The Laboratorian - Volume 5, Issue 1

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The Laboratorian - Volume 5, Issue 1
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July 2013 - Volume 5, Issue 1

Article Index

- Specimen Acquisition
- NBS 50th Anniversary
- LRN: Texas Style

 

 

Editorial

Texas:  A Big State and a Big Responsibility

Once a month, I am asked to give an overview of what the Laboratory does at a new employee orientation for the division. Somehow our range of services has been boiled down to two slides, which just does not do the Lab justice.  So, I try to provide a “tour” of sorts by discussing what types of testing are done, floor by floor. I have given many tours of the Lab and it never fails that someone in the group says, “I never knew you did all of that,” or ”that is a lot of samples you get every day.” Texas is a big state and we have a lot of people to serve. All you have to do is stand on the first floor in the morning and you will see what I mean. The first floor is the doorway to the heart and soul of the Lab; everything that comes into the Lab is through the first floor – people, samples, supplies, etc. The first article highlights just what I mean.

DSHS is also very well known for our Newborn Screening Program. The Lab performs more newborn screening tests than any other state in the nation. We were fortunate to be asked to participate in a nationwide celebration of the 50th Anniversary of start of Newborn Screening. Read the article about how we celebrated and how the changes in our Newborn Screening Program have impacted the lives of Texans.

Of course you cannot talk about Texas without mentioning BBQ. Check out the story from a visitor to our great state who attended a conference at a dude ranch about the Texas Laboratory Response Network and left as a believer in the Texas way!

by Grace Kubin, PhD

 

Lab Tour: Specimen Acquisition

Check-In staff check that each specimen meets required acceptance criteria. Photo courtesy of Andrew Vinyard.

Comfortable shoes are important for Laboratory tour attendees. Specimen Acquisition – the first stop on tours – is spread out along much of the first floor and a portion of the second floor of the Laboratory building. The space is needed. “We process approximately 1.25 million specimens per year,” said Microbiology Check-In Group Manager Walter Douglass.

The Specimen Acquisition Branch (SAB), when fully staffed, has 45 employees. However, the SAB currently has fifteen vacancies. Despite the challenge of working short-staffed, the reason is a positive one. SAB employees have moved on to other positions in the Laboratory. “A good portion of the testing labs' employees get their start in Check-In,” said Douglass. Because turnover is high, the only way to get the job done is to cross-train all branch employees in other areas. “Movement of staff between areas is very fluid,” said Chemistry Check-In Group Manager Priscilla Gonzales. “This promotes teamwork and cohesiveness between groups, easing the burden of any group with co-workers who come to the rescue when you need it most.”

Check-In

Most specimens arrive at the Laboratory in the morning, between 7 and 11. Many of these specimens are picked up by someone from Check-In; a van goes to the bus station and post office almost every day of the year.

Handling packages can sometimes be challenging. Although most packages received at the bus station are small to medium in size, a few are exceedingly large. Most specimens/samples picked up at the bus station are properly packaged, but in some cases protocols are not followed.

Specimens arriving at the Laboratory.

Receiving an animal head for rabies testing can be quite unpleasant if the Styrofoam packer is leaking or has broken open completely. “Picking up a package with a glaring dog head staring back at you is not how you want to start your day,” said Gonzales. 

First rought sort of specimens. Photo courtesy of Andrew Vinyard.

Once in the Laboratory, packages are logged and a rough sort is done. Check-in staff make sure that specimens are kept and/or stored according to specimen criteria until the specimens are delivered to their respective laboratories, depending on the type of specimen received and the test requested. Specimen types include dry blood spots for newborn screens, serological specimens for the Texas Health Steps program, sputum (mostly) for tuberculosis specimens, water samples, food samples, reference bacteriological specimens, Clinical Chemistry specimens, and serological samples such as HIV and Syphilis.

Check-In staff check that each specimen meets required acceptance criteria and enter each specimen into the Laboratory Information Management System (LIMS) according to specimen test requests. Between 3 and 5pm, specimens are picked up or delivered to the testing areas.

Entering NBS specimens into LIMS. Photo courtesy of Andrew Vinyard.

