Transport of Pathology Specimens Register No:10125 Status: Public

Transcription

1 Transport of Pathology Specimens Policy Register No:10125 Status: Public Developed in response to: Clinical Pathology Accreditation Standards Contributes to CQC Outcome number: 16 Consulted With Post/Committee/Group Date Ryan Curtis Health& Safety Manager Technically Approved By Gary Spooner, Dangerous Goods Safety 8 April 2015 Adviser, Independent Safety Services Ltd Professionally Approved By Pathology Risk Forum 16 th April 2015 Version Number 5.0 Issuing Directorate Pathology Ratified by: Document Ratification Group Ratified on: 28th May 2015 Executive Management Board Sign Off Date June 2015 Implementation Date 10 th June 2015 Next Review Date May 2018 Author/Contact for Information Karen Edwards, Pathology Quality Manager Policy to be followed by (target staff) All MEHT Staff Distribution Method Intranet & Website Pathology Q-Pulse document control system Related Trust Policies (to be read in conjunction with) Decontamination policy Standard Infection Prevention Blood Borne Virus Policy Mandatory Training Policy and Training Needs Analysis Document Review History Review No Reviewed by Active Date 2.0 (Pathology Directorate Document only) M. Enkel November M. Enkel February M. Enkel 5.0 K Edwards 10 th June 2015 Q-Pulse Number PATH-ALL- TRUST-1 1

2 Index 1.0 Purpose 2.0 Aims 3.0 Scope 4.0 Roles and Responsibilities 5.0 Equality and Diversity 6.0 Staffing and Training 7.0 Definitions 8.0 Regulations for the Transport of Pathology Specimen 9.0 Category A, Infectious Substances 10.0 Category B, Infectious Substances 11.0 High Risk and Danger of Infection Specimens 12.0 Transportation of Pathology Specimens within the Hospital 13.0 Transportation of Pathology Specimens by Transport Drivers 14.0 Transportation of Specimens 15.0 Use of the Pneumatic Air Tube Transport System Transport of samples using the Postal System 17.0 Public Transport / Air Passenger Provisions 18.0 Infection Control 19.0 Risk Management 20.0 Audit 21.0 References Appendices A B C D E Category A Infectious Substances Model Rules for Porters Model Rules for Transport Drivers Spillage Instructions for Hospital Transport Drivers Pneumatic Tube - Pathology User Guide 2

3 1.0 Purpose 1.1 The transportation of specimens is governed by National and European regulation and as such this document is written to provide a robust process for Trust staff to follow that ensures all aspects of these regulations are adhered to. 1.2 The process described is intended to formulate rules and methods of working which will safeguard, so far as is reasonably practicable, the health, safety and welfare of all persons who have need to transport pathological specimens for the Mid Essex Hospital Services Trust, or may be affected by such work activity. 2.0 Aims 2.1 To ensure that that all clinical specimens transported within, between and from the Trust premises are handled in a manner that supports all regulatory requirements. 2.2 To ensure that model rules are available and followed to support the safety of the consigner, the general public and the receiving laboratory. 2.3 To ensure that transportation systems are appropriate to support the delivery of specimens within an appropriate timeframe to protect the sample from deterioration. 3.0 Scope 3.1 This policy applies to personnel who have need to prepare for transport or transport pathological specimens for the Trust, or may be affected by such work activity. 3.2 The document sets out safe working practices to support all personnel that are required to transport or who may come into contact with clinical specimens and the confidentiality of the patient. 4.0 Roles and Responsibilities 4.1 All employees at the Trust are responsible for the health and safety of themselves and all other persons who may be affected by their acts or omissions in the course of their work. 4.2 Responsibility for the safe collection and packaging of clinical specimens shall rest entirely upon the sender / consignor. It is therefore imperative that all areas where clinical materials are generated remain conversant with current regulations and up to date safety codes of practice. 4.3 All staff involved in the preparation, transportation and receipt of pathology specimens have a responsibility to ensure:- clinical material is handled in a manner to ensure the safety of all those persons with whom it may come in contact with clinical material is packaged in a manner that supports the integrity of the material, the safety of all those persons who may come in contact with the package and that all packaging complies with relevant regulatory requirements the timely arrival of the package to support the integrity of the material within the reporting of any incidents that do not support the integrity of the specimen, the safety of personnel or relevant regulatory packaging requirements 3

