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CLEANING, DISINFECTION AND STERILIZATION Medical and surgical devices may serve as a vehicle for the transmission of infectious disease to susceptible hosts, Damani (1997). • • The aim of these guidelines is to promote the removal of visible soil/dirt and invisible microorganisms thus making the patients’ equipment and environment safe to prevent cross infection between patients and to protect personnel from potentially infected items and equipment. Decontamination is a general term that is used for the destruction or removal of microbial contamination to render an item safe. This will include methods of cleaning, disinfection and sterilization, (Ayliffe 1993). METHODS OF DECONTAMINATION Cleaning and drying 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 micro-organisms cannot multiply on a clean dry surface. • Thorough cleaning with soap/detergent and hot water is adequate for most surfaces. • Efficient cleaning removes a high proportion of any micro-organisms present including bacterial spores. • All cloths/towels used should be disposable. • Cleaning is an essential prerequisite to disinfection and sterilization. Disinfection by either heat or chemicals will destroy micro-organisms but not bacterial spores. The process does not necessarily kill or remove all micro-organisms but reduces their level to one that is not harmful to health. • Disinfection can be achieved by moist heat (thermal disinfection). • A combination of cleaning and thermal disinfection is used in bedpan washer disinfectors, washing machines and dishwashers. • Chemical disinfectants should only be used if heat treatment is impractical or may cause damage to the equipment. This process may be described as high level disinfection. • Chemicals used to kill micro-organisms on the skin or living tissue are known as antiseptics. Sterilization is a process that can achieve the complete destruction or removal of micro-organisms including bacterial spores. • Equipment and materials used in procedures involving a break in the skin or mucous membranes must be sterile, e.g. surgical instruments, products for parenteral use or instillation into sterile body cavities. • Sterilization can be achieved by physical methods such as heat, low temperature steam or by the use of chemical such as Ethylene Oxide. • Autoclaves are widely used throughout the Trust for sterilization. (page 10-C) • Autoclaves are unsuitable for heat labile items of equipment such as flexible fibreoptic endoscopes and many plastic devices. The choice of methods used depends mainly on the type of material, level of decontamination required for the procedure and micro-organisms involved. REMEMBER: Appropriate protective clothing should be worn. I C Guidelines 1-C September 2000 CATEGORISING EQUIPMENT BY RISK All equipment should be categorised as to the risk it poses for patients/clients. Single patient use equipment must never be used on more than one patient/client and single use equipment should always be used according to the manufacturers’ recommendations. The risks of infection from equipment may be classified into four categories, (Coates and Hutchinson 1993). All items should be placed in one of the following categories to assist in ascertaining the appropriate level of decontamination needed to protect the patients/clients and staff. RISK CATEGORY Minimal Risk Low Risk Intermediate Risk High Risk DEFINITION AND EXAMPLES Items some distance away from the patient such as environmental surfaces and fittings, e.g. walls, floors, ceilings, sinks and drains. Items in close proximity to the patient but unlikely to be contaminated with a significant number of pathogens, e.g. bedframes, lockers, flower vases. Items in contact with normal intact skin. e.g. stethoscopes, wash bowls, crockery, cutlery, mobile telephones. Items in contact with intact mucous membranes, e.g. respiratory equipment, clinical thermometers, gastroscopes. Items in contact with particularly virulent or readily transmissable organisms. e.g. commodes during an outbreak of diarrhoea. Items to be used on highly susceptible patients. Items in close contact with a break in the skin or mucous membranes, e.g. dressings. Items introduced into a normally sterile body site, e.g. surgical instruments, needles, implants, urinary catheters. DECONTAMINATION LEVEL Cleaning and Drying adequate Cleaning and Drying usually adequate Disinfection Sterilization Legal requirements relating to the decontamination of equipment include :- • Health and Safety at Work Act (1974). • Health Service Circular HSC 1999/123 Controls Assurance Statements 1999/2000: Risk • • • • Management and Organisational Controls. Health Service Circular 1999/179 Controls Assurance, Infection Control. Decontamination of Medical Devices. Medical Devices Agency (1998) – MDA