Microbiology Laboratory Users Manual - East Surrey Hospital Microbiology Laboratory Users Manual Issue

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  • Microbiology Laboratory Users Manual

    Produced by the Microbiology Quality Management Team and the

    Infection Prevention & Control and Antimicrobial Stewardship Teams

    Version 5 Issue Date: April 2017 Review Date: April 2018

    8194

    http://www.ukas.com/wp-content/uploads/schedule_uploads/00007/8194%20Medical%20Single.pdf http://www.ukas.com/wp-content/uploads/schedule_uploads/00007/8194 Medical Single.pdf

  • This document is uncontrolled when printed

    Surrey and Sussex Healthcare NHS Trust Issue date: April 2017 Microbiology Laboratory Users Manual Issue 5 Page 2 of 37 Review date: April 2018

    MICROBIOLOGY LABORATORY USERS MANUAL

    CONTENTS Page

    1. Scope of document 3

    2. Introduction 3

    2.1 Frontier Pathology NHS Partnership 3

    2.2 The Department of Microbiology 3

    2.3 Microbiology Specimen Processing 3

    2.4 Protection of personal information 3

    2.5 Service suggestions and complaint procedure 3

    3. Departmental contact numbers and laboratory opening hours 3–4

    3.1 Departmental address 3

    3.2 Laboratory opening times 4

    3.3 Departmental contact numbers 4

    3.4 Other contacts 4

    4. Specimen collection 5–7

    4.1 Optimum time of and conditions for specimen collection 4

    4.2 Health and safety issues relating to specimen collection 5

    4.3 Types of specimen container 5

    5. Urgent specimens 7

    6. Ordering Microbiology Tests 7–9

    6.1 Electronic orders – hospital 8

    6.2 Electronic orders – GP 8

    6.3 Manual orders 8

    6.4 Verbal requests 9

    7. Transport of specimens to the laboratory 9–10

    7.1 Standard procedure 9

    7.2 Pneumatic Tube Transport System 9

    7.3 Transport timetable – Pathology Reception ESH to Microbiology Laboratory (Crawley)

    10

    7.4 Routine non-urgent specimens 10

    7.5 Urgent specimens – taken within normal Laboratory working hours up until 15h30

    10

    7.6 Urgent specimens – taken out of normal Laboratory working hours 10

    7.7 Community specimens 10

    8. Test repertoire and guidelines for specimen collection – General Microbiology 11–26

    9. Test repertoire and guidelines for specimen collection – Virology 27–34

    10. Specimen turnaround times for in-house tests 35–36

    11. OOH Transport of Microbiology Samples from ESH to Crawley – Quick Guide 37

  • This document is uncontrolled when printed

    Surrey and Sussex Healthcare NHS Trust Issue date: April 2017 Microbiology Laboratory Users Manual Issue 5 Page 3 of 37 Review date: April 2018

    MICROBIOLOGY LABORATORY USERS MANUAL

    1 SCOPE OF DOCUMENT

    This document describes the optimum use of the Microbiology Laboratory, repertoire of tests offered, methods for specimen collection, and transport of microbiology specimens. This document has been drawn up in discussion with Users.

    2 INTRODUCTION

    2.1 Frontier Pathology NHS Partnership

    Frontier Pathology NHS Partnership (www.frontierpathology.nhs.uk) is a joint venture between the Pathology departments of Surrey & Sussex Healthcare NHS Trust and Brighton & Sussex University Hospitals NHS Trust. The partnership was established in April 2015 and aims to place pathology services at the forefront of healthcare delivery. The pathology service provided by Surrey and Sussex Healthcare NHS Trust consists of Integrated Blood Sciences and Cellular Pathology departments at East Surrey Hospital (ESH) and the Microbiology department at Crawley Hospital.

    2.2 The Department of Microbiology

    The Microbiology Laboratory for the Surrey and Sussex Healthcare NHS Trust site of Frontier Pathology NHS Partnership is at Crawley Hospital.

    The Microbiology Department at Crawley is accredited by the United Kingdom Accreditation Service (UKAS) to ISO 15189:2012 for the test repertoire stated on the Schedule of Accreditation, which can be accessed at http://www.ukas.com. A clinical service is provided by three Consultant Microbiologists on a rotational basis. Infection Control for SASH NHS Trust is managed by the Infection Prevention, Control and Antimicrobial Stewardship (IPCAS) Team.

    2.3 Microbiology Specimen processing

    In excess of 200,000 specimens are processed in the Microbiology Laboratory on an annual basis. A list of available in-house and commonly referred tests can be found in Section 8 (General Microbiology) and Section 9 (Virology) of this document.

