SPECIMEN HANDLING PRECAUTIONS AND PERSONAL PROTECTIVE EQUIPMENT

Full Personal Protective Equipment (PPE) to be used when processing specimens that have not been properly bagged, transported, or inactivated with fixative, or for autopsy procedures:

• In addition to the PPE stated below, follow the usual level three respiratory isolation precaution procedures, outlined in your safety manual and the CC Isolation Guidelines flip chart.
• Refer to procedure for donning/removing PPE (Appendix A).
• Double Gloves. For autopsy procedures, use interposed layer of cut resistant gloves between rubber gloves.
• Impervious disposable gown, coverall, and/or apron, as appropriate.
• Disposable surgical cap and shoe covers.
• All employees must be re-trained to wear the PAPR and be fit tested for the N-95 respirator mask prior to handling unfixed specimens from Special Respiratory Specimens.
• A full face shield must be worn with an N-95 mask, but not required when using a PAPR.
• Autopsy down draft table (autopsy procedures only) in negative pressure autopsy suite. See room preparation for autopsy procedure (below).
• The biosafety cabinet (BSC) located in the Cytology Section (10/2A21) may be used to process specimens, if needed, while wearing full PPE.
• It is acceptable to wear the N-95 respirator while working at the BSC, but a PAPR should be worn when handling unfixed specimens outside of the BSC (e.g., Autopsy procedure in the negative pressure autopsy suite).

Notes:

1. DO NOT add fixative to active specimens delivered to the LP, in the grossing hood or down draft table. Use the BSC for this purpose.
2. ALL EMPLOYEES MUST BE RE-TRAINED TO WEAR THE PAPR AND FIT TESTED FOR THE N95 RESPIRATOR PRIOR TO HANDLING SPECIAL RESPIRATORY ISOLATION SPECIMENS THAT ARE NOT FIXED. Contact CC Safety at extension (301) 496-5281 to arrange for an N-95 mask fit test and/or PAPR training in advance of performing the procedures.
3. Personnel who cannot wear fitted N-95 face mask must wear a PAPR.
4. Pay careful attention to procedures for hand hygiene, disposable waste, particulate aerosols, and environmental cleaning (see below, for more details)

Personal Protective Equipment (PPE) to be used when processing formalin fixed, or otherwise inactivated specimens.

• Follow universal precautions when handling the specimen throughout the remainder of the testing.
• Wear gloves and lab coat.
• Employees may wear additional PPE and a PAPR or N-95 mask if desired, but these are not necessary for inactivated specimens.

Cytology Specimens/Surgical Pathology Specimens/Ultrastructural (EM) Pathology Specimens:

• Verify specimen was collected, transported, and labeled properly. If not, do the following:
  1. Notify your supervisor immediately and complete an ORS report.
  2. The supervisor will notify HES and contact the Hot Seat or Autopsy Resident to assist with placing the sample on fixative in the BSC located in the Cytology Section (10/2A21), while wearing full PPE.
  3. Transfer the specimen directly into a properly labeled container containing 10% neutral buffered formalin, or add the fixative to the specimen. Tighten lid securely. Double check to make sure it does not leak.
  4. Wipe with CC approved disinfectant (Dispatch or 95% EtOH).
  5. Change gloves.
  6. Place specimen in bag.
  7. Place bagged specimen in secondary bag.
  8. Dispose of gloves, gowns, shoe covers, empty specimen container, and any other biomedical waste as instructed below.
• All specimens must be fixed for at least 24 hours prior to additional handling. A longer time period is required if the specimen is greater than 3 mm thick. Larger specimens should be sectioned as thin as possible by the resident wearing full personal protection equipment (see above), under the biological safety cabinet (BSC) in room Cytology (10/2A21), and placed in 20 volumes of 10% neutral buffered formalin.
• All cytology specimens will be processed as a cell block.

All other Laboratory of Pathology specimens:

• Collection, retrieval, transport, and processing of specimens should be carefully coordinated with Section Chief and study investigators.

Autopsy:

IMPORTANT: STRICT PROCEDURES MUST BE ADHERED TO BY ALL STAFF PATICIPATING IN THE AUTOPSY.

