DEPARTMENT OF PATHOLOGY AND CLINICAL LABORATORY

 Department of Pathology/Clinical Laboratory Safety Manual

Formal Policy Statement

The Laboratory Department is committed to providing a safe working environment and believes that employees have a right to know about health hazards associated with their work. So that employees can make knowledgeable decisions about any personal risks of employment, this Safety Manual is established to define policies, procedures, and job responsibilities that will help all employees develop an awareness of potentially hazardous conditions in the workplace. The Safety Manual is also intended to help train employees in appropriate safe working conditions.

It is important that employees assume responsibility for laboratory safety. All employees will have access to pertinent safety information through their supervisory staff. The people who work in any given laboratory are best able to detect potential hazards in either the facility or work procedures. When safety concerns arise, employees are encouraged to contact their supervisor.

A training program has been designed for the benefit and protection of all laboratory employees. Necessary information will be available to inform the employee how best to handle laboratory hazards and how to make use of the laws.

________________________________

Laboratory Manager

Effective Date: ____________________

Administrative Controls

All job classifications within the laboratory are assessed for occupational exposure to bloodborne pathogens. Table 1 identifies those jobs.

Table 1: Job classification

Department of Pathology                                               Verified by:

   

Department of Pathology/Clinical Laboratory Safety Manual

                                                                                   Extension:

Job Classification	Regular Exposure	Some Exposure	No Exposure
Clerical Personnel			X
Phlebotomists	X
Technical Personnel	X
Supervisors	X

The Laboratory Manager makes an assessment of all laboratory operations with regard to the use of personal protective equipment. Safety policies are then established for each task performed, and engineering controls or work practice controls as well as personal protective equipment are assigned. As a minimum, all employees wear a laboratory coat that meets defined fabric requirements, gloves, and appropriate eyewear when dealing with chemicals or blood and body fluids. Table 2 identifies tasks in the laboratory requiring additional protective equipment and engineering controls.

 

Table 2: Task assessment

 Department of Pathology/Clinical Laboratory Safety Manual

Section: Chemistry                                                      Verified by: Navin Khatri

                                                                                    Extension: 83044

Task	Additional Equipment	Engineering Controls
De-capping tubes	Gloves, Lab coat	Hemogard tubes, gauze covering Biohazard shield
Aliquot samples	Gloves, Lab coat	Disposable transfer pipettes
Pipetting	Gloves, Lab coat	Rubber bulb or auto pipettes
Patient testing, manual	Gloves, Lab coat	None
Patient testing, automated	Gloves, Lab coat	Instrument Safety Features
Decontaminating equipment	Gloves, Lab coat	Face shield if potential for splashing is present.

Section: Hematology                                                   

Task	Additional Equipment	Engineering Controls
Blood film preparation	Gloves, Lab coat	Mylar wrapped or plastic hematocrit tubes

Section: Phlebotomy/Processing                                

Task	Additional Equipment	Engineering Controls
Venipuncture	Gloves, Lab coat	Safety needles Safety-Lok blood collection set. Disposable tube holder Disposable tourniquet.
Skin puncture	Gloves, Lab coat	Neat Nick sterile single use retracting lancets. Owen Mumford Unistik Lancet.
Accessioning	Gloves, Lab coat	None

Section: Microbiology                                     

Task	Additional Equipment	Engineering Controls
Plating/Processing	Gloves, Lab Coat	Biosafety cabinet Disposable “loops”
Evaluating cultures	Gloves, Lab Coat	None
Processing blood cultures	Gloves, Lab coat	Sharps containers Biohazard shield

Engineering Controls

 Department of Pathology/Clinical Laboratory Safety Manual

All biohazard and fume hoods are inspected annually for proper function and air velocity. Any hood not passing inspection is taken out of service immediately and not used until such time as the hood has passed inspection.

Eyewash fountains are inspected weekly and records maintained by the supervisors.

Safety showers are inspected, tested, and flushed annually.

Fire extinguishers are inspected annually.

All chemical stockrooms/storerooms are adequate and well ventilated.

Storage cabinets for chemicals are provided as needed and have a separate exhaust duct
where necessary.

