HISTOPATHOLOGY DEPARTMENT

Transcription

1 HISTOPATHOLOGY DEPARTMENT TITLE: Cytology and andrology user guide INDEX ORGANISATIONAL UNIT AREA OF APPLICATION DOCUMENT TYPE AUTHOR(S) AUTHORISED BY AUTHORISATION DATE DATE PRINTED COPY NUMBER LOCATION OF COPY Histopathology-366 Histopathology Department Hillingdon - Histology Cytology Ann Stephens Elaine Moore 14-Jun Jun :13 1 Hillingdon - Histology VERSION NO: SIGNATURE(S) SIGNATURE 1.2 The master copy of this document is held and controlled on ipassport QMS

2 Introduction and Scope: Document Cytology and andrology user guide Introduction and Scope User guide for the intranets Page 1 of 11

3 Hillingdon Hospital NON GYNAECOLOGICAL CYTOLOGY AND ANDROLOGY USER MANUAL 1.0 About us The non-gynaecological cytology and andrology service of The Hillingdon Hospital NHS Foundation Trust (THFT) is located within the histology laboratory on the 1st Floor of the tower block. The department receives approximately 1,500 non gynae cytology samples per annum and offers a comprehensive service, reporting on a wide range of samples including serous fluids, urine, cerebrospinal fluid, respiratory samples and fine needle aspirates (FNAs). The cytology department also carries out semen analysis for investigation of infertility. The department is staffed by approximately 3 WTE consultant pathologists 5.0 WTE biomedical scientists with medical laboratory assistant support and provides a diagnostic service to THFT and general practices. The department is fully CPA accredited and is fully committed to maintaining this accreditation by an established quality management system and standards determined by the Royal College of Pathologists together, with scheduled clinical and quality audits and national guidelines. All patient information will be used and stored in accordance with the Data Protection Act. 2.0 Opening hours The department is open from 08:00 hrs - 17:00 hrs Monday to Friday (except bank holidays). Non-gynaecological samples should be received in the department by 16:00 hrs. There is an appointment system for the acceptance of fertility samples. Page 2 of 11

4 3.0 Telephone Enquiries Complaints Policy The department has a complaints policy and all formal complaints received in writing will be fully investigated using the non-conformance reporting process. Complaints can be made directly to the department or through the hospital PALS Phone: PALS are available from 9:00am to 5:00pm, Moday to Friday. Fax: PALS@thh.nhs.uk 4.0 Specimen acceptance policy All specimens must be accompanied by a sample request form. All specimen containers must be clearly labelled with the patient s: 1. Full name 2. Date of Birth 3. NHS and/or Hospital number 4. Specimen type Please ensure that the patient details on the sample match those on the request form before sending the sample to the laboratory. All specimens must be delivered to the laboratory as soon as possible in order to provide the best service possible and keep turnaround times to a minimum. Page 3 of 11

5 5.0 Turn around Times The non-gynaecological cytology department is mandated by the guidelines of the Royal College of Pathologists (RCPath) on turn around times, that is, 80% of cases to be reported within seven calendar days and 90% of all cases to be reported within ten calendar days except for: One stop Breast FNA s, which will be reported the same day, Urgent samples which must be marked as urgent on the request form. Any verbal report is provisional pending assessment of all material and/or ancillary testing. Non-gynaecological cytology reports are sent out daily, addressed to the consultant or GP who requested the test. Reports of any malignancy are marked XXX. To discuss the cytology report with the Consultant contact the department between 09:00 hrs and 17:00 hrs on NON-GYNAECOLOGICAL CYTOLOGY SAMPLE COLLECTION SEROUS FLUIDS including: pleural, ascitic, pericardial fluid and peritoneal fluid. Up to 50ml of fluid should be sent in a clean dry container with a screw cap. Please do not send large volumes of fluid. The fluid should be submitted as soon as possible to minimise cell deterioration. If there is a delay in delivering the sample to the laboratory, the sample should be kept refrigerated at 4 C (Note the sample should NOT be frozen). Page 4 of 11