4 the processing of material in a timely manner that protects the material from deterioration 4.4 It is the duty of care of all involved in the consignment process to ensure this is observed at all times and never allowed to lapse at busy periods or because of a failure to maintain adequate supplies of transportation materials. 4.5 Members of staff employed within the Trust, the general public and private contractors must not be put at risk because of ignorance, negligence or bad technique. Specimens transported in an unsafe manner may be refused to be transported by the Carrier, refused to be received or disposed of and a repeat sample requested, if deemed to be of risk at any point in the process. 5.0 Equality and Diversity 5.1 The Trust is committed to the provision of a service that is fair, accessible and meets the needs of all individuals. 6.0 Staffing and Training 6.1 The Trust is committed to ensuring that all staff receives information, instruction and training in accordance with the Trust s Mandatory Training Policy and Training Needs Analysis. 6.2 All laboratory staff that handle specimens as part of their job role receive training on the safe handling of biological materials. Competency assessment is undertaken as part of their knowledge and skills on-going development and where indicated update training initiated. 6.3 The Pathology department shall provide information and guidance for training (as appropriate) to both employees of the Trust, contracted staff and users of the service in the safe practices to be used. 7.0 Definitions 7.1 Infectious Substances: substances which are known or are reasonably expected to contain pathogens. 7.2 Pathogens: micro-organisms, including bacteria, viruses, rickettsiae, parasites, fungi and other agents such as prions, which can cause disease in humans or animals. 7.3 Patient Specimens: human or animal materials, collected directly from humans or animals, including but not limited to, excreta, secreta, blood and its components, tissue and tissue fluid swabs, and body parts being carried for purposes such as research, diagnosis, investigational activities, disease treatment and prevention. 8.0 Regulations for the Transport of Pathology Specimen 8.1 Biological materials are assigned to UN Class 6.2 Infectious Substances as defined by the WHO in the United Nations Dangerous Goods List. 8.2 Infectious substances are divided into two categories 4

5 Category A Infectious substances capable of causing permanent disability, life-threatening or fatal disease in otherwise healthy humans or animals. Category B An infectious substance which does not meet the criteria for inclusion into Category A. It should be noted that a specimen is any biological material being consigned for the purpose of diagnostic examination. This is not restricted to bodily fluid, urine or excreta but may also include tumours, organs or limbs etc. In all cases the requirements of P620 and P650 must be observed as appropriate. 9.0 Category A - Infectious Substances 9.1 Infectious substances meeting these criteria which will cause disease in humans or in both humans and animals shall be assigned to UN number UN 2814, packaging instruction 620.The proper shipping name for UN 2814 is INFECTIOUS SUBSTANCE, AFFECTING HUMANS. 9.2 Assignment to UN number UN 2814 shall be based on known medical history and symptoms of the source human or animal, endemic local conditions, or professional judgement concerning individual circumstances of the source human or animal. 9.3 Appendix A lists indicative examples of Category Ainfectious substances. 9.4 Microbiology must be contacted for advice if a specimen is suspected to contain a category A pathogen. 9.5 A courier, with ADR (see references) qualified drivers who are licensed to transport Category A pathogens, must be used and the receiving laboratory informed of its expected arrival. Microbiology holds category A packaging, and the receiving laboratory should inform the referring laboratory of receipt of Category A infectious substances within 24 hrs of receipt. This also applies to the deregulated E.coli (verocytotoxigenic 0), M tuberculosis and S dysenteriae type o1, but these may be transported as Category B samples. Couriers used to transport Category A specimens must work to a documented Security Plan. In some circumstances the National Office for Security and Counter Terrorism will also have to be informed prior to a specimen being consigned to the public highway. Ebola Viral Fever for example Category B - Infectious Substances 10.1 Infectious substances meeting these criteria will be assigned to UN number UN 3373, packaging instructions P The decision as to whether a sample can travel as a category B instead of the more rigorous option of Category A, lies with the health professional responsible for sending the sample P650 packaging instruction consists of three layers:- Primary receptacle: A primary leak-proof receptacle containing the specimen. The receptacle is packaged with enough absorbent material to absorb all fluid in case of breakage. Secondary packaging: A second durable, leak proof packaging to enclose and protect the primary receptacle(s) from breakage, puncture or leakage of contents 5