    2.4 Protection of personal information

    The laboratory complies with the requirements of the Data Protection Act, the Caldicott principles on safeguarding patient confidentiality and patient information, and with guidance from the Royal College of Pathologists. All patient identifiable information is regarded as confidential and is passed on only for official purposes e.g. to professionals with responsibility for patient care or public health. Confidential data is held only as long as necessary for operational purposes, and is stored securely.

    2.5 Service suggestions and complaint procedure

    The needs of pathology service users are kept under regular review. Service users are encouraged to provide feedback via the biennial pathology user survey. For further information, contact:

    Service and Quality Director michael.rayment@sash.nhs.uk 01737 231894

    Head of Microbiology and Infection clare.reynolds@bsuh.nhs.uk 01273 664621

    Head of Quality Management john.mcbride@bsuh.nhs.uk 01273 696955 ext 3678

    3 DEPARTMENTAL CONTACT NUMBERS AND LABORATORY OPENING HOURS

    3.1 Departmental address

    Postal Address:

    Department of Microbiology Ground Floor Crawley Hospital West Green Drive Crawley West Sussex RH11 7DH

    DX Address:

    CRAWLEY HOSPITAL (MICROBIOLOGY)

    DX 6560200 CRAWLEY 90 RH

    https://www.frontierpathology.nhs.uk/ http://www.ukas.com/ mailto:michael.rayment@sash.nhs.uk mailto:Clare.Reynolds@bsuh.nhs.uk mailto:john.mcbride@bsuh.nhs.uk

  • This document is uncontrolled when printed

    Surrey and Sussex Healthcare NHS Trust Issue date: April 2017 Microbiology Laboratory Users Manual Issue 5 Page 4 of 37 Review date: April 2018

    3.2 Laboratory opening times

    Monday to Friday: 09:00 to 17:15 Saturdays: 09:00 to 13:00 Sundays & Bank Holidays: 09:00 to 13:00 An on-call system is in operation at all other times (see section 7.6).

    3.3 Departmental contact numbers

    The extensions for the department can be reached via Crawley Hospital Switchboard 01293 600 300 (speed dial from ESH 5332) Microbiology Laboratory Laboratory results enquiries Crawley Hospital ext 3079 (available only during laboratory opening times)

    Laboratory Fax number 01293 600 404 Clinical advice Routine hours Monday to Friday 09:00 to 17:00 Contact ESH ext 2778 Saturday, Sunday and bank holidays 10:00 to 13:00 Contact via switchboard This is a Consultant delivered service. As demand for advice is very high, please ensure that calls are clinically necessary, the case/query has been discussed with a senior medical team member (preferably the Consultant in charge), and that all relevant clinical information is to hand before calling the Duty Consultant Microbiologist (DCM). In addition:

     If the DCM cannot be reached on ESH ext. 2778, please call back at a later time;

     If the query is clinically urgent, the DCM can be contacted via switchboard, but please note that there is generally only one microbiologist taking calls, so other calls cannot be taken if ESH ext. 2778 is engaged, or switchboard has put a call through to the DCM’s mobile ‘phone;

     For urgent advice after 5 pm Mon-Fri and during weekends/public holidays, the DCM can be contacted via switchboard – the DCM will be out of the hospital during these periods and there may be times when calls cannot be answered immediately;

     Overnight calls (11 pm to 9 am) may be made to the DCM ONLY where there is a pressing need for urgent clinical advice – where indicated, we would expect these calls to be made by a doctor of some seniority (SpR and above). Clinical discussions regarding infection issues are usually more helpful to patient management when made the following day, when adequate laboratory and clinical information is available to inform the discussion;

     The DCM should NOT be contacted for results enquiries, general Microbiology enquiries, or other issues unrelated to clinical patient management or infection control / antimicrobial stewardship issues.

    Please consult the Trust antimicrobial policy before contacting the Consultant Microbiologist. The Trust Antimicrobial Prescribing Policy is available in the Policy section of the Trust intranet http://intranet.sash.nhs.uk/department-directory/clinical-support/mic/ipcas-guidance-resources- specific-organisms-guidance/antimicrobial-prescribing/ The Duty Consultant Microbiologist should NOT be contacted for results enquiries.

    3.4 Other contacts East Surrey Hospital 01737 768 511 Infection Prevention & Control Nurses: ESH - ext 6481, 6477 and 6478 ESH bleep 479 Pathology supplies: pathstores@sash.nhs.uk Surrey and Sussex HPT (South East): Phone: 0344 225 3861 (notification of infectious diseases) Facsimile: 01403 251 006 Out