key: cord-0907276-45dw5jl7 authors: Virk, Renu K.; Wood, Teresa; Tiscornia‐Wasserman, Patricia G. title: Impact of COVID‐19 pandemic on functioning of cytopathology laboratory: Experience and perspective from an academic centre in New York date: 2021-01-19 journal: Cytopathology DOI: 10.1111/cyt.12953 sha: c39f03fcc8738a65625a5b8452dc08e38c032570 doc_id: 907276 cord_uid: 45dw5jl7 COVID‐19 has extraordinarily impacted every facet of the health care facilities’ operations. Various strategies and policies were implemented promptly to preserve resources, not only to provide medical care to the expected massive numbers of COVID‐19 patients, but also to mitigate the contagion spread at the workplace to ensure safety of healthcare workers. All routine, non‐essential medical services and procedures were ramped down and workers deemed non‐essential were directed to work remotely from home to reduce the number of people at hospital premises and preserve much needed personal protective equipment that were in short supply at the outset of the pandemic. The laboratories did not remain unscathed and were under immense pressure to maintain workplace safety while being operational and provide best patient care with limited resources. In this paper, we share our experience and challenges that we faced in a cytopathology laboratory at a major academic centre in New York, USA during the peak of infection. March in our hospital). The guidelines were developed promptly to mark essential clinical and research work from non-essential work. The university mobilised their resources to readjust and facilitate the new work routine and all non-essential workers were directed to work remotely from home when practicable. These steps were taken to preserve resources, essential staff and hospital supplies, especially personal protective equipment (PPE) to deal with a tsunami of COVID-19 patients that we were about to face in upcoming weeks. Our pathology department and cytopathology laboratory continued to function through this challenging situation that was evolving with continuous revision of institutional policies. We had three goals for this demanding and trying time: (1) maintain safety of staff; (2) provide best patient care with excellent diagnostics; and (3) maintain resident/trainee education. The guidelines provided by our institution as well as local and national organisations were quickly adopted and implemented for safe specimen handling. [1] [2] [3] [4] Our staff remained available and all services including fine needle aspiration (FNA) and on-site adequacy evaluation continued to be provided during this time. Nonetheless, cancellation of routine patient visits, surgeries and procedures had a direct and substantial impact on the quantity as well as quality of specimens received in our laboratory. In this article, we share and summarise our local experience of COVID-19 pandemic on the everyday functioning of our cytopathology laboratory and the modifications that helped us adapt to a new work environment. All cytology specimens, including gynaecological and non-gynaecological, accessioned in our laboratory during the period of lockdown 16 March-15 May 2020 were recorded and analysed for specimen types and diagnostic categories. The results were compared with the number of cases accessioned, specimen type and diagnostic categories during the same time period in 2019. Absolute numbers as well as proportions were calculated for each specimen type and diagnostic category. Statistical analysis was performed using χ 2 test and P value <.05 was considered statistically significant. In addition, we describe modifications in faculty and staff arrangements and educational activities. Cytology service has a very limited role in the direct management of patients with COVID-19 acute respiratory disease and we received limited specimens for that issue. Nonetheless, there was a significant reduction in gynaecological as well as non-gynaecological specimen volume during COVID-19 pandemic. There was 89.5% reduction in gynaecological specimens (n = 8128 in 2019, compared to n = 853 in 2020) logged in our laboratory. There was 76% reduction in non-gynaecological cytology specimen volume (519 in 2020 vs 2169 in 2019). Minimum number of daily cases went as low as two in 2020 with a range of two to 29 compared to 2019 with a daily range of 28-85 during the same period. Table 1 shows the number of specimens received during the lockdown period in 2020 and corresponding same time in 2019. Decrease in absolute volume for all types of specimen was noted across all specimen types (Table 1) increase was noted in the suspicious category (151% increase) followed by positive (61% increase) and atypical (40% increase) categories. Rapid on-site evaluation (ROSE) was performed on 43 (43/519; 8%) specimens during this lockdown time, of which 24 (56%) constituted touch imprints of biopsy specimens. The majority of these biopsies were obtained from lung (n = 11/24). FNA was performed in 19 cases, with the most common site being pancreas (n = 4), followed by liver In our laboratory, ROSE is provided by cytotechnologists (CT) on-site while CP is available as backup for challenging cases. We continued to provide ROSE during this time for FNAs and for biopsy touch imprints, though the number of requests was significantly reduced, as expected. Our laboratory had adequate, albeit limited, PPE. All CTs were provided with one N95 mask and surgical masks/face shields to cover the N95 masks for prolonged use. All universal precautions