"Steam Sterilization Sheet Template - DOC"
2011 ORAL HEALTH STERILIZING ORIENTATION MANUAL TEMPLATE 1 The Oral Health Sterilizing Orientation Manual covers key areas which provide you with a basic knowledge and understanding of safe and effective practice within Queensland Health Oral Health facilities. The manual has been divided into the following parts. TABLE OF CONTENTS PART 1 Introduction 2.1. Overview of Sterilizing Services PART 2 2.2. Resources and Training 2.3. Self-Assessment 2.4. Standard Operating Procedures and Workplace Skills Assessment Sheet 2.5. Individual Learning Plan Information PART 3 Attachments 3.1. Sterilizing Services Orientation Checklist 3.2. Manual Handling in the CSD booklet 3.3. Standard Operating Procedures and Workplace Skills Assessments v2 March 2011 2 PART 1 v2 March 2011 3 Introduction Your mentor for the next three months of your sterilizing orientation program within the Oral Health Service (OHS) is INSERT NAME HERE, who will assist you during your induction phase within your facility. The Oral Health Sterilizing Orientation Manual has been developed for staff new to the instrument reprocessing environment. The manual is to be used in conjunction with the Queensland Health Orientation Program to assist new employees gain an understanding and develop a sense of belonging in their local work area. Oral Health Sterilizing Services Orientation Checklists have been included in part 3 for you and your mentor to work through. Once the orientation checklists are completed this information will be kept as part of your personnel file. The Oral Health sterilizing orientation program contains: The sterilizing services orientation manual An individual self assessment form An individual learning plan Other specific information relating to sterilizing in Oral Health Services v2 March 2011 4 - Recommended Resources The table below lists additional resources for you to reference. CHRISP website http://www.health.qld.gov.au/chrisp/default.asp Sterilizing Services in Oral Health http://www.health.qld.gov.au/chrisp/sterilising/oral_he Including supporting documents specifically for Oral Health services alth.asp CHRISP website section relating to http://www.health.qld.gov.au/chrisp/sterilising/overvie sterilizing services w.asp Queensland Health Disinfection and http://www.health.qld.gov.au/chrisp/ic_guidelines/cont Sterilization Infection Control Guidelines ents.asp QH Prevention and Control of Healthcare http://www.health.qld.gov.au/chrisp/policy_framework/ Associated Infection - Policy, Standards, overview.asp Protocols and Guidelines CHRISP Sterilizing Services Supporting http://www.health.qld.gov.au/chrisp/sterilising/sterile_s Documents upport.asp PRIME http://connect.health.qld.gov.au/prime/ Occupational Health and Safety http://qheps.health.qld.gov.au/safety/home.htm Manual Handling Information Booklet – http://qheps.health.qld.gov.au/safety/safety_topics/gui Central Sterilising Department des/Mhb_csd.pdf v2 March 2011 5 v2 March 2011 6 PART 2 v2 March 2011 7 2.1 Overview of Oral Health, Policy, Standards and Guidelines relating to reprocessing and sterilization. Within Queensland Health (QH), the Centre for Healthcare Related Infection Surveillance and Prevention (CHRISP) has the statewide responsibility for the Infection Prevention and Control program (including sterilizing). The CHRISP website has a number of resources to assist Oral Health Sterilizing Services staff in the course of their work, including, QH Disinfection and Sterilization Infection Control Guidelines, Easi- Sterilise® and the Policy, Standards, Protocols and Guidelines (http://www.health.qld.gov.au/chrisp/policy_framework/overview.asp) documents. Many associated documents and resources relating to cleaning, disinfection and sterilization of instruments and equipment are also available. To access the CHRISP website go to or click on the following link: http://www.health.qld.gov.au/chrisp CHRISP also plays an important role in representing the interests of sterilizing services on the relevant Australian Standards committees that relate to sterilizing practice: including: Australian/New Zealand Standard AS/NZS 4187:2003 ‘Cleaning, disinfecting and sterilizing reusable medical and surgical instruments and equipment, and maintenance of associated environments in health care facilities’ (AS4187); Australian/New Zealand Standard AS/NZS 4815:2006: ‘Office-based health care facilities - Reprocessing of