Mar 08, 2017 | 1536 Views

By Lisa Waldowski
Infection Control Specialist
Standards Interpretation Group

In 2016, 43% of ambulatory care centers, and 53% of office-based surgery settings surveyed by The Joint Commission had non-compliant findings associated with breaches in high-level disinfection (HLD) and/or sterilization processes.

Ambulatory settings are among the top group of Joint Commission accrediteds who are challenged with breaches in HLD and/or sterilization and it’s the number one threat to patient health and safety in these organizations.

Reviewing Risk Assessment
Keeping this in mind, it’s a good time to examine the reality of your organization’s risks when it comes to the HLD of endoscopes and/or probes or the sterilization of surgical or dental instruments.
If your ambulatory care organization owns devices/equipment that require reprocessing, are HLD/sterilization processes included within your Infection Prevention and Control activities?
If your answer is no, it’s probably a good time to re-visit square one.

Though developing a risk assessment process isn’t a linear activity, key elements include:

• Risk Identification (don’t forget to look at all surgical locations and procedures that involve HLD or sterilization)
• Goal creation
• Development and implementation of infection control plan
• Evaluation of plan

It’s a seemingly simple concept, but risk assessment drives absolutely everything in infection prevention and control!

Sterilization Specifics
Both HLD and sterilization processes require exact steps to be conducted each and every time. These steps are included in device/equipment/product manufacturer instructions for use, as well as evidence-based guidelines specific to HLD and sterilization.

But the sterilization and HLD breaches we’re increasingly hearing about in the news cannot be avoided by sitting at a desk writing policy. You will need to see the point-of-use, storage, etc. at your facilities first-hand, regardless of where they’re physically located, and well before your potential survey date.

For example, everyone knows endoscopes are difficult to clean, but a breach means your organization is not following HLD or sterilizations processes each and every time. You need to HLD or sterilize it the same way, each and every time to avoid potential harm to a patient.

In the accreditation manual, compliance with this standard falls under:

• IC.02.02.01 – The organization reduces the risk of infections associated with medical equipment, devices and supplies.
  • EP2 – Intermediate and high-level disinfectant and sterilization
  • EP4 – Storing medical equipment and supplies

Evidence-based guidelines drive our reprocessing process for sterilization and these include:

• Point-of-use (pre-clean)
• Cleaning
• Prep and pack
• Sterilization
• Storage

Similarly, the reprocessing process for HLD for endoscopes encompasses:

• Pre-clean at the point of use
• Leak testing
• Cleaning
• Rinsing
• HLD
• Rinsing
• Drying and storing

View this thorough presentation – from JCR’s 2016 Annual Ambulatory Care Conference – it’s an especially helpful tool for addressing HLD processes.

Frontline staff, supervisors, managers, and infection preventionists with oversight responsibilities (for signing-off frontline staff), need initial and on-going competency and training of HLD and sterilization processes, to include the products, devices, and equipment used. Regardless of their title, staff performing HLD/sterilization must be able to demonstrate those competencies, not just the human resources paperwork certifying they’ve been trained to do so.

As intimidating and time-consuming as this all sounds, Joint Commission provides a resource that outlines this work step-by-step, in a single source for healthcare organizations.

The Joint Commission developed a BoosterPak™ on HLD and sterilization, which may contribute to the identification and prevention of HLD and sterilization breaches as supported by evidence-based guidelines in ambulatory care and office-based surgery practices. The HLD and Sterilization Booster Pak™ provides specific content needed to understand and correctly interpret standard IC.02.02.01 EP2 with additional related standards.  The content is short, clear, and applicable for use with frontline staff, those with oversight responsibilities (managers/supervisors), and infection preventionists