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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 96-100

Timeliness of surgical pathology results: a departmental audit of histopathological services


Department of Pathology, University of Uyo, Akwa Ibom State, Nigeria

Date of Web Publication04-Nov-2019

Correspondence Address:
Dr. Charles Nwafor Chukwuemeka
Department of Pathology, University of Uyo, Akwa Ibom State
Nigeria
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DOI: 10.4103/ssajm.ssajm_30_16

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  Abstract 


Aim To determine the turnaround time (TAT) for surgical pathology specimens (SPS) seen in our department and to identify the various determinants (variables) that affect it.
Materials and method This is a cross-sectional descriptive study (prospective) of all SPS that were sent to the histopathology laboratory of University of Uyo Teaching Hospital (UUTH). A special proforma/questionnaire was designed for this study taking into account the various stages of converting a histopathological request to a result.
Results Following specimen accessioning, the mean number of days before grossing was 1.65 ± 0.97 days. Tissue processing took a mean of 2.30 ± 2.05 days. Many of the processed SPS (histopathological slides) were reviewed and reported by histopathology resident doctors and consultant histopathologists within second and third days after processing in the laboratory (24.1% and 23.2% respectively), with a mean of 5.18 ± 13.07 days. Typing of result and verification of result took a mean of 2.99 ± 13.16 days. The shortest time interval to transform a histological request to a standard result was four days while the mean TAT was 8.47 ± 3.34 days. There was a significant correlation between the histological diagnosis and TAT.
Conclusion Overnight fixation should be limited to large operating room specimens and not generalised. Provision of automated tissue processor, multi-headed and projecting microscopes will improve the TAT. All laboratory staff should be made to know that each stained glass slide represents a living patient and that the results are awaited.

Keywords: Turnaround time, surgical pathology specimen, histological request


How to cite this article:
Nwafor Chukwuemeka C, Ekpo Memfin D. Timeliness of surgical pathology results: a departmental audit of histopathological services. Sub-Saharan Afr J Med 2019;6:96-100

How to cite this URL:
Nwafor Chukwuemeka C, Ekpo Memfin D. Timeliness of surgical pathology results: a departmental audit of histopathological services. Sub-Saharan Afr J Med [serial online] 2019 [cited 2019 Nov 14];6:96-100. Available from: http://www.ssajm.org/text.asp?2019/6/2/96/270247




  Introduction Top


Important determinants of the clinical usefulness of pathology results are its timeliness (rapidity), reliability, efficiency, and affordability.[1],[2] Of these characteristics, timeliness is perhaps the most important to the clinician, who always want faster turnaround time (TAT).[3] Timeliness of a pathology report is closely associated with its TAT. TAT is defined as the time lapse from when the case (specimen) is accessioned to when it is released electronically by the pathologist.[4],[5] By the College of American Pathologists standards, ideal TAT for most routine cases are 2 days.[5]

Usually the decision to perform a biopsy on a patient is most often driven by a clinician’s uncertainty about the presence or extent of malignancy, as a result, clinicians and their patients expect not only accurate, but also rapid surgical pathology reports.[4] Additional pressures for short TAT in surgical pathology come from economic issues that aim at reducing the lengths of hospital stays and to finalize bills shortly after discharge.[4],[6]

TAT is an integral component of quality assurance and one of the key indicators of laboratory performance and influences the perception of the laboratory in the community of health care providers.[4],[7]

TAT varies depending on a number of factors such as the volume and type of specimen, nature of fixation, number of pathologists, representation of sub-speciality interests, availability of adjunctive diagnostic services, ownership of the histopathology laboratory (private or government owned), and availability of various forms of data entry, such as voice recognition or canned computer text and existence of undergraduate and/or postgraduate teaching responsibilities.[8],[9],[10] Other determinants of TAT are disease category, availability of ancillary studies, and the expectation/need to further sub classify tumors.10

The aim of this study was to determine the TAT for surgical pathology specimens (SPS) seen in our department and to identify the various determinants (variables) that affect it.


  Materials and method Top


This is a cross-sectional descriptive study (prospective) of all SPS that were sent to the histopathology laboratory of University of Uyo Teaching Hospital (UUTH) for two months (October and November 2015). UUTH is the only tertiary hospital in Uyo, Akwa Ibom State, and its histopathology laboratory renders services to the hospital and many privately owned hospitals within Uyo. These specimens were fixed in 10% formalin, processed manually, embedded in paraffin, and stained with Haernatoxylin and Eosin. Tissues that required special stains and additional processing were excluded. A special proforma was designed for this study taking into account the date of SPS arrival/accessioning, the nature and type of tissue, the date of surgical cut up (grossing), duration of tissue processing/handling in the laboratory, duration of handling of the SPS slides by the resident doctors and pathologist, histological diagnosis, and duration of typing and verification of results. Information from these proformas were later entered into an Excel sheet and analyzed using predictive analytical software, version 17 (IBM, SPSS Inc, Chicago, IL, USA) and simple frequencies were calculated.

