Pathological Tissue Sample Handling Manual (The Japanese Society of Pa-thology) - Preventing Mix-up of Patho-logical Tissue Samples -

The Pathological Tissue Sample Handling Manual - Prevent-ing Mix-up of Pathological Tissue Samples issued in July 2016 by the Japanese Society of Pathology (in collaboration with the Japanese Association of Medical Technologists), recom-mends that stained tissue samples be checked daily for stain-ing quality and signed off by the histotechnologist in charge.

Features of the Automated Slide StainerTissue-Tek Prisma® Plus- Showa General Hospital’s ExperienceBy Shinji Hamakawa, MT. CT (AC)Department of Clinical Laboratory, Showa General Hospital, Tokyo JapanPresented at Sakura Finetek Japan’s Sponsored Oral Seminar Sessionat The 56th Annual Autumn Meeting of the Japanese Society of Clinical Cytology Nov. 2018

At the same time, the manual prohibits histotechs from sub-mitting tissue samples to pathologists without checking the staining quality and suitability of the tissue sample.

The manual further lists specific precautionary instructions regarding the quality of HE staining, such as, [1] tissue samples should be stained following the staining manuals of each institution; [2] if inadequate staining occurs, investigate and determine the cause to improve staining quality; and [3] adopt a standard staining method so that the same stained quality can be achieved at every institution.

Clearly, it is very important to ensure traceability – in other words, to put in place an environment where problems can be reviewed so that prevention measures can implemented.

One way to do this efficiently is to automate manual processes.

History of Automated Slide Stainers and Coverslippers at Showa General Hospital

Showa General Hospital began using two rotary-type automated slide stainers and an automated coverslipper 30 years ago (Fig-ure 1). In those days, hospitals using these instruments were rare.

Figure 1 History of Automated Slide Stainers andCoverslippers at Showa General Hospital

Rotary typex 2 (Brand A)

[1] Flat typex 1 (Brand B)

[2] Flat typex 1 (Brand B)

HEstaining

Manual staining/manual coverslipping

[1] Flat typex 1 (Brand B)

Papstaining

[1] Automatedcoverslipper x 1 (Brand C)

Coverslipping

30 years ago 15 years ago 10 years ago 5 years ago

[1] Automatedcoverslipper x 1 (Brand D)

2

Because exchanging solutions – particularly the solution stations located at the back – was difficult and staining effi-ciency was poor with the rotary-type stainers, we then shift-ed to the more effective flat-type stainer about 15 years ago.

When implementing the stainers, programming that com-plies with our staining manual, improvement of operational efficiency and improvement of the work environment were among the benefits we considered. Having a solution sta-tion configuration that prevents installation errors when ex-changing reagents, easy management of staining solutions and staining accuracy were also key points when managing automated slide stainers.

Effective Utilization of Tissue-Tek Pris-ma® and Tissue-Tek® GlasTM g2

Five years ago, we implemented the automated slide stain-er Tissue-Tek Prisma® to cope with an increasing workload and histotech shortage. We decided to introduce the state-of-the-art automated slide stainer to achieve operational efficiency, speed, and consistent staining performance. At the same time, we adopted the automated coverslip-per Tissue-Tek® GlasTM g2 and linked it to the slide stain-er which significantly improved the work environment and work efficiency. We also shifted to the Tissue-Tek®

Hematoxylin 3G to control the accuracy of HE staining.

Our initial plan was to use the Prisma and Glas g2 solely for HE staining, but we decided to use them also for other stain-ing jobs that were required daily, such as the Alcian Blue/PAS (Al-B/PAS) double staining, EVG staining, and Papani-colaou (Pap) staining after all. To use multiple staining meth-ods, we needed many solution stations (see Figure 2) and

therefore opted for the small solution reservoirs and 20-slide staining baskets. In order to optimize the daily throughput of each slide stainer, we scheduled Pap staining between 8 to 10am and 3 to 4pm, both outside the HE staining hours.

The Prisma and Glas g2 were also used for various other purposes such as dewaxing and the dehydration → clearing → coverslipping processes during manual staining using special stains or IHC staining, thus contributing to greater operational efficiency (Figure 3).We sought further operational efficiency and considered adding rapid Pap staining and rapid PAS reaction (Figure 4), but after encountering staining delays, we decided that running these processes concurrently was difficult.

Introduction of Tissue-Tek Prisma® Plus

With expected improvements in the processing capability, work flow efficiency and visibility, implementation of accu-racy control, and traceability we implemented the Prisma

Figure 2 Prisma Solution Station Configuration

Xylenesubstitute

Xylenesubstitute

Xylenesubstitute

Hematoxylin

Hydrochloricacid AL

Washstation

Washstation

Washstation

Drying

Hematoxylin Eosin 95%AL

95%AL

EA-50 95%AL OG-6 95%AL

100%AL100%AL

100%AL100%AL

100%AL100%AL 100%AL100%AL 100%AL100%AL

100%AL

Resorcin-fuchsin

VanGieson

Nuclearfast red

Xylenesubstitute

Xylenesubstitute

Xylenesubstitute

Xylenesubstitute

unload station

Distilled waterdewaxing

unload station

Start of95% AL

dehydration/clearing

Xylenesubstitute

unload station

Xylenesubstitute

Periodicacid Schiff Sulfurous

acid solution

Ironhematoxylin

Hydrochloricacid AL

Sulfurousacid solution Alcian blue

START START

Figure 3 Effective Utilization ofAutomated Slide Stainer Prisma and Glas g2

Pap

9:00 to 15:00

10:00 to 14:00

10:00 to 15:00

10:00 to 12:00 12:00 to 17:00

H・E Al-BPAS

Dewaxingonly EVG Pap

Dehyd-ration/

clearingCover

slipping

Refer to 2016 Tissue-Tek Today Vol. 17.

