for it to be effective. In order to do that, you need to know what to look for- be aware of the lab safety regulations so you can discern between right and wrong when it occurs. Next, you need to practice. That is the most effective development method for “Safety Eyes.” Knowing where to start can be difficult, so it is best to start by focusing on one safety topic at a time.

Begin by looking at Bloodborne Pathogens issues. For example, are people wearing correct PPE? Are waste receptacles properly labeled? Are spill kits in place and not expired? Next, look at chemical hygiene issues. Are secondary containers labeled correctly? Are acids and bases stored near the floor? There are a large variety of safety items under each topic that can be checked visually in the laboratory. Move to fire safety and on to other topics. Choose one area per week to start, and over time you will become proficient in spotting safety issues with your now-powerful “Safety Eyes.”

During the first year of my role as a Lab Safety Officer, I would become angry with the lab managers who didn’t seem to support the safety program- those who would walk through their labs and not see what I considered to be obvious safety issues. Then I had to remember my days as a manager- did I pay attention to those things? No, I didn’t. In part that was because I had so many things on my plate that I was focused elsewhere- just like the manager talking to Joan about the schedule. I also did not have any Safety Eyes training, so I simply wasn’t equipped to see all of the problems.

Today, I provide Safety Eyes training to lab managers. I use photographs of safety issues- pictures taken of real issues in the lab. Using these visual aids hones their ability to see the issues the next time they walk through the lab, and it raises safety awareness for everyone. If you lead a laboratory, and if you do not focus on safety, I understand that. However, you should understand that is important to make a change- develop those Safety Eyes and advance your safety culture in a way your staff can appreciate and support.

 

Scungio 1

-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.