ASCLS Today Volume 34, Number 8

Constance Stager, MT(ASCP), ASCLS Region IX Director

The reliance on air travel for healthcare professionals in Southeast Alaska has added barriers to the already complex situation dealing with COVID-19. Photo credit: Steve Halama, Unslpash

We have all been impacted by this global pandemic, and Southeast Alaska is no exception. I am the director of laboratory services for two high-complexity laboratories, five moderate-complexity laboratories, and about 30 point of care (POC) sites in Southeast Alaska. These labs are physically distant, on separate islands; travel between the sites is accomplished by small plane or ferry service. This makes commuting to work, in an area about the size of Florida, a unique experience. On good weather days there are fabulous views of beautiful scenery and ice blue glaciers. Often though, travel is fraught with numerous weather delays, and I have had more than a few white-knuckle experiences due to a rough and bumpy ride in a seven-seat Cessna plane.

Challenges of Distant Communication

Due to our unique geography, the labs that I oversee are used to dealing with the challenges of distant communication. Many of our POC sites are in remote Alaska villages with a small clinic as the only healthcare serving the several hundred residents of that village and the surrounding area. Specimens from the village sites are flown to one of the larger sites to be run or processed for send-out to a reference lab. When the weather is bad, there are times when there is no travel in or out of the village for over a week. In-person travel and training are often not an option.

Despite these challenges, it is our mission to provide high quality healthcare and lab services to all patients, and we take pride in our ability to accomplish this goal. My staff and I have worked to implement cutting edge tools that allow even our most remote POC labs to be interfaced with our robust and dynamic laboratory information system (LIS), which has QC and maintenance function built in. My lab staff can oversee POC testing and review quality control from anywhere in the system. Use of these technologies has been vital to our ability to maintain the highest quality standards despite turnover of lab staff, use of locums, and POC testing without onsite laboratory oversight.

“Frequent communication has allowed us to relay changes concerning the ability to obtain supplies, changes in shipping, and other challenges affecting our ability to provide services, and has allowed us to meet the needs of our patients.”

The pandemic, though, has just added another layer of complexity. In March we began to find that not only did we have difficulty obtaining collection supplies that would allow us to collect COVID-19 specimens for send-out to our reference laboratory, but disruptions to flights coming from the lower 48 meant that we had difficulty obtaining basic laboratory supplies and difficulty shipping our specimens out for testing. Many of these issues are not unique to Alaska, but our reliance on air travel was certainly an added barrier. Flights in and out of the Alaska were curtailed as routes were reduced and even the small carriers with flights between villages were dramatically cut back leaving limited options and opportunity to fly specimens out for testing or get supplies in.

Rapid and Frequent Change

Like everyone else, we have had to adapt to a rapidly changing environment. It has been my experience that those that choose to enter the lab field do not, as a rule, like rapid change. Generally, laboratorians prefer to be methodical and take the time to carefully implement new instruments, procedures, and workflows after careful consideration. Dealing with this pandemic has turned much of that on its head. Laboratories have had to deal with rapid and frequent change just to stay current, and I am proud to say that I have seen my staff adapt, doing whatever is necessary to serve our patients.

Despite the challenges, and personnel shortages, we have implemented rapid testing in our village locations and new analyzers in our labs. We have relied heavily on the use of telecommunications tools to stay in touch with each other despite the distance, and we even have the employee who oversees our LIS working from her home in North Carolina. With video we have provided remote sites training on new instrumentation and overseen their quality using our LIS tools. Frequent communication has allowed us to relay changes concerning the ability to obtain supplies, changes in shipping, and other challenges affecting our ability to provide services, and has allowed us to meet the needs of our patients.

What will be next in this global pandemic and how it will affect all of us in the laboratory has yet to be seen. We are all preparing for the fall and the coming flu season. As we all know, most of us in the lab cannot work remotely and must come to work and process the samples and perform the testing to give the doctors the tools they need to save lives. The tools available to me as a manager have allowed me to direct the efforts of the lab heroes who come to work each day despite the risk and provide this vital service to our patients, even those in the most remote places.

