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University Policy

Sterile Processing

 

Policies

3364-139-1-01 Sterilization Records
3364-139-1-02 Reprocessing and Sterilization of Surgical Instruments
3364-139-1-03 High Level Disinfection
3364-139-1-06 Call Off Notification
3364-139-3-12 Utility Shutdown
3364-139-4-01 Food and Drink in Work Areas
3364-139-6-12 Reprocessing of Single use Items
3364-139-6-18 Sterilization of Instruments Received from Non-UTMC Source
3364-139-6-19 Reusable Brushes

Procedures and Protocols

General
SP1-1 Employee Breaks
SP1-2 New Employee Orientation and Training
SP1-3 Medical Equipment Inspection
SP1-4 Loaner Trays
SP1-5 Case Cart Set Up
SP1-6 HLD Testing and Disinfection Protocol
SP1-7 CVL Instrument Pickup
SP1-8 Case Cart Missing Items List
 
Decontamination
SP2-1 Decontamination Area
SP2-2 Decontamination of Surgical Instruments
SP2-3 Decontamination of Case Carts
SP2-4 Unknown Item Bin
SP2-7 Daily Test For Washer/Disinfectors
 
Sterilization
SP3-1 Peel Pouches
SP3-2 Assembly and Sterilization of Instrument Sets
SP3-3 Operation of Steam Sterilizers in Sterile Processing
SP3-4 BI and Integrator Process for Steam Sterilization
SP3-5 Computerized Sterilization Record Management
SP3-6 Use of Chemical Indicators and Integrators
SP3-7 Positive Culture and Recall of Hospital Items
SP3-8 Daily Function Tests for Leaks and Vacuum (Bowie-Dick Test)
SP3-9 BI Test for Gas Plasma Sterilizers (STERRAD)
SP3-10 Operation of Gas Plasma Sterilizers (STERRAD)
SP3-11 3+3 Sterilizer Test After Maintenance
SP3-12 Loading of Steam Sterilizer Carts
SP-3-13 C41B Rectal Probe-MR Fusion Procedure
 
O.R.
SP7-1 Diagnostic Cycle for STERIS System 1E
SP7-2 Routine BI Test in the O.R.
SP7-3 BI Testing, Implants, O.R. Sterilization
SP7-4 High Level Disinfection of Instruments in the O.R.
SP7-5 Operation of the STERIS System 1E
SP7-6 Immediate Use Steam Sterilization in the O.R.

 

 

Last Updated: 9/8/23