Histopathology Laboratory User Manual...Control Policy. ©WHSCT. Histopathology Laboratory User Manual To be used for all Histopathology referrals to the: Histopathology Laboratory

Western Health and Social Care Trust

Cellular Pathology

Histopathology/Mortuary User Manual Page 1 of 23

CELLPATH/MAN/014 1.3 06/12/2018 This is a controlled document. Revision status and dates of review are recorded on Q-Pulse. The format, presentation and

distribution of authorised Cellular Pathology documentation is regulated by CELLPATH/POL/004 – Cellular Pathology Document Control Policy. ©WHSCT.

Histopathology Laboratory User Manual

To be used for all Histopathology

referrals to the:

Histopathology Laboratory Altnagelvin Hospital

Glenshane Rd

Londonderry

Co. Londonderry

BT47 6SB


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1.0 INTRODUCTION This purpose of this manual is to provide all users of the Histopathology

within the WHSCT with information on the optimum procedures for: The collection and handling of primary samples destined for

examination in the histopathology laboratory at Altnagelvin Hospital The procedures for sending muscle biopsies, medical renal biopsies

and skin biopsies for immunofluorescence The process for transfer of bodies to the mortuary in Altnagelvin

Hospital and SWAH

Please note this manual is intended for use as a guide only, should you require any other information or clarification, please contact the relevant

personnel below.

The Laboratory follows the Code of Practice on Protecting the

Confidentiality of Service User Information which is available at Department of Health Social Services and Public Safety website and the

WHSCT Data Protection and Confidentiality Policy (Nov 2018) which is available on the Western Health & Social Care Trust website.

A Guide to the Complaints Procedure is available on the Western Health &

Social Care Trust website.

2.0 LOCATION AND USEFUL CONTACTS

The Histopathology Laboratory for the Western Health and Social Care Trust (WHSCT) is located in the 1st Floor of the Laboratory Building at

Altnagelvin Hospital (see building number 22 on the site map shown in

Appendix 1). The full postal address is:

Histopathology Laboratory Altnagelvin Hospital

Glenshane Road Londonderry

Co. Londonderry BT47 6SB

For clarification on sample collection and reporting procedures contact the

laboratory on Telephone: 028 71345171 Ext 213400

Name Position Contact

Nora McDonald BMS Service Manager Ext. 213975

Louise Matson Section Lead Ext. 213433/213400


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Immunohistochemistry

Jayne Donaghy Section Lead – Main

Laboratory and Processing

Ext. 213404/213400

Paul Magee Section Lead–

Specimen Dissection, and Body Stores

Ext. 213404/213400

Clinical Advice and interpretation of Histopathology samples can be given

by the Pathologists by contacting them on the relevant extension number

between 9.00 am – 5.00pm, Monday to Friday.

Consultant Position Contact Number

Dr Michael McKenna Consultant

213436

Dr Iain Cameron Consultant

213986

Dr Kathleen Mulholland Consultant

213987

Dr Igho Diegbe Consultant

213432

Dr Ciaran Flynn

Consultant 213975

3.0 CLINICAL SERVICE

The Laboratory provides a fully UKAS accredited service number 7911 and functions as part of the Western Health and Social Care Trust (WHSCT)

Cellular Pathology laboratory. It is the aim of the Histopathology Laboratory to maintain the highest of professional and service standards

to clinicians and patients. The laboratory operates Quality Assurance policies and participates in National Accreditation and Quality assurance

policies. In addition, there are internal quality control and audit procedures. The Histopathology laboratory has an established Quality

Management System and Policy which are governed by the Cellular Pathology Policy.


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3.1 Complaints

Any complaints either verbal or written should be directed to the BMS Service Manager for investigation.

3.2 Hours of Service The Histopathology Laboratory is open for sample receipt and processing

from 08:00 hrs to 20:00 hrs Monday to Friday and 08.00 hrs – 12.00 hrs Saturday. The laboratory is closed on Sundays and on Bank Holidays. As

no on-call service is available all samples taken outside these hours must be stored appropriately (see section 3.2.4 Sample Collection). Samples

taken on Friday afternoons will not normally be processed until Monday (Tuesday or Wednesday in the case of a Bank Holiday weekend); direct

arrangements must be made with a Consultant Pathologist and Laboratory if earlier processing and reporting are required for urgent or

red flag cases.