DB9804. The validation and periodic testing of Bench top Vacuum Steam Sterilizers. MDA. London. Personal Protective Equipment at Work Regulations (1992) – Health and Safety Regulations. Control of Substances Hazardous to Health Regulations (1988) – Statutory Instrument No 1657. HMSO. London. I C Guidelines 2-C September 2000 GUIDELINES FOR THE USE OF SKIN DISINFECTANTS There are three principles for removing or reducing the number of micro-organisms present on the skin or mucous membranes: • To reduce the number of skin micro-organisms present prior to an invasive procedure. • To remove or destroy potentially pathogenic micro-organisms present on the hands of staff. • Occasionally to treat a carrier or disperser of a resistant, virulent or highly communicable strain of bacteria. AGENT Alcohol 70% impregnated swab Alcohol 70% with glycerol TRADE NAME Steret/Mediswab Alcohol gel Spirigel Chlorhexidine 4% Hydrex Surgical Scrub Skin cleanser Chlorhexidine 0.5% with alcohol Chlorhexidine/Hibitane tincture Chlorhexidine 0.5% with Savlodil/Ti-sept Cetrimide 0.015% Chlorhexidine Acetate Hexachloraphane dusting powder Industrial Methalated Spirit CX Antiseptic dusting powder Sterzac IMS BP INDICATION FOR USE Rapid disinfection of skin, e.g. prior to injection. Swabbed area must be allowed to dry prior to injection being administered. Disinfection for physically clean hands where handwashing facilities are unavailable or unsuitable. Hand disinfection for surgery or aseptic procedures. Pre operative preparation. Cleansing of site prior to insertion of a urinary catheter. Skin and wound disinfection but not routinely. Umbilicus of neonates and some cases of S.aureus skin colonization. Umbilicus of neonates and some cases of S.aureus skin colonization. Disinfection for physically clean hands where handwashing facilities are unavailable or unsuitable. Hand disinfection for surgery or aseptic procedures. Pre operative skin preparation. Povidone iodine skin cleanser Betadine surgical scrub Povidone iodine 10% Betadine Antiseptic Solution Betadine Alcohol Solution Pre operative skin preparation. Povidone iodine 10% with alcohol Triclosan 2% skin cleanser Aquasept skin cleanser Treatment of S. aureus skin colonization. NOTE: All areas should be physically clean (i.e. cleaned with soap and water) prior to being disinfected, (Ayliffe et. al. 1993). I C Guidelines 3-C September 2000 ENVIRONMENTAL DISINFECTANTS It is essential that any equipment or surface is physically clean prior to a disinfectant being applied, (Wilson 1995). Environmental disinfectants can be used for a wide range of tasks including:- • • • • Rapid disinfection of equipment and surfaces. Treatment of spillages of potentially hazardous matter, (wear gloves and apron). Disinfection of re-usable items of equipment that are heat labile. Cleaning during outbreaks on the advice of the Infection Control Team. The properties of disinfectants vary from one product to another and also the concentration of disinfectant being used. DISINFECTANTS SHOULD BE MADE UP AS REQUIRED AT THE TIME OF USES AGENT Alcohol 70% Hypochlorites TRADE NAME Sterets/Mediswabs Alcowipes Azowipes Chloros, Domestos, Milton Sodium Dichloroisocyanurates (NaDCC) Presept granules, Sanichlor, Actichlor and Covchlor Clear soluble phenolic Clearsol 1% INDICATION FOR USE Rapid disinfection of certain items of equipment and hard surfaces. Chlorine based solutions should be used for blood spillages in non carpeted areas, terminal cleaning of an isolation area, cleaning during outbreaks of infection and for disinfecting surfaces and equipment in some cases. Dilutions are shown on page 7-C. Must only be used for terminal cleaning of an isolation room after confirmed Tuberculosis or clearing up sputum from a known Tuberculosis patient. DISINFECTANTS FOR INSTRUMENTS Instruments must be physically clean prior to being disinfected. AGENT Glutaraldehyde I C Guidelines TRADE NAME Cidex, Asep, Totacide 4-C INDICATION FOR USE A useful disinfectant for equipment that cannot be heat sterilized such as endoscopes. It has a wide range of bacterial, viricidal and fungicidal activity. Slow activity against spores. IRRITANT TO EYE AND SKIN Refer to page 9-C and Trust Health and Safety Policy. September 2000 CHEMICAL DISINFECTANTS GUIDELINES FOR GENERAL USE There are a number of important factors that must be considered when using chemical disinfectants: • The efficacy of chemical disinfection is often uncertain and, wherever possible, disinfection by heat is preferable to chemical methods. • All chemical disinfectants must be clearly labelled and used within the expiry date. They should be freshly prepared. They must be used at the correct concentration and stored in an appropriate container. • Chemical disinfectant solutions must not be mixed or detergents added unless they are