ipac checklist for clinical office practice: endoscopy · 2019. 7. 26. · ipac checklist for...

IPAC Checklist for Clinical Office Practice: Endoscopy

This checklist was reformatted for College of Physicians andSurgeons of Ontario (CPSO) to include additional space under

Notes and Recommendations section. To see the original checklist, please visit Public Health Ontario website.

https://www.publichealthontario.ca/en/health-topics/infection-prevention-control/ipac-lapses

2nd Revision: July 2019

IPAC Checklist For Clinical Office Practice – Endoscopy 1

IPAC CHECKLIST FOR CLINICAL OFFICE PRACTICE

Endoscopy

When to use this checklist? This infection prevention and control (IPAC) checklist:

helps guide public health units (PHUs) and regulatory colleges in conducting inspections/assessments/investigations related to infection prevention and control (IPAC) practices.

supports clinical office practices in examining, evaluating (e.g., self-assessment) and comparing theircurrent IPAC practices using provincial recommendations.

does not replace legislative requirements.

Public Health Ontario (PHO) has developed this Checklist for Endoscopy in Clinical Office Practice based on content from the Provincial Infectious Disease Advisory Committee’s (PIDAC’s) Best Practices for Cleaning, Disinfection and Sterilization of Medical Equipment/Devices.

For more information about this IPAC Checklist, please contact [email protected].

Legend Legislated Requirement (LR): Must be compliant with the relevant Act or regulation (e.g., Occupational Health and Safety Act).

High Risk (H): Immediate health hazard exists. Correct the specific high risk activity/activities immediately. The act or failure to act immediately may lead to the transmission of infection or risk of illness or injury.

Medium Risk (M): Correct the medium risk activity/activities. Timelines for compliance or agreement on alternate process to be determined during the inspection.

Inform and Educate (IE): Provide information on best practices and mandatory legislated practice requirements (where applicable). Just-in-time education may be provided.

These categorizations represent the minimum risk level. Based on judgment and circumstance, public health units or any others using the IPAC Checklist, may increase the risk category.

https://www.publichealthontario.ca/en/eRepository/PIDAC_Cleaning_Disinfection_and_Sterilization_2013.pdfhttps://www.publichealthontario.ca/en/eRepository/PIDAC_Cleaning_Disinfection_and_Sterilization_2013.pdfmailto:[email protected]

LR: Legislated Requirement R: Risk C: Compliant NC: Not Compliant NA/NR: Not Applicable/Not Reviewed


Types of endoscopes For the purpose of this checklist, two types of endoscopes will be considered:

Critical Endoscope: Endoscopes used in the examination of critical spaces, such as joints and sterilecavities. Many of these endoscopes are rigid with no lumen. Examples of critical endoscopes arearthroscopes, bronchoscopes and laparoscopes. Critical endoscopes are to be sterilized prior to use(PIDAC CDS, pg 43).

Semicritical Endoscope: Fibreoptic or video endoscopes used in the examination of the hollow viscera.These endoscopes generally invade only semicritical spaces, although some of their components mightenter tissues or other critical spaces. Examples of semicritical endoscopes are laryngoscopes,nasopharyngeal endoscopes, transesophageal probes, colonoscopes, gastroscopes, duodenoscopes,sigmoidoscopes and enteroscopes. Semicritical endoscopes require a minimum of high-level disinfectionprior to use.

Contents

1. Policies and Procedures ..........................................................................................................................................3

2. Education ................................................................................................................................................................4

3. Personal Protective Equipment ..............................................................................................................................5

4. Safe Medication Administration .............................................................................................................................5

5. Environmental Cleaning .........................................................................................................................................6

6. Physical Space .........................................................................................................................................................7

7. Point-of-Care Cleaning ............................................................................................................................................8

8. Cleaning of Endoscopes in Reprocessing Area .......................................................................................................9

9. High Level Disinfection (HLD) .............................................................................................................................. 11

10. Automated Endoscope Reprocessors (AER) ...................................................................................................... 13

11. Drying and Storage of Endoscopes .................................................................................................................... 14

12. Endoscope Transport ......................................................................................................................................... 15

13. Record Keeping .................................................................................................................................................. 15

14. Occupational Health and Safety ........................................................................................................................ 17

Opinions differ regarding the reprocessing requirements for flexible bronchoscopes and cystoscopes. Since they are entering a sterile cavity, it is preferred that bronchoscopes and cystoscopes be sterilized; however, if the cystoscope or bronchoscope is not compatible with sterilization, high-level disinfection is the minimum requirement.