The Histopathology Laboratory provides clinical advice 09:00hrs to 17:00hrs Monday to Friday only.

The Histopathology Laboratory Office (Ext 213986/213436) is available 09:00 to 12:00hrs and 14:00 to 17:00hrs for all other telephone

enquiries. This should not be used to get reports readily available electronically (see 3.2.1 below).

3.2.1. Accessing Reports A hard copy report is posted to the test requestor after report

authorisation.

The authorised report may be accessed electronically using the Northern Ireland Electronic Care Record (NIECR).

Phoning the laboratory office to ask for reports to be read out is an

inefficient use of laboratory resource and ultimately causes delay to

reports being generated on other cases. Requestors are required to await the hard copy report or access the electronic report through NIECR.

In exceptional cases only the reporting consultant can be contacted

directly for a verbal report, for example sudden deterioration in patient condition.


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3.2.2. Sample Triage

The laboratory operates a system of sample triage in which cases are

prioritized using the information provided on the request form.

The expected turnaround times for all samples are also noted below.

Table 1: Priority Categories

GP

referral status

Consultant

or other diagnostic

modality finding

Information

that MUST be provided on

histopathology request form

Priority

Status

Lab

Code

Pathology

standard

Routine Not obviously

malignant

Salient clinical

history

ROUTINE R 80% reported

within 7 calendar days

90% reported in 10 calendar days

Routine Suspicious of malignancy

Salient clinical history

+

Suspicious of malignancy and

reason for suspicion

SUSPICIOUS S 90% reported within 5 calendar

days

Red flag Any Salient clinical history

+ RED FLAG

RED FLAG RF 90% reported within 5 calendar

days

Any Clinically

malignant with likely

patient deterioration*

*Must be

discussed with consultant

pathologist

Salient clinical

history +

URGENT +

Name of consultant

pathologist case discussed with

URGENT U 90% reported

within 3 calendar days

N/A

Resection case

Salient clinical history

Routine 80% reported within 7 calendar

days 90% reported in

10 calendar days


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On occasion it will be necessary to refer cases to other centres for specialized diagnostic testing or expert opinion. A preliminary report will

be issued indicating the case has been referred. It may take up to 4-6 weeks for some externally referred tests to be reported.

3.2.3. Urgent Cases

Samples will only be treated as urgent if prior direct contact is made with a consultant pathologist who in turn has agreed to accept the case for

urgent reporting. A case will not be dealt with as urgent if direct contact with a consultant pathologist has not been made.

An example of an urgent case is; superior vena cava obstruction query

small cell carcinoma.

Cases will not be made urgent where there is no immediate therapeutic

benefit and the primary reason is to simply expedite a report.

There is a provision for Urgent samples to be processed and reported at the weekend if prior notice is given.

3.2.4 Sample Collection

All samples for routine histological examination MUST be placed into

suitable containers with 10% neutral-buffered formalin. There MUST be sufficient formalin in the container to completely cover the sample.

(Ideally there should be at least 3 times the volume of fixative in ratio to the size of the sample to ensure adequate fixation).

An appropriately sized container must be used and samples that have

been forced into containers may be returned unprocessed. It is important to ensure that samples are properly sealed before transportation.

Containers should not be overfilled as they tend to leak and obviously leaking containers should not be sent to the laboratory under any

circumstances.

Sample containers for large specimens used in theatre/DESU in both

acute hospitals are supplied by the histopathology department. Pre-filled 60ml formalin sample containers can be obtained through the e-

procurement system through EMM stores. Note: the histopathology laboratory provides these sample containers to low turnover users; e.g.

health centres.

10% Neutral Buffered Formalin is a hazardous substance and due care must be taken when working with it. Beware of spillages or inhalation of

the vapour as it is a toxic agent that may cause mild to severe irritation to skin and mucous membranes. Appropriate Personal Protective

Equipment must be worn when dealing with histopathology samples. If


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any advice is needed in relation to leaking formalin containers or 10% neutral buffered formalin please contact the Histopathology

Department directly.

Samples MUST NOT be placed into any other solution or into a dry container (except for those in Table 2), as irreversible deterioration of the

sample will take place, making accurate microscopic interpretation impossible. Large surgical resection samples SHOULD NOT be sliced or

opened by the surgeon, but sent directly to the laboratory without delay. Samples in 10% neutral buffered formalin MUST NOT be placed in the

fridge as this may affect the fixation of the specimen.

