Author: Peggy Coulter Document Number: Equ10-04

Effective (or Post) Date: 15 Jan 09

Review History Date of last review: 10-Feb-20
Reviewed by: Heidi Hanes
SMILE Comments: This document is provided as an example only. It must be revised to accurately reflect your
lab’s specific processes and/or specific protocol requirements. Users are encouraged to ensure compliance with local
laws and study protocol policies when considering the application of this document. If you have any questions
contact SMILE.
Quality Control and Maintenance of Microbiology Laboratory Equipment
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Proc. #G.27.2

Procedure: Quality Control and Maintenance of Microbiology Laboratory Equipment

Initial Review and Approval Date:

Assistant Administrator
Technical Supervisor
Technical Supervisor
Prepared By
Director
Director
Director
Director
Director
Adopted: Retired:
Reviewed: Replaces: New Date: 8/30/2003

Procedure Locations
General Operating Procedures
Authorized to Approve:

Authorized to Review:
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Proc. #G.27.3
PERSONAL PROTECTIVE EQUIPMENT

Performance of this procedure will expose testing personnel to biohazardous material and possible
chemical hazards.

All specimens must be handled as potentially infectious material as outlined in the hospital Safety
Manual.

The reagent(s) and/or chemical(s), which are used in this assay, may be hazardous to your health if
handled incorrectly. A brief listing of precautions for each chemical hazard is included in the reagent
section of this procedure.

More extensive information concerning the safe handling of the reagents and/or chemicals used in this
assay, as well as other important safety information, may be obtained by consulting the Material Safety
Data Sheet (MSDS) and HAZ-COM Manual, and hospital safety manual. Before performing any part
of this assay, the technologist must take any and all precautions and adhere to all prescribed policies.

This procedure may expose you to:

[ ] Bloodborne pathogens
[ ] Airborne pathogens
[ ] Hazardous reagents

To perform this procedure, you must use:

[ ] Gloves
[ ] Face shield, or safety glasses with mask
[X] Laboratory coat
[ ] Gown
[ ] Biological safety cabinet
[ ] Fume hood
[ ] Ventilator
[X] Disinfectant following procedure:
[X] Diluted bleach (1:10v/v solution made fresh daily)
[ ] Amphyl
[X] Caltech Dispatch with Bleach
[ ] Miscellaneous, after Hospital Infection Control Department approval

Reference for spill/decontamination:

[ ] MSDS
[X] Chemical hygiene plan
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Proc. #G.27.4
PRINCIPLE:
Every instrument and piece of equipment used in the Microbiology Laboratory must
function properly and perform according to established standards to ensure accurate and reliable
diagnostic test results. Manufacturers’ recommended instructions are followed for cleaning and
disinfecting procedures.

A. TEMPERATURE:
1. Incubators, water baths, heat blocks, refrigerators and freezers are equipped with
“Standard” verified thermometers.
2. All temperature critical equipment is checked on a daily basis. Temperatures are
recorded on a temperature control log and must be reviewed by the
supervisor/designee monthly.
3. Temperature recording responsibilities are to be completed by 12 noon by assigned
staff.
4. Locations:
a. BIOCHEMISTRY – Mon-Fri: Biochemistry tech/Lab Specialist
Sat/Sun: Anaerobe tech
b. MOLECULAR MICRO – Mon-Fri: Molecular tech
Sat/Sun: Fluid Technologist
c. MISC/AGAR – Daily: Agar tech
d. SPECIAL MICRO – Daily: Special Tech
e. MIDDLE ROOM – Daily: RDS Tech
f. BLOOD ROOM – Daily: B/F MLT
g. MEDIA ROOM – Daily: Media Room Staff
h. PARASITOLOGY – Mon-Fri: Parasitology Tech
Sat/Sun: Virology Tech
i. VIROLOGY/OUTSIDE VIROLOGY/AFB – Daily: Virology Tech
j. AFB – Mon-Fri: AFB Tech
Sat/Sun: AFB processor
k. MYCOLOGY – Mon-Fri: Mycology Tech
Sat/Sun: B/F MLT
l. PROCESSING AREA – Daily: Processing Staff
m. QC ROOM – Daily: Processing Staff
n. STOREROOM – Mon-Fri: Media Room Staff
Sat/Sun: Processing Staff
o. B107 LAB– Mon-Fri: Molecular Tech
Sat/Sun: Lead Tech
5. Abnormal Results:
a. Report discrepancies to supervisor or lead in the area.
b. The supervisor or lead will determine what actions will be taken for the contents
of refrigerators, freezers or incubators. Depending on the failure, the supervisor or
lead will make the decision whether to discard the reagents or media; QC the
reagents or media for usage; or take no action.
c. In the case of patient specimens, the supervisor or lead will determine how to
proceed based on the type of failure.
d. If current clinical samples need to be discarded, the physicians will be notified.
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Proc. #G.27.5
e. If repository samples need to be discarded, the faculty member responsible for the
area will be notified.
f. In the case of incubator failure, the supervisor or lead will determine what actions
will be taken based on the type of failure. Biochemical reactions may be discarded
and re-set; QC may be performed to determine the viability of the tests; or no
action may be taken.
g. Patient cultures may be compromised based on the type of failure. Physicians will
be notified of any compromised specimen.
h. The supervisor or lead will initiate any repairs necessary for the equipment.

