IPPOL26 Safe Handling and Packaging of Specimens by Provide Community

Safe Handling and Packaging of Specimens

Version: V5

Ratified by: Infection Prevention and Control Group

Date ratified: 16/10/2024

Job Title of author: Head of Infection Prevention

Reviewed by Committee or Expert Group Infection Prevention Group

Equality Impact Assessed by: Head of Infection Prevention

1. Introduction

Specimens should be regarded as potentially infectious - the same as exposure to blood/body fluid - and all staff involved in the procedure must adhere to standard infection control precautions to minimise exposure when obtaining, handling and transporting specimens. Specimens must be transported in accordance with the Carriage of Dangerous Goods Regulations (CDG), (2009).

Laboratory reports are essential to confirm diagnosis of infectious diseases and to ensure that patients receive appropriate treatment and care. Specimens should be collected properly and promptly to enable laboratory results to be fed back to clinical teams. Accurate laboratory reports will only be possible if specimens are collected properly and if accurate patient details are provided with the request.

Clinical staff must request specific investigations to be carried out when patients have clinical signs and symptoms of infections only, to avoid unnecessary investigations. Specimens may also be requested by the local Health Protection Unit (HPU), Infection control or occupational health adviser or as part of a response to outbreaks under direction of the UK Health Security Agency UKSHA. (Please refer to IPPOL16 –Control of an Outbreak of Infection in a Community).

2. Purpose

The purpose of the policy is to provide staff with safe systems for collection, handling, and storage of specimens

3. Definitions

TERM

Control of Substances Hazardous to Health COSHH

DEFINITION

COSHH is the set of regulations under the Health and safety Work Act that requires employers to prevent or reduce the risk of exposure to workers when undertaking work related tasks that involve substances that are hazardous to health. colonisation Colonisation describes when bacteria grow on body sites exposed to the environment, without causing infection, they are non-pathogenic. These bacteria may form part of the normal flora of the individual.

DIPC Director of Infection Prevention and Control

HCAI Health Care Associated Infection

IPCG Infection Prevention and Control Group

IPCT Infection Prevention and Control Team

IPCN Infection Prevention and Control Nurse

Micro organisms

Microorganisms refer to any living thing that is so small it cannot be seen by the naked eye and can only be seen under a microscope. Types of microorganisms include bacteria, viruses, algae, fungi, and are often cited clinically as the

Pathogenic organisms

Transient flora

causative organism of infection and termed a pathogenic organism.

Pathogenic organisms are those bacteria or microorganisms which become invasive due to their ability to damage any host defence i.e. skin barrier and cause infection.

Transient flora are microorganisms that colonise the skin surface for a brief duration of time and are usually easily removed by ordinary hygienic measures such as bathing and hand washing.

Specimen A specimen refers to any small quantity of body fluid or tissue including blood, urine, pus, saliva, sputum etc taken in order to aid diagnostic and clinical treatment of an individual.

Specimen collection

Specimen collection is the method taken to obtain a specimen for the purposes of diagnosis, treatment, and recovery.

Specimen transport The transport of specimens describes the minimum standard which should be applied by staff when transporting specimens within and between hospital/clinical premises, to and from community sources and to outside agencies.

4. Duties

• The Board and the Chief Executive have collective responsibility for infection prevention and control

• The Director of Infection Prevention and Control (DIPC) is responsible for overseeing this policy

• The Infection Prevention Team is responsible for developing the policy and for the provision of training and expert advice

• Any staff member who is responsible for handling specimens has duties under the Health and Safety at Work Act and the Control of Substances Hazardous to Health (COSHH) regulations

• The person obtaining specimens is responsible for ensuring that they are collected in a safe manner, contained to avoid spills and to prevent contamination of the container

• The ward/department managers are responsible for ensuring compliance with the policy

• Lead for Estates & Facilities is responsible for ensuring that the waste management policy is kept up to date

• Assistant Directors are responsible for ensuring that the policies are implemented in their clinical areas and that the appropriate equipment is available for all staff to access

5. Consultation and Communication

The development of this policy has been in line with the COSHH and HSE requirements the organisation as an employer needs to comply with. All members of the IPG are consulted for comments when policy is due for review or updated.