Table 2: As stated above all samples should be received in 10% neutral buffered formalin except;

SAMPLE TYPE RECEIVED IN

POC for Medical Genetics Container with saline

Placenta for Post Mortem Dry Container

Frozen Section Dry Container

All samples from known or potential carriers of Hazard Category 3

pathogen (TB, Hepatitis B, Hepatitis C or HIV) MUST be clearly labelled with Category 3 stickers on both the request form and the sample

container and sealed in a separate specimen bag. All samples must be transported to the laboratory in a safe and timely

manner. In accordance with Trust policy they MUST NOT be sent via VTS within the hospital and must be delivered by hand to the main laboratory

reception. Samples can be sent to the laboratory via porter staff or Trust transport as per the clinic/wards current protocol. Samples from GP

practices, Tyrone County Hospital, North West Independent Hospital and the South West Acute Hospital should be transported to the main

laboratory reception on the ground floor by van. Samples being sent to the laboratory from within Altnagelvin Hospital should be brought to the

main laboratory sample reception by relevant staff. Samples which are not fixed in 10% buffered formalin i.e. dry or in saline should be sent to

the laboratory or body store in a timely manner to avoid deterioration of

the sample. It is imperative that there is good communication between source and laboratory when transporting frozen section samples.

For all Muscle Biopsies, Medical Renal Biopsies and Skin

Immunofluorescence please contact:

Institute of Pathology Royal Victoria Hospital

Grosvenor Road Belfast


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Contact Telephone: 02890240503

These specimens may require immediate transportation under specialized

circumstances. It is the responsibility of the requestor to directly arrange with the provider in Belfast.


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3.2.5 Histopathology Request form

All samples must be accompanied by a fully completed Histopathology Request Form – CELLPATH/FORM/044 (see Appendix 2). This can be

obtained through internal EMM stores and must not be photocopied.

Breast service examination requests are made using CELLPATH/FORM/060 – Breast pathology Request Form (see Appendix 3).

The Request forms MUST include the Mandatory information and ideally the preferable information and should be documented in a legible

manner (Table 3 – Request Form Information). An addressograph label if available should be attached.

Table 3: Request Form Information

Mandatory Criteria

Preferable Criteria

Request Form

Surname

Health and Care number.

Date Of Birth Consultant

Sample type Date sample taken

Relevant patient history

Gender Patient address

Requestor signature Clinical Details

Source Identification Number of jars on the

form match what was

received Time sample taken

Note: Failure to provide the MANDATORY data required on the

Histopathology Request form will result in the sample being returned.

Omission of PREFERABLE criteria may result in a delay in processing the sample. If Source Identification is not on request form then a report shall

be returned by default to the consultant listed on the Patient Administration System.

Responsibility for full and correct completion of the Histology request form lies solely with the requesting clinician (Hospital or GP based). Request

forms will not be accepted under any circumstances if MANDATORY information is absent and the sample will not be processed until the

discrepancy is amended.

The sample will be returned with an accompanying form highlighting the reason for rejection, the problem and on correction at requesting level

should be signed and dated by the member of staff dealing with the case (see Appendix 4).


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3.2.6 Early Miscarriage: Products of Conception

The histopathology laboratory provides an efficient and dignified service

for all early miscarriage cases throughout the WHSCT. A histopathology request form and Consent form must accompany all Products of

Conception cases and the following details must be completed:

Date and time of specimen Patients full name

Health & Care Number Date of birth

Source (ward/clinic/theatre/health centre) Address

Requesting Clinician

Confirmation that the patient has read and understood the contents of the form

Completion of the relevant consent section on the form(See Appendix 5)

Confirmation or Refusal of the consent Patients Signature & Date

Doctors/Healthcare Professional Taking the Consent Print & Signature & Date

Job Title.

Product of Conception consent forms must be checked to ensure consent

has been taken and noted by the appropriate staff. The consent form should be completed by the medical professional taking consent, signed

and dated by that person and the patient. If there is any discrepancy

with the consent forms the POC and relevant forms are BOTH returned to the ward for correction. The sample cannot be examined until the fully

completed consent form and sample have been returned. This may ultimately cause a delay the diagnosis/report.

