RUSSELLCOUNTYHOSPITAL
Policy/Procedure Title: Laboratory Safety and Infection Control Plan
Policy/Procedure Number: 736-EC-102 Issued: Unknown Revised: 5/20/06
RussellCountyHospital
1610 Dowell Road
RussellSprings, KY 42642
270-866-4141
DEPARTMENT:LaboratoryIssued: Unknown
Revised: 6/30/02, 9/7/02, 7/21/04, 5/20/06
POLICY/PROCEDURE TITLESupercedes:
Laboratory Safety and Infection Control PlanPrepared by: R. Johnson
Approved:Reviewed:
Medical Director
POLICY/PROCEDURE NUMBER:Approved:Reviewed:
400-EC -102
Laboratory Director
______
- POLICY. It is the policy of the RussellCountyHospital laboratory to provide a work environment for its employees that is as safe as possible. These employees have a right to know about health and safety hazards associated with their work. This is accomplished by defining standard work procedures and practices in this plan and in other policies within the Laboratory safety program. This policy has been established to document the laboratory safety program, to orient personnel to the safety policy and procedures of the laboratory, and to outline standard work procedures and practices that will minimize employee exposures to biological, chemical, and other safety hazards. In addition to the information contained herein, many other laboratory policies and procedures contain safety information and guidelines that must be followed.
A.Safety procedures shall be developed, reviewed periodically, and revised as necessary, following local, state and federal guidelines, and considering recommendations of the Joint Commission on Accreditation of Hospitals, the College of American Pathologists, OSHA, and Medicare.
B.Employee orientation and training. During the first three-month period of employment, each new employee will be oriented to the laboratory safety, chemical hygiene, and infection control policies and procedures. Documentation of the completion of this orientation and training shall be kept in the employee’s education file.
C.Employee inservices. All employees are required to attend the yearly inservices, covering safety, infection control, chemical hygiene, and others as needed. These inservices are given as part of hospital-wide inservices or within the laboratory. Documentation of the completion of this orientation and training shall be kept in the employee’s education file.
D.Laboratory employees will be notified of changes / revisions in the safety, infection control, and chemical hygiene polices and are expected to read and sign off on these procedures at the time of revision and at least annually thereafter.
II.LABORATORY OPERATIONS/RESPONSIBILITIES.
- The Laboratory Administrative Director is responsible for the safe operation of the laboratory and will continually assess the risk of all operations. The Administrative and Medical Directors will approve and sign all safety/infection control/chemical hygiene policies and procedures prior to implementation.
B.The Administrative Director is a member of the hospital-wide Safety Committee. She or a designee will attend and participate in at least 50% of the meetings.
C.The Administrative Director is responsible for the safety program in the laboratory. These responsibilities include:
- Works with the hospital Safety Officer and hospital Risk Manager, and other employees to develop and implement appropriate practices based on information from:
a.Hospital Safety, Infection Control, and Chemical Hygiene Plans.
b.Material Safety Data Sheets (MSDS).
c.Manufacturer's package inserts for test kits and reagents.
d.Local, State, and Federal regulations.
e.Regulatory bodies (JCAHO, Medicare, HCFA, OSHA).
- Provides new employee Safety, Chemical Hygiene, and Infection Control orientation and provides an annual safety inservice to all laboratory employees.
- Maintains the Laboratory Hazardous Chemical List and MSDS files, updating them at least annually.
4.Evaluates and monitors the performance of protective equipment.
5.Monitors the use and disposal of chemicals used in the Laboratory. NOTE: Our laboratory does not store or use any significant amounts of hazardous chemicals.
6.Helps department employees to use special precautions necessary for the safe operation of their sections.
7.Knows the current legal requirements concerning regulated substances used in the Laboratory.
III.ENGINEERING CONTROLS/LABORATORY SAFETY EQUIPMENT. Engineering controls shall be used to eliminate or minimize employee exposure to hazardous and infectious materials and to unsafe physical threats. The following is a list of laboratory safety equipment. See individual policies/procedures for use and maintenance.
