Great Western Hospitals NHS Foundation Trust
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Pathology Service
Department of Histopathology
Histopathology Service
User Handbook
VERSION No
Version 1.2
DATE OF ISSUE
28/03/2013
REVIEW INTERVAL
24 months
AUTHORISED BY
Dr J Armstrong
AUTHOR
A Bryant
COPY
One
LOCATION OF COPIES
1. General Procedures Folder
2. Q-Pulse™
Document review history
Review date
Reviewed by
Signature
User Handbook - Histology
Great Western Hospitals NHS Foundation Trust
DCN
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Pathology Service
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CONTENTS
0
1
2
3
4
5
6
7
8
9
10
11
Contents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Document Control. . . . . . . . . . . . . . . . . . . . . . . . . . 3
General Information. . . . . . . . . . . . . . . . . . . . . . . . . 3
Contact Details. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Service Availability. . . . . . . . . . . . . . . . . . . . . . . . . .4
Laboratory Location. . . . . . . . . . . . . . . . . . . . . . . . .4
Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Clinical/Technical Advice. . . . . . . . . . . . . . . . . . . . .5
Tests. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Referred Tests. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
8.1
HER2 Testing
8.2
Flow Cytometry
Specimen Collection / Transport. . . . . . . . . . . . . . .6
9.1
Specimen Containers
9.2
Specimen acceptance/rejection
9.3
Products of Conception
9.4
Health & Safety
Quality Management. . . . . . . . . . . . . . . . . . . . . . . . .7
Histology Tests. . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
User Handbook - Histology
Great Western Hospitals NHS Foundation Trust
DCN
Document1
Page
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Date of Issue
28/03/2013
Pathology Service
Department of Histopathology
0 DOCUMENT CONTROL
This handbook is subject to the document control procedures used in the Pathology directorate.
As this version is controlled electronically, any printed copies or locally-saved electronic copies
will no longer be subject to the document control procedures. Please ensure that any
reference is made to the current active version of the document.
1 GENERAL INFORMATION
The Histology Service is provided by the laboratory at the Great Western Hospital, Swindon.
We provide an analytical and interpretative service on a wide-range of clinical specimens.
Since we receive over 19,500 specimens each year, our efficiency depends to a large extent
on your cooperation. Your compliance with a few rules concerning safety, specimen
identification and transport will greatly help us to deliver the service you need. We hope that
this handbook outlines all the information you require to use our service. However, please feel
free to contact us to discuss any problems or issues you may have. Any comments or
suggestions about the User Handbook should be addressed to the Laboratory Manager.
We aim to be a model of excellence in the delivery of a clinical pathology service. In order to
achieve this, we are committed to the following:








Service user involvement
Good professional practice & evidence-based practice
Efficient utilization of resources
Valuing our staff in order to realize their full potential
Commitment to the health, safety and welfare of our patients, staff and visitors
Keeping a safe environment in compliance with current environmental legislation
Working as teams and partnerships
Continuous improvement
2 CONTACT DETAILS
Histology
Histology
Histology
Hsitology
Histology
Cellular Pathology
Consultant Pathologist
Dr Lawrence John
Consultant Pathologist / Dr Janette Armstrong
Head of Department
Consultant Pathologist
Dr Darko Lazic
Consultant Pathologist
Dr Sam Banerjee
Laboratory Manager
Mrs Alyson Bryant
Secretaries
Ext 4999, 5000, 5002
4282
4279
4280
4797
4277
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3 SERVICE AVAILABILITY
The laboratory is open for receipt of specimens from 0830 to 1700 between Monday and
Friday. All specimens must be delivered to Pathology Reception. Any specimens delivered to
Pathology reception out-of-hours must be in formalin otherwise diagnostic interpretation may
be affected.