Major limitations of this study include the lack of special studies and immunohistochemistry which when done may increase the TAT, the small sample size, and lack of patient outcome data. We did not survey patients to see the extent of effect on their management due to delayed availability of pathology reports.

The research was approved by review board of the hospital.


  Results Top


Following specimen receiving and accessioning, grossing was done after day 1 or day 2 in 41.1% and 41.1% of cases, respectively. Grossing was done the same day in 6.2% of cases and after 3 days of receiving the specimen in 6.2% of cases as shown in [Table 1]. The mean number of days before grossing was 1.65 ± 0.97 days.
Table 1 Interval in days before surgical cut up of tissue specimens

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[Table 2] shows the duration of tissue processing in our laboratory. In 53.6% of cases, the tissue processing was completed in 2 days, while in 34.8% of cases it was completed in a day, with a mean of 2.30 ± 2.05 days.
Table 2 Number of days in laboratory tissue processing

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Many of the processed SPS (histopathological slides) were reviewed and reported by histopathology resident doctors and consultant histopathologists within second and third days after processing in the laboratory (24.1% and 23.2% respectively), with a mean of 5.18 ± 13.07 days. Three (2.7%) cases were resolved following intradepartmental consultation, while two cases (1.8%) are yet to be resolved as shown in [Table 3]. There is a significant correlation between intradepartmental consultation and TAT.
Table 3 Pathology resident and pathologist review of cases

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[Table 4] shows the time interval between the pathologist’s review, typing of result, and verification of result for onward transmission to the requesting doctor or collection by the patient, with a mean of 2.99 ± 13.16 days. Many of these results (75.5%) were ready within one day after the pathologist review.
Table 4 Interval between pathologist review of cases and report verification

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The shortest time interval to transform a histological request to a standard result was 4 days as seen in only 5.4% of cases. TAT of 7 days accounted for the highest number of cases (15.2%). Within 10 days, 70.6% of the reports were ready for dispatch, while by 14 days, 96.4% of all the requests had been appropriately attended to as shown in [Table 5]. The mean TAT was 8.47 ± 3.34 days. A total of 39.3% of the specimens were excision biopsies, while trucut biopsies and amputations accounted for 23.2% and 20.5% of specimens, respectively. No significant correlation existed between the TAT and the type of tissue sent in for histological examination.
Table 5 Turnaround time (TAT) in relation to the tissue specimen type

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There was a significant correlation between the histological diagnosis and TAT as shown in [Table 6].
Table 6 Turnaround time (TAT) in relation to the histopathological diagnosis

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  Discussion Top


Though with the widespread use of laboratory computer systems, measuring and reporting TATs has become routine in developed/advanced settings, such cannot be said of our environment. The shortest TAT in this study, adjusted for weekend and holidays, was 4 days with a mean TAT of 8.5 ± 3.3 days. This is far higher than 2 days recommended by the College of American Pathologists, 1.5 days reported in Durham, 2 days in Atlanta, 3.02 days reported in a pooled study involving centres in USA, Canada, and Saudi Arabia, and 6.24 days in Barcelona.[2],[4],[5],[10],[11] However, reports from Kenya observed a mean TAT of 16 days.[7] Various reasons are responsible for prolonged TAT in our setting. Following accession, almost all SPS are allowed to fix for at least a day, with a mean of 1.65 ± 0.97 days before grossing and a mean of 2.30 ± 2.05 days for laboratory manual tissue processing. This is closer to 2.2 days observed in Kenya for the number of days spent between accession and trimming.[7] In the developed settings, grossing is mainly done on the same day as specimen accession with some exceptions. Studies have shown that overnight fixation of SPS are associated with prolonged TAT and are usually for two main reasons: time of receipt of the specimen in the gross room and specimen type. In the multicentre pooled study, about 44.6% of laboratories reported overnight fixation due to late time of receipt and 57.1% attributed overnight fixation to specimen type, with emphasis on specimens like breast, lower gastrointestinal tract, and genitor urinary specimens.[10]

Manual tissue processing contributed to the prolonged TAT in our setting as against the use of automated tissue processors which can process SPS in 12–18 hr. The non-availability of materials like mountant and other chemical reagents added to the prolonged TAT. Public/government-owned laboratories/hospitals like in our case are known to have longer TAT compared to privately operated ones due to inadequate response to shortage of materials, repair/replacement of bad equipments, low staffing, and different staffing patterns.[7],[10]

Review by doctors (residents/pathologists) lasts for a mean of 5.18 ± 18 days. The grossing and first reviews are done by resident doctors while the pathologists review and sign out the results. Studies have shown that specifically longer specimen TAT are associated with institutions where routine grossing responsibility is assigned to residents only and have residents involved in sign-out.[10] In our centre, the junior resident first looks through the SPS slides, passes it on to the senior resident before it finally gets to the pathologist, who are the only people with the authority to sign out the results. Another factor contributing to the longer duration caused by doctors in our centre is lack of multi-headed and projecting microscopes which causes waste of time during teaching sections because as the pathologist reviews the SPS slides, the residents are taught.