compatible. • Disinfectant or detergent solutions must not be prepared and stored in multi-use containers for occasional use. Solutions prepared and stored in this manner may easily become contaminated with micro-organisms; using such solutions will therefore readily contaminate a surface rather then clean it. • Manufacturer’s instructions must be consulted on compatibility of materials with the method of sterilization or disinfection. • Alcohol does not penetrate well into organic matter it should therefore only be used on surfaces that are physically clean. USE OF SINGLE USE DEVICES (MDA 1995) The expression “Single Use”* on the packaging of medical devices indicates that the manufacturer: • intends the item to be used once and then discarded; and • considers that the items are not suitable for use on more than one occasion. The term “Single Patient Use” refers to items that are used by an individual patient only throughout the course of their course of treatment. They should only be re-used according to the manufacturer’s recommendations and must be kept in a clean condition, stored appropriately and only re-used by the same patient. Some devices are intended by their manufacturers to be used more than once and with different patients provided that they are appropriately decontaminated in between each use. Where reprocessing may affect the performance and safety of the device the manufacturer should supply details of the recommended cleaning process to be followed and the number of re-uses which may be undertaken. * As an alternative to the expression “single use”, other statements may be used, these include “Do not re-use”, or a symbol comprising of the figure 2 with a diagonal line drawn through it which may appear on packaging. All Trust staff who use medical devices/equipment should follow the manufacturers guidelines on use and re-use. I C Guidelines 5-C September 2000 CLEANING OF A SIDE WARD POST ISOLATION NURSING Terminal cleaning of a room is indicated when a patient/client has been under source isolation and is discharged or transferred to another area. The following procedure should be followed. When special cleaning arrangements are required the domestic services supervisor should be informed of the risk of infection not the patient’s/client’s diagnosis. 1. Domestic staff must wear a disposable plastic apron and use appropriate colour coded household gloves. 2. Terminal cleaning should commence only after the patient/client and his/her belongings have been removed from the room or the area. 3. Any disposable items or equipment should be discarded as clinical waste. 4. Seal yellow clinical waste bags before leaving the room and discard as clinical waste for incineration. 5. Place all linen including bed linen, screens, curtains etc. into the appropriate bags and ensure they are sealed prior to leaving the room or area. 6. Remove any items of nursing equipment to the dirty utility area for cleaning and disinfection. All autoclavable items should be processed appropriately or sent to CSSD. 7. The bed mattress should be wiped with warm water and general purpose detergent (GPD) and dried thoroughly. If disinfectant is indicated, wipe with a freshly prepared hypochlorite (1000 ppm) solution. 8. Dust the high ledges, windows and curtain tracks. Vacuum clean fixtures, fittings and floor. 9. Wet clean all ledges, fixtures and fittings, including taps and door handles. 10. Wash sink with hypochlorite (1000 ppm) or a detergent cleanser, rinse and dry thoroughly. 11. Wash floor with hypochlorite (1000 ppm) or steam clean carpet clean with appropriate detergent solution. Spot clean walls as necessary. Rinse and ensure all areas are thoroughly dry. 12. The room may be used again for patients/clients when all surfaces are clean and dry. If the patient is isolated in an open ward, then the entire surrounding area up to the next bed should be cleaned as above. Seek advice from the Infection Control Nurse if you require specific advice or information. I C Guidelines 6-C September 2000 MANAGEMENT OF BLOOD OR BODY FLUIDS SPILLAGE Spillages of blood and body fluids must be disinfected and cleaned promptly. Spillage kits can be purchased but the use of a chlorine based solution (or Presept granules) is recommended for blood spillages in areas that will not be damaged by the use of bleach. The alternative method should be used for blood spills in areas where a chlorine based solution cannot be used or when the spillage is of urine. (Lewis and Meese 1997). Gloves and Plastic Apron must be worn. RECOMMENDED METHOD ALTERNATIVE METHOD • Cover spill with NaDcc powder, (Saniclor/Precept) or 1% Hypochlorite (bleach)solution. • Remove as much of the spillage as possible with paper towels. • Clean the area with a detergent solution. • Leave for a few minutes, then mop up with paper towel. • Leave