UCLA Infection Control Manual

Dr. Andy Wong

California Continuing Education Credits: 6 units

PIC HOMEPAGE


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APPENDIX

MONITORING INFECTION CONTROL COMPLIANCE

1. Clinic Infection Control Officer (ICO). The clinic infection control officer will conduct on-going monitoring of infection control procedure compliance within the clinic.

2. Clinic Infection Control Officers. Clinic infection control officers will conduct on-going monitoring of infection control procedure complaince.

3. Quarterly Clinic Infection Control Meeting. The infection control officer, administrative assistant, and clinic infection control officer (doctor in charge) will hold a quarterly meeting. Minutes of this meeting will be documented and personnel attending will initialize document.

4. Quarterly Self Assessment Inspections. Clinic infection control officers will conduct quarterly self assessment inspections utilizing Infection Control Inspection forms.

5. Semi-annual Inspections. The clinic infection control officer will conduct semi-annual inspections of the clinic to ensure that infection control guidelines set forth in this manual are being followed. A report is to be submitted to the clinic director as to the areas deficient and needing attention.

6. Central Sterilization Room (CSR) Log Book. A CSR or sterilization area log book will be utilized. All sterilization loads will be entered in the log with content names. Packs will be labeled i.e., date, expiration date, sterilization load #, and appropriate sterilization testing monitor.


CARE AND MAINTENANCE OF STEAM STERILIZERS (AUTOCLAVES)

1. Prior to performing maintenance of autoclaves, disconnect all electrical sources.

2. Steam sterilizers must be cleaned and maintained in accordance with the manufacturer¹s instructions. Failure to do so can result in processing problems. For example, if a sterilizer chamber is not properly cleaned, mineral deposits condensing from the steam will accumulate on the walls and may stain items in the load. If the chamber drain is not cleaned, it will eventually interfere with the air and steam evacuation, and may result in wet packs.


ULTRASONIC CLEANING SYSTEM

Use GLOVES, SAFETY GLASSES and GOWN when handling instruments in Central Service Room.

OPERATION:

1. Maintain enough solution in tank to cover all items being cleaned.

2. PLACE INSTRUMENTS IN BASKET. Open jointed instruments (e.g. scissors, forceps etc.); disassemble component parts readily detachable.

** ALWAYS KEEP TANK COVERED TO AVOID AEROSOLS **

3. SET TIMER TO FROM THREE (3) TO SIX (6) MINUTES (Follow Manufacturer¹s Directions.)

4. When cycle completed, REMOVE INSTRUMENTS TO SINK, RINSE, AND DRY.

MAINTENANCE:

Change solution daily or more frequently if murky or with sediment.


INSPECTION REPORT
NON-COMPLIANT = DEFICIENT AREAS
Unnecessary items
Personal gear
Food
Non-labeled container & no expiration date
Sharps too filled (3/4 or more)
Disinfectant problem
Patient, Doctor, Technician
Gloves worn (without overgloves) outside CSR
Inappropriate personal protective equipment
No patient safety glasses
Inappropriate needle recapping
Lab
Containers not labeled
Disinfectant problem
Inappropriate personal protective equipment
Instrument Packs and Drawers
Pack improperly labeled; no processing date
Unpackaged, non-sterile instruments in drawers, trays
Unpackaged, non-sterile burs in storage
Preloaded syringes left on trays for future patients
Sterilization
No chemical indicators in packs
No processing dates
Insufficient biological monitoring
Insufficient CSR log (monitoring, cycles & maintenance)
Floors, walls swabbed with inappropriate product
High/low evacutors insufficiently flushed with water

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