CELLULAR PATHOLOGY AND MORTUARY USERGUIDE 2014

Transcription

1 Department Of Laboratory Medicine CELLULAR PATHOLOGY AND MORTUARY USERGUIDE 2014 Page:1 of 47 Date of Issue: Dec 2014

2 CONTENTS Page HISTOLOGY Key Personnel and Laboratory Telephone Numbers 5 The Cellular Pathology Request Form (CELPTHY FRM-KPN-CEL-004) 6 Sample submission/sample container 7 Histology Service 7 Routine Histopathology 8 Rapid Frozen section service 8 Rapid Processing and Urgent Histopathology 8 Skin Immunofluorescence 8 Lymph Node Analysis 8 MOHs Section 9 The Processing Of Foetuses, Retained Products And Placentas 10 Muscle Biopsies 11 Videoconferencing 12 Multidisciplinary Meetings 12 Digital Macro and Microphotography 12 CYTOLOGY Key Personnel and Laboratory Telephone Numbers 13 Sample submission/sample container 14 The LBC Request Form (HMR101) 15 Labelling the Cytology sample 16 Liquid Based Cytology Samples Uncertainty of Measurement 19 Effusions 19 Urines 19 Respiratory Tract Specimens 19 Approved by: Dr M Perenyei Page: 2 of 47

3 Fine Needle Aspirations 20 Nipple Discharges 20 Aspirates of Breast Cysts 20 Cerebrospinal Fluids and Joint Aspirates 21 ANDROLOGY Key Personnel and Laboratory Telephone Numbers 22 Semen Analysis for Subfertility 23 Requesting a Semen Analysis 23 Producing the Semen Sample 24 The Semen Analysis Test 25 Results 26 Interpretation of Results 26 Repeat Tests 27 Post vasectomy semen analysis 27 Requesting a Post Vasectomy Analysis 27 Producing the Semen Sample 28 Post Vasectomy Analysis 29 Results 30 Clearance 30 Special Clearance 31 MORTUARY Key Personnel and Laboratory Telephone Numbers General Information 34 Autopsies 34 Retained Products of Conception and Fetuses 35 Deaths 35 Death of a Patient Approved by: Dr M Perenyei Page: 3 of 47

4 Medical Certificate of Cause of Death 37 Post Mortem Examinations 37 Coroners Cases 38 To Report a Death to the Coroner 39 Circumstances when a Death Must be Reported to the Coroner Reporting Deaths Involving MRSA or other Infective Related Deaths 42 Reporting Obstetric/Neonate Deaths to the Coroner 42 Cremation Certificates 42 Bereaved Relatives 43 List of Referral Centres Approved by: Dr M Perenyei Page: 4 of 47

5 INTRODUCTION The department of Cellular Pathology is centralised on a single site at the William Harvey hospital, Ashford. It provides diagnostic Histopathology and Cytopathology services. KEY PERSONNEL & LABORATORY NUMBERS Head of Service Dr Miklos Perenyei (Ext: ) Head Biomedical Scientist Mr Paul Williams (Ext: ) HISTOPATHOLOGY Subspecialties Consultants Phone number Dr Aminu Abdulkadir Lung, Gynae, Soft Tissue, (Ext: ) Perinatal, Urology Dr Kareem Aboualfa Gynae, Lung, Skin, Urology (Ext: ) Dr Salim Anjarwalla Upper and Lower GI, (Ext: ) Lung,Cytology, Urology Dr Nipin Bagla Lymphoreticular, Upper and Lower (Ext: ) GI,Skin Dr Nicola Chaston Upper & Lower GI, Liver, Head and (Ext: ) Neck, Urology, Endocrine Dr Matthias Koslowski Urology, Gynae, Lower GI (Ext: ) Dr Charles Lawson Lymphoreticular, Breast, Head and (Ext: ) Neck, Soft Tissue, Upper GI Dr Brigid Maguire Skin (Ext: ) Dr Miklos Perenyei Endocrine, Breast, Upper & Lower (Ext: ) GI, Cytology, Lymphoreticular Dr Doraline Phillips Gynae, Breast,Cytology (Ext: ) Dr Konstantinos Skendros Liver, Upper and Lower GI, Skin, (Ext: ) Urology Dr Susanna Szakacs Head and neck, Skin (Ext: ) Dr George Vittay Upper and Lower GI, Breast, ( Ext: ) Cytology, Endocrine Dr Cate Wight Gynae, Breast,Cytology (Ext ) Chief Biomedical Scientist Mr Brian Murphy (Ext: ) Results Enquiries (Ext: ) MDM Co-ordinator (Ext: ) Out of hours emergency services (including Bank holidays) are available via the hospital switchboard Laboratory Opening hours 8.00am 8.00pm Monday - Friday 9.00am 5.00pm Saturday Sunday Approved by: Dr M Perenyei Page: 5 of 47

6 USE OF SERVICE All specimens must be accompanied by a histology request form CELPTHY FRM-KPN-CEL-004 which is LEGIBLE AND PROPERLY COMPLETED. Essential information includes:- HS NUMBER SURNAME FORENAME FULL NAME DOB NHS / HOSP NO HOSPITAL / WARD SPECIMEN DOB DATE / TIME CONSULTANT/GP MANDATORY FIELDS * SIGNATURE / INITIALS ADDRESS P/SURGERY SPECIMEN TYPES/SITES CLINICAL DETAILS HIGH RISK STICKER (IF APPLICABLE) INSTRUCTIONS FOR SAMPLE SUBMISSION Approved by: Dr M Perenyei Page: 6 of 47

