POLICY DOCUMENT. Specimen Transportation Policy

Transcription

1 POLICY DOCUMENT Specimen Transportation Policy Owner: DGM - Pathology Date Created: 01/10/2004 The following fields are updated automatically: Version No: 2.0 Status: Approved Next Review Date: 22/01/2013 Approved By: Infection Control Committee Adopted by SEQOL as IPC21 (June 2012) through the Quality Safety & Performance Unit This document has been adopted by Swindon Borough Council Children Services under the Section 75 agreement (Oct 2012).

2 Table of Contents 1. Document Definition References & Further Reading Glossary / Definitions Purpose Scope Equality Impact Statement Comments Policy Details Background General Recommendations Principles for the Collection of Specimens Specimen Containers Storage of Specimens Transportation of Specimens GWH Site Specimen Bags Specimen Transport Boxes Leakages and Breakages Specimens from High Risk Patients Additional Information Transportation of Specimens External Sites Sending Specimens by Post Category A Category B Sample Labelling & Request Forms Sample Labelling Request Form Completion Transport Box Decontamination Appendix Pneumatic Tube Operational Policy Version 2.0 Page 2 of 15

3 1. Document Definition 1.1 References & Further Reading Document Title Biological agents: Managing the risks in laboratories and healthcare premises Advisory Committee on Dangerous Pathogens, 2005 The Carriage of Dangerous Goods (Classification, Packaging and Labelling) and Use of Transportable Pressure Equipment Regulations, 2007 Health & Safety at Work etc Act, 1974 Management of Health & Safety at Work Regulations, 1999 Document Location HSE Website HSE Website HSE Website 1.2 Glossary / Definitions ACDP CJD PCT TSE VHF Advisory Committee on Dangerous Pathogens Creutzfeldt Jakob disease Primary Care Trust Transmissible Spongiform Encephalopathy Viral Haemorrhagic Fever 1.3 Purpose To provide clear guidelines for the safe transportation of Pathology laboratory specimens, in order to reduce risks from potentially infectious organisms contained within those specimens, which may present a hazard to the health of those who are in contact with them. 1.4 Scope Standard: Exceptions: Implementation: Staff Involved: Guidelines are available and risk assessments undertaken to ensure safe practices are observed and risks described above are reduced. None. All wards and departments Great Western Hospitals NHS Foundation Trust; all health care settings including those of independent contractors within Swindon Primary Care Trust who transport specimens to the Pathology Department of Great Western Hospitals NHS Foundation Trust All healthcare workers no matter where they are working involved in transporting specimens to the Pathology Department of Great Western Hospitals NHS Foundation Trust. 1.5 Equality Impact Statement Great Western Hospitals NHS Foundation Trust aims to design and implement services, policies and measures that meet the diverse needs of its service, population and workforce, ensuring that none are placed at a disadvantage over others. This document has been assessed against the Trust s Equality Impact Assessment Tool. This document has been assessed as not relevant to the duty. Version 2.0 Page 3 of 15

4 1.6 Comments Any comments on this document should, in the first instance, be addressed to the author. Version 2.0 Page 4 of 15

5 2. Policy Details 2.1 Background Any potentially infectious material that is being transported from place to place could present a hazard to the health of people who come into contact with it. Packaging and transport of specimens therefore needs to be strictly regulated in accordance with the UN 602 and 650 regulations and the guidance contained within Biological agents: Managing the risks in laboratories and healthcare premises ACDP, General Recommendations Everyone involved in collecting, handling and transporting specimens should be educated about standard infection control precautions and trained in: hand hygiene the use of personal protective clothing equipment the safe use and disposal of sharps This includes SBC and GP practice staff. In addition, staff should be familiar with the infection control policies for: handling / disposal of clinical waste blood / body fluid spillage, and prevention management of exposure to blood-borne viruses Patients and their carers should be given advice on the collection, storage and transportation of specimens, where appropriate. 2.3 Principles for the Collection of Specimens It is not the intention within this Policy to dwell on specimen collection. However, success in the laboratory is dependent upon correct collection and transport of clinical specimens. Good quality specimens are obtained when the following are adhered to: The request form is completed accurately (refer to Section 10) and the identity of the patient confirmed The specimen container is labelled correctly The patient is appropriately prepared Effective hand washing is performed, before and after collection of the specimen The specimen is collected correctly and the appropriate protective equipment clothing is worn; i.e. gloves, apron and, where splashing is possible or expected, goggles or a visor A vacuum collection system is used when performing phlebotomy The correct specimen is taken at the correct time Version 2.0 Page 5 of 15