Trucut and small incision biopsies accounted for 23.2% and 17% respectively of all SPS seen, though there was no correlation between the tissue types and TAT. This was because of the departmental policy of overnight fixation. Trucut biopsy specimens and small-sized specimens were not processed as emergencies. All specimens were processed in the same way.. Observations in Barcelona and the study with a pooled data from three countries show that endoscopic and small-sized specimens were processed more quickly with a shorter TAT compared to large SPS.[2],[10] Endoscopic/small-sized specimens in advanced laboratories are frequently prioritized as stat because of the necessity to establish an aetiological diagnosis, and are not usually subjected to special procedures. In contrast, large operating room specimens require more time for an adequate fixation before embedding in paraffin, may be accompanied by calcified tissue which should be decalcified prior to inclusion, and evaluation is more complicated and time consuming.[2],[7],[10]Malignant diagnoses are known to cause increased TAT for SPS and laboratories that serve cancer centres are known to have longer TAT than those that do not.[10],[11] Our findings collaborated this, because there was a significant correlation between our TAT and pathologic diagnoses.

Improving TAT is a complex task involving education, equipment acquisition, and planning.[4]All staff of the pathology department should be made to understand that the specimens and glass slides generated from them are living patients and the outcome of the investigations has been awaited. In conclusion, we have documented a baseline data for future studies and have generated the following proposal to reduce our TAT; overnight fixation should be limited to large operating room specimens, hospital management should provide needed facilities (automated tissue processor, multi-headed and projecting microscopes) and resident doctors (both junior and senior) should pre-review slides together to reduce time spent among the doctors.

Acknowledgement

All resident doctors in department of histopathology University of Uyo Teaching Hospital Uyo.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Neuberger J, Peters M. The clinical interface − a British physician’s view. Clin Chim Acta 1996;248:11-18.  Back to cited text no. 1
    
2.
Adriana R, Teresa R, Rafael L, Gloria T, Miguel AA et al. Evaluation of turnaround times as a component of quality assurance in surgical pathology. International Journal for Quality in Health Care 1998;10:241-245.  Back to cited text no. 2
    
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Watts NB. Reproducibility (precision) in alternate site testing. A clinician’s perspective. Arch Pathol Lab Med 1995;119:914-917.  Back to cited text no. 3
    
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Robin TV. Analysis of turnaround times in pathology an approach using failure time analysis. Am J Clin Pathol 2006;126:215-220.  Back to cited text no. 4
    
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Commission on Laboratory Accreditation. 1994 Inspection Checklist: Anatomic Pathology and Cytopathology. Section 8. Northfield, IL: College of American Pathologists; 1994. p. 9.  Back to cited text no. 5
    
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Howanitz JH, Howanitz PJ. Laboratory results timeliness as a quality attribute and strategy. Am J Clin Pathol 2001;116:311-315.  Back to cited text no. 6
    
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Macbaria BN, Ndiangui FM, Chumba DK. Evaluation of turnaround time of biopsy and surgical specimens in Mol Teaching and Referral Hospital, Eldoret, Kenya. Kenya Journal of Health Sciences 2015;3:16-22.  Back to cited text no. 7
    
8.
Ramsay AD, Gallagher PJ. Local audit of surgical pathology. 18 months experience of peer review-based quality assessment in an English teaching hospital. Am J Surg Pathol 1992;16:476-82.  Back to cited text no. 8
    
9.
Zuk JA, Kenyon WE, Myskow MW. Audit in histopathology: description of an internal quality assessment scheme with analysis of preliminary results. Clin Pathol 1991;44:10-16.  Back to cited text no. 9
    
10.
Volmar KE, Idowu MO, Souers RJ, Karcher DS, Nakhleh RE. Turnaround time for large or complex specimens in surgical pathology. A college of American pathologists Q-Probes study of 56 institutions. Arch Pathol Lab Med 2015;139:171-177.  Back to cited text no. 10
    
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Patel S, Smith JB, Kurbatova E, Guarner J. Factors that impact turnaround time of surgical pathology specimens in an academic institution. Human Pathology 2012;43:1501-1505.  Back to cited text no. 11
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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