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Easi-Sterilise Information session for Clinicians

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Easi-Sterilise Information session for Clinicians Getting it right, every step of the way 1.5 Pre Cleaning Pre cleaning (initial cleaning) allows for the ... – PowerPoint PPT presentation

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Title: Easi-Sterilise Information session for Clinicians


1
Easi-Sterilise Information session for
Clinicians
  • Getting it right, every step of the way

2
Why are we here?
  • Patient and staff safety
  • Directives from QH EMT for rapid implementation
    of education and training following incidents
  • Implementing a continuous quality improvement
    program
  • Acknowledge an absence in effective communication
    when changes are made
  • To build on current level of knowledge in light
    of ever changing technology, standards,
    guidelines, advisories and legislation

3
Aim of this workshop
  • Provide participants with an overview of the Easi
    Sterilise Standard Operating Procedures and
    outline the responsibility of the clinician in
    ensuring that items have been through the correct
    reprocessing and are able to be used safely for
    patient care.

4
QH Commitment
  • Is to
  • Appropriately train and skill staff
  • Provide information and resources so that
    step-by-step quality processes are consistently
    followed
  • Assist in identifying gaps in knowledge and
    provide opportunities for improvement

5
SOPs WSAs
  • To assist Oral Health facilities operationalise
    QH policy and guidelines
  • A resource for staff
  • Update and supersede the OH Critical Instrument
    Tracking (2003)
  • A framework to assist staff identify competence
    and areas where education and improvement may be
    needed
  • A resource to identify opportunities for
    improvement within the department that will
    require further education and training

6
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7
1.1 Standard Precautions
  • Standard precautions are applied as a first-line
    approach to infection control. These form the
    basis for your decision-making and practice.
    Standard precautions are a set of guidelines
    based on the assumption that all blood and body
    fluids are potentially infectious.

8
1.1 Standard Precautions
  • In the context of sterilising practice and ALL
    the Standard Operating Procedures, standard
    precautions include
  • Hand Hygiene
  • Hand cream approved by infection control not
    in packing area or handling of sterile stock
  • Personal Protective Equipment
  • Gloves
  • Face shields, hair protection, safety glasses and
    masks
  • Fluid resistant gowns/aprons
  • OHS Requirements

9
1.2 Soiled Pickup Collection
  • Standard Precautions - PPE
  • Contaminated items - dedicated collection
    trolley/container
  • Keep instrument sets together
  • Secure sharps
  • Collection containers are
  • puncture-resistant
  • leak-proof and made of either plastic or metal
  • with a lid or liner that can be closed

10
1.3 Sorting Prior To Cleaning
  • Instruments and items sorted by
  • Type
  • Method of cleaning e.g. Manual , ultrasonic,
  • Instruments and items are checked for
  • Completeness
  • Defects
  • Sharps or blades that have not been removed
  • Heavily soiled items
  • Single use only items must not be returned for
    reprocessing
  • Report concerns to supervisor

11
Cleaning
  • Cleaning removes organic and inorganic soil,
    blood, fats etc which contain pathogenic
    micro-organisms
  • Gross Debris should be removed chairside
  • Cleaning minimises contamination levels of
    bioburden (number of micro-organisms) prior to
    sterilisation
  • For sterilisation to occur the aim is to have a
    low number of micro-organisms present on
    instruments

12
Cleaning
  • Steam will not penetrate contamination left on
    instruments
  • If the item is not clean it wont be sterilised

13
1.5 Pre Cleaning
  • Pre cleaning (initial cleaning) allows for the
    removal of visible blood, body fluids and debris
    from items prior to cleaning (definitive
    cleaning). Pre cleaning shall be undertaken as
    soon as possible (e.g. during and post procedure
    chairside).
  • If blood, proteins and other debris are allowed
    to dry or remain in crevices and joints, the
    instruments become very difficult to clean and
    are prone to stiffness and accelerated corrosion.

