Section 205.410  Equipment and Related Policies


Equipment shall be in good working order and shall be available in numbers sufficient to provide quality patient care based on the types of procedures to be performed in the facility.


a)         Monitoring equipment, suction apparatus, oxygen and related items shall be available within the surgical and postoperative recovery areas.  Cardiac and pulmonary resuscitation equipment shall be available in all facilities.


b)         The facility shall have written policies and procedures and shall maintain documentation governing the care, use, decontamination, sterilization, storage and disposal of all materials to ensure that an adequate supply of sterile equipment, instruments and supplies is available for each procedure. Written policies and procedures shall include documentation that the facility has considered, selected and implemented nationally recognized guidelines, including the Centers for Disease Control and Prevention publication, "Guidelines for Disinfection and Sterilization in Healthcare Facilities" or "Guide to Infection Prevention in Outpatient Settings"; or the Association of periOperative Registered Nurses (AORN) publication "Perioperative Standards and Recommended Practices for Inpatient and Ambulatory Centers".  The policies, procedures and documentation shall include and address:


1)         Staff orientation and in-service training to understand and implement facility policies and procedures for infection control, and to adhere to manufacturer's instructions for receiving, decontaminating, cleaning, preparing, sterilizing and high-level disinfection, handling, storage and quality control of equipment, supplies and instruments;


2)         Preventive maintenance of all central supply service equipment pursuant to manufacturer's instructions or infection control guidelines; and


3)         The Infection Control Program (Section 205.550), which shall be under the direction of a designated qualified health care professional with training in infection control.


c)         The facility shall have written procedures to assure safety in storage and use of inhalation anesthetics and medical gases in accordance with NFPA 99.


d)         The facility shall have written procedures to assure the safety in storage and use of all narcotics and medications in accordance with State and federal law.


e)         Facilities using laser equipment shall maintain documentation that the equipment is registered with the Illinois Emergency Management Agency as is required by the Laser System Act of 1997.  The facility shall also have a written safety and maintenance program related to the use of the laser equipment.


f)         To protect patients, staff, and occupants in the operating or treatment room from the hazards of surgical smoke plume, the facility shall adopt policies to ensure the elimination of surgical smoke plume by use of a surgical smoke plume evacuation system for each procedure that generates surgical smoke plume from the use of energy-based devices, including, but not limited to electrosurgery and lasers.  (Section 6.9(b) of the Act)


1)         The facility's surgical department shall perform a risk assessment to identify all procedures that are performed with energy-based surgical devices (e.g. lasers, electrosurgical instruments, and ultrasonic devices) that generate a surgical smoke plume and will require the use of a surgical smoke plume evacuation system.


2)         All surgical team members shall be trained on the methods for mitigating the hazards and minimizing exposure to surgical smoke plume, positioning and operating surgical smoke plume evacuation pursuant to the manufacturer's instructions, and the requirements in facility policies and procedures for management of surgical smoke plume.


3)         Staff shall wear appropriate respiratory protection when needed as secondary protection against residual surgical smoke in accordance with the hospital's respiratory protection plan.


4)         To protect against potential smoke hazards, the facility's policy and procedure shall, at a minimum, include:


A)        During utilization of the smoke evacuator, the suction nozzle inlet shall be positioned as close to the surgical site as possible to maximize capture of airborne contaminants.


B)        The smoke evacuator shall be turned on (activated) at all times when airborne particles are produced during all surgical or other procedures.


C)        New tubing shall be used before each procedure and the smoke evacuator filter shall be replaced as recommended by the manufacturer.  Consider all tubing, filters, and absorbers as infectious waste and dispose of appropriately.


D)        The facility shall perform regular inspection, including inspection immediately prior to use, of surgical smoke evacuator systems to ensure proper functioning.


5)         The facility shall report to the Department that policies under subsection (f) have been adopted.  (Section 6.9(c) of the Act)  The facility shall provide the Department a letter identifying the date of the adoption of the facility's policy for the utilization of surgical smoke evacuation systems.


(Source:  Amended at 46 Ill. Reg. 14215, effective July 28, 2022)