Dear FREEDOM OF INFORMATION – COSTRIDIUM
Contents
1. Empty and clean tip waste container 70 alcohol Clean up any spills Clean pipette spigot with Alcohol wipe or swab soaked in 70 alcohol Clean the area where tips are dropped into the tip waste container Weekly Decontamination Add 500 ml of 70 alcohol to Wash bottle A and B and 100mls to clean line bottle Select File Worklist Editor Select New sample batch OK untick LIS Select 96 samples Assign and Next Select Decontamination and Add Assay Select Done The matrix software time line will now appear Accept the proposed assay and Skip to start the assay straight away 10 Follow the on screen instructions 11 lnsert a standard microtitre plate into the plate carrier when requested 12 Enter assay name e g Decontamination date initials 13 Follow the on screen instructions 14 The robot arm will move around the instrument at this point 15 Priming of the system and wash head decontamination will now be performed 16 When the assay is finished rinse all the bottles and replace the contents with distilled water 17 Repeat decontamination steps 1 13 OHONDARWNH Monthly 1 Check tubing for any Microbial Growth 2 Visual inspection of the Washer manifold 3 Wipe exterior surfaces 1905 NHS Lothian GDH Antigen Testing The C DIFF QUIK CHEK is a rapid membrane immunoassay for use as a screen to detect Clostridium difficile antigen glu2. Lothian Officer and Scottish Environmental Protection Agency SEPA it was identified as unsuitable for discharge into the waste water system It is classified as a Schedule 1 poison under UK Poisons Rules After consultation with the Trade Effluent Officer Estates Department WGH and a commercial chemical disposal company currently LANSTAR it was decided that the following disposal procedure be strictly adopted Procedure 1 Pour all liquid from the waste container in the DS2 into a 5 litre plastic container that is clearly labeled Thimerosal Waste 2 All wash buffer when finished with should also be discarded into the same container 3 Do not overfill the container 4 When 2 containers are full organise the pick up of the waste 5 Phone 24242 and have the following details to hand Description of waste Thimerosal liquid waste Volume to be uplifted e g 10 litres Room Number amp extension 5244 Ext 27011 Name of lab Enteric Lab Microbiology REPORTING See Clinical Authorisation LP MIC R APEX REFERENCES Bartlett JG Rev Infect Dis 12 5243 S251 Sullivan NIM Pellett S Wilkins TD Infect Immun 35 3 1032 1040 Brazier JS Antimicro Chemotherapy 1998 41 Suppl C 29 40 Johnson S Kent SA O Leary KJ Merrigan MM Sambol SP Peterson LR Gerding N Ann Intern Med 2001 135 434 438 http www documents hps scot nhs uk hai sshaip quidelines clostridium difficile cdiff protocol v3
3. 11 Press the Status button at any point to see how many strips are required for testing Full rows are required in the microtitre tray Spare cups are in blue tray at side of DS2 Press Exit to close window and maximize Load Consumables to continue 12 In Plate Identifier enter kit batch number the date and your initials 13 Wash buffer should be made up every 2 days in 1000ml amounts 950mls distilled water 50mls wash buffer store at 4 C Discard Monday Wednesday amp Friday 14 Machine can be paused before starting by pressing the Pause button top left of screen 15 Once DS2 starts stay near machine to deal with any samples that may require to be entered manually follow the on screen instructions use the small pastettes that 1905 NHS Lothian come with kits When entering samples manually only draw up liquid to add to microtitre tray 16 The DS2 time line will show an approximate finish time machine can be left until finished An Alarm will sound if there are any problems 17 When finished highlight the run on left hand side of screen then click on Report This will show a results page that shows whether the run has passed or failed Print this off and check the results 18 Once checked proceed next stage Transfer of Results Transfer of Results from DS2 to iLab Results can only be transferred once so be careful E NS 6 Minimise the Matrix Double click