6 The normal flora of the patient or the person collecting the specimen does not contaminate the specimen An adequate quantity and appropriate number of specimens is provided The risk of interchange of samples and sub samples is minimized All materials used in specimen collection are disposed of in a safe manner High risk specimens are identified and processed correctly (refer to Section 7.4) Specimens are clearly labelled and transported to the laboratory in approved containers only All spillages and breakages are dealt with correctly The safety of the specimen collector, carrier, the general public and receiving laboratory is ensured by minimising risk 2.4 Specimen Containers Specimen containers must be sufficiently robust to withstand the stresses likely to be put upon them, and must not leak in normal use. Only containers approved by the Pathology Department may be used, so that the integrity of the specimen is suitably ensured during transit to the laboratory. Specimens that are sent in non-approved containers may not be processed by the laboratory. The person sending the specimen must ensure that the container used for the transportation to the laboratory is the appropriate one for the purpose. It must be properly closed and checked to ensure no external contamination by the contents of the specimen container. Every specimen container, and request form, must describe the nature of the specimen. The identity and location of the patient should be detailed as described in Section 10 of this document. 2.5 Storage of Specimens For accurate results to be obtained, specimens should be received by the laboratory as soon as possible. Specimens for microbiological investigation should, ideally, be examined as soon as possible. Where this is not practicable, delays in transportation should be kept to a minimum and specimens should be refrigerated. Specimens may be kept in a refrigerator (4-8 o C) for a maximum of 24 hours prior to transportation. This will help prevent bacteria and contaminants from multiplying and giving misleading results. However, it must be noted that samples taken for blood culture examination must not be refrigerated. These must be transported to the laboratory as soon as possible for incubation at 37 C (a small incubator is located in the Pathology Reception area for this purpose). Semenology samples: The Pathology Reception staff stamp date and time the front of the form as soon as a semen specimen reaches the pathology reception department and then places the sample in the white lidded box in the 37C incubator in the small lobby room by reception. These samples must not be refrigerated under any circumstances. Any Version 2.0 Page 6 of 15

7 specimens received out of hours must be handed straight to a member of the cytology department. Non-gynae specimens: Any non-gynae specimens received between 5pm-8:30am must be refrigerated. All non-gynae cytology samples must be placed in the Cytology box for transportation from specimen reception to the cytology department. Samples obtained for non-microbiological investigation also must not be refrigerated. If any clinical specimens are to be stored in a refrigerator, it is essential that: There is a refrigerator for the purpose of specimen storage only, which should be labelled with an external biohazard sign. The temperature in the refrigerator should be kept between 4-8 C (minimum and maximum temperatures should be checked and recorded daily) The specimen refrigerator must not be accessible to the public The specimen refrigerator should be cleaned on a weekly basis, defrosted regularly, and cleaned and disinfected after any spillage or leakage 3. Transportation of Specimens GWH Site Under the Health and Safety at Work Act (1974), all staff have an obligation to protect themselves and others, e.g. the public, from inadvertent contamination from hazardous substances. All staff must therefore be aware of how to deal safely with clinical specimens and how to avoid any spillage or leakage of body fluids. 3.1 Specimen Bags All specimen containers, which are to be transported to the laboratory, must be sealed in the plastic bag which is attached to the request forms. All specimens must routinely be carried in the transport boxes. Carrying specimens by hand should be by exception only, as follows: 24-hour urine bottles: these bottles must be placed in large self-sealing plastic sacks provided by the pathology department. The request form must be placed within the second pocket situated on the side of the specimen bag. Blood gases: when blood samples are obtained for blood gas analysis, the needle must be removed (using the needle removing device on a sharps container) and a sterile red cap fitted to the end of the syringe prior to transportation to the point of analysis. N.B. there is no provision for blood gas analysis to be undertaken within Pathology. 3.2 Specimen Transport Boxes Special secure specimen transport boxes must be used. These boxes must not be used for any other purpose than carrying Pathology specimens. Boxes should have exterior safety labels, warning of the risk of infection. The boxes must be made of a smooth impervious material, which can be easily cleaned, disinfected or autoclaved and must retain liquid in the event of leakage of a specimen. Version 2.0 Page 7 of 15

