cleaning and decontamination for infection prevention and

Policy and Procedures Cleaning and Decontamination

for Infection Prevention and Control

Trust Reference B5/2006

Approved By Policy and Guideline Committee

Date Approved 25 June 2010

Version Final Version June 2010

Supersedes B5/2006

Author / Originator(s) Matt Hull

June Woodcock

Islwyn Jones

Infection Prevention and Control Team

Name of Responsible Committee / Individual

Infection Control Committee

Next Review Date June 2013

CONTENTS –

Section Page

1. Introduction and Background 3

2. Policy Aims and Scope 3

3. Definitions 3

4. Roles and Responsibilities 4

5. Education and Training 5

6.Policy Statements and Procedures 6

7. Audit and Review 7

8. Evidence Base 7

9. Development Consultation and Review 8

10. Legal Liability 8

11. Appendix 1- Quick reference guide responsibilities and methods of cleaning equipment. When using Chlorclean or Sanitiser powder

10-11

11. Appendix 2- Quick Reference Guide on Cleaning Methods

when Chlorclean or sanitiser powder is not appropriate, 12-14

12. Appendix 3- Guidelines for cleaning Ice machines 15-16

13. Appendix 4- Procedure for decontamination of endoscopes 17-18

14. Appendix 5- Guidance for the decontamination of re-usable components of sigmoidoscopes in Out Patients Departments

19

15.Appendix 6- Guidance for the decontamination of re-usable components of sigmoidoscopes in Theatres and Endoscopy Units

20

16.Appendix 7- National colour coding guidance

21

17.Appendix 8- Procedure for cleaning portering wheelchairs between patients

23

18.Appendix 9- Procedure for Dealing with Blood Spillages 24-27

19.Appendix 10- Procedure for Dealing with Body Fluid Spillages other than Blood

27

V CHANGES KEY CHANGES FROM PREVIOUS DOCUMENT

RE-FORMATTED TO TRUST FORMAT

MONITORS NOW DECONTAMINATED WITH TRIGENE WIPES

COMPUTERS ON WHEELS MONITORS AND KEYBOARDS NOW DECONTAMINATED WITH TRIGENE

WIPES

FEEDING BOTTLES REMOVED AS NOW SINGLE USE

PCA AND EPIDURAL PUMPS NOW DECONTAMINATED WITH TRIGENE WIPES

Policy and Procedures for Cleaning and Decontamination for Infection Prevention and Control of 27 Approved by Policy and Guideline Committee on Final Draft June 2010

1 INTRODUCTION

1.1 All staff must possess an appropriate awareness of their role in the prevention and containment of infection control in their area of work. Not only is this part of their professional duty of care to the patients with whom they are involved, but it is also their responsibility to themselves, to other patients and members of staff under the Health and Safety at Work Act (1974). The Control of Substances Hazardous to Health (COSHH) Regulations (2002), require actions to be taken to control the risk of hazardous substances, this policy applies solely to reducing micro-organisms risks. 1.2 Patients can be protected against infection by ensuring that disease-producing microbes are reduced as much as possible from potential sources of infection. This involves the cleaning, disinfection and sterilisation of contaminated materials, equipment and surfaces. The choice of method can be based on the infection risks to the patient, which can be classified as high, intermediate and minimal risks (Ayliffe et al 2002)

2 POLICY AIMS AND SCOPE

2.1 This policy applies to all staff employed within University Hospitals of Leicester NHS Trust and staff working in a contracted capacity. 2.2 The following policy identifies the principles, responsibilities and methods associated with cleaning and decontamination of equipment and the environment.

3 DEFINITIONS

All items are categorised according to the risk of introducing infection to a person. Items in each category require different levels of decontamination according to the level of risk. Shared equipment that is used ‘clinically’ must be decontaminated after each patient `used. Other items must be decontaminated in accordance with minimum cleaning frequencies Personal Protective Clothing (PPE) Gloves and aprons must be worn when cleaning and disinfecting items/surfaces. Appropriate face protection must be worn if there is a risk of splashing bodily fluids or cleaning agent into the eyes or mouth or creating an aerosol.

Single Use Medical devices identified as single use are intended to be used on an individual patient during a single procedure and then discarded. It is intended that it is not reprocessed and used on another patient or the same patient again. The following symbol is used on medical device packaging indicating “Do Not Reuse” and may replace any wording


Single use equipment may need to be reprocessed in exceptional circumstances. Where this occurs the following must be in place:

• a risk assessment be undertaken

• reprocessing of the single use item identified on the Trust risk register

• documented approval and a written approved method of decontamination must be used

Devices labelled as "single patient use"

"Single patient use" means - "more than one episode of use of a medical device on one patient only, the device may undergo some form of reprocessing between each use."