Exception: If Products of Conception are NOT to be examined then this

case MUST be sent directly to the body store with no histopathology request form.

3.2.7 Product of Conception cases for Medical Genetics.

The Histopathology Laboratory will process cases for medical genetics (up to 12 weeks gestation) between the hours of 8 -4 Monday – Friday. The

histopathology laboratory will process the sample as per laboratory protocols. Samples for medical genetics will be sent to the regional

medical genetics laboratory in Belfast City hospital at the first available

opportunity via hospital transport.


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Should a sample be retrieved outside normal working hours it MUST be placed in a saline filled container and sent to the laboratory where it will

be kept in a fridge until processed.

For Intrauterine death, stillbirth and neonatal death after 12 weeks it may be important to undertake genetic analysis. If the baby is for post mortem

examination in Belfast the paediatric pathologist will submit a sample of skin for genetic testing if required.

If there is to be no post-mortem then the clinicians may request genetic

analysis. The clinician MUST contact the regional medical genetics laboratory directly for advice.

Please see Appendix 6: Flow chart detailing the process for handling

Products of conception.

3.2.8 Frozen section

Frozen sections should only be requested if the immediate management of the patient is likely to be altered as a result. This service is only

available between the hours of 09:00hrs and 16:00hrs Monday to Friday.

In cases where an unplanned frozen section is required, as much warning as possible should be given to the laboratory as the equipment used

requires appropriate preparation. If the operation is delayed, or if it is subsequently found that the frozen section is not required, please notify

the Histopathology Department without delay.

Urgent requests for frozen section MUST always be discussed with a Consultant Pathologist. Otherwise a letter requesting a frozen section will

be accepted provided the letter states;

- Date of Biopsy and time

- Specimen type - Clinical suspicion

- Consultant in charge - Ward/Area frozen section will take place and

EXTENSION NUMBER.

ALL correspondence should be sent to Dr. Michael McKenna, Clinical lead.

Please note that Hazard Category 3 cases e.g. High TB risk, known HIV, Hepatitis B or C are contraindications to frozen section. If such a sample

is inadvertently processed, full decontamination of the equipment used will be required, and during this time no further frozen sections can be

performed for at least 24hrs. Such instances will be recorded as clinical

incidents. However, if clinical indications highlight the need for a


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frozen section then Consultant in charge should contact the laboratory to speak to the relevant consultant pathologist.

Frozen Sections should arrive after prior notification of its transportation

to the laboratory. Lab Staff have to be notified of its transportation to ensure adequate preparation and collection of the specimen from

Specimen reception.

The frozen section should arrive with - Accompanying Histology request form with details to

allow patient identification - Clinical Details

- Extension Number for result - Consultant in charge

The Result of the frozen section is phoned by the consultant pathologist to the consultant in charge.


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4. Mortuary Building

During the period 08:00hrs and 16:00hrs Monday to Sunday all deaths in hospital must be reported to the staff member covering the body

store/mortuary as soon as possible after the event.

Altnagelvin Body Store/Mortuary Ext 214559/214560

Bleep 8141

SWAH Body Store/Mortuary Ext 254458

Bleep 139

During the period 16:00hrs and 08:00hrs all deaths in hospital must be

reported to portering staff for transport to the body store/mortuary building.

In exceptional circumstances a member of laboratory staff is on-call

for the body stores and can be contacted through switchboard.

On notification of a death the body of the deceased is transported to the

body store. The deceased should have an armband/addressograph label on the right wrist with corresponding band on left leg. Body Store/

portering staff must complete register in the Body Store and the appropriate sections of the transfer form, identification is only carried out

by Body Store staff not portering staff. Ankle and wrist identification bands must be placed on the deceased by ward staff before the deceased

can leave the ward. These identification bands must include the following information as indicated below in Table 4.

Table 4 - Criteria for Body store Acceptance

Arm/ wrist bands

Mandatory Criteria Preferable Criteria

Surname Forename

Health and Care number

Date Of Birth

Ward Address

Hospital Number

Consultant Date of Death


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All Hazard Group 3 Cases must be clearly identified to either the Body Store staff member or portering staff

A body will not be released until the staff member in the body store

receives the Death Certificate.

