Daniel M. Baer, M.D., Richard E. Belsey, M.D.
Daniel M. Baer, M.D., Richard E. Belsey, M.D.
Laboratory Safety Issues
Health care workers, by virtue of their involvement in trying to diagnose and treat human illness, are more likely to be hurt on the job than workers in most other industries. In an office practice the staff is likely to be frequently exposed to infectious processes. As a result, health care workers are frequently advised to receive immunization (eg, to hepatitis B virus), because they are more likely to be exposed to infection and because prevention will allow them to continue to fulfill their responsibility to help care for the sick. Physicians must be aware of these hazards and take steps to minimize safety risks because they are professionally and legally responsible for exposing their staff to such risks.
Clinical laboratory testing brings to physicians' offices some infectious, chemical, and electrical hazards not previously found in the office setting. Among the risks are the infectious hazards associated with collecting and preparing blood and body fluid specimens and with performing microbiological testing. Every specimen, calibrator, control sample, and proficiency testing specimen, for example, must be handled as if it were contaminated.
All human specimens should be considered a potential source of pathogens and should be handled with caution. Office staff collecting or handling specimens or performing test analyses should wear laboratory coats to keep their own clothing from becoming contaminated and from possibly exposing others, in or away from the office, to infectious hazards. Office staff performing specimen collection, handling specimens, or performing patient, control, or proficiency test analyses should always wear gloves and, if there is any hazard of splashing, they should wear safety goggles.
In the hospital setting these safety issues are the responsibility of the infection control officer and the laboratory and hospital safety officers, who are supported by interdepartmental multidisciplinary committees. In the office laboratory the physician-director is responsible for safety. Virtually every laboratory accreditation and licensing program places a major emphasis on evaluation of a laboratory's safety program, policies, and practice.
General Safety Practices
Laboratory professionals almost universally accept certain practices as essential for safe laboratory operation. These are listed in table 1. Laboratory associated hazards must be confined to the laboratory area, and people who are not aware of the risks should be kept out. Eating, drinking, smoking, and applying cosmetics-especially around the mouth and eyes-are hazardous, so employees should have another convenient area for breaks and lunch. Food should never be stored in refrigerators used for patient specimens, laboratory reagents, or culture media.
Laboratory specimens should be considered an infectious hazard. A broken specimen tube not only presents the hazard of broken glass but also may be the source of bacterial or viral contamination. Specimens should always be handled carefully and placed in a rack for transporting from one place to another. It is safest to avoid carrying other objects at the same time.
Reaching for supplies stored in high places out of ordinary reach increases the risk of an accident. Heavy objects should be placed within easy reach of someone standing on the floor. If this is not possible, a sturdy ladder or step stool must be available. Employees should not lift or move heavy equipment alone but should use a suitable dolly or hand truck or get help from others. If they must lift a heavy object, they should use the proper stance, with trunk erect and with the actual lifting done by straightening the legs.
Preventing Infection
A major hazard in any health care setting is infectious disease and exposure to infectious agents from patient specimens. Concern about spread of hepatitis B virus and human immunodeficiency virus (HIV) led the Occupational Safety and Health Administration (OSHA) to issue regulations in December 1991 to protect health care workers and other employees from the spread of blood-borne pathogens. You can read the regulations at http://www.osha.gov/SLTC/bloodbornepathogens/index.html. These regulations require employers to establish a written blood-borne pathogen exposure control plan that identifies workers with occupational exposure to blood and other potentially infectious materials and specifies means to protect and train them. The plan must have been implemented on or before May 5, 1992. The standard also includes requirements for housekeeping, including decontamination procedures, a written schedule for cleaning and discarding of contaminated needles and other sharps, and handling of regulated infectious wastes. Employers must provide appropriate warning signs, labeling, and training to alert workers to the risks of blood-borne pathogens.
Workers must be provided with protective clothing, barrier shields to protect them from splatter when blood and serum tubes are opened OSHA regulations require or sampled, and puncture-proof receptacles for contaminated needles and other sharps.
The employer must offer vaccination against hepatitis B virus Employees who choose not to accept the vaccine must sign a waiver form. They may be vaccinated at a later date if they change their minds. If an exposure incident occurs, employees must be counseled and provided with appropriate follow-up. Although universal precautions should be used, assuming that all body fluids have an infectious potential, we believe that patients who are hepatitis B and HIV positive should also be identified clearly in their medical records. This allows immediate appropriate therapy with anti-HIV drugs or hepatitis B immune globulin for a laboratory staff member in case of known exposure to the patient's body fluids.
