Best Practice Guidelines For Cleaning, Disinfection and ...

1 Best Practice Guidelines for cleaning , Disinfection and Sterilization in Health Authorities - December 2011. Best Practice Guidelines For cleaning , Disinfection and Sterilization of Critical and Semi-critical Medical Devices In BC Health Authorities THIS DOCUMENT IS INTENDED TO DESCRIBE BEST practices . HEALTH CARE SETTINGS ARE ENCOURAGED TO WORK TOWARDS THESE BEST practices IN AN. EFFORT TO IMPROVE QUALITY OF CARE. BC Ministry of Health First published March 2007. Reviewed & revised December 2011. | Page 1 of 136 pages Best Practice Guidelines for cleaning , Disinfection and Sterilization in Health Authorities - December 2011. Foreword This document was originally developed in 2006 by the Ontario Provincial Infectious Diseases Advisory Committee (PIDAC) and was approved by the Ontario Ministry of Health and Long-Term Care (MOHLTC). PIDAC is a multidisciplinary scientific advisory body that provides evidence-based advice to the Chief Medical Officer of Health regarding multiple aspects of infectious disease identification, prevention and control.

2 PIDAC s work is guided by the best available evidence and updated as required. Best Practice documents and tools produced by PIDAC reflect consensus positions on what the committee deems prudent Practice and are made available as a resource to public health and health care providers. In 2006, the British Columbia (BC) Ministry of Health (the Ministry) received permission to adopt PIDAC s Best practices for cleaning , Disinfection and Sterilization of Medical Devices. Permission was also granted at that time for the Ministry to amend contextual material within the document to better fit BC s health services environment. An adapted version of the PIDAC Guidelines was issued as BC's provincial policy in 2007. The policy applies to all critical and semi-critical single use and multiple use devices and patient care equipment used within health authority facilities and programs, as well as private and non- profit facilities providing public healthcare services under contract to health authorities.

3 In February 2010, PIDAC published a revised version of the Guidelines and the MOHLTC once again gave permission to the BC Ministry of Health to use its updated best practices document to further improve patient safety in BC. The Ministry extends its thanks and appreciation to its colleagues in Ontario for supporting inter-provincial learning in the area of medical device reprocessing. Key Revisions in this Document: This document incorporates revisions from the following updated Canadian standards: CSA Effective Sterilization in Health Care Facilities by the Steam Process CSA Effective Sterilization in Health Care Facilities by the Ethylene Oxide Process CSA Decontamination of Reusable Medical Devices The Provincial Infection Control Network s (PICNet) recommendation for a provincial minimum standard for the reprocessing of flexible endoscopes has been adopted in this revision. New information from the Centers for Disease Control and Prevention s Guideline for Disinfection and Sterilization in Healthcare Facilities , published in 2008, is also reflected in this revision.

4 Key Revisions in BC's Provincial Medical Device Reprocessing Policy: BC s revised provincial policy for medical device reprocessing (2011) reflects advances in the oversight and delivery of safe, high quality medical device reprocessing services, including: Updated Best Practice Guidelines for cleaning , Disinfection , and Sterilization of Medical Devices in Health Authorities (2011);. Clear requirements for halting activities known to be inconsistent with best practices ( , reprocessing of "in-house" manufactured devices);. Clear expectations regarding the education, training, and competency assessment of reprocessing staff;. Expanded requirements for ongoing quality assurance planning, risk assessment and remediation;. | Page 2 of 136 pages Best Practice Guidelines for cleaning , Disinfection and Sterilization in Health Authorities - December 2011. Updated requirements for ongoing Practice auditing; and Clear expectations for submission of status reports and other materials to the Ministry on an ongoing basis.

5 This updated provincial reprocessing policy also reflects recommendations made by Dr. Douglas Cochrane, Chair of the BC Patient Safety & Quality Council, to the Ministry and health authorities in September 2010. Acknowledgement Ontario Ministry of Health and Long-Term Care & the Provincial Infectious Diseases Advisory Committee. Best practices for cleaning , Disinfection and Sterilization in All Health Care Settings. February 2010. Available at: Content from Ontario / PIDAC best Practice document is Ontario Ministry of Health and Long-Term Care/Public Health Division / Provincial Infectious Diseases Advisory Committee Toronto, Canada February 2010. ISBN: 978-1-4435-1526-9. In February 2010, the BC Ministry of Health was granted permission by PIDAC to adopt and adapt their document entitled Best practices for cleaning , Disinfection and Sterilization in All Health Care Settings'. All updated content is BC Ministry of Health / BC Health Authorities / Providence Health Care.