Although most specimens received meet the acceptance criteria, sometimes a crucial component is missing. For example, a requisition form may arrive without a specimen or missing information needed for testing. We are all aware of how busy the day can be for nurses and clinic staff. One time, Special Chemistry staff called a submitter to get a missing date of collection for a specimen. In the course of the conversation, the staff member mentioned that another form was also received without a specimen and to expect an unsatisfactory report for that patient. The hurried nurse asked if she could fax in the specimen. She was so busy that it took her a while to realize what she was asking. “If only the laboratory had the technology to 'beam' specimens directly to the laboratory,” said Gonzales.

Check-In staff member checking specimens in serology. Photo courtesy of Andrew Vinyard.

It is fairly common for Check-In staff to find that the patient name on the specimen tube and the form do not match. “The submitter is sure it does match because they wrote it themselves,” said Specimen Acquisition Branch Manager Lisa Simpson. “When confronted with the realization that the specimens were incorrectly labeled they ask us to change the name because they know it is the correct tube for that patient.” That is against policy. The debate is resolved by faxing, to the submitter, a copy of the tube with the label visible.

Each day brings interesting challenges. Whole animals for rabies testing are not accepted (except for bats). One customer brought in a whole squirrel. The customer was informed that we cannot accept the whole animal with an added recommendation that he could take it to a vet or animal control facility to be processed. He was extremely angry and slammed out the door, cursing. “He came back a few minutes later with the head of the squirrel, after taking care of it himself in the parking lot,” said Simpson.

The work volume varies from day to day and can also be seasonal. Thus far in 2013, the Laboratory has received 409,488 Biochemistry and Genetics specimens (of which the largest component is newborn screens), 64,519 Microbiology specimens (ranging from consumables to tuberculosis blood cultures to parasitology samples and even bioterrorism suspects) and 13,491 Environmental Sciences specimens (including safe drinking water testing and radiation control).

Checking blood spot specimens. Photo courtesy of Andrew Vinyard.

Specimen volume was highest in January, mostly due to an increase in Newborn Screening specimens. Another increase in May was largely the result of higher numbers of serology and virology specimens.

Specimen Check-In is not without its humorous moments. One such involved a bloodspot card where the circles were filled in with a red Sharpie. The source turned out to be a child who was tired of doing finger sticks for Phenylketonuria (PKU) monitoring.

When there is an outbreak, laboratorians from throughout the Laboratory pitch in to help Check-In staff. During the H1N1 outbreak, help had to come from numerous areas of the Laboratory. “I remember it like it was yesterday,” said Team Lead Salvador Areola. “We were receiving over 1,000 specimens a day for about four or five days; that’s a big jump from just getting 5-10 a week. I was supposed to go on vacation that week, but postponed it because of all of the specimens that were coming in. As the Team Lead in [Check-In], I worked with my supervisors to create a mass triage workflow. Because of the specimen load, we had to cross-train people from other check-in and testing areas to help out. Between keeping cold specimens cold and frozen specimens frozen it was a little crazy. We were running out of freezers and trying to find space for them. I worked 10-11 hour days along with others in check-in, but we all pulled together and made sure all acceptable specimens were checked-in and sent to the Lab.”

Container Preparation

The Container Preparation (CP) Group is also a part of the Specimen Acquisition Branch. Visitors frequently ask, “Do you provide supplies for all testing done at the Austin and South Texas Laboratories?”

“No,” said Trevino. “The Container Preparation Group provides supplies to submitters sending in specimens for testing at the Austin Lab according to program guidelines.” The South Texas Laboratory supplies their submitters with what is needed for testing at that laboratory. Another common assumption is that the Container Preparation Group provides supplies for all tests conducted at the laboratory. This is also incorrect; materials for collecting many sample types are not provided by the DSHS Laboratory or programs.

A typical day for the CP group starts at 7:30am. Orders received after business hours and before staff start times are gathered, date stamped and separated into two groups:  Newborn Screening orders and regular orders such as Texas Health Steps, tuberculosis, ova and parasite, HIV/STD, GenProbes, bacteriological water, pertussis, influenza and food borne outbreaks. As orders are entered, staff ensure that supplies are being fulfilled according to program guidelines. Once this review is complete, air bills are generated and attached and logs are created to track orders through the process. Staff then work to fill and release orders. Simultaneously, cold boxes received with specimens have to be cleaned, processed and shipped back to the submitter. The cold boxes are used many times before they are replaced by the Container Preparation group once the integrity of the boxes are compromised. Orders and cold boxes need to be released and transported to the loading dock by 4:00pm to ensure pick up by the courier.

