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DISINFECTION AND DECONTAMINATION POLICY

(PATIENT CARE EQUIPMENT)

December 2015

Disinfection and Decontamination Policy (Patient Care Equipment)

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Title: Disinfection and Decontamination Policy (Patient Care Equipment)

Author(s): Karen Martin, Infection Prevention and Control Nurse

Ownership: Fiona Hughes, Head of Infection Prevention and Control

Approval By: Chief Executive HCAI Accountability Forum

Approval

Date:

04 November 2015

Original

Operational

Date:

February 2011

Revised Date: December 2015 Next

Review:

December 2019

Version No.: 1.0 Supersedes: Disinfection and Decontamination Policy (Patient Care Equipment and Immediate Patient Environment) (June 2013)

Reference

Number:

Med11/001

Links to other

policies,

Procedures,

Guidelines or

Protocols

Policy for the Management of Decontamination

Policy for Decontamination of Reusable Invasive Medical Devices

Policy for the Management of Medical Devices available at www.mhra.gov.uk.

Regional Infection Prevention & Control Guidelines, including those for MRSA and Cleaning and Disinfection www.infectioncontrolmanual.co.ni

Support Services Infection Prevention Cleaning Procedures

Laundry Handling Guidelines

Waste Manual

Guidelines for Use and Decontamination of Infant Feeding Equipment in Hospital

http://www.mhra.gov.uk/

http://www.infectioncontrolmanual.co.ni/

http://whsct/IntranetNew/Documents/Support%20Services%20Infection%20Prevention%20Cleaning%20Procedures%20(Jul15).pdf

http://whsct/IntranetNew/Documents/Laundry%20Handling%20Guidelines%20(Nov%2012).pdf

http://whsct/intranetnew/Documents/Waste%20Manual%20Feb2013.pdf

http://whsct/IntranetNew/Documents/Guidelines%20for%20Decon%20of%20Infant%20Feeding%20Equipment%20_Nov%2010_%20SIGNED.pdf



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CONTENTS

Section Page

1.0 Introduction 1.1 Background 1.2 Purpose

5 5 5

2.0 Scope of the Policy 5

3.0 Roles and Responsibilities 3.1 Trust Board and Chief Executive 3.2 Seniors Managers/ Ward Managers 3.3 All Healthcare Employees within the WHSCT

5 5 6 6

4.0 Key Principles 6

5.0 Patient Care Equipment/ Medical Devices 5.1 Single Use and Single Patient Use 5.2 Classification of Risk 5.3 Medical Devices 5.4 Personal Protective Equipment

7 7 7 8 8

6.0 Methods Of Decontamination 6.1 Cleaning and Drying 6.2 Disinfection 6.3 Antiseptic 6.4 Sterilisation 6.5 Choosing a Method 6.6 When Should Reusable Medical Equipment be Cleaned 6.7 Cleaning Schedules

8 8 8 9 9 9 9 9

7.0 Chemical Disinfectants and Their Uses 7.1 Chlorine-Based Disinfectants/ Non-Chlorine Based Disinfectants 7.2 Alcohol 7.3 Chlorhexidine 7.4 0.2% Chlorhexidine Gluconate & 70% Isopropyl Alcohol 7.5 Iodine and Iodophors

9 9

10 10 11 11

8.0 Treatment of Infectious/ Potentially Infectious Spillages 11

9.0 Cleaning of an Isolation Room 12

10.0 Equipment Sent for Service or Repair, Including Use of Decontamination

Certificate

12

11.0 Cleaning of Vehicles 13

12.0 Implementation 12.1 Dissemination 12.2 Exceptions

13 13 13

13.0 Monitoring 13

14.0 References 14


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15.0 Consultation Process 14

16.0 Equality Statement 14

17.0 Appendices 14

18.0 Signatories 15

Appendix 1 Disinfection Procedures for Individual Items and Equipment 16

Appendix 2 Cleaning and Disinfection of Beds Poster 32

Appendix 3 Recommendations with Regard to Ultrasound Probes 33

Appendix 4 Actichlor Plus Poster 34

Appendix 5 Difficil-S Poster 35

Appendix 6 Bedpan Washer-Disinfectors 36


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1.0 INTRODUCTION

1.1 Background Patient equipment may serve as a reservoir for the transmission of infectious agents to susceptible hosts. In order to ensure safe systems of work and to prevent transmission of infectious agents, it is essential that the decontamination of reusable patient equipment is carried out.

Decontamination is a combination of processes used to make a reusable item safe for further use on patients and handling by staff. It is achieved at three levels:

Cleaning

Disinfection

Sterilisation

This policy contains information for staff involved in decontaminating equipment, instruments and surfaces at ward or department level.

1.2 Purpose The purpose of this policy is to ensure a system is in place for effective decontamination of all equipment used before and between each patient and that risks associated with decontamination facilities and processes are properly managed across the Trust

2. 0 SCOPE OF THE POLICY

That the Trust will continually review and develop practices in order to comply with all present and future medical device legislation within resources available.

That equipment will be adequately cleaned, disinfected or sterilised according to its function so as to protect as far as reasonably practical the health, safety and welfare of staff, patients and those who are involved in inspection, service, repair or transportation of medical devices or equipment.

That the Trust will ensure adequate provision of disinfectants, cleaning agents and the equipment necessary to achieve the required standard of decontamination.

3.0 ROLES AND RESPONSIBILITIES

3.1 Trust Board and Chief Executive Have an overall governance role in Infection Prevention and Control in relation to staff, patients and visitors.


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3.2 Senior Managers/ Ward Managers

When purchasing new equipment, a pre-approval questionnaire must be completed and accompany the requisition to the Procurement Sub-Group for Medical Devices & Decontamination. The WHSCT Non-stock Requisition Pre-approval Questionnaire is available on the Trust intranet, located under P in the Useful Documents section.

