DISINFECTION AND DECONTAMINATION POLICY (PATIENT CARE EQUIPMENT)

Transcription

1 DISINFECTION AND DECONTAMINATION POLICY (PATIENT CARE EQUIPMENT) December

2 Title: 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: Links to other policies, Procedures, Guidelines or Protocols Med11/001 Policy for the Management of Decontamination Policy for Decontamination of Reusable Invasive Medical Devices Policy for the Management of Medical Devices available at Regional Infection Prevention & Control Guidelines, including those for MRSA and Cleaning and Disinfection Support Services Infection Prevention Cleaning Procedures Laundry Handling Guidelines Waste Manual Guidelines for Use and Decontamination of Infant Feeding Equipment in Hospital Page 2 of 36

3 CONTENTS Section 1.0 Introduction 1.1 Background 1.2 Purpose Page Scope of the Policy Roles and Responsibilities 3.1 Trust Board and Chief Executive 3.2 Seniors Managers/ Ward Managers 3.3 All Healthcare Employees within the WHSCT 4.0 Key Principles 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 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 7.0 Chemical Disinfectants and Their Uses 7.1 Chlorine-Based Disinfectants/ Non-Chlorine Based Disinfectants 7.2 Alcohol 7.3 Chlorhexidine % Chlorhexidine Gluconate & 70% Isopropyl Alcohol 7.5 Iodine and Iodophors Treatment of Infectious/ Potentially Infectious Spillages Cleaning of an Isolation Room Equipment Sent for Service or Repair, Including Use of Decontamination Certificate 11.0 Cleaning of Vehicles Implementation 12.1 Dissemination 12.2 Exceptions 13.0 Monitoring References Page 3 of 36

4 15.0 Consultation Process Equality Statement Appendices 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 Page 4 of 36

5 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. Page 5 of 36

6 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. Page 6 of 36

7 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. Single Patient Use DO NOT REMOVE STERILISED ITEMS FROM PACKAGEING UNTIL IMMEDIATELY BEFORE 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 Intermediate Low Items in close contact with a break in the skin or mucous membrane or introduced into a sterile body area/ invasive procedure. Items in contact with intact skin, mucous membranes or body fluids, particularly after use on infected patients or prior to use on immunocompromised patients. Items in contact with healthy skin or mucous membranes or not in contact with patients. Disinfection and sterilisation processing within HSDU. Sterilisation or disinfection required using appropriate disinfectant. Cleaning may be acceptable in some agreed situations. Cleaning. Page 7 of 36

8 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. Page 8 of 36

9 6.3 Antiseptic Antiseptic is the term usually employed to indicate that a particular nontoxic 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. Page 9 of 36

10 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 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. Page 10 of 36

11 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 % 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. Page 11 of 36

12 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 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 Page 12 of 36

13 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 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: ext 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 Exceptions There are no exceptions 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. Page 13 of 36

14 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: [Accessed: January 2014]. NHS Estates (1997). Washer-Disinfectors, Validation and Verification, Health Technical Memorandum London: The Stationery Office [Online] Available at: ogq344r1qpn1nos5npq5pn8482pp [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.s 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: Page 14 of 36

15 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 Infection Prevention & Control Nurse Date Fiona Hughes Head of Infection Prevention & Control Date Page 15 of 36

16 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 Ampoules Anaesthetic Equipment Nursing assistants/ auxiliaries daily clean outside of dispensers with warm water and neutral detergent and dry with a paper towel. Weekly clean inside. 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). Tubing should be single use / disposable N/A N/A N/A Auroscopes Wipe over handle with 70% isopropyl alcohol wipe after each use. N/A Baby Changing Mats Babies Feeding Disposable auroscope speculae to be used. 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. Refer to the Guidelines for Use and Decontamination of Infant Feeding N/A Page 16 of 36

17 Equipment or Site Routine or Preferred Method Acceptable Alternative or 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 Baths Bath Hoists Bath Water Beds and Cots Beds (Pressure Relieving) Clean with warm water, neutral detergent or a neutral detergent impregnated wipe after every use then dry. Non-infected patients: Clean with neutral detergent / cream cleanser and warm water then rinse after use by each patient. Non-infected patients: Clean after each patient with warm water and neutral detergent and rinse. Disassemble hoist weekly for thorough clean. Medicated bath additives only on prescription. 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. 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/ Infected patients following clean with neutral detergent. Decontaminate with a 70% isopropyl alcohol wipe 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). Infected patients: Disinfect as outlined in Actichlor Plus Dilution Chart (Appendix 4) or Difficil-S (Appendix 5) Infected patients: Disinfect as outlined in Actichlor Plus Dilution Chart (Appendix 4) or Difficil-S (Appendix 5). 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 Page 17 of 36