6 into the secondary packaging. Several cushioned primary receptacles may be placed in one secondary packaging, but sufficient additional absorbent material shall be used to absorb all fluid in case of breakage. Outer packaging. Secondary packaging is placed in outer shipping packagingof adequate strength for its capacity, mass and intended use. It shall include suitable cushioning material. Outer packaging protects their contents from outside influences, such as physical damage, whilst in transit. The outer packaging must be properly closed and secured within the collecting vehicle. The smallest overall external dimension shall be 10 x 10 cm 10.4 P650 states that the package must display the UN3373 mark (below) and be labelled BIOLOGICAL SUBSTANCE, CATEGORY B adjacent to the diamond. UN3373 BIOLOGICAL SUBSTANCE, CATEGORY B Minimum dimension: the width of the line forming the square shall be at least 2 mm, and the letters and numbers shall be at least 6 mm high. For air transport: each side of the square shall have a length of at least 50 mm Colour: none specified, provided the mark is displayed on the external surface of the outer packaging on a background of contrasting colour and that it is clearly visible and legible The words BIOLOGICAL SUBSTANCE, CATEGORY B in letters at least 6 mm high shall be displayed adjacent to the mark 10.4 Shipping packages can be reused. If shippers plan on reusing a package, it must be appropriately disinfected. Disinfecting facilities should be available inside Path department! Where a box exchange system is in place Path staff should disinfect the box ready for collection. Before reusing a package, the shipper must make sure all markings and labels reflect the substances actually being shipped. If the shipper plans on shipping an empty package, all non-applicable markings and labels must be removed or covered. This is actually impractical in the case of courier collection boxes Before an empty package is returned to the shipper, or sent elsewhere, it must be appropriately disinfected or sterilized to nullify any hazard. Any label or marking indicating that it had contained an infectious substance shall be removed or covered. 6

7 11.0 High Risk and Danger of Infection Specimens 11.1 All specimens should be treated as potentially infective. Certain pathogens, ACDP Risk Group 4 (UN / WHO Category A),may not be handled by the laboratories at the Trust for example:- Ebola fever, Marburg disease, Lassa Fever or other haemorrhagic fevers Rabies, plague or anthrax 11.2 Microbiology must be contacted for advice if you suspect you may have a Risk Group 4 patient Clinical specimens from the following categories must be classified as Danger of Infection Known carriers of Hepatitis B surface antigen (HBsAg) Cases of suspected acute hepatitis Patients with a higher than average chance of being HBsAg positive who have not been screened e.g. IV drug users Known or strongly suspected cases of enteric fever (Typhoid) Sputum, urine, pleural and other aspirates or biopsy material from known or strongly suspected cases of tuberculosis Patients known or suspected to be HIV antibody positive or when symptoms, signs or epidemiological details suggest the possibility of HIV antibody positivity Minimal risk patients with a pyrexia of unknown origin beginning within 21 days of leaving Africa but from a major city where the risk of Viral Haemorrhagic Fever is considered negligible All specimens classified as Danger of Infection as detailed in 11.3, must be clearly labelled with Danger of Infection stickers. Labels must be placed on the primary receptacle, the plastic specimen bag and on the accompanying request form Danger of infection specimens must not be mixed with the routine specimens; they should be clearly marked and segregated Transportation of Pathology Specimens within the Hospital 12.1 All clinical specimens must be placed in a primary container and either: placed inside a sealed plastic bag. (The request form must be placed in the separate component of the bag). supported upright in a purpose made rack or tray so as to prevent accidental contamination of persons, request forms or other specimens in the case of blood and tissue slides, placed into an appropriate slide transport box For transporting multiple specimens the sealed bags or slide box should also be placed into a rigid container. All racked samples must be transported using a rigid container with the lid secured Specimens must never be carried unprotected in the open hand or given to other members of staff in this way. Safe working practices as described in Appendix B must followed. 7

