Laboratory Safety Policy

Procedure

A. a. Guidelines for Personal and Environmental Safety in the Microbiology Laboratory
- b. Employees should read and understand the Laboratory Manual and Employee Handbook
  - A. Located on the Clinical laboratory intranet and Human Resources Website respectively
- c. To prevent the transmission of infectious agents, OSHA requires hand washing after glove removal regardless of whether gloves "look" clean.
- d. The microbiology safety technologist/s, section director and supervisor, and Quality Assurance and Performance Improvement Coordinator should be notified of safety violations and/or potential/confirmed exposures.
- e. Hands should be washed frequently and especially prior to leaving the laboratory.
  - A. Hand-washing is considered the most important single procedure for preventing and controlling the spread of infection. Proper hand-washing has been shown to eliminate or greatly reduce hand carriage of pathogens.
- f. Hand-washing to be used in the laboratory:
  - A. When coming on duty
  - B. Before and after eating (not in the laboratory)
  - C. Before and after using the restroom
  - D. Before going off duty (leaving the laboratory)
  - E. After contact with contaminated objects
  - F. After contact with patient specimens, Universal Precautions apply to all specimens
  - G. After removal of protective gloves
- g. Hand-Washing Procedure:
  - A. Wet hands under running water
  - B. Keep hands lower than elbows, apply soap
  - C. Work into a lather scrubbing fingers, palms, backs of hands, wrist and forearms creating friction for at least 15 seconds. Cleaning under nails should be attempted.
  - D. Thoroughly rings hands under running water, preferably hot/warm water
  - E. Use paper towels to blot and dry hands
  - F. Use dry paper towel to turn off faucet, then discard
- h. Laboratory Acquired Infections are often acquired through spills and splashes of infectious material onto BARE intact or non-intact skin and mucous membranes.
  - A. Examples of how this commonly occurs:
    - a. Touching mouth or eyes with fingers or contaminated objects.
    - b. Eating, drinking, using lipstick, lip balm or chewing gum while in the lab.
  - i. To prevent laboratory acquired infections the following are mandatory:
    - A. No food, drinks or chewing gum are allowed within the laboratory.
      - a. No food can be placed in laboratory refrigerators.
        
        A. Employees and visitors are shown where the designated eating and refrigeration areas are by the safety officer or lab supervisor
        
        B. Laboratory Personnel should not utilize cell phones within the laboratory. Do not bring cell phones into the laboratory; these should remain securely locked within personal lockers.
        
        C. PPE must be utilized:
        
        a. Gloves for handling all potentially contaminated materials, containers, equipment, or surfaces
        
        b. Protective laboratory coats, gowns, or uniforms should be worn fully buttoned to prevent contamination of personal clothing while working on a "dirty" bench of the laboratory.
        
        A. If the lab bench is decontaminated and free of cultures or specimens then a lab coat is not mandated when performing paperwork review only.
        
        c. Additional PPE may be necessary depending on which hazards you are working with. This is not an inclusive list of PPE requirements. See additional Sections (Biohazard levels, risk assessment).
        
        D. PPE should NOT be worn in any area designated a "clean" room. This includes offices, and the lounge area.
        
        a. Remove protective clothing before leaving for non-laboratory areas (e.g., cafeteria, break room, administrative offices).
        
        E. Dispose of single-use protective clothing with other contaminated waste.
        
        F. Dispose of re-useable laboratory coats in appropriate "to be cleaned/dirty" basket at least 1x per week or when visibly dirty.
        
        G. Additionally, if it is noted that visitors to the Microbiology laboratory (such as medical students, attending clinicians, etc.) have food, drinks or water on their person, they must be instructed to place those items outside of the laboratory immediately.
        
        H. Visitors cannot and should not utilize cell-phones at the laboratory work areas.
        
        a. They should be asked to wash hands and leave laboratory area in order to use cellular phones.
        
        I. N95 respirators are to be worn when working with any potential BSL-3 organism (i.e. M. tuberculosis complex) in the negative airflow room (219A Pavilion) within the BSC.
        
        a. N95 Respirators:
        
        A. A licensed medical doctor/University Health Services (UHS) employee must first examine anyone requiring the use of any type of respirator.
        
