The safe handling and despatch of specimens in the operating theatre

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• Specimens SOP – Practical Guide for Practitioners
  
  
• Introduction
• Staff Responsibilities
• Classification of Specimens
• Patient Identification
• Departmental Documentation - Recording of Specimens
• Specimen Identification within the Operating Theatre
• Specimen Labelling
• Demand Print Labels - Order Comms
• Blood Transfusion Samples
• Pneumatic Tube System
• Receiving Specimens (The Process)
• Receiving Specimens When a Scrub Practitioner is Not Required
• Handling Specimens
• Process for Arranging Frozen Sections - SJUH
• Process for Arranging Frozen Sections - LGI
• Urgent Specimens - SJUH
• Urgent Specimens - LGI (including CHOC and WGH)
• Non Urgent Specimens - Week Day Collections - LGI/ CHOC/WGH
• Non Urgent Specimens - SJUH
• Non Urgent Specimens - Out of Hours/ Weekends/ Bank Holidays - All Sites
• Muscle Biopsies - Specialist Lab
• Battens Disease - Specialist Lab
• Skin Biopsies - Cytogenetics Lab
• Localised Excision of Breast Lesion
• Foreign Bodies/ Orthopaedic Implants/ Medical Devices/ Bronchial Lavage & Brushings/ Cervical Cytology Samples
• Retained Products of Conception - All Sites
• Suction Termination of Pregnancy (STOP) - All Sites
• Breach Reporting
• Specimen Discrepancies & Exceptions - Missing Specimens/ Unlabelled Specimens
• Unknown Patients
• “High Risk” Danger of Infection Samples
• Handling “Danger of Infection” Specimens
• Appendix One - List of Micro-Organisms that Require “Danger of Infection” Labels Hazard Group 3
• List of Micro-Organisms that Require “Danger of Infection” Labels - Hazard Group 4
• Appendix Two - LTHT Pathology Directorate Labelling Standards
• Appendix Three - Occupational Health Guidelines - Splash Injury

Introduction

The laboratory examination of specimens is important for determining subsequent treatment of the patient. The care and handling of specimens is therefore a critical step in the investigations.
Perioperative staff should be aware of the procedures involved in the care of specimens, including correct documentation, safe handling and appropriate despatch.
The overall responsibility lies with the Medical Practitioner.
Specimens that are not handled correctly can pose an infection risk to all of those who come into contact with them.

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Staff Responsibilities - All Theatre Suites within LTHT

In the operating theatre, specimens are regularly taken during surgical procedures. It is essential that every specimen reaches the pathology, histology, bacteriology or cytology department without undue delay and in optimum condition to facilitate the survival and identification of organisms.

It is the responsibility of all staff involved in the process of collection, handling and transportation of specimens to ensure that they follow the guidance in this Standard Operating Procedure.

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The Classification of Specimens

1. Transfusion Specimens
2. Retrievable Specimens
3. Irretrievable Specimens

Classification of Irretrievable Specimens

• Cerebrospinal Fluids (CSF’s)
• Specific dynamic function tests and specific test requirements
• Bone Marrow specimens
• Amniotic Fluids
• Histological and Cytological samples (excluding voided urine and sputa)
• Some samples from post mortems
• Certain forensic samples under the auspices of a Pathologist
• Clinical Microbiology - Sterile fluids, Outbreak samples other than faeces, specimens from temporary residents,
• Specimens from the operating theatre.

ALL OTHER SPECIMENS ARE RETRIEVABLE  i.e.  ABLE TO BE REPEATED

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Patient Identification

• All Patients will be positively identified as per LTHT Positive Identification of Patients Policy.
• Pre-printed patient addressograph labels are acceptable on request/investigation forms as long as ALL the information is checked with the patient wristband and case notes. The labels must also be confirmed as being up to date and correct for that patient.
• The Patient’s addressograph label should be checked by the receiving practitioner and the scrub practitioner or where there is no scrub practitioner, two circulating practitioners, one of whom must be registered, using the details on the patient wristband and appropriate (Patient Agreement to Investigation or Treatment) Consent Form prior to the label being placed onto the specimen container.
• The white copy of the Consent Form is to be stapled to the Pathology Request Form so Pathologists will know which investigation is to be performed on the removed body tissue.

