Specimens Collecting, Handling and Transporting Ref IPC-0001-015 v2 Status: Approved Document type: Procedure
Contents 1 Purpose... 3 2 Related documents... 3 3 General principles for all specimens to be sent to laboratory... 4 3.1 Labelling specimens... 4 3.2 Sputum specimens... 5 3.3 Blood specimens... 5 3.4 Other specimens... 5 4 Transporting specimens... 5 4.1 Using cars or taxis to transport specimens... 6 4.2 Dealing with a spillage or broken specimen container while transporting specimens... 6 4.2.1 In a healthcare setting... 6 4.2.2 In the community... 6 4.2.3 Procedure... 6 5 Accident/injury... 7 6 References... 7 7 Equality Analysis Screening Form... 8 8 Document control... 12 Ref IPC-0001-015 v2 Page 2 of 12 Ratified date: 27 July 2016
1 Purpose Following this procedure will help the Trust to:- Ensure the safe collection and handling transportation of specimens; Ensure that staff only collect specimens if they are trained and competent to do so. 2 Related documents This procedure describes what you need to do to implement the collecting, handling and transportation of specimen of the Infection Prevention and Control Policy The Standard (Universal) Precautions for Infection Prevention and Control defines the universal standards for IPC which you must read, understand and be trained in before carrying out the procedures described in this document. This procedure also refers to:- Accidental Inoculation Creutzfeldt-Jacob Disease (CJD) Hand Hygiene Infectious Diseases Ref IPC-0001-015 v2 Page 3 of 12 Ratified date: 27 July 2016
3 General principles for all specimens to be sent to laboratory Step Action Done () Reason 1 Explain the procedure to the patient. To obtain patient consent and cooperation. 2 Wash hands as per Trust Hand Hygiene and wear nitrile gloves and disposable apron 3 Place specimens or swabs in the appropriate container and label with full patient s details. 4 Ensure that the pathology request form has been completed correctly including diagnosis and date of onset of suspected illness and any current antibiotic therapy. 5 Ensure that the pathology request form is signed by the doctor (if appropriate). 6 Place specimen into appropriate transport box if available. 7 Transport to the laboratory as soon as possible. To reduce the risk of organisms being transferred to the specimen. To enable laboratory staff to perform the required investigation(s). To enable laboratory staff to select the appropriate test(s) and interpret the results. To enable the laboratory to contact the correct doctor in case of queries regarding the specimen. To ensure security of specimen. In order that the laboratory receive specimens (as soon as possible) while still viable. 3.1 Labelling specimens Label specimens clearly with patient s name, date of birth etc and place into a specimen bag with the pathology request form. The pathology request form must identify the patient s relevant clinical details, including any current antibiotic therapy and the test required. Any specimen which presents a danger of infection to staff, e.g. from a patient with HIV, Hepatitis B, Hepatitis C or Creutzfeldt-Jacob Disease (CJD), must be placed into a minigrip plastic bag before being placed into the bag including a pathology request form. Label the specimen container and both copies of the pathology form with yellow High Risk Danger of Infection stickers. If unlabelled or incorrectly labeled specimens are received, they will be disposed of at the discretion of the relevant Pathology department. Ref IPC-0001-015 v2 Page 4 of 12 Ratified date: 27 July 2016
3.2 Sputum specimens Action 1 Encourage patient to cough up sputum first thing in the morning into the appropriate container. 2 Encourage patients who have difficulty in producing sputum to cough deeply. Alternatively ask a physiotherapist to help. 3 Salivary samples must not be submitted. If sent they will be discarded by the laboratory. 4 Send sputum specimen to the laboratory as soon as possible. Reason To obtain specimen for examination. To facilitate expectoration. To prevent poor quality samples from being sent to the laboratory. Sputum is never totally free of organisms and these can rapidly multiply therefore prompt delivery to the laboratory will ensure accurate results. 3.3 Blood specimens See Venepuncture procedure or contact local laboratory. 3.4 Other specimens Contact local laboratories. 4 Transporting specimens All pathology specimens must be transported in a leak-proof container; The leak-proof container must be secured, complying with UN 3373 standards; The container must bear a hazard warning label stating that it should not be opened or tampered with; The transport boxes must be cleaned and disinfected regularly weekly, or immediately if contaminated with blood or body fluids. If a disposable tray is used, disposed of appropriately; (See Clinical Waste Policy) The containers must not be left unattended, unless in a secure designated area. Ref IPC-0001-015 v2 Page 5 of 12 Ratified date: 27 July 2016
