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IV. Engineering and Work Practice Controls

Blood specimen acquisition

Centrifuge tube breakage

Contaminated instrument repair





Glassware, reusable


Hepatitis B vaccination


Housekeeping & cleaning

Labels & signs


NICU & Newborn Nursery


Sharps disposal


Specimen handling

Specimen storage

Specimen, interlocation transport

Spills, biological

Universal Precautions

Waste disposal

  1. Standard (Universal) Precautions
    Since the potential for infectivity of patients' blood and body fluids cannot be known, all blood, fluids and tissues are considered to be potentially infectious and precautions are taken in handling all patient specimens. Standard (Universal) Precautions are observed throughout the laboratory to prevent contact with blood and potentially infectious material.

    Standard Universal Precautions means all blood and body fluids are handled as if known to be infectious with HIV, HBV, and other bloodborne pathogens. Standard (Universal) Precautions apply to all body fluids that contain visible blood or have the potential to have blood in them.

    When differentiation between body fluid types is difficult or impossible, all body fluids are considered infectious material.
  2. Smoking, tobacco use, food and beverages
    1. The use of tobacco and tobacco products is prohibited on UCL’s premises; in any UCL owned, leased or rented vehicles; in any employee owned or operated vehicle while parked on UCL, patron or client premises; and on the premises of our patrons and clients.
    2. Eating and drinking are not permitted within the laboratory technical, secretarial (with the exception of the C.S. office), or patient waiting areas. Designated food-safe refrigerators are provided for the staff to store lunches and perishable food.
    3. Glucose Tolerance test doses are stored in the food-safe refrigerators. These refrigerators are cleaned monthly and the cleaning documented on the appropriate log.
  3. Cosmetics/Hair/Nails
    The application of cosmetics or lip balm in the technical and secretarial work areas is prohibited. Hair is to be clean and well maintained to prevent contamination of the work area from bacteria and/or skin fungus. Hair that is shoulder length or longer must be pulled back off the shoulders with some kind of fastening when working in a technical area. Beards are neatly trimmed and no longer than one inch in length. Fingernails are no longer than one/quarter inch beyond the end of the finger. Artificial nails and nail enhancements are not worn by any staff having direct patient contact.
  4. Waste and Sharps Disposal
    1. "Biohazard" or "contaminated" refers to material containing residues of blood, body fluid, or microbiologic culture material.
    2. Waste containers are numerous and conveniently located to prevent excessive movement of biohazard waste prior to disposal.
    3. Sharps Containers
      1. A site-specific hazard analysis is done at each UCL site to determine the kind, size and placement of sharps containers.
      2. Disposable syringes with needles, scalpel blades, and other sharp items capable of causing injury are placed intact into puncture resistant sharps containers.
      3. Sharps containers are located as close as practical to the area in which the sharp item is used in all patient rooms, exam rooms, phlebotomy rooms, and appropriate laboratory departments. They are replaced routinely when they are three fourths filled.
      4. Laboratory staff visually inspects the sharps container for integrity and possible replacement before performing blood collections or other procedures where sharps are used.
      5. Replacement/Disposal
        1. Sharps containers are disposable and are not reused unless they are designated as re-usable by a contracted waste disposal service.
        2. Sharps containers in patient and exam rooms are replaced and disposed of by hospital staff. Containers in phlebotomy rooms and laboratory departments are replaced and disposed of by laboratory staff.
        3. Sharps containers remain upright throughout use.
        4. Filled containers are sealed according to direction, and are labeled with a biohazard sticker.
    4. All biohazard waste containers are labeled with the universal biological hazard symbol.
    5. Red or orange bag liners designate contaminated waste.
    6. Any leakage of fluid from contaminated waste during storage, handling, or shipping is reported immediately to a UCL Supervisor. (An Incident Investigation Report Form is also completed. See VII.A.)
    7. Go to Table I for additional detail.
  5. Storage of Specimens
    Specimens are stored in designated biohazard areas of the laboratory. Liquid specimen containers and blood tubes are stored with tight fitting lids or stoppers or are covered with parafilm.
  6. Laundry
    Clean lab coats are stored separately from contaminated lab coats. Contaminated laundry is handled as little as possible. It is placed in designated containers at each UCL site/department. All laundry, wet or dry, that is sent to Mercy Medical Center for laundering is placed into designated laundry bags. All persons handling contaminated laundry follow Standard (Universal) Precautions. UCL staff are reminded to empty lab coat pockets and remove nametags, pens, markers, etc., before putting lab coats into the designated bags.
    Any towels or rags used with xylene are aired out before being sent for laundering.
  7. Hepatitis B Vaccination
    1. All new hires, regardless of job duties or exposure, are offered the Hepatitis B vaccination series at no charge as part of the Post Hire/Pre-Placement Physical. Employees are counseled by TSOH staff regarding the efficacy and safety of the vaccine and the benefits of being vaccinated before making the decision whether or not to receive the vaccine. The employee’s decision to accept or decline is documented on the TSOH Hepatitis B Vaccination form and also noted on the Report of Physical Exam form returned to the employer. If a new employee elects to receive the vaccine, the first dose is administered at the time of the physical. Employees who decline the vaccine upon hire may receive it free of charge at any time upon request.