4. All toxin positive samples regardless of GDH result should be stored at 20 C in a small serum tube If there is insufficient sample to store a note should be added to the sample in iLab Print off a 10 day list for the ICNs this will inform them of that days Toxin GDH positive samples only Take it to the ICN office as close to 1500 as possible QUALITY CONTROL e Internal QC See LP MIC R ENTQC QR MIC R IQCBATC2F e External QC LP MIC R UKNEQAS CLOSTRIDIUM DIFFICILE EIA TOXIN SNAPSHOT PROGRAMME In line with HPS epidemiology study in Scotland the PROTOCOL FOR THE CLOSTRIDIUM DIFFICILE SNAPSHOT PROGRAMME version 1 0 November 2008 requests that NHS Lothian Universities Hospitals Division submits 22 isolates quarterly in March June September and December Culture stored positive C difficile stool samples as per LP MIC R ENTCUL for Clostridium difficile DISPOSAL OF WASTE amp EXCESS REAGENTS The Techlab Clostridium difficile ELISA test uses 0 2 and 0 02 Thimerosal as a preservative Thimerosal is included in the following solutions 1 Diluent Conjugate Positive control Wash Buffer Concentrate Oi ee Ge Wash buffer at working strength Thimerosal is a mercuric inorganic divalent compound with a long term Occupational Exposure Standard OES of 0 025 mg m as Hg Bmgv This substance is highly toxic to aquatic organisms and after consultation with the Western General Trade Effluent 1905 NHS
5. 0 March 2009 10 paf POD o 1905 NHS Lothian CONTACT TELEPHONE NUMBERS The Duty Medical Microbiologist at the RIE can be contacted on extensions 26066 or 26028 The ICNs for the RIE can be contacted using Ext 26062 26063 26097 The ICN for WGH RVH Ext 31948 31246 The Health Protection team can be contacted on extension 89189
6. 4 C 3 If assay is not to be processed on day of receipt freeze at 20 C for processing with next batch 4 All samples should be spun in microcentrifuge at 12000rpm for 5 minutes before testing Ordering test in iLab C difficile toxin must be requested in iLab before proceeding with testing Need scanned forms and the worksheets from specimen processing area Need New Enterics smartpad from L drive Once logged on e Click on Go to coding e Then List on screen and enter 1 and last number for modifying 1905 NHS Lothian e First number will appear press return then previous CD If TRAK sample press TRAK details button details will appear and then press Quit TRAK If you have a form check that everything has been requested e g micro e Any toxins done in the last 28 days will appear on the screen with results if they were all negative press validate button and CDT will be requested e f formed press formed button if a previous positive is shown press the previous positive button if lt 15 from a GP press Delete CDT if lt 15 and from RHSC press the lt 15 years old button If insufficient sample press insufficient button These results will go out automatically e Duplicate samples from the same day will show altogether the most recent sample if not formed is the one that CDT will be performed on e Highlight the number to be processed using the mouse and click on the copy button
7. MIC R GPROCG LP MYB R MYCSAF MP MIC A RECCTRL LF MIC W ENTCD2 LP MIC R GENPROC PD C A USERHDK COPY w J LOCATION OF COPIES Copy 1 Enteric Bench RIE DOCUMENT REVIEW HISTORY Revewedby Signature Date 1905 NHS Lothian Staff Review Form for Standard Operating Procedures SOP FILENAME LP MIC R ENTCDT have read and understood the above Standard Operating Procedure and related COSHH and Manual Handling Risk Assessment SIGNATURE DATE 1905 INDEX OF CONTENTS 1905 PRE EXAMINATION Specimen Collection PD C A USERHDK Specimen Reception Procedure LP MIC R SPECR Data Entry LP MIC R APEX SAFETY COSHH amp RISK ASSESSMENT RA Containment Level 2 work RA 003 RA Containment Level 3 work RA 004 RA Containment Level 3 laboratory waste disposal RA 016 RA Esch coli 0157 amp non Esch coli 0157 VTEC work RA 005 RA Working with samples containing HIV Hepatitis B C RA 011 RA Working with Salmonella typhi paratyphi amp Mycobacterium species RA 009 RA Use of PVC amp Nitrile Gloves RA 007 RA Needle stick injury RA 013 RA Working with electrical equipment RA 019 CA Sulphuric acid CA 060 CA Tetramethyl benzidine CA 076 CA Microsol CA 064 CA Thimerosal CA 068 IMMUNOASSAY Perform C difficile toxin A and B ELISA on semi unformed or liquid specimens selected using the following criteria C Difficile Toxin A amp All diarrhoeal samples i e sampl
8. on LIS Link Enter password dynex case sensitive Click on sign at Assays then XISCDE and results will appear Each sample should be marked Send the first sample has Leave also marked unmark it and ensure Send is re marked Click on Operations Commit Operations Send data to LIS host Reporting in iLab All positive toxins need to have their OD entered in iLab Go into SRE and the OD investigation XISCDO will be present and record the result ALL positive toxin samples then require a GDH antigen test test protocol further on in document The GDH investigation will be added automatically Toxin negatives can be released by going into SRE at level N S and put in the first and last numbers Scroll through each sample by pressing F10 Results will be released automatically Keep the print out from the DS2 in the black C difficile worksheet folder DS2 Maintenance All maintenance should be logged on sheets in Maintenance Folder situated at side of DS2 Any problems should be brought to the attention of a senior BMS 1905 NHS Lothian Daily Empty the waste container into 5 litre container for Thimerosal waste Then return waste container to DS2 Wash Check Assay Select File Worklist Editor Select New Sample Batch OK untick LIS Leave Sample batch ID and No of samples at 1 Select Assign and the Next Select Wash che