Airflow through the laboratory should be relatively uniform and be exhausted to the exterior of the building.

Standard Operating Procedures

Standard Precautions are observed throughout the laboratory to prevent contact with blood and other potentially infectious materials. All body fluids are considered potentially infectious.

Employees wash their hands immediately or as soon as possible after removal of gloves or other personal protective equipment and after hand contact with blood or other potentially infectious materials. Hands are washed between all patient contacts, before eating, drinking, smoking, applying cosmetics or lip balm, or manipulating contact lenses and after using lavatory facilities. Facilities for handwashing are provided and are separate from those used for washing equipment or for waste disposal. Where this option is not available, thorough cleaning of the sink and surrounding area with an intermediate disinfectant after chemical/biohazard waste disposal is required before handwashing is allowed. Antiseptic hand cleaner or towelettes are used whenever clean running water is not readily available; however, they are not used as a substitute for handwashing and hands are washed with soap and water as soon as feasible. Wearing gloves does NOT mean you do not have to wash your hands!

Food and drink are not stored in refrigerators, freezers, or cabinets, or on shelves, countertops, or bench-tops where blood or other potentially infectious materials are stored or in other areas of possible contamination. Food and drink are stored in areas marked “for food only.”

Only authorized personnel are allowed in the laboratory. Casual visitors (e.g., family members, tour groups, etc.) are discouraged. Non-laboratory personnel are to be closely supervised and use appropriate protective measures (e.g., clothing, etc.) to ensure that they do not cause a hazard to themselves or to the laboratory staff.

Service and maintenance personnel are not permitted to enter a biohazard area until the laboratory’s safety requirements are reviewed, instrument to be serviced is decontaminated, and appropriate personal protective equipment is issued and worn.

Department of Pathology/Clinical Laboratory Safety Manual

Personal Protective Equipment (PPE)- Gloves, Lab Coats, Eyewear

Personal protective equipment (PPE) in appropriate sizes is readily available to employees. All PPE is assigned based on the task assessment, which does not allow blood or other potentially infectious materials to pass through to or otherwise reach the employee’s work clothes (e.g., scrubs), street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time the protective equipment is used.

All PPE is removed immediately upon leaving the work area, or as soon as possible, and placed in an appropriately designated area or container for storage, washing, decontamination, or disposal in the washroom.

Employees are required to wear disposable, single-use gloves when the employee has the potential for direct skin contact with chemicals, blood and infectious materials, mucous membranes, and non-intact skin when touching or handling contaminated items or surfaces. Gloves in various sizes can be found in the phlebotomy storage area or the hospital central store room. Gloves are removed inside out aseptically and are replaced as soon as possible when visibly soiled, torn, and punctured or any time their ability to function as a barrier is compromised. They are not washed in disinfectant for reuse. All gloves are powder free. Hypoallergenic gloves (e.g., nitrile or vinyl) or glove liners are provided to employees who are allergic to the regularly provided gloves. (NOTE: Employees with contact dermatitis due to gloves may use protective skin creams to help prevent further irritation.)

Knee-length fluid-repellant lab coats with long sleeves are to be worn only in the work area and are to be closed (e.g., snapped) so as to protect the employee’s clothing. Aprons are worn in addition to the lab coat when the lab coat cannot provide adequate protection (e.g., when the employee is pregnant) or when fluid contamination is likely. Aprons do not substitute for lab coats, but they serve as additional protection. Lab coats are worn only in the work area and are not worn on meal or rest breaks or in any public areas (e.g., cafeteria, lobby, gift shop). Lab coats are provided by the facility at no cost to the employee.

Soiled lab coats are removed immediately upon leaving the work area or as soon as possible and placed in a designated area for storage or in an appropriate laundry hamper.

Masks and eye protection or chin-length face shields are worn to prevent splashes, sprays, spatter, or droplets of blood or infectious materials if there is a potential for eye, nose, or mouth contamination. This equipment is located in the hospital’s central store room. Splashguards are located at benches requiring opening of vacutainer tubes and may be used instead of goggles.

PPE (e.g., gloves, lab coat) must be worn by all outside service and maintenance personnel when there is a potential exposure to blood and body fluids. This equipment is provided by the laboratory and located in the store room.