Setting name:

Setting address:

☐ Self-Assessment ☐ Inspection Date: Time:

Name(s) and designation of Inspector/Investigator/Assessor:

Setting contact name(s) and phone number(s):

1. Policies and Procedures

1 Policies and Procedures LR R C NC NA NR

1.1

The purchase of endoscopes that cannot be cleaned and reprocessed according to recommended standards is prohibited; there is a written policy to support this.

Resource: Refer to the section on Purchasing and AssessingMedical Equipment/Devices and/or Products for Disinfection orSterilization Processes

IE

1.2

There are written, detailed device-specific procedures for the handling (including disassembly and reassembly), cleaning, and disinfection/ sterilization of each type of endoscope and accessories that follow the manufacturer’s instructions for use (MIFU).

Resource: Refer to the section on Reprocessing EndoscopyEquipment/Devices Additional

Additional Resource: CAN/CSA – Z314-18 Canadian medicaldevice reprocessing (2018).

IE

http://www.publichealthontario.ca/en/eRepository/PIDAC_Cleaning_Disinfection_and_Sterilization_2013.pdfhttp://www.publichealthontario.ca/en/eRepository/PIDAC_Cleaning_Disinfection_and_Sterilization_2013.pdfhttp://www.publichealthontario.ca/en/eRepository/PIDAC_Cleaning_Disinfection_and_Sterilization_2013.pdfhttp://www.publichealthontario.ca/en/eRepository/PIDAC_Cleaning_Disinfection_and_Sterilization_2013.pdfhttp://www.publichealthontario.ca/en/eRepository/PIDAC_Cleaning_Disinfection_and_Sterilization_2013.pdf



1 Policies and Procedures LR R C NC NA NR

1.3

There are written procedures and MIFU for the use of automated endoscope reprocessors (AERs), sterilizers, or other equipment used in reprocessing.

Resource: Refer to CAN/CSA – Z314-18 Canadian medical device reprocessing (2018).

IE

Notes and Recommendations:

2. Education 2 Education LR R C NC

NA NR

2.1

Staff assigned to reprocess endoscopes receive device-specific reprocessing instructions to ensure proper cleaning and high-level disinfection or sterilization; education includes theoretical and practical components.

Resource: For 2.1 & 2.2, refer to the section on Reprocessing Endoscopy Equipment/Devices

Additional Resource: CAN/CSA – Z314-18 Canadian medical device reprocessing (2018).

M

2.2 Competency testing of personnel reprocessing endoscopes is performed at least annually and documented. M

2.3

Staff involved in reprocessing are trained in the correct use, wearing, limitations, and indications for PPE.

Resource: Refer to the section on Occupational Health and Safety for Reprocessing: Personal Protective Equipment (PPE).

M


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3. Personal Protective Equipment 3 Personal Protective Equipment (PPE) LR R C NC

NA NR

3.1

PPE, such as gown, gloves, mask, and eye protection, is available. Resource: For 3.1 and 3.2, refer to the section on Occupational

Health and Safety for Reprocessing: Personal Protective Equipment (PPE).

Additional Resource: Occupational Health and Safety Act, RSO 1990, c O.1, s.25.

LR M

3.2

PPE (gloves, gown, mask, eye protection) is worn during a procedure and during reprocessing activities (e.g., endoscope cleaning) that are likely to result in splashes or sprays of blood or other body fluids.

Resource: Occupational Health and Safety Act, RSO 1990, c O.1, s.28.

LR M


4. Safe Medication Administration 4 Safe Medication Administration LR R C NC

NA NR

4.1

There are facilities for hand hygiene in the medication room/area. These include either a dedicated hand hygiene sink and/or alcohol based hand rub (ABHR).

Resources: For 4.1 to 4.10, refer to PIDAC Infection Prevention and Control for Clinical Office Practice (April 2015). See sections on Medications, Vaccines and Skin Antisepsis, and Appendix H: Checklist for Safe Medication Practices.