Unless the manufacturer specifies otherwise, "single patient use" devices are able to be reprocessed and reused on the same patient in accordance with the manufacturer's instructions. The intended purpose of the device has not changed, and the reprocessing for reuse is consistent with the manufacturer's instructions/intent. This may include items such as disposable slings, nebuliser masks. Please contact the infection prevention and control team if further advice is required about decontamination of such devices.

4 ROLES AND RESPONSIBILITIES

4.1 Division and Clinical Business Unit Management Structure 4.1.1 Divisional directors, Managers and Heads of Nursing are responsible for ensuring compliance with the cleaning and decontamination policy within their divisions. 4.1.2 The clinical business unit medical leads, lead nurses/midwife and managers are responsible for ensuring compliance with the policy within their business units auditing annually against the policy and implementing the business units action plan. 4.2 Matrons 4.2.1 Matrons have a particular role in ensuring that the environment in which care is provided meets expected standards. They are responsible at a local level for leading and driving a culture of cleanliness in clinical areas and for monitoring, recording and reporting compliance with standards. 4.3 Ward Sister/Charge Nurse/Department Manager 4.3.1 The Ward Sister/Charge Nurse/Departmental Manager is accountable for the standards of infection prevention and control within the clinical area managed. The Ward Sister/Charge Nurse/Departmental Manager is expected to audit, observe and report compliance with infection control policies and guidelines and to personally demonstrate and promote compliance within their ward/department. The Ward Sister/Charge Nurse/Departmental Manager is expected to challenge and correct poor practice when observed and identify through appraisal and observation training


and development needs of team members and to make appropriate arrangements to have these training needs met in co-operation with the Infection Prevention and Control Service. 4.4 Facilities 4.4.1 Facilities are responsible for the quality of the domestic and estates services across the Trust to ensure a safe clean patient care environment. 4.5 Staff 4.5.1 Individual staff members are responsible for following the policy at all times. 4.6 Infection Prevention and Control Team 4.6.1 The infection prevention & control team are responsible for monitoring overall compliance with the policy in conjunction with the clinical audit, standards and effectiveness (CASE) team.

5 EDUCATION AND TRAINING

5.1 All training regarding this policy is the responsibility of the department or business unit supported by the infection prevention and control team using the approved blended approach to learning. This utilises a number of resources including work books, formal presentation and e-learning programmes.

6 POLICY STATEMENTS AND PROCEDURES

6.1 Following Spillage of Bodily Fluids 6.1.1 In clinical areas it is the responsibility of the nursing staff to ensure that spillages of blood, vomit, urine, faeces and other body fluids are cleaned up safely. The cleaning procedure may be delegated to domestic staff under supervision. It is vital that all staff take all reasonable precautions to protect themselves and patients from transmission of infections by wearing PPE. If a staff member who is not trained to deal with a spillage finds one then they must inform the staff member in charge of that area.

6.1.2 Non clinical areas – it is the responsibility of domestics who have undergone an appropriate level of training. It is however the responsibility of all staff to ensure that the area is safe and that the domestics are contacted to deal with the spillage. 6.1.3 See appendix Ten for procedural guidance 6.2 Equipment service request / decontamination status certificate 6.2.1 Pads of forms are available to order from the supplies department quoting reference W804/0908


6.2.2 This form must be completed prior to the inspection, servicing, repair or return of medical or laboratory equipment or maintenance work involving contact with potentially contaminated surfaces or plumbing. 6.3 Sanitiser 6.3.1 All general items must be routinely decontaminated after use with sanitiser either Chlor-clean solution or sanitiser powder. A description of responsibilities of cleaning and decontamination is available in Appendix 1 6.3.2 Chlor-clean is used by pouring into a clean receptacle for use or poured directly onto the item to be decontaminated, a used cloth should never come into contact with the bottle. Chlor-clean should be allowed to air dry but a minimum of 5 minutes contact time is required for disinfection to take place. Chlor-clean is only viable for 24hrs therefore it is imperative the container is labelled with the date and time when the solution is made. When making a new solution of Chlor-clean decontaminate the outside of the container by wiping with a clean cloth and the new solution. Any item that is contaminated with blood or blood stained body fluid must be treated with sodium hypochlorite 1% prior to decontamination with Chlor-clean.