reusable medical and surgical instruments and equipment, and maintenance of the associated environment’ (AS4815). Your role within INSERT FACILITY HERE Oral Health Service Staff undertaking sterilizing practices in Oral Health Services are responsible for preparation, reprocessing, storage and distribution of sterile dental instruments and equipment. The process of sterilization removes or destroys potentially infectious material on reusable devices. The sterilizing role is of vital importance in ensuring that reusable instruments are handled, cleaned, disinfected and sterilized appropriately thereby eliminating the risk of infection transmission to patients and staff. v2 March 2011 8 The Oral Health Environment Oral Heath Services are delivered in a number of types of facilities with varying types of instrument reprocessing areas, for example: fixed clinics with a single room instrument reprocessing area fixed clinics with 3 room sterilizing area mobile dental clinics with a separate sterilizing area Infection Prevention and Control The role of infection control is primarily to prevent healthcare associated infections. The ongoing use of the Easi-Sterilise Standard Operating Procedures (SOP) and Workplace Skills Assessments (WSA) is one way of ensuring safe practice and minimising the spread of infection to patients and staff. In your work area it is important to take care when handling instruments to prevent sustaining a sharps injury. Items that have been attributed to sharps injuries within a sterilizing service include but are not limited to: Blades that have not been removed and disposed at the point of generation, Dental needles and fine sharp instruments such as burs, scalers, and probes. One of the most important strategies to prevent injuries and occupational blood and body fluid exposures whilst working in the cleaning area is wearing appropriate personal protective equipment such as waterproof gowns/aprons, utility gloves, goggles and masks or face shields. Within the district there is an Infection Prevention and Control Practitioner who can be contacted by phone on INSERT PHONE NUMBER HERE or by paging INSERT PAGE NUMBER HERE. For further information about Infection Prevention and Control go to the following link via the District Intranet site: INSERT LINK HERE. v2 March 2011 9 Building Maintenance and Engineering Services (BEMS) This information may not be relevant to your facility – delete or modify to suit your facility. Within this facility BEMS personnel are responsible for steam and water supply to the large steam sterilizers, as well as the coordination of maintenance and repairs for all equipment, machinery. If any equipment in sterilization service fails a required test (e.g. large steam sterilizer fails the leak rate test). The failure is to be reported to your shift supervisor. The machine is to be placed out of order until reviewed by BEMS or by the service contractor. Biomedical Technical Services (BTS) Within each district there is access to Biomedical Technical Services (BTS). The scope of services provided by local BTS may vary. Within this district BTS is responsible for (please add or delete as required): Instrument and handpiece maintenance and repair Maintaining biomedical equipment Insert details of local servicing representative Occupational Health and Safety (OHS) Queensland Health is committed to providing a safe, supportive and healthy environment for its staff, volunteers and other persons at the workplace. Workplace incidents are to be reported to the local Occupational Health and Safety Unit (http://qheps.health.qld.gov.au/safety/communications/contact_us2.htm) as soon as possible following their occurrence. Within each facility there are Occupational Health and Safety Officers who can be contacted by phone on INSERT PHONE NUMBER HERE or by paging INSERT PAGE NUMBER HERE. As part of QH’s commitment to ensuring staff safety the Occupational Health and Safety Unit has developed a Manual Handling Booklet for Central Sterilizing Departments (CSD). This booklet is equally applicable for use in Oral Health facilities that undertake reprocessing activities. This booklet has been included in part 3 of this manual and will be discussed with you by your mentor. v2 March 2011 10 Patient Safety Officer Within each district there is a designated Patient Safety Officer who provides advice and resources to units/departments to assist manage patient incidents and implement strategies to prevent reoccurrence of incidents. CHRISP in consultation with the Patient Safety and Quality Improvement Service have developed a fact sheet to assist oral health staff report potential and actual patient incidents. Patient incidents are reported electronically on PRIME http://connect.health.qld.gov.au/prime/. Your mentor will assist you to organise PRIME incident reporting training during your three month orientation period. 