Spring 2020 | Vol

Official publication of:

PM #40063021 Spring 2020 | Vol. 82, No. 1

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©Roche 2020 CONTENTS

IN FOCUS COVER STORY SOCIETY NEWS

4 19 35 Message from the Automation and the Computer-Based Testing at CSMLS Chief Executive Officer Re-Imagined Future eNEWS by Aliza Prodaniuk 4 2019 Annual Report Message from the President National Volunteer Week April 19–25

5 36 Walking You Through an 2019 CSMLS Lab Tours Accreditation Visit: How to Prepare for Success by Mike Halpenny

37 National Medical Laboratory Week 2020 April 26–May 2 8 Building a Culture of Resource Stewardship at Bluewater Health COMMUNITY by Amanda VanSpronsen 23 Inspiring the Future Around 10 the Globe: International Get the Picture? Founders’ Fund Troubleshooting CBC Result Patterns Notice to Members: by Nadine Roussy Annual General Meeting

38 National Voice 2020 Adopt-A-Donor Centre

24 Newly Certified Members in 2019 12 “Now What?” 5 Ways to Create SCIENTIFIC the Right Career 29 Opportunities for You Arterial Blood Gas Accuracy: by Andrea Livingstone Should plastic syringes be transported at room temperature 14 or on ice? Speaking Up for Safety Rapid Review by Eoin O'Grady by Micayla N. Matthews ENGLISH EDITION | SPRING 2020

csmls.org 3 MESSAGE FROM THE MESSAGE FROM CHIEF EXECUTIVE OFFICER THE PRESIDENT

Call to Action — Everyone Is an The Time is Now Advocate

wo years ago, CSMLS issued have been a member of the CSMLS a Call to Action (CTA) to for over 36 years, but it feels like I address the national, regional, graduated from the MLT program Timmediate and long-term efforts Iand successfully wrote my CSMLS required to change the health human exam yesterday. My beginnings into this resource (HHR) shortage of medical profession started out like many others, laboratory technologists (MLTs) however, you never know where this within Canada. In this midst of a global career will take you. I’m honoured to be pandemic, we are seeing the effects writing this message as President of the of the shortages and how it impacts Christine Nielsen national society for my profession. I take Nancy Bergeron CHIEF EXECUTIVE 2020 CSMLS patient care. Now more than ever, we OFFICER this role very seriously and understand PRESIDENT need a united effort on finding solutions the unique privilege I have in this for this issue. position. I know that I am your voice for the next year. For those who may not remember, the CTA came in response In the past few months since officially taking over the to multiple governments’ inaction regarding the MLT labour presidential title, I’ve been doing some thinking about what I want shortage crisis. The problem is that without a national effort to to accomplish throughout this year. But in my thinking, I’ve come change our profession's situation, lab professionals will continue to realize that many of the accomplishments I am planning could to experience challenges with workload, burnout and succession be done even if I wasn’t president. Yes, in this role I am representing planning in the workplace. While automation and amalgamation the more than 14,000 CSMLS members, plus the thousands more may help alleviate some of the pressure, the problem will not within the profession across the country — but so are you. disappear unless something is done. You are just as much of an advocate for the entire membership The Call to Action works on a national level and focuses on and the profession as I am. That’s a lot of responsibility to carry, several ways medical laboratory stakeholders can contribute. but it means that you are in control of how the world sees the This multi-pronged approach helps to address several potential medical laboratory profession. In the past few months, our solutions from educators, employers and policy-makers. For profession has had a spotlight on us and our work. Being central example, to alleviate the bottleneck caused by transitioning to the COVID-19 solution has earned us a platform. Whether you students into the workplace, we have to move to support the like it or not, your actions, words and behaviours are reflective creation of the 400 additional student seats per year needed to of the profession. Give some thought as to how you would like close the gap between the number of retiring MLPs and those to be seen as a professional. What are some of the characteristics entering the workforce. you believe should be attached to your work? What would you The problem with these kinds of initiatives is that real change like medical laboratory professionals to be seen as? Dedicated? takes time. But, I want to assure you that there has been progress. Problem-solvers? Knowledgeable? Generous? Caring? Do any of As of now, one-tenth of the seats have been created, including 24 these strike a chord with you? to 32 new positions as part of a new private program that opened Now, give some thought to how you, as a person and as a in 2019, and 10 to 12 government-requested seats. And this is just professional, present yourself to the world. Would you use the the beginning, as we have not been idle. Many new initiatives are same words? Are you embodying the characteristics that you in the works that will push us towards our goal. Some positive want the rest of the world to know you and your profession by? If changes we have been working on so far include pilot studies to there is a disconnect, perhaps this is a good time to readjust. Once reduce clinical hours, such as the creation of a guide for simulation- you feel you are in sync, or if you are already, that’s great! Now, based testing that helps educators reduce the number of clinical you can lead by example to help your colleagues exude positive placement hours needed. We have also been working to create professional behaviours. a more open dialogue with provincial decision-makers amid the The CSMLS is here to support you and advocate on your behalf, rising trend of centralization so that medical lab professionals especially during Lab Week, where we work together to put a are part of the conversations on change. There are many more spotlight on the lab. But it’s important to remember that you have changes ahead. Our commitment is to keep you updated on all our the power to be an advocate for yourself and your colleagues every initiatives and developments through our website and eNEWS. day, not just for one week of the year.

4 CJMLS Spring 2020

IN FOCUS

EDITORIAL AND BUSINESS OFFICE 33 Wellington Street North Hamilton, ON L8R 1M7 Phone: 905-528-8642 Fax: 905-528-4968 Email: [email protected] Editorial Team Cathy Bouwers Walking You Through Michael Grant Christine Nielsen Scientific Editor Denise Evanovitch an Accreditation Visit: Contributors Mike Halpenny Andrea Livingstone Micayla N. Matthews How to Prepare for Success Eoin O'Grady Aliza Prodaniuk Nadine Roussy Amanda VanSpronsen

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Dovetail Communications Inc. 30 East Beaver Creek Road, Suite 202, Richmond Hill, ON Canada L4B 1J2 Phone: 905-886-6640 www.dvtail.com

Managing Editor Popi Bowman Assistant Editor Jana Manolakos Art Director Katrina Teimo Graphic Designer Charlene Everest Associate Publisher Chris Forbes Director, Sales Operations Beth Kukkonen he preparation for accreditation inspections and the overall accreditation process Production Manager Crystal Himes can be both stressful and labour intensive, especially for initial accreditation. Dovetail Communications With time and experience, the goal is to get to a model where inspectors can show Susan A. Browne, President Tup anytime; you should always be in a current “inspector friendly” state of operations. I have been working in the cellular therapy field for over 25 years, starting my career in a research setting and progressing to working in a regulated manufacturing environment. PUBLISHER’S STATEMENT AND POLICY As with all other areas of medical laboratory science, cellular therapy has been a rapidly The editorial team determines and edits content for the Canadian Journal of Medical Laboratory Science. Contributors evolving field, with accreditation standards developing alongside it. In 2010, I was recruited include staff, partners and CSMLS members. Although to oversee the design, development, validation and implementation of the manufacturing CSMLS encourages the sharing of various opinions and perspectives in an effort to promote thoughtful discourse, process for the Canadian Blood Services’ Cord Blood Bank. Currently, our laboratory, or contributors’ views do not necessarily reflect the views of more accurately our manufacturing environment, is accredited by both AABB (American the Society. We reserve the right to edit all submissions for Association of Blood Banks) and FACT (Foundation for the Accreditation of Cellular length and clarity. Contents may be reproduced only with permission. Therapy). In addition, I am currently a volunteer FACT inspector. With my experience Scientific papers are accepted by the Canadian Journal of on both sides of the inspection process, I’d like to share some common good practices I Medical Laboratory Science on the understanding that they have learned so that you can be better prepared for accreditation inspection. have not been published elsewhere. One of the first steps in preparing for any accreditation visit is to assemble a The Journal is a quarterly publication and is owned and knowledgeable, motivated team that understands the standards and accreditation process. published by the Canadian Society for Medical Laboratory Science (CSMLS). Canada Post Publications Mail Agreement Since some responsibilities may be delegated to achieve the overall goal of accreditation, #40063021. you will want to be confident in your team. For subscription information contact [email protected]. Next, you will need to perform a detailed self-assessment or gap assessment of your Advertising inquiries can be sent to [email protected]. current work instructions and processes to identify gaps or non-compliances with each RETURN POSTAGE GUARANTEED of the specific standards. With this assessment, work instructions and processes may

ISSN 1207-5833 need to be developed and implemented to obtain a compliant state with standards. Many Printed in Canada

csmls.org 5 IN FOCUS

accrediting bodies will have helpful hints or supporting documents that you can use to assist with this accreditation activity, so look for resources to help guide you through your assessment. This self-assessment and document development will be critical in the accreditation application process, as most accrediting bodies will require a document submission as a pre-accreditation visit activity. Once the submitted application has received final approval, with all submission documents received and reviewed by the accrediting body, inspectors will be assigned and a mutually agreed upon date will be set for the on-site inspection. Make sure you be available to answer questions during the lot release, staff training and competency have adequate space and key staff on hand to tour. But remember inspection etiquette: records. spend time with the inspectors on this date. Be specific with answers, no reason to add At the end of the inspection process, The inspection process usually begins additional information unless requested. there is usually an exit interview. At this with an initial overview meeting. At this Following the facility tour, the inspection point, inspectors provide an overview of any meeting, be prepared to demonstrate both will focus on two main areas. The first deficiencies and observations that were noted support for your program and respect for is the observation of front-line staff during the inspection. The exit interview the inspection process. Showing that your performing operational activities. Observing gives the facility the opportunity to address team made significant effort before the day staff performing activities is critical inspector findings. It should be noted that of inspection, and having everyone on board to demonstrating current compliance. inspector findings at this point are just that for the initial meeting to greet inspectors, Ensuring staff are following existing work — the inspector’s interpretation of non- is a great way to demonstrate this required instructions will be a focus. The second main conformances. Inspectors will then typically support. Create a short presentation for the focus, and the majority of the inspection present the findings to an accreditation board inspectors to provide an overview of your process, is on documentation review. Have a that will determine the final accreditation program, staffing structure, quality program designated space for the inspector to spend report based on all submitted documents and facility. time reviewing documents, preferably with and the on-site inspection report. After the initial meeting, a facility tour internet access as accrediting bodies now Although accreditation is a significant is usually performed. Inspectors will expect have electronic documentation systems. amount of work, I believe it is well worth the opportunity to see your workspace and From my experience, the documentation the investment. An accredited facility ask specific questions related to compliance review consists of a standards checklist, and has demonstrated itself to be a quality with standards. Although inspectors have all standards must receive some sort of review organization, dedicated to performing reviewed the documents you submitted through documentation or observation. quality laboratory practices and providing before the inspection, visual inspection allows As the inspector completes the inspection an elevated level of patient care. I hope the you to demonstrate standards compliance, checklist, it is important to have documents practices I’ve shared help prepare you for verifying that what you submitted is readily available for review. Marking or successful accreditation of your facility. implemented into operations. For the initial flagging your documents to demonstrate Through accreditation, we all play a role in tour, expect a review of the operational specific standard compliance and having upholding the standards of our profession workspace, including product and sample them available will be very useful at the time and ensuring excellent patient care. storage areas, critical supply inventory, of inspection. For example, an inspector documentation of cleaning, adequate facility might ask for all the related documentation MIKE HALPENNY, MLT space and staffing, alarm systems and any associated with the previously performed Manager, Cord Blood Bank and other specific safety requirements. This is operational review of front-line staff Stem Cell Manufacturing for why a knowledgeable person should be performing procedures. These documents the Canadian Blood Services with the inspectors at all times. Staff should would include equipment records, reagent

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Building a Culture of Resource Stewardship at Bluewater Health

The University of Alberta and the CSMLS have been collaborating on a project called Lab Wisely to explore medical laboratory professional (MLP) involvement in initiatives to improve the utilization of health care resources. Our activities to date include the formation of an expert panel to develop recommendations and a national survey, select statistics from which you will find in our new article series.

