Title Page

  • RMCSJ High Level Disinfection (HLD) Auditing Tool

  • Conducted on

  • Prepared by

  • Personnel

POINT OF USE

  • Instruments are manually pre-cleaned with a manufacturer approved solution within one hour of use. *Ensure all gel is removed prior to pre-cleaning.

  • If transported, dirty instruments must be transported in a rigid container with biohazard label or in a sealed biohazard bag.

  • If applicable, transport devices are decontaminated between each use. *Instruments used on C. diff. patients-containers must be cleaned with bleach (C. diff positive containers should be marked with an identifier).

  • Once transport containers are designated clean or dirty; the designation cannot change.

HLD PROCESS

  • Detergent/enzymatic is appropriately diluted according to manufacturer IFUs.

  • Instruments are soaked in detergent/enzymatic for the appropriate time according to manufacturer IFUs.

  • Instruments are rinsed under running water after soaking in detergent/enzymatic solution.

  • Instruments are thoroughly dried prior to immersing in high level disinfectant (HLD) solution.

  • Test strips utilized before every use to verify the Minimum Effective Concentration (MEC) of HLD solution and results are recorded in log.

  • Expiration date of HLD solution located inside soaking container is documented in log and also on soaking container.

  • HLD solution located inside soaking container is discarded according to manufacturer IFUS, even if the test strips indicate a concentration above the MEC. (Solution should be discarded on the expiration date at the end of the shift.)

  • Temperature is taken before every use to verify the appropriate temperature of HLD solution and results are recorded in log for each load.

  • Instruments are soaked in HLD solution for manufacturer recommended time.

  • Following soak in HLD solution, devices undergo a soak/rinse for 1 minute. Repeat process for a total of 3 soaks/rinses with fresh water each time.

  • Dry with a clean, lint-free cloth(paper towels are appropriate for colorectal ultrasound probes only).

  • Storage is clean, organized, and prevents contamination.

  • Tips do not touch bottom of cabinet or towels.

  • Sinks/basins are cleaned after every use. Or if high volume area, sinks/basins are rinsed after every use and cleaned at the end of shift.

TEST STRIP QUALITY CONTROL(QC) :MPU USE

  • QC performed on new bottle of Test Strips and results are recorded in log.

  • Positive and Negative controls set up appropriately for test strip QC(Positive control contains full strength HLD solution and negative control contains a 1:1 ratio of water and HLD solution).

RECORD KEEPING

  • HLD records are stored in the area and easily retrieved.

  • Logs are organized chronologically.

  • UCLA approved logs are used.

  • Logs are accurate and complete without missing fields. If applicable, all items are documented with follow up.

  • Patient information and instrument/device identifier (e.g. serial number) are logged for each HLD load.

HLD ENVIRONMENT

  • Department is maintained in a clean and orderly manner (e.g. no clutter, no dust, nothing on the floor, no overflowing trash).

  • Ventilation and airflow are appropriate in the decontamination and clean processing areas.-At a minimum; no strong fumes and air return vent present in room.

  • Door to decontamination area is closed at all times.

  • Fans are not present in the decontamination and clean processing area.

  • Inappropriate or unnecessary equipment and supplies are not present or stored in the area (e.g. medical equipment and supplies, sterile supplies ).

  • Hand washing is only performed in clean sink.

  • Appropriate PPE is available and appropriately used (liquid-resistant gowns/sleeves, mask and eye protection, adequate decontamination gloves).

  • Workflow in the department promotes a clear separation of dirty and clean work processes.

  • Lighting is sufficient for detailed inspection of instruments during processing.

  • All open bottles of solutions and test strips should have an "open date" and "use by" date written on the label according to manufacturer. "use by" date should not exceed the manufacturer expiration date.

COMPETENCY

  • Instruments/device manufacturer IFUs are readily available/accessible to end user.

  • The HLD policy and procedure is available and/or current staff can articulate how to obtain a copy.

  • Department has a designated person responsible for annual staff competency review.

  • Documentation of annual competencies is readily available/accessible.

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