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Departmental Documentation

Recording of Specimens

• A Specimen Register (LTHT Specimen Register (WN1000) is kept at each Theatre Departments Specimen Collection Point.
• All entries into any patients health record, including amendments, must be clearly dated, timed, signed and the designation of the person making the entry must be clearly recorded.
• It is the responsibility of the requester (Medical Practitioner) to ensure that specimens and investigative request forms are correctly labelled.
• It is the responsibility of the person sending the specimen (usually the Scrub Practitioner or Practitioner In Charge of the list) to ensure that specimens and investigation request forms are correctly labelled to the agreed standard.(Standards for the Labelling of Request Cards and Specimens for Pathology Investigation - Pathology Directorate LTHT January 2018)
• It is the responsibility of the medical practitioner to sign the investigation / request form and state what particular investigations are required. This should generally be the surgeon / lead clinician, but on occasion may be another medical practitioner such as the anaesthetist. Whoever provides the detail, must supply all the information, including clear identification of who they are, their grade and contact details.
• Every specimen retrieved within the theatre department will have the following details documented in the Specimen Register at the Specimen Collection Point by the perioperative scrub practitioner for the case:

• Date and time of when the specimen was taken
• Patient name
• NHS PAS or A&E number
• Date of Birth
• Theatre Number
• Details or nature of specimen and number of samples
• The responsible practitioner (depositing specimen) must also sign and print their name.
• Any comments applicable to registered specimen that will be of use to the Pathology Team on receipt.

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Specimen Identification within the Operating Theatre

• Both the scrub practitioner and the receiving practitioner who will assist in the specimen retrieval process must be present at the WHO Time Out so that everyone involved in the patients treatment and care is informed of the intention to retrieve specimens. If unplanned then the scrub practitioner should inform the receiving practitioner as soon as the request is known.
• The scrub practitioner must verify with the operating surgeon the nature and site of the specimen that is being taken. The scrub person will also confirm with the surgeon whether the sample should be placed in a container containing preservative or other transport medium, or whether it should be a dry specimen.
• The scrub practitioner must relay this information to the receiving practitioner who will assist in the specimen collection process.
• Specimens should be handled as little as possible in order to maintain the integrity of the sample.
• Action must be taken to prevent drying out of specimens. This may include putting the lid on the specimen container (if the retrieved tissue is to be sent fresh) as soon as it is received from the scrub practitioner. Or if the tissue is to be dissected by the surgical team at the operating table, that a saline damp swab be placed over the specimen (in the receiver/ kidney dish) until such time dissection can take place.
• Specimens and cultures should be handed off the sterile field to the receiving practitioner as soon as they are taken and the surgeon has given consent.
• For histopathology specimens placed in formalin, the container should be large enough to ensure that the specimen floats freely, is completely covered by appropriate fixative and is sealed for transportation.
• It is essential that staff follow Standard Precautions (H&SE) when handling body fluids and hazardous substances therefore gloves, eye protection and masks must be worn. These are provided as standard within the Operating Suites
• Care should be taken not to contaminate the outside of the container being used to store and transport the specimen.
• All staff should adhere to COSHH Regulations (HMSO 2002) and Occupational Health Guidelines in respect of splash injury from specimen fixative or body fluids(Refer to Appendix Three)
• At WHO Sign Out the surgeon must confirm with the scrub practitioner what specimens have been taken and that the Investigations on the Request Forms have been completed.

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Specimen Labelling

After checking the patients’ identity is correct, the following details must be recorded on the specimen pot label:

Details on the label must include:

• Forename and Surname in full - no initials 
• Date of Birth 
• Date of collection 
• NHS / PAS / A&E Number

• When patient adhesive addressograph labels are used they must be attached to the body of the specimen container (NEVER the lid).
• It is essential that the receiving practitioner labels the specimen container, and that it must be done after the details (of the specimen) have been confirmed by the surgeon to the scrub practitioner but before the specimen is placed in the container. The label must NOT be placed on the lid of the container.
• The labelled container must be shown to the scrub practitioner in conjunction with the details as they are recorded on the patients’ Case Notes/ Request Form/ consent form (Patient Agreement to Investigation or Treatment). The documentation used must previously have been checked for accuracy at the WHO Time Out.

N.B where the specimens are from paired structures the side should be clearly stated on the specimen container

• The information on the Request Form must correspond with the details on the specimen container and the patients Case Notes. It must also contain relevant clinical information to assist the laboratory staff.
• At the end of the procedure and before closure of the wound, the details of the specimens taken during the procedure should be read out to the operating surgeon.
• At WHO Sign Out as a final check with the scrub practitioner and receiving practitioner that all specimens have been received and correctly labelled.
• It is vital that all information is checked and accurate before the specimen(s) leave(s) the operating theatre. The specimen(s) must have all relevant documentation with it (them) at all times.
• Specimens must be documented in the patient care record, stating how many of each specimen type have been taken. 
• The security and labelling of any retrieved specimen is the responsibility of the scrub practitioner responsible for that patient episode.

Microbiology Specimens

• When specimens are required for microbiology, the Order Comms ICE booking system must be used to print the labels. If this is not done, specimens will not be accepted. 

Refer to Appendix Two for Labelling Standards (Standards for the Labelling of Request Cards and Specimens for Pathology Investigations - Pathology Directorate LTHT)

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Demand Printed Labels - Order Comms

Demand printed labels must be

• Generated at the point of care and at the time of the sample being taken
• Be checked against the Request Form for accuracy
• Not be used to confirm the identity of the patient. Patient identification must be done from the Request Form

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Blood Transfusion Samples

Demand printed labels MUST NOT be used for blood transfusion specimens. All specimens for Blood Transfusion must be completed by hand and have the name and signature of the person taking the blood along with the date and time the sample is taken.