7 LABELLING INSTRUCTIONS FOR SAMPLE CONTAINER Please note:- Accepted printed adhesive labels should never be placed on the container lid. SAMPLE TYPE Histology Histology - Frozen section Histology - Skin samples for immunofluorescence Histology MANDATORY Surname and at least one Forename NHS* Number Minimum mandatory criteria :- Date of Birth Patient's Address (including Postcode) High Risk sticker (if applicable) - this must not cover patient details Site of sample Date/Time of collection REQUIRED CONTAINER Labelled 10%formalin container showing appropriate hazard warning Sent to Histology ASAP in a dry labelled container Sent to Histology ASAP One sample in a labelled histology container One sample in Michels medium (cryotube to be placed in a clean 60ml sterile container) Two of these three patient identifiers The importance of handwritten labels on specimen containers should be emphasised. Clinics regularly dealing with multiple samples during a single procedure (i.e. endoscopy, colposcopy, and prostate biopsy clinics) may consider printed labels which must be created at the time and location of the procedure. Only data trace labels (or equivalent) are acceptable. Samples identified with both acceptable printed labels and legible handwritten container labels must be clearly dated, signed or initialled by the person who took the sample. Pre-printed labels such as addressograph labels are unacceptable. The department of Cellular Pathology will carry out site visits to clinics to audit and monitor adherence to this policy. This activity is required by CPA (Clinical Pathology Accreditation) and the aim is to standardise specimen labelling throughout the Trust minimising risk. *NHS number in some cases (e.g. A&E, new born, unregistered, oversees visitors) may not be available. In these cases hospital number/emergency number may be substituted. Some patients identity may be anonymous (e.g. GUM clinic, blind clinical trials): these patients will have a coded identifier, and will not have name, address nor NHS/hospital number. Please ensure that the tops of bottles etc. are securely fastened and not cross threaded to prevent leakage. High risk specimens should be clearly labelled double bagged and labelled Biohazard. Any samples failing to meet these acceptance criteria will result in delay and possibly the return of the sample to the requesting clinician for appropriate labeling. The range of services offered by the department are as follows: Approved by: Dr M Perenyei Page: 7 of 47

8 Routine diagnostic Histopathology Rapid Frozen sections Rapid processing for urgent histopathology Skin Immunofluorescence Lymph node analysis Mohs sections Muscle Biopsies The Processing Of Foetuses, Retained Products And Placentas Videoconferencing Multidisciplinary meetings Digital macro and microphotography Referral centres High Risk Specimens e.g. HIV, Hepatitis, TB, nv CJD including all specimens suspected of being high risk or from patients in a high risk category such as immuno compromised patients must be clearly labelled with a DANGER RISK OF INFECTION sticker. The nature of the risk MUST BE CLEARLY stated on the request form. The specimen MUST be sent to the laboratory double bagged. Routine Histopathology Specimens must be placed in an appropriate container with sufficient 10% Formalin to submerge the specimen. Certain specimens are best preserved with alternative fixatives e.g. Phaeochromocytoma, testicular biopsies. For information about alternative fixatives contact the laboratory. Turnaround time for reporting the result: Diagnostic biopsies 80% expected within 7 working days from collection date. All histology specimens 80% expected within 10 working days from collection date. Results are electronically available after authorisation by Pathologist. Cases for further opinion are always sent to a CPA accredited laboratory. Rapid Frozen section service This service offers an immediate diagnosis on specimens from patients who are under anaesthetic and must be booked at least 24 hours in advance with a Pathologist. When booking a frozen section with a Pathologist on extn it is essential to give all patient details and an indication of the expected time of arrival of the sample. Approved by: Dr M Perenyei Page: 8 of 47

9 The Cryostat is used to cut sections from fresh (unfixed) frozen tissue. Tissue debris collected in the cryochamber is potentially contaminated with pathogens from any hazard group (see ACDP guideline). There is a risk samples will be sent to the laboratory from patients known to be infected with hazard group 3 pathogens. These samples are not cut as frozen sections in this laboratory. Specimens must be sent immediately in a dry container with a properly completed request form. Please inform the laboratory when the specimen has been despatched. If at the time of surgery, it is decided not to proceed with the frozen section, please inform the laboratory. Urgent specimens including rapid access (other than frozen sections) A report can be issued on biopsies on the same day if the specimen is received before 11.30am. This service is by prior arrangement with the Subspecialist Pathologist on extn Skin Immunofluorescence Biopsies for immunofluorescence should be sent to the laboratory in Michels medium which can be obtained from Histology. Please inform the laboratory if such specimens are being sent on ext: Samples must be received on the same working day. Lymph Node analysis Lymph nodes biopsy may be required to establish a diagnosis in cases of: Infection or Pyrexia of Unknown Origin (PUO) Unresolved lymphadenopathy Suspected lymphoma or haematological malignancy Metastatic disease In cases of suspected infection or PUO, a full serological work up should be instituted prior to biopsy. The sample should be divided and part sent fresh to the Microbiology department. (Typical sample size 0.5 cm³). The remainder of the node should be divided in half and placed in formalin. Approved by: Dr M Perenyei Page: 9 of 47