B. CARBON DIOXIDE INCUBATORS:

1. Carbon dioxide incubators are checked on a daily basis for their concentration of
carbon dioxide, by reading the CO2 digital display when the switch is in “CO2”
position, and recorded on the CO2 incubator chart.
2. Carbon dioxide incubators are checked on a monthly basis for their concentration of
carbon dioxide using the Fyrite SOP and recorded on the CO2 incubator chart.
3. Acceptable ranges are posted on chart.
4. Abnormal Results:
a. Deviations from normal range are reported to supervisor or lead tech in area, who
will initiate corrective measures with follow up.
b. CO2 content will be checked with Fyrite.
c. Contents will be transferred to another incubator immediately until problem is
corrected.
5. Corrections:
a. All corrections will be made following manufacturer’s guidelines.
b. Repairs are made by the Pathology Biomedical Engineering Department.

C. CENTRIFUGES:
1. Centrifuges receive regular maintenance checks by the Pathology Biomedical
Engineering tech on a six-month schedule. This check includes oiling the bearings
and checking brushes and timing.
2. Centrifuges are calibrated every six months and documented on the Maintenance Log
attached to the side of the instrument.
3. Cleaning is performed as needed for usage in specific laboratory areas.

D. MICROSCOPES:
1. Microscope lenses and stages are cleaned monthly and documented on the
Preventative Maintenance Log sheet.
2. Microscopes are serviced by an outside provider every six months and documented in
the Microscope Records notebook.
3. Any performance problems must be reported to a supervisor or lead who will initiate
repairs.

E. FREEZERS, ULTRA LOW:

1. Freezers are defrosted and cleaned every six months.
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Proc. #G.27.6
2. Freezers are serviced every six months and documented in the Equipment
Maintenance notebook.
3. Any performance problems must be reported to a supervisor or lead who will initiate
repairs.

F. AUTOCLAVES:
1. Autoclaves are serviced every 2-3 months and documented in the Equipment
Maintenance notebook.
2. Weekly sterility checks are performed following the Autoclave Sterility Testing
Procedure and documented in the Autoclave Sterility Record notebook.
3. Routine Autoclave cleaning procedure is performed monthly and is included in the
Autoclave Sterility Procedure.

G. REFRIGERATORS:
1. Refrigerators are cleaned every six months.

H. WATERBATHS:
1. Waterbaths are drained and cleaned as recommended by the manufacturer every six
months.
2. Distilled water is used to fill and maintain the recommended fill level.
3. Several drops of “Clear Bath” solution are added with each water change.

I. ANAEROBIC CHAMBERS:
1. Chambers are maintained following manufacturer’s recommendation. See Anaerobic
Chamber S.O.P.
2. Gas pressures and temperature are checked daily and recorded on the Q.C. log.
3. The anaerobic indicator strip is checked, results recorded on the Q.C. log and
replaced with a fresh strip daily.
4. The catalyst is replaced daily.
5. Excess moisture in the chamber interior is wiped up daily.

J. BACT/ALERT:
1. The BacT/Alert instruments are maintained following manufacturers’
recommendation as per the BacT/Alert Analyzer S.O.P.

K. HEATING BLOCKS:
1. Heating blocks are wiped off using a cloth dampened with an appropriate
disinfectant/cleaner, as needed.
2. Electrical cords are checked when temperatures are recorded.

L. INCINERATOR BURNERS:
1. Incinerators are located at each Bacteriology work bench. These incinerators are
turned on at the beginning and off at the end of each shift, as needed.
2. The ceramic core is checked daily for cracks and proper heating.
3. Incinerators that do not work properly are turned in, to the QC Lead, for repair.
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Proc. #G.27.7
M. SAFETY CABINETS:
1. Safety cabinets are maintained following Biosafety Cabinet Use S.O.P.

N. OVEN:
1. Oven temperature is recorded on temperature chart daily.
2. Spills are wiped up as needed with an approved disinfectant.
3. Any repairs needed are performed by the Pathology Biomedical Engineering
Department.

REFERENCES:
1. Clinical Microbiology Procedure Handbook, American Society of Microbiology,
Washington, DC, 2004.
2. Cumitech 3A, Quality Control and Quality Assurance Practices in Microbiology, ASM,
1990.