    2. The CDC recommends testing for the antibody to Hepatitis Bs after the completion of the vaccination series for indication of vaccine efficacy. When the third vaccination in the series is administered, TSOH gives the employee a written order for the Hepatitis Bs antibody test to be performed by UCL in eight weeks. Results of the antibody test are sent to TSOH and TSOH notifies the employee of the results.
  8. Pipetting
    1. Mouth pipetting of specimens and reagents is prohibited.
    2. Pipetting of all specimens, reagents, diluents, and all other "infectious" and/or "noninfectious" materials is accomplished using a rubber bulb or automatic pipettor.
  9. Labels and Signs
    Communication to employees and clients about the hazards of bloodborne pathogens is accomplished, in part, by the use of signs and labels.
    1. Individual Specimen Containers:
      Since Standard (Universal) Precautions are observed with all laboratory specimens, each individual specimen container, e.g., blood tube or urine container is not labeled as hazardous since it can be identified by UCL staff as potentially infectious. The only exception to this is specimens from patients with suspected SARS. Specimens from patients with suspected SARS are labeled accordingly by nursing staff to insure proper specimen handling. (See section
      VI. Task Assessment of this manual.)
    2. Refrigerators and freezers that store blood or other potentially infectious materials are labeled with a sticker that says no food can be stored within, and also with a biohazard warning label.
    3. Containers used for transport of blood and other potentially infectious material are labeled with a biohazard warning label.
    4. Signs are posted at the entrances to the technical areas of all UCL sites stating that authorized persons only may enter. Such signs are also posted at the entrance to phlebotomy areas if the areas are separate from the main laboratory rooms.
    5. Contaminated equipment that cannot be decontaminated and is transported for service or repair is labeled with a biohazard-warning label.
    6. Red (or orange) bags or red containers are also used to designate biohazard material.
  10. Housekeeping and Cleaning
    Note: All cleaning is done according to the
    Routine Surface Cleaning and the Drawing Chair/Table Cleaning procedures, based on the type of surface to be cleaned, type of soil present and tasks being performed.
    1. All equipment, environmental surfaces (e.g., telephone handles, intercom receivers, keyboards, paperwork, countertops, etc.) and work surfaces (e.g., countertops where technical work is done) are decontaminated and cleaned immediately after contact with blood or other potentially infectious materials.
    2. Work surfaces are cleaned once per shift if they have been used since the last cleaning.
    3. Instruments and other laboratory equipment and work areas have a cleaning schedule based on use and procedure. (See the Site Specific Sections of this manual for cleaning schedules.)
    4. General cleaning takes place in two stages:
      1. Stage 1. - Disinfection: Wipe off the area with a 1:10 solution of bleach.
      2. Stage 2. - Cleaning: Wipe off the area with a 2% Lysol I.C./Amphyl solution to remove any residual dirt.
    5. All cleaning is documented on an appropriate log sheet.
  11. Disinfectants
    1. approved laboratory disinfectants are:
    2. Various dilutions of bleach to water, including 1:10 that is prepared weekly. Instructions are written on stock containers.
    3. 2% solution of disinfectant (Lysol I.C./Amphyl). Instructions for preparation are on stock containers.
    4. Formic Acid
  12. Biological Spills (See the UCL Safety Manual for chemical spill clean-up)
    Biological spills (e.g. blood, body fluid, microbiologic culture material) are cleaned up in the following manner:
    1. Put on gloves. (If there is broken glass, wear puncture resistant "house-cleaning" gloves and use a hemostat to pick up pieces of glass.)
    2. Use disposable towels to absorb the spilled material. Place the towels and material into a biohazard bag. Pieces of broken glass are placed in a “sharps container.”
    3. Dispose of the first pair of gloves in a biohazard bag. (This stops contamination of the disinfectant bottle.)
    4. Put on a fresh pair of gloves and clean as in the "Routine Surface Cleaning" policy, but allow the spill area to soak in 1:10 bleach solution for 10 minutes before wiping, air drying, and cleaning with 2% Lysol I.C./Amphyl.
    5. Dry the area with disposable towels and discard the material and the gloves into a biohazard bag. If housekeeping type gloves were used, they are disinfected with 1:10 bleach, washed with soap and water and allowed to air dry.
  13. Centrifuge tube breakage
    All tubes are inspected before centrifuging. Cracked or scratched tubes are not used.
    When tube breakage does occur in the centrifuge:
    1. Turn off the centrifuge.
    2. Wait 20 minutes after the centrifuge stops, if possible, before opening the centrifuge.
    3. If the centrifuge must be opened before the 20 minute waiting period is elapsed, either a full face shield, or a mask covering nose and mouth and approved safety glasses is/are worn when opening it.
    4. Wear heavyweight, puncture resistant gloves.
    5. Use a hemostat to remove the broken tubes.
    6. Clean the centrifuge according to the Centrifuge Maintenance procedure with the appropriate disinfectants.
