STANDARD 3: Preventing and Controlling Healthcare Associated

InfectionsA Case Study

Best Practice and Compliance: Commissioning a Sterile Processing

Department for Improved Patient Care Roel Castillo

Chris O’Brien Lifehouse

Introduction – Does it fit?

• Facility • SSD

Challenge- Commission a Compliant SSD

Standard 3: Preventing and Controlling Healthcare Associated Infections

We have about 3 criteria that directly impacts on SSD:

• Governance and systems for infection prevention, control and surveillance

• Infection prevention and control strategies

• Cleaning, disinfection and sterilisation

Challenge

3.1 Developing and implementing governance for effective infection prevention and control to minimise the risks to patients in healthcare associated infections

– Risk management approach for policies and procedures implemented in reprocessing of reusable medical devices

– Monitoring and improvement.

Strategies and results

• Development of policy and procedure for processing of reusable medical devices – 2 main policies in SSD- Endoscopy reprocessing (GENCA)/reusable medical device reprocessing (4187:2003) plus all procedures and related workflows in all stages of reprocessing. 17 for Endoscopy and 42 for all other RMDs

• Monitoring its effectiveness – reviews are in place from departmental agendas to IC, WHS, Device manufacturers

1.Policy on Reprocessing RMDs and2.Policy on Endoscopic Devices

17 Procedures – Endoscopy 42 Procedures on RM Devices

Strategies and results –cont.’• Accessibility – Available on the intranet, hard copies

in relevant areas• Standardised format/version control system –

Version/format in collaboration with Quality and Risk with scheduled annual review on procedures and 3 years on Policies

• Support from executive governance – Executive delegation of responsibility

• Inclusion of orientation and education programs –Formulation and implementation of 21 week training/induction program to suit the requirements of assessments of the NSW Health Core Competencies for sterilising technicians

Accessibility

Strategies and results –cont.’

• Risk management and reminder systems – Riskman as the facility risk management software application is compliant with this structure

• KPI, Reporting, review and action consequences –Weekly departmental tabulation of KPIs, monthly reporting to IC Committee, monthly reporting to Quality and Risk and WHS Committees

Riskman and KPI reporting table

Challenge – Cont.’

• 3.2 Undertaking surveillance of healthcare associated infections

– Surveillance systems and monitoring

• 3.3 Developing systems of reporting, investigating and analysing HAI and aligning this system to

– Mechanisms and actions to reduce HAI

Strategies and results –cont.’

Strategies and results –cont.’

• Surveillance systems and monitoring –SSD specific –– Equipment monitoring –

Swabs for protein/blood carbohydrate residues, microbial cultures,

– Reusable medical device monitoring – Swabs for protein/blood carbohydrate residues

– Endoscopy monitoring –Scheduled microbial testing

– Biological challenge monitoring

• Mechanisms and actions to reduce HAI – reporting systems in the Riskman application for review and feedback

Challenge – Cont.’

3.4 Undertaking quality improvement activities to reduce HAI through changes in practice

– Implementation/compliance with changes are monitored

– Effectiveness is evaluated

3.5 Development and implementation of Hand hygiene

Strategies and results –cont.’

• Implementation/compliance with changes are monitored –

• Effectiveness is evaluated –100% of our scopes passed microbial testing and protein residue hence correlation is established

• ATP – Bioluminescence will be adopted at a later stage

• Development and implementation of Hand hygiene -

• In collaboration with IC – Facility wide initiative

Strategies and results –cont.’

Challenge – Cont.’

3.6 Implementing immunisation program

3.7 Collaboration with WHS to decrease the risk of infection and injury to HCW

Strategies and results –cont.’

3.6 Implementing immunisation program –HR – a requirement for employment/start of work

3.7 Collaboration with WHS to decrease the risk of infection and injury to HCW –

– PPE compliance audits “live on hubs”

– Skin allergies - ensure that powder free nitrile gloves are in use

– Evaluation of new products and procedures –product evaluation committee

– Safe work practices for all equipment for HCW

Strategies and results –cont.’

Challenge – Cont.’

• 3.8 Developing and implementing a system for use in the management of invasive medical devices used on patients

• 3.11 Implementing standard precautions –Transmission based precaution/additional precaution

Strategies and results –cont.’• Incident reporting – procedure driven• Failure of process e.g.. sterilisation – procedure and

reporting – Riskman• Failure of equipment e.g. HLD – reporting recall procedure• Flagging of positive biological challenges and microbial test

result – RCA – review and existing procedure• Audits are done in all areas of reprocessing to ensure

procedures are followed in the processing of RMDs –evaluation of results and feed back reported monthly to IC/QS/WHS

• Standard precautions – include HH, PPE, additional precautions in collaboration with IC/WHS

• Facility Policy driven -

Process result monitoring

Challenge – Cont.’

3.15 Using risk management principles to implement systems to maintain hygienic and clean environment

Schedule and compliance with standards

3.16 Reprocessing reusable medical equipment, instruments and devices in accordance with relevant national and international standard

Compliance

Monitoring

Strategies and results –cont.’

3.15Using risk management principles to implement systems to maintain hygienic and clean environment

– Schedule and compliance with standards – department procedure on environmental cleaning in all areas of reprocessing in SSD and endoscopy reprocessing area

– Monitoring and audit – weekly documented and feedback on meetings

Strategies and results –cont.’

Challenge – Cont.’

3.16 Reprocessing reusable medical equipment, instruments and devices in accordance with relevant national and international standard

– Compliance

– Monitoring

Strategies and results –cont.’

• Compliance –• Policy on RMD reprocessing (4187:2003); Policy on

endoscopy reprocessing (GENCA 2010)

• plus 42 and 17 respective procedures ensuring quality– Annual review of the above

• Steriliser compliance and commissioning

• Associated Equipment compliance with current standards and subsequent commissioning – Annual recommissioning of the above

• Standards relating to consumables

• Environmental control monitoring

• Suitably trained workforce

Strategies and results –cont.’

Strategies and results –cont.’

Strategies and results –cont.’

Strategies and results –cont.’

Strategies and results –cont.’

Strategies and results –cont.’

Monitoring –• from collection to delivery of processed items devices

leave a footprint,

• the relevant equipment monitored daily for status of cleanliness and functionality to effectiveness of purpose -

• Process or equipment failure contingency planning –requirement for release on all stages of reprocessing

Strategies and results –cont.’

Challenge – Cont.’

3.17 Implementing systems to enable the identification of patients on whom reusable medical devices have been used

Traceability system that identifies patients who have a procedure using a sterile medical instruments in place

3.18 Ensuring workforce who decontaminate reusable medical devices undertake competency based training in these practices

Competency based program to decontaminate RMDs –

Strategies and results –cont.’

– Instrument tracking system – was not put in place-manual traceability – compliant marketed solutions ensuring information and documentation required are addressed – with audits and sign offs provided

– Internal audits and sign off designed to compliment that solution

– Additional audits for end users compliance– Formulation and implementation of 21 week training

induction program to suit the requirements of assessments of the NSW Health Core Competencies for sterilising technicians• Annual In service for new instruments• Annual retraining schedule on equipment used for reprocessing

Strategies and results –cont.’

Conclusion

It is essential to comply with regulatory bodies and "best practice" in setting up a new Sterile Processing Department to ensure patient safety in providing quality processed items for use between patients.

MessageThere is a need for higher sense of commitment to improved practices and ultimately better patient care.

Final Message - Evidence