Concurrent Education Session - 60 minutes

2103 - Implementing a High-Level Disinfection/Sterilization Observation Program across a Large Pediatric Network

Thursday, June 15
10:15 AM - 11:15 AM
Location: Oregon Convention Center, B 110-112

Lack of compliance with high-level disinfection and sterilization (HLD/S) practices is reported to be one of the top five Joint Commission findings. Many organizations struggle with a decentralized structure for reprocessing activities, particularly as healthcare networks continue to merge and grow. Using our organization’s Hand Hygiene Observation Program as a model, we created a robust HLD/S observation program to audit and report compliance with reprocessing activities across the Children’s Hospital of Philadelphia’s (CHOP) large ambulatory pediatric network. CHOP has 23 locations outside of the central processing department, including four ambulatory surgical facilities, located in several locations across two states. Activities at these locations are varied between sites and include cleaning, packaging, and sterilization of instruments, cleaning and HLD of channeled and nonchanneled endoscopes, or a combination of any of the preceding. Infection prevention and control (IPC) collaborated with the central processing department and key ambulatory site leaders to develop standard operating procedures that detail expectations for reprocessing activities at each location. We also developed electronic monitoring tools that facilitate data collection on compliance with reprocessing activities and generate reports on performance. To maintain compliance across all sites, a centralized governance structure, an HLD/S Task Force, was established with representatives from multiple departments, including endoscopy, respiratory, biomedical engineering, operative services, ambulatory surgical services, specialty care clinics, central processing department, regulatory and accreditation, and IPC. The HLD/S Task Force sets standards and goals for the network to drive improvement and ensure compliance with reprocessing activities. This structure, combined with a robust observation program, has decreased reprocessing deficiencies and improved transparency in an ongoing effort to support patient safety.

Learning Objectives:

Susan Rettig

Senior Infection Preventionist
Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania

Susan (Susy) Rettig is a senior infection preventionist at the Children's Hospital of Philadelphia. Susy earned her BSN from Thomas Jefferson University and worked as a nurse in adult and pediatrics, both in acute care and ambulatory settings. Susy was a research nurse in the Special Immunology Family Clinic, assisting with enrollment and care for clinical drug trials for HIV-positive patients. Susy’s strong interest in global health spurred travel to Nicaragua and Botswana to assess healthcare needs and provide medical attention and education. Susy has been certified in infection prevention and control for over 10 years and involved in the field for 15 years. As an active member of the Delaware Valley APIC chapter, Susy presented posters at APIC and SHEA in the areas of infection prevention in oncology and high-level disinfection and sterilization. As a senior infection preventionist, Susy mentors new infection preventionists in her specialty areas.


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Sarah Smathers

Manager Infection Prevention and Control
Department of Infection Prevention and Control, Children's Hospital of Philadelphia
Philadelphia, Pennsylvania

Sarah Smathers, MPH, CIC, FAPIC is the Manager of Infection Prevention and Control at the Children’s Hospital of Philadelphia (CHOP). Sarah has conducted research in infectious diseases and infection prevention and control in the areas of Clostrium difficile, multidrug-resistant organisms, and healthcare-associated infection prevention. She has worked in infection prevention at CHOP since 2009, was CIC certified in 2010, and became an APIC Fellow in 2016. She is the vice chair of the Infection Prevention and Control Committee at CHOP and serves on the Awards and Nominating Committee for the APIC Delaware Valley chapter and the Public Policy Committee for national APIC. She has presented abstracts at national conferences, including SHEA and IDWeek, and has published on the epidemiology and prevention of infectious diseases. Sarah earned a bachelor's degree in biology from Kalamazoo College and master of public health in hospital and molecular epidemiology from the University of Michigan.


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Sara Reese

Infection prevention specialist
Denver Health Medical Center
Denver, Colorado

I received my PhD in Microbiology from Colorado State University in 2008. I did a 2 year post doctoral fellowship at the Centers for Disease Control working on tularemia and plague from 2008-2010. I then worked in the Health Facilities Division at the Colorado Department of Public Health and Environment from 2010-2012. I am currently an Infection Prevention Specialist at Denver Health Hospital.


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2103 - Implementing a High-Level Disinfection/Sterilization Observation Program across a Large Pediatric Network

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