Part IV: Building a Lean Pathology Lab

The first three articles in this series focused primarily on surgical pathology and histology workflow. This article will focus on the cytology area of pathology and examine how we are using lab design, equipment and Lean workflow to maximize our output in this area.

The goal of any cytology department is the ability to process, review and sign out cytology specimens in the most accurate and efficient manner possible. As desirable as it may be to have ever decreasing turn around times and ever increasing quality, there are a number of factors that may impact those goals. Some of the key factors that have the potential for the greatest impact are facility design, equipment, informatics, staffing and Lean processes.

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Facility Design

In planning the cytology area of the lab, we decided to locate the cytology screening room directly adjacent to the processing area. Placing a sliding glass pass-through window between the preparation area and the screening room allows the pathology technician (path tech) to move specimens into the cytology screening room without having to leave the preparation area. The window also allows the cytotechnologists direct oversight of the cytology processing activities performed by the path tech. This is a key feature that has proven valuable in those situations when assistance is needed in the preparation area or when direct and immediate communication is necessary.

A staging table in the prep area is located directly below the pass through window. Six steps from the staging table our Leica Multistainer has been placed so when gyn and non-gyn slides are finished, stained and coverslipped, the prep personnel can readily move the slides from the stainer/coverslipper to the staging area. This facility design allows us to enjoy a Lean workflow as specimens are processed, staged and placed through the pass-through to the cytotechnologists in a linear flow pattern. Once slide review is complete, those cases requiring pathologist review are placed into trays that are labeled with each pathologist name. These trays are shared with histology and are located at the histology pass-through window, just seven steps beyond the cytology screening room door.

Since the pathology lab is on the third floor of the hospital, we incorporated the hospital’s pneumatic tube transport system into our basic facility design to rapidly move reports and some specimen slides from various parts of the hospital to the pathology lab. We modified one of the transport tube canisters to safely accommodate plastic slide holders. This gives us the capability to utilize the transport tube to rapidly send fine needle aspiration (FNA) specimen slides from Radiology, CT and the Endoscopy Clinic to the pathologists for immediate assessment. This reduces the amount of time that the cytotech is away from the clinic specialty areas where the FNA procedure is being performed and greatly reduces the time interval from specimen procurement to immediate assessment and diagnosis.

Equipment

We utilize Leica’s IPS slide printers to label all gyn and non-gyn slides. In addition to correctly labeling gyn slides with ThinPrep codes that are required for use in the Imager, these units are configured to print 2D bar codes and patient identifying information on the slides. We employ two T2000 ThinPrep processors to process both gyn and non-gyn cytology specimens. These processors allow for nearly continuous processing of ThinPrep samples. Path techs do not have to wait for the machine to finish one slide before starting on the next. Four steps from our muti-stainer, is the Dako Artisan Link special stainer. This equipment is routinely utilized for special stains on both non-gyn Thin Prep slides and on the cell block slides produced from these specimens. During the processing of certain non-gyn specimens, we anticipate the need for special stains and process accordingly, making sure to have either Thin Prep processed slides or cyto spin processed slides available for special stains. This has proven extremely useful when special stains for fungus are needed on a respiratory specimen or when stains for Mucin are needed on pancreatic FNA specimens.

Plans are to upgrade to Hologic’s T5000 processor when it becomes available. The T5000 processor is a “walk away” gyn and non-gyn Thin Prep processor which will significantly reduce the time required to process Thin Prep specimen. It’s load and walk away features will free up tech time for other tasks while the specimens are being processed.

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The equipment is positioned in a linear configuration that dictates the flow of specimens in one direction. Processing flows from specimen and slide preparation to staining and coverslipping, slide drying, slide imaging, staging and slide screening. Bar code readers are employed throughout the processing and screening process to ensure positive patient/specimen match. Bar code matching occurs during specimen processing, staging and slide screening.

Within the screening room, each cytotechnologist has a computer workstation and both a conventional Leica DM 3000 microscope and an Olympus microscope to use with the Thin Prep Imager. Although we currently have two cytotechnologists, we purposely configured this room to accommodate three workstations to account for the potential of future growth and increasing work volume. Modular design desks and cabinets in the screening room give us the ability to quickly reconfigure this room if necessary.

Informatics

The SoftPath Laboratory Information System (LIS) allows the pathology supervisor and the cytotechnologists a real time monitoring capability to assess the status of the specimens as they move through the accessioning, processing, screening and pathologist review phases of specimen workflow. SoftPath supports our small batch processing philosophy by giving our path techs the capability to selectively print gyn slides for only the specimens currently being processed. Processing errors and specimen mix up is averted by excluding those specimens which are not part of the current processing batch. An additional feature of the LIS is the ability to perform multiple functions from a single display screen. This adds to the efficiency and Lean aspect of the workflow. While within the result entry function of SoftPath, the cytotechnologists use bar code readers to positively match slides to patients. In addition to adding patient gyn Pap results to a case, cytotechnologist are also able to import HPV results into the Pap report to give the clinician a comprehensive patient report.

The LIS gives a full range of quality control and quality management reports that allow individual cytotechs and the pathology supervisor to review and track quality monitors. To aid in quality control monitoring of gyn slide imaging, the ThinPrep Imaging System is set up to automatically print reports at the end of every run. While the instrument itself is located in the processing area of the lab, the printer is located in the cytology screening room, which allows the cytotechnologists easy access to this information.

Staffing

We employ two full-time cytotechnologists and two rotating path techs. Since the path techs are trained to support both histology and cytology, they rotate through the two sections on a weekly rotation basis. This dual functionality of having path techs trained in all areas of the laboratory give us a great deal of flexibility in personnel utilization. Cytotechnologists are available to assume processing duties when conditions dictate.

Cytotechnologists review routine gyn and non-gyn specimens and support an active and growing FNA service. They assist in these procedures in the Radiology, Breast Clinic and the Endoscopy departments of the hospital. In the CT area of the Radiology department, an area adjacent the procedure room is equipped with a microscope and staining line to aid in rapid adequacy assessments or diagnosis of FNAs. A mobile cart with a microscope and stain set-up is utilized for this purpose in other areas of the hospital where this service is requested. Cytotechnologists also assist on a weekly basis with HPV testing.

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Conclusion

The cytology service at Catholic Medical Center is an active and growing area. Designed with Lean processing and workflow in mind, we employ continuous throughput processing for both routine specimens and for specimens requiring special processing. Future enhancements in automated processing by employing Hologic’s T5000 processor will further enhance the Lean aspects of this service. Eventual incorporation of molecular testing of cytopathology specimens, whole slide imaging and the use of digital images for FNA rapid diagnosis procedures are planned for future expansion of this area.

Eliza Enstine, CT (ASCP) and Hollie Sale, CT (ASCP)cm are cytotechnologists and Brittany Touchette is a pathology technician at Catholic Medical Center in Manchester, NH.

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