Sterilising Services Audit

STERILISING SERVICES AUDIT
CRITERIA	þ	RISK RATING & ACTIONS REQUIRED	REVIEW DATE	BY WHOM
1. OPERATIONS
1.1 CLEANING REUSABLE MEDICAL DEVICES
1.1.1 All reusable items are cleaned in an area that is physically separate to other areas within the sterilising processing facility Building and Refurbishment	r
1.1.2 Before reusable items are returned to the sterilising processing facility gross soil such as blood, body fluids and skin preparation solutions are removed as close as possible to the point of use by either dry wiping, damp wiping and rinsing or both. Cannulated instruments are not allowed to become dry. QH ICG Section 3	r
1.1.3 Collection trays/trolleys for the collection of used reusable items are puncture and leak resistant with a lid or liner that can be securely closed SOP1.1 & QH ICG Section 3	r
1.1.4 The collection container/trolley is cleaned at the end of each collection round of used reusable items SOP1.1 & QH ICG Section 3	r
1.1.5 All items that have been unwrapped are considered to be contaminated and undergo a full cleaning process SOP1.2	r
1.1.6 All items including specialised items (eg loan sets, powered tools, multi-part instruments and flexible and rigid endoscopes) are cleaned in accordance with manufactures guidelines and appendix’s B&C of AS/NZS 4187 SOP1.8 & Cleaning Resources	r
1.1.7 In order to prevent damage to the surfaces of instruments or residue, abrasive cleaners such as steel wool or abrasive cleaning powders are not used SOP1.5	r
1.1.8 Chemicals are packaged and dispensed in a safe manner which prevents contamination SOP1.3	r
1.1.9 Cleaning methods within the department do not generate aerosols nor add to the formation of  bioburden SOP1.5 SOP1.4 SOP1.6	r
1.1.10 Prior to the cleaning, items are sorted according to type and cleaning method plus instrument trays are checked for completeness and defects SOP1.2	r
1.1.11 Cleaning methods used are appropriate for the design of the items being processed SOP1.2	r
1. OPERATIONS cont.
1.1 CLEANING REUSABLE MEDICAL DEVICES
1.1.12 Any defective instruments are cleaned, dried and sterilised prior to being sent for repairs SOP1.2	r
1.1.13 Loan instruments undergo a cleaning process prior to being wrapped for sterilisation. Any soil or debris found on the loan instruments are reported to the supplier SOP1.2	r
1.1.14 Prior to returning loan instruments to the source they are to undergo a cleaning and sterilising process QH ICG Section 3	r
1.1.15 At the completion of the cleaning process, items are visually inspected to ensure they are clean and free from detergent residue SOP2.4	r
1.1.16 All equipment and instruments undergo a mechanical cleaning process appropriate for the item and the items are processed for the complete cycle SOP1.9 to SOP1.11	r
1.1.17 Automated washer disinfector machines have the following cycles: ·         pre-rinse with water ·         wash, in warm water and cleaning agent as per manufacturers recommendations ·         one or more rinses with hot water at 80°C-90°C, with drying agent added ·         drain, leaving contents at a temperature for quick drying ·         drying, either by radiant heat from an element or hot air blast SOP1.9 to SOP1.11	r
1.1.18 All anaesthetic equipment undergo mechanical cleaning are disassembled as required prior to processing and care taken to ensure all surfaces and lumens are exposed to the cleaning process SOP1.13	r
1.1.19 Each time the ultrasonic cleaner is filled, water is added first, next the manufacturers recommended detergent followed by degassing of the machine before instruments are placed in the basket for processing SOP1.13	r
1. OPERATIONS cont.
1.1 CLEANING REUSABLE MEDICAL DEVICES
1.1.20 Ultrasonic cleaner is used to clean jointed, serrated, cannulated instruments not insulated instruments, mirrors or lenses SOP1.13	r
1.1.21 When items are removed following being cleaned in an ultrasonic they are rinsed in warm to hot water prior to drying SOP1.13	r
1.1.22 The ultrasonic solution is replaced at least daily or when the solution is contaminated SOP1.13	r
1.1.23 On completion of a mechanical cleaning cycle items (including anaesthetic equipment) are placed in a drying cabinet where the temperature range is between 65° C to 75° C SOP1.15	r
1.1.24 Safety instructions are followed during the operation of all mechanical washers eg mechanical lifters for heavy equipment, lid is kept closed during ultrasonic operation and no part of the operators body is submerged inside the water tank of an ultrasonic cleaner during operation SOP1.13	r
1.1.25 At the end of each cleaning session the manual cleaning equipment is cleaned and thermally disinfected or sterilised  SOP1.5	r
1.1.26 Powered instruments and hoses are cleaned as follows- ·         kept clean during surgical procedure ·         cleaned with non-linting cloth, detergent and water ·         not immersed in water ·         not placed in a mechanical washer ·         hose and handpiece to stay attached during cleaning ·         inspect for wear and tear ·         detergent rinsed off items ·         drying cabinet to dry items ·         test prior to sterilisation ·         damaged tools and hoses sent for repair by a qualified person SOP1.8	r