POLICY STATEMENT
All instruments used in patient procedures must be sterilized after use in order to minimize the transmission of blood-borne pathogens and infectious illness. Proper use of an autoclave for this purpose is an essential infection prevention mechanism.
REASON FOR THIS POLICY
To outline the processes for proper instrument sterilization and autoclave usage and maintenance.
ENTITIES AFFECTED BY THIS POLICY
Campus Health Services
WHO SHOULD KNOW THIS POLICY
All CHS staff working directly in the medical clinic
DEFINITIONS
None
POLICY
1. Instrument sterilization
a. All soiled instruments must be washed, disinfected with a germicidal solution, rinsed, and dried in a soiled utility area prior to sterilization. Proper personal protective equipment (PPE) should be worn.
b. Instruments should be placed into approved pouches with heat-sensitive autoclave strips or indicators in order to confirm that proper temperature was achieved during the sterilization process.
c. Hinged instruments should be placed in the open position when placed in the pouches.
d. The pouches are to be placed on edge in an instrument rack and not placed flat or on top of each other.
e. All items will be labeled with the date and the initials of the person running the load.
f. Confirm that the heat-sensitive indicators have appropriately changed upon removal.
g. Use caution when opening the door after a sterilization cycle and ensure that the cycle is complete. Autoclaved items must be cooled for a sufficient amount of time after sterilization before handling to avoid injuries or burns.
h. All sterilized instruments are considered sterile until an event causes the item to become contaminated (e.g. tear in packaging, packaging becomes wet, seal is broken).
2. Autoclaves
a. Scheduled, annual preventive maintenance is required. Cleaning and routine maintenance shall comply with manufacturer’s recommendations. All maintenance shall be documented and recorded in the appropriate logbook.
b. Autoclaves should be run per manufacturer’s recommendations and guidelines; standard cycle parameters calibrated by the manufacturer may be used.
3. Use of Biological Indicators
a. Autoclaves should be monitored with biological testing procedures for live spores (per manufacturer’s recommendations) no less than once per week. Results should be recorded and maintained in a clinic logbook maintained in the clean utility room housing the autoclaves.
b. Under appropriate conditions, spore tests results should be negative.
c. Should biological testing indicate a positive result:
i. Notify supervisor
ii. Take sterilizer out of service until further testing can be completed
iii. Repeat biological indicator test in 3 consecutive cycles. If results remain positive, all instruments should be considered non-sterile (since the last acceptable negative spore test) and be recalled and reprocessed. The autoclave should be inspected by CHS-contracted biomedical personnel.
d. After use, biological indicators should be properly disposed of/destroyed according to manufacturer’s recommendations.
RESPONSIBILITIES
Medical assistants working in the CHS medical clinic will be assigned these duties.
PROCEDURES
See policy above.
RELATED INFORMATION
Forms or Tools
There are no forms or tools associated with this policy.
Cross-References
There are no cross-references associated with this policy.
Sources
U.S. Centers for Disease Control and Prevention, “Guideline for Disinfection and Sterilization in the Healthcare Setting,” 2008. https://www.cdc.gov/hicpac/Disinfection_Sterilization/13_0Sterilization.html
https://www.cdc.gov/oralhealth/infectioncontrol/faq/sterilization.htm
University of Ottawa, “A Guideline for the Safe Use of Autoclaves,” 2003.