Most commonly cited TJC standards of 2017

Most commonly cited TJC standards of 2017

The citations were related to cleaning, disinfection, and sterilization of medical equipment (e.g. instruments, flexible endoscopes, and ultrasound probes).

To avoid a citation, standardize cleaning, disinfection and sterilization processes, including point of use cleaning in all areas performing high-level disinfection or sterilization throughout the facility.  If point of use cleaning (e.g. using an enzymatic gel on the instruments prior to sending to the reprocessing area) is performed in a treatment or procedure room, wait for the patient to leave the room before performing point of use cleaning.

Staff should have immediate access to manufacturer’s instructions for use for all equipment and products (e.g. enzymatic detergent, washer-disinfector, sterilizers, instruments, scopes, and probes, etc.).  Policies and practice should reflect manufacturer’s instructions for use, or accepted practice as indicated by national or professional association guidelines if the instructions aren’t specific enough. However, for specialized instruments (e.g. batter operated orthopedic drills and saws, endoscopes, ultrasound probes, robotics, etc.) contact the manufacturer to obtain specific instructions for cleaning, disinfection, and sterilization.

Once standardized processes are in place, have a competent, qualified person supervise the high-level disinfection and/or sterilization processes and perform competency assessments.

Coordinate with the Infection Prevention Department to determine the best method to periodically monitor practice in addition to the routine practice monitoring that should occur within each department performing high-level disinfection or sterilization throughout the facility.

Citations were primarily related to cleaning, disinfection and sterilization of medical equipment and supplies.

To avoid citations under this standard, train staff using the manufacturer’s instructions for equipment, instruments, probes, and endoscopes as well as national or professional guidelines such as the Association for the Advancement of Medical Instrumentation (AAMI) ST79 for instrument decontamination and sterilization.  Standardize documentation following national or professional organization guidelines (e.g. AAMI or the AORN) for each phase of instrument, scope or probe reprocessing and include documentation in staff training. Once staff have been trained, competency assessment by a competent, qualified person who observes the staff performing their duties should occur.  Frequency of competency assessment is set by the organization.

After decontamination, all instruments, scopes and probes must be inspected in a well-lit clean area.  Some guidelines recommend quality testing certain instruments, scopes or probes after decontamination or cleaning but before sterilization or high-level disinfection.   Ensure your processes mirror the guidelines that you are following!

Another problematic area for facilities is Immediate Use Steam Sterilization or IUSS.  According to the IUSS statement developed by several professional organizations (AORN, ASC Quality Collaboration, etc.), IUSS should not be used routinely to accommodate an instrumentation shortfall.   Any instruments undergoing IUSS must be prepared the same as they would in the Sterile Processing Department (SPD). A container specifically created for IUSS must be used and the sterile item must be transferred to the sterile field using the proper sterile technique. According to AORN, documentation of IUSS should include the name of the patient on which the instruments are used, the items that underwent IUSS, time, temperature and pressure, type of sterilization cycle used (e.g. prevacuum, gravity displacement, etc.), monitoring results, date and time of the IUSS cycle, identification of person who ran the cycle and the person who retrieved the instruments from the sterilizer, and the reason for IUSS. Additionally, AORN recommends documenting what could have been done differently to avoid IUSS to assist with performance improvement.  Documentation should be analyzed regularly to determine appropriate actions to prevent the use of IUSS.

The last area of concern is disinfection of patient care equipment such as glucometers, medication scanners, etc. All areas using the same equipment should follow the same process to disinfect the equipment as well as the frequency.  For example, if the Post Anesthesia Recovery Unit (PACU) disinfects the medication scanner after every use with a hydrogen peroxide wipe, then other areas using a medication scanner should disinfect it after every use with a hydrogen peroxide wipe. The only exception would be if the manufacturer listed several disinfectants, then some variation in the disinfectant might be acceptable to accrediting organizations as long as staff could verbalize the rationale for using the disinfectant of choice.