In addition to needle sticks, potential sources of laboratory acquired infection are splatter and aerosolization of infectious material during removal of a vacuum tube stopper, sample preparation, and test processing. Specimen containers should be checked for cracks before centrifugation. Aerosols produced when excess blood is expelled from the needle tip can be minimized if the syringe is held vertically and the blood deposited directly on a cotton pledget. Plunging a flamed bacteriologic loop into a culture before it has cooled adequately is another source of potential infectious aerosols that can be avoided with proper technique.
Much of the responsibility for avoiding infection rests with the employee. The office should have an active safety program. As part of this program, employees working with potentially infectious material should be taught to keep their hands away from their face, eyes, nose, and mouth to prevent self inoculation. They should be taught that frequent hand-washing during the day is an easy and efficient way to reduce the potential for carrying and being infected with a pathogen. Serum separated from blood should not be decanted but should be transferred by pipette and never by mouth pipetting. There should be no eating drinking, or smoking in the laboratory.
Chemical Hazards
Many of the reagents used in physicians' office laboratories are self-contained in dry form, but some systems still use chemical reagents that may present a variety of hazards, such as skin irritation or burning, toxic fumes, or fire. Knowing the properties of the reagents and how to handle them will minimize the risk of accidents. Mouth pipetting must never be used. Only a minimum amount of hazardous reagents should be stored in the office laboratory. If volatile materials are to be stored in the office the quantity must be as small as possible and appropriate storage containers must be used. Highly flammable materials, such as ether, should never be stored in an ordinary household refrigerator that has a spark hazard. Other flammable liquids should only be stored in safety containers. All containers must be clearly labeled with the contents and associated hazards. Carcinogenic chemicals must be clearly marked, inventoried, and have access controlled, as specified in OSHA regulations. Material Safety Data Sheets (MSDS) for all hazardous materials must be available for all employees.
Caustic reagents are not hazardous as long as they are confined to the test tube, but they can easily cause burns if they are spilled or the test tubes break. Every laboratory that uses caustic or hazardous liquid chemicals should have a clearly written cleanup procedure and cleanup materials, including absorbent materials and waste containers for disposal of the hazardous waste. Many laboratories use absorbent cat litter for immediate control of spills. Cleanup procedures should include instructions for dealing with the waste container of the chemical analyzer and treatment of anyone splashed with caustic materials.
Electrical Hazards
Wherever there are electrical wires and connections there is the potential for shock and fire hazards. The external wiring of all instruments and other electrical appliances, including lights and extension cords, must be periodically inspected and worn wires replaced. Do not handle electrical equipment and connections with wet hands since some instruments are not adequately grounded or may have an internal current leak. Analytical instruments should be installed with a three-prong grounded plug, and if there is a shortage of outlets it is much safer to install additional electrical service than to use extension cords or multiple tap plugs in the duplex wall outlet. Placing too many electrical instruments or appliances on a single circuit can overload the circuit and result in instability in some of the analytical instruments.
Fire Safety
The presence of a laboratory in the physician's office increases the risk of a fire hazard due to the increased number of electrical appliances and connections, use of heaters, sterilizers, and occasionally open flames, and the presence of volatile chemicals. The laboratory should be organized to allow easy exiting in case of fire. Fire extinguishers should be kept in or near the laboratory to extinguish small contained fires, but the fire department should always be notified of any larger fire and the office should be evacuated. The guiding principle of fire safety is to protect employees and patients from possible harm.
Fire extinguishers should be well maintained and tested, and employees should know how to use them. The laboratory staff should understand the hazards of using liquid extinguishers on instruments or when live electrical connections are exposed. There should be periodic drills to ensure that employees know how to respond to a fire and use the equipment properly. Although this seems disruptive to daily routine it minimizes the hazard of serious injury. Local fire departments are usually glad to instruct people in the selection and use of fire safety equipment.
Disposal of Infectious Wastes
Potentially infected wastes from the office laboratory should be dealt with in a way that minimizes the risk of infection among the office staff, cleaning staff, and people who handle the waste after it leaves the office. Infectious wastes should be discarded into a separate container from other office or laboratory trash. The container should be conveniently located for all staff members dealing with such waste. It should be lined with a disposable, autoclave-resistant bag that is appropriately labeled as containing biohazardous material. The disposal bag with the contaminated material should be taken from the container, closed, and decontaminated prior to being discarded. Because many states and cities have specific requirements for disposal of medical waste, it is important to check for these local rules.
