VELINDRE NHS TRUST POLICY FOR THE TRANSPORT OF PATHOLOGICAL

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VELINDRE NHS TRUST POLICY FOR THE TRANSPORT OF PATHOLOGICAL

transport of specimens

Velindre NHS Trust Policy for the Transport of Pathological Specimens

Trustwide Policy Policy Lead: D O’Brien, SICN



VELINDRE NHS TRUST




Ref: Yellow 11







POLICY FOR THE TRANSPORT OF PATHOLOGICAL SPECIMENS



Policy Lead: D. O’Brien, SICN




CONTENTS






.



Page No.


Summary

3

1.

Introduction

4




2.

Transport of specimens within the hospital and Divisional Buildings

5


2.1 Specimen forms and Bags

2.2 Specimen Carrier Container

5

6

3.

Transport Of Routine Specimens By Designated Person e.g Portering Service In Velindre Cancer Centre

7




4.

Transport or urgent specimens

7




5.

Transportation of high risk specimens

8




Transport of specimens by Road

10




7.

Communications and monitoring

12




8.

Contacts

13




9

Bibliography

14









SUMMARY


The policy aims to ensure all specimens are transported in a manner which will maintain the safety of all staff who are involved in the handling and transport of the specimens.


Main Points


  1. The appropriate forms must be fully completed with the correct relevant clinical information.


  1. Specimens must be placed in a transport bag and placed in specially designated carriers for use within the hospital/divisional building.


  1. High risk specimens must be labelled as such and transported separately from other non high risk specimens


  1. Specimens to be transported by road must be in leak proof boxes (boxes must display the UN3373 regulation diamond shape and marked Biological Substances Category B) and packed to absorb and contain possible spillages (Section 6)






1. INTRODUCTION.



The guidance in this policy is intended for all Divisions that send or transport pathological specimens (e.g. blood samples) both within the Velindre NHS Trust and to other hospitals or institutions, and departments who receive pathological specimens.


The aim of this guidance is to protect all staff involved in the routine handling of specimens.


All specimens that are known to be, or are potentially in the "Danger of Infection Group" (i.e. Hazard Group 3 organisms) must only be handled in accordance with the guidance in Section 5 "Transport of High Risk Specimens".


NB: This Policy does not include guidance for the Research Department, who will be responsible for developing/maintaining their own Policy which addresses their own specific specialised risks.




Specimens that are incorrectly packaged put others at risk, and it is the responsibility of all members of staff to ensure that this does not occur. Failure to do so is a breach of the Health and Safety at Work Act (1974) as it applies to internal transport and adr 2005 for external road transport.




2. TRANSPORT OF SPECIMENS WITHIN THE HOSPITALS AND DIVISIONAL

BUILDINGS



    1. SPECIMEN FORMS AND BAGS


      1. All specimen forms must be filled in correctly, to ensure that all the necessary clinical information is supplied to the laboratory processing the specimen. Forms must be signed by the clinician who is making the request for investigation of the sample or by the delegated appropriate nurse. The receiving laboratory may not process any sample which arrives with incomplete documentation or without a signature.

      2. The specimen must be placed in a transport specimen bag and sealed by means of the integral sealing strip. Bags must not be sealed using staples, pins, paper clips etc. Where fold over forms are used (for confidentiality purposes) they should be sealed accordingly.

      3. For larger specimens where integral forms and bags cannot be used, the specimen should be placed into a robust plastic container. The form should then either be placed in a side pocket (if present) or into a plastic envelope, which can be attached to the specimen container.

      4. At each Ward/Department there will be a pre-agreed, designated collection point. A specimen collection container will be placed at each of these points. Individual specimen bags must not be handed to Porters or other personnel, but must be placed in the approved specimen collection container with entire sides, located at Ward/Department areas prior to being collected. It will be the responsibility of the staff from that area to ensure that these containers are regularly cleaned or disinfected with an approved disinfectant. Contact Infection Control for advice if the container has been knowingly contaminated, records should be kept of all cleaning/disinfection procedures.

      5. It is essential that specimen bags are segregated from postal collections.

      6. The Porter must transfer the specimen bags from the specimen collection container held on the ward into a specimen carrier container, prior to being removed from the Ward/Department.