were followed as during pre-COVID-19 time. Our CTs prepared air-dried smears for on-site evaluation and triaged the specimens based on the findings. Telecytopathology was utilised as needed. Alcohol-fixed slides, liquidbased preparations (ThinPrep) and cell blocks were prepared in the laboratory in biosafety hoods following universal precautions. All staff involved in specimen processing and handling were provided with N95 masks and all specimens were prepared in the biosafety hood while following universal precautions. All CTs stations were spaced out in the laboratory to follow required physical/social distancing. CTs volunteered to be redeployed to other parts of the hospital. These CTs were predominantly involved in specimen shipping from collection site to the testing facility, helping with supply chain in the hospital, and assisted in morgue activities. The residents on cytopathology rotation sign-out on a one-onone basis with their assigned attending during daily sign-outs. However, this sign-out model was not feasible as 6-feet distance at a dual-headed microscope could not be maintained. Dual-headed microscopes allow for approximately 2-feet distance. We substituted direct teaching with microscopes with virtual platforms for daily sign-out. Residents could preview the cases and sign-out with a pathologist utilising live audio-video streaming. In addition, residents were also guided to our in-house education resources available on our cytology-dedicated shared drive as well as web-based education provided by American Society of Cytopathology and United States and Canada Academy of Pathology. We adopted a password protected virtual platform (Zoom) for daily consensus conference, resident teaching, and all other educational and administrative meetings and conferences. The university provided guidelines to maintain privacy and security. The quality of images and live streaming of audio and video was of excellent quality with no interruption or delay. This virtual platform was also highly helpful for our daily consensus conference. We were able to achieve consensus in the majority of cases except rare cases where they were left for personal slide review by CP on sign-out schedule for the day. We encountered an unparalleled and challenging situation during this pandemic. It has impacted all specialties of medicine, some of the effects are broad spectrum affecting all specialties while others are unique to each specialty. In this paper, we have reviewed the scale of COVID-19 impact on cytopathology volume and specimen types, staffing and trainee's education at our institution. We faced several unprecedented challenges during this pandemic. The most notable ones included the maintenance of best patient care while providing a safe work environment for both staff and faculty. The cytology team suffered significant stress and anxiety due to the uncertainty of the crisis combined with limited access to PPE and mandatory requirement to maintain social distancing. Numerous operational steps were taken at the beginning and were continuously updated based on the guidelines issued by national and regional organisations as the situ- Having one CP on-site helped with social distancing but gave us another challenge of maintaining continuity of patient care while preserving the fair schedule for CPs. The cases were shared by all CPs covering the block service and handed over daily at the end of the day to the CP on a sign-out schedule for the next day. Handing over the cases is not routinely done in our cytopathology laboratory and we relied heavily on encrypted e-mail communications and virtual platforms. All challenging cases that could potentially be pending for the next day were reviewed over virtual platforms by CPs on service and a consensus was obtained for preliminary diagnosis and strategy for additional ancillary studies, whenever needed. In addition, an encrypted email including details about all cases pending for additional studies and addenda was sent to all three CPs on sign-out schedule and the cytology laboratory director at the end of each day. The sharing of information, including preliminary diagnosis with clinical history, was immensely helpful to maintain the best patient care without significantly extending the turnaround time while minimising the CP's physical presence in hospital premises. Although the overall volume of daily logged cases was strikingly low, the cases were more challenging either due to the limited quantity or quality of cellular material. The majority of these specimens were obtained from patients with urgent medical needs, most common being oncological issues that required immediate attention. Our laboratory lost almost 76% of its volume compared to the 2019 for a similar time span. However, the effect on proportion of cases was not uniform across different specimen types. In this study, we included the change in absolute numbers as well as the proportion of cases, as we expected the latter to be more informative of the impact of COVID-19 on cytology specimens, therefore reflecting the prompt effects of changes in clinical practice due to the pandemic. We established that the effect on absolute numbers (reduction) was uniform, whereas the effect on proportion was variable as more specimens from patients with urgent care needs, mostly oncological diagnosis, continued to receive medical care at our hospital. Among specimen types, the most remarkable change was noticed on body fluids (including pleural, peritoneal, pericardial and ascites fluid) as their proportion almost doubled compared to that of 2019, similar to a report published by a cytology laboratory from Italy. 