This article is the first in a Lab Wisely series that highlights laboratory utilization projects across Canada. In this article, we outline our conversation with Debbie Croteau, medical laboratory technologist (MLT) and Director of Diagnostic Services at Bluewater Health in Sarnia, Ontario, to learn about the success of Choosing Wisely initiatives at Bluewater Health.

HOW IT ALL STARTED n 2015, Debbie Croteau and a small group of colleagues from the physicians consider removing the “hard check” (the automatic Bluewater Health took a leadership course through the World ordering option) for these tests on their order sets? By priming the Health Innovation Network. They were challenged to find doctors with evidence about the potential for overuse, physicians Ia project for the course, so the group chose to focus on Choosing were more open to reconsidering their practices. As a result, the “Top Wisely Canada. They wondered how it could be put into effect at their 7” tests were unbundled from many order sets, and testing dropped institution, and this led to the development of the Choosing Wisely dramatically. Serum folate testing alone dropped by about 94 percent, Committee at their 300-bed hospital in Sarnia, Ontario. Four years and BUN testing dropped by 74 percent. Credit for the success, says later, they now have an expanded, engaged and diverse committee, Debbie, goes to Choosing Wisely Canada for making high-quality, along with a list of successful initiatives that have improved the credible evidence readily available for distribution. appropriateness of care in their institution. It is well known that some laboratory tests are prone to PHYSICIAN ENGAGEMENT inappropriate use, and many institutions are trying to tackle Though a team approach to address overtesting is important, overtesting — an issue that became Debbie’s focus. Debbie and her gaining physician buy-in and participation is critical due to their colleagues drew inspiration from Toronto’s North York General influence and role in test ordering. In addition to filling physician Hospital, which addressed high-volume testing and found success committee positions, such as committee chair, something that after they focused on reducing requests for ten specific tests. At the staff at Bluewater Health focused on was providing venues for Bluewater Health, they decided to focus on their “Top 7” lab tests, physician peer-to-peer interaction. Debbie described a time when targeted for improved utilization: blood urea nitrogen (BUN), the committee presented Choosing Wisely recommendations about aspartate aminotransferase (AST), thyroid stimulating hormone blood transfusion to surgeons and anesthesiologists. They noticed (TSH), erythrocyte sedimentation rate (ESR), serum folate, creatine that by allowing open discussion time, the physicians began to kinase (CK) and urine cultures. Many of these low-value lab tests compare practices while sifting through the evidence, helping one existed on prearranged test bundles that were automatically ordered another understand how to implement the new recommendations. together. A year later, ordering single units of blood, as opposed to habitually ordering multiple units, had become second nature. WHAT HAPPENED The physicians have also been engaged in other ways. They are The committee approached the issue by first providing physicians encouraged to create “tips of the month” that are circulated broadly, with evidence about test misutilization before shifting to more specific and they deliver presentations about improving resource utilization Bluewater Health objectives. Then, they made a clear request: Would to other health care professionals, such as physiotherapists and

8 CJMLS Spring 2020 chiropractors. By putting Choosing Wisely on as many agendas as ADVICE FOR MLTs AND MLAs possible, it is becoming part of the culture of the organization. Debbie acknowledges that she is often the sole representative of the lab on the Choosing Wisely Committee. Shiftwork can make VALUE FOR MONEY it difficult to attend regular meetings, so ensuring the lab has a Much like creating a brand, making key messages clear can be helpful voice requires intention. While in the lab, team huddles to discuss when you are trying to get buy-in. The message that Bluewater Health’s utilization initiatives are vital, as MLTs and medical laboratory Choosing Wisely Committee wanted to convey was that it wasn’t just assistants (MLAs) can offer insight and feedback into ordering and about saving money. It was about improving care and doing “what testing patterns. was best for the patient,” as Debbie states. While a full cost analysis Being aware of local initiatives may reveal opportunities for wasn’t performed, approximately $50,000 per year was saved just on lab professionals to support work that is already going on. Data laboratory testing by modifying the order sets. This also provided an collection and analysis is always important to ongoing efforts, and opportunity — the savings were put towards higher-value tests that falls within the skill sets of many lab professionals. At Bluewater physicians requested, such as brain natriuretic peptide (BNP). The Health, the contribution of one of the MLAs who initially helped opportunity to tell stories like this went a long way in gaining vital with collecting data on transfusion practices was so valuable that the support from upper administration. activity is now a protected part of her job. For one half-day every month, she compiles and analyzes data to support the sustainability THOUGHTFUL COMMITTEE COMPOSITION of the utilization initiatives. Debbie also stresses that it’s important Another component of success was the effort to expand beyond the to be aware of broader campaigns and recommendations, as well as four founding members of the Choosing Wisely Committee. They the evidence supporting best practices in utilization guidelines. By sought to diversify in order to bring in new perspectives. In addition having this knowledge, MLTs and MLAs are better prepared to raise to a variety of health professionals, the committee now has business questions about the ordering practices that they are observing. directors, communications specialists and a patient experience advocate. Subject matter experts are often included for short stints KEY TAKEAWAYS on specialized projects, such as the Charge MLT for blood banks Much can be learned from the Choosing Wisely story at Bluewater when the committee addressed transfusion recommendations. The Health. Factors contributing to their success include sharing committee also includes many physicians for short-term efforts. By available evidence in thoughtful and diverse ways, engaging encouraging brief but intense participation times, the committee can physicians, focusing on meaningful outcomes beyond cost savings, gain insight from relevant voices as well as capitalize on energy and being intentional and proactive about committee membership and momentum before it wanes. harnessing existing strengths of the health care team. Laboratory professionals can and do have a role to play in realizing the more efficient use of health care resources, particularly if they According to our national Lab Wisely survey, express interest and secure the lab’s role in implementing solutions ONLY inspired by Choosing Wisely. Does your institution have a Choosing Wisely Committee? Do you have a venue to talk about laboratory 9.6% 34.3% test utilization issues? Ask around and see — you might become of MLPs reported that reported having conversations instrumental in building a culture of laboratory resource stewardship they had an opportunity about improving resource where you work! to participate in a task utilization with other health force or committee. care providers.

61% of MLPs feel a sense of accountability to help improve the appropriateness of laboratory utilization. AMANDA VANSPRONSEN MSc, BSc (MLS), MLT PhD Student, 71.6% feel that MLPs have an important role to play. University of Alberta

csmls.org 9 IN FOCUS

Get the Picture? Troubleshooting CBC Result Patterns

hen doctors receive laboratory results, accuracy is including lipemia, icterus, hemolysis, abnormal proteins, and certain critical to the diagnosis, treatment and monitoring of medications. In this case, a plasma replacement procedure will disease. Physicians and other health care providers rely remove the interfering substance along with the additional colour Won the lab to provide the correct result for each sample submitted. picked up by the analyzer. In lipemic samples where the patient As laboratory technologists, we must do everything in our power has hyperlipemia syndrome or dislipemia, multiple replacements to ensure that this is the case. When analyzing a complete blood may be necessary in order to get accurate results. To replace the count (CBC), many problematic samples follow a known pattern plasma, spin down an aliquot of whole blood and remove a precisely which can be dealt with using simple additional manipulations. measured amount of plasma with a pipette. Always leave a tiny We need to be aware of these patterns and have alerts built into our amount of plasma atop the white blood cells and platelets. Then, add analysis equipment to let us know when there’s a problem. Once a diluting fluid in the exact amount of the plasma that was removed, an issue has been detected, recognizing the pattern will dictate our and mix thoroughly. The sample in this case required six rounds of next steps. These usually include pre-warming the sample, doing a replacement before accurate results were obtained, though samples plasma replacement, a manual spun hematocrit, a 1 in 5 dilution or can be checked after a single replacement to see if the H&H fail is a combination of several of these. Let’s look at a few cases where an gone. unusual pattern leads to additional manipulations. Case 2: A multiple Case 1: Dislipemia leads to an interfering myeloma results in a substance in the sample less obvious interfering substance In this case, the initial run of the blood sample shows high Hgb, high MCH, high MCHC, and hemoglobin and hematocrit (H&H) check Not all interfering substances are as failure, with the differential voted out. obvious as what we see in the case This pattern points to an interfering above. In Case 1, the initial run had substance of some sort. Reading high MCH and high MCHC, with hemoglobin relies on the absorbance a slightly lowered Hgb and an H&H of light, so the analyzer is looking for check fail. Once the sample was spun colour, and any additional colour, down, it looked normal, but a plasma even if it comes from the plasma, will replacement was still performed due increase this reading. The indices we to the unusual pattern of results. receive are calculated parameters, Once the plasma was replaced, the so these will show an even more H&H check fail went away. The smear pronounced increase. The patient’s appeared much shorter than usual Top: The protein has picked up RBC is normal, which is why we get the and picked up a lot of blue stain, a blue tint and gives the red H&H fail — the numbers don’t make which could also be seen under the blood cells a shiny appearance. Bottom: The abnormal smear sense. There are a number of possible microscope. has picked up more blue stain substances and conditions that may In Case 2, the interfering substance and is shorter than the normal Lipemic blood sample interfere with the Hgb measurement, is an abnormal protein. During the smear above

10 CJMLS Spring 2020 Learn More Visit webinars.csmls.org to watch Nadine Roussy’s webinar “Get the picture? Troubleshooting classic and not so classic CBC result patterns” to learn more and earn PEP hours. When analyzing a complete blood count (CBC), many problematic samples follow a known pattern which can be dealt with using simple additional manipulations. plasma replacement, the protein isn’t visible in the plasma on the spun for Auer rods. Their presence indicates a aliquot, but there are clues to be found. Viewed under the microscope, myeloid rather than a lymphoid leukemia, the protein seems to be coating all the red blood cells, giving them a though not all myeloid leukemias present shiny appearance. You can also see a marked rouleaux formation. If with them. If you see multiple Auer rods you look very closely at the smear, you may find circulating plasma within a cell, these are called “faggot cells. These are all clues that this might be a multiple myeloma. In cells,” named after their resemblance to some instances, plasma replacement doesn’t work because when the a stack of cigarettes, and this can point sample is spun down, the protein deposits down with the red blood to a promyelocytic leukemia, where cells and can’t be removed. In these instances, accurate results can Butterfly nucleus things can go bad very quickly — and sometimes be obtained by pre-warming the sample to disassociate a fast diagnosis is critical. Seen in some the protein from the red blood cells and making a 1 in 5 dilution. hypogranular subtypes of acute promyelocytic leukemia (APL), the Plasma electrophoresis may be recommended for these samples. faggot cell nucleus is shaped almost like butterfly wings. In these cases, coagulation studies, including PT, PTT, fibrinogen levels Case 3: Pancytopenia is a leukemia until and D-dimers, will be very valuable to the physician. With new proven otherwise leukemias, fast detection can make all the difference in a patient’s treatment options and prognosis. This case shows the one pattern that everyone should memorize. When a sample gives a low white As medical laboratory technologists, we are the blood detectives. blood cell count combined with a low It is our duty to make sure the results we send physicians contain red blood cell count and a low platelet the most accurate information so they can make the best decisions. count without any explanatory factors, Knowing patterns is a valuable tool. The numbers we see aren’t it should be considered a leukemia until just digits — they have to fit together in a way that makes sense. If proven otherwise. Look very closely at not, we need to take appropriate measures and do any additional the blood smear for evidence of blasts. manipulations needed to obtain accurate results. Familiarity with There may not be many, and they may different disease processes and their patterns is key because they look like abnormal lymphocytes or usually appear in the same way from one case to the next. Once we monocytes. Look for cells with a low get familiar with these patterns, it becomes much easier to determine nuclear cytoplasmic ratio, nucleoli, and what’s happening and what we need to do. a nucleus with a non-opaque, “sheer curtain” appearance to it. Some can also be stuck on the feathered edge of the smear. If you have any doubt, consult with a senior morphologist. If you’re fairly certain they are blasts, notify NADINE ROUSSY, MLT your hematopathologist immediately, Top: Auer rod Moncton Hospital as this is the typical pattern of a new Bottom: White blood acute leukemia. You should also check cell blast

csmls.org 11 IN FOCUS

Christine Bruce, Administrative Director at Mount Sinai Hospital, has spent much of her 20-year career leading the delivery of laboratory services in both the private and public sectors

Denise Evanovitch, Regional “Now What?” Manager of Ontario Regional Blood Coordinating Network, 5 Ways to Create has applied most of her 42 years of experience in the field of the Right Career transfusion medicine Jennifer O’Leary, faculty at The Michener Institute for Education Opportunities for You at University Health Network, and former Senior Genetics MLT, taught Clinical Genetics MLTs for 15 years and is now a teaching technologist in Ontario n June 2019, CSMLS hosted a live learning event where a group of longtime medical laboratory professionals shared strategies on how Karen Scraba has a career’s to create opportunities for career development. The panelists shared worth of diversely applied Itheir career journeys with the audience, and discussed strategies on getting experience in clinical recognized in the workplace and gaining a seat at the table. Through this diagnostics and medical vibrant and motivating discussion, attendees came away with new tools and devices sales, marketing and ideas on taking charge of their careers. Now, we’d like to pass on to you some clinical education of the panelists’ tried-and-true tips and strategies.

