SECTION: 18 - INFECTION PREVENTION AND CONTROL POLICY /PROCEDURE: 18.02 NATURE AND SCOPE: SUBJECT: TRUST WIDE PROCEDURE OBTAINING CLINICAL SAMPLES FOR MICROBIOLOGY This procedure has been developed to ensure that the processes used within the organisation when obtaining clinical samples are robust, reflect best practice, and also comply with DH requirements and legislations. The quality of clinical specimens and the method by which they are collected, stored and transported can have a significant impact on ensuring an accurate diagnosis. DATE OF LATEST RATIFICATION: JUNE 2014 RATIFIED BY: TRUSTWIDE INFECTION CONTROL COMMITTEE IMPLEMENTATION DATE: AUGUST 2014 REVIEW DATE: JUNE 2017 ASSOCIATED TRUST POLICIES & PROCEDURES Hand Hygiene - 18.04 Legionella Control 18.08 MRSA Prevention and Control 18.07 Occupational Exposure to Blood Borne Viruses - 18.06 Management of Waste - 16.08 Personal Protective Equipment - 18.20 Carbapenemase-Producing Enterobacteriaceae (CPE) in Inpatient Facilities 18.16 ISSUE 1 AUGUST 2014
NOTTINGHAMSHIRE HEALTHCARE NHS TRUST OBTAINING CLINICAL SAMPLES FOR MICROBIOLOGY PROCEDURE CONTENTS 1.0 Introduction 2.0 Definitions 3.0 Legislative Requirements 4.0 Duties 4.1 Director of Infection Prevention and Control 4.2 The Infection Prevention and Control Team 4.3 Managers/Team Leaders/Matrons 4.4 Employees 5.0 Specimen Collection 5.1 Principles of Specimen Collection 6.0 Storage of Specimens 7.0 Transportation of Specimens 8.0 General Recommendations 9.0 Patient Consent and Education 10.0 Relevant Trust Policies and Procedures 11.0 Training 12.0 Monitoring Compliance 13.0 Implementation 14.0 Target Audience 15.0 Consultation 16.0 Equality Impact Assessment 17.0 Review Date 18.0 Champion and Expert Writer 19.0 References Appendix 1 - Collection of Clinical Samples Appendix 2 Bristol Stool chart Appendix 3 Flowchart for screening patients for Carbapenemase- producing Enterobacteriaceae Appendix 4 - Record of Changes Appendix 5 - Employee Record of Having Read the Procedure ISSUE 1 AUGUST 2014 1
1.0 INTRODUCTION NOTTINGHAMSHIRE HEALTHCARE NHS TRUST OBTAINING CLINICAL SAMPLES FOR MICROBIOLOGY PROCEDURE 1.1 This procedure has been developed to ensure that the processes used within the organisation when obtaining clinical samples are robust, reflect best practice, and also comply with DH requirements and legislations. This is a specific requirement of the Health and Social Care Act 2008: code of practice for the prevention and control of healthcare associated infections that the Trust has a policy on the packaging, handling and delivery of laboratory specimens. 1.2 The quality of clinical specimens and the method by which they are collected, stored and transported can have a significant impact on ensuring an accurate diagnosis. 1.3 This procedure outlines the precautions required to prevent transmission of infection to staff and the wider community whilst obtaining, transporting and handling specimens. These measures are required to ensure that high quality specimens are obtained for accurate diagnosis. 2.0 DEFINITIONS 2.1 A specimen: Defined as any bodily substance taken from a person for the purpose of analysis, such as blood or urine. All specimens will be regarded as potentially infectious, and all members of staff involved in collecting, handling and transporting specimens are to be trained in and follow infection control precautions to prevent transmission of infection. 3.0 LEGISLATIVE REQUIREMENTS 3.1 The collection, storage and transportation of specimens are governed by legislations relating to both transportation and health and safety at work. 3.2 The following legislation applies: Health and Safety at Work Act 1974 Management of Health and Safety at Work Regulation, 1999 Control of Substances Hazardous To Health Regulations (COSSH),2002 The Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations, 2009 as amended by the Carriage of Dangerous Goods and Use of Transportable Pressure Equipment (Amendment) Regulations, 2005. 4.0 DUTIES The duties of all infection prevention and control policies are described in the Infection Prevention and Control Policy. In summary; the 4.1 Director of Infection Prevention and Control The DIPC will oversee local control of infection policies and their implementation and that the effectiveness is monitored and reviewed as necessary. The three Network Managers across the Trust are responsible for the co-ordination of Heath and Safety activities within the Networks and for ensuring that decisions are implemented in accordance with this policy and associated guidelines. ISSUE 1 AUGUST 2014 2
