Celebrate National Healthcare Central Service & Sterile Processing Week!

Transcription

1 M Sterile U Network 3M Sterile U Web Meeting October 13, 2011 A Panel Discussion with Infection Prevention and CSSD Leaders 1 Today s meeting times: 9:00 a.m., 11:00 a.m. and 1:00 p.m. CST Celebrate National Healthcare Central Service & Sterile Processing Week! Thank you for all your hard work! Thank you for making a difference in patient care! 2 Welcome! Topic: Ask the Experts! A Panel Discussion with IP and CSSD Leaders Facilitators: Diane Koch, 3M Susan Flynn, 3M Housekeeping Questions Mute feature (*7 = unmute; *6 = mute) Chat feature Technical difficulties Post session follow-up For more information: 3

2 3M Sterile U Webinar /13/2011 How do I get a CE Certificate? Next week, all of today s meeting participants will be sent an containing instructions for obtaining a CE Certificate for today s meeting. The will be sent to the address you provided when you logged-in to today s meeting. If there are others listening with you today who did not log-on, you may forward the CE certificate to them. 4 Learning Objectives Discuss development of competencies for CSSD personnel. Discuss the use of AAMI standards in the development of CSSD policies and procedures Review the role of CSSD in your facility s Infection Prevention strategies. 5 Meet the Expert Panel Sue Klacik, CRCST, CHL, FCS, ACE CSS Manager St. Elizabeth Health Center Youngstown, Ohio Joe LeBouef RST, CST, CRCST Regional Sterile Processing Educator Kaiser Foundation Health Plan of the Northwest Clackamas OR USA 6 Boyd Wilson MT(ASCP), MS, CIC System Director Infection Prevention & Control/Epidemiology HealthEast Care System St Paul, Minnesota, USA

3 3M Sterile U Webinar /13/2011 Boyd Wilson, MT(ASCP), MS, CIC 7 3M All rights reserved. HOT TOPICS 8 Patient Safety Surgical Site Infection Prevention Process Monitoring Cleaning Instrument Assembly/Packaging High Level Disinfection Sterilization Immediate Use Steam Sterilization ( Flash ) Wraps, Packs, Trays and Containers Supply Storage and Transport Minimize risk for infection outside of the OR Continuum of Care Hospitals, Clinical Departments, Outpatient Clinics, Ambulatory Surgery Centers, Dental Clinics... 9

4 3M Sterile U Wbinar /13/2011 Worker Safety OSHA (Federal and state) AWAIR Program (Minnesota) Bloodborne Pathogens Sharps Safety Personal Protective Equipment Hazardous Materials Ventilation/Air Quality Ergonomics Education and Training - For CS/SPD - For Infection Prevention & Control 10 Regulatory/Accreditation Compliance State Rules and Regulations Federal Standards and Compliance Directives OSHA FDA EPA The Joint Commission CMS 11 The Joint Commission 2012 National Patient Safety Goals NPSG Implement evidence-based practices for preventing surgical site infections Accreditation Standards Infection Prevention and Control IC EP1: The hospital implements infection prevention and control activities iti when doing the following: Cleaning and performing low-level disinfection of medical equipment, devices, and supplies. EP2: The hospital implements infection prevention and control activities when doing the following: Performing intermediate and high-level disinfection and sterilization of medical equipment, devices, and supplies. EP4: The hospital implements infection prevention and control activities when doing the following: Storing medical equipment, devices, and supplies 12

5 3M Sterile U Webinar CMS Hospital Conditions of Participation (CoP) Infection Control Interpretive Guideline Surgery-related infection risk mitigation measures: Addressing aseptic technique practices used in surgery and invasive procedures performed outside the operating room, including sterilization of instruments; Requiring disinfectants, antiseptics, and germicides to be used in accordance with the manufacturers' instructions; Ambulatory Surgery Centers (ASC) Condition for Coverage Infection control Infection Control Surveyor Worksheet Organizational Resources: APIC (Association for Professionals in Infection Control & Epidemiology), ASC Quality Collaboration 13 Evidence-Based Best Practices Guidelines Implementation APIC/SHEA/IDSA AAMI AORN ASHRAE CDC FGI SGNA 14 Problem Identification and Resolution Recalls Internal External System Failures Utility Disruptions/Construction/Renovation Policy/Procedure Breaches Environmental Rounding Sentinel Events/Root Cause Analysis Outpatient Sterilization Practices Difficult to Kill Micro-organisms Difficult to Process Instruments 15