8 The boxes should be cleaned and disinfected or autoclaved regularly and whenever contaminated (see decontamination procedure). Specimens that are incorrectly packaged should not be removed but brought to the attention of the person in charge of the ward/department. 3.3 Leakages and Breakages Should leakage into a transport box or bag occur, the laboratory reception staff should be informed immediately on arrival at the Pathology Department. On the rare occasion that a specimen is dropped and accidentally broken, ensure the ward/department is notified immediately. All spillages should be removed and cleaned in accordance with the Guidelines for the Decontamination of Medical Devices, found on the Trust Intranet. NB: Although urgent specimens from a single patient may be taken to the laboratory by hand, they must always be transported within a sealed specimen collection bag. 3.4 Specimens from High Risk Patients All specimens should be regarded as potentially infectious. Certain specimens from patients who are known or suspected to have the following diseases / conditions constitute a potential higher risk of infection to persons handling the specimens (nursing, portering, transport, reception and laboratory staff): Typhoid/paratyphoid fever (faecal specimens only) Dysentery (faecal specimens only) Tuberculosis (specimens from sites where tuberculosis infection is likely) Anthrax Transmissible Spongiform Encephalopathy (including CJD) Viral haemorrhagic fever Pandemic Flu To minimise the risks, ensure that such specimens are packaged as follows: Attach a Danger of Infection label (available from Phlebotomy Dept, GWH) on specimen container Place the specimen in a sealable plastic bag and close the seal Attach a Danger of Infection label (available from Phlebotomy Dept, GWH) to the request form and the appropriate section of the Pathology form should be circled Yes - Danger of Infection Risk Present Specify on the request form the nature of the risk eg typhoid, etc 3.5 Additional Information Additional information about blood borne viruses can be found on the intranet: Additional information on Transmissible Spongiform Encephalopathies (TSE) can be found on the intranet: Version 2.0 Page 8 of 15

9 For potential TSE / CJD cases, the Consultant Microbiologist must be contacted before specimens from these patients are taken. Additional information on Viral Haemorrhagic Fevers (VHF) can be found on the intranet: Before any specimens are collected from a patient suspected of having a viral haemorrhagic fever, the Consultant Microbiologist must be contacted by the clinician in charge of the case. Special transport arrangements are required for these specimens and details of this can be obtained from the Consultant Microbiologist. Rarely, other biological agents that can cause severe human disease and present a serious hazard to employees may be present in specimens. If this is suspected clinically, advice on specimen collection and transport should be sought from the Consultant Microbiologist. 4. Transportation of Specimens External Sites Under the Health and Safety at Work Act (1974), all staff have an obligation to protect themselves and others, e.g. the public, from inadvertent contamination from hazardous substances. All staff must, therefore, be aware of how to deal safely with clinical specimens and how to avoid any spillage or leakage of body fluids All clinical staff transporting specimens from a patient s home to a surgery, clinic or health centre must be provided with a rigid, robust, leak proof container with a tight fitting lid. This container must be identified with both a biohazard sticker and contact telephone number in case the box is lost. Clinical staff must not transport specimens unless such a container is used. Containers designated for the transport of clinical specimens must never be used for the transportation of any other items. The specimens must be protected from breakage during transport and only the person collecting the sample and the laboratory staff unpacking the samples should be required to directly handle the outside of the specimen container. The container housing the specimen must be placed in a self sealing, single pocket plastic bag by either the nurse/healthcare worker collecting the sample or the patient on arrival to the surgery. The plastic specimen bags are either attached to the request forms, or contain the printed request form in a side pocket. The number of specimens in the bag must not exceed the capacity of the bag. When specimens in screw-top containers are submitted by patients at surgeries, the staff must check the lids are tightly closed once they have been placed in the plastic bag. High infection risk specimens and forms must be labelled as described in Section 7.4 (above). Specimens must be transported to the laboratory in special secure transport boxes with fastenable lids. Each box must bear a warning label stating that the box must not be opened or tampered with and given a telephone number to be contacted if the box is found unattended. Transportation of specimens by vehicle is usually by a courier service or PCT van to the local hospital laboratory. Vehicles used for the transportation of clinical specimens must have the following available for use in the event of an accidental spillage: Version 2.0 Page 9 of 15

