Ms Jagroop (Jay) Kaur1, Ms Barsha Baral1
1Northern Health, Epping, Australia
Biography:
With over 15 years' experience, Jay holds a Master of Nursing. Jay has Worked in medical-surgical areas, community health, aged care, and Local public health Unit. I have been committed to Infection Prevention and Control since 2019 as Clinical Nurse Consultant. I believe in power of continuous learning and collaboration.
Abstract:
Introduction
Semi-critical reusable medical devices (RMDs) are medical instruments that come into contact with mucous membranes or non-intact skin require high-level disinfection (HLD) to minimize the risk of pathogen transmission. Semi-critical RMDs represent a significant infection control concern if not properly reprocessed. This paper outlines the systematic implementation of a high-level disinfection process, addressing key operational, clinical and compliance challenges.
Problem
In 2024, the Infection Prevention and Surveillance (IPS) team identified inconsistencies in high-level disinfection (HLD) practices across the organization. Key issues included lack of awareness of semi critical RMDs present in departments, discrepancies in reprocessing procedures, and inadequate traceability systems.
Interventions
A multi-faceted strategy was adopted, including development of a comprehensive semi-critical device inventory; standardisation of processes through meetings and a risk assessment flowchart; a Learning Management System (LMS) module and education sessions; and introduction of a standardised audit tool to monitor compliance. Monthly audits are conducted with a target of 100% compliance across all components.
Results
The structured implementation of HLD processes has led to improved compliance, greater staff awareness. 50% (n=11) new areas identified requiring HLD process standardisation. Traceability components such as patient details require further improvement. Audits demonstrate improved use of standardised procedures and strengthened traceability. However, full engagement and compliance remain inconsistent.
Conclusion and Lessons learnt
The combination of education, process standardisation, and regular auditing has strengthened reprocessing practice. To address uptake inconsistencies, COM-B (Capability, Opportunity, Motivation–Behaviour) assessments will be conducted over the next three months to identify additional barriers and inform targeted interventions.