Have you ever wondered what happens to blood, urine, or other types of patient specimens after they are collected?
Specimen Management Services, or SMS, is a 24-7 operation of UR Medicine Labs. Its main headquarters is located on the ground floor of Strong Memorial Hospital, down the hall from the Emergency Department and Wilmot Cancer Center where patients are waiting on lab test results.
In addition to inpatient specimens processed at Strong, SMS receives many samples from outpatient facilities that include area nursing homes and 29 patient service centers across the Greater Rochester region.
Lab couriers pick up samples from these various outpatient sites and transport them to SMS collection points that include the SMS lab at Strong, a smaller SMS lab at the Ridgeland Road facility, Surgical Pathology, and Microbiology.
SMS, which includes Surgical Pathology, Accessioning, and Cytology, is the first point of contact for incoming specimens ranging from blood to urine, stool, spinal fluid, pap smears, and patient tissue samples.
Millions of specimens pass through SMS collection points each year. The lab at Strong processes over 8,000 specimens every day, with another 3,500 outpatient-only specimens delivered to Ridgeland Road.
The Microbiology specimen receiving area also receives specimens of all types for culture, while Surgical Pathology receives 465 surgical specimens – many directly from the operating room – on a daily basis.
“We’re the front end,” said Sue Hurlbutt, chief supervisor of SMS. “We’re the pre-analytical operations. We tell our staff to think about getting that sample out to the labs as if it belonged to you or your loved one.”
Once they arrive at SMS, each specimen sample is scanned by barcode and entered into an electronic database to be tracked.
The SMS lab in Strong is a beehive of activity with about 90 full-time-equivalent employees. On any given day, you will see technologists in white lab coats moving briskly with specimens in hand.
SMS technicians are non-licensed and cannot release final test results (these must come from a physician). Nevertheless, they play a key role in preparing each sample for final diagnosis.
“There’s a very technical aspect to the job,” said Scott Musial day shift supervisor. “There is a lot of work that goes into getting a specimen resulted.”
In order to be analyzed, most blood samples are put through an instrument called a modular pre-analytics system, or MPA. This spins each blood sample at high speed, separating it into its component serum and plasma.
Next, the samples are labeled, capped, sorted, and transported to another lab area for testing. Those that stay in the SMH laboratory for testing are strategically sorted and taken to another instrument to be analyzed.
Not all blood samples start at the MPA. Others needed for certain testing – hematology, coagulation, or toxicology, for example, will be delivered to the appropriate testing area and/or stabilized according to protocol for each laboratory.
Once logged and sorted, courier staff known as “scouriers” are responsible for taking samples to various in-house laboratories, like Microbiology, Flow Cytometry, or Cytogenetics, for specialized testing.
Many steps in specimen processing are high priority and time sensitive in nature. When Blue 100, Urgent or Stat tests come to the lab from Emergency and/or Cancer Center, turnaround time is extremely critical to ensure results are reported back as soon as possible so that patient treatment can be determined.
Outpatient testing is generally more routine, although healthcare providers will often ask for additional tests, known as add-ons, to tests that had been done previously.
As you might imagine, the workload for SMS is always a heavy lift. The team at Strong has managed to form its own sense of community through different efforts.
For example, SMS has a staff newsletter and large whiteboard where workers draw pictures, or start writing a story that’s continued by the next person.
Their “Ever Better Board,” or “E.B.B.” is a place where staff can share suggestions or offer feedback. The board was also featured in a university-wide training video as an example of best workplace practices, and staff celebrated the 200th E.B.B. post with a party.
“I think everyone works really well together,” said Musial. “Our group is relatively tight-knit. And although the lab seems big, you’re in a relatively confined space. You move through the same area and are working together each and every day.”
And by “every day,” he means just that. Even if the hospital loses power or extreme weather hits Rochester, SMS will stay open. They still need to service Emergency at Strong, and in inclement weather, that need is often greater than ever.
The fast pace is something Nathan Giles, a senior tech at Strong SMS, has grown accustomed to. Explaining the work of “the lab” to others can sometimes be difficult, he says, largely due to misconceptions about what happens to patient specimens.
When you see fictional doctors running their own lab tests on TV shows, it can seem like lab technologists are obsolete. The opposite is true. For doctors and nurses to start with the best information possible, it all starts in the lab.
“It’s not often that patients think about this part,” said Giles. “If I’d want them to know anything, it’s that we exist and that we’re a huge part of their treatment every day.”
Top: A technician prepares to place blood samples onto the modular pre-analytics system, or MPA, which spins the samples at high speed to separate them into serum and plasma.
Middle: Specimens arrive at the SMS lab at Strong Memorial Hospital via courier. Each sample is scanned by barcode into an electronic database so it can be tracked.
