VHA-V16-564-SPS-SOP-1018.pdf

VETERAN HEALTH

CARE SYSTEM OF

THE OZARKS (564)

Standard Operating Procedure for

Courier Service Transportation of Sterile and

Contaminated Reusable Medical Devices (RMD)

Version:

Status: FINAL Owner: SPS Approver: ADPCS

VHA-V16-564-SPS-SOP-1018 Print Date: 01/06/2022 Approval Date: 01/05/2022 Page: 1 of 3

This document is uncontrolled when printed. Refer to document owner for controlled document version

1.0 Policy

It is the policy of the medical center to ensure compliance with regulatory entities regarding the transportation of contaminated and sterile reusable medical devices (RMD). The purpose of this Standard Operating Procedure (SOP) is to outline the process required to transport contaminated RMD from Community Based Outpatient Clinics

(CBOCs) and to return sterilized RMD back to the CBOCs. The following critical steps must be followed to prevent events of cross contamination and to ensure the package integrity of sterilized RMD as it relates to event related sterility.

2.0 Procedure

A. Courier Service

Transportation of All Reusable Medical Devices (RMD)

NOTE

Transport pick-up and delivery times will be determined by contract.

Items should be packed in a manner that protects the devices from damage during transport.

Any sterile items that are dropped should be considered contaminated and reprocessed, even if no damage is visible. Compression upon landing can force dust and airborne microorganisms into the package.

After delivery of RMD VHA staff will inspect all packaging prior to placing the products in their designated temperature/humidity-controlled locations. VHA staff will perform immediate delivery of sterile/clean items, post event related sterility verification.

1. To guarantee that cross contamination does not occur at any point, vehicles will not transport Reprocessed and

Soiled RMD at the same time.

2. Sterile or contaminated RMD items should never be left unattended or in unsecured areas.

3. All transport containers should be carefully secured during transport to prevent damage from shifting.

4. The containers must be medical grade, rigid, enclosed, and appropriate color; clean (blue), contaminated (red).

5. Food or drink cannot be stored or consumed in the vehicle at any time as this pertains to infection control standards that must be followed.

6. The courier must ensure that the vehicle meets the temperature/humidity requirements prior to picking up

RMD, throughout transit, and upon delivery. The minimum and maximum values will be recorded on the vehicle temperature and humidity log prior to departure and upon arrival to the receiving facility. Note:

Temperature 66 °F to 72°F, humidity 20% to 60% relative humidity R/H.

7. Items should never be left in a vehicle that is not running, especially on very cold, hot, or humid days, as the temperature and humidity levels can change quickly.

Transportation of Sterile Reusable Medical Devices (RMD)

1. Sterile Processing Service (SPS) at the Fayetteville campus will inspect identified items for integrity and place them in an appropriate and designated clean transport container (blue). An inventory listing (shipping manifest) will accompany each transport container identifying the contents within.

2. Items selected for transport are processed and stored in a temperature and humidity-controlled environment until the designated time of transport.

3. At the determined pick-up time the courier will contact SPS staff to have RMD containers delivered to the clean transport vehicle.

4. Upon arrival to the receiving facility, the courier driver will contact the designated staff and /or deliver the contents to the designated location. VHA staff will immediately receive the delivered RMD, inventory listing of contents received, and the recorded temperature & humidity values. (Note: the documented temperature and

THE OZARKS (564)

Standard Operating Procedure for

Courier Service Transportation of Sterile and

Contaminated Reusable Medical Devices (RMD)

VHA-V16-564-SPS-SOP-1018 Print Date: 01/06/2022 Approval Date: 01/05/2022 Page: 2 of 3

3.0 Appendices: Courier Transport: Temperature and Humidity Log

3.1 Courier Transport: Vehicle Cleaning Log

4.0 References: VHA Directive 1116(2): Sterile Processing Services (SPS); Date March 23rd, 2016 humidity logs are to be kept within the vehicle until the end of each week and are then to be given to SPS administration for filing purpose).

Transportation of Contaminated Reusable Medical Devices (RMD)

NOTE

Per VHA regulation, “when transporting soiled instruments/devices, facilities must comply with the applicable

City, State, and Federal Department of Transportation (DOT) regulations.

No contaminated item is to be left in the soiled utility room overnight.

Items should not be transported in the trunk of a car because temperature and humidity levels cannot be controlled.

The vehicle must carry a Hazardous material spill containment kit.

