AAMI News December 2019

Asked & Answered: Routine Equipment Cleaning and Maintenance Processes

This regular feature showcases questions and answers from professionals participating in AAMI’s online discussion groups, collectively known as AAMI Connect. AAMI does not endorse specific practices or advice. Participants in these forums are sharing their own experiences and insights.


Q: What routine medical equipment cleaning and maintenance processes do you follow, and how does your facility document this work for surveyors from The Joint Commission (TJC)?


A: My facilities’ policies and procedures state that daily, weekly, and monthly medical equipment cleaning is typically done by the person using the equipment as part of their normal routine and should be covered during in-service laboratory and operating room training. Documenting this maintenance is not necessary unless the manufacturer says it is required.

Each facility determines where they will store equipment cleaning and maintenance records. For example, daily and shift-change temperature readings for warmers and coolers are recorded and kept by each department. Devices that connect to patients, such as IV pumps and deep-vein thrombosis pumps, are cleaned and maintained either by nursing staff or environmental services staff after each use. However, these data are not recorded because the device manufacturers do not require cleaning and maintenance documentation.

Our facilities’ policies and procedures also instruct us on equipment usage and training. For example, we are not allowed to release new equipment to staff until we get documentation confirming that they completed the manufacturer’s in-service training. The in-service training can include maintenance tasks, like how to change batteries or how to keep devices with rechargeable batteries, like CareFusion infusion pumps, plugged in and charged.

This is just scratching the surface of our maintenance and cleaning policies and procedures. Others may refer to standards that address the question more directly. If anyone has standards they use for reference, such as ISO 14971:2019, Medical devices—Application of risk management to medical devices, please speak up.

—Kris F. Ongchangco, certified biomedical equipment technician at Southside Regional Medical Center in Petersburg, VA

A: A TJC surveyor will ask to see your cleaning and maintenance logs to prove that you have really taken care of all your equipment and that it is working correctly.

You should keep different logs for different machines (e.g., sterilizers, automatic washers, washers, ultrasonic cleaners, cart washers).

Automatic washer cleaning should be verified using a Test Object Surgical Instrument (TOSI) test. This should be done at least once per week, but preferably every day. Results from the TOSI test verification should be documented along with the date and the name of the technician who completed the test. The regular washers should also be cleaned at least weekly if a cleaning schedule is not specified by the manufacturer. You should keep a log for this as well.

There are also verification tests for cleaning carts and ultrasonic washers. These tests should be performed at least weekly, with daily testing being preferable, and they should be documented.

Sterilizers should be cleaned once per week if a cleaning schedule is not specified by the manufacturer. Results from these tests should be documented with the date, sterilizer number, and the name of the technician who completed the task.

In my department, we also keep records for cleaning the sterilizer drain and the strainer baskets from the washers and cart washers.

—Joan Richard, manager at Trinitas Regional Medical Center in Elizabeth, NJ


 Do you have a question? Get answers from your peers on AAMI Connect, www.aami.org/connect.