        B. The employee must then provide a written report signed and dated by the examining physician/UHS documenting that the person's state of health is suitable to withstand the use of the respirator without incurring health problems.
        
        C. Upon receiving medical approval, the employee must be fitted and trained in the proper care and use of the respirator before wearing it. The initial fit testing occurs at UHS. Annually thereafter, UHS receives the employee health questionnaire from the employee and UHS certifies that the employee is able to use a respirator and provides the documentation to the Microbiology/Clinical Lab designee that is trained to perform respiratory fit testing.
        
        D. The microbiology laboratory designee then schedules fit testing to be performed by the employee needing annual retesting.
        
        a. If an employee were to fail the department fit testing, the employee is referred back to UHS for further evaluation.
        
        E. The designee is responsible for completing the necessary paperwork and forwarding the results to the TJUH Environmental Safety and Health Officer (Cherry Morangne, 1620 Edison Bldg, x34711).
        
        a. The designee also keeps a current list/file of Microbiology lab employees and the dates fit tested and type/size respirator worn.
B. Dress Code
- a. As clearly stated in the Jefferson Laboratory policy, section LABORATORY DRESS CODE. http://tjuh3.jeffersonhospital.org/policy/index.cfm/clinical_labs_pnp/view/id/200962
  - b. LABORATORY DRESS CODE
    - A. To maintain a professional image and insure safe working conditions, all employees must adhere to the established dress code. Jefferson employee identification badges are to be displayed at all times while on hospital and/or university property.
    - B. Employee-purchased scrub suits are acceptable clothing to be worn with laboratory coats. Personal clothing may be worn under the laboratory coat providing it meets acceptable standards as determined by the section director and supervisor [If policy is not adhered to by everyone, an enforced scrub unit or Hospital Logo T-shirt with scrub bottom policy will become implemented]. Blue jeans are not to be worn by any person having patient contact.
      - C. Open toe shoes, sandals, perforated clogs and cloth sneakers (clothe sneakers are only allowed if a backup pair of closed toe shoes are kept in the locker in case of contamination) are unacceptable apparel for working in the laboratory.
      - D. Head coverings, except for religious purposes, are not to be worn in the laboratory.
      - E. Bare legs or feet are not allowed within the laboratory.
C. Laboratory Environment Considerations:
- a. Prohibit entry of unauthorized personnel into the laboratory.
  - b. Any personnel entering the lab must have appropriate identification
  - c. The Microbiology laboratory (BSL2) doors must remained closed at all times and key pad locked. Do not give unauthorized persons the key code.
  - d. Maintain maximum light (windows, overhead lights, etc.) necessary for clear visibility of all equipment and fixtures.
  - e. Keep extraneous and unnecessary noises at a minimum to avoid distractions.
  - f. No personal calls are allowed within the laboratory
    - A. Emergency calls require that the technologist step out of the laboratory to accept.
  - g. No cell phones/mp3 (portable device) music in the laboratory. Excessive Noise GEN.77300
    - A. Music from a computer desktop must be acceptable to all persons within hearing range and the volume must be kept low to avoid being a distraction.
    - B. Noise is monitored in the laboratory by the Quality Assurance and Performance Improvement Coordinator.
    - C. Clinical Laboratories and kept to a minimum so as not to become excessive.
      - a. Excessive noise is defined as distracting or damaging to staff hearing capacity.
    - D. Monitored noise levels with the assistance of Environmental Health and Safety Dept.
    - E. NOTE: The laboratory should provide protection against the effects of noise exposure when sound levels equal or exceed an 8-hour time-weighted average sound level of 85 decibels.
      - a. The laboratory should monitor noise exposure if there is an indication that excessive noise levels are present (for example, when noise levels exceed 85 decibels, people have to shout to be heard). See Clinical Laboratories Policy.
    - D. Benchtop Decontamination and Organization:
      - a. Utilize 10% bleach and 70% ethanol to disinfect surfaces.
      - b. Benchtop decontamination is to be performed:
        
        A. At the beginning and end of the shift
        
        a. This is documented for each bench in the LIS or a QC worksheet for each bench.
        
