Lab with Ebola experience: COVID more complicated

Anne Ford

August 2020—If there’s one thing scarier to experience than COVID-19, it’s Ebola. Or so you might think.

“Ebola was easier,” says Beverly Dickson, MD, medical director of the clinical laboratory at Texas Health Presbyterian Hospital Dallas.

Not that she herself has experienced shortness of breath or body aches. Rather, she’s contrasting her experiences at a hospital that has treated patients with Ebola and patients with COVID-19. How those events stack up from the laboratory’s point of view may yield helpful insights for others in this time of pandemic.

Texas Health Dallas in 2014 diagnosed and treated three patients with Ebola virus disease—a man who had recently arrived from Liberia (and who went on to die from the disease) and two Texas Health Dallas nurses involved in his care (who survived). It was the first time that a case of Ebola had been diagnosed in the United States.

Dr. Dickson and her team ran, and still run, the tertiary care laboratory in the 800+-bed hospital. The clinical lab has a main core laboratory, which is across the hall from the microbiology/molecular laboratory. “Like a lot of hospitals, the core laboratory does the bulk of the testing for the hospital and is a very large single room with lots of modular furniture and lots of instrumentation,” she says. “The microbiology lab is a much smaller space but has several rooms that are closed off from the rest of the lab for molecular and AFB/fungal testing. We have a negative-pressure room with a biosafety hood, and technologists who are accustomed to working with airborne isolation.”

As with COVID-19, the fear around Ebola was intense and widespread. “The only thing everybody knew about Ebola was that you get it and you die,” says Dr. Dickson, who spoke with CAP TODAY in May. “That’s one of the worst things about COVID now—all of the information that floats around on the internet and everywhere else. People talk to other people, and sometimes get the wrong idea about things.”

With both Ebola and COVID-19, Dr. Dickson and her team were able to strategically communicate in a way that minimized internal gossip and confusion. “Phone calls normally come to the lab, and client services answers the phone, or the central processing area answers the phone. But during Ebola and also with COVID, the group communicating information is a much tighter, smaller select group,” she says, “so that the information that goes out is always current and the best information at that point in time.

“One thing about COVID and Ebola is, things change every day,” she continues, “and sometimes a couple of times a day in a couple of hours. So it’s impossible for everybody in the whole laboratory to know what’s going on every moment of every day, and it’s confusing for them to keep getting new information. Having a core group who are the go-to people for questions and concerns is pretty important to the communication part, because communication with the other areas, whether it be pre-op or radiology or ED, needs to be correct all the time.”

Having a tight team at a supervisory level meet daily has an additional benefit, Dr. Dickson says: “When you use a really small team, that team becomes very engaged with the small teams in the different areas of the hospital. So the ICU team and the lab team now know each other very well and work well together.”

Looking back at her experience with Ebola, Dr. Dickson also thinks it was helpful to regularly offer her laboratory staff a chance to ask her questions directly. “Everybody would gather around and we would talk,” she remembers. For instance, a team member might ask, “Will the decontamination that’s set up in the instruments kill Ebola?” This gave Dr. Dickson the chance to discuss the differences between enveloped and non-enveloped viruses and the substance the instruments used for decontamination, and provide scientific answers to staff concerns.

Or, with the COVID-19 pandemic, the phlebotomy staff members might express concern about their own safety. One has to be transparent, provide information that is known, but sometimes Dr. Dickson’s answer was or is, “I don’t know. I don’t know if anybody knows.” But, she says, these kinds of conversations go “a long way to letting them know that, A, you’re thinking about their safety, and B, you thought through the process. It stops the rumor mill.”

Another lesson from Texas Health Dallas’ Ebola experience that has come in handy during the time of COVID-19 involves the way the laboratory creates and implements protocols. Many protocols followed the arrival of Ebola, and those protocols evolved as the CDC issued new information, as do COVID protocols and processes.

With Ebola patients the daily timing of testing was controlled to mitigate exposures of staff to Ebola specimens. Administrative controls minimized the number of workers exposed to Ebola samples. If a person under investigation for Ebola came to the emergency department, the nurses were provided with a written set of instructions so that “there was no question in their mind what tests they were allowed to order and what types of tubes needed to be drawn,” Dr. Dickson says. “That way, they could take care of everything at one time and would not have to put on high-level PPE over and over and go back and forth and in and out of the room.” Once the nurses had bleach-wiped and bagged a specimen multiple times in series, laboratory staff would bring a biosafe transport container to the ED and have the nurses drop the specimen into the container, without lab staff having to enter the hot or warm zones.

“As far as the specimens that did not go on the robotic line, those specimens—mostly green-top heparinized tubes and EDTA tubes—could be opened in the core laboratory under a biosafety hood if needed,” Dr. Dickson recalls. “But most of our testing was done on the [robotic] line, so we were semi-protected from open tube exposure.” At the beginning, they put the tubes on the line and let the line de-cap them and spin them. “That process seemed safer,” she says, “but a centrifuge accident could have been a huge problem.” Once they got rotor caps in the core laboratory, they started spinning them all off-line and in a capped centrifuge. “We’d never really had a use for a capped centrifuge in the core lab until Ebola. So we were basically able to do whatever testing could be performed by the instruments on the line, which were duplicate Abbott Architects, both the chemistry and the immunochemistry sides.”

“Then CBC-wise, we had a Sysmex, and we provided clinicians with the CBC results but no differential slide was prepared,” she continues. “We didn’t allow the Sysmex to make a slide, since that process was thought to possibly cause aerosolization. There is a fan inside the Sysmex that dries the instrument prepared slide, so we kept test results limited to just a straight wet CBC. Coag testing we couldn’t really do, because we had an open tube system, but we had an i-Stat that we used to do a PT if it was necessary.”