Chemical Hygiene

General precautions for handling all laboratory chemicals are in place to include minimizing exposure. The following procedures are used when working with chemicals.

Department of Pathology/Clinical Laboratory Safety Manual

Accidents and Spills

·         Eye contact: Promptly flush eyes with water for a prolonged period (15 minutes) and seek medical attention.

·         Ingestion: Encourage the victim to drink large amounts of water or as indicated on the MSDS.

·         Skin contact: Promptly flush the affected area with water and remove any contaminated clothing; use a safety shower when contact is extensive. If symptoms persist after washing, seek medical attention.

·         Cleanup: Promptly clean up spills, using appropriate protective apparel and equipment and proper disposal.

Avoid Unnecessary Exposure to Chemicals

·         Do not smell or taste chemicals. Any apparatus that may discharge toxic chemicals (vacuum pumps, distillation columns, etc.) should be vented into local exhaust devices.

·         Inspect gloves before use.

·         Use only those chemicals for which the quality of the available ventilation system is appropriate.

·         Eating, drinking, smoking, or application of cosmetics or lip balm or manipulating contact lenses in areas where laboratory chemicals are present is prohibited. Wash hands before conducting these activities.

·         Storing, handling, or consuming food or beverages in storage areas, refrigerators, glassware, or utensils that are also used for laboratory operations is prohibited.

·         Handle and store laboratory glassware with care to avoid damage; do not use damaged glassware. Use extra care with Dewar flasks and other evacuated glass apparatus; shield or wrap them to contain chemicals and fragments should implosion occur. Use equipment only for its designed purpose.

·         Wash areas of exposed skin well before leaving the laboratory.

·         Avoid practical jokes or other behavior, which might confuse, startle, or distract another worker.

·         Do not use mouth suction for pipetting or starting a siphon. Mechanical pipetting devices are used for all liquids. Mouth pipetting/suctioning is prohibited. Dispose of pipette tips in biohazard containers.

·         Confine long hair and loose clothing.

·         Wear shoes at all times in the laboratory, but do not wear sandals, perforated shoes, sneakers, or any shoes made of canvas.

·         Keep the work area clean and uncluttered, with chemicals and equipment being properly labeled and stored; clean up the work area on completion of an operation or at the end of each day.

·         Ensure that appropriate eye protection, where necessary, is worn by all persons where chemicals are stored or handled.

·         Wear appropriate gloves when the potential for contact with toxic materials exists; inspect the gloves before each use, and if they are reusable, wash them before removal and replace them periodically.

·         Use appropriate respiratory equipment when air contaminant concentrations are not sufficiently restricted by engineering controls, inspecting the respirator before use.

·         Use any other protective and emergency apparel and equipment as appropriate.

·         Avoid use of contact lenses in the laboratory unless necessary; if they are used, a supervisor will be informed. Eye protection in the form of glasses, goggles, or appropriate eyewear will be used when handling hazardous chemicals.

·         Remove laboratory coats immediately on significant contamination. Seek information and advice about hazards, plan appropriate protective procedures, and plan positioning of equipment before beginning any new operation.

·         Leave lights on, place an appropriate sign on the door, and provide for containment of toxic substances in the event of failure of a utility service (such as cooling water) to an unattended operation.

·         Use a hood for operations that might result in release of toxic chemical vapors or dust. As a rule of thumb, use a hood or other local ventilation device when working with any appreciably volatile substance with a threshold limit value (TLV) of less than 50 ppm. Confirm adequate hood performance before use. Keep hood closed at all times except when adjustments within the hood are being made. Keep materials stored in hoods to a minimum, and do not allow them to block vents or airflow. Leave the hood on when it is not in active use if toxic substances are stored in it or you are uncertain whether adequate general laboratory ventilation will be maintained when it is off.

·         Be alert to unsafe conditions and see that they are corrected when detected.

           

Chemical Storage

Chemical storage is kept as small as practical. Storage on bench tops and in hoods may cause potential exposure to fire and spills. Refrigerators storing chemicals are for chemical storage only. No food is permitted in these refrigerators.