14
1.5 Pre Cleaning
  • Pre cleaning can be performed by methods such as
    dry wiping, damp wiping or use of a commercially
    available single use only instrument sponge
  • Place the dry wipe, damp wipe or sponge on the
    bracket table and carefully wipe the instrument
    across the material

15
1.6 Hand Cleaning For Immersible Items
  • Drying As per manufacturers instructions
  • Drying cabinet
  • Disposable low-lint cloth for hose, battery and
    external parts
  • Air pressure gun (for removal of excess moisture)
  • Disposable syringe
  •  

16
1.6 Hand Cleaning For Immersible Items
  • Problems associated with incorrect drying
  • Items should NOT be air dried/ dripped dry
  • Good conditions micro-organisms multiply in
    20-30 minutes
  • Wet packaging result in unsterile item
  • Can cause rusting, corrosion, pitting to the item

17
Handpieces
  • handpieces
  • outside surfaces cleaned using detergent wipe,
  • rinsed by wiping
  • dried
  • slow speed motors
  • outside surfaces cleaned using detergent wipe,
  • rinsed by wiping,
  • dried
  • lubricated (manually or automatic) may need
    special adaptors
  • Dried, wrapped processed in a wrapped cycle

18
Special adaptors may be needed
19
Special adaptors may be needed
Ideally, handpieces and slow speed motors are
cleaned and lubricated using mechanised cleaning
equipment
20
Special adaptors may be needed
21
1.8 Ultrasonic Cleaner
  • Purpose
  • Ultrasonic cleaning is a form of mechanical
    cleaning that uses high frequency ultrasonic
    waves (cavitation) that dislodges fine particles
    from the surfaces of instruments.

22
1.8 Ultrasonic cleaner
Ultrasonic cleaning is an effective cleaning
method for instruments prior to the reprocessing
23
1.9 Washer Disinfector Machines
  • Batch and continuous type washer disinfectors
    clean and remove bio burden/micro-organisms
    (blood and debris)
  • Thermal (high level) disinfection using time at
    temperature final rinse
  • Means the cleaning process is verifiable
  • Lumened items still require Flush brush Flush
  • Unlock and open items
  • Use appropriate washer baskets/inserts
  • Keep sets together

24
1.9 Washer Disinfector Machines
  • REPORT IMMEDIATELY
  • Cycle parameters not meeting set requirements or
    variations to cycle parameters failed cycles
  • Items that appear dirty or stained are returned
    to the cleaning area for recleaning/destaining
  • Excess water check the following the machine
    temperature, amount of rinse aid going into the
    machine or the way in which the machine was
    loaded
  • Damaged instruments

25
1.9 Washer Disinfector Machines
  • Releasing the load and unloading the washer
    disinfector
  • Authorising release of the load occurs on
    completion of washer disinfector cycle and prior
    to opening the door.
  • Check cycle parameters have been met and print
    out/log (or equivalent) is signed
  • Care opening the doors due to heat and moisture
  • Inspect load not become dislodged or displaced
  • Avoid injury and damaging the equipment/instrument
    s

26
Washer disinfector printout
27
Section 2
  • Packaging and Wrapping Procedures

28
2.1 Organisation Of Packing Area
  • Organised packing area ensures a clean, safe work
    working area that reduces the risk of equipment
    damage/loss and unsafe work practices.

29
2.2 Assembly Of Instrument Trays And Hollowware
  • Prepare equipment for sterilization
  • Check multi-part equipment / instruments
  • can be assembled and functioning
  • then disassembled or loosely assembled for
    sterilisation as per manufacturers instructions
  • Hinged or ratchet instruments are opened and
    unlocked
  • Sharp items protected with a tip protector or
    enclosed in a cassette

30
2.2 Assembly Of Instrument Trays And Hollowware
  • When packaging hollowware sets
  • Openings are to face in the same direction,
  • Hollowware should not be able to move, and
  • If hollowware is nestled - insert separators
  • Individual packs do not include combinations of
    hollowware, instruments, gauze dressings, drapes
    or tubing

31
2.3 Wrapping and Packaging
  • Provides a protective barrier against sources of
    potential contamination. Wrapping/packaging
    methods must facilitate aseptic removal of
    contents

32
2.3 Wrapping, Packaging Labelling
  • Wrapped items
  • The method shall be envelope fold or square fold
    technique
  • The type and method of wrapping and packaging is
    facility specific
  • Check prior to use the wrapping material is not
    damaged or expired
  • The class 1 chemical indicator tape used for
    sealing will be specific to the mode of
    sterilisation (pressure sensitive, non-toxic and
    adhere to clean surface)
  • Ensure tape is adhered to wrapping/packaging
    material 