6 RESPIRATORY TRACT SAMPLES Sputum samples Sputum has been defined by the RCPath as a specimen of limited or no clinical value. The emphasis in respiratory cytology for cancer diagnosis has been altered by the introduction of the fibre optic bronchoscopy. The British Thoracic Society (BTS) guidelines recommend biopsy, brushings and washings at bronchoscopy. However, sputum cytology has the advantage of being a non-invasive, cheap and easily repeated test. It is still used by clinicians but guidelines for clinical requests should be agreed upon and periodically audited. Induced sputum cytology may be useful in patients who are unfit for bronchoscopy and has a role in immunosuppressed patients. Please only send samples for cytology after ruling out other pathology e.g. infection. Best results are achieved with a fresh early morning sputum obtained following chest physiotherapy and before the patient has eaten. Contamination with large amounts of saliva or food leads to unsuitable, non-diagnostic specimens. Multiple specimens (usually x 3) may be necessary, but these should be sent on 3 separate days, not all taken at the same time. Send in a clean, dry container with a screw cap. Bronchial aspirate/trap/wash/lavage & bronchoalveolar lavage samples Fresh specimen should be placed in a clean dry container with a screw cap. Bronchial brush samples The sample should be spread on a clean dry slide and fixed immediately in 95% alcohol. Containers and fixative can be collected from the laboratory. Page 5 of 11

7 URINE (including voided, catheter, urethral washings and ileal conduit samples) Please only send samples for cytology after ruling out other pathology e.g. infection. Collect urine in a clean, dry 20ml or 50ml container with a screw cap. Please do not send urine for cytology in red-lidded containers as these contain boric acid which damages the cells. A suitable urine sample is the second voided of the day, preferably mid morning. The first sample in the morning is unsuitable for cytological analysis Urine can be collected from catheters as well as washings from the bladder or upper urinary tract. The request form must state the method of collection. If there is a delay in delivering the sample to the laboratory, the urine sample should be kept in a fridge at 4 C. CEREBROSPINAL FLUID SAMPLES A clean, dry container with a screw cap should be used. CSF samples are liable to degenerate rapidly and so must be delivered to the laboratory as soon as possible. If out of hours sampling is unavoidable, the sample should be kept in a fridge at 4 C. GASTROINTESTINAL TRACT BRUSH SAMPLES The sample should be spread on a clean dry slide and fixed immediately in 95% alcohol. Containers and fixative can be collected from the laboratory. Page 6 of 11

8 FINE NEEDLE ASPIRATION SAMPLES (FNA) All slides MUST be labelled with the patient s name and date of birth. Please use a pencil as ink washes off in processing. Expel a small drop of the aspirate onto a glass slide, place a clean slide (spreader) above the drop and spread gently but swiftly. Leave to air dry before placing in the container. Containers and slides can be collected from the laboratory. SEMINAL FLUID ANALYSIS The Seminal Fluid analysis service provided by The Hillingdon Hospitals NHS Foundation Trust assesses the number, motility and appearance of sperm in fresh ejaculate and forms part of preliminary investigations only. Post vasectomy samples are no longer accepted or processed and will be rejected if received. Semen analysis is performed by appointment only. The clinician must give a request form, instructions and container to the patient. The instructions and container are provided together and should be ordered from pathology supplies by from: thh-tr.pathologysupplies@nhs.net using the supplies requisition form. The GP s or Clinician must make an appointment for dropping the sample off to the laboratory by using the choose and book system. Patients that turn up with samples without an appointment will be rejected. Appointments are available Monday to Friday (except Bank Holidays) between 8am and 1pm. On the day of their appointment the patient must produce their sample at home and bring their sample to Pathology main Reception which is on the first floor of the tower block. The patient must hand their sample directly to a member of laboratory staff who will check that the acceptance criteria for the specimen have been met. The patient will be asked to wait while the sample is delivered to the laboratory where staff will also check for acceptance criteria. Once the sample has been accepted the patient is free to leave. Page 7 of 11