Flammable liquids in larger volumes are stored in flammable storage cabinets with self- closing doors and proper ventilation. Safety cans with a spring-loaded spout are to be used if it is necessary to transport flammable liquids.

Toxic chemicals including carcinogens are stored in ventilated storage areas in unbreakable chemical-resistant secondary containers. These containers are labeled “CAUTION: HIGH CHRONIC TOXICITY OR CANCER-SUSPECT AGENT.”

Cylinders of compressed gases are strapped or chained to a wall or bench top and are capped when not in use.

Bloodborne Pathogens

Used needles and other sharps may not be bent, broken, recapped, or re-sheathed by hand. Shearing or breaking of contaminated needles is prohibited. Used needles are not removed from disposable syringes. Needles and sharps are disposed of in impervious disposable containers located near the point of use.

All procedures involving blood or other potentially infectious materials are performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets of these substances. For example, blood specimens are opened using an impervious gauze square or plastic stopper remover to minimize contamination of skin and clothing. All specimens that are centrifuged are spun in a closed centrifuge with the lid firmly latched to reduce the risk of infection by spattering. Plastic shields or boxes may also be used to reduce splashing.

Needles are not used for sampling unless no alternative method exists (e.g., blood culture bottles).

All specimens from patients should have clean and dry outside containers with a secure lid. All specimens are transported in a secondary container (e.g., impervious plastic bag) that prevents leakage during handling, processing, storage, transport, or shipping. If the specimen could cause a puncture, then a puncture-resistant secondary container is used. If specimens are transported via a pneumatic tube system, the primary and secondary containers are tested in the system to ensure that they remain leak-proof.

Unfixed or unstained slides are considered infectious and transported via a secondary container.

Laboratory surfaces are made of impervious materials to facilitate disinfection.

Each laboratory’s SOPs further delineate precautions and actions.

Phlebotomy

Tourniquets used for phlebotomy are single use. Employees use gloves during tourniquet
procedures.

Safety needle devices are used to minimize employee exposure to blood. This laboratory evaluated safety needles and selected Eclipse and Safety-Lok blood collection sets as best suited to the needs of the employees.

Needle holders are single use and discarded along with the safety needle in a sharps container

Phlebotomy trays are decontaminated when visibly contaminated with blood and routinely on a weekly basis.

Hematology

Sealant used for hematocrit tubes is used once and not reformed for reuse. Plastic tubes may be used.

Sedimentation racks are decontaminated with bleach after use.

Microbiology

All contaminated culture plates, tubes, slides, etc., are discarded in closed biohazard bags and disposed of in the biohazard container.

Blood cultures, AFB smears, and other high risk activities are handled in a class II Biosafety Level 3 biological safety cabinet.

Counters are disinfected with bleach before and after work.

Biological safety cabinets are equipped with UV lights. The UV light is turned on immediately after finishing work in the cabinet and stays on for a minimum of one to two hours.

A container of bleach is in every room where specimens and cultures are handled or stored. In case of an accident, broken culture or specimen containers are covered with paper towels, flooded with bleach, and allowed to stand for at least one hour before being mopped up.

Tubes and plates containing cultures are carried to and from the incubators, biological safety cabinets, and other locations in racks and baskets to avoid dropping.

The work area of the biological safety cabinet is scrubbed with bleach before and after work.

Slide warmers are used to heat fixed smears.

Suspicious colonies of Yersinia pestis, Brucella species, Francisella tularensis, Rickettsia, and Coxiella species are processed with a Class II biological safety cabinet.

All mold-like fungi are manipulated within a biosafety cabinet.

Chemistry

Sample probes may deliver a fine spray of sample. Sample probes are covered by a shield recessed within a reservoir or contained by a hood. The equipment is decontaminated automatically after each testing event.  Waste from analyzers is considered contaminated and discarded with the medical waste (there is no liquid waste).

Disposal of contaminated materials is divided into the categories listed below:

·         Contaminated glass: Tubes that have been used for dilutions or analysis are placed into sharps containers.

·         Contaminated syringes: Syringes are placed into biohazard containers (e.g., blood
gas samples).

·         Contaminated samples: Samples are stored for 5 days. Samples of blood and/or urine are then discarded into biohazard waste drums.