as dry as possible . • Clean area with a detergent solution Dispose of Waste into a Yellow Clinical Waste bag. RECOMMENDED METHOD:- For use on spillages of blood or vaccines that are on surfaces not damaged by bleach based products. ALTERNATIVE METHOD:- For use on spillages of urine, vomit or diarrhoea. Also to be used for spillages of blood/vaccine on surfaces that are damaged by bleach based products. USE OF HYPOCHLORITE AND STRENGTHS OF SOLUTION Prior to using Hypochlorite solutions, surfaces/equipment should be physically cleaned with hot water and General Purpose Detergent (GPD) except in the case of blood spills. USE Blood spills Laboratory discard Environmental disinfection Disinfection of clean instruments Infant feeding utensils, catering surfaces and equipment DILUTION OF STOCK SOLUTION Undiluted 1 in 10 1 in 40 1 in 100 1 in 200 1 in 800 AVAILABLE CHLORINE % P.P.M.** 10* 100000* 1.0 10000 0.25 2500 0.1 1000 0.05 500 0.0125 125 *Approximate value of some brands, e.g. Chloros, Domestos ** PPM – parts per million I C Guidelines 7-C September 2000 I C Guidelines PREPARATION AND USE OF HYPOCHLORITE BASED SOLUTIONS Hypochlorite Preparations Strength To prepare Uses Decontamination of blood and bloody body fluid spills, especially if the spill may contain a pathogenic virus, eg Hepatitis B, HIV To make dilute solution (1,000 Decontamination of surfaces that may be lightly (ie not visibly) 4 tablets in 5 litres of water PPM) contaminated with pathogenic viruses Decontamination of blood and bloody body fluid spills, To make concentrated solution 10 tablets in 1 litre of water especially if the spill may contain a pathogenic virus, eg Actichlor tablet (10,000 PPM) Hepatitis B, HIV 1.7 g To make dilute solution (1,000 Decontamination of surfaces that may be lightly (ie not visibly) 1 tablet in 1 litre of water PPM) contaminated with pathogenic viruses To make concentrated solution Decontamination of blood and bloody body fluid spills, (10,000 PPM) Add 50 mls water especially if the spill may contain a pathogenic virus, eg Milton tablet Hepatitis B, HIV (800 mg) To make dilute solution (1,000 Decontamination of surfaces that may be lightly (ie not visibly) Add 500 mls water PPM) contaminated with pathogenic viruses To make concentrated solution Dilute 1:10 in water (Add bleach Decontamination of blood and bloody body fluid spills, (10,000 PPM) solution to water and not vice especially if the spill may contain a pathogenic virus, eg Domestos versa) Hepatitis B, HIV solution To make dilute solution (1,000 Decontamination of surfaces that may be lightly (ie not visibly) Dilute 1:100 in water PPM) contaminated with pathogenic viruses Decontamination of blood and bloody body fluid spills, To make concentrated solution 1 tablet in 100 mls of water especially if the spill may contain a pathogenic virus, eg (10,000 PPM) Covchlor tablets Hepatitis B, HIV To make dilute solution (1,000 Decontamination of surfaces that may be lightly (ie not visibly) 1 tablet in 1 litre of water PPM) contaminated with pathogenic viruses Always check dilutions with product instructions. If in doubt, follow manufacturer’s guidelines. Use preparation as soon as it is made up. Actichlor tablet 2.5 g (not 5g or 500 mg tablet To make concentrated solution (10,000 PPM) 7 tablets in 1 litre of water 8-C September 2000 GUIDELINES FOR THE SAFE USE AND HANDLING OF GLUTARALDEHYDE Glutaraldehyde is a hazardous substance, it is toxic if used incorrectly. Care should be taken to avoid inhalation, skin and eye contact. 1. Wear suitable gloves, e.g. Nitrile for prolonged exposure. 2. Wear a plastic apron to prevent penetration through clothing. 3. Improve ventilation by using low level extraction ventilation or activated charcoal filters. 4. Wear eye protection e.g. safety glasses, during decanting or when splashing is likely. Respirator/mask for use with gas/vapour should be available for use. 3M 5. Following immersion, rinse items thoroughly. 6. Replace rinse water frequently. 7. Dilute with further water prior to discharge to drain. 8. Do not spray or use liberally on environmental surfaces. 9. Ensure containers are secure during storage. 10. Do not subject to extremes of temperature. 11. Ensure lids remain in place on immersion tanks. 12. Ensure items are thoroughly cleaned before immersion, glutaraldehyde is a fixative. 13. Preferably do not use in busy densely populated areas. 14. Position exhaust outlet away from inlets or windows. 15. Once activated the solution must only be used for the recommended period, i.e. number of cycles or time period. 