10 Appropriate serological work up should be completed before biopsy of unresolved lymphadenopathy typically to exclude EB virus (monospot), toxoplasma, viral screening and HIV if appropriate. A fresh sample may be sent if appropriate. In other cases especially suspected lymphoma or haematological malignancy the sample should be divided in half along the longest axis and placed in 10% formalin for histological analysis. Dividing the node allows for better fixation and cell preservation. Mohs Sections This service is provided by the laboratory in co-operation with the Consultant Dermatologist and should always be arranged at least one week in advance at KCH Dermatology unit between 0830 and 1700 hrs. Requirement for service beyond this time requires arrangement with Head BMS The Processing Of Foetuses, Retained Products And Placentas. The clinician / midwife should discuss with the Guys Hospital Regional Genetics Centre, the appropriate samples required from a foetus for cytogenetics investigation. The samples usually e.g. cord blood and skin must be taken by the clinician / midwife and dispatched to the regional genetics centre. The foetus can then be sent to the appropriate department as defined below according to gestation. In the case of suspected infection the clinician / midwife must take a swab of placenta and send promptly to microbiology. Depending on gestation age the foetus and placenta should promptly be sent via porter to the appropriate department as defined below. Terminations of pregnancy must be taken from the EAPU or Gynaecology Ward via porter directly to the hospital site mortuary. Foetus, retained products (suspect or clinical diagnosed products of conception labelled POC) and placentas not requiring post mortem or foetuses <16 weeks Send directly from the EPAU or gynae ward in an appropriate sized specimen container with sufficient 10% formalin to the histology department at the William Harvey Hospital via the pathology specimen reception at each site. It must be accompanied by a completed histology request form clearly stating whether an external examination of the foetus is required, and / or histopathological examination of the placenta. The form must clearly state: Patient s Name NHS/Hospital Number Time event took place and Date Approved by: Dr M Perenyei Page: 10 of 47

11 Signature Of Doctor Ward Consultant Name Date of Specimen Clinical Details The Method and Date of Disposal The pot must also bear a completed label included patient s name, DOB, hospital number, what the specimen is (labelled POC if retained products), the date the event took place. A certificate must accompany the specimen that includes: Name of Patient NHS/Hospital Number Time event took place and Date Signature of Nurse or Doctor certifying products of conception < 24 weeks gestation This certificate must accompany the specimen until final collection for disposal. If the specimen consists of retained products from a live birth it should be stated in the clinical details as post partum and therefore does not require a certificate. Inform the porters who will transfer the specimen in a pot with formalin to pathology reception. Specimens from QEQM and KCH will be transported to the histopathology department at the William Harvey site in a secure transport container via the pathology specimen transport system. The laboratory staff will allocate a histology specimen number to the request form and specimen pot(s). A signed duplicated POC certificate should accompany products of conception. Please refer to: East Kent Hospitals NHS Trust Procedure For The Management Of Early And Mid- Term Pregnancy Loss (Under 24 Weeks Gestation) Policy which is available on Sharepoint. Muscle Biopsies Protocol for sending to Neuropathology department, King s College Hospital, London. Tel no: or This protocol applies to both open and needle biopsies. The Neuropathology department at King s College Hospital, London should be contacted to arrange mutually suitable times for the biopsy to be taken. Tel no: or Approved by: Dr M Perenyei Page: 11 of 47

12 On removal from the patient, the muscle tissue should be placed in a dry specimen pot. A piece of dampened gauze should be placed in the pot also to create a humid atmosphere. This should not actually touch the tissue. (Open muscle biopsies may be stretched by applying sutures at either end and attaching them to dental wax, but this is not essential). The biopsy and relevant patient data should then be urgently dispatched to Neuropathology, King s College Hospital, London with a request form noting of the time that the biopsy was taken. Neuropathology, King s College Hospital, London should then be contacted to be told the estimated arrival time of the biopsy. Tel no: or Videoconferencing This service provides microscope images from the Cellular Pathology Department at the WHH site to remote stations including Queen s Centre for Clinical Studies, QEQM Hospital, Margate, Kent and Canterbury Hospital and also Oncology at Maidstone Hospital. Use of this equipment is arranged at least one week in advance with the multidisciplinary meetings secretary on ext: Multidisciplinary Meetings The list of patient cases to be discussed is compiled one week in advance by co ordination with Meeting Secretary on ext: Pathologist representation at every meeting is provided via videoconferencing or by a Pathologist attending in person. Late inclusion of patient cases is possible up to midday two working days prior to a forthcoming meeting by arrangement with the departments MDM coordinator on ext: Digital Macro and Microphotography of Surgical Specimens. This facility is available to clinicians for clinically important cases. This can be arranged through the multidisciplinary meeting, sub specialist Pathologist or stated on the Histology request form Approved by: Dr M Perenyei Page: 12 of 47

13 CYTOLOGY INTRODUCTION The department of Cellular Pathology is centralised on a single site at the William Harvey hospital, Ashford. It provides diagnostic Histopathology and Cytopathology services. KEY PERSONNEL & LABORATORY NUMBERS Head of Service Dr Miklos Perenyei (Ext: ) Diagnostic Cytopathologists Dr George Vittay (Ext: ) Dr Miklos Perenyei (Ext: ) Dr Salim Anjarwalla (Ext: ) Dr Doraline Philips (Ext: ) Dr Cate Wight (Ext: Head Of Gynaecological Dr Matthias Koslowski Cytology (Ext: ) Chief Biomedical Scientist Mrs Shirley Moses (Ext: ) Cytology Office For Results / Enquiries (Ext: or ) Out of hours emergency services (including Bank holidays) are available via the hospital switchboard Laboratory Opening hours 8.00am 8.00pm Monday Friday 9.00am 1.00pm Saturday Approved by: Dr M Perenyei Page: 13 of 47

14 GENERAL INFORMATION The following information although comprehensive may not cover all eventualities, and when any doubt exists as to the optimum way in which a sample should be collected and sent to the laboratory please telephone the laboratory for instructions BEFORE THE SPECIMEN IS OBTAINED. Fixative, special containers and transport boxes, if required are obtainable from the laboratory on request. INSTRUCTIONS FOR SAMPLE SUBMISSION SAMPLE TYPE Gynae cytology(liquid based Cytology) Non gynae fluids Non gynae slides REQUIRED CONTAINER LBC container labelled prior to leaving the patient using the information confirmed during the positive patient identification process Labelled sterile container(25ml or 60ml) Slides labelled with patient Name, Date of Birth and site of specimen LABELLING INSTRUCTIONS FOR REQUEST FORM Non Gynae Cytology and Andrology. Complete the request form CELPTHY FRM-KPN-CEL-004 for The same acceptance criteria applies as in the Histology section. Please see page 5 Gynae Cytology. Complete the request form HMR101. In addition to the above the request form must state Smear Taker s ST No and signature and also indicate Source of Smear, Reason for Smear, LMP, Last Smear Date, Previous History, Approved by: Dr M Perenyei Page: 14 of 47