        B. In the event of any gross contamination
        
        C. When switching from culture reading to non-culture work (i.e. paperwork)
      - c. Benchtop organization and cleanliness:
        
        A. Keep workspace clean and organized and dusted regularly
        
        B. Keep aisles clean of all obstructing items
        
        C. Keep shelves clean, organized, free from clutter and dusted regularly
        
        D. The full cleaning of each workspace is assigned and documented 2 times a year, see Attachment #1.
E. Ergonomics:
- a. Employees are educated on Ergonomic Hazards and Muscoskeletal Disorders (MSDs) through mandatory online in-service (Healthstream).
- b. Address any concerns about ergonomics to Rehabilitation Medicine. An Ergonomic Survey is conducted annually by Rehabilitation Medicine.
- c. Contact information for Rehabilitation Medicine:

▪ Jason Melnyk, OTR\L, MS, CEAS II
▪ Clinical Specialist- Working Conditioning & Ergonomics
▪ JeffFIT-Thomas Jefferson University Hospital
▪ 215-955-1214
▪ [email protected]

F. Equipment Use and Maintenance:
- a. Equipment can produce aerosols
- b. Centrifugation of specimens should be done using capped tubes, closed centrifuges
- c. Pipetting, when indicated in specific SOPs, should be done inside of a BSC to contain aerosols that may be produced during use
- d. Proper maintenance of equipment is necessary for safe use (PMs performed by Izzy or Manufacturer).
- e. Safety equipment such as biological safety cabinets, autoclaves, U. V. lights, etc., are to be checked as described in the instrument quality control manual.
- f. Routine maintenance is listed in each SOP incorporating the instrument.
- g. Annual preventive maintenance is scheduled through the QC technologist, Lead technologist or Supervisor.
G. Patient Specimen Handling:
- a. Patient specimens pose a significant risk of transmitting pathogenic microorganisms
  - A. All specimens are to be treated as though they are potentially infectious
  - B. Patient specimens are only to be opened with proper precautions
    - a. Specimens for culture are only to be opened in a BSC
    - b. Serum and whole blood specimens should only be opened while utilizing a face shield, enclosed containment hood or tabletop shield.
  - C. Gloves are to be worn when handling any specimen
    - a. Change gloves in the event of contamination
  - D. Wash hands frequently when working with patient specimens
- b. Use care when processing specimens using sharps such as scalpels and needles. Penetration of the employee's skin by sharp objects contaminated with infected blood or other body material is one of the most certain methods to produce infection in susceptible individuals
  - A. Read and understand package insert instructions for using scalpels
    - a. Safety Scalpels are now in place. The Handles are reusable and must be cleaned between uses.
  - B. Use only safety needles and vacutainer vents (supplier: BD) when processing blood cultures and body fluids
  - C. Promptly discard of all needles, scalpels, and other sharps in the sharps bin provided under the hood.
    - a. Avoid leaving sharps lying on the bench-top or in the hood
- c. Pipetting specimens by mouth is not permitted. To pipette specimens use automated pipettes or propipettes for all materials and patient specimens in the lab.
- d. Leaking specimens pose a significant risk to all personnel as well as the integrity of the specimen itself.
  - A. All received containers should be visually inspected for leakage.
  - B. In the even a specimen is leaking, notify the floor or office responsible for collection
    - a. If this is not a unique specimen (i.e. sterile body fluids, specimens collected invasively) request that the specimen be recollected
      - A. Cancel as "Specimen leaked in transit" (Code: SL)
      - B. Do not attempt to open and clean the specimen
    - b. In the event the specimen cannot be recollected, i.e. the specimen is unique; it may warrant you to complete the request.
      - A. Notify the supervisor
      - B. Assess the degree of leakage and determine which tests can be run
      - C. Notify the floor or doctor's office of the leakage
        
        a. Request a new requisition slip if contaminated with specimen
        
        b. Have physician prioritize test orders if not all can be completed with remaining specimen
      - D. Clean the specimen in the BSC
        
        a. Remove specimen from the contaminated bag
        
        b. Decontaminate the exterior of the specimen using CiDecon.
        
