ROP SELF ASSESSMENT AND ACTION PLAN ACCREDITATION CANADA

Transcription

1 CLIENT SAFETY AREA: Infection Control ROP: Reprocessing (ROP: pg.63) WRH monitors its processes for reprocessing equipment, & makes improvements as appropriate. VP Champion: Rosemary Petrakos Leader: Barb Havens Guidelines: Team Members: Rosemary Petrakos; Barb Havens; Kathy Karkus; Julie Girard; Shannon Sampson; Jennifer Cameron; Jeff Richer; Daniella Dickens; Mayra Leal Perez; Marie Marchand; Stacey Dusik Reprocessing includes the processes for cleaning, disinfecting, and sterilizing, and the level of reprocessing used depends on the risk of infection associated ( do we have proof of this captured below?) with the use of medical devices/equipment (Spaulding classification). Monitoring their reprocessing processes helps organizations identify areas for improvement and reduce health care-associated infections. (Review Appendix to see if we missed any of these ) Examples of methods to measure the effectiveness of reprocessing include: monitoring water quality and washer function; and measuring organic residuals, adenosine triphosphate (ATP), and total viable count. Organizations reprocess equipment according to manufacturers instructions. (Do we have proof of this captured below?) ) If the organization does not reprocess equipment, it has a process to ensure equipment has been appropriately reprocessed prior to use. Tests for Compliance: Major 1. There is evidence that reprocessing processes & systems are effective. Minor 2. Action has been taken to examine & improve reprocessing processes where indicated. Status of ROP ROP Assessment & Evidence (2015) 1. There is evidence that reprocessing processes & systems are effective. See Appendix below which outlines decontamination, sterilization, storage & transporting processes & systems. 2. Action has been taken to examine & improve reprocessing processes where indicated. There are many monitoring tools which are used in real-time to make changes as needed. Also, many machines have alarms/alert systems if standardized processes are amiss (i.e. alarm sounds if temperature & times not met) Does not meet tests for compliance Examples of improvements: o Parasitic acid is being removed and replaced with hydrogen peroxide acid at Met (in trail) o o o Replacing archaic equipment with new technology (less room for error) Staff safety improvements: changes to PPE guidelines to ensure that staff are wearing the right equipment; work to ensure staff are eating in appropriate places (not dirty rooms); high/low sinks (both campuses); anti-fatigue mats; & electronic high/low working stations (already at Met, at Ouellette in March); Patient Safety & Flow: realigned staffing schedules to allow for higher numbers of staff at peak times; & all staff are required to be certified under CSAO Partial Meets tests for Compliance compliance Accreditation Milestone Dates: Establish Team, Self Assessment Completed, ROP Draft Action Plan to Accreditation Team: Jan 30 V.P. Review of Draft Action Plan: Feb 6 Work through action plan tasks: Feb-Oct, 2015 Page 1 of 6 Revised 3/30/2015

2 ROP Action Plan (2015) Date Tasks Timelines MRP Done 1. Generate and implement solutions to concerns surrounding the transportation of soiled instruments to MDRD at Met campus. 2. Update policies and documentation about reprocessing & sterilization processes. 3. Address flashing concerns at Ouellette & Met (Dental). (Note that Ouellette reported to Accreditation surveyors (2011) that flashing was being addressed. 4. Investigate & resolve concerns with physicians bringing in their own equipment (dental at Met) regarding flashing and the use of our equipment 5. Look into storing data on equipment electronically instead of taperolls. 6. Develop a process & job role assignment for the completion of Tosi Tests. 7. Replace three of the Endo machines. March 8. Build a new scope room for the new machines. 9. Review & address process & systems in: a. Eye (Investigate possible solutions to address performing clean and dirty processes in the same room). b. Cysto at WRO (Look at getting new instrumentation as there is currently a lack of needed instruments; i.e. three scopes should not be cleaned at a time. Also, implement best practices surrounding Cyto instruments by also sterilizing them). c. Bronch (investigate job responsibilities of Respiratory techs and relocate MDRD tasks to MDRD staff) d. Cath Lab (investigate the possibility to stop using a disposable bowl & start using syringes instead (to decrease the chance of contamination) 10. Complete implementation of electronic tracking system at WRO. 11. Tighten processes surrounding loaner equipment being returned Page 2 of 6 Revised 3/30/2015

