key: cord-0817283-4h3wx81q
authors: Hasan, Abdulkarim; Nafie, Khalid; Abbadi, Osama
title: Histopathology Laboratory Paperwork as a Potential Risk of COVID-19 Transmission among the Lab Personnel
date: 2020-08-06
journal: Infection prevention in practice
DOI: 10.1016/j.infpip.2020.100081
sha: 6d5b04d4e1c861e4338ac803e71124084fbca949
doc_id: 817283
cord_uid: 4h3wx81q

ABSTRACT. Background Healthcare workers have a higher risk of acquiring COVID-19 infection. The process of requesting pathology investigations is usually handled manually through the paper-based forms. We evaluated the potential of paper-based request forms to transmit COVID-19 to laboratory staff to make recommendations for dealing with hospital paperwork in a post COVID-19 world. Methods We tracked paper-based forms from time of test ordering till the release of the pathology report by calculating the time taken for the papers to reach the lab and the exposure of each staff group to the received papers from both high and moderate COVID-19 risk areas. Results Four hundred and thirty two (83%) out of 520 forms were received in the laboratory within 24 hours. The remaining 88 (17%) forms took 24 hours or more to be handled by lab personnel. The mean daily exposure time to the paperwork for various laboratory staff was as follows - receptionists: 2.7 minutes, technicians: 5.5 minutes and pathologists: 54.6 minutes. Conclusion More than 80% of the manual paper request forms will take less than 24 hours to be handled by laboratory personnel; carrying a high potential risk for viral transmission. We recommend replacing hardcopy paper-based request forms with electronic requests that could be printed in the laboratory if required. The other option would be to sterilize received papers to ensure the safety of the laboratory personnel. More studies are required to detect stability of the SARS-COV-2 on the different surfaces and the potential risk of COVID-19 transmission through papers.

. However, SARS-CoV-2 has already infected more than 4,000,000 individuals across 210 countries and territories with more than 250,000 deaths around the world.

The higher transmission rate of SARS-CoV-2 as compared to SARS-CoV could be due to a genetic recombination event at the S protein in RBD region of SARS-CoV-2 that may have enhanced its transmission ability [3] . The lower mortality rate of COVID-19 with a higher proportion of infectious patients with mild disease could also account for the higher and more widespread transmission of this virus.

Health care workers (HCWs) have a higher risk of contracting COVID-19, including hospital and laboratory staff. This has consistently been observed since the first reported cases of 15

infected HCW in Wuhan city in China [4] . The presence of SARS-CoV-2 in the air and on surfaces in hospital environments implies a potentially high infection risk for medical staff and other close contacts [5] . However, histopathology and cytology laboratories cannot stop offering the diagnostic services to patients during this outbreak.

The process of requesting laboratory investigations for patients usually occurs manually through paper-based forms. The requesting clinician completes the paper form and hands it to the patient or another HCW in order to deliver the hardcopy manually to the laboratory receptionist who usually receives the specimen along with its paper-based request form [6] . After registering the case, the form would be handed to the laboratory technician for specimen preparation and thence Strain P9 on different types of inanimate surfaces and reported 4-5 days persistence on paper at room temperature [8] . Lai et al(2005) reported persistence of SARS-CoV, strain GVU6109 on paper for 24 hours in room temperature [9] . To our knowledge no studies have assessed the potential risk of exposure from paper coming from different hospital departments to the laboratory during the Coronavirus pandemic. Many studies discussed the use and implementation of electronic laboratory request forms showing a clear advantage in the implementation of electronic over manual laboratory request forms with respect to service quality. In this study we focused on defining the major hospital departments that request histopathology (by frequency and percent), measuring the time from handling the paper by clinician staff till handling by laboratory personnel, and comparing the possibility of COVID-19 transmission by paperwork to laboratory personnel, according to their exposure time to these papers.

