ENDOSCOPE PROTEIN RESIDUE TESTING STANDARD OPERATING PROCEDURE

Transcription

1 ENDOSCOPE PROTEIN RESIDUE TESTING STANDARD OPERATING PROCEDURE Version Number V1 Date of Issue December 2017 Reference Number Review Interval Approved By Name: Seamus Hussey Title: Chairperson Endoscopy Committee Authorised By Name: Ann Marie McGuinness Title: Clinical Nurse Manager III Author/s Location of Copies EPRT MSRC-V1 3 yearly Signature: Date: December 2017 Signature: Date: December 2017 Name: Mary Scully Title: Clinical Nurse Manager II Name: Robert Conlon Title: Quality Improvement Facilitator On Hospital Intranet and locally in department Document Review History Review Date Reviewed By Signature 2020 Document Change History Change to Document Reason for Change

2 Date of Issue: December 2017 Page 2 of 5 CONTENTS Page Number 1.0 Introduction Definition of Standard Operating Procedure Applicable to Objectives of Standard Operating Procedure Definition of terms Procedure Implementation Plan Evaluation and Audit References 4

3 Date of Issue: December 2017 Page 3 of Introduction This SOP outlines the test for detection of protein residue in flexible endoscope channels. 2.0 Definition of Standard Operating Procedure SOP: The term Standard Operating Procedure is a way of carrying out a particular course of action and includes operations, investigations, pharmaceutical treatment, examinations and any other treatment carried out. 3.0 Applicable to This SOP is applicable to CNM2 and HCA staff in the Endoscopy Theatre washroom who carry out testing for protein residue in Endoscopes following the Automated Endoscope Reprocessor processing. 4.0 Objectives of Standard Operating Procedure To test for protein residue in channeled endoscopes to ensure that there are no microbiological contamination within the endoscopes after processing. 5.0 Definition / Terms Endo Swabs: Manufacturer Pyromol E 1.0, 1.4, 2.8, 3.8, 5.0 mm Channel size Protein Residue Test Swabs. 6.0 Procedure The following procedure is to be carried out on a sample basis once per week. Sample one type of scope and from week to week alternate the type of scope sampled 6.1 Moisten the Endo Swab tip with a drop of clean water. 6.2 Insert the Endo Swab into the channel to be tested and push it all the way through, once only. Do not force it down the channel. 6.3 Cut the Endo Swab 2cm behind the tip with a sterile scissors and place into the test vial, close the lid and let it stand for 5 minutes. 6.4 A colour change to blue - green on the Endo Swab indicates protein residue. Positive Results: If positive then inform the CNM2 and carry out the following of the affected Endoscope: Rewashed Reprocessed Water sampled Protein Test repeated Submitted to Quarantine

4 Date of Issue: December 2017 Page 4 of 5 Note: If still positive from the protein test OR there is a microbiology alert then contact Infection Control. Infection Control will decide if they require further repeat tests OR if the scope should be sent out for repair. Record all details of actions in the log. 6.5 Record the following main details in the log: date tested; pass / fail; endoscope type; barcode; serial no.; model no.; and size of Endo Swab used. (Note: 1 micro gram of protein residue on the Endo Swab will develop a small blue-green spot. A large amount of soluble protein can turn the whole test solution blue-green.) 6.6 Reprocess the scope after testing. 7.0 Implementation Plan The implementation of this SOP should be included as part of the Endoscopy HCA Competency Workbook. 8.0 Evaluation and Audit This processes in this SOP will form part of an overall audit to ensure compliance with the processing of endoscopes in Theatre. 9.0 References Health Services Execute (2010) Medical Devices / Equipment Management Policy (Incorporating the Medical Devices and Equipment Management Standard). Dublin: Health Service Executive. Health Service Executive (2010) Medical Devices / Equipment Management Compliance with the HSE s Medical Devices Standard. Guidance for Service Areas. Dublin: Heath Service Executive. Health Service Executive (2011) HSE Standards & Recommended Practices for Healthcare Records Management. Dublin: Health Service Executive. Health Service Executive (2011) Risk Management in the HSE: An Information Handbook. Dublin: Heath Service Executive. Health Service Executive (2013) National Consent Policy. Dublin: Health Service Executive Nursing & Midwifery Board of Ireland (2007) Guidance to Nurses and Midwives on Medication Management. Dublin: Nursing & Midwifery Board of Ireland. Nursing & Midwifery Board of Ireland (201) Code of Professional Conduct and Ethnics for Registered Nurses and Registered Midwives. Dublin: Nursing & Midwifery Board of Ireland. NMBI 2016 Recording Clinical Practice Nursing & Midwifery Board of Ireland (2015) Scope of Nursing and Midwifery Practice Framework. Dublin: Nursing & Midwifery Board of Ireland.

5 Date of Issue: December 2017 Page 5 of 5 Royal College of Physicians in Ireland / Health Service Executive (2014) Prevention of intravascular Catheter-related Infection in Ireland. Dublin: HSE Health Protection Surveillance Centre. Royal College of Physicians in Ireland / Health Service Executive (2015) Guidelines for hand hygiene in Ireland Healthcare settings: Update of 2005 guidelines. Dublin: HSE Health Protection Surveillance Centre. Nurses & Midwives Act (2011) Freedom of Information Act 2014, Government of Ireland. Medicinal Products (Prescription and Control of Supply) (Amendment) (No.2) Regulations 201 (S.I. No. 504/201) Copyright and Our Lady s Children s Hospital Crumlin, Dublin 12. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means without the prior written permission of the copyright holder. Every effort has been made to ensure that the information provided is accurate and in accord with standards accepted at the time of printing.