      Note: Beckman TJ-6 models: remove the black rubber cushions and individually clean them. Clean underneath the cushions also.
    7. Clean all other tubes present in the centrifuge during the tube breaking incident with 1:10 bleach.
  14. Reusable glassware
    Counting chambers are soaked in 2% Lysol I.C. or Amphyl solution for 15 minutes before cleaning. Counting chambers may be washed with alcohol if they are to be used immediately but must be soaked in 2% Lysol I.C. or Amphyl and cleaned before storing. Counting chambers are cleaned with soap and water and rinsed with Type I water before drying. Pipettes are soaked and washed according to the
    Macro Pipette Washing Procedure.
  15. Repair of contaminated instruments
    All lab equipment that has been contaminated with blood or body fluids is decontaminated and cleaned before shipping parts or equipment to other UCL sites or outside repair services.
  16. Handwashing
    All staff members wash hands and any other skin with soap and water, or flush mucous membranes with water, immediately or as soon as feasible following contact of such body areas with blood or other potentially infectious materials.
    Hands are also washed with soap and water or with an approved hand gel:
    1. When leaving the work area for any reason.
    2. After removing contaminated gloves.
    3. Before eating, drinking, applying make-up and using the restroom.
    4. After using the restroom.
    5. After handling or touching any item in a contaminated area.
    6. As applicable in blood collection procedures. (See the Blood Specimen Acquisition section and the NICU and Nursery section of this manual.)
  17. Transportation of specimens between locations.
    1. Standard (Universal) Precautions are followed when transporting specimens between locations.
    2. All specimens for transport (e.g. blood tubes, urine or body fluid containers, etc.) are placed into a sealed secondary container. (e.g. ziplock bag) The secondary container must be clearly labeled with a biohazard label. If the primary containers are fragile (e.g. glass), they must be separated in the secondary bag by a barrier so they do not break against each other. (Paper towel or rubber bands can be used.)
      Use of absorbent for liquid specimens: When UCL couriers and UCL contracted couriers are picking up and transporting UCL specimens, no absorbent is required. They are UCL couriers transporting UCL specimens, only to UCL. When Mercy hospital couriers pick up UCL specimens from DV and transport them to any UCL site, the specimens are packed with an absorbent capable of absorbing all the contents in the primary container(s). If the Mercy hospital couriers transport a specimen(s) from a UCL Dubuque site to UCL DV , the specimens are packed for transport with an absorbent capable of absorbing all the contents in the primary container(s). Specimens sent to any other reference lab are packed for shipping with an absorbent capable of absorbing all the contents in the primary container(s).
    3. Secondary containers are placed into a third container (e.g. courier cooler) for transport. The words "Diagnostic Specimen" must be written on the outside of the third container.
    4. Specimen containers and tubes known to be contaminated on their external surfaces are decontaminated with a 1:10 dilution of bleach prior to shipment.
    5. Waste or specimen containers are carried and transported upright to avoid spills. Any spills of specimens or waste during transport are reported by the couriers to the Materials Management Supervisor and the Education Specialist.
  18. Manipulation of specimens
    Caution is taken when blood or body fluids are handled to assure that skin, mucous membranes, and clothing are not contaminated. The following steps are taken to minimize splashing or spraying of blood and body fluids:
    1. Gloves are worn when unstoppering a tube or opening a specimen container.
    2. Caps and lids are removed with the specimen container pointing away from the person opening it.
    3. Tubes that are not Hemoguard tubes are covered with an impervious backed gauze pad when removing stoppers.
    4. Glass vials or ampoules (e.g. control materials) are covered with an impervious back gauze pad or a cracker fracture safety collar when snapping off the top of the vial.
    5. Specimens are transferred with a pipette rather than pouring them if there is an increased risk of splash or spill, for example a viscous knee fluid or unusual specimen container.
    6. Masks, goggles, full face shield, disposable gowns, or a biological safety hood are used during procedures that are likely to generate droplets of specimen, e.g., vigorous mixing.
    7. Waste is carefully dropped, not thrown, into a waste container.
  19. Histology
    1. Handling of brain tissue obtained for diagnosis of dementia (Possible Creutzfeldt-Jacob disease) See the written procedure, protocol for Spongiform Encephalitis, Handling Possible Transmissible, in the Histology Staining Procedure Manual.
    2. All Histology procedures are done in a manner to minimize or avoid aerosolization of tissue particles.
  20. Blood specimen acquisition
    1. Only unused, sterile needles and blood collection devices are used for blood collection. It is the responsibility of each UCL staff person performing blood collection procedures to inspect all needles and equipment for defects or signs of contamination before performing the blood collection procedure.
    2. Gloves are worn when performing all blood collection procedures, including bleeding times.
    3. A fresh pair of gloves is used for each patient. Gloves are put on in view of the patient.
      1. Hands are washed before having direct contact with patients. Hands are washed after removing gloves.
        Approved alcohol-based hand gel may be used to wash hands between patients during routine blood collection procedures.