6 3M Sterile U Webinar Partners in Infection Prevention Collaboration and Communication Regular Meetings Department Tours Committee/Work Group SPD Advisory Materials Value Analysis Infection Prevention Patient Safety Risk Management Quality Council 16 The use of AAMI standards in the development of CSSD policies and procedures Sue Klacik, CRCST, CHL, FCS, ACE 17 3M 3M All All rights reserved. Standards Development The Standards result from strong input from industry and the professions, FDA manufacturers users of the technologies Standards are incorporated by reference in regulations. For this reason, the standards must be relevant to the current state of technology. 18

7 3M Sterile U Webinar AAMI Standards for CSSD ST 79 Comprehensive Guide to Steam Sterilization Assurance in Health Care Facilities ST 41 Ethylene Oxide sterilization hospital practices WG ST58 Chemical Sterilization and High-Level Disinfection in Health Care Facilities 19 Standards & Recommended Practices The Joint Commission Court of law 20 Guidance provided on: Department layout Education of CSSD Staff Attire Decontamination processes Assembly &Packaging Disinfection or Sterilization Quality Control Storage Annexes 21

8 3M Sterile U Webinar ReprintedfromANSI/AAMIST79:2010&A1:2010withpermissionofAssociationfortheAdvancementof 22 MedicalInstrumentation,Inc.(C)2010AAMIwww.aami.org.Allrightsreserved.Furtherreproductionor distribution prohibited. Cleaning & Decontamination 23 Assembly & Packaging 24

9 3M Sterile U Webinar Disinfection or Sterilization 25 Quality Control 26 Storage 27

10 3M Sterile U Webinar Annexes Workplace Design Infection Transmission CJD processing User verification Chemical disinfectants Thermal disinfection Return of devices to manufacturer OSHA Bloodborne pathogens Prepurchase evaluation Heat up of containers Development of 16 towel PCD Steam quality TASS Bibliography 28 Policy Review Hospital and departmental policies are periodically reviewed and updated. During the review, the AAMI documents are checked to assure the processes in CSSD are still within AAMI Standards 29 Reference AAMI Standards Policy Scrub uniforms worn in CSSD shall consist of attire which are provided and laundered by the hospital. Employees are to change in the approved locker area and are to discard their scrubs in this area. Head coverings shall be worn by all persons in the CSSD area. Head coverings must enclose all hair at all times Reference: AAMI ANSI/AAMI ST79:2010 Comprehensive guide to steam sterilization and sterility assurance in health care facilities Section Attire, General considerations 30

11 3M Sterile U Webinar Joe LeBouef RST, CST, CRCST 31 3M All rights reserved. Rationale The Joint Commission expects initial and ongoing verification of staff skills in regard to performing required tasks AAMI recommends annual verification Mostly, maintaining current and relevant staff competencies gives you a better understanding of the actual skill level of your staff at a given point in time 32 Where to Start? List all major and/or technical tasks performed List the critical steps required to successfully complete those tasks 33

12 3M Sterile U Webinar Self-assessment Can serve as a starting point for verifying competency Staff attest to whether they have performed the required steps/tasks before, and whether or not they feel comfortable/competent performing said steps/tasks 34 Action Plan Can simply be derived from the self-assessment, or may be edited at managements discretion Could look like: Never performed before: fully train, then practice, then verify competency Performed before, but not fully competent/comfortable: practice, then verify Performed before and fully competent/comfortable: simply verify 35 Verification Should be performed via return demonstration Signature/initials of both Preceptor & Preceptee State mode of verification (simulation vs. actual work) 36

13 3M Sterile U Webinar Tips Review most current regulations/industry standards prior to creating or updating Ensure competencies match policies/procedures Decide up front how much detail to include If the competencies include considerable detail, they will likely need to be updated whenever steps performed change. However, enough detail must be included to realistically assess staff performance 37 Ask the Experts! 38 3M All rights reserved. Chat your questions, or To ask verbally, press *7 on your telephone 45 3M All rights reserved.

14 3M Sterile U Webinar Thank you! Next 3M Sterile U Web Meeting November 17, 2011 Flexible Endoscopes: Monitoring the Efficacy of Manual Cleaning Register at 46 References Association for the Advancement of Medical Instrumentation (AAMI) Comprehensive guide to steam sterilization and sterility assurance in health care facilities, ANSI/AAMI ST79:2010 & A1:2010 (Consolidated Text) Note: AAMI documents can be purchased through AAMI by credit card using the following four options: Internet: Call: Fax: Mail: AAMI Publications, P.O. Box 0211, Annapolis Junction, MD