A JOINT BULLETIN FROM CHESHIRE PATHOLOGY SERVICES JULY 2015 DELAYS IN HISTOLOGY

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1 A JOINT BULLETIN FROM CHESHIRE PATHOLOGY SERVICES JULY 2015 DELAYS IN HISTOLOGY You may be aware that there are currently vacant Consultant posts within the Histopathology Department. At present, there are four vacant posts out of a total of eight Consultants. There is, unfortunately, a National shortage of Histopathology Trainees and adverts for substantive posts have not been successful. We are endeavouring to cover the vacancies with locum appointments and this is being progressed through the Medical Staffing department. For July and August, no Locums are available and so it will be necessary to send non urgent work to an external UK based agency for reporting. These agencies use UK Consultant Histopathologists to report work sent to them. Whilst these agencies that can be used attempt to have a turnaround time from receipt of the slides of five to seven days, this is not always possible depending on amount of work sent to them. For this reason, it is imperative that all specimen request cards have full clinical details on them to allow proper triage of cases and that, as should currently be happening, all those Patients who are on Cancer Pathways, including two week waits, are correctly identified to us. We would not envisage sending any major resection cases, urgent cases or cancer cases out of the department but it would, of course, be entirely counterproductive to mark cases as urgent inappropriately, in the mistaken hope of getting a faster report, as this will merely overload the entire system. With such a significant shortage of substantive Consultants, it will also not be possible to cover the full range of MDT meetings over this same period. I would ask for your patience and understanding during this difficult period whilst we try to rectify the Consultant staffing situation. I would be happy to discuss issues with people if they should so wish. Dr D M Butterworth Consultant Histopathologist Associate Medical Director : : david.butterworth@mcht.nhs.uk

2 NO BARTONELLA TEST We recently received a letter from Public Health England (PHE) informing us that they have withdrawn serology tests for Bartonella (the cause of cat scratch disease). This is now only available as a test carried out on tissue samples. The test was withdrawn on 1 st July. Any blood specimens with a request for Bartonella will generate a result which indicates that the test is no longer available. The decision has been taken by PHE because of the availability of tests of a reliable quality, we will let you know if the situation changes. Kevin Wright Service Lead, Microbiology : : kevin.wright7@nhs.net BIOCHEMISTRY DEPARTMENT RESPONSE TO PATHOLOGY USER SURVEY 2014 We should like to thank everyone who responded to the Pathology user survey. It is an important tool for the laboratory to help improve our service to you, and the many positive comments received were much appreciated. Where we have been able, we have responded directly and for those comments where the respondent could not be identified we have responded below. Unfortunately, we are unable to change some things, but hopefully we have explained the reasons in these instances. Issues around need for Glucose Tolerance Test (GTT), use of HbA1c to diagnose pre diabetes need to be resolved we are now ignoring advice to do a GTT. Comments advising that a GTT should be done are only added on the basis of current and previous glucose results in individuals not known to be diabetic. Clinicians wishing to use HbA1c for the identification of diabetes mellitus and impaired glucose handling are advised to request HbA1c alone and not to measure glucose at the same time. We shall shortly be issuing specific guidance about the use of HbA1c in this context. However, there are a number of clinical situations where using HbA1c for the diagnosis of diabetes is not appropriate, so fasting glucose measurements and GTTs will still need to be done. Therefore, comments will continue to be added to abnormal glucose results in individuals not known to be diabetic, including in some instances advice to do a GTT. We are not routinely doing fasting lipids as only Triglyceride related but biochemistry keep telling us to repeat samples fasting again needs clarification. While random lipid measurements are suitable for screening, and also for monitoring patients with normal random triglyceride levels, the total cholesterol level may be misleading in random samples if the triglycerides are raised, particularly if >4.0 mmol/l, due to the presence of chylomicron-associated cholesterol post-prandially. In addition, determination of the fasting triglyceride level is desirable if the random triglyceride level is significantly raised, to ensure effective management of the dyslipidaemia treatment aimed at the cholesterol level alone in individuals with significantly raised fasting triglycerides (>4. 0 mmol/l) may not be fully effective.

3 Therefore, a comment advising a repeat fasting lipid profile when the random triglyceride level exceeds 4.0 mmol/l will continue to be added. However, where a comment is added advising a repeat lipid profile in 3 months when the cholesterol level is raised but the triglyceride level is normal, in future we shall just suggest a repeat lipid profile and not specify that this repeat sample needs to be fasting. Time and hassle taken to get a weekend xanthochromia is unacceptable. Although the laboratory handbook states that CSF Xanthochromia testing is only available during normal working hours Monday-Friday (excluding bank holidays) from 09:00-17:00h Biomedical Scientists who work outside of these hours / at weekends do always provide this assay if clinically approved by the on call consultant biochemist. As staff work alone out of hours and are responsible for analysing and reporting all tests and requests received during these periods, this may result in a slower turnaround time than during routine hours as it is a labourintensive manual test which requires careful cross-checking to ensure calculations and interpretation are correct before reporting. In certain critical clinical situations, having the lab contact requesting clinicians directly when urgent blood results are available would certainly be helpful This is an area that the laboratory recognises and wishes to develop. The issue has been raised with IT and although this will not be available immediately we are working with our main supplier to look into the possibility of screens in A/E and the lab to inform users when urgent results are available. It will be useful to have more transport runs to improve turnaround time. The current transport tender is 9 years old and is due for renewal, this is currently being looked at by the Trust Procurement Team. We understand and recognise that some transport runs need to change and the Pathology laboratory will work with procurement, the Transport provider and yourselves to ensure that we have a quality courier service with a flexible approach that can respond to the needs of our users and the service. It would be nice for the lab staff to contact doctors directly if they have a serious result with any suggestions for further tests and things to be done. I don't think we utilise the lab staffs expertise and knowledge in this respect. All critically abnormal results are phoned through to the requesting clinician or location. Wherever relevant, clinical interpretation / comments are provided on the report, with suggestions for further tests where appropriate, and the Consultant Chemical Pathologist and Clinical Scientist are available to contact for any additional advice. Please contact the Department if you feel that we have not fully responded to your comments. We are always willing to listen and are open to suggestions to ensure that we continue to provide you with the highest quality service. David Oleesky, MA MB BS FRCPath Consultant Chemical Pathologist : : david.oleesky@nhs.net Sarah Robinson, BSc MSc FRCPath Consultant Clinical Scientist : : sarah.robinson@mcht.nhs.uk Jane Clarke, MSc CSci FIBMS Technical Service Lead Biochemistry : : jane.clarke11@nhs.net Ian Johnson MSc CSci FIBMS Service Lead Biochemistry : : ian.johnson@mcht.nhs.uk

