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Sop Infection Control Part 2
Sop Infection Control Part 2
LABORATORY
Replaces: MC-
DEPARTMENT Approved Date:
Category LPCI 2 and 3
Prevention and Control of 15-01-2017
Infections
1. CONTENT
This policy describes the Standard Precaution procedures to be complied in the Laboratory
Department
2. PURPOSE
2.1 To minimize the risk of transmission of blood borne pathogens and other potential hazards by
following proper techniques and safe work practices or Standard Precaution at all times.
2.2 To achieve higher compliance rate of hand hygiene in the department.
2.3 Ensure that all laboratory staff receive Infection Control Orientation training upon hire and
updated annually.
2.4 To ensure all personnel in the laboratory received Hepatitis B vaccine upon hire and other
mandatory vaccines.
3. DEFINITION
3.1 Standard Precaution- are set of procedures and measures designed to be practiced in
preventing spread of infection to patients, staff colleagues and community.
3.2 Disinfection- process of reduction of microorganism to a level that cannot cause infection
using standard recommended disinfectant.
3.3 Sterilization- total removal or elimination and killing of microbes or pathogens using
recommended sterilant or disinfectant.
4. SCOPE
4.1 Hand hygiene- is the first most important means of preventing spread of infection. It includes
Handwashing with soap and water and hand rubbing using alcohol gel for 60 seconds
following prescribed techniques recommended by WHO (World Health Organization)
4.2 PPE (Personal Protective Equipment) apparels designed as barrier protection during work
namely gloves, gown, aprons, mask, goggles, face shield, head cover, shoe cover. PPE is
used to create a barrier between staff and patients, substances and surfaces.
4.4 Immunization
MC-LPCI-002
15-01-2017
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4.4.1 Administration of vaccine free of charge to all staff upon hire (Hepatitis B) and other
required immunization like Flu vaccine etc.
4.5 Disinfection
4.5.1 Surface disinfection of work areas in the laboratory using standard disinfectants
recommended by IPC unit is essential procedure.
4.5.2 Proper housekeeping is required.
5. POLICY
5.1 Standard precaution shall be strictly complied at all times by the personnel in the laboratory. It
shall be followed when handling specimens, when performing phlebotomies, and when in
technical area.
5.2 Hand hygiene shall be practiced, complied by all laboratory staff. It is the most important
means of preventing spread of infection and must be done correctly and frequently following
the WHO prescribed techniques.
5.2.1 Hands shall be washed with soap and water vigorously rubbing all surfaces of
lathered hands for 15 minutes and rinsing underwater entire procedure is 60
seconds. (Refer to GC-PCI-014 Hand Hygiene)
5.2.2 Hand hygiene is also done using alcohol gel for 60 seconds following same
prescribed technique designated by WHO and 5 moments.
5.2.2.1 Before Patients Contact
5.2.2.2 Before aseptic technique
5.2.2.3 After blood and body fluid exposure
5.2.2.4 After patient contact
5.2.2.5 After contact with patient environment
5.2.3 Hand Hygiene is also recommended
5.2.3.1 When coming to duty
5.2.3.2 Whenever hands are visibly soiled
5.2.3.3 After personal use of toilet
5.2.3.4 Before eating and after eating or smoking
5.2.3.5 After removal of gloves
5.3 Personal Protective Equipment (PPE) and Primary Barriers
5.3.1 Properly maintained Biosafety Cabinets class II and other appropriate protective
barriers and device must be used and available such as laboratory coat, gowns,
smocks, uniforms designated for laboratory used must be worn while working with
hazardous materials. Remove and dispose protective apparels for laundry. Do not
take laboratory gowns and coats home.
5.3.2 Eye and eye protection
Goggles, mask, face shield and other splatter guards are used for anticipated
splashes or sprays of infectious or hazardous materials. Dispose eye and face
protection devices or decontaminate before re-use.
5.3.3 Gloves
5.3.4 Latex-free, nitrile gloves must be worn to protect hands from exposure to hazardous
materials and must not be worn outside laboratory work areas
5.3.4.1 Gloves must be changed after each patient in phlebotomy with proper hand
hygiene before and after use.
