Page 175 - policy and procedure infection control

Policies and Procedures on Infection Control

11.5.1 Administrative monitoring
• Work practices must be supervised.
• Written policy and procedures are strictly followed by all personnel
responsible for sterilizing and handling sterile supplies.
• Policies and procedures pertain to the following:

- Decontaminating, cleaning and terminally sterilizing.
- Packaging and labeling
- Loading and unloading the sterilizer
- Operating the sterilizer
- Monitoring and maintaining the record of each cycle
- Adhering to safety precaution and preventive maintenance protocol
- Transporting sterile packages to the sterile storage room.
- Cart should be enclosed.
- Storage of sterile items
- Handling of sterile items
- Tracking and recalling items if an item in a particular load is not safe for use.
11.5.2 Mechanical Monitoring
Routine maintenance to check efficiency and accuracy of autoclave consist of
the following:-
• Dummy Run
A complete sterilizing cycle carried out with an empty chamber to get rid of
the remaining air in the chamber.
• Recording Gauge
In the form of charts, printouts, or gauges, this reflects the current status of
cycle parameters (pressure, temperature and duration) during sterilization.
Gauge should be calibrated at regular intervals against standard instruments
by autoclave operator.
• Leak Rate Test
Pre vacuum steam sterilizer must be tested at least once a week for the
rate of air leakage into the chamber during air removal and drying stages.
• Thermocouple Test
To detect temperature achieved and maintained during sterilization stage.
This procedure should be done during commissioning, after major repair
and validation.
• Bowie-Dick Test

Test packs are run daily, to monitor the function pre-vacuum sterilizers and
check the efficacy of vacuum system.

164 Ministry of Health Malaysia