Each head of department should ensure that new items of equipment have a written decontamination protocol, which complies both with the manufacturer's recommendations for decontamination and Infection Prevention and Control guidance.

Department managers are responsible for all aspects of environmental cleanliness within their clinical area, including the cleanliness of reusable medical equipment.

Equipment used for sterilisation or disinfection must be commissioned on installation, regularly serviced, maintained and tested in accordance with the manufacturer's instructions and current advice from the DHSSPNI.

All reusable surgical instruments and devices MUST BE SENT TO HSDU for processing. These instruments MUST NOT BE WASHED AT WARD OR DEPARTMENT LEVEL.

Equipment should be disposed of when effective cleaning can no longer be achieved.

3.3 All Healthcare Employees within the WHSCT

Staff involved in decontaminating medical equipment must ensure they are appropriately trained in the use and decontamination of patient equipment.

Educate families and their carers in relation to decontamination of equipment within the home.

Encourage colleagues, patients/ client and visitors to comply with IPC precautions within this guideline.

Cleaning products should be used in accordance with Control of Substances Hazardous to Health (COSHH) Regulations and manufacturers’ instructions.

4.0 KEY PRINCIPLES

The overarching principle/ statement for this policy is to ensure that staff are informed and instructed in the management of disinfection and decontamination of patient equipment and patients’ environment, thus reducing the risk of transmission.


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5.0 PATIENT CARE EQUIPMENT/ MEDICAL DEVICES

5.1 Single Use and Single Patient Use

Patient care equipment is classified as:

Single Use All single use items carry the single use logo.

Single use medical devices must only be

used once.

DO NOT REMOVE STERILISED ITEMS FROM PACKAGEING UNTIL IMMEDIATELY BEFORE USE.

Single Patient Use Single patient use means equipment may be

used more than once on one patient only.

The device will require cleaning/ decontamination between each use following the manufacturer’s instructions.

5.2 Classification of Risk Equipment can also be categorised according to the infection risk (Low, Medium or High). The following table classifies the risk of infection associated with equipment.

Risk Application Recommendation

High Items in close contact with a break in the skin or mucous membrane or introduced into a sterile body area/ invasive procedure.

Disinfection and sterilisation processing within HSDU.

Intermediate Items in contact with intact skin, mucous membranes or body fluids, particularly after use on infected patients or prior to use on immuno-compromised patients.

Sterilisation or disinfection required using appropriate disinfectant. Cleaning may be acceptable in some agreed situations.

Low Items in contact with healthy skin or mucous membranes or not in contact with patients.

Cleaning.


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5.3 Medical Devices A medical device may be defined as any instrument, apparatus, appliance, software, material or other article, whether used alone or in combination, including the software intended by its manufacturer to be used specifically for diagnostic and/ or therapeutic purposes and necessary for its proper application, intended by the manufacturer to be used on human beings for the purpose of:

Diagnosis, prevention, monitoring, treatment or alleviation of disease

Diagnosis, monitoring, treatment alleviation or compensation for an injury or handicap

investigation, replacement or modification of the anatomy or physiological process

control of conception

The Medicines and Healthcare products Regulatory Agency (MHRA) regulates medical devices in the UK under European legislation. Medical devices must not be mistaken for medicinal products.

5.4 Personal Protective Equipment Personal protective equipment (PPE) should be worn when carrying out cleaning, e.g. apron or gown and gloves and eye/ face protection if splashing is likely to occur, and this should be disposed of into the orange clinical waste bin.

6.0 METHODS OF DECONTAMINATION

6.1 Cleaning and Drying Thorough cleaning with detergent and hot water is adequate for most surfaces in the healthcare environment. Cleaning is essential before disinfection or sterilisation of any equipment or instrument can take place. Cleaning is a process which removes soil, e.g. dust, dirt and organic matter, along with a large proportion of micro-organisms. A further reduction will occur on drying as many micro-organisms cannot multiply on a clean dry surface.

6.2 Disinfection Disinfection by either heat or chemicals will destroy micro-organisms, but not bacterial spores. Chemical disinfection does not necessarily kill all micro-organisms present, but reduces them to a level not harmful to health. Heat treatment should always be chosen in preference to chemical disinfection if the equipment can withstand it. Some disinfectants, if used under strictly controlled conditions, may be considered sterilants, although this process may be more accurately described as high level disinfection.


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6.3 Antiseptic Antiseptic is the term usually employed to indicate that a particular non-toxic disinfectant may be used on skin or living tissues. An antiseptic solution should not be used to disinfect instruments or the environment.

6.4 Sterilisation Sterilisation is a process which achieves the complete destruction or removal of all micro-organisms, including bacterial spores, but with the exception of prion proteins. Equipment and materials used in procedures involving a break in the skin or mucous membranes should be sterilised, e.g. surgical instruments.

6.5 Choosing a Method The choice of method of disinfection or sterilisation depends on a number of factors, which include:

risk to patients and healthcare workers from equipment

micro-organisms involved

type of material to be disinfected

level of decontamination required for the procedure

facilities for decontamination

manufacturers recommendation

6.6 When Should Reusable Medical Equipment Be Cleaned? Cleaning should take place:

between each patient use

at regular predefined intervals as part of an equipment cleaning schedule

immediately after contamination with blood or body fluids

before disinfection or sterilisation

before inspection, servicing or repair

prior to disposal.

6.7 Cleaning Schedules Local schedules should be established to indicate the frequency of regular cleaning. Cleaning should be documented by the person who cleaned the equipment and cleaning schedules should be audited. Clean indicator tape should be applied, signed and dated.

7.0 CHEMICAL DISINFECTANTS AND THEIR USES

7.1 Chlorine-Based Disinfectants/ Non-Chlorine Based Disinfectant Chlorine-based disinfectants are available from pharmacy in tablet form for dilution at Ward/ Department level.

They act rapidly by the release of available chlorine.

Diluted solutions are unstable and should be freshly prepared.


