Use of Personal Protective Equipment, 1022
POL-5251202
- Applicability
- AHN Entity
- Content Type
- Policy
- Responsible Area
- Laboratory - General/Safety
- Executive Sponsor
- Claudia Velosa Ramirez
- Owner
- KRALOVIC, Judith
- Former Numbers
- PolicyStat ID: 9436987
- Effective Date
- 5/1/2021
- Last Approved Date
- 4/12/2022
- Last Revised Date
- 4/12/2022
- Next Review Date
- 4/12/2023
- Related Authoritative Sources
- Related Content
- Related Documents
- Overview Statement
-
Forbes Hospital recognizes the importance of providing a safe work environment for all health care workers, patients and visitors.
The purpose of this policy is to establish guidance and policy control procedures for all laboratory employees regarding the proper use of PPE.
- Terms and Definitions
-
PPE - Personal Protective Equipment
BSL2 - Biosafety Laboratory Level 2
- Administration
-
The laboratory performs laboratory testing in accordance to OHSA guidelines. The laboratory requires staff to wear PPE as determined for appropriate tasks. The Clinical Laboratories are designated as BSL2, and accordingly requires personnel to wear barrier protection between themselves and specimens; (long sleeved, liquid resistant, closed-front lab coats, gloves, and eye/face protection when there is a risk of aerosol or splash). Appropriate PPE are items that do not permit blood or other potentially infectious materials to pass through to the employee's work clothes, skin, and mucous membranes etc. Training is required upon hire and annually at a minimum.
** Note - this policy does not apply to private offices or designated "clean" workspaces
This policy governs all Forbes Hospital Laboratory employees.
PPE use for specific task (Gen.74200)
Lab Section
Tasks and/or Procedures where Occupational Exposure Occurs
Required PPE
Additional Protective Devices
Chemistry/Hematology/
Coag/Immuno
Removal of Stoppers from specimen containers, vacutainers etc.
Long sleeve, liquid barrier-resistant, closed front lab coat or tie-back wrap around gown; gloves*, goggles or face shield.
Use of lab shield, face shield or biosafety cabinet for opening and manipulating unknown samples.
Aliquotting Specimens
Long sleeve, liquid barrier-resistant, closed front lab coat or tie-back wrap around gown; gloves*, goggles or face shield.
Use of lab shield, face shield or biosafety cabinet for opening and manipulating unknown samples
Discarding specimens in waste container or sink (urines)
Long sleeve, liquid barrier-resistant, closed front lab coat or tie-back wrap around gown; gloves*, goggles or face shield.
Cleanup of body fluids from instruments, counter tops, floors
Long sleeve, liquid barrier-resistant, closed front lab coat or tie-back wrap around gown; gloves*, goggles or face shield.
Use Commercial Spill kit. If using 0.5% sodium hypochlorite (bleach) solution, it must be prepared daily.
Operation/Troubleshooting equipment
Long sleeve, liquid barrier-resistant, closed front lab coat or tie-back wrap around gown; gloves*,
Securing waste bags for proper disposal
Long sleeve, liquid barrier-resistant, closed front lab coat or tie-back wrap around gown; gloves*
Sharps, broken glass and broken plastic tubes must be discarded into biohazard bags placed within a rigid box or waste container for protection
Specimen Receiving
Removal of Stoppers from specimen containers, vacutainers etc.
Long sleeve, liquid barrier-resistant, closed front lab coat or tie-back wrap around gown; gloves*
Use of lab shield, face shield or biosafety cabinet for opening and manipulating unknown samples
Labeling/delivering specimens to testing areas
Long sleeve, liquid barrier-resistant, closed front lab coat or tie-back wrap around gown; gloves*,
Aliquotting Specimens
Long sleeve, liquid barrier-resistant, closed front lab coat or tie-back wrap around gown; gloves*, goggles or face shield.
Use of lab shield, face shield or biosafety cabinet for opening and manipulating unknown samples
Packing/Removing specimens from pneumatic tube carriers
Long sleeve, liquid barrier-resistant, closed front lab coat or tie-back wrap around gown; gloves*
Cracked glass tubes should be discarded into sharps container. Do not handle broken glass.
Discarding specimens in waste container or sink (urines)
Long sleeve, liquid barrier-resistant, closed front lab coat or tie-back wrap around gown; gloves*, goggles or face shield.