4.1 Autopsies Where there is cause to inform the Coroner this should be done at the

earliest opportunity and the staff member covering the body store should be made aware. These cases can be transported to the body store as per

section 4 above as the procedure for transport of a body to the body store is the same.

Ward staff must inform Body Store immediately if immediate transport is

required.

If a Coronial Autopsy is required the PSNI will, on behalf of the coroner,

arrange for the deceased to be transported to Belfast.

When the death of an adult occurs in the hospital and no coronial autopsy has been ordered the death certificate should be completed without delay.

Failure to do so will mean a delay in the release of a body to family.

There is no adult consented autopsy service available in the WHSCT.

4.1.1 Paediatric Autopsies Coronial Paediatric autopsies should be dealt with in the same manner as

that for any other reportable death.

Consented Paediatric autopsies are carried by the Northern Ireland

Regional Perinatal/Paediatric Pathology Service which is based at the Royal Victoria Hospitals, Belfast Health & Social Care Trust and which

uses the facilities at the RVH mortuary. For further information contact the Duty Paediatric Pathologist; Trust Tel: 028 90894746.

All requests for this service must be pre-booked through the

Paediatric Office.

Body Store staff must be informed as soon as possible so they can arrange transport of baby to Belfast. The baby and placenta must be sent

to the mortuary Altnagelvin at least 2 hours before the appointed time of autopsy to allow for travelling to Belfast.

The following documents must also accompany the baby to the body

store,

a signed and witnessed consent form,


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a concise and complete clinical summary in association with a completed perinatal autopsy proforma.

In cases of a foetus that is less than 24 weeks gestation the Regional

consent form regarding burial intentions must be completed and signed. Where family burial has been indicated the body store staff will liaise with

either the undertaker or appointed nurse.

It is important that ward staff do not make arrangements for the eventual release of a body without first contacting the body store

staff to ensure that families are not given unnecessary expectations of return of a body.

4.1.2. Early Pregnancy Loss

In most cases the miscarriage consists of placenta, blood clots and lining

cells from the uterus. The placental tissue is microscopically examined to see if there is a reason for the miscarriage. If only a small amount of

tissue is miscarried it may be necessary to process all of the tissue for examination under the microscope and so there will be no tissue

remaining for burial.

Following examination and if there is foetal tissue/placental tissue remaining the tissue will be sensitively dealt with in accordance with the

mother’s wishes as indicated on the Consent for Histopathological Examination and Disposal of Early Miscarriages form.

In the Western Health & Social Care Trust, this method is burial. This is

scheduled on the first working Monday of each month at Ballyoan Cemetery. If the first Monday of the month is a bank holiday, then

burials are scheduled for the second Monday of that given month. There

is a service followed by the burial. Any parent can attend this service.

If the mother decides to bury her early pregnancy loss, she has to contact the body store directly and arrange a date and time for collection. If

contact is not made within 3 months then the hospital will bury the early pregnancy loss at the next scheduled hospital burial.


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Appendix 1: Map of the Altnagelvin Hospital site.


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Appendix 2: Histopathology Request Form.


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Appendix 3: Breast Pathology request Form.


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Appendix 4

Cellular Pathology FSM Form

We are returning this form and/ or sample to you as information is missing that

prevents the Cellular Pathology laboratory processing this sample/ test request. We have identified what information is missing by ticking or providing

information in the relevant box/ boxes below.

Please provide the relevant information and then return the sample and or test request form to the Cellular Pathology laboratory as soon as possible to prevent

any further delay. The patient’s date of birth has not been provided OR is illegible.

The patient’s full name is illegible OR has not been provided.

No health and care number has been provided for this patient.

The consent form has not been signed.

The name of the referring Clinician has not been provided. Data set information on the request form and sample container

do not correspond.

Other reason outlined:

Please return to:

Cellular Pathology laboratory Altnagelvin Hospital

Glenshane Road

Londonderry Co. Londonderry

N. Ireland BT47 6SB

Tel: 028 71345171 ext. 213403 (U.K.) Tel: 048 71345171 ext. 213403 (R.O.I)


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Appendix 5: POC consent form.


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Appendix 6: Flow chart detailing the process for handling Products of conception.

Documents

Histopathology Laboratory User Manual...Control Policy. ©WHSCT. Histopathology Laboratory User Manual To be used for all Histopathology referrals to the: Histopathology Laboratory