6 | Page 3 of 136 pages Best Practice Guidelines for cleaning , Disinfection and Sterilization in Health Authorities - December 2011. The BC Ministry of Health would like to acknowledge the contribution and expertise of PIDAC s subcommittee that developed the original best Practice document: Infection Prevention and Control Subcommittee: Dr. Mary Vearncombe, Chair Pat Piaskowski Medical Director Network Coordinator Infection Prevention and Control, Microbiology Northwestern Ontario Infection Control Network Sunnybrook Health Sciences Centre and Women s Thunder Bay, Ontario College Hospital Toronto, Ontario Dr. Virginia Roth Director, Infection Prevention and Control Dr. Irene Armstrong The Ottawa Hospital Associate Medical Officer of Health Ottawa, Ontario Toronto Public Health Toronto, Ontario Dr. Kathryn Suh Associate Director, Infection Prevention and Control Donna Baker The Ottawa Hospital Manager, Infection Prevention and Control Ottawa, Ontario Bruy re Continuing Care Ottawa, Ontario Liz Van Horne Senior Infection Prevention and Control Professional Mary Lou Card Infectious Disease Prevention and Control Manager, Infection Prevention and Control Agency for Health Protection and Promotion London Health Sciences Centre and St.

7 Joseph s Toronto, Ontario Health Care London, Ontario Dr. Dick Zoutman Professor and Chair Dr. Maureen Cividino Divisions of Medical Microbiology and Infectious Occupational Health Physician Diseases St. Joseph's Healthcare Medical Director of Infection Control Hamilton, Ontario South Eastern Ontario Health Sciences Centre Queen s University Dr. Kevin Katz Kingston, Ontario Infectious Diseases Specialist and Medical Co-Chair, Provincial Infectious Diseases Advisory Microbiologist Committee (PIDAC). Medical Director, Infection Prevention and Control North York General Hospital Dr. Beth Henning (ex-officio). Toronto, Ontario Senior Medical Consultant Ministry of Health and Long-Term Care Dr. Allison McGeer Director, Infection Control Director, Infection Control Mount Sinai Hospital Mount Sinai Hospital Toronto, Ontario Toronto, Ontario PIDAC would also like to acknowledge the writing of this best practices guide provided by Shirley McDonald.

8 | Page 4 of 136 pages Best Practice Guidelines for cleaning , Disinfection and Sterilization in Health Authorities - December 2011. The BC Ministry of Health would like to acknowledge the contribution and expertise of the following people in the development and adaptation of this best Practice document for use in British Columbia: BC Provincial Reprocessing Working Group: Penny Brawn Sheila Konishi Regional Coordinator, Sterile Processing, Northern Program Director, Sterile Processing Fraser Health Health Authority Authority Janet Bristeir Darren Kopetsky Regional Medical Device Reprocessing Practice & Director, Medical Affairs (Risk Management), Quality Coordinator, Vancouver Coastal Health Vancouver Coastal Health Authority Authority Viola Tang Laurie Buist Infection Control & Reprocessing practices Manager, Reprocessing Practice Leader, Interior Health Provincial Health Services Authority Authority Dianne Trudeau Fern Christensen Operations Leader, Sterile Processing, Mount.

9 St. Coordinator, Medical Device Reprocessing, Joseph s & St. Paul s Hospital, Providence Health Vancouver Island Health Authority Care Ruby Fraser Petra Welsh Coordinator, Quality, Risk Management & Education, Administrative Director, Infection Control, Fraser Northern Health Authority Health Authority Content Review Sub-Committee Dianne Trudeau (Chair) Laurie Buist Operations Leader, Sterile Processing, Mount St. Reprocessing Practice Leader, Interior Health Joseph s & St. Paul s Hospital, Providence Health Authority Care Sheila Konishi Barbara Bolding Program Director, Sterile Processing, Fraser Health Medical Device Reprocessing Consultant Authority Penny Brawn Viola Tang Regional Coordinator, Sterile Processing, Northern Infection Control & Reprocessing practices Manager, Health Authority Provincial Health Services Authority Other Contributors: Dr. Michelle Alfa Medical Director, Clinical Microbiology Discipline, Diagnostic Services of Manitoba Dr.

10 Elizabeth Bryce Co-Director, Provincial Infection Control Network Regional Medical Director, Infection Control, Vancouver Coastal Health Authority | Page 5 of 136 pages Best Practice Guidelines for cleaning , Disinfection and Sterilization in Health Authorities - December 2011. Albert Csapo Manager, Sterile Processing, Vancouver Coastal Health Authority Sandra Daniels Coordinator, Infection Prevention and Control, Fraser Health Authority Bruce Gamage Network Manager, Provincial Infection Control Network Dr. Judith Isaac-Renton Co-Director, Provincial Infection Control Network Public Health Laboratory Director, BC Centre for Disease Control College of Physicians & Surgeons of BC. Provincial Infection Control Network's Community of Practice All other provincial contributors from the fields of infection control, medical device reprocessing, risk management and health operations. | Page 6 of 136 pages Best Practice Guidelines for cleaning , Disinfection and Sterilization in Health Authorities - December 2011.