Download Obtaining Clinical Samples For Microbiology

Obtaining Clinical Samples for Microbiology – 18.02
SECTION:
18 - INFECTION PREVENTION AND CONTROL
POLICY /PROCEDURE:
18.02
NATURE AND SCOPE:
TRUST WIDE PROCEDURE
SUBJECT:
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
ISSUE 1 – AUGUST 2014
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
Obtaining Clinical Samples for Microbiology – 18.02
NOTTINGHAMSHIRE HEALTHCARE NHS TRUST
OBTAINING CLINICAL SAMPLES FOR MICROBIOLOGY PROCEDURE
CONTENTS
1.0
Introduction
2.0
Definitions
3.0
Legislative Requirements
4.0
Duties
5.0
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
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
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NOTTINGHAMSHIRE HEALTHCARE NHS TRUST
OBTAINING CLINICAL SAMPLES FOR MICROBIOLOGY PROCEDURE
1.0
INTRODUCTION
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:
4.0
•
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.
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.
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4.2
The Infection Prevention and Control Team
•
4.3
Managers/Team Leaders
•
4.4
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.
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.
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.
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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.
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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
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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
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APPENDIX 1
COLLECTION OF CLINICAL SAMPLES
1.0
COLLECTION OF BLOOD
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
3.2
•
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.
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.
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•
4.0
5.0
Urine samples collected for culture should not be refrigerated for more than 48 hours.
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.
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.
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APPENDIX 2
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Obtaining Clinical Samples for Microbiology – 18.02
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
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APPENDIX 4
Policy/Procedure for:
Obtaining Clinical Samples for Microbiology
Issue:
1
Status:
Approved
Author Name and Title:
Annie Clarke, Head of Infection Prevention & Control and
Physical Healthcare
Issue Date:
August 2014
Review Date:
June 2017
Approved by:
Trustwide Infection Control Committee
Distribution/Access:
Normal
RECORD OF CHANGES
DATE
AUTHOR
ISSUE 1 – AUGUST 2014
POLICY/
PROCEDURE
DETAILS OF CHANGE
11
Obtaining Clinical Samples for Microbiology – 18.02
APPENDIX 5
EMPLOYEE RECORD OF HAVING READ THE POLICY/PROCEDURE
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
ISSUE 1 – AUGUST 2014
SIGNATURE
12
DATE