CODE OF PRACTICE
CONTAINMENT LEVEL 3 LABORATORY
Room: Department:
This is a Containment Level 3 laboratory. It contains ?…. Class I microbiological safety cabinet (insert make). It is a fully self-contained facility. An autoclave for disposal of waste is located ?…. Storage of samples is in the laboratory. There is a small entrance lobby to the laboratory.
The location of the laboratory is:
The number of the telephone in the laboratory is
The …………..(e.g. Lab manager) holds overall responsibility for the management of this laboratory (including supervision of safety).
The type of work carried out in this laboratory is:
A list of authorised users of the laboratory is given in Appendix 1. Other key personnel and contacts are listed in Appendix 2.
GENERAL ARRANGEMENTS
Access
Access to the laboratory is restricted to authorised users and visitors approved by ………. (the person named above as responsible for the management of the lab). An authorised user must accompany visitors at all times. The laboratory door must be kept closed at all times and locked when the room is unoccupied. Access to the room is controlled by swipe card system?(or number key pad) located outside the main door. Only authorised persons will have their swipe cards validated/issued with entry code for entry into the room. Continued use of the laboratory is subject to approval by the Laboratory Supervisor, who may stop all or any work in the laboratory without notice considered to be risk to users.
Staff Training
· Safety training must precede the first encounter with retro-virus in the laboratory. The ability to recognise hazards, assess risks, and select appropriate practices and the skill to handle retro-virus safely must be learned through careful instruction and experience supervised by expert and responsible personnel.
· No experimental procedure involving retro-virus should be performed until the laboratory worker can demonstrate proficiency with the procedure when handling a less serious pathogen (e.g. an empty virus)
· In addition to learning safe techniques, the laboratory worker must be trained in emergency procedures before being allowed to work unsupervised in the laboratory.
· Records will be kept of staff training using the format in Appendix 3. Initial training in the use of this facility will be undertaken by the Laboratory Supervisor. All personnel must read the Code of Practice as part of this training and on completion must sign their training record to say they have read and understood the protocols and will comply with the Code at all times.
· New personnel are assigned to an authorised user for a probationary period for further training (including scientific procedures where necessary) and supervision of their work in the Containment Level 3 laboratory until the supervisor considers the new person to have reached an acceptable level of competence to work safely unsupervised.
· When individuals have satisfactorily completed the training they will become authorised users and their names added to the list (Appendix 1). If at anytime anyone working in the laboratory fails to comply with the Code of Practice for any reason or in the opinion of an authorised user, further safety training is required, they will be suspended as an authorised user pending retraining. During this time the suspended person is not allowed to work unsupervised in the Containment Level 3 laboratory.
Permitted Work
The Hazard Group 3 pathogens that may currently be used in the laboratory are listed in Appendix 1 and in a notice at the entrance of the room. Work that does not require Containment Level 3 containment should, whenever possible, be conducted elsewhere. For example the manipulation of fixed or non-infectious material, the cultivation of uninfected cells, the storage of most chemicals and the making up of buffers and media should be done in external labs.
Out of Hours Working
Working in the laboratory out of normal working hours [8am - 6pm] should be avoided and is subject to approval by the Laboratory Supervisor. A risk assessment will be undertaken to determine whether the particular work proposed is safe to be undertaken in an unoccupied building where there is no one nearby to offer immediate help in the event of an accident. The security guard should always be told of the expected completion time for the work (and be updated if necessary) in order that they can take action if the worker fails to contact them at the expected time.
Entry and Exit Procedures
· Always remember to take your door card for entry into this facility.
· Enter CL3 laboratory in the IMM room ?…. via the door that gives access to the anteroom. Before entering the main laboratory you must put on disposable shoes, long gauntlet gloves and your back-fastening laboratory coat. Pull the gauntlets of the gloves over the cuffs of the gown.