        c. Discard requisition slip if also contaminated
      - E. Indicate in the culture results that the results may be affected due to specimen leakage.
- e. Culture Handling:
  - A. The majority of cultures can be worked up on the benchtop while wearing gloves
  - B. Refer to Biosafety levels of organisms for specific guidelines by level and suspected agent
- f. Exposures and Laboratory Accidents:
  - A. All Laboratory accidents are to be reported through the Online Accident Reporting form found in each individual's PeopleSoft Employee Account.
  - B. During dayshift, if an employee is exposed to an infectious agent or gets injured with a contaminated sharp object, the employee must report to University Health Services with the completed Accident Reporting Form.
  - C. On second or third shift, the employee reports to the emergency department with the completed Accident Reporting Form.
H. Biological Spill Clean-up (Handling) Procedure: MIC.18985
- a. Personal exposure takes priority over clean up.
  - A. If you are exposed, immediately remove contaminated clothing and other protective equipment and wash affected areas with soap and water.
    - a. If medical follow-up is warranted it should be sought immediately. NOTE: follow appropriate doffing of PPE order for a BSL2 or BSL3 location (Attachment 1)
    - b. Emergency Shower use (pull down on large ring to activate shower, pull down on small ring to deactivate/stop shower).
    - c. Emergency Eyewash use (flush eyes for at least 15 minutes using the nearest eyewash).
  - b. The following supplies should be kept assembled in case of a spill.
    - A. Spill kit
      - a. Located in processing cabinet next to sink labeled "Spill Kits."
I. Laboratory Spill Clean-up Procedures:
- a. Spills involving microorganisms requiring BL-1 or BL-2 (low to moderate risk agents) containment
  - A. Alert people in immediate area
  - B. put on protective equipment
  - C. Cover an area twice the size of the spill with disinfectant soaked-paper towels. Or, surround the spill with dry disinfectant per label directions.
    - a. DO NOT directly poor disinfectant onto the spill. Gently cover with paper towels, and then add disinfectant in a circular motion, starting at edge of paper towels and moving inward. This helps prevent aerosol formation.
  - D. Allow 20 minutes of contact period with disinfectant.
  - E. Wipe down any contaminated stationary equipment or furniture with disinfectant
  - F. Use forceps, tongs, or broom to remove broken glass and other items; place in sharps container or red bag as appropriate. Use the spill kit scoop for picking up small amounts of broken glass. Never use fingers to pick-up broken glass or sharp objects.
  - G. Remove towels and re-clean area with disinfectant solution.
  - H. Decontaminate (autoclave, chemical treatment) reusable clean-up items and other reusable equipment, as appropriate.
  - I. Inform laboratory personnel when the cleanup is complete.
  - J. Complete Accident Report Form in PeopleSoft account if there is an employee exposure.
- b. Spills inside a Biological Safety Cabinet:
  - A. Keep the cabinet running
  - B. Clean-up as per directions above, making sure to wipe down back and side walls of cabinet
  - C. If material has spilled into the catch basin beneath the work surface, add a volume of disinfectant equal to the quantity in the basin, wait 20 minutes, and absorb with paper towels
  - D. After completion, allow cabinet to run for ten minutes before resuming work.
- c. Spills inside a centrifuge:
  - A. Shut centrifuge off and do not open the lid for 20 minutes to allow aerosols to settle.
  - B. put on PPE
  - C. Use a squeeze bottle to apply disinfectant to all contaminated surfaces within the chamber, taking care to minimize splashing
  - D. Allow 20 minute contact period and then complete clean-up of the chamber.
  - E. Remove buckets and rotors to nearest Biological Safety Cabinet; disinfect and clean as per manufacturer's instructions.
- d. Spills outside the Laboratory:
  - A. Viable organisms should only leave the laboratory in a well-sealed primary (inner) and secondary (outer) container with a closable top. A test-tube rack inside a tray is not acceptable.
  - B. The exterior of the secondary container should be wiped down with disinfectant prior to leaving the laboratory so that it can be transported without wearing gloves.
  - C. Obtain an Infectious Spill Cleanup kit and follow instructions or carry paper towels and if a spill occurs use the towels to cover the spill but do not attempt a clean-up without appropriate disinfectant and personal protective equipment.
  - D. Notify people in the immediate area and collect clean-up material and proceed with clean-up.
J. Infection Prevention Checklist:
- a. The employee understands that all laboratory accidents are to be reported to the supervisor and/or section director and subsequently handled by Employee Health Services and the Laboratory Safety Officer.
- b. Hospital employees must protect other employees and patients from infectious diseases.
  - A. The employee understands that when he/she has diarrhea, skin lesions, respiratory illness, fever, etc., he/she must report these symptoms to the supervisor and then EHS if needed.
- c. The employee understands that he/she is to have continuing routine health checks.
  - A. The minimum is a PPD test or quantiferon TB gold annually.
  - B. Other checks, such as a test for Hepatitis & HIV may be necessary in certain exposure
  - situations
K. Material Handling:
- a. All materials that are considered corrosive, toxic, or flammable must be handled with caution. The following in particular require such care. See Environmental Health and Services information.
  - A. Strong oxidizing agents
  - B. Strong mineral acids and alkalis
  - C. Chlorinated hydrocarbons
  - D. Suspected carcinogens
  - E. Cyanide solutions
  - F. Mercury
  - G. Sulfides in solution
  - H. Flammable and explosive solvents
  - I. Radioactive materials
L. General and Specific Rules:
- a. Refer to SDS Online for specific information regarding hazardous material utilization, storage, cleanup and first aid. (https://msdsmanagement.msdsonline.com/9fa73862-fcb2-4c8e-929fe6b7c17125db/msdsonline-search/)
- b. Handle all dangerous materials with special care - do not splash splatter or spill. If accidents occur, clean up immediately by appropriate means.
  - A. Remove soiled clothing immediately.
  - B. Flush immediately all cuts, burns and punctures obtained when handling dangerous materials with running water. Obtain first aid. Know the location and operation of safety showers.
- c. Conduct all work on toxic and flammable materials under fume or exhaust hoods. When heating flammables, electric heating must be used - not open burners
- d. Wear approved safety masks/goggles/UV eyeglasses when eye hazards exist. Contact lenses should not be worn in work areas.
- e. If testing of chemicals by smell is necessary, hold bottle a short distance from the nose, brush vapors toward the face gently, then, immediately fill the lungs with clean air to expel fumes completely.
- f. For disposal, all corrosives go through Environmental Health & Safety and the Chemical Hygiene Officer should be contacted for consultation.
- g. Toxic materials are disposed of through the Environmental and Safety department (retrieves the acids and corrosive material). Special pick-ups are scheduled.
- h. Identify all containers holding radioactive materials or toxic agents by a warning label with the contents.
- i. Do not pipette radioactive or toxic agents.
- j. Cover work surfaces for radioactive materials with absorbent or blotter type paper. Spillage must be wiped immediately and decontaminated.
M. Chemical Storage:
- a. Clinical Laboratories SOP # 11.05 Chemical Hygiene Plan Subsection Chemical Storage provides all documentation of Chemicals and how to handle carcinogens and other toxic materials.
- b. Acid Cabinet and Corrosive Cabinet room 219 Pavilion, next to Fume Hood
- c. Flammable Cabinets locations: Room 401
N. Other Hazards:
- a. UV Light is associated with corneal and skin burns, exposure should be kept to a minimum
  - A. UV emitting devices are clearly labeled
  - B. PPE (i.e. UV goggles) are provided for work with UV emitting devices
  - C. UV light used for decontamination should not be on while there are personnel present.
  - D. MAKE SURE DOORS ARE CLOSED AND NO ONE IS IN ROOMS WHEN BSC UV LIGHTS ARE ON!
- b. Liquid Nitrogen is in Clinical Laboratories Policies and Procedures SOP 11.05 Cryogenic Liquids.
- c. Latex is addressed in the Clinical Laboratories Policies and Procedures: SOP 11.15 Disposable Gloves.
- d. Sodium Hypochlorite (Bleach) - See table:


