COVID‐19‐another influential event impacts on laboratory medicine management

Abstract Background Before public health emergencies became a major challenge worldwide, the scope of laboratory management was only related to developing, maintaining, improving, and sustaining the quality of accurate laboratory results for improved clinical outcomes. Indeed, quality management is an especially important aspect and has achieved great milestones during the development of clinical laboratories. Current status However, since the coronavirus disease 2019 (COVID‐19) pandemic continues to be a threat worldwide, previous management mode inside the separate laboratory could not cater to the demand of the COVID‐19 public health emergency. Among emerging new issues, the prominent challenges during the period of COVID‐19 pandemic are rapid‐launched laboratory‐developed tests (LDTs) for urgent clinical application, rapid expansion of testing capabilities, laboratory medicine resources, and personnel shortages. These related issues are now impacting on clinical laboratory and need to be effectively addressed. Conclusion Different from traditional views of laboratory medicine management that focus on separate laboratories, present clinical laboratory management must be multidimensional mode which should consider consolidation of the efficient network of regional clinical laboratories and reasonable planning of laboratories resources from the view of overall strategy. Based on relevant research and our experience, in this review, we retrospect the history trajectory of laboratory medicine management, and also, we provide existing and other feasible recommended management strategies for laboratory medicine in future.

accreditation. [7][8][9] Based on history trajectory, we determined that the previous management goal of laboratory medicine only aimed to develop, maintain and improve the quality of accurate laboratory results.
However, since the COVID-19 outbreak, the laboratory management system has become particularly vulnerable. The most prominent issue is that tremendous burden is placed on clinical laboratory resources. Generally, because of cost containment strategies and laboratory space size, clinical laboratories have been designed and organized to sustain a customized volume of tests for local health system, 10 rather than concern rapidly expand their testing capabilities. Therefore, existing laboratory management system is implemented in a planned way under this context and related laboratory material and personnel resources are deployed in separate laboratories, less considered the time efficiency for rapid-launched laboratory-developed tests (LDTs) and the efficient network of regional clinical laboratories. Unfortunately, with COVID-19 continues to spread, the daily activity in separate clinical laboratories is rapidly saturated or even overwhelmed and disrupted by the large numbers of tests for COVID-19. 10  Besides personnel and material resources, huge amount of information processing and large database management also become more critical during COVID-19 pandemic. 11,12 Recent computer science technology in laboratory medicine is more than just simple laboratory information system (LIS) as before. Development of artificial intelligence (AI) technology in medical laboratory is necessarily trend and could actually be addressed some current management problems, especially in decreasing the burden on the healthcare system and rational resource allocation. [12][13][14] Some experts indeed provide automated intelligent frameworks which show great potential benefits in many aspects, such as laboratory diagnosis, laboratory treatment, epidemiological investigation, and biological data mining for fighting COVID-19. [13][14][15][16][17] However, due to some technical aspects (inappropriate analysis methods, limitations of utilizing data mining and machine learning algorithms, low accuracy and computational efficiency), 12,15 such applications still remain insufficient given this worldwide crisis posed by COVID-19 to global public health. Proper and effective handling of these problems facilitates appropriate transformation for medical laboratories. In this review, we introduce the brief history trajectory of laboratory medicine management and also, from the view of overall strategy, provide existing and potential feasible management strategies for laboratory medicine in future.

