Thinking Outside the Box: Development of an Audit Tool to Track Reusable Instruments Outside of SPD

Abstract

<h3>Background</h3> Infection Control (IC) standard IC.02.02.01 is the most common finding by The Joint Commission (TJC). The primary focus for proper implementation of this standard has historically been the Sterile Processing Department (SPD) and endoscopy lab. This study, however, focuses on bedside staff's implementation of IC.02.02.01 by deploying an internally developed audit tool to quantify knowledge and compliance with safe instrument transport. <h3>Methods</h3> Meetings with SPD were held to ascertain the list of departments utilizing instrumentation undergoing HLD or sterilization. Infection Prevention (IP) developed a nine-question audit tool to measure elements of guidelines from the Association for the Advancement of Medical Instrumentation (AAMI), the Association of periOperative Registered Nurses (AORN), and the Occupational Safety and Health Administration (OSHA). A rating for each question of ‘Yes,' ‘No,' or ‘Not Applicable' and one open-ended question of ‘Other findings' was included. An IP and a member of SPD leadership visited each department. The standardized monitoring tool was completed, and recommendations on practice changes were communicated. <h3>Results</h3> Twenty-three patient care areas were identified as receiving reusable instrumentation from SPD. Each area was evaluated using the audit tool, and no area was found to be 100% compliant. The most often cited non-compliant measures were: (1) staff not wearing appropriate personal protective equipment and (2) compliance with moistening and removing gross soil at the point of use. <h3>Conclusions</h3> Decentralized hospital departments working with reusable instrumentation are sometimes forgotten when educating on the importance of standard IC.02.02.01. After auditing the end user in this study, IP determined that more education on bloodborne pathogen exposure and the importance of precleaning at point of use are needed. Routine compliance monitoring with a standardized tool is helpful to quickly find staff knowledge gaps and address issues.