6. Monitoring

The policy and its implementation will be monitored and ratified through the Infection Prevention Group and will be included in the procedural documents report that goes to Quality Provide Leadership Team.

The Infection Prevention Team will audit compliance with standard infection control precautions as part of the annual audit programme. Results will be reported to the Infection Prevention Group and Quality & Safety Committee.

7. Labelling Procedure

All specimens should be labelled and transported correctly. It is essential that confidentiality is maintained, and that sensitive information is not revealed unnecessarily.

Specimens should be requested using the dedicated forms, e.g. virology forms for Influenza or other viruses including Norovirus during outbreaks of diarrhoea; micro biology forms for MRSA or other suspected bacterial causes including suspected food poisoning.

Appropriate forms and specimen containers are available from laboratory staff at Mid and South Essex Hospital Services Trust (Basildon Hospital, and Broomfield hospital) or from Colchester Hospital University NHS Foundation Trust (CHUFT) for service users in North Essex. Please do not use GP forms for in-patients’ services. Accurate information should be entered on the forms to ensure patient and specimen identification.

The following information will be required:

• Patient’s full name

• Hospital ward or clinic address/GP / clinicians name

• NHS number

• Patient’s hospital number

• Tests required

• Blood/universal container (appropriately labelled)

• Date and time of collection

• Relevant patient information e.g., symptoms and antibiotics

Information should be supplied about the patient’s condition e.g. immune status, clinical condition, suspected organisms and if part of an outbreak. Information about current medication and treatments, recent antibiotics, steroids or other immune-suppressive drugs is essential.

The source of the specimen should be identified e.g. the particular body site, type of body fluid. The method of collection should be identified e.g. mid-stream urine (MSU),

catheter urine (CSU), or anatomical site, e.g. nose, throat, perineum, or if from an infected wound the exact site should be identified. This will enable the laboratory to determine the correct growth medium for the sample.

All specimen containers and request cards must describe the nature of the specimen, the source and any other relevant information to allow the laboratory staff to identify the source quickly in the event of a laboratory accident. No changes should be made to laboratory specimen collection containers unless agreed by the relevant laboratories.

Place the specimen into the container which must be placed in the appropriate plastic bag with the request form in the separate pocket.

High risk ‘Biohazard’ Specimens

Specimens containing or suspected of containing high risk microorganisms e.g tuberculosis (TB) require different handling and processing methods in the laboratory. To prevent cross infection to staff handling them, all high-risk specimens and request forms must have a biohazard sticker label attached. Consult the local Consultant Microbiologist or IPCT for advice prior to collecting a high-risk specimen.

The Health and Safety Advisory committee on dangerous pathogens produces the approved list of biological agents and their risk status (updated 2023): There are 4 category groups. Level 3 and 4 are high risk and include the following:

Category 3

Category 4

Human Immuno-Deficiency Virus (HIV) Viral Haemorrhagic fevers e.g. Ebola

Hepatitis B virus (HBV) Rabies

Hepatitis C virus (HCV) Anthrax etc

Tuberculosis (TB)

Enteric fevers, Salmonella Typhi

MERS/ SARS related coronavirus and SARS-CoV-2 (COVID 19)

Mpox virus (formerly known as Monkeypox virus)

Please note not all high-risk microorganisms are listed here to see full list updated 2023 use link The Approved List of biological agents: Advisory Committee on Dangerous Pathogens (hse.gov.uk) If in doubt, please contact IPCT

8. Specimen collection

Wear appropriate personal protective equipment (PPE) e.g. gloves and aprons, when collecting specimens or additional PPE based on an assessment of the risk associated with the procedure.

Poorly collected specimens can result in delayed results with increased patient anxiety, delays in essential treatment, and wasted resources. Laboratory staff are required to reject specimens that are poorly collected as results may be unreliable. Inaccurate or inadequate patient information could lead to incorrect patient identification.

Damaged or leaking specimens will be disposed of by the laboratory staff without any investigation being carried out. The significance of the specimen will be discussed with the requesting clinician. Unlabelled specimens will also be discarded.

Wash hands prior to and after specimen collection. Collect fresh material only from the site of the suspected infection, avoiding contact with the surrounding areas. Prior to collecting swabs from dry wounds or from the nose or other sites, moisten the swab with sterile normal saline. If none is available use a small amount of the transport medium supplied with the swab instead. All swabs for culture should be done with swabs with transport medium.