        f gloves are visibly soiled with blood or body fluids, hands are washed with soap and water after properly removing gloves. Approved hand gel may be used immediately if soap and water is not readily available, but hands are also washed with soap and water as soon as feasible.
      2. Gloves are disposed of in the patient room or immediate drawing area.
    4. If the drawing room bed, cot or special table (for babies and young children) is used, a clean surface covering is provided for each new patient. This can be a linen sheet for an adult, a clean towel for a baby or small child or clean paper that is pulled over the bed surface.
    5. Approved safety glasses are worn when performing all blood collections.
    6. Needles are not recapped by hand or unscrewed from the adapter/holder by hand. Blood is transferred from all syringes using a designated transfer device.
    7. Care is taken to avoid the drop of blood found on the gauze used to apply pressure following blood collection and also sometimes found on the rubber stoppers of blood collection tubes.
    8. Contaminated materials from the blood collection procedure, including sharps, are disposed of in the patient room or phlebotomy room.
    9. Single-use tourniquets are used for blood collection procedures that require a tourniquet.
    10. When collecting blood from known combative patients, either a mask that covers nose and mouth and approved safety glasses, or a face shield are/is worn.
    11. Patients in isolation
      Note: Standard (Universal) Precautions are used with all patients and clients. Additional categories of precaution (isolation) include “Contact Precautions”, “Droplet Precautions”, and “Airborne Precautions”.
      1. Precautions are tailored to the infective material and route of transmission. Reverse/Protective Precautions may be used to minimize susceptible patient exposure to pathogens.
      2. An appropriate isolation/precaution card is visibly posted on or adjacent to the door. Laboratory personnel follow instructions as posted on the isolation/precaution card in addition to Standard (Universal) Precautions which are always in effect.
      3. Appropriate PPE is placed by the nursing staff in a stocked cabinet or cart outside the patient room.
      4. Laboratory phlebotomy trays or carts taken from the laboratory for routine use are left outside the patient room. Only the equipment to be used is taken into the isolation area.
  21. NICU and Newborn Nursery
    When laboratory personnel enter nurseries, the following precautionary steps are taken:

