AUTOCLAVE: STERILITY TESTING *

Effective Date: 
Wed, 06/01/2005
Reviewed: 
Wed, 12/22/2021
Revised: 
Wed, 12/22/2021

Test: In-house sterility testing for autoclaves
Equipment:

Sterility Spore Test Pack
Ritter M11 UltraClave
Dry incubator

Principle:

Sterility spore tests are intended for use in the monitoring of saturated steam sterilization cycles at 121ºC. Each ampule contains a spore suspension within a growth medium that functions as a pH indicator. The acid production associated with growth causes a change in color from purple to yellow.

Frequency of Testing: For greatest control of sterilized goods, and per manufacturer guidelines, sterility spore testing should be performed weekly.

Precautions: Do not use after expiration date on box. Sterility spore test ampules should be handled with care since they contain live cultures.

Disposal: All ampules should be disposed of in a sharps container.

Procedure: Autoclave Operator

1. Autoclave operator will include one sterility spore test pack in back, bottom area of chamber. The pack should be place in the autoclave face up and run with instruments.

2.  Label the outside of the pack with the following information:

  • Ritter 1 or Ritter 2
  • Date of spore test
  • Operator initials

3.  Document on "Autoclave Monthly Activity Log", HC: 899:  Operator's Initials, Date/Time In, Spore Test Done = "Yes"

4. Sterilize according to normal procedure.

5. Autoclave operator places lab orders in EMR to document spore tests:

  • Open Chart > Encounter Pad > Primary Care Chart Note (non-appt), MA places orders on both test patients:
  • Test, Autoclave Floor 1 (Break the Glass note – Weekly Spore Test)
  • Test, Autoclave Floor 2 (Break the Glass note – Weekly Spore Test)
  • In chart note, in Notes field, enter “Weekly autoclave spore check”
  • Orders > Order Sets > Autoclave Check > Autoclave Sterilization Check
  • Change Ordering Provider to Medical Director's name
  • Diagnosis:  Find – change to ICD-10 - enter Z00.00 Normal General Exam
  • Sign each note

6. After autoclave cycle is complete, remove pack from autoclave. Verify both temperature indicators:

  • One on the outside of pack
  • One on the Load Record Card inside the pack

7. Carefully remove sterilized ampule from pack, wrap tape around the top and label with “1” or “2”. Remove the Load Record Card and document “Ritter 1” or “Ritter2”, date, and initials on card. Submit ampules and Load Record Cards to Lab.

CAUTION: Contents of the ampule are hot and under pressure. Failure to allow sufficient cooling time (10-15 minutes) may result in bursting of the ampule.

8. Autoclave operator is responsible for following up with Lab if no notification of spore test result ~10 hours after delivery to Lab.

Procedure: Laboratory

1. Place labeled ampule(s) into dry incubator.

4. After a minimum of 10 hours incubation, enter results of both spore tests into respective EMR charts and dispose of ampules in a sharps container.

A failed sterilization cycle is indicated by turbidity and/or a change in color to or toward yellow. A test ampule that retains its purple color indicates an adequate sterilization cycle.

Documenting Results and Follow Up

1. Negative results:

  • The laboratory staff documents the negative result(s) in the Laboratory Information System, which uploads to the EMR chart.
  • By end of week, Clinic Director or Assistant Clinical Operations Coordinator reviews and acknowledges results in EMR.
  • Clinic Director or Assistant Clinical Operations Coordinator sends results to autoclave operator via IM. Autoclave operator records results on respective Autoclave Monthly Activity Logs (HC: 899).

2. Positive results:

  • Lab makes stat call to the Charge Nurse indicating that autoclave spore test was “Positive at (#) hours: please repeat test."
  • The Charge Nurse notifies appropriate manager/supervisor.
  • The laboratory staff documents the positive result(s) in the appropriate EMR chart.
  • Nursing staff and/or manager/supervisor, upon receiving positive results, will:
    • Consult Autoclave Monthly Activity Log (HC: 899) to identify whether any unwrapped equipment/instruments have been autoclaved since the previous negative spore test run.
    • Arrange for any wrapped and unwrapped equipment/instruments processed since the previous negative spore test to be removed from use and reprocessed.
    • Asses possible patient involvement (instruments used in procedures, etc.) and notify patients as needed.
    • Compete and submit an Incident Report via the RLS system.

Quality Control: A non-autoclaved ampule is included with incubation of autoclaved ampules to ensure spore viability.

Reference: Product insert located in the Student Health Center Lab.