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Pneumatic Tube Delivery System (PTS)

There is a PTS at both the LGI and SJUH. The system is designed to be used for transporting pathology samples and some pharmacy items. Please see the above link for a full copy of the policy.

Excluded Pathology Items

The following MUST NOT under any circumstances be sent via the PTS:

• Respiratory specimens from patients suspected or known to have Tuberculosis
• Blood Culture Bottles
• Samples for Frozen Section
• Used Blood Bags
• Any primary sample container showing visible signs of leakage/ damage or external contamination

Packaging samples to be sent via PTS

• Samples must be within a primary rigid container (ensure the lid of the container is securely fastened.
• All samples must be appropriately labelled and accompanied by the correct request form.
• All sample containers must be enclosed within a re-sealable plastic specimen bag. The sealable strip of the specimen bag must be properly sealed.
• Ensure there is sufficient packing material within the PTS carrier to prevent movement of sample bottles.
• Do not cram packed specimen bags into PTS carrier - this may result in damaging delicate specimens and the possibility of jamming the PTS.

PTS Carriers are NOT leak proof; please see the policy link below for guidance on spillages and breakages when using the Pneumatic Tube Delivery System (PTS)

Please Note:

Blood Bank and PTS - Blood Bank will not dispatch any blood products in the PTS under any circumstances.

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Receiving Specimens (The Process)

• To receive the specimens at the operating table the Scrub Practitioner will offer the surgeon a suitably sized container to receive it with (kidney dish / galley pot / sterile bowl) to place the specimen into.

• For specimens or tissue that is adherent to surgical instruments and therefore difficult to collect, for example endometrial curetting, it is acceptable that the receiver can contain saline into which the sample can be placed before transfer to a container.

• Specimens must not be placed onto swabs to pass to the Scrub Practitioner.

• If more than one specimen is to be taken each specimen should be identified by number…1, 2, 3 etc. and clearly identified to the scrub practitioner. A separate dish is to be used for each specimen.

• Prior to the specimen being placed into a container the Scrub Practitioner must ask the operating surgeon to clarify the nature of each of the specimens. This information is then repeated clearly to the receiving practitioner who is preparing the addressograph label.

• For paired structures the side must always be denoted and they should be submitted independently on the Request Form.

• Where Request Forms contain mandatory boxes, these must all be filled in to ensure acceptance of the specimen.

• Never pre-label sample tubes. The practice of pre-labelling specimen containers either by hand or with printed labels prior to the sample being taken is a well-established cause for error.

• The information on the investigation Request Form must correspond with the details on the specimen container label, patient’s Case Notes and consent form (Patient Agreement to Investigation or Treatment).
  It must also include relevant clinical information, written by the Medical Practitioner, to assist the laboratory staff.

• It is the responsibility of the Medical Practitioner to complete and sign the investigative Request Form, checking that the labelling is correct and stating what particular investigations are required.

• It is imperative that ALL information is checked and accurate before the specimen(s) leaves the operating theatre.

• The Scrub Practitioner responsible for the patient episode should transport the specimen to the Theatre Department Collection Point ensuring that the labels are all correct for the patient episode on the specimen container and the investigation Request Form.

• The specimen(s) must be accompanied by the correct documentation including the white copy of the Patient Agreement to Investigation or Treatment (Consent Form) as specimens cannot be processed if the required information is not present.

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Receiving Specimens When a Scrub Practitioner Is Not Required

For some surgery a Scrub Practitioner is not required, the process remains largely the same for these procedures.

The perioperative practitioner (Registered) who sets up the equipment and counts the Accountable Items for the patient episode will be known as the Responsible Practitioner (Registered Practitioner).

The Patient Identification will be in accordance to the LTHT Positive Identification of Patients Policy and the Responsible Practitioner and Receiving Practitioner must still confirm positive identification of patient, procedure as per policy.

• The receiving of the retrieved tissue must only be done by the Responsible Practitioner, whilst the receiving practitioner organises the documentation including labelling.

• The Responsible Practitioner must verify with the operating surgeon the nature and site of the specimen that is being taken.

• The Responsible Practitioner will also confirm with the surgeon whether the sample should be placed in a container containing preservative or other transport medium, or whether it should be a dry specimen.

• The Responsible practitioner must relay this information to the Receiving Practitioner who will assist in the specimen collection process by providing document and labelling support.

• Where Request Forms contain mandatory boxes, these must all be filled in to ensure acceptance of the specimen.

• Never pre-label sample tubes. The practice of pre-labelling specimen containers either by hand or with printed labels prior to the sample being taken is a well-established cause for error.

