Procedure Serial Number: CPSOP 12 Controlled Document. Do Not Photocopy. Department of Cellular Pathology
Procedure: Delivery of urgent samples / frozen sections to Cellular Pathology
Procedure serial number: CPSOP 12
Prepared by: H. J. Hemsworth
Area of application: OUH Theatres
and Wards
Authorised by:
Original issue date: 15/04/2009
Reviewed by: Helen Hemsworth
Number & location of copies : 1. CSU Electronic Master File
2. Cellular Pathology Master SOP file
 Section B sent to the ORH switchboard for
reference
Read only files sent electronically to:
3. Cellular Pathology Web sites
4. Deputy Director of Operations, Cancer
Clinical Centre, CH
5. Theatre Manager, Churchill Hospital
6. Theatre Manager JRII
7. Theatre Manager JRI (Gynae)
8. Renal Transplant Unit
9. Renal Ward
10. Wytham Ward, Churchill (SBTx)
11. City Sprint
12. Transport Coordinator
Personnel requirement: Theatre staff
Couriers/taxi drivers
Porters
Biomedical Scientist / Associate Practitioner / Biomedical
Support Worker- Histopathology
Document review:
Review
Altered Y/N
(Reason for
Date
Version
number
No. of
pages
Signed
Next review
New Document
N
Y
No major change
1.0
1.0
2.0
3.0
5
5
5
5
H.J. Hemsworth
H. J. Hemsworth
A.Goodall
Karen Austin
15/04/10
Nov 2010
Sept 2010
24/1/2014
More detailed info for
taxi drivers. Addition of
red phone.
Adding Web sites as a
location and clarifying
delivery route to
reduce number of
drivers visiting the
mortuary
4.0
7
Anne Goodall
02/12/2017
5.0
8
change)
15/04/09
02/08/10
13/9/10
24/1/201
2
02/12/13
27/01/15
27/01/2019
YOU ARE INSTRUCTED TO READ THE FOLLOWING THOROUGHLY
UNDER NO CIRCUMSTANCES ARE THESE INSTRUCTIONS TO BE AMENDED OR
ALTERED IN ANY WAY OTHER THAN BY THE AUTHOR / SIGNATORY OR A
REVIEWER AS IDENTIFIED IN CPP14 DOCUMENT CONTROL.
Date 27/01/2015
Version Number 7.0
Page 1 of 8
Procedure Serial Number: CPSOP 12 Controlled Document. Do Not Photocopy. Department of Cellular Pathology
COSHH (H&S) INFORMATION:
N/A
Linked procedural risk assessments:
RA Histo 03 Use of formaldehyde
RA Histo 38 High Risk Specimens.
OUTLINE:
Instructions for the safe delivery of urgent frozen section and renal biopsies to Cellular
Pathology only
To prevent delays due to incorrect delivery
PRINCIPLE:
To ensure that staff involved in sending extremely urgent specimens to Cellular
Pathology can provide clear information for delivering the sample safely to the carrier,
be they a porter, a taxi driver or a courier.
This procedure is only for samples where a rapid result is required through frozen
section (i.e. the patient is still under anaesthetic and further treatment is dependent on
the Pathology report from the sample) and urgent renal biopsies.
DO NOT USE THESE BOXES FOR ANY OTHER SAMPLES (e.g. this is not to be used
for delivering bloods, urines, faecal material etc.)
REQUIREMENTS:
Mobile Telephone
Contact numbers
Map
Identification badge
Blue specimen box (see below)
CPP20 Specimen Transport (available on Trust Intranet)
Delivery Address – 2 options
Cellular Pathology or
Return to the sender only
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Version Number 7.0
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Procedure Serial Number: CPSOP 12 Controlled Document. Do Not Photocopy. Department of Cellular Pathology
URGENT CELLULAR PATHOLOGY RENALS OR
FROZEN SECTIONS?
Non - Urgent Cellular Pathology
samples use routine delivery
processes
No
Other specimen types:
Refer to other laboratory instructions
via the intranet
Churchill site – deliver to lab medicine
Yes
USE PALE BLUE BOXES
Discuss with the Pathology speciality lead:
Direct dial or via secretaries 20498/99/500 during Core hours
Or switchboard out of hours
Cancelled
?
Between 08.30 and 16.45?
Update the laboratory
On call service covering
 urgent renal biopsies
 small bowel transplant biopsies
No
Yes
Book with the Cellular Pathology laboratory supplying:
 Patient name
 Specimen Type
 Name of caller
 Contact number/bleep
 Expected date and time of delivery
Telephone extension: 20493
JRII:
Via hatch – do not leave without
speaking to a lab person
Date 27/01/2015
Version Number 7.0
Contact the ‘technician on call’
(Histology Biomedical Scientist)
via switchboard
Arrange delivery:
WEST WING
& GYNAE:
Via porters
CHURCHILL SITE:
City sprint: 01442 281 483
Account number: M40006
Page 3 of 8
Supply map & directions
from CPSOP 12: Section
C & Appendix 1a and 1b
Procedure Serial Number: CPSOP 12 Controlled Document. Do Not Photocopy. Department of Cellular Pathology
METHOD: SECTION A: PROCEDURE WITHIN THE CORE HOURS
IMPORTANT INFORMATION:
The following information relates to samples to be delivered within the core working
hours for Cellular Pathology.