2.2 Resources and Training When you commence working in your facility you will be orientated to the reprocessing and sterilizing processes in a planned and systematic manner. Your mentor will assist you by providing training and skills assessments as you move through each process. Your mentor will assist you to complete the requirements of the Queensland Health Orientation Program, the Standard Operating Procedures (SOP) and Workplace Skills Assessments (WSA). Each week your mentor will discuss and arrange for training and supervision within the reprocessing area. These discussions will include your education and training needs, workload and service expectations. v2 March 2011 11 CHRISP Resources In 2010, CHRISP developed in consultation with Oral Health Staff a set of Standard Operating Procedures and Workplace Skills Assessments. These resources are available on the CHRISP website at Sterilizing Services, Oral Health section (http://www.health.qld.gov.au/chrisp/sterilising/oral_health.asp). The Standard Operating Procedures (SOP) and Workplace Skills Assessments (WSA) have been developed in accordance with published guidelines and standards. They recognise the importance of the role of Oral Health staff performing sterilizing and assist them to perform their duties safely and efficiently. The Oral Health SOPs and WSAs provide a framework for the minimum set of standards required for sterilizing practice within Queensland Health Oral Health facilities. They are a key component in the ensuring that staff performing sterilizing tasks have the necessary skills, knowledge and experience to undertake the allocated activity, task or job. Copies of the Oral Health Easi-Sterilise SOPs and WSAs have been provided for you in part 3.3. You can also access the current version of these resources on line via the CHRISP website using the following link: http://www.health.qld.gov.au/chrisp/sterilising/oral_health.asp. The sections of the SOP and WSA modules included as part of the manual include: Cleaning Procedures Packaging and Wrapping Procedures Sterilizing Procedures Sterile Storage Area Procedures Quality Assurance A Standard Operating Procedure & Workplace Skills Assessment Checklist has been designed to assist you, your mentor and your line manager to determine which SOPs and WSA need to be undertaken during your 3 month orientation period. On completion, this checklist can be included as evidence for your performance planning and review and can be included in your personnel file. v2 March 2011 12 Certificate III in Sterilizing Services Queensland Health’s (QH) is committed to ongoing education and training. There is an expectation that staff that perform sterilizing functions will undergo formal training in the reprocessing of reusable medical devices known as Certificate III in Sterilising Services. There are numerous advantages when you undertake formal study and gain a Certificate III in Sterilising Services, which include: ability to work in other areas such as hospital Central Sterilizing Department (CSD) the theoretical knowledge associated with the duties you are to perform within the facility confidence to participate in discussions that relate to service improvements and work environment improvements potential to participate in the establishment of a portfolio within your role CHRISP Forums and Training CHRISP Sterilizing Program established DAS-Net, a Dental Assistant Sterilizing Network in June 2010. This network provides an opportunity to communicate and implement new initiatives and information through a network of District-based representatives to Dental Assistants and other personnel undertaking sterilizing activities. Each District has a DAS-Net representative INSERT NAME OF THE DAS NET REP whose role is to communicate information and training requirements from the Network back through your district. Our facility communicates to the DAS NET representative via INSERT HOW YOU CO-ORDINATE THE FACILITIES QUESTIONS/ COMMUNICATIONS TO THE DAS NET representative . e.g communication book. CHRISP also liaises with medical industry when coordinating statewide inservice programs. Information is distributed by INSERT NAME OF SDA to all staff within the department as these programs become available within your department. v2 March 2011 13 What’s Next: After your three month orientation program Once you have completed your three month Oral Health sterilization orientation program you will now plan your ongoing learning needs with your manager in line with the Workplace Skills Assessments (WSA). 