9. Date 19 05 10 Your Ref Our Ref RM 1905 Enquiries to Richard Mutch Extension 89441 Direct Line 0131 536 9441 Direct Fax 0131 536 9009 Email richard mutch nhslothian scot nhs uk Dear FREEDOM OF INFORMATION COSTRIDIUM DIFFICILE write in response to your email request of 21 April 2010 for information in relation to Clostridium difficile within NHS Lothian have been provided with information to help answer your request by Ms Fiona Cameron Head of Infection Control NHS Lothian e Does the Trust Board currently provide in house laboratory testing for Clostridium difficile on stool samples If not is there an arrangement for samples to be processed elsewhere e g another NHS Trust Board or private external laboratory NHS Lothian provides in house laboratory testing for Clostridium difficile e Is testing for Clostridium difficile available 7 days a week in the Trust Board Yes e As at 21 April 2010 please provide the exact method of testing for Clostridium difficile used in the laboratory If a commercial kit is used please state the name and manufacturer e g Meridian Premier Toxins A B Enzyme Immunoassay C DIFFICILE TOX A B II TECHLAB immunoassay C DIFF QUIK CHEK TECHLAB glutamate dehydrogenase GDH assay e Please provide the Standard Operating Procedure used in the laboratory for testing of Clostridium difficile See attached Standard Operating Procedure e How many sample were
10. at the top of the screen Then press Duplicate 1 on the smartpad Next press the paste button at the top of the screen to copy the number to be processed then press Duplicate 2 and a report will be sent out saying that the sample is a duplicate and refer to the sample that is to be processed If there is more then one duplicate repeat the above process e Ifthe sample is to be processed for toxin press the Validate button on the smartpad and the test will be requested e Next you need to choose what type of culture is required for the sample Press Code R for routine culture Press Code R M for routine culture plus micro Press Code R V M for routine TAM etc e Once you ve scrolled through each number you ll be thrown out of the system when you get to the end e Mark V F DUP PREV lt 15 in the CDT code column and R or R whatever in the MEC column Sign the bottom of each page once tests are all ordered Toxin tests are now requested and a worklist can be printed from the smartpad press List outstanding C diff toxins This is the list of tests to be done From the list add pre spun samples to the DS2 sample racks before proceeding to Running Clostridium difficile fast Toxin A B ELISA 1905 Clostridium difficile Toxin A B Testing using DS2 Instrument Start Up 1 Turn on the DS2 then the PC in that order 2 When prompted select Normal Mode and OK 3 The robot arm will move around th
11. ck Assay and Add Assay Select Done The Matrix software with time line will now appear Accept the proposed assay and Skip to start the assay straight away Follow the on screen instructions 10 Insert a standard microtitre plate into the plate carrier when requested 11 Enter an assay name e g Wash check date initials 12 Follow on screen instructions 13 Place distilled water into wash bottles when and where prompted 14 Machine will start up O 0 ATO Or o Note The robot arm will move around the instrument at this point Keep the lid closed Priming and a test wash will now be performed When the Wash Check is finished remove the plate and check that all the wells are empty and virtually dry Inform a senior member of staff if the wells are not dry End of Day Follow 1 4 of Wash Check Assay Select End of Day and Add Assay Follow 6 10 of Wash Check Assay Enter an assay name e g End of day date initials Follow 12 14 of Wash Check Assay Close the Software File and Close Switch off PC and DS2 Empty waste tips container Take the waste container out of DS2 and add a Haztab to decontaminate the waste put the lid back on and leave overnight oOo Ot a 1905 Weekly 70 Alcohol is required for the weekly maintenance 2 5 litre containers of 100 methylated spirits are available from SMRL culture laboratory when required Make 70 alcohol up using water
