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Currerrt Stratus:Active, PolicyStM ID: 536373 <br /> Effective: 6/1/2012 <br /> Final Approved: 4/14/2014 <br /> Last Revised: 4/1/2013 <br /> Next Review: 4/13/2017 <br /> Sutter Health Owner: Heidi Ridenour:Environmental <br /> Sutter Tracy Community Hospital Svcs Mgr <br /> Policy Area: Environmental Services <br /> References: Infection Control <br /> Applicability: Sutter Tracy Community <br /> Hospital <br /> Biological tetftoofAmo Clave, L.S-81 -35-05 <br /> PURPOSE <br /> A. To assure the effectiveness of the sterilization process of biological waste. <br /> POLICY <br /> A. Sutter Tracy Community Hospital (STCH)Environmental Services will monitor the efficacy of sterilization <br /> of hospital biological waste. <br /> B. Biological testing of autoclave/sterilizers is part of the Environmental Services quality assurance <br /> measures of patient and environmental safety. <br /> C. A biological indicator test for Bacillus stearothermophilus shall be used one time per week to test the <br /> autoclave/sterilizer used to sterilize hospital biological waste. <br /> SCOPE <br /> A. Some biological waste is disposed of through Waste Management Healthcare Solutions, Inc., a <br /> contracted service;however;some of it is sterilized onsite in an autoclave unit managed by the <br /> Environmental Services department(EVS). <br /> B. Content of this policy is only applicable to medical waste that is process on hospital site. <br /> DEFINITION <br /> A. For the purpose of this policy, autoclave is defined as a device that sterilizes instruments or other objects <br /> using steam under pressure.The length of time required for sterilization depends on temperature, <br /> vacuum, and pressure. <br /> Note:Autoclave and sterilizer shall be used interchangeably in this policy. <br /> PROCEDURE <br /> A. Biological indicator test packs shall be used during initial installation testing of steam sterilizers and after <br /> any major repairs of the sterilizer. <br /> 1. Biological indicator testing is done once per week with the first load of biological waste of the day. <br /> 2. Place culture in a small box,tape box so that culture does not fall out. <br /> Biological Testing of Auto Clave,ES-81-35-05.Retrieved 12/27/2016.Official copy at http://sh-stch.policystat.com/policy/536373/. Page 1 of 2 <br /> Copyright C 2016 Sutter Tracy Community Hospital <br />