15 FULL NAME, ADDRESS DOB NHS NUMBER NAME AND ADDRESS OF SENDER IF NOT GP PLEASE COMPLETE BOXES HIGH RISK STICKER MUST BE APPLIED (IF APPLICABLE) BOX 20 ST NUMBER BOX 20 ST NUMBER AND SIGNATURE MUST BE INCLUDED PRACTICE NAME AND ADDRESS BOX FOR LABORATORY USE ONLY BOXES 8 AND 9 - PLEASE USE THIS BOX FOR LOCAL CODES Page:15 of 47

16 LABELLING INSTRUCTIONS FOR SAMPLE CONTAINER Please note:- Accepted printed adhesive labels should never be placed on the container lid. LBC Samples and Non Gynae Cytology Fluids MANDATORY Surname and at least one Forename, NHS* Number Minimum mandatory criteria :- Date of Birth Patient's Address (including Postcode) High Risk sticker (if applicable) - this must not cover patient details Sign/Initial Date/Time of collection Site of sample (Non Gynae Cytology Fluids) Two of these three patient identifiers Criteria for Sample Acceptance Non Gynae Slides Minimum mandatory criteria:- All patient identifiers Surname and at least one Forename, Date of Birth Site of Sample Criteria for Sample Acceptance Non Gynae Slide Boxes MANDATORY Surname and at least one Forename, NHS* Number Minimum mandatory criteria :- Date of Birth Two of these three patient identifiers Patient's Address (including Postcode) High Risk sticker (if applicable) - this must not cover patient details The importance of handwritten labels on specimen containers should be emphasised. Clinics regularly dealing with multiple samples during a single procedure (i.e. endoscopy, colposcopy, and prostate biopsy clinics) may consider printed labels which must be created at the time and location of the procedure. Only data trace labels (or equivalent) are acceptable. Samples identified with both acceptable printed labels and legible handwritten container labels must be clearly dated, signed or initialled by the person who took the sample.pre-printed labels such as addressograph labels are unacceptable. The department of Cellular Pathology will carry out site visits to clinics to audit and monitor adherence to this policy. This activity is required by CPA (Clinical Pathology Accreditation) and the aim is to standardise specimen labelling throughout the Trust minimising risk. Page:16 of 47 Date of Issue: Nov 2014

17 *NHS number in some cases (e.g. A&E, new born, unregistered, oversees visitors) may not be available. In these cases hospital number/emergency number may be substituted. Some patients identity may be anonymous (e.g. GUM clinic, blind clinical trials): these patients will have a coded identifier, and will not have name, address nor NHS/hospital number. Any samples failing to meet these acceptance criteria will result in delay and possibly the return of the sample to the requesting clinician for appropriate labeling. *NHS number in some cases (e.g. GUM, A&E, new born, unregistered, oversees visitors) may not be available. In these cases hospital number/emergency number/special code may be used. Please ensure that the tops of bottles etc. are securely fastened and not cross threaded to prevent leakage. High risk specimens should be clearly labelled double bagged and labelled Biohazard. Each specimen must be accompanied by the correct completed request form, CLEARLY LEGIBLE. For all gynae specimens the request form HMR101 must be used For all non gynae specimens the Kent and Medway Cellular Pathology request form must be used. In the case of cervical samples each request must include the full postal address of the woman and the full postal address of her GP. The smear takers number and signature must be included on the request form. Samples will be rejected by practitioners who do not hold a valid sample taker number Request form HMR101 must be used and all demographic, clinical and personal details must be completed on the form and include previous smear report if abnormal. The request form accompanying a High Risk specimen must show a biohazard sticker and the precise hazard must be clearly stated (e.g. Hepatitis B etc) Cervical Samples (LBC) Sample taking kits are available from the laboratory including request forms, vials of fixative, sample bags and sample taking devices (cervex brush). The brush should be rotated 5 times through 360º in the cervical os. Add the sample to the fixative by agitating the brush against the bottom of the vial 10 times. DO NOT detach the brush head into the vial. Secure the lid firmly. Ensure the vial is labelled with the patients details in ink. All samples must be accompanied by a fully completed cytology request form signed by the sample taker and indicating their sample taken number. Page:17 of 47

18 Indicate on the request form if the cervix was not visualised, also mention whether a vault or vaginal sample was taken. In some instances an endocervical brush may be used. It is important to state clearly if a specimen has been obtained using an endocervical brush rather than a cervical brush. For routine smears when both cervix and endocervical brushes are used the cervical brush sample should be taken first. Material from both devices should be placed in the same vial. Non- water based lubricants must not be used as they can lead to an inadequate sample report. Contact the laboratory for further details on the use of lubricants if required. Dispatch to laboratory without delay. The patient s GP and/or sample taker are informed of the result by the laboratory. The patient is informed of the result by the Kent Primary Care Agency. 98% of results are available within 14 days. Human Papilloma Virus (HPV) Testing The aetiological role of Human Papilloma Virus (HPV) in the development of cervical cancer is well established. The NHSCSP has therefore introduced additional High Risk (HR) HPV testing on selected cervical cytology samples which has the benefit of fast tracking women at risk for treatment and also reduces unnecessary repeat tests. HPV Triage The HPV triage test is performed on routine cervical samples showing a low grade cytological abnormality. This includes borderline changes and mild dyskaryosis. A negative (not detected) HPV test allows a woman to return to normal recall whereas a positive (detected) HPV test initiates a referral to colposcopy. HPV Test of Cure The HPV Test of Cure (ToC) is performed on samples taken following large loop excision of the transformation zone (LLETZ) treatment for an abnormality. Negative samples and those showing low grade abnormalities (borderline changes and mild dyskaryosis) are tested. A negative (not detected) HPV test allows a woman to have a repeat test in 3 years before her return to normal recall. A positive (detected) HPV test returns the woman to colposcopy for further investigation. Histologically proven CGIN and women with invasive or micro invasive disease are excluded from the ToC protocol. Page:18 of 47