| HIS TORY OF L ABOR ATORY MED I CINE MANAG EMENT
In the past, influential events impacted laboratory medicine as well as advancements in the management development (Table 1). The development process can be summarized in two aspects, including the scope of laboratory management and the application of advanced technology ( Figure 1).
The scope of laboratory management is increasing compared to previously. Initial important milestones were established as reference measurement system (first biological standardization meeting; 1921 1 ). In addition, the introduction of quality control (by Levey and Jennings;1950 3,18 ) transformed the practice of quality management in the analytical phase. With time, scholars realized errors in clinical laboratory tests did not only occur in the analytical phase 19 and thus a wider scope of quality management was required. Peer-consensus SOPs were previously established and implemented into medical laboratories, which would ensure quality during the pre-analytical and post-analytical phases. 5 During the 1990-2000s, more researchers and related personnel emphasized the importance of laboratory quality management systems (QMS). Laboratory accreditation became an essential aspect of laboratory medicine management and swept worldwide. 20,21 The most unique QMS for medical laboratories is ISO 15189, which obtained rapid international adoption in the 2000s. 8 Laboratory accreditation further strengthened the goal for laboratory management and extended the scope not only for improving the quality of the entire analytical phase but also offered an overarching management structure, including personnel safety and customer satisfaction. [22][23][24] Another aspect impacting management development of laboratory medicine is the application of advanced technology. LIS and laboratory automation were introduced into medical laboratories.
Advanced automated analyzers allow for increased workload capacity and reduce personnel resources, increasing skilled manpower focusing on value-added activities. 25 LIS is a connecting platform that facilitates automatic data transfer, leading efficient management in the communication between laboratory and clinicians. Other influential technology that impacts laboratory medicine includes the polymerase chain reaction (PCR) that was developed in the 1990s. 26 It comprehensively revolutionized diagnostic techniques and contributed to the rapid development of LDTs for nucleic-acid-based methods. It also greatly transformed general legislative and regulatory proposals regarding LDTs.

| E X TENDED SCOPE AND RE S P ONS IB ILITIE S OF L ABOR ATORY MANAG EMENT AF TER COVID -19
Due to the increase in advanced technology applications and other influential public health emergencies impacting the laboratory medicine discipline, the management of laboratory medicine faced many challenges (Figure 1). Previous laboratory management models may not have adapted to the new requirements outside of laboratory, including LDTs and POCT management, the efficient network of regional clinical laboratories and laboratories resources management, information processing and database management, etc.

| Conditions for rapid LDTs
Since PCR was generated in the 1990s, a variety of LDTs were established and launched in clinical laboratories. Management activities of laboratory medicine were extended to interact with manufacturers, developers, and researchers, 10,27 as well as involving legislative and regulatory proposals. 28,29 In general, an LDT may need validation in large-scale clinical practice. It takes time to develop routine clinical laboratory testing. Furthermore, to effectively acquire an available license, the development of LDTs generally tends to operate commercially rather than in hospital laboratories. 28,29 However, during the COVID-19 pandemic, many countries launched heterogeneous LDTs for COVID-19 detection 27 and clinical laboratories contributed support to associate with manufacturers and other research institutions. 10,27 In China, at least 11 nucleic-acid-based methods and 8 antibody detection kits were approved for the clinic. 30 Also, other emerging LDTs for detecting COVID-19 were generated. Selecting appropriate LDTs for rapid clinical application was a new issue for medical laboratory management in urgent situations. Certain conditions need to be fulfilled for an LDT to be rapidly applied into medical laboratories. These conditions are as follows: A five-phase examination process model was proposed, referred to as "filter model" or "NEXUS vision", covering a wider scope of laboratory medicine

Effective evaluation of heterogeneous LDTs for selection.
Daily laboratory management mainly sustains the quality of routine laboratory results. However, since the recent rapid devel- detection LDTs, modifications and optimization of protocols in order to meet hospital laboratory requirements is indispensable. 28 The foremost prerequisite is to understand potential pre-analytical and analytical vulnerabilities in laboratory diagnosis. 33

| POCTs and LIS
Point-of-care devices (POCT) reduce turnaround time or even exempt unnecessary steps during the sample collection process. 39,40 Considering these advantages, most countries realized an urgent priority in launching and establishing proper POCTs for rapid  In reshuffling laboratory medicine resources, a feasible solution is reinforcing the efficient network of regional clinical laboratories involving those not directly challenged by the outbreak. However, in turn, the frequent activities of regional clinical laboratories give rise to several unavoidable issues, such as infectious specimen transportation, biosafety requirements, and result consistency. 10 Another effective alternative is to create new facilities within already existing buildings that can help perform tests in large volumes. 10 New facilities should be constructed nearby medical sites, such as clinical wards, ICUs, and emergency departments, to fulfill minimum pre-analytical quality requirements (especially sample transportation and collection). 50 New facilities should be designed as mobile structures, such as trucks or caravans, as well as performed inside tents, shelters, or already constructed structures, such as sport stadiums, convention centers, and other public buildings. 47   detection tools in new facilities may introduce portable equipment or POCTs. 10 The availability and extended use of these new facilities can be viewed as additional efficient laboratory medicine resources outside of centralized facilities during outbreaks and other biological hazards. 30 To tackle the issue of personnel shortage, personnel can be recruited from other departments of laboratory medicine, healthcare fields, or as volunteers from other groups. Laboratory medicine staff may need to temporarily move to a new laboratory (eg, moving from a biochemistry to a virology laboratory) or may have to move to a new regional clinical laboratory. 10 Since urgent personnel may lack direct experience, professional skills in virologic-related assays, and awareness of biosafety protection, hands-on training is required as soon as possible. Existing laboratory professionals may also provide a critical guide for urgent recruited personnel on-site or online and define clear and temporary guidelines for their operations is an efficient manner.