4.2 The Infection Prevention and Control Team The Infection Prevention and Control Team will review any urgent communications from the Department of Health or other bodies and decide on what action is necessary prior to the next meeting of the Infection Control Group. 4.3 Managers/Team Leaders Managers / Team Leaders have a responsibility to ensure that all staff are aware of their responsibilities under this policy and associated guidelines. Managers are to inform new employees of their responsibilities under the policy. In addition they will ensure that all employees within their area of responsibility comply with this policy and associated guidelines. 4.4 Employees All employees have a responsibility to abide by this policy, associated guidelines and any decisions arising from the implementation of them. This policy is enforceable through Health and Safety Legislation and Nottinghamshire Healthcare NHS Trust disciplinary procedures. If employees are aware that the policy or associated guidelines are not being complied with they will first take the issue to their line manager. 5.0 SPECIMEN COLLECTION 5.1 Principles of Specimens Collection 5.1.1 All specimens from known or suspected high risk infection such as hepatitis B or HIV positive patients should be clearly labelled as danger of infection. It is the clinician s responsibility to ensure that tests that have been requested have the adequate clinical information documented on the request form and that danger of infection is clearly labelled on the request forms and on the containers for all high risk specimens. 5.1.2 For high risk organisms such as viral haemorrhagic fevers e.g. Lassa and Ebola viruses advice must be sought from the consultant microbiologist in consultation with Public Health England and the IPC team prior to any specimens being obtained from a patient with suspected viral haemorrhagic fever. 5.2 Success in the laboratory is dependent on the correct collection packaging, storage and transportation of specimens. 5.3 Clinicians should ensure that samples: Are only taken when clinically indicated Are of a good quality The specimen is taken at the correct time of day The correct specimen container is used Specimen containers are checked for exterior contamination and cleaned as necessary The container and request from are both labelled with the patient s name, date of birth, hospital or NHS number, and the date and time the sample was obtained. The appropriate request from is fully completed with details of the patient s relevant medical history, investigation required and details of any antibiotic treatment received. The specimen container is placed in an approved specimen bag and correctly sealed The specimen is stored correctly and transported to the laboratory promptly. The patient s confidentiality is maintained at all times. ISSUE 1 AUGUST 2014 3
5.4 The clinician taking specimens will ensure that the following principles are followed: Effective hand hygiene is performed before and after collection of the specimen. Appropriate protective clothing is worn when collecting the specimen, i.e. non-sterile gloves, apron and where splashing is possible or expected, goggles or visor. Measures are taken to prevent any contamination of the sample 5.5 All staff will therefore be aware of how to deal safely with clinical specimens and how to avoid any spillage of leakage of body fluids. In the event of accidental spillage, the management of spillage of blood and body fluid and vaccine policy must be followed. 5.6 Microbiological results are important factor in prescribing appropriate antibiotic therapy. To ensure that accurate microscopy, culture and sensitivity results are obtained steps should be taken to avoid contamination of the specimen with the patient s or clinician s own normal flora. 5.7 Samples for microbiological investigation will be sent to the laboratory as soon as a patient is considered to have an infection, and ideally prior to the use of antibiotics. Specimens taken during antibiotic therapy may produce misleading results. 5.8 All samples should be obtained using an aseptic non-touch technique (ANTT) 6.0 STORAGE OF SPECIMENS 6.1 For accurate results to be obtained, specimens ideally should be received and processed by the laboratory as soon as possible. 6.2 However, where this is not possible, urine and sputum specimens should be stored within a designated refrigerator, but only for a maximum of 24 hours, at 4-8 C. This will help prevent bacteria and contaminants from multiplying and giving misleading results. 6.3 Blood cultures must not be refrigerated and they must be transported to the laboratory straight away for incubation at 37 C. 6.4 If any clinical specimens are to be stored in a refrigerator, it is essential that: There is a refrigerator for the purpose of specimen storage only. The temperature in the refrigerator is maintained between 4-8 C A member of staff is allocated to check and record the fridge temperature daily And that this is evidenced using the appropriate documentation. Records of fridge monitoring are kept for 2 years. 7.0 TRANSPORTATION OF SPECIMENS 7.1 Under the Health and Safety at Work etc (1974), all staff have a responsibility to protect themselves and others e.g. the public, from any contamination from hazardous substances. All road transport of samples must be in accordance with current Carriage of Dangerous Goods by Road legislation (ADR). 7.2 Staff who transport any clinical samples should ensure that samples are placed in a lidded, rigid, wipeable container which is to prevent the risk of contamination in the event of spillage or leakage of the specimen. All transport containers should be decontaminated following each use and if contaminated with blood or body fluids should be disinfected using chlorine. ISSUE 1 AUGUST 2014 4
