LABORATORY OF PATHOLOGY ONLINE POLICY MANUAL
- Autopsy Service
- General Policy
- During the autopsy, full barrier protection is utilized. The autopsy assistants and medical staff performing the autopsy wear surgical scrub suits, disposable gowns, shoe covers, plastic aprons, and double surgical gloves at all times. Masks, goggles, double gloves, and wrap-around-disposable converters are used in cases of known infection with mycobacteria, Creutzfeldt-Jakob disease (CJD), hepatitis, HIV, or severe viral and bacterial infections. All of these materials are disposed of before leaving the autopsy room. Maintaining sharp instruments and keeping tissues wet minimizes spread of infections. A clean technique is emphasized.
- Containers with samples being sent to other departments during the autopsy (microbiological cultures, eyes, etc.) are kept clean. Containers are well constructed with a secure lid to prevent leakage during transport. Autopsy assistants change gloves to handle containers and assist the prosector in obtaining the sample. The sample containers are transported in impervious bags.
- When mycotic or mycobacterial infection is diagnosed at frozen section, the cryostat and microtome blade, as well as all the utensils used during the frozen section procedure, are decontaminated with a 10% sodium hypochlorite solution.
- Unauthorized personnel are denied access to the autopsy area and frozen section room while procedures are in progress.
- For information on blood spills or other potentially infectious material, refer to the Clinical Center Isolation Guidelines Flipchart, revised 1998, and Clinical Center web page (see http://www.cc.nih.gov/hes/isoguide/index.html).
- Cleaning of equipment: All utensils used are soaked in Tergol 800 for a minimum of 30 minutes.
- Protective clothing (i.e., shoe covers, aprons, gloves, etc.) will be available on a cart at the door of the autopsy area during all cases.
- Creutzfeldt-Jakob Disease (CJD)
- CJD is one of a group of neurological disorders caused by “unconventional” (“slow” viral) agents (transmissible virus dementia and subacute spongiform encephalopathy are related terms) that are not inactivated by ordinary methods, i.e., formalin fixation. From time to time, such cases may be sent to NIH for autopsy. Somewhat more commonly, a brain biopsy is performed on a patient for whom this diagnosis is a possibility (i.e., atypical dementia, or encephalitic illness).
- The following recommendations for the safe handling of tissue:
- It should be noted that all tissues, body fluids, or blood are considered infectious in this context. However, it must be pointed out that epidemiologic evidence quite clearly shows that the infectivity of the agent is extremely low (i.e., compared to hepatitis B); rare cases of CJD have been reported in neuropathology/histology personnel. (NEJM 318:853-854, 1988).
- General Decontamination
- Instruments are soaked in 2N NaOH for 60 minutes, then further cleaned as after non-CJD procedures.
- Work surfaces are cleaned in 2N NaOH for 1 hour at room temperature. Please note that a 5 to 10 minute exposure of contaminated skin reportedly results in only minor irritation when washed thoroughly with water.
- Fixation in formalin-formic acid can inactivate virus infectivity and allow preservation of tissues for histology (Neurology 40:887–890, 1990). If suspicion of CJD arises after review of slide, inactivate prions in tissue (including brain, spinal cord, and eyes) in 95-100% formic acid-formaldehyde for at least 48 hours.
- Tissue for Histology
- Keep the tissue separate from other biopsies or autopsy sections.
- All tissues from patients with suspected CJD will be fixed in formic acid-formaldehyde for at least 48 hours.
- All tissue shavings from histology should be collected
from around the microtome and disposed of by
- The microtome blade and other working surfaces should be autoclaved or sterilized with 2N NaOH.
- Unstained slides should be maintained in a protected environment, segregated from other material, and labeled with warnings for CJD.
- Tissue for confirmatory diagnosis
- If Prion disease is suspected, the pathologist will collect tissue to be sent to the National Prion Center for confirmation.
- Freeze 0.5 g of tissue for biochemical studies in a -70°C freeze until ready to ship. S hip in dry ice to the National Prion Center. Five grams (5g) of tissue is the ideal amount, but as little as 10 mg is sufficient.
- The remaining tissue should be fixed in 10% buffered formalin for at least 24 hours followed by 1 hour formic acid (range of formic acid should be between 88-98%) and then by at least 24 hours of additional fixation in formalin. If fresh tissue is unavailable, the tissue extracted from melted paraffin block can be inactivated and sent for limited testing.
- Notifications required:
- Primary care physician–the individual responsible for notifying the patient’s family in non-NIH cases. If NIH CC patient, Clinical Center Epidemiology Department will notify the family.