• The information on the investigation Request Form must correspond with the details on the specimen container label ,patient’s notes and consent form (Patient Agreement to Investigation or Treatment). It must also include relevant clinical information, written by the Medical Practitioner, to assist the laboratory staff.

• It is the responsibility of the Medical Practitioner to complete and sign the investigative Request Form, checking that the labelling is correct and stating what particular investigations are required.

• At Sign Out as a final check with the Responsible Practitioner and Receiving Practitioner that all specimens have been received and correctly labelled.

• It is vital that all information is checked and accurate before the specimen(s)  and patient leave(s) the operating theatre. The specimen(s) must have all relevant documentation with it (them) at all times.

• The Responsible Practitioner for the patient episode should transport the specimen to the Theatre Department Collection Point ensuring that the labels are all correct for the  patient episode on the specimen container and the investigation Request Form have been filled in by the Medical Practitioner.

• The specimen(s) must be accompanied by the correct documentation including the white copy of the Patient Agreement to Investigation or Treatment (Consent Form) as specimens cannot be processed if the required information is not present.

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Handling of Specimens

• Care must be taken when selecting an appropriate container, in relation to its size and purpose. For Histopathology specimens, the container must be large enough to ensure that the specimen floats freely when it is completely covered by a fixative and securely sealed for transportation.

• Formaldehyde is recognised as a substance hazardous to health and subject to COSHH regulations. ‘Formalin’ as used at LTHT is a 10% dilution of 40% formaldehyde with normal saline and is used as a fixative and preservative of tissue for histological examination.

• Use of formalin effectively protects staff from exposure to potentially infectious organisms within the specimen.

• Standard COSHH Precautions need to be followed by the receiving practitioner when placing the specimen in the container. These precautions must be taken to prevent any contamination of the outside environs contaminating the inside of the container.

• All staff must adhere to COSHH Precautions and Occupational Health Trust Guidelines (Appendix Three) for the treatment of splash injuries from specimen fixative or body fluids.

• For Chapel Allerton and Wharfedale Theatres microbiology specimens must be placed in a biohazard bag and sealed for transportation.

• At Chapel Allerton Theatres there is a dedicated specimen fridge for storage of microbiology specimens out of hours.

• All staff must adhere to COSHH Regulations when handling specimens in accordance to local policy.

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Process for Arranging Frozen Sections - SJUH

• It is the responsibility of the Medical Clinician to notify the Histology Department of specimens requiring frozen section and complete the investigation request prior to starting the procedure. The Surgical Team must check that this has happened before surgery starts (i.e. at Team Brief).

• “FROZEN SECTION” should be printed clearly on the top of the investigation Request Form, it should also contain the telephone number (usually of the designated Theatre) to which the report should be phoned.

• Patients who are undergoing surgery that require frozen section must have this requirement commented on the operating list and should be discussed at WHO Team Brief prior to the commencement of the theatre session.

• The telephone extension number for the specific theatre must also be provided on the histology form for the result to be phoned through to the Surgical Team.

• The patients details must be placed in the Specimen Register (labelled as Frozen Section)and the name of the porter transporting the specimen must be obtained by the theatre staff prior to handover.

• Specimens for frozen section are placed in dry containers and must be despatched immediately either via porter or member of the theatre team to the  laboratory Level 5 in Bexley Wing  SJUH

• Only a Medical Practitioner can receive the message regarding the results of the frozen section.

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Process for Arranging Frozen Sections - LGI

All frozen sections are done at the Bexley Wing Laboratory on Level 5.

• It is the responsibility of the Medical Clinician to notify the Histology Department of specimens requiring frozen section and complete the investigation request prior to starting the procedure. The Surgical Team must check that this has happened before surgery starts (i.e. at Team Brief).

Management of Frozen section specimens - Theatre Staff responsibilities:

Specimens for Frozen Section will be transported to the Bexley Wing at St James’s Hospital from LGI Theatres organised with the LTHT Transport Department, that will be on continual standby between 9.00am and 7.00pm from Monday to Friday except on Bank Holidays.  Theatre staff can arrange transport of specimens for Frozen Sections by following the protocol listed below.

1. To confirm a frozen section, theatres should contact the laboratory well in advance, stating the date and likely time of the frozen section.  There will be occasions when advanced warning of a specimen requiring Frozen Section is not possible.  The laboratory will inform the pathologist. 

Laboratory Telephone Number:           Extension 67771 (0113-206-7771)

1. Theatre staff should also contact the driver (who will be based at the LGI), and let him know the location and time for collection.  The driver can be contacted either by mobile phone or by bleep:

Drivers Mobile Number:      07767478845

Drivers Bleep Number:        80 6646

If unable to obtain a response on either number use: 07786260487 

            The driver should also be contacted 10-15 minutes before the frozen section will be ready for collection.