4 LABORATORY LOCATION
The laboratory is part of the Directorate of Pathology, within the Great Western Hospitals NHS
Foundation Trust. The department is sited on the fourth floor of the main hospital building (see
diagram). The postal address is as follows:
Department of Histology
Great Western Hospitals NHS Foundation Trust
The Great Western Hospital
Marlborough Road
Swindon
Wiltshire
SN3 6BB
Directorate of
Pathology (69)
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5 RESULTS
Please note that we need to establish the caller’s identity before giving results over the
telephone. We are unable to give results directly to patients or their relatives.
Authorised results are available on the Medway system, ICE, and the Winpath Ward Enquiry
system. Results may also be obtained by telephoning extension 4999, 5000 or 5002 (direct dial
01793 604999 / 605000 / 605002).
In general, results are not available until they have been authorised. In exceptional
circumstances, preliminary results may be available direct from the Consultant Pathologists.
However, please bear in mind that this may delay the testing of other samples.
6 CLINICAL/TECHNICAL ADVICE
For clinical advice on the interpretation of results, please contact the relevant Consultant
Pathologist. Laboratory and office staff are not authorised to provide advice on the
interpretation of results.
For advice on technical aspects of histology testing, contact the Laboratory manager or
Biomedical Scientists in the laboratory.
7 TESTS
A list of services provided by the Histology laboratory is detailed in Section 11. Routine
Histopathology only should be requested at the time of submitting the specimen to the
laboratory. The need for additional tests is only usually determined by the Consultant
Pathologists.
8 REFERRED TESTS
We only refer work to laboratories which have an accredited quality management system. The
accreditation status and turnaround times of these laboratories are regularly reviewed.
The following services may be obtained via the Histology laboratory:
8.1
Molecular Testing
When a molecular test (Her2, KRAS, EGFR, etc) is required, this must be discussed with, and
authorised by a consultant histopathologist. Discussion usually takes place at an MDT, and
requests are submitted to the department via the histology.department@gwh.nhs.uk email
address, copying in the laboratory manager. The Consultant will then choose the most
appropriate block from the case to be referred for testing.
8.2
Flow Cytometry
Lymph node biopsies for which lymphoma is suspected should be sent fresh to the laboratory.
The laboratory must be contacted prior to delivery of these samples, and Dr Lazic should be
contacted for any clinical advice. Samples cannot be accepted on Fridays as the referral lab
will not accept samples on weekends. Any samples where TB is suspected must be sent in
formalin and flow cytometry will not be carried out. Samples of the lymphoma cases are sent to
a referral laboratory for flow cytometry testing.
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8.3
Network MDTs
Some cases will require referral to Network MDTs following discussion at a local MDT.
Requests for cases to be sent to a Network MDT must be made by email to the
histology.department@gwh.nhs.uk email address, copying in the laboratory manager. The
request must be sent as early as possible in order to allow the laboratory time to process the
request, and must detail what is to be sent (i.e. blocks and/or slides). Blocks AND slides will
always be sent to the Lymphoma Network MDT.
8.4
Ophthalmic Specimens
Ophthalmic specimens are booked into the GWH Histology IT system but are sent to the
National Specialist Ophthalmic Pathology Service (NSOPS) at University College London for
processing and reporting. The report is uploaded to Winpath from NSOPS’ web portal.
8.5
Cases sent for external reporting
A proportion of our cases are sent to an external provider for reporting due to limited capacity
in-house. These will usually be non-urgent cases, and are dissected and processed at GWH.
The slides are sent away for reporting, and the report returned by email to
GWH.histology@nhs.net for uploading to Winpath. There may be occasions where urgent
cases are sent away for reporting when consultant capacity in-house is reduced. The decision
to send urgent cases will be made by the laboratory manager and/or lead consultant.
