Unprecedented in our lifetimes, the COVID-19 pandemic has had far-reaching effects on the safe practice of laboratory medicine. Although incredible strides have been made in identifying this novel virus, much remains unknown regarding its makeup, mode(s) of transmission, and aspects of immune response, among others. However, as the pandemic evolves, new information is gained every day. Health agencies such as the World Health Organization (WHO), the US CDC, and the FDA have done their best to remain abreast of the virus and communicate essential emergency response guidance, but this continues to be an evolving and dynamic crisis.
In clinical laboratories, the rapidly changing influx of information regarding updated safety protocols has led to some confusion and concern for the health and well-being of lab staff. Compounding the matter, international shortages of personal protective equipment (PPE) and an overwhelming demand for new testing platforms and methods in multiple lab settings have exacerbated this confusion and these concerns. What PPE is needed specifically for suspected COVID specimen collection and testing? Is fit-testing still required? How should specimens be transported? These are just a few of the wide range of questions facing lab leadership today.
As necessity is the mother of invention, some laboratory leaders have been able to find successful solutions to novel safety issues while also allaying the fears and anxieties of their staff members in these uncertain times. Fortunately, there are a number of safety “hacks” which can work well during a crisis situation and several bridge-methods that can be utilized at other times to bolster laboratory safety.
Proper Specimen Handling & Transportation
In the first weeks of the COVID-19 pandemic in the US, fear began to run high in clinical laboratories. Every major news outlet ran non-stop stories regarding this virulent and incurable disease along with terrifying images of overwhelmed hospitals filled with isolated and dying patients. Naturally, among the initial concerns in hospital-based and stand-alone labs were safe, secure, and proper transportation of COVID-19-suspected patient specimens. Given the seemingly highly contagious nature of the disease, many wondered whether normal methods of specimen packaging and transport would suffice.
In an effort to provide clarity and guidance for clinical laboratories, the CDC began weekly Clinical Laboratory COVID-19 Response calls.1 Early on, the CDC recommended that all specimens (including blood and urine) from suspected COVID-19 patients be transported to the lab by hand; ie, pneumatic tube systems were not to be utilized. Within a couple weeks, the recommendation was changed to state that only respiratory samples should be manually transported to the lab; all other specimen types could be safely sent using a tube system if available.
With this type of shifting guidance, reminders about basic lab safety quickly gained in value. Clinical laboratorians handle bloodborne pathogens, microorganisms, and viruses every day as part of their jobs, and most are well-prepared to do so safely. That preparation includes a high degree of education on the nature of such organisms, in concert with the skilled use of engineering controls and safe work practices, including proper use of PPE. When facing unexpected and unknown organisms, be sure to fall back on established protection practices well-vetted in biosafety.
For example, while SARS-CoV-2 was a relatively new organism, it was known that it belonged to the coronavirus family, and many decisions could be safely made with that knowledge alone. The virus did not fall into the same class of high mortality infectious disease-causing agents such as Ebola, so safe transport of positive patient specimens should mimic that of most other lab specimens, even if the virus is present in blood and urine samples. Labs transport biohazardous specimens safely via the pneumatic tube system every day; specimens that contain many types of viruses including HIV and hepatitis, so there should be no reason to alter transport methods based on the presence of this new virus.
Regardless, unusual specimen transport practices were enacted at some facilities. Often, COVID-19 specimens were double-bagged before transport and many staff members donned specific gloves just to carry specimens down the hallways to the lab. Both actions are unnecessary, though, and potentially contribute to unsafe practices. Specimens collected in a primary container (like a blood collection tube or a swab holder) are required to be placed in a leak-proof secondary container for transport, and the outside of that secondary container (usually a plastic bag) should be considered clean. It should be transported without the use of gloves.
The safety element to remember here is that a new virus has no more ability to leap through a properly bagged specimen than any other microorganism. It is wasteful to use two bags and it will take more time to unbag a double-bagged specimen creating a delay. Using gloves to transport specimens in a hospital hallway sends the wrong message to others and using gloves to open and close lab doors becomes an issue as well. Lab staff enter the department with ungloved hands and they wash hands before leaving. Doorknobs should be considered clean by all staff and treated as such (assuming proper cleaning protocols are in place to begin with). Again, when one considers the basics of laboratory biosafety, containment, and specimen transport, sensible and safe decisions can be made even when handling new or unknown pathogens.2
New Laboratory Safety Practices
While the CDC’s Standard Precautions3 are used daily in laboratories to protect staff from infection and injury, many “normal” practices were called into question as the COVID-19 pandemic advanced. Questions I encountered included: Can hematology and pathology slides continue to be moved into clean areas? Can lab testing on COVID-19 patient samples be done without a BSC (biological safety cabinet)? Are staff surgical masks to be treated like other PPE?
