1. David McNamara CSSD Manager Holy Spirit Northside Private Hospital 2015 SRACA Qld State Conference - Townsville

2.  Abstract  Aim  Identified Issues – Risk  Risk reporting and Analysis  Actions  3 Month Review and Review  Further Actions and Results  Summary

3.  Preamble ◦ Use of T.O.E. Probe  Diagnostic  Pre-surgical ◦ Change of use in Cath Labs & Cardiac Theatre  Review of Literature ◦ Part of International scene ◦ Highlight of Potential Issues – Cross Contamination  Reporting and Action ◦ Infection Control Committee ◦ Local review – Processing / procedural ◦ Summary

4.  Action undertaken at a HSO: ◦ Confirmation of Risk ◦ Risk Analysis ◦ Process review ◦ Local testing regime ◦ Manufacturer IFU review ◦ Presentation at a reporting committee and ◦ Risk assessment and closure of Reported Potential Risk

6.  Cross Contamination reported  Potential for occurrence at this HSO  Cleaning regime compliance to Manufacture’s IFU  Confirmation of contamination site – control handle  Review of procedural usage  Circulation of reports to Clinical Proceduralists

8.  Local RISKMAN – electronic incident reporting system entry as a Hazard  Escalation of Hazard to National Organisation registry  Compliance of Safe Work Practise (SWP) Competency processing review to Manufacturer’s IFU  Request to Manufacturer to any variation / review to current IFU’s

10.  Actions ◦ E mail to suppliers for comments and comments regarding reports ◦ Processing compliance review ◦ Testing regime to confirm / negate potential Risk ◦ Review date for presentation at next IFC meeting ◦ Initial tests indicated no issue with cleaning T.O.E. Probe sheath – only Control handle / Console plug

11.  Cardiac Theatre ◦ ~ 30% Contaminated after 1 st wash  Cath Lab ◦ < 10% Contaminated after 1 st wash  Cleaning Process compliant with IFU’s  Suppliers deferring to Manufacturer’s IFU’s and initial ignorance of reports  Testing Regime to continue  Proceduralists notified and Probe handling discussed

12.  9 Month review  Reprocessing ◦ Requiring > 2 nd clean to 10%  Result of Proceduralists / Anaesthetic Nursing staff review of practice  Consistency of Cleaning Process

13.  Infection Control Committee Review ◦ Manufacturer IFU responses  No change x 2  Eliminate Rubbing alcohol x 1  Suggestions to ‘Proceduralists on how to do procedure” x 1 – deferred to VMO meeting! ◦ RISKMAN Hazard report closed as  Actions performed  Risk assessed to have been addressed ◦ CSSD Response ◦ Single testing incorporated into Probe Processing

14.  Review research / articles when presented  Demonstrate / identify local risk  Escalate to relevant Committee as Risk  Come bearing proposed review / results  Seek Manufacturer’s Imput  Continue testing to show + or – results  Aim for Risk Resolution  Quality Report activity  Know you have done a good job