Imagine the scenario:
It’s 9am and the Senior Biomedical Scientist knocks on your door “ummm the laboratory has inadvertently processed a tissue sample containing Brucella melitensis on the open bench!”
a) Close the door and pretend you didn’t hear?
b) Run screaming from the building?
c) Phone a friend or Ask the audience?
d) Or sit calmly and listen to the rest of the story whilst starting to plan what to do in your head…?
First steps - gather the facts
Has the lab really processed the microorganism of concern? Check the laboratory details, look at any clinical details for the patient and see if this is a likely diagnosis, is the lab identification good. Brucellosis is rare in the UK with about 10 cases a year diagnosed, usually in patients who acquired their infection overseas, so make sure the identification is correct before you start the ball rolling on a misidentified organism.
Ask the audience
If it all looks genuine then start to assemble a team to deal with the problem. In my experience this is not always the most senior lab manager, although they should be involved, but rather a couple of your most calm and common sense Band 7 Biomedical Scientists (BMS) or Clinical Scientists (CS).
Check if there is any known policy or procedure for how to deal with your situation
This is unlikely to be in your “go-to” HELP! hospital manual but a quick scan of the Internet will usually give you a clear and simple process from experts about how to deal with your problem.
Phone a friend
Think whether you ought to speak to someone outside of your organisation to get advice. In the Brucella example there is an excellent Public Health England guideline produced in conjunction with the Brucella Reference Unit (BRU) in Liverpool which tells you exactly what to do (there is even a staff information sheet as well!)… but if there wasn’t I would phone the Ref Lab anyway and ask them… they handle possible Brucella spp. every day and are likely to know what to do if something goes wrong.
Plan your response
Sit down with your team and decide who is going to do what. Think about who is best for doing each task, rather than thinking who is senior or who is responsible. For example, I would ask a respected and calm BMS or CS to start investigating who was exposed and how, and start to liaise with Occupational Health about what will need doing.
I would ask someone who is a good communicator to do the speaking to external agencies including the Trust Risk Department, Trust Senior Managers (Medical Director or Director of Nursing), Public Health England, Trust Health and Safety Manager, Reference Laboratories for further patient and staff testing (you usually need some form of incident number).
Who’s at Risk?
Don’t give the “risk stratification” to just one person, it’s probably the most stressful bit as you worry you might get it wrong, miss someone out, or end up making “everyone” high-risk starting a panic because you can’t make the distinction! Share the decision making.
For Brucella, staff are classified as high, low or no risk:
- Worked with a Brucella isolate in culture or within 5 feet of someone working with a Brucella isolate
- Sniffed or opened culture plate (DO NOT sniff any culture plate… EVER!)
- Mouth pipetted specimen material (NEVER DO THIS EITHER!!!)
- Not used Biological Safety Level 3 procedures to process sample
- Anyone in the room were an aerosol of the bacterium has been created (centrifuging without sealed carriers, vortexing or sonicating, spillages or splashes)
- Everyone else present in the lab at the time the Brucella isolate was being processed!
- Handling Brucella in a Class II safety cabinet using Biological Safety Level 3 precautions
- Handling request forms or unopened samples
- Processing samples in other pathology laboratories e.g. blood or urine, in biochemistry, haematology, blood sciences, serology, etc.
Arrange for any prophylaxis or testing of staff
Talk to other departments and ask for help with any medical assessment, prescribing or blood testing that may be required BEFORE doing it. The departments that might be able to help are Occupational Health, Emergency Department or Ambulatory Care Units. This is an extra burden of work for everyone concerned but in my experience these kinds of incidents bring out an amazing team spirit and everyone jumps through hoops to do whatever they can to make things as easy as possible for those exposed, as long as you ask nicely before sending 40 cases their way!
Talk to staff and provide written information about what is going on at a regular time interval. People normally only start to worry when they think there is something they are not being told… so tell them… Set up a “Incident - Communication Brief” document containing the things people might need to know or want answers to.
What actually is needed!?