33
2.3 Wrapping, Packaging Labelling
  • Flexible packaging materials
  • Check for damage and expiry date
  • Correct size pouch for contents
  • Hollowware openings are against non-laminate
    surface
  • Any writing required should be done on the outer
    parameter of the flexible packaging material.
  • Self sealing pouches must be sealed by folding
    the flap along perforation/dotted line as
    indicated by the manufacturer.
  • Pouches shall only be filled up to ¾ of the
    overall space, allowing approximately 5 cm seal
    area

34
2.3 Wrapping, Packaging Labelling
  • Labelling of packs
  • All packs, bags, pouches and wrapped items must
    be labelled if contents are not visible
  • Use a non-toxic, water resistant, felt tipped
    marking pens and rubber stamps using similar ink
    or pre-printed tape
  • Writing on wrapping could damage the integrity of
    the material

35
2.3 Labelling
  • To occur prior to the sterilizing process
    utilising
  • Batch labels (piggyback)
  • Details on the batch label gun must be checked
    and updated for each sterilizer cycle. The
    minimum information required on each label must
    include
  • Date of sterilization
  • Sterilizer number
  • Sterilizer cycle number 

36
Blue Unprocessed
Sterilizer number
37
Colour interpretation chart
38
2.4 Using and Reloading Batch Label Gun
  • Upper adjustable print display - Setting the date
    and the steriliser number
  • Date must appear as DD(space)MM(space)YY starting
    from the far left
  • The sterilizer number must be positioned to the
    far right

39
White mark
(R) Side - Steriliser number
(L) Side Date - dd mm yy
Steriliser cycle number
White mark
40
Chemical Indicators
  • Class 1 Process indicator exposure to a
    sterilisation process shows processed/unprocesse
    d e.g sterilising tape, external chemical
    indicators.
  • Class 2 Specific tests e.g Bowie Dick type test
  • Class 3 Single parameter critical parameter
    e.g. dry heat
  • Class 4 Multi parameter eg. Time at Temp.
  • Class 5 Integrating indicator time temp and
    moisture
  • Class 6 Emulating indicator (cycle
    verification) eg. 134C _at_ 3.5 min

41
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42
Chemical Indicators do not indicate
sterilization
  • Written information about the indicators shall
    be obtained from the supplier covering
  • (a) How to interpret indicator results.
  • (b) The factors affecting end-point colour change
    during storage of sterilized items.
  • (c) The sterilization conditions that the
    indicator will detect.
  • (d) The storage requirements and shelf-life of
    the indicator itself.

43
Packaging Instruments Class 1 Chemical
Indicators
44
Packaging Instruments
45
Dental Instruments
  • Sterile at point-of-use
  • must be stored to maintain sterile conditions
  • must be tracked when used

Extraction instruments
46
The way we were
47
Section 3
  • Sterilising

48
3.1 Batching Recording of a load prior to
sterilisation
  • MUST HAVE DOCUMENTED EVIDENCE OF ALL ITEMS of a
    sterilising process tracking/tracing proof
  • Assists in the recall of an item/load
  • Recording of load contents assists in compiling
    of statistical data on production volume

49
Warning Do Not Store Unprocessed Items In The
Sterilizer
  • The sterilization cycle shall be commenced
    immediately after loading.
  • Warm, moist atmosphere of the chamber can lead
    to
  • (a) release of unprocessed items for use
  • (b) contamination of packaging by condensate
  • (c) an increase in bioburden on unprocessed
    items and
  • (d) the deterioration of
  • (i) chemical indicators, packaging and labelling
    and
  • (ii) adhesive of self seal pouches, labelling and
    sterilizing tape.

50
Downward Displacement Validator Plus Steriliser
  • .

bench top class N downward displacement autoclave
capable of processing both wrapped and unwrapped
loads
51
Small Pre vacuum
52
Lisa 500 series
53
Large Pre-vacuum Sterilisers
54
3.2 LOADING AND RECORDING OF ITEMS FOR STEAM
STERILISATION
  • Sterilant needs to have contact and/or penetrate
    all surfaces of the all items
  • Do not
  • crush items together
  • allow items to touch the floor, top, door or
    walls of the chamber
  • Allow enough space between each item for
  • air removal,
  • steam penetration,
  • draining of condensate
  • drying to occur