7.3 In the event of accidental spillage, the management of Spillage of Blood and, body fluid and vaccine policy must be followed. 8.0 GENERAL RECOMMENDATIONS 8.1 To reduce risks, the number of persons handling specimens will be kept to a minimum. It is also essential that staff follow the correct procedures to maximise the potential for accurate laboratory results. 8.2. Everyone involved in collecting, handling and transporting specimens should be educated about standard infection control prevention control precautions and be familiar with relevant policies, including; Hand hygiene The use of personal protective equipment The safe use and disposal of sharps Waste management 9.0 PATIENT CONSENT AND EDUCATION 9.1 Clinical staff are to ensure that all tests are fully explained to patients so that they are able to give fully informed consent and this be documented in the patient s notes. If a person has been assessed and deemed to lack capacity, that is, there is an impairment of, or disturbance in the functioning of the person s mind or brain and that a person is unable to make that particular decision at the relevant time, then the decision to obtain a sample should be made only if this is in their best interest and if this has been made in agreement with the multidisciplinary team. The procedure should be fully explained to ensure that the patient is informed as to what to expect or what they need to do e.g. when providing midstream urine sample, and this will be then documented within the Multi Disciplinary Notes. 9.2 There are to be clear local systems for informing patients of test results. At the time of the test, the patient will be advised of how long they will have to wait for the test result and the method by which they will be informed of it e.g. during their in patient stay, a follow up appointment or by post. 9.3 When results are returned to a clinical area, there should be robust systems in place to ensure that results are: Documented within the Multi Disciplinary Notes The appropriate Clinician that has requested the test or procedure is informed in a timely manner. 10.0 RELEVANT TRUST POLICIES & PROCEDURES 10.1 The policies identified below are associated with obtaining samples policies: Hand Hygiene - 18.04 Health, Safety and Welfare 16.01 Legionella Control 18.08 MRSA Prevention and Control 18.07 Control of Substances Hazardous to Health (COSHH) - 16.06 Decontamination 18.01 Occupational Exposure to Blood Borne Viruses - 18.06 Management of Waste - 16.08 Infection Prevention and Control -18.05 Management and control of Carbapenemase-Producing Enterobacteriaceae (CPE) in inpatient facilities 18.16 ISSUE 1 AUGUST 2014 5
11.0 TRAINING 11.1 Training for infection prevention and control will be disseminated through Infection Prevention and Control teams. 12.0 MONITORING COMPLIANCE 12.1 Arrangements are in place for the monitoring and review of the effectiveness of the sample process through the Ulysses reporting system. 13.0 IMPLEMENTATION 13.1 This policy will be implemented after ratification by General Managers with the support of the Infection Prevention & Control Team. 14.0 TARGET AUDIENCE 14.1 It is the responsibility of all staff that work within the clinical areas, that they are fully aware of the procedure. 15.0 CONSULTATION 15.1 Consultation has taken place with a range of groups including ELC and Infection Prevention and Control Teams across the Trust. 16.0 EQUALITY IMPACT ASSESSMENT 16.1 This policy has been assessed using the Equality Impact Assessment. The outcome of the Initial Screening Assessment was that the policy could not adversely affect different groups on the grounds of disability, gender, age or sexual orientation. 17.0 REVIEW DATE 17.1 This policy will be reviewed 3 yearly (June 2017) or earlier if research, evidence or a change in practice or legislation requires a review to be undertaken. 18.0 CHAMPION AND EXPERT WRITER 18.1 The Champion of this policy is Dean Howells, Executive Director, Nursing, and Quality and Patient Experience. The Expert Writer is Annie Clarke, Head of Infection Prevention and Control and Physical Healthcare. 19.0 REFERENCES European Agreement concerning the International carriage of Dangerous Goods by Road (ADR) Regulations, July 2005. Health and Safety at work Act 1974 ISSUE 1 AUGUST 2014 6
1.0 COLLECTION OF BLOOD COLLECTION OF CLINICAL SAMPLES APPENDIX 1 Standard infection prevention and controls precautions will be applied whenever obtaining a Specimen.. 2.0 COLLECTION OF STOOL SPECIMENS Stool specimen to be collected when a patient exhibits type 6 or 7 on Bristol stool chart (Appendix 2) and infectious cause suspected. Stool specimen collection is to begin on day one of any outbreak or suspected viral diarrhoea. Specimens should be obtained during the acute phase of the illness e.g. within the 48-72 hours after onset while the stools are still liquid (type 6 or type 7 on the Bristol stool chart). Stool specimens will be of a consistency that when put into a container they are loose enough to take the shape of that container. A minimum of a 1ml specimen is required for microbiological (sample up to the lower part of label on the specimen pot) Stool specimens should be collected in a disposable container. A specimen pot and bag should be labelled with the name of the service user, their date of birth, date of collection and any other required information. Please note that formed stools (stool samples other that type 6 or 7 on the Bristol stool chart) will not be tested. 