Valerie Neff Newitt
September 2018—Quality management, communication, and consent are among the issues addressed in new and revised requirements in the autopsy pathology section of the latest edition of the CAP accreditation program anatomic pathology checklist. The same checklist, released in August, now contains an all new section on forensic autopsy pathology, which will be used to inspect forensic autopsy services provided in hospitals.
“Until now, CAP-accredited labs were doing forensics without detailed guidance for these specialized undertakings. We felt strongly that certain standards needed to be called out to ensure things are done in a proper way,” says Robert Ross Reichard, MD, chair of the CAP Forensic Pathology Committee and associate professor of pathology, Mayo Clinic College of Medicine and Science, Rochester, Minn.
In the general autopsy section, which applies also to forensic autopsies performed in hospitals, one of the new requirements is ANP.30080 “Autopsy Quality Management Program.” It calls for a written quality management program for autopsy services, including processes to review autopsy performance and the quality of reports. Records of quality monitoring must be available as evidence of compliance.
“We will not only use autopsy as a quality assessment tool, but we will assess our own quality,” explains Jody E. Hooper, MD, chair of the CAP Autopsy Committee and associate professor of pathology and director of the autopsy service, Johns Hopkins Hospital. “It was not separated out as a requirement before. Previously there were items that talked about utilizing autopsy results for quality assurance, but not about examining your own program.”
A revised requirement, ANP.30160 “Significant and Unexpected Findings,” says reasonable effort must be made to ensure that health care providers and/or medical examiners and coroners receive communications. This requirement, which previously called for a written policy on communication, now says records of communications must be retained.
Dr. Hooper
“I think this is going to be the biggest change for people,” Dr. Hooper says. “There was always a checklist item about the policy of communicating significant and unexpected autopsy findings, but now we have much more specific requirements for how that has to be done and what has to be recorded, including date, time, and content of the communication. This again parallels what is done in other areas of pathology, but it hasn’t been this specific in autopsy before.” As with all critical values, she says, people whose medical practice is affected by results have to know about the results. “Making sure doctors are informed so they can act on significant unexpected findings is certainly the least we can do.”
Other new requirements in the general autopsy pathology section are as follows:
- ANP.32180 “Limited Access” says access to the morgue or body receiving and handling areas and autopsy suite must be limited and controlled. Family viewing areas must be separate to prevent visual and biohazard exposure. “Most facilities already do this because it is common sense,” but it wasn’t a requirement, says William W. West, MD, chair of the CAP Checklists Committee and staff pathologist at CHI/Creighton University Medical Center.
- ANP.33070 “Handling of Personal Effects” requires written procedures for the “recording, safekeeping, handling and disposition of money and personal items, prescription drugs, illicit drugs, and evidence, as applicable” and notes that legal chain-of-custody procedures must be followed when appropriate. This required mechanism for handling personal items may be common in forensic autopsy labs, Dr. West says, “but it has not been common in general autopsy labs.”
- ANP.33240 “Ancillary Testing” requires that records pertaining to specimens collected for ancillary testing, including toxicology, include the anatomical site. “Initially we were going to put that in the forensic section only, then realized it could apply to almost any autopsy,” says Dr. West. “It reminds people to record the anatomical site from which the specimen was collected because it may make a difference in subsequent interpretations.”
- ANP.33380 “Photograph/Digital Image Labeling and Storage” requires photos and/or digital images to be labeled and stored appropriately and a system to prevent loss. “Again, we were just going to put it in the forensic section, but we realized people doing general autopsies also take a lot of photographs,” says Dr. West. “So why wouldn’t the same requirements apply to general autopsy cases? You must have useful photographs, properly labeled, easily sorted, and backed up so you don’t lose data.”
The new forensic autopsy section, to be used in concert with the autopsy section, is a framework for excellence in forensic autopsy pathology. “This is meant to afford those working in accredited labs support in knowing they are doing these autopsies to a high standard,” Dr. Reichard says. “These requirements have been vetted by forensic pathologists in CAP’s Forensic Pathology Committee, so they are significant.”
Dr. West advises that even if a lab does only an occasional autopsy for a coroner service, “you should not only view what is now in the general autopsy section of the checklist and make sure you are meeting those requirements, but also pay close attention to these new requirements in the forensic autopsy pathology section. It highlights important issues that need to be addressed if you are even considering doing forensic work.”
Members of the CAP Forensic Pathology Committee voiced concern, Dr. Hooper says, that “because CAP was inspecting a facility’s general autopsy services, there might be an assumption that CAP was endorsing those services as also being qualified for forensic autopsies.”
“This was a problem,” she adds, “because we weren’t even inspecting things pertaining to forensics. It was a component of practice that was falling through the cracks.”