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Chlorine-based disinfectants discolour fabrics, carpets or soft furnishings and are corrosive against metals.

Uses

Dealing with viruses/ bacteria.

All environmental decontamination, including blood spillages.

Precautions

Refer to manufacturers’/ COSHH instructions/ assessments and Health and Safety Manual when handling disinfectants.

Disposable nitrile gloves must be worn when handling disinfectants.

7.2 Alcohol Do not penetrate well into organic matter, especially protein-based and should, therefore, be used only on physically clean surfaces. Uses

Alcohol impregnated swabs are used for disinfection of skin prior to venepuncture.

Can be used as a base for other bactericides, such as chlorhexidine and iodine for pre-operative skin disinfecting, e.g. 70% alcohol with 2% chlorhexidine.

Alcohol may be used for disinfecting physically clean equipment or hard surfaces as specified in these guidelines or following consultation with the Infection Prevention & Control Nurse and according to manufacturer’s recommendations.

Hand decontamination – for further information see appropriate section in the Northern Ireland Regional Infection Prevention and Control Manual, available either via the WHSCT Intranet or www.infectioncontrolmanual.co.uk.

Precautions

Refer to manufacturers’/ COSHH instructions/ assessments and Health and Safety Manual when dealing with disinfectants.

7.3 Chlorhexidine Inactivated by soap, organic matter and by some emollients. Only emollients supplied by Pharmacy should be used.

Uses

To be used exclusively as an antiseptic for decontamination of skin and mucous membranes.

Chlorhexidine solutions combined with detergent are used for hand disinfection.

Combined with alcohol for rapid disinfection of physically clean hands.

Combined with alcohol for skin disinfection.

http://www.infectioncontrolmanual.co.uk/


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Precautions

Refer to manufacturers’/ COSHH assessments and Health and Safety Manual when dealing with disinfectants/ antiseptics.

DO NOT USE FOR CLEANING ANY TYPE OF INSTRUMENTS OR EQUIPMENT.

7.4 2% Chlorhexidine Gluconate & 70% Isopropyl Alcohol Formulated to work against skin microbes.

Broad spectrum – Gram positive micro-organisms, Gram negative micro-organisms as well as most viruses and fungi.

Rapid – Good reduction in level of organisms within 30 seconds.

Has residual effect for 48 hours. Uses

Decontaminate the skin site prior to the insertion of venous access devices or prior to surgical procedures

Should be used to clean venous access device insertion site during dressing changes and allowed to air dry. An aqueous solution of chlorhexidine gluconate should be used if the manufacturer’s recommendations prohibit the use of alcohol with their products.

Precautions

Refer to manufacturers’/ COSHH instructions/ assessments and Health and Safety Manual when dealing with antiseptics.

Not licensed for paediatric use.

7.5 Iodine and Iodophors

Inactivated by organic matter.

May corrode metals.

Uses

Alcoholic preparations containing iodine and iodophors can be used for pre-operative skin preparation.

Povidone iodine detergent preparations are suitable for surgical hand-disinfection

8.0 TREATMENT OF INFECTIOUS/ POTENTIALLY INFECTIOUS

SPILLAGES

All blood and body fluid spillages should be treated as potentially infectious regardless of their source

Wear disposable gloves and apron. If there is a risk of splashing wear eye protection.

Remove gross contamination with paper towel before washing with neutral detergent solution diluted with water.

Decontaminate with an Actichlor Plus/ Difficil-S solution. Allow to air dry for at least 5 minutes before rinsing the area with fresh water.


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Refer to Appendix 2 and 3 for correct dilution and precautions when using Actichlor Plus/ Difficil-S.

If using chlorine granules leave for 3 minutes.

Place all disposable equipment, including protective equipment in an orange clinical waste bag.

Tightly seal and tag the bag and leave in designated area for collection.

9.0 CLEANING OF AN ISOLATION ROOM

Instructions for Night Staff:

For additional information refer to the: Support Services Infection Prevention Cleaning Procedures, which

can be accessed via the Trust Intranet, in the Infection Prevention & Control Guidelines section.

A room that is vacated after 8pm and is not required until the morning should be left closed. The Support Services supervisor should be informed at 8am the following day.

If the room is required before 8am a Nursing Assistant/ Auxiliary should carry out terminal cleaning.

The nurse in charge of the ward should instruct the Nursing Assistant/ Auxiliary regarding correct procedures.

The nurse in charge should inspect the room and sign the terminal clean audit sheet. The room should be allowed to air dry before use.

Isolation cleaning equipment should be stored dry until the following morning when Support Services should be informed.

10.0 EQUIPMENT SENT FOR SERVICE OR REPAIR, INCLUDING USE OF

DECONTAMINATION CERTIFICATE

A wide range of equipment is in use within the Trust. It is essential to keep equipment clean, disinfected or sterilised (depending on the type of equipment) before patient use. This is also necessary when equipment requires repair.

It is the Head of Department's ultimate responsibility to ensure that Technicians/ Engineers who are asked to service, inspect or repair equipment are not put at risk by doing so. There is a legal requirement to carry out decontamination prior to inspection/ service or repair (Health and Safety at Work Act 1974).

A Decontamination Certificate MUST be filled in and attached to

EVERY piece of equipment which is sent for inspection, service or

http://whsct/IntranetNew/Documents/Support%20Services%20Infection%20Prevention%20Cleaning%20Procedures%20(Jul15).pdf


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repair, before returning equipment to an equipment library or if

equipment is loaned to another ward/ department. A

Decontamination Certificate must be completed before the loaned

equipment is returned to its original ward.

11.0 CLEANING OF VEHICLES

Used for the:

Transportation of dirty laundry

Transportation of hospital waste

Delivery/ pick up of surgical instruments

Transportation of equipment to Central Equipment Stores

The above mentioned transport vehicles should be cleaned as per Transport Policy Guidelines which may be obtained by contacting the Transport Department, Altnagelvin Hospital, Tel: 028 71345171 ext. 214609.

