Policy & Procedure Manual / Policy #MI/WASH/06/v05 / Page 1 of 21
Section:MicrobiologySterilization and Glass Washing Manual Workflow
Wash-Up Room Workflow
Autoclave
Autoclave Maintenance
Cleaning the Autoclave
Autoclave MISDM1
Autoclave MISDM2
How to Autoclave
Replacing the Autoclave Receipt
Dishwasher
Cleaning the Dishwasher
How to Use the Dishwasher
Freezers
Cleaning Freezer Filters
Garbage
Biohazard Boxes
Confidential Papers
Dumpster
Orange Biohazard Bins
Stericycle Boxes
Green Towels
Hot Air Oven
Incubator
Cleaning Incubators
Incubator Readings
Temperature
CO2
Manual CO2 Readings
Lab Coats
Metal Containers
PHL Bags
Pipette Tips
Plastic Containers – Mycology/ Respiratory Specimens
Recycling
Recyclable Boxes and Containers
Recyclable Paper
Solutions
Acetone/Alcohol
70% Ethanol
Distilled Water
Sodium Phosphate Technical Autoclave Cleaner
Tubes
Day 1
Day 2
Washing Aluminum Slide Trays
Washing Bottles
Washing Bottletop Saline Dispensers
Washing Forceps
Washing Long Tubes with White Caps
Washing Sandy Spring Tubes
Yellow Gloves
Autoclave
Autoclave Maintenance
FREQUENCY: Every Wednesday
- Get two vials of 3M Attest from the tan boxes in the glass cabinet above the sink
- Wrap each vial in a green towel
- Tape the towel shut with autoclave tape
- On the autoclave tape, indicate the autoclave number and the sterilization time (e.g. 30 minutes)
- Autoclave MISDM1 is #1
- Autoclave MISDM2 is #2
- Put each vial in the specified autoclave and autoclave for the specified time
- Can be autoclaved under both “Gravity” and “Liquids”
- “Liquids” is preferred
- Unwrap each vial and write on the vial either #1 or #2
- Attach a piece of tape to each vial
- On each piece of tape, indicate the autoclave number and the sterilization time
- E.g. #1 – 30 minutes
- Bring the completed and labeled vials to Specimen Receiving
Cleaning the Autoclave
FREQUENCY: Clean every two weeks
Autoclave MISDM1
- Remove the autoclave shelf by sliding it out
- Take out 1st circular disk nearest you located on the bottom of the autoclave
- Use a funnel to pour Sodium Phosphate Technical Autoclave Cleaner into hole where the 1st circular disk goes until the cleaner runs out of the 2nd disk at the back (no need to remove 2nd disk)
- Cleaner is located in the cabinet under the autoclaved tubes
- Place the 1st circular disk back into the hole
- Put shelves back into the autoclave
Autoclave MISDM2
- Remove the autoclave racks by sliding them onto the long metal trolley
- Take the dust pan located in front of the fan
- Dust the inside of the autoclave
- Remove the circular filter on bottom of the autoclave and dust
- Put the filter back and fill it with Sodium Phosphate Technical Autoclave Cleaner
- Cleaner is in the cabinet under the autoclaved tubes
- Put racks back into autoclave
How to Autoclave
-For Autoclave MISDM2, press the button labeled “Door” to open
-To close Autoclave MISDM2, continuously press the green button labeled “Door” until the door is shut
-Both autoclaves CANNOT be used at the same time
- Remove any existing tape or labels off of items to be autoclaved
- Put new autoclave tape on items to be autoclaved and write the date on the tape
- If needed, wash items before hand (e.g. glass bottles, tubes etc.)
- Leave lids on bottles and tubes loose for autoclaving, or else the lids will not open after. For sharps jugs, secure the lid with packing tape and put a piece of autoclave tape on top.
- Open the autoclave by pushing the black knob on the bottom right of the autoclave; door will open automatically
- Place items inside the autoclave and slide the autoclave door closed
- Click “Next Cycle” to adjust for liquids or solids
- Select “gravity” for solids
- Select “liquids” for liquids
- Autoclave under the default setting
- “Ster Time” should be 30 minutes
- “Dry Time” should be 20-30 minutes
- Autoclave will signal when the cycle is complete
- Slide the door open – CAUTION: CONTENTS ARE HOT! (use the orange rubber mitts if necessary)
- If autoclaving bottles or tubes, tighten the lids once contents are cool
- Rip off the autoclave receipt at the end of every day and put it inside the box in the shelf above the sink
Replacing the Autoclave Receipt
- Replacement tape is stored in the cabinet above the sink inside the cardboard box on the right side.