16. Never use glutaraldehyde when safe alternatives are available, e.g. heat, chlorine releasing agents or alcohol. Advice on safe alternatives and processing of equipment is available from the Infection Control Team. Following accidental contact with the skin or splashing to the eye or mouth, wash with large quantities of cold water for 10 – 15 minutes and obtain medical advice. Complete an incident/accident report form and notify Occupational Health. All staff should be aware of the Trust’s Glutaraldehyde policy in the Health and Safety Policies binder. This page can be photocopied and displayed in staff areas. I C Guidelines 9-C September 2000 THE USE OF BENCH-TOP AUTOCLAVES There are many factors to be taken into account when considering the provision of sterile equipment. Where possible equipment should be decontaminated and sterilised by a recognised Sterile Services Department. The following guidance is intended to promote the safe and effective use of bench-top autoclaves. All practitioners using bench-top autoclaves should comply with this guidance. • Instruments used for vaginal examination and the insertion/removal of intrauterine devices should be decontaminated after use by steam sterilisation. Disposable instruments used for these purposes should be discarded as clinical waste immediately after use, (MDA 1995). • Instruments to be used in minor surgical procedures must also be decontaminated after use, using steam sterilisation and MUST be sterile at the time of use. PRE CLEANING OF INSTRUMENTS Pre-cleaning is an essential part of the decontamination process. The sterilisation process will not be effective if the item is contaminated with organic matter. • A dedicated sink should be used for pre-cleaning instruments. • Protective clothing (heavy duty gloves, plastic apron and eye protection) should be worn. • General purpose detergent and hot water is sufficient for pre-cleaning. Instruments should be submerged whilst being cleaned, rinsed thoroughly and dried with disposable paper towel prior to placement in the autoclave. Care should be taken throughout these procedures to avoid splashing and/or the creation of aerosols. • Ultrasonic cleaning baths are an effective way of cleaning fine bore instruments and may be useful for delicate instruments, eg those used in dentistry or some minor surgery. Ultrasonic baths must be used in accordance with the manufacturer’s instructions. The following points should also be considered: • • • A detergent solution should be used in ultrasonic baths. The detergent solution should be changed according to the manufacturer’s recommendations. This may be at least twice daily or more often if heavily contaminated. On removal from ultrasonic baths instruments should be rinsed in water and inspected for residual debris. The cleaning process should be repeated if residual debris is present. Ultrasonic baths should be emptied, cleaned and left dry at the end of each session. Instruments should be checked for wear or damage (e.g. joints move freely but are not loose, scissors are sharp, forceps align correctly etc.). Items identified as defective should be immediately taken out of use, sent for repair or discarded and replaced. I C Guidelines 10 - C September 2000 OPERATION • Bench-top autoclaves should not be situated in staff areas, and ideally not in rooms where staff are working during their operation. • Bench-top autoclaves should be positioned so as to facilitate the movement of instruments from a “dirty” to clean area after autoclaving. • Bench-top autoclaves should only be operated by designated personnel, who have an understanding of the principles involved. • Bench-top autoclaves are only suitable for unwrapped instruments and equipment of a non-porous nature unless using a vacuum cycle. • The basket/tray should not be overloaded. Instruments should not overlap and be open so all surfaces are exposed to steam. Instruments should be autoclaved for: Temperature (oC) Minimum Hold Time Pressure Bar 134 3 minutes 2.25 126 10 minutes 1.50 121 15 minutes 1.15 Please note that these temperatures must be reached before timing commences. MAINTENANCE • Autoclave pressure, temperature and cycle time should be checked daily and these details recorded in a log book, by designated personnel. The operating manual should be kept next to the autoclave in a protective folder. A quarterly service should be carried out by a qualified technician, (most manufacturers will provide this service). • Maintenance records and operating manual entries should be retained for 11 years. NB: Requirements for the servicing of bench-top autoclaves are set out by the Department of Health in Health Technical Memorandum (HTM) 2010. The autoclave will also need servicing by the Trust insurers every 14 months as a pressure vessel. A designated operating manual is available for every Trust owned autoclave. STORAGE OF INSTRUMENTS • Instruments should be stored dry and covered to protect them from dust. • Instruments which are required to be sterile at the time of use (eg those used in minor surgery, coil insertion) must be used