· You may work in the CL3 laboratory wearing a single layer of gloves when dealing with non-biological materials. However as soon as you want to work with infectious material or if you wish to take samples from the deep freeze or handle other biological materials, you must put on a second pair of latex gloves over your surgical gloves. Change the outer pair of gloves whenever you believe them to have become contaminated.
· When you want to leave, make sure all equipment and waste are disinfected appropriately (see below). Turn off the safety cabinet and any equipment not being used. Ensure that the bypass system of the cabinet remains on and the extractor continues to run. Discard your outer latex gloves. If you know your gown has been contaminated or torn, dispose of it in the autoclave bin otherwise keep it on. Return to the anteroom. Remove your gown. The gown may be retained in the anteroom for subsequent use if it has not been contaminated or damaged. Dispose of your gloves. Wash your hands with LabGuard. Turn off the lights if you are the last person to leave.
Maintenance and Cleaning
· When access to the laboratory is required for maintenance purposes a temporary shut down will be implemented and the room and equipment disinfected or sterilised as appropriate.
· Maintenance and repair staff working in the Containment Level 3 laboratory will be provided with information on the nature of the hazards in the area supplemented with adequate instruction and supervision to ensure they work safely.
· Any equipment released from the laboratory for maintenance or repair must be disinfected or sterilised by an authorised user of the laboratory before being released whether to staff within the University or to contractors. In addition the Laboratory Supervisor must sign a release certificate for equipment on each and every occasion of such repair or maintenance work after she has satisfied herself that sufficient disinfecting or sterilisation has been carried out.
· If it is not possible to completely disinfect or sterilise equipment potentially contaminated with pathogens, the release certificate must give details of the parts of the equipment that remain contaminated and the precautions that have to be taken to prevent infection. The equipment must not be released until the Laboratory Supervisor is satisfied that the recipient understands the measures that have to be taken to avoid infection and the matter has been discussed with the University Biological Safety Officer.
· Authorised users will undertake all cleaning in the laboratory. Individual workers are responsible for routine cleaning and disinfection on completion of each work session. The floor will be cleaned and disinfected at least once every two weeks by authorised users on a rota system (see appendix 9).
Occupational Health Surveillance
All staff must register with the University Occupational Health Service before working in the Containment Level 3 laboratory. This includes visiting workers even if they only expect to stay for a short time. Health surveillance will be commenced and continued as necessary. Staff must inform the University Occupational Health Service that they work in the Containment Level 3 laboratory and provide details of the nature of their work.
Female workers should inform the head of department of their pregnancy as soon as they are aware they are pregnant. Where necessary they will be referred to the Occupational Health Physician for advice.
Exposure Records
Details of all persons working in the laboratory will be maintained. This will include for each person the type of work undertaken, the pathogens handled, any accidents or incidents occurring and the dates (start and finish) of working in the laboratory.
LABORATORY RULES AND PROCEDURES
Laboratory Code of Practice
The Laboratory Code of Practice must be complied with at all times. Whilst working in the laboratory the rules set out below must be followed. A copy of the laboratory rules (see Appendix 4) is displayed in the laboratory.
· Do not work in the laboratory if you are suffering from skin abrasion, cuts or conditions that seriously impair the integrity of the skin. Protect very minor abrasions by applying plasters before you put on your gloves. Do not apply petroleum jelly or other agents that weaken the latex to the hands before you put on your gloves.
· Do not eat, drink, chew, smoke or handle contact lenses, touch your face, eyes or hair in the laboratory. If touching your face, glasses, eyes or hair is necessary remove your outer pair of gloves, exit the lab, remove long gauntlet gloves and wash your hands before doing it. Storing of food and outdoor clothing in the laboratory is banned.
· Keep all laboratory doors closed because safety can be compromised by disruptions to the ventilation system or airflow. Place a sign on the laboratory door that informs colleagues that an experiment is in progress. Avoid opening and closing the door during this period.
· Back fastening laboratory coats, disposable shoes, disposable long gauntlet must be worn at all times whilst working in the laboratory. Contaminated laboratory coats must be autoclaved before being discarded. You must wear conventional shoes rather than flip flops or open toe shoes under the disposable shoes.