2.3 Self Assessment This tool has been designed to assist you to assess your level of knowledge and skills in key functions of sterilization. It is important that your self assessment is completed on or before day 1 of your sterilization orientation as we believe this process assists us to streamline your training needs. The idea of the self assessment is to identify your specific learning needs. Step 1: Please complete the following questions to assess (1) your current level of knowledge and (2) your current skill level by circling the most appropriate response. It is expected for new staff members who have never reprocessed oral health instruments to self assess as ‘Nil’ or ‘Limited’. Step 2: You are to discuss the results of your self assessment with your mentor/manager and the results will be used to develop your individual learning plan for the next 3 months. v2 March 2011 14 2.3 Self Assessment cont. Cleaning Knowledge in sorting instruments prior to cleaning Nil Limited Some Extensive Skills in sorting instruments prior to cleaning Nil Limited Some Extensive Knowledge in Chemical & Detergent Mixtures Nil Limited Some Extensive Skills in replacing and checking Chemical & Detergent Nil Limited Some Extensive Mixtures Knowledge in pre & post rinsing of dental instruments Nil Limited Some Extensive Skill in pre and post rinsing Nil Limited Some Extensive Knowledge of manual cleaning processes Nil Limited Some Extensive Skill in manual cleaning including cleaning of complex and Nil Limited Some Extensive cannulated instruments (handpieces) Knowledge of how Batch Type Washer Disinfector Nil Limited Some Extensive Machines operate (where present) Skill in operating Batch Type Washer Disinfector Nil Limited Some Extensive Machines (where present) Knowledge of how Ultrasonic Cleaners operate Nil Limited Some Extensive Skill in operating Ultrasonic Cleaners Nil Limited Some Extensive Knowledge of De-Staining instrument processes Nil Limited Some Extensive Skill in De-Staining instruments Nil Limited Some Extensive Knowledge of how and when to use an air pressure gun Nil Limited Some Extensive Skill in Operating the air pressure gun Nil Limited Some Extensive Knowledge of how a Drying Cabinet operates (where Nil Limited Some Extensive present) Skill in operating a Drying Cabinet (where present) Nil Limited Some Extensive v2 March 2011 15 Preparation and Packaging Knowledge in general practice dental instruments Nil Limited Some Extensive Knowledge in Periodontal set ups Nil Limited Some Extensive Knowledge of handpieces and ultrasonic scalers Nil Limited Some Extensive Knowledge in Endodontic set ups Nil Limited Some Extensive Knowledge in Crown and Bridge set ups Nil Limited Some Extensive Knowledge in Oral surgery set up Nil Limited Some Extensive Knowledge of orthodontic and implant technology Nil Limited Some Extensive Knowledge in how to organise preparation and packaging Nil Limited Some Extensive work area Skill in organising the preparation and packaging work Nil Limited Some Extensive area Knowledge of how to set up instrument trays/cassettes Nil Limited Some Extensive Skill in setting up instrument trays/cassettes Nil Limited Some Extensive Knowledge of packaging and wrapping techniques used in Nil Limited Some Extensive the department Knowledge of how to load and use a batch label gun Nil Limited Some Extensive Skills in loading and using a batch label gun Nil Limited Some Extensive Skills in packaging and wrapping techniques Nil Limited Some Extensive Knowledge of how the heat sealer operates (where Nil Limited Some Extensive applicable) Skill in operating a heat sealer (where applicable) Nil Limited Some Extensive v2 March 2011 16 Sterilizing Knowledge in the requirements for batch labelling and Nil Limited Some Extensive recording of a load prior to sterilization Skill in batch labelling and recording of a load prior to Nil Limited