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SUBJECT: Spore testing procedure for San -I -Pak <br />PURPOSE: To ensure the appropriate sterilizing of medical waste <br />RESPONSIBILITY: Designated Kaiser Permanente EVS staff (operator) will be responsible for <br />conducting the spore test and Lab staff will be responsible for running and <br />documenting the results. <br />EQUIPMENT: The 3M 1276 Attest Steam Pack, heat tempered gloves, safety goggles or <br />shield <br />PROCEDURE: Open the sterilizer chamber door and load the chamber with a normal waste <br />load. Place the 3M 1276 Attest Steam Pack in the center of the load. <br />Close the sterilizer chamber door and insert the sterilizer key into the lock. <br />Them make a 3/4 turn of the key to the right and push the key one time. (This <br />action will disengage the automatic discharge sequence making for easier <br />retrieval of the test kit.) <br />Upon completion of the sterilization cycle, a blue light on the control panel <br />will begin to flash. Open the sterilizer door and retrieve the 3M 1276 Attest <br />Steam Pack and then close the sterilizer chamber door. Re-insert the sterilizer <br />key into the lock, make a 3/4 turn of the key to the right and push the key one <br />time. This action will complete the automatic discharge of the waste inside the <br />sterilizer chamber. <br />After removal from the San -I -Pak, the biological indicators contained within <br />the 3M 1276 Attest Steam Pack should be taken to the Laboratory for <br />incubation. <br />The Laboratory is responsible for completing the spore testing and <br />documenting on the `Biological Indicator Test Form" (Attachment A). If the <br />spore test is positive, the Laboratory is responsible for immediately contacting <br />the EVS manager. The EVS staff is then responsible for repeating the spore <br />testing process. <br />All tests shall be documented and placed in the Biological Indicator Binder in <br />the EVS manager's office. <br />The spore testing process should be repeated at least monthly. <br />EMERGENCY If unable to achieve a negative spore test result after two consecutive attempts, <br />ACTION PLAN Engineering will be contacted. <br />