    Note: Personnel with draining sores, wounds, or pustules are not to enter the nursery even if the lesions are covered. Personnel with non-draining sores or wounds may enter the nursery if the lesions are covered. Gloves are used to cover non-draining sores or wounds on the hands. Personnel with active genital and non-genital Herpes virus infection (cold sores, etc.) are not to enter the nursery. When Herpes virus lesions are crusted over, the individual may enter and complete work in the nursery. If questions arise, the Infection Preventionist or Employee Health Nurse will make the necessary decisions.

    The laboratory phlebotomy trays/drawers in the nursery are cleaned and stocked by laboratory staff.
    1. Wrist watches and rough pointed rings are not worn. Only plain band style rings are allowed.
    2. Hair that is shoulder length or longer must be pulled back off the shoulders with some kind of fastening. Beards must be neatly trimmed and no longer than on inch in length. Fingernails are no longer than one/quarter inch beyond the end of the finger. Artificial nails and nail enhancements are not worn.
    3. A mask is worn whenever the individual entering the nursery has an upper respiratory tract infection (cold, sinus trouble, etc.).
    4. The following procedures are used while working with nursery babies:
      1. Designated laboratory phlebotomy trays or carts stationed in the nursery are used for nursery work. Phlebotomy trays taken from the laboratory for routine rounds are left outside the nursery areas and only the equipment to be used is taken into the nursery.
      2. A clean gown is carried into the nursery scrub area.
      3. A three minute hand scrub is performed with an iodophore before entering the nursery area. The three minute scrub is required with each entry into the nursery.
      4. The clean surgical gown and gloves are put on.
      5. A clean pair of gloves is used for each baby. Gowns need not be changed between blood collections in the nursery unless they become visibly contaminated.
      6. A hand wash is required between each infant after gloves are removed. Use the germicidal nursery soap or iodophore, then re-glove.
      7. Babies in isolation are routinely handled after laboratory work is obtained from the non-isolated babies. After handling a baby in isolation, a one minute elbow to fingertip scrub is repeated. A clean surgical gown is put on, if designated by the posted isolation/precaution instruction card, before handling another baby. Gloves are always changed between babies.
      8. After completing laboratory work on the babies, the surgical gowns are discarded into the provided container. Gowns used in the isolation nursery are discarded in a hamper provided inside the door of the isolation nursery.
      9. A hand wash is completed before leaving the nursery area.
  22. Inspection Schedule to Repair, Replace, and/or Revise Engineering Controls
    1. All personal protective equipment is inspected by the user before each use.
    2. UCL staff report any defects in engineering controls or potential revisions to their representative on the Safety/Exposure Control Committee or to their immediate supervisor, who will evaluate the need for an incident report.
    3. The Exposure Control Plan is reviewed on an on-going basis by the Policy and Procedure Review Safety and Exposure Control Sub-Committee, and updated as necessary to reflect new or modified tasks in the laboratory, changes in technology that eliminate or reduce exposure to bloodborne pathogens, and implementation of appropriate, commercially available and effective engineering controls. The Laboratory Materials Management department documents when laboratory approved engineering controls are not available due to supply shortages, back orders, shipping delays, etc. The Safety Officer is informed and staff are given instructions as to what engineering controls will be used. The chosen controls will again be implemented when they become available.

