MAIN ED High Level Disinfection (HLD) of Ultrasound Transducers Standard Operating Procedure

Required Transport Equipment:

1. Non-permeable solid plastic transport container with lid

2. Interchangeable Biohazard/Clean signage for transport container

3. Approved compatible disinfectant wipe for Low Level Disinfection (LLD) of ED transducer. (per MIFU)

4. Peel Pack Pouch

5. 2 Patient identification labels

Emergency Room Caregiver

1. Performing provider removes transducer from clean peel pack pouch, retains pouch

2. Performs procedure followed by low level disinfection (LLD) of transducer in the procedure room

a. Remove transducer cover

b. Remove all excess gel off transducer using hospital approved disinfectant wipes (as per MIFU)

c. Place transducer into the original peel pack pouch

d. Place packaged transducer in plastic transport container and secure lid.

e. Remove PPE and perform hand hygiene

f. Secure signage on container lid to display “Biohazard” prior to transporting the soiled transducer.

g. Print two (2) patient identification labels for Ultrasound, required information: Patient’s full name and birthdate CCAG Medical Record Number One label will be affixed to hand-off ledger in U/S Utility Room the other placed in the clear view window of the transport container.

h. ED Caregiver will deliver the transducer in the transport carrier to Ultrasound Utility Room AEM1-801 located in Split Flow. The carrier will be placed in the identified/designated area under the counter in the soiled section of the room. THIS IS NOT THE SOILED UTILITY ROOM

i. Tracking: ED Caregiver delivering the transducer is required to complete the hand-off ledger located in U/S Utility Room. Affix Patient ID label to ledger, legibly print the physician’s name who performed the ultrasound, their full name, time/date of delivery, transducer model and serial number (S/N) j. After delivery, ED Caregiver will call “ED Ultrasound” via the Vocera and notify the Ultrasonographer that a transducer has been delivered to the utility room.

3. Troubleshooting Communication via Vocera: Deviations from any one of the Standard Operating Procedures will be reported by the Ultrasonographer to the ED Resource Nurse on duty. After corrective action is complete and is communicated back to Ultrasonographer, HLD of the transducer will be performed.

4. ED New or Loner Transducers: To assure accurate HLD documentation, prior to use, ED leadership is responsible to provide the Radiology Ultrasound Coordinator the transducer model and serial number.

Ultrasound Caregiver

1. Perform HLD following Trophon Standard Operating Procedure as per MIFU

2. After HLD is complete, a clean sheath will be placed over transducer, entire device will be placed in a new peal pack pouch and sealed closed. The exterior of the pouch will be identified with a label on which the Ultrasound Caregiver will document their initials and the date of cleaning.

3. Clean entire interior and exterior of transport container with hospital approved disinfectant.

4. Remove PPE and perform hand hygiene

5. Place HLD transducer in peel pack in transport container. Secure signage on container to display “Clean”

6. Tracking: Ultrasound Caregiver who performed HLD and who is returning the transducer in the transport container is required to complete the hand-off ledger in U/S Utility Room. Legibly print full name, time/date returned to designated ED clean storage location.

7. Ultrasound Caregiver who performed HLD is responsible to complete the Radiology HLD Trophon Log.

Timeline and Criteria for Trophon HLD Services

1. Trophon HLD services will be available on all shifts, 365 days a year.

2. Timeline of HLD will be dependent on Radiology Ultrasound inpatient and ED workload.

3. ED Physician or designee will contact Radiology Ultrasound Caregiver to discuss need to expedite HLD. Issue Date 7/21/2020 Radiology Program Manager Compliance/Safety, Radiology Ultrasound Coordinator

(Last update 07/2020)