Download infection control notification protocol

Policy QPCMI15003.33
Page 1 of 13
Department of Microbiology
Quality Manual
Section: Process Control
Prepared by: QA Committee
Issued by: Laboratory Manager
Approved by: Laboratory Director
Subject Title: Isolate Notification and
Freezing Table
Original Date: October 16, 2000
Revision Date: May 13, 2015
Annual Review Date: April 17, 2015
ISOLATE NOTIFICATION PROTOCOL
REPORTING PROCEDURE
Calling/Paging Infection Control Practitioner:
All isolates identified in the table below should be reported to the infection control practitioner
responsible for the patient care area in the Hospital (refer to the Infection Control Contact List
QPCMI15004) as soon as possible, or within one hour. If Infection Control Practitioner cannot
be reached by phone (where paging is not required), leave a detail message with patient’s name,
medical record number, organism and specimen source and collection date on their voice mail.
Document the call in the electronic work card.
Reporting to MSH ICPs:
Use Microsoft e-mail to report significant isolates to MSH Infection Control Practitioners on
Monday to Friday from 8 am to 5 pm. No phone call to MSH ICP is needed.
Procedure:
1. Log in the computer with your own network login and password
2. Open Microsoft e mail (as you would for outside e mail and vacation requests in the New
Year).
3. Under “New” tab, create a “New Mail Message”.
4. From the address book, look for “Infection Control Results MSH”
([email protected])
-For Positive C. diff results, also ADD “MSH C. diff Research”
-For Positive Influenza results, also ADD “MSH FLU RESEARCH”
5. On the “Subject” line, type “New IC Reportable”
6. Go to the e mail content, type in the following order:
 Ward
 Patient MRN and Name (copy and paste from LIS first line)
 Date of specimen
 Isolate (MRSA, VRE, Flu A….. etc.)
7. Use a new line for the next reportable.
8. All reportable can be put into the same e mail. No need to differentiate ICP’s responsible
areas.
UNIVERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY" are not
controlled and should be checked against the document (titled as above) on the server prior to use.
D:\81928591.doc
Page 2 of 13
Policy QPCMI15003.33
Department of Microbiology
Quality Manual
Section: Process Control
Subject Title: Isolate Notification and
Freezing Table
For Weekends and after hours, use the Microsoft e-mail to report significant isolates to the
Microbiologist on-call and to the MSH Infection Control Practitioners and PHONE the ward.
Calling the Ward:
All significant isolates must be PHONED to the patient care area.
After three unsuccessful attempts, document the time the attempt was made and bring to the
attention of the microbiologist. If the patient has been discharged, call the doctor's office.
Reporting to UHN ICPs:
Hospital Working hours (Mon-Fri 8 am - 4 pm)
TG
TW
PMH
TRI
email [email protected]
email [email protected]
email [email protected]
email [email protected]
After hours (Evenings/Nights;
Saturday, Sunday, Holidays)
email [email protected]
email [email protected] (NEW)
email [email protected]
email [email protected] (NEW)
Use Copy and Paste of the LIS report when emailing. DO NOT use print screen.
ISOLATE NOTIFICATION and STORAGE TABLE





GRAM POSITIVE BACTERIA
GRAM NEGATIVE BACTERIA
VIRUSES
FUNGUS, MYCOBACTERIUM, LEGIONELLA, SEND OUTS
SPECIMENS
Organism
UHN including TRI
MSH (perform all duties
listed)
Baycrest, Bridgepoint, CAMH,
Grace
GRAM POSITIVE BACTERIA
MRSA/VISA-new isolate
- Call Ward
 Call ward
- Freeze
 Email ‘Infection
- Email or call as per Reporting to
Control Results
UHN ICPs Table.
MSH’ (Mon-Sun)
- Page ICP if >1on a unit
 Email Microbiologist
on-call for weekends
& after hours
Call ICP & ward; freeze
1. MRO = Multi-resistant gram neg. organism; Defined as intermediate or resistant to >2 of the following 3 classes:
Aminoglycosides, Quinolones, 3rd Generation Cephalosporins (for P. aeruginosa, resistance to ceftazidime).
* For additional positive blood culture notification and freezing requirements, see Blood Culture Manual.
