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As recently as eight weeks ago, Ontario had no established method for COVID-19 testing in hospitals.
Since then, the shared Microbiology Lab of Sinai Health and UHN has established itself as the first Ontario hospital lab to go live with testing, and continues to lead the way, expanding test capacity to meet the needs of patients and healthcare centres across the province.
"They have been seamless and relentless," says Dr. Kathryn Tinckam, Interim Medical Director, Laboratory Medicine Program, UHN, who describes the requirements for expanding lab operations as – needing the instruments, the supplies for the instruments, the people to perform testing and then the resources for analysis and reporting.
"What they've really done, in an extraordinary way – is ramp up all of those in parallel," says Dr. Tinckam. "All while still maintaining outstanding microbiology support and routine care for the rest of the hospital and its partners."
Preparation for the lab began in the last week of February, with Dr. Tony Mazzulli, Microbiologist-in-Chief, Sinai Health-UHN, and Christine Bruce, Administrative Director of the Sinai Health-UHN Microbiology Lab, determining preferred testing platforms, navigating available supply chains, and validating tests to ensure accuracy.
Within two weeks, the lab went live and operationalized a diverse range of testing platforms to ensure sustainability.
"What we tried to do is look at the instrumentation we already had to give us a starting point to build on," says Dr. Mazzulli.
"We didn't want to put all of our eggs in one basket given potential problems with accessing supplies – so when we determined we had three viable testing platforms, we decided to move forward with all three."
The lab initially validated its COVID-19 tests by comparing in-house testing to Public Health Ontario results. But then it was taken a step further by introducing external controls to ensure results are both highly sensitive and specific, minimizing the risk of false negatives and false positives.
Despite all these efforts, Dr. Mazzulli says, "if you don't have people, you aren't going anywhere."
Dr. Mazzulli says he is largely working on making sure the tests are functional. Christine is addressing staffing, training, scheduling, and all the pieces needed to go live with 24/7 testing and increased capacity.
Since launching in March with a capacity of 600 tests per day, the lab has grown to test upwards of 2,000 patients per day. An additional 15 staff have been hired to meet testing demands. The lab also expects to hire another 15 staff as operations continue to increase and the lab targets a nearly 11,000 test-per-day capacity by the end of May.
Among the new hires are former staff who have come out of retirement to offer help, as well as residents and medical students who are volunteering their time to help keep things flowing and limit interruptions that could delay analytical staff.
"We realized that every time a laboratory technologist on a COVID line had to stop to answer the phone or an incoming request, it completely upheaved our workflow," says Christine.
"So we've taken all of those distractions off our technologists' shoulders, so they can just focus on getting the test loaded, running and delivering accurate results, so we can maintain what have been the best turnaround times in the province."
Navigating supply chains
In addition to sourcing supplies for in-lab instrumentation, the Sinai Health-UHN shared Microbiology Lab has supported the challenging task of procuring swab-kits to collect patient samples for COVID-19 testing.
"What we have to remember is – by the time Canada was facing community spread, much of the supply chain for swab testing kits globally had already been exhausted," says Rebecca Repa, Executive Vice-President, Clinical Support and Performance, UHN, and one of the leads for UHN's COVID-19 response.
"So, the question we had to ask the microbiology team was – what's a substitute product? What could perform the same way in terms of making an accurate diagnosis, but still have available supply."
The most-common swabs for COVID-19 testing around the world are nasopharyngeal, which are inserted about six centimeters into a patient's nose to collect a sample. What the team ended up finding was a swab diagnostically similar to these standard kits, however it lacked the flexibility to make them safe to bend through a patient's nasal passage.
Dr. Mazzulli says, "it then became a question of, can we still use them?"
"So instead of collecting at the back of the nose, we started collecting samples from the top of the throat as well as both sides of the nose to try and maximize our yield – and so far results have all been successful."
Ultimately, the labs inventive thinking led both Sinai Health and UHN to two essential shipments of swabs that arrived just prior to the United States restricting exports of medical supplies.
Now, the lab plans to go another step with this thinking and is exploring the use of saliva – where swabs wouldn't be a requirement, and patients would simply spit into a testing container to be sent to the lab.
"Just like people coming together around the world, we are no longer practicing in our historical silos limited by institution or limited by specialty," Dr. Tinckam says.
"Nowhere has this been better demonstrated than in the microbiology lab, which is accepting tests from centres all over the province to support vital public health measures."
To this end, Dr. Mazzulli and Christine are participating on provincial calls every morning with microbiology labs from across Ontario, discussing best practices, current volumes, supply shortages and coming together to tackle issues related to COVID-19 testing.
Additionally, the microbiology lab is working closely with referring centres to report test results, Toronto Public Health for confirmed case tracing, and Ontario's Medical Officer of Health to provide test volumes and confirmed cases for provincial review.
The labs' success so far in responding to COVID-19 has largely been a collaborative effort of so many throughout Sinai Health, UHN and health organizations across the province. However, laboratory professionals in particular deserve special recognition for their commitment, especially as their response coincides with National Medical Laboratory Week, celebrated the last week of April every year.
"Our laboratory staff are scientists at heart," says Rebecca. "They understand the science behind disease and are able to methodically walk us through challenges in testing to help find solutions.
I just can't say enough. They are the ones that truly understand the nature of the beast."