Chương IV: Thông tư 33/2016/TT-BYT Các hoạt động chính của khoa vi sinh

Chapter IV

MAIN ACTIVITIES OF DEPARTMENT OF MICROBIOLOGY 

Article 12. Department of Microbiology’s taking, storage, transport and receipt of patient specimens  

1. Formulate the procedure and instructions for taking, storing, transporting and receiving patient specimens in emergency and normal cases in accordance with technical specifications for clinical departments, and submit them to the hospital’s director for approval.

2. Receive and store patient specimens taken by nurses or doctors of clinical departments in accordance with the approved procedure.  Such patient specimens must be enclosed with written requests for testing, including required testing items and confirmation by attending physicians.  The transport of patient specimens must ensure biosafety.

a) Infectiousness-prone specimens must be treated in accordance with regulations in Circular No. 43/2011/TT-BYT dated December 05, 2011 by Ministry of Health providing for the management of infectious specimens; 

b) If a test requires special specimens, clinical department/ward should participate in medical consultation with the department of microbiology to take such specimens.

Article 13. Performance of testing techniques and returning microorganism testing results

1. Perform tests in conformity with techniques and procedure. Emergency tests and tests which must be performed in a timely manner shall be given priority.

a) The accuracy and reliability of testing techniques must be ensured. Logbook for culture and classification of bacteria must be prepared by using the form stated in Annex V to this Circular;

b) Testing results must be clearly and sufficiently specified in testing result records and the microorganism testing logbook according to the form stated in Annex VI to this Circular;

c) Basic microorganism testing techniques are recorded by using the form stated in Annex VII to this Circular.

2. Testing result records must be examined and signed by the department's head or authorized official before they are delivered to requesters. Abnormal or suspicious testing results must be reported to the chief test technician or the department’s head for comparing with clinical records or retesting, where necessary.  

3. Testing results must be delivered in full and within prescribed time. The record of delivering microorganism testing results shall be prepared by using the form stated in Annex VIII to this Circular.

4. Tested specimens shall be stored and destroyed in accordance with specific regulations for each type of specimen.

5. Nurses of clinical departments shall directly receive emergency testing results at department of microbiology or microorganism testing unit.

6. Take turn working night shifts as assigned.

Article 14. Storage and use of chemicals, reagents, biological products and medical equipment

1. Chemicals, reagents and biological product:

a) Monitor, manage and use chemicals, reagents and biological products in accordance with regulations on management and use of medicines. Hazardous, toxic, corrosive and flammable chemicals must be stored in conformity with regulations on safety of laboratories.

b) Chemicals, reagents and biological products must be stored in accordance with requirements by manufacturers thereof in order to avoid variation in testing results.

2. Management of medical devices, machinery and equipment:

a) Prepare records, including origin, of each type of medical equipment; prepare records of delivering, monitoring and managing medical equipment;

b) Post machinery operating procedure at the place where such medical machinery is located;

c) Logbook for use, repair and maintenance of medical equipment must be prepared by using the form stated in Annex IX to this Circular;

d) Medical devices and equipment must be properly used in accordance with their technical procedures;

dd) Written record for daily operations and hand-over of medical equipment between shifts must be prepared by using the form stated in Annex X to this Circular;

3. Use of medical equipment and supplies:

a) Technical specifications of installed equipment must be properly used in order to ensure operating efficiency;

b) Carry out the inspection of medical equipment as regulated for ensuring its safety during use and the result of such inspection must be recorded;

c) The operation of medical equipment must be stopped upon the occurrence of equipment failure which must be promptly reported to the department's head in order to make a written record of such failure, find causes thereof and adopt measures for repair. Records of lost, broken or damaged reagents, chemicals, biological products and medical equipment are prepared by using the form stated in Annex XI enclosed to this Circular;

d) The use of medical equipment for unauthorized purposes and self-repair are prohibited;

dd) The liquidation of irreparably damaged equipment must be carried out in accordance with the laws. The record of liquidation of reagents, chemicals, biological products and medical equipment must be prepared by using the form stated in Annex XII enclosed to this Circular.

Article 15. Bacterial contamination control

1. Formulate regulations for storage of reagents, chemicals, biological products and patient specimens; procedure for treatment of tested specimens, animal carcasses and sterilization of medical equipment before being delivered to bacterial contamination control department.

2. Collect wastes, steam disinfected devices, clean and prepare sterilized devices; clean the floors of microorganism laboratories by antiseptics.

3. Do not pour tested specimens which are not properly treated into sewer or wash-basin on the testing table.

Article 16. Safety in laboratories

1. Biosafety and biosecurity must be ensured in conformity with regulations in the Government's Decree No. 103/2016/ND-CP dated July 01, 2016 providing for biosafety in laboratories.

2. Personnel protective equipment must be sufficiently provided to persons working in laboratories.

3. Employees must be provided with training in the use and operation of medical machinery and equipment for ensuring safety.

4. Employees must be careful when contacting with biological products which are prone to communicate diseases, and strictly abide by regulations on biosafety and bacterial contamination control in hospital.

5. All employees working in department must go for periodical check-up.

6. Employees must be trained for response to laboratory accidents such as spill of specimens, chemicals, biological products or reagents during the transportation, and must attend training courses for prevention and first aids in case of acid burns, alkali burns, thermal burns, poisoning, electrocution, or explosion.