• Before starting the autopsy, refer to the CDC website for the latest recommendations. Prepare autopsy suite by clearing unneeded items from countertops and draping desks and unneeded equipment. Verify air pressure differential is not in alarm status.
• Set up a specimen cart by placing absorbent pads on each shelf.
• Before transporting the body to the autopsy suite, drape all benches within 10 feet from the table with linen drapes.
• Deactivate door, so people can not push button for entrance.
• Place signs in front of door
1. Hexagon magnetic stop sign: “STOP DO NOT ENTER, SPECIAL RESPIRATORY ISOLATION AUTOPSY IS IN PROGRESS THANKS”
2. Hang banner across the doors to the suite to prevent entrance. This banner states “STOP DO NOT ENTER, SPECIAL RESPIRATORY ISOLATION AUTOPSY IS IN PROGRESS.”
• Only the section chief, the resident, and the autopsy assistant will be present to perform the autopsy. No others will be permitted in the suite without prior discussion with the section chief.
• Use the same protocol used for multi drug resistance tuberculosis (MDR TB) protocol.
• Don all PPE (see above) before opening the body bag. Save the outer bag, but discard the inner bag into biohazard waste.
• The extent of the autopsy and the approach used in dissection will be limited based on the autopsy permission and the discretion of the section chief.
• Use an autopsy head drape (under evaluation) to contain particulate matter. The drape is easily adjusted for use over the head or torso. Entry ports are available on all four sides with cover flaps. Minimize the number of ports entered at one time. If possible, enter only one port at a time.
• Use the bone dust collector attachment with HEPA filter on the Stryker saw.
• Do not cut rib cage with clippers. Use the Stryker with bone dust collector to cut rub cage.
• Specimen collection
1. Collect clinical autopsy specimens directly into containers of formalin.
2. Collect specimens for the CDC (check website for details). At the time of this writing, the CDC recommends collection of the following specimens for the evaluation of potential cases of SARS.
1. Fixed tissue: all major organs (e.g. lung, heart, spleen, liver, brain, kidney, adrenals).
2. Frozen tissue: lung and upper airway (e.g. trachea, bronchus)
3. Upper Respiratory: nasopharyngeal aspirate; nasopharyngeal and oropharyngeal swabs.
4. Lower Respiratory: Broncheoalveolar lavage (BAL), tracheal aspirate or pleural tap.
5. Blood: Serum, whole blood.
6. Stool.
3. Collect research tissue for NIAID, as specified, if requested.
4. If tissue cannot be fixed, carefully coordinate collection requirements, bagging, and transportation between the Principle Investigator, CC/DLM, and/or CDC. Wipe with a CC approved disinfectant (Dispatch or 95% EtOH). Change gloves. Place specimen in bag. Place bagged specimen in secondary bag. Arrange for transportation of the samples.
5. Wipe down all formalin fixed tissue containers with a CC approved disinfectant (Dispatch or 95% EtOH). Place in double bags if possible. Place all large containers on the cart covered with absorbent pads, and cover with clear plastic. Allow samples to fix for 24 hours before further processing.
• After the autopsy is complete, prepare the body for transportation according to the latest CDC recommendations for handling remains of SARS patients. After placing the body back into the body bag, disinfect outer surface with Dispatch disinfectant. Place the shrouded body in a new (clean) secondary body bag, before transporting back to the morgue. Place a “Special Respiratory Isolation” sticker on the outside of the new body bag.
• Disinfect all work surfaces and instruments with disinfectant (Dispatch, 95% EtOH, TB Quat2) using a two step cleaning method.

NOTE: DO NOT USE BLEACH PRODUCTS. AS A PRECAUTION, ADHERE TO THE MANUFACTURER’S RECOMMENDATIONS FOR THE LONGER CONTACT TIME (USUALLY THREE MINUTES).

1. Clean surfaces with disinfectant and allow disinfectant to remain on surfaces for at least three (3) minutes, or the longest contact time recommended by the disinfectant man
2. Change gloves and repeat.


• Housekeeping after autopsy is critical because of the potential fomite transmission. Notify housekeeping (5-3075) to send staff which have been specifically trained in Special Respiratory Isolation procedures to clean floors and walls and pick-up MPW waste (see below), wearing full personal protective gear.
• An LP employee will transport samples. Patient Escort Services will not transport these specimens. Package samples for the CDC in accord with the CDC website.
• The Admissions Office should inform the funeral home that this is a special respiratory isolation case. Please remind them to notify the funeral home that the patient has a specific disease (SARS, smallpox, etc).

Last Updated 12/28/2009 10:54:30 AM