18 Equipment or Site Routine or Preferred Method Acceptable Alternative or 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 Bedpans/ Urinals Birthing Pool Clean with warm water and neutral detergent and dry following every patient use. 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 washerdisinfector (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). 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. Infected patients: Disinfect as outlined in Actichlor Plus Dilution Chart (Appendix 4) or Difficil-S (Appendix 5). 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). Manufacturer s recommendations to be followed. Page 18 of 36

19 Equipment or Site Routine or Preferred Method Acceptable Alternative or 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) Bowls (Surgical, Sterile) Bowls (Vomit) Breast Pumps Machine Carpets Catheter drainage Bags 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. Return to HSDU. Single use/ Disposable Non-disposable Where racks are available use bedpan washer or send to the HSDU. Clean after use with neutral detergent and dry with paper towel Use Single use disposable kits. 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 Single use (disposable) 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 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. N/A Page 19 of 36

20 Equipment or Site Routine or Preferred Method Acceptable Alternative or Additional Recommendations Computer Monitor and keyboard Clean weekly with detergent wipe (do not use alcohol based product on touch sensitive screens) Crockery and Cutlery Cleaning Equipment Commodes Couches (Treatment) Defibrillator 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. 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. Wash after each use with warm water and neutral detergent, dry with a disposable paper towel. Always leave clean and ready for use. Wash with warm water and neutral detergent and dry after each patient. Change paper towel/ roll between each patient. Clean after use Damp dust weekly or if visibly dusty. Refer to Manufacturer s recommendations. NB. Patients on isolation should all have separate equipment should be disposed of in orange bag after 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. 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). Page 20 of 36

21 Equipment or Site Routine or Preferred Method Acceptable Alternative or Additional Recommendations Denture Tubs Disposable/ single patient use. Mugs to be washed with warm water and neutral detergent daily. Diabetic Blood Glucose Monitors External Drains (not sink wastes) Dressing Trays/ Trolleys Drip Stands/ Counters Drug Fridge Clean with neutral detergent wipe after every use - should be included in cleaning schedule. DO NOT LET LIQUID DRIP INTO THE METER. Clean regularly. Chemical disinfection is not required. Clean daily with warm water and neutral detergent including the wheels and dry with paper towel. Decontaminate with alcohol prior to and after use. 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 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. 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. When blockage occurs, contact Inter service (Help desk No ). Disinfect as outlined in Actichlor Plus Dilution Chart (Appendix 4). Rinse, dry or use 70% alcohol if no organic material is present. 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. Page 21 of 36

22 Equipment or Site Routine or Preferred Method Acceptable Alternative or 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 ECT Machine Emergency Trolley/ Equipment Endoscopes Clean after use with neutral detergent wipes or if visibly dirty and dry with paper towel. Include in weekly schedule. Refer to manufacturers instructions 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 Clean after use with neutral detergent and include in cleaning schedule 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 Disinfect as outlined in Actichlor Plus Dilution Chart (Appendix 4) or use 70% alcohol if no organic material present. 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 manufacturer s instructions. Decontaminate after use as outlined in Actichlor Plus Dilution Chart (Appendix 4). Dry or use 70% alcohol if no organic material is present. 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. Page 22 of 36

23 Equipment or Site Routine or Preferred Method Acceptable Alternative or 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 Floors (Dry Cleaning) Floors (Wet) Fixtures and Fittings 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. Vacuum or use a dust-attracting dry mop. Never use brooms in patient areas. Non-disposable dust mops must be vacuumed after each use. Microfibre Mop System/ traditional lay flat mopping system to be used In clinical areas damp dust daily with warm water and neutral detergent or if visibly dirty. 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. In known contaminated areas, disinfect as outlined in Actichlor Plus Dilution Chart (Appendix 4). Page 23 of 36

24 Equipment or Site Routine or Preferred Method Acceptable Alternative or 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 Hair Rollers Rollers must not be shared Humidifiers (O 2 Therapy) Ice machines (Not recommended for human consumption) Infant Incubators Surgical Instruments Follow units/ manufacturers protocol for decontamination of haemodialysis machine/ dispose of used lines and dialyser in clinical waste. Patients own to be used. Wash with warm water and neutral detergent and dry. Use single patient use/ disposable. Wash with warm water and neutral detergent if soiled between uses. 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. Follow protocol available in each unit. Send to HSDU for reprocessing. DO NOT DECONTAMINATE AT WARD/ DEPARTMENT LEVEL. Humidifiers must only be filled with sterile water which must be changed every 24 hours or sooner if necessary. Requirements will vary with the make/ model of machine. A record of cleaning frequency/ maintenance should be retained. Follow protocol available in each unit. Page 24 of 36