1. “ FROZEN SECTION” must be printed clearly on the top of the investigation Request Form, and must also contain the telephone number (usually of the designated Theatre) to which the report should be phoned. The specimen and request form should be given to the driver who will collect the specimen from the theatre reception area.  The driver will have a specimen transport box for the specimen.
2. Theatre staff must sign the drivers form (Facilities) to indicate the time the specimen was collected (this information will be used for audit purposes).
3. As soon the driver collects the specimen, theatre staff should telephone the laboratory (number above), and inform them that the specimen is in transit.
4. The driver will deliver the specimen to Specimen Reception, Level 5, Bexley Wing, and laboratory staff will sign & time the delivery.  After delivery of a specimen to Bexley Wing, the driver will return to the LGI base.  If a second frozen section is required the process should be repeated. 

After 7.00pm, at weekends and Bank Holidays, specimens should be transported by taxi:

Taxi Telephone:  Jubilee Wing Reception  Extension 22351           

1. The laboratory On Call service operates between 5.00pm until 9.00am and can be accessed via the switchboard.

If you need to speak a member of laboratory staff about an issue with a Frozen Section, please ask to speak to Jane Ramsdale, Sarah Caton or the duty Advanced Biomedical Scientist using the laboratory number above.

(LTHT Department of Cellular Pathology: HPQARecord 009.03 - July 2017)

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Urgent Specimens - SJUH

If a specimen is taken and is deemed urgent then the laboratory staff should be notified as soon as possible and the respective Theatre should ensure that the specimen is delivered to the laboratory and dealt with, with minimum delay.

The request for facilities porter collection is placed onto CARPS with Urgent Specimen Collection Required

All non-urgent specimens must be checked into the Specimen Collection Point and collected via the racetrack system.

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Urgent Specimens - LGI (including CHOC and WGH)

Monday to Friday except on Bank Holidays

The Theatres will inform the laboratory who will inform the pathologist.

Laboratory Telephone Number: 

Extension 67771 (0113-206-7771)

Theatres will contact the driver (who will be based at the LGI), and let him know the location and time for collection.

The driver can be contacted either by mobile phone or by bleep

Drivers Mobile Number: 07767478845

Drivers Bleep Number: 80 6646

If unable to obtain a response on either number use: 07786260487

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Non Urgent Specimens - Week Day Collections - LGI/ CHOC/ WGH

• Collections from these sites are by Facilities using the Portering Service and Transport. The porter will collect specimens from each department’s Specimen Collection Point at a time agreed by both Facilities and the Theatres.

• The specimens must be suitable for transportation i.e. in an appropriate sealable transport bag or box with the Specimen Register accompanying it.

•  Do not seal the Specimen Register in the bag/box.

• Ensure that all the lids are on tight to reduce the risk of spillage.

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Non Urgent Specimens SJUH

Transporting Specimens to the Laboratory Via Porter Racetrack Service - SJUH Theatres

Collection Times Includes Geoffrey Giles Theatres/ DBDU/ Chancellor Theatres (both levels) and Bexley Wing Theatres: 07:30-08:30 / 12:30-13:30 / 15:30-16:30

Non Urgent Specimens must not be CARPS’d but checked into the Specimen Collection Point to await transportation

For each Theatre Suite:

• The specimens and corresponding forms including the white copy of the patient consent form are checked against the Specimen Register entry by the facilities porter before transporting to the laboratory.

• It is important to check in all areas of the specimen fridge (Theatres Specimen Collection Point) to ensure that there are no specimens left behind when a collection is being made.

• The facilities porter will check against the Specimen Register as to how many specimens he needs to collect (this is not checked patient and number of specimens at this point). It is therefore important that the responsible practitioner has checked in the patients specimens accurately the Specimen Collection Point.

• The facilities porter transports the specimens, forms and the specimen registers to both the Bexley and Chancellor Wing Laboratories. The facilities porter signs the Specimen Registers as the person transferring the specimen and records in the Register the time delivery is completed.

• At the laboratory specimen reception the technician then checks that the specimens and documentation is present and correct. The Lab Technician then signs and prints their name in the Specimen Register to confirm time of receipt.

• The racetrack porter then delivers the specimen registers back to the appropriate Specimen Collection Point

• Local specimen collection times are agreed between the theatre, facilities and pathology management teams and displayed at specimen collection points and on specimen refrigerators.

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Non Urgent Specimens - Out of Hours/ Weekends and Bank Holidays - All Sites

Under the direction of the Medical Practitioner requesting the investigation of Non-Urgent Specimens the options would be to:

• Fresh specimens stored in dry containers will remain viable overnight if kept in the fridge but must be transported to histology labs as soon as normal hours return the next day.
• Place the specimen into the specimen refrigerator at the Theatre Specimen Collection Point.(Out of Hours Only).
• Specimens such as microbiology and cytology will be stored in the fridge at the Theatre Specimen Collection Point until next collection.

If there are any queries as to the storage of non-urgent out of hours specimens a member of the on call laboratory team can be contacted via the hospital switchboard.

