LABORATORY OF PATHOLOGY ONLINE POLICY MANUAL

GENERAL INFECTION CONTROL POLICIES

These procedures apply to all Laboratory of Pathology (LP) clinical staff who come in
contact with human tissues, blood, or potentially infectious materials: staff pathologists,
residents and fellows in pathology, medical technologists, cytotechnologists, autopsy
assistants, photographers handling human tissues, histology technicians, and program support
staff.
I.

New employees receive training on Universal Precaution & Tuberculosis training in

collaboration with the Hospital Epidemiology Service. See the Universal Precautions
Overview for training information. In addition, all such employees receive instruction on the
principles of infection control, with particular emphasis on mycobacterial diseases, and blood
and body fluid precautions. Principles of infection prevention and control are discussed in the
Residents' Manual that is given to each new resident upon the initiation of training. Universal
precautions and biosafety are covered in the LP Safety Manual that is reviewed annually by
all clinical employees of LP.
II.
All employees who come in contact with blood, potentially infectious materials, or
human tissues are required to take annual Universal Precautions & Tuberculosis Training
sessions. The Safety Committee monitors compliance of technical personnel and will notify
supervisors of delinquencies or problems. The professional staff (MDs) members are
monitored through the Clinical Center (CC) Credentials office.
III.
Employees receive basic instruction about tuberculosis exposure and use of barrier
protection devices. All specimens with a potentially airborne route of transmission must be
manipulated in a biological safety hood. Departmental control measures are reviewed on an
annual basis and modifications made as necessary. Structural renovations that may assist in
infection prevention and control are instituted.
IV.
Compliance with Universal Precautions is monitored by individual supervisors. Noncompliance with Universal Precautions is documented as part of annual performance
appraisals.
V.
Tuberculosis Surveillance Program. Healthcare workers who may be exposed to
unfixed human tissues (e.g. grossing surgical specimens, performing autopsies) or those who
see patients in the clinics (e.g. assist with FNA) must be enrolled in the OMS Tuberculosis
(TB) Surveillance Program. The LP Clinical Laboratory Manager, the OMS Nurse
overseeing the Tuberculosis Surveillance Program, and the Epidemiologist on the Hospital
Epidemiologist Service coordinate activities and data to ensure appropriate employees are
enrolled in the program on an ongoing basis, at least quarterly. New employees must report to
OMS when they are hired for their initial physical and receive a PPD skin test if appropriate
and are recalled annually for repeat testing. It is the employees' responsibility to follow-up by
contacting OMS or by attending one of their walk-in clinics, after they receive their annual
notice. If the employee fails to follow-up, the employee is sent a second reminder notice.
Through a coordinated effort with OMS and HES, the employees who remain non-compliant
or not enrolled may receive an e- mail from the Clinical Laboratory Manager informing them
of the necessity to enroll and become compliant. Any healthcare worker who tests positive
for a PPD will receive appropriate counseling and follow-up by OMS, including education on
TB symptoms.
VI.
Employees are similarly counseled by OMS regarding OSHA requirements for
hepatitis B vaccination, and are required to comply with OSHA regulations.
VII.
A retroviral surveillance program is available for personnel but is not mandatory.

VIII.
IX.

All specimens are treated as potentially infectious by using Universal Precautions.

Supervisors must provide specific safety training related to the work that students or
visitors would do.
X.
Suspected cases of CJD should be communicated to LP by the healthcare provider via
the order placed in the CRIS; however, a CJD or prion disease patient does not always
present with symptoms of CJD. These cases are usually diagnosed at the time of autopsy,
however, precautions for containment are carried out on surgical specimens from the
following patients:
A.
Patients with neurodegenerative disease if CJD has entered the differential diagnosis
B.
Patients with a familial prion disease
C.
Recipients of tissues from human cadavers (pituitary derived hormones or dura mater)
XI.
Suspected cases of CJD should be communicated to LP by the healthcare provider via
the order placed in the CRIS; however, a CJD or prion disease patient does not always
present with symptoms of CJD. These cases are usually diagnosed at the time of autopsy,
however, precautions for containment are carried out on surgical specimens from the
following patients:
.
Pathologists will notify technical staff of precautions that need to be taken on a caseby-case basis. Departmental Procedures for the Autopsy Service (see below) can be adapted
for other service areas as needed.
A.
Unusual or unexpected preliminary results are called to both the surgeon and the
clinical care team within 24 to 48 hours of collection. A note should be placed in the report
stating when and who was notified.
B.
All cases suspected of CJD or prion disease are sent to a reference laboratory for
confirmation.
C.
Suspected and confirmed cases are reported to the Hospital Epidemiology Service
(HES, 496-2209) with a note in the report stating when and who was notified.
D.
The turn around time interval between specimen receipt and final report is monitored
and reviewed on a periodic basis to assure shortest result reporting time.
XII.
All healthcare workers shall practice good hand hygiene to reduce the risk of
transmission of organisms to patients, themselves, and coworkers. Careful attention should be
given to hand hygiene after removal of gloves and especially before touching the eyes or
mucosal surfaces. General hand hygiene practices are:
.
Indications for hand washing include:
i.
Before and after patient contact
ii. Contact with environmental surfaces in the immediate vicinity of
patients.
iii. After glove removal.
iv.
Before eating and after using the restroom.
A. Techniques for hand hygiene (See Special Respiratory Isolation
Procedure)
.
Select the proper amount of hand hygiene solution or agent and wash hands
thoroughly.
i.
When decontaminating hands with alcohol-based hand rub, apply one
full pump depression of the product to palm of hand and rub hands
together, covering all surfaces of wrists, hands, fingers, and nails, until
hands are dry. This should take 15 to 25 seconds. Follow
manufacturers recommendations regarding product use.
ii. Soap and water are recommended for visibly soiled hands. Wet hands
first with warm water, apply product and rub hands vigorously for at
least 15 seconds, covering all surfaces of wrists, hands, fingers, and

nails. Rinse with water and dry with disposable towel. Use towel to
turn off faucet. The use of compatible lotions and creams are
recommended to prevent or minimize dryness and irritation. Central
Hospital Supply can provide guidance on product selection, if needed.
iii. Avoid the use of bar soaps and multiple-use towels.
B. Indications for, and limitations of, glove use:
.
Gloves are worn for all contact with blood, body fluids and other potentially
infectious materials, and non-intact skin.
i.
Hand contamination may occur as a result of small, undetected holes in
gloves.
ii. Contamination may occur during glove removal.
iii. Wearing gloves does not replace the need for hand hygiene.
iv.
Failure to remove gloves after caring for a patient may lead to
transmission of microorganisms from one patient to the other.
v.
Supervisors and safety officers of each area should monitor hand
hygiene technique and provide feedback to employees as needed.
XIII.
Lab coats are cleaned using the NIH Laundry Service:
Using indelible ink, write your name and room number on the tag of your lab coat.
i.
Complete a laundry slip.
ii.
Place lab coats in a laundry bag or plastic bag.
iii. Deliver bag to lab coat bin outside of room B1N-35A.
iv.
Clean lab coats will be delivered back to the room number on the lab coat.

Last Updated 12/28/2009 10:55:44 AM