For Brucella the high risk exposure staff need prophylactic antibiotics for 3 weeks (usually Doxycycline 100mg BD) as well as serum for Brucella serology immediately, at 6 weeks and at 24 weeks to look for evidence of infection (known as seroconversion because the person has converted their serum from showing “no evidence of infection” to showing “evidence of infection” through the production of antibodies).
Prophylaxis is very effective. Of 733 high risk exposed staff in the USA from 2008-2011 only 1 developed brucellosis, and they had started their prophylaxis very late (after 2 weeks). Everyone who started prophylaxis before this time was protected. Tell this to staff affected in the incident, it’s nice to be reassured.
Low risk staff require a baseline blood sample to be stored in case future tests are required.
The staff’s GPs should be made aware of the exposure in case of future problems. Both high and low risk staff are then made aware that if they develop symptoms potentially consistent with brucellosis then they need to let their Doctor know and further investigations and treatment can be arranged as appropriate.
The main symptoms and signs of brucellosis are:
- Loss of appetite and weight loss
- Fatigue (extreme tiredness)
- Back and joint pain
Brucellosis can also be asymptomatic hence the need to take blood samples from the high risk exposed staff.
Brucellosis is rarely fatal in humans, although some cases can lead to life-threatening infections such as endocarditis and meningitis, hence the reason why lab exposure is taken so seriously.
Breathe, take a medicinal cold beverage or cuppa tea and then breathe again!
Once the immediate dust has settled look into why the incident happened and see if there are any lessons that can be learned. What went well, what didn’t go so well. Use the Root Cause Analysis (RCA) process to see if there was anyway the incident should or could have been prevented and put systems in place to do this.
Keep talking to staff, don’t switch off after the incident has been dealt with as further questions and concerns may come to light e.g. could someone pass the infection on to their family when they went home after they were exposed, what happens if they don’t get on with their antibiotics, should they be excluded from work, etc. Add these questions and answers to the list of “things you might want to know” contained in your “Incident - Communication Brief” document. In case you’re wondering, no you won’t pass on Brucella if you have been exposed and then go home, there are alternative antibiotics to Doxycycline for post-exposure prophylaxis if required and sadly no you don’t get a long holiday just because you have been exposed to Brucella in the lab!
Experience from dealing with lab incidents
So what have I learned from dealing with lab incidents over the years?
- They usually occur because of poor communication e.g. failure to fill out request cards with clinical information such as the all-important travel history or exposure to animals, failing to alert lab staff internally about the risk of specific samples, or failure to tell lab staff when the clinical history has changed in relation to older samples
- They can be made worse by poor practice e.g. not complying with basic biological safety practices such as wearing gloves, using a Category 3 facility to process high risk samples, not cleaning up spillages properly and in accordance with standard operating policies
- It can be hard to keep track of who has been exposed e.g. who’s accessing your lab? Managers and visitors are often brought through laboratories as short cuts when they should take a longer but safer route to get where they are going. Or staff moving between benches frequently; this makes knowing their exact times within specific areas of the lab difficult
- Monitoring of staff for symptoms of infections e.g. fever, this can be even more problematic over winter as every time someone gets a cough or a cold you have to assume it might be the target infection…its stressful and a nightmare
- Immediately assemble a small team to manage the incident; calm and common sense are the ideal qualities
- Communicate as soon as possible with everyone who needs to be involved so that false rumours don’t take hold, both within the laboratory (an FAQ document can be helpful) as well as externally e.g. Trust Managers, Public Health England, Health and Safety Executive
- Gather information before making decisions; have all the facts, what is the exposure, what is the risk, who has been exposed and when?
- Ask for help e.g. from departmental and Trust Managers, Occupational Health staff, Emergency Department colleagues, etc.
- Laboratory staff almost never overreact to a situation; their calm and professional approach always make the situation much easier to handle, praise them for this!
Dealing with incidents and outbreaks can be stressful but it can also be very rewarding. Making sure you friends and colleagues are safe and that they feel safe makes a massive difference. So don’t shy away from these situations, tackle them head-on in a calm and common sense manner, but hopefully not too often… after all the best incident to deal with is the one that never actually happened.