Constance Stager is Director of Laboratory Services at the SouthEast Alaska Regional Health Consortium (SEARHC).

Ian Wallace, MLS(ASCP)^CM

Throughout our schooling, laboratory professionals are taught the importance of utilizing platelet and white blood cell (WBC) estimates to verify a potential analyzer error or an issue with the specimen tested. However, with how efficient analyzers have become, I have recognized that we repeatedly forget that estimates remain important—even if the analyzer is functioning correctly.

Take for instance, a 66-year-old male who came through the emergency department with a chief complaint of a headache. According to the patient’s wife, the male was consistently experiencing headache, fatigue, lethargy, decreased oral intake, dehydration, confusion, and felt “warm to the touch.” The patient stated he had a carcinoma removed a few weeks earlier and had symptoms “off and on” ever since. He visited an urgent care earlier in the week to discuss his symptoms, but nothing remarkable came back from his results. Patient admitted that he traveled a lot; he was not concerned that he encountered any insect bites, but he did have malaria when he was younger—from a visit to Africa. Now, you may think you know where this case is going, but I can assure you, you don’t.

Specimens received in the lab on this patient were a CBC, automated urinalysis, and a CMP. Of note, the patient had the following abnormal results:

While none of these values are critical, our hematology department has rules set in the middleware that are set to “flag” and reflex a slide review of any specimen that has a platelet count of <75 × 10³/μL. The operator alert translates to, “Thrombocytopenia: Clot check. Scan slide and perform PLT estimate if first time on admission and add comment.”

This is where the story and the importance of estimates becomes very significant. When the specimen came off the analyzer, I checked the tube for a clot, and nope, no clot present. So, the specimen is acceptable. Next, I slid a slide under the scope.

I was taught when doing any type of review, always be on the lookout for abnormalities, even if you are simply scanning a slide. As I scan my slide, I am looking and can definitely agree that this patient is thrombocytopenic. However, just as I’m about to result out the patient, something catches the periphery of my eye.

As I start to look more, I know I need to call pathology immediately. Pathology asks if I can send them pictures of what I see. I send them the following:

Click here for a high-resolution image.	Click here for a high-resolution image.

Pathology responded accordingly:

It was an incredible feeling to find Borrelia in a blood smear, especially as it had previously been missed since a slide review had never been performed. Even though we consulted infectious disease physicians, they never did decide to speciate the bug. However, the patient was placed on a 14-day dose of doxycycline and discharged the following morning.

Turns out, after some more investigation into the patient history, he lives on six acres in rural Colorado, which is most likely where they encountered the tick that bit him.

This case goes to show that even though we have become so accustomed to our top tier analyzers performing their jobs efficiently and effectively, they cannot identify everything. This further emphasizes the critical role we play as laboratory professionals in the healthcare setting.

Ian Wallace is a Medical Laboratory Scientist and Hematology Technical Specialist at Saint Joseph Hospital in Denver.

ASCLS is rolling out a new and improved Mentorship Program for the 2020-21 Society year. The program pairs up mentors and mentees for one year to create a supportive environment that fosters a feeling of belonging and value as a member of the ASCLS community. Participants will develop meaningful relationships with mentors to promote personal and professional growth within ASCLS and beyond.

New this year the mentor matching is now available all year round through ASCLS Connect, and mentors and mentees can self-select each other through an online process.

1. Interested participants, complete your member profile and mentor matching criteria.
2. Once your profile is completed, you may enroll to be a mentor, mentee, or both.
3. Once enrolled you may use the Mentor Directory to search for your potential mentor/mentee.
4. Click on the name of the member who you are interested in establishing a mentor/mentee connection with and view their profile.
5. If you think you’ve found a good match, look for the Mentor Match badge on their page to request a connection.
6. You will receive an optional Mentorship Program curriculum to guide your discussions and mentorship experience.
7. Additionally, special ASCLS Connect online communities will be available to you—one for mentors only, one for mentees only, and one for all program participants.

Mentorship is a win-win relationship that benefits both the mentee and mentor.

