Microbiology Laboratory Handbook

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NHS GENERAL9693MicrobiologyLaboratory HandbookMicrobiology LaboratoryNorth Tyneside General HospitalRake LaneNorth ShieldsTyne & WearNE29 8NHThis SOP supersedes all previous versionsREFERENCE AND VERSION No.LH-MIC-GEN-G-001v1REPLACES DOCUMENT No.LP-MIC-GEN-N-181v16LOCATION OF COPIES1. Q-pulse2. Northumbria Healthcare NHS Trust Intranet3. InternetTitle: Clinical Microbiology Users HandbookQP Ref: LH-MIC-GEN-G-001v1Author: Jennifer Challoner & Alex DugganAuthorised by: Microbiology Specialty boardCreated Date:23rd April 2020Disposal date: 22nd April 2050Page 1 of 75

NHS GENERALTable of ContentsINTRODUCTION AND SCOPE . 4OVERVIEW OF SERVICES OFFERED . 5LOCATING AND CONTACTING THE LABORATORY. 5Directions and transport . 5Microbiology laboratory opening hours . 6Enquiries for results . 6Visitors . 7Microbiology contact telephone numbers . 7Clinical advice . 8Clinical Microbiology service telephone numbers . 8Infection Control Advice including outbreaks . 9Infection control team telephone numbers . 9CONSENT, COLLECTION AND TRANSPORT OF SPECIMENS . 10Request forms. 10Clinical details . 11Patient consent . 12Private patients – Non NHS tests . 12Specimens . 13Multiple specimen requirements . 14High risk specimens and safety . 14Health and safety . 15Specimen Ordering on ICE/Electronic Requesting - Guidance for Use . 15Contact Names for ICE . 16Specimen collection – Microbiology and Virology . 16Specimen collection – Serology . 21Specimen collection – QuantiFERON Gold . 22Specimen collection – Semen analysis . 22Packaging routine specimens for microbiology . 25Packaging urgent specimens for microbiology . 26Transport of specimens to microbiology . 27At NTGH . 27At NSECH, WGH and HGH . 27Urgent transport of specimens from NSECH, WGH AND HGH . 27Transportation of urgent Microbiology samples from NSECH to NTGH . 29Courier contact details . 30Blood bikes: . 30Connection Express: . 30Title: Clinical Microbiology Users HandbookQP Ref: LH-MIC-GEN-G-001v1Author: Jennifer Challoner & Alex DugganAuthorised by: Microbiology Specialty boardCreated Date:23rd April 2020Disposal date: 22nd April 2050Page 2 of 75

NHS GENERALTaxis: . 30GP surgeries . 30Additional tests . 30Microbiology supplies . 30Wansbeck General Hospital . 31Hexham General Hospital . 31North Tyneside General Hospital . 31Northumbria Specialist Emergency Care Hospital . 31General Practitioners . 31TEST REPERTOIRE . 32MICROBIOLOGY INVESTIGATIONS. 32SEROLOGY INVESTIGATIONS. 40VIROLOGY INVESTIGATIONS . 44OTHER/MISCELLANEOUS INVESTIGATIONS . 44Tests referred to other laboratories . 46Referral laboratory address and contact details . 61REPORTING OF RESULTS. 70Urgent results. 70Written reports . 70Electronic reports . 70Referred tests reports . 70Interim reports . 70Final reports: . 71Additional reports . 71Amended reports . 71Requests for duplicate previously authorised reports. 71Result enquiries . 71Interpreting laboratory results. 71Uncertainty of measurement and results . 71Factors that may affect results . 72QUALITY ASSURANCE AND GOVERNANCE . 73Quality Assurance: . 73Accreditation status:. 74Information Governance . 74Concerns and Complaints. 74Changes to our service . 75REFERENCES . 75Title: Clinical Microbiology Users HandbookQP Ref: LH-MIC-GEN-G-001v1Author: Jennifer Challoner & Alex DugganAuthorised by: Microbiology Specialty boardCreated Date:23rd April 2020Disposal date: 22nd April 2050Page 3 of 75