- Rip off autoclave receipt
- Remove the cover of the receipt feeder by sliding it down
- Pull out the empty paper roll with the black paper holder still attached
- Press the black button on the bottom left of the panel to dispense remaining paper
- Feed in new roll of paper through the metal slot
- Press the black button to feed paper through completely
- Insert black paper holder into the roll of paper
- Insert the right side of the black paper holder first in the cavity
- Place left side of the black paper holder in after
- Feed the paper through the slot in the cover and replace cover by it sliding upwards
Dishwasher
Cleaning the Dishwasher
FREQUENCY: Clean every month/ month and a half
- Get metal stick found in glass cabinet above the autoclaved tubes, to the right of the wooden box of pens
- Use this stick to clean the dishwasher spraying sticks (these are the stick that make up the dishwasher racks)
- Do so by inserting the metal stick into the hole at the top of each spraying stick and sliding all the way to the bottom to ensure no dirt is caught
How to Use the Dishwasher
- Open the door by turning the handle counterclockwise.
- Pull the dishwashing rack out in order to place items to be washed on the rack
- Ensure that the items are spaced apart
- Remove all labels on the items before washing; the labels will clog the dishwasher
- Push the rack back in, and close the door
- When sliding the dishwasher rack back into the dishwasher, ensure that the pole on the back of the rack inserts into the hole at the back of the dishwasher
- To run an initial rinse cycle, press “Start”
- To add Suma Classic Mechanical Dishwashing Detergent (soap), open the door and pour soap into the gap between the rack and the door
- Soap is located on the metal cart opposite the door in a big white container
- Pour the soap until it reaches the black line on the small plastic cup located in the metal box next to the soap container
- Extra dishwasher soap is located next to the work table or on the bottom shelf of the metal cart opposite the work table
- Cut an opening on the lid of the soap container to pour out the soap easily
- If there is no extra soap, ask Norman to order more
- Press “Start” to run a cycle with soap (this should take about10 minutes)
- When the cycle is finished, open the door part way to let some steam escape, and close the door again
- Repeat this until most of the steam has evaporated
- Wait one minute before opening the door once more
- Pull out the dishwashing rack, lift it upwards and rest it on a metal container to drain water
- Once water has drained, remove the metal container and remove washed items from the rack
Freezers
Cleaning Freezer Filters
FREQUENCY: Clean every month/ month and a half
- Remove the filters (usually located below the freezer door)
- Get the vacuum from the storage closet next to the Wash-Up Room
- Vacuum the filters using the brush vacuum
- Get the metal trays from next to the cardboard boxes
- Slide the larger metal tray inside the slots in the dishwasher above the washing racks
- Put the filters on top of the tray in a single layer
- Put the smaller metal tray on top of the filters
- Rinse for one cycle
- Add Suma Classic Mechanical Dishwashing Detergent and wash for a new cycle
- Fill soap up to the black line on the plastic soap measuring cup
- Remove from the dishwasher
- Put the filters in the Autoclave MISDM2 to dry
- Do not run a cycle, simply close the door
Garbage
Biohazard Boxes
- Extra boxes are in the Wash-Up Room next to the dirty green towels
- Extra yellow bags are behind the metal cart opposite the door of the Wash-Up Room
- Use two yellow bags per box
Confidential Papers
FREQUENCY: Collect the bags when too full
- Empty the bags in the blue confidential papers bin outside the washrooms
Dumpster
- Go to the Soiled Return area next to the 14th South Nurses’ Station and retrieve the big grey dumpster
- Bring the dumpster back to the Wash-Up Room and empty the contents of the yellow dumpster located in the room into the grey dumpster
- Bring the grey dumpster back to the Soiled Return area at 14th South to be emptied
Orange Biohazard Bins
- Seal with clear packing tape
- Apply autoclave tape
- Autoclave the bins
- Put inside Stericycle Boxes
Stericycle Boxes
FREQUENCY: Collect from Virology daily at around 2pm
- Seal the boxes with clear packing tape
- Leave them in front of the yellow dumpster in the Wash-Up Room to be collected
- Extra Stericycle boxes are located in Virology across from the shelf of binders, or in the Molecular Clean Room across from the 2nd Virology entrance
- Extra yellow Stericycle bags are in the cabinet under the sink next to the shelf of binders
- Use one bag per box
Green Towels
FREQUENCY: Empty the bags when too full
- Clean green towels will be dropped off at the entrance near the University Ave. elevators every Wednesday morning
- Pick up the bag of new green towels and place in large grey container across from the door in the Wash-Up Room
- Bring the used green towels to the big blue bins in the room behind the 14th South Nurses’ Station
- Replace clear bags for dumping the green bins
- Use two clear bags to avoid ripping
- Clear bags can be found behind the metal cart opposite the door in the Wash-Up Room
Hot Air Oven
Located to the left of the dishwasher
- To open, pull the handle
- Place the items on the first rack
- Do not use other shelves as they are covered in food grease
Incubator
Cleaning Incubators
FREQUENCY: As indicated on the calendar next to the clock in the Wash-Up Room
- Remove incubator shelves
- If the incubator is full, put the Petri dishes in a cart, and put them in Incubator MIIM8
- Pull out the top shelf first
- Remove the left side shelf of the incubator at a 45° angle
- Some incubators may have a glass pan
