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NORTHWEST HILLS SURGICAL HOSPITAL

6818 AUSTIN CTR BLVD SUITE 100

AUSTIN, TX 78731

INFECTION CONTROL PROFESSIONAL

Tag No.: A0748

Based on interviews with staff and review of available records, it was determined that the facility through the infection control officer did not ensure policies were implemented to avoid sources of infection as approximately two-thirds or more of the surgical instruments sterilized in calendar year 2011 to date were flash sterilized.

Findings were:

The facility sterilization log revealed that in January 2011, 199 total sterilizing loads were run and 144 of those were flash loads; in February 2011, 155 total loads were run and 107 were flash loads; in March 2011, 195 total loads were run and 174 were flash loads; in April 2011, 200 total loads were run and 151 were flash loads; in May 2011, 174 total loads were run and 162 were flash loads; in June 2011, 176 total loads were run and 164 were flash loads; in July, 180 total loads were run and 160 were flash loads; in August 2011, 181 total loads were run and 160 were flash loads; in September 2011, 176 total loads were run and 157 were flash loads; in October 2011, 190 total loads were run and 150 were flash loads.

The Infection Control Director stated in interviews on 11/7/11 that the flash sterilization should " only be used in an emergency, such as a dropped instrument. " The above was confirmed with the Infection Control Director.

Facility policy, OR PROTOCOL: FLASH STERILIZATION, policy #OR065 states that, " Flash sterilization will be only utilized as needed. "

The Centers for Disease Control and Prevention (CDC) website article, GUIDELINE FOR DISINFECTION AND STERILIZATION IN HEALTHCARE FACILITIES, 2008, by William A. Rutala, Ph.D., M.P.H., David J. Weber, M.D., M.P.H., and the Healthcare Infection Control Practices Advisory Committee (HICPAC), found at: , states on page 60 that " it [flash sterilization] is not recommended as a routine sterilization method because of the lack of timely biological indicators to monitor performance, absence of protective packaging following sterilization, possibility for contamination of processed items during transportation to the operating rooms, and the sterilization cycle parameters (i.e., time, temperature, pressure) are minimal. "