3.1. The responsibility for implementation of these policies is ultimately with the Chief, Pathology and Laboratory Medicine Service. Supervisory personnel will identify deviations from these policies to the Chief, Pathology and Laboratory Medicine.

3.2. All laboratory staff will be knowledgeable of and demonstrate good infection control practices. They will receive annual training on this subject. The Infection Control Practitioner is available to assist in the development and presentation of training programs.

4.1. General procedures:

4.1.1. Do not eat, smoke or apply cosmetics in the work areas. Lunches requiring refrigeration will be stored in a refrigerator designated for that purpose, outside of the work area. Smoking is prohibited throughout the hospital.

4.1.2. Technical personnel will wear protective clothing and gloves (Personal Protective Equipment, PPE) while performing their duties in the laboratory. Protective garments will not be worn outside of the laboratory. Ward provided protection garb, including gowns, gloves and masks as required, will be worn by laboratory workers prior to entering the rooms of isolated patients.

4.1.3. Mouth pipetting is not allowed. All pipetting is done (e.g., patient samples, toxic, biologic caustic compounds, or radioactive material) by mechanical pipettes or transfer devices.

4.1.4. All specimens are considered potentially infectious. If a sample spills, leaks, or is dropped, wipe up immediately with 10% volume per volume household bleach. Gloves and protective clothing are to be worn when such cleanup is necessary.

4.1.5. Place all specimens, pipette tips and other contaminated trash in designated bags, which are to be autoclaved or incinerated by support personnel at least once a day. Do not allow biohazard bags to overflow. Leaking bags are to be rebagged.

4.1.6. Regular handwashing is required to minimize health risks to personnel. Use antiseptics when ministering to patients on isolation, before performing venipuncture, and prior to working with granulocytopenic patients.

4.1.7. Specimen centrifugation is done in closed containers.

4.1.8. Benchtops will be cleaned daily with a germicidal solution, such as 10% volume per volume household bleach, and more frequently if obviously soiled.

4.1.9. Dropped or spilled CSF samples are to be covered with 10% household bleach for 15 minutes. The area must then be thoroughly cleaned with water. Gloves and protective clothing are to be used by personnel cleaning the area.

4.1.10. All specimens are to be considered potentially infectious, and there is to be no direct handling. Rubber gloves, forceps, or other protective garb are to be used.

4.1.11. All procedures are to be performed in properly ventilated areas.

4.1.12. All solvents will be covered when not in use.

4.1.13. Injuries: Eyes must be exhaustively rinsed immediately whenever contacted by contaminated material or irritating or dangerous substances. All needle sticks and cuts sustained during procedures should be cleaned immediately with disinfectant and dressed properly. Report the accident to the supervisor and Employee Health immediately. All injuries and accidents, including minor cuts or dirty needle punctures, must be reported to the supervisor as soon as possible and then to Employee Health where proper medical attention will be given as needed. Appropriate forms must then be obtained from the Laboratory Secretary and filled out by both the injured party and the supervisor. On irregular tours, the Medical Officer of the Day (MOD) should be contacted regarding employee injuries. The MOD should contact the Chief, Pathology and Laboratory Medicine Service, if necessary.

4.1.14. All patient specimens will be treated as potentially infectious: i. e., universal precautions.

4.2. Specific Procedures:

4.2.1. Blood Collection.

4.2.1.1. Glove Usage for Phlebotomy Guidelines.

4.2.1.1.1. All personnel receiving training in phlebotomy will wear gloves.

4.2.1.1.2. Outpatient Blood Drawing:

4.2.1.1.3. Skilled phlebotomists drawing blood on the outpatient population must wear gloves. Gloves will be changed when:

4.2.1.1.3.1. There is blood contamination on the gloves, or
4.2.1.1.3.2. Gloves become sticky or tear.
4.2.1.1.3.3. Hands will be washed upon removal of gloves.

4.2.1.1.4. Inpatient Blood Drawing:

4.2.1.1.4.1. All phlebotomists will wear gloves when drawing blood on patients located in the various patient care units.

