Infection preventionists who have oversight or consulting work with community health centers should be aware that The Joint Commission (TJC) is zeroing in on high-level disinfection problems in these settings.

“Our surveyors at community health centers are observing many serious infection control-related risks concerning high-level disinfection and sterilization practices during recent onsite survey events,” notes Pam Komperda, BS, project manager of TJC accreditation for community health centers.

“Any immediate threat to the health or safety of patients or staff that is identified during your onsite survey can lead to a Preliminary Denial of Accreditation decision.”

In a TJC blog¹, Komperda said the top noncompliance item is the accreditation requirement for infection prevention measures when “performing intermediate and high-level disinfection and sterilization of medical equipment, devices, and supplies.”

Some of the lapses accreditation surveyors are citing include:

• Poor Training: Lack of documented frontline staff competency and training specific to the sterilization processes specific to infection control. Lack of trained, documented managerial/supervisory oversight specific to this area.

• Overlooking Evidence: Little use or adherence to any sterilization evidence-based guidelines. Use of chemical indicators for ultrasound probes expired. Poor adherence to manufacturers’ instructions for use for medical and dental instruments and supplies.

• Ignoring Indicators: Premature release of instruments prior to the 24-hour read time of biological indicator result as required per the manufacturer’s instructions. Inconsistent use of chemical indicators in paper-plastic peel pouches. Inadequate documentation of physical/mechanical monitoring that sterilization parameters were met (time, temperature, pressure).

• Noncompliant Use of Instruments: Failure to use personal protective equipment, including protective gowns or eye shields, during decontamination activities. Instruments being cleaned, decontaminated, and left to dry in the only sink available in the procedure room. No clean sink available for hand hygiene.

REFERENCE

1. Komperda P. High Level Disinfection Control Alert for Health Centers. Joint Commission Blog: On Infection Prevention & Control. Mar. 19, 2018. Available at: https://bit.ly/2pRttzc.