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RUSSELLCOUNTYHOSPITAL
Policy/Procedure Title: Laboratory Safety and Infection Control Plan
Policy/Procedure Number: 736-EC-102 Issued: Unknown Revised: 5/20/06
A.EYE WASH STATION is used for flushing the eyes should a biohazardous or chemical splash occur. There is one located in the hospital laboratory and in each of the clinic laboratories.
B.Biological Safety LEVEL II Cabinet is located in Microbiology. It creates a work area for the safe handling of low to moderate risk level bio-hazardous material. All cultures are set up under this cabinet. All AFB and fungal culture specimens will be kept intact and transported directly to a reference laboratory for initial inoculation and smear preparation.
C.FIRE EXTINGUISHERS. There is one fire extinguisher for the laboratory, which is located in the main laboratory room. Each of the clinical laboratories has an easily accessible fire extinguisher.
D.FIRE BLANKET. The fire blanket is located just inside the door to Microbiology. It is used to wrap the body of a person whose clothes catch fire.
E.EMERGENCY SHOWER is located in the hospital laboratory, next to the eyewash station. It is used when a person's face or clothing is badly splashed with a large quantity of acid or caustic material.
- VENTILATION. The heating and air conditioning for the laboratory is inspected, serviced, and documented by Maintenance on a regular basis. NOTE: The hospital laboratory door leading to the hallway must be kept closed at all times when not in use.
IV.PERSONAL PROTECTION.
A.Personal protective equipment includes, but is not limited to, gloves, gowns, aprons, face shields, masks, eye protection, hair and shoe coverings, and lab coats, and will be provided to laboratory personnel at no cost to them. These items must be changed when they become contaminated.
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RUSSELLCOUNTYHOSPITAL
Policy/Procedure Title: Laboratory Safety and Infection Control Plan
Policy/Procedure Number: 736-EC-102 Issued: Unknown Revised: 5/20/06
1.Gloves are located on the countertops throughout each of the laboratories and in the storerooms. Wear them when there is potential for contact with toxic or biohazardous materials. Inspect them before each use. NOTE: Powder-free and non-latex gloves are available for all employees.
2.Other types of PPE are located in the hospital laboratory storeroom.
3.Personnel may request a specific type of PPE should the available items not meet their needs. The clinic laboratory personnel should contact the hospital laboratory for any needed supplies and equipment.
B.Lab coats.
- Disposable lab coats are kept in each storeroom and are used by employees and working visitors.
- Dirty coats are never to be worn outside the dirty areas of the laboratory and the hospital.
C.Approved respirator masks must be worn by all personnel coming into contact with patients who are or should be in respiratory isolation. When in doubt, wear the respirator. All employees who routinely come into contact with such patients must be fit-tested with documentation of such training kept.
D.Everyone who collects and/or processes patient specimens or handles contaminated materials and hazardous chemicals will wear latex or vinyl gloves and appropriate protective clothing. Always wear masks, protective eyewear, and buttoned lab coats when splashes, spray, spatter, or infectious materials may come in contact with mucous membranes. Change gloves and wash hands immediately after completion of specimen processing or whenever they become soiled.
V.GENERAL SAFETY MEASURES FOR WORKING WITH CHEMICAL AND BIOLOGICAL HAZARDS IN THE LABORATORY.
A.The laboratory is divided into contaminated ("dirty") and uncontaminated ("clean") areas.
1.Contaminated: All work areas where biological specimens or biologically contaminated materials are collected, handled, processed, or discarded. This includes the bathrooms, main laboratory rooms, phlebotomy areas, and the area to the immediate left of the front door entrance of the hospital lab.
2.Uncontaminated: Office areas.
3.Make every effort to prevent or reduce the introduction of contaminated materials into the clean areas.
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RUSSELLCOUNTYHOSPITAL
Policy/Procedure Title: Laboratory Safety and Infection Control Plan
Policy/Procedure Number: 736-EC-102 Issued: Unknown Revised: 5/20/06
B.Hand-washing.