6.3.3 Sanitiser powder must be used to decontaminate all sanitary equipment including plastic items (patient washbowls and bedpan holders) by sprinkling the sanitiser powder onto the item and spread with a damp cloth or scourer, rinsed and dried if possible. Any item that is contaminated with blood or blood stained body fluid must be treated with sodium hypochlorite 1% prior to decontamination with sanitiser powder. 6.4 Other methods of decontamination 6.4.1 Any items that require a method of decontamination that does not use Chlor-clean or powder sanitiser powder are described in Appendix 2 Departments/business using an alternative method of decontamination it must firstly be approved by Infection Prevention and Control in conjunction with the appointed Infection Control Doctor (Consultant Microbiologist). 6.5 National Colour Coding for Cleaning Materials 6.5.1 National colour coding scheme for hospital cleaning materials and equipment is used within the Trust see appendix 7 for details. 6.6 Curtain changing 6.6.1 Curtains are routinely changed in accordance with minimal cleaning frequency standards. 6.6.2 Otherwise bed curtains in a bay or nightingale ward and all single room curtains are changed:

• When visibly soiled

• When used as part of MRSA patient environment for more than 8 hours

• Following increased incidence of viral gastro-entiritis on IPCT advice

• Following a patient with clostridium difficile


7 AUDIT AND REVIEW

7.1 CASE (Clinical Audit Standards and Effectiveness) Team in conjunction with the Infection Prevention and Control Team send audits to all wards and departments on a yearly basis in regards to equipment, cleaning and decontamination. 7.2 Maximiser audits are completed monthly by domestic services and matrons.

8 EVIDENCE BASE

• Anson J.J. and Allen, K.D. (1997) Hospital Ice Machines. Journal of Hospital Infection, 37:4, p.335-336.

• Ayliffe, G.A.J., Lowbury, E.J.L., Geddes, A.M. & Williams, J.D. (2002) Control of Hospital Infection: A Practical Handbook Chapman & Hall.

• Department of Health (1993) HSG (93) 26 Decontamination of equipment prior to inspection, service or repair.

• EPIC 2 National Evidence based guidelines for preventing healthcare associated Infections in NHS hospitals in England (2006)

• Great Britain (1974) the Health & Safety at Work Act 1974.

• Great Britain (1999) The Control of Substances Hazardous to Health Regulations 1999.

• HSC 1999/179 Controls Assurance in Infection Control: Decontamination of Medical Devices Department of Health 1999

• HSG(93)26 Decontamination of Equipment prior to inspection, service or repair. Department of Health. 1993.

• Institute of Sterile Services Management, Standards & Practice 2001.

• MDA DB 9501 The Reuse of Medical Devices Supplied for Single Use only Medical Devices Agency. 1995

• MDA SN 9619 Compatibility of medical devices and their accessories and reprocessing units with cleaning, disinfecting and sterilising agents. Medical Devices Agency Adverse Incident Centre. 1996.

• Medical Devices Agency (2002) Decontamination of Endoscopes. MDA DB 2002 (05).

• Medical Devices Agency Safety Action Bulletin SAB (93) 32) (1993) Endoscope washer/disinfectors: recontamination of equipment (appears in DB 1999(03)).

• Microbiology Advisory Committee to the Department of Health (1997) Sterilisation, Disinfection and Cleaning of Medical Equipment: Guidance on Decontamination Medical Devices Agency.

• NHS Estates, A Guide to the Decontamination of Surgical Instruments and Equipment 2003.

• Sterilisation, Disinfection and Cleaning of Medical Equipment: guidance on Decontamination from the Microbiology Advisory Committee to Department of Health Medical Devices Directorate. Parts 1 to 3. Medical Devices Agency. 1996-1999.

• The epic Project 2001 Developing National Evidence-based Guidelines for Preventing Healthcare Associated Infection Journal of Hospital Infection 47(Supplement)

• The Institute of Environmental Health. (1996) Basic Food Hygiene Teaching Package


• The Royal Marsden Hospital (1992) 3rd Edition Manual of Clinical Nursing Procedures Blackwell Scientific.

• Wilson, J. (2006) 3rd Edition Infection Control in Practice Balliére Tindall.