NHS GENERALINTRODUCTION AND SCOPEThe Microbiology laboratory for Northumbria Healthcare NHS Foundation Trust islocated at North Tyneside General Hospital serving a population of over 550,000 withinthe Northumberland and North Tyneside areas.The department provides a diagnostic service to Northumbria Specialist EmergencyCare Hospital (NSECH), Wansbeck General Hospital (WGH), Hexham GeneralHospital (HGH) and the community Hospitals.The Microbiology department is committed to providing a quality service and as suchis accredited by the United Kingdom Accreditation Service (UKAS) to ISO 15189standards. This is the national accreditation body for the UK ensuring laboratoriesmeet the required national standard for Medical laboratories necessary for quality andcompetence. The department was awarded UKAS accreditation on the 13th October2017. As part of the on-going requirement to maintain compliance with ISO 15189standards UKAS will undertake annual surveillance visits with a full inspection every4 years.Not all tests in the laboratory repertoire fall under the scope of accreditation thereforeit is recommended that the UKAS website is checked for an up to date list of all /schedule uploads/00007/9693%20Medical%20Single.pdfThe test repertoire includes diagnostic testing for bacteriology, serology, virology,parasitology and mycology. We also provide semen analysis for post vasectomysamples, and pregnancy testing.We provide this service to local hospitals, General Practitioners, Health ProtectionUnit, private companies and individuals. We also provide infection control services.Immunology investigations are referred to the Immunology Department at QueenElizabeth Hospital, Gateshead. Results are then reported by the MicrobiologyLaboratory at North Tyneside General Hospital.Where we are unable to offer in house testing as outlined in our test repertoire samplesare prepared and processed by the laboratory prior to referral to the most appropriatereferral laboratory. Once we are in receipt of the results the Microbiology Laboratoryat North Tyneside General Hospital will issue a report to the requestor.The efficiency of the service provided is reliant on the cooperation of all service usersensuring the necessary requirements are met as outlined in this user manual. It isimportant to follow the guidelines in relation to all aspects of health and safety, patientand specimen identification, specimen collection and transport, as well as providingus with essential clinical details.The intended use of this document is by users of our service, such as clinicians,General practitioners and other healthcare professionals. Advice on specimencollection is given in this manual but must be explained to patients by a healthcareprofessional.Title: Clinical Microbiology Users HandbookQP Ref: LH-MIC-GEN-G-001v1Author: Jennifer Challoner & Alex DugganAuthorised by: Microbiology Specialty boardCreated Date:23rd April 2020Disposal date: 22nd April 2050Page 4 of 75

NHS GENERALAdvice on antibiotic treatment and infection control is not covered in this user manual.Appropriate advice can be located on the Trust intranet page or by contacting aConsultant Microbiologist or Infection control team.Please refer to the following guidelines for further information: Guide to the use of antimicrobials - adult and paediatric guidance:https://viewer.microguide.global/NHCT North of Tyne Area Prescribing Committee, Primary Care Guidelines for theManagement of Guidelines-APC-August-2012.pdfOVERVIEW OF SERVICES OFFEREDThe Microbiology laboratory offers a wide range of diagnostics tests includingbacteriology, serology, virology, parasitology, mycology, semen analysis andpregnancy testing. In addition the department carries out screening for infection controlpurposes including Methicillin Resistant Staphylococcus aureus (MRSA) Clostridiumdifficile (C. diff), and Carbapenemase Resistant Enterobacteriacae (CPE). We alsoscreen for seasonal infections such as Norovirus and Influenzae.Requests for CPE and Norovirus screening must either be authorised by a ConsultantMicrobiologist or an Infection control Nurse.Clinical advice is provided by Consultant Microbiologists and technical advice is givenby Biomedical Scientists.LOCATING AND CONTACTING THE LABORATORYThe Microbiology laboratory for Northumbria Healthcare NHS Foundation Trust islocated at North Tyneside General Hospital.Directions and transportAddress:North Tyneside General HospitalRake LaneNorth ShieldsTyne & WearNE29 8NHNorth Tyneside General Hospital is situated on the A191 approximately 8 miles eastof Newcastle.Title: Clinical Microbiology Users HandbookQP Ref: LH-MIC-GEN-G-001v1Author: Jennifer Challoner & Alex DugganAuthorised by: Microbiology Specialty boardCreated Date:23rd April 2020Disposal date: 22nd April 2050Page 5 of 75

