Special Edition on Sterile Processing Imperatives Special Edition- Sterile Processing Imperatives | Page 29

sign for case-cart transport to decontamination along with
a competency process.
Let’s also talk about how we maintain quality and
develop an audit process with reporting capabilities, along
with instructions and signs to explain the process. More
importantly, tying all this together with consistent language
and correct wording that all can follow. We also must
determine who will be involved with audits and if there is
a system to track them that is readily available with ease of
reporting and follow-up.
The infection prevention department must be involved
and will need to complete scheduled audits, as will the OR
and SPD leadership. We cannot simply implement such
an important process without a functional and sustainable
audit procedure.
Every hospital’s SPD should have a point-of-use policy
with a competency component that explains what the
precise process is, to include biohazard instrument transport
containers, use of open or closed case carts, and use of wet
towels. Today, we also need to include any and all users of
surgical instruments that are processed by a central sterile
processing department.
We are talking about five to six documents that
support the process, along with signage and 17 or more
definable elements:
1. Point-of-use policy
2. Point-of-use biohazard sign/audit form
3. A sterilization request form
4. Point-of-use audit and tracking form
5. Competency completed annually
6. Signage: point-of-use directions with pictures

Elements of the policy and related documents:
1.
2.
3.
4.
5.
6.
7.
8.

9.

10.

11.

12.

13.

14.
15.
16.
17.
Purpose
Population
Definitions
Policy statements
Procedure
Special notes for use of moisture and wet towels
Transport containers type used and how
Competency/education which includes the
OR, pertinent hospital departments, clinics
and ASCs
Quality/auditing: how this is completed
and reported
Computer-based tracking system: Hospital
event tracker or SPD-based instrument
tracking system
Define vendor and loaner instruments: What
is allowed by vendors
Forms used and why – sterilization request
form for facility and vendor
Operational considerations: Transport contain
er management policy
Glossary
References
Keywords for systems look-up
Examples of signs and forms
Click here to view
Red Sheet Audit Form
All of this, plus training material that addresses using
transport spray and how a wet towel is used to maintain
humidity for delayed deliveries, should be available to OR
and SPD personnel.
There is an example from AORN of a point-of-use policy
and competency that helps get this started; however, it must
model what your facility or health system currently does
and combine the aforementioned elements. Regarding the
question of how often should a point-of-use competency
policy be reviewed, the answer is, annually and to anyone
utilizing surgical instruments processed by the SPD.
Consider that every case cart coming from the OR to the
decontamination area of the SPD must include a biohazard
sign or device that identifies what’s in the cart. An 8x10
red-colored paper with a printed biohazard symbol developed
with audit form that is initiated by the scrub tech and RN
circulator post-op with final signoff for approval by the SPD
provides the tool used to track the process in real time. We
will call this the red sheet audit tool.
Containers used by all other hospital-supported areas — to
include any offsite clinics and other services — must use an
opaque, red-colored container that is sealable/lockable with a
biohazard symbol on the lid. Some will ask, why an opaque,
red container? The answer is, we do not want transporters
or the general public to see what’s inside; these containers
are readily available with locking lids and biohazard symbols
in sizes to meet all needs.
Who “owns” and maintains the red biohazard containers?
The SPD should maintain one to two standard sizes so that
they are managed and disinfected correctly. Allowing clear
plastic bins that are not washable or sterilizable opens the
door to a number of issues that you do not want to explain
during an accreditation survey or state audit.
A sterilization request form should be developed and
used by all outside services that are sending containers of
instruments to the SPD as a tracking form. In larger systems,
SPDs receive instruments without knowing who to contact
for pick-up or there ends up being a discrepancy in what
was delivered and returned. This form eliminates that when
develop as a two-part form. The form can also include a
point-of-use audit to keep users aware of the process.
A red sheet audit form/tool would be designed for
tracking compliance and can be built in a computer-based
SPD instrument tracking or hospital event tracking system.
The audit form/tool is divided into two parts, audit of the
OR process on the top and audit by the person in decon-
tamination receiving the case cart on the bottom.
There is also the possible need for tracking within
ASCs, as they play an equally important role in the process.
ASCs connected to a hospital will use closed case carts to
www.healthcarehygienemagazine.com • Sterile Processing Imperatives 2020
29