19 Uncertainty of measurement In cervical cytology the examination of the sample is used to indicate the presence or absence of disease. Where biological variation in samples occurs, this can lead to difficulties in interpreting results. Where there is genuine doubt as to whether cells changes are abnormal an equivocal report Borderline changes is issued. This report will initiate either an HPV test on the original sample to aid patient management or a repeat test. Within the NHSCSP the sensitivity and specificity of the test is well understood and ed. All laboratories and screening individuals are monitored and expected to achieve sensitivities in excess of 90% for all abnormalities and more than 95 % for high grade abnormalities Diagnostic (Non-gynaecological) Samples Effusions Fluid should be sent to the laboratory in a labelled sterile container. DO NOT send the specimen in a catheter drain bag. Ideally 20ml of fluid should be collected particularly where malignancy is suspected so that immunohistochemistry, if necessary, can be performed. The specimen should be sent to the laboratory immediately. If collected at the weekend, the specimen should be kept in a refrigerator at 4ºC. Urines Voided urine should be sent from the second urine of the day, a catheter specimen or mid stream specimen is not satisfactory for cytological investigation. If the only specimen which can be obtained is a catheter, post cystoscopic or ileal conduit, it must be clearly stated on the request form. Urine must be collected into a labelled 25ml sterile container (not boric acid preservative) and sent to the laboratory immediately whilst fresh as cell morphology deteriorates rapidly in voided urine and specimens more than a few hours old maybe unsatisfactory for cytological assessment. Refrigerate if a delay in transportation is anticipated. Respiratory Tract Specimens Sputum: Early morning specimens should be sent fresh to the laboratory. Specimens should be collected on three consecutive days if carcinoma is suspected. Check the quantity is adequate Page: 19 of 47

20 and sputum is not contaminated with food, saliva, tobacco or toothpaste. A specimen after physiotherapy or postural drainage is very useful Bronchial Brush/Touch Preparation: Smears made from bronchial brushing/biopsies should be spread evenly and quickly on clean glass slides clearly labelled in pencil with the patient details shown in the table on page 13. The slides should be immediately air dried and placed into the slide transport box. Broncho alveolar lavages / induced sputum: These specimens should be taken into a labelled sterile containers and sent immediately to the laboratory (double bagged if known as a High Risk specimen).. Fine Needle Aspirates (FNA) Appropriate for palpable lumps in breast, thyroid, salivary gland and superficial lymph nodes, subcutaneous skin nodules and for imaging guided non palpable lesions. The sample must be spread onto clean slides that have been clearly labelled with the patient details shown on page 13. These labelled slides should be air dried, put into plastic slide mailer boxes and sent to the laboratory with completed accompanying request form. There are one stop breast and head and neck clinic sessions provided at Kent and Canterbury Hospital, Queen Elizabeth the Queen Mother Hospital (QEQM) and William Harvey Hospital (WHH) sites. Nipple Discharge The discharge should be smeared on to a slide clearly labelled with the patient details shown in the table on page 13, and air dried immediately. Aspirates of Breast Cysts The aspirate should be transferred to a labelled sterile container, or if less than 0.5 ml placed directly onto a glass slide labelled in pencil with the patient details shown in the table on page 13, then air dried. Fixative is not necessary. CSF Send as much of the specimen as can be spared to the Cytology and Microbiology laboratory, in a labelled sterile container. If there is unavoidable delay in sending a fresh specimen to the laboratory, it should be stored at 4º C. CSF investigations for Leukaemia should be suitably marked. Joint Aspirates Page:20 of 47

21 Joint aspirates requiring crystal identification should be collected into a clearly labelled sterile container. Results: Urgent samples: from sample receipt 24 hours (excluding weekends) Non urgent samples: from sample receipt 7 days (excluding weekends) Document number: CEL EXDO 615 Author: S Moses Approved by:p Williams Page:21 of 47 Date of Issue: Sept 2013 Revision:12

22 ANDROLOGY INTRODUCTION Andrology in East Kent and Maidstone is carried out in the Cytology Department of the William Harvey Hospital (WHH), Ashford and at Queen Elizabeth the Queen Mother Hospital (QEQM), Margate. KEY PERSONNEL & LABORATORY NUMBERS Clinical Lead Dr Matthias Koslowski Chief Biomedical Scientist Mrs Shirley Moses Results Enquiries Availability of Service for Post Vasectomy Samples (Ext: or ) This service is available on any weekday Monday Friday (excluding Bank Holidays) Samples can be taken to Pathology Reception at any of the following hospitals at the times indicated: William Harvey Hospital, Ashford Queen Elizabeth the Queen Mother Hospital, Margate Kent and Canterbury Hospital, Canterbury Availability of Service for Subfertility Samples: Please note that patients with High Risk samples (Hepatitis, HIV) must go to the William Harvey Hospital for their semen analysis. Please ensure that the patient is aware that they can take samples to Pathology Reception at the following hospitals at specified times only (excluding Bank Holidays). Queen Elizabeth the Queen Mother Hospital Wednesday 8.30am to 2pm by appointment Document number: CEL EXDO 615 Approved bydr M Perenyei Page:22 of 47 Date of Issue: Sept 2013 Revision:12

