Autopsy updateproposals, pointers, and PR
P. Ridgway Gilmer Jr., MD
Though not a topic of discussion at the commission meeting, the CAP’s Autopsy Committee has requested a checklist change to eliminate the arcane distinction between "routine" and "complicated" cases. When was the last time we encountered a routine autopsy, with the obligatory 30-day turnaround time? Yes, many efficient pathology departments can handle autopsy materials essentially as major surgicals and turn out their final reports within a week or so. But, as most inspectors discover, the vast majority of cases lie dormant for weeks, and many do not meet even the 90-day limit.
The Autopsy Committee proposes to delete the two-tiered classification, to retain the optimal 30-day turnaround time, and to extend the grace period to 60 days. Delays longer than this would require written explanation to the attending physician.
During a recent CAP inspector training seminar, the regional commissioner from Texas, Francis Sharkey, MD, discussed inspection of the autopsy pathology service. All the quality control and quality improvement practices that apply to surgical and cytopathology apply equally well to the autopsy service, he said. He emphasized the autopsy’s consultative nature and the need to review and assess the clinical record before conducting the postmortem examination. Inspectors should evaluate whether the final reports contain sufficient information to ascertain the patient’s major disease processes and probable cause of death.
Does the autopsy quality improvement program actively survey the quality of diagnostic reports, and is the information used to enhance patient care? The report should include reference to clinical-pathological correlation, but the format used is at the discretion of the pathologist.
Dr. Sharkey offered pointers on what inspectors should look for in conducting their on-site assessment of the autopsy service:
- The routine turnaround time, with preliminary reports within two working days and final report within 30 days.
- Quality measures, for example, staining, legibility and uniformity of repo formats, cross-reference files, tumor grading, formalin and xylene monitoring, and procedures for handling suspected Creutzfeldt-Jakob disease cases.
Not surprisingly, the most common deficiencies for autopsy pathology are failure to meet either 30- or 90-day turnaround times and failure to monitor or control formaldehyde and xylene vapor concentration standards.
Pathology service directors and inspectors can turn to two CAP publications for additional information:
- An Introduction to Autopsy Technique, Grover M. Hutchins, MD, editor. This may be useful to departments that train residents in pathology, because it contains sample anatomic diagrams that can be used as protocol templates.
- Cause-of-Death Statements and Certification of Natural and Unnatural Deaths, Randy L. Hanzlick, MD, editor. Directed to the forensic autopsy service, this document was prepared by the CAP’s Autopsy and Forensic Pathology committees in conjunction with the National Association of Medical Examiners. Many an unsuspecting hospital pathologist, including your editor, has been confronted with the request or demand to conduct an autopsy with potential medical-legal impact, so generalists should not overlook this book, despite its target audience.
The Boston Globe on Dec. 12, 2000, and the New York Times on Jan. 9 ran long stories on the reasons behind the decreasing hospital autopsy rates. The public’s consciousness is being raised; whether it will result in improved compensation or only unfunded mandates for higher percentages remains to be seen.