LifeBridge Health - Department of Pathology Anatomic Pathology

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INTRODUCTION

The Division of Anatomic Pathology, Department of Pathology at LifeBridge Health of Baltimore is a full service laboratory committed to providing quality and timely patient care in conjunction with clinician support and the educational mission of the hospital. The division is composed of the traditional sections of Anatomic Pathology which include Surgical Pathology, Cytopathology and Autopsy Pathology. There are specialized laboratories that are associated with Anatomic Pathology which include: Immunofluorescence, Histochemistry and Immunohistochemistry. The Division also employs the facilities of Molecular Pathology and Flow Cytometry.

The Division is staffed by eight pathologists and numerous support and technical staff employees. The pathologists are all certified by the American Board of Pathology. The laboratory is federally certified under CLIA '88 and licensed by the State of Maryland. The quality of work is continuously monitored by internal quality control programs, participation in proficiency testing and participation in hospital wide quality improvement programs. The laboratory operates 24 hours/day, 7 days/week. Staff pathologist are also on call and available for consultation and can be contacted through the page operator.

This guide is designed to provide a convenient resource of information for the services provided by Anatomic Pathology, The summations are an attempt to provide accurate, procedural information related to specimen acquisition and interpretation of results. Because of the complexities of biologic testing, this document cannot be encyclopedic. The medical staff of the Division are available to answer any questions and provide professional advice as the situation requires.

MEDICAL STAFF

USE OF MANUAL

This manual is divided into two parts. Part one contains general information and policies related to the operation of Division of Anatomic Pathology. Part two is an alphabetized listing of the tests offered by Anatomic Pathology. This section is cross-referenced utilizing appropriate synonyms. The basic format where appropriate is as follows:

The test will be discussed in detail under its most commonly used name and will be cross-referenced according to its synonyms. A short designation as to what will be included in a specific test will be indicated as appropriate. Logistics including request form, phone number of appropriate section, availability, special instruction for handling, specific specimen requirements and turnaround time will be indicated as appropriate. The pathology staff will be available for the interpretation of these tests and consultation as to their clinical significance. Examples of appropriate requisition forms are included for reference.

EMERGENCY, STAT, RUSH CASES

An anatomic pathologist is available by telephone or page 24 hours/day, 7 days/week for consultation. The staff pathologist assigned to the operating rooms is available during regular working hours and can be contacted at 601-5103 (ext. 5103). During night and weekend hours, the page operator can reach the on call pathologist at all times. The pathologist is available for consultation, intraoperative gross evaluations, frozen sections and any other questions related to anatomic pathology issues. Rush cases can be designated by the clinician and generally will be available the next working day by noon. The clinician or their office will receive a telephone call as soon as results are available, either final or preliminary. In special circumstances, an adjustment in reporting time can be achieved after discussion of the case and nature of the specimen with the clinician.

PATIENT IDENTIFICATION POLICY

The physician(s) of record, attending physician, consultative physician, surgeon, nursing personnel and/or secretarial staff are responsible for the accurate identification of the patient. Special attention should be given to the identifying wrist or ankle tag. The name and hospital number should be confirmed and correlated with the requisition form prior to transporting the specimen to the Pathology Department.

SPECIMEN IDENTIFICATION POLICY

1. Both a specimen requisition form and label(s) must be completed in full for each patient; confirm that the designations are identical.

2. Patient identification must be verified in each case.

3. Always label at the bedside, in the operating suite or in the examining room.

4. Never give the specimen to someone else to label.

5. Required information includes complete patient name (first, middle, last), hospital identification number, date of birth, time and date of procedure, physician and/or nurse name and badge number and any special identification comments as needed including type of specimen and clinical history.

HOURS OF SERVICE, LOCATION, TELEPHONE NUMBERS

SPECIMEN REJECTION POLICY

Proper specimen procurement and handling are an essential part of obtaining valid, timely laboratory test results. All test requisitions and specimens delivered to Anatomic Pathology must meet mandatory defined criteria for identification, demographic information and packaging. If these criteria are not met following appropriate consultation with the responsible physician or nursing personnel, the specimen may be rejected. The appropriate attending physician, surgeon and/or nursing station will be notified.

Criteria for Rejection:

1. Unlabelled specimen defined as absence of complete patient and specimen identification on the received container. If the specimen container itself is not directly labeled, it will be treated as an unlabelled specimen
2. Mislabeled specimen defined as different patient identification on the specimen requisition and container. If one of multiple specimens is mislabeled, the entire case will be considered mislabeled.
3. Incompletely or improperly labeled specimen deferred as absence of any of the minimally acceptable patient identification data i.e. name, unit number, case number, sex, etc.
4. Inadequate requisitions deferred as absence of minimally acceptable information i.e. name, PIN, case number, sex, physician name, specimen designation, etc.
5. Unsatisfactory specimens defined as inadequate fixation, storage and quantity; the physician will be notified immediately
6. Specimens posing potential biohazards defined as inappropriately packaged specimens i.e. leaking containers or inappropriate containers.

Corrective Action: The laboratory is required by accrediting agencies to reject any specimen not properly identified. Specimens that can be re-obtained will have the source location notified and a request for an new specimen will be made. Specimens that cannot be re-obtained require that the pathologist be informed and that the physician and nursing personnel be notified. The physician of record and/or the nursing supervisor or her designate must come to the Department of Pathology and must correct the deficiency to the satisfaction of the on call pathologist. All cases requiring corrective action will be documented in the in the QA field of the laboratory computer system. No specimen will be released from the department. Inadequate requisitions and sub-optimal specimens not fulfilling mandatory rejection criteria will also be documented in the QA field of the laboratory computer system.

BIOHAZARDOUS SPECIMENS

Vigorous efforts must be made to protect hospital personnel from biologic hazards associated with handling laboratory specimens. Universal precautions will be utilized for all specimens received in Anatomic Pathology. Regulations require that if external contamination of the primary specimen container has occurred, the specimen must be placed in a secondary container. Specimens with external contamination will not be accepted in the department until corrective action has been taken.

ANATOMIC PATHOLOGY REPORTS

Preliminary Reports:

The non-pathologist staff is not permitted to divulge the diagnosis(es) or other patient report information when the report is not complete. An incomplete report is defined as a report not in the computer system or not having the pathologist signature on the hardcopy of the report. The staff will direct the inquiry to the pathologist of record responsible for the case. If the pathologist of record is not available, another staff pathologist will be consulted.

Rush Reports:

Surgical Pathology: Rush reports will be available the following working day (Mon-Sat). All physicians' offices listed on the requisition sheet will be called either with a final report or a status report.

Cytology: Rush reports will be available the following working day (Mon-Fri). All physicians' offices listed on the requisition sheet will be called either with a final report or a status report.

Final Reports:

1. The secretarial staff can provide reports to physicians and staff with appropriate identification.
2. The secretarial staff can provide verbal, telephonic and faxed reports as needed.
3. Final reports will be mailed to all clinicians designated.

GENERAL REPORT INQUIRY

Computer:
Accessioned Cases: Registered in Cerner Powerchart. Completed Cases: Final diagnosis and complete report available in Cerner Powerchart.