25 Equipment or Site Routine or Preferred Method Acceptable Alternative or 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) Laryngoscope Blade Handle Lifting/ Hoist Slings Mattresses/ Pressure Relieving Devices Medicine Cups Nail Brushes (surgeon's hand) Nebuliser After each use decontaminate in bedpan washer-disinfector, return to HSDU or single use. 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. Launder as per protocol/ manufacturer s instructions. 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. Single use only Use sterile pre-packed single-use disposable. Should not be routinely available at ward level. Nebuliser tubing and mask are single patient use only. Nebuliser chamber (ACORN) to be Use disposable slings if lifting equipment is compatible, otherwise reserve sling for patient and send to laundry following discharge. 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. Disposable single-use only. Page 25 of 36

26 Equipment or Site Routine or Preferred Method Acceptable Alternative or Additional Recommendations changed after each treatment. Peak Flow Meters Pillows Portanebs: - Inline Filters & - Inlet Filters Pumps/ IV Infusion Razors (Wet Shave) Razors (Electric) Rooms Scales Scissors Use disposable mouth piece and bacterial viral filter. 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. Refer to manufacturer s recommendations. A written protocol must be in place 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. For hygiene purposes - use disposable. Dispose of into a sharps container. Patient s own razors must be used. No sharing of razors permitted. Refer to Support Services Infection Control Cleaning Procedures Clean after use with neutral detergent or if visibly dirty include in weekly schedule. If scissors are not required to be sterile: wipe before and after use with a 70% alcohol impregnated wipe. Single patient use. Refer to manufacturer s recommendations. A written protocol must be in place. Decontaminate after use with Actichlor Plus (see Appendix 4) Infected patients: Disinfect as outlined in Actichlor Plus Dilution Chart (Appendix 4). Rinse and allow drying. Page 26 of 36

27 Equipment or Site Routine or Preferred Method Acceptable Alternative or 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 topup. 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. Page 27 of 36

28 Equipment or Site Routine or Preferred Method Acceptable Alternative or 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 nonsterile 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 Speculae Sputum Containers Wash with warm water, neutral detergent and dry. Clean weekly or if visibly dirty. Single use/ disposable Disposable. Seal and discard as clinical waste daily or sooner if required. Page 28 of 36

29 Equipment or Site Routine or Preferred Method Acceptable Alternative or 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 Syringe Drivers/ Pumps Thermometers (Electronic) Thermometers (Tympanic) Clean bell, ear pieces and diaphragm after each use with a 70% alcohol impregnated wipe and allow drying. 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. 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. Use disposable cover for each patient use and discard. Clean holder as per manufacturer s recommendations. Infected patients: After cleaning wipe with a 70% alcohol impregnated wipe and allow drying. 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. Decontaminate immediately following use as per manufacturer s recommendations. Page 29 of 36

30 Equipment or Site Routine or Preferred Method Acceptable Alternative or 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 Tubing (Anaesthetic/ Ventilator) Ultrasound Head/ Probe (See Appendix 3) Urinals 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. Use disposables Use a single patient use transducer cover. Refer to manufacturer s recommendations. Avoid alcohol based products See Bedpans 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. Use a single patient use transducer cover. Refer to manufacturer s recommendations Page 30 of 36

31 Equipment or Site Routine or Preferred Method Acceptable Alternative or 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 X-Ray Equipment 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. 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. Page 31 of 36

32 Appendix 2 CLEANING AND DISINFECTION OF BEDS Poster may be accessed via Trust intranet Infection Prevention & Control Guidelines section. Page 32 of 36

33 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. Clean with wipe system which includes traceability log book. Low After use on intact skin of infected/ colonised patients. Prior to use on an immunocompromised patient Probes in contact with healthy skin. Continue to use sheath in conjunction with above cleaning system. 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. Page 33 of 36

34 Appendix 4 DISINFECTING YOUR GENERAL ENVIRONMENT & BLOOD SPILLS WITH ACTICHLOR PLUS TABLETS WARNINGS AND PRECAUTIONS Page 34 of 36

35 Page 35 of 36 Appendix 5

36 Appendix 6 Automatic Control Test BEDPAN WASHER-DISINFECTORS 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 Page 36 of 36