M

4.2 There is a dedicated medication refrigerator as needed (e.g., vaccine). M

4.3 Single-dose injectable medications are preferred and prepared at the time of use, used once on a single patient and discarded immediately. H

http://www.publichealthontario.ca/en/eRepository/PIDAC_Cleaning_Disinfection_and_Sterilization_2013.pdfhttp://www.publichealthontario.ca/en/eRepository/PIDAC_Cleaning_Disinfection_and_Sterilization_2013.pdfhttp://www.publichealthontario.ca/en/eRepository/PIDAC_Cleaning_Disinfection_and_Sterilization_2013.pdfhttps://www.ontario.ca/laws/statute/90o01https://www.ontario.ca/laws/statute/90o01https://www.ontario.ca/laws/statute/90o01https://www.ontario.ca/laws/statute/90o01https://www.publichealthontario.ca/en/eRepository/IPAC_Clinical_Office_Practice_2013.pdfhttps://www.publichealthontario.ca/en/eRepository/IPAC_Clinical_Office_Practice_2013.pdf



4 Safe Medication Administration LR R C NC NA NR

4.4 Unopened vials and other products are discarded according to the manufacturer’s expiration dates. M

4.5 If a multidose vial is used, it is to be used for a single patient/client whenever possible and labelled with the patient’s/client's name. M

4.6 The multidose vial is labelled with the date it was first used and discarded according to the MIFU or within 28 days, whichever is shorter. M

4.7 All needles are single-use only. H

4.8 All syringes are single-use only. H

4.9 Once medication is drawn up, the needle is immediately withdrawn from the vial; a needle is never left in a vial to be attached to a new syringe. H

4.10 Multidose vials are discarded immediately if sterility is compromised or questioned. H


5. Environmental Cleaning

5 Environmental Cleaning LR R C NC NA NR

5.1

The treatment area and endoscopy suite are cleaned between patients, after each case and at least twice per day.

Resource: Refer to PIDAC Best Practices for Environmental Cleaning for Infection Prevention and Control (April 2018). See Appendix 21.

M

https://www.publichealthontario.ca/en/eRepository/Best_Practices_Environmental_Cleaning.pdfhttps://www.publichealthontario.ca/en/eRepository/Best_Practices_Environmental_Cleaning.pdf



5 Environmental Cleaning LR R C NC NA NR

5.2

Laundry is handled with minimum agitation to avoid contamination of the air, surfaces, and persons.

Resource: For 5.2 and 5.3, refer to: PIDAC Infection Prevention and Control for Clinical Office Practice (April 2015). See section on (Laundry and Bedding)

IE

5.3 The setting considers the MIFU of the washer and dryer, the materials to be laundered, and the detergent used when laundering. IE


6. Physical Space 6 Physical Space LR R C NC

NA NR

6.1

There is a one-way work flow from dirty to clean with adequate separation to minimize risk of cross-contamination.

Resource: For 6.1 – 6.6, refer to the section on Reprocessing Endoscopy Equipment/Devices: Physical Space


H

6.2

There is adequate space for the storage and holding of soiled materials that is separate from other activities and controlled to prohibit public contact.

M

6.3 Processing/decontamination room(s) is/are provided with utility sink(s) appropriate to the size and type of endoscope used, the volume of work and method of decontamination used.

M

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6 Physical Space LR R C NC NA NR

6.4 There are sufficient flat, cut-resistant, seamless, and, non-porous work surfaces that can be cleaned, disinfected, and dried to handle the volume of work.

M

6.5 Dedicated hand washing sinks, preferably hands-free, and/or ABHR are conveniently located in or near all reprocessing and preparation areas and at all entrances to and exits from the reprocessing area.

M

6.6

The reprocessing area has engineering controls to ensure good air quality, specifically:

air-exchange equipment (e.g., ventilation system, exhaust hoods) is in place to minimize the exposure of all persons to potentially toxic vapours;

documented, regular maintenance of the air-exchange equipment; and

chemical products are maintained in closed, covered, labelled containers at all times.

M


7. Point-of-Care Cleaning

7 Point-of-Care Cleaning (immediately following completion of the endoscopy procedure)

LR R C NC NA NR

7.1

Chemical products containing a disinfectant are licensed for use in Canada.

Resource: Refer to the section on Methods Of Disinfection For Semicritical Medical Equipment/Devices

H

http://www.publichealthontario.ca/en/eRepository/PIDAC_Cleaning_Disinfection_and_Sterilization_2013.pdfhttp://www.publichealthontario.ca/en/eRepository/PIDAC_Cleaning_Disinfection_and_Sterilization_2013.pdf



7 Point-of-Care Cleaning (immediately following completion of the endoscopy procedure)

LR R C NC NA NR

7.2

All endoscope channels are flushed with enzymatic detergent or water, according to the MIFU.