10 Appropriate protective clothing (gloves and aprons) Spillage kit and written instructions Alcohol gel for hand hygiene In addition, the vehicle must have impervious internal surfaces that can be cleaned down with hot water and detergent in the event of a spillage. If other goods are transported, there must be a physical barrier between clean and dirty items. Staff transporting clinical specimens must always keep the vehicle locked when unattended. In the event of vehicle breakdown or road traffic accident, the driver must not allow members of the public to handle clinical specimens. 5. Sending Specimens by Post The Royal Mail defines pathological specimens as any biological material sent for medical analysis, or substances which may contain living organisms, e.g. blood products, serum, vaccines and semen. The UN Regulations (effective from 1 January 2005) make provision for: Classification Definition UN assignment Packaging code Category A Infectious substance transported in a form that, when exposure to it occurs, is capable of causing lifethreatening or fatal disease UN2814 infectious substance for humans (UN2900 infectious substance for animals) 602 Category B Diagnostic specimen with no known risk of serious human or animal disease UN3373 diagnostic specimen Category A Diagnostic specimens from a patient who has or may have a serious disease which can be readily transmitted from one individual to another, directly or indirectly, and for which effective treatment and preventive measures are not usually available, must be assigned to UN2814. This category consists mainly of Hazard Group 4 biological agents (e.g. Lassa Fever), new and emerging organisms, and concentrated laboratory cultures. For guidance on these types of specimens contact the local pathology laboratory or the Health Protection Unit. Failure to comply with correct guidance on the transportation of Category A specimens may lead to prosecution. Version 2.0 Page 10 of 15

11 5.2 Category B Diagnostic specimens are usually assigned to UN3373. Specimens may be sent by the postal system, provided they comply with the basic triple packaging instructions 650. This consists of three layers as follows: Primary receptacle A labelled primary, watertight, leak-proof receptacle containing the specimen (as normally used by clinical staff). This receptacle should be wrapped in enough absorbent material to absorb all fluid in case of breakage. Secondary receptacle A second durable, watertight, leak-proof receptacle to enclose and protect the primary receptacle(s). Several wrapped primary receptacles may be placed in one secondary receptacle. Sufficient additional absorbent material must be used to cushion multiple primary receptacles. Information concerning the specimen, such as request forms or letters that identify or describe the specimen and the identity of the sender and receiver should be taped to the outside of the secondary receptacle. Outer shipping package The secondary receptacle is placed in a rigid outer shipping package which should protect it and its contents from outside influences such as physical damage and water while in transit. The outer package must bear the UN packaging specification and be marked Diagnostic Specimens. Specimens must always be sent by 1 st class post or Datapost. The name and address of the sender (to be contacted in case of damage or leakage) must be shown on the outer cover. Safebox from Royal Mail has been designed for sending diagnostic specimens (UN3373) by post and is fully compliant with packaging instruction 650. It can be ordered by telephone or ( Further information on the packaging of specimens can be obtained from the Microbiology Department on (01793) Sample Labelling & Request Forms 6.1 Sample Labelling As a minimum requirement, all samples must be labelled with the patient s surname, forename and date of birth. Samples for Blood Transfusion must carry the patient s full name, unit number or emergency number, date of birth, address and ward. Samples from unconscious or incoherent patients should be labelled with UNKNOWN MALE OR FEMALE and the emergency unit number. Cytology specimens need to be labelled with full name and date of birth or hospital number. Addressograph labels (except those produced by the hospital s electronic wristband patient identification system) are not acceptable on blood samples, as they interfere with the tube s Version 2.0 Page 11 of 15

12 passage through the analysers and may have found their way into the wrong notes. All unlabelled samples will be discarded on arrival at the laboratory and the requester informed. The requesting clinician has legal responsibility for the correct labelling of both sample and request forms. 6.2 Request Form Completion Haematology, Biochemistry and Microbiology requests on blood samples should be made on the red forms. The green forms should be used for Histology, Cytology and all non-blood requests for Biochemistry and Microbiology. A special form is required for all Blood Transfusion requests. Samples for semenology may be accepted without a request form. The patient must be asked to fill in a Temporary Semenology Request Form for Semen specimens received without a request form (CYT-F-071) and informed that a result will not be released until an official request form is received. In order to ensure reports being sent to the correct destination, request forms should be correctly and legibly completed with the following minimum details: Patient identity Case Number Surname First Names Date of Birth Sex Ward or surgery Date and time of collection Consultant or General Practitioner Tests required Nature of specimen submitted Relevant clinical details The name of the person making the request should be signed legibly on the form. Relevant history and details of medication (including antibiotics) should be included. This is particularly important and allows the laboratory to select further tests as appropriate and to be aware of analytical interference. It is essential to use a ballpoint pen when completing request forms. Use of felt tip and fountain pens can lead to delay in processing samples, or requests being missed altogether, as carbon copies are often incomplete. When addressograph name labels are used, please ensure that a label is fixed to EACH part of the request form. Addressograph labels must not be used for requests for blood or blood products from the Blood Transfusion laboratory (except those labels produced by the hospital s electronic wristband patient identification system). 7. Transport Box Decontamination Specimen boxes will be decontaminated routinely every month, as a minimum, by the Pathology Reception staff. More frequent decontamination is required should there be obvious blood, body fluids, or evidence of spillage. Cleaning with a detergent wipe followed by thorough drying with paper towel would be acceptable in routine circumstances. Version 2.0 Page 12 of 15