8 12.3 Patient confidentiality must be observed at all times 12.4 The use of the pneumatic air transport system poses additional risks; see separate section for details of how to use the system (Section 15) Never leave specimens unattended in a public area Urgent specimens must be taken directly to the appropriate Pathology reception and handed to a member of staff in person informing them that they are urgent Histology specimen must be placed in a plastic bag with absorbent material and clipped so as leak proof. The plastic bag is then placed upright in a blue transport bag, which is zip fastened. The bags are then taken directly to Cellular Pathology Blood Cultures must be handed to Microbiology reception staff or placed in the Microbiology incubator out of hours. Microbiology Specimens (other than blood cultures) must be placed in the Microbiology refrigerator out of hours Transportation of Pathology Specimens by Transport Drivers 13.1 ADR regulations are relaxed for all Category B specimens transported on the public highway provided the packaging system meets compliance with Packing Instruction 650 explained in 10.3 and Safe working practices as described in Appendix C must followed Specimens should be placed into a primary receptacle and in a specimen bag with the request form in a separate compartment The individual specimen bags are then placed in a separate large plastic bag containing absorbent material and clipped in a manner to ensure it is leak proof by the consigners. This is placed into the green pathology bag, zip fastened and transported to Pathology Reception where the bags are exchanged for a new inner and disinfected if required Urgent or small specimen numbers being transported can be packaged as described in section Histology Specimens should be placed in an appropriate container with lid confirmed to be secure. These are then placed in a separate large plastic bag containing absorbent material and clipped in a manner to ensure it is leak-proof. These are placed upright in the blue bags marked for Cellular Pathology and zip fastened by the consigners. The drivers transport the bags directly to Cellular Pathology, where the bags are exchanged for a replacement blue bag and disinfected if required Transportation of Specimens by Private Courier / Contracted Taxi Firm Specimens must always be transported within closed boxes which are clearly marked as defined by ADR 2015and described in Section 10.4 and safe working practices as defined in Appendix C,are adhered to As an added precaution packing specification P620 is used for private courier / taxi delivered specimens, this entails Specimens(which are not frozen) during transport should be placed into an appropriate primary receptacle and then into a specimen bag 8

9 with a request form in the separate compartment. These are then placed in a plastic screw capped container, with sufficient absorbent material to absorb the contents of the specimen if leaked and to act as cushioning. This is then placed in a cardboard outer appropriately labelled with the UN-3373 requirements as described in section When transporting specimens to the laboratory, the carrier must ensure that the samples are not subjected to extreme temperatures; this includes keeping them away from direct heat (including windowsills in the hot months, and direct heat from heaters in vehicles in the winter months) as this can cause the sample validity to be compromised Specimens requiring transport to ensure the samples remain frozen must be packaged by the referring laboratory in a manner that supports the integrity of the specimen: 14.4 All three packaging components must adhere to ADR regulations with the outer package clearly marked with the UN-3373 label as described in section 10.4 with additional marking advising the coolant, i.e. Packed in Dry Ice, or Liquid Nitrogen etc. consult the DGSA if this option is required Refrigerants may be used to stabilize infectious substances in Categories A and B during transit. Packed infectious substances requiring cooling assigned to packing instructions P620 or P650 shall meet the appropriate requirements of that packing instruction. Ice, ice pads or dry ice shall be placed outside the secondary receptacle or in an outer packaging or in an over pack Wet ice shall be placed in a leak-proof container; the outer packaging or over pack shall also be leak-proof Dry ice must not be placed inside the primary or secondary receptacle because of the risk of damage caused by the gas expanding as it thaws. A specially designed insulated packaging may be used to contain dry ice. The packaging must permit the release of carbon dioxide gas if dry ice is used. Packing instruction P003 (ICAO/IATA PI954) shall be observed The secondary receptacle shall be secured within the outer package to maintain the original orientation of the inner packages after the refrigerant has melted or dissipated. The outermost packaging shall carry the hazard label for dry ice, the appropriate markings, including the UN number and the proper shipping name followed by the words AS COOLANT, for example: UN 1845, CARBON DIOXIDE,SOLID, AS COOLANT. and an indication of the net quantity of dry ice in kilograms Specimens must be properly packaged as described above before being given to the Driver. Specimens must never be transported unprotected or only in plastic bags. The driver should be informed if urgent and of the destination. All this information must be clearly visible on the outer packaging. Additional requirements exist for Category A consignments in terms of package markings, documentation requirements, vehicle marking, security etc.. Consult the DGSA for further information 9