55
Loading the steriliser
  • All loads/cycles must have a chemical indicator
    to distinguish between processed and unprocessed
    loads
  • A control pouch containing a class 5 or 6
    chemical indicator and batch label attached is
    included in all loads as per direction from the
    Chief Dental Officer, Jan 2010

56
Loading of Laminated Packaged Instruments
57
Loading hollow ware pouches
Place hollow ware on a 45 degree angle
58
Lisa 500 series
59
Examples of sterilisation cycles
  • Recognised International
  • Temperature, Pressure, Time
  • Relationship

60
Physical checks
  • Cycle completed check print out for
  • Temperature has reached 134C
  • Time at 134C gt 3 mins penetration time
  • Pressure 203kpa or 2030mb or 30psi

61
stand alone printer
Other types?
In built printer
62
Top of the printout
63
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64
New Lisa 500 series manual
WH Lisa Manual
65
3.3 Releasing Unloading a Sterilised Load
  • To ensure that the staff unloading the steriliser
    check that sterilisation has occurred in
    accordance with the validated process and
    authorises the release of the load

66
3.3 Releasing Unloading a Sterilised Load
  • Ensures that the sterilant has contact with,
    and/or penetrates all surfaces of all items being
    reprocessed
  • Immediately cycle has completed - Visually check
  • Chemical indicators have changed colour correctly
  • No visible wet packs packs intact
  • Printout confirms sterilisation parameters are
    met sign
  • If no printer, check the class 4,5 or 6 chemical
    indicator

67
3.3 Releasing Unloading a Sterilised Load
  • Only in exceptional circumstances (such as
    involved in providing direct patient care) would
    a delay to removing a completed sterilization
    load, be considered acceptable and no more than
    30 minutes from when the cycle has finished.

68
3.3 Releasing Unloading a Sterilised Load
  • When releasing and authorising the load for use
  • Check items unloaded correspond with load
    documentation
  • Check and record results of process challenge
    devices (if used) on sterilizing log chart
  • Check and record results of biological indicator
    (if used) on sterilizing log chart

69
3.3 Releasing Unloading a Sterilised Load
  • Document in steriliser record/log
  • Sign the sterilizer cycle printout and attach
  • Document time of release
  • Signature or identification of person releasing
    the load
  • Ensure the items unloaded correspond with load
    documentation
  • Attach the control pouch batch label
  • Attach the control class 5 chemical indicator
  • Immediately notify the supervisor if not met.

70
Cooling items
?
  • Away from high activity areas
  • Do not use forced cooling by fans or air con.
  • Do not place on solid surfaces, as condensation
    from vapour (still within the pack) can result.
  • Items dropped on the floor, placed on a dirty
    surface, compressed, torn, have broken seals, or
    are wet, are considered non-sterile and shall be
    reprocessed.

71
The key pieces of legislation relating to
recordkeeping are
  • Public Records Act 2002
  • Public Services Act 1996
  • Electronic Transactions (Qld) Act 2001
  • Evidence Act 1977
  • See also QH clinical records retention and
    disposal schedule
  • http//paweb.sth.health.qld.gov.au/sqrm/hims/recor
    ds/documents/disposal_retention_sched.pdf

72
Each Sterilizers information is written once on
the front page
73
Found on CHRISP Oral Healthwebsite
74
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75
In the case where one or more items (but not all)
have failed, in a successful cycle
76
Section 4
  • Stock management

77
4.1 Dedicated Area For Sterile Goods
  • Only those sites that can ensure environmental
    control (temperature and humidity) and meet
    sterile stock storage requirements of AS/NZS 4815
    can move to event related sterility. If these
    storage requirements can not be met the unused
    items must be reprocessed after 3 months

78
4.1 Dedicated Area For Sterile Goods
  • Environmental considerations for Event Related
    Sterility
  • Temperatures in this area are in the range 18?C -
    22?C with a relative humidity ranging from 35 -
    68
  • Secure from public access
  • Limited staff thoroughfare/working in this area
  • Sterile goods shall always be segregated from
    non-sterile goods
  • Protected from direct sunlight

79
4.1 Dedicated Area For Sterile Goods
  • Environmental considerations for Event Related
    Sterility
  • For open shelving store items 250mm above floor
    level at least 400mm from ceiling fixtures
  • Surfaces such as walls, floors, ceilings and
    shelving shall be non-porous, smooth and easily
    cleaned
  • Air-conditioning ventilation conditions should
    be in accordance with AS1668.2
  • New overhead lighting is fitted flush to the
    ceiling to minimise dust entrapment