Benefits for Mentees:

• Increase your sense of belonging in the medical laboratory community
• Develop your professional skills, such as writing, scheduling, communication, and problem solving
• Enhance your leadership skills
• Expand your networking opportunities
• Have fun!

Benefits for Mentors:

• Improve your listening skills
• Learn new developments from your mentee
• Give back to the medical laboratory community
• Feel a sense of personal satisfaction

Find, connect, and share experiences with other medical laboratory scientists, while also growing professionally and personally.

Stacy E. Walz, PhD, MT(ASCP), ASCLS Patient Safety Committee Chair

Way back in the late 1990s, patient safety and medical errors were highlighted in a groundbreaking report entitled, “To Err Is Human,” followed quickly by another report entitled, “Crossing the Quality Chasm,” suggesting six aims for high quality healthcare. Those six aims—safety, effectiveness, efficiency, patient-centeredness, timeliness, and equity—became goals for healthcare facilities and professionals alike, but not overnight, and not evenly across regions or professions. In fact, the medical laboratory field remains in the fledgling stage of adoption and application of these aims, both in practice and in education.

But even in fields and regions where patient safety initiatives have made their way into education and practice, the United States is having only limited success in reducing medical errors and improving patient safety, even 20 years after the initial reports were published. To temper a “doom and gloom” statement like that, though, the definition of what constitutes a medical error has broadened, and improvements have been made in detecting them.

The experiences the U.S. healthcare system is having in the throes of this pandemic continue to highlight the importance of these fundamental aims and how they intersect with a public health response.

Safety

In a pandemic response, the focus is on a population of people and less on individuals. However, individual behaviors, health status, socioeconomic status, and a variety of other factors all impact the population. In an attempt to keep an entire population safe, public health officials ask individuals to employ strategies to reduce the spread of the organism, such as wearing masks in public and staying home if feeling ill. The strategies employed, unfortunately, are never 100 percent effective, and neither is the buy-in from all individuals in the community. It is virtually impossible to keep an entire population safe!

Patient-Centeredness

In a public health response, patient-centeredness almost goes out the window as we strive to set aside personal preferences and consider the bigger picture. When individuals present to the healthcare setting for diagnosis and treatment, of course they are evaluated as individual patients. But data collected from individuals in a pandemic is shared at a population level in an effort to learn more about the spread of the organism, the manifestation of the disease, procedures and medicines that work or don’t work, and risk profiles of those most gravely affected.

Effectiveness

With a novel organism, it is challenging to employ the most effective treatments or mitigation strategies because we haven’t yet learned what those are. From the public’s standpoint, what looks like confusion and conflicting information, is actually the scientific process happening in front of our very eyes. The quality aim of effectiveness is a huge challenge to achieve in this situation.

Efficiency and Timeliness

As everyone knows, the laboratory received a lot of press in regard to testing for the novel coronavirus. The challenges surrounding test methodologies, supply chain shortages, personnel shortages, and communication of test results with public health entities were played out in the public’s eye. Laboratory professionals were tasked with implementing new systems and new tests in rapid fashion, dealing with an enormous influx of specimens for testing, training staff to perform the tests, creating new lines of communication for public health reporting, and sometimes even getting involved in the mass collection of nasopharyngeal swab specimens. The quality aim of timeliness in turnaround of test results was impacted greatly in many settings. With some less sensitive and/or specific test methodologies and platforms being released quickly under the FDA’s Emergency Use Authorization, efficiency was negatively impacted as laboratories had to repeat testing using more accurate methods.

Equity

Last but not least, the pandemic has highlighted inequities in access to care, access to testing, and inability to undertake some of the measures recommended by the public health agencies (such as self-quarantining) to mitigate the spread of the virus.

Although the pandemic has disrupted virtually every aspect of life, guiding principles will be important in many areas as we move toward a new version of “normal.” If we keep the six aims in our sights, these concepts can provide guidance to keep us on track for a higher quality healthcare system.

Stacy Walz is Associate Professor and Chair of the Clinical Laboratory Science Department at Arkansas State University in Jonesboro.