Policy & Procedure for Autoclave Use in a Physician's Office

As most patient encounters happen in an outpatient setting, such as a doctor’s office, it is important that office staff follow infection control practices. Along with hand washing before and after contact with a patient and proper needle precautions, sterilization of equipment is an important procedure in preventing the spread of infectious agents. An autoclave is a familiar tool in this process.

Policy for Using an Autoclave

• Sterilization of equipment in the physician’s office can be accomplished by using an autoclave. It works by using pressurized steam to sterilize instruments. Items must be cleaned with soap and water before autoclaving. This removes organic debris. Use distilled water in the autoclave machine. Expose the instruments to a temperature of 121 degrees Celsius to 132 degrees Celsius. Expose instruments that are not wrapped for 20 minutes, and expose small packs for 30 minutes. Immediately transfer sterile instruments to a sterile container. Autoclaves are a serious burn hazard, so read and be thoroughly familiar with the owner’s manual.

Procedures

• As different autoclaves have different features, you must follow the manufacturer’s instructions on loading and load sizes. The manufacturer will also give directions on cycle types and unit settings. Ensure that the drain strainer is clean before every run. Pack materials so the heat and pressure can sterilize the entire load. Make sure the gaskets are in place and lock the doors firmly before running a load in the autoclave. Check to make sure items have been thoroughly sterilized by wrapping an item with autoclave tape. The autoclave tape changes color when the correct temperature has been reached. Attach a string to it and place it in the load. Attach the other end of the string to the exterior of the bag. At the end of the cycle, pull the string out and check to see if the color is correct. If the dye on the tape fails, examine the autoclave to see if the problem can be identified. If so, correct the issue and run the load again.

Maintenance Procedures

• On a regular basis, use a biological indicator to ensure that the autoclave is working correctly. Some examples of biological indicators are Amsco’s Proof System or BBL’s Kilit. Perform maintenance procedures daily.

Tips

• Write out office policies and procedures concerning sterilization and disinfection. This will ensure that everyone in the office knows and follows procedures properly. Regularly review policies and procedures.