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External quality assesment in a pandemic

What impact has the lockdown had on UK NEQAS and the services it provides? Barbara De la Salle, Director of UK NEQAS Haematology, and colleagues explain.

It’s Monday 23 March and the country has just gone into lockdown. UK NEQAS teams arrive at work and wonder what the next fortnight or so will bring. As I write this three months later, we inhabit a world where people avoid each other like repellent molecules, corridors are festooned with marker tape at two-metre intervals and some colleagues have only appeared on a computer screen for weeks.  We have had crash courses in video conferencing and live in hope that the NHS has procedures to remove the telephones permanently attached to our ears. So, how did UK NEQAS cope and adapt to the challenges and what have we learnt?

Initial steps

Early in the pandemic, the professional bodies in laboratory medicine published guidance on the prioritisation and deferral of pathology work, which recognised the variation observed in laboratory testing in the UK by the Get It Right First Time (GIRFT) programme and said that tests deemed not essential to managing a patient’s condition safely should be stopped.  

The objectives were to provide pathology service providers with guidance and permission to review services, thus preventing pathology from being overwhelmed and freeing up sufficient staff to expand SARS-CoV-2 testing. The number of “routine” tests requested also dropped as a consequence of reduced attendance in A&E and a reduction/suspension of face-to-face GP and routine outpatient consultations.

UK NEQAS’ comprehensive range of pan-disciplinary external quality assessment (EQA) services is provided for non-UK as well as UK pathology providers, many of which were affected by the SARS-CoV-2 virus on a different timetable from the UK.  

UK NEQAS centres updated and tailored their business continuity plans as the pandemic’s path across the globe became apparent. The unknowns taken into account were the potential impacts on staff numbers, supplies of raw materials (especially the critical non-clinical issue (NCI) blood products from NHSBT) and on postal delivery services. NHSBT were able to supply all the NCI blood products required, with the exception of materials from the Cord Blood Bank, which was closed at the start of the pandemic. Supplies of commercially prepared products from outside the UK arrived by air freight without problem and delivery by road 
was timelier because of reduced traffic.  

UK NEQAS centres that provide lyophilised or frozen assay material were able to draw on their stored materials. UK NEQAS staffing was affected in the same way as laboratories, with team members in isolation, shielding and those with children home schooling.  

Disruption

The difference from our participating laboratories is that a substantial part of EQA provision can be done from home. With the exception of material preparation, packing and despatch, the use of technology enabled the remote administration and generation of exercises, data analysis, report preparation and performance assessment. Office phones were diverted to mobiles, however, the majority of participants’ queries are made by email, which can be picked up remotely. The major problem both anticipated and in reality, was disruption to specimen delivery. If there is one learning point from the pandemic it is never to send out a major EQA exercise in the first two weeks of lockdown just before Easter: it is a perfect storm. Deliveries outside the UK were slower than usual due to restrictions to international postal and courier services and some regions in the world were in total lockdown. The UK Post Office coped well but the increased demand for postal services had an impact.  

This was anticipated and UK NEQAS extended survey closing dates, where survey material stability allowed, and/or removed penalties for the late or non-return of results.

Extending survey closing times unavoidably affected report turnaround times, so reporting deadlines were relaxed to give participants the maximum opportunity to return data.

UK NEQAS amended some schedules of services – suspension or deferment of haematology morphology exercises – in line with advice from professional bodies and suspended programmes with labile survey material likely to be adversely affected by extended delivery times.  

Clinical chemistry services continued uninterrupted, but schemes where the assessment process requires a number of expert advisors to physically meet and review glass slides and reports were deemed impossible, as were those from centres where team members were redeployed by the host organisation to other COVID-19-related work activities. We also had to respond to changes in the services provided by participating laboratories. Participants based in gyms, fitness centres and some POCT locations ceased participation, and others faced shortages of reagents and consumables, as these were prioritised for SARS-CoV-2 testing, and chose not to process EQA.

Test accuracy

Readers will be aware of the debate on the reliability and performance of both the antigen (molecular) tests for the SARS-CoV-2 virus and the corresponding antibody tests, both of which are essential to the identification of infected individuals and to assess those who have already had the virus. The accurate performance of these tests is vital to controlling the future spread of the virus.  

UK NEQAS has worked in recent weeks to provide EQA for both tests. The first molecular test EQA was distributed in May, using material representing a low viral load. As per postal regulation requirements, all necessary health and safety precautions were adhered to. Challenging laboratory techniques at the limit of detection is good practice in EQA to detect any lack of method sensitivity.  

The first antibody EQA distribution was made in the first week in June, one week after implementation of antibody testing in laboratories. This timing was deliberate, as a rapid assessment of these tests via EQA is essential, given their importance to the healthcare system. The specific SARS-CoV-2 diagnostic tests are not the only laboratory methods that have been identified as necessary for the monitoring and treatment of COVID-19 patients. UK NEQAS has established pilot EQAs for procalcitonin and interleukin 6 and developed educational competency assessment modules to support COVID-19 testing, as well as maintaining EQA for other established tests vital for the COVID-19 cohort of patients. The new EQA pilots were set up in very short periods of time with UK NEQAS staff pooling expertise and resources across centres, where required.

The work by UK NEQAS in this time has not all been about EQA. The Chief Medical Officer, Professor Chris Whitty, requested that UK NEQAS participate in a governmental initiative relating to the production of control materials for COVID-19 antibody testing. It was agreed that UK NEQAS would work with the National Institute for Biological Standards and Controls (NIBSC) and other stakeholders to produce and distribute internal control materials for use in the development and validation of COVID-19 laboratory antibody tests. This project is ongoing with regular governmental calls each week and we are extremely proud to be a part of the work.

The future The EQA exercises will continue to be produced from our laboratories, but the teams processing and reporting results are likely to be more dispersed and working far more flexibly. In many ways, this will be to the advantage of participants in different geographical locations and time zones, or working in a shift pattern. We also hope that some benefit will come from the need for social distancing and the challenges to long-distance travel. We are looking actively to expand the use of the virtual world for many educational and scientific events. For example, the popular UK NEQAS Parasitology Teaching Days will be delivered this year in a mixture of formats, depending on the availability of university teaching laboratories, and will incorporate video and online delivery. This model will also be used for the next UK NEQAS pan-disciplinary meeting in late 2020, focusing on pre- and post-analytical errors.  

Timely EQA provision during the implementation stage of the new COVID-19 tests has been a key driver within UK NEQAS. This will continue to be of high importance as laboratories catch up with backlogs and resume normal services. We have all embraced the recent changes within our working areas to ensure patient testing is not compromised. Provision of services has continued to the best of our abilities and we have learnt many new skills. The future will involve reflecting on which changes we can and need to continue and we hope that the increased use of technology, where possible, will provide environmental and health benefits for current and future generations. Whilst we have all faced significant challenges in service delivery, let’s hope that our experience of the pandemic is channelled towards positive changes that will sustain a beneficial impact on our future.  

Barbara De la Salle, Dina Patel and Liam Whitby are directors at UK NEQAS. For more on SARS-CoV-2 Antibodies-UK NEQAS Immunology, email [email protected], for SARS-CoV-2 Molecular Detection-UK NEQAS Microbiology, see ukneqasmicro.org.uk
 

Picture Credit | iStock

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