Saud Hospital in Saud Arabia, between March 3 rd , 2020 (one day after declaration of the first confirmed case in our country) up to May 10 th , 2020. Paper-based request forms(either paper forms with computer-typed data or hand-written requests in addition to any other accompanied paper-based documents) were tracked from time of writing till release of the pathology report.

All histopathology and non-gynecological cytology cases from all hospital departments were included. Documents without mention of time were excluded. Request forms printed inside the laboratory were also excluded from the study. The total time taken from requesting (paper is handled by HCW and exposed to the hospital environment) to receiving (first contact withlaboratory personnel) was measured by calculating the difference between the ordering time on the request form and the time of receipt. The cases were divided into two groups: less than 24 hours, and 24 hours or more (according to the Center for Disease Control and Prevention (CDC) and Guo et al.; SARS-Cov-2 can sustain on paper surface up to 24 hours) [5] .

Requesting departments and units were divided into two groups: high COVID-19 risk areas(which included Emergency Room (ER), Intensive Care Unit (ICU) and quarantine section) and moderate COVID-19 risk areas (including Wards, Outpatient Department (OPD) and

Operating Room (OR)). This was based on local Infection Control Department categorization J o u r n a l P r e -p r o o f and the Guo et al report which mentioned that COVID-19 contamination is greater in intensive care units than general wards [5] .

Laboratory Staff were categorized into three groups: receptionists, laboratory technicians and pathologists. The total times of exposure to papers of each staff category were calculated daily using a stopwatch.

Statistic analysis was performed using Microsoft Excel 2007 version. Data exhibited as means and standard deviations. Differences between means were tested for significance using t-test for time of paper handling difference and using (ANOVA) test for staff exposure difference.

Ethical approval was done by the local Ethics Committee (Number LA3001/2020).

A total of 520 requests and other accompanied paper pieces were delivered to the histopathology department in the above-mentioned period (Figure 1 ). The sites of origin of this paperwork were as follows -Inpatient wards 227 (43.7%), OR 97 (18.7%), OPD 88 (16.9%), ER 51 (9.8%) and

ICU 57 (10.9%). According to the risk classification, 108 (20.7%) were from high-risk areas and 412 (79.3%) from moderate COVID-19 risk areas. The above results are summarized in Table 1 and Figure 2 . papers took at least 24 hours to reach the laboratory and were handled by the laboratory personnel within a mean time of 46.6 hours. The difference between the two means was statistically significant (P value= 0.00001); see Table 2 .

During the period of this study, the mean daily exposure time to the paperwork for various laboratory staff was as follows; receptionists: 2.7 minutes, technicians: 5.5 minutes and pathologists: 54.6 minutes.

During the 58 day study period it was found that receptionists were exposed, for 2.7 minutes/ day, while the histopathology and cytology lab technicians were exposed for 5.5 minutes and the pathologists were exposed for an average of 54.6 minutes each day. The differences between J o u r n a l P r e -p r o o f these mean exposure times were significant, particularly that between pathologists and receptionists/ technicians, see Table 3 . J o u r n a l P r e -p r o o f 

After Middle East Respiratory Syndrome (MERS) Coronavirus and SAR-CoV-1, SARS-CoV-2 is the third highly pathogenic coronavirus that has emerged during the last two decades. Person to person transmission has been described in both hospital and family settings [10] .

SARS-CoV-2 virus may be present in samples of patients without known COVID-19; in presymptomatic patients, in undiagnosed patients, in minimally symptomatic patients or asymptomatic patients and in convalescent patients, who could still be shedding the virus [11] . Contamination of frequently touched surfaces in the healthcare settings are therefore potential sources of viral transmission. Studies have documented presence of SARS COV viruses in nonviable material for up to 9 days, on paper for 1-5 days with the expectation that SARS-CoV-2 behaves in a similar fashion [12] . Request forms are the most commonly received paperwork in the pathology laboratory. Dealing with paper-based request forms in Histopathologyis still a routine practice in most laboratories, whether they have laboratory information systems or not [13] .

