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Current Status:Active PolicyStat ID: 3185906 <br /> Origination: 61112012 <br /> Effective: 211012017 <br /> Final Approved: 211012017 <br /> Last Revised: 211012017 <br /> Next Review: 211012020 <br /> Sutter Health <br /> Owner: Dawn Kent:Mgr, Environmental <br /> Sutter Tracy Community Hospital Svcs <br /> Policy Area: Environmental Services <br /> References: Infection Control <br /> Applicability: Sutter Tracy Community <br /> Hospital <br /> Biological T esting of Autoclave/Sterlifizer r <br /> 00 <br /> ffiolog'cal Was <br /> , ES-81 -35-05 <br /> , PURPOSE <br /> A. To assure the effectiveness of the sterilization process of biological waste and reduce the possibility that <br /> items will be processed under suboptimal conditions. <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 alltoclavelsterilizers 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 processed on hospital site. <br /> DEFINITION <br /> A. For the purpose of this policy, autoclave is defined as a device that sterilizes biological waste using <br /> steam under pressure. The length of time required for sterilization depends on temperature, vacuum, and <br /> pressure. <br /> Note: Autoclave and sterilizer shall be used interchangeably in this policy. <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 /> Biological Testing of Autoclave/Sterilizer(for Biological Waste),ES-81-35-05.Retrieved 12/21/2018.Official copy at Page I of 3 <br /> http://sh-stch.policystat.com/policy/3185906/,Copyright 0 2018 Sutter Tracy Community Hospital <br />