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Muscle Biopsy Protocol - Specialist Lab

Patient Identification Procedure and Receiving Process MUST be followed in conjunction with this protocol 

Prep of Sample:

Prepare a Petrie dish with slightly dampened saline gauze. Two pieces of muscle are required.

1. Check with the Chancellor Wing Lab (Ext 64710) that the biopsy has been booked with them. This is usually done by the requesting physician.
2. The surgeon must fill out the Request Form prior to starting the procedure.
3. The Receiving Practitioner (using Patient Identification Procedure) must ensure that a photocopy of the Referral Letter (if available) is enclosed with the white consent form (Patient Agreement to Investigation or Treatment) in the specimen bag.
4. Book the Driver prior to starting the case as they will need to be in the department ready to transfer the specimen (the Muscle Biopsy must be in the Lab at SJUH within 20 minutes).
5. The Lab closes at 17:00hrs, it is important that all samples are transported before 16:30hrs to ensure they are booked in at the Lab. 

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Battens Disease (Rectal Biopsies) - Specialist Lab

The Theatre will inform the laboratory will inform the pathologist of rectal biopsy prior to sending as the specimens are sent fresh

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Skin Biopsies

Patient Identification Procedure and Receiving Process MUST be followed in conjunction with this protocol

All Skin Biopsies are processed in the Cytogenetic Laboratory listed below, if these specimens are sent alongside muscle biopsies, it is imperative that the muscle biopsy is booked in first (the theatre practitioner) at the specialist lab before proceeding the Cytogenetic Lab.

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Localised Excision of Breast Lesion

Patients Who Have A Breast Specimen Taken With A Wire In Situ

• Staff MUST ensure that the relevant Investigation Forms, Consent Form, X-Ray Form accompany the specimen.
• The telephone extension number of the theatre in which the procedure is being performed MUST be marked on the Investigation Form
• The patients existing X-Ray MUST also accompany the specimen
• To receive the specimen at the operating table the Scrub Practitioner will offer the surgeon a plastic kidney dish to place the specimen into.
• Prior to the specimen being placed into a container the Scrub Practitioner must ask the operating surgeon to clarify the nature of each of the specimens. This information is then repeated clearly to the receiving practitioner who is preparing the addressograph label.

• For specimens or tissue that is adherent to surgical instruments and therefore difficult to collect, for example endometrial curetting, it is acceptable that the receiver can contain saline into which the sample can be placed before transfer to a container.
• Specimens must not be placed onto swabs to pass to the Scrub Practitioner.
• The Receiving Practitioner (accepting the specimen) will provide a labelled specimen bag (clear) that has been check with the Scrub Practitioner for accuracy,
• A Specimen container MUST also be provided and checked by the Scrub Practitioner to ensure it is accurately labelled and large enough for the specimen to be placed in following X-Ray.
• The patients details MUST be placed in the Theatre Specimen Register and the name of the person transporting the specimen must also be recorded.
• Specimens MUST be taken directly to the X-Ray in the Breast Unit for processing.
• The Receiving Practitioner will phone X-Ray (Breast Unit) to inform them that the specimen is en-route.
• Once X-Ray has processed the specimen, they will contact the Theatre to inform the Surgeon if the excised margins if the specimen are adequate.
• The specimen will be returned (in a specimen container) to the operating theatre and processed along with any other specimens that may have been collected during the procedure.

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Foreign Bodies

• Foreign bodies must be clearly labelled and retained for inspection.

• Forensic specimens must be saved in accordance with local policy ensuring that there is a total traceability of the specimen at all times until it reaches its destination.

• Some forensic samples will not necessarily be body tissue e.g. bullet or shot removed during surgery from firearm wounds. 

Orthopaedic Implants or other Medical Devices

The following must be ascertained

• Whether the implant is to be sent for bacterial, pathological, metallurgical or mechanical examination

• Legal ownership of the implant before any destructive testing is carried out, MUST be clearly labelled and retained for inspection.

• Specimens comprising items retained as a consequence of procedures undertaken at LTHT require an incident report through Datix.  

Bronchial Lavage / Brushings - All Sites

Lavage samples should ideally be sent in a sterile universal container, if traps are used to collect the sample they must be securely sealed using a sterile bung on each port, enclosed in a histology specimen bag (Clear) along with all Checked documentation and then placed in the transport bag / box as leaks are common. 

Cervical Cytology Samples - All Sites

It is imperative that all cervical samples are dispatched to the laboratory on the next available transport (where applicable) and are not batched processed.

Cytology specimens must be delivered to Pathology Reception Area, link corridor between Gledhow and Chancellors' Wing SJUH.

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Retained Products of Conception - All Sites

The Histopathology Request form [HPQA Form 552.01.01 March 2015] for these types specimens must be completed by the medical practitioner before starting the procedure.

• The patient addressograph label must be checked using the details on the patient wristband/ Case Notes and consent form before the label is attached to the VacSax® tissue collection device which is used as the specimen container.