12. e machine at this point 4 The machine will initialize and then perform an instrument check 5 A self test report will be created and shown and all units should be shown as passed Inform a senior BMS of any problems 6 Close the report to enable the machine to complete initialization 7 Perform Daily Maintenance See maintenance section 8 DS2 is now ready for use Running Clostridium difficile fast Toxin A B ELISA 1 Make sure wash buffer and water have been changed over in wash bottle A 2 Select File then Worklist Editor 3 Select New Sample Batch ensure LIS is ticked then press OK 4 Select number of tests to be run 5 Click on Scan Barcodes and unclick Verify Barcodes 6 Select Next and follow the on screen prompts for scanning the specimen barcodes If barcode doesn t read enter manually 7 Polling LIS box will appear information is being transferred from APEX do not cancel it may take a few minutes 8 Select Techlab Cdiff fast Tox A B Il from menu on right hand side of screen and select Add Assay only do this once Ensure all have tick by clicking the top of each row then click on Done Accept the run and use the skip button to move the testing on quicker 9 Follow the prompts and graphics placing the required consumables and fluids in the appropriate positions 10 Yellow topped universal should be changed per kit and use fresh controls daily
13. e that conform to the B ELISA shape of the container from patients aged 15 years old and over All samples except those positive within the last 28 days Children under 15 years old only on clinical request GDH Antigen Assay To be performed on ALL C difficile toxin A B positives 1905 CULTURE Please refer to LP MIC R ENTCUL The following criteria are provided here for convenience only Please cross reference with the above SOP Only on special request by Medical Microbiologist Clostridium difficile in line with the Protocol for the Scottish Surveillance programme for Clostridium difficile Associated Disease User Manual Version 3 0 Revised January 2009 1 Severe cases e Admission to a healthcare facility for treatment of community associated CDAD e Admission to ITU for treatment of CDAD or its complications e Endoscopic diagnosis of pseudomembranous colitis with or without toxin confirmation e Surgery for the complications of CDAD toxic megacolon perforation or refractory colitis e Death within 30 days following a diagnosis of CDAD where it is either the primary or a major contributory factor e Persisting CDAD where the patient has remained symptomatic and toxin positive despite 2 courses of appropriate therapy 2 Suspected outbreaks e When an outbreak is suspected and stools are positive for Clostridium difficile toxin 3 Suspected infections and or outbreaks with ribotype 027 e When infection w
14. ill be undertaken by Mr Whyte as he was not involved in the original decision making process FOI responses subject to redaction of personal information may appear on NHS Lothian s Freedom of Information website at http Avww nhslothian scot nhs uk your_rights foi foi_ 09 asp Yours sincerely ALAN BOYTER Director of Human Resources and Organisational Development Cc Chief Executive Continued 1905 NH S Lothian ENTERIC BACTERIOLOGY CLOSTRIDIUM DIFFICILE TOXIN STANDARD OPERATING PROCEDURES Purpose amp Scope Examination amp reporting of specimens for Clostridium difficile toxin investigation Responsibilities Band 7 with Organisational Responsibilities for band 6 Band 5 and BSW staff References CPA UK Ltd F2 Examination procedures ISO 15189 2003 5 5 Examination procedures ISO IEC 17025 1999 5 4 Test and calibration method and method validation ISO 9001 2000 7 5 Production and service provision EC4 Essential Criteria 8 3 Working Procedures EC4 Essential Criteria 8 4 Quality control and assessment Definitions SERL Scottish Escherichia coli 0157 Reference Laboratory OBIS Oxoid Biochemical Identification System Documentation LI MIC R ENTCDL LF MIC W ENTECO LP MIC W CDWASTE LI MIC R ENTHS LF MIC W ENTCD1 LP MIC R EQUIPM LI MIC W ENTECL LF MIC W REFER LP MIC A REFSOP LI MIC R ENTPARA LF MIC W ENTCD3 LP MIC R APEX LI MIC A RESTEL LF MIC R ENTRE QR MIC R IQCBATC2 LF