Following collection, secure the lids immediately to avoid spills and contamination during transport. Ensure that the label is fixed and signed, dated and fully completed prior to filling the containers.

Do not overfull containers especially faecal containers (these can explode on opening) but ensure that there is adequate volume of specimen to avoid a false negative result. Wear appropriate personal protective equipment (PPE) e.g. gloves and aprons, when collecting specimens or additional PPE based on an assessment of the risk associated with the procedure.

N.B For specimen collection:

• where the patient is identified suspected or known high risk with a category 3 pathogen the clinician is required to contact local Consultant Microbiologist or IPCT to discuss collection and transport arrangements prior to obtaining a high-risk specimen.

Specimen Collection Procedure

Nose

Throat

Perineum

Groin (if requested only)

Eye swabs

Wounds/skin lesions

Wash hands prior to taking swabs from the nose; moisten the swab with sterile saline or transport medium. One swab should be rolled inside both nostrils.

One swab should make contact with one tonsil. The patient should stick out their tongue whilst the swab is guided down the side of the throat to make contact with the tonsil, a tongue depressor may be required.

One swab should be rolled over the area between the genitalia and the anus. Hygienic cleaning of the area should be undertaken, if required, prior to swabbing.

One swab should be rolled along the area of skin on the inner part of the thighs closest to the genitalia. Moisten with sterile saline or use transport medium

The exudates from the eye can be swabbed to identify some bacteria but others need to be identified by conjunctivae scrapings which should be taken in an eye clinic. If both eyes are to be swabbed a separate swab must be used for each eye.

One swab should be rolled over the area. If remnants of dressing or debris the wound may be irrigated with saline to remove surface debris before

Catheter specimen of urine (CSU)

5-10ml is required

Midstream specimen of urine (MSU)

5-10ml is required

Stool/faecal specimens

High vaginal swabs

Indwelling devices

taking the swab. For large wounds, roll the swab in a zig-zag motion to include all wound surfaces.

Swabbing of dry crusted areas is unlikely to be helpful. When necessary to take a swab from a dry wound, moisten the swab with normal saline.

Urine specimens should only be taken from the urine sampling port of the catheter using a sterile syringe (most manufacturers provide needleless ports) Swab port with 2% chlorhexidine in 70% alcohol and allow to air dry prior to sampling. Urine specimens must not be taken from the catheter bag as misleading results will be obtained due to bacteria having multiplied in the previously drained stale urine.

The first few ml of urine should be discarded and the mid-stream specimen collected into a sterile container. The value of cleaning the perineum prior to taking the specimen is questionable.

15ml of liquid or approximately the size of a walnut is sufficient. Stool specimens can be obtained from a bedpan containing urine. This does not affect results

A vaginal speculum (sterile before use) must be used in order to separate the vaginal walls, using a strong light source the swab is taken from as high in the vagina as possible.

One swab to be rolled over the area of skin surrounding the device. Premoisten swab with sterile saline if necessary.

Pus Pus may be collected using a sterile syringe and transferred into a sterile specimen container.

Reference: The Royal Marsden Manual of clinical and Cancer Nursing procedures 10th Edition Chapter 13 -diagnostic Chapters - Royal Marsden Manual (rmmonline.co.uk)

9. Specimen Storage

Specimens must not be stored in a clean clinical treatment room at any time. Specimens must be stored in a fridge at 4°C that is not used for the storage of food, drugs or vaccines, in a designated area, e.g. nurses’ sluice room.

The fridge should have a min/max thermometer and be cleaned and serviced regularly, in line with the planned preventative maintenance policy.

Urine should be examined in the laboratory within 2 hours if possible; otherwise it may be stored in a fridge for up to 24 hours. Bacteria multiply at room temperature and can give misleading results.

Sputum specimens should be sent to the laboratory immediately as respiratory pathogens will not survive for prolonged periods.

Blood cultures must not be stored in a fridge as they need to be kept at body temperature and must be sent to the laboratory immediately where they can be held in an incubator until processed.

Stool specimens should be examined within 12 hours unless parasites are suspected when a fresh warm stool is required.

Wound swabs should reach the laboratory on the day that they are taken, within 24 hours, but can be stored in a specimen fridge overnight if this is not possible.