2.2 SPECIMEN CARRIER CONTAINER


2.2.1 Specimen carrier containers must be appropriate for the specimen being sent, so

that they can withstand the stresses, which may be placed upon them and to avoid leakage, which could cause a potential hazard to other members of staff who will have to handle them.

2.2.2 The specimen carrier container should be made of a smooth impervious material

with entire sides which can be easily disinfected or cleaned and must be able to retain any fluid in the case of a spill.

2.2.3 The container must have a secure lid for transport purposes. The carriers should be

cleaned or disinfected at least weekly by portering staff or immediately if known to be contaminated and records kept of the procedure.

2.2.4 Specimen carriers should not be used for any other purpose other than carrying

specimens. The carrier / container must have a box that must displays the UN3373 regulation diamond shape and marked Biological Substances Category B sign displayed on its outside as well as a notice: “ If found, do not open contact…………………………...

2.2.5 All the relevant clinical information required on the specimen label must be filled

in so that laboratory staff can identify the source of the specimen if the need arises (e.g. in the case of a spillage/or accident).

2.2.6 It is the responsibility of the person requesting the investigation to ensure

that all relevant information is completed on the specimen form and container, that an approved container is being used, that it is securely closed. It is inserted into the pocket of the specimen transport bag; the outer container used for transport must then be securely closed.

2.2.7 Disinfection - The carriers must be routinely wiped down with a 70% alcohol

wipe. However, if blood spillage has occurred then the appropriate spillage kit containing hypochlorite granules (NaDCC) must be used, or in the case of dried blood spillages liquid sodium hypochlorite. See Yellow Policy 4.

If there are no spillage kits available, large blood spillage may be soaked up with paper towels and the area washed with a chlorine releasing agent eg. chlorclean tablets at 10,000ppm.


NOTE: Do not use on acidic spills e.g. urine, as the two will react to release chlorine gas.




3 TRANSPORT OF ROUTINE SPECIMENS BY DESIGNATED PERSON E.G PORTERING SERVICE IN Velindre Cancer Centre


3.1 Specimens should only be carried using a secure specimen carrier container. This will limit hand contact with the specimen and in the case of leakage, contain the spill within the carrier, which can then be dealt with by the receiving department/laboratory.


3.2 It will be the responsibility of the Ward/Department Manager to ensure that sufficient supplies of specimen carrier containers are held in key designated areas.


3.3 The specimen carrier containers will be available upon request from the Operational Services Manager.



Specimens must not be transported in any way other than in the approved specimen carrier CONTAINER.



4 TRANSPORT OF URGENT SPECIMENS BY ROAD


4.1 Collection of specimens in the hospital will be on a regular portering round (10.00am, 12noon and 4.00pm), unless they are deemed to be urgent. In this case the porter’s office should be contacted and a member of the portering staff will collect the specimen and take it to the collection point using the designated specimen carrier container.


  1. Urgent specimens must be taken to switchboard. The nurse will fill in a transport request form and will phone the taxi, however if the sample is not collected within the hour switchboard staff will notify the nurse who will then be responsible for pursuing the original request. The specimen must be packaged as in 6.4. The originator of the specimen should inform the taker company how it must be transported i.e in the boot of a vehicle and not in the passenger compartment.


  1. Other division dealing with specimens must have their own protocols for collection of specimens for transport.






5 TRANSPORT OF HIGH RISK SPECIMENS


5.1 The following diseases are considered as high risk and require special procedures:

If you any unsure whether to mark a specimen as high risk, the Prevention and Control of Infection Department can be contacted for advice on Ext 6129.


5.2 A senior member of the receiving laboratory staff must be contacted before any high-risk specimen is sent.


5.3 The request form and container must be properly labelled and both marked with a yellow hazard-warning sticker.


5.4 The specimen should then be placed in the transport bag which is sealed. The biohazard sticker must be clearly visible on the request form (e.g. on the outside of fold over forms)


5.5 Specimens must not be placed in the sealed container with other samples, which are not categorised as high risk, boxes must display the UN3373 regulation diamond shape and marked Biological Substances Category B.





5.7 Transportation


The following must be contacted to arrange for the transportation of high-risk specimens: -


  1. During Working Hours:


Phlebotomy Department to arrange transportation.