- Use a hospital-approved germicidal soap. Wash hands before, after, and between contacts with patients, before eating, drinking, smoking, or the application of cosmetics or contact lenses, upon leaving the laboratory work areas, before and after using the toilet, upon removal of gloves, and frequently during the work day as needed.
- Should it not be possible to wash hands immediately after patient contact, use a hospital-approved germicidal foam in the interim.
C.Sharps.
1.Laboratory personnel must always use sterile, disposable multiple or single draw needles with safety devices to obtain specimens. Use sterile lancet devices for capillary puncture. Do not use glass capillary tubes to collect specimens. Use only needle-locking syringes or one-piece needle syringe units to aspirate fluids from patients, or, in the laboratory, working with specimens from these patients.
2.Never recap, bend, break, remove from disposable syringes, or otherwise manipulate needles or other sharps by hand.
- Immediately after use, place all sharps in leak-proof, puncture-resistant, hospital-approved sharps containers, which are located throughout the hospital and laboratory. NEVER attempt to force a sharp into a full container!
- Handle and store glassware with care to avoid damage. Do not use broken or damaged glassware. When broken, dispose in a hard-sided sharps container.
D.Mucous membrane/mouth contact.
1.Avoid all hand-to-face contact in the laboratory dirty work areas.
2.Never put anything into the mouth. Mouth pipetting is ABSOLUTELY forbidden. Use mechanical devices such as syringes or bulbs instead.
3.Avoid contamination of any mucous membrane or any break in the skin.
4.To avoid spray to the face, open all specimen tubes away from the body and other people. Most Vacutainer tubes have a hooded cap/stopper, which minimizes aerosolization. If not, cover the cap/stopper with a gauze square or Kimwipe. Firmly grasp the cap/stopper and slowly use a twisting and pulling motion to open. Restopper tubes as soon as possible. Never store tubes uncapped! Wear eye protection and use a plastic shield if necessary.
5.Never sniff or taste chemicals. Avoid all unnecessary exposure to laboratory chemicals and biohazardous materials.
E.Centrifugation.
- Take special precautions to prevent aerosol formation when centrifuging specimens. All specimen tubes are centrifuged with the caps on.
- Always close the top of the centrifuge when the instrument is in motion. Do not open until it has come to a complete stop.
- Position centrifuges so that the air exhausting from the vent located at the base is directed away from the operator.
- Should there be breakage or spills inside the centrifuge, carefully remove broken glass. Wipe interior to remove gross blood or fluids and discard paper towel(s) in a biohazard red bag. Disinfect interior and carrier caps with a 0.5% sodium hypochlorite (bleach) solution before using the centrifuge again.
F.General housekeeping rules.
- Wear gloves and wash hands immediately upon removal of such gloves when performing any housekeeping procedures.
- When small amounts blood, urine, or other patient specimen materials are spilled, immediately wipe away and clean area with detergent and germicidal solution such as Dispatch, Envy, or 0.5% sodium hypochlorite (10% Bleach), prepared by mixing one part bleach with nine parts water. For a large spill, isolate the area and use a Spill Kit to soak up the liquid as follows and notify Environmental Services:
- Put on gloves and other PPE as appropriate and spread clean-up powder onto liquid spill. This powder will absorb liquid and form gel beads within 10-30 minutes.
- Use spatulas to scoop up gel beads and any other materials such as broken glass and place in a small black disposable bag with twist tie.
- Once the area is free of all solid materials, use germicidal cloth to wipe down the area and place in the bag containing the gel beads.
- Immediately place the black bag inside of a red biohazard bag or in a hard-sided red biohazard container if there is broken glass or other sharps within the black bag.
- Use extreme caution at all times when cleaning up spills.
- Clean and disinfect work surfaces once a day and as necessary with a germicidal solution like Envy. Alternately a 0.5% sodium hypochlorite (10% Bleach), prepared by mixing one part of bleach with nine parts of water, may be used.
- Clean sinks daily and as necessary with a germicidal solution and scrub with an abrasive cleaner.