Do not leave specimens over the weekend or bank holidays.

10.Specimen Transport

Specimens must be transported in accordance with the Carriage of Dangerous Goods Regulations, 2009. Ensure that the specimen is placed in a sealed plastic specimen bag with the form placed in the second compartment to avoid accidental contamination of the form. The plastic bag should then be placed in a rigid container in a designated collection area until ready for collection. Specimens must always be transported in UN approved rigid leak proof containers. Managers must ensure that the appropriate rigid containers are available in all in-patient areas and community clinics. If health care workers are required to carry specimens from a client’s home to a GP surgery or a local laboratory in the boot of their car, these transport containers for specimens must be labelled with UN code 3373.

Specimens to be sent by post to specialist laboratories should be sent to the local microbiology laboratory to ensure that they are sent in packaging which conforms to the current transportation of dangerous goods regulations. This includes Influenza specimens sent to a local virology laboratory who will then be responsible for arranging transportation to the agreed reference laboratory. In the community, care home outbreak Influenza swabs are couriered directly to Addenbrookes Hospital under agreement with Public Health England. Please refer to IPSOP01: Standard operating procedure Influenza in care homes.

Any specimens that are required to be posted must be placed in the appropriate specimen container according to the postage requirements. The specimen must then be placed into a rigid tube that contains sufficient absorbable material in the event of a spill. These items of packaging are supplied by the postal service. The secure specimen can then be placed inside the appropriate padded bag/container supplied by the post office. Always consult the local laboratory and the post office for advice before sending any specimens by post. The post office has published its own guide on the packaging requirements for sending by post via Royal Mail.

If sending to the laboratory from patients receiving treatment from radioactive sources always get advice from the laboratory before collecting the specimen. Specimens from radioactive sources should not be sent by post.

Specimens from patients who are receiving cytotoxics may contain unchanged drug or active metabolites. For correct labelling and transportation, advice should be sought from the nurse specialist or clinical team.

Specimens and request forms should be appropriately labelled. Sputum specimens for TB investigations must not be sent by post.

11.Spillages

If spills occur during transportation of specimens, they should be dealt with according to IPPOL21 Policy on Standard Precautions for Infection Prevention and IPPOL12 Waste Management Policy regarding management of body fluids spills. Where transport of specimens is undertaken on a regular basis a bio-hazard spill kit should be carried in vehicles

12. References

Advisory Committee on Dangerous Pathogens. Categorisation of pathogens according to hazard and categories of containment. London, HMSO 1995

Carriage of Dangerous Goods (Classification, Packaging and Labelling) regulations 1996; 2004; updated 2009

Health Services Advisory Committee. Safe working and the prevention of infection in clinical laboratories. London HMSO 2003

Management and disposal of healthcare waste 20 March 2013: Guidance (HTM 0702)

NHS England » (HTM 07-01) Management and disposal of healthcare waste

Ionising radiation regulations 1999

Approved Code of Practice: the protection of persons against ionising radiation arising from any work activity. London HMSO 2000

Department of Health (2007) Transport of Infectious Substances – Best Practice Guidance for Microbiology Laboratories

Health and Safety (2009) Carriage of Dangerous Goods and Use of Transportable Pressure Equipment

HSE (2023)The Approved List of biological agents Advisory Committee on Dangerous Pathogens, Crown copyright.

The Approved List of biological agents - MISC208 (hse.gov.uk)

Royal Marsden NHS Foundation Trust (2020) The Royal Marsden Hospital Manual of Clinical Nursing Procedures (tenth Edition)

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 1: ‘Screening’

Name of project/policy/strategy (hereafter referred to as “initiative”):

Safe Handling and Packaging of Specimens

Provide a brief summary (bullet points) of the aims of the initiative and main activities:

The policy aims to provide all clinical staff with the knowledge and skills to handle and transport all specimens’ safety in line with the transport of infectious substances.

Project/Policy Manager: Head of IPC Date: 09/10/2024

This stage establishes whether a proposed initiative will have an impact from an equality perspective on any particular group of people or community – i.e. on the grounds of race (incl. religion/faith), gender (incl. sexual orientation), age, disability, or whether it is “equality neutral” (i.e. have no effect either positive or negative). In the case of gender, consider whether men and women are affected differently.