15. ith the hypervirulent strain 027 is suspected the C difficile reference service must be contacted This is required when e Isolates of ribotype 027 have been identified e Patients have been recently hospitalised in England or abroad 1905 EQUIPMENT REAGENTS amp MATERIALS Equipment is used according to the provisions specified in the operating procedures for individual investigations Storage of specimens by refrigeration at 4 C deep freeze refrigeration at 20 C and ultra deep freeze refrigeration at 80 C is used according to the provisions specified in the operating procedures for individual investigations Reagents are used according to the provisions specified in the operating procedures for individual investigations Materials are used according to the provisions specified in the operating procedures set out for individual investigations CODING 1 Request forms are screened by the bench BSW and given a basic Enteric examination subject to modification of the investigation by a qualified Biomedical Scientist BMS trained in the enteric section 2 Decisions made on immunoassay carried out on a given specimen depend on the diagnosis and meeting of criteria set out in the HPS publication Protocol for the Scottish Surveillance Programme for Clostridium difficile Associated Diseases User Manual Version 3 0 Revised March 2009 http www documents hps scot nhs uk hai sshaip guidelines clostridium difficile protoc
16. mixture into the sample well of the membrane device When loading the sample make sure the tip of the pipette is angled towards the reaction window large hole in the middle of the device 1905 NHS Lothian 4 Incubate the device at room temperature for 15 minutes Occasionally a sample cannot be tested because it clogs the membrane and the reaction window does not wet properly If the sample fails to migrate properly within 5 minutes of adding the sample add 100l of diluent to the sample well and wait an additional 5 minutes 5 After the incubation add 300ul of wash buffer to the reaction window Allow the buffer to flow through the reaction window membrane and be absorbed completely 6 Add 2 drops of substrate white cap to the reaction window Read and record results visually after 10 minutes Interpretation of Results 1 Is most reliable when the device is read immediately at the end of the 10 minute reaction period Read the device at a normal working distance in a well lit area 2 Observe device for the appearance of a blue line on the C side of the Reaction Window representing the internal positive control Observe device for the appearance of a blue line on the T side of the reaction window representing the test line The lines may appear faint to dark in intensity 3 Positive Result A positive result may be interpreted at any time between the addition of substrate and the 10 minute read time T
17. ol scottish surveillance programme cdad 2009 03 pdf 3 The tops of the stool containers are marked as shown below according to the investigations to be performed The patient request form is coded at the same time using iLab set up codes See LP MIC R SPECR Specimens may then be processed by trained BSW staff or BMS staff CODE EXAMINATION CDT ONLY Assay for C difficile Toxin A amp B only CDT CD CUL Culture for Clostridium difficile only usually from 20 C stored CDT positive stools but may be requested by Medical staff ICN s and IC Surveillance BMS staff Please refer to LP MIC R ENTCUL for 1905 aS culture protocols CLOSTRIDIUM DIFFICILE EIA TOXIN A amp B ASSAY DEFINITION A qualitative enzyme immunoassay for the detection of Clostridium difficile toxin A amp B directly in stool specimens from patients with antibiotic associated diarrhoea Intended for use in the diagnosis of C difficile associated disease DIAGNOSTIC MATERIALS Techlab Toxin A amp B II ELISA kit EQUIPMENT Class 1 Safety MSC See LP MYB R MYCSAF Dynex DS2 See LP MIC R EQUIPM Microcentrifuge See LP MIC R EQUIPM Freezer 20 C See LP MIC R EQUIPM Graduated cylinder Graduated Pipette See LP MIC R EQUIPM Sterile applicator sticks Microtube vials Vortex mixer See LP MIC R EQUIPM REAGENTS Distilled Water sterile NOTE Toxin assay is performed on a daily basis Monday to Sunday or by special arrangement b
18. submitted to the laboratory for testing of Clostridium difficile in 2008 1st January 2008 to 31st December 2008 and how many of these tested positive Headquarters Deaconess House 148 Pleasance Edinburgh EH8 9RS Conti Chair Dr Charles J Winstanley ontinued Chief Executive Professor James Barbour O B E Lothian NHS Board is the common name of Lothian Health Board 1905 NH eee ae Lothian Number submitted 15 008 Number positive 1 451 e How many sample were submitted to the laboratory for testing of Clostridium difficile in 2009 1st January 2009 to 31st December 2009 and how many of these tested positive Number submitted 15 647 Number positive 892 It should be noted that patient activity within NHS Lothian during 2008 09 inpatient day cases outpatients and A amp E attendances reached 1 141 357 patients hope this information helps with your request If you are unhappy with our response to your request you do have the right to request us to review it Your request should be made within 40 working days of receipt of this letter and we will reply within 20 working days of receipt If our decision is unchanged following a review and you remain dissatisfied with this you then have the right to make a formal complaint to the Scottish Information Commissioner If you require a review of our decision to be carried out please write to Mr Whyte FOI Reviewer at the address at the foot of this letter The review w
