August 2008
Feature Story

Anne Ford

Of all the factors affecting the ability to obtain funding for an autopsy facility from the parent medical center, visibility—or rather, the lack thereof—may be No. 1. Tucked in an out-of-the-way basement or outlying building, many autopsy facilities are susceptible to contracting a disease that doesn’t appear in any edition of the Diagnostic and Statistical Manual of Mental Disorders: Out of Sight, Out of Mind Syndrome.

So when Marcus Nashelsky, MD, set out in 2003 to convince the administration at the University of Iowa Hospitals and Clinics that the institution’s 74-year-old autopsy facility was in serious need of upgrading, he had his work cut out for him. Yet in the end, he persuaded senior leadership to invest in a new, customized autopsy space—this in an era of low autopsy rates and often-scarce financial resources. Dr. Nashelsky is clinical associate professor of pathology, director of autopsy services, and co-director of anatomic pathology at UI Hospitals and Clinics.

It wasn’t that anyone in his own department needed convincing. Dr. Nashelsky’s supervisor, John Kemp, MD, director of clinical laboratories, is the first to call the old autopsy facility “decrepit, far away, inconvenient, uncomfortable.”

“The ventilation and the heating and cooling systems there have failed on more than one occasion,” he says. “The working conditions for the staff—not only the staff pathologists, but the residents and the other support staff—have clearly been suboptimal.”

There was the bereavement factor to think about, too. The old autopsy facility, which will continue to function until its new counterpart opens this fall, “is not at all designed for the comfort or safety of a grieving family,” Dr. Nashelsky says. “It is entirely inadequate for a very sensitive occasion.”

The most persistent challenge, however, has been the inability to fully segregate the area in which autopsies are actually performed: “There can be the presence of biological material, including bodies, in areas that are not fully dedicated to performance of autopsies. We aggressively employ modern personal protective equipment, but the porous nature of our autopsy and administrative areas can’t be overcome in the current facility. Additionally, the airflow is intermittently not fully independent of airflow in the rest of the building. That can introduce odors into other areas of the building, which is unacceptable,” Dr. Nashelsky notes. Not to mention that it played a part in recurring CAP checklist dings. “We had repeated phase I deficiencies regarding insufficient space, inadequate location relative to the rest of the university hospital facility, and inadequate ventilation,” he adds.

But, of course, recognizing that working conditions are inadequate is one thing; securing capital funding to improve them is another. “Things like autopsy facilities tend to fall to the bottom of the list because they’re viewed strictly as a cost center,” Dr. Kemp says. “And not being commonly in people’s minds as a part of the key functions of the hospital, it would never automatically rise to first place in most people’s considerations about how to spend money. If you don’t have an image of the place and you don’t understand what its role is in the delivery of medical care and how it can become a very emotional place for some patients’ families, then it’s hard to get it to rise to the top of the list.”

A letter to the hospital and medical school administration, laying out the challenges of working in the antiquated facility and describing how a new autopsy suite would improve clinician education and service to physicians and families, yielded little reaction from administration, Dr. Nashelsky says. “Perhaps the pathology chair and I were simply writing what many people [already] knew,” he adds. Undaunted, in January 2004 he formally requested capital planning.

“Marcus did a great job of pulling together the documentation needed to concisely and in a very articulate way state all of these things and present them as we were going through our request for funding,” Dr. Kemp says. Nonetheless, Dr. Nashelsky calls the application “a fairly dry document.” To augment it, he invited several senior leaders to tour the existing autopsy facility. That’s when the tide started to turn.

“It appeared to be an extraordinarily enlightening experience for them,” Dr. Nashelsky says. “It was our impression that most of them had not even seen our autopsy facility in its current form.” By fortunate coincidence, the tour took place on a particularly busy day, when two autopsies were underway—one of them a medical examiner consent autopsy that entailed, as he delicately puts it, “the removal and description of many articles of clothing contaminated by blood.”

“It was the critical point in the whole process,” Dr. Kemp says. “Most hospital CEOs and COOs are used to getting tours of fancy new operating rooms, brand-new outpatient clinics, all bright and gleaming facilities. And so I’m sure it was an experience on multiple levels for our COO to realize that this fundamental facility of the hospital was woefully out of date and that families of deceased patients had to come there. It was very clear to me that after the tour occurred, the COO had a very strong impression that something had to be done.”