· An outer pair of disposable gloves must be worn on top of the long gauntlet gloves for all work with infectious material. If gloves become damaged or contaminated, remove them carefully, wash the hands immediately, and put on new pairs of gloves. Disposable gloves must not be reused.
· All procedures that involve the handling of infectious material in open vessels must be performed in a certified and properly functioning microbiological safety cabinet. Important precautions for use of biological safety cabinets are given under “Biological Safety Cabinets”.
· Because the major causes of laboratory infections are cuts, needle-stick injuries and scratches, use of syringes, needles, glass Pasteur pipettes, capillary tubes, scalpels, and other sharp instruments is prohibited. Plastic disposable alternatives must be used.
· Microscope slides should be disposed of in small autoclavable sharps bin.
· When pipetting always use a mechanical pipetting device, never mouth pipette.
· In the event of an accident resulting in a wound immediately encourage it to bleed without squeezing the wound. Wash thoroughly with soap and water but DO NOT SCRUB, cover with waterproof dressing. In the event of contamination of skin, conjunctivae or mucous membrane immediately wash thoroughly. Accidents must be reported to the Laboratory Supervisor and the Departmental Biological Safety Officer.
· Use secondary leak-proof containers to move or transfer cultures and other infectious materials between areas where they are kept, such as freezers, centrifuges or incubators, and biological safety cabinets.
· Always use the biological safety cabinet for ………..
· Samples must be centrifuged only in the sealed, aerosol-proof, centrifuge safety container. Close tubes containing ……….. tightly and always carry them in a rack placed in a leak proof container when moving to and from the centrifuge. Do not overfill tubes containing …………..
· All waste materials must be made safe before leaving the laboratory. Decontaminate waste cultures and all other waste materials that are potentially contaminated with ……..(see ‘Disposal of Laboratory Waste’ and/or Appendix 8) before autoclaving?.
· Keep the laboratory scrupulously clean, and decontaminate work surfaces daily with ……… followed by 70% ethanol to remove residual detergent.
· Wash hands as soon as a procedure is completed, and always before leaving the laboratory (see Entry and Exit Procedures).
Practices for Improving Containment within Biological Safety Cabinets
Biological safety cabinets provide primary protection for the laboratory worker against accidental or inadvertent release of ……... Any procedure that involves the manipulation of liquid suspensions or culture of ………. must be carried out within a biological safety cabinet. Always be conscious of the fact that class I cabinets are not absolute containment devices. Disruptions in intake airflow may increase leakage or escape of aerosols from the front opening of the cabinet. The following additional practices are considered excellent techniques for improving containment:
· Plan the experiment in advance.
Make sure you have provided yourself with a usable stainless-steel autoclave bin, liquid disposal container and a screw-topped plastic container for contaminated small items. Designate areas on the work surface where clean supplies, the experimental agent, disinfectant, and contaminated waste will be placed. Do not handle contaminated materials over areas designated for clean materials.
· Place all materials needed for the experiment into the cabinet before beginning the experiment. When this is not possible, use a cart or bench next to the cabinet only for excess clean material.
· Use slow and deliberate movements when bringing items into or out of the cabinet. Erratic movements will disrupt the intake airflow and cause reverse air currents that can draw aerosols out of the cabinet. Reduce both lateral and in-and-out motions across the front opening to an absolute minimum.
· Avoid opening and closing the door during this period. Movements of colleagues near the cabinet can also cause disruptions in the airflow.
· When using the biological safety cabinet, always work at least 4 inches beyond the front exhaust grill.
· Always disinfect the surfaces of containers before removing them from the cabinet.
· Remove protective gloves carefully before leaving the cabinet. Double-gloving offers an advantage when the outer glove becomes contaminated before a task is completed. The contaminated outer glove can be removed in the cabinet and replaced with a new one without having to wash hands.