SOP - Autoclave

This standard operating procedure outlines the use of autoclaves Autoclaves are used to sterilize equipment through a process that incorporates high pressure and high temperature.

Autoclaves pose several potential hazards to labs who frequently use them. Among the physical hazards are heat, steam, and high pressure. Biological hazards, including improperly autoclaved infectious materials, are also present.

Controls for different brands of autoclaves may have their own unique characteristics for loading, load sizes, cycle types and cycle settings. The type of materials to be sterilized will determine the sterilization cycle that will be used. For this reason it is important to read and understand the user’s manual for the specific model of autoclave that is being used prior to first time use. Always ensure that the user’s manual is readily available in case questions or concerns arise during the operation of the autoclave.

Autoclave monitoring and maintenance is an important aspect of a safe and properly functioning autoclave. Follow the manufacturer’s recommendations for preventive maintenance and ensure that all contractors hired to perform regular maintenance and repairs are approved by the manufacturer. Autoclave operators shall ensure that each autoclave is monitored as follows:

Heat Sensitive Tape Monitoring – Operators shall use heat sensitive sterilization indicator tape for each load to indicate that the load has undergone an effective steam sterilization process.

• Change on autoclave tape means the proper temperature was achieved, but does not mean that temperature was maintained for the proper length of time.
• Place a small piece of autoclave tape on each bottle and tip box.

Biological Indicators – Operators who autoclave medical/biohazardous waste need to do the following:

• At least once a month use a biological indicator such as Bacillus Stearothermophilus (e.g. Prospore2) placed at the center of a load processed under standard operating conditions to confirm the attainment of adequate sterilization conditions.

Do not autoclave items containing corrosives, solvents, volatiles or radioactive materials.

Prior to loading

• Before using the autoclave, be sure previous users have cleared the autoclave, and that no broken items have been left inside.
• Check to be sure the drain is clear.
• Verify that the interior of the autoclave is in usable condition.

Loading

• Carefully load items to be autoclaved, DO NOT overload the autoclave.
• Bottles containing liquids should be placed inside a heat resistant plastic tray (secondary container) containing an inch of water.
• Bottles should not be filled more than 2/3.
• Keep 1-2 inches of space between bottles.
• DO NOT tighten caps on bottles fully.
• Individual glassware pieces should be within a secondary container on a shelf or rack and never placed directly on the autoclave chamber bottom or floor.
• Make sure that the door of the autoclave is fully closed and latched and ensure that the correct cycle for the items being autoclaved has been selected before starting the cycle.

Opening

• Wear the proper PPE, including autoclave gloves and close toed shoes when opening the autoclave door after a cycle.
• When the cycle is complete, open the door slowly to minimize exposure to steam. Keep appendages away from the opening.

When autoclaving liquids:

• When running an autoclave cycle with liquids, choose the liquid cycle setting.
• To prevent bottles from shattering during the pressurization, the caps of containers with liquids must be loosened before loading.
• Use only borosilicate glass (Pyrex™ or Kimax™).
• Use a secondary container with a solid bottom and walls to contain the contents and catch spills.
• Set a timer to come and unload the autoclave, to ensure it is available for use by other labs.
• Wait 10 minutes after the cycle ends before removing autoclaved liquid load items.
• Let the liquids stand for at least a full hour before touching with ungloved hands. Be sure to let others in the area know that a heat hazard is present.

When autoclaving dry loads:

• Add ¼ to ½ inch of water to the tray so that the bottles will heat evenly. Do not fully tighten bottle caps, this could lead to the bottle shattering. Loose caps allow in inside of the bottle to be sterilized.
• Check plastic materials to ensure that they are compatible with being autoclaved.
• Choose the dry porous materials cycle.
• Set a timer to come and unload the autoclave, to ensure it is available for use by other labs.
• Before removing autoclaved items, wait 5 minutes after the cycle ends for loads containing only dry glassware.
• For dry loads, let the glassware cool for a minimum of 15 minutes before touching it with ungloved hands.

