Flash Sterilization Index Number: OR-0120 Type - Gundersen ...

Flash Sterilization
http://glapps.gundluth.org/apps/policyproc.nsf/bc0155f9ef62e4fd872567dd005e9b5a/00ec7...
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1/5/2009
14. Circulator and Scrub Tech using flash sterilized instruments are responsible for filling out
sterilization logbook.
Note: If the steam chemical integrator has not adequately changed, or if any of the
sterilization parameters have not been met:
• Do not use instruments from the load in question.
• Refer to Gundersen Lutheran policy GL-9705 Sterilization and Sterility
Assurance for appropriate actions.
• Report situation to:
1. Surgery Support Tech
2. Charge Nurse
3. Infection Control
4. Hospital maintenance B#0040 if needed
• Take the instruments back to the dirty workroom and re-clean the instruments.
• Use another autoclave to re-sterilize the load if necessary.
• Circle "not used" in the logbook and fill out adverse event reported to
documentation and incident report.
• If necessary, take the autoclave out of service.
Flash sterilization for Implants
Follow the steps as for non-implants (above) with the following additions:
1. Add an Attest Rapid Readout Biological indicator to the load in addition to the steam
chemical integrators.
2. Use a 10-minute sterilization cycle for all implant loads.
3. When removing the biological from the load, allow the biological to cool for 5 minutes.
Page Surgery Support Tech or Charge Nurse to incubate biological indicator.
4. Write operating room number on biological indicator.
5. "Close, Crush, and Tap" the biological indicator.
6. Place vial into incubator well.
7. Document in 3M logbook for biological indicator in and out time, initials, Mfg. Lot No, and
results. Refer to Gundersen Lutheran SOP CS-8715 Sterilization Monitor and Control.
8. Monitor Biological Indicator for proper readout results. According to the 3M Attest 290
Auto-reader, the final negative readout determination is made in one (1) hour. Scrub Tech
places implant off to the side of sterile field until the BI results are known.
9. Document results in sterilization logbook and place load sticker on patient’s preference
card.
10. Discard biological indicator in regular garbage after use.
11. Fill out Premature Release of Implant Form any time implants are flash sterilized. Make a
copy of the form to send to Infection Control and place the original release form in back of
the sterilization logbook.
12. Biological control is done daily by Surgery Support Tech.
Note: If the Biological Indicator is Positive:
• Do Not use implants and instruments from the load in question.
• Refer to Gundersen Lutheran policy GL-9705 Sterilization and Sterility
Assurance for appropriate actions.
• Place a sign on the autoclave indicating the sterilizer is "Out of Order"