D8PRE-_1.pdf

D8. PRE-TREATMENT AND TRANSPORTATION OF SOILED CRITICAL AND SEMI-CRITICAL REUSABLE

MEDICAL EQUIPMENT 2

36C25922R0102

Department of

Veterans Affairs

Date: f EB 1 1 2016

Memorandum

From: Assistant Deputy Under Secretary for Health Operations and Management (1ON) s ubj : Pre-treatment and Transportation of Soiled Critical and Semi-Critical Reusable

Medical Equipment (RME) r o: VISN Directors, VISN CMOs, VISN QMOs, VISN Nurse Executives, VISN Sterile

1. This memorandum is to improve current processes for pre-treatment and transportation of soiled RME from the point of use to a econtamination area in accordance with professional practice standards.

2. Pre-Treatment:

a. Responsibility of end user

b. Manufacturer's Instructions for Use (IFUs) must be followed

c. Removal of all gross debris must occur prior to application of enzymatic solution

d. Use of Food and Drug Administration (FDA) approved pretreatment enzymatic solution (Note: If IFUs delineate specific validated solution, said solution must be used)

e. Thoroughly spray enzymatic solution directly onto instruments to be cleaned allowing for each instrument to remain covered to dissolve bioburden.

f. Application of enzymatic solution is to be done immediately following

RME use. This can occur at point of care or within soiled utility room.

3. Transport of RME from point of care to soiled utility/appropriate holding area:

a. Properly labeled medical grade puncture resistant biohazard rigid container or an enclosed cart is to be used to transport all RME

b. Two methods:

i. Exchange transport container - the container with the soiled RME is placed in the utility room and a clean container (which has been intermediate level disinfected between uses) acquired from clean storage is taken back to the point of use.

ii. Point of use transport container - the container with soiled RME at point of care is transported to soiled utility room where end user will don appropriate PPE to transfer soiled RME to designated collection container that is a properly labeled medical grade puncture resistant biohazard rigid container. The point of care

D8. PRE-TREATMENT AND TRANSPORTATION OF SOILED CRITICAL AND SEMI-CRITICAL REUSABLE

MEDICAL EQUIPMENT 2

36C25922R0102

Page2

Pre-treatment and Transportation of Soiled Critical and Semi-Critical Reusable

Medical Equipment (RME) transport container must be intermediate level disinfected before returning to patient care area for subsequent use.

4. Transport of RME from soiled utility room/appropriate holding area, at facility and offsite locations, to decontamination area:

a. A process for regular scheduled pick-up times and deliveries must be established to facilitate prompt removal of soiled RME from soiled utility rooms/appropriate holding areas. This will require multiple pick ups from the using service and deliveries to decontamination areas for reprocessing.

b. RME treated with an enzymatic solution MUST NOT be left in a soiled utility room/appropriate holding area beyond 4 hours. Note: This does not apply to flexible lumen endoscopes due to need for reprocessing within 1 hour or an extended soak must occur.

c. Soiled RME should not be left over night or over weekends/holidays.

d. To ensure employee safety, the exterior surfaces of transport containers must remain clean/disinfected so PPE is not needed for transport.

e. For offsite locations, there are two methods of transportation, both of which must comply with applicable Department of Transportation

(DOT) and state regulations:

i. Separate vehicles for soiled and clean - Soiled RME will be placed in a properly labeled medical grade puncture resistant biohazard rigid container.

ii. One vehicle for soiled and clean - Clean and soiled RME must be segregated and soiled RME will be placed in a properly labeled medical grade puncture resistant biohazard rigid container placed inside a second rigid transport container with an external lock.

5. This memorandum remains in effect until further notice of additional updates and/or replacement thereof.

6. For questions regarding this memorandum, please contact Teresa Wells, Director National Program Office for Sterile Processing at Teresa.Wells3@va.gov or Seaton West, Deputy Director National Program Office for Sterile Processing at Seaton.West@va.gov.

Janet P. Murphy, MBA mailto:Teresa.Wells3@va.gov mailto:Seaton.West@va.gov