13 Disinfection with a 70% hard surface alcohol wipe is advised after the cleaning process should obvious contamination with blood/body fluids be present. The Pathology Reception Supervisor will be responsible for co-ordinating the cleaning of the boxes and be responsible for keeping an accurate log of the boxes and their dates of decontamination. 8. Appendix Pneumatic Tube Operational Policy Pneumatic Tube System AC 3000 (Aerocom UK Ltd) Operational Policy Staff must not use this system until they have read and understood the operational policy and have been trained, or have sought assistance from, a member of staff trained in the use of the system. Introduction The AC 300 Pneumatic Tube System (PTS) is an effective and efficient method of delivering urgent specimens to the Pathology department. It is important that all users of the system read, understand, and adhere to this policy to ensure the system is used correctly. Management of the System Carillion Services manage the system. System Failure Any failure of the system is to be reported to the Facilities Management Help Desk on Ext Spillage If an individual carrier tube appears to require routine cleaning and it is not suspected or proven to have suffered an actual spillage of blood products or body fluids, then it may be cleaned using a soap and water preparation. Care must be taken to avoid damaging, or exposing to water, the Velcro rim of the carrier. The carrier is then to be dried thoroughly. Do not completely immerse the carrier in water. If a carrier tube is suspected or proven to have suffered an actual spillage of blood products or body fluids, the carrier is to be placed in a yellow contaminated waste bag. An IR1 form is to be completed and is to accompany the carrier. Guidance is then to be sought by ringing Pathology Specimen reception on Ext: (between the hours of and Monday Friday) If there is a suspected spillage within the system, the station reporting the spillage is to cease using the station immediately. Facilities Management Help Desk Ext: 4600 are to be contacted immediately. What can/cannot be sent through the system? Version 2.0 Page 13 of 15

14 The system is for the transport of urgent pathology specimens only. No other material of any kind is to be transported. The following items must not be sent through the system: Any items not correctly sealed in a specimen bag Any specimen container known or suspected of being faulty Blood packs (full or empty) Blood culture specimens Histopathology/Cytology slides/specimens Pharmacy products Food Any specimen deemed an Infectious Risk Alternative Specimen Transport Services Non urgent specimens, or specimens that are not for transport through the system are to be delivered to Pathology by hand or by use of the Portering Service on Ext Use of the System Carrier SENDING A Station Number is marked on each carrier (this number should match your Station Number. These numbers are NOT to be changed or defaced. Prior to dispatch please ensure that the specimens are correctly sealed in a polythene specimen bag (with request form) and that the carrier is not overfilled. Ensure the carrier is securely closed. All specimens are to be sent to Pathology Station No No addressograph labels or labels of any description are to be attached to the outside of the carrier. Select the Pathology Station No Insert the carrier in the dispatch tube. If the GREEN light is FLASHING then you have entered an incorrect station address. Remove the carrier and start again. If the GREEN light is ON, then the address has been accepted. If the YELLOW light is ON, then the tube system is busy. Leave the carrier in the dispatch tube and it will go automatically when the system is free. IF THE RED LAMP IS ON, then there is a fault. Please report the fault to the Facilities Management Help desk on Ext 4600 RECEIVING On receipt of a carrier, first cancel the ARRIVAL indicator by pressing * followed by the appropriate lamp number showing on the display (1-16) to which it corresponds. Then remove the carrier from the basket. Version 2.0 Page 14 of 15

15 Out-of-Hours Specimens Between the hours of 5pm and 8am, only those specimens specifically deemed as urgent are to be transported through the system. All other specimens are to be placed in the overnight fridge provided for this purpose in Pathology Reception. Security Specimens in transit in the system are secure provided that the carrier is directed to Pathology. Carriers not in the system are to be stored in an accessible place ready for use. Station Locations No. Department Room No 101 Chronic Disease Microbiology Pathology SCBU EPU Paediatrics Theatre A&E G AAU G ASU Cardiology ITU Ampney/Aldbourne 116 Meldon 117 Treatment Centre Recovery 118 Shalbourne Version 2.0 Page 15 of 15