Q1. Who will benefit from this initiative? Is there likely to be a positive impact on specific groups/communities (whether or not they are the intended beneficiaries), and if so, how? Or is it clear at this stage that it will be equality “neutral”? i.e. will have no particular effect on any group.

Neutral

Q2. Is there likely to be an adverse impact on one or more minority/under-represented or community groups as a result of this initiative? If so, who may be affected and why? Or is it clear at this stage that it will be equality “neutral”?

Neutral

Q3. Is the impact of the initiative – whether positive or negative - significant enough to warrant a more detailed assessment (Stage 2 – see guidance)? If not, will there be monitoring and review to assess the impact over a period time? Briefly (bullet points) give reasons for your answer and any steps you are taking to address particular issues, including any consultation with staff or external groups/agencies.

Neutral

Guidelines: Things to consider

Equality impact assessments at Provide take account of relevant equality legislation and include age, (i.e. young and old,); race and ethnicity, gender, disability, religion and faith, and sexual orientation.

The initiative may have a positive, negative or neutral impact, i.e. have no particular effect on the group/community.

Where a negative (i.e. adverse) impact is identified, it may be appropriate to make a more detailed EIA (see Stage 2), or, as important, take early action to redress this – e.g. by abandoning or modifying the initiative. NB: If the initiative contravenes equality legislation, it must be abandoned or modified.

Where an initiative has a positive impact on groups/community relations, the EIA should make this explicit, to enable the outcomes to be monitored over its lifespan.

Where there is a positive impact on particular groups does this mean there could be an adverse impact on others, and if so can this be justified? - e.g. are there other existing or planned initiatives which redress this?

It may not be possible to provide detailed answers to some of these questions at the start of the initiative. The EIA may identify a lack of relevant data, and that data-gathering is a specific action required to inform the initiative as it develops, and also to form part of a continuing evaluation and review process.

It is envisaged that it will be relatively rare for full impact assessments to be carried out at Provide. Usually, where there are particular problems identified in the screening stage, it is envisaged that the approach will be amended at this stage, and/or setting up a monitoring/evaluation system to review a policy’s impact over time.

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 2:

(To be used where the ‘screening phase has identified a substantial problem/concern)

This stage examines the initiative in more detail in order to obtain further information where required about its potential adverse or positive impact from an equality perspective. It will help inform whether any action needs to be taken and may form part of a continuing assessment framework as the initiative develops.

Q1. What data/information is there on the target beneficiary groups/communities? Are any of these groups under- or over-represented? Do they have access to the same resources? What are your sources of data and are there any gaps?

n/a

Q2. Is there a potential for this initiative to have a positive impact, such as tackling discrimination, promoting equality of opportunity and good community relations? If yes, how? Which are the main groups it will have an impact on?

n/a

Q3. Will the initiative have an adverse impact on any particular group or community/community relations? If yes, in what way? Will the impact be different for different groups – e.g. men and women?

n/a

Q4. Has there been consultation/is consultation planned with stakeholders/ beneficiaries/ staff who will be affected by the initiative? Summarise (bullet points) any important issues arising from the consultation.

n/a

Q5. Given your answers to the previous questions, how will your plans be revised to reduce/eliminate negative impact or enhance positive impact? Are there specific factors which need to be taken into account?

n/a

Q6. How will the initiative continue to be monitored and evaluated, including its impact on particular groups/ improving community relations? Where appropriate, identify any additional data that will be required.

n/a

Guidelines: Things to consider

An initiative may have a positive impact on some sectors of the community but leave others excluded or feeling they are excluded. Consideration should be given to how this can be tackled or minimised. It is important to ensure that relevant groups/communities are identified who should be consulted. This may require taking positive action to engage with those groups who are traditionally less likely to respond to consultations, and could form a specific part of the initiative. The consultation process should form a meaningful part of the initiative as it develops, and help inform any future action.

If the EIA shows an adverse impact, is this because it contravenes any equality legislation? If so, the initiative must be modified or abandoned. There may be another way to meet the objective(s) of the initiative.

Further information:

Useful Websites www.equalityhumanrights.com Website for new Equality agency www.employers-forum.co.uk – Employers forum on disability www.disabilitynow.org.uk – online disability related newspaper www.efa.org.uk – Employers forum on age