These inspiring women offered countless tips and insights for anyone looking to develop their career, but we’ve narrowed it down to our favourites. Here you do not know everything but you can draw on your are five ways the panelists recommend you create career opportunities for experience. Be the person who finds answers. It is about yourself. learning the right skills along the way so you can offer your expertise in various roles.

1. Take the Time to Explore 3. Additional Education Take the time to understand where your passion lies in the field. Build your The education you choose depends on your career goals. network to explore what’s out there. That may sound intimidating, but it is as Find your gaps in knowledge and look for formal or simple as talking to people. Another great way to learn about your passions informal education that is right for you. You can look and what skills to develop is to find a mentor, either someone inside or outside of formal institutions and try informal education, outside of your organization. Having a network and a mentor gives you a such as workshops, conferences or webinars. When you chance to explore your interests through other people’s passions. tailor education to your needs, it will have the most value.

2. Transfer Your Skills 4. Stand Out All the skills you develop as a laboratory professional are transferable; we Don’t be afraid to show your personality to stand out from tend to forget that when we are looking for other opportunities. Push yourself the crowd. Take your experience and show others how to use those skills in different circumstances. Put yourself in situations where it relates to your career. Highlight volunteer positions,

12 CJMLS Spring 2020 There are many more resources like this one in the CSMLS Career Centre. courses you completed, etc. When applying to job opportunities, consider including these Visit csmls.org/Career-Centre extra details in your cover letter. for more.

5. Show Interest Put yourself out there. Talk to people, have a good attitude, be willing to help, ask questions and show your interest. A great way to do this would be to set up a quick meeting with a leader from an organization. You can also volunteer for stretch assignments or shadow a colleague in a role that you would like to perform to let leaders know that you are interested in — and prepared to take on — new challenges. Remember, not all jobs are posted, so showing interest can foster hidden opportunities.

Whether you’re looking for change or you’re happy in your position, creating career ANDREA LIVINGSTONE opportunities is a great way to take charge of your career. The more opportunities you have, Learning Specialist, CSMLS the more prepared you are for change. By expanding the number of opportunities available to you, you can take control of your career path and be ready for whatever comes your way.

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csmls.org 13 IN FOCUS

Speaking Up for Safety

peaking up for safety is increasingly are reluctant to voice safety concerns. The uncomfortable speaking up for safety, it may accepted as necessary in health care young workers fear they may be viewed impact safety performance, productivity, settings where patient safety is a negatively, feel they have insufficient budget and patient outcomes. Negative Spriority for health care professionals such as experience or are intimidated by superiors.6 consequences arising from interpersonal nurses and doctors.1,2,3 Medical laboratory In certain situations, workers may feel it is conflict, demanding workloads and professionals (MLPs) play a crucial role in inappropriate to intervene and challenge the ineffective teams are far too common in health diagnoses, care and outcomes for patients status quo. With the impending shortage of care settings. Supervisors and management in need of medical expertise. Therefore, MLPs across Canada, it’s more important can encourage speaking up by enabling speaking up for safety in the medical than ever that all workers, including young workers to gather and speak as a group. After laboratory should be considered necessary. workers, are encouraged to speak up about listening, management must take action as a We each have a role to play in creating this safety concerns or hazards. necessary next step to reinforce the message change. Management has a formal responsibility that safety is important to everyone. It takes Safety culture exists in every organization, to provide a healthy and safe working a lot of effort to convince organizations, and but the relative health of the culture depends environment — some would say this is the people within, to speak up for safety. It is on many factors. When speaking up about challenging given a constantly changing lab a noble effort worth fighting for! safety is not actively encouraged by the environment. Think about a time when a new leadership, it can lead to fearful workplaces. process or system was introduced into the lab. These workplaces suffer in terms of How was the change-over planned, and what productivity, burnout and turnover, as well led to a successful transition? Perhaps some REFERENCES as decreased adaptability, to name a few of the best solutions were brought forward  1Rainer, J. (2015). Speaking Up. Journal of issues. In contrast, fearless organizations by those directly affected, i.e. the MLPs Nursing Care Quality, 30(1), 53-62. — those with psychological safety — create with functional expertise and the ability to  2Schwappach, D., & Gehring, K. (2014). opportunities for “learning, innovation and translate that need into lab operations. MLPs Silence That Can Be Dangerous: A Vignette growth,”4 which are all necessary ingredients are often more intimately aware of the needs, Study to Assess Healthcare Profession- for cutting-edge diagnostic laboratories in pitfalls and potential hazards and can offer als’ Likelihood of Speaking up about Safety Concerns. Plos ONE, 9(8), e104720. today’s ever-changing world. up solutions to improve safety controls in  3Brennan, P., & Davidson, M. (2019). Improv- The fear of speaking up for safety can lead the lab environment. It’s important to share ing patient safety: we need to reduce hierar- to problems in many workplaces. Therefore, ideas, brainstorm options and apply critical chy and empower junior doctors to speak up. identifying ‘safety silence’ as a contributing, thinking to achieve a successful outcome. BMJ, l4461. 4 organizational problem is key. A feeling You can play a role in improving the safety  Edmondson, A. (2018). The fearless organization. Newark: John Wiley & Sons, Incorpo- of inability to speak up was determined to culture in your lab and throughout your rated. have contributed to the tragic deaths of the organization. Watch out for signs of safety  5NASA - Report of Columbia Accident Inves- Space Shuttle Columbia crew in 2003. A complacency in your workplace. Are hazards tigation Board, Volume I. (2019). Retrieved lack of acceptance that safety concerns were identified and compiled? Are corrective from https://www.nasa.gov/columbia/home/ legitimate ultimately led to the disaster.5 actions completed? Are there unresolved CAIB_Vol1.html 6 Across any discipline, it’s important to hazards in plain sight? The safety department  Tucker, S., & Turner, N. (2013). Waiting for safety: Responses by young Canadian be vocal about safety. While some people can’t be the only team responsible for workers to unsafe work. Journal of Safety might believe that younger generations are identifying hazards across the organization. Research, 45, 103-110. more vocal than previous ones, it’s hard From the parking lot to building entrances to say if that is true when safety is at stake. to the lab and equipment within, workplace Young workers, as well as others, including safety relies on everyone promoting safety to EOIN O'GRADY internationally-trained MLPs, may find ensure safety performance remains on track. PhD, CRSP themselves in tough situations with regard Encouraging others to speak up can lead Occupational Health and to raising safety concerns. For example, a to collective improvement in different areas Safety Consultant to CSMLS Canadian study showed that young workers of the organization. When workers are

14 CJMLS Spring 2020 Journal_ad_FINAL.indd 1 4/2/2020 11:09:54 AM Thank goodness for the Officially out of bench “other medical staff” that tech retirement. Back are actually performing on the front lines doing the #Covid19 testing and keeping the lab afloat! COVID-19 testing #MedLab #Lab4Life tomorrow. #imback #WeSaveLivesEveryday

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@thefirstjoel @Robmar702 Joël Rivero Marc Robichaud

Journal_ad_FINAL.indd 2-3 3/23/2020 9:52:53 AM Thank goodness for the Officially out of bench “other medical staff” that tech retirement. Back are actually performing on the front lines doing the #Covid19 testing and keeping the lab afloat! COVID-19 testing #MedLab #Lab4Life tomorrow. #imback #WeSaveLivesEveryday

@MedLabMaven @jessicabankey Krista Urchenko Jessica Bankey

Just got pulled into the infectious disease lab from my genetics lab today to help. All hands on deck for this one!

@meagangarrison_ Meagan Garrison

@glenmcdaniel @heyheypaula7 Glen McDaniel Paula Steeves

@thefirstjoel @Robmar702 Joël Rivero Marc Robichaud

Journal_ad_FINAL.indd 2-3 3/23/2020 9:52:53 AM Journal_ad_FINAL.indd 4 3/23/2020 9:53:04 AM COVER STORY

AUTOMATION AND THE RE-IMAGINED FUTURE There are not enough medical laboratory technologists (MLTs) in Canada to meet the growing demands of the health care system, and the problem is only getting worse.1 »

csmls.org 19

Journal_ad_FINAL.indd 4 3/23/2020 9:53:04 AM COVER STORY

CSMLS released a Call to Action (CTA) to address the national, worked with the laboratory at the Peterborough Regional Health regional, immediate and long-term efforts required to amend the Centre (PRHC) to create their bench-top, robotic histology slide shortage of MLTs within Canada.2 According to the CTA, without archiving system called SlideTrack. The vision for this initiative, a national effort to alter this trend, laboratory professionals will developed by Bernard Schaan, laboratory manager at PRHC, was only continue to experience more considerable hardship in the inspired by a time-consuming and monotonous task. Bushell says workplace. The document itself cites a variety of contributing that, at the time, "The hospital's lab staff were spending up to six factors, including a high retirement rate for professionals, increased hours each day manually sorting and filing pathology slides." With demand for laboratory services, a change in practice due to a growing workload demand on the technologists at PRHC of at technological advances and vacancy rates that exceed the number of least eight percent per year, something needed to change, and quick. MLT graduates.3 This trend is not isolated to the Canadian health PRHC and Lab Improvements received a $25,000 development grant care system. The trend is echoed by other societies, including the and a $15,000 procurement grant from Ontario's MaRS innovation American Society for Clinical Laboratory Sciences (ASCLS). In mid- hub to develop a solution that would also help other hospitals in the 2018, ASCLS published a position paper that reflected the CTA made province experiencing the same problem. When implemented, the by CSMLS. In that paper, ASCLS stated that, "Several factors impact SlideTrack device was able to sort and file all the slides that passed the clinical laboratory workforce shortage" and, by extension, the through PRHC in 2019, more than 150,000 slides; a task that once quality of patient care the system can provide.4 took up valuable hours of MLTs' time.7 The success of SlideTrack Before 2014, total laboratory automation systems were thought has led Lab Improvements to begin exporting the technology into to be one of the primary solutions to technologist labour shortages. internationals markets. Many laboratories across Canada began looking into investing in this technology to automate up to 99 percent of lab processes. The hope ADAPTING THE ROLE OF TECHNOLOGISTS was that total laboratory automation systems would allow health care During the peer review process of SlideTrack, Bushell noted that facilities to reduce costs, improve patient care, increase efficiency and many labs wanted to automate additional repetitive tasks, not replace greatly reduce the number of trained in-house technologists needed technologists: "With the constantly increasing volumes and fixed/ to run labs.5 shrinking budgets, management seems keen to explore new ways of While total laboratory automation would work well for large, high- helping the lab achieve maximum efficiency of the staff's time so they volume labs, the costs and complexities kept total lab automation focus on higher-yield activities. Previously, automation was about systems out of reach for smaller labs. Many smaller laboratories replacing people all together, but that mindset has changed." found that they were unable to invest the millions of dollars required Along with this new model comes the conversation about the to purchase the specialized equipment. As well, many health-science adapting role of technologists. More than ever before, technologists hubs that could afford to invest in this technology found the cost of are required to be able to work effectively with automation, while maintenance and updates unsustainable over time. Total laboratory having niche training to interpret findings and perform tasks not automation was not an end-all solution.6 covered by machine operation. The Core Laboratory at Sunnybrook Health Sciences Centre in Toronto is one centre that gives a sneak CREATING A SYMBIOTIC RELATIONSHIP peek into how the role of technologists will become more specialized In the last few years, the interest in total laboratory automation has in the future as MLTs work co-dependently with automation. shifted. Now, laboratories are increasingly investing in islands of In 2018, the Core Laboratory featured Ontario's first end-to- automation as a response to labour shortages. Under this model, end automated biochemistry lab. This new equipment allows blood technologists and automation exist in a symbiotic relationship rather samples to go from receipt to result without interruption, making than as two separate entities that work against each other. testing more efficient than ever before. Instead of manually running What is unique about this model is that it does not seek to eliminate tests, technologists are fulfilling a different role: "A highly specialized human involvement in the lab, but uses automation to make the team of technologists, technicians and biochemists work around limited number of trained technologists as efficient as possible. As the clock. [They utilize the] state-of-the-art laboratory automation a result, laboratories are investing in bench-top machines that are system for both testing and specimen archiving.”8 Together, this team more efficient and affordable then the total laboratory automation of experts works with automation to process around 4.5 million tests systems of the past. per year for Sunnybrook patients, government research agencies and Last year, Alex Bushell, CEO of Laboratory Improvements, other private laboratories and hospitals across the province.8

20 CJMLS Spring 2020 Both Bushell and Bak agree that there needs to be a real focus on these developed-in-the-field, grassroots solutions as the lab combats labour shortages. As Bushell says, “there is such a high return on solutions designed in the lab for the lab,” and automation may be one part of this.

