CMHS Sterile Processing Department Audit - Part 2

Information

Section 1: Cleaning and handling Used Items

Is gross tissue removed and is enzymatic solution applied at point of use?
Are Standard Precautions used at all stages of handling used items? (PPE is used)
Are written procedures for handling of used equipment available?
Are all single-use items discarded at point of use? Were disposable items sent to SPD?
Are there policies/ procedures for the collection of used items and delivery of sterile items?
Are collection containers puncture resistant, leak proof and lidded?
Is the container / cart cleaned at the end of each collection round?
Are all instruments that have been unwrapped for use considered contaminated whether used or not and subjected to full cleaning process?
Are there written procedures for handling specialized equipment? (Power, delicate, etc.)

Instruments with hinges or ratchets remain open or unlocked during sterilization.
Multi part instruments are disassembled prior to packaging to permit effective sterilization.
Basin sets are packed so all openings face the same direction.
The color change of the sterilizing indicator tape following exposure is distinct and uniform and markedly different to the unprocessed tape.
Cleaning agents or other chemicals are not allowed to come in direct contact with personnel.
Abrasive cleaners, steel wool, powders and paste are not used.
Safety Data Sheets information has been reviewed with staff.
Ultrasonic is degassed after each fill before instruments are reprocessed.
Ultrasonic is tested daily to establish efficiency of transducers. This is documented.
The ultrasonic is emptied and cleaned at least daily or more frequently depending on use.
Cleaning brushes are disinfected at the end of each day.
The functions of the washer disinfector and the detergent dispenser are checked daily.
Is there a process to ensure that the internal cleanliness of the washer is maintained ie: descaling?
Staff is able to state the acceptable temperature setting for drying cabinet and actions taken if out of range.

Bowls/basins are tilted on edge in a draining position so that only minimal resistance to removal of air, the passage of steam and condensate will be met.
Packs of towels are loaded in vertical layers to allow air to be removed rapidly from packs.
Items are loaded within boundaries of the sterilizer cart so that they do not touch the chamber walls or fall from the cart.
Flexible packaging materials are loaded on edge.
Sterilizer carts are loosely loaded to capacity with only a single layer of wrapped packs placed on each shelf.
The department has clear written procedures on the loading of sterilizers and all staff performing this task have had the formal training to do so.

On completion the load is visually inspected to ensure it is dry and that sterilizing indicators have made the required color change.
When removing of the load from the sterilizer the operator checks printouts and signs that the parameters have been met.
The load is quarantined and the supervisor is notified immediately if any deviation from the parameters is detected.
Steriliser carts containing cooling items are kept away from high activity areas.
Cooling items are never placed onto solid surfaces as condensation may result. <br>
Items that have been dropped on the floor, placed onto a dirty surface, have torn wrap or broken seals, or are wet are considered non sterile and reprocessed.
When plastic dust covers are used the items are cool before placing into the cover.
Dust covers are placed onto cooled items within 2 hours of sterilizing.
If dust covers are used they are labelled 'dust cover only'.

The person in charge of the sterile processing department is responsible / involved in the selection process prior to the purchase of instruments.
Manufacturers recommendations are available for processing equipment and instruments.
All staff working in the sterile processing department has had education and training on the correct handling of instruments.
Instrument repairs are only performed by a qualified person.
Any instrument that appears defective is cleaned, dried and sterilized prior to being sent for repairs.
Lumens, grooves and articulations are free of debris and stylets are passed through lumens.
The tips of instruments do not have hooks or snags and approximate accurately.