In addition to the substantial disruptions to health care PPE supply chains, essential cleaning items and disinfectants became difficult to acquire and supplies could be backordered for months at a time. This forced laboratories that used commercially available disinfectant sprays or wipes to find viable and useful alternatives. In the search for disinfectants with efficacy against coronaviruses, the US Environmental Protection Agency (EPA) made available a list of disinfectants for use against SARS-CoV-2.4 Another option for disinfection is to employ what is considered the gold standard for use against bloodborne pathogens—a 10% bleach solution. For most, bleach remained available to purchase, so the seemingly old-fashioned disinfection method became new again.
Pathologists and related staff who harbored concern about exposure risk associated with the slides and other items being brought into their offices from labs also could use the EPA list for helpful agents. During the staining process, if the slides are fixed in certain listed ethanol products, viruses are inactivated, and therefore it becomes safe to transport slides into clean offices. Some laboratories added fixation steps, and others altered procedures such that all slides would be reviewed while remaining inside the laboratory only.
The CDC continues to provide COVID-19 biosafety guidance for routine lab testing, point-of-care testing, and operations in the anatomic pathology area.5 Whenever possible in the lab, procedures that create aerosols should be performed using a biological safety cabinet (BSC). There is no need to perform all COVID-19 testing steps inside a BSC; however, Standard Precautions and appropriate PPE must be utilized (as would always be expected when handling any other lab specimens). In the absence of a BSC, the CDC recommends that a surgical mask and a face shield be used if there is a risk of creating an aerosol.
The use of surgical masks while working in the lab has become a requirement in many facilities. While not exactly considered PPE, during the pandemic, these masks are being used to protect others from the wearer; to contain potentially contaminated droplets from being widely expelled. Normally, OSHA does not permit PPE that is used inside of a lab to be taken out of the department (eg, lab coats or gloves), but it is acceptable to leave the lab while wearing a surgical mask. In fact, many facilities require the use of masks in all areas.
Given the volume of change to lab practices, it is important to remain abreast of the available resources from various organizations, including the CDC, the FDA, and OSHA.6 Always be sure to clearly communicate to lab staff any process changes and alterations to lab safety measures. Providing information and explanations will help quell fears that may naturally arise during these chaotic times.
The Case of Autopsies
Given the shortages of various PPE, as well as other factors, many locations have reduced the number of autopsies being performed. However, certain autopsies must still be performed, and a few agencies have opted to continue those procedures as usual. Questions have arisen about safety in these settings, as given the high percentage of asymptomatic patients who may be infected with COVID-19, pathologists and dieners (morgue workers) are concerned about exposure in the autopsy suite. Among its vast safety guidance, the CDC made specific recommendations about how to handle autopsy cases as the pandemic progressed, although the guidance created some safety concerns for those who perform post-mortem duties.7
Remind those who work in autopsy areas that they need to continue to use Standard Precautions as always. Follow the CDC guidance, eliminate processes that create aerosols (such as the use of a bone saw), and limit the number of personnel who remain in the area during autopsy procedures. The CDC states that autopsy suites need to have a minimum of six air exchanges per hour, and that the space should have its air exhausted directly outside or through a high efficiency particulate aerosol (HEPA) filter. However, those requirements are not specific for working with COVID-19 patients. These are typical autopsy suite requirements, and while it is a good idea to review whether the area meets the standards in your facility, let your staff members know they can operate in the suite safely for any routine, potentially infectious autopsy case.
The safety of laboratory staff must remain a priority at all times, but during a crisis, we cannot lose sight of the tried and true safety practices that have protected lab workers for decades. Those Standard Precautions and safe work habits can provide a consistent level of safety for all who work in the department, no matter the circumstances. Make sure staff follow these precautions always and when unusual variables are introduced, such as new procedures, new testing, or changing uses of familiar PPE, they will be well-equipped with a knowledge base rooted in sound protection. The COVID-19 pandemic is no small event for laboratories, but with the use of some simple safety hacks (such as those found in FIGURE 1), staff can adjust to a new lab environment while remaining protected every day. Remind your staff that they work safely with dangerous pathogens routinely, provide clear and concise information when changes are made, and utilize the many resources and references that are available.
Daniel J. Scungio, MT(ASCP), SLS, CQA(ASQ), has over 25 years of experience as a certified medical technologist. He worked as a laboratory generalist in hospitals ranging from 75 to 800 beds before becoming a laboratory manager, a position in which he served for 10 years. Dan is now the laboratory safety officer for Sentara Healthcare, a system of more than seven hospitals and over 20 laboratories and draw sites in the Tidewater area of Virginia. As “Dan the Lab Safety Man,” he also serves as a professional speaker, trainer, and lab safety consultant. Dan received his BS in medical technology from the State University of New York at Buffalo.
Enter our Sweepstakes now for your chance to win the following prizes:
Just answer the following quick question for your chance to win:
Entries are limited to one entry per person in any active sweepstakes.
Thank you for your entry.