4.1 Using cars or taxis to transport specimens If specimens are transported in cars or taxis, all pathological material and cultures of microorganisms must be placed into a securely-closed container which is robust and leak-proof, complying with UN 3373 standards; Each specimen container must be in a plastic bag with sufficient material to fully absorb any leakage of the specimen; Place the container into a cardboard transport box and label the box with destination and the sender s name and address; There must not be container-to-container contact 4.2 Dealing with a spillage or broken specimen container while transporting specimens 4.2.1 In a healthcare setting Collect the spillage kit or equipment from the nearest ward or department. 4.2.2 In the community Drivers or community staff who transporting specimens in their cars must have a spillage kit, or equipment for cleaning spillages, with them. 4.2.3 Procedure Do not put chlorine release granules on a large urine spillage as will release toxic fumes. You must: Wear disposable apron and gloves; Cover the broken specimen with disposable paper towels soaked in a 10,000ppm solution of available chlorine; OR Use chlorine release granules. (These are available in spillage kits with all other necessary equipment). Sprinkle over the specimen. Leave for 2 minutes (this allows the chlorine release agent to inactivate any virus particles that may be present); OR Use the spillage kits with super absorbent peracetic acid pads and universal wipes (can be used with all blood and bodily fluids) Pick up any broken glass and place into a sharps container; Wash over the area with chlorine release agent and dry with paper towels; Place disposable paper towels, gloves etc into a clinical waste bag; secure and label; place in a designated collection area. Spillages or broken samples that occur in a vehicle away from a ward or clinic must be transported to a site that has clinical waste disposal facilities; Inform the housekeeper in in-patient facilities who will ensure the floor is cleaned. Ref IPC-0001-015 v2 Page 6 of 12 Ratified date: 27 July 2016
5 Accident/injury If you sustain a sharps injury while handling specimens: Stop what you are doing; Gently squeeze the injury to encourage bleeding; Wash injury under running water; Cover injury with a waterproof dressing; Report to supervisor or manager and complete a Datix incident form online; Contact Occupational Health Department Follow the Accidental Inoculation Procedure 6 References Health Services Advisory Committee (1991) Safe Working and the Prevention of Infection in Clinical Laboratories. HMSO: London Health & Safety at Work Act 1974 Control of Substances Hazardous to Health Regulation (1999) The Royal Marsden on line Manual of Clinical Nursing Policies and Procedures. Harper and Row, pp 371-38. Ayliffe, GAJ, Collins BJ, and Taylor, LJ (1995) Hospital Acquired Infection. Wright PSG London DoH (2006) Essential steps to safe, clean care. Reducing healthcare-associated infections in Primary Care Trust; Mental Health Trusts; Learning disability organisations; Independent Healthcare; Care Homes; Hospices; GP practices and Ambulance Services. Ref IPC-0001-015 v2 Page 7 of 12 Ratified date: 27 July 2016
7 Equality Analysis Screening Form Please note; The Equality Analysis Policy and Equality Analysis Guidance can be found on InTouch on the policies page Name of Service area, Directorate/Department i.e. substance misuse, corporate, finance etc. Nursing and Governance/IPC and Physical Healthcare Name of responsible person and job title Name of working party, to include any other individuals, agencies or groups involved in this analysis Elizabeth Moody, Director of Nursing and Governance Elizabeth Moody, Dr D Allison, Dr R Bellamy, Angela Ridley, Emma Rolfe and the Infection Prevention and Control Committee Policy (document/service) name Is the area being assessed a; Policy/Strategy Service/Business plan Project Procedure/Guidance Code of practice Other Please state Geographical area Trustwide Aims and objectives Start date of Equality Analysis Screening (This is the date you are asked to write or review the document/service etc.) End date of Equality Analysis Screening (This is when you have completed the analysis and it is ready to go to EMT to be approved) To set standards in practice to ensure the delivery of patient care is carried out safely and effectively by the trust staff. To comply with the HCAI Code of Practice of the Health and Social Care Act 2008. 26 th July 2016 11 th August 2016 Ref: IPC-0001-012 v2 Page 8 of 12 Ratified date: 27 July 2016 Fleas Lice and Scabies Management of Patients Last amended: 27 July 2016
