applies to procedures - advocate health care...2020/05/06 · please follow the “skin care of...

SUPPLY CHAIN PROCEDURES – Non-acute Process Name: Collection and Re-sterilizing Contaminated N95 Respirators Last Revised: 10/26/20

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Process for:

Advocate Aurora Procedures for Collecting and Re-sterilizing Contaminated N95 Respirator Masks

Applies to

Supply Chain and business units impacted including – Clinical Team, Distribution and Logistics Team,

Medspeed and Battelle Team.

Procedures

PPE Warehouse Team

1. Inbound new masks will be marked in a designated clean area, requirements:

a. Enclosed space must be free of dust and debris

b. Area is clear of all trash receptacles

c. No trash is collected or stored in the area

2. Marking procedures:

a. Proper hand hygiene must be completed before entering the designated processing area for N95

masks

b. Gloves and universal mask must be worn while handling N95 masks in the processing area

c. Use a sharpie to mark the N95 masks with the label “CEM” on the bottom center of the mask

d. Mask must not leave the clean designated space

e. After a mask is marked, they should be immediately place back in the original packaging

labeling the box as “clean” with a black sharpie

3. Inventorying procedures:

a. Proper hand hygiene must be completed before handling sterilized N95

b. Quantities will be reviewed and broken down placed back in normal packaging and marked

“clean”

Clinical Team

4. Upon receiving an N95 respirator, the clinical staff should label check the N95 respirators for “CEM”

written on the inside outside at the bottom of the mask, where it would fit on the chin, with a sharpie.

(See Photo Below).

5. If the “CEM” marking is missing, please make sure to mark the mask with “CEM” using a sharpie.

6. Clinical staff is to deposit their used N95 mask, traditionally the duckbilled Haylard brand or domed 3M

brand (MFG # 1860, 1860S, 46767, 46867, or any “N95”) into the designated collection containers

lined with bio hazard bags as long as the mask is free of any soiled-contamination:

a. Blood


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b. Mucus

c. Any other forms of human liquids

Please follow the “Skin Care of Mask Wears” on the COVID-19 Toolkit. Please discard N95 if

excessively soiled by:

d. Makeup

e. Lip Balm

f. Lip Stick/Gloss

g. Facial Moisturizers/Creams

h. Sunscreen

i. Topical Medications (i.e. acne)

7. Clinical staff should place their not excessively soiled N95 masks into the Collection Bins once a per

day (see PPE Resource Guide) or when wet or hard to breathe through.

8. Collection containers will be deployed in a designated area in coordination with non-acute site

leadership. It is recommended that they are located in the dirty/soiled storage/utility area in applicable

units.

a. Place Biohazard Sticker on Collection Container

b. Affix Yellow Collection Container Label on front and lid of the collection bin

i. Label will say: “Used N95 Collection Bin” (See Photo Below)

c. Hang Collection Point Flyer above Collection Bin on wall (See Photo/PDF Below)

9. If the mask does contain soiled contamination, the mask must be thrown away.

10. If staff receives a re-sterilized mask and it has the number 20 on it, the mask must be thrown away after

use.

11. Staff must still subscribe to the PPE Resource Guidelines and extended use and reuse parameters located

on the COVID-19 Toolkit.

12. For questions on the Biohazard bags for your unit see local Supply Chain or EVS Manager.

Designated Non-Acute Team Member

13. A non-acute designee will round to the designated area with collection containers daily or as often as

seen fit by each non-acute site.

14. Non-acute site team member should wear appropriate PPE when collecting contaminated N95s

including: procedure mask, gown, and gloves during entire bagging and collection process.

15. Locate the designated collection container that will be labeled for N95 at each location.

16. When half full or more remove the biohazard bag containing the used N95 masks from its location and

secure it closed.

17. Replace the bag with a new biohazard bag.


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18. Collect all of these bags into a designated cart on wheels or traveling trash bin, must be a clean cart/bin.

19. Each site must designate a dirty location by the dock to perform the following remaining steps.

20. Once the masks are delivered to the soiled dock, the non-acute team member will prepare them for

shipment to Battelle.

a. The non-acute team member will wipe the red bag with alcohol or other suitable decontaminant

before it goes into the box. Clorox, PDI, or prefilled Quat bottle with paper towel

21. Place the biohazard bags into the secondary biohazard bag that is inside a corrugated box (photo below).

Ensure the box is full before closing the red bag.

a. Close the red bag by knotting the bag and then decontaminate the top of the red bag with alcohol

or other suitable decontaminant. Clorox, PDI, or prefilled Quat bottle with paper towel

22. The non-acute team member will close the corrugated box and tape it shut.

23. The non-acute team member will perform following steps when box is ready to ship.

24. Affix the “Box Exterior Label” to the outside of the box.

a. Label should be on an 8’’x11’’ sheet of normal paper

b. Should Note:

ATTENTION MEDSPEED

Ship to Battelle

3633 Pierstorff St

Madison, WI, 53704

25. The non-acute team member designee will complete the Chain of Custody Form (example below) and

attach it to the boxes to be picked up by Medspeed.

26. The non-acute team member designee will contact the Medspeed line (866-825-9210) to request a

special on-demand pickup of the used N95’s.

27. The non-acute team member deisgnee will contact PPE Warehouse for supply of the boxes and liners as

they need them and stage them.