Incompatible material	Possible result from mixing
▪ alum (aluminum sulfate) ▪ aluminum chloride ▪ ferrous or ferric chloride ▪ ferrous or ferric sulfate ▪ nitric acid ▪ hydrochloric acid (HCl) ▪ sulfuric acid ▪ hydrofluoric acid ▪ fluorosilicic acid ▪ phosphoric acid ▪ brick and concrete cleaners ▪ chlorinated solutions of ferrous sulfate	▪ Release of chlorine gas, might occur violently.
▪ ammonium hydroxide ▪ ammonium chloride ▪ ammonium silicofluoride ▪ ammonium sulfate ▪ quaternary ammonium salts (quats) ▪ urea	▪ Formation of explosive compounds ▪ Release of chlorine or other noxious gases.
▪ fuels and fuel oils ▪ amines ▪ methanol ▪ organic polymers ▪ propane ▪ ethylene glycol ▪ insecticides, solvents and solvent-based cleaning compounds	▪ Formation of chlorinated organic compounds. ▪ Formation of explosive compounds. ▪ Release of chlorine gas, may occur violently.
▪ copper ▪ nickel ▪ vanadium ▪ cobalt ▪ iron ▪ molybdenum	▪ Release of oxygen gas, generally does not occur violently. ▪ Could cause overpressure/rupture of a closed system.
Hydrogen peroxide	Release of oxygen gas, might occur violently.
▪ sodium sulfite ▪ sodium bisulfite ▪ sodium hydrosulfite ▪ sodium thiosulfate	Evolution of heat might cause splashing or boiling.
sodium chlorite	Release of chlorine dioxide, chlorine, or oxygen gas. Increased rate as pH is lowered.
Avoid direct contact with sunlight or UV light.	Release of oxygen gas, generally does not occur violently. Could cause overpressure/rupture of closed system.