12.0 IMPLEMENTATION

12.1 Dissemination This policy is relevant to all healthcare staff employed by the WHSCT and those employed by external agencies providing healthcare for patients/ clients on behalf of the Trust. The policy will be posted on the Trust Intranet under the Infection Prevention and Control Guidelines section. A Trust Communication will be issued to highlight that the policy has been updated.

12.2 Exceptions There are no exceptions.

13.0 MONITORING

Compliance with this policy shall be monitored by individual managers and overall responsibility will lie with the director of their service. Multi-disciplinary teams monitor clinical areas on a regular basis as part

of the environmental cleanliness strategy.


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14.0 REFERENCES

Infection Control Team. (2012). Standard Infection Control Precautions, Literature Review: Management of patient care equipment in the hospital setting. Health Protection Scotland [Online] Available at: http://www.documents.hps.scot.nhs.uk/hai/infection-control/ic-manual/sicp-lr-equipment-v1.0.pdf [Accessed: January 2014]. NHS Estates (1997). Washer-Disinfectors, Validation and Verification, Health Technical Memorandum 2030. London: The Stationery Office [Online] Available at: http://www.publications.spaceforhealth.nhs.uk/stream.php?id=04s9Zn92oGq344R1qpn1nos5npq5pn8482pp [Accessed: January 2014] Pratt, R.J., Pellowe, C. M., Wilson, J.A., Loveday, H.P., Harper, P.J., Jones, S.R.L.J., McDougall, C., & Willcox, M.H. (2007). epic2: National evidence based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection, 65(S), pp.S1-64.

15.0 CONSULTATION PROCESS

Infection Prevention and Control Team Consultant Microbiologists Support Services Members of IP&C Policies & Guidelines Working Group Members of Chief Executive HCAI Accountability Forum

16.0 EQUALITY STATEMENT

In line with duties under the equality legislation (Section 75 of the Northern Ireland Act 1998), Targeting Social Need Initiative, Disability discrimination and the Human Rights Act 1998, an initial screening exercise to ascertain if this policy should be subject to a full impact assessment has been carried out. The outcome of the equality screening for this policy is: PENDING

Major impact

Minor impact

No impact

17.0 APPENDICES

Appendices to this policy are as follows:

http://www.documents.hps.scot.nhs.uk/hai/infection-control/ic-manual/sicp-lr-equipment-v1.0.pdf

http://www.documents.hps.scot.nhs.uk/hai/infection-control/ic-manual/sicp-lr-equipment-v1.0.pdf

http://www.publications.spaceforhealth.nhs.uk/stream.php?id=04s9Zn92oGq344R1qpn1nos5npq5pn8482pp

http://www.publications.spaceforhealth.nhs.uk/stream.php?id=04s9Zn92oGq344R1qpn1nos5npq5pn8482pp


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Appendix 1 – Disinfection Procedures for Individual Items and Equipment

Appendix 2 – Cleaning and Disinfection of Beds Poster Appendix 3 – Recommendations with Regard to Ultrasound Probes Appendix 4 – Actichlor Plus Poster Appendix 5 – Difficil-S Poster Appendix 6 – Bedpan Washer-Disinfectors

18.0 SIGNATORIES

Signed for and on behalf of the Western Health & Social Care Trust:

Karen Martin Date Infection Prevention & Control Nurse Fiona Hughes Date Head of Infection Prevention & Control


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Appendix 1

DISINFECTION PROCEDURES FOR INDIVIDUAL ITEMS AND EQUIPMENT Below is a list of equipment in alphabetical order. This list is not exhaustive. If the information you require is not included, use the procedure for a similar item. Alternatively, refer to the manufacturer’s recommendations, particularly for complicated and unusual pieces of equipment.

Equipment or Site

Routine or Preferred Method Acceptable Alternative or

Additional

Recommendations

Airways and

Endotracheal tubes

Single-use/ disposable only.

Alcohol Gel/ Hand

Rub Wall Dispensers

Nursing assistants/ auxiliaries daily clean outside of dispensers with warm water and neutral detergent and dry with a paper towel. Weekly clean inside.

N/A

Ampoules Wipe neck with a 70% isopropyl alcohol impregnated swab and allow drying before opening or piercing (if ampoule has a rubber bung scrub for 30 seconds and allow 30 seconds to dry).

N/A

Anaesthetic

Equipment

Tubing should be single use / disposable

N/A

Auroscopes Wipe over handle with 70% isopropyl alcohol wipe after each use. Disposable auroscope speculae to be used.

N/A

Baby Changing Mats Cover with a disposable paper towel roll and discard towel roll afterwards. Then wash with warm water and neutral detergent. Dry thoroughly with a paper towel. Discard mat if cracked or torn.

N/A

Babies Feeding Refer to the Guidelines for Use and Decontamination of Infant Feeding




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Equipment or Site


Additional

Recommendations

Bottles, Teats and

Dummies

Equipment in Hospital, which may be accessed via the WHSCT intranet, Infection Prevention and Control Guidelines section.

Baby Weighing

Scales

Clean with warm water, neutral detergent or a neutral detergent impregnated wipe after every use then dry.

Infected patients following clean with neutral detergent. Decontaminate with a 70% isopropyl alcohol wipe

Baths Non-infected patients: Clean with neutral detergent / cream cleanser and warm water then rinse after use by each patient.

Infected patients and for patients with unhealed wounds and those who are immunocompromised, disinfect the bath before and after use as outlined in Actichlor Plus Dilution Chart (Appendix 4) or Difficil-S (Appendix 5).

Bath Hoists Non-infected patients: Clean after each patient with warm water and neutral detergent and rinse. Disassemble hoist weekly for thorough clean.

Infected patients: Disinfect as outlined in Actichlor Plus Dilution Chart (Appendix 4) or Difficil-S (Appendix 5)

Bath Water Medicated bath additives only on prescription.

