Fixation on Histology

A Closer “Look” at Grossing

Those of us that gross are often called the eyes of the pathologists. This is because of how important it is to look carefully at all steps of the grossing process, and – believe it or not – some of the most important steps happen even before a specimen is grossed.  Let’s take a close “look!” 

Verify the Sample!
Before you even start grossing, first verify that the information on the sample corresponds to the information on the requisition. Namely, check that the patient’s name and site are correct. The pathologist may receive the requisition with the slide, but generally does not see the specimen container so they depend on the grosser to make sure it is correct.  

Note, if the case will be grossed on a laboratory information system, you must also verify that the information entered at accessioning is correct.  This step requires vigilance on the part of the tech.  Sometimes a case may have to be rejected and sent to QA for verification.  
Know Your Rejection Criteria. A tech grossing should be trained to know rejection criteria.  Obviously, if the name does not match – reject it.  If the site does not match – well – this part can be tricky. Sometimes a client may write Stomach on the requisition, but then write Gastric on the specimen vial.  This would be acceptable.  Stomach and Gastric are words that refer to the same site.  But if the sites are completely unrelated – reject it and send it for QA verification.  If you are unsure, you can always check with your supervisor.

In some cases, the case does not necessarily need to be sent to QA. Cases are sent to QA when the error made was done by the client.  However, if the error made was done by accessioning, this is a laboratory problem. Depending on your lab, you may correct the error yourself and carry on with grossing. Some labs prefer if you return the case to the person who accessioned it for that person to correct.  It depends on the lab and on your level of comfort using the laboratory information system.
Confirm Processing Requirements. Generally, cases sent to histology should be received in formalin to keep the tissue fixed and viable for the processing step. If a case is received at grossing and it is not in formalin and does not specify a test, this case should be sent to QA.  You will want to verify with the client how they want the tissue to be processed. The sample might be meant for another department.
Know Your Billing Codes and Process: Depending on the type of cases that you gross you may be trained to look out for sites that require you to add additional billing codes. There are agencies that do not want laboratories to bill patients for unnecessary tests.  For this reason, some billing codes are entered at grossing after the tech looks over the requisition.  

At grossing, a tech will be trained to know when a site will require a specific stain necessary for diagnosis. If working on a GI case, a tech grossing will be trained to add the H. pylori or Giemsa stain to specific sites such as Antrum or Body. If working on a DERM case, a tech will be trained to add the PAS billing code for nail specimen or when looking to R/O Fungus.  

A tech grossing will always be on the lookout for key words to know if they need to add a code or how to treat the tissue received.  If the tech fails to add the code at grossing, the case will be delayed because the codes are usually what alerts the techs cutting to cut another slide for H pylori or for PAS.
Select a Grossing Template. A template is a form of writing in the laboratory that serves as a guide or roadmap for how a specific specimen should be grossed. For example, there will always be a line that tells what solution the specimen is received in.  Specimen submitted for histology is generally received in formalin, so the template will include this information. In most labs, this information is stated at the start of the sentence like this, “Received in formalin …”.  However, it is also possible for a specimen to be received fresh and is intended for histology.  In that case, the tech must edit the template to reflect this information. This goes back to the original idea mentioned earlier that grossers are the eyes of the pathologists. Grossing templates are extremely useful in increasing efficiency, but the tech is responsible for making sure that the information stated in the template corresponds to the specimen. It may appear as a small irrelevant detail that the tissue is received fresh but is a very important detail. Specimen not placed in formalin immediately after removal from the patient can affect diagnoses and treatment, and so it is useful for the pathologist to know that the tissue was compromised.  

Luckily, most labs have a laboratory information system with grossing templates that correspond to the tissue type being grossed.  These template make it easy – but you must become acquainted with choosing the template that match the tissue you have.  This makes it easy.  You don’t have to worry about finding your own words.  

Also, there will always be a line about how much of the tissue the person grossing will submit for processing.  Biopsies are submitted entirely 100% of the time. However, other routine cases such as tonsils or cysts may or may not be submitted entirely depending on its size.  Therefore, there will be a line in the template that says, “Entirely submitted …” or “Representative sections are submitted … “.

The body of the template contains the description of the specimen.  This is where techs describe what they see.  Small GI biopsies are generally described as “tan soft tissue” however some tissue may be “pale tan” or “tan brown”.  For this reason, templates make provision for a person to add the color, measurement and quantity of tissue received.  Labs that use templates have a system where a tech chooses a template based on the tissue received.  A GI template will have a different content than a lumpectomy template, and can be completed in 2 to 3 minutes, but it will still include the values mentioned. Histotechs may be called to gross small biopsy or routine cases.

A lumpectomy case can be completed in half an hour to an hour, sometimes longer, depending on whether the specimen is received inked.  It requires additional work besides plugging in the color, measurement, and quantity into the template.  A lumpectomy template will have the basic ingredients as the other templates; however, the tech must draw from their own words and pathology knowledge to describe abnormalities seen.  For this reason, hospitals prefer to hire licensed Pathologists’ Assistants to gross lumpectomies.  

Can you imagine having to type out these words for each case you gross, 8 hours per day, five days a week? If you can imagine how tedious that would be, then you will appreciate how the use of templates saves time and makes labs more efficient.

Written By: Jeniesha Russell, HTL (ASCP)