8:00 to 10:00 15:00 to 16:00

RapidPap

RapidPAS

Figure 4 Use at Our Hospital (Prisma and Glas g2)

Pap H・E Al-BPAS

Dewaxingonly EVG Pap

Dehydration/

clearingCover

slipping

3

Plus in May 2017, in addition to the Prisma. We wanted to link the new automated slide stainer to our existing auto-mated coverslipper and we decided that the Prisma Plus was the best fit.

In our dual-instrument setup consisting of the Prisma and Prisma Plus, the Prisma was designated as a dedicated in-strument for cytology, programmed to include regular and rapid Pap, PAS reaction and Al-B staining. Meanwhile, the newly introduced Prisma Plus is used primarily for tissue samples. Using the two instruments for different purposes allows us to do our jobs efficiently.

Features of Tissue-Tek Prisma® Plus

As for solution exchange management, the Prisma Plus has a slide count management function in addition to the days/runs function offered by the Prisma, to keep track of the number of processed slides and notifies the user to ex-change solutions. When the number of slides exceeds the set number, the instrument displays an alert message to urge the user to exchange solutions (Figure 5). The user can set its own default number of slides. For example, when you select HE staining, the display prompts you to enter the default number of slides to be stained. At our hospital, the default is set to “20” because we normally use 20-slides staining baskets.

At our hospital, reagents are exchanged on Fridays to pre-pare for staining operations starting next Monday. Hema-toxylin 3G, which we are currently using, is a two-solution mixture staining solution. After mixing solution 1 and solu-tion 2, the mixture is stored for at least a day to make it chemically stable.

In our daily operations, we mix the solutions on Friday and stabilize the mixture by storing it over the weekend. As for the management of Hematoxylin 3G, we use one small solu-tion reservoir (that contains approx. 290 mL) to comfortably cover one week of HE staining. The number of slides range from 200 to 300 slides per day.

We currently use Hematoxylin 3G (Prisma package) con-sisting of 8.5 mL of solution 1 and 283 mL of solution 2, as well as 285 mL of Tissue-Tek® Eosin (Prisma package). The staining solutions come in just the right amount to fill a small Prisma solution reservoir (Figure 6).

Management of staining reagents can now be performed easily using barcodes. Pressing the barcode button on the menu screen and scanning the barcode on the solution package automatically inputs the lot number, shelf life and expiration date.

With the Prisma Plus, all information that helps manage the staining solutions and processes, including the information above are recorded in the compact flash memory card in-serted to the side of the instrument. The solution name, set time, soak time, staining start and end time, staining meth-od, staining sequence are recorded. The number of actu-ally stained slides, versus the maximum number of slides that can be stained is also recorded. Furthermore, the lot number, shelf life and expiration date are also recorded for each staining solution. This is an excellent function from the viewpoint of ensuring traceability.

With the old Prisma, the setting screen for each solution station on the monitor supported a simple color palette. The Prisma Plus, on the other hand, lets us set 50 different col-ors (Figures 7 and 8) so that we can visually differentiate the reagent configuration for each staining solution to pre-

Figure 5 Solution and Slide Quantity Control ChartMonday, December 5, 2016 LABORATORY

ADMIN 110 : 57

Edit Solution Station Configuration > Station 1

Group

Cancel Clear

Change

Caution!

Confirm

Save

Management Method

Standard Solution

Sakura Solution

Solution Included in Kit

Solution Setting

Solution Management Method Setting

Set Value Entry

Solution NamePcs : Slide count management

Hematoxylin

Set

Set Value 2000

The set number has been exceeded at one or more stations.To change the entered value, touch the Change button. To keep the current setting as is, touch the Confirm button.

Figure 6 Management of Staining Reagents

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vent solution filling errors.

When thick samples (such as cytology slides) are loaded to the coverslipper air bubbles may form due to lack of mount-ing medium. Accordingly, we wanted to be able to stop the process at the staining end station instead of having the au-tomated slide stainer linked to an automated coverslipper. The great advantage of the Prisma Plus is that it enables us to select whether or not to link to the coverslipper for each individual staining program.

Expectations for Future StainerDevelopment

There are two expectations we have for the development of stainers in the future. Firstly, the complete traceability of staining processes. As

mentioned earlier, the Prisma Plus can record all staining processes, but we hope to be able to manage who per-formed each staining. Since we are linking a stainer and a coverslipper, a function to manage and record stained tis-sue samples by slide would also be appreciated.This enhanced management and recording capabilities should include improvements to the optional barcode scan-ner function of the automated coverslipper Glas g2 to allow for automatic recording and saving of data to the anatomic pathology laboratory information system.

Secondly, it would be incorporation of functions to ensure medical safety during reagent exchanges. When we use automated slide stainers, solution configuration errors can have fatal impact on staining results. We are exchanging reagents manually now and we see some concerns over medical safety in this approach. Going forward, we would like to see enhanced functions that prevents reagent ex-change mistakes.

L751.1906.2000.D

End station status Detailed monitorRemove BasketsPause

Log Off Add Baskets Menu

Stain Process Monitor (Continuous Mode)

Figure 7 Color Setting for Staining Stations(for Improved Visual Identification)

November 14, Tuesday12 : 35

Figure 8 Color Setting for Staining Stations(for Improved Visual Identification)