Purpose/ Applicability: 

The purpose of this SOP is to provide the proper procedure for packaging items for sterilization.

Scope:

To be used when sterilization of items is necessary to ensure the effective elimination of transmissible agents. 

Definitions:

Sterilization – The process of eliminating, removing, killing, or deactivating all forms of microorganisms present on a specific object. 

- Heat Sterilization/Autoclave/Steam

• • Used for solid metal objects and cloth material such as packs/gauze.

-Gas Sterilization/Ethylene Oxide (EO)

• • Used for anything containing plastic parts or pieces.

 - Hydrogen Peroxide Sterilization (H2O2)

• • Used for things requiring quick turnaround or items gas cannot fully sterilize.

When packaging is uncompromised, the contents of the package remain sterile for one year.  Once expired, the item will need to be sterilized in new packaging.  Packaging that has a hole, is wet, is opened, or is otherwise visibly damaged is no longer considered sterile and will need to be repackaged and re-sterilized.

Equipment:

Autoclave

EO unit

H2O2 unit (Sterrad)

Items to be sterilized

Packaging materials –

             Non-woven drape wrap and/or woven cloth drape

             Sterrad drape material

             Self-sealing pouches in an appropriate size and for appropriate sterilization unit

             Sleeve roll in an appropriate size and for appropriate sterilization unit

             Sterilization indicator tape (Green = EO, Brown = Autoclave, Sterrad tape = H2O2)

             Sterilization indicator strip for Autoclave

          Sterilization indicator strip for H2O2

Procedure:

1. Determine the proper type of sterilization required for item(s)
2. Ensure items are clean, free of foreign material, and completely dry
3. Package in the appropriate material
   1. Self-sealing pouch-
      • Needs to be folded at the dotted perforation to ensure proper closure.
      • H2O2 requires a sterilization indicator strip placed within the pouch.
      • Items with sharp or pointed ends need to be double-packaged to prevent holes. The inner package must not be folded in order to allow for proper sterilization.
      • Items with multiple separate pieces need to be individually packaged and then packaged together.
        
        
   2. Sleeve roll-
      • Cut sleeve to the desired length.  Provide enough material at each end to allow room for the package to be opened without contamination. 
      • Insert item to be sterilized.
      • Fold over each end ¾-1” and tape closed.  Ensure tape wraps around packaging from the front to back and completely seals the package, leaving no holes/gaps on the sides.  Create tabbed ends of tape to aid in opening packaging.  Use green indicator tape for EO items, brown indicator tape for the autoclave items and Sterrad indicator tape for H2O2.  
      • H2O2 requires sterilization indicator strip placed within the package.
      • Items with sharp or pointed ends need to be double packaged to prevent holes. The inner package must not be folded in order to allow for proper sterilization.
      • Items with multiple separate pieces need to be individually packaged then packaged together.
        
        
   3. Non-woven drape wrap and/or woven cloth drape (for Autoclave)
      • Use new appropriately sized blue non-woven drapes and check for holes/tears.
      • When using non-woven drape, use 2 drapes to create a double layer.
      • Lay items intended for pack on the drape.
      • Place Sterilization Indicator strip for Autoclave on top of items.
      • Fold drape
      • Use brown indicator tape to seal the pack             
        
        
   4. Drape for Sterrad (H2O2)
      • Use new appropriately sized drapes and check for holes/tears. 
      • Use 2 drapes to create a double layer.
      • Lay items intended for pack on the drape.
      • Place Sterilization Indicator strip for H2O2 on top of items.
      • Fold drape
      • Use Sterrad H2O2 indicator tape to seal the pack.
        
        
4.  Labeling requirements for each package:
   1. Date (month/day/year) it was packaged
   2. Service dropping of pack for sterilization
   3. Description of what is in pack
   4. Initials of person responsible for packaging
      
      
5.  Bring to appropriate area for sterilization.