ICP = Infection Control Practitioner
IP = Inpatient
OP = Out-patient
UNIVERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY" are not
controlled and should be checked against the document (titled as above) on the server prior to use.
D:\81928591.doc
Page 3 of 13
Policy QPCMI15003.33
Department of Microbiology
Quality Manual
Section: Process Control
Organism
Subject Title: Isolate Notification and
Freezing Table
UHN including TRI
MSH (perform all duties
listed)
Baycrest, Bridgepoint, CAMH,
Grace
 freeze
MRSA/VISA-old isolate (<3 months)
No
No
No
CNST Vancomycin = I or R
Freeze
Freeze
Freeze
VRE-new isolate (either vanA or
- Email or call as per Reporting to  Call ward
Call ICP & ward; (except
vanB phenotype) or new vanA result
UHN ICPs Table.
Bridgepoint)
 Email ‘Infection
from Eswab PCR
freeze
Control Results
MSH’ (Mon-Sun)
 E mail Microbiologist
on-call for weekends
& after hours
 freeze
VRE – VanB PCR result, but no
isolate
VRE-old isolate (of the same
genotype <3 months)
Group A Strep – sterile sites
Group A Strep –non-sterile sites
except throat swabs – on In-patients
or ER patients only
Group A Strep from throat swabs
No
No
- No call
- Email ‘Infection
Control Results
MSH’ (Mon-Sun)
No
No
No
- Email or call as per Reporting to  Call GAS study
Call ICP; call ward & GAS
UHN ICPs Table.
Study office; freeze
office
- Call Ward & GAS Study Office  Call ward
- Freeze
 Email ‘Infection
Control Results
MSH’ (Mon-Sun)
 E mail Microbiologist
on-call for weekends
& after hours
 Freeze
- Email or call as per Reporting to  Call ward for
Call ward, freeze
UHN ICPs Table.
 Email ‘Infection
- Call Ward
Control Results
- Freeze
MSH’ (Mon-Sun)
 E mail Microbiologist
on-call for weekends
& after hours
 Freeze
Call ward or physician; freeze
For Out-patient:
Call ward or physician;
freeze; for IP call ICP
 Call ward or
physician
For In-Patient:
1. MRO = Multi-resistant gram neg. organism; Defined as intermediate or resistant to >2 of the following 3 classes:
Aminoglycosides, Quinolones, 3rd Generation Cephalosporins (for P. aeruginosa, resistance to ceftazidime).
* For additional positive blood culture notification and freezing requirements, see Blood Culture Manual.
ICP = Infection Control Practitioner
IP = Inpatient
OP = Out-patient
UNIVERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY" are not
controlled and should be checked against the document (titled as above) on the server prior to use.
D:\81928591.doc
Page 4 of 13
Policy QPCMI15003.33
Department of Microbiology
Quality Manual
Section: Process Control
Organism
Subject Title: Isolate Notification and
Freezing Table
UHN including TRI
MSH (perform all duties
listed)
Baycrest, Bridgepoint, CAMH,
Grace
 Call ward
 Email ‘Infection
Control Results
MSH’ (Mon-Sun)
 E mail Microbiologist
on-call for weekends
& after hours
 Freeze
Freeze
Other beta-hemolytic streptococcus
Freeze
except Group B strep from urine and
GBS Screen
Group B streptococcus – In-patient
Call ward
Call ward
and female >12 - <60 years old;
Neonates
S. pneumoniae
- Email or call as per Reporting to  Call ward
(Only if Penicillin is intermediate or
UHN ICPs Table.
 Email ‘Infection
resistant, Erythromycin is resistant, or - Call Ward
Control Results
Quinolones are resistant)
- Freeze
MSH’ (Mon-Sun)
 E mail Microbiologist
on-call for weekends
& after hours
 freeze
 Call TIBDN (Agron)
and send isolate and
urine to Sylvia
C. difficile toxin – Positives
- Email or call as per Reporting to  Call ward
UHN ICPs Table.
 Email ‘Infection
- Call Ward
Control Results
MSH’ (Mon-Sun)
 E mail “MSH C. diff
Research” (Mon-Sun)
 E mail Microbiologist
on-call for weekends
& after hours
Freeze
Call Ward (except
Bridgepoint)
Call ICP & ward; freeze
Call ICP & ward
1. MRO = Multi-resistant gram neg. organism; Defined as intermediate or resistant to >2 of the following 3 classes:
Aminoglycosides, Quinolones, 3rd Generation Cephalosporins (for P. aeruginosa, resistance to ceftazidime).
