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Kaiser Permanente Stockton <br /> Environmental Services <br /> KAISER pE FACILITY POLICY AND PROCEDURE <br /> TITLE: 3M Tm Attest Biological Indicator Sterile Approval Date: 5/13/04 <br /> Processing Policy and Procedure Approving Committee: Facilities P&P <br /> 1) ATTACHMENTS: None <br /> SUBJECT: SANI-PAK SPORE TESTING ORGINAL DATE: 5/13/04 <br /> LAST REVIEW DATE: <br /> REVIEW INTERVAL: Every Three years/As Needed <br /> Basis <br /> NEXT REVIEW DATE: <br /> LAST REVISED DATE: 7/29/04, 07/05/06, 07/20/06 <br /> Incubation and Readout Procedure using the 3MTM AttestTM Auto-Reader: <br /> • While wearing PPE, the Engineer opens the 3M Biological Indicator Test Pack and removes <br /> the Biological Indicator Tube. The Engineer then closes the biological cap by pressing down. <br /> • The Engineer crushes the glass ampule in the designated crushing well built into the indicator. <br /> • The Engineer holds the biological indicator by the cap and taps the bottom of vial on <br /> countertop until growth media wets the spore strip at bottom of vial. <br /> • The Engineer places the biological indicator in the 3MTM AttestTM Auto-Reader well. (Do not <br /> remove the biological indicator once it is placed in the well. Otherwise, the test will be invalid.) <br /> • Close the cover and wait for results (at least 3 hours). <br /> HOW TO READ THE RESULTS <br /> • The Engineer(or designee) reads the results. <br /> • Negative Results (green light-): Indicates an acceptable sterilization process. Test results will <br /> be read after 3 hours. The Control Tube will always be Red (positive), and the sterilized tube <br /> SHOULD always be Green (negative). <br /> • Positive results (red light+): Indicates an unacceptable sterilization process. Control tube will <br /> ALWAYS be Red (positive), and the sterilized tube will be Red (positive). <br /> • In the event of a positive test result, the same load will be run only one additional time using a <br /> new 3M Biological Indicator Test Pack. After incubation, if the sterilized tube result is also <br /> positive, the Engineering Department will schedule repairs (internal or contact Sani-Pak), and <br /> this load and all untreated infectious waste will be placed in Stericycle Tubs for off-site waste <br /> treatment until the Sani-Pak is operational again. <br /> Reviewed by Nursing Department Approved by Facility P&P Committee Meeting 5/13/04 <br /> P:\MyDocs\QualityUoAnn\Pohcies\Updated Policies\Urgent-Emergent Triage 6.8 <br />