The Accession Triage

Specimen receiving unit with the accession person as a main player is often underestimated one of the central parts of the grossing room in the surgical pathology division. Smooth work flow with concentration on accuracy and quality of processing is the main indicator of efficiency of specimen accession. This is a place where the many severe troubles are generated in surgical pathology grossing.

The accession work in surgical pathology requires predominately common sense and appropriate medical and pathology education. Common sense is not teachable, but medical and pathology knowledge can be acquired. These remarks are intended to make a blend of both medical and pathology training for initial treatment of diagnostic material upon receiving at the pathology department.

Different institutions understandably have different work load, specialization, established traditions, and simply a concrete cast of players. Nevertheless, there are common principles that ought to be followed otherwise the quality and speed of processing suffers or the specimen can be even ruined.

Perhaps, it would be superfluous to mention that the specimen must be checked for labeling, consistency of the requisition form and specimens, if it were not for so many occasions when these inconsistencies should be clarified. For many practical reasons these discrepancies should be straighten out as soon as possible, because delays eliminate the immediate participants on the clinical part of the specimen that complicates the situation. Sometimes, the specimen requires immediate processing for many reasons before the discrepancies are straighten out that request from the accession personal adequate training and common sense to send for processing with a provisional accession.

In essence during the accession the specimen acquires a surgical number but the work includes much more elements. Big laboratories replaces community hospitals laboratories like malls mom and pop shops. The specimens often arrive in droves. These circumstances require established protocols of specimen’s handling in different situations.

The main aim of the accession as a medical action is triage in literal meaning of this word. as setting priorities. The quality of the accession unit and the accession person is The first step reflected by how triage is executed. The accession triage determines the direction of examination and grossing triage. The accession triage should be under supervision and direction of grossing person, in institution with residency under supervision the resident in charge.

The accession person has to solve following immediate triage questions:

Does the specimen belong to surgical pathology?

Not so rarely microbiology samples are sent to surgical pathology as a division of pathology, or together with surgical pathology specimens, or, the worse case that surgical pathology is required to take material from the main specimen and send to microbiology that is wrong by essence. The accession person should alert the grossing person about the letter situation to solve the problem keeping in mind the sterility of collecting the material for microbiology.

Of course, the cytology material often is sent to surgical pathology by mistake or intentionally, especially in a case of PAP that is distinguishable by the specific container’s design. Sometimes, the material sent to surgical pathology is apparently insufficient, that requires attention of the grossing person as soon as possible to direct the examination to cytology or alert the clinicians without an unnecessary delay.

Cytogenetics, molecular biology specimen often get lost at surgical pathology specimen receiving that require proper recognition of them with immediate redirection.

What kind of speed of processing does the specimen require?

We do not discuss the rush  “irrational exuberance” epidemic that occur in some institutions or departments. There are three main definitions of the expedition of the specimen processing in surgical pathology: Frozen section (FS), Rush (same day or overnight), and Routine.

Frozen section priority is understandable. The work of the accession person in this situation should be under strict control of the pathologist, resident in charge, or grossing person. Accurate timing (better by computer) and following the sequence of the specimens is essential if they arrive as multiple in a short time, or from different patients.

Routine processing now becomes more blurred and unclear due to the lamming rush of the pathology departments to same day processing of biopsies. The discussion of this big issue is out of the scope of this review, but this is the every day reality of processing in large laboratories. The accession has to deal with prioritizing some specimens out of the routine group for routine/rush processing.

The real triage problem is a “Rush” specimen. No all “Rush” are meant equally, some are real “Rush”, some are “Rush”, but can be postponed, some are phony “Rushes” when the clinician meant “not too slow”. There are clinicians who are abusers of this definition thinking that their specimens have a special priority value, as well as situation when the mark “Rush” in the requisition form is directed to the delivery personal for immediate specimen’s transfer to the pathology department. Needless to say, that some “Rush” specimens are imposed by internal pathology department considerations, including evening stay, weekend, children’s soccer lesson, and etc.

Real “Rush” are specimens for transplant acute rejection, in opposite to annual surveillance for transplant rejection that is not a “Rush” specimen although often is considered as a “Rush”. Another example of a real “Rush” is acute necrotizing skin

( Toxic Epidermal Necrolysis TEN)   that has its protocol that includes “Rush” examination.

A renal biopsy for acute renal failure is undisputable “Rush” same day specimen.

Bone marrow biopsies usually arrive in fixative that requires monitoring of the fixation.

What kind of preliminary treatment does the specimen need before processing?

Although preliminary treatment is the prerogative of the grossing person, it starts during accession triage. This is the question of preservation the specimen. It is discussed in detail in the post “Introduction to Biopsy Grossing Techniques.”

This article does not touch such crucial question as mixed  up specimens. This question is discussed in the article “Root Cause Analysis in Specimen Misidentification Prevention in Surgical Pathology Accession and Grossing”

at the link Perspectives in Grossing Technology. The modern bar coding methodology makes the specimen’s correct identification almost a solved problem. There are plenty literature on this subject. For example, PRIMERA company offers equipment that make indeed possible to print very small Datamatrix 2D bar codes which include a lot of data. And what is very important that PTLab Software ties everything together and connects back through most popular LIS systems.









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