10 15.0 Use of the Pneumatic Air Tube Transport System 15.1 The pneumatic tube system has been installed within the Blood Science Reception area of Pathology (Biochemistry, Haematology and Immunology) to support the transportation of urgent and routine specimens from service users. Routine requests for Microbiology may be sent through the system during normal working hours, however a portering system is in operation at this period to forward the samples to Microbiology at set times throughout the day. All urgent requests for Microbiology must be delivered by hand directly to the Microbiology laboratory Samples that must not be sent through the pneumatic system are: Blood Cultures CSF (Cerebro-Spinal Fluid) Early Morning Urine for Mycobacterial Culture Blood Products Used Blood Product Packs Andrology Specimens Cytology Specimens Histology Specimens 24 Hour Urines These sample types have been forbidden in order to support the health, safety and well being of Trust staff, patient and the general public and to support the integrity of specimens being forwarded for analysis During normal working hours, the laboratory should be notified of urgent specimens by telephone. Outside of these times and bank holidays urgent requests must be telephoned to the on-call biomedical scientist within the relevant laboratory using the bleep system Specimens should be placed into a primary receptacle and placed within a sealed specimen bag with the completed request form placed in the adjoining pocket Place the sealed specimen bag inside the carrier and pack the carrier with absorbent material e.g. pink absorbent padding available from Pathology or paper towel, to prevent movement, breakage and possible deterioration of sample Due to the vibration in the air tube, it is important to ensure that lids especially paediatric and urine containers, are tightened in order that samples do not leak. Sample bottles that have had their lids removed must be secured in place to prevent sample leakage Ensure that all contents are contained within the carrier and that it is closed securely at both ends to avoid obstructing the tube network. Samples may be batched to conserve carriers. However, do not force specimens into a carrier, where necessary send two Only one carrier at a time should be placed in a delivery station Only staff who have received training in the use of the system may send Pathology specimens via this method. A cascade training system is in operation. If you have not received training, seek assistance from a colleague who has been trained. 10

11 16.0 Transport of samples using the Postal System 16.1 All samples sent via postal methods must adhere to ADR 2015 and P650 packaging instructions. The Postal Service will accept only Category B specimens for carriage Only Postal Service approved containers and packaging may be used Blood and Tissue slides must be regarded as sharps and placed in appropriate slide transport boxes before packing Samples known to contain Risk Group 4 pathogens (Category A) (Appendix A) must not be sent by post. Contact the Consultant Microbiologist for advice. This will require movement by a specialist carrier If specimens are sent directly to other laboratories from wards and departments, not via the Trust Pathology department, packaging instructions under ADR still apply Public Transport / Air Passenger Provisions 17.1 Category A or B infectious substances must not be carried by a member of staff in person on public transport. A patient may take a sample to a GP s surgery via public transport because this is outside the requirements of ADR. A member of staff transporting clinical samples as part of their work would be expected to comply with ADR and related packaging instructions Infectious substances in category A or B are not permitted for air passage in carry-on or undeclared checked baggage and must not be carried on the person Infection Control 18.1 All Pathology samples must be considered to be potentially hazardous Safe working and infection prevention practices are defined within specific job tasks. As a minimum all staff would be expected to work in a manner that supports the standard infection prevention precautions as detailed in the policy ref Hand washing and Alcohol gel use is advised to support the reduction of Hospital Acquired Infections Racks, transport bags and containers will be designed to allow for decontamination and sterilisation at specified intervals. Where outer packaging is rigid cardboard, excessive wear or visible contamination will result in its replacement and the appropriate disposal method of the contaminated item Decontamination materials should be carried in each vehicle to enable small spillages of biological samples to be contained and the drivers trained in their use Risk Management 19.1 Standard infection prevention procedures apply and safe working practices as detailed in Appendix B and C should be followed at all times The containment of specimens within motor vehicles, used to transport specimens, must be such as to restrain, retain and protect the contents in the event of an 11