23 SEMEN ANALYSIS FOR SUBFERTILITY Approximately 1 in 6 couples have difficulty conceiving and are referred for infertility investigations. The single most common cause of infertility is sperm dysfunction, which is apparent in approximately 30% of the men referred for analysis. A high quality Andrology service is therefore essential for correct management of the male patient. Staff in the East Kent Hospitals University Trust are fully trained scientists and are highly proficient in performing quality diagnostic semen analyses in line with current World Health Organisation and Association of Biomedical Andrologist guidelines. Currently we perform some 1200 semen analyses a year for infertility investigation. The laboratories conduct regular internal and external QC and participate in the National External Quality Assurance scheme for Andrology. REQUESTING A SEMEN ANALYSIS Please provide the patient with the following: Request form containing Patients full name, address with postcode, date of birth, partners name, NHS number (if known) clinical information and reason for request (infertility/ reversal of vasectomy). Please indicate requesting clinician s name and location. Patients that are known to be an infection risk must have their forms clearly labelled. Please note that due to a change in facilities in the laboratory at Queen Elizabeth the Queen Mother Hospital samples from known High Risk (Hepatitis, HIV) patients can no longer be handled. These patients will need to go to the William Harvey Hospital for their semen analysis. Patients should be advised that they must bring the request form with them when delivering the specimen pot to the laboratory. Patient instruction sheet. Please ensure that the patient is aware of the different opening times for the following laboratories: Queen Elizabeth the Queen Mother Hospital Wednesday 8.30am to 2pm An appointment must be booked for this test by ringing the blood test appointment line on (It is essential to ask for a semen test). Appointments are available at 45 minute intervals. William Harvey Hospital - Monday and Wednesday 8.30am to 1pm - Friday 8.30am to 5pm. No appointments are needed at the William Harvey Hospital Document number: CEL EXDO 615 Author: P.Williams Approved by: Dr M. Perenyei Page:23 of 47 Date of Issue: Sept 2013 Revision:12

24 A wide mouthed 60ml specimen pot that has a CE mark (This is marked on the label by the manufacturer to indicate that it is fit for purpose). Please ensure that the patient is aware that they must label the pot in ink with their full name and date of birth as well as indicating the date and time of emission. Specimen bag. PRODUCING THE SEMEN SAMPLE PLEASE NOTE THAT FACILITIES ARE NOT AVAILABLE TO PRODUCE SEMEN SAMPLES AT HOSPITALS WITHIN THE EAST KENT HOSPITALS UNIVERSITY TRUST Prior to producing the sample the patient must have abstained from sexual intercourse/ masturbation for at least 2-3 days and no more than 7 days. He must be hygienic and wash his hands and genital area. Make sure that all soap is washed off as this will kill sperm. Check that the pot is free of cracks as leaking samples will be rejected. He must only use the pot supplied by his GP/Clinic as inappropriate pots will be rejected. The sample must be produced by masturbation directly into the clean plastic pot supplied by his doctor/consultant. It is important that the entire sample is collected in order that an accurate analysis can be carried out. The use of lubricants such as K-Y jelly must be avoided. Samples produced by the withdrawal method or into an ordinary condom are unsuitable for analysis. Ensure that the pot lid is tightly screwed up as if the pot leaks in transit it will not be analysed. Labelling the pot and completing the patients section of the request form. It is essential that the following information is written in ink on the label of the pot. Full name of patient (first name and surname). Date of birth Date of collection Time of collection Home postcode (as a patient identifier) Please add your initials at the bottom of the label to indicate that the information is correct. Page: 24 of 47

25 Fill in the patients section at the back of the instruction sheet to confirm that the complete sample has been collected and that the appropriate period of abstinence (sexual intercourse / masturbation) has been carried out. This section should be torn off and attached to the request form. What if the patient has problems collecting the sample? Be re-assured that when most men get over the initial embarrassment they usually manage to provide a specimen. However, for those who still can't, or have some religious or cultural objection, we can provide a non-spermicidal condom for specimen collection. If the patient needs to request one of these condoms please ask them to ring and ask for Shirley Moses or Josephine Coglan Delivery of the Specimen Sperm are sensitive to temperature and the semen sample must therefore be protected from direct sunlight or extremes of cold. In order to keep the sample as close to body temperature as possible it is best to carry it close to the body, ideally in an inside pocket. The sample must reach the laboratory as soon as possible after production. Ideally this should be within 1 hour, but patients travelling greater distances are allowed up to 2 hours from the time of production. Rejection of Specimens for Infertility Investigation The laboratory will reject any specimen that is: Not produced into an appropriate container. Produced into an unlabelled container. Found to have leaked in transit. Delivered to any hospital other then the William Harvey Hospital or sent via the hospital or GP transport. Delivered at a time/day other than those specified. Received without a request form. THE SEMEN ANALYSIS TEST We examine the semen sample for a number of important factors according to the World Health Organisation Guidelines Document number: CEL EXDO 615 Author: P.williams Approved by: Dr M. Perenyei Page:25 of 47 Date of Issue: Sept 2013 Revision:12

