Russell County Hospital
Policy/procedure name: Microbiology Safety/Infection Control Plan
Policy/procedure number: 400-PE-MIC-149 Issued: 7/21/04 Revised: 5/6/06
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Russell County Hospital
1610 Dowell Road
Russell Springs, KY 42642
270-866-4141
DEPARTMENT: Laboratory Issued: 7/21/04
Revised: 5/6/06
POLICY/PROCEDURE TITLE Supercedes:
Microbiology Safety/Infection Control Plan Prepared by: R. Johnson
Approved: Reviewed:
Medical Director
POLICY/PROCEDURE NUMBER: Approved: Reviewed:
400-PE-MIC-159
Laboratory Director
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I. GENERAL POLICY. The microbiology section of the RCH laboratory falls under the guidance of all general laboratory safety, infection control, and chemical hygiene guidelines. The purpose of this policy is to elaborate on safety and infection control issues that are specific to microbiology. Additionally, because of the increased worldwide threat of bioterrorism, our microbiology section and its personnel must be familiar with potential bioterrorism organisms and how to culture, recognize, identify, transport, dispose of, and report them to appropriate authorities.
II. DISCUSSION:
A. Biosafety levels: There are four levels which consist of combinations of laboratory practices and techniques, safety equipment, and facilities appropriate for the operations performed and hazard posed by the infectious agents. Ours is a biosafety level II A laboratory. Hepatitis B virus, Salmonella, and Toxoplasma species are representative of the microorganisms assigned to this containment level. The primary hazards to personnel working at this level may include accidental autoinnoculation, ingestion, and skin or mucous membrane exposure to infectious materials. In addition to the general safety and infection control practices listed in the Laboratory Safety and Infection Control Plan, 400-EC-102, the following measures apply:
1. Laboratory personnel assigned to work in microbiology must have specific training in handling pathogenic agents and must be directed by a competent scientist (i.e., competence + experience + education).
2. Access to the microbiology laboratory is limited or restricted when work with infectious agents is in progress. Only persons who have been advised of the potential hazards and meet specific entry requirements (such as immunization) may enter the laboratory. In general, those who are at risk of acquiring infection are not allowed in the laboratory.
3. A biohazard sign must be placed on the entrance to the microbiology laboratory.
4. When appropriate, considering the agent(s) handled, baseline serum samples for at risk personnel are collected and stored. This is most applicable when a known high-risk organism is later identified as having been processed in our laboratory and personnel have been exposed.
5. Cultures, stocks, and other regulated waste must be placed in red, biohazard, leak-proof, hard-sided containers, which are designated for incineration.
6. The main laboratory door must be closed at all times. It must be locked when no one is in the laboratory.
7. Inoculated media must be kept closed at all times unless they are being “read”. Minimize the amount of time the media are exposed. Do not sniff inoculated media or any growth on them – it is best to hold one’s breath when closely examining a plate, both to avoid inhaling organisms and to prevent contamination of the plates. Do not open media with mold or Level III organisms.
8. Do not do anything to create splashing or aerosols such as “waving” plates or vortexing open containers. Do not wave slides in the air to hasten drying.
9. All work surfaces must be thoroughly disinfected each day of use and more often as needed.
B. Specimens for culture. To minimize risk of exposure to laboratory and other health care workers, only suitably collected specimens will be accepted and processed. See the following procedures for guidance on the collection and processing of microbiology specimens:
1. Microbiology Collection Guidelines, 400-PE-MIC-132.
2. Processing Microbiology Specimens, 400-PE-MIC-151.
3. General policy - rejection of specimens, 400-PE-COL-108.
C. Biological safety cabinet/hood. All specimens must be processed within the biological safety hood, which has a negative airflow and a filter designed to prevent the escape of pathogens into the environment. The hood creates a work area for the safe handling of low to moderate risk level bio-hazardous material. Routine cultures are suitable for this bio-safety level; however, all fungal and AFB culture specimens will be kept intact and transported directly to a reference laboratory for initial inoculation and smear preparation, as will any other known high-risk organisms. See Biosafety Cabinet Operation, 400-PE-MIC-149 for instructions on operation and maintenance. The cabinet is certified by an inspector twice a year to ensure it functions properly.
D. Biological spills and contamination. If this occurs, first assess the degree and nature of contamination and assess the risk to personnel to determine if the immediate area should be evacuated and the level of personal protective equipment needed. Generally, for most incidents, the use of protective gloves (1-2 pairs), a buttoned lab coat, and perhaps fluid-resistant shoe covers are most appropriate. Use the emergency spill kit to clean up large spills and notify Environmental Services if assistance is needed. To use the kit:
1. 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.
2. 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.
3. Once the area is free of all solid materials, use the germicidal cloth to wipe down the area and place in the bag containing the gel beads.
4. 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.
5. Use extreme caution at all times when cleaning up spills.
III. REFERENCE. CDC, 1993, Biosafety in Microbiological and Biomedical Laboratories, 3rd edition.
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