Section: Administration Date of Issue: 05/09/2011 Issued By: Administration Part: Pneumatic Tube System Revision #: Revision Date:

Transcription

1 STANDARD OPERATING PROCEDURE VETERINARY HEALTH COMPLEX Section: Administration Date of Issue: 05/09/2011 Issued By: Administration Part: Pneumatic Tube System Revision #: Revision Date: Pages: Board Approval 6/22/2011 Date: SOP #: 90 Introduction: The Computerized Tube System (CTS) is a pneumatic system used for transporting specific items. Only the vigilance of each person expected to use the CTS will assure the integrity of the CTS for the transport of authorized materials using this pneumatic transport system by authorized personnel. This standard operating procedure (SOP) establishes those procedures and guidelines for the transportation of authorized items and how to handle breaches in the safety and the security of the CTS. It is expected that all persons using the tube system for authorized transports shall take appropriate actions to both assure the CTS s integrity during normal operations and immediately report a suspected breach of the system s safety, especially with the discovery of an unknown substance, to NCSU Public Safety for immediate investigation to determine threat credibility. Threat credibility is a systematic process used by law enforcement to determine if a threat exists upon the discovery of the suspicious circumstances in the area of interest - in this case, the CTS. This SOP policy applies to all authorized CTS users defined as and limited to Veterinary Health Complex staff that have been trained to use the system. Procedures: I. Authorized Transport Items A. The CTS will be utilized to transport items directly related to patient care. B. Authorized items for transport include: 1. Laboratory a. Blood specimens b. Urine and stool specimens c. Cytology slides and fluids (<50 ml) d. Frozen sections e. Microbiology samples in transport media.

2 Note: Only laboratory samples for Clinical Pathology, Microbiology, and frozen sections for Histopathology will be transported through the CTS. 2. Pharmacy a. Medication (non-controlled substances) 3. Other a. Nursing notes b. Laboratory reports c. Supplementary medical support items (meeting size and weight requirements) d. C. Non Authorized Items for Transport include: 1. Laboratory a. Formalin and/or alcohol preserved specimens b. Body fluids with volume greater than 50 ml c. Urine specimens with volume greater than 50 ml 2. Pharmacy a. Hazardous drugs in the liquid form [any non-liquid hazardous drug (tablet, capsule, cream, etc.) can be tubed.] b. Live vaccines c. Controlled substances d. Drugs that are denatured or altered by tube transportation i. Albumin ii. Alteplase iii. Antivenin iv. Chorionic gonadotropin v. Darbepoetin alfa vi. Epoetin alfa vii. Filgrastim viii. Interferon products ix. Octreotide acetate 3. Radiology and Nuclear Medicine a. Radioactive pharmaceutical doses 4. Other a. Edible food or drink b. Contaminated items c. Money / Checks d. Sharps e. Non-leak-tight containers containing liquids or powder f. Items that may become damaged by bending or folding II. CTS Security: Immediately report to NCSU Public Safety (911) any person or persons observed near the CTS who do not have authorized access to the CTS or who are acting suspiciously.

3 III. Handling and Packaging A. In accordance with the universal guidelines developed by the Centers for Disease Control (CDC) and adopted by the Occupational Safety and Health Administration (OSHA), all blood and body fluids shall be handled as a potentially infectious material and are therefore considered hazardous. Potentially infectious items must be contained and transported in a manner that prevents breakage, leakage, or contamination of the system. Leakage is primarily due to improper packaging, non-immobilization of contents, use of non-leak-tight containers or failure to tighten container lids. To prevent spillage or breakage, remember that containment prevents leakage and immobilization ensures integrity. A combination of Zip-lock baggies and foam liners will be used to immobilize and package items. Both carriers and station control panels may be handled as non-contaminated (meaning using an ungloved hand) provided they do not show any evidence of contamination on the surface to be touched by the ungloved hand. This allows for the unhampered used of station controls without additional gloving to be performed. However, if the panels or carriers display any evidence of contamination a gloved hand is required. Station control panels or carriers believed to be contaminated should be decontaminated using appropriate personal protective equipment (PPE) and using a soft cloth dampened with properly diluted HDQ. Gloves used to handle contaminated carriers are removed and replaced with a fresh pair of gloves to control the spread of accidental contamination from contaminated carriers. Regular sanitation and inspection of all transport vessels should be performed by each service for their assigned carriers and station. This will help to assure minimal interruption of CTS service. B. All items transported within the PTS will meet certain physical characteristics to ensure safe, successful transport to the intended destination station. 1. Item (s) will remain within a size scale of 6 x Combined weight of item (s) will remain less than 7 pounds. 3. Bulk of item (s) will allow for tube carriers to close and fasten securely. C. Operating Requirements 1. Tube must close with a clean seal. 2. Both clips must lock completely All carriers must be returned to their designated station. 5. An audible beep every 4 seconds along with a station message prompt that reads Empty Your Receiver indicates a full station alarm (5 carriers). The station will be out of operation until excessive carriers in the receiver bin are removed. 6. Hoarding and borrowing of carriers is not authorized as this reduces the efficiency and ability of the system to distribute carriers effectively. All carriers must be transported via the tube system s normal operation method and not hand carried to/from individual stations. 7. Specific operational training can be obtained through the Clinical Pathology Lab Supervisor