• The scrub practitioner must confirm with the surgeon the use of saline or formalin to flush the uterine high vacuum tubing through with at the end of the procedure.

• Standard Precautions (H&SE) must be applied when handling body fluids and the correct personal protection equipment must be worn.

• Collection of the specimen will be achieved using the VacSax® tissue collection device in combination with wide bore high vacuum tubing for uterine aspiration. The specimen details are recorded on the addressograph label and checked as correct by the scrub practitioner and receiving practitioner and then the addressograph labels must be attached directly to the container and specimen box.

• The white copy of the consent form (Patient Agreement to Investigation or Treatment)  is to be attached to the Investigation Request Form so the technicians in the mortuary can deal with the removed body tissue appropriately.

• The VacSax Tissue Collection Pack (Part #9410-001) is the standard pack to be used across all sites for this procedure and Suction Terminations. The VacSax should also be used alongside the using Pennine Healthcare uterine aspiration wide bore, high vacuum tubing with swivel handle (REF: KHS3000).

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Suction Termination of Pregnancy [STOP]

• The collection process for products of conception following suction termination of pregnancy utilises the VacSax® tissue collection device in combination with wide bore high vacuum tubing for uterine aspiration.

• The products of conception are placed in the designated container (found in the VacSax® procedural pack).

• The patients NHS / PAS number is written on a white label (found in the VacSax® procedural pack) and placed on the outside of the container which is placed in a plastic bag which then goes inside the dedicated box (found in the VacSax® procedural pack) which also has a white sticker with the patient’s NHS / PAS number written on it.

• The specimen box is then placed in the Specimen Fridge at the Specimen Collection Point and labelled “Foetal Remains”

• The completed Request Forms, White Pathology STOP Consent Form (Patient Agreement to Investigation or Treatment) must be placed in folder labelled ‘Foetal Remains’ completed forms” which is situated with the Mortuary Specimens Register at the Theatre Specimen Collection Point.

• All Specimens are to be transported to the Mortuary and NOT Histopathology Laboratory unless otherwise requested by the Medical Clinician

• A separate Histopathology Specimen Register dedicated to Mortuary Transfers should be available in each Theatre Department that carries out such procedures.

HistologyVacSax® Tissue Collection Device (procedural pack) Part #9410-001

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Breach Reporting

If an error is made with a specimen, this indicates that protocol has not been followed and / or an error has occurred that impacts on the safe management of a specimen. In all such cases an Incident Form (DATIX) must be completed, the incident must be reported to the Theatre Co-ordinator and investigated.

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Specimen Discrepancies & Exceptions

The Specimens have not been labelled and the patient episode has ended

• Do Not label the specimen
• Inform the responsible Medical Practitioner immediately 
• Inform the Practitioner In Charge or Theatre Co-Ordinator immediately 
• Complete an Incident Form (DATIX)

Incorrect Number of Specimens Delivered to the Laboratory Facilities

• Upon finding a discrepancy when handing over at the laboratory specimen reception, the facilities porter should first return to check the Specimens Fridge and Specimen Collection Point within that Theatre Department. If the specimen remains unaccounted for the porter must report the discrepancy to the Theatre Co-ordinator.

• The Theatre Co-ordinator will contact the theatre in question to organise an immediate search

• The responsibility for locating missing specimens will rest ultimately with the responsible scrub practitioner and the theatre team.

Specimens reported as ‘Not Received’ by Histopathology

• Identify which specimen is missing

• Inform the Team Leader / Theatre Co-ordinator

• The responsibility for locating missing specimens will rest ultimately with the responsible scrub practitioner and the theatre team

• Inform the Responsible Medical Practitioner/ Consultant

• Complete an Incident Form (DATIX)

• If the specimen is from a Frozen Section. This must be located as a matter of urgency as the specimen is fresh and will be decaying.

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Unknown Patients

If the patients Surname and / or Forename are given as Unknown, a PAS or A&E Number is acceptable to use as patient Identification.

• The PAS or A&E Number must be on the sample and request form. The details on the request form and specimen / sample must match.

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High Risk” Danger of Infection Samples

To comply with national Health and Safety guidance and to alert laboratory staff that a
specimen may require processing differently, some specimens must be labelled as ‘High Risk' (Danger of Infection).

Clinical judgement must be used to label specimens correctly, and the onus for this is on the requestor (Medical Practitioner).

Reason for labelling High Risk Samples

To comply with National Health and Safety guidance and to alert laboratory staff that the specimen may require processing differently.

What is a “high risk” Danger of Infection specimen?

Clinical judgment must be used to label specimens correctly, and the onus for this is on the requestor.

Specimens from the following MUST have a “High Risk” Danger of Infection labels:

1. Patients with proven infection with a Hazard Group 3 & 4 (Please see list).
2. Patients suspected of having a HG3/4 pathogen (information from clinical
   history and examination- please see list).
3. A patient who is part of an on-going outbreak caused by a HG 3 & 4 pathogen.
4. Inmates of His Majesty's Prison Service.