Resource: For 7.2 – 7.6 refer to the section on Reprocessing Endoscopy Equipment/Devices: Cleaning Procedures

H

7.3 The exterior is wiped with a soft lint-free cloth or endoscope sponge. H

7.4

The endoscope and accessories should be kept moist during transport and until manual cleaning occurs.


M

7.5 The endoscope and accessories are placed in a covered, leak proof container and transported to the designated decontamination area. H

7.6

Transportation to decontamination area should be completed and full manual or AER cleaning started within one hour of bedside pre-cleaning.


H


8. Cleaning of Endoscopes in Reprocessing Area 8 Cleaning of Endoscopes in Reprocessing Area LR R C NC

NA NR

8.1 The MIFU for cleaning and cleaning products are followed.

Resource: For 8.1 to 8.16, refer to the section on Reprocessing Endoscopy Equipment/Devices

H

8.2 A leak test is performed after each use, prior to cleaning, according to the MIFU.

H ☐ ☐ ☐

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8 Cleaning of Endoscopes in Reprocessing Area LR R C NC NA NR

8.3 There is a policy and procedure that ensures that an endoscope that fails the dry leak test does not undergo the immersion leak test and is sent for repair.

IE ☐ ☐ ☐

8.4 All immersible endoscope components are soaked and manually cleaned with water and a recommended cleaning agent prior to automated or further manual disinfection or sterilization.

H

8.5 Endoscope components (e.g., air/water and suction valves) are disconnected and disassembled as far as possible and completely immersed in enzymatic cleaner.

H

8.6 All channels and lumens of the endoscope are flushed and brushed (where appropriate) while submerged to remove debris and minimize aerosols.

H

8.7 The endoscope and all components are thoroughly rinsed with clean, fresh tap water prior to disinfection/sterilization and excess rinse water is removed from the channels by purging with forced air.

M

8.8 Damaged endoscopes/accessories are identified and immediately removed from service.

H

8.9 Enzymatic cleaner is discarded after each use and sink is cleaned M

8.10

Brushes, cloths, syringes, and other cleaning devices used for cleaning lumens are of a correct size, and inspected for cleanliness and good repair before use.


M

8.11

After each use, cleaning devices are discarded (e.g., single-use, damaged) or cleaned, high-level disinfected or sterilized, dried, and inspected before reuse.


M

8.12 Reusable semicritical endoscopic accessories are cleaned (e.g., in an ultrasonic washer), then receive high-level disinfection (HLD) according to MIFU.

H

8.13 Reusable critical endoscopic accessories (e.g., biopsy forceps, cytology brushes, papillatomes) are cleaned, then sterilized according to MIFU.

H

8.14 The water bottle, cap, and its connecting tube used for cleaning the endoscope lens and irrigation during the procedure are sterilized according to MIFU.

H



8 Cleaning of Endoscopes in Reprocessing Area LR R C NC NA NR

8.15 The water bottle is filled with sterile water. H

8.16

Fully cleaned and rinsed endoscopes do not sit longer than 30 min. prior to proceeding to the HLD process.


M


9. High Level Disinfection (HLD)

9 High Level Disinfection (HLD) LR R C NC NA

NR

9.1

Semicritical endoscopes receive, at a minimum, high-level disinfection.

Resource: For 9.1 to 9.9, refer to the section on Methods of Disinfection for Semicritical Medical Equipment/Devices: Liquid Chemical Disinfection.

H

9.2 Disinfectant/chemical sterilant is compatible with the endoscope. M

https://www.publichealthontario.ca/en/eRepository/PIDAC_Cleaning_Disinfection_and_Sterilization_2013.pdfhttps://www.publichealthontario.ca/en/eRepository/PIDAC_Cleaning_Disinfection_and_Sterilization_2013.pdfhttps://www.publichealthontario.ca/en/eRepository/PIDAC_Cleaning_Disinfection_and_Sterilization_2013.pdf



9 High Level Disinfection (HLD) LR R C NC NA

NR

9.3

Minimum effective concentration (MEC) testing is performed before each medical device is processed for manual high-level disinfection; MEC testing is performed in each cycle for automated high-level disinfection.