5.3.4.2 Do not wash, re-use gloves.
6. PROCEDURE
6.1 Standard microbiology procedure must be followed on entry-exit of microbiology area. All staff
and visitors must be aware of potential hazards.
6.2 Lab equipment should be routinely decontaminated before and after use, before repair,
maintenance or removal from laboratory.
6.3 All procedure involving manipulation of infectious materials that may generate aerosol must
be done within BS Cabinets II or fume hood.
6.4 Phlebotomy Standard Operating Procedure (SOP) is available in MC LCP Laboratory
Collection Policy 002.
7. ATTACHMENTS
8. REFERENCES
MC-LPCI-002
15-01-2017
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8.1 Infection Prevention and Control Manual 2nd Edition 2013
8.2 GC-IPC-014 Hand Hygiene
8.3 GC-IPC-016 Donning and Doffing of PPE
8.4 MC-LSF-011 Spill Response for laboratory personnel
8.5 MC-LSF-013 Management of Sharps and Sharp injuries
8.6 MC-LSF-006 Hazardous Material Waste Management and Disposal
8.7 GC-PCI-012 Standard Precaution
8.8 GC-PCI- 016 Donning and Doffing of PPE
8.9 GC-HSK 023 Blood and Body Fluid Spill Cleaning
9. REVISION
10. DISTRIBUTION
MC-LPCI-002
15-01-2017
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Revised by : __________________________________ Date: 05-01-2017
FARIDA JAMALUDDIN
Laboratory IPC Coordinator
MC-LPCI-002
ATTACHMENT A
MC-LPCI-002
15-01-2017
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ATTACHMENT A
MC-LPCI-002
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ATTACHMENT A
MC-LPCI-002
15-01-2017
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BLOOD AND BODY FLUID SPILL CLEANING PROCEDURE
PROCEDURE:
Major Spill
B. Place precaution sign near the spill.
C. Immediately inform the area supervisor
D. Perform Hand Hygiene then, wear the personal protective equipment.
Sequence of wearing P.P.E.
1. Personal Protective Gown
2. Surgical Mask
3. Face Shield
4. Head Cover
5. Shoe Cover
6.2 Pairs of Gloves
ATTACHMENT B
F. Prepare the Yellow Infectious Waste Bags (big & small), make sure it is properly open.MC-LPCI-002
15-01-2017
G. Open the Presept Powder Container and sprinkle powder over the spill. Allow spill to solidify
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before removing (contact time 2-3 minutes recommended time by the manufacturer for
disinfection )
H. Remove solidified waste material with scoop and scraper(if scoop & scraper are not available
use paper towel). Carefully place all contaminated materials(.including scoop & scraper and the
1st layer gloves) inside the yellow (small) waste bag. Secure seal bag with cable tie and place
inside the yellow (large) waste bag. If reusable scoop and scraper is used, place in a separate
plastic bag and send to CSSD for disinfection.
I. Routine floor mopping follow there after.
J. Remove P.P.E.
Sequence of Removing P.P.E.
1. Shoe cover
2.2nd Layer Gloves
3.Gown
Note: Perform Hand Hygiene
4. Head Cover
5. Face Shield
6.Mask
K. Place all inside the large waste bag and seal with cable tie. Fill-up all the information written
on the large waste bag ( be specific in writing the type of waste cleaned), put inside the
infectious waste transportation trolley and send to the infectious waste room Level – 0
L. Promptly wash hands thoroughly with soap and water.
M. Once blood and Body Fluid Spill Bucket is used, always refill and be ready for the next ATTACHMENT
use. B
MC-LPCI-002
N. Minor Spills use Steri-7 and paper towel (spray – wipe – spray ) one (1)minute contact15-01-2017
time.
Page 2 of 3
ATTACHMENT B
MC-LPCI-002
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ATTACHMENT C
MC-LPCI-002
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ATTACHMENT D
MC-LPCI-002
15-01-2017
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