Jose Fernandez, director of capital management at UI Hospitals and Clinics, confirms that “the capital committee was convinced the project needed to move forward partly because of the tour they had of the facility.” He says “the question really came down to where and when” a new autopsy suite would be constructed. Still, even after Fernandez had an outside architecture firm perform a feasibility study and obtained the board of regents’ permission to proceed, the project was far from home free.

Hospital administration had to decide whether to create the new autopsy suite as part of a planned separate, $500 million replacement and expansion of existing hospital facilities—which would have meant a seven- or eight-year delay—or find an existing space to renovate. “From my perspective, the bigger challenge was finding a location,” not finding the financial resources, Fernandez says. “I would say that space is far more scarce in a hospital environment than dollars.” The search for space was made more difficult because the location had to be easily accessible internally and externally—and discrete. “People die in hospitals, but it’s not something that you really want to advertise,” Fernandez says. And without an identified location, “it was difficult to approve the money.”

In the end, administration decided to renovate an existing space, and in 2006 an architect was selected. Work on the new facility began in the summer of 2007; it’s scheduled for completion next month.

The new facility will not only have segregated administrative and autopsy areas, but also a large isolation autopsy room and another autopsy room with two adjacent tables, the latter being a better arrangement for an attending pathologist to supervise concurrent resident-performed autopsies. A separate space will be dedicated solely to family viewing. In addition, the new facility will feature a fully independent air-handling system and a secure area for body pickup and delivery. “I can’t think of a single feature of the existing facility that will not be improved in the new facility,” Dr. Nashelsky says.

“It was pretty much custom-built,” says Kirk Gossett, the Mopec national sales manager who worked with Dr. Nashelsky to select and design much of the new facility’s equipment, including the dissection table, cadaver lift, floor scale, and storage cabinets. “The cooler design we’re doing is one of only two in the country that I know of.” In that cooler, cantilevered, wall-mounted storage arms will accommodate some 20 cadavers in case of emergency, rather than the five or six that can be accommodated on carts.

Mopec president Rick Bell says the situation at UI Hospitals and Clinics was far from unique. In his travels, he visits outdated autopsy facilities regularly. Some of the places are appalling, he says. “There’s no data on it, but if you asked me to guess, I would tell you that two-thirds [of autopsy facilities nationwide] are over 25 years old.” Common problems in those older facilities: ventilation, poor ergonomics, and equipment too small to handle heavier bodies. “A lot of people are promoting autopsies—they just can’t get their administrators to pay for them,” he says. Nonetheless, “we have been outfitting a lot more hospitals.”

Like UI Hospitals and Clinics, the University of Alabama, Birmingham Health System found itself with an outdated autopsy facility several years ago. The health system’s old autopsy area was inaccessible to physicians and medical students, says C. Bruce Alexander, MD, professor and vice chair of the UAB Department of Pathology and section head of autopsy pathology. Unlike UI Hospitals and Clinics, UAB’s new autopsy service benefited from piggybacking on another project—the construction of a new hospital. “The economy of scale was easy. If you’re buying equipment for 42 operating rooms, you can add three more, and it’s cheaper than starting from scratch,” he says. The major drawback: “waiting on that $350, $400 million hospital” to be built.

After an eight-year delay, UAB’s new autopsy facility opened in 2005. Despite the lengthy wait, Dr. Alexander says, creating a new autopsy facility “can be a very positive experience if you have the resource support.” At UAB, a family counseling room is adjacent to the anatomic pathology suite, and everything is located between the hospital and the chief outpatient clinic. The new facility is now “compatible with UAB’s mission,” Dr. Alexander points out.

Missions can, in fact, come in handy. “We found it useful to link many of our justifications with the mission and vision of our university hospital,” Dr. Nashelsky says. To other autop­sy service directors faced with coaxing resources out of their institution’s administration, Dr. Nashelsky advises, “Use the existing goals of your institution in your favor.” In addition, “there should be clear, respectful, and persistent communication with administrators about the deficiencies of the existing facility and the tangible benefits of an improved facility.”

“He [Dr. Nashelsky] did not waver. He did not stop,” Fernandez says. “I think his persistence was critical. The facility had been substandard for 10, 15 years before he came, but I don’t think anyone had championed it. What you usually find is that unless there’s a champion to say, ‘This is not okay,’ it usually falls by the wayside. This was probably not a strong priority within the pathology department until Dr. Nashelsky came in and made it so.”

What aspect of the new facility is Dr. Nashelsky himself most looking forward to? “Space,” he says happily. “Increased space in which to perform autopsies, work with residents, and interact with clinicians—and the luxury of having two autopsy tables in one room. It will be excellent.” And the old space? “I won’t miss anything about it.”