By Susan Klacik
The Joint Commission (TJC) published its top five challenging requirements for 2022, and three of them pertain to the sterile processing department (SPD). Ambulatory care facilities, office-based surgery, critical access hospitals and general hospitals have a low comliance score for IC.02.02.01, EP 2: The organization implements infection prevention and control activities when doing the following: Performing intermediate and high-level disinfection and sterilization of medical equipment, devices, and supplies. Most of these processes are performed in the SPD.
It is vital that all processes for sterilization and disinfection are performed, monitored and documented according to the most current standards and guidelines. As the experts in disinfection and sterilization, SP professionals are often consulted about how to perform these tasks. SP professionals should set an example of best practices in their health care facilities and share their distinctive expertise with the rest of the organization.
Environmental management is another frequent area of noncompliance, according to TJC. Critical access hospitals and hospitals had an overall low score for the environment of care requirement, EC.02.05.01, EP 15: In critical care areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, filtration efficiencies, temperature, and humidity. For new and existing health care facilities or altered, renovated or modernized portions of existing systems or individual components (constructed or plans approved on or after July 5, 2016), heating, cooling and ventilation are in accordance with NFPA 99-2012. This includes 2008 ASHRAE 170 (or state design requirements if more stringent).
Ambulatory care settings scored low in EC.02.05.01, EP 7: In areas assigned to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation systems provide appropriate pressure relationships, air-exchange rates, filtration efficiencies, relative humidity, and temperature. The Environment of Care is a facility-wide requirement, and there are specific humidity, temperature and airflow requirements for each area of the SPD. While SP leadership is responsible for assuring these requirements are in place and monitored, all SP staff must be diligent in keeping doors and windows that control airflow closed when not in use.
Staff safety must always be a priority; however, TJC identified the use of personal protective equipment (PPE) as another area of low compliance, especially in ambulatory care and office-based surgery settings (IC.02.01.01, EP 2: The organization uses standard precautions, including the use of personal protective equipment, to reduce the risk of infection). Wearing PPE in the decontamination room is a requirement, not an option. One of the chief complaints regarding PPE is it becomes hot and uncomfortable to wear. There are products available to keep staff cool when wearing PPE, and work practices – such as rotating staff more often throughout the shift – can also help prevent overheating and discomfort.
Note: The March/April 2022 and January/February 2023 issues of HSPA’s PROCESS magazine featured updates on the Ofstead & Associates American Journal of Infection Control (AJIC) studies on decontamination splashes and aerosolization. The study results provided evidence of the critical importance of proper PPE use, among other vital requirements. Also, HSPA’s Process This! podcast (Episode 83: Keeping Cool with Decontamination PPE) features an SP team from Lebanon VA Medical Center that shared about their unique and creative methods for maintaining comfortable decontamination PPE.
To read more about TJC’s infection prevention and control resources and the organization’s approach to standards compliance, visit www.jointcommission.org/resources/patient-safety-topics/infection-prevention-and-control/.
– Susan Klacik, BS, CRCST, CIS, CHL, ACE, FCS, is a clinical educator with HSPA.
