AUTOCLAVE: AUTOCLAVE OPERATIONS *

Effective Date: 
Fri, 04/01/2005
Reviewed: 
Mon, 04/16/2018
Revised: 
Thu, 05/07/2015

SUBJECT: AUTOCLAVE OPERATIONS

PERSONNEL: RN, LVN, MA

EQUIPMENT: MIDMARK RITTER M11 ULTRACLAVE AUTOCLAVES

PROCEDURE: REFER TO THE OPERATION MANUALS FOR INSTRUCTIONS

Only those individuals orientated to the autoclave may operate the autoclave.

Precautions: Sterilizer chamber may be hot, use caution when loading and unloading sterilizer and in general when operating the sterilizer.

Clean and dry instruments before putting them into sterilizer, as per "Processing Prior to Autoclaving" policies.

Loading the sterilizer:

  • Sterilize jointed items in an open position.
  • Pouches may overlap in the racks but do not pile or stack (to permit proper steam flow and penetration to the items.) All packs to have a minimum of 1/4 inch clearance away from all sterilizer surfaces.
  • Place steam indicator strip on lowest point of tray with each load.

Maximum Capacities:

  • Per manufacturer specifications.

Standard Cycle Operation:

  • Use autoclave with printer. See NOTE below.
  • Verify water level is adequate per manufacturer instructions; add distilled water if needed.
  • Carefully close and latch door: sterilizer will not operate unless door is closed and latched properly.
  • Initiate proper cycle per manufacturer instructions as determined by either wrapped, unwrapped or pack sterilization.
  • Complete top of printer strip with machine ID, operator initials, date and time of run.
  • Do not attempt to open until cycle is complete.
  • Document on "Autoclave Monthly Activity Log", HC: 899:  Operator's initials, date/time in, wrapped or unwrapped, Spore Test done or not.
  • NOTE: The autoclave without the printer is only used if the printing autoclave is not operational.  If used, the non-printing autoclave must be continuously monitored for the duration of the cycle, ensuring that the temperature and pressure are maintained. The monitoring must be documented and initialled on the the autoclave log.

DOCUMENTATION AND FOLLOW-UP:

Post sterilization verify that the  indicator strip has changed appearance indicating the steam sterilization process has been achieved.

  • Document on "Autoclave Monthly Activity Log", HC: 899:  Operator's initials (staff member removing load),  date/time out, verify steam indicator strip appearance has changed per manufacturer directions.
  • Manually advance paper strip until "Cycle Complete" is visible, tear off paper and initial at bottom, file paper strip in designated location for monthly reconciliation.
  • If the steam indicator strip did not change appearance, or if cycle did not finish correctly per the printout, indicate this on the "Autoclave Monthly Activity Log", HC:  899 and rerun the load.
  • If after the second run the indicator strip has still not changed appearance, indicate this on the "Autoclave Monthly Activity Log",  attach the red "Autoclave Down" tag to the door of autoclave, and notify Charge Nurse or supervisor.
  • Remove packs/pouches  or unwrapped instruments from the failed cycle from circulation and tag as non-sterile. Packs and pouches will be re-wrapped prior to next sterilization. Unwrapped instruments will be reautoclaved.
  • Servicing of the autoclave will be initiated. 

 ROUTINE MAINTENANCE OF EQUIPMENT

Routine maintenance (weekly/monthly/yearly) performed by designated staff as per manufacturer instructions.