Some Extensive sterilization Knowledge of loading a trays/trolley for steam sterilization Nil Limited Some Extensive Skill in loading a trays/trolley for steam sterilization Nil Limited Some Extensive Knowledge in identifying and operating the appropriate Nil Limited Some Extensive steam sterilizer cycle Skill in steam sterilizer operation and ability to select the Nil Limited Some Extensive correct cycle Knowledge of required parameters when releasing a Nil Limited Some Extensive Sterilizer load Skill in assessing and inspecting all parameters when Nil Limited Some Extensive releasing a Sterilizer load Knowledge of the requirements when cooling a Sterilizer Nil Limited Some Extensive load Skill in managing items following sterilization that require Nil Limited Some Extensive cooling prior to release Knowledge of identifying and reporting requirements when Nil Limited Some Extensive a Sterilizer load fails Skill in identifying and reporting requirements when a Nil Limited Some Extensive Sterilizer load fails v2 March 2011 17 Quality Assurance Knowledge in cleaning efficiency testing Nil Limited Some Extensive Skill in performing clean efficiency testing Nil Limited Some Extensive Knowledge of test/s required to determine ultrasonic machine Nil Limited Some Extensive efficiency Skill performing ultrasonic machine testing Nil Limited Some Extensive Knowledge of mechanical washer cycle monitoring for thermal Nil Limited Some Extensive disinfection Skill in interpreting and documenting mechanical washer cycle Nil Limited Some Extensive monitoring for thermal disinfection Knowledge of routine cleaning and checking of mechanical Nil Limited Some Extensive washers Skill in performing routine cleaning and checking of mechanical Nil Limited Some Extensive washers Knowledge of internal and external chemical indicators and Nil Limited Some Extensive when they are used Skill in determining the appropriate internal and external Nil Limited Some Extensive chemical indicator for their use Knowledge of biological indicators when they are used Nil Limited Some Extensive Skill in the use of biological and enzymatic indicators Nil Limited Some Extensive Knowledge of requirements of leak rate test for pre-vacuum Nil Limited Some Extensive sterilizers Skill in setting the appropriate steam sterilizer cycle for leak rate Nil Limited Some Extensive test and interpreting and documenting the sterilizer printout Knowledge of the requirements of a Bowie Dick type test and Nil Limited Some Extensive interpreting the results Skill in undertaking Bowie Dick type testing and interpreting and Nil Limited Some Extensive documenting the results Knowledge of routine cleaning and checking of sterilizers Nil Limited Some Extensive Skill in performing routine cleaning and checking of sterilizers Nil Limited Some Extensive v2 March 2011 18 2.4 Standard Operating Procedures & Workplace Skills Assessments The Standard Operating Procedures (SOP) provides a framework for the minimum set of standards for Oral Health sterilizing practice within Queensland Health facilities (http://www.health.qld.gov.au/chrisp/sterilising/oral_health.asp). These resources can be used: As a resource for you are undertaking sterilizing services within Oral Health Help you recognize areas in which they are competent and those in which they still need to improve Identify problem areas where you may require further assistance and training The SOP’s are divided into 5 sections and can be found at http://www.health.qld.gov.au/chrisp/sterilising/oral_health_SOP.asp Section 1 Cleaning Procedures Section 2 Packaging & Wrapping Procedures Section 3 Sterilizing Procedures Section 4 Sterile Storage Area Procedures Section 5 Quality Assurance v2 March 2011 19 Workplace Skills Assessments (WSA) A key component in the implementation of SOP’s is ensuring that you have the necessary skills, knowledge and experience to undertake the allocated activity, task or job. Each SOP criteria is aligned with a WSA and is designed to be used as part of the Oral Health Services sterilizing orientation program and for your ongoing professional development. The WSA’s are divided into 5 sections and can be found at http://www.health.qld.gov.au/chrisp/sterilising/oral_health_SOP.asp The rating criteria for the WSA are based on the Benner Scoring Legend (refer to table 1). A template for WSA sheet (included in this section) is to be used as your personal record. To undertake a WSA the