9 DEVELOPMENT, CONSULTATION AND REVIEW PROCESS

9.1 This policy has been approved for development to replace existing guidelines in the trust. The policy has been written by the infection prevention and control team with contributions from key stakeholders. 9.2 Supporting Documentation UHL Guidelines for the use of Personal Protective Equipment DMS No 12536 UHL Waste Management Policy DMS No 12213 UHL Management of Exposure to Blood Borne Virus Policy DMS No 12681 The National Specifications for Cleanliness in the NHS – a framework for setting and measuring performance outcomes (NPSA April 2007) http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59818

9.3 This policy will be reviewed every three years or more frequently if required so that current evidence continues to underpin policy statements, guidelines and procedures. 9.4 Compliance with this policy will be monitored through a trust wide audit programme of annual decontamination audits and environmental and equipment cleanliness audits. The frequency of the latter audits will be determined by the Trust. 9.5 Annual decontamination audits will be collated by the CASE team and reported to the Trust Infection control committee. Non compliance with policy will require an action plan to be completed with remedial actions. 9.6 Environmental cleaning audits are subject to an escalation protocol which can be found in appendix 11.

10 LEGAL LIABILITY

The Trust will generally assume vicarious liability for the acts of its staff, including those on honorary contract. However, it is incumbent on staff to ensure that they:-

• Have undergone any suitable training identified as necessary under the terms of this policy or otherwise.

• Have been fully authorised by their line manager and their Division to undertake the activity.

• Fully comply with the terms of any relevant Trust policies and/or procedures at all times.

• Only depart from any relevant Trust guidelines providing always that such departure is confined to the specific needs of individual circumstances. In healthcare delivery such departure shall only be undertaken where, in the


judgement of the responsible clinician it is fully appropriate and justifiable - such decision to be fully recorded in the patient’s notes.

It is recommended that staff have Professional Indemnity Insurance cover in place for their own protection in respect of those circumstances where the Trust does not automatically assume vicarious liability and where Trust support is not generally available. Such circumstances will include Samaritan acts and criminal investigations against the staff member concerned.

Suitable Professional Indemnity Insurance Cover is generally available from the various Royal Colleges and Professional Institutions and Bodies.

For advice please contact: Assistant Director - Head of Legal Services on Ext 8585


Quick Reference Guide

Responsibilities and Methods of

cleaning Equipment

Appendix One Cleaning and Decontamination Policy

The following table defines the responsibilities for equipment that is cleaned and decontaminated using Chlor-clean or powder sanitizer. RESPONSIBILITY AND FREQUENCY ITEM OF EQUIPMENT

Clinical staff after each use / between patients with Chlor-clean. Clinical staff after each use/between patients with Sanitiser powder.

Arjo baths Bed cradles Bed frames / rails BP cuffs (inpatients including recovery areas) For clinics BP cuffs to be decontaminated at the end of each session Commodes Dialysis machines Dressing trolley ECG leads Examination couches/Plinths Enteral feeding pumps Hoists / manual handling equipment Intravenous infusion pump / syringe driver Intravenous infusion stands Mattresses Nurse call buzzers Operating theatre tables Pillows (inpatient and recovery areas) Pillows (in outpatient areas change pillow case between patients and Chlorclean after each session) Plastic covered foam wedges (uncovered) Portering trolley Pulseoxymeters and probes Scissors Slings Stethoscope Suction canisters Thermometer Treadmills Sanitiser dispenser (bed space) x-ray table Anti slip bath mats Baths Bed pan/slipper pan holders Plastic wash bowls Shower seat

Clinical staff daily with Chlor-clean Bedside fans


RESPONSIBILITY AND FREQUENCY ITEM OF EQUIPMENT

Keyboards (unplug before cleaning) Telephones Wheelchairs in outpatient areas

Clinical staff weekly with Chlor-clean Plastic and wooden toys Domestic / facilities staff as per minimum cleaning frequency standard with Chlor-clean

Domestic / facilities staff as per minimum cleaning frequency standard with Sanitiser powder

Bed base and below Bed tables Chairs Fixtures and fittings Light and emergency pull cords Locker tops Portering trolley Shower head Wall/ceiling mounted fans Macerator Sanitiser dispenser wall mounted Baths Clinical hand wash basins Patient wash basins Raised toilet seats Shower base /seat Toilets

Portering wheelchairs See appendix 8


Quick Reference Guide on Cleaning

Methods Appendix Two

Cleaning and Decontamination Policy

The following tables describe other methods of cleaning and decontamination and the staff responsible when Chlor-clean or powder sanitizer is not appropriate