O. Waste Disposal:
- a. Contaminated and potentially contaminated trash and waste must be placed in laboratory waste cans for contaminated materials.
  - A. Sharps are defined as any item that can potentially pierce a plastic bag
    - a. Sharps are to be disposed of in RED Plastic sharps bins
      - A. These bins are managed by Stericycle
    - b. Examples of Sharps: Scalpels, needles, test tubes (glass and plastic), culture plates, glass (broken and intact)
- b. Biohazardous waste that is not considered "sharps" waste are disposed of in the clearly labeled Biohazard Waste containers, lined with a clearly marked RED trash bag.
  - A. Environmental Services personnel are responsible for lining the cans with heavy plastic liners.
    - a. Environmental Services securely closes the bag when it is full and inserts it into another bag which is also securely closed
    - b. The double bagged waste is marked as a biohazard by the color of the outer bag (red) or by a biohazard sticker
    - c. The contaminated waste is removed in special carts which are disinfected after each use. The waste is incinerated on campus in the hospital incinerator. The employee must double check that Environmental Services is safely following their procedures while in the laboratory.
  - B. Gloves and other PPE are always considered contaminated waste with or without know contamination
  - C. Examples of contaminated, non-sharp waste: PPE, contaminated paper towels and gauze, specimen bags, patient specimens to be discarded.
- c. The Red Hard walled, leak proof containers are handled by Stericycle Bio Systems, Healthcare Compliance Solutions (1 866 783 9816)
  - A. This company services the Clinical Laboratory Biohazard waste disposal of Medical Biohazard waste in Sharps containers. The Department of Environmental services, Manager Debbie Sandberg, Main Building, Ground floor, 215 955 3737 has the necessary Certification and Disposal records from Stericycle Bio Systems.
  - B. Red Bag Biohazard waste, non-sharp, is disposed of by Environmental Services and brought to the Autoclaves at the receiving dock. This is also monitored by Debbie Sandberg.
P. Creutzfeldt-Jakob Disease (Prion) Precautions:
- a. Clean out biohazard hood, remove all extraneous equipment. Don a disposable lab coat and double layer gloves.
- b. Place absorbent place mat on working surface of hood.
- c. Thoroughly saturate this absorbent paper with undiluted Clorox.
- d. If it is a tissue place a scalpel, disposable grinder, all labeled plates and tubes, loops, disposable forceps, petri plate and any other materials in hood.
- e. If the specimen is a CSF and greater than 1 CC is received, spin the CSF in the Beckman Coulter centrifuge (Micro 2 area) in the plastic insert holding the 15 ml conical tubes, program number 2, 2200rpm for 10 minutes. After centrifugation bring the entire plastic insert under the laminar flow hood for processing.
- f. The plastic insert and tube holder must be cleaned with undiluted Clorox after processing.
- g. For tissue specimens that are small place it in the 2 ml disposable sterile grinder and macerate; inoculate media.
- h. If the specimen is large, transfer the piece to a sterile petri plate. Section off pieces with a scalpel and disposable forceps. Use large grinder to grind and inoculate media.
- i. For Fungal requests, large or small tissue transfer small pieces to fungal media and place on top of media.
- j. All media is sealed with parafilm and marked CJ disease.
- k. All disposable loops, transfer pipets, grinders, tubes, mat, gloves must be put in a double autoclave bag marked CJ disease, autoclave at 131 degrees C for 1 hour.
- l. Store the remaining tissue or CSF in a sterile container, cup or tube; seal with parafilm; place in double layer autoclave bag; label clearly as to the patient name, date and contents. In addition, put a biohazard label on the bag marked possible CJ disease. Put the bag in the storage refrigerator. After 7 days the specimen is autoclaved at 131 degrees C for 1 hour.
- m. Wipe down the scalpel handle with undiluted Clorox. Decontaminate the entire hood surface and side walls with undiluted Clorox.
- n. Send email message to entire lab with the patient demographics and note: Possible CJ disease precautions.
Q. Non-contaminated waste is to be kept separate from biohazard waste:
a. Biohazardous waste is removed at high cost to the hospital; therefore, non-contaminated waste should be disposed of in a separate receptacle.
b. The GREY receptacles are to be used for non-contaminated waste only.
c. Examples of non-contaminated waste: packaging for reagents and panels, small boxed, paperwork NOT containing protected patient information
A. The locked BLUE recycling bins are to be used for paperwork containing protected patient
information.
R. Waste Disposal: Chemical
- a. Contact Environmental Health and Safety Department, extension 3-6260
- b. Do not dispose of any chemicals by flushing down the sink or putting them into any trash receptacle.
- c. Contact Environmental Health and Safety department for proper disposal procedure.
- d. Biohazard Classification of Infectious Agents, Table 4, 5.
- e. Biosafety Precautions:
  - A. Level 1
  - B. Level 2
  - C. Level 3
  - D. Level 4


