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Use of Containers for Clinical Specimens (2.5.1)

Use of Containers for Clinical Specimens (2.5.1) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Labs/Specimens

2.5.1


UW HEALTH CLINICAL POLICY 1
Policy Title: Use of Containers for Clinical Specimens
Policy Number: 2.5.1
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: December 1, 2015

I. PURPOSE

To reduce the risk of exposure to potentially infectious materials during transport by ensuring that
appropriate containers and w ork practices are consistently used.

II. POLICY ELEMENTS

Patient specimens, laboratory isolates and any other potentially infectious materials w ill be transported
w ithin UW Health, as w ell as to and from off -site locations, in a manner consistent w ith the stipulations of the
OSHA Bloodborne Pathogens Rule and the Wisconsin Department of Commerce.

III. PROCEDURE

A. All patient specimens must be assumed to be potentially infectious and handled under Standard
Precautions, as described in UWHC policies #13.07, "Standard Precautions and Transmission-Based
Precautions (isolation) for Inpatient Settings," and #13.28, “Standard Precautions and Transmission-Based
Precautions (isolation) for Ambulatory Settings.”
B. Specimens of blood or other potentially infectious materials shall be placed in a container w hich prevents
leakage during collection, handling, processing, storage, transport, or shipping.
i. Each specimen must be collected in a standardized specimen container that is leak proof.
Examples include sterile screw capped jars, vacuum blood collection tubes, blood culture bottles,
formalin vials, and commercial vials for transport of specimens collected on sw abs.
ii. The lid must be aff ixed properly and tightly to prevent leakage of the contents.
iii. When the label containing patient identif ication information is placed on the container, ensure that
the label does not cover bar code or w arning labels, and is not aff ixed to the container lid.
iv. Whenever patient materials are transported via the pneumatic tube system, the primary container
must be placed w ithin a sealed color-coded plastic bag indicating the contents are biohazardous,
prior to being placed into the carrier.
v. Patient biological specimens, except those covered under UWHC policy #7.01 (Pathology
Specimen Care and Handling) as described in III. E., w ill be transported in a sealed plastic bag
(Ziploc™ or comparable) labeled w ith the universal biohazard symbol.
C. If the exterior of the primary container is visibly contaminated, it must be decontaminated before transport.
i. If the primary container is leaking or the exterior of it cannot be decontaminated, transfer the
specimen to a new leak-proof container.
ii. UWHC Clinical Laboratories w ill not accept patient specimens w hich arrive in leaking, or otherw ise
contaminated, containers.
D. If the specimen could puncture the primary container, the primary container shall be placed w ithin a
secondary container w hich is puncture-resistant in addition to being leak proof.
E. For large specimens, including limbs, that are collected in the Operating Room, see UWHC Policy #7.01
(Pathology Specimen Care and Handling.)
F. Patients should be provided w ith appropriate containers w hen they leave UWHC w ith instructions to collect
specimens at home. When instructions are given by phone to a patient w ho is off site, it should be made
clear that specimens are to be collected in clean, leak proof, screw capped containers.
G. New brands or types of specimen containers must be evaluated by Nursing, Infection Control and Clinical
Labs before they are introduced into the system.
H. When a specimen is being transported outside of any UW Health location, the outermost container for
storage, transport, or shipping must be labeled w ith the universal biohazard symbol. The label shall be
f luorescent orange or orange-red or predominately so, w ith lettering or symbols in a contrasting color. The
universal biohazard symbol must be imprinted on the container, or aff ixed by string, w ire, adhesive or other
method that prevents it's loss or unintentional removal.
i. Off-site recipients of specimens include laboratories w ithin the Clinical Sciences Center that are not
physically part of UW Health (e.g., Medical School research laboratories), sites elsew here on
campus (e.g., State Laboratory of Hygiene, Waisman Center, McArdle Labs), and locations outside
of UW Health facilities including commercial and research laboratories.



UW HEALTH CLINICAL POLICY 2
Policy Title: Use of Containers for Clinical Specimens
Policy Number: 2.5.1


IV. COORDINATION

Author(s): Infection Control Practitioner
Senior Management Sponsor: SVP, Patient Care Services and CNO
Review ers: Director, Microbiology Laboratory; Chairs, Clinical Laboratory Safety Committee
Approval committees: Infection Control Committee; UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: October 19, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

V. APPROVAL

Jeff Grossman, MD
UW Health CEO

Teresa Neely
SVP and CAAO

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VI. REFERENCES

29 CFR Part 1910.1030 Occupational exposure to Bloodborne Pathogens; Final Rule, 2001 49 CFR Part
173, Shippers - General Requirements for Shipments and Packaging
UWHC policy #13.07, "Standard Precautions and Transmission Based Precautions (Isolation) for Inpatient
Settings."
UWHC policy #13.28, "Standard Precautions and Transmission Based Precautions (Isolation) for
Ambulatory Settings."
UWHC policy #7.01, "Pathology Specimen Care and Handling."
UWHC Clinical Laboratory Departmental Policy 5.07, “Specimen Rejection”
UWHC Clinical Laboratory Departmental Policy 1502.5.06, “Acceptance Policy for Specimen Identif ication”
UWHC Clinical Laboratory Guidance Document, “Transport of Specimens (via Pneumatic Tube)” accessible
on U-Connect at https://uconnect.w isc.edu/clinical/references/clinical-laboratories/specimen/transport-tube/

VII. REVIEW DETAILS
Version: Revision
Next Revision Due: December 1, 2018
Formerly Know n as: Hospital Administrative policy #13.15