- LP physicians and technical staff having any involvement with the case;
- NIH Clinical Center Occupational Medical Service (OMS);
- NIH Clinical Center Epidemiology (complete a NIH Clinical Center Occurrence Report). LP manager will document notifications
- Funeral Home and Diener
- Maryland Department of Health and Mental Hygiene (agency is responsible for notifying the Centers for Disease Control (CDC)):
Montgomery County Office Telephone: 240-777-1755 2000 Dennis Avenue, Suite 238 Silver Spring, MD 20902
- Useful links:
- CDC’s Office of Health and Safety, Creutzfeldt-Jakob Disease (CJD) in Healthcare Settings
- CDC’s Infection Control Practices for CJD
- MD public health reportable list
- Clinical Center ’s Occurrence Reporting System website
- National Prion Disease Pathology Surveillance Center
- NPDPSC test request form and contact information
- The World Health Organization Infection Control Guidelines for Transmissible Spongiform Encephalopathies
- Cases with Bloodborne Pathogens (e.g. HIV, HTLV-I, hepatitis B, hepatitis C)
- In addition to following Universal Precautions for these cases, we recommend the following:
- No tissue distribution to investigators, with the exception of those who are specifically studying the infectious agent in question, e.g., HIV.
- Notifying mortuary personnel by ensuring that this information is stated in the Report of Death Form.
- Avoiding frozen sections on these autopsy cases.
- Decontaminating instruments and working surfaces with a 10% solution of household bleach. (However, bleach is not to be directly added to the tissue sections to be taken for histology.)
- Disposal of Tissue
- Tissue is fixed in 10% formalin for 6-12 months before it is discarded. We follow the Clinical Center guidelines for disposal of Medical-Pathological waste. Contaminated gloves and towels are treated in the same manner as tissue. A “discard” bucket containing formaldehyde is made available at all times for the decontamination of tissues, etc.
- Labeling of Potentially Hazardous, Infectious Tissue
- Cases requiring specialized precautions for infection control are on documentation (death report forms) submitted to mortuary personnel. Cases with a history of Creutzfeldt-Jakob slow virus disease should be specifically labeled as such.
- Infectious Aerosols/Formaldehyde Fumes
- As much as possible, exposure to aerosols of infectious agents and toxic fumes are minimized by keeping tissues damp during dissections, appropriately stored in covered containers, and extensively washing them in water prior to presentation at conferences.
- Employee Health
- The autopsy assistants, residents, and other personnel that may come in contact with human tissues, blood, and/or potentially infectious materials are enrolled in a surveillance program provided by OMS. Screening for M. tuberculosis and hepatitis B exposure is provided. (see below)
- The Report of Death Form (NIH Form 1082) has been modified to require notification in the case of known transmissible, infectious diseases or the presence of radioactive substances.
- All postmortem reports are made available to a nurse epidemiologist who reviews all the autopsy diagnoses searching for clinically unsuspected or undiagnosed infections detected at autopsy.
- All laboratory personnel handling potentially infectious human tissues are encouraged to participate in the hepatitis B vaccination program that includes education, serological testing, and immunization. Individuals who are not immune from hepatitis B and who refuse HBV vaccination are required by OSHA standards to sign an informed declination.
- All employees with potential for exposure to blood/potentially infectious materials are required to have annual Universal Precautions training, which is provided by the Hospital Epidemiology Service. Records of training will be kept by the HES.
- Management of Blood Spills & Other Potentially Infectious Material in the Clinical Center (see Clinical Center Exposure Control Plan for spills http://intranet.cc.nih.gov/hospitalepidemiology/resources/index.shtml NIH DOHS Incidents and Spills http://www.ors.od.nih.gov/sr/dohs/BioSafety/incidents/Pages/hazmat_incident_spills.aspx).
- Supplies /Equipment Needed:
| Absorbent paper towels
|| NIH Stock No. 47990
| Wescodyne Solution 1.6% min titratable Iodine
|| NIH Stock No. 41830
| Sodium Hypochlorite Solution 5.25% (Bleach)
|| NIH Stock No. 41600
| Disposable plastic gloves
|| NIH Self-Service Store or CHSS, B1N234, ext. 496-2243
| Impervious bags—plastic or wax
|| NIH Self-Service Store and Dept.of Housekeeping and Fabric Care
| Tergol 800
|| NIH Self-Service Store
- NIH Self Service store is located in B1N105, ext. 496-2051
- Equivalent supplies may be substituted
- Don gloves and, if indicated, other personal protective equipment, before cleaning spills of blood or other potentially infectious material.