3 within 48 hours. 12. (Nice to have) Lean/mapping session at Ouellette. 13. Send team the HDGH results from last assessment (2011) February Sherri done Future Actions (Actions to be done beyond Accreditation date) Indicators: Meeting of CSA standards (re: time, temperature, & method) Meeting recommended parameters from manufacturers (WRH has an electronic catalogue for every instrument/equipment; which is provided to staff as standard work) Monitoring Tools and Instruments: MDRD tapes record data (water temps, etc.) Job roles and responsibilities/standard work There are alarms on new machines on if the Tosi Test (to monitor and alerts if problems with MDRD equipment) Audit pre-cleaning process ATE Monitoring Lean Assessment completed (at Met 2 years ago) VP Review and approval of Action Plans: Decontame: APPENDIX Cleaning and Disinfecting Sinks, all sinks at Met Campus in the decontame area and in cysto clinic have built in Steris Acu-sinQ Enzymatic Dosing System 2 Temperature Monitor alerts when water temperature is out of range and holds steady when within range. Multiple Dosing Levels of ounces per gallon can be selected automatically computes how much run time is needed based on half or full sink volume setting. Easy to use start button initiates self-priming of enzymatic. Washer and Dryer (Miele) With automated feed detergent dispenser Sanitize cycle Pasteurmatic semi-critical items Page 3 of 6 Revised 3/30/2015

4 Washes and Pasteurizes Steris Automated Enzymatic dispensers 6-step wash cycle for thorough cleaning High-level disinfection through pasteurization by submersion in hot water at o C for 30 minutes. Print out must be validated by MDRD tech signature that all parameters have been meet, and hard copy added to daily record. Steris Vision Single Chamber Washer/Disinfector Integrated flow meters to ensure dosing accuracy. Racks are capable of lumen flushing. Immediate-level disinfection phase helps reduce the risk of infection for patients and staff. Instrument, Orthopaedic, utensil cycles Integrated cycle printer on clean side Provides cycle parameter verification Tosi tests need to create a process for staff Descaling of machine process for staff Steris Utensil Washer/ Disinfector Self-Priming Automatic Chemical Dispenser Descaling of machine process for staff Steam Autoclaves Leak test performed once a week on Sunday before the Bowie Dick test, the measure leak rate is printed out at the end of the run and should not be higher than 1mm Hg/min. A higher leak rate indicates a problem with the sterilizer. The record is signed by tech performing test and added to daily record. Met recorded electronically with Alex Gold. Bowie Dick Test is performed first load of the day a chemical indicator is located in the center of each pack. The test pack is placed directly into an otherwise empty steam sterilizer chamber. During processing, steam must displace the air through the barrier material within the pack. A uniform change from yellow to blue/purple on the indicator sheet indicates that all the air was removed and replaced by steam. The tech performing the test will validate results with signature, date, sterilizer number, and pass or fail and add to daily records. Met recorded electronically with Alex Gold. Biological Indicator Attest Test Packs Ouellette site this is performed on the first regular load of the day and for every load with a implantable device. Met site this is performed on every load and is electronically recorded in Alex Gold Page 4 of 6 Revised 3/30/2015

5 Biological indicators provide the best assurance of sterility by challenging the sterilizer with quantifiable, highly resistant spores. A non-autoclaved control is placed in incubator as a positive control for bacterial growth. This is performed at the beginning of the day or if a new box of attest are opened. This positive result and temperature of incubator is recorded in logbook The attest with matching lot# to control is placed in the autoclave in an area that provides the greatest challenge to the steam sterilization process. At the end of cycle the attest is removed and placed in the 56 o C incubator and incubator will read after 3 hrs. Results will be recorded in logbook and on attest. The mechanical parameters will also be read, signed by tech. Sterilizer number, date and time of sterilization, temperature of sterilization, total length of the sterilizing cycle, conditioning time, and sterilization cycle count. Steris system 1 A diagnostic cycle is performed daily, tech will sign recorded a pass. A control is placed in incubator weekly, and recorded with lot# and temperature of incubator. Biological is performed on the first load or daily, with a chemical indicator. Parameters are read, signed by tech. Temperature, Concentration, Exposure time, Fill time, cycle completed. Printouts are collected and added to daily records. All loads after first load have a chemical indicator add that verifies the minimum recommended concentration of Sterilant Concentrate use dilution has been met to achieve liquid chemical sterilization Sterrad Biological indicator completed once each day at first short cycle of the day. The cycle consists of these stages Vacuum stage, Diffusion stage, and Plasma stage. The cycle record is printed out at the end of the cycle. Cycle stages and times and process and monitors the critical cycle parameters and generates an error message if they are not met. All printouts are signed and logged by tech. Met site electronically added to Alex Gold. Cidex OPA Test Strips are performed daily provides a rapid measure of the minimum effective concentration required for high-level disinfection. All results are recorded in a logbook. The date the solution was poured, expired date of solution, test strip expire date and the medical device that was soaked. Safe step contamination monitoring system Is performed in Endo at the Ouellette site for auditing the scopes. Cath Lab Improvement Cath lab was using basin bowls with saline; WRH has switched to a disposable container. Page 5 of 6 Revised 3/30/2015

6 Future actions steps: To investigate the possibility to stop using a disposable bowl & start using syringes instead (to decrease the chance of contamination. Page 6 of 6 Revised 3/30/2015