Contaminated items should be handled as little as possible. Contaminated reusable items should be contained in such a way that the contents of the containers are readily identifiable as contaminated by everyone who subsequently handles the items; and in a containment device that complies with the health care facility’s established infection prevention and control and hazardous waste management procedures.

Upon receipt of contaminated RMD VHA staff will deliver to SPS decontamination area for reprocessing.

1. The courier must be knowledgeable of and comply with all city, state, and federal DOT regulations when transporting contaminated items/devices. Including all personal protective equipment (PPE) requirements.

2. Contaminated items for transport will be removed from patient care areas, placed in a closed biohazard (red) container, and transported to dirty utility room. This container will then be placed inside a second leak proof, biohazard (red), tamper proof (locked) container within the designated soiled utility area for courier pickup.

3. At the designated transport time the courier will contact VHA staff and / or load the vehicle with the contaminated items to include an inventory listing of contents being delivered.

4. Upon arrival to the receiving facility (Fayetteville Campus), the courier driver will contact SPS staff to receive the contaminated RMD, inventory listing of contents received, and the recorded temperature & humidity values. (Note: the documented temperature and humidity logs are to be kept within the vehicle until the end of each week and are then to be given to SPS administration for filing purpose).

Cleaning of the Transport Vehicle.

NOTE

Cleaning and maintenance of the transport vehicle is important to protect instruments from dust, dirt, and other contaminants.

1. The vehicle is to be cleaned (intermediate level disinfected) daily and/or after each contaminated delivery.

2. All surfaces of the interior vehicle that come into contact with deliverable items during transport must be wipeable surfaces. The transportation vehicle must not contain cloth seats, cloth ceiling liner, or carpet.

3. Cleaning of the vehicle must be performed when no RMD items are present within the vehicle.

4. Remove all trash that might be present and wipe all applicable areas of the interior of the vehicle (floors, walls, horizontal surfaces, etc.) with facility approved disinfectant wipe. Note: “Purple Top” Super Sani-Cloth.

5. Ensure the disinfectant manufacturer guidelines for contact time are followed. Note: Purple Top: Super Sani-

Cloth has a contact time of (2) two minutes.

6. Documentation of the daily cleaning performed will be done on the facility approved vehicle cleaning log.

Note: The vehicle cleaning log is to be kept with the vehicle until the end of each week when it is turned in to

SPS administration.

THE OZARKS (564)

Standard Operating Procedure for

Courier Service Transportation of Sterile and

Contaminated Reusable Medical Devices (RMD)

VHA-V16-564-SPS-SOP-1018 Print Date: 01/06/2022 Approval Date: 01/05/2022 Page: 3 of 3

4.1 September 5th, 2017 VHA Memorandum: Interim Guidance for Heating, Ventilation and Air-Condition

(HVAC) Requirements Related to Reusable Medical equipment (RME) Reprocessing and Storage.

4.2 April 2nd, 2018 VHA Memorandum: Clarification on Current Processes for Pre-Treatment and

Transportation of Soiled Reusable Medical Equipment (RME)

4.3 Association for the Advancement of Medical Instrumentation. ANSI/AAMI ST79:2017 & 2020

Amendments A1, A2, A3, A4 (Consolidated Text). Comprehensive Guide to Steam Sterilization and

Sterility Assurance in Health Care Facilities.

5.0 NEXT REISSUE / REVIEW DATE: Review: 12/16/2024 Reissue Date:

Revision DATE EDITOR CHANGES (be specific)

1 12/2018 Zachary

Hines

Initial Detailed SOP for courier transportation to include, ANSI/AAMI ST79 guidelines.

3/19/2019 Kindra

Dial Initial SOP to include Assigned new SOP Number, per System Redesign.

No Changes to SOP Content.

2 12/16/2021 Wendy

Kircher

Added Section “Transportation of All Reusable Medical Devices (RMD) – moved the steps that involve both sterile and contaminated transport to this section to decrease repetition.

5.0 DISTRIBUTION: SPS, Courier Vehicle

5.1 SPS SharePoint

5.2 SPS Original File/Folder

APPROVED BY:

Department Manager/Chief- Signature: N/A

Date: N/A

Facility RME Coordinator- Signature: Wendy Kircher, RN

Date: 1/5/2022

Infection Control- Signature: William Edgemon, RN

Chief of Sterile Processing- Signature: Zach Hines, MSN, RN

Associate Director for Patient Care Services– Signature: Amy Huycke, RN

DATE OF APPROVAL: 1/5/2022