[Histonet] Frozen Section TAT

Phyllis Thaxton dchihc <@t> yahoo.com
Mon Jun 29 08:58:21 CDT 2009

Hi All,
  I haven't been on in a couple of weeks, but thank all of you for the discussion on FS turnaround time reporting. I thought we had everything in place, but one thing we didn't even consider is when breast biopsies are send for radiology before arriving for FS. 
  We are also reporting receiving time as order time because they come in a pneumatic zip tube in  -60 seconds. I guess if there is more than one room trying to send and are in line waiting to be zipped, then the order time would be inaccurate the way we are reporting it.
  Thanks all!!
 Phyllis Thaxton HT(ASCP)QIHC
DCH Regional Medical Center
Tuscaloosa, AL 

From: "Lott, Robert" <Robert.Lott <@t> trinitymedicalonline.com>
To: histonet <@t> lists.utsouthwestern.edu
Sent: Friday, June 26, 2009 11:00:27 AM
Subject: [Histonet] Frozen Section TAT

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
turnaround time.

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
35213/ 205-592-5387 

Message: 19

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

critical tests.

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

the specimen.

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.

Becky Garrison

Pathology Supervisor

Shands Jacksonville

Jacksonville, FL  32209


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