9 SPECIMEN COLLECTION / TRANSPORT
9.1
Specimen Containers
Specimens must be submitted in 10% formalin unless prior arrangement has been made with a
member of laboratory staff. The volume should be at least 10 times the volume of the
specimen. All specimens must be placed in appropriate sized containers and sufficient formalin
should be added to cover them. Any specimens being delivered after 5pm MUST be in an
appropriate container with an adequate volume of formalin as they will not be handled by
laboratory staff until the following morning (or Monday morning if delivered after 5pm on
Friday). If specimens are in an inadequate volume of formalin they will undergo bacterial
autolysis and the quality of diagnostic interpretation able to be carried out will be affected.
Specimen containers can be obtained from the Directorate Support Administrator for
Diagnostics and Outpatients (extension 5188).
9.2
Specimen acceptance/rejection
All specimens must be accompanied by a complete and legible Histology Specimen Request
form. A MINIMUM of three matching unique patient identifiers are required on samples and
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request forms. Where multiple pots are accompanied by a single form, each pot must be
detailed on the request form, and the unique patient identifiers must match on all pots and the
request form. See table below for information which should appear on completed request
forms and specimen containers. Unique Patient Identifiers are listed in bold.
REQUEST FORM
a) Surname
b) First name
c) Date of Birth
d) Hospital Number (if available)
e) NHS Number
f) Patients address
g) Ward
j) Patients Gender
i) Requesting Doctor / GP’s Name
j) Clinical Details
k) Type of specimen and, where
appropriate, anatomical site of
origin
l) The test required must be clearly
marked
m) Date and Time of Sampling.
n) Requesting Doctor’s Bleep number
SPECIMEN
a) Surname.
b) First name.
c) Date of Birth.
d) Hospital Number (if available).
e) Ward.
f) Date and time sample taken.
Specimens received unlabelled (specimen pot and/or request form), where there are not 3
matching unique patient identifiers, or where there is insufficient clinical information will be
rejected by the department.
If a specimen is received leaking, it is still accepted into the department. If the form has been
contaminated with formalin and/or body fluids, the source department will be contacted and
requested to provide a new form.
9.3
Products of Conception
Specimens of Products of Conception (POC) that require cremation after processing need to
be accompanied by a cremation form. The legislation surrounding this is very stringent, and the
form needs to be completed with care. Incomplete cremation forms will be returned to source
to be completed while the specimen is being processed. POCs are still subject to the
acceptance/rejection criteria detailed in point 8.2.
9.4
Health & Safety
Samples thought to constitute a risk to staff because of inadequate packing/fixation or warning
may be rejected.
Formalin is harmful by inhalation, in contact with the skin/eyes, and if swallowed. It shows
limited evidence of a carcinogenic effect. Spillages should be absorbed using commercially
available spillage granules or spillage kits. Out-of-date formalin should be brought to the
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histology department for disposal. For further advice/material safety data sheets etc, contact
the laboratory manager.
10 QUALITY MANAGEMENT
The Pathology Service is committed to maintaining accreditation for its quality management
system. Accreditation is undertaken by Clinical Pathology Accreditation (UK) Ltd, an
independent external organisation.
Details of our accreditation, together with performance data, are available from the Laboratory
Manager. As part of our quality management system we routinely monitor certain performance
indicators. These include External Quality Assurance (EQA) scores and specimen Turnaround
Times (TAT). Any failures/poor performances in these indicators are investigated.
In order to help us improve our service, we may ask you to complete a questionnaire. We
greatly value the information obtained from these surveys, and we would like to thank you in
anticipation of your assistance in completing the questionnaires.
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11 HISTOLOGY TESTS
Investigation
Test
Sample
Container
TAT
Routine Histology
Histopathology
Investigation
Various
Container with 10%
formalin
6 weeks
Urgent Histology
Histopathology
Investigation
Various
Container with 10%
formalin
7 days
Limitations
Out-of-Hours
Rejection Criteria
none
no
Insufficient /
inappropriate
clinical/patient data
(see point 9.2)
By request only
no
Insufficient /
inappropriate
clinical/patient data
(see point 9.2)
User Handbook - Histology