ITEM METHOD RESPONSIBILITY & FREQUENCY

Anaesthetic face masks Return to SSD Clinical staff after each use

ANTT Plastic trays Clean tray with Chlor-clean and leave to air dry (3 minutes contact time minimum) Or Clean with Chlor-clean dry with paper towels and then disinfect with 70 % Industrial Methylated Spirit or alcohol wipe

Clinical staff prior to each use

Auroscope ear pieces / aural specula Plastic Reusable metal

Use Chlor-clean and soak in 70% methylated spirit for 10 minutes, allow to dry Return to SSD

Clinical staff after each use Clinical staff after each use

Breast imaging machines Trigene wipes or other cleaning and disinfectant agent authorised by Infection Control.

Clinical staff daily

Carpets

Vacuum and clean according to domestic schedule

Domestic staff – as per minimum frequency standard

Cassette for x-ray machines

Disinfectant agreed with infection control

After each use/ between patients

Computers on wheels monitors and keyboards

Clinical staff daily with Trigene wipes or other cleaning and disinfectant agent authorised by

Clinical staff daily



Infection Control. Crockery and cutlery Return to central catering

Dishwasher Double sink wash method

As per contract

Electric clippers Use disposable heads Clinical staff – discard after each use

Feeding bottles Use single use disposable bottles and discard

Clinical staff after each use

Gamma Ray xray Camera Trigene Wipes Clinical staff after each use/between patients

Ganzfield Box Trigene Wipes Clinical staff after each use /between patients

Ice Machines See appendix 3 Clinical staff (as per agreed protocol)

Laryngeal masks if not disposable

Return to SSD Clinical staff after each use

Laryngoscopes Return to SSD


Multi-dose vials for single patient use

Wipe with 2 % Chlorhexidine and 70% isopropyl alcohol wipe and leave to air dry

Clinical staff before each use

Nasal specula Return to SSD Clinical staff after each use

Patient line equipment Agent approved by Infection control

Patient line staff weekly

PCA and Epidural Pumps Trigene wipes (due to coating on machines not withstanding chlorclean)


Reusable anaesthetic tubing

Return to SSD Clinical staff after each session

Reusable self inflating bags e.g. AMBU please


Shower curtains Return to central laundry Facilities as per agreed protocols

Slings Launder between patients Or use disposable slings

Clinical staff between patients

Soft toys Use patients own Communal - launder

Clinical staff weekly

Surgical / dressing instruments


Surgical bowls Reusable

Return to SSD


Ultrasound Probes Trigene Wipes or alternative agreed by infection control




Toshiba Ultrasound Machine

Trigene Wipes or alternative agreed by infection control


X-ray machines Trigene Wipes or alternative agreed by infection control

Clinical Staff daily

ENDOSCOPES

ITEM METHOD RESPONSIBILITY AND FREQUENCY

Flexible channelled Endoscopes

Clean and Disinfect according to agreed protocol See pages 16 and 17

Clinical staff Before session, routine between patient procedure and after session

Nasendoscopes Tristel Wipes Clinical staff after each use

Rigid Endoscopes Send to SSD (AERs to be used under approved protocol)


Sigmoidoscopes and Proctoscopes

Use disposable attachments and see page 18 for decontaminating reusable components



Guidelines For Cleaning Ice

Machines Appendix Three


Ice making machines

• The environment around the machines must be kept sufficiently clear to allow for air circulation and prevent contamination

• Organisms such as Stenotrophomonas maltophilia, pseudomonas and coliforms may cause infections to immunosuppressed patients if ice machines are not properly maintained.

To reduce the risk to patients the following procedure should be undertaken when cleaning ice making machines.

Daily

- Wash hands thoroughly before removing ice. - Remove ice using scoop. Ensure minimal contact with surfaces of machine. - Scoop is to be kept in a clean lidded container, and be available for use at all

times. - Scoop and container to be cleaned and disinfected daily. Wash in detergent

and hot water, rinse and dry, followed by disinfection with Sodium Hypochlorite 1% (10,000 ppm) and rinsed thoroughly before drying.

- The scoop must be washed and disinfected immediately if contaminated. - Record date of cleaning and disinfection of scoop and container.

Weekly

- Prior to cleaning, switch off the machine, remove ice and drain the water. - Clean all interior surfaces with detergent and hot water, using a disposable

cloth. Rinse and dry. - Disinfect all interior surfaces with Sodium Hypochlorite 1% (10,000 ppm). Rinse

thoroughly before drying. - Record date of cleaning and disinfection of ice making machine.