Sources for Safety Supplies, Signs, and Labels
Laboratory supply companies sell a large selection of personal protective equipment, signs, and labels that meet OSHA requirements for laboratory safety. Some of the larger laboratory supply companies are:
Exercise
Examine your laboratory's safety policies and practices using the questionnaire that you can print.
Commentary
A fire drill, including the evacuation of the office, review of the evacuation, protection of patients, and inspection and review of the use of fire extinguishers, should occur once a year. Several of the accrediting and licensing agencies require annual fire drills. You should keep a record of yearly training to satisfy agencies and as a reminder to have the drills.
All electrical instruments should be grounded using a three-prong plug that attaches to a proper grounded receptacle with the correct polarity. Inexpensive grounding and polarity testers are available at hardware stores. If there are not adequate receptacles, a fused and grounded power strip should be used instead of an ordinary extension cord. Heavy duty multireceptacle grounded adapters are available for outlets so that additional connections can be made.
Flammable liquids should be kept to a minimum. Whenever possible, use alternative methods that do not require flammable liquids. Ether is hardly ever needed in the laboratory. Flammable liquids should be kept in approved metal containers in a well ventilated location.
OSHA has extensive and strict rules intended to reduce the exposure of health care workers to blood-borne pathogens. You can download these rules as well as OSHA's explanations about them. ( http://www.osha.gov/SLTC/bloodbornepathogens/index.html). Review the rules carefully. Failure to comply can subject you to a fine. The rules apply to medical office activities that expose individuals to blood or body fluids, including obtaining specimens from patients and performing laboratory tests. An exposure control plan must be developed and updated and reviewed annually. This needs to identify every job that has a potential for exposure. The bulk of the plan must indicate the measures that are taken to reduce hazards to the staff and patients.
In November 2000, Congress passed the Needlestick Safety and Prevention Act, PL106-430. This act will require changes in the way needles are used, handled and disposed of. Check with the OSHA website for more information as the rules are written to implement this legislation.
Universal precautions must be observed. Employees must wear gloves whenever they obtain, handle, or process patient specimens. They must wash their hands when the gloves are removed. Laboratory coats are required to keep blood or other potentially infectious materials off of the employee's uniform or street clothes. Laboratory coats should be removed prior to leaving the lab work area, taking a break, or eating lunch. When a laboratory operation, such as removing a stopper from a blood tube, might cause blood droplet splatter, a plasfic shield should protect the employee.
There should be a procedure for routine decontamination of work surfaces at the end of the workday. Spills of patient specimens and reagents occasionally occur. Procedures and materials for spill cleanup are necessary. Needles and other sharps must be placed in a puncture-proof container.
All employees subject to hepatitis B virus exposure must be offered vaccination against the virus. If an employee declines vaccination, this must be documented using the wording given in the OSHA rules and regulations, and signed by the employee. The employee may reconsider and receive the vaccination at any future time.
If there is an exposure incident, this must be completely investigated and documented. The source individual's blood must be tested for hepatitis B virus and HIV as soon as feasible. The exposed individual is also to be tested or observed, and counseled.
Biohazard signs or labels are required on refrigerators containing pafient specimens, containers used to ship specimens, and regulated waste.
Annual training about reducing the risks of blood-borne pathogens must he provided to all employees, and should be documented. The specific content required for the training is provided in the OSHA rules and regulations.
Daniel M. Baer, M.D., Richard E. Belsey, M.D.
Adapted from Diagnosis (October 1996:27), Copyright 1996, Medical Economics Publishing Co.
Daniel M. Baer, M.D., Richard E. Belsey, M.D.
Waste management has become necessary for medical offices over the past few years because of federal and state regulations that control and restrict the disposal of waste generated by all medical facilities. There are now federal rules and regulations in at least 44 states affecting infectious or toxic wastes from medical offices. Even if medical offices have already complied with these rules regarding waste, the addition of an office laboratory may require different waste management strategies. Since medical and hazardous chemical wastes are now regulated and require special methods of handling and disposal, complete documentation of your waste management program is especially important.
Kinds of Waste
There are three distinct kinds of waste generated by medical facilities:
Regulation
Many federal and state agencies regulate storage and disposal of wastes produced in medical offices and their laboratories. The best way to find out what rules apply in your area is to call all of the federal and state agencies that might be interested in your wastes. These include the Occupational Safety and Health Administration (OSHA), the Environmental Protection Agency (EPA), and your state's Departments of Labor, Health, Environment, Public Services, and Waste Management. In addition, some local jurisdictions have regulations. A local waste management company should he able to help you with the regulations that apply in your area. The local medical society may have information about the rules governing waste management.