Transfusion Services

·         Contaminated glass: Tubes that have been used for dilutions or analysis are placed into sharps containers.

·         Contaminated samples: Samples are stored for 15 days. Samples of blood are then discarded into biohazard waste containers.

Fire Safety

Fire drills are conducted periodically. Fire extinguishers are located at throughout the laboratory. They are checked annually for appropriate function. This is documented on the fire extinguishers. All employees are trained in the operation of a fire extinguisher. The date of the employee’s training is kept on file in the department.

Electrical Safety

All equipment is grounded by the use of a three-prong plug. All electrical outlets are checked annually for proper grounding. Three-to-two plug conversion adapters are prohibited. Extension cords are prohibited . Electrical cords are unplugged by holding the plug cap and not by pulling on the cord.

Employees are expected to notify their supervisor if any frayed wires or other electrical problems are encountered. Employees know the location of emergency power sources.

The procedure for securing malfunctioning clinical equipment and restoring the equipment to proper functioning is as follows:

·         Equipment is to be taken out of service immediately and reported to supervision.

·         Designate equipment that is inoperable. Place date, time, problem, and contact person on the equipment.

·         Call Engineering to report malfunctioning equipment.

·         Do not use the equipment until it has been reevaluated.

·         Test the equipment prior to using to ensure that it is in proper working order. If questionable as to whether it is working properly, call Engineering for verification.

·         Check inspection due date prior to use to ensure that equipment has been inspected within the recommended time interval.

If an electrical fire occurs, do the following:

·         Disconnect the source of electricity if possible.

·         Pull the fire alarm box and report the exact location of the fire.

·         Use the ABC fire extinguisher present in the area (electrical fires are Class C fires). Do not use a type A (liquid fire) extinguisher on an electrical fire.

If shock injury occurs, do the following:

·         Do not touch the person until the source of electricity is disconnected, or use a non-conductive material to free the victim (such as plastic or wood).

·         Call a physician immediately.

·         Cover the victim with a blanket and lower the victim’s head. If trained, use cardiopulmonary resuscitation (CPR) as needed until the physician arrives.

If an electrical burn occurs, do the following:

·         Disconnect the source of electricity.

·         Refer the victim to the Employee Health Department or Emergency Department (depending upon the severity of the injury) immediately. All injuries and incidents should be documented for further review and investigation.

Compressed Gases

Compressed gas cylinders are secured by means of a chain to the wall and positioned upright in an appropriate non-tip base.

Compressed gases in the laboratory do not exceed two working day’s needs. Tanks are kept in rooms with temperatures below 85° F. Empty cylinders are marked “empty” and are returned to the supply area outside.

Signs and Labels

Warning labels are affixed to

·         containers of regulated waste

·         refrigerators and freezers containing blood and other potentially infectious materials

·         other containers used to store, transport, or ship blood or other potentially infectious materials

Labels are either an integrated part of the container or are affixed as close as feasible to the container by string, wire, adhesive, or other methods that prevent them from being lost or unintentionally removed.

Red bags or red containers may be substituted for biohazard labels. Blood and blood products are exempt from the biohazard labeling requirements. Areas where food is stored or prepared (e.g., lounge, supervisor’s office, etc.) are labeled as non-biohazard areas.

Labeling is done on all hazardous chemicals that are shipped and used in the workplace.

Shipped Chemicals

Chemical manufacturers, importers, and distributors make sure that each container of hazardous chemicals leaving the workplace is labeled, tagged, or marked with the following information:

1. Identity of the hazardous chemical

2. Appropriate hazard warnings

3. Name and address of the chemical company

In-Plant Chemicals

Each hazardous chemical transferred outside the laboratory that is not in its original container must also be labeled. These workplace labels must contain

1. identity of the hazardous chemical

2. route of entry (e.g., eyes, nose, mouth, skin)

3. health hazard

4. physical hazard

5. target organ affected

Emergency Procedures and Cleanup

The laboratory in cooperation with Infection Control determines and implements an appropriate written schedule for cleaning and decontamination. All equipment and work surfaces are decontaminated with bleach.