* For additional positive blood culture notification and freezing requirements, see Blood Culture Manual.
ICP = Infection Control Practitioner
IP = Inpatient
OP = Out-patient
UNIVERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY" are not
controlled and should be checked against the document (titled as above) on the server prior to use.
D:\81928591.doc
Page 5 of 13
Policy QPCMI15003.33
Department of Microbiology
Quality Manual
Section: Process Control
Subject Title: Isolate Notification and
Freezing Table
Organism
UHN including TRI
MSH (perform all duties
listed)
Baycrest, Bridgepoint, CAMH,
Grace
GRAM NEGATIVE BACTERIA
3rd Gen. Ceph. Resistant E. coli or K.
pneumoniae or P. mirabilis
No call; freeze
New Class A/New Class C Klebsiella
pneumoniae
Previous Class A and Class C E. coli
From Wards 15M,
ODU, 15MB, 15MS,
15ULD, 15UNN,
15UNS, 15UNR,
17MMS, 17MBS,
17UNA, 17UNB,
17UNC
 Call ward
 Email ‘Infection
Control Results
MSH’ (Mon-Sun)
 E mail Microbiologist
on-call for weekends
& after hours
 freeze
Other wards:
-all ESBL clinical
isolates Email : Infection
Control Results MSH
(Mon-Sun)
- Freeze
No call
other non Class A or C
No call;
Freeze if new
MRO Gram Neg1 – new
Freeze
No call
No call




Ertapenem Intermediate or Resistant
No call; freeze
No call;
Freeze if new
No call to ward or
ICP
Email ‘Infection
Control Results
MSH’ (Mon-Sun)
E mail Microbiologist
on-call for weekends
& after hours
freeze
- Email or call as per Reporting  No call to ward or
No call;
Freeze if new
Call ICP (except
Bridgepoint); freeze
Call ICP & ward; (except
1. MRO = Multi-resistant gram neg. organism; Defined as intermediate or resistant to >2 of the following 3 classes:
Aminoglycosides, Quinolones, 3rd Generation Cephalosporins (for P. aeruginosa, resistance to ceftazidime).
* For additional positive blood culture notification and freezing requirements, see Blood Culture Manual.
ICP = Infection Control Practitioner
IP = Inpatient
OP = Out-patient
UNIVERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY" are not
controlled and should be checked against the document (titled as above) on the server prior to use.
D:\81928591.doc
Page 6 of 13
Policy QPCMI15003.33
Department of Microbiology
Quality Manual
Section: Process Control
Organism
Subject Title: Isolate Notification and
Freezing Table
UHN including TRI
Enterobacteriaceae,
when ROSCO is being set up and
again with ROSCO results
Meropenem Screen=Resistant
E. coli or K. pneumoniae or P.
mirabilis
when ROSCO is being set up and
again with ROSCO results
Other Enterobacteriaceae
when ROSCO is being set up and
again with ROSCO results
MSH (perform all duties
listed)
Baycrest, Bridgepoint, CAMH,
Grace
to UHN ICPs Table.
- Call Ward
- Freeze
ICP
Bridgepoint: call ICP only)
freeze
 Email ‘Infection
Control Results
MSH’ (Mon-Sun)
 E mail Microbiologist
on-call for weekends
& after hours
 freeze
- Email or call as per Reporting  No call to ward
to UHN ICPs Table.
Call ICP & ward (except
 Email ‘Infection
- Call Ward
Bridgepoint, only call ICP);
Control Results
- Freeze
freeze
MSH’ (Mon-Sun)
 E mail Microbiologist
on-call for weekends
& after hours
 freeze
 No call to ward or ICP
 No call to ward or
ICP
 Email ‘Infection
Control Results
MSH’ (Mon-Sun)
 E mail Microbiologist
on-call for weekends
& after hours
 freeze
Meropenem Intermediate or Resistant - Email or call as per Reporting  No call to ICP
Call ICP & ward (except
Gram Negative Bacilli
to UHN ICPs Table.