- To clean a small spill (<20 ml): carefully remove visible material with paper towels or some other absorbent paper; apply a disinfectant solution (i.e., Dispatch®, a CHS-issued stabilized bleach solution). Alternatively, a freshly mixed (no older than 24 hours) 1:10 dilution of bleach (i.e., 1 part bleach to 9 parts water) may be used. The area should remain wet with disinfectant for 10 minutes. Contaminated sharp objects shall be disposed in a puncture-resistant, leak proof, closeable container that is color coded or labeled with a biohazard symbol; contaminated biohazardous material should be carefully disposed into a Medical Pathological Waste box.
- To clean a large spill (= 20 ml): contact Housekeeping and Fabric Care Department (6-2417). Prior to the arrival of housekeeping personnel, close the spill area to traffic. Do not cover the spill with paper towels and do not apply disinfectant (e.g., bleach, or Dispatch® ) or any other liquid cleaner to the spill. If desired, powder absorbent may be applied to spills on hard surfaces. Do not apply powder absorbent, bleach, or Dispatch® to spills on carpets.
- When cleaning spills of blood or other potentially infectious material on hard surfaces, staff will: first, ensure that the spill has been appropriately contained; second, carefully remove visible blood, other potentially infectious material, or other organic material; third, sanitize the area through application of a CC-approved disinfectant to the spill area, keeping the area wet with disinfectant for 10 minutes.
- Contaminated sharp objects shall be disposed in a puncture-resistant, leak proof, closeable container that is color coded or labeled with a biohazard symbol; contaminated biohazardous material should be carefully disposed into a Medical Pathological Waste box.
- Blood or other potentially infectious body fluid contamination from patients on "CNS Precautions" may require special procedures. Refer to "CNS Precautions" or call the Hospital Epidemiology Service at 6-2209.
- Cytology Service
- Universal precautions as outlined by OSHA/NIH Clinical Center requirements are routinely utilized when preparing all specimens, i.e. gloves, lab coats, protective eye wear.
- In addition to the above universal precautions, all sputum samples, bronchoalveolar lavages, washes and brushes, as well as any specimen from a patient in whom TB is suspected are prepared in a Class II laminar flow hood. Preparation in hood includes: opening of, pipetting, pouring or smearing of such sample before fixation, i.e. any manipulation of the sample that might create an aerosol. Cytospin samples are loaded and unloaded within the hood. In suspected TB cases, disposable, single use, capped sample chambers are employed. In addition to protective barriers noted in A above, masks are required when handling such specimens.
- All disposable items (i.e. pipets, filter cards and cuvetts) are placed in a bucket containing disinfectant vesphene for a minimum of 10 minutes to decontaminate before disposal.
- The laminar flow hood, cytospin machine, centrifuge, and all bench tops are washed each day with a 10% chlorine bleach solution.
- Any specimen from a suspected or known TB/MDR-TB, respiratory-isolation level III patient, submitted to cytology for evaluation of infection will be re-routed to the microbiology lab-room 2C-385. If a malignancy is clinically suspected in a suspected or known TB/MDR-TB respiratory-isolation level III patient, the specimen is fixed in 10% buffered formalin for a 24 hour period to de-activate the mycobacteria. This procedure is performed in a Class II hood with an equal amount of 10% buffered formalin added to the specimen following step B above
- It is contraindicated to prepare slides for review on-site from a fine needle aspiration (FNA) on a suspected or known TB/MDR-TB, respiratory-isolation level III patient without a Class II hood and proper fixation. When performing an FNA procedure, if a malignancy is to be ruled out the specimen is put directly into sterile preservation-free normal saline and brought to cytopathology for handling as per step E. If infection is the primary concern the sample should be sent to microbiology (room 2C385) for processing and evaluation.
- Other Diagnostic Services
- Procedures for other diagnostic services that require handling blood, human tissues, and potentially infectious materials (Surgical Pathology Service, Cytopathology Service, Hematopathology Service, and Clinical Cytogenetics) are comparable to those described above for the Autopsy Service. Barrier protection required as noted above.
- Tissues not utilized immediately for histological examination are fixed in 10% formalin and kept within the department for a minimum of 8 weeks. If the case has been signed out and if the tissues are no longer required, fixed tissues are disposed of according to Clinical Center guidelines for medico-pathological waste. Cells and/or potentially infectious materials may be autoclaved before disposal.
Last Updated 2/5/2014 3:32:53 PM