Preparing specimen container orders for shipment. Photo courtesy of Andrew Vinyard.

The Container Preparation Group usually processes 30 to 90 orders a day. Approximately 30 to 60 cold box returns also need to be processed daily. Ninety percent of the orders are received via fax, although they can be emailed or called in over the telephone. Newborn Screening (NBS) orders are the only exception to the rule. NBS orders must be faxed or scanned in and received via email because a signature must be obtained before the order can be processed.

Although normal operations are enough to keep staff busy, special events occur that CP must accommodate. “The initial flu supply send-out was one of them,” said Trevino. “It is critical for submitters to receive media and supplies that are going to be needed by submitters. It is a major coordination between the CP group and the Emerging and Acute Infectious Disease Branch.”

Refridgerating Environmental Chemistry Check-In specimens.

Specimens are submitted by hospitals, clinics, midwives, public health laboratories, the U.S. Food and Drug Administration (FDA), Texas rural water districts and Texas citizens. Submitters with questions about specimen types and testing criteria should refer to the Laboratory website, particularly the Manual of Reference Services (MRS) pages. The general public should contact their doctor.

“As you can see, Specimen Receiving Staff handle a variety of duties, from containers to specimens to supplies to shipping to customer service. I am very proud of the work my staff performs on a daily basis; everyone works together to get the job done,” said Simpson.

by Jimi Ripley-Black 

 

 

 

Celebrating the 50th Anniversary of Newborn Screening

NBS 50th anniverseary brown bag celebration

A ceremony was held in the DSHS Laboratory on May 14, 2013 to commemorate the 50th anniversary of Newborn Screening in the United States. This celebration was also the first of a Brown Bag Lunch series to be held at the Laboratory.

Attendees included laboratorians and Clinical Care Coordination personnel. They first viewed the Association of Public Health Laboratories (APHL) traveling Newborn Screening Display. Speakers then shared personal stories and knowledge about Newborn Screening (NBS).

Annalisa Clayborn, a parent advocate of newborn screening, told of her child’s diagnosis with a mild form of hemoglobin Sickle Cell disease through the Texas NBS Program. Additional stories were shared by Clinical Care Coordination nurses Paula Geurin, Daisy Johnson, and Julianna Ybarbo, and Public Health Technician Esmerelda Garcia who all work vigilantly with doctors and parents answering questions about disorders and screening results and quickly track down parents whose children have critical abnormal screening results.

Patty Hunt, from the NBS Laboratory, shared the history of the newborn screening program at the DSHS Laboratory – beginning with the first test for Phenylketonuria (PKU) through the 29 disorders currently tested – working toward the goal of testing all the disorders recommended on the uniform screening panel (a listing of tests recommended for all state programs by the US Department of Health and Human Services, Secretary’s Advisory Committee). Carl Danford, also from the NBS Laboratory, discussed two key founders of newborn screening in the United States, Dr. Brad Therrell and Dr. Harry Hannon, and their vision of expanding newborn screening worldwide. Salvador Arreola, Coordinator for the DSHS Statewide Courier Service, told how the courier service started in 2010 and is currently used by 410 hospitals and clinics. In particular, the courier program has decreased false positives, such as for Galactosemia, by facilitating timely testing.

On May 15, the APHL traveling NBS display was exhibited at the Bernstein building on the DSHS campus and, from May 16-18, at the Travis building downtown before it was displayed at the Texas State Capital from May 19-24.

Dr. Lakey and Dr. Tanksley talk in front of a NBS 50th Anniverseary poster displayed at the Capital celebration

A ceremony was held on May 19 to mark the arrival of the exhibit at the Texas State Capital. In attendance were families and children who have benefitted from the Texas NBS Program, along with legislators who support the importance of NBS. DSHS Commissioner Dr. David L. Lakey and Representative Crownover gave introductory remarks, followed by parents who spoke about NBS and how it has impacted their lives. To highlight a few: Lilliam Osowski, from the Houston area, has a son born with propionic acidemia. When her son was born Texas was not screening for this disorder.