following conditions need to be applied: When undertaking the WSA you are able to: Complete the task on your own Locate equipment used in the process without delay; Use unit equipment according to manufacturers instructions; and Completes the WSA within the boundaries of legislation and the WSA’s Each step within the WSA has boxes which can be used as a prompt and ticked (√) for achievement and (X) if the performance criteria is not achieved at this stage. The rating criteria for the WSA are based on the Benner Scoring Legend (refer to table 1). At the completion of each assessment your mentor/assessor undertaking the assessment will discuss with you the assessment outcomes Table 1: Benner Scoring Legend SCORING LEGEND WSA RATING Requires immediate action by manager to manage risk. NOVICE (1) Requires guidance: performs within set Inadequate parameters Requires reassessment in one (1) week. Performs routine functions: requires some ADVANCED BEGINNER (2) Improvement Requires reassessment assistance in complex situations and setting Required within one (1) month. priorities Prioritises and completes functions Meets current best practice COMPETENT (3) Adequate independently: can adapt practice to requirements. Review manage complex situations. annually. v2 March 2011 20 WORKPLACE SKILLS ASSESSMENT - ORIENTATION CHECKLIST Staff Member Name: Competency Assessor Assessment & Signature Title Date Adequate Improvement required Inadequate CLEANING 1.1 Standard Precautions 1.2 Soiled Pick-Up Schedule 1.3 Sorting Prior to Cleaning 1.4 Chemical & Detergent Mixtures 1.5 Pre cleaning 1.6 Manual Cleaning for immersible items 1.7 Manual Cleaning for non- immersible items 1.8 Handpieces, Ultrasonic Scalers and Triplexes 1.9 Ultrasonic Cleaners 1.10 Washer Disinfector Machines 1.11 De-staining 1.12 Air Pressure Gun 1.13 Drying Cabinet PREPARATION 2.1 Organisation of Packing Area 2.2 Assembly of Instrument trays and Hollowware 2.3 Wrapping / Packaging / Labelling 2.4 Using and reloading Batch Label Gun 2.5 Restocking Consumable Materials v2 March 2011 21 Competency Assessor Assessment & Signature Title Date Adequate Improvement required Inadequate STERILIZING 3.1 Batching & Recording of a Load Prior to Sterilization 3.2 Loading and Recording of Items for Steam Sterilization 3.3 Releasing and Unloading a Sterilized Load 3.4 Managing a failed sterilizer cycle and load STERILE STORAGE 4.1 Dedicated Area for Sterile Goods 4.2 Stock Rotation 4.3 Delivery of Sterile Stock QUALITY ASSURANCE 5.1 Water Quality 5.2 Cleaning Efficacy Test (Optional) 5.3 Ultrasonic Machine Testing 5.4 Mechanical Washer Cycle Monitoring 5.5 Internal and external Chemical Indicators 5.6 Biological Indicators 5.7 Leak Rate (Vacuum) Test 5.8 Bowie Dick Type Test Routine Cleaning of 5.9 Reprocessing Equipment v2 March 2011 22 2.5 Individual Learning Plan Note: Performance Appraisal and Development information for managers, supervisors and employees can be found on the Human Resources web page and include up-to- date Performance Appraisal and Development templates http://www.health.qld.gov.au/hrpolicies/g_learndevperf.asp v2 March 2011 23 v2 March 2011 24 PART 3 v2 March 2011 25 3.1 Oral Health Sterilizing Services Orientation Checklist Staff Member Name: Activity Date Mentor Signature Day 1 Introduction to reprocessing and sterilizing environment Meeting with key staff Completed self assessment Scheduled weekly meeting with line manager Week 1 Organise District orientation Read Manual Handling Information Booklet- CSD http://qheps.health.qld.gov.au/safety/safety_topics/guides/Mhb_csd.pdf Navigate the CHRISP website 1 Month 2 Months 3 Months Complete Individual Learning Plan- PA&D Complete and sign off all relevant WSA v2 March 2011 26 Staff Member Name: Activity Date Mentor Signature Sterilization Services Rotation where applicable (Week 1 to 3 months) Cleaning area Inspecting and tray set-up Wrapping and packaging Sterilizing Dispatch v2 March 2011 27 3. 2. CSD Manual Handling booklet Insert/provide a copy of CSD Manual handling booklet found at http://qheps.health.qld.gov.au/safety/safety_topics/guides/Mhb_csd.pdf v2 March 2011 28 3.3 Standard Operating Procedures and Workplace Skills Assessment Insert copies of the current Standard Operating Procedures and Workplace Skills Assessments here or provide direction as to where they are located in the clinic Go to http://www.health.qld.gov.au/chrisp/sterilising/oral_health.asp v2 March 2011 29