| Improvement of laboratory safety management
Presently, specimens for COVID-19 detection collected from the upper respiratory tract or blood are often assigned to microbiological or molecular laboratories. 36 These infectious disease related laboratories are traditionally categorized as having a high exposure risk. However, recent research already reported that SARS-CoV-2 could be isolated from the blood, feces, and urine of patients. 23,47,51 These findings indicate that the virus can survive and is infectious through these specimens. 52 Although data show the probability of contracting this virus by specimen contact is very low, it is still a potential risk. With the spread of COVID-19 in many countries, numerous infected individuals are asymptomatic. 53 Specimens from these individuals often involve other clinical laboratories, such as hematology or biochemistry laboratories, which are generally observed as low-exposure risk departments 27,54 and often lack essential personal protective equipment (PPE). With updated information regarding risk of viral spread, such safety awareness and security protection facilities in these departments will most likely improve. 10,27 Proper laboratory safety regulations will be revised and covered in a wider scope in low-exposure risk laboratories. 55

| "Big data" management in laboratory and policy-making
Presently, laboratory data management may face more advanced requirements, especially on epidemic disease investigation and surveillance. Rather than merely maintenance LIS data inside separate laboratories as usual, current big data survey need sufficient sharing data from wider regional clinical laboratories. For example, during the period of COVID-19 pandemic, big data comes from two aspects (molecular-based testing and routine testing). 56 However, how to effectively access and analyze "big data" from wider regional laboratories without additional burden on the laboratory is an unprecedented challenge for laboratory management.
Fortunately, with recent progress in digitized data acquisition and machine learning methods, AI as another computing science technology is gradually changing medical laboratory practice, especially in huge of information processing and big data management. 14 including classifying blood types, serological/protein biomarker criteria, and rational hospital distribution. 15 Despite the relatively low number of studies in this field, but it can really contribute to make a difference in large database management in future.
In a word, qualified epidemic disease investigation and survey are critical for policymaking and laboratory resources redistribution.
In addition to provide big data from wider regional clinical laboratories timely and accurate, the prerequisite of beneficial laboratory management strategies should also be fully combined with the situation and conditions of local regions.

| OPEN ISSUE S AND INNOVATIVE K E Y SOLUTIONS
Here, we summarize related issues surrounding laboratory medicine management. Some solutions may not be the only option but can be used as an alternative solution. It is worth mentioning that different solutions also bring new unexplored problems which make laboratory management involved in other multidimensional fields (Table 3).

| CON CLUS ION
Although some academic literature recently mention related topics (laboratories findings, laboratories diagnosing tools, method sensitivity, and specificity for COVID-19), they rarely discuss laboratory management from the view of overall strategy. Under current or future urgent public health situations, laboratory management must involve in multidimensional fields. For controlling outbreaks and epidemic disease surveillance, the important and essential management issues are rapid-launched related LDTs or P2+ biosafety laboratories, which demand advanced requirements on existing quality management system. Besides traditional quality management (such as increasing workload demands, reducing errors and enhancing laboratory performance, etc.), time efficiency and reasonable laboratory resources reallocation are also major aspects of current laboratory management.
In order to do the best, strategy and activities of laboratory management must be appropriate, involving consolidation of the efficient network of regional clinical laboratories, big data survey timely, accurate planning of laboratories resources and local political context, etc.