80
4.1 Dedicated Area For Sterile Goods
  • The environment shall be
  • Dedicated storage areas
  • Store in a clean, dry, dust free environment
  • Insects and vermin free
  • Protected from direct sunlight
  • 250mm above floor level at least 400mm from
    ceiling fixtures

81
4.2 Stock Rotation
  • The purpose of stock rotation is to use sterile
    stock according to the date of manufacture.
  • /sterilisation
  • Rotate stock so previously sterilised and stored
    items will be used first
  • Take from left replace to the right
  • Handle only when necessary
  • Do not overstock damage compromise

82
Time-Related Sterility
  • based upon an arbitrary date allocated to
    sterilised packs/pouches etc by which they should
    undergo re-processing and sterilisation if they
    have not been used
  • if storage handling conditions are not ideal,
    or if the packages are frequently handled, items
    may need to be reprocessed more frequently

83
Event-Related Sterility
  • This process is a method of determining if an
    item is still sterile by assessing whether it has
    undergone any events, which may have compromised
    its sterility, such as
  • Incorrect cleaning in storage areas
  • Moisture and condensation
  • Exposure to harsh as well as external climatic
    conditions
  • Dust, Vermin and insects
  • torn/soiled wrapping or poor storage

84
Maintain sterile stock
  • Do Not
  • Handle without washing and drying hands
  • Pack in a manner that could damage the wrapping
  • Bundle using rubber bands or similar
  • Stack on top of each other - they should be
    stored vertically
  • Place on or near potentially wet surfaces
  • Exposed to aerosolising procedures only take to
    chairside what is needed.

85
Section 5
  • Quality

86
5.1 Water Quality
  • To ensure water used in cleaning of re-usable
    medical devices is of optimum quality for
    effective and efficient processing

87
Water quality for cleaning
  • Water quality affects cleaning procedures
  • Water must be potable (drinking quality)
  • Hard water calcium and magnesium
  • Damages instruments
  • Damages equipment
  • May prevent chemicals working as intended
  • Unfiltered tap water may contain excessive
    amounts of microorganisms depending on source

88
5.3 Ultrasonic Machine Testing
  • Ensures that the machine is functioning
    effectively.
  • Testing can be accomplished using validated test
    methods to prove that the transducers are working
    effectively soil is able to be removed new test
    methods in development
  • Daily test or each day of use
  • Document results
  • Report test failures

89
5.4 Mechanical Washer Cycle Monitoring
  • Proof that the mechanical washer disinfector
    attains the correct parameters for the set cycle
    and thus enables the conditions for effective
    cleaning and/or thermal disinfection

90
5.4 Mechanical Washer Cycle Monitoring
  • Washer/disinfectors usually operate within the
    following temperature ranges
  • Rinsing 40C - 50C
  • Washing 50C - 60C
  • Disinfecting 70º for 100mins
  • 75º for 30 mins
  • 80º for 10 mins
  • 90º for 1 min
  • Final rinsing 80C - 90C
  • All results shall be checked prior to the release
    of each load and the printout signed

91
5.5 Internal External Chemical Control
  • External and or internal chemical control
    (indicators) shall be used to identify that an
    item has been through a sterilising process. The
    indicators are specific to the sterilising
    process being used eg. Steam, hydrogen peroxide,
    ethylene oxide, peracetic acid

92
5.5 Internal External Chemical Control
  • Control Pouch (Mandatory)
  • A separate sterilising pouch with a 'control'
    Class 1 chemical indicator and batch label
    attached and a Class 5 or 6 Chemical Indicator
    inside, must be placed onto a sterilizer tray and
    used in every sterilization cycle.

93
5.5 Internal External Chemical Control
  • Internal
  • An appropriate internal multi parameter time and
    temperature chemical indicator (Class 5 or 6) is
    used in the following circumstances
  • In the mandatory OH Control pouch
  • Where delays to access to on-site technical
    support to undertake calibration, operational
    qualification and performance qualification for
    new sterilizers or temporarily loaned sterilizers
    occur.

