JOL'RNAL OF SOCIAL ISSUES VOLUME 30, NUMBER 1 , 1974

Establishing and Maintaining a Laboratory

Flo Pollock

Washington Free Clinic, Washington, D.C.

Pollock helped to set up a laboratory in the Washington Free Clinic. She gives us the tests that the lab offers, the supplies needed to conduct them, the setting up of the lab facility. The on-the-job training that is required for lab technicians became more and more apparent as the lab grew in responsibilities; its importance is indicated. There are also suggestions as to how to keep a good filing system, the use of a nightly logbook and a culture logbook. Many hints are given to other labs to enable them to avoid some of the pitfalls that the WFC encountered.

The lab was set up at the Washington Free Clinic to aid in diagnosis and treatment of patients. The prevalence of certain types of health problems in the community (i.e., V.D., hepatitis, birth control) helped determine the nature of our lab facilities and the type of work performed. Also, an important factor in deciding the scope of the lab was the free clinic's cooperation with existing community services; particularly the District of Columbia Public Health (through the Department of Human Resources).

Presently we offer:

sensitive, easy to read and has no storage problems) pregnancy tests (two minute Pregnosticon, Dri Dot-as it is quite

micro-urinalysis and dipstick urine test basic hematology (white blood count (WBC), hematocric and differen-

monilia and trichemonas wet preps Monospot test for mononucleosis gonorrhea cultures (Thayer-Martin media for female, homosexual and

asymptomatic male diagnosis) pap smears and gram stains (primarily for male G.C. diagnosis)

tial)

Also, we draw blood for VDRL's (for syphilis) and other serologies and blood chemistries which are processed by D.C. Public Health

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labs, at present, free of charge. At times we have offered throat cultures and urine cultures but have found these to be a little tricky for our limited resources.

Because we now do 15% of D.C.’s venereal disease diagnosis and treatment, our relationship with Public Health has been one of mutual advantage so far. They refer patients to WFC and receive V.D. statistics from us (no names-only numbers).

SUPPLIES From Public Health we receive some necessary materials:

penicillin G.C. culture plates lab slips pap smear slide holders transport tubes for bloods rubber bands 3 x 5 cards

A number of our supplies in the lab have come through “appro- priation,” as many of our people work in other labs. At times, depending on the stability of the clinic’s budget, we buy some items. The pregnancy tests are obtained at cost from Organon, who makes them. Many places are sympathetic to WFC so we use this to our advantage and get as good a price as we can. It is also helpful to buy things in bulk (ethanol, vacutainer tubes and needles, methanol, gauzes, cotton balls) as it is cheaper and insures better supply.

LAB FACILITIES They have fluctuated over the last 3 1 /2 years, but there

seems to be a steady trend toward improvement. Since we are housed in a church basement we have serious plumbing and electrical limitations. However, we have managed a sink in the lab and a small 37” (C) incubator, clinical centrifuge and hematocrit centrifuge (which are on loan from Public Health). We also own one good oil immersion scope and one fair hi and lo dry power scope (and pieces of several others). Lab personnel built cabinets, desks and drawers themselves.

TRAINING PROGRAM The lab has not always offered as many tests nor done them

perhaps as competently as it does now. Fortunately, our training

ESTABLISHING AND MAINTAINING A LABORATORY 125

program has improved. Initially, a doctor and a clinic administrator trained almost exclusively lay personnel to do lab tests. We had a training manual which documented tests and how and why to do them. On-the-job training was haphazard at best. Later came “lab training sessions,” a certain number being required before you became more proficient. After about a year of this approach a guy (with two years of college) took charge of the lab and proceeded to build equipment and to improve training. He organized the staff nightly to insure equal hours and experi- ence. We began to have lab meetings and set a voting representative to the Clinic Board meetings.

Eventually, we seemed to be attracting more experienced people-some qualified lab techs and Navy corpsmen. Also, we began to make attempts at cross-training and cross-integration into the rest of the clinic. That is, if there were extra lab people available on a night, we trained them as lay nurses who gave first aid, assisted in gynecological exams, and helped V.D. coun- selors. Unfortunately, we never did have too many people to spare from the lab.

About a year later this man left and another, a conscientious objector, stepped in to take his position. He had a college degree in biology, an interest in medical school, and wanted to further improve the lab. Also, at this time, a clinical pathologist volunteered to be in charge of the lab and help supervise training. Training now included sessions with slides to explain theory with concomi- tant supervised sessions in the lab to practice and improve technique. More access to clinical technique textbooks became possible. By the second year the lab had evolved into a more cohesive and contributing force to the WFC.

SUGGESTIONS FOR OTHER LABS Other innovations at WFC that have proven valuable include

a file-keeping system, a nightly log book, a separate G.C. culture log book, and for a time, a separate book for recording pregnancy tests. The file system is necessary for recording tests that are sent out of the lab (pap smears, VDRL‘s, blood chemistries, etc.) The date the test is sent out is recorded. This way we can keep track of tests and results, how long tests are taking to return, and a more accurate record keeping system is established. We use the administrative staff people, who work in the afternoon when the lab is not open, to check to see when and if a patient’s results are in, and if not, to follow up on them. We do not give

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test results out over the phone in order to protect our patients. The nightly log book lets us know what’s happening on a

night-to-night basis-it also lets us know who performed what tests so that we have a record of proficiency. The separate G.C. culture book facilitates recording results of the culture plates at 24 and 48 hours, as growth, no growth, oxidase positive or negative and gram stain, if necessary. Keeping records makes it easier for us to gather statistics on many areas, e.g., percent positive and negative gonorrhea cultures and number of culture plates we will need, etc. When we were anticipating the possibility of changing pregnancy tests we started a special book in which we recorded duplicate tests of samples over a period of time. This enabled us to decide which pregnancy test was most sensitive and accurate.

Keeping these suggestions in mind, I want to remind you that there are three major aspects of running a free clinic laboratory: 1) supplies, 2) the people who work in the lab, and 3) the training of these volunteers. Supplies are a function of what kind of tests and how many tests you decide to do. This in turn is related to your clinic’s budget and co-operation from community agencies. At WFC our policy is-if you can’t beg or borrow-then buy it.

We have found that our volunteers have varied from lay people to trained technicians. We began mostly with the former but now we are taking only trained volunteers mainly because it requires less training on our part and they are more proficient and knowledgeable in clinical procedures. We have been able to do this as availability and interest of trained people have increased. We still continue our training sessions to refresh memories, discuss new methods, work with old tests, etc. The supervision by a clinical pathologist has helped upgrade the lab’s performance, efficiency, and morale. This supervision has been fortuitous also, since we were hassled earlier about having to obtain an operating license due to a new D.C. law requiring all public medical labs to be inspected and licensed. Currently, because we are under a physician’s supervision we can be defined as a doctor’s private laboratory, thereby circumventing the problem of meeting all the new legal requirements for public laboratories.