Quarterly Maintenance

• The removable parts of the machine should be disassembled for cleaning and checked for breakage, according to manufacturer’s recommendations.

• A record of manufacturer’s or Estate’s department maintenance contract should be kept.

• No articles or equipment should be stored on or around the ice machine which could block the air vents.

• Ice in the ice machines shall be tested quarterly by Infection prevention and Control

Staff are advised to

• Wash hands before handling ice.

• Ensure ice is made from quality drinking water.

• Handle ice with care to avoid contamination; using only a designated scoop.

• Do not pick ice out with hands or use a glass or jug to scoop out the ice.

• The scoop should be washed with hot detergent water and dried thoroughly before being stored in a clean dry lidded container.

• Store ice for the shortest practical time.

• Ensure machine is cleaned weekly and is on a planned maintenance programme.

• Maintain a visible record of defrosting and cleaning.


Procedure For Decontamination Of flexible channelled Endoscopes

Appendix Four Cleaning and Decontamination Policy

The following guidance indicated the Trust position on the decontamination of

endoscopes. All departments undertaking Endoscopy procedures must adhere to the

guidance.

Local guidance must be available for specialised procedures and equipment.

Procedure For Decontamination of Endoscopes

No Action

1 Put on protective clothing, disposable powder free latex gloves apron and eye

protection (to prevent contamination splashing into eyes).

2 Each scope must be air leak tested prior to the cleaning process as per

manufacturer’s instructions. If a leak is detected the scope must be returned to

the manufacturer in its unclean state and a Decontamination of Equipment

Certificate completed indicating that decontamination has not taken place.

3 Clean the scope as per manufacturer’s instructions using a double sink method

for cleaning and rinsing, with brush, warm water and an enzymatic detergent,

going down each channel a minimum of three times each until the brushes

come out clean, regardless of whether the channel has been used or not.

Clean the removable buttons and valves at the same time.

4 Each department must have detailed guidance regarding the procedure for

cleaning scopes based on the manufacturer’s instructions.

5 Disposable brushes are the preferred method. Where disposable are not

available, items should be reprocessed in accordance with manufacturers

instructions and not exceed recommended number of processes (MDA 2002).

Reusable accessories must be also be re-processed after every use.

Paediatric accessories are available with the scopes.

6 Following cleaning an inspection must be made to ensure that all visible

contamination has been removed.

7 Place the scope into the AER (automated endoscope reprocesssor) ensuring that the channels are connected to the correct ports.

8 Remove protective clothing and dispose as clinical waste, if reusable eye

protection is worn, decontaminate as per Infection Control guidance. Wash

hands.


Procedure For Decontamination of Endoscopes

9 Select the appropriate cycle and turn on. See departmental guidance for

further information for department machines regarding the cycle to select.

Appropriate tracking system and cycle validation data must be completed.

10 Once the cycle is complete, stop machine wash hands and put on clean,

disposable gloves. Remove the scope.

11 After disinfection, scopes must be hung in designated cupboards. Where trays

are used, these must be cleaned and disinfected with Chlor-clean and a sterile

tray liner used. In the case of using a tray the scope must be required for a

clinical procedure imminently. If this is not the case the scope must be hung in

the designated cupboard.

12 Scopes can be used within a 3 hour period following decontamination. If the

scope is required to be used out of this time frame due to a clinical emergency

a risk assessment must be performed to support the decision made.

12 Following storage and prior to use, all scopes must follow procedure steps 7-11


Guidance for the decontamination of re-usable components of sigmoidoscopes in Out Patients Departments

Appendix Five Cleaning and Decontamination Policy

Disposable sigmoidoscopes and proctoscopes should be used where available. Reusable sigmoidoscopes must be decontaminated in the Sterile Services Department (SSD).