12 accident. The bags must be zip fastened during transport to prevent leakage of contents. Bags must be placed inside the boot or load compartment which must be locked at all times during transit In the event of a vehicle breakdown do not allow persons other than Trust staff or the emergency services to handle specimens Decontamination materials should be carried in each vehicle to enable small spillages of biological samples to be contained and the drivers trained in the use of. In the event of major contamination or no spillage kit being on board, follow the model rules described in Appendix C If Histology samples are being transported formalin spillage kits should be carried in the vehicle and the drivers trained in the use of. In the event of a major formalin spillage or no kit being on board, wind the windows down or leave the vehicle and follow the model rules described in Appendix C Any spillage must be reported immediately to a senior member of the department concerned. If the spillage is reported by any driver who is away from the laboratory action must be taken without delay. The same procedure applies to spillages of Methanol from Liquid Based Cytology specimens All decontamination of Trust equipment and vehicles shall be in accordance with the Trust Decontamination Policy ref All spillage incidents or incidents which may affect the quality of the specimens (such as delay due to traffic conditions) must be reported to the pathology reception staff and a Trust incident (DATIX) form completed It is also a regulatory requirement that any incident involving the release of infectious materials during the transport operation must be reported to the Dangerous Goods Safety Adviser (DGSA) who has a legal duty to investigate and prepare a management report. It is however the view of the DGSA that IF the Packing Instructions are followed fully then paragraphs 19.4 onwards become purely academic as the system is designed to contain any leakage within the absorbency placed inside the packaging Audit 20.1 This procedure will be considered and prioritised for audit as part of the Pathology department annual audit programme Non-conformances will be discussed with any department concerned to support the identification of root cause and enable corrective action implementation. Progress of actions will be reviewed as part of the Pathology Quality Management forum. Trends will be monitored The Pathology Quality Management forum will review audit non-conformance trends and where necessary inform to the Trust via the DATIX recording system The Pathology Risk Management forum will review Incidents and complaints recorded through the Trust DATIX system relating to this document. Investigation and trend analysis will be undertaken to promote the elimination of root causes. 12

13 21.0 References Department for transport, the civil aviation authority and the maritime and coastguard agency guidance document on the Transport of infectious substances Health Services Advisory Committee Safety in Health Service laboratories: Safe working and the prevention of infection in clinical laboratories The Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations (CDG - Current edition) The CDG Amendment Regulations 2011 ADR: European Agreement Concerning the International Carriage of Dangerous Goods by Road (Current edition) Biological Agents: managing the risks in laboratories and healthcare premises. HSE Advisory Committee on Dangerous Pathogens Control of Substances Hazardous to Health Regulations 2002 Control of substances hazardous to health (5th edition) : the Control of Substances Hazardous to Health Regulations 2002 (as Amended) 2005 Guidance on Regulations for the Transport of Infectious Substances Management of health and safety at work : Management of Health and Safety at Work Regulations Personal Protective Equipment at Work 2005 Safety signs and signals: the Health and Safety (Safety Signs and Signals) Regulations. Guidance on Regulations. European Regulation (EC) No 1272/2008 on classification, labelling and packaging of substances and mixtures Chemicals (Hazard information and Packaging for Supply) Regulations 2009 Approved List of Biological Agents: HSE Advisory Committee on Dangerous Pathogens 2013 The Health & Safety at Work Act 1974 Transport of Infectious Substances : Best Practice Guidance for Microbiology Laboratories Department of Health

14 Appendix A Category A Infectious Substances INDICATIVE EXAMPLES OF INFECTIOUS SUBSTANCES INCLUDED IN CATEGORY- A (IN ANY FORM UNLESS OTHERWISE INDICATED) Bacillus anthracis (cultures only) Brucella abortus(cultures only) Brucella melitensis(cultures only) Brucella suis(cultures only) Burkholderia mallei - Pseudomonas mallei Glanders (cultures only) Burkholderia pseudomallei Pseudomonas pseudomallei (cultures only) Chlamydia psittaci - avian strains (cultures only) Clostridium botulinum (cultures only) Coccidioides immitis(cultures only) Coxiella burnetii(cultures only) Crimean-Congo hemorrhagic fever virus Dengue virus (cultures only) Eastern equine encephalitis virus (cultures only) Escherichia coli, verotoxigenic (cultures only) Ebola virus Flexal virus Francisella tularensis (cultures only) Guanarito virus Hantaan virus Hantaviruses causing haemorrhagic fever with renal syndrome Hendra virus Hepatitis B virus (cultures only) Herpes B virus (cultures only) Human immunodeficiency virus (cultures only) Highly pathogenic avian influenza virus (cultures only) Japanese Encephalitis virus (cultures only) Junin virus KyasanurForest disease virus Lassa virus Machupo virus Marburg virus Monkeypox virus Mycobacterium tuberculosis (cultures only) Nipah virus Omsk hemorrhagic fever virus Poliovirus (cultures only) Rabies virus(cultures only) Rickettsia prowazekii (cultures only) Rickettsia rickettsii (cultures only) Rift Valley fever virus(cultures only) Russian spring-summer encephalitis virus (cultures only) Sabia virus Shigella dysenteriae type 1 (cultures only) Tick-borne encephalitis virus (cultures only) Variola virus Venezuelan equine encephalitis virus (cultures only) West Nile virus (cultures only) Yellow fever virus (cultures only) Yersinia pestis (cultures only) 14