Beds and Cots Wash with warm water and neutral detergent and dry with a paper towel. Mattresses should be cleaned and checked following discharge. Unzip cover and inspect for signs of damage/ contamination. Report to Nurse in charge. Mattresses should be replaced when damaged.

Infected patients: Disinfect as outlined in Actichlor Plus Dilution Chart (Appendix 4) or Difficil-S (Appendix 5).

Beds (Pressure

Relieving)

Refer to manufacturer instructions. Must be included in Nursing Assistants/ Auxiliary cleaning schedules. Clean between each patient use. Unzip cover and inspect inner cells for signs of damage/

Refer to manufacturers instructions about suitable disinfectants. Ensure that untrained staff is aware of manufacturer’s instructions. If manufacturer’s instructions are at variance with



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Equipment or Site


Additional

Recommendations

contamination. Report same to nurse in charge. Mattresses should be replaced whenever damaged.

these guidelines seek advice from the Infection Prevention & Control Staff.

Bed Frames/ cradles

Clean with warm water and neutral detergent and dry following every patient use.

Infected patients: Disinfect as outlined in Actichlor Plus Dilution Chart (Appendix 4) or Difficil-S (Appendix 5).

Bedpans/ Urinals

The washer-disinfector is for the

emptying, cleaning and

disinfection of bedpans,

commode buckets, their lids,

urine bottles, urine collection

jugs and kidney bowls. Heat disinfection in a washer-

disinfector (80C for 1 min). Select the correct cleaning programme depending on the degree of soiling i.e. short/ normal/ intensive. After removal from the machine, ensure that there is no visible soiling. If soiling persists re-process. Store dry and inverted. Alternatively, single-use disposable items may be used. These should always be disposed of into a macerator unit. Ensure the lid is kept closed for 1 minute after cycle has ended. The user must complete a daily automatic control test as specified in HTM 2030 (see Appendix 6).

Infected patients: Patients with enteric infections should preferably have en suite facilities. Enteric illness: Enhanced cleans will be required. Particular attention should be paid to the cleaning and decontamination of door handles, lavatory handle and taps. Same should be requested from Support Services. If en suite facilities are not available supply the patient with a clean commode and ensure that bedpans are removed immediately following use. Commodes should be cleaned and disinfected as outlined in Actichlor Plus Dilution Chart (Appendix 4) or Difficil-S. (Appendix 5).

Birthing Pool Wash with warm water and neutral detergent after use. Followed by an acticlor clean Liner should always be used. Manufacturer’s recommendations to be followed.

Manufacturer’s recommendations to be followed.


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Equipment or Site


Additional

Recommendations

Blood Gas Analysers

(at ward/ department

level)

Refer to manufacturers instructions. A written protocol must be in place with clear guidance about who is responsible for decontaminating the machine and how it should be carried out.

Bowls (Washing)

For All Patients Individual washbowls should be available for each patient. After each use, clean with Actichlor Plus used as per dilution chart (Appendix 4) or Difficil-S (Appendix 5) and dry and store inverted.

Bowls (Surgical,

Sterile)

Return to HSDU.

Bowls (Vomit) Single use/ Disposable Non-disposable Where racks are available use bedpan washer or send to the HSDU.

Breast Pumps

Machine

Clean after use with neutral detergent and dry with paper towel Use Single use disposable kits.

Breast pump machine for use at home by mothers when baby remain in hospital. On return to ward decontaminate with Actichlor Plus see (Appendix 4) use single use disposable kit

Carpets Carpets should be avoided in clinical areas. Where they already exist: Vacuum clean or when soiled clean by hot water extraction. Scheduled rota for cleaning to be in place

For known contaminated spills: Disinfect with an agent that does not damage carpet then clean with a detergent. Seek advice from Support Services. Following an outbreak, steam cleaning may be required, consult Infection Prevention & Control Team.

Catheter drainage

Bags

Single use (disposable) N/A


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Equipment or Site


Additional

Recommendations

Computer Monitor

and keyboard

Clean weekly with detergent wipe (do not use alcohol based product on touch sensitive screens)

Crockery and Cutlery

Machine wash with rinse

temperature above 80C and dry or hand wash in detergent and hot

water (approx. 60C), rinse and dry thoroughly. Household gloves will be required at this temperature.

Cleaning Equipment

Colour coded cleaning equipment should be used for each area i.e. Red - bathroom and toilet area Blue - general areas ward Green - catering department and food service areas Yellow - isolation Buffer machine: drain reservoir after use and store dry.

NB. Patients on isolation should all have separate equipment should be disposed of in orange bag after use.

Commodes Wash after each use with warm water and neutral detergent, dry with a disposable paper towel. Always leave clean and ready for use.

Infected patients and / or if faecal contamination has occurred clean and disinfect as outlined in Actichlor Plus Dilution Chart (Appendix 4). Place clean indicator tape across the front and over the arms ensure signature by staff member.

Couches (Treatment) Wash with warm water and neutral detergent and dry after each patient. Change paper towel/ roll between each patient.

Infected patients and/ or if contaminated with body fluids i.e. blood, urine or faeces; disinfect as outlined in Actichlor Plus Dilution Chart (Appendix 4).

Defibrillator Clean after use Damp dust weekly or if visibly dusty. Refer to Manufacturer’s recommendations.


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Equipment or Site


Additional

Recommendations

Denture Tubs Disposable/ single patient use. Mugs to be washed with warm water and neutral detergent daily.

Diabetic Blood

Glucose Monitors

Clean with neutral detergent wipe after every use - should be included in cleaning schedule.

DO NOT LET LIQUID DRIP INTO

THE METER.

Infected patients: Use patients own if possible. If not, contact the diabetic nurse practitioner to who will supply an individual monitor for the patient. Following discharge of the patient disinfect as outlined in Actichlor Plus Dilution Chart (Appendix 4). Cleaning should include the nylon carrying case.

