Microbiology laboratories, by definition, are places full of bacteria, viruses, fungi, and other infectious organisms. What reduces risks in the lab and keeps the people and environment safe are a variety of protocols, stringent quality and safety measures, plus highly trained and knowledgeable staff.
Not all infectious organisms are treated the same and only certain types of laboratories are permitted to work on higher ‘risk group’ (RG) pathogens. For example, a Biosafety Level 3 (BSL-3) laboratory can handle bacteria like Mycobacterium tuberculosis or viruses such as SARS-CoV-2 (both RG-3 pathogens), whereas a BSL-2 laboratory (most hospital microbiology laboratories) cannot.
In a hospital microbiology laboratory, pathogens are often handled before their identity (and thus risk group category) is known. One example of an RG-3 organism that could be encountered is a bacteria called Brucella - the cause of the disease brucellosis - which is usually acquired through the consumption of unpasteurized dairy products. Brucellosis can be especially infectious to humans when grown in a laboratory as it can become aerosolized, with the potential to expose laboratory staff to infection and subsequent disease.
When an infectious agent of a higher risk group is suspected, there are procedures to minimize the risk of an exposure. However, the risks cannot be completely eliminated within clinical laboratories, so when an exposure does occur, an assessment process must be followed to document and report the exposure to the Public Health Agency of Canada (PHAC). When PGY4 Medical Microbiology resident, Dr. James Burns and PGY2 Clinical Microbiology Postdoctoral trainee, Dr. Joe Zeppa, were completing rotations through various hospital sites in the Greater Toronto Area, they noticed this procedure was not performed in a standardized way. They therefore sought to develop a project to improve the documentation and reporting of such incidents.
Burns was the on-call medical microbiology resident when there was a recent Brucella exposure; he was tasked with making the initial assessment. “I realized there was no real guidance – no document or template to help me compile my report. That initial documentation process is largely unstandardized, but the information that PHAC needs is very defined and specific. We realized that there was a similar experience at other hospital sites - there was a lack of structure in getting the information biosafety officers need to submit to PHAC”.
What makes the documentation process complicated is the number of people involved. From the laboratory manager to the microbiologist, the biosafety officer and occupational health, the gathering of information can be time-consuming. “If you don't have a regimented way of documenting this information and you're the person that's being contacted by PHAC without access to all the information, the process can be very difficult,” explains Zeppa.
Burns and Zeppa proposed this issue to be their Quality Improvement Project, something PGY4 residents and second year Postdoctoral Fellows complete together as part of the Co-learning Curriculum in Quality Improvement - integrated as part of their microbiology programs at the University of Toronto with Dr. Manal Tadros as their faculty supervisor. They were excited to be able to tackle a gap they had personally experienced across different hospital sites.
They worked with biosafety officers, laboratory managers and other key stakeholders to create a single, fillable document that collates the mandatory information in a logical, efficient way to meet the PHAC requirements. “We surveyed several hospitals, and the process was variable at all sites. Documentation is often being completed by people who have never dealt with an exposure before so the need for standardization was there,” explains Zeppa.
They took the form one step further. Not only does the form capture all the information needed from the parties concerned, but it includes a ‘line list’ template – a structured table documenting the individuals involved in the incident, a task occupational health would normally complete. “Even though occupational health would traditionally compile the line list, the information usually comes from the microbiologist or the lab manager so we thought it would be pragmatic to also provide a structure for that at this stage,” explains Burns. They have also included a summary of key evidence and guidance documents for the most common pathogens that may be implicated in a laboratory exposure. This aims to save time in making decisions on what action to take following an exposure such as providing post-exposure medications to affected staff to prevent infection.
Testing such an intervention is tricky given exposures are unpredictable and occur sporadically; they circumvented this by creating role-play scenarios they are testing with stakeholders who have experienced assessing exposures before. Their new proforma is currently being evaluated at SickKids (with Dr. Tadros as site supervisor) and Mount Sinai (with Dr. Susan Poutanen as site supervisor), and they hope it can be adopted by other hospitals once proven to be effective. So far, feedback has been extremely positive says Burns.
“The best-case scenario is that these exposures never happen, but when they do, we want to ensure that everyone involved can deal with it effectively and efficiently,” says Zeppa.
The LMP Quality Council: enhancing patient care and lead to the harmonization of quality indicators and critical values in clinical laboratories across the GTA.