  1. Out of Hours:


Operational Senior Nurse to arrange transportation.


5.8 Any specimens that are received leaking or in a dangerous condition will be destroyed. In

this event the clinician will be informed.


5.9 In the event of a breakage during transport contact the relevant ward immediately

and/or a member of the Infection Control Team. If the breakage occurs out of normal

working hours, the specimen must be taken back to base where the operational senior

nurse must take control and sort out decontamination. A member of the Infection Control

Team must be informed the following day.





6. TRANSPORT OF SPECIMENS BY ROAD


N.B. This section applies to the transport of specimens by hospital van or taxi.


6.1 It is the responsibility of the receiving laboratory, which accepts specimens from places outside their own site, to ensure that the sender is aware of the correct procedures, and that they are able to obtain a supply of the standard containers, labels and transport boxes. They should also receive written instructions on when and how to use them.


6.2 It will be the responsibility of District Transport to ensure that they comply with their requirements as stated under the applicable regulation and/or standard.


6.3 Carriage of pathological specimens between hospitals and/or GP clinics and the hospital by road comes under the remit of the ADR 2005 (Road Regulation). The approved methods to the regulations describe the packaging requirements.


6.4 The specimen must consist of 3 layers: -



    1. Specimens must be transported in a secure transport box with a fastenable lid. Each box must display the UN 3373 in its diamond and “Biological Substance Category B” warning sign and must also state that the box must not be tampered with or opened and a telephone contact number included for emergency purposes.

The transport box must be placed in the boot of any vehicle used by the Hospital (including Taxis)or the rear compartment of a hospital van and firmly secured, and MUST NOT be transported in the same compartment as passengers. Mail must not be transported in the same carrier box as specimens. The container must also be appropriately secured in any vehicle.


6.6 Arrangements must be made with Taxi Services and any other transport services used by

Velindre to ensure that they are made aware of their duties to meet the above requirements.

6.7 SPILLAGES


In the unlikely event of a specimen spillage, the following must apply:


All spills of blood and other body fluids from any source must be disinfected and removed as soon as possible, whether or not they have a known or suspected blood-borne virus:-

NB spillage of urine, do not use NaDDC granules but follow number 5.


In large open areas e.g. roads and yards, the spillage should be hosed down with large amounts of water.


Please also refer to Yellow Policy No:9.


6.8 WITHIN THE HOPSITAL


Staff must contact the source of the specimen in consultation with the Control of Infection Nurse, following the blood spillage procedure in force within the Trust








6.9 DURING TRANSPORTATION


The driver must not attempt to deal with the spillage, but must return to the Hospital and inform Switchboard staff, who will then notify the Senior Nurse on call, who will then pursue the blood spillage procedure as above and inform the ward from where the specimen originated.



7 COMMUNICATION AND MONITORING


It will be the responsibility of the Health and Safety Co-ordinator to ensure that:



It is the responsibility of the manager to ensure that:




It is the responsibility of the member of staff to ensure that:


  1. CONTACTS FOR ADVICE


Prevention and Control of Infection Department Velindre Cancer Centre

Ext 6129/2293

Direct Line 029 20196129

Bleep Number 215


Stewart Gray – Health and Saftey Advisor NPHS

Direct Line 029 2074 4172



9. BIBLIOGRAPHY


1. Categorisation of Dangerous Pathogens According to Hazard and Categories of Containment - Advisory Committee on Dangerous Pathogens 1995 and Supplement to: 2000.


2. Safe Working and the Prevention of Infection in Clinical Laboratories and similar facilities. HSAC 2003.


3. Health and Safety at Work Act 1974.


4. Carriage of Dangerous Goods and Use of transportable Pressure Equipment Regulations

2004 as amended by ADR 2005 (Road Transport Regulation) – Department for Transport.

1 The list is not exhaustive – If in doubt please discuss with Consultant Microbiologist.

2 WBS use Virisolve Plus according to manufacturers instructions

Ref: Yellow 11 Page 14 of 14

Approved by: Infection Control Committee Approval Date: October 2006

Next Review Date: November 2009 Issue Number: 2





Tags: pathological specimens, of pathological, transport, trust, policy, pathological, velindre