within 3 hours of removal from the autoclave. I C Guidelines 11 - C September 2000 PURCHASE • When purchasing a bench-top autoclave always seek independent advice regarding the autoclave’s compliance with British Standard and Department of Health guidance prior to purchase. Independent advice can be obtained from the Infection Control Team or the Facilities Department Inability to comply with any of this guidance indicates the need to have equipment sterilised by a local Sterile Services Department. I C Guidelines 12 - C September 2000 DECONTAMINATION OF MEDICAL OR LABORATORY EQUIPMENT Action in response to HSG 93/26 Decontamination of Equipment prior to Inspection, Service or Repair • Anyone who inspects, services or repairs medical and laboratory equipment either on NHS premises or elsewhere has the right to expect that articles have been properly treated so as to remove or minimise the risks of infection. • Equipment and articles used for invasive procedures, analysis and diagnosis which comes into contact with blood, body fluids/tissue or other pathological specimens will require decontamination prior to examination. • Equipment which is visibly soiled with blood/body fluids and is accessible to cleaning must never be presented or sent to a third party for maintenance or repair. • All decontamination procedures should be undertaken by suitably qualified staff. The method of decontamination used must be one that does not damage the article or any of its components. In cases of doubt about the appropriate method, advice can be sought from: • • • • The manufacturer or agent Facilities Department/EBME Sterile Services Department A member of the Infection Control Team. Where appropriate Hospital Engineers/EBME technicians should have sight of equipment before any further action is taken. • A Declaration of Contamination Status (page 14-C) must be fully completed by an authorised person in the department before the equipment is sent for repair. This should be given to the porter/technician when equipment is collected for repair/service, and remain with the equipment until it reaches its final destination. If equipment is being sent to an outside company/agency for repair/service:- • A Declaration of Contamination Status (page 14-C) must be completed by an authorised person in the department before the equipment is collected for repair/service. The declaration should be attached to the outside of the equipment and marked “examine enclosed document before unpacking”. User department must always ensure safe packaging and despatch of goods with official order to repair company and enclose a Declaration of Contamination Status form. In certain situations equipment may not be decontaminated prior to inspection, service or repair, either because the equipment is subject to investigation as the result of a complaint or it may not be adequately decontaminated without engineering assistance. In such cases the advice of the investigating body should be sought. If such an item is to leave the Trust, the following precautions must be taken:- • A prior warning should be given to the intended recipient. • The condition of the item should be clearly labelled on outer packaging. • The packaging must be suitably robust to ensure contamination will not occur during transportation. • The agreement of the transporter may be required. I C Guidelines 13 - C September 2000 WORCESTERSHIRE COMMUNITY AND MENTAL HEALTH NHS TRUST DECLARATION OF CONTAMINATION STATUS prior to the inspection, servicing, repair or return of medical and laboratory equipment To: Make and description of equipment/items: Model/Serial/Batch number: Other distinguishing marks: Has this equipment been exposed internally or externally to hazardous materials as indicated below? Blood, body fluids, respired gases or pathological samples. Other biohazards YES YES NO NO Chemicals or substances hazardous to health Other Hazards YES YES NO NO COMMENTS: Has this equipment been cleaned? YES NO Has this equipment been decontaminated?(Disinfected or sterilized after cleaning)YES Please give details of methods and materials used for cleaning/decontamination: NO If the equipment could not be cleaned/decontaminated please indicate why: Such equipment must not be returned/presented without the prior agreement of the recipient whose reference or contact name must be given above. Has the equipment been suitably prepared to ensure safe handling/transportation? YES Signature: Unit: Name: Tel. no. Position: Date: I C Guidelines 14 - C NO September 2000 DECONTAMINATION GUIDELINES Equipment Agent/Method Comments and Instruction for Use Manufacturer’s guidelines must always be checked prior to carrying out the Decontamination process Airways Disposable Discard as clinical waste immediately after use. Auriscope General Purpose Detergent Clean between each