4.2.1.1.4.2. Gloves will be removed and hands washed after each patient contact.

4.2.1.1.4.3. Clean gloves will be put on before contact with the next patient.

4.2.1.2. Needle Disposal

4.2.1.2.1. Needles will not be recapped. Vacutainer needles will be unscrewed using the holder on top of the needle boxes. If recapping is unavoidable, a resheathing device will be used. When containers are filled they will be sealed and then incinerated by Environmental Management Service personnel.

4.2.1.3. All personnel responsible for specimen collection on inpatients will be thoroughly familiar with the isolation policies and procedures published in the Medical Center Memoranda 111-253 and 111-186. When isolation patients are to be drawn, wear the protective clothing provided outside the room; discard everything used into the containers provided when leaving the room. Vacutainer barrels are to be left in the room for the next use. When removing a specimen from strict, contact, or respiratory isolation, double bag.

4.2.1.4. Dropped or spilled blood specimens are to be cleaned up, while wearing gloves, with 10% volume-per-volume household bleach.

4.2.2. Specimen Containers.

4.2.2.1. Broken glassware and/or pipettes are to be discarded immediately into "Sharps Containers". Environmental Management Service will dispose of these items.

4.2.2.2. Plastics and other disposables are to be disposed of immediately after use in designated bags to be processed by Environmental Management Personnel.

4.2.2.3. Filter holders for Cytology preparations are to be filled with 10% household bleach after specimens are filtered and then followed by 10% household bleach.

4.2.2.4. Coplin jars in which specimens are fixed are to be washed with a 10% household bleach and followed by a 10% household bleach rinse.

4.2.2.5. When removing the tops from blood tubes, the tops are to be held at an angle pointing away from the employee.

4.2.3. Morgue.

4.2.3.1. All patients and their blood/body fluids are considered potentially infectious. When in contact with these fluids or specimens, gloves and protective clothing are to be worn.

4.2.3.2. All persons participating in an autopsy will wear a mask, fluid impervious gown, gloves, goggles, cap, and shoe covers. There are to be no unnecessary personnel in this area during an autopsy.

4.2.3.3. Spills are to be kept to a minimum. Those that do occur are to be cleaned promptly with lO% household bleach that remains in contact for 15 minutes.

4.2.3.4. All working surfaces and the floor are to be thoroughly cleaned with 10% household bleach immediately after autopsies.

4.2.3.5. All viscera that are to be discarded are placed in DISPOSIT (RED BIOHAZARD) double bags and incinerated. Viscera to be saved for more than 24 hours are to be sealed in plastic bags with formaldehyde.

4.2.3.6. Handwashing with an antiseptic is the single most important procedure to prevent the spread of disease.

4.2.3.7. All outer protective garments worn in the autopsy room are to be properly disposed of in the autopsy area prior to leaving the morgue.

4.2.3.8. All articles, e.g., specimen bottles, pans, utensils, etc., leaving the autopsy room are to be cleaned and disinfected if there has been any contact with infectious materials, tissues, or body fluids.

4.2.3.9. Laboratory doors are to be kept closed, except for necessary entrances and exits.

4.2.3.10. All instruments utilized within the autopsy or histopathology areas are to be sterilized after each autopsy or procedure. This includes soaking in 10% household bleach for one hour, followed by autoclaving.

4.2.3.11. All autopsies are considered high risk or potentially high risk cases. These especially include AIDS, viral hepatitis, Jakob-Creutzfeldt disease, active tuberculosis, Rocky Mountain spotted fever, undiagnosed encephalitis, etc.

4.2.3.11.1. Detailed instructions are included in Procedure 202. AUTOPSY PROCEDURE MANUAL, in particular, Procedure 213. Safety Policies for Creutzfeldt-Jakob Disease and undiagnosed encephalitis cases. Guidelines for high-risk or potentially high-risk autopsy cases., and they must be consulted before performing autopsies in these cases.

4.2.3.11.2. General rules.

4.2.3.11.2.1. Remove all unnecessary material from the autopsy room. Work in a limited area. Only the prosector, autopsy assistant, and supervising pathologist are allowed in the room. The autopsy room door is locked from the inside for the duration of the autopsy.

4.2.3.11.3. Extreme care must be taken to avoid accidental wounds and other contamination. Double protective gear as well as steel mesh gloves should be used. Scalpel blades should not be changed during the procedure; make up enough scalpels before hand.