26 Sperm Concentration Sperm count in millions per ml of semen. Normal samples have over 15 million per ml or 39 million for the whole ejaculate. Sperm Motility Sperm are graded according to their ability to swim. Sperm that swim in a progressive manner are graded as having rapid or sluggish motility. Normal samples should contain at least 32% progressive sperm and at least 40% motile sperm (progressive and non progressive) at 1 hour. Sperm Morphology The shape and size of the sperm are assessed on a stained preparation. The normal value in a fertile population is 4% or above. Vitality Test This test is included in results where the number of immotile sperm are greater than 60%. It is a staining technique that will identify if the immotile sperm are dead or just immotile and is reported as a percentage vitality. The normal value is 58% or above RESULTS A written report is sent back to the referring practitioner within 7 10 working days. If further copies are needed to forward onto other practices/ clinics please make a note on the original request form. Patients should be made aware that they cannot receive the result directly from the laboratory. If a report is required for a specific appointment date, this should be stated on the request form to allow the report to be fast tracked. INTERPRETATION Although there are strict guidelines for the measurement and quality control of semen variables they are not an absolute guide to a man s fertility and no one parameter should ever be considered in isolation unless he has no sperm at all. Procedural errors are minimised by standardised methods of collection, analysis and reporting, therefore it is essential that the patient understands the instructions prior to production of the sample. Page: 26 of 47

27 The overall balance of the sample is much more indicative of fertility potential and should be considered alongside any investigations of the female partner. For example the term low sperm count is ambiguous and is often misinterpreted by the patient. His count may be rather low but an increased motility may be sufficiently high enough to compensate for any shortfall. The following table shows the distribution of values for semen parameters from men whose partners became pregnant within 12 months of discontinuing contraceptive use. WHO 2010 Parameter (units) N Centile Semen volume (ml) Sperm concentration (10 6 per ml) Total sperm number (10 6 per ejaculate) Progressive motility (PR, %) Non-progressive motility (NP, %) Immotile spermatozoa (IM, %) Normal forms (%) Vitality (%) REPEAT TESTS If any of the factors tested are below the normal range it is advisable to repeat the semen analysis test. Abnormalities in the sample can occur for a number of reasons eg patient did not collect the whole sample. In addition illness, stress or medication can also affect sperm quality. Confirmation of a true sperm problem may require a second test. POST VASECTOMY SEMEN ANALYSIS Sperm tests to confirm the success (or otherwise) of a vasectomy operation are absolutely essential. Patients are required to produce a sample of seminal fluid at 18 WEEKS, 22 WEEKS and possibly an additional test at 28 WEEKS following vasectomy. REQUESTING A POST VASECTOMY SEMEN ANALYSIS Please provide the patient with the following: Request form containing Patients full name, address with postcode, date of birth, NHS number, reason for request and date of vasectomy. Please indicate requesting clinician s name and location. (Patients that are known to be an infection risk must have their forms clearly labelled). Document number: CEL EXDO 615 Author: P.Williams Approved by: Dr M. Perenyei Page:27 of 47 Date of Issue: Sept 2013 Revision:12

28 Patients should be advised that they must bring the request form with them when delivering the specimen pot to the laboratory. The patient declaration section at the end of the instruction sheet must be completed to indicate whether the complete sample was collected. This must be attached to the request form Patient instruction sheet. This will give details of the times that samples can be delivered to the nearest hospital to the patient. Please ensure that the patient is aware that they must label the pot in ink with their full name, date of birth and home post code as well as indicating the date and time of emission. Please note that the service is available Monday to Friday (excluding Bank Holidays) Samples can either be brought directly to Pathology Reception at the William Harvey Hospital, Ashford between 8..45am and 5.00pm or taken to Pathology reception at the times specified for each of the other hospitals: Queen Elizabeth the Queen Mother Hospital, Margate 8.45am- 3.45pm Kent and Canterbury Hospital, Canterbury 8.30am- 4.00pm A wide mouthed 60ml specimen pot that has a CE mark (This is marked on the label by the manufacturer to indicate that it is fit for purpose) Specimen bag. PRODUCING THE SEMEN SAMPLE PLEASE NOTE THAT FACILITIES ARE NOT AVAILABLE TO PRODUCE SEMEN SAMPLES AT HOSPITALS WITHIN THE EAST KENT HOSPITALS TRUST He must be hygienic and wash his hands and genital area. Make sure that all soap is washed off as this will kill sperm. Check that the pot is free of cracks as leaking samples will be rejected. He must only use the pot supplied by his GP/Clinic as inappropriate pots will be rejected. The sample must be produced by masturbation directly into the clean plastic pot supplied by his doctor/consultant. It is important that the entire sample is collected in order that an accurate analysis can be carried out. The use of lubricants such as K-Y jelly must be Page: 28 of 47

29 avoided. Samples produced by the withdrawal method or into an ordinary condom are unsuitable for analysis. Ensure that the pot lid is tightly screwed up as if the pot leaks in transit it will not be analysed. Labelling the pot and completing the patients section of the request form. It is essential that the following information is written in ink on the label of the pot. Full name of patient (first name and surname). Date of birth Date of collection Time of collection Home postcode Please add your initials at the bottom of the label to indicate that the information is correct. Fill in the patients section at the back of the instruction sheet to confirm that the complete sample has been collected. This section should be torn off and attached to the request form. Delivery of the Specimen Sperm are sensitive to temperature and the semen sample must therefore be protected from direct sunlight or extremes of cold. In order to keep the sample as close to body temperature as possible it is best to carry it close to the body, ideally in an inside pocket. The sample must reach the laboratory as soon as possible after production. This should be on the day of production. Rejection of Specimens for Post Vasectomy Investigation The laboratory will reject any specimen that is: Not produced into an appropriate container. Produced into an unlabelled container. Found to have leaked in transit. Received without a request form. Produced earlier than 16 weeks after vasectomy. POST VASECTOMY ANALYSIS Document number: CEL EXDO 615 Author: P.Williams Approved by: Dr M.Perenyei Page:29 of 47 Date of Issue: Sept 2013 Revision:12