patient/client. (GPD) then 70% alcohol wipe. Clean speculum with hot water and GPD, using a cotton bud for the inside. Wipe with alcohol. Allow to dry. Store dry. Baby Changing Mats General Purpose Detergent Cover with disposable paper towels. (GPD) Change these between each baby. Mats should be washed with hot water and GPD at the end of each session, using a disposable cloth. If visibly soiled, treat as a spillage (see Spillages page 7-C). If the plastic covering becomes torn or damaged, the mat should be thrown away. Hard surface wipes could be used for extra decontamination between each use. Baby Scales General Purpose Detergent Cover with disposable paper towel. (GPD) Change between each baby. Clean with GPD and hot water at the end of each session. Use a disposable cloth. If visibly soiled treat as a spillage (see Spillages page 7-C). Baths Detergent Solution/Cream Wipe with detergent solution and rinse. Cleanser Cream cleanser may be used for stain and scum removal. Bed Frames General Purpose Detergent Wash with GPD and hot water. Rinse, (GPD) dry thoroughly with disposable towels. Bed Pans, Urinals, General Purpose Detergent Empty contents down toilet. Wash with Commode Pans (GPD) hot water and GPD to remove visible contamination. Rinse. Avoid splashing. - in client’s home Dispose of cloth after use. Store dry. If disposable bed pans are used, contents should be emptied as above. Place empty container in clinical waste sack. Arrange clinical waste collection through Facilities Department. Cracked/damaged equipment should be removed from service. Report any malfunction immediately to the Facilities Department. I C Guidelines 15 - C September 2000 Equipment Agent/Method Comments and Instruction for Use Manufacturer’s guidelines must always be checked prior to carrying out the decontamination process Bed Pans, Urinals, Commode Pans - on return from client Bed pan washer Place in bed pan washer for routine cycle if available. Wash with General Purpose Detergent if bed pan washer not available. Store dry. - In hospital Bed pan washer Place in bed pan washer for routine cycle. If disposable items are used they should be placed in a macerator. If this is not possible, contents should be emptied down toilet. Bed railings, monkey poles, cradles General Purpose Detergent (GPD) Wash with GPD and hot water. Rinse. Dry thoroughly with disposable paper towel. Bowls - surgical Autoclave Return to Sterile Services Department or use a bench-top autoclave (see Use of Bench-top Autoclaves page 10-C). Prior to autoclaving wash with general purpose detergent to remove visible organic matter. Avoid splashing. General Purpose Detergent (GPD) General Purpose Detergent (GPD) Clean with GPD and hot water. Store dry and inverted. Allocate BP cuff for patients in isolation. Wipe over with detergent and warm water if soiled and after use on infected patients. - for washing of patients/clients BP cuffs Breast Pumps loaned out in community settings - pump box Wipe over with a clean damp cloth between each loan - accessory kit/pump collection kit Send to be autoclaved at a sterile supplies department - hand pumps Between each individual loan Whilst equipment is on loan it is the responsibility of the user to ensure it is adequately decontaminated. Trust staff should ensure users have been given the correct instructions for this and the importance of adequate cleaning prior to disinfection or steam sterilisation. ALWAYS check suitability of equipment for autoclaving. Contact ICN for further advice Cracked/damaged equipment should be removed from service. Report any malfunction immediately to the Facilities Department. I C Guidelines 16 - C September 2000 Equipment Agent/Method Comments and Instruction for Use Manufacturer’s guidelines must always be checked prior to carrying out the decontamination process Carpets Avoid carpeting clinical areas. - clinical areas Detergent - clients’ homes General purpose Detergent (GPD) Deal with spillage then use General Purpose Detergent not hypochlorite to avoid damaging the carpet. Single Use (Disposable) Overnight drainage bags should be nondrainable and discarded each morning. It is not recommended to re-use drainable bags after washing them each morning. Autoclave after each use Return to Sterile Services Department or use a bench-top autoclave (see Use of Bench-top Autoclaves page 10-C). Catheter Drainage Bags Cervical Caps (Practice Caps) Vacuum clean. Washing should be by hot water extraction using approved detergent. Spillages of blood/body fluid should be dealt with using the principles outlined in Spillages of Blood or Body Fluids on page 7-C. Prior to autoclaving, either place in ultrasonic cleaner or wash with General Purpose Detergent to remove visible organic matter and rinse. Avoid splashing. Cleaning cloths Dispose of daily Wash daily at 90o C. If