DO NOT LET LIQUID DRIP

INTO THE METER.

External Drains

(not sink wastes)

Clean regularly. Chemical disinfection is not required.

When blockage occurs, contact Inter service (Help desk No 258888).

Dressing Trays/

Trolleys

Clean daily with warm water and neutral detergent including the wheels and dry with paper towel. Decontaminate with alcohol prior to and after use.

Disinfect as outlined in Actichlor Plus Dilution Chart (Appendix 4). Rinse, dry or use 70% alcohol if no organic material is present.

Drip Stands/

Counters

Clean daily with neutral detergent wipe while in use or if visibly dirty. Clean weekly if not in use, including wheels. Refer to manufacturers instructions

Clean daily with neutral detergent wipe whilst in use. Disinfect as outlined in Actichlor Plus Dilution Chart (Appendix 4), rinse and dry or use 70% alcohol if no organic material is present. Refer to manufacturers instructions.

Drug Fridge Wash with warm water, neutral detergent and dry. Clean weekly or if visibly dirty. Scheduled rota for cleaning to be in place. A record of cleaning frequency/ maintenance should be retained.


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Equipment or Site


Additional

Recommendations

Duvets Water-impermeable cover: Wash with warm water, neutral detergent and dry. Non water-proof duvets: Launder regularly or if soiled.

Send to laundry as infected linen for decontamination, follow manufacturer’s instructions.

ECG Machine Clean after use with neutral detergent wipes or if visibly dirty and dry with paper towel. Include in weekly schedule. Refer to manufacturers instructions

Disinfect as outlined in Actichlor Plus Dilution Chart (Appendix 4) or use 70% alcohol if no organic material present. Refer to manufacturers instructions.

ECT Machine Clean after use with neutral detergent wipes or if visibly dirty and dry with paper towel. Include in weekly schedule. Refer to manufacturer’s instructions

Disinfect as outlined in Actichlor Plus Dilution Chart (Appendix 4) or use 70% alcohol if no organic material present. Refer to manufacturer’s instructions.

Emergency Trolley/

Equipment

Clean after use with neutral detergent and include in cleaning schedule

Decontaminate after use as outlined in Actichlor Plus Dilution Chart (Appendix 4). Dry or use 70% alcohol if no organic material is present.

Endoscopes Manual cleaning, disinfection and storage of endoscopes according to unit’s protocol and in accordance with manufacturers and AER (automated endoscope reprocessors) instructions.

ALL FLEXIBLE ENDOSCOPES

MUST BE REPROCESSED

WITHIN THE CENRALISED

ENDOSCOPY DECONTAMINAION

UNIT AT EACH HOSPITAL SITE

ADVICE ON THE

DECONTAMINATION OF

ENDOSCOPES CAN BE SOUGHT

FROM THE DECONTAMINATION

MANAGER WHSCT

All staff must receive training in the safe use, decontamination and storage of endoscopes in line with departmental policies, manufacturers and the relevant regulatory body’s recommendations. Advice on the decontamination of endoscopes can be sought from the Decontamination Manager, Western Health & Social Care Trust.


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Equipment or Site


Additional

Recommendations

Enteral Feeding Lines Follow manufacturer’s instructions Disinfect as outlined in Actichlor Plus Dilution Chart (Appendix 4) or use 70% alcohol if no organic material present. Refer to manufacturer’s instructions.

Fans

NB: fans are not

advised for use in

areas where patients

have/ are suspected

of having infection

Remove front grill and clean at least weekly with neutral detergent or if visibly dirty. Allow to dry before returning to use. A regular cleaning schedule for fans that cannot be opened is essential and must be agreed with Estate Services. When purchasing new fans a removable front cover is essential.

Floors (Dry Cleaning)

Vacuum or use a dust-attracting dry mop. Never use brooms in patient areas. Non-disposable dust mops must be vacuumed after each use.

Floors (Wet) Microfibre Mop System/ traditional lay flat mopping system to be used

An isolation pack must be obtained from Support Services. It must be returned after use for decontamination. Separate packs are required for each patient in isolation. Following discharge of an infected patient, disinfect mop bucket, handle etc as outlined in Actichlor Plus Dilution Chart (Appendix 4) or Difficil-S (Appendix 5). Mop heads must be removed for laundering daily.

Fixtures and Fittings

In clinical areas damp dust daily with warm water and neutral detergent or if visibly dirty.

In known contaminated areas, disinfect as outlined in Actichlor Plus Dilution Chart (Appendix 4).


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Equipment or Site


Additional

Recommendations

Furniture and Ledges

In clinical areas damp dust daily with warm water and neutral detergent or if visibly dirty.

Following discharge of an infected patient, refer to the Support Services Infection Control Cleaning Procedures, which can be accessed via the Trust Intranet, under the Infection Prevention & Control Guidelines section.

Haemodialysis

Equipment

Follow units/ manufacturers protocol for decontamination of haemodialysis machine/ dispose of used lines and dialyser in clinical waste.

Hair Rollers

Rollers must not be

shared

Patients own to be used. Wash with warm water and neutral detergent and dry.

Humidifiers

(O2 Therapy)

Use single patient use/ disposable. Wash with warm water and neutral detergent if soiled between uses.

Humidifiers must only be filled with sterile water which must be changed every 24 hours or sooner if necessary.

Ice machines

(Not recommended

for human

consumption)

A regular maintenance programme compatible with the manufactures instructions should be in place. Exterior/ interior clean weekly or as per manufacturer’s instructions. Ice scoops must be washed daily in a dishwasher or wash in warm water and neutral detergent. Store in a container outside the ice machine.

Requirements will vary with the make/ model of machine. A record of cleaning frequency/ maintenance should be retained.

Infant Incubators Follow protocol available in each unit.

Follow protocol available in each unit.

Surgical Instruments Send to HSDU for reprocessing.

DO NOT DECONTAMINATE AT

WARD/ DEPARTMENT LEVEL.


