[Histonet] Frozen Section TAT
Robert.Lott <@t> trinitymedicalonline.com
Fri Jun 26 11:00:27 CDT 2009
Becky Garrison makes some very valid and interesting points below....
First of all, the point about what a "critical test" is, as defined by
She is correct, in that these are tests defined by the individual
institution in policy, but not by JCAHO.
Second, the item (ANP.11820) on the CAP checklist concerning turnaround
time of intraoperative frozen sections reads as follows:
The institution must "periodically" evaluate TAT and document reasons
for delay BUT only if 90% of FS are not completed within 20 minutes.
ANP.11820 Phase 1
Does the laboratory periodically evaluate turnaround time for
intraoperative frozen sections?
NOTE: If 90% of frozen sections are not completed within 20 minutes,
the laboratory must document evaluation
of the reason(s) for the delay. This turnaround time is intended to
apply to the typical single frozen section.
In cases where there are multiple sequential frozen sections required on
a single specimen (e.g., resection margins),
or in cases where additional studies such as radiographic correlation
are required, longer turnaround times may be expected.
Novis DA, Zarbo RJ. Interinstitutional comparison of frozen section
A College of American Pathologists Q-Probes study of 32,868 frozen
sections in 700 hospitals.
Arch Pathol Lab Med. 1997;121:559-567.
Robert L. Lott, HTL(ASCP) / Manager, Anatomic Pathology
Trinity Medical Center/ LabFirst/ 800 Montclair Road / Birmingham, AL
Date: Thu, 25 Jun 2009 10:49:43 -0400
From: "Garrison, Becky" <becky.garrison <@t> jax.ufl.edu>
Subject: RE: [Histonet] Re: tracking turnaround time of
To: "Della Speranza, Vinnie" <dellav <@t> musc.edu>, "Robert Richmond"
<rsrichmond <@t> gmail.com>, <histonet <@t> lists.utsouthwestern.edu>
<B3CA1BAF6C5E4541867E4E79AD2412E003C2910F <@t> jaxmail.umc.ufl.edu>
Content-Type: text/plain; charset="us-ascii"
Sorry I did not respond yesterday. The reason we just started measuring
order to sign out for frozens was also prompted by preparation for our
next JCAHO inspection. However, there is this distinction. The Joint
Commission does not define a frozen as a critical test. The designation
of critical test is left up to the individual institution. However,
once your institution defines the frozen as a critical test, (indicated
somewhere in a policy), you must conform to JCAHO guidelines for
And apparently this is the buzz with JCAHO watchers right now.
Here we designate the IntraOp consultations for frozens (not gross only
or Touch prep) and IntraOp PTH (Clinical test) as a critical tests
and have started tracking order to sign out. Order time is the time the
surgeon indicates 'send this to pathology' not when pathology receives
We are somewhat in uncharted waters as there is no national standard
that defines target time from order to sign out. We set a 40 minute
time (20-OR to Path and 20-path to completed frozen). I campaigned
against a 30 minute total time (15 each) because we do have some frozens
that do take over 15 minutes and this was an absolute value (unlike the
CAP goal of 90% within 20 minutes). Our approach is to monitor,
evaluate the data we retrieve. There will certainly be adjustments made
to target time and how and what we monitor.
The data collection raises more questions: how do you come up with
meaningful data for multiple specimens on a single case; multiple
frozens (different patients) received together or before we are finished
with the first patient's frozen). This is one of those ideas that
sounds good in theory but presents some challenges in execution. But it
is a valid process to monitor as we periodically have surgeons complain
of the time they are
waiting for frozen results. This is really a joint quality management
review which involves multiple departments (OR and Pathology) and how we
make it better for the patient.
Jacksonville, FL 32209
Disclaimer: This electronic message may contain information that is
Proprietary, Confidential, or legally privileged or protected. It
is intended only for the use of the individual(s) and entity named
in the message. If you are not an intended recipient of this
message, please notify the sender immediately and delete the
material from your computer. Do not deliver, distribute or copy
this message and do not disclose its contents or take any action in
reliance on the information it contains.
More information about the Histonet