We were just inspected by JCAHO a couple of weeks ago. I work second
shift and we do all the "environmental" cultures on our shift. I've
worked for my current employer for two years. We are an "integrated"
facility, i.e. we do micro (and other) work for four hospitals in our
city. We have never done specimens as you have described for
environmental monitoring. The JCAHO inspector met with our Ph.D. and
from what I hear, we passed just fine.
The only specimens we do are things like John mentioned - if there's a
problem with a cluster. The environmental cultures are a loose umbrella
in our place that consist of Central Supply spore strips, autoclave
ampule checks, DI water cultures for dialysis machines and lab water
cultures. We also do extensive cultures for the regional Tissue Bank,
which consists of racks of samples put into thio broth by tissue bank
personnel. We monitor these for turbidity on a day 2,7, and 14 basis,
and subculture any turbid broths and ID what is in there. We also do
occasional cornea cultures as we have a large ophthalmology/retina
specialty group in the hospital across the street.
The main hospital we do work for, a large trauma center directly across
the street, does a LOT of surgery (we get the helicopters and the whole
deal). We also do micro work for the local medical school, which again
does lots of surgery, especially orthopedic. We don't do any type of OR
monitoring for either place.
I'm not in management, but I'll run this question by our clinical
microbiologist next week. He's been there for 30 years, so I'm sure
he'd know why we're not doing these. I'm curious now.
Judy Dilworth, M.T. (ASCP)
Microbiology
John Gentile wrote:
>> JCAHO has never asked to see environmental surface cultures. They do go over
> our Infectious Disease protocols with a find tooth comb. We have always
> passed with little or no problems.