We are pleased to announce that two Pathology faculty from URMC have been named to the American Society of Clinical Pathology (ASCP) 2016 40 Under Forty List.
Drs. Jennifer Findeis-Hosey and Raul Gonzalez have been chosen from a pool of national candidates.
“I think it’s outstanding that two of our faculty are paving the way for others in the field of pathology,” said Dr. Bruce Smoller, Pathology Department Chair.
About the award:
Each year, the ASCP chooses 40 members under the age of 40 whose achievements and leadership qualities are making a significant impact on the fields of pathology and laboratory medicine. This year’s number of applicants was the largest and most competitive yet.
About the honorees:
Dr. Jennifer Findeis-Hosey, 36, joined the University as an assistant professor in 2012. She is a gastrointestinal and hepatobiliary pathologist with a research focus on Lynch syndrome.
Her research at URMC extends from immunohistochemical markers of Lynch syndrome to the development of a multidisciplinary high risk colorectal carcinoma program. She serves as the director of pathology curriculum for the UR School of Medicine and oversees high school and undergraduate students in the Pathology Information Technology program.
She earned her B.S. from Bucknell University and M.D. from the Pennsylvania State University College of Medicine. She completed her residency at URMC and Surgical Pathology fellowship at the University of Michigan. A native of State College, Pa., she and her husband Dan live in Pittsford with their children, Emily, 7, and William, 2.
Dr. Raul Gonzalez, 34, joined the University in 2014 as an assistant professor. He specializes in gastrointestinal (GI) pathology. He has done much collaborative research in the field, with a focus on subtypes of colorectal carcinoma; he has published findings on adenoma-like adenocarcinoma and micropapillary carcinoma.
He trained at Emory University for residency, where he also earned his B.S. He completed fellowships in surgical and GI pathology at Vanderbilt University, where he was also an instructor. His M.D. is from the Medical College of Georgia, in his home state.
This year, he co-authored a textbook on non-neoplastic liver disease scheduled to be released in June. He was recently named the co-director of the GI pathology fellowship and teaches pathology residents and graduate students. He and his wife Lindsey live in Rochester.
UR Medicine Central Labs and UR Medicine Labs have been providing essential, behind-the-scenes services for sites across the U.S. participating in a clinical trial for cancer immunotherapy.
An Elmira man was featured in the local news because he was the first person enrolled at the Wilmot Cancer Institute to participate in the national clinical study of CAR T-cell therapy, which uses a patient’s own immune system to fight cancer. The trial is limited to people with certain types of lymphoma who have not responded to conventional treatment, and who meet strict eligibility criteria.
UR Medicine labs first partnered with a pharmaceutical company in 2015 to adapt and validate as assay for the presence and quantity of CAR19 T-cells in a patient’s blood, based on an a model developed by the National Cancer Institute. Since then the UR labs team has worked to refine and validate the assay for large-scale implementation.
The immunotherapy trial is designed to manipulate the body’s built-in defense mechanisms to fight cancer. Regular antibodies can be effective in fighting infection but are not so useful in killing tumor cells. Research has shown that a certain type of lymphocytes (a disease-fighting category of white blood cells) called T lymphocytes can target and kill lymphoma cells.
These "T-cells" must first receive permission from the body to fight, however. The patient's T-cells are introduced to DNA that first incorporates itself into their genome to produce a new protein – a chimeric antigen receptor (CAR) – that activates each cell, giving it the ability to detect and bind to a lymphoma cell.
"You're bypassing a lot of the regulatory checks and balances that have prevented previous attempts to generate tumor-killing T-cells," said Dr. Dan Ryan, director of Central Labs. "If (the cells) don't become activated, they die off."
Bill Crowe and Paul Rothberg from the Molecular Diagnostics Laboratory are leaders of the group that expanded the NCI test. Central Labs closely monitors test results from participating patient treatment sites across the U.S., and a vast network of lab professionals completes a series of time-sensitive steps.
Staff at Ridgeland Road assembles and sends out testing kits to each treatment site. The blood samples are then received via mail by Specimen Logistics staff six days a week. Technologists at the Tissue Typing Lab at Strong Memorial Hospital, Lymphoma/Leukemia Tissue Bank (SMH), Hematology Lab and Microarray Lab (Ridgeland) are responsible for processing and freezing all of the peripheral blood mononuclear cell blood tubes (PBMCs) for storage.
Phil Rock is a lab technician at SMH whose duties include tracking frozen samples for the CAR T-cell trial. He says the number of samples has skyrocketed since the trial began, which is a positive sign for immunotherapy.
"I think this trial, and the fact that (Central Labs) is growing is great for the department," said Rock. "I enjoy it immensely because having a hand in it allows me to use things that I went to school for and I've been trained to do that previously had no application."