A new hydrophobic filter must be used for each patient *

All re-useable components (light head/bellows) of the sigmoidoscopes must be decontaminated as described below:

Procedure / Process for the decontamination of re-usable components of sigmoidoscopes in Out Patient Departments

No Action

All reusable equipment to be thoroughly washed with an enzymatic detergent and water to remove all debris

Following washing and rinsing the light head, the inflation bulb (bellows), tubing, and light handle/source/lead must be thoroughly decontaminated with Chlor-clean ensuring that all surfaces are covered and left to air dry or a minimum of five minutes contact time before rinsing

An area needs to be identified for the decontamination of this equipment. This must be dedicated to the cleaning and decontamination of clinical equipment. The following must be in place:

� A laminated copy of these guidelines displayed � Supply of PPE including eye protection, mask and aprons for staff use

when decontaminating equipment � Facilities for thoroughly drying the equipment � Staff who undertake the task of decontaminating this equipment must be

competent, properly trained and supervise

� *If disposable bellows are used a hydrophobic filter is not required


Guidance for the decontamination of re-usable components of sigmoidoscopes in Theatres and Endoscopy Units

Appendix Six Cleaning and Decontamination Policy

Disposable sigmoidoscopes and proctoscopes should be used where available. Reusable sigmoidoscopes must be decontaminated in the Sterile Services Department (SSD).

A new hydrophobic filter must be used for each patient *

Procedure / Process for the decontamination of re-usable components of sigmoidoscopes in Theatres and Endoscopy Units

No Action

All re-useable components (light head/bellows) of the sigmoidoscopes must be decontaminated as described below:

� All reusable equipment to be thoroughly cleaned with enzymatic detergent and water to remove all debris

� Following cleaning the light head must be appropriately decontaminated.

This must be undertaken in an Automatic Endoscope Reprocessor using Peracetic acid

� The inflation bulb (bellows), tubing, and light handle/source/lead must be

thoroughly decontaminated with Chlor-clean ensuring that all surfaces are covered for a minimum of five minutes.

An area needs to be identified for the decontamination of equipment. This must be dedicated to the cleaning and decontamination of clinical equipment. The following must be in place:

� A laminated copy of these guidelines displayed � Supply of PPE including eye protection, mask and aprons for staff use

when decontaminating equipment � Facilities for thoroughly drying the equipment � Staff who undertake the task of decontaminating must be competent,

properly trained and supervised. *If disposable bellows are used a hydrophobic filter is not required


National colour coding guidance Appendix Seven


Use appropriate colour coded cleaning equipment as per national guidance. APRONS Green aprons shall be worn for kitchen duties and giving out of food and drinks. White aprons shall be used for general ward/department duties and yellow shall be used for patients who are source isolated. Domestic staff when cleaning shall wear appropriately colour coded aprons as below


Procedure for cleaning wheelchairs

between patients (portering

wheelchairs)

Appendix 8 Cleaning and Decontamination Policy

1. Introduction / Scope

For the safety of the next patient a wheelchair must be rendered free from contaminants. This assists in the prevention of the spread of infection. This procedure also provides reassurance and confidence to patients

Procedure for Cleaning Wheelchairs Between Patients

Action

1 Collect wheelchair

2 Ensure there are detergent wipes in the back of the chair’s note holder (replenish pack if necessary)

3 Take wheelchair to patient’s bed end

4 Put on disposable gloves and apron (Personal Protective Equipment – PPE)

5 Remove wipe from back of wheelchair

6 Wipe over all areas of the chair that has patient contact including arm rests

7 Remove PPE carefully wrapping the cloth within the gloves and dispose of into appropriate waste bin

8 Clean Hands

9 Return to patient and help into the wheelchair

10 Return wheelchair to a central point

11 Process must be repeated for the next patient movement

This procedure does not replace the weekly deep cleaning of wheelchairs using either steam or Chlor clean Wheelchairs must be Chlor cleaned AFTER USE by Patient in Source Isolation Wipes replacement packs are available in the porter’s lodge Chlor Clean is available on the ward/department Wipes provided by the facilities portering department MUST NOT be removed from the back of the chairs and used for other duties.


Procedure for Dealing with Blood

Spillages Appendix Nine Cleaning and Decontamination Policy

1. Introduction ALL spilled blood or blood stained body fluids should be regarded as potentially infectious, and should be treated accordingly. When treating a spillage, staff must wear disposable non powdered latex gloves and a disposable plastic apron. Eye/face protection is required if there is a risk of splashing.

Procedure for Dealing with Minor Blood Spillages

Action

1 Determine if this is a minor or major blood spill – A minor blood spillage is considered as a splash or drip of blood. For larger volumes follow procedure for major blood spills

2 Gather all equipment

• Disposable gloves

• Apron

• Eye protection

• Orange Waste Bags

• Disposable Wipes

• Sodium Hypochlorite 1% Solution

3 Put on appropriate PPE

4 Wipe area with a cloth soaked in sodium hypochlorite 1% solution and leave to air dry or at least two minutes contact time.