Table I. Waste and Sharps Disposal



Waste Container

Container Handling

Final Disposition

Soft Uncontaminated Waste

Uncontaminated soft items which will not puncture plastic bags (e.g., office paper, gloves, packing materials, paper toweling, reagent containers, with the exception of blood bank reagents which are considered soft biohazard waste)

Gray, black, tan or clear bags

Tie the bag


Soft Biohazard Waste

Items that are contaminated and will not easily puncture plastic bags (e.g., urine and chemistry cups, vacutainer tubes.)

Biohazard Box, which is lined with a heavy biohazard bag

Mercy Sites: Seal cardboard box with clear tape.

Finley: Remove bags from the container at the bench and place into the red biohazard environmental service bin.

The containers are sealed when full. At Mercy vacuum tubes and glass tubes are placed into a heavy biohazard bag and then into a lined biohazard box.)

Tie Bag. Seal cardboard box with tape.

Dispose of by licensed contracted waste disposal company.


Items with sharp edges, contaminated or not, which are easily capable of puncturing plastic bags. (e.g. scalpel blades, needles, glass Pasteur pipettes, glass slides, and broken glass)

Hard Plastic puncture proof Containers

Lock container lid. Label with biohazard sticker (if not already pre-labeled).

Dispose of by licensed contracted waste disposal company.

Cathedral Square Microbiology Waste

Items contaminated with micro-organisms

Waste is placed in a biohazard box that is lined with a clear bag and a biohazard bag. Swabs, etc. from Cathedral Square microbiology stations are placed in a 24 hr urine container containing 2% Lysol I.C. solution prior to disposal.

Both bags are closed with rubber bands and the box is taped shut. A Stericycle Regulated Medical Waste label is placed on each box.

Dispose of by licensed contracted waste disposal company.

Chemical Waste

Spent and no longer used reagents, and outdated and no longer used chemicals.

See UCL Safety Manual and/or Safety Officer II

See UCL Safety Manual and/or Safety Officer II

See UCL Safety Manual and/or Safety Officer II

Liquid Biohazard Waste

Urine, instrument effluents, decanted specimens, etc.

If a waste container is used, follow the manufacturer’s recommendations.


Pour the liquid biohazard waste or bleach solution down a sanitary sewer drain daily, or more often if necessary if manually disposed of, immediately rinse the sink and drain with tap water.

Pathology Waste

Surgical tissues, limbs, etc.

Finley Site: Recycle formalin and place tissues first in a biohazard bag, then into a hard plastic secondary container that is labeled “incinerate only”

Mercy Site: Recycle formalin and place tissue in a biohazard bag.

The hospital housekeeping policy is followed.

Dispose of by licensed contracted waste disposal company.

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