Bridgepoint); freeze
 Email ‘Infection
- Call Ward
Control Results
- Freeze
MSH’ (Mon-Sun)
 E mail Microbiologist
on-call for weekends
& after hours
 freeze
N. meningitides
Isolates from blood & CSF,
Call ICP & ward - Blood and
 Call ward
respiratory if predominant:
CSF; freeze
 Email ‘Infection
Control Results
- Email or call as per Reporting
MSH’ (Mon-Sun)
to UHN ICPs Table.
 E mail Microbiologist
- Call Ward
on-call for weekends
1. MRO = Multi-resistant gram neg. organism; Defined as intermediate or resistant to >2 of the following 3 classes:
Aminoglycosides, Quinolones, 3rd Generation Cephalosporins (for P. aeruginosa, resistance to ceftazidime).
* For additional positive blood culture notification and freezing requirements, see Blood Culture Manual.
ICP = Infection Control Practitioner
IP = Inpatient
OP = Out-patient
UNIVERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY" are not
controlled and should be checked against the document (titled as above) on the server prior to use.
D:\81928591.doc
Page 7 of 13
Policy QPCMI15003.33
Department of Microbiology
Quality Manual
Section: Process Control
Subject Title: Isolate Notification and
Freezing Table
Organism
UHN including TRI
MSH (perform all duties
listed)
Baycrest, Bridgepoint, CAMH,
Grace
- Freeze
Enteric pathogens from any site
- In - patient
Enteric pathogens from any site
– Out-patient
N. gonorrhoeae
B. cepacia
& after hours
 Blood and CSF –
freeze
- Email or call as per Reporting  Call ward
to UHN ICPs Table.
 Email ‘Infection
- Call Ward
Control Results
MSH’ (Mon-Sun)
 E mail Microbiologist
on-call for weekends
& after hours
Call Ward (clinic) OR physician
Call ward; daily LIS report
Freeze
Call Ward (clinic) OR
physician
 Call ward
 daily LIS report
Freeze
Call ICP & ward
Call Ward (clinic) OR
physician
Call ward; daily LIS report
Freeze
VIRUSES
Influenza
RSV
Respiratory Viruses – new
- Email or call as per Reporting  Call ward (except
to UHN ICPs Table.
MSH ER)
- Call Ward
 Email ‘Infection
Control Results
MSH’ (Mon-Sun)
 Email ‘MSH Flu
Research ‘ (MonSun)
 E mail Microbiologist
on-call for weekends
& after hours
- Email or call as per Reporting  Call ward (except
to UHN ICPs Table.
MSH ER)
- Call Ward
 Email ‘Infection
Control Results
MSH’ (Mon-Sun)
 E mail Microbiologist
on-call for weekends
& after hours
- Email or call as per Reporting  Call ward
to UHN ICPs Table.
 Email ‘Infection
- Call Ward
Control Results
Call ICP & ward
Call ICP & ward
Call ICP & ward
1. MRO = Multi-resistant gram neg. organism; Defined as intermediate or resistant to >2 of the following 3 classes:
Aminoglycosides, Quinolones, 3rd Generation Cephalosporins (for P. aeruginosa, resistance to ceftazidime).
* For additional positive blood culture notification and freezing requirements, see Blood Culture Manual.
ICP = Infection Control Practitioner
IP = Inpatient
OP = Out-patient
UNIVERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY" are not
controlled and should be checked against the document (titled as above) on the server prior to use.
D:\81928591.doc
Page 8 of 13
Policy QPCMI15003.33
Department of Microbiology
Quality Manual
Section: Process Control
Organism
Subject Title: Isolate Notification and
Freezing Table
UHN including TRI
VZV PCR
Enteric viruses
Parvovirus B19 PCR
MSH (perform all duties
listed)
MSH’ (Mon-Sun)
 E mail Microbiologist
on-call for weekends
& after hours
- Email or call as per Reporting  Call ward
to UHN ICPs Table.
 Email ‘Infection
- Call Ward
Control Results
MSH’ (Mon-Sun)
 E mail Microbiologist
on-call for weekends
& after hours
- Email or call as per Reporting  Call ward
to UHN ICPs Table.
 Email ‘Infection
- Call Ward
Control Results
MSH’ (Mon-Sun)
 E mail Microbiologist
on-call for weekends
& after hours
 freeze
- Email or call as per Reporting
to UHN ICPs Table.
