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Lodi Memorial Hospital 8420-EC3-Section C2 Facilities Management 9 0 Page C-6 of 10 Environment of Care; Hazardous Materials and Wastes Management Revised: July, 2006 MEDICAL WASTE MANAGEMENT GUIDELINES SPECIAL INSTRUCTIONS WASTE TYPE The only material to be sterilized in this unit shall be that which is determined to be Biohazardous Waste as defined at the beginning of these guidelines 2. TRAINING Only employees in Facilities Management, including both Environmental Service and Maintenance divisions may perform operation of the waste sterilizer unit. a) All employees that are required to operate the waste sterilizer must be trained and oriented to the full operation of the unit prior to initiating any operational actions. b) Training will be provided and documented by Environmental Services Manager or designee. c) Training documentation will remain on file. 3. OPERATION Each load will run for a minimum of 30 minutes and be maintained at a temperature reading of 250 degrees F. a) The pressure gauge must hold at 40 -lbs. pressure while the unit is in operation. b) Chart readings must be clearly visible when processed or repeat completion of the cycle will occur after changing the marking pen. Not more than 1 cycle with pale markings will be accepted. c) Cycle must be allowed to cool to a temperature of 120 degrees F prior to opening the door. d) Full face shield, protective gown and rubber gloves must be worn by all operators when preparing or removing a load from the sterilizer unit. 4. REPLACEMENTS OF TEMEPATURE RECORDING CHARTS a) Replacement or 'new' charts will be obtained from the Facilities Management office at the time replacement is indicated. b) Following replacement, the filled or 'old' chart will immediately be given to Facilities Coordinator whether in person or by using the departments' office mail boxes. c) Each Monday, an Environmental Services technician prior to noon of that day will inspect the recording area of the chart. d) If the recording area of the chart is 1/2 or more filled, the technician will obtain a `new' chart and replace the 'old' one. e) If the recording area has more than 1/2 of the chart space free, then a notation will be made in the margin after the last run cycle showing the date, time, number of cycles already charted and initials of person who inspected the chart (example: 12/30/99 -11:00 AM - #7 - DM). f) During periods of high sterilizer processing, the recording area will be monitored more frequently (daily) to avoid filling the chart at night or on a weekend. g) Each Environmental Services technician authorized to service the sterilizer unit is responsible to monitor the fullness level of the recording chart prior to each operation regardless of the hour of the day. h) Should the chart become filled without appropriate monitoring, the Environmental Services