·         after completing procedures

·         when surfaces are overtly contaminated

·         immediately after any spill of blood or other potentially infectious materials

·         at the end of the work shift

All floors in the laboratory are wet-mopped weekly by Environmental Services.

Protective coverings such as imperviously backed absorbent paper are used to cover environmental surfaces. These coverings are removed and replaced at the end of the work shift or when they become overly contaminated.

Equipment that is contaminated is checked before servicing or shipping and is decontaminated as necessary according to the manufacturer’s recommendations.

Equipment or bins, pails, cans, and other similar receptacles intended for reuse are inspected daily (when in use) and decontaminated immediately (or as soon as possible) upon visible contamination.

Broken glassware that may be contaminated is not picked up directly with the hands. It is handled by using mechanical means, such as a brush and dust pan, tongs, or forceps.

Blood or other potentially infectious specimens are placed in a closable, leak-proof container and labeled or color-coded before being stored or transported. If outside contamination of the primary container is likely, then a second leak-proof container that is labeled or color-coded is placed over the outside of the first and closed to prevent leakage during handling, storage, or transport. If puncture of the primary container is likely, it is placed in a secondary container that is leak-proof and puncture-resistant.

Spills are decontaminated as soon a possible by absorbing the spilled material with disposable absorbent materials (e.g., paper towels or gauze pads), flooding or wiping the site with disposable towels soaked in disinfectant, then wiping the site with clean, dry paper towels or gauze pads, placing all contaminated items in a biohazard bag, and disposing of the bag according to laboratory policy.

Waste Disposal

Laboratory waste is segregated at the point of use into categories that include

·         infectious/biohazard waste

·         needles/sharps

·         chemical waste

·         regular trash

Biohazard containers are kept upright throughout use and are routinely disposed of when three-quarters full.

All infectious waste is placed in leak-proof biohazard containers marked Biohazard Regulated Medical Waste and are disposed of by the hospital’s medical waste contractor.

All sharps and glassware are disposed of immediately after use in containers that are closable, puncture-resistant, leak-proof on the sides and bottom, and appropriately labeled with a biohazard label. These containers are placed in the immediate area of use no more than 100 feet from the user. When the containers of sharps are moved from the area of use, the containers are closed and placed in a secondary container if they may leak.

Regulated waste is placed in containers that are closable and constructed to contain all contents and to prevent fluids from leaking during handling, storage, transport, or shipment. The containers are labeled and closed before removal to prevent the contents from spilling or protruding during handling, storage, transport, or shipping. If outside contamination of the regulations containers occurs, it is placed in a second container that has the same qualities as the first and is handled in the same manner.

Regular trash includes the remainder of waste in the laboratory that poses no health or environmental risk. This is disposed of through routine facility waste streams in appropriate containers.

Incineration in an environmentally acceptable manner is the most practical disposal method for combustible laboratory waste. All excess or waste chemicals which may not be placed in drain disposal are disposed of in accordance with environmental laws in coordination with Clean Harbors.

Recordkeeping

Medical records are kept on all laboratory employees in Employee Health and should include the following:

·         Employee name

·         Employee Social Security number

·         Hepatitis B vaccination record/eligibility

·         Results of physical exams, testing, and follow-up procedures related to vaccination and past exposures

·         Medical consultation, physical, and written opinion report (if necessary because of exposure)

·         Environmental monitoring, if applicable

·         Respirator fit tests, if applicable

All medical records are kept for the length of employment plus 30 years.

Accident records are written and retained by Employee Health.

Inventory and usage records for high-risk substances are maintained by the department of use.

If Prince George’s Hospital Center ceases to do business and there is no successor employer to receive and retain the records for the prescribed period, the Director of Employee Health will notify the area’s OSHA director and transfer the records to that person within three months.

Training

Training is a necessary and important part of laboratory safety. All employees are trained on this policy and related procedures at the time of their initial assignment to a work area where hazardous chemicals, radiation, or blood-borne pathogens are present and prior to assignments involving new exposure situations. Initial information regarding specific chemical hazards is provided by the section supervisor.  Refresher information and retraining is held periodically and no less than annually. All training is documented in writing by attendance records.