Wear the proper PPE, including heat resistant gloves, and close toed shoes when opening the autoclave door after a cycle.

Place waste in a university approved autoclave bag; avoid over packing of autoclave bags. Do not seal bags or close bottles and other containers tightly. After sterilization cycle, close and seal bag. The sterilized waste can be transported directly to the dumpster by Building Services or laboratory staff without boxing or labeling. Contact OSEH-HMM at (734) 763-4568 for waste containers, labels, manifests, waste collection and for any questions regarding proper waste disposal. Also refer to OSEH’s Hazardous Waste webpage for more information.

 If the employee is in need of emergency medical attention, call 911 immediately.   

Discontinue use immediately if an autoclave is not working properly. Post a sign alerting others not to use the autoclave. Mechanical failures need to be attended to by a trained technician, DO NOT try to fix it yourself. Contact facilities to have it repaired. If you are burned, you should seek medical treatment immediately. Burns to the face, third- degree burns or burns over large areas of the body should be treated as emergencies. (Call 911). Minor burns should be treated by using first aid procedures, including immersing the burn in cool water immediately, removing clothing from the burn area and keeping the injured area cool for at least 5 minutes. Regardless of the severity, notify your Laboratory Director/Supervisor!

Contact OSEH for advice on symptoms of chemical exposure, or assistance in performing an exposure assessment.

Report all work related accidents, injuries, illnesses or exposures to WorkConnections within 24 hours by completing and submitting the Illness and Injury Report Form. Follow the directions on the WorkConnections website Forms Instructions to obtain proper medical treatment and follow-up.

Complete the OSEH Laboratory Incident and Near-Miss Report form.

TREATMENT FACILITIES:

U-M Occupational Health Services -- Campus Employees

Mon-Fri 7:30 am - 4:30 pm After hours - go to UM Hospital Emergency Dept. – Urgent Care Clinic C380 Med Inn building 1500 East Medical Center Drive, Ann Arbor (734) 764-8021

University Health Services -- University students (non-life threatening conditions)

Mon-Fri 8 am – 4:30 pm, Sat 9 am – 12 pm Contact for current hours as they may vary 207 Fletcher Street, Ann Arbor (734) 764-8320

UMHS Emergency Department -- after clinic hours or on weekends

1500 East Medical Center Drive, Ann Arbor, (734) 936-6666 Click here for more information.

Report all emergencies, suspicious activity, injuries, spills, and fires to the University of Michigan Division of Public Safety and Security (DPSS) by calling 911 or texting 377911. Register with the University of Michigan Emergency Alert System via Wolverine Access.

All personnel are required to complete the Autoclave Safety training online through MyLINC (Course BLS013w). All users shall be trained before operating an autoclave; the Laboratory Director/Supervisor is responsible for ensuring that each person in the lab is appropriately trained. All training must be documented and the records maintained in the lab with other safety training certificates. The Laboratory Director/Supervisor is encouraged to use this policy as a guide for training new personnel.

I have read and understand the above SOP. I agree to contact my Supervisor or Lab manager if I plan to modify this procedure. Sign by logging in and typing * ~~~~ in the list below:

• Mollyec (talk) 16:13, 19 October 2016 (UTC)
• Davebridges (talk) 14:53, 8 November 2016 (UTC)
• Pfeiferl (talk) 18:11, 5 June 2017 (UTC)
• Snyderds (talk) 19:43, 7 June 2017 (UTC)
• Reddj (talk) 14:04, 9 June 2017 (UTC)
• Elhabbal (talk) 22:09, 12 June 2017 (UTC)
• Nlambrec (talk) 21:27, 17 February 2019 (UTC)
• Kkistler (talk)

Prior Approval required – Is this procedure hazardous enough to warrant prior approval from the Laboratory Director? X YES ☐ NO Laboratory Director - Dave Bridges Revision Date - 2016-10-19