19. tamate dehydrogenase in faecal samples from persons suspected of having C difficile disease Intended Use To be performed all ALL Clostridium difficile toxin A B positive samples Precautions 1 Reagents from different kits should not be mixed Bring ALL components to room temperature before use 2 Do not freeze the reagents 3 Specimens should be stored between 2 8 C test samples that are less than 24 hours old whenever possible On opening a new kit test the positive control to ensure kit is working Sample Preparation 1 Bring all reagents and the required number of devices to room temperature before use 2 Set up and label one small tube for each specimen 3 Add 500uI Diluent to each tube using the graduated black dropper provided in kit 4 Holding the dropper bottle in a vertical position add one drop of Conjugate red cap to each tube 5 Mix all soecimens thoroughly regardless of consistency 6 Pipette 25ul 1 graduation on pipettes provided of specimen into Diluent Conjugate tube Test Procedure 1 Need one membrane device per sample Bring to room temperature before using Label each device appropriately and orientate it on a flat surface so the letter C on the device is on the left the letter T is on the right and the Sample Well is located in the top right corner of the device 2 Vortex each sample before testing 3 Using a new pipette transfer 400 2 graduation of pipette of sample
20. wo blue lines are visible the control line C and the test line T The lines may appear faint to dark in intensity The appearance of these 2 blue lines is interpreted as a positive result An obvious partial line is also interpreted as a positive result Do not interpret membrane discolouration as a positive result A positive result indicates the presence of C difficile antigen 4 Negative Result A test cannot be interpreted as negative or invalid until 10 minutes following the addition of substrate A single blue line is visible on the control C side of the reaction window and no test line is visible on the T side of the reaction window A negative result indicates C difficile antigen is either absent in the sample or is below the detection limit of the test 5 Invalid Result A single line is visible on the test T side of the reaction window or no lines are visible in the reaction window The test result is invalid if the control line is not present at the completion of the reaction period Reporting In SRE at level N report the GDH Antigen result i e POS NEG or INV and press F10 and return out Reports will self authorise adding the necessary comments required Toxin A B amp GDH positive goes out as C difficile Toxin Screen POSITIVE Toxin A B positive and GDH negative or invalid go out as 1905 NHS Lothian C difficile Toxin Screen Equivocal please repeat if clinically indicated
21. y the Medical Microbiologist SELECTION CRITERIA A faecal specimen should be obtained from any patient aged 15 or over with diarrhoea defined as the passage of 3 or more loose liquid stools per day or more frequently than 1905 NHS Lothian is normal for the individual and with no other underlying cause Only diarrhoeal specimens should be tested see definition below Screening of symptom free patients is not recommended When symptoms have resolved clearance testing is not recommended Definition of a diarrhoeal specimen is a specimen that conforms to the shape of its container e All Diarrhoeal samples received from patients in the healthcare settings including general practices hospices nursing homes acute and non acute hospitals aged 15 or over e All patients with exception of those positive in the last 28 days unless specially requested by the attending physician and agreed by the Duty Microbiologist or ICN staff e On the contrary a negative test if symptoms persist should be retested as it is known that a one off negative can occur e Onclinical request only from children under 15 years of age PROCESSING See LI MIC R ENTCDT NOTE Only process semi unformed or liquid specimens for C difficile toxin assay 1 All samples received in the laboratory before 12 00 should be processed that day 2 Add 100ul or lentil size piece of stool to 400ul of diluent pre made up in small sarstedt tubes stored at
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