Pathologists and the other laboratory personnel deal with paperwork daily, mostly coming from different hospital departments within a short period of time. The main problem with paper-based work is that, at room temperature the virus can be viable for more than 24 hours. It is difficult to sterilize every single paper without compromising their contents.

This research was carried out to report an observation in relation to the current COVID-19 pandemic. We report that laboratory receptionists are potentially exposed directly to SARS-CoV-2 by touching request forms daily for a mean of 2.7 minutes (technicians for 5.5 minutes andPathologists are exposed to a mean of 54.6 minutes). It is noteworthy that the three staff groups are subjected to the virus within its viable interval. About 21% of the observed paper forms were from high risk departments (ICU and ER), and that 79% were from areasthat are considered moderate risk for COVID-19 infectivity. It was also found that more than 80% of paper forms reach their final destination in the laboratory (Pathologist) within less than 24 hours (mean 5 hours, 42 minutes) and this raises the possibility of contact with a viable coronavirus. Forae and Obaseki (2017) studied pathology request forms to evaluate adequacy of the provided clinical information and reported that 1382 forms (83.3%) were sent by surgeons while 277 (16.7%) were a request sent by physicians [14] . The establishment of an electronic request and handling system for Pathology laboratories is fundamental to ensure the safety of staff, particularly during such a Public Health crisis [15] . We recommend implementation of hospital information systems (HIS) and laboratory information systems (LIS); using only electronic requesting through the system in addition to following the WHO guide to laboratory safety [16] and good clinical practice [17] to ensure non-contamination from infected papers. Moreover optimal methods such as ultraviolet light irradiation to sterilize the received paper forms without affecting its contents should be investigated [18] . More studies are required to detect stability of SARS-COV-2 on paper surfaces and other surfaces and the potential risk of COVID-19 transmission through paper and card.

This study is concerned about paper material as a potential risk for coronavirus transmission and incorporated a suitable sample size (520 paper forms) however; these forms were not tested for the presence of SARS-CoV-2.

We found that 80% of paper request forms reach the laboratory from other departments within 24hours, during this time the virus may remain viable. We also report that all pathology personnelare susceptible to contamination from paperwork.We recommend to stop handling hardcopy paper request forms coming from both high and moderate risk areas of the hospital. We suggest replacement by electronic requesting Where paper forms are unavoidablewe suggest finding a way to sterilize them alongside the application of strict and clear laboratory precautions to ensure the safety of pathology laboratory staff. More studies are required to detect stability of the SARS-COV-2 on different surfaces and the potential risk of COVID-19 transmission through papers.

Assessing Viral Shedding and Infectivity of Tears

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): The epidemic and the challenges

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Risk Factors of Healthcare Workers with Corona Virus Disease 2019: A Retrospective Cohort Study in a Designated Hospital of Wuhan in China

Aerosol and Surface Distribution of Severe Acute Respiratory Syndrome Coronavirus 2 in Hospital Wards

The impact of automating laboratory request forms on the quality of healthcare services

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The COVID-19 pandemic: implications for the cytology laboratory

Persistence of coronaviruses on inanimate surfaces and its inactivation with biocidal agents

Quality-Improvement Measures as Effective Ways of Preventing Laboratory Errors

Adequacy of clinical information supplied by clinicians for histopathologic diagnosis: The university of Benin teaching hospital experince

Integrating Electronic Systems for Requesting Clinical Laboratory Test into Digital Clinical Records: Design and Implementation

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Ultraviolet radiation: a method of sterilization in the pharmaceutical industry

The author s would like to thank Dr Murali varma, FRCPath (Consultant of Cellular Pathology, University Hospital of Wales, UK) for his helpful advice, insightful comments and proof reading. Also thanks for all the lab staff in our hospital for cooperation.

None J o u r n a l P r e -p r o o f