PPE Warehouse Team

28. The distribution and logistics team will order corrugated boxes (from Daniels) and red liners for

hospitals.

a. Laura Dietenberger Sourcing Leader to support supply procurement to enable this process from a

supply procurement standpoint.

29. Non-acute team members to email Matthew Dixon when more supplies are needed (backup Curtis

Stray).


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Medspeed Team

30. Shipments to Battelle should occur Monday through Friday, and possibly Saturdays depending on

volume.

31. Medspeed Driver to pick up at designated location at the hospital and sign Chain of Custody Form for

Pickup.

32. Medspeed driver will use a hand cart to transfer boxes between designated location and vehicle. Boxes

with contaminated N95 masks will be stored in designated area for contaminated items in the vehicle

and secured to avoid shifting during transportation.

33. Delivery Address:

Battelle’s Location

3633 Pierstorff St

Madison, WI, 53704

Battelle POCs:

John Ostrowski 573-337-2807

Addie Newman 614-940-9528

Cardinal POC (if difficulty accessing the grounds)

Daniel Puente

Look for the white tents.

34. At the security gate, announce that delivery is for “Project Buckeye”

35. The driver will unload boxes of contaminated masks and the chain of custody form at Battelle’s

Campus.

36. The driver will disinfect the areas for contaminated before placing sterilized boxes into the vehicle.

EPA list N disinfectant.

37. The driver will load boxes of re-sterilized masks that have completed the process which will contain the

updated Chain of Custody Form for Drop-off.

38. The driver will transfer the re-sterilized masks to the vehicle and store them in designated area for clean

items.


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39. The driver will disinfect the areas for contaminated and clean items upon conclusion of the route. EPA

list N disinfectant.

40. Medspeed will deliver all sterilized boxes of N95’s to PPE Warehouse at:

AAH Warehouse

8100 North Teutonia Ave

Milwaukee, WI, 53209

Battelle Team

41. Delivered items will be scanned into their assigned container location by box.

42. Battelle will perform the re-sterilization process (NOTE: re-sterilization occurs in batches, so items may

be returned in a different order than delivered).

a. In full PPE, inside the chamber, Battelle members will:

i. The biohazard bags will be opened, and masks placed on racks in the chamber, approx.

time (4 hrs. load chamber), overly soiled items will be discarded

ii. The cycle will be run in the container (4 hrs. VHP [sterilize], 4 hrs. degas)

iii. The container will be unloaded (~ 4 hrs. unload and box)

iv. Numbers will be added to each mask in the “marking area” to indicate number of times

re-sterilized, numeric numbers will be used, i.e. 1 2 3 4 5 etc.

v. Each re-sterilized mask will be labeled with a Green dot sticker

vi. Sterilized mask will be placed in a corrugated box with a plastic liner, approx. 130 to 200

mask per box

43. The items will be packaged in clean plastic bags, then placed in a clean corrugated box.

44. The Chain of Custody Form will be either placed inside the box or taped to the box. Boxes will be

delivered to PPE Warehouse by Medspeed “clean dock”. The Chain of Custody Form will contain:

a. Quantity received at Battelle for sterilization

b. Quantity that passed sterilization and returned to AAH

45. If Advocate Aurora sterilized boxes are not picked up within 72 hours Battelle will contact Matthew

Dixon from Advocate Aurora Health and he will coordinate pickup. 414-326-0996 or

[email protected]

PPE Warehouse Team

46. Medspeed will deliver re-sterilized masks daily to:

AAH Warehouse

8100 North Teutonia Ave

Milwaukee, WI, 53209

mailto:[email protected]


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47. Receive reprocessed items into PPE Warehouse storage location.

48. The Chain of custody document delivered with the shipment will be added to a tracking document by

the PPE Warehouse Team.

a. The document will track:

i. Quantity received at Battelle for re-sterilization

ii. Quantity that passed re-sterilization and returned to AAH

49. The re-sterilized masks will be moved to the designated review area.

50. Re-sterilized mask sorting preparation:

a. Use proper hand hygiene

b. Don an ISO mask and gloves

51. The boxes will be opened, and the masks will be sorted by type (1860, 1860s, etc..) and size (S, Reg).

52. They will be put in a clear bag with the appropriate labeling indicating “clean” designated at 20 per bag.

53. Masks will be added to inventory using the following unique item number information:

Item MMIS # Lawson # 3M Reg Reprocessed 548040 457163

3M Small Reprocessed 548041 457164

Haylard Reg Reprocessed 548043 457165

Haylard Small Reprocessed 548044 457166

Miscellaneous Reg Reprocessed 548045 457167

Miscellaneous Small Reprocessed 548046 457168

54. Masks will be issued from stock by the bag to the hospitals after all unused N95s are depleted.


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N95 Masks accepted for Re-sterilization

Note: Prestige N95’s acceptable as well


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Example of Marking N95 Masks Marking

Corrugated Box & Red Bag Liner


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Biohazard & Collection Bin Label


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Collection Container


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Collection Point Flyer


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Resources

Chain of Custody Form


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Process Owner

VP Operations Supply Chain

Revision History

No. Revision date Submitted By Description of Change

1 04/08/2020 Bill Moir Initial Documentation

4 04/09/2020 Bill Moir 1) Updated AAH standards and pictures 2) Updated MMIS/Lawson numbers

1)

applies to procedures - advocate health care...2020/05/06 · please follow the “skin care of...

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