8 This laboratory also reported statistically significant increase in urine, breast and lymph node specimens. In our lab, urine specimens showed marginal increase of 1% (statistically non-significant) while breast (0.8% and 1% in years 2020 and 2019 respectively) and lymph nodes (1.5% and 2.2% in 2020 and 2019, respectively) decreased in proportion, but this decrease was not statistically significant. The other specimen type that showed an increased proportion was CSF specimens from leukaemia patients, but this increase was not statistically significant. The specimens from the respiratory system were also reduced except for BALs, which we continued to receive from transplant patients as our hospital is an advanced transplant care centre. Thyroid FNAs, which is one of the most prevalent specimens in our laboratory, got significantly reduced not only in absolute numbers but also in proportion as the majority of the thyroid nodules do not need immediate attention. Among diagnostic categories, malignant cases showed a 61% increase. One of the most remarkable increases was noted in the suspicious category (almost 150% increase), which indicates the challenges that we faced. These specimens were obtained from patients with clinical suspicion of malignancy and these specimens lacked either qualitative or quantitative criteria to reach a definitive diagnosis. All suspicious cases were reviewed by multiple cytopathologists virtually as well in office when available, highlighting the difficulty in achieving a definitive diagnosis. Similarly, the 40% increase in the atypical category highlights the fact that, even though specimen volume went down, cases were more than ever challenging and difficult to diagnose. Virtual platforms played an essential role helping us in managing cases. 9 We conducted a daily intradepartmental consensus conference on a virtual platform that was open to all CPs, CTs and trainees. We also used a virtual platform for our daily sign-out with residents. The COVID-19 pandemic had a significant adverse effect on trainee's education. In anatomic/clinical pathology residency training, residents typically receive only 3 months of cytopathology training as part of their core curriculum, following Accreditation Council for Graduate Medical Education guidelines. During the lockdown status of 2 months, we had two residents who rotated in cytology. One month is a significant duration for cytology training as it makes one third of their total training time and limited specimen volume and specimen range can have negative impact on education and confidence in diagnosis. The COVID-19 pandemic has changed the traditional ways of medical practice, many changes were short-term, but some other changes will persist in the future. It required staff deployment and workflow to be redesigned and reorganised according to each hospital's situation. Web-based applications/platforms played an essential role in medicine, not only for patient care but also for medical education and teaching. Our community came together to rapidly adapt to this new normal in a very short period of time. Now that we have adjusted to a new normal and practices are slowly returning to pre-COVID time, we still continue to take measures to prevent infection spread. Uniform mask policy at work and virtual platforms will be our go-to option to maintain social distancing. There is always a learning curve to any new crisis and we will continue to evolve as we will face new challenges until a permanent cure and/or a vaccine are found. This is an opportunity to make our operations more robust and technology-friendly while providing secure patient care with excellent quality. To conclude, this pandemic started with heightened anxiety for everyone; however, looking back over the last several months, we were able to maintain work continuity and provide timely essential services with utmost quality. In this paper, we have shared our laboratory's operational experience during the peak of infection in New York and report the diverse ways that we explored to provide best patient care and continuous education to our trainees. None of the authors have any relevant conflict of interest to disclose. The data that support the findings of this study are not publicly available due to privacy restrictions. Renu K. Virk https://orcid.org/0000-0002-2984-4202 Laboratory biosafety guidance related to coronavirus disease 2019 (COVID-19) Interim guidance Centers for Disease Control and Prevention Interim guidance for healthcare facilities: preparing for community transmission of COVID-19 in the United States Centers for Disease Control and Prevention Laboratory biosafety guidelines for handling and processing specimens associated with SARS-CoV The COVID-19 pandemic: implications for the cytology laboratory International perspectives: impact of the COVID-19 pandemic on cytology Biosafety in the preparation and processing of cytology specimens with potential coronavirus (COVID-19) infection: perspectives from Taiwan Cytologic and histologic samples from patients infected by the novel coronavirus 2019 SARS-CoV-2: an Italian institutional experience focusing on biosafety procedures Cytology in the time of coronavirus disease (covid-19): an Italian perspective How to cite this article: Virk RK, Wood T, Tiscornia-Wasserman PG. Impact of COVID-19 pandemic on functioning of cytopathology laboratory