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Equipment or Site


Additional

Recommendations

Jacuzzi/ Whirlpool

Baths

Wash with warm water and neutral detergent after use. Manufacturer’s recommendations to be followed regarding cleaning, maintenance and servicing. Baths not regularly used must be flushed as per legionella controls.

*Patients with unhealed wounds, who are immunocompromised or those who have a known infection should not use Jacuzzi/ whirlpool baths.

Jugs (for measuring

urine/ emptying urine

bags)

After each use decontaminate in bedpan washer-disinfector, return to HSDU or single use.

Laryngoscope

Blade

Handle

Disposable blades should be used. Reusable blades: Send to HSDU for reprocessing after each use. Neutral detergent wipe then wipe over handle with 70% isopropyl alcohol wipe after each use.

Lifting/ Hoist Slings Launder as per protocol/ manufacturer’s instructions.

Use disposable slings if lifting equipment is compatible, otherwise reserve sling for patient and send to laundry following discharge.

Mattresses/ Pressure

Relieving Devices

To be protected by a waterproof cover. Wash with warm water and neutral detergent and dry. Maintenance to be carried out as per protocol/ manufacturer’s recommendations. Inspect regularly for signs of damage to mattress/ cover. Report same to nurse in charge. Mattresses should be replaced whenever damaged or every 4 years.

Infected patients: Disinfect as outlined in Actichlor Plus Dilution Chart (Appendix 4). Allow 5 minutes contact time then rinse and dry. Follow any specific instructions advised by the manufacturer.

Medicine Cups Single use only

Nail Brushes

(surgeon's hand)

Use sterile pre-packed single-use disposable. Should not be routinely available at ward level.

Disposable single-use only.

Nebuliser Nebuliser tubing and mask are single patient use only. Nebuliser chamber (ACORN) to be


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Equipment or Site


Additional

Recommendations

changed after each treatment.

Peak Flow Meters Use disposable mouth piece and bacterial viral filter.

Single patient use.

Pillows Use only with water impermeable cover. Clean (warm water and neutral detergent)/ change cover if visibly soiled or following discharge of each patient. Pillows to be inspected routinely and disposed of if found to be torn or damaged.

Portanebs:

- Inline Filters &

- Inlet Filters

Refer to manufacturer’s recommendations. A written protocol must be in place

Refer to manufacturer’s recommendations. A written protocol must be in place.

Pumps/ IV Infusion Clean daily with neutral detergent wipe while in use or if visibly dirty. Clean weekly if not in use, including wheels. Refer to manufacturer’s instructions.

Decontaminate after use with Actichlor Plus (see Appendix 4)

Razors (Wet Shave) For hygiene purposes - use disposable. Dispose of into a sharps container.

Razors (Electric) Patient’s own razors must be used. No sharing of razors permitted.

Rooms Refer to Support Services Infection Control Cleaning Procedures

Scales Clean after use with neutral detergent or if visibly dirty include in weekly schedule.

Infected patients: Disinfect as outlined in Actichlor Plus Dilution Chart (Appendix 4). Rinse and allow drying.

Scissors If scissors are not required to be sterile: wipe before and after use with a 70% alcohol impregnated wipe.

http://whsct/IntranetNew/Documents/Support%20Services%20Infection%20Control%20Cleaning%20Procedures%20(Nov%2012).pdf

http://whsct/IntranetNew/Documents/Support%20Services%20Infection%20Control%20Cleaning%20Procedures%20(Nov%2012).pdf


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Equipment or Site


Additional

Recommendations

Use disposable scissors, if there is a possibility of contact with blood, body fluids and sterile sites.

Shaving Brushes Each patient should have their own individual shaving equipment. Brushes should be cleaned after use and stored dry.

Slip/ Slide Sheets Single patient use Single patient use

Soap Liquid soap: should be supplied in a dispensing container. Do not top-up. If hands are physically clean an alcohol hand rub can be used instead of soap and water. Tablet soap: is not acceptable in public/ clinical areas. Patients’ personal soap to be stored dry.

Antiseptic hand wash must always be available in patient isolation rooms and for use prior to aseptic procedures. Alcohol hand rubs must be available at the end of every bed and outside single rooms unless contraindicated. Chlorhexidine hand wash should available in the clinical area.


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Equipment or Site


Additional

Recommendations

Suction Equipment

Equipment: Machines – after use clean outside

with neutral detergent wipes or if visibly soiled.

Catheters – single use/disposable. Do not leave open catheters attached to tubing.

Tubing – single patient use / disposable.

Filters – change in accordance with manufacturers instructions.

Jars – preferably use disposable liners, alternatively send to the HSDU.

* Wear a plastic apron and non-sterile disposable nitrile gloves for this procedure. Disposable systems are discarded to clinical waste bags if gelling agent has been used. The reservoir of the suction apparatus should be kept empty and dry when not in use. Suction tubing must be changed following discharge/ transfer of every patient or more frequently if necessary.

Specimen fridge Wash with warm water, neutral detergent and dry. Clean weekly or if visibly dirty.

Speculae Single use/ disposable

Sputum Containers Disposable. Seal and discard as clinical waste daily or sooner if required.


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Equipment or Site


Additional

Recommendations

Sphygmomanometer

Sphygmomanometer

Cuff

Clean after use with neutral detergent wipe.

Wipe with a neutral detergent and allow drying. Ensure that cuff is dry prior to use. Disposable cuffs can be ordered. These are single patient use only.

Infected patients: After cleaning with neutral detergent, wipe with a 70% alcohol impregnated wipe and allow drying. Follow manufacturer’s recommendations. Disposable cuffs to be used – single patient use.

Stethoscope Clean bell, ear pieces and diaphragm after each use with a 70% alcohol impregnated wipe and allow drying.