30 The semen sample is initially examined as a direct wet preparation and any spermatozoa present in a 10ul aliquot are counted and the result per ml of sample is calculated. Due to the delays between time of emission and examination there is no comment for non- motile sperm. There is no guarantee that nonmotile sperm were always non- motile and therefore a comment is only made if there are motile sperm present. If sperm are not seen in the original preparation a portion of the sample is centrifuged at high speed to produce a pellet and this provides a concentrate of the original sample. An aliquot of this concentrate is analysed for the presence of sperm and if any sperm are counted the result per ml of original sample can be calculated. Samples found to have very high counts and motile sperm will be analysed as infertility specimens. The test will be based on the numbers of spermatozoa. The presence of large number of spermatozoa may indicate a failed surgical procedure/ recanalisation. This is an infrequent event which will need to be confirmed by a sample delivered to the laboratory within 2 hours. The laboratory will advise the need for a repeat sample or re referral to the surgeon. RESULTS Reports will record the absence of sperm as:- NO SPERMATOZOA SEEN IN A CENTRIFUGED DEPOSIT Reports will record the presence of sperm as:- SPERM CONCENTRATION ie Number of sperm per ml TOTAL COUNT ie Number of sperm per ml x volume of semen Only sperm concentrations greater than 10,000 spermatozoa per ml are significant. CLEARANCE Will require either 2 samples with No spermatozoa seen or 1 sample with No spermatozoa seen and another with Less than 10,000 spermatozoa per ml This will be adequate to confirm vasectomy. The laboratory will include in the report that no further samples are required. Document number: CEL EXDO 615 Author: P.Williams Approved by: Dr M. Perenyei Page:30 of 47 Date of Issue: Sept 2013 Revision:12

31 SPECIAL CLEARANCE Evidence based studies have shown that in a small minority of men non-motile spermatozoa persist after vasectomy. In such cases special clearance may be given if less than 10,000 spermatozoa per ml are seen in a sample examined at least 28 weeks after vasectomy. If all three samples (at 18, 22 and 28 weeks) show the presence of non motile sperm in concentrations of less than 10,000 spermatozoa per ml special clearance should be given to the patient by the doctor/ surgeon who performed the vasectomy. In these cases the report will read: PERSISTENT RARE (< 10,000 spermatozoa/ml) SPERMATOZOA PRESENT. ADVISE SPECIAL CLEARANCE. NO FURTHER SPECIMENS REQUIRED. If you have any further queries or have any problems regarding the production and delivery of your semen sample please contact us on (Ext: or Page: 31 of 47

32 MORTUARY INTRODUCTION The department of Cellular Pathology currently provides a hospital and public mortuary service on three East Kent hospital sites. These include Kent and Canterbury, Queen Elizabeth the Queen Mother, and William Harvey hospitals. KEY PERSONNEL & LABORATORY NUMBERS Lead Pathologist/ Designated Individual Dr Miklos Perenyei (Ext: ) Deputy Lead Dr Nicola Chaston (Ext: ) Lead Anatomical Pathology Technician Mr Adam Berry (Ext: ) Lead Pathologist for perinatal Dr Aminu Abdulkadir Investigations (Ext: ) Head Biomedical Scientist Mr Paul Williams (Ext: ) Opening hours William Harvey Hospital 7.30 am 4.00pm Monday-Friday Queen Elizabeth the Queen Mother Hospital 7.30 am 4.00pm Monday-Friday Kent and Canterbury Hospital 8:00 am 4.00pm Monday-Friday (Access outside these hours covered by portering services) Advice may also be obtained from the Consultant Histopathologists Contacting the On Call Mortuary Technicians out of normal working hours is done via the hospital switchboard. Viewings/ID s by Police and/or Next of Kin will require prior arrangement with Mortuary staff or the On Call Technician. Page:32 of 47

33 Contacts Kent and Canterbury Hospital Relative Support Office (Ext: ) Queen Elizabeth the Queen Mother Hospital Relative Support Office (Ext: ) William Harvey Hospital Relative Support Office (Ext: ) Senior Chaplain Rev. Christopher White (Ext: ) Alternatively Coroner s Office Ashford, Dover and Folkestone telephone: Alternatively Alternatively Alternatively Canterbury and Margate telephone: Maidstone telephone: Page: 33 of 47

34 General Information The three mortuaries each provide cold body storage. Autopsies are presently performed at Queen Elizabeth the Queen Mother Hospital and William Harvey Hospital mortuaries. Identification of deceased in the mortuary Identification of the deceased with the Notification of Death sheet must accompany the deceased. Patient identification labels should have been placed onto the deceased by the ward and must have at least two identification means i.e. full name, date of birth and ward or first line of address. Any property and valuables must be checked and recorded. A body that is known to be at risk of infection of a category 3 or 4 disease, must be treated with extra precaution. The body must be placed in a sealed body bag. Danger of Infection must be clearly marked on the outside of the bag Autopsies When an autopsy (Hospital Post Mortem) is requested for a patient dying in hospital, where there is no Coroner s involvement, the ation required is: a) A completed, signed informed consent form (available from the Bereavment office) b) The patient s notes c) A concise summary of the case d) Medical Certificate of Cause of Death completed e) Completed cremation form where relevant These s should then be taken to the Relative Support Office who will then make contact with the Mortuary & the Duty Pathologist to arrange a suitable time and day to carry out the autopsy. In certain circumstances deaths must be reported to the Coroner. Please refer to the guidelines issued by the Coroner, (Guidelines for Hospital Doctors on Reporting Deaths to Her Majesty s Coroner). In these cases the Coroner will decide if an autopsy is required and make appropriate arrangements. Page:34 of 47