H

9.4 High-level disinfectant test strip bottles are dated when opened and discarded as per the MIFU. M

9.5 When high-level disinfectants are opened, the container is dated and the disinfectant is not used past the expiry date or date indicated by MIFU.

M

9.6

The MIFU are followed regarding the disinfectant’s ambient temperature and duration of contact.


M

9.7 If manual disinfection is performed, the disinfectant container is kept covered during use and washed, rinsed, and dried when the solution is changed.

M

9.8

The endoscope/endoscope components are completely immersed in the disinfectant/chemical sterilant and all channels are perfused.

Additional Resource: For items 9.8 to 9.9, refer to the section on Reprocessing Endoscopy Equipment/Devices

H

9.9

Following high level disinfection, the endoscope is rinsed and the channels are flushed with filtered or sterile water; sterile water is preferred. Tap water followed by a 70-90% alcohol rinse may be acceptable depending on the intended use of the device.

H


http://www.publichealthontario.ca/en/eRepository/PIDAC_Cleaning_Disinfection_and_Sterilization_2013.pdf



10. Automated Endoscope Reprocessors (AER) 10 Automated Endoscope Reprocessors (AER) LR R C NC

NA NR

10.1

The sterilizer/AER is licensed in Canada; the unit appears on Health Canada’s listing of active medical device.

Resource: CAN/CSA – Z314-18 Canadian medical device reprocessing (2018).

H

10.2

The AER is compatible with all endoscopes to be reprocessed in the AER.

Resource: For 10.2 to 10.7, refer to the section on Reprocessing Endoscopy Equipment/Devices-Automated Endoscope Reprocessor (AER)

H

10.3 There is a process to routinely review alerts and advisories for reports of AER deficiencies. IE

10.4 AER process indicators are monitored for each run and results are recorded in a logbook that includes identification of endoscopic equipment processed (see Record-Keeping).

H

10.5 Once started, the AER is not opened or stopped for any reason; if a cycle is stopped, the entire process is repeated. H

10.6 There is a documented preventive maintenance program for the AER(s). M

10.7 If an AER with a drying cycle is used, verification of a rinse with 70% isopropyl alcohol and forced air drying is done as required. H


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11. Drying and Storage of Endoscopes 11 Drying and Storage of Endoscopes LR R C NC

NA NR

11.1

During the final drying of semicritical endoscopes:

all channels are initially flushed with medical or filtered air; all channels are then flushed with 70% isopropyl alcohol to aid in the

drying process; and the channels receive a second flush with medical or filtered air or are

placed to dry in in a HEPA-filtered drying cabinet. Resource: For items 11.1 to 11.9, refer to the section on

Reprocessing Endoscopy Equipment/Devices Additional Resource: CAN/CSA – Z314-18 Canadian medical

device reprocessing (2018).

H

11.2 Reprocessing date is identified for each endoscope. M

11.3 Caps, valves, and other detachable components are removed during storage and reassembled just before use. M

11.4 Detachable components are stored close to the endoscope in a manner that minimizes contamination. M

11.5

After cleaning and disinfection/sterilization, endoscopes are stored by hanging vertically in a dedicated, closed, ventilated cabinet that has a sealed door outside of the reprocessing area, procedure room, hallway, or high traffic area.

M

11.6 Endoscopes are prevented from coiling or touching the floor or bottom of the cabinet while hanging. H

11.7 Endoscope storage cabinets are constructed of non-porous, cleanable material. M

11.8 Endoscope storage cabinets are cleaned and disinfected (LLD) at least weekly. M

11.9 Colonoscopes are reprocessed if not used within seven days. M


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12. Endoscope Transport 12 Endoscope Transport LR R C NC

NA NR

12.1

Immediately following the completion of the endoscopic procedure, endoscopes are transported in a lidded, leak proof container that protects the endoscope from damage.

Resource: Refer to the section on Reprocessing Endoscopy Equipment/Devices

M

12.2

Transport containers used to carry contaminated endoscopes are cleaned and disinfected after each use.

Resource: Refer to the section on Transportation and Handling of Contaminated Medical Equipment/Devices

M

12.3

There is a system in place to differentiate transport containers used for clean and contaminated endoscopes (e.g., colour-coding).

Resource: CAN/CSA – Z314-18 Canadian medical device reprocessing (2018).