Syringe Drivers/

Pumps

After use surface clean with neutral detergent wipe. If spillages occur whilst in use, clean immediately. Wipe over with 70% alcohol impregnated wipe. Refer to manufacturer’s recommendations. Syringe driver cloth covers to be single patient use.

Infected patients: After cleaning wipe with a 70% alcohol impregnated wipe and allow drying. Refer to manufacturer’s recommendations.

Thermometers

(Electronic)

Use a single-use sleeve and change after each use. Wipe thermometer tip with neutral detergent wipe after use. Ensure holder is cleaned at least daily with warm water and neutral detergent. Refer to manufacturer’s recommendations.

Infected patients: Use a single-use sleeve. Holder should be cleaned with 70% alcohol following each use, or confined to the single room only. Refer to manufacturer’s recommendations.

Thermometers

(Tympanic)

Use disposable cover for each patient use and discard. Clean holder as per manufacturer’s recommendations.

Decontaminate immediately following use as per manufacturer’s recommendations.


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Equipment or Site


Additional

Recommendations

Toilet/ Toilet Seats Wash as per schedule with warm water and neutral detergent and dry. More frequent cleans are necessary in high usage areas. Use cream cleaner for stubborn stains. Use appropriate PPE Refer to Support Services cleaning schedules for frequencies in individual departments.

Infected patients/ faecal stained toilets: Disinfect as outlined in Actichlor Plus Dilution Chart (Appendix 4)/ Difficil-S (Appendix 5). Rinse and dry. Follow recommended frequency cleaning. Increased frequency for C. difficile. Use appropriate PPE.

Tonometer Prisms Use disposable prisms

Tourniquet Single use

Re-usable should be replaced by single use

Trolleys

Wash trolley and wheels daily with warm water and detergent, rinse and dry with a paper towel. Decontaminate prior to and after dressings/ procedures using an alcohol impregnated wipe.

Infected patients: Disinfect as outlined in Actichlor Plus Dilution Chart (Appendix 4)/ Difficil-S (Appendix 5) or if no organic material present 70% impregnated alcohol wipe before and after use.

Tubing (Anaesthetic/

Ventilator)

Use disposables

Ultrasound Head/

Probe

(See Appendix 3)

Use a single patient use transducer cover. Refer to manufacturer’s recommendations. Avoid alcohol based products

Use a single patient use transducer cover. Refer to manufacturer’s recommendations

Urinals See Bedpans


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Equipment or Site


Additional

Recommendations

Ventilators

(Mechanical)

Refer to manufacturer’s recommendations for decontamination. Single patient use disposable tubing and filter must always be changed between patients. Whilst in use with a single patient change disposable filters in accordance with manufacturer’s recommendations. Change disposable tubing (circuit) every 7 days or more frequently if contaminated.

Refer to manufacturer’s recommendations for decontamination.

Waterbed Wash the mattress with warm water and neutral detergent. The removable cover can be laundered to eliminate dust mites. Refer to manufacturer’s recommendations regarding maintenance and water changing. To be included in cleaning schedule.

X-Ray Equipment Refer to manufacturer’s recommendations. Damp dust with warm water and neutral detergent. Do not over-wet and allow surface to dry before use.

Clean with warm water and neutral detergent and then wipe with a 70% alcohol impregnated wipe unless contraindicated by the manufacturer. For specialised equipment, draw up local protocol for cleaning and disinfection, based on the manufacturer's recommendations.

Methods of decontamination are listed on the previous pages. This list is not exhaustive and it must be remembered that a piece of equipment may require different types of decontamination for various uses. If in doubt it is always advisable to refer to the manufacturer’s recommendations, or contact the Decontamination Manager or an Infection Prevention & Control Nurse. If it is not possible to decontaminate a piece of equipment properly, this should be stated on the Decontamination Certificate.


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Appendix 2

CLEANING AND DISINFECTION OF BEDS

Poster may be accessed via Trust intranet – Infection Prevention & Control Guidelines section.


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Appendix 3

RECOMMENDATIONS WITH REGARD TO ULTRASOUND PROBES Please note the following recommendations with regard to ultrasound probes:

Initially refer to manufacturer’s guidelines

The use of Chlorine Dioxide Sporicidal Foam as a method of decontamination should only be used if unable to process in an endoscope washer disinfector.

The following guidelines are for equipment that cannot be processed through HSDU.

Risk Application Recommendation Product Codes

Significant Probes in contact with non intact skin, mucous membranes or bodily fluids. After use on intact skin of infected/ colonised patients. Prior to use on an immuno-compromised patient

Clean with wipe system which includes traceability log book. Continue to use sheath in conjunction with above cleaning system.

Low Probes in contact with healthy skin.

Clean with detergent and hot water or detergent impregnated wipes. Continue to use sheath in conjunction with above cleaning system.

A written standard operating procedure (SOP) must be available, easy to read and clearly visible to staff using the equipment. The SOP should be based on the manufacturer’s instructions and this guidance. Manufacturer’s instructions which contradict the principles outlined in the guidance must be discussed with the IP&C Team. Staff using the equipment must receive appropriate training in the agreed decontamination procedure.

Traceability The log book must be completed by the person who decontaminates each device and the traceability labels must be sited in log book and Patient Notes.


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Appendix 4

WARNINGS

AND

PRECAUTIONS

DISINFECTING YOUR GENERAL ENVIRONMENT &

BLOOD SPILLS WITH ACTICHLOR® PLUS TABLETS


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Appendix 5


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Appendix 6

BEDPAN WASHER-DISINFECTORS

Automatic Control Test

This is completed weekly by Test Person from WHSCT to ensure that the operating cycle functions correctly.

Daily Check This is carried out by the user and recorded in the log book. Use a normal cycle and record the result. The test should be considered satisfactory if the following requirements are met:

A visual display indicating ‘cycle complete’ occurs

The time for the disinfection temperature is maintained at that established by the manufacturer or the performance qualification test.

The door cannot be opened until the cycle is complete

The person conducting the test does not observe any mechanical or other anomaly