The core hours are: 8.30 until 17.00 (deliveries after 16.45 are likely to cross over
into the out of hours samples)
Do not follow these instructions outside of these hours as this will be detrimental to the
patient and the sample because the appropriate staff will not be available.
For specimens outside of these hours please refer to the information in SECTION B.
Planned Frozen Section’s or renal biopsies
1. Contact the relevant Consultant Pathologist prior to surgery to book and discuss
the case for frozen section or renal biopsy. This is essential to the provision of
the service.
a. Contact numbers are available via switchboard or the intranet
b. If assistance is required with nominating a relevant pathologist contact
histology secretaries on 20498/ 99/ 500.
2. Contact the Biomedical Scientist (laboratory staff, BMS) to book the frozen
section/ renal biopsy with the lab. This is also essential to the provision of the
service.
a. Call (2) 20493 (or (2) 20492 in the unlikely event that your call is
unanswered)
b. Provide the following pieces of information, these are critical to ensure the
process is efficient:
 Patient Name
 Specimen Type
 Name of caller and their contact number/bleep
 Expected date and time of specimen arrival in Cellular Pathology
3. Arrange the delivery of the sample via the appropriate specimen delivery service.
 From the Churchill theatres and renal/ transplant wards this will be via 001
Taxis or City Sprint.
 You will need to provide an account number.
 From the West Wing and Gynae theatres this will be via porters
 From JRII theatres this will be directly to the specimen hatch.
4. Ensure that clear contact details are present on the request form for telephone the
results from the pathologist.
5. Frozen sections and urgent renal biopsies only must be placed inside a pale blue
specimen box for transportation to cellular pathology. See photo above.
a. Ensure the correct delivery address is visible i.e. ‘cell path’ from the
changeable address window on the front of the box.
b. Blue transport boxes are located at designated areas within each site;
 JRII theatres in the specimen bucket/ pot storage room
 JRI theatres (gynae) in the specimen bucket/ pot storage room
 Churchill theatres in the specimen room
 West wing theatres
 level 1- on the fridge with the booking in book
 level 0- in the specimen bucket/ pot storage room
 Renal Transplant unit in the nurses room
 Renal ward in the doctors room
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Procedure Serial Number: CPSOP 12 Controlled Document. Do Not Photocopy. Department of Cellular Pathology
6. Ensure the sample is ready for collection at the arranged pick up point and the
person delivering the sample to Cellular Pathology is aware that:
a. This is NOT a routine sample and requires a rapid result.
b. It can ONLY be delivered to the Cut up room of Cellular Pathology, JRH,
level 1
 delivery elsewhere will delay the procedure and
 will be detrimental to the patient
c. Taxi drivers must follow the directions in appendix 1 (delivery & directions)
 Specific instructions for taxi drivers/ couriers see SECTION C.
d. Specimens from JRII theatres, Gynae theatres and West Wing theatres
must be handed directly to a member of staff through the specimen
reception hatch.
 Do not leave the specimen in the hatch without speaking to a
member of the specimen reception team
Incidental finding during surgery- Unable to pre book a Frozen Section.
7. Telephone Cellular Pathology as soon as possible to alert the lab staff and
relevant pathologist of the impending sample.
a. Use the telephone numbers listed in point 1 and 2 if necessary.
b. Without prior warning of the sample a Consultant Pathologists will need to
be found at short notice who can diagnose and report the sample.
Significant delay to the procedure will occur if the sample is not pre booked.
c. Without prior warning additional delays may be caused as the required
equipment may be unavailable.
d. Where possible, always pre book frozen sections.
e. Un booked frozen sections cannot be dealt with out of the core hours of the
lab normally
8. Follow from step 3 above
SECTION B: PROCEDURE OUTSIDE THE CORE HOURS
IMPORTANT INFORMATION
 Frozen sections due to arrive in the department after 16.45 will fall outside of the
core hours of the department as it takes approx. 15mins to prepare the sample for
diagnosis.
 Frozen sections arriving in the department after this time will become an on-call
request.
 The Trust has not authorised an on call system for the Consultant Pathologists.
However, a frozen section may be processed provided a Consultant Pathologist
has agreed to be available to diagnose and report the sample and a BMS has
been contacted in time to prepare the sample.
 Only a Consultant Pathologist can agree to an out of hours frozen section
a. The BMS is not the correct person to agree
b. It is not the BMS responsibility to contact a Consultant Pathologist.
1. Contact the relevant Consultant Pathologist via JRH switchboard.
a. Should it prove difficult to contact a Pathologist from the relevant speciality,
a Consultant Pathologist from another speciality must be found who will
accept the specimen.