15 Appendix B Rules for Porters Introduction Some of the work carried out by laboratory porters and messengers in the hospital may involve accidental contact with material that could be infectious. You should always follow the general precautions outlined below and observe the following guidelines:- General Precautions Cover any cuts, grazes or broken skin on your hands with a waterproof dressing; Always wash your hands thoroughly after handling specimens, before meal breaks and at the end of a work period. Alcohol hand sanitizer dispensers are available in the pathology reception; Carry all specimens in the containers provided, never in your hands or pockets; Specimens must never be left unattended, as patient confidentiality must be observed at all times; Spillage and Leaks If a specimen leaks into a container or onto a trolley, tell one of the reception staff. They will ensure one of the laboratory staff make it safe; Any leakages when moving bodies should be reported to the mortuary staff; If you drop and break a specimen, do not touch it or try to clear it up. Stay with the specimen to prevent other people touching it and contact the laboratory or the infection prevention team for help; If you spill the specimen onto your work clothes, you should remove the contaminated clothing at once and then wash your hands and put on clean work clothes. The contaminated clothing should be dealt with following the local procedure for laundering or as detailed in the Trust dress code / uniform policyref Risk Reporting Report all accident to your supervisor; Complete a Trust Incident Report (DATIX) form as soon as possible. 15

16 Appendix C Rules for Transport Drivers Introduction Some of the work carried out by transport drivers and couriers may involve accidental contact with material that could be infectious. You should always follow the general precautions outlined below and observe the following guidelines:- General Precautions Cover any cuts, grazes or broken skin on your hands with a waterproof dressing; Always wash your hands after handling specimens, before meal breaks and at the end of a work period. Alcohol hand sanitizer dispensers are available in the pathology reception. Carry all specimens in the containers provided, never in your hands or pockets. In the event of your vehicle breaking down or you have an accident; do not let anyone touch the specimen container, unless they are from the Trust or emergency services. Make sure the appropriate hazards data sheets are made available to them. Ensure when lifting that Trust manual handling guidelines are followed Always wash or gel your hands after delivering the specimens Ensure your transport bags are disinfected weekly or following a spillage. Report any spillage or incident which may affect the quality of the specimen (e.g. long delays in traffic) to the reception staff and complete a Trust incident (DATIX) report. Specific Requirements The containment of specimens within motor vehicles must be such as to restrain, retain and protect the contents in the event of an accident. Place all specimen containers into the boot or load compartment and lock securely. All transport containers must be securely closed to prevent any leakage of contents Specimens must never be left unattended when not secured in the van as patient confidentiality must be maintained at all times Specimens must not be left in transport boxes or vehicles overnight Each Van must have the following: Disposable gloves, a spillage kit and instructions for use. Biohazard Spillages If a specimen leaks and runs out of the container, make safe the area and follow your local procedure for dealing with spillages. If it is contained within the transport container drive to the laboratory who will deal with the spillage when unpacking the delivery. If it is outside of the vehicle in a public area contact the Emergency Services for assistance. If it is outside of the vehicle but within a collection site request assistance from on site employees. Formaldehyde and Methanol Spillages These specimens must only be transported in vehicles which contain the Spill-X-FP spillage kit. If a specimen leaks and runs out of the container, secure the area ensuring it is well ventilated If it is contained within the vehicle, open all windows or doors and follow the instructions supplied with the spill kit. If it is outside of the vehicle in a public area contact the Emergency Services for assistance and inform the Cellular Pathology Laboratory of the situation ( ). If it is outside of the vehicle but within a collection site request assistance from on site employees.. Report all incidents to your supervisor and complete a Trust Incident Report (DATIX) form as soon as possible, ensuring a copy is forwarded to the DGSA. 16