HELPFUL RESOURCES • Hendriks, K. Innovation Revolutionizes Slide Management. CJMLS 2019;81(4):14–15 • The 2019 LABCON Webinar featuring Richard Bak, manager of Laboratory Medicine at London Health Sciences Centre. • CSMLS The Objective Lens, The New Frontier, available at https:// podcast.csmls.org/podcast/episode-22-the-new-frontier/.

Automation, as described by Sunnybrook, does not do away with ALIZA PRODANIUK the technical skills that MLTs require to perform their job. Instead, Special to CJMLS it refines their abilities while making technologists more attentive to the results they can produce. Having begun his career in 1987, Richard Bak, manager of Laboratory Medicine at London Health Sciences Centre, has REFERENCES  1Young L, Bimman A. Lab personnel shortage means you could wait worked with both manual and automated laboratories and has longer for medical test results: association. Global News. April 30, 2019. seen enormous advances in automation. In his opinion, improving Accessed January 10, 2020 at https://globalnews.ca/news/5222813/ automation and manual processes in smaller or specialty laboratories lab-tech-shortage-medical-tests/ is a move towards improving staff safety, improving result quality  2CSMLS The Canadian Medical Laboratory Profession’s Call to Action. and reducing transcription, all with an added increase in capacity Accessed January 23, 2020 at https://www.csmls.org/Research/ and throughput. Efficiencies can be gained in both scenarios, Projects,-Reports-Presentations/The-Canadian-Medical-Laboratory- Profession-s-Call.aspx but advances to all aspects of lab collection, specimen reception,  3CSMLS. Backgrounder: The Canadian Medical Laboratory Profession’s processing and reporting need to be optimized before reducing Call to Action. Accessed January 23, 2020 at https://www.csmls.org/ staffing complements becomes viable. Research/Research-Reports/Backgrounder-The-Canadian-Medical- Laboratory-Prof.aspx RE-IMAGINING THE FUTURE  4ASCLS. Addressing the Clinical Laboratory Workforce Shortage. August Laboratory professionals have always been exposed to automation 2, 2018. Accessed December 16, 2019 at https://www.ascls.org/position-papers/321-laboratory-workforce/440-addressing-the-clinical- cycles in the workplace. As technology ages, more advanced products laboratory-workforce-shortage are purchased for laboratories that require a new level of adaptation  5Bushell, A. Personal communication. January 27, 2020 for MLTs. However, Bushell suggests that despite advances in  6Bushell, A. Personal communication. January 27, 2020 automation, technologists will never be entirely replaced; the  7Device developed at PRHC improving medical slide archiving. Peterbor- future will be about developing pockets of automation that aim to ough Examiner. July 31, 2019. Accessed January 10, 2020 at https:// alleviate staffing problems and benefit patient care. He says, “Delays www.thepeterboroughexaminer.com/news-story/9530060-device- developed-at-prhc-improving-medical-slide-archiving/ in diagnosis and treatment lead to patient anxiety, and if we use 8  Nazimek K. A walk through Ontario’s first end-to-end automated automation in smart, effective ways, then it’s the patient that wins biochemistry lab. Sunnybrook Magazine. October 4, 2018. Accessed in the end.” January 10, 2020 at http://health.sunnybrook.ca/magazine/fall-2018/ Bak agrees on the future of automation in the lab. “Automation ontarios-first-end-to-end-automated-biochemistry-lab/ does not replace the need for highly competent staff. Continual training and supervision are staples within each area to continue to improve and provide the highest level of diagnostic care.” Instead, it is essential to remember that the future of laboratories, regardless of size, is dependent on more than just automation. Current laboratory Test Your Knowledge roles need to be evaluated, and new role-related elements like Answer a quiz on this article at learn.csmls.org to procurement, informatics, pre-analytics, post-analytics, technical earn Professional Enhancement Program (PEP) quality specialists and other factors need to be implemented. hours towards your professional development plan.

csmls.org 21 COVER STORY

Automation: Skills of the Future

“Ideally, automation should free technologists from time- analysis, organization, and distribution — could determine the consuming duties so that they can expand their role in more value of the system itself. Lab professionals involved in data challenging aspects of laboratory operation.”1 Sound like management and LIMS (laboratory information management the modern lab? This is from an article published in 1973. system) will be vital to automated lab operations.4 Discussion around how automation will affect the role of medical lab professionals remains largely the same almost Be the Voice of the Lab 50 years later. So why is it still such a popular topic? As automation increases throughput and data, having a liaison Automation, and its role in the medical lab, has evolved between the laboratory and outside stakeholders will be key.5 since 1973 — and it continues to evolve today. As automation Think about who calls your lab with issues and questions. changes workflow and roles in the lab, the key to having your Why do the calls come in? How are they resolved? Re-evaluating lab ready for the future may lie in continually evaluating how these calls as a task and assigning someone to this specific medical laboratory professionals can adapt to meet new role is the first step in establishing a liaison. Medical laboratory challenges and priorities. Here are some predictions we’ve assistants (MLAs) with customer service, problem-solving and collected. communication skills may be best positioned to fill this role.

Be Ahead of the Curve Customer Service in Health Care When asked about the future of the pathology lab, Dr. While automation flows into the pre- and post-analytical Timothy Stenzel, director of the FDA’s Office of In Vitro workflow, it does not fill the need for human touch. The Diagnostics and Radiological customer service culture will be Health, says, “Learn the basics key in setting your lab apart from and keep learning, because the the rest. Consider how to apply field is going to keep changing customer service in multiple areas in the future.”2 Keep on top of automation trends of the lab to ensure your whole Automation is a big part and news. Knowing what’s out system supports patient care.6 of this change, so embrace Interpersonal and communication it. Keep on top of automation there will prove valuable when it skills (again, think customer trends and news. Knowing enters your lab, as you can quickly service) will be vital to fulfilling what’s out there will prove this role in a way that upholds the valuable when it enters your integrate automation into your reputation of your institution. lab, as you can quickly integrate current systems, making the most automation into your current systems, making the most of of your resources and time. your resources and time.

Troubleshooting the Lab Hone in on technical know-how. REFERENCES It’s one thing to use the equipment, but it’s another skillset  1Automation and the Medical Technologist, Laboratory Medicine, to understand it. John Morgan, director of marketing at Volume 4, Issue 8, 1 August 1973, pp. 20–22, https://doi.org/10.1093/ Elemental Machines states, “You can’t control what you labmed/4.8.20 don’t understand.”3  2Silva B. Clinical lab industry AMPed for future of molecular pathol- Gain the knowledge needed to truly understand the ogy, Medical Laboratory Observer, Volume 52, Number 2, February machine — what exactly it does, how it works and what it 2020, pp. 36–37 3 needs to run smoothly. Knowing when something isn’t right  Kridelbaugh D. Lab Equipment Maintenance: Be Prepared for the and identifying the issue will be critical when working with Unknown with Preventative Care, Lab Manager, Volume 14, Number 11, December 2019, pp. 18–21 new forms of automation. If you have the right technical  4Tennenhouse E. How LIMS Are Helping Clinical Labs, Lab Manager, knowledge, you might be a breakout hero when things go www.labmanager.com/product-focus/how-lims-are-helping-clini- wrong. cal-labs-4314  5Anderson V L. Customer Service and Its Importance in the Clinical Data Scientists Laboratory, LABMEDICINE, Volume 39, Number 4, April 2018, A large change from automation is the drastic increase in pp. 197–200 DOI: 10.1309/AYKRJTBJ4EE6WMCW throughput, and with greater testing volume come greater  6Pickett R B. Beyond Customer Service, Lab Manager, www.labman- amounts of data. What labs do with that data — in terms of ager.com/business-management/beyond-customer-service-9866

22 CJMLS Spring 2020 Community

Inspiring the Future Around the Globe: International Founders’ Fund

aving the world recognize the exceptional members of CSMLS and knowledgeable medical laboratory professionals throughout Canada is important to us. That’s why we are proud to provide grants from the HInternational Founders’ Fund to members taking part in activities that promote the image and status of Canadian medical professionals or the CSMLS on the international stage. We caught up with 2019 grant recipient Athena De Marco, who attended the 33rd World Congress of the International Federation of Biomedical Laboratory Science (IFBLS) in Florence, Italy, in 2018 as part of the Student Forum. She gave us an update on what that experience meant for her both personally and professionally and told us about the next international conference she will attend.

I was lucky enough to attend the IFBLS World Congress in Florence, Italy, in September 2018 as one of two Canadian students taking part in the Student Forum. The Forum was created to actively involve students in the IFBLS World Congress, helping us interact with IFBLS members and Congress delegates from around the world and take part in discussions with the international biomedical laboratory science (BLS) community. Meeting members of the BLS community to share ideas and different perspectives while representing Canadian MLTs was an absolutely invaluable experience. I went to the Congress to showcase my leadership skills, but I gained Athena De Marco (middle row, right) with fellow delegates so much more. I learned that MLTs all over the world seem to face the same issues in Italy and that if we work together on a global scale, we can help solve worldwide health problems. Of course, the experience also gave me the opportunity to enjoy Italian culture, food and wine. I plan on attending the next IFBLS World Congress in Copenhagen, Denmark, in September 2020. Since the 2018 World Congress, I passed the CSMLS exam Planning to attend an to become a certified MLT. I am looking forward to contributing to the global international conference? community as a member of a profession instead of as a student. I definitely look forward to experiencing the Danish culture, and I hope to see more Canadian Learn more about the International students and MLTs at this next congress. Founders’ Fund and many more grants, I am very grateful to have received a grant from the International Founders’ scholarships and awards offered by Fund. This grant contributes to not only my future but the future of the industry. CSMLS at csmls.org/awards. Thanks to the grants and events available to me through my CSMLS membership, I can keep developing my skills and knowledge along with the growth of the profession.

csmls.org 23 COMMUNITY

Newly Certified Members in 2019

Congratulations and welcome to the following new members who successfully passed their certification exam in 2019. Current verified members as of February 12, 2020.