You must contact the EDHR team as soon as possible where you identify a negative impact. Please ring Sarah Jay or Tracey Marston on 0191 3336267/3542 1. Who does the Policy, Service, Function, Strategy, Code of practice, Guidance, Project or Business plan benefit? Trust staff and patients 2. Will the Policy, Service, Function, Strategy, Code of practice, Guidance, Project or Business plan impact negatively on any of the protected characteristic groups below? Race (including Gypsy and Traveller) Disability (includes physical, learning, mental health, sensory and medical disabilities) Gender (Men, women and gender neutral etc.) Gender reassignment (Transgender and gender identity) Sexual Orientation (Lesbian, Gay, Bisexual and Heterosexual etc.) Age (includes, young people, older people people of all ages) Religion or Belief (includes faith groups, atheism and philosophical belief s) Pregnancy and Maternity (includes pregnancy, women who are breastfeeding and women on maternity leave) Marriage and Civil Partnership (includes opposite and same sex couples who are married or civil partners) Yes Please describe anticipated negative impact/s Please describe positive impacts/s barriers to access or implementing this procedure Ref IPC-0001-012 v2 Page 9 of 12 Ratified date: 27 July 2016 Fleas Lice and Scabies Management of Patients Last amended: 27 July 2016
3. Have you considered other sources of information such as; legislation, codes of practice, best practice, nice guidelines, CQC reports or feedback etc.? If, why not? Sources of Information may include: Feedback from equality bodies, Care Quality Commission, Equality and Human Rights Commission, etc. Investigation findings Trust Strategic Direction Data collection/analysis National Guidance/Reports Yes Staff grievances Media Community Consultation/Consultation Groups Internal Consultation Research Other (Please state below) 4. Have you engaged or consulted with service users, carers, staff and other stakeholders including people from the following protected groups?: Race, Disability, Gender, Gender reassignment (Trans), Sexual Orientation (LGB), Religion or Belief, Age, Pregnancy and Maternity or Marriage and Civil Partnership Yes Please describe the engagement and involvement that has taken place Please describe future plans that you may have to engage and involve people from different groups t relevant to this procedure Ref IPC-0001-012 v2 Page 10 of 12 Ratified date: 27 July 2016 Fleas Lice and Scabies Management of Patients Last amended: 27 July 2016
5. As part of this equality analysis have any training needs/service needs been identified? Please describe the identified training needs/service needs below t relevant to this procedure A training need has been identified for; Trust staff Service users Contractors or other outside agencies Make sure that you have checked the information and that you are comfortable that additional evidence can provided if you are required to do so The completed EA has been signed off by: You the Policy owner/manager: Type name: Elizabeth Moody Date: 11/8/16 Your reporting (line) manager: Type name: Angela Ridley Date: 11/8/16 If you need further advice or information on equality analysis, the EDHR team host surgeries to support you in this process, to book on and find out more please call: 0191 3336267/6542 or email: traceymarston@nhs.net Ref IPC-0001-012 v2 Page 11 of 12 Ratified date: 27 July 2016 Fleas Lice and Scabies Management of Patients Last amended: 27 July 2016
8 Document control Next review date: 26 July 2019 This document replaces: IPC-0001-015 v1 Specimens collection handling and transporting Lead: Name Title Angela Ridley Head of IPC and Physical Health and Back Care (Nursing) Members of working party: Name Title Angela Ridley Emma Rolfe Andrea Brodie Senior Nurse IPC and Physical Health and Back Care Lead Nurse IPC and Physical Healthcare Information Mapping and Policy Development Manager This document has been agreed and accepted by: (Director) Name Elizabeth Moody Title Director of Nursing and Governance This document was approved by: An equality analysis was completed on this document on: Date Name of committee/group 26 July 2016 Infection Prevention and Control Committee 11 August 2016 Change record Version Date Amendment details Status 1 7 Mar 2013 Withdrawn 2 26 July 2016 Full revision Published Ref IPC-0001-015 v2 Page 12 of 12 Ratified date: 27 July 2016