5 Dispose of used wipes into orange waste bag and remove PPE

6 Clean hands

More extensive spillages of blood must be treated with absorbent, chlorine-releasing granules. The granules will ensure that the active disinfecting agent comes into contact with any micro-organisms throughout the spillage and will also limit the spread of liquid blood. Attempts to treat significant volumes of blood with a conventional solution will merely spread the spillage, without achieving homogenous mixing and effective disinfection. The granules are available through NHS Supply chain and each ward, clinic, theatre, and department must have at least one container in stock at all times, although some areas e.g. Accident and Emergency Department will need to maintain larger stocks. Each ward or department must also be equipped with 2 suitable plastic scoop and spatulas.


Procedure for Dealing with Major Blood Spills

Action



• Apron

• Eye protection


• Disposable Wipes

• Chlorine releasing granules and scoop

• Chlorclean

2 Because free chlorine gas is released during the inactivation process, windows should be opened to ensure adequate ventilation; if the spillage is in a confined, poorly ventilated area, staff and patients (where possible) should not remain in the vicinity of the spillage during the inactivation process.

3 Granules should be sprinkled evenly over the spillage until the whole surface is covered, leave undisturbed for 2 minutes.

4 If any areas of liquid blood remain after this period, more granules should be applied and left for a further 2 minutes, to ensure complete disinfection.

5 Once all liquid blood has been absorbed, the granule mass can be scooped up and placed together with the scoop and spatula in a clinical waste bag.

6 Wipe area with Chlorclean and dry.

7 Dispose of used apron, gloves, and paper towels in a clinical waste bag.

Blood Spilled on Staff (a) On intact skin. The spilled blood should be washed off with copious warm

water and soap, paying particular attention to the finger nails. No further action is necessary.

(b) On broken skin. The spilled blood should be washed off with copious warm

water and soap. The incident must then be reported. Follow the UHL Management of Exposure to Blood Borne Virus Policy

(c) On mucous membrane. Splashes of blood or body fluids entering the eye

should be removed by immediate irrigation. Ideally sterile saline "eye-wash" packs should be used if available, but if not, running mains water (drinking water) can be used instead. Irrigation should be continued until all traces of the contaminating material have been removed. The incident must then be reported. Follow the UHL Management of Exposure to Blood Borne Virus Policy


Procedure for Dealing with Body

Fluid Spillages other than Blood Appendix Ten Cleaning and Decontamination Policy

Introduction At the present time, the risk of blood-borne virus transmission through body fluids other than blood is low. If the body fluid is blood stained then follow procedure for dealing with blood spills.

Body Fluid Spillage/Splash

Action



• Apron

• Eye protection (if required)


• Disposable dry Wipes/Paper towels

• Chlorclean

2 Eye protection and face mask must be worn if risk of splashing into face

3 Disposable non powdered latex gloves and a plastic apron must be worn.

4 The spillage should then be cleaned up using disposable wipes

5 Use Chlorclean and leave to air dry

6 Gloves, apron and all paper towels, dry cloths etc., must be discarded into a orange bag for incineration.

7 If bed clothes contaminated, treat as infected linen


Escalation Protocol if a Ward fails to

achieve over 90% during

environmental audits

Appendix eleven Cleaning and Decontamination Policy

Matron and Domestic Supervisor undertake audit –

Look at domestic and Nursing scores separately

Domestic Nursing

Is score

over 90%?

Is score

over 90%? Yes –Identify and address

issues and re-audit

monthly

No No

Yes – Identify and address

issues and re-audit

monthly. Inform domestic

office once actions

completed

Identify and address

issues and reaudit

with Matron within

1 wk

Identify and address issues and reaudit

within 1 wk. Maximiser available from

domestic offices. Inform domestic office

once actions completed

Is score

over 90%?

Is score

over 90%? Is score

over 90%?

Is score

over 90%?


issues and re-audit

monthly


issues and re-audit


office once actions

completed


issues and re-audit


office once actions

completed

No

No

Identify and

address issues.

Inform domestic

office once

actions

completed

Contact IP+C

and Head of

Nursing.

Reaudit within

1wk

Identify and

address issues

Contact IP+C

and Domestic

manager.

Reaudit within

1wk


issues and re-audit

monthly

No No

Identify and address issues.

Inform domestic office once

actions completed.

Contact Director of Nursing

Identify and

address issues

Contact Head

of Facilities

cleaning and decontamination for infection prevention and

Documents