Bill Morris, who lives in Canyon Lake, has a healthy 13-year-old son who was diagnosed at birth with polyketonuria. Sarah Lowry, from the Dallas area, has a daughter who was born with propionic academia. Testing was available at the time of her daughter’s birth so the condition was detected through NBS; she is healthy because of this. Trish Cook, who also lives in the Dallas area, is the mother of Maggie Grace, who has been featured on the Texas NBS poster and the APHL Public Health LabLog. Maggie Grace has isovaleric acidemia disorder that was detected by NBS.

NBS is a complex process involving many dedicated public health and health care workers who demonstrate a real passion for their work and its impact on improving the lives of our littlest Texans. It is fitting that we celebrate NBS, not only as we mark the 50th anniversary, but each and every day. NBS saves lives and improves the quality of life for both babies and their adoring families.

by Lucendra "Cindy" Corrigan

 

Representative Crownover speaks at the NBS 50th Anniversary Capital celebration

 

 

 

Laboratory Response Network: Texas Style

When was the last time you went on an evening hayride at a meeting, or had homemade barbecue brisket for dinner? If you’re part of the Texas Laboratory Response Network (LRN), it wasn’t that long ago.

Dallas County Police. Photo courtesy of the APHL.

 

Texans being Texans, this meeting doesn’t take place at some sterile airport hotel. As you might guess from the aforementioned hayrides and barbecue, this meeting was held at a dude ranch, specifically the Mayan Ranch of Bandera, TX. Far from being distracting, the relative isolation of the ranch completely cuts out the usual attrition to local tourist spots. And unlike meetings in big cities, the cost is low and there’s only one place (and time) for meals and limited activities for your evenings, so you end up spending a lot more time with your fellow attendees than you might otherwise.  It’s all Texas laboratory talk, all the time, and the end result is a lot more brainstorming than you often get at large meetings.

Like any state, the laboratories of Texas have some unique challenges and it was interesting to learn more about them. One issue that never occurred to me as a native New Englander was fertilizer control. Texas is a big agricultural state so there are plenty of farmers who need fertilizer for their soil, but it can also be used for bomb-making. To prevent this, the Texas State Chemist’s office has put some very strict controls in place to limit who can buy this fertilizer and in what quantities. Only certain dealers are allowed to sell it, and when they encounter any customer who seems suspicious, they can call the Chemist’s office to get a second opinion. Incidentally, the Texas State Chemist is authorized to make arrests.

LRN meetings. Photo courtesy of the APHL.

Another benefit to this meeting was that some of the lesser-known laboratories and agencies were able to re-introduce themselves to the rest of the network and emphasize the services and help they’re able to offer. In addition to the Texas State Chemist, we saw some great presentations from the Chemical Threat Laboratory for the Texas Department of State Health Services, as well as presenters from the nearby Brooke Army Medical Center, the National Guard 6th

Civil Support Team, and Texas-office FBI Weapons of Mass Destruction Coordinator. Turnover can be high in public health, so reminders like this are valuable to maintain current information and contacts.

Key takeaways from this meeting:

  • The LRN is strong across Texas with the Austin laboratory being a central resource
  • The LRN does more than terrorism preparedness – laboratories are actively engaged in influenza surveillance and other routine public health activities
  • Inexpensive in-person meetings in isolated locations are great ways to network
  • And things really are bigger in Texas!

Originally published in the APHL Public Health LabLog.

by Kara MacKeil, Associate Specialist, Public Health Preparedness and Response, APHL

 

Note: External links to other sites are intended to be informational and do not have the endorsement of the Texas Department of State Health Services. These sites may not be accessible to people with disabilities.

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THE LABORATORIAN
July 2013, Volume Five, Issue One                          (Publication #E14-13156)
Published by DSHS Laboratory Services Section
PO Box 149347, MC 1947
Austin, TX 78714

512 458 7318
888 963 7111, ext 7318 Toll Free
email The Laboratorian

 

LABORATORY DIRECTOR
Grace Kubin, PhD
512 458 7318
email Grace

NEWSLETTER EDITOR
Jimi Ripley-Black
512 458 7318, ext 6505
email Jimi

Last updated September 13, 2013