Hillerød hospital in North Zealand has recently been appointed as a specialised regional hospital for the Capital Region of Denmark, one of the five administrative regions in the country, and will be responsible for acute healthcare in this region. CLi spoke to Hanne Bjørn, Senior Chief Biomedical Laboratory Scientist, who together with the head pathologist is responsible for the runnning of the hospital’s pathology department, to discover how she and her colleagues are meeting this challenge by embracing automated methods and LEAN principles.
Q: Could you first give us some background on Hillerød hospital. What patient population does the hospital serve and what are the main areas of care it covers?
A: Hillerød hospital is a 24-hour acute care hospital offering emergency, medical, surgical and intensive care services. The hospital serves approximately 350.000 residents in North Zealand, and has recently been appointed as the specialised regional hospital for the Capital region of Denmark. This is an exciting challenge.
Q: What are the main activities of the histopathology department? How many samples, and what type of samples, does the lab process per year?
A: In 2009 the histology lab processed 36.000 requests, involving 57.000 samples, 100.000 cassettes and 165.000 slides. Common tissue types included gastrointestinal tract, urogenital and female genital tract, skin and thyroid gland. In addition the cytology lab processed 42.500 specimens, the large majority of which were for cervical cancer screening.
Q: Was your workload increasing over time? Were there sufficient trained laboratory staff and other resources to handle the workload and deliver patient results in a timely fashion?
A: Four years ago we were experiencing a problem recruiting sufficient biomedical scientists to deal with our increasing workload and the demand for results to be reported within five days. Many of the staff were people with a general education who were trained in-house. All staff faced a back-log of work each morning and were stressed because of their inability to meet the desired output time. Our conventional tissue processing method, involving fixation with formalin, dehydration with alcohol and cleaning with tissue clear prior to embedding in paraffin, was very time-consuming, and was usually carried out overnight, delaying diagnosis by a day and resulting in batch production.
Q: When was the lab reorganised to embrace lean principles? What problems were encountered and how were these solved?
A: In 2006 a project was initiated to enable the histology laboratory to become more LEAN. It was important to achieve continuous throughput processing of specimens and avoid the bottleneck of batch processing. An overall project leader coordinated the efforts of five component projects dealing with issues including automation for process optimisation, staff motivation and training, lab layout, quality control and LEAN principles.
Q: At what point were automated tissue processing systems introduced? Which systems are being used and what were the reasons for choosing these systems?
A: An automated microwave processor, namely the Tissue-Tek Xpress Continuous Rapid Tissue Processor from Sakura was introduced in 2007. We chose this tissue processor because of its continuous high throughput of up to 120 specimens an hour, and because we have had good experience with the Tissue-Tek VIP processor from Sakura, which was already installed in our lab. We carried out a blind comparative study once the Xpress was installed to find out if the histomorphological quality was as good as with conventional processing. The results proved very positive for most tissue types and turn-around times were much improved.
In 2007 an automated embedder, the Tissue-Tek Autotec and Paraform Sectionable Cassette System (also from Sakura) was added. This was an obvious choice, as we wanted a continuous work flow from processing to embedding [Figure 1] and this was the only system on the market that allowed fully automated embedding and continuous loading of blocks after processing, with a throughput of 120 blocks per hour. Now, once the cassettes are closed after grossing [Figure 2], they do not need to be opened any more. This saves a large amount of labour, and because the orientation of the tissue is fixed and there is no human intervention until sectioning, the risk of an error occurring is reduced to almost zero.
We later added a second Xpress, and use one for one hour microwave processing of 2mm thick specimens and the other for two hour processing of 3mm thick specimens, as well as fatty tissues.
Q: Are the Xpress processors used for all specimens, or are other tissue processing methods still used for some samples?
A: Up to 90% of our tissue processing is carried out with our two Xpress processors. We still use the VIP for large colon sections, and the Xpress is not used for thyroid tissue. Initially skin sections thicker than 3mm were not processed in the Xpress but we solved this problem. Bone marrow specimens need decalcification and are currently not processed in the Xpress, but we have now developed a protocol for this with good results.
Q: What are the advantages for the laboratory personnel of using the automated systems compared to using the previous tissue processing methods?
A: There are many advantages for staff. Firstly because the workflow is steady and there are no batches to face each morning, staff are no longer so stressed. We have been able to recruit and retain biomedical scientists as they are free to take on challenging new tasks, such as modifying staining protocols for optimal results and solving the problems we encounter with more difficult tissues. Our in-house trained staff without biomedical qualifications take care of many of the routine tasks such as checking labels are correct and providing pathologists with completed slides. Our pathologists also benefit from the smooth workflow and no longer have a backlog of slides to examine. And of course staff are no longer constantly exposed to unpleasant chemicals such as formalin: the Xpress process does not use such reagents.
Q: In what ways has the introduction of the automated systems allowed the histopathology laboratory to become LEANER in terms of quality, efficiency and increased throughput?
A: We certainly generate good, quality-controlled
results now. Part of the LEAN project involved motivating all our staff to contribute to an optimal workflow. We now have a whiteboard where anyone can
write their relevant questions and observations, and we hold a very brief meeting each Tuesday where the whole group can consider any problem and suggest a solution. We are really one team now focussed on patient service, with all of us looking to continual improvement in our services.
The increased automation, as well as other innovations resulting from LEAN, have lead to a greatly improved workflow and processing time, and reduced standby time. Our output time has improved and continues to get better. We can provide same day diagnosis for urgent specimens, including the report from the pathologist, which is provided using voice recognition software (from Max Manus) so that the dictated report is received by the requesting physician in real time. For half of the other specimens, results are reported within three days and 95% are reported within five days. We hope to have all results reported within five days in the near future.
Because of more automation we are now delivering a better service to more patients. The number of patient cases to be diagnosed has increased since we introduced the first Xpress, and will probably continue to increase still further. Our two Xpress processors have sufficient capacity to keep pace with this growing number of samples to be processed, and the AutoTEC can also handle more cassettes than it does at present, so we are able to face the future with confidence.
Q: Are there any additional benefits from the LEAN project and installing the automated systems which were not anticipated?
A: Our improvements have had a knock-on effect on the cytology lab personnel who have also increased output and become more patient focussed. Of course LEAN is an ongoing process, and we are more aware now of how we can become even more efficient, possibly with further automation. We are also utilising the lab space we have at our disposal better than previously to ensure optimal thoughput and this is continuing to improve. Our aim is to help Hillerød become the best acute care hospital in Denmark!