2. Provide information stated in point 2b Section A and arrange transport/ pick up/
drop off directly with the pathologist,
3. The pathologist must contact the on call BMS via the switchboard (known to
switchboard as the ‘technician on call’)
4. Follow points 3 onwards in Section A for delivery instructions.
Date 27/01/2015
Version Number 7.0
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Procedure Serial Number: CPSOP 12 Controlled Document. Do Not Photocopy. Department of Cellular Pathology
SECTION C: SPECIFIC INSTRUCTIONS FOR TAXI DRIVERS
Pick Up
1. From Churchill theatres pick up sample from the Main Reception desk
 This sample will be an emergency frozen section for immediate delivery.
 The patient will remain under general anaesthetic until a result is obtained.
 The result of this sample may change the course of the operation so
immediate delivery of the sample is imperative.
2. From Renal Ward or Renal Transplant Unit pick up sample from main desk in
designated area.
 This sample will be an urgent renal biopsy for immediate delivery.
 The clinicians will require a result the same day and these samples take
approx. 3 hours to process for diagnosis.
 The patient may have renal failure or undergoing transplant rejection so
immediate delivery of the sample is crucial.
3. The sample will be inside a pale blue specimen transport box.
Cellular Pathology Contact number
Delivery Address – 2 options
Cellular Pathology or
Return to the sender only
Drop Off
4. Take sample to the Cellular Pathology entrance at the rear of the hospital.
 See appendix 1a for detailed written instructions of delivery point.
 See appendix 1b for map of delivery point.
5. Contact a member of laboratory staff using the designated telephone. This is the
red handset located on the wall inside the entrance, beyond the glass doors, on
the left hand side.
 The telephone is clearly labelled for delivery of emergency blue boxes only.
 Lift the handset and the telephone will connect directly to the specimen
reception (cut-up) room.
 Let the lab staff know who you are, and that you are delivering a sample in
a blue specimen box.
Additional Information
6. In the event of an incident which may hinder or delay the delivery of the specimen
box ie vehicle accident, contact histopathology specimen reception on the
telephone number in delivery address window on the front of the box. This number
is also on the top of the box 01865 (2)20493.
7. Due to the nature of the samples the likelihood of a formalin spillage is extremely
low.
 Frozen sections are always fresh and are double bagged within the
specimen box.
 Renal biopsies are sent in a tiny volume of fixative (formalin based) and are
double bagged within the specimen box.
 Authorised staff must open the specimen transport box
 Specimen transport box is padded and sealed posing no risk of sample
leakage.
Date 27/01/2015
Version Number 7.0
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Procedure Serial Number: CPSOP 12 Controlled Document. Do Not Photocopy. Department of Cellular Pathology
APPENDIX 1a: DELIVERY and DIRECTIONS OF SPECIMENS FOR FROZEN
SECTION/URGENT ATTENTION ONLY to CELLULAR PATHOLOGY, JRH on level 1
IMPORTANT INFORMATION
1. Deliver the samples for frozen section directly to a BMS who works in Cellular
Pathology
2. Deliver the sample to the Cellular Pathology entrance. See appendix 1b
3. DO NOT deliver the sample anywhere else except to Cellular Pathology i.e. do not
deliver to JR porters desk, main reception level 2 or level 4 specimen reception
Directions from Headley Way:
4. Turn into the hospital site and follow signs to car park 1 by:
a. Turning left at the first roundabout (The West wing building and children’s
hospital are behind the roundabout)
b. Taking the next right, uphill (still following signs for car park 1)
c. Bearing right at the road fork towards car park 1
5. DO NOT turn into car park 1
6. Turn right at the next entrance after car park 1 (This is a small road between the
trauma unit and staff car park L, signposted for the Coroner’s office)
7. Park in the spaces at the bottom of the slope opposite the Trauma Unit next to the
Coroner’s Office
8. Walk through the grey slatted gates marked ‘No parking beyond this point’
See map 1b and follow
 Do not park beyond the gates as it must be kept clear for undertakers’ cars
and is a fire access point
 Do not go to the mortuary entrance
9. Walk towards the building straight ahead then head right to the entrance
10. Enter the hospital through the glass doors circled on the map 1b
11. Continue through the next set of doors straight ahead.
12. Pick up the red telephone located on the wall on the left just inside the door
 This will connect you directly to the specimen reception room in cellular
pathology.
13. Inform the staff member that you are delivering an urgent sample in a blue box
14. Wait for the staff member to collect the blue box who will confirm they are from
cellular pathology
 Never hand the sample to any other personnel
 Do not deliver specimen to the Mortuary staff
 Staff from theatres also use this entrance but are not authorised to accept
samples for Cellular Pathology
Date 27/01/2015
Version Number 7.0
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Procedure Serial Number: CPSOP 12 Controlled Document. Do Not Photocopy. Department of Cellular Pathology
APPENDIX 1b: MAP
CAR PARK
1
Mortuary

P


Delivery pointCellular
Pathology
Entrance
Only for
samples in a
blue specimen
box
Red telephone
located on the
wall inside
entrance.
To access Cellular Pathology with a samples for a frozen section
Contact numbers are located on the address
panel on the front of the blue box
Date 27/01/2015
Version Number 7.0
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