Waste Management Strategies
Waste minimization is an effective technique for converting regulated medical waste into unregulated trash For instance, test tubes containing blood are considered infectious medical waste. It is permissible to discard the blood down the drain into the sewage system in most locations. Once the tube no longer contains blood, it is ordinary trash. Remember, however, that emptying and rinsing the tube creates a risk to your personnel. This risk, due to the additional handling of potentially infectious materials, must be weighed against the cost of disposal of additional medical waste.
Conversion of the hazardous material so that it is no longer a threat to the public is another possible strategy. Infectious materials, including cultures, can be disinfected by autoclaving or immersion in a disinfecting solution such as sodium hypochlorite (household bleach). Some toxic chemicals, such as formaldehyde containing solutions, can be converted to nontoxic ones by chemical processing.
Recycling is a form of waste minimization. Some solvents can be redistilled, recovering them for reuse. Another means of minimization is substitution of a toxic or hazardous product with one that is not.
Segregation of hazardous from nonhazardous waste reduces the volume of regulated waste. Placing a blood-soaked gauze pad in a garbage can containing otherwise ordinary trash converts the entire container into medical waste.
Disposal of medical and hazardous waste in most locations requires special containers, marking, transportation, record-keeping, and, ultimately, incineration or special burial in a sanitary landfill. Frequently, a specially certified waste disposal company must be used. The waste may need to be buried in a special landfill area covered by elaborate rules designed to protect the public and the waste disposal workers from the potential hazards of the wastes.
Recommendations
It may be possible for you to arrange for disposal of the medical waste through a hospital or referral laboratory, if the amounts are small. Otherwise, you may need to contract with a medical waste disposal company. Be sure to verify that the company is licensed or approved to dispose of medical waste, and find out what method of disposal-incineration or landfill disposal-it uses. If it is improperly disposed of, you may be held responsible. Transport of medical waste is regulated in some areas, so even if you arrange for disposal through a hospital or referral laboratory, you need to check into any restrictions on transporting the waste.
Any agreement with a medical waste disposal company should be in writing, and should be part of your written medical waste management documentation. The documentation should include (1) instructions and procedures for your office employees concerning waste disposal; (2) information about segregation of types of waste, bagging, and disposal of infectious waste; (3) agreements or contracts with a disposal company; and (4) logs of transfer of waste to the disposal company. Find out how long the records need to be kept.
The overriding principals in waste management are (1) minimize waste, (2) use the sewer, (3) convert as much waste as possible to non-regulated ordinary waste, and (4) protect your staff, the public, and the waste disposal personnel.
Exercise
Commentary
Infectious waste needs to discarded into a special thick plastic bag. Protecting staff, cleaning people, and patients from contamination is important. Be sure that the office cleaning staff knows the significance of infectious waste, and uses appropriate precautions when handling it. When the bags are full, or sooner if it takes a long time to fill one, they should be securely closed and stored for pickup by the hazardous waste disposal company.
When handling hazardous waste within the office, be sure that it is handled in a way that provides protection to your staff. This means ensuring that all staff members know that needles should not be recapped before disposal, that proper well-marked containers are used, and that the staff uses protective devices such as gloves when handling waste that could contaminate them. It is also necessary to provide a storage place for the waste until it is picked up by the waste disposal company. Hazardous waste needs to be segregated from ordinary trash and garbage so that it will not be accidentally disposed of with the trash.
Daniel M. Baer, M.D., Richard E. Belsey, M.D.
Addison LA, Fischer PM. The Office Laboratory. 2nd ed. East Norwalk, Conn: Appleton & Lange; 1990:69-77.
Clinical Laboratory Waste Management. Approved Guideline GP5-A 1993. Wayne, Pa: National Committee for Clinical Laboratory Standards.
Protection of Laboratory Workers from Instrument Biohazards and Infectious Disease Transmitted by Blood, Body Fluids, and Tissue; Approved Guideline M29-A 1997, Wayne, Pa: National Committee for Clinical Laboratory Standards;
Videos
Luebbert PP, Laboratory safety and infection control, 20 min VHS, 25-page monograph, 1990. Chicago, IL ASCP Press
Luebbert PP, OSHA'S blood borne pathogens standard: compliance in the clinical laboratory. 20 min VHS, 40-page monograph, 1992. Chicago, IL ASCP Press