94
5.5 Internal External Chemical Control
  • External (Mandatory) Class 1 chemical indicator
  • Examples include
  • sterilizer indicator tape
  • chemical indicators found on commercially
    manufactured packs/pouches

95
5.6 Biological Indicators
  • Biological indicators are used to verify the
    microbial killing power of 10-6 of the
    sterilisation process by using a population of
    calibrated bacterial spores, on, or in, a carrier
    and packaged in a manner that the integrity of
    the inoculated carrier is maintained.
  • Routine biological testing is not mandatory for
    steam sterilisers if process is validated

96
5.7 Leak Rate (Vacuum) Test
  • To verify that air has not leaked into the
    sterilising chamber.
  • The leak rate/vacuum test is not a sterilisation
    cycle.
  • It is a special programmed cycle that draws a
    vacuum and holds the vacuum for a minimum of 10
    minutes. If the rate of air that leaks into the
    chamber via a leaking chamber seal or hole in
    piping, a pressure rise will be measured that is
    greater than 1.3 kPa/min over 10 minutes, a fault
    indicator and printout.
  • The level of vacuum will be different for each
    machine. The important thing is that it remains
    within 1.3kPa/min of the vacuum over the 10
    minute period.

97
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98
5.7 Leak Rate (vacuum) Test
  • Class B and Class S sterilisers with air detector
    weekly
  • Class B and Class S sterilisers without air
    detector daily
  • Record the results.

99
5.8 Bowie Dick Type Test
5.8 BOWIE DICK TYPE TEST
  • To detect air entrapment and evaluate the ability
    of a pre-vacuum steriliser to remove residual air
    that will then allow the steam penetration and
    attainment of the correct conditions for steam
    sterilisation.
  • Needs a special cycle
  • Daily on a warmed up steriliser before loads
  • Different types on the market

100
5.9 Routine Cleaning of Reprocessing Equipment
101
Validation Documentation
  • Important to document all the procedures!
  • pre-cleaning
  • cleaning
  • drying of instruments
  • packaging
  • loading steriliser
  • unloading steriliser
  • physical checks
  • sterilisation log book
  • storage of sterile items
  • validation of YOUR sterilisation process

102
Annual validationperformance qualification (PQ)
  • What is validation?
  • A documented procedure for obtaining, recording
    and interpreting the results required to
    establish that a process will consistently yield
    product complying with predetermined
    specifications.
  • What does this mean?
  • The entire process is documented, challenged and
    repeatable, and establishes the efficacy (or not)
    of the sterilising process, that is monitored by
    the measurement of the critical requirements of
    time, temperature and pressure and parameters
    during each cycle.

103
Commissioning of sterilisers
  • Installation Qualification (IQ)
  • Proves that the steriliser and the where
    installed comply with the manufacturers
    specifications
  • Operational Qualifications (OQ)
  • Determines that the installed steriliser and
    equipment is working within the defined limits
    when used as per manufacturers procedures.
  • These shall documented and recorded and include
    calibration of all gauges, parameter monitoring,
    the recording device, specific performance tests
    (eg leak test) and process indicator tests (bowie
    dick tests)

104
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105
Installation qualification (IQ)
  • Heat distribution study
  • Temperature profile Cold Spot
  • Service technician performs (empty chamber)
    whilst calibrating the temperature gauge.
  • Or may be provided by the manufacturer.
  • Doesnt need to be routinely checked every time.

106
Performance qualification (PQ) physical
qualification
  • Time at temperature and pressure testing
  • Thermocouple testing to ensure the inside of the
    packs of your challenge load has reached the
    selected temperature x 3 times with BIs
  • Hold at or slightly above this temperature and at
    the correct pressure
  • Must be done at every validation
  • Whole load that will be considered your
    validated, challenged load needs to be
    available.

107
When
  • Validation shall be repeated annually and every
    time significant changes are made.
  • Examples of such changes include, but are not
    limited to, the following
  • (a) Any change to the sterilization parameters
  • (b) Changes in packaging or loading specification
    which would provide a greater challenge to the
    sterilization process.
  • (c) Changes in the items or types of instruments
    to be sterilized, such as the addition of a new
    complex medical item which would provide a
    greater challenge to the sterilization process.

108
More Information
  • Contact
  • Email CHRISP_at_health.qld.gov.au
  • Intranet for SOP WSA http//www.health.qld.gov.
    au/chrisp/sterilising/oral_health_SOP.asp
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