- Remove that as well
- Spray the inside of the incubator with 70% alcohol and leave it there until washing of shelves has completed
- Make sure to spray the corners of the incubators
- Spray and wipe off the alcohol on the outside door
- Wipe off the alcohol inside the incubator after washing the shelves
- Put the shelves in the dishwasher
- Remove the thermometer located on the side of one of the shelves and sterilize with 70% alcohol
- Press start to rinse for one cycle, put Suma Classic Mechanical Dishwashing Detergent in, then press start again
- Return incubator shelves after washing
- The top shelf has a hole
- Ensure that the pin goes into the hole when putting the shelf back into the incubator
- Return the glass pan to the incubator
- Fill the pan a little less than half way with white labeled container of distilled water (found in front of the distilled water machine in the Wash-Up Room)
- For incubator MIIM7, fill the blue container with a whole bottle of distilled water
- Incubators MIIM15 and MIIT12 do not have a glass pan
- Every month,3L of distilled water must be poured into these incubators
- Get the funnel located on the top of Incubator MIIM15
- Screw the plug attached to the funnel to the hole on the top of the left side of the incubator
- Pour in water through the funnel
- Be careful not to pour too much water, or the incubator will leak water
Incubator Readings
-The readings are to be recorded on the clipboard sheets that hang next to the clock
-Extra sheets are located in the red folder in the shelf on top of the sink
Temperature
FREQUENCY: every morning
- Record the number indicated on the front of the incubator
CO2
FREQUENCY: every morning
- Record the number indicated on the front of the incubator
Manual CO2 Readings
FREQUENCY: every Monday
- Get CO2meter (Fyrite) from the cabinet under the distilled water machine
- Put the rubber tube from the meter into the “Sample” hole in the incubator
- Press the button at the top of the meter three times, release, and flip the meter. Repeat this action three times.
- Put the meter upright and check to see if red liquid hits the zero mark
- Use the knob on the side to adjust the meter to zero if needed
- Attach the tube to the CO2meter
- Pump the black pump 8 times
- Flip the CO2meter so all the red liquid falls to the bottom, then flip it back so it is upright
- Read the meter
- Record the reading
- Check to see that the reading is within the range indicated on the left column of the recording sheet
- If the reading if significantly different from range indicated, inform Glen
Lab Coats
- Dirty lab coats should be placed in the first clear plastic bag on the far left corner of the Wash-Up Room
- Dirty lab coats are usually picked up on Tuesdays
- Clean lab coats will also be delivered at this time
Metal Containers
-Used to hold items that enter the autoclave or hot air oven
-Located in the cabinet below the right of the sink
PHL Bags
- Pick up empty blue PHL bags from Specimen Receiving under the desk across from the fax machine
- Drop off blue PHL bags at the 6th floor closet located opposite the Rapid Response Lab entrance (Room 6-308) before 10am
- Put the bags on the shelf labelled “Microbiology”
- Check the wire rack on the left side of the closet to see if the stock of yellow paper has been depleted
- If so, more yellow paper can be found outside the washrooms in the Microbiology Lab
- Pick up bags from the 6th floor closet at 12:15pm
- Also pick up the envelope of reports located on the same shelf
- Bag UN3373 may have been picked up earlier
- Drop off envelope of reports at Barb’s desk
- Drop off empty PHL bags at Specimen Receiving under the desk across from the fax machine
Pipette Tips
- Empty pipette tip boxes will be placed on the work table to be filled and autoclaved
- New pipette tips are located in the boxes under the work table
- Refill the pipette tip boxes and autoclave the box
- Remember to put autoclave tape on the box
Plastic Containers – Mycology/ Respiratory Specimens
Containers will be brought to the Wash-Up Room
- Spray containers and lids with 70% Alcohol to sterilize
- Wash containers and lids in dishwasher under normal cycle
- Dry containers using green towels
- Clean containers should go under the first bench in Bacteriology
- Separate containers into different stacks for Mycology and Respiratory Specimens
Recycling
FREQUENCY: Once a week or as needed
Recyclable Boxes and Containers
- Collect recycling
- Replace the metal recycling holder with two empty plastic clear bags
- Clear bags are behinds the metal cart opposite the door in the Wash-Up Room
- Bring the recycling to the big grey dumpster in the Soiled Return area next to the 14th South Nurses’ Station
Recyclable Paper
- Bring the full grey Recyclable Paper bin located outside the Wash-Up Room to the area in front of the Staff Elevator by the 14th South Nurses Station
- Exchange the full bin for the empty one
Solutions
-Empty cans to be filled with solutions will be brought to the Wash-up Room and placed on the metal cart opposite the door
-Cans of ethanol and acetone are located in cabinet under the fume hood in Media Room
-If cans of ethanol or acetone are empty, put them on the metal cart opposite door in the Wash-Up Room
-When more than three containers are empty, ask Glen or Iris-Ann for a requisition
- Take empty containers down to Closet 6-302-3-1 in the former Surgical Pathology Room on the 6th Floor
- Put the requisition and the empty containers on the shelves and they will be filled
- Containers get filled on Tuesday and Thursday mornings
- Bring the containers down on Monday and Wednesday afternoons
- Pick up the containers labeled Microbiology when filled and return them to the cabinet under the fume hood in the Media Room
Acetone/Alcohol