- Call Ward
Baycrest, Bridgepoint, CAMH,
Grace
Call ICP & ward
Call ICP & ward; freeze
1. MRO = Multi-resistant gram neg. organism; Defined as intermediate or resistant to >2 of the following 3 classes:
Aminoglycosides, Quinolones, 3rd Generation Cephalosporins (for P. aeruginosa, resistance to ceftazidime).
* For additional positive blood culture notification and freezing requirements, see Blood Culture Manual.
ICP = Infection Control Practitioner
IP = Inpatient
OP = Out-patient
UNIVERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY" are not
controlled and should be checked against the document (titled as above) on the server prior to use.
D:\81928591.doc
Page 9 of 13
Policy QPCMI15003.33
Department of Microbiology
Quality Manual
Section: Process Control
Organism
Subject Title: Isolate Notification and
Freezing Table
UHN including TRI
MSH (perform all duties
listed)
Baycrest, Bridgepoint, CAMH,
Grace
FUNGUS, MYCOBACTERIUM, LEGIONELLA, SEND OUTS
A. fumigatus and A. flavus – one
isolate per patient per 3 months
AFB smear – Positives-new
Freeze IP-TG, TW;
Freeze IP & OP for PMH
- Email or call as per Reporting
to UHN ICPs Table.
- Call Ward



AFB smear – Positives-old (<3
months)
- Email or call as per Reporting
to UHN ICPs Table.



TB AMTD – Pos. or Neg
- Email or call as per Reporting
to UHN ICPs Table.
- Call Ward
Mycobacterium tuberculosis Susceptibility results
- Email or call as per Reporting
to UHN ICPs Table.
- Call Ward
Legionella sp. (isolate or positive
urine antigen or PCR) including
“indeterminate” results
- Email or call as per Reporting
to UHN ICPs Table.
- Call Ward
Freeze In-patients
isolates
Call ward
Email ‘Infection
Control Results
MSH’ (Mon-Sun)
E mail Microbiologist
on-call for weekends
& after hours
Call ward
Email ‘Infection
Control Results
MSH’ (Mon-Sun)
E mail Microbiologist
on-call for weekends
& after hours
Call ICP & ward
Call ICP
Call ICP & ward
 Call ward
 Email ‘Infection
Control Results
MSH’ (Mon-Sun)
 E mail Microbiologist
on-call for weekends
& after hours
Call ICP & ward
 Call ward
 Email ‘Infection
Control Results
MSH’ (Mon-Sun)
 E mail Microbiologist
on-call for weekends
& after hours
Call ICP & ward
 Call ward
TRI: Page ICP & call ward
 Email ‘Infection
Control Results
MSH’ (Mon-Sun)
 E mail Microbiologist
on-call for weekends
& after hours
1. MRO = Multi-resistant gram neg. organism; Defined as intermediate or resistant to >2 of the following 3 classes:
Aminoglycosides, Quinolones, 3rd Generation Cephalosporins (for P. aeruginosa, resistance to ceftazidime).
* For additional positive blood culture notification and freezing requirements, see Blood Culture Manual.
ICP = Infection Control Practitioner
IP = Inpatient
OP = Out-patient
UNIVERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY" are not
controlled and should be checked against the document (titled as above) on the server prior to use.
D:\81928591.doc
Page 10 of 13
Policy QPCMI15003.33
Department of Microbiology
Quality Manual
Section: Process Control
Organism
Subject Title: Isolate Notification and
Freezing Table
UHN including TRI
All isolates referred-out to PHL for
further workup (except enterics)
Freeze
MSH (perform all duties
listed)
Baycrest, Bridgepoint, CAMH,
Grace
Freeze
Freeze
SPECIMENS
CSF Cultures and PCR – Positives
Blood Cultures – Positives
Sterile Sites other than CSF and
Blood – Positives
Central catheter tips: Staphylococcus
aureus, Gram negative bacilli and
yeast in any amount
 Call ward
 daily LIS report
(For freezing requirements of (For freezing
blood cultures, see Blood Culture requirements of blood
Isolates to be Frozen and Saved) cultures, see Blood
Culture Isolates to be
Frozen and Saved)
Call Ward (clinic)
Call Ward (clinic)
Call ward; Call ICP for TWH
Call Ward (clinic)
Call ward & page ICP
(For freezing requirements
of blood cultures, see Blood
Culture Isolates to be
Frozen and Saved)
Call Ward (clinic)
Call Ward (clinic)
Call Ward (clinic)
1. MRO = Multi-resistant gram neg. organism; Defined as intermediate or resistant to >2 of the following 3 classes:
Aminoglycosides, Quinolones, 3rd Generation Cephalosporins (for P. aeruginosa, resistance to ceftazidime).
