Infection Control Audit of Disinfection/Sterilization Practices outside of Central Sterile Services

Abstract

ISSUE: Inadequacies in reprocessing medical devices in Canadian hospitals were recently brought to public attention. PROJECT: In December 2003, infection control practitioners at the University of Alberta Hospital (UAH) and Stollery Children's Hospital conducted an audit of disinfection and sterilization practices outside of Central Sterile Services (CSS). Ninety-five inpatient, clinic, and diagnostic areas were contacted. Processes of cleaning, disinfecting, and sterilizing critical and semi-critical items outside of CSS were documented and compared to Health Canada Infection Control Guidelines for Disinfection and Sterilization (1988). Areas were notified of any deficient practices, and recommendations for improvement were made in writing. RESULTS: Practices that did not comply with Health Canada Guidelines were identified in several outpatient and diagnostic areas. No inappropriate practices were identified in inpatient areas. No critical failures requiring patient look-back were identified. Noncompliant practices included: lack of indicator monitoring or less-than-recommended monitoring of stand-alone autoclaves, using water instead of detergent to clean equipment prior to disinfection, inadequate testing of the strength of chemical disinfectants prior to use, inadequacies in the frequency of changing chemical disinfectants, and handwashing feeding utensils. Resolution of these practices included: redirecting equipment processing to CSS and purchasing additional equipment to reduce problems in turn around time, replacing manual disinfection with automated processes, and modifying procedures for chemical disinfectants. LESSONS LEARNED: This audit demonstrated a high frequency of disinfection and sterilization occurring outside of CSS and the importance of documenting practice in order to detect and correct deviations from established guidelines. Adherence to guidelines reduces the potential for patient and staff exposure to infectious hazards and decreases the hospital's risk of adverse publicity and/or legal liability.