Dr. Reichard
The new forensic requirements could build the confidence of laboratories that have few calls for forensic autopsies and of those requesting their forensic autopsy services. “Labs will gain additional guidance and credibility through the checklist,” Dr. Reichard says. “When someone asks, ‘What did your lab do on this forensic case?’ a pathologist can say, ‘We followed these checklist requirements, vetted through CAP’s Forensic Pathology Committee. We are accredited by CAP.’ That is a pretty robust defense of your process.”
The forensic autopsy checklist requirements will appear in the anatomic pathology checklist only when a laboratory indicates (on its activity menu) it performs forensic autopsies. “If labs indicate they perform forensic cases, both the general autopsy requirements and the new forensic section requirements will appear in their ANP checklist,” Dr. West says. “If they perform only general autopsies, only the general autopsy requirements will appear.”
Dr. Hooper characterizes the forensic requirements in two broad ways: expertise and services. “Facilities providing forensic autopsy services must have the ability to access appropriate consultation and provide appropriate expertise for a particular specialty area,” she explains. “They also must offer necessary services—be able to do toxicology, have the appropriate kind of imaging, be able to collect trace evidence and keep it secure, etc.”
One of the requirements in the forensic autopsy section, ANP.35000 “Forensic Pathologist and Expert Consultants,” requires that the laboratory have access to a forensic pathologist and expert consultants in forensic neuropathology, forensic dentistry/odontology, forensic anthropology, and radiology. “We have basically asked labs to think about who they can turn to for consultations ahead of time,” Dr. West says. “You don’t have to retain experts on site, but you do need to be able to contact them, send a slide, and so on.”
Another requirement, ANP.35025 “Analysis of Post-Mortem Specimens,” says forensic toxicology and clinical laboratory services must be available as needed for analysis of postmortem specimens. Testing services must be available on site or at a referral lab for ethanol, volatiles, carbon monoxide, major drugs of abuse, major acidic drugs, and major basic drugs. It also calls for compliance with toxicology guidelines.
Dr. West
ANP.36000 “Trace Evidence Collection” requires collection of such evidence, including hair samples, swabs, and nail clippings and scrapings. “This requirement reminds participants that in some situations, such as in sexual assault or a case of a pedestrian struck by a motor vehicle, you need to collect trace evidence, which is important in the subsequent handling of the case and in making medical legal determinations,” Dr. West says.
ANP.36025 “Specimen Collection” says specimens must be routinely collected and retained for toxicology, potential DNA analysis, and histological examination. Inspectors must examine chain-of-custody procedures pertaining to specimens and evidence. “This is a high-level addition that stands out to me,” Dr. Reichard says. “The need to apply a rigorous process of chain-of-custody to specimens and evidence is overarching. It requires more detailed documentation from the point when it is first collected, how it was collected, the time and date, right up to the moment it is stored.” Dr. West urges labs to spend time thinking about how to collect specimens for toxicology, for possible DNA analysis, and for histology. “Consider the possibilities before the time comes when you face them.”
Additional forensic autopsy requirements are as follows:
- ANP.36050 “Unidentified Bodies” requires a written policy defining actions to be taken before the disposition of unidentified bodies, such as fingerprinting and DNA sample storage.
- ANP.36075 “Photographs” details the types of photographs that should be taken during a forensic autopsy. “This requirement is intended to remind people of the items to be addressed when taking photographs in a medical legal case in order to have as complete a photographic record as possible,” Dr. West says.
- ANP.36100 “Autopsy Notes and Photographs” requires written notes and photographs that would make it possible to reconstruct the autopsy report in the event dictations are lost or damaged.
To help pathologists improve the quality and consistency of forensic autopsies performed in hospitals, members of the CAP Council on Accreditation had directed the Checklists Committee to delineate what is required in the autopsy section of the AP checklist. To do so, members of the Checklists and Forensic Pathology committees came together in a workgroup and, armed with a National Association of Medical Examiners guideline, identified which forensic requirements needed to be in the CAP checklist.
“We found there were items applicable to forensic autopsy that also benefited general autopsy, so we welcomed the Autopsy Committee into the workgroup,” Dr. West explains. When the members began to look at the needs of both types of autopsies, he says, “it became clear they must be aligned. Dr. Hooper was helpful in guiding that alignment.”
It was Dr. Hooper, too, who made the case for a separate forensic autopsy section in the AP checklist. “There are requirements of a genuinely forensic nature that are not necessary for general hospital autopsies, which already have vigorous requirements,” she says. “We didn’t want to impose burdensome forensic-level requirements on all hospitals and risk having a hospital say, ‘We just won’t offer autopsies anymore.’
“We were sensitive to the fact that autopsies are already an endangered species,” she continues, “and we needed to find that sweet spot with the checklists. So when the workgroup brought their draft requirements to the Autopsy Committee, we decided to put forensic requirements into their own section.”
Valerie Neff Newitt is a writer in Audubon, Pa.