MLA Bree Baskin Anabelle Cosme Vanessa Francisco Vicki Benson Shauna Costigan Ana Eloisa Francisco Hazel Joyce Acepcion Shahad Benzreiba Sarah Crawford Courtney Fromm Frances Abad Katherine Berakos Stacey Crawshaw Darcy Fullerton Naeem Abo Khashreef Erika Bermeo-Chong Phoenix Cross Amy Gagnon Charlene Kim Abulencia Bhimraj Bhurtel Katie Cross Jennie Gaitana Adelaide Acton Cerila Bilacaol Jenna Crowley Margie Galicinao Danielle Adams Melissa Billard Brandee Cusack Elyse Gallant Florije Ademaj Sara Billard Mitchie Janice Cutting Cindy Garcia Shamso Aden Matthew Blais Snezana Dabic Darlene Garcia Meena Al Saigh Melvin Blanco Jofelyn Mae De Castro Lisa Geauvreau Joan Alcantara Michal Blatnicky Debbie Rose De Erit Nicole Gerow Marwa Al-dulaimi Shna Blbas Kay De Fiesta Angela Gibson Alyana May Algarme Rina Bondoc Rowella De Guzman Brianna Gillis Lisa Alger Brittany Bonnar Timora De Matas Sukhvinder Kaur Girhotra Saed Ali Kate Angela Boo Maribel De Roxas Jamie Alexandra Gonzales Osman Ali Sarah Bottomley Sabrina Decuzzi Shawna Googoo Hanna Ali Caitlin Bourgeois Jae Anne Dela Cruz Kimberlin Goorahoo Joy Ann Almacen Brittany Boutilier Kim Chadnie Delos Santos Katrina Gordon Mary Jeannine Alviar Krystle Bowskill Rajwinder Dhillon Denay Green Mica Amolo Christopher Bradley Sukhjinder Dhillon Kylie Gregory Taylor Andrews Allison Budinski Denise Donovan Ma Kathleen Guevarra Aneela Anjum Andreea Bugeac Ma Alison Dulin Teisha Gullekson Ginalyn Antolin Sheryl Burns Hannah Alyssa Dulin Samaah Hachem Paul Apolinario Michaela Burt Bethea Katrine Dultra Jessica Harrison Grace Apostol Remelieh Cacayurin Hennie Ivy Dungog Rupal Hatkar Cirlynne Arenas Jessa Cadaeg Dylan Durham Elizabeth Hatty Valerie Armstrong Ronalyn Calixto Emily Edge Emilie Hebert Jane Armstrong Ryan Christian Capitle Anusha Edirisinghe Jacquelyn Helliwell-Davies Chaudhry Asif Kelsey Carter Ler Wah Eh Daniel Henley-Billard Ayanleh Attayeh Runa Marie Castillo Parvaneh Eilbeigi Kelly Henshaw Nancy Ayap Heidi Chamberlain Fathiya Elmi Kai Lun Dennis Ho Kazi Md Azimuddin Bobby Bao Tian Chang Balbino Estabaya Richelle Hogan Eprex Balucay Hedwidge Charles Eugenio Joaquin Estacio Carly Holloway Chryszchyl Bambo Makayla Charters Pamela Fanning Courtney Hoorelbeck Jill Barr Rebecca Chartrand Corey Ferguson Jordan Hrynkiw Felicia Barraco Katie Cheung Yared Fisseha Ericka Jen Huelgas Madison Barrette Michelle Chieu Shirley Fitzpatrick-Wong Kristen Hughes Benjamin Bartel Rikki Colombe Cajetan Fobisong Kimberly Huismans Kianna Trishia Bascug Amanda Conrad Kristen Forrest Amjad Hussain Solome Basdeo Maddison Correa Kathrine Fougere Madina Ibiro

24 CJMLS Spring 2020 Shaista Iftikhar Ma Ruth Lucas Megan Pardy Deanne Santiago Eva Ilic Samantha Macdonald Krutika Patel Nicole Santos Samuel Ireland Laura MacInnes Mayuri Patel Jhayme Anne Santos Tuhinur Islam Jade Mackey Khushbuben Patel Sarah-May Savard Sanaa Ismail Heather MacKillop Milindkumar Patel Sumeet Sekhon Rania Issa Breanne MacKinnon Sharlin Patel Natalia Semenova Johnathan Jack Jessica MacKinnon Zinal Patel Janki Shah Carmen Jacob Shelby MacLeod Jharanaben Patel Renu Sharma Jiyoung Jang Noemi Mago Amishaben Patel Jennifer Shaw-Preece Jasmine Jardine Taras Makhnevych Anjali Patel Julie Sheehan Ashok Kanumuri John Michael Mapula Sarah Peacock Alicia Sheehan Harneet Kaur Jenneth Marquez Jenyne Penaflorida Joohyun Shin Suhanthi Karuna Ketheeswaran Nicole Martel Lorraine Ann Perejan Ramandeep Sidhu Aatif Khan Helen Martens Melica Perez Amy Simon Noorjahan Kidwai Danie Martin Madeline Perry Emily Singer Libby Kingston Kimberly McDonald Vivian Pham Stephanie Smith Jacqueline Kirby Estri McGarty Jocelyn Phavivongkorn Alana Smith Brittany Kitt Kelsey McIvor Lorraine Angela Pinote Lineth Solidarios Connor Korsten Mary Jane McKay Shalini Pirabakaran Euniqa Dancille Soriano Magdalena Kosciuk Indira Meka Amela Plavotic Jerikka Sotelo Tamnna Kumari Janna Mae Merino Sarah Poirier Jade Soulliere Kaija Kuokkanen Amanda Mess Jenilyn Pollicar Elisa-Jean Speziale Donalyn Lacasandile Iryna Mileuskaya Marilou Pontejos Lauren Staats Vimon Lacey Chris Millard Sabina Portnoy Jennifer Steenson Mansi Lad Tanese Miller Nanji Pal Singh Puri Amanda Stevens Aleshia Lahey Stacey Miller Gillian Quenneville Erika St-Onge Leah Landriault Kishana Mohamed Genedine Quisumbing Nusrat Sultana Kelsie Lane Andrea Mok Jane Rado Abeda Sultana Johanna Lazaro Andrew Moore Megan Raeburn Nathalie Surprenant Julie Le Lea Morales Allison Raftis Dipal Suthar Natasha LeBel Kathleen Moran Alarice Ramsay Jenny Ta Zachary LeBlanc-Cottreau Forouzan Moslemi Radostina Raykova Huma Tasneem Melvyn Ledda Darling Mpinganzima Lea Rayner Amanda Tate Haeun Lee Jenna Mullins Rachelle Razon Marwah Tawfeeq Bhagya Leelananda Kumiko Murakami Rebecca Redden Tsion Tewoldebrhan Jessica Lemoine Shamsoulsadat Naziri Allison Reeves Akhila Thampi Chade Leopoldo Onajite Nesimeye Aillan Resurreccion-Lozano Andrea Tingley Merissa Lesovich Susan Nguyen Michele Rook Megan Topolinski Jong Leu Tuan Nguyen Kristine Rosario Anne Ugobor Noémie Levesque Milica Nikitovic Scott Rosborough Khadiija Ulusow Meng Li Kristin O'Brien Jillian Rose Carly Umbach Carolyn Jane Libre Angelica Ochoa Sarah-jane Rovedillo Allison Van Herk Seungbin Lim Iola Oguneko Angela Ryan Sanjay Vashishtha Arianna Livadas Jane Organ Lina Sabbagh Emily Vaughan Haley Livingstone-Fletcher Megan Osborne-Sobers Fritchie Santos Sagalongos Jessica Veldman Lillan Jennifer Llanes Sammi Ou Yang Sarah Saido Kim Ventura Emilia Lloyd Maryjoy Pagulayan Meenakshi Saini Vilma Vito Eileen Loayon Rikilkumar Pandya Mohsen Salameh Cindy Vo Shelley Loi Fehmida Panhwer Umme Salma Jesse Wagner Mariah Longmore Danika Paquet Janina Sampson Nermin Wasef

csmls.org 25 COMMUNITY

Antoinette Wasef Marvy Medina Bates Alicia Benak Angel Chien Kasandra Watson Kristen Morandin Samuel Benedicto Parameswari Chockalingam Shane Weatherby Alec Bryan Santos Hajar Benlahcen Chemsoul Choi Tracy White Vikarnan Thiruvarooran Gillian Berg Yeiyun Choi Mary Lee White Patricia Wu Mary Beshay Joyce Chong Cheyenne Whiteway Simon Bester Mark Chopaping Kylie Whyte Yasser Bheekun Jasmyne Choy Justin Winny MLT Catherine Bineau Frances Clark Redeate Wolde Rosemarie Blancaflor Jeremy Coate Jennifer Wong Wesal Abdelrawf Sheena Bonayog Sebastian Coll Bota Yu Wu Jahangir Abdi Shaun Borgula Ric Narciso Combes Emily Xie Bayan Abo Samra Savannah Bouchard Shanie Comeau Marisol Young Lorraine Abril Danielle Bouthillier Melissa Coombs Victoria Zieroth Julia Acker Julia Boutsabouabane Chelsea Corrigan Micaela Adamski Tristen Bowers-Handerek Stephanie Cote Girard MLT CLINICAL Vania Adan Sanz Melissa Bradley Heather Cottingham GENETICS Andrea Afiuni Vengoechea Michael Briere Danika Crabs Nimra Afzal Luigi Bruno Rebecca Cromwell Nicole Agpalo Madison Bueckert Jade Crozier Nadia Al Youssef Hira Ahmad Kim Bui Malachi Cruz Stacey Anderson Denise Alano Tina Bulych Xerxes Laurence Cubelo Stephanie Buzzanca Jafar Al-Baghdadi Katie Bumbacco Caryn Joyce Cueto Shahira Chadha Refka Al-Bayati Trisha Jeanelle Cabiling Yu Si Cui Yao Chen Maria Alfano Di'isha Roxane Cabingan Jessica Cunningham Christianna Dennison Iqra Ali Christine Caharian Matthew Cuzner Lorian Fay Danah Almoneef Arvelene Camama Patrick Daiz Daryl Foot Farah Al-Shami Katie Cameron Beverly Joy Danao Keely Greenfield Clementina Amah Marli Cameron Steven Dang Brittney Grondin Rosette Amegah-Wovoe Amira Nizamae Campong Michael Dantes Cadence Hope Arvin John Amo Michelle Cao Jessie Darrow Valerie Jabra Michael Andrada Kes Carson Faranak Dastranj Olivia King Brittany Angus Yancy Cayunda Hilary Dawe Shawna Lee Diana Anuscenko Adriana Ceron Barcenas Antonio Jr. De Guzman Amanda Lieu Deborah Aquintey Dara Chahal Athena De Marco Matthew McKechnie Jeffrey Archer Nathalie Chamberlain Carine De Wit Tiffany Mitchell Monica Aspra Rubi Carolyne Chan Burklynn Dehn Md Obaidur Rahman Christine Austerman Elijah Chan Michael DesRoches Kim Anh Tran Neven Awad Kathy Chan Safire Dhanji Synthia Wou Katherine Azzopardi Kwok Yan Maggie Chan Robyn Dickner Ji Hye Yoon Eley Badr Breanna Charleson Julie Do Lindsay Baertl Matthew Chaulk Gaofeng Dong MLT CYTOLOGY Jessica Bain Cassandra Cheeseman Shannon Donnelly Nenuchka Kyra Baltazar David Chen Selina Dooley Naghmeh Amintaheri Susan Banfield Jia Yi Chen Nicole Dordolo Kristen Doktor Carelle Grace Bantatua Sharon Xue Hui Chen Ayana Douse Ibrahim Elsharawi Suzanne Barakat Victor Cheung Ashley Doyle Hailey Gordon Ashley Beauchamp Katherine Cheverie Brittany Dragicevic Pavel Goriainov Julie Bégin Man-Tzu (Bay) Chiang Diana Drljevic Maham Hijazi Christina Bell Randy Chiasson Isabella Duncan Warda Ibrahim Natalia Bembenek Roxanne Chiasson Shannon Duncan