4 D. When an unscheduled down time occurs, CTS users should be aware of the following: 1. Problems with the CTS should be immediately reported to the CVM Senior Building Liaison Stat items requiring immediate transport and routine specimens are to be handled by each service s individual personnel and hand delivered. 3. The station ready message will indicate when the system is functioning again. E. In the event of a specimen, blood, or body fluid spill immediately following emergency CTS shutdown procedure. 1. From the CTS station, select Menu 2. Select User Special Function 3. Select the Enter key 4. Select Emergency Shutdown 5. Select the Enter key 6. Contact Clinical Pathology at IV. Specific Laboratory Packaging Procedures for the CTS A. Blood 2. Make sure container cap is secure. 3. Place sealed and labeled specimen in appropriate clean Zip-lock bag. 4. Tubes from multiple patients may be placed in the same bag. (extra bags are available from Clinical Pathology) 5. Completely close Zip-lock bag. 6. Place bagged specimen in carrier and send. B. Iced Blood Specimens (Ammonia) 2. Make sure container cap is secure. 3. Add crushed ice to clean Zip-lock bag. 4. Place sealed and labeled specimen in separate, clean Zip-lock bag, remove as much air as possible so that the Zip-lock bag is tight around the specimen, and seal. 5. Place the sealed Zip-lock bag containing the specimen into clean Ziplock bag containing ice (double-bagging prevents specimen label from getting wet and smearing). THE ZIP-LOCK BAG WITH THE SPECIMEN SHOULD BE SURROUND BY ICE. Completely close second Zip-lock bag. 6. Place bagged specimen in carrier and send. C. Blood products from Transfusion Medicine (TBD) D. Urine / Stool / Body fluids 2. Make sure container cap is secure (screw cap only). 3. Place sealed and labeled specimen container in a clean Zip-lock bag.

5 4. Completely close Zip-lock bag. 5. Place specimen in carrier and send. E. Blood Gas specimens 2. Remove needle from syringe using mechanical device and replace with syringe luer lock tip (caps are available from central supply) 3. Place labeled specimen in Zip-lock bag. 4. Completely close Zip-lock bag. 5. Place Zip-lock bag in carrier and send. F. Surgical Specimens for Frozen Section 1. Use frozen section kit, available from histopathology. 2. Place sample in cassette. 3. Moisten gauze with a few drops of saline and place over cassette. 4. Place cassette in small plastic container from kit. 5. Put patient label on container, place in bag and send. 6. Call histology at when sample is sent to let them know to go to Clinical Pathology to retrieve frozen section sample. G. Culture Specimens (All cultures in transport media) 1. Make sure specimens are properly labeled and includes the UVIS request #. 2. All materials for culture will be submitted in transport media. 3. Place sealed and labeled specimen in appropriate Zip-lock bag. 4. Completely close Zip-lock bag. 5. Place sealed bag in carrier and send to Clinical Pathology station. H. Blood Culture Bottles 1. Make sure all specimens are properly labeled and includes the UVIS request #. 2. Place each labeled bottle into a separate Zip-lock bag. 3. Completely close the Zip-lock bag. Double bag each bottle by placing sealed Zip-lock bag into a second Zip-lock bag. Completely close second Zip-lock bag. 4. Place double-bagged specimen in carrier and send to Clinical Pathology Lab. V. Decontamination Procedure Involving Blood and Body Fluid Spills A. Procedure for a Spill Contained within Carrier 1. Always use Standard (Universal) Precautions when handling carriers that may be contaminated. 2. Notify Clinical Pathology laboratory supervisor. 3. Discard specimen and Zip-lock bag. 4. Call the send station to make them aware of incident and need to collect new specimen.

6 5. Discard foam liner. Decontaminate tube using properly diluted HDQ. B. Procedure for a Spill NOT Contained within Carrier 1. Stop sending carriers from the station where the contamination was first noticed and proceed with EMERGENCY SHUTDOWN. 2. Personnel should not perform the EMERGENCY SHUTDOWN procedures unless the spill is blood/body fluids. 3. Clinical Pathology will need to be notified that an emergency shutdown has occurred due to a blood/body fluid spill. Provide the following information. a. Receiving station's number b. Sending station's number (if known) c. Type of spill (specimen type and suspected amount) d. Time the contaminated carrier arrived (or was first noticed) e. Number of contaminated carriers that have arrived 4. Clinical Pathology will initiate the Decontamination Procedure. 5. If the contaminated carrier containing the spill is received at your assigned station, follow the steps in the Procedure for Spill Contained within Carrier. C. In either case above, the Spill Incident form (Exhibit A) is completed and forwarded to Environmental Health and Safety within 24 hours of this event.