NHS GENERALBy road: From the A19 Northbound, go through the Tyne Tunnel (toll) and leave theA19 after 2 miles, to join the A191 toward North Shields & Tynemouth. Continue overthe next 5 roundabouts and at the 6th turn right.From the A19 Southbound, follow A19 Southbound and join the A191 toward NorthShields & Tynemouth. Continue over the next 5 roundabouts and at the 6th turn right.By bus: For up to date bus information, please use the Traveline serviceBy rail: The closest railway station is Newcastle Central Station. CheckThe Trainline for timetables of all services.For more information, and to view an external and internal map of the hospital pleasevisit the hospital web site: tyneside-general-hospitalMicrobiology laboratory opening hoursThe Microbiology department provides a diagnostic service and technical advice 24hours, 7 days a week.For all urgent specimens where results will affect patient management, followingcollection of the sample please contact the laboratory by telephone to arrange for thesample to be processed urgently. Results will be telephoned to the requestor oncethey are available.The main Pathology Specimen reception at North Tyneside General Hospital is openfrom 08:30 to 21:30 Monday to Friday and is closed at weekends to the general public;however the microbiology laboratory is still contactable via telephone.Enquiries for resultsPlease check ICE or electronic GP links for diagnostic test results, before telephoningthe laboratory.Please note that we need to establish the caller’s identity before giving results overthe telephone and you may be required to provide a password. Passwords areassigned to GP surgeries and are confidential to their healthcare professionals.The laboratory is unable to give results directly to patients or their relatives. Patientsshould contact their GP or the requesting doctor for their results.These policies are in place for data protection, confidentiality and clinical risk. Resultsmust only be given to healthcare professionals bound by these policies to ensure theprotection, safety and care of all patients.Title: Clinical Microbiology Users HandbookQP Ref: LH-MIC-GEN-G-001v1Author: Jennifer Challoner & Alex DugganAuthorised by: Microbiology Specialty boardCreated Date:23rd April 2020Disposal date: 22nd April 2050Page 6 of 75

NHS GENERALVisitorsAll visitors must report to Pathology specimen reception where they must sign into thedepartment and receive a visitor’s badge. Whilst in the department, visitors must wearthe badge so that it is visible to all staff.Microbiology contact telephone numbersNon- urgent result and general enquiries DirectInternal0191 293 2528ext.: 32528Urgent resultsDirect0191 293 2528Internalext.: 34617Or bleep the Biomedical Scientist bycontacting switchboard extension 31100or 0344 8118111.Bacteriology laboratoryDirectInternal0191 293 2528ext.: 32528laboratory, DirectInternal0191 2932528ext.: 34689Consultants and Microbiology Secretary DirectVal TwizellInternalEmail: Valerie.twizell@nhct.nhs.uk0191 293 2538ext.: 32538Chief Biomedical Scientists (BMS3)Jennifer ChallonerEmail: Jennifer.challoner@nhct.nhs.ukDirectInternal0191 293 4173ext.: 34173Jane HaswellEmail: Jane.haswell@nhct.nhs.ukDirectInternal0191 293 4173Ext: 34173Senior Chief Biomedical Scientist Direct(BMS4)InternalKaren MorrisEmail: Karen.morris@nhct.nhs.uk0191 293 4005ext.: 34005PathologyOperationalServicesManagerAnge BrownEmail: Ange.brown@nhct.nhs.ukPathology Quality ManagerJonathan BoxshallEmail: Jonathan.boxshall@nhct.nhs.ukDirectInternal0191 293 4005ext.: 34005DirectInternal0191 293 4005ext.: 34005Serology&VirologyImmunology enquiriesTitle: Clinical Microbiology Users HandbookQP Ref: LH-MIC-GEN-G-001v1Author: Jennifer Challoner & Alex DugganAuthorised by: Microbiology Specialty boardCreated Date:23rd April 2020Disposal date: 22nd April 2050Page 7 of 75

NHS GENERALClinical adviceClinical advice is available regarding the appropriateness of tests and diagnosticinvestigations, management of patients and the use of antimicrobials.There is a Northumbria Healthcare NHS Foundation Trust Consul

Title: Clinical Microbiology Users Handbook QP Ref: LH-MIC-GEN-G-001v1 Author: Jennifer Challoner & Alex Duggan Authorised by: Microbiology Specialty board Created Date:23rd April 2020 Disposal date: 22nd April 2050 Page 1 of 75 9693 Microbiology Laboratory Handbook Microbiology Laboratory North Tyneside General Hospital Rake Lane North Shields Tyne & Wear NE29 8NH This SOP supersedes all .

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