If there is doubt as to whether a specimen is “high risk”, please contact the microbiology laboratory.

Patients suspected of having any pathogen in Hazard Group 4 require consultation with the on-call medical microbiologist/virologist before sending sample.

Specimens from patients known or suspected to be suffering from the following clinical conditions/micro-organisms must have “Danger of Infection” labels on both specimen and request form.

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Handling “Danger of Infection” Specimens

• Danger of Infection labels should have black print on a yellow ground, and should be self-adhesive.

• A Danger of Infection label MUST be placed on the high-risk specimen container and its request form. The Request Form must give sufficient clinical information to enable the experienced laboratory staff who will receive it to know what special precautions are necessary in the laboratory.  N.B. Writing “Danger of Infection” is not acceptable

• The Request Form may be folded so that the information need not be conspicuous to other people, but the “Danger of Infection” label must be clearly visible.

• The specimen container must be placed in an individual transparent plastic bag, which should then be sealed. The specimen should then be transported by the usual system.

• High Risk specimens must not be transported to the laboratory via the air tube.
  Further information is available from LTH Infection Control

Danger of Infection Labels can be obtained from the print unit - Code WRN502

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Appendix One

List of Micro-Organisms that Require "Danger of Infection” Labels

Hazard Group 3

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Appendix One

List of Micro-Organisms that Require "Danger of Infection” Labels

Hazard Group 4

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Appendix Two

Labelling Standards (Standards for the Labelling of Request Cards and Specimens for Pathology Investigations - Pathology Directorate LTHT)

In line with LTHT Trust “Improving the Quality of Diagnostic Testing” the completion of the Request Form and Specimen Container is mandatory and where information is missing or illegible the request will be rejected.

Labelling of the REQUEST FORM

• Forename and Surname in full no initials
• Date of birth
• PAS Number/  NHS number or A&E Number
• Location (Ward/ OP/ Unit)
• Consultant
• Investigation required
• Date of request
• Time of collection (where relevant)
• Clinical details
• Investigation/ Tests required
• Infection status (where relevant)
• Signature

Labelling of the SPECIMEN

• Forename and Surname in full no initials 
• Date of Birth 
• Date of collection 
• PAS / NHS / A&E Number

The details on the specimen MUST match that on the Request Form

For further details please follow the link below

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Appendix Three

Occupational Health Guidelines LTHT

Sharps and Splash Injuries

All healthcare workers including students on clinical placements need to be aware of the actions to take if they are exposed to blood and / or bodily fluids.

This section covers the immediate action to be taken following a needle stick or splash injury.

More information can be found in The Trust Needlestick Policy which is available on the Infection Control Website.

I've had a Sharps/Splash injury.  What do I need to do? 

Immediate First Aid Measures

• Percutaneous injuries (those from a needle/sharp instrument) should be squeezed gently to encourage the wound to bleed. DO NOT SUCK THE WOUND. Wash the wound with soap and water, dry and cover with a waterproof plaster.
• Splashes onto broken skin should be cleaned liberally with clean water.
• Splashes to mucous membranes should be irrigated with copious amounts of clean water.
• The incident should be reported to the senior person on duty at the time and an incident form (DATIX) should be completed as soon as possible after the injury.

 What Happens Next?

During office hours all sharps/splash injuries must be reported to the Occupational Health Service as soon as possible so that relevant advice can be given and any immediate and follow up action can take place.

 The numbers to call are:

St James’s University Hospital  (Mon - Fri 08.30 - 17.00) 0113 2065228 (ext. 65228)

Leeds General Infirmary  (Mon - Wed 09.00 - 17.00) 0113 3923267 (ext. 23267)

For Chapel Allerton and Wharfedale Theatres either phone numbers are applicable.

Following contact with the Occupational Health Service, a risk assessment of the donor must take place. This should be done by the clinical lead for the area as soon as possible after the injury. It is considered to be unethical for the member of staff who sustained the injury to carry out the risk assessment or take blood from the patient. If the donor is unable / unwilling to give consent for blood taking, then the information provided in the risk assessment will form the basis for any follow up care.

Blood must then be taken from both donor and recipient. If the blood sample is being sent directly from the recipients ward / clinical area, the risk assessment form WKU958 should be completed and one copy sent to OHS and one copy sent to the lab with the blood samples. An example of how to complete the microbiology request form can be found on the Infection Control Website (refer to the Trust Needle stick Policy).

The bloods must be sent to Microbiology. The donor results will be posted on the Results server. The recipient results will NOT be posted on the server and will be sent directly to OHS.

If the donor is unknown, specialist advice must be sought from the OHS within office hours.

Out of Office Hours

Advice from relevant specialists in line with local protocols is essential. Such cases will be risk assessed on their individual merit before further action and/or treatment will be advised.

There is a dedicated phone number for out of hours injuries:

0113 3925011 (extension 25011)