As the UK’s leading orthopaedic hospital, The Robert Jones and Agnes Hunt Orthopaedic and District Hospital (RJAH) treats patients from all over the country. A specialist hospital with a worldwide reputation for innovation and research, the trust provides elective orthopaedic surgery and muscloskeletal medical services with specific additional areas of expertise including spinal injuries and metabolic disorders affecting muscular development.
The hospital was founded by a visionary nurse, Dame Agnes Hunt, and an eminent orthopaedic surgeon, Sir Robert Jones, early in the last century, and the RJAH trust is committed to continuing their legacy by leading the way in the treatment of musculoskeletal disorders, raising standards and taking a multidisciplinary approach to patient care. Located in Oswestry, on the Shropshire and North Wales border, the hospital serves a local population of approximately 1.8 million with a customer service base extending both nationally and internationally.
Bone tumour specialty
The hospital is one of only five specialist sites in the UK approved for the diagnosis and surgical management of bone tumours, a service fully funded by the National Commissioning Group (NCG). The bone tumour service has continued to grow year-on-year since its introduction in 2004. Patients are seen from a large geographical area covering Shropshire, Greater Manchester, the north-west Midlands and Wales, and all patients to date have been seen within the national access times for assessment and treatment for both England and Wales.
Establishment of the joint multidisciplinary team with clinicians from the Manchester area has recently led to the development of the Greater Manchester and Oswestry Sarcoma Service (GMOSS). This bone and soft tissue tumour service works jointly with Manchester Royal Infirmary and The Christie Hospital. The GMOSS specialist regional team takes referrals from the Greater Manchester and Cheshire Cancer Network, the Greater West Midlands Cancer Network and also further afield. There are established GMOSS clinics in the Manchester area and a dedicated out-patient facility has been developed on site at RJAH to provide a suitable environment for patients diagnosed with a bone tumour and while being treated.
Each year, the GMOSS team sees in excess of 200 new patients with soft tissue sarcoma and 70 new patients with primary bone sarcoma. The multidisciplinary team provides patients with the best possible courses of treatment and links some of the most highly regarded specialist staff in bone and soft tissue oncology and orthopaedics. A key component in this service provision is the RJAH histopathology laboratory.
The RJAH histopathology laboratory provides a wide spectrum of sample preparation and staining techniques that include routine tissue processing, sectioning and staining, resin processing, immunohistochemistry, molecular biology techniques and electron microscopy. In addition to providing a service to the hospital, the laboratory also receives samples from across north-west England, North Wales and further afield.
Routine tissue processing is similar regardless of sample type; however, particular conditions must be applied if the most conclusive results are to be achieved for specific tissue types. Bone presents particular challenges for the biomedical scientist when trying to maintain morphological integrity, particularly with the increased emphasis on speed and reduced turnaround times, and tissue processing can either be undertaken manually or automatically by means of a dedicated tissue processor.
Optimising new instrumentation
The RJAH histopathology laboratory had been experiencing challenges with its existing tissue processing equipment, with the time needed for the preparation of tissues being of particular concern. To improve the efficiency of its tissue processing, the RJAH histopathology laboratory recently replaced its tissue processors with Thermo Scientific Excelsior equipment. The Excelsior was chosen for its ability to meet RJAH’s most challenging tissue processing applications. The Excelsior ES incorporates an advanced reagent management system and provides the laboratory with a safe and reliable instrument that offers consistent results, particularly for bone samples.
To optimise tissue processing in the department, the team at RJAH has modified its existing protocols to work with the new Excelsior. Leading the implementation process was laboratory manager Nigel Harness, who has over 20 years’ experience at Oswestry.
Nigel’s initial findings indicated that a simple transfer of existing protocols from the original equipment to the new processors was not an option as this produced ‘overprocessing’ of tissues. The reason for this was found to be due to the lack of any diffusion gradient between reagents, as reagent carryover is reduced in the Excelsior ES. To adjust for this improved reagent quality, the timings of tissue immersion had to be reduced gradually until optimal results were obtained.
“In the past the shrinkage of marrow/soft tissues from bony structures was seen commonly in many of our cases,” comments Nigel. “Although I doubt it is possible to eradicate this processing artefact completely, we’ve noticed a marked reduction in its incidence since starting to use the Excelsior ES. I’d certainly say it’s an indicator of the improved processing quality that the new processor provides.”
The resulting slide preparations were examined by consultant orthopaedic histopathologist Dr David Mangham, a founding member of the International Society of Bone and Soft Tissue Pathology, who was able to confirm that the Excelsior ES provided high standards of processing quality, particularly for bone specimens.
Orthopaedic objectivity
The implementation of the Thermo Scientific Excelsior ES in RJAH’s histopathology laboratory has set new standards for the efficiency of tissue processing. The overall effect on processing time achieved by moving to the Excelsior ES was a significant reduction of 38%, from 52 hours to 32.5 hours, resulting in a reduction in turnaround time in the laboratory. In addition, the advanced reagent management system incorporated in the new processor not only saves the laboratory considerable staff time during reagent refills, but also brings objectivity to the rotation of reagents which further enhances reproducibility of processing.
This significant decrease in processing times allows RJAH to meet its high standards of performance. In the NHS performance rating report, the Annual Healthcheck, the Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust was named the top performing NHS organisation in Shropshire and was also ranked in the top two orthopaedic hospitals in the country for 2005/2006. The 2008 heath inspectorate’s annual survey of patients’ experiences revealed that 77% of the hospital’s patients rated their quality of care as excellent, while the hospital’s overall performance scored 92%.
Quality maintained
The Excelsior tissue processor is equipped with special features that provide benefits such as safety, ease of use, increased productivity, reagent cost saving, and quality of results to the histopathology laboratory at RJAH. The instrument automatically performs the tissue processing procedure, taking samples through the stages of fixation, dehydration, clearing and impregnation.
Nigel Harness says: “We selected the Thermo Scientific Excelsior ES for its excellent efficiency and its capability to meet the most demanding processing applications. Overall, laboratory productivity has been enhanced considerably and sample turnaround time has been accelerated while ensuring optimum processing quality. The impact of a reduction of 38% in our tissue processing times means that diagnoses are achieved more quickly and therefore patients can be treated faster.”
Nigel continues: “With the increasing demands placed on histopathology laboratories, the maintenance of morphological integrity often proves to be difficult, particularly with today’s emphasis on speed and the reduction in turnaround times. We required a tissue processor capable of achieving accelerated processing times without compromising the consistency or validity of its results. Choosing the Excelsior ES means we have found a highly efficient instrument that saves staff time, reduces processing times and does not compromise our quality standards.”
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