17 Appendix D Spillage Instructions for Hospital Transport Drivers Biohazard Spillages If a specimen leaks and runs out of the transport container, open the Blood and Body Fluid Spill Pakand put on the gloves and apron Cover the spillage with the absorbent granules. Encircle spillage and then work inwards until completely covered Wait at least 2 minutes Open the yellow disposal bag and place next to the spill. Using the scoop and scraper collect the spill and granules and discard into the yellow disposal bag. If the spillage is within a collection site; request help from on site employees. If the spillage is outside of the vehicle; add the 4 small tablets to the granules container and fill with the water supplied to the marked Fill Line and wait 2 minutes. When the granules have dissolved, close the cap and mix by inversion. Use the solution with paper towel to wipe the spillage area and any splashes. Place all materials, gloves last, into the disposal bag. Tie the top of the bag in a knot, secure the bag and return immediately to the laboratory for assistance. If the spillage is contained within the vehicle; place all materials, gloves last, into the disposal bag. Tie the top of the bag in a knot, secure the bag and return immediately to the laboratory for assistance. Telephone the Blood Sciences Laboratory on to inform them of the spillage and your expected arrival time. Formaldehyde and Methanol Spillages If a specimen leaks and runs out of the container, secure the area ensuring it is well ventilated Within the vehicle this will require opening all windows and / or doors. Treat the spillage with SPILL-X-FP powder. Wearing gloves and an apron encircle the spillage and then work inwards until completely covered. Wait 15 minutes until the Formalin is completely neutralised Using a scoop and scraper collect the spill and granules and discard into the yellow disposal bag. Place all materials, gloves last, into the disposal bag. Tie the top of the bag in a knot, secure the bag and return immediately to the laboratory for the vehicle to be decontaminated. Telephone the Cellular Pathology Laboratory on to inform them of the spillage and your expected arrival time. 10% Formal Saline may cause sensitisation by skin contact. The vapour should not be breathed in.. Report all incidents to your supervisor and complete a Trust Incident Report (DATIX) form as soon as possible, ensuring a copy is forwarded to the DGSA. 17

18 Appendix E Pneumatic Tube- Pathology User Guide Pathology Carriers are YELLOW Blood Science Reception Station Address: Routine Specimens send to station 292 or 372 Urgent Specimens send to station 172 and telephone the lab to advise of its arrival Microbiology urgent and on-call request must be delivered to the department by hand. Pneumatic Tube Use by Wards / Departments: Wards and departments must ensure specimens are contained within sealed bags, with request forms in the separate pocket before placing in the carrier Absorbent, cushioning material e.g. pink absorbent material is supplied by Pathology or paper towel, must be placed in the carrier to prevent the sample(s) from being excessively shaken during transit The ward/department takes responsibility for ensuring the carrier is sent to the correct location The ward/department takes responsibility for ensuring patient confidentiality when sending multiple carriers The ward department must take responsibility for informing pathology staff that urgent specimens are being sent for analysis. Restrictions: The following items MUST NOT be sent in the pneumatic tube:- Blood Cultures CSF (Cerebro-Spinal Fluid) Early Morning Urine for Mycobacterial Culture Blood Products Used Blood Product Packs Andrology Specimens Cytology Specimens Histology Specimens 24 Hour Urines Pathology use of the pneumatic tube: Pathology will use the tube to return empty carriers to their chipped homing location The system will not be used to deliver Pathology supplies (bags, QC materials etc) The Pathology service cannot retrieve carriers from other areas Pathology does not hold stock of any carriers. Infection Control: Only Yellow carriers may be used for Pathology Pharmacy carriers are Yellow with a Green Cross Any spillage inside a Yellow carrier should be cleaned by the department / ward to remove visible soiling using Sani-cloth Active (green lid) and delivered by hand to Pathology for decontamination Wards and departments will be responsible for cleaning the carriers with appropriate wipes e.g. Sani-cloth (red lid) on a daily basis Contaminated canisters will be removed from use until decontaminated by Pathology Pathology samples received in Pharmacy carriers will result in the carrier being removed from service until appropriate decontamination has been performed. Maintenance / Failures: In the event of a system failure a job should be logged with ETDE FM Ltd on ext An engineer will respond to resolve the problem. An ETDE FM engineer is on site 24/7. If the problem is beyond ETDE FM experience and training, ETDE FM will call the specialist contractor to send an engineer as soon as practicable. If the system is inoperable wards and departments must implement contingencies to ensure samples are delivered to the Pathology reception areas to ensure timely processing of samples. 18