Top: Clinical tech specialist, Jonathan Hoffmann, treats PBMC samples in the Human Leukocyte Antigen (HLA) Laboratory at URMC. Middle: Dr. Dan Ryan, director of UR Medicine Central Labs, which coordinates participation in clinical trials. Bottom: UR Medicine Central Labs kit production coordinator Deidra Davis, left, and Morgan Devaney.
It’s 9:05 on a Wednesday morning and a group of apron-clad pathologists' assistants (PAs) are gathering for morning rounds.
This is a daily meeting during which the pathologists, PAs, and residents meet on the floor of the gross room at the University of Rochester Medical Center.
Raman Baldzizhar, a resident doing his Surgical Pathology rotation, reads the schedule aloud for the group. He states the age and gender of each patient along with their procedure and the name of the doctor doing the surgery.
Today’s agenda includes a prostate, a pancreas, a kidney, a spleen, esophagus, and two stomachs.
After hearing the schedule, the team decides how they’ll divide up the day's work. Moments later, a colleague walks through the door carrying a frozen section specimen. It's a dark brown piece of tissue that was removed just moments ago from a patient's thyroid.
The team has to move quickly: A frozen section specimen is sent for immediate analysis while a patient is in the operating room (OR) under anesthesia. A diagnosis must be made within 20 minutes, which will help the surgeon make a decision during the procedure.
For this procedure, the tissue is literally frozen in a chamber called a cryosat. Once frozen, it is cut into extremely thin slices. A section of the tissue is placed on a glass microscope slide and stained with dye. The pathologist will examine the tissue under a microscope, render a diagnosis and report the results to the surgeon in the OR.
Each day, the PA team works against the clock; tissue specimens start to deteriorate soon after it is removed from the body and deprived of oxygen. For instance, breast tissue has a one-hour window before it must be submerged in formalin fixative to help preserve it.
The hospital’s Accessioning Unit is responsible for transporting specimens between the OR and the gross room. Technicians use an air-powered tube transport system similar to outdoor teller stations used at banks. Or, if the specimen is too large, it will be hand delivered to Surgical Pathology.
On this particular day, Dennis Dening, a PA, is examining a portion of tissue removed from a heart. I ask, What made you want to become a PA in the first place?
“I knew I wanted to do something medical, and I always enjoyed dissection,” he said, keeping his eyes fixed on the specimen.
Specimens come in all shapes and sizes. On average, the Surgical Pathology unit at URMC receives an average of nearly 500 specimens a day. They may be malignant or benign and can vary from small biopsies, such as an atypical mole removed by a dermatologist, or polyp removed during a colonoscopy. Other times, a specimen will be an entire breast or lung removed.
The PAs are responsible for dissecting and describing the specimens, in a process known as "grossing." A detailed gross examination includes information about the appearance of the specimen such as size, shape, color and consistency.
In cancer cases, the PA must identify the tumor and describe the relations of the tumor to the surrounding normal tissue. Once the gross description is completed the PA will determine what sections of the specimen will be examined microscopically by the pathologists.
Laurie Baxter was hired as URMC's first PA 21 years ago and now serves as the supervisor for a team of eight full-time PAs. During her time, has seen a lot of changes in the gross room as more people have shown interest in the profession.
"Once people come here to shadow and realize this is what they want to do," she said.
Since Baxter started her career, she's seen a greater number of students choose to go into the field. She has had four employees that started as biopsy technicians and returned to school to become PA's - and expects more will follow suit in the future.
Currently there are 10 PA training programs in North America with all but one culminating in a 2-year master's degree.
“This is a pretty satisfying job,” said Baxter. “Although we never come face to face with patients, PAs play a critical role in patient care. What we describe and submit for diagnosis directly impacts future treatment options for the patient."
In addition to grossing, PAs train residents and sometimes assist in autopsy procedures. The workflow in the gross room is steady, so the team must work together productively.
Biopsy specimens have the quickest turnaround time (one to two days) but larger specimens can be more work intensive and take several days to complete.
“Every specimen represents a patient," Baxter said. “We can't ever forget that."
And don’t be fooled by the term “gross.” The human body is amazing, after all, she tells me with a laugh.
"Who says it's gross?"
In photos (from top):
Dennis Dening, a PA, dissects a ventricular core (a heart tissue specimen).
Trista Skedel, a PA, checks dictation reports in the gross room at URMC.
A frozen tissue sample that will be cut, stained, and examined under a microscope by a pathologist.
Hilary Haefner, a PA, grosses a breast specimen.
Elizabeth Sharratt dissects a uterus at the grossing station in Surgical Pathology at URMC.