1. CHESAPEAKE BAY PERIOPERATIVE CONSORTIUM
MANAGEMENT OF SURGICAL SPECIMENS
CHESAPEAKE BAY PERIOPERATIVE CONSORTIUM
2017

2. Specimens are Serious Business!
Imagine you are the patient that has just been told a diagnosis cannot be determined because of the careless handling of the specimen obtained in your surgery.
Think of the time, planning and anxious moments spent by the patient waiting for answers to their health questions.
During a surgical procedure, not only are you removing tissue or bone that is causing pain, but you are also removing a piece of the puzzle or clue into a patient’s diagnosis.
A mishandled specimen could result in a misdiagnosis and subsequent inappropriate treatment since they can be so instrumental in diagnosing certain conditions and diseases.
Nolan’s Story: A 3 year old underwent a routine tonsillectomy for chronic tonsillitis. The procedure went as planned without any complications. The tonsils were sent to pathology as a routine specimen and resulted with rhabdomyosarcoma. The specimen from a routine tonsillectomy diagnosed this child with cancer, which might have otherwise gone on undetected.

3. OBJECTIVES Identify types of surgical specimens
Identify the perioperative team’s responsibilities in regards to specimen management
Identify requirements for labeling and documentation of surgical specimens

4. Joint Commission Requirement
All specimens are sent to pathologist for evaluation. The clinical staff, in consultation with the pathologist, decides exceptions to submitting specimens removed during the surgical procedure. The exemption list must be in writing (facility policy).
Medical staff and pathology should approve the exemption list. This list should be included in a policy.
Exemptions should only be made when the quality of care is not compromised.
If a specimen is exempt from sending to lab, its removal should still be documented in the chart.

5. DEFINITIONS
Portion or quantity of material taken for use in testing, study or examination
Specimen
Grow living material, such as microorganisms or tissue in an artificial nutrient (medium)
Culture
Pathology
The science/study and diagnosis of disease
A combination of methanol, water, and formaldehyde frequently used to preserve specimens.
Formalin

6. Commonly Handled Specimens
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Blood
Soft Tissue
Bone
Body Fluids
Foreign Bodies

7. Assess and plan before the procedure!
Planning
Assess and plan before the procedure!
Department/Personnel needed
Supplies
Documentation
Special Considerations (Policies should be in place)
- Cultural
- Patient requests
- Explants
Coordinate with other departments ahead of time to make sure appropriate personnel will be available when needed, such as radiology and laboratory.
Culture: Does your patient have any cultural or religious beliefs that requires the specimen to be handled in a specific way?
-Jewish and Muslim patients may ask to have tissue, limbs or blood returned so that they could be buried. Follow facility policy.

8. Containers
Containers and collection devices of appropriate size and correct preservative should be used.
Can be either sterile or clean.
Should be large enough and have a securely fitting lid to contain the specimen and fluids, and to prevent any leakage.
If formalin is used, the container should be large enough to allow formalin to contact all areas of the specimen.
The specimen should be contained and labeled immediately after transfer from the sterile field.

9. Select size appropriate for specimen
Containers cont.
Select size appropriate for specimen

10. Specimen Types Routine Diagnostic
Routine: Tissue removed that does not require diagnosis.
Diagnostic: When immediate tissue identification or identification of malignancy is needed.

11. Routine Specimens Do not require immediate attention
Usually gets placed in formalin and requires refrigeration
Exceptions include:
Renal calculi
Cytology
Lymph nodes
Wire-directed biopsies
Cultures
Radioactive
Formalin is used unless otherwise directed by pathologist or protocol.
Formalin can alter the chemical component of calculi.
Formalin may prevent sterile preservation for cultures or chromosome studies.
Specimens may require examination for entirely by use of mammography or sonography (wire-directed biopsies).
Radioactive specimens may necessitate containment in lead box.

12. Routine Specimens
Keep specimens moist on field until transfer unless protocol requires different handling
Separate and label multiple specimens as directed by surgeon
Specimens meant for re-implantation should be handled per protocol.
Bone graft
Amputated digits/limbs
Multiple specimens from the same source should be numbered accordingly

13. Special Considerations
Amputations
Products of Conception
Amputated extremities are wrapped before sending to lab/morgue. Usually have sharp edges that could be a safety concern to staff. Could be too large to go to lab immediately and would have to go to the morgue.
Prepare for your experience with amputations. May be unsettling for some staff. Disposable mayo covers or large biohazard (doubled) bags may be used to contain limb. Remember cultural considerations.

14. Foreign Bodies TEXTUALIZE IT HERE Food, coins, pins, etc. Explants
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Food, coins, pins, etc.
Explants
(Plates, screws, medical devices)
Forensic Evidence
Follow the Chain of Custody

15. Foreign Bodies

16. Formalin Hazardous material Reference MSDS if spilled
Use Standard Precautions
- gloves
- goggles
- mask
Make sure container is labeled with formalin content and biohazard information
Formalin is considered a hazardous substance that can cause watery eyes, respiratory irritation and burns.
OSHA standards require the following:
- posted warning signs of formaldehyde
- eye wash stations in the immediate area
- standard precautions followed
- adequate ventilation required
- specific institutional procedures followed for a spill
MSDS should be readily available.

17. Diagnostic Specimens Cultures
Identification of infection
2 Types
Aerobic
Anaerobic
Includes frank pus, serous fluid or soft tissue
Collect in sterile conditions and in sterile container
Taken on patient’s who come to the OR with a known or suspected infection.
Aerobic – requires oxygen to grow.
Anaerobic – grows in the absence of oxygen.
Collected in a similar way but may require a different medium for growth, should be taken to lab immediately to start this process.
Cultures may be used to determine the antibiotic that will specifically affect the organism. This is referred to as sensitivity.
Cultures are obtained using a cotton swab, syringe or tissue. There may be transfer medium required and these may have an expiration date.
Brushings – disposable forceps may be placed in a sterile container.

18. Diagnostic Specimens Frozen Section
Requires immediate attention
Immediate diagnosis
Specimen is sent fresh WITHOUT formalin
Label appropriately with contact info
Biopsy of any organ or tissue
Specimens are quick-frozen, sliced, stained, and examined in the lab under a microscope.
A verbal report is given to the surgeon by the pathologist during the surgical procedure.
The operating room phone number should be provided to the lab so the pathologist can call immediately.
A fixed or permanent setting will take place afterwards to reaffirm preliminary findings.
Pathology must be available.

19. Special Considerations
Handle tissue with care
Label and collect specimens from field ASAP
NEVER pass a specimen off on a counted sponge
Use sterile technique to prevent other microorganism from contaminating specimen.
Handle with care to avoid damaging the cellular structure of the tissue.
Keep moist and do not place on dry, absorbent material, it can removed the surface.

20. Specimen Labeling SO IMPORTANT!! Patient Identification
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Patient Identification
Specimen Description and Source
Location & Laterality
Special Markings
Need for Precautions

21. Specimen Labeling
Specimen identification should be confirmed with the surgeon
Patient identification should be confirmed using two identifiers
Label should be securely fixed to the container
Use ink
Communicate chemical preservative and biohazard information
Should include at minimum:
Patient identifiers
Originating source of the specimen including laterality if applicable
Type of tissue
Date and time of collection
Additional pertinent clinical information (ex. suture tags)
Again, follow facility policy.
Don’t put the label on the lid.
Use ink that cannot be smeared off.
Chemical and biohazard communication is a requirement.

22. Documentation Patient’s full name Specific Information
Second patient identifier
Location of suture
Date & Time
Pre-op and Post-op diagnosis
Surgeon
Pertinent medical history
Tissue Type
Previous related surgeries
Location
Laterality
Type of pathology required
Requests for special handling
Using a write down, read back technique can help avoid communication errors.
Any descriptive information should be included (ex. suture at 6 o clock).
If paper specimen requisitions are used, they should follow the specimen.

23. Post- procedure Confirmation
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An end of procedure debrief should include:
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Visual confirmation that the specimen is in the container
Verification that the patient information on the label and requisition are correct
Verification that the number and type of specimens are correct
Verification that the specimens have been correctly fixed as applicable
Confirmation of other pertinent information such as documentation of suture tags

24. Laboratory personnel are the experts when dealing with specimens and are a good source of information. Don’t hesitate to call them for immediate assistance.
Whenever in question about how a specimen should be handled, call the lab!

25. Summary What constitutes a specimen Routine vs. Diagnostic Specimens
Collection
Disposition
Labeling and Documentation

26. Where to get more information:
Hospital Policies & Procedures
AORN Guidelines for Perioperative Practice
Laboratory Personnel
Infection Control
CDC

27. References A.O.R.N., 2017 Guidelines for Perioperative Practice
Rothrock, Jane C. “Alexander’s Care of the Patient in Surgery”, 14th Edition, 2011
Phillips, Nancymarie, “Berry & Kohn’s Operating Room Technique”, 11th Edition, 2007
The Joint Commission RC

28. Any Questions?