- Inspect phlebotomy baskets daily for evidence of soiling. Never leave trash in a basket. At least once a week, or as necessary, clean basket with a germicidal solution.
- Examine and decontaminate equipment as necessary before using or servicing. At minimum, clean at least once each day of use.
G.Other measures:
1.Since medical history and examination cannot reliably identify all patients infected with blood-borne pathogens, always use standard blood and body fluid precautions, as dictated by OSHA, anytime exposure to such is possible.
2.Seek information and advice about hazards, plan appropriate protective procedures, and plan positioning of equipment before beginning any new operation. Be alert to unsafe conditions and see that they are reported for corrective action.
3.Confine long hair and wear low-heeled, closed shoes at all times in the work areas. Keep fingernails trimmed. Rings should be small and free of snags that can catch and tear gloves. Do not wear large earrings and necklaces.
4.Never engage in horseplay or practical jokes or other behavior that might confuse, startle, or distract another worker.
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RUSSELLCOUNTYHOSPITAL
Policy/Procedure Title: Laboratory Safety and Infection Control Plan
Policy/Procedure Number: 736-EC-102 Issued: Unknown Revised: 5/20/06
5.Use proper body mechanics at all times to avoid injury. Adjust equipment such as stools and chairs as possible to avoid ergonomic stresses or injuries. Avoid repetitive motion injuries by varying tasks and positions.
VI.DISPOSAL OF HAZARDOUS CHEMICALS AND BIOHAZARD INFECTIOUS WASTE. Laboratory waste and trash will be segregated into infectious (biohazardous), chemical, and non-infectious waste. Environmental services personnel will remove this trash from the laboratories daily and will replace trash liners.
A.Infectious waste is that which will release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed. It also includes sharps that have been contaminated with blood and other infectious materials. Infectious waste will be placed in the following containers for disposal:
1.Red hard-sided container is used for sharps, such as needles, hard or pointed plastic, wooden sticks, glass, and sharp metal, which would otherwise have the potential to puncture a plastic trash bag.
2.Red plastic trash bag, which is placed in a red trashcan, is used for all other infectious waste that does not need to be placed in the hard-sided container.
B.Non-infectious waste is trash that will not release blood and other infectious materials in a liquid state if squeezed. It may contain gloves, gowns, tissue paper, etc., which are soiled with small amounts of blood, urine, feces, and other biological materials. Emptied urine cups and recapped stool containers are considered safe to dispose as non-infectious waste. Non-infectious waste will be placed in brown or clear plastic trash bags that are in tan, gray, white, or beige trash containers.
C.Hazardous chemical waste is disposed according to the hospital waste management plan. Refer to the hospital policy. Unless specifically approved, do not discard hazardous chemicals down the drain. The RCH safety officer will arrange for disposal of any chemicals through a cradle-to-grave paper trail. NOTE: The laboratory does not use or store significant amounts of hazardous chemicals.
VII.FIRST AID/MEDICAL CONSULTATION AND EXAMINATION.
A.First aid:
1.Eye contact - flush eyes with water for prolonged period and report to Emergency Room for medical evaluation.
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RUSSELLCOUNTYHOSPITAL
Policy/Procedure Title: Laboratory Safety and Infection Control Plan
Policy/Procedure Number: 736-EC-102 Issued: Unknown Revised: 5/20/06
- Ingestion - consult MSDS first-aid section for the specific substance ingested. Report to the Emergency Room for medical evaluation.
- Skin contact - flush affected area with water, use shower station if necessary, and remove contaminated clothing. If symptoms persist, report to the Emergency Room for medical evaluation.
B.Medical consultation and evaluation. The employee will report to the RCH Emergency Room should she be exposed to hazardous chemicals or biohazards or is otherwise injured due to fall, equipment failure, accident, etc. She will notify her supervisor and will fill out an occurrence report, which is used to ensure complete follow-up of the accident. The ER physician will make the initial examination. Associate Health will schedule a follow-up examination, if needed, with a physician, at no loss of pay or cost to the employee, and at a reasonable time and place.