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Division

East Florida

Hospital

HCA Florida Westside Hospital

Specialty

Pathology

Document Type

Poster

Publication Date

2024

Keywords

breast cancer, formalin, protocol, quality improvement

Disciplines

Medicine and Health Sciences | Neoplasms | Pathology | Quality Improvement | Skin and Connective Tissue Diseases

Abstract

Background: The current guidelines of the American society of Clinical Oncology (ASCO) and College of American Pathologists (CAP) regarding laboratory testing of estrogen receptor (ER), progesterone receptor (PR) and HER-2 in breast cancer have been in place since 2010. Optimal tissue handling requires a cold ischemic time of less than 1 hour and a formalin fixation time between 6 and 72 hours. In July 2023 HCA Westside hospital implemented a new Formalin Fixation Time documentation protocol. The data is presented quarterly at the Cancer Committee meeting.

Goal: To standardized the cold ischemic time and formalin fixation time reporting and measure compliance of this CAP required quality metric that directly impact patient care.

Method: A document titled “Breast Tissue/Node Specimen to Formalin Protocol” is completed for every breast specimen. The procedure area personnel assigned to the case records the “Out of Body Time” and “In Formalin Time” for the case. The histology laboratory personnel record the “Time out of Formalin”. The pathologist is responsible for the documentation in the EMR, provided the form is appropriately filled and included with the case.

Results: Data was recorded from Q3 and Q4 2023 as well as Q1 and Q2 2024. The average percentage of compliance between all four quarters was 95.3%. In Q1 of 2024 compliance was the lowest at 88%. In February 2024 out of 12 cases, only 80% complied with the guidelines.

Conclusion: Implementation of this documentation protocol enables a quantitative method of adhering to CAP/ASCO guidelines regarding handling of breast tissue.

Original Publisher

HCA Healthcare Graduate Medical Education

Standardization of Operating Room (OR) Formalin Fixation Time Reporting in Breast Cancer Cases. An Institutional Experience.

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