4 ADDITIONAL REQUESTS RECEIVED IN BIOCHEMISTRY Whilst we advocate limiting additional venepuncture in patients where possible, we are struggling to cope with the number of add on requests that we receive. As add on testing is a manual process, it can interrupt the usual laboratory workflow and contribute disproportionately to the laboratory workload. Outside normal working hours ( Monday-Friday, excluding bank holidays), there is usually only 1 biomedical scientist at work. At these times, please do not telephone the laboratory to add on extra tests or chase the results of these extra tests, as this interrupts the biomedical scientist, who is already extremely busy processing urgent requests. Retrieval of samples already in the laboratory to add on additional requests may take some time, particularly if the sample is still being processed for the tests originally requested. They can therefore not be processed as urgent tests. If the further tests are urgent, please send a new request form and sample(s). Process: A signed completed additional request form is required and must be sent to the laboratory before the sample can be processed for any additional tests. For internal hospital requests, the additional request form can be sent to the laboratory via the air tube. For requests from GP surgeries or satellite hospitals, the additional request form can be posted, sent in an envelope with the pathology sample collections or faxed to the laboratory on (Macclesfield) or (Leighton Hospital, Crewe). Samples are generally retained for 1 week and in most instances tests can be added for up to 1 week after the initial sample has been sent. However, certain analytes are less stable and in these instances, the requesting clinician will be notified that the sample is too old to be assayed for the requested additional test(s). We regret that the pathology department is unable to accept additional request forms for immunology and serology tests. This is because separate samples are needed for these tests, as they are generally done in other departments or laboratories than that to which the original blood sample has been sent. Therefore, please send additional blood samples with the appropriate forms for these tests. Contact Numbers for Macclesfield: Jane Clarke, MSc CSci FIBMS Technical Service Lead Biochemistry : : jane.clarke11@nhs.net Contact numbers for Leighton: Ian Johnson MSc CSci FIBMS Service Lead Biochemistry : : ian.johnson@mcht.nhs.uk David Oleesky, MA MB BS FRCPath Consultant Chemical Pathologist : : david.oleesky@nhs.net Sarah Robinson, BSc MSc FRCPath Consultant Clinical Scientist : : sarah.robinson@mcht.nhs.uk

5 MICROBIOLOGY UPDATE UKAS, VITEK AND SEROLOGY Microbiology at Macclesfield have now joined the few who are able to display a certificate from the United Kingdom Accreditation Service (UKAS) indicating compliance with ISO standards. The original assessment took place with four assessors over four days in May of last year and accreditation is valid for the procedures which were being used at the time. The service is constantly changing and developing and each change requires notification to UKAS. We have recently brought on line a new susceptibility and identification mechanism using the Vitek Compact equipment (Biomerieux). This allows us to test large numbers of antibiotics for each isolate and is particularly useful in characterising multi-drug resistance mechanisms in bacteria. The accreditation for this equipment, as part of our overall repertoire, will be part of an assessment visit by UKAS which is scheduled for November of this year. The other development which UKAS will need to assess for our continued accreditation, is the movement of serology testing from dedicated equipment on the Leighton site to high-throughput analysers in the blood sciences section at Macclesfield. This move will lead to better turnaround times, increased quality control and more efficient working. The tests affected are: Hepatitis B surface antigen Hepatitis B core antibody Hepatitis B surface antibody (post vaccination) Hepatitis C antibody Hepatitis A antibody HIV 1&2 antibody and p24 antigen Syphilis antibody Varicella Zoster (chicken pox) IgG (immunity) Rubella antibodies Microbiology and Blood Sciences will be working together over the coming months to ensure that this development is fully controlled and that the only effects on the service are positive ones. If you have any questions, particularly about the changes mentioned in the article or the accreditation process please contact me. Kevin Wright Service Lead, Microbiology : : kevin.wright7@nhs.net UPGRADE OF HAEMATOLOGY FBC ANALYSERS From Monday 13 th July 2015, the Haematology Departments at both Mid and East Cheshire NHS Trusts have upgraded their Full Blood Count analysers to Beckman Coulter Unicel DxH 800 analysers. Although all reference ranges will remain as previous, there may be a slight difference in certain red cell parameters for specific patients. Also, nucleated red cells will now be reported for each patient directly from the analysers as standard. Should you need to discuss any results with the Haematology Department at either site, please telephone: Leighton: Extensions 2645/2646 Macclesfield: