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POLICY: Evidence of an effective sterilization process will be documented. <br />Rationale: In compliance with the Medical Waste Management Act, and California State and County <br />regulations, this process ensures that monthly biological indicator testing of treated medical waste <br />occurs to ensure that medical waste treated on-site is rendered non-infectious. All Engineering <br />Personnel will follow this procedure for sterilizing, incubating and reading of biological indicators. <br />THIS PROCEDURE WILL BE PERFORMED MONTHLY ON THE 20TH OF EACH <br />MONTH, OR ON THE 18TH OR 19TH IF THE 20TH FALLS ON A WEEKEND OR <br />HOLIDAY. <br />PROCEDURE: <br />1. The Sanipak Spore Testing Checklist will be filled out as each step is completed, and will be <br />submitted to the Chief Engineer for review and signature. <br />2. The 3MTM AttestTM Auto -reader is housed in the Laboratory Microbiology Section. Always leave <br />the 3MTM AttestTM Auto -reader plugged in. If found unplugged, allow 30 minutes warm up time. <br />3. Utilize Biological Indicator 1296 Rapid Readout tubes. Tubes will be discarded as medical <br />waste 30 days prior to the expiration date, new tubes will be ordered. <br />4. Always wear Personal Protective Equipment (PPE), when operating the machine. <br />• Safety Goggles <br />• Heat Resistant Gloves <br />5. The Chief Engineer verifies the 3M Biological Indicator Test Pack and the Control Spore Tube <br />are from the same manufacturer. The date and the lot number for each 3M Biological Indicator <br />Test Pack and Control Spore Tube are verified prior to giving the 3M Biological Indicator Test <br />Pack to the Engineer who will autoclave the 3M Biological Indicator Test Pack with the <br />Reviewed by Nursing Department Approved by Facility P&P Cotrnnittee Meeting 5/13/04 <br />P:\MyDoes\Quality\JoAnn\Policies\Updated Policies\Urgent-Etnergent Triage 6.8 <br />5^ <br />Kaiser Permanente Stockton <br />Environmental Services <br />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: SANT-PAK SPORE TESTING <br />ORGINAL DATE: 5/13/04 <br />ST 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, 07/20/06 <br />POLICY: Evidence of an effective sterilization process will be documented. <br />Rationale: In compliance with the Medical Waste Management Act, and California State and County <br />regulations, this process ensures that monthly biological indicator testing of treated medical waste <br />occurs to ensure that medical waste treated on-site is rendered non-infectious. All Engineering <br />Personnel will follow this procedure for sterilizing, incubating and reading of biological indicators. <br />THIS PROCEDURE WILL BE PERFORMED MONTHLY ON THE 20TH OF EACH <br />MONTH, OR ON THE 18TH OR 19TH IF THE 20TH FALLS ON A WEEKEND OR <br />HOLIDAY. <br />PROCEDURE: <br />1. The Sanipak Spore Testing Checklist will be filled out as each step is completed, and will be <br />submitted to the Chief Engineer for review and signature. <br />2. The 3MTM AttestTM Auto -reader is housed in the Laboratory Microbiology Section. Always leave <br />the 3MTM AttestTM Auto -reader plugged in. If found unplugged, allow 30 minutes warm up time. <br />3. Utilize Biological Indicator 1296 Rapid Readout tubes. Tubes will be discarded as medical <br />waste 30 days prior to the expiration date, new tubes will be ordered. <br />4. Always wear Personal Protective Equipment (PPE), when operating the machine. <br />• Safety Goggles <br />• Heat Resistant Gloves <br />5. The Chief Engineer verifies the 3M Biological Indicator Test Pack and the Control Spore Tube <br />are from the same manufacturer. The date and the lot number for each 3M Biological Indicator <br />Test Pack and Control Spore Tube are verified prior to giving the 3M Biological Indicator Test <br />Pack to the Engineer who will autoclave the 3M Biological Indicator Test Pack with the <br />Reviewed by Nursing Department Approved by Facility P&P Cotrnnittee Meeting 5/13/04 <br />P:\MyDoes\Quality\JoAnn\Policies\Updated Policies\Urgent-Etnergent Triage 6.8 <br />5^ <br />