26 CJMLS Spring 2020 Meaghan Dunn Massomeh Haddadizonoz Myles Kazakoff Larissa Longstaff Montana Dunn Soraya Hadjirul Amy Keough Xu Lou Mary Duval Justin Hahn Laura Kielek-Caster Hailie Ludington Jennifer Earle Connie Amor Halim Grace Ha Eun Kim Henry Luu Vanessa Ebert Morgan Hallett Jihee Kim Albert Ly Marnie Edwardson Cali Hamilton Min Ji Kim Jonathan Mach Heather Egan Leah Hawkins Christine Kirby Christopher MacKenzie Samantha England Elizabeth Hebert Georgianna Knox Joseph MacKenzie Kerri Erlandson Erin Helmer Kelly Knox Tracy MacMullin Arezou Eslami Farsani Maria Hibbs Karen Kong Kaitlyn MacPhee Kristine Eugenio Cynthia Hildebrandt Kailee Kowalenko Jessica MacPherson Ahmad Fatehzadah Hayley Hiscock Kathleen Kreiser Ryan Madadi Maryam Fazal Melissa Hiscock Stephanie Kretzer Huda Mahgoub Ibrahim Lauren Fedak Jonathan Wing-Fai Ho Kimberly Kruesel Jocelyn Shui Lam Mak Kristin Feyen WingYan Ho Andre Nicolo Kua Raghad Makhlouf Ericka Fietz Melanie Hogan Nadezda Kuchuk Lesia Maksymiak Annika Fitzsimmons Leanne Holdaway Jaw Chyi James Kuo Taraneh Maleki Nicole Forrest Morgan Holland Gloria Kwon Ranvir Manan Meaghan Fox Pacwin Ho-Ly Aurora Kwong Antonio Mancuso Anne-Katerine Frechette Shua Hong Justin Lacoursiere Angelique Manguino Ryan Fry Carly Hoover Teagan Lalonde Amelie Martin Yu Fu Jennifer Horner Andy Lam Monica Matija Charlotte Galbraith Natalie Hoy Mary Lam Kristen McAuley Katherine Garber Ivy-lynn Huber Mei Shun Lam Cheryl McConachie Marilyn Garcia Lisa Hudyma Robert Lam Natalie McDermott Kelly Garrow Jacqueline Hughes Vashti Lamanilao Estelle McGuigan Delca Genuis Matthew Hulett Krysta Lamothe Katelyn McKay Stephanie Gervin Joseph Humphrey Irna Lasam Shelby McKenna Afshin Ghodrati Cairo Humphries Brittany Lassel Harley McMurdo Neha Ghulam Steven Hutchins Anne Lee Brian McNish Amanda Giasson Queenie Huynh Audrina Lee Kellsi McNulty Sandeep Giddha Iwao Ichisaka Jeffrey Lee Samrin Mekki Megan Gill Francis Lorraine Intrepido Vivian Lee Maxine Merin Amanda Girling Abdoulkader Jaamac Meagen Lepage Kristen Merke Meenakshi Gogar Abin James Payton Lepla Aislinn Michie Jean Gonzales Solomon Adeolu James Erica Leshane Kate Mitchell Nicolette Goodridge Bettina-Sarah Janesch Angela Leung Hilary Mobuogwu Krista Gosché Kyle Jansen-Moulton Ka Hei Leung Shelby Mollard Joseph Grabowski Angela Jantz Keith Leung Murphy Monczka Douglas Grant Olukayode Jegede Lexi Lewarne Sara Monell Bobbie Gray Amanda Jellison Andrea Li Tiffany Moore Maria Greene Yichang Jiang Gina Li Julie-Pier Moreau Lisa-Anne Greenidge Kelsey Johansen Jerry Li Brandon Morgan Tylor Grimsdale Natalie Johnson Katie Li Crescens Joy Morillo Hilary Groom Dakotah Jones Xintian Li Sunita Mukhood Jessica Groulx Cheraley Jorgenson-Harbaruk Yiying Liang Rachel Murray Donald Grynoch Jeffy Joyees Jia Ni Liao Tyler Murray Chaelyn Guckert Jeeyee Kang Jonathan Lin Ali Naghaway Emily Johanne Guignard Zainab Kanuga Aurora Lindley Christina Naismith Michaela Guilas Ken Kariuki Arianna Ling Joshinta Nand Amanda Gurnsey-Clarke Kamola Kasimova Yun Ying Liu Amy Nguyen

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28 CJMLS Spring 2020 SCIENTIFIC SECTION

Arterial Blood Gas Accuracy: Should plastic syringes be transported at room temperature or on ice? Rapid Review

MICAYLA N. MATTHEWS, BHSC, MLT, MPH Candidate

ABSTRACT having the greatest impact on patients who are critically ill, and for Background: Arterial blood gas (ABG) testing is prone to several being the most frequently ordered test in the Intensive Care Unit preanalytical variables including gas diffusion and red cell metabolism. (ICU).1,2 ABG analysis became available in the 1950s, which allowed

Transporting ABG samples on ice slows metabolism, but it may for the measurement of partial pressures of oxygen (PO2) and carbon 3,4 accelerate gas diffusion. dioxide (PCO2), as well as acid-base status. At this time, samples were collected in a glass syringe. Objectives: To determine whether ABG samples collected in plastic ABG analysis is prone to a number of preanalytical errors, 1 syringes should be transported on ice or at room temperature (RT) to including anticoagulant dilution and air bubbles falsely elevating PO2. improve result accuracy. Metabolic processes also continue after blood collection, especially in leukocytes, thrombocytes and reticulocytes, which consume oxygen

Methods: A systematic literature search was conducted in April 2019 (O2), and release carbon dioxide (CO2) and lactate. Metabolism can be using PubMed, CINAHL, EMBASE, and Cochrane Library databases. effectively slowed by transporting ABG syringes on ice.1 Bias was assessed using the Cochrane Collaboration framework. In the 1970s, glass syringes were replaced with plastic, usually polypropylene or another polymer.5 Subsequent studies on ABG Results: Primary and secondary searches revealed 43 articles. storage in plastic syringes revealed significant deviations in gas Inclusion criteria identified four articles, all of which experimentally composition almost immediately after collection.6-8 This effect has investigated the effects of ABG storage temperature on PO2, PCO2, been attributed to the fact that glass is impermeable to atmospheric and pH in human samples collected in plastic syringes. gasses, whereas pores in plastic may allow for the diffusion of 2O and 6 CO2.

Discussion: Accuracy was measured by comparing PO2, PCO2, and Despite consensus that glass is superior to plastic for ABG pH values over time. ABG transport on ice improved statistical, measurement,6-9 most medical facilities use plastic due to ease-of-use but not clinical accuracy. RT transport is recommended in order to and lower infection risk. Many facilities also transport these samples avoid potential overestimation of PO2, which may undervalue patient on ice. Ice transport is inconsistent with the most recent Clinical hypoxemia. Laboratory Standards Institute (CLSI) guidelines on blood gas measurement, which recommend room temperature (RT) transport Conclusions: There is insufficient evidence to support ice transport for up to 30 minutes.10 of ABG samples collected in plastic syringes. Samples should be Preanalytical errors in ABG testing can adversely impact patient transported at RT and analyzed as soon as possible. Future studies care decisions. Therefore, this review seeks to determine whether ABG should focus on creating controlled, within-subject experiments with samples collected in plastic syringes should be transported on ice or at a large sample size. RT in order to improve result accuracy.

Key Words: Blood gas analysis; Syringes; Temperature METHODS A primary search was conducted in April 2019 using PubMed, INTRODUCTION CINAHL, EMBASE, and Cochrane Library databases. Medical Subject Arterial blood gas (ABG) analysis is essential in determining the Heading (MeSH) terms included “blood gas analysis”, “syringe(s)”, oxygenation and ventilatory status of patients with cardiac and and “temperature”. A hand search of reference lists was conducted respiratory problems. This diagnostic test has been credited with on the selected primary articles. Studies were limited to English and

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human publications. No date limitations were applied due to the small blood, comparison of plastic to glass, and shunt studies. Figure 1 number of articles available. provides an overview of the study selection process.

Study Selection Characteristics of Included Studies Studies selected for this review experimentally investigated the All four studies included in this review investigated the effects of composition of PO2, PCO2 and pH in ABG’s that were transported in storage temperature on PO2, PCO2, and pH using human ABG plastic syringes on ice versus RT. Only samples collected directly from samples collected in plastic syringes. The majority of patient samples humans in a hospitalized setting were included in order to reflect the were collected in the ICU, thus reflecting hospital practice. Additional true patient population. This excluded studies that used tonometered details on study characteristics are available in Table 1. or arterialized human blood to imitate normal values. Minimal limitations were applied to ensure inclusion of all relevant studies. RESULTS The author of this review conducted the primary and secondary Summary of Included Studies searches and abstract review. Studies that did not meet selection criteria Mohammadhoseini, et al. (2015) conducted a multistep experimental based on title, abstract, or full text were eliminated. The Cochrane study on ABG samples from the arterial line of 50 ICU patients. A Collaboration risk of bias evaluation framework was used to assess total of 45 samples were included, as five were discarded due to material bias based on low, high, and unclear risk.11 Authors were clot formation. A single collection was divided into five syringes, of not contacted to retrieve missing information that was not included which one was tested immediately, two were stored on ice, and two within the selected articles. Study objective, population, interventions, were stored at RT. The stored samples were tested in parallel at 30 and findings were organized for qualitative analysis. and 60 minutes.12 Statistically significant changes in gas composition

included an increase in PCO2 in samples stored at RT and an increase

Systematic Review Process in PO2 in samples stored on ice. However, researchers found no The search of PubMed, CINAHL, EMBASE, Cochrane Library, and clinically significant differences within the 60-minute timeframe. reference lists identified 43 articles. Eight duplicates were removed, They cautioned that samples stored on ice may increase the likelihood leaving 35 articles to be screened for inclusion. Articles with unrelated of overestimating PO2 and concluded that it is not necessary to store title and abstract were excluded; such as capillary/venous/unspecified ABG on ice when analysis is delayed for up to one hour.12 blood gasses, umbilical cord sampling, and point-of-care testing. A Woolley and Hickling (2003) conducted three separate preanalytical full-text screen was conducted on the remaining 17 articles. Additional studies to evaluate the effects of processing delay, sample quality, and articles were excluded based on the use of arterialized/tonometered temperature storage on ABG accuracy. The study on temperature

COCHRANE REFERENCE PubMed CINAHL EMBASE LIBRARY SEARCH 8 Citation(s) 5 Citation(s) 19 Citation(s) 3 Citation(s) 8 Citation(s)

35 NON-DUPLICATE Citations Screened Figure 1: Search flow diagram

18 Articles Excluded Inclusion/Exclusion After Title/Abstract Criteria Applied Screen

17 Articles Retrieved

Inclusion/Exclusion 13 Articles Excluded 0 Articles Excluded Criteria Applied After Full Text Screen During Data Extraction

4 Articles Included

30 CJMLS Spring 2020 storage was a multistep experiment from Table 1: Characteristics of included studies 10 ICU patients. Samples were drawn in duplicate and placed on RT or ice. Testing Author, Risk of Main Objective Population Sample size Intervals Analyses were performed at <5, 5, 10, year Bias Findings 20, 30, and 60 minutes.13 The researchers (minutes) found a statistically significant increase Moham- Within-subject ICU pa- 45 samples < 3 Low No clinically significant in PO at 30 minutes on ice. They also madho- multistep tients with separated 30 Risk differences in gas 2 seini, et experiment arterial into five sy- 60 composition for up to noted a statistically significant increase al., 201512 to investigate line. ringes: one 60 minutes. of PCO2 at 20 minutes, and decrease in sample analyzed storage immedi- Storage on ice may PO2 at 60 minutes for samples kept at RT. No changes in gas composition were temperature ately, two cause overestimation and time on ice (0oC), of PO . found to be clinically significant, leading 2 delay on PO2, and two at researchers to conclude that there was no o PCO2, pH, and RT (22 C). Not necessary to store difference in ABG accuracy with storage bicarbonate on ABG on ice when on ice versus RT.13 human ABG analysis is delayed up samples. to 60 minutes. Liss and Payne (1993) collected 119 samples from 75 hospitalized patients. Woolley & Within-subject ICU pa- 10 pairs < 5 Low Statistically significant Hickling, multistep tients with of ABG 5 Risk increase in PO2 at 30 Samples were randomized to 60 on ice and 200313 experiment arterial samples, 10 minutes on ice and 59 at RT. Measurements were conducted to investigate line. analyzed 20 statistically significant 14 at 0, 15, and 30 minutes. The researchers sample stor- immediately 30 decrease in PCO2 at 20 determined that PO was elevated in both age tempera- and placed 60 minutes at RT. 2 ture and time on ice groups at 30 minutes, but the increase o delay on PO2, (< 1 C) and No clinically significant was greatest in samples stored on ice. o PCO2, and pH, RT (~ 20 C). improvement from

