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a <br />a <br />Kaiser Permanente Stockton <br />Environmental Services <br />KAISER PFJ211AANENTE FACILITY POLICY AND PROCEDURE <br />TITLE: 3M TM Attest Biological Indicator Sterile <br />Approval Date: 5/13/04 <br />Processing Policy and Procedure <br />Approving Committee: Facilities P&P <br />1) ATTACHMENTS: None <br />SUBJECT: SANI-PAK SPORE TESTING <br />ORGINAL DATE: 5/13/04 <br />LAST REVIEW DATE: <br />REVIEW INTERVAL: Every Three years/As Needed <br />Basis <br />NEXT REVIEW DATE: <br />LAST REVISED DATE: 7/29/04,07/05/06 <br />Incubation and Readout Procedure using the 3MTM AttestTM Auto -Reader: <br />• While wearing PPE, the Sani-Pak Operator opens the 3M Biological Indicator Test Pack and <br />removes the Biological Indicator Tube. The Sani-Pak Operator then closes the biological cap by <br />pressing down. <br />• The Sani-Pak Operator crushes the glass ampule in the designated crushing well built into the <br />indicator. <br />• The Sani-Pak Operator holds the biological indicator by the cap and taps the bottom of vial on <br />countertop until growth media wets the spore strip at bottom of vial. <br />• The Sani-Pak Operator places the biological indicator in the 3MTM AttestTM Auto -Reader well. <br />(Do not remove the biological indicator once it is placed in the well. Otherwise, the test will be <br />invalid.) <br />• Close the cover and wait for results (at least 3 hours). <br />HOW TO READ THE RESULTS <br />• The Environmental Services Manager (or designee) reads the results. <br />Negative Results (green light -): Indicates an acceptable sterilization process. Test results will <br />be read after 3 hours. The Control Tube will always be Red (positive), and the sterilized tube <br />should always be Green (negative). <br />Positive results (red light +): Indicates an unacceptable sterilization process. Control tube will <br />ALWAYS be Red (positive), and the sterilized tube will be Red (positive). <br />• In the event of a positive test result, the same load will be run using a new 3M Biological <br />Indicator Test Pack. After incubation, if the sterilized tube result is also positive, the Engineering <br />Department will be contacted for repairs, and this load and all untreated infectious waste will be <br />placed in Stericycle Tubs for off-site waste treatment until the Sani-Pak is operational again. <br />Reviewed by Nursing Department Approved by Facility P&P Committee Meeting 5/13/04 <br />P:\MyDocs\QuahtyUoAnn\Policies\Updated Policies\Urgent-Emergent Triage 6.8 <br />