BSL	Agents	Practices	Primary barriers and safety equipment	Secondary barriers (facilities)
1	Not known to consistently cause diseases in healthy adults	Standard microbiological practices	None required	Laboratory bench and sink required
2	▪ Agents associated with human disease ▪ Routes of transmission include percutaneous injury, ingestion, mucous membrane exposure	BSL-1 practice plus: ▪ Limited access ▪ Biohazard warning signs ▪ "Sharps" precautions ▪ Biosafety manual defining any needed waste contamination or medical surveillance policies	Primary barriers: ▪ Class I or II BSC or other physical containment devices used for all manipulations of agents that cause splashes or aerosols of infectious materials PPE: ▪ Protective laboratory clothing; gloves; respiratory protection as needed	▪ BSL-1 plus: Autoclave available
3	▪ Indigenous or exotic agents with potential for aerosol transmission ▪ Disease may have serious or lethal consequences	BSL-2 practice plus: ▪ Controlled access ▪ Decontamination of all waste ▪ Decontamination of laboratory clothing before laundering ▪ Obtaining baseline serum from staff	Primary barriers: ▪ Class I or II BSC or other physical containment devices used for all open manipulation of agents PPE: ▪ Protective laboratory clothing; gloves; respiratory protection as needed	BSL-2 plus: ▪ Physical separation from access corridors ▪ Selfclosing, doubledoor access ▪ Exhaust air not recirculated ▪ Negative airflow into laboratory

See the TJUHBB Glossary.

Revisions

POL ID	Date Revised	Author	Summary of Changes
POL 03.001	08/05/2016	Patel, Miraj	Policy finalized

VERSIONS & APPROVAL

Version	Category	Approval	Date
03.001	Administration	Stephen Peiper, MD	08/05/2016