* For additional positive blood culture notification and freezing requirements, see Blood Culture Manual.
ICP = Infection Control Practitioner
IP = Inpatient
OP = Out-patient
UNIVERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY" are not
controlled and should be checked against the document (titled as above) on the server prior to use.
D:\81928591.doc
Page 11 of 13
Policy QPCMI15003.33
Department of Microbiology
Quality Manual
Section: Process Control
Subject Title: Isolate Notification and
Freezing Table
Record of Edited Revisions
Manual Section Name: Isolate Notification and Freezing Table
Page Number / Item
Date of Revision
Annual Review
Annual Review
Annual Review
Annual Review
Annual Review
Annual Review
Annual Review
Annual Review
Freeze Meropenem I or R organisms
Annual Review
MSH – removed call ICP for Class C ESBL
MSH - Added Ertapenem I or R in Enterobacteriaceae to page ICP
and freeze
MSH – added page ICP for mero I or R
Updated viruses to reflect PCR methods
Added Urine antigen to Legionella
Freeze va=I/R CNST
Annual Review
M. tb culture and susceptibilities - change call resistant only to call
IP only
ESBL – MSH call Class A only, UHN – removed call any class
GAS Throat from UHN – removed call ICP
MRSA old – MSH – changed to No call
VRE old – MSH – change to No call
Erta, mero I/R – UHN – added call ICP and ward
Erta, mero I/R – RVHS, CAMH, TRI, CAMH, Baycrest,
Bridgepoint, Grace – added call ICP and ward
Updated ICP e mail procedure with new e mail address
Annual Review
Change Page ICP for MSH to E mail ICP (Mon-Fri, for weekendspage Microbiologist on-call) inside the table
Change VZV DFA to VZV PCR
Change to UHN ICP call for MRO and added Parvovirus
Changed Page MSH Microbiologist on call to E mail microbiologist
Updated the table – Email ICP (Mon-Sun) , Email microbiologist on
call (weekend & after hours)
Added “No overnight calls” for positive C. diff. to UHN ICP
Annual Review
Signature of
Approval
May 1, 2001
May 1, 2002
May 1, 2003
May 3, 2004
March 2, 2005
May 31, 2006
May 31, 2007
May 30, 2008
Sept 10, 2009
Sept 10, 2009
May 11, 2010
May 11, 2010
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
May 11, 2010
May 11, 2010
May 11, 2010
July 25, 2010
October 15, 2010
October 15, 2010
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
October 15, 2010
October 15, 2010
October 15, 2010
October 15, 2010
October 15, 2010
December 14, 2010
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
April 1, 2011
May 31, 2011
October 28, 2011
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
October 28, 2011
December 12, 2012
March 1, 2012
March 1, 2012
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
March 15, 2012
May 31, 2012
Dr. T. Mazzulli
Dr. T. Mazzulli
1. MRO = Multi-resistant gram neg. organism; Defined as intermediate or resistant to >2 of the following 3 classes:
Aminoglycosides, Quinolones, 3rd Generation Cephalosporins (for P. aeruginosa, resistance to ceftazidime).
* For additional positive blood culture notification and freezing requirements, see Blood Culture Manual.
ICP = Infection Control Practitioner
IP = Inpatient
OP = Out-patient
UNIVERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY" are not
controlled and should be checked against the document (titled as above) on the server prior to use.
