DALLAH HOSPITAL MC-LPCI-002 ISSUE # 1

LABORATORY
Replaces: MC-
DEPARTMENT Approved Date:
Category LPCI 2 and 3
Prevention and Control of 15-01-2017
Infections

LABORATORY STANDARD Effective Date: Due for Review:

Title
PRECAUTIONS 30-01-2017 14-01-2019

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.

4.3 Waste Management and Sharps Disposals

4.3.1 Proper waste disposal in the laboratory are categorized and disinfection procedure
are followed before disposal (See LSF 006- Hazardous Material Waste Management
and Disposal)
4.3.2 Sharp disposal, management and practice for safe handling of sharps, needles and
glassware must be implemented as described in LSF 013 Management of Sharps
and Sharp injuries.

4.4 Immunization
MC-LPCI-002
15-01-2017
Page 1 of 4
 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.

4.6 Spill response

4.6.1 Spill kits availability and spill response training drills are essential procedure done in
the laboratory department.
(See MC-LSF-011 Spill Response for Laboratory Personnel)

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.

5.4 Laboratory Facilities

MC-LPCI-002
15-01-2017
Page 2 of 4
 5.4.1 Laboratory doors should be self-closing with locks in accordance to hospital policies.
5.4.2 Laboratory must have sink for handwashing manually or hand-free automatically
operated and preferably located near exit door.
5.5 Infectious Waste Management and disposal
5.5.1 Proper handling and disposal of laboratory infectious waste includes cultures and
stocks of infectious agents (Culture dishes, inoculates, etc.) pathological wastes (wet
tissues, blood, body fluids, organs, blood products) and isolation waste, machine
waste etc. Microbiology laboratory waste must be autoclaved before disposal (See
LSF 006 Hazardous Material waste management and disposal)
5.5.2 Contaminated sharps, needles, scalpels, broken glass, pipette tips, slides are
discarded into punctured resistant containers which are disposed when ¾ full (See
LSF 013 Management of sharps and sharp injuries.
5.5.3 No recapping of needless. Needles shall not be bent, broken or manipulated. All
needle stick or needle prick injuries must be reported to Employee Health Clinic and
algorithm of needle prick exposure is followed. Post exposure serologic test is
important.
5.6 All laboratory personnel must receive Hepatitis B vaccine free of charge upon hire and other
mandatory vaccine such as fluvax when necessary.
5.7 All specimen transported to the laboratory must be labelled properly and packed in biohazard
ziplock containers or package in trays, racks and specimen box. Specimen must not be
carried in hands, pockets logbooks.
5.8 Hand and arm jewelry shall be minimized. Fingernails trimmed with no nail polish.
5.9 Proper housekeeping is essential in disinfection of work areas before and after duty “wipe-
spray-wipe” method leaving 1 minute contact time of standard disinfectant to surfaces,
tabletops, countertops, and work benches is necessary.
(See Attachment Standard Disinfectant PC Policy I General overview.
5.10 Biohazard Spill kits other chemical spill kits shall be available in the laboratory.
Training on use and drills on spill response must be done on regular schedule. (See
LSF 011 Spill response for lab personnel)
5.11 Phlebotomy shall follow standard precaution, practices and principles of aseptic
technique and frequent hand hygiene. (See MC LCP Blood Sample collection policy
and SOP)

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

7.1 Attachment A: Sequence of putting on PPE (Donning and Doffing of PPE)

7.2 Attachment B: Blood and Body Fluid Spill Cleaning
7.3. Attachment C: WHO 5 Moments of hand Hygiene
7.4. Attachment D: Standard Precautions

8. REFERENCES
MC-LPCI-002
15-01-2017
Page 3 of 4
 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

9.1 Major Revision

9.2 Format Changed

10. DISTRIBUTION

10.1 Available in E-manuals

10.2 All Departments

MC-LPCI-002
15-01-2017
Page 4 of 4
Revised by : __________________________________ Date: 05-01-2017
FARIDA JAMALUDDIN
Laboratory IPC Coordinator

Reviewed by : _____________________________________ Date: 10-01-2017

DR. ELHAMY SAMY RIZK
Head of the Laboratory Department

Reviewed by : _____________________________________ Date: 10-02-2017

DR. MOHAMMED NAGUIB EL-HADIDI
IPC Unit Physician

Reviewed by : _____________________________________ Date: 10-01-2017

DR. SAEED I. ALI
QI and Risk Manager

Approved by : _____________________________________ Date: 15-01-2017

DR. SALAH AL-FAQIH
Chief of Medical Staff

MC-LPCI-002
ATTACHMENT A
MC-LPCI-002
15-01-2017
Page 1 of 3
ATTACHMENT A
MC-LPCI-002
15-01-2017
Page 2 of 3
ATTACHMENT A
MC-LPCI-002
15-01-2017
Page 3 of 3
 BLOOD AND BODY FLUID SPILL CLEANING PROCEDURE

PROCEDURE:

A. Blood Spill Bucket includes:

1. P.P.E. – (Personal Protective Equipment)

a. Personal Protective Gown
b. Surgical Mask
c. Face Shield
d. Head Cover
e. Shoe Cover
f. Disposable Gloves -2pairs
2. Yellow Infectious Waste Bags – 10 gal and 50 gal.(with Biohazard label)
3. Presept Powder
4. Scoop and Scraper or Paper Towel
5. Cable Ties
6. Hand Sanitizer

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
Page 1 of 3
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
15-01-2017
Page 3 of 3
ATTACHMENT C
MC-LPCI-002
15-01-2017
Page 1 of 1
ATTACHMENT D
MC-LPCI-002
15-01-2017
Page 1 of 1