A preanalytics push in accreditation checklists

ANP.23350 and BAP.07400 Paraffin Baths, Flotation Baths, and Embedding Stations now recommend the use of high-quality, low-melt paraffin because low-melt paraffin is removed more efficiently during de-paraffinization and/or antigen retrieval, which is essential for molecular analysis.

Also revised is ANP.11670 Specimen—Gross Examination, which now says “the ideal thickness for specimen sections submitted in cassettes is 5 mm or less.”

“If you don’t cut the specimen thinly enough,” Dr. Compton says, “it won’t get fixed on the inside. It will be raw. We want the formalin to be able to penetrate the entire thickness of the specimen.”

ANP.12500 Record and Material Retention—Surgical Pathology says paraffin blocks used for patient diagnostic, prognostic, and/or predictive purposes must be stored (for 10 years) in a manner that “preserves their identity and integrity,” and tissue blocks must be stored in a temperature-controlled, pest-free environment.

“The quality of the storage is important,” Dr. Compton says, “and not all institutions have space for storage so they farm it out. If you are paying someone to store your blocks, they will have to provide you with evidence that they’ve maintained temperature control and that rats aren’t gnawing through the paraffin blocks in their facility in order for you to pass a CAP inspection.”

In the laboratory general checklist is a revision to GEN.40100 Specimen Collection Manual Elements—Clinical Pathology Specimens. “In this revision we’re calling out phlebotomy draw order, as well as fill volume and proper mixing,” Dr. Compton says. “Some tubes in which you’re drawing blood for a molecular study have additives in them. The ratio between the additives and the blood in the tube is important and has been precisely calculated to get optimal outcomes. If you don’t fill a tube to the proper level or you don’t mix the additive with the blood thoroughly enough, you won’t get optimal results.”

GEN.40115 Specimen Collection Manual Elements—Surgical Pathology and Cytopathology Specimens is a new requirement that “puts CAP’s stamp on the importance of preanalytical factors for surgical pathology and cytopathology specimens,” she says.

The requirement lists the seven elements for which instructions must be included in the manual, including special timing for collection, type of collection container and amount of specimen to be collected, and types and amounts of fixatives or special media, among others. “Before, the check­list required some of the seven points but only suggested others. Now they are all mandated,” Dr. Compton says.

In this requirement is a note that addresses fixation and cold ischemia time, she says, noting the use of the word “must.” “These requirements will come as no surprise to anyone. They’re well known, but now they are being enforced. This is a big stick and a big step forward.”

Says Dr. Mahmoud: “Cold ischemia time and fixation are the two preanalytical factors that most affect molecular testing. These are the biggies that show up throughout revisions and demand a lot of attention. For instance, the note spells out types and amounts of fixatives, such as 10 percent neutral buffered formalin. Some hospitals collect specimens in nonconformance to that 10 percent, send them for molecular testing, and it never works. It is a disservice to patients who could never have the chance to get that testing done.”

Requiring records on cold ischemia time and fixation generated a lot of discussion, Dr. Goodman says, “because many labs are not able to control or obtain the data pertaining to cold ischemia time and when the specimen was placed in fixative. But the idea is to make sure people acquiring specimens are aware of this. I think for labs to be compliant they’ll have policies and procedures in place on how to handle specimens, educate other physicians, and make sure their OR staff, gastroenterology staff, pulmonology staff, and others are aware of them.”

In the all common checklist, COM.06300 Specimen Rejection Criteria requires labs to define and follow criteria for the rejection or special handling of specimens that do not meet established laboratory criteria for the requested test, and to retain records of these specimens in the patient/client report or quality management records or in both. Eight examples of specimens that do not meet established preanalytic parameters are provided, such as broken slides or specimens submitted beyond their stability time limits.

“Each lab must define its own criteria for rejection based on the kind of tests it does and with knowledge of the types of preanalytical factors that can compromise or preclude getting the right molecular analysis result,” Dr. Compton says. “If a specimen must be rejected, that’s serious. It means the patient will not get an answer.” The people who procure and handle the specimen, including those outside the purview of the pathology department, may be implicated. With feedback from pathology, she says, they will get the message it’s their fault. “This assigns responsibility to everyone in the chain of custody. Colleagues handling specimens in the operating room or clinic suite may need to change their own practices to ensure that the molecular quality of their patients’ specimens is preserved.” To pathologists who want to run tests on good specimens and get the right answers for patients, she says, “the entire upstream process is important.”

This requirement indicates that laboratories have choices to make, Dr. Goodman says. “For example, if I receive a specimen that’s hemolyzed, I cannot measure the potassium in it, but I can measure other analytes like sodium. So I have a choice: reject the entire specimen, analyze for sodium and not potassium, or analyze everything and add a disclaimer noting hemolysis may affect the result.”

In surgical pathology, the choice to analyze or reject is a more difficult one, he says, “because we can’t just take out another gallbladder or breast mass, in the same way lab medicine could request another urine or blood sample.” Even though a specimen may not have been handled perfectly, it still may be good for some analysis, he says. “This requirement establishes that if you decide to analyze a less than optimal specimen, information must be recorded to indicate there may be a problem. We must make sure doctors understand there’s an anomaly.”

The preanalytics team weighed in on the COM.30750 Temperature Checks requirement, noting patient specimens, reagents, and controls may be stored in a frost-free freezer only if protected from thawing and that thermal containers within the freezer can be used. It also says: “Repeated freeze-thaw cycles contribute to biomolecular degradation and are detrimental to biospecimen quality” and that avoiding freeze-thaw altogether by aliquoting specimens before freezing is prudent.

“This is a data-driven recommendation to keep freeze-thaw cycles to a minimum,” Dr. Compton says, adding that data show that freezing and thawing disrupt the molecular integrity of the sample. “If you’ve done this three times, it’s like putting a little grenade into the middle of the molecule and blasting it apart. You’ve destroyed your sample. We want people to aliquot it up front, freeze all of the aliquots, and only thaw each aliquot once.”

In the molecular pathology checklist, MOL. 32365 Specimen Preservation/Storage now says the same about repeated freeze-thaw cycles contributing to degradation and avoiding it altogether. And it says peripheral blood specimens shouldn’t be frozen, unless otherwise validated.

In the cytopathology checklist is a new section on predictive markers, the requirements of which are similar to those in the anatomic pathology checklist. “This section was added,” Dr. Goodman says, “to take into account labs that perform predictive markers on cytopathology specimens. While it’s rare for there to be a cytology lab doing this without an anatomic pathology lab associated with it, this covers such a lab if that is the case.”

In the new section consisting of six requirements, ranging from report elements to cytology slide and block storage, is “nothing revolutionary or unique,” he says. “We just want users of the cytology checklist to be aware of information and language adapted from the ANP checklist. In short, as more testing for predictive markers is done on cytopathology specimens, we want to make sure it is done correctly.”

And with more ancillary testing performed now on cytology specimens, Dr. Mahmoud says, other cytopathology requirements were revised to include language that is more inclusive of specimens other than tissue.

The key takeaway from the checklist additions and revisions, Dr. Goodman says, is that “preanalytic variables affect our results in all areas of pathology. If we don’t have the right raw materials on which to perform our tests, the rest doesn’t make any difference. We need quality specimens to get the right results.”

Dr. Compton says it’s an initiative that changes the standard of care by improving the quality of specimens for patient care and translational research “in one fell swoop.”

“It has never before been required to record what happens to a specimen on its way to analysis in a lab. Now we must document these important preanalytics. Now every specimen will have a history.”

Valerie Neff Newitt is a writer in Audubon, Pa.