Cracked glass tubes should be discarded into sharps container. Do not handle broken glass.
Cleanup of body fluids from instruments, counter tops, floors
Long sleeve, liquid barrier-resistant, closed front lab coat or tie-back wrap around gown; gloves*, goggles or face shield.
Use of commercial Spill kit. If using 0.5% sodium hypochlorite (bleach) solution, it must be prepared daily
Gross Room
Specimen Registration and Accessioning
Lab coat, Gloves* if specimen handling is necessary
Gross Surgical Examination
Long sleeve, liquid barrier-resistant, closed front lab coat or tie-back wrap around gown; gloves*, goggles or face shield.
Bladex scalpel exchanging system OR another approved protocol for scalpel safety (i.e., hemostats)
Picking up specimens from OR
Scrubs (lab approved) or disposable OR suit; hand holding specimen shall be gloved
Specimens shall be in placed in sealed bag, dish, etc. and put inside secondary, properly marked transport containers (i.e., cooler); containers shall be transported on secure cart using non-visitor elevators
Frozen Section
Long sleeve, liquid barrier-resistant, closed front lab coat or tie-back wrap around gown ;gloves*, goggles or face shield.
Consider sharps protection on non-dominant hand (i.e., metal mesh glove, hemostats)
Cytology
Preparing specimens
Long sleeve, liquid barrier-resistant, closed front lab coat or tie-back wrap around gown; gloves**, goggles or face shield.
Recommend respiratory protection or use of biosafety cabinet when processing lung samples or suspected airborne pathogens
Microscopic slide screening
No PPE required Histology
Processing specimens
Long sleeve, liquid barrier-resistant, closed front lab coat or tie-back wrap around gown; gloves*, goggles or face shield.
Recommend respiratory protection or use of biosafety cabinet when processing lung samples or suspected airborne pathogens
Staining
Long sleeve, liquid barrier-resistant, closed front lab coat or tie-back wrap around gown; gloves*, goggles or face shield.
Be sure proper ventilation available for staining; as needed perform stain inside chemical hood
Tissue Processor
Long sleeve, liquid barrier-resistant, closed front lab coat or tie-back wrap around gown; gloves*, goggles or face shield.
Recommend respiratory protection or use of biosafety cabinet when processing lung samples or suspected airborne pathogens
Embedding fixed tissue
Strongly recommend Long sleeve, liquid barrier-resistant, closed front lab coat or tie-back wrap around gown; gloves*,
Microtome cutting of fixed blocks and slide preparation
Long sleeve, liquid barrier-resistant, closed front lab coat or tie-back wrap around gown; gloves*
Consider sharps protection (i.e., metal mesh glove, hemostats);
Virology/
Molecular/
Microbiology
Processing Specimens
Long sleeve, liquid barrier-resistant, closed front lab coat or tie-back wrap around gown; gloves*, goggles or face shield.
Unknown specimens should be opened/processed inside biosafety cabinet or behind shield
Discarding samples and media
Long sleeve, liquid barrier-resistant, closed front lab coat or tie-back wrap around gown; gloves*, goggles or face shield.
Staining
Long sleeve, liquid barrier-resistant, closed front lab coat or tie-back wrap around gown; gloves*,, goggles or face shield.
Be sure proper ventilation available for staining;
Phlebotomy
Venipuncture
Gloves*
As necessary for combative patients: goggles or face shield
*Note: Gloves must fit properly. Replace gloves immediately when torn or contaminated. Washing or reusing gloves is prohibited. Hypoallergenic, non-latex gloves are available when indicated. Hands must be decontaminated after glove removal.
**Note: Individual offices or “clean” workspaces will be evaluated on a case by case basis. For these areas, safety will be addressed in department specific policies. For example: fixed slides should be cleaned prior to removal from lab and before taken to clean offices.
- Exceptions
-
None
- Violations
-
Violations of this policy or procedure may result in disciplinary action up to and including termination of employment.
- Additional References
-
RELATED POLICIES
SOP# S011 "PPE Usage for Lab Tasks" - Allegheny Health Network Laboratories
- People Applicability
- Employees (including residents and fellows)
- Entity Applicability
- Contact(s)
- List of Approver(s)
-
JASON HUGHES - DIRECTOR LABORATORY - 4/6/2022,
CLAUDIA VELOSA RAMIREZ - PHYSICIAN - 4/12/2022