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I. Policy To ensure the efficacy of sterilization monitoring of hospital biological waste on Hospital site. Biological testing of auto clave/ sterilizer is part of the Environmental Services quality assurance measure of patient and environment Safety. II. Purpose A. To assure the effectiveness of the sterilization process of biological waste. III. Applicability A. Some biological waste is disposed of through Stericycle; however some of it is sterilized onsite in an autoclave unit managed by Environmental Services department. Content of this policy is only applicable to medical waste that is process on hospital site. B. In keeping with California Health and Safety Code: Section 117600-118360, Pg. 38 Which states that "Recording or indicating thermometers shall be checked out during each complete cycle to ensure the attainment of 121 * Centigrade (250* Fahrenheit) for at least one-half hour, depending on the quantity and density of the load, to achieve sterilization of the entire load. Thermometers shall be checked for calibration annually by an approved vendor. Records of the calibration checks shall be maintained as part of the facility's files and records for a period of three years or for the period specified in the regulations." Definition For the purpose of this policy, autoclave is defined as a device that sterilizes instruments or other objects using steam under pressure. The length of time required for sterilization depends on temperature, vacuum, and pressure. Note that autoclave and sterilizer shall be use interchangeable in this policy. Biological indicator test for Environmental Services shall be used routinely one time per week to test for Bacillus stearotherrnophilus Procedure Biological indicator test packs shall be used during initial installation Of testing of steam sterilizers and after any major repairs of the sterilizer and shall be recorded as a "test". Sutter Tracy CommunityHospital Environmental Services POLICY AND PROCEDURE Index No: ES 81.03.00-B Title: Biological Testing of Medical Waste Auto clave Submitted By: Hawa Suah, Manager, Environmental Services Department Approved By: Date Adopted: Date Reviewed: 11/20/10 Date Revised: 11/19/10 I. Policy To ensure the efficacy of sterilization monitoring of hospital biological waste on Hospital site. Biological testing of auto clave/ sterilizer is part of the Environmental Services quality assurance measure of patient and environment Safety. II. Purpose A. To assure the effectiveness of the sterilization process of biological waste. III. Applicability A. Some biological waste is disposed of through Stericycle; however some of it is sterilized onsite in an autoclave unit managed by Environmental Services department. Content of this policy is only applicable to medical waste that is process on hospital site. B. In keeping with California Health and Safety Code: Section 117600-118360, Pg. 38 Which states that "Recording or indicating thermometers shall be checked out during each complete cycle to ensure the attainment of 121 * Centigrade (250* Fahrenheit) for at least one-half hour, depending on the quantity and density of the load, to achieve sterilization of the entire load. Thermometers shall be checked for calibration annually by an approved vendor. Records of the calibration checks shall be maintained as part of the facility's files and records for a period of three years or for the period specified in the regulations." Definition For the purpose of this policy, autoclave is defined as a device that sterilizes instruments or other objects using steam under pressure. The length of time required for sterilization depends on temperature, vacuum, and pressure. Note that autoclave and sterilizer shall be use interchangeable in this policy. Biological indicator test for Environmental Services shall be used routinely one time per week to test for Bacillus stearotherrnophilus Procedure Biological indicator test packs shall be used during initial installation Of testing of steam sterilizers and after any major repairs of the sterilizer and shall be recorded as a "test".