M


13. Record Keeping 13 Record Keeping LR R C NC

NA NR

13.1

For each procedure, the following are documented: patient’s name and record number, date and time of the procedure, type of procedure, name of endoscopist, serial number, or other identifier of both the endoscope and the AER to facilitate contact tracing, as required.

Resource: Refer to section on Reprocessing Endoscopy Equipment/Devices

M

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13 Record Keeping LR R C NC NA NR

13.2

A record is kept of each sterilizer/HLD cycle, including: the load control label which includes the sterilizer/AER number,

load number and date of HLD; recording chart or printout of the physical parameters of the

sterilization/HLD cycle; load contents; and person responsible for the sterilization/ HLD cycle.

Resource: For 13.2 to 13.8, refer to CAN/CSA – Z314-18 Canadian medical device reprocessing (2018).

H

13.3

The following is recorded for AERs: date of any maintenance performed; fault codes recorded and corrective actions taken; filter changes; cycle printouts; and resetting or verification of correct cycle parameters following

repair or maintenance.

H

13.4

A written log of high-level disinfectant concentration monitoring is maintained.


H

13.5 The following is recorded for endoscopes:

endoscope inventory; and repair and maintenance history.

M

13.6 A log is kept of chemical indicator monitoring results. H

13.7 A log is kept of all maintenance and interventions associated with a positive chemical indicator. H

13.8 Records are retained according to the policy of the health care facility. IE




14. Occupational Health and Safety 14 Occupational Health and Safety LR R C NC

NA NR

14.1

Setting reviews all policies and procedures for reprocessing medical equipment/devices to verify that worker safety measures and procedures to eliminate or minimize the risk of exposure are followed and are in compliance.

Resource: Refer to the section on Occupational Health and Safety for Reprocessing Additional resource.

Additional Resources: CAN/CSA – Z314-18 Canadian medical device reprocessing (2018).

Occupational Health and Safety Act, R.S.O. 1990, c.0.1

LR IE

14.2

There is a policy or procedure in place to prevent the transmission of blood-borne pathogens (i.e. hepatitis B, hepatitis C and HIV) that includes an immunization policy for hepatitis B vaccination and a record of documented immunity to hepatitis B by serology.

Resource: Refer to PIDAC Infection Prevention and Control for Clinical Office Practice (April 2015). See section on Administrative Control

Additional Resource: Blood- borne Diseases Surveillance Protocol for Ontario Hospitals developed by the OHA/OMA in collaboration with the MOHLTC.

IE

14.3

An eyewash fountain is provided when there is the potential for injury to the eye due to contact with a biological or chemical substance.

Additional Resource: Refer to Canadian Centre for Occupational Health and Safety

LR IE

14.4

There is a plumbed or self-contained eyewash station within a 10-second walk (16 to 17 metres [55 feet]) of the reprocessing area.

Resource: Refer to the Appendix C: Recommendations for Physical Space for Reprocessing.

IE

14.5 There is a policy that prohibits eating/drinking, storage of food, smoking, application of cosmetics or lip balm, and handling contact lenses in the reprocessing area.

IE


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Please print and sign:

Owner/Operator (print name):

Signature: Date:

Inspector/Assessor/Investigator Signature:

Additional Inspector/Assessor/Investigator Signature(s):

Additional Notes:

Citation Ontario Agency for Health Protection and Promotion (Public Health Ontario). IPAC checklist for clinical office practice: Endoscopy. Toronto, ON: Queen's Printer for Ontario; 2018.

Disclaimer This document was developed by Public Health Ontario (PHO). PHO provides scientific and technical advice to Ontario’s government, public health organizations and health care providers. PHO’s work is guided by the current best available evidence at the time of publication. The application and use of this document is the responsibility of the user. PHO assumes no liability resulting from any such application or use. This document may be reproduced without permission for non-commercial purposes only and provided that appropriate credit is given to PHO. No changes and/or modifications may be made to this document without express written permission from PHO.

Public Health Ontario Public Health Ontario is a Crown corporation dedicated to protecting and promoting the health of all Ontarians and reducing inequities in health. Public Health Ontario links public health practitioners, front-line health workers and researchers to the best scientific intelligence and knowledge from around the world.

For more information about PHO, visit publichealthontario.ca.

Publication History Published: July 2016

1st Revision: November 2018

2nd Revision: July 2019

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