9 INSTRUCTIONS FOR PATIENTS Your GP or clinic must give you a copy of these instructions. There is an appointment system for delivery of the sample to the laboratory. Your GP should make the appointment for you on the choose and book system. Please note that the sample should be collected at home as there are NO facilities at the hospital for collection, it is a criminal offence to produce a sample in a public toilet. Collection of sample It must be at least 2 days but no more than 7 days since you last had sex or masturbated. Before producing the sample wash your hands and genitals with soap and water, ensure removal of all soap residues and dry thoroughly. The container Please use the sterile container provided. Collect the sample by masturbation only directly into the container, ensuring that the whole sample is collected. (Do not use a sheath/condom for collection as they are harmful to sperm). Replace the lid on the container and ensure that it is on firmly. Write your name and date of birth on the container label. Record details of the specimen on the form provided below. Delivery of sample The sample should be delivered to pathology specimen reception at Hillingdon Hospital within ONE hour of production. The specimen should be kept warm during transit (an inside pocket is ideal) the specimen request form and this completed form should be handed directly to a member of staff. Please do not just leave the sample without attracting someone s attention. Pathology reception is on the first floor of the tower block, come in the Out Patient entrance go up the stairs and follow the corridor to the right, pathology reception is on the left. Results will be returned to the GP/clinic within 10 days of the sample being received in the laboratory. Page 8 of 11

10 PLEASE NOTE: Samples WILL NOT be accepted for testing if: You do not have an appointment or are more than 30 minutes late for your appointment. You have not used the correct container. They are leaking. They are more than 1 hour old when received in specimen reception. You have not abstained from intercourse for the required number of days You do not have a request form If you have not completed a specimen details form. This is to ensure that the results obtained from the sample are reliable. For any queries concerning sample collection and delivery please contact the laboratory on Monday - Friday Please do not telephone the laboratory for your results. Please note failure to follow these instructions may compromise the results of the analysis. PAGES IN THIS SECTI Page 9 of 11

11 Appendix: Document Cytology and andrology user guide Appendix Links Please note: links are only correct at time of printing Linked to Controlled Document - Document: Histopathology-366: Cytology and andrology user guide v1.0 (Superseded) - Document: Histopathology-366: Cytology and andrology user guide v1.1 (Superseded) Document Revision History Authorised on 14-Jun :12 by Elaine Moore Authorised version details updated to include choose and book. The following users will be notified when a review is due for this document: Ann Stephens Document was scheduled to be released on Superseded on 14-Jun :12 by Elaine Moore Version 1.1 superseded by version 1.2 Draft Created on 14-Jun :03 by Elaine Moore Reason: details updated to reflect chose and book changes Authorised on 03-Apr :51 by Elaine Moore Authorised version RCPath guidance added. The following users will be notified when a review is due for this document: Ann Stephens Document was scheduled to be released on Superseded on 03-Apr :51 by Elaine Moore Version 1.0 superseded by version 1.1 Draft Created on 03-Apr :36 by Ann Stephens Reason: New information added Page 10 of 11

12 Appendix: Document Cytology and andrology user guide Authorised on 09-Jan :14 by Elaine Moore Authorised version The following users will be notified when a review is due for this document: Ann Stephens Pending tasks were closed with reason: checked verbally Document was scheduled to be released on Creation on 09-Jan :46 by Ann Stephens New Document created Peer Review Requested on 09-Jan :46 by Ann Stephens Peer Review tasks were assigned to the following users: Ann Stephens. This review is to be completed by 12-Jan-2018 Authorisation This document was securely signed and authorised by Elaine Moore on 14-Jun-2017 Page 11 of 11