The researchers concluded that clinically and O2 satura- storing ABG on ice for significant changes in ABG concentration tion on human up to 60 minutes. ABG samples. do not occur on ice or at RT for up to 30 minutes after collection. They recommend that plastic syringes be transported at RT Liss & Randomized Unspeci- 119 sam- 0 Unclear Clinically significant to prevent additional O diffusion into the Payne, multistep fied hos- ples from 15 Risk changes in ABG 2 14 14 1993 experiment pitalized 75 patients. 30 concentration do not sample. to investigate patients Rand- occur on ice or at RT Nanji and Whitlow (1984) conducted a sample stor- from arte- omized to for up to 30 minutes multistep experiment on 21 ICU patients. age tempera- rial punc- 59 samples after collection. Samples were collected in duplicate and ture and time ture at at RT (25oC delay on PO , discretion - 27oC) and Plastic syringes separated to ice or RT. Samples were 2 PCO2, and pH of treating 60 samples should not be placed analyzed 0, 5, 10, 15, 20, 25, 30 and on human ABG physician. on ice. on ice because this 60 minutes after collection.15 Similar samples. may result in additional O diffusion into gas composition trends were recorded 2 the sample. between samples stored on ice and at RT, though samples stored at RT were furthest Nanji & Within-subject ICU pa- 21 pairs 0 Low Changes in gas Whitlow, multistep tients with of ABG 5 Risk composition are from the initial results. The researchers 198415 experiment arterial samples, 10 statistically greater in concluded that these changes became to investigate line. analyzed 15 samples kept at RT, clinically significant after 20 minutes. sample stor- immediately 20 but this change is not They stated that ABG samples routinely age tempera- and placed 25 clinically significant ture and time on ice (0oC) 30 until 20 minutes after need not be kept on ice, except in cases of delay on PO , and RT 60 collection. 15 2 long delay or high leukocyte count. o PCO2, and pH (22 C). on human ABG ABGs do not need DISCUSSION samples. to be stored on ice if analyzed within 20 Statistical Significance minutes. Storage on Data accuracy is a scientific measure of ice is recommended exactness relative to true measurement.16 when there are longer Accuracy in the selected studies was delays in testing or high leukocyte count. assessed by comparing interval PO2, PCO2,

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and pH values to initial measurements. Studies by Mohammadhoseini, Association of Respiratory Care (AARC) recommends that RT et al. (2015), Woolley and Hickling (2003) and Nanji and Whitlow transport not exceed 30 minutes, with the exceptions of five minutes for (1984) discovered that ABG samples stored on ice were closest to the shunt studies and high leukocyte counts. When transport exceeds 30 initial values; whereas Liss and Payne (1993) found similar accuracy in minutes, AARC recommends collection in a glass syringe and chilled.22 both ice and RT storage methods. Overall, ABG samples stored on ice The Clinical and Laboratory Standards Institute (CLSI) recommends resulted in the most statistically accurate measurements. RT transport within 30 minutes. They advise that samples for shunt studies and high leukocyte counts be analyzed sooner.10 Clinical Significance Clinical significance is defined as a variation in an outcome that Limitations is considered important for patient management.17 Studies by ABG testing is subject to several preanalytical variables including Mohammadhoseini, et al. (2015), Woolley and Hickling (2003), and anticoagulant dilution, air bubble contamination, clot formation, Liss and Payne (1993) documented no clinically significant changes syringe size, ambient room temperature, instrument calibration, and in ABG samples during the timeframe of their experiments; whereas the technique applied by the technologist. Additionally, ABG results

Nanji and Whitlow (1984) documented a potentially clinically can be impacted by variation in patient O2 concentration, leukocyte, significant deviation in ABG concentration at RT after 20 minutes. and thrombocyte counts. Most studies attempted to control for these Despite a lack of clinically significant data, the major clinical variables; but there were limitations, which are discussed below. concern documented in these studies was the risk of overestimating Mohammadhoseini, et al., (2015) calculated heparin ratio,

PO2 values in ABG samples stored on ice. This may cause practitioners eliminated bubbles, calibrated the analyzer between each sample, and to underestimate patient hypoxemia, thus decreasing fractions of compared patient demographics. However, they did not assess patient inspired oxygen or missing indications for supplemental oxygen.12,14,18 leukocyte and thrombocyte counts, or disclose if samples were mixed Thus, all studies suggest that ABG’s be transported at RT when before analysis.12 Nevertheless, the overall risk of bias was low due to collected in plastic syringes. the strength of a within-subject experimental design. Woolley and Hickling (2003) controlled for heparin contamination, Supporting Scientific Theories bubble elimination, analyzer calibration, and sample mixing. However, Transporting ABGs on ice is supported by basic theories of metabolism. patient demographics, including leukocyte and thrombocyte counts Metabolic processes continue after blood collection, especially within were not included.13 Risk of bias was assessed as low due to within- leukocytes, thrombocytes, and reticulocytes. These cells continue to subject experimental design, but a sample size of 10 was small to form consume O2 and expel CO2, thus falsely decreasing PO2 and increasing definitive conclusions.

PCO2 in samples stored at RT. The process of metabolism is effectively The study by Liss and Payne (1993) used a randomized design to slowed by sample cooling.1 allocate samples to storage at RT or on ice. The researchers disclosed Transporting ABGs at RT is supported by laws of diffusion. Plastic that they controlled for leukocyte and thrombocyte counts, bubble exposed to cold temperatures constricts, which increases pore size.19 removal, and heparin contamination.14 However, the bias assessment

This facilitates small molecule diffusion, especially O2 which is smaller determined unclear risk, as samples were only collected at the than CO2. Furthermore, Henry’s and Gay-Lussac’s laws of solubility discretion of the treating physician, the random sequence generation and partial pressures substantiate that O2 concentration is high in process was undisclosed, and randomization only took place after cold liquids. Thus, 2O is likely to diffuse across a gradient of higher the initial analysis. Thus, samples initially collected on ice were concentration outside the syringe, to lower concentration inside the subsequently tested at RT, which may have impacted result accuracy. 20 syringe. This leads to the overestimation of PO2. Nanji and Whitlow (1984) disclosed that they controlled for heparin contamination, leukocyte count, and hematocrit. However, there was Additional Findings no disclosure of bubble elimination, sample mixing, or instrument Studies excluded from this review due to the use of arterialized/ calibration.15 The within-subject experimental design made the overall tonometered human blood had similar conclusions. A study by risk of bias low, but a sample size of 21 is too small to form definitive

Knowles, et al. (2006) found a clinically significant increase in PO2 conclusions. concentration when samples collected in plastic syringes were stored on ice for 30 minutes. They concluded that samples drawn in plastic CONCLUSION syringes should be transported at RT, or collected in glass when there This review sought to determine whether ABG samples collected is a delay in analysis.18 A study by Mahoney, et al. (1991) found that in plastic syringes should be transported on ice or at RT in order to results vary by plastic syringe type, but they concluded that plastic improve result accuracy. Included studies investigated the effects of syringes should be transported at RT.7 ABG storage temperature on samples from patients in the ICU or The International Federation of Clinical Chemistry (IFCC) other hospital locations. Contradictory to statistical results, all studies 12-15 recommends RT transport within 15 minutes for PO2 measurement, recommended RT transport. and RT transport within 30 minutes otherwise.21 The American It is evident that ABG samples should be analyzed promptly in order

32 CJMLS Spring 2020 to minimize the effects of metabolism and diffusion. Current studies, and related measurements; Approved guideline. 2nd ed. Document C46- A2. Wayne (PA): CLSI; 2009. guidelines and theories suggest RT transport in order to avoid the  11The Cochrane Collaboration. Cochrane handbook for systematic overestimation of PO2, which could undervalue patient hypoxemia. reviews of interventions. Version 5.1.0. Rev. Mar 2011. London (UK): Thus, this review maintains that there is insufficient evidence to Cochrane Collaboration; 2011. Available from: https://handbook-5-1. support ice transport of ABG samples collected in plastic syringes. cochrane.org/chapter_8/8_assessing_risk_of_bias_in_included_stud- Pending further investigation, ABG samples should be transported ies.htm 12 at RT and analyzed as soon as possible to provide the most accurate  Mohammadhoseini E, Safavi E, Seifi S, Seifirad S, Firoozbakhsh S, Pei- man S. Effect of sample storage temperature and time delay on blood results for patient care. gases, bicarbonate and pH in human arterial blood samples. Iran Red Studies included in this review were limited by preanalytical Crescent Med J [serial online]. 2015 Mar; 17(3):e13577. [cited 12 Apr variables and small sample sizes. The impact of ABG results on patient 2019]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=10. care makes this an area worthy of further investigation. Future studies 5812%2Fircmj.13577. DOI:10.5812/ircmj.13577 should focus on well-controlled within-subject experiments with  13Woolley A, Hickling K. (2003). Errors in measuring blood gases in the a large sample size. These studies should control for a wide range of intensive care unit: effect of delay in estimation. J Crit Care [serial online]. 2003 Mar; 18(1):31-7. [cited 12 Apr 2019]. 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Available Available from: https://www.mayoclinicproceedings.org/article/S0025- from: https://journals.lww.com/asaiojournal/Citation/1956/04000/Moni- 6196(11)61793-X/abstract DOI:10.4065/77.4.371 18 tor_and_Control_of_Blood_and_Tissue_Oxygen.7.aspx  Knowles TP, Mullin RA, Hunter JA, Douce FH. Effects of syringe mate-  4Severinghaus JW, Bradley AF. Electrodes for blood pO2 and pCO2 deter- rial, sample storage time, and temperature on blood gases and oxygen mination. J Appl Physiol [serial online]. 1958 Nov; 13(3):515-20. [cited 12 saturation in arterialized human blood samples. Respir Care [serial Apr 2019]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term= online]. 2006 Jul; 51(7):732-6. [cited 12 Apr 2019] Available from: https:// 10.1152%2Fjappl.1958.13.3.515 DOI:10.1152/jappl.1958.13.3.515 www.ncbi.nlm.nih.gov/pubmed/?term=Effects+of+Syringe+Material%2C  5White G. Basic clinical lab competencies for respiratory care. 4th ed. +Sample+Storage+Time%2C+and+Temperature+on+Blood+Gases+and+ Clifton Park (NY): Delmar Publishers; 2003. Oxygen+Saturation+in+Arterialized+Human+Blood+Samples 19  6Scott PV, Horton JN, Mapleson WW. Leakage of oxygen from blood and  Schmidt C, Muller-Plathe O. Stability of pO2, pCO2 and pH in heparin- water samples stored in plastic and glass syringes. BMJ [serial online]. ized whole blood samples: influence of storage temperature with regard 1971 Aug; 3(5773):512-6. [cited 12 Apr 2019]. Available from: https://www. to leukocyte count and syringe material. Eur J Clin Chem Clin Biochem ncbi.nlm.nih.gov/pubmed/5565518 DOI:10.1136/bmj.3.5773.512 [serial online]. 1992 Nov; 30(11):767-73. [cited 12 Apr 2019]. Available  7Mahoney JJ, Harvey JA, Wong, RJ, Van Kessel A. Changes in oxygen from: https://www.ncbi.nlm.nih.gov/pubmed/1489849 20 measurements when whole blood is stored in iced plastic or glass  Goldman S, Solano-Altamirano JM, Ledez KM. Gas bubble dynamics in syringes. Clin Chem [serial online]. 1991 Jul; 37(7):1244-8. [cited 12 Apr the human body. Toronto (ON): Elsevier; 2018. DOI:10.1016/B978-0-12- 2019]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/1823532 810519-1.00002-6 21  8Pretto JJ, Rochford PD. Effects of sample storage time, temperature and  Burnett RW, Covington AK, Fogh-Andersen N, Kulpmann WR, Maas syringe type on blood gas tensions in samples with high oxygen partial AH, Muller-Plathe O. Approved IFCC recommendations on whole blood pressures. Thorax [serial online]. 1994 Jun; 49(6):610-2. [cited 12 Apr sampling, transport and storage for simultaneous determination of pH, 2019]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/8016801 blood gases and electrolytes. Eur J Clin Chem Clin Biochem [serial on- DOI:10.1136/thx.49.6.610 line]. 1995 Apr; 33(4):247-53. [cited 12 Apr 2019]. Available from: https://  9Harsten A, Berg B, Inerot S, Muth L. Importance of correct handling of www.ncbi.nlm.nih.gov/pubmed/7626698 22 samples for the results of blood gas analysis. Acta Anaesthesiol Scand  Davis MD, Walsh BK, Sittig SE, Restrepo RD (2013). AARC clinical [serial online]. 1988 Jul; 32(5):365-8. [cited 12 Apr 2019]. Available from: practice guideline: Blood gas analysis and hemoximetry. Respir Care https://www.ncbi.nlm.nih.gov/pubmed/?term=Importance+of+correct+ha [serial online]. 2013 Oct; 58(10):1694-703. [cited 12 Apr 2019]. Available ndling+of+samples+for+the+results+of+blood+gas+analysis from: https://www.ncbi.nlm.nih.gov/pubmed/?term=10.4187%2Frespc  10 Clinical & Laboratory Standards Institute. Blood gas and pH analysis are.02786 DOI:10.4187/respcare.02786

csmls.org 33 CSMLS BOARD OF DIRECTORS ELECTION

CSMLS is governed by the Board of Directors, which means these elected volunteers provide the strategic direction of everything that happens at CSMLS. Throughout the year, the elected members of the Board of Directors also work together to advocate on behalf of members. Together, the Board serves as the voice and the face of the medical laboratory profession. Vote

As a CSMLS member, the Board of Directors election is your chance to choose who speaks for you and the profession. How do you want fellow medical now laboratory professionals and the public to perceive the Society and the profession? Get to know this year’s candidates below, and think about who you feel represents you best. Then, use your voice and vote!

