Testing Approaches
Editor's Note: AAMI members can pose questions to JCAHO standards experts and obtain official responses by e-mailing questions to [email protected].
Q: What is the Joint Commission's standard for frequency of spore testing in autoclaves? Weekly? Monthly? Should we just follow the manufacturer's guidelines?
A: Generally speaking, the Joint Commission avoids issuing tightly prescriptive rules on clinical specifics. In the area of medical equipment management, our role is to make sure organizations design and implement adequate processes for ensuring the safety and effectiveness of medical devices. Therefore, the Joint Commission does not specifically address the frequency of spore testing for autoclaves. It is up to you to develop a reasonable and effective policy for this class of testing.
When determining testing intervals for medical equipment, healthcare organizations should take into account criteria such as manufacturer recommendations, risk level, and hospital experience (see EC.6.10, EP 5). You should also be aware that your state health department may have guidelines covering different kinds of equipment testing. In addition, we expect you to take serious note of any testing recommendations issued by relevant professional organizations—in this case, from the Association of peri-Operative Registered Nurses (AORN) or the Association for Professionals in Infection Control and Epidemiology (APIC). Any decision not to follow widely accepted recommendations should be underpinned by a risk assessment that justifies the departure.
With regard to sterilizer maintenance in general, it is a good practice to hold periodic meetings between all the parties involved to ensure the safe and effective use of the equipment. We recommend that hospital engineers, central sterile staff, clinical users, and representatives from infection control meet two to four times per year to discuss issues that affect sterilizer safety.
Reprinted with permission of Joint Commision Resources, Inc., www.jcrinc.com.