D:\81928591.doc
Page 12 of 13
Policy QPCMI15003.33
Department of Microbiology
Quality Manual
Section: Process Control
Subject Title: Isolate Notification and
Freezing Table
Page Number / Item
Clarify Isolate notification chart regarding “Call Ward”
Added “indeterminate” to Legionella
Removed CHC/Ajax
List reviewed and revised by MSH Infection Control
Added e mail “MSH C. diff Research” for positive C. diff
Copied from Critical Result Reporting Procedure
Annual Review
Reviewed by MSH IC, see changes in turquoise – VRE vanB; Class
C ESBL
Revised ESBL reporting at MSH, Baycrest, Bridgepoint, CAMH and
Grace
Revised erta I/R and mero I/R reporting
Updated Isolate notification chart regarding MDR GN no call to
wards
Annual Review
New MSH ICP Email ‘Infection Control Results MSH’ email added.
*B19 PCR* added to Parvovirus
Removed calling positive Flu to MSH ER
Updated MSH Mother/Baby wards to new codes
Updated UHN email addresses
Annual Review:
No changes from UHN (Reviewed by Anne-Marie Gonzalez)
Bridgepoint changes: Reviewed by Sharon O’Grady
p.3:VRE-new isolate or new vanA result from Eswab PCR: Call ICP
& ward (except Bridgepoint); freeze
p.4: Group B streptococcus – In-patient and female >12 - <60 years
old; Neonates: Call Ward (except Bridgepoint)
p.5 Ertapenem I or R Enterobacteriaceae, when ROSCO is being set
up and again with ROSCO results: Call ICP & ward (except
Bridgepoint, only call ICP); freeze
p.6 Meropenem Screen=R E. coli or K. pneumoniae or P. mirabilis
when ROSCO is being set up and again with ROSCO results: Call
ICP & ward (except Bridgepoint, only call ICP); freeze
p.6 MeroI or R GNB: Call ICP&ward (except Bridgepoint); freeze
MSH Changes: Reviewed by Christine Moore
p.5 3rd Gen. Ceph. Resistant E. coli or K. pneumoniae or P. mirabilis
New Class A/New Class C Klebsiella pneumonia : Other wards: all
clinical isolates of ESBL’s Email “Infection Control
Results”(Mon–Sun)
p.6: Meropenem Screen=R E. coli or K. pneumoniae or P.
mirabilis when ROSCO is being set up and again with ROSCO
Date of Revision
Signature of
Approval
January 11, 2013
January 29, 2013
January 29, 2013
January 29, 2013
February 27, 2013
April 16, 2013
April 16, 2013
June 13, 2013
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
November 04, 2013
Dr. T. Mazzulli
November 19, 2013
May 6, 2014
Dr. T. Mazzulli
Dr. T. Mazzulli
May 6, 2014
September 3, 2014
Dr. T. Mazzulli
Dr. T. Mazzulli
January 06, 2015
April 17, 2015
April 17, 2015
April 17, 2015
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
Dr. T. Mazzulli
May 13, 2015
Dr. T. Mazzulli
May 13 2015
Dr. T. Mazzulli
1. MRO = Multi-resistant gram neg. organism; Defined as intermediate or resistant to >2 of the following 3 classes:
Aminoglycosides, Quinolones, 3rd Generation Cephalosporins (for P. aeruginosa, resistance to ceftazidime).
* For additional positive blood culture notification and freezing requirements, see Blood Culture Manual.
ICP = Infection Control Practitioner
IP = Inpatient
OP = Out-patient
UNIVERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY" are not
controlled and should be checked against the document (titled as above) on the server prior to use.
D:\81928591.doc
Page 13 of 13
Policy QPCMI15003.33
Department of Microbiology
Quality Manual
Section: Process Control
Page Number / Item
Subject Title: Isolate Notification and
Freezing Table
Date of Revision
Signature of
Approval
results: Do not call Ward
No changes from CAMH (Reviewed by Trish Szwalek)
Added PMH and TW ICP email addresses
May 13, 2015
May 13, 2015
1. MRO = Multi-resistant gram neg. organism; Defined as intermediate or resistant to >2 of the following 3 classes:
Aminoglycosides, Quinolones, 3rd Generation Cephalosporins (for P. aeruginosa, resistance to ceftazidime).
* For additional positive blood culture notification and freezing requirements, see Blood Culture Manual.
ICP = Infection Control Practitioner
IP = Inpatient
OP = Out-patient
UNIVERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red "MASTER COPY" are not
controlled and should be checked against the document (titled as above) on the server prior to use.
D:\81928591.doc