In accordance with CSMLS bylaws, the Nominating Committee presents the slate of nominees for the Election of Officers commencing in 2021. Nominee biographies are available at election.csmls.org.

Nominees for Director, Manitoba & Saskatchewan

Linda Kappel Lisa Kendrick Twyla Pearce Michele Sykes

Nominees for Director, Quebec

Hélène Lanigan Nancy Lemelin

Voting is now open: All certified members in good standing are eligible to vote. 1. Go to election.csmls.org 2. Log in to confirm your eligibility to vote 3. Review all the candidates, read their bios and cast your vote by May 16, 2020.

Spring_Journal_BOD_Election.indd 1 10/03/2020 1:31:25 PM CSMLS BOARD OF DIRECTORS ELECTION

CSMLS is governed by the Board of Directors, which means these elected volunteers provide the strategic direction of everything that happens at CSMLS. Society News Throughout the year, the elected members of the Board of Directors also work together to advocate on behalf of members. Together, the Board serves as the voice and the face of the medical laboratory profession. Vote COMPUTER-BASED 2019 ANNUAL As a CSMLS member, the Board of Directors election is your chance to choose TESTING AT CSMLS REPORT who speaks for you and the profession. How do you want fellow medical now laboratory professionals and the public to perceive the Society and the Exam day now looks a bit different for CSMLS exam candidates. One year ago, The CSMLS 2019 Annual Report will be available as profession? Get to know this year’s candidates below, and think about who you CSMLS began the shift to computer-based testing (CBT) for all four National an online publication through the CSMLS website in feel represents you best. Then, use your voice and vote! Certification Examinations (Exam): MLA, General MLT, Diagnostic Cytology April 2020. and Clinical Genetics. We piloted the testing platform in February 2019 with the MLA Exam, then rolled out the General MLT Exam in June Visit csmls.org/annualreport to view the full 2019 In accordance with CSMLS bylaws, the Nominating Committee presents the slate of nominees for the 2019, the Clinical Genetics Exam in October 2019 and the Diagnostic Annual Report. Election of Officers commencing in 2021. Nominee biographies are available at election.csmls.org. Cytology Exam in February 2020. We now offer all exams through CBT.

We partnered with Prometric (prometric.com), an internationally recognized Nominees for Director, Manitoba & Saskatchewan test development and delivery organization, in the implementation of this testing. We have been able to deliver a secure, leading-edge testing platform with their expertise.

As often happens when implementing a major technological system, the shift was not without a few setbacks and bumps in the road, but we persevered and ENEWS have had an overall successful transition in our first year of CBT for the exams. Thanks to the work of our Certification team, and our partners at Prometric, Stay up-to-date on all things CSMLS. Sign we have been able to hit all of our major deliverables. up for CSMLS eNEWS to receive our digital publication biweekly. Receive updates on Linda Kappel Lisa Kendrick Twyla Pearce Michele Sykes CSMLS would also like to thank our stakeholders in the regulatory and society announcements, upcoming events, education communities who supported us throughout this transition. volunteer opportunities, new programs and so much more! Visit csmls.org to subscribe. Nominees for Director, Quebec For information about what to expect on exam day, please visit go.csmls.org/ OnExamDay. Please direct any questions regarding CBT to the Certification department at [email protected].

At the time of publication, we expect the June exam sessions to proceed. We are investigating the addition of exam sessions before October.

National Volunteer Week Hélène Lanigan Nancy Lemelin April 19–25

s National Volunteer Week approaches, CSMLS would Voting is now open: like to thank all our volunteers. Our success would not be possible without your passion and dedication. All certified members in good standing are eligible to vote. AWe would like to recognize the dedicated volunteers who contribute their time, knowledge and expertise to both the 1. Go to election.csmls.org Society and the medical lab profession. Thank you! We look 2. Log in to confirm your eligibility to vote forward to another year of memories and growth working alongside you. 3. Review all the candidates, read their bios and cast your vote by May 16, 2020. csmls.org 35

Spring_Journal_BOD_Election.indd 1 10/03/2020 1:31:25 PM SOCIETY NEWS

2019 CSMLS LAB TOURS

Advocacy for the medical laboratory profession is part of CSMLS’s mission. We strive to make sure that your voice is heard in order to bring attention to current issues affecting Health Minister Petitpas Taylor, Oulton College, Moncton, NB the profession and to simply let Canadians know just how important medical laboratory professionals are to the health care system. One of the best places to do so might just be Parliament Hill.

For more than 10 years, CSMLS has carried on something of a political tradition. Every year, CSMLS Board members and staff make the trek to Parliament Hill. Why? For Lobby Day, a day of face-to-face meetings with some of the top decision-makers in the country to advocate for issues facing the medical laboratory community.

But the conversation doesn’t end there. We invite Members of Parliament (MPs) to take a tour of a laboratory in their Senator Percy Downe, Queen Elizabeth Hospital, Charlottetown, PEI local riding to see your work for themselves. In the lab, the MPs not only see the physical space and equipment, they meet their own constituents behind the tests that help patients every day. The lab tours also show the MPs just how important legislative support is to the profession and their constituents’ health.

Our focus for Lobby Day in 2019 was the MLT labour shortage. Once again, we went to Parliament Hill, and we shared our message: Increasing the supply of new medical laboratory professionals, serving our rural and remote communities and using the current labour force to its full potential will help address the impact of the reduced health care workforce throughout Canada. MP Mel Arnold, Vernon Jubilee Hospital, Vernon, BC Then, we hosted eight lab tours in 2019. From former Green Party leader MP Elizabeth May touring the Saanich Peninsula Hospital lab in British Columbia to Health Minister Ginette Petitpas Taylor learning about the MLT program in New Brunswick, we initiated conversations about the value of the lab to health care across Canada. As MPs saw for themselves the skill and expertise needed to navigate the sheer volume of work in the lab, we explained that the labour shortage will impact medical labs, some of which are already understaffed, and patient care.

We are proud to serve as your voice, and we look forward to the conversations and opportunities for change that this year’s tours will bring. MP Wayne Long, Saint John Regional Hospital, Saint John, NB

36 CJMLS Spring 2020 NATIONAL MEDICAL LABORATORY WEEK 2020 APRIL 26–MAY 2

We’ve shown the world that #WeAreLab. The entire world is watching and understanding the true value of the lab in patient care. While this year's Lab Week may look different, it's a perfect time to use the platform we've been given.

We’re excited to help reveal who lab really is — with your help! This MLA students at Oxford College, Burlington, Ontario. Photo: Abdul Shakoor is a week for all medical laboratory professionals to show pride in the profession, celebrate our hard work and educate the public about what we do. Together, we will help educate Canadians about our vital role in health care and show them who medical laboratory professionals really are.

GET IN ON THE ACTION We’ll help you get started. 1. Visit csmls.org and go to Advocacy > Be a LabAdvocate for tools and tips to help you tell others about the work medical lab professionals do and raise awareness for the profession. 2. Go to labweek.csmls.org to access the toolkit created especially for Lab Week. Items are free to download. 3. Share on social media and tag us in the post using our handle @csmls! Let others know what it's really like to work in the lab. Royal Inland Hospital, Kamloops, British Columbia. Photo: Larissa Nygaard Share behind-the-scenes action or how you're celebrating with colleagues.

Keep up to date on everything #LabWeek by following us on Facebook and Twitter (@csmls). Use the hashtags #WeAreLab and #LabWeek when you post. Together, we can show the world how NOTICE TO MEMBERS: vital lab is now, and for the future of health care. ANNUAL GENERAL MEETING

In light of recent developments related to COVID-19 and the cancellation of LABCON2020, the CSMLS is making considerations for the 2020 Annual General Meeting (AGM).

At the time of publication, the AGM, as originally scheduled, has been cancelled. The membership will be notified of the new date and time as it becomes available, via email and the CSMLS website homepage.

Eligible CSMLS members are entitled to vote at the AGM. If you cannot join us at the AGM, you can still submit your vote to have your voice heard by assigning a proxy to vote on your behalf. Learn more about proxy voting at go.csmls.org/proxy/

William J. Cadzow - Lac La Biche Healthcare Centre, Lac La Biche, Alberta. Photo: Abida Sharmin

csmls.org 37 SOCIETY NEWS

NATIONAL VOICE

As the national voice of Canada’s medical laboratory profession, CSMLS represents the needs and concerns of medical laboratory professionals when working with laboratory and health care-related organizations. CSMLS Board of Directors, staff and volunteers attend meetings, conferences and events on behalf of CSMLS members and the entire medical laboratory profession. Here is where your voice was heard recently:

NOVEMBER DECEMBER JANUARY CAMLPR-CSMLS Meeting Canadian Coalition for Public Budget Consultation Roundtable with TORONTO, ONTARIO Health in the 21st Century Ontario Minister of Finance (CCPH21) OAKVILLE, ONTARIO Government of Canada Evaluation of the Foreign Credential TELECONFERENCE Recognition Program EQual Canada Program Council TELECONFERENCE Meet and Greet with Premier Meeting Jason Kenney TELECONFERENCE Exam Preparation for New Brunswick Community College OTTAWA, ONTARIO WEBINAR CSA: Gender Diversity and the Health Action Lobby (HEAL) Laboratory Exam Preparation for Northern Alberta Institute of Technology OTTAWA, ONTARIO TELECONFERENCE WEBINAR Liberal Party of Canada Meet and Inclusion Conference Presentation: Diversity in the Workplace — Greet Please Don’t Reinvent the Wheel OTTAWA, ONTARIO GATINEAU, QUEBEC Credit Valley Hospital Student Presentation — Ontario Tech University Presentation: Ethics and the OSHAWA, ONTARIO Profession EQual Canada Program Council Meeting MISSISSAUGA, ONTARIO TELECONFERENCE

2020 ADOPT-A-DONOR CENTRE

CSMLS is proud to continue its partnership with Partners for Life, a national program run by Canadian Blood Services. Thanks to the public’s contribution of blood donations, this program helps save lives. Last year, 34 units of blood were donated by 39 active CSMLS members. We also saw 17 new donors sign up — well above the average of five to six new donors!

Once again, CSMLS will hold Adopt-a-Donor Centre days in centres across the country in 2020. Designed to help members advocate for the profession, Adopt-a-Donor Centre days allow donors to come face to face with our members — the professionals who complete the process to create a life-saving resource from each donation. During these events, CSMLS volunteers greet donors and chat with them about the lab’s role in the blood donation system. This is our way of letting donors and the public know what happens to their donations and how lab professionals ensure patient safety at every step of the process.

Keep an eye out for updates on an Adopt-a-Donor Centre event near you during National Medical Laboratory Week, and join us in showing Canada that the medical laboratory community supports the blood donation system. When donating, don’t forget to use the CSMLS Partner for Life code CANA160391.

38 CJMLS Spring 2020 CJMLS_ROCHE_Automation Ad_2_EN_2.pdf 1 1/23/2020 2:26:52 PM

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Spring_Journal_Free_Courses.indd 1 23/01/2020 11:50:06 AM