3.0 COLLECTION OF URINE SAMPLES 3.1 Urine Specimens A mid stream specimen of urine is the best sample for culture and sensitivity. Urine can easily be contaminated during collection by bacteria, which colonise the perineum. If possible, the perineum should be cleaned with soap and water prior to specimen collection to help reduce bacterial contamination. Discarding the first several millilitres of urine and collecting 5 10mls of midstream urine in a sterile container will reduce contamination. The infecting organism is more likely to be detected in concentrated or early morning urine. 3.2 Catheter Urine specimens A specimen of urine from a catheterised patient will be obtained by aspiration from the self-sealing sampling port using Aseptic non touch technique (ANTT). The port should be cleaned with an alcowipe (70% isopropyl alcohol). Needles should never be used when obtaining catheter samples. The catheter should never be disconnected to obtain a sample as this will break the closed system and serve as a portal of entry for micro-organisms. ISSUE 1 AUGUST 2014 7
Urine samples collected for culture should not be refrigerated for more than 48 hours. 4.0 SPUTUM COLLECTION Sputum samples will ideally be collected in the morning before eating, drinking or cleaning teeth. The specimen should be delivered to the laboratory as soon as possible. 5.0 WOUND SWABS Taking a wound swab is only recommended when clinical signs of infection are identified and the information gained will affect treatment. As with all investigations the findings should be reviewed alongside other clinical signs and symptoms, and treatment will not be based on swab results alone. If pus is present, a sample obtained by aspiration with a syringe will be the most informative. Loose debris on the wound should be removed, as this is likely to contain high levels of colonising bacteria, which are not representative of the infective organism. If the wound is dry, moisturising the swab with sterile normal saline makes it more absorbent and increases the survival of bacteria prior to culture. The swab should touch all areas by wiping in a zigzag and rolling motion over the surface of the wound. The swab should then be placed directly into the tube and carefully labelled and sent to the laboratory as quickly as possible. It is important that the specimen is supported with sound clinical information recorded on the microbiology request form. Details relating to the service user s symptoms of infection and treatment history will assist the microbiologist in making an accurate diagnosis and appropriate recommendations for management. Sensitivities for antibiotic treatment are not always returned with culture results because many isolates reflect bacterial colonisation, rather than infection. It maybe necessary to obtain advice from the microbiologist to discuss the results and treatment of the case. ISSUE 1 AUGUST 2014 8
APPENDIX 2 ISSUE 1 AUGUST 2014 9
APPENDIX 3 FLOWCHART FOR SCREENING PATIENTS FOR CARBAPENEMASE- PRODUCING ENTEROBACTERIACEAE Assess all patient on admissions for carbapenemase- producing Enterobacteriaceae (CPE) status [document on inter/transfer form] has the patient been in hospital abroad in last 12 months has been in UK hospital with known incidents with CPE has previously been colonised,with infection or in close contact with CPE Suspected case of colonised or infection Inform Infection Prevention and Control Team Isolate patient with own toilet Take rectal swab ( insert 1-1.5 inch into rectum and rotate gently) Strict standard precautions and barrier nursing Confirmed cases Remain in isolation Strict barrier nursing Single patient use equipment Consult microbiology for correct antimicrobial prescribing and advice [Presently limited treatment available] Treat as positive throughout admission If first sample is negative patient to remain in isolation further rectal sample to be taken 48 hours later with Third rectal sample to be taken 48 hours later [i.e. Day 0 initial sample, day 2 and day 4] Following 3 negative screens patient s room to have terminal clean Risk assessment to be completed in discussions with IPCT and microbiologist for management plan Communicate patient s positive status to GP and other community care providers on discharge Complete inter/transfer form ISSUE 1 AUGUST 2014 10
APPENDIX 4 Policy/Procedure for: Obtaining Clinical Samples for Microbiology Issue: 1 Status: Author Name and Title: Approved Annie Clarke, Head of Infection Prevention & Control and Physical Healthcare Issue Date: August 2014 Review Date: June 2017 Approved by: Distribution/Access: Trustwide Infection Control Committee Normal RECORD OF CHANGES DATE AUTHOR POLICY/ PROCEDURE DETAILS OF CHANGE ISSUE 1 AUGUST 2014 11
EMPLOYEE RECORD OF HAVING READ THE POLICY/PROCEDURE Obtaining Clinical Samples for Microbiology 18.02 APPENDIX 5 Title of Policy/Procedure: Obtaining Clinical Samples for Microbiology I have read and understand the principles contained in the named policy/procedure. PRINT FULL NAME SIGNATURE DATE ISSUE 1 AUGUST 2014 12