not disposable in (domestic) isolation rooms use a clean cloth per bed space. Commode Chairs General Purpose Detergent Clean with GPD and hot water. Use (GPD) disposable cloth. If visibly soiled, treat as spillage (see Spillages page 7-C). During outbreaks of gastroenteritis clean as normal then wipe with a 1000 ppm chlorine solution. Crockery and Cutlery General Purpose Detergent Use dishwasher if available. If not, hand (GPD) wash in GPD and hot water. Dry according to local policy. Curtains Routine change 6 monthly and Routine change may be advised by - bed and window when soiled. infection control when a disperser of MRSA or known infection has been nursed on the open ward. Cracked/damaged equipment should be removed from service. Report any malfunction immediately to the Facilities Department. I C Guidelines 17 - C September 2000 Equipment Agent/Method Comments and Instruction for Use Manufacturer’s guidelines must always be checked prior to carrying out the decontamination process Dental Mirrors for Autoclave after each use Return to Sterile Services Department or School Inspection use a bench-top autoclave (see Use of Bench-top Autoclaves page 10-C). Diaphragms - Autoclave after each use vaginal (Practice Caps) Drains Dressing Trolleys and Attachments General Purpose Detergent (GPD) Duvets - water-impermeable cover General Purpose Detergent (GPD) Ear Syringe Nozzle Autoclave ECG electrodes Endoscopes Examination Couches Use of disposable electrode pads See separate policy General Purpose Detergent (GPD) Prior to autoclaving wash with General Purpose Detergent to remove visible organic matter. Avoid splashing during this process. If mirrors will not withstand autoclaving they should be cleaned with with GPD and then soaked in Chlorhexioline Gluconate. Return to Sterile Services Department or use a bench-top autoclave. Prior to autoclaving wash with General Purpose Detergent to remove visible organic matter. Avoid splashing during this process. Clean regularly. Chemical disinfection is not advised. At beginning of each session and/or when visibly soiled wash with GPD. Use disposable cloth. Ensure surface is dry before placing sterile pack on top. Hard surface wipes can be used if physically clean. Wash with detergent and warm water, and dry. If heavily contaminated, wash with chlorine releasing solution 1000 ppm, rinse and dry. NB bleach will damage the cover if used too often. Wash in hot water and General Purpose Detergent. Squirt hot water and GPD carefully through nozzle. Autoclave after cleaning. Please refer to section on Use of Bench-top Autoclaves (page 10-C). None Cover with disposable paper roll. Wash with hot water and GPD at the end of each session. If visibly soiled treat as a spillage. (See Spillages page 7-C). If the plastic covering becomes torn or damaged it should be replaced. Couch can be wiped with hard surface wipes between clients/patients. Cracked/damaged equipment should be removed from service. Report any malfunction immediately to the Facilities Department. I C Guidelines 18 - C September 2000 Equipment Agent/Method Comments and Instruction for Use Manufacturer’s guidelines must always be checked prior to carrying out the decontamination process Floors General Purpose Detergent Wash with GPD and hot water. - wet clean (GPD) Allow to dry. Disinfection not routinely required. If necessary chlorine releasing agent may be used. - dry clean Vacuum Clean Dust attracting mop Flower Vase General Purpose Detergent Change water and wash vase with GPD and hot water weekly. Hands See Handwashing. Headphones General Purpose Detergent Wash with GPD and hot water. Dry (GPD) thoroughly. Disposable Ice making machines Switch machine off and discard all ice. Wipe over with warm water and General Purpose Detergent (GPD). Rinse thoroughly to ensure no detergent remains. Ice should be handled using the scoop provided. The scoop should be cleaned with warm water and GPD daily, rinsed and left in a clean, dry uncovered container after each use. NEVER return unused ice to the ice storage chest. NEVER use patients’ water jug, glasses or other utensils as a scoop. Access door must be kept shut when not removing ice. (Refer page 13-B). Instruments Autoclave Where possible use disposables. If not - forceps etc possible return to Sterile Services if not disposable Department for cleaning or use a benchtop autoclave (see page 10-C). IV stands/pumps General Purpose Detergent Damp dust after each patient or if soiled. (GPD) Hard surface wipes Laryngoscope General Purpose Detergent After use remove bulb. Wash bulb and (GPD) then 70% Alcohol wipe. blade with GPD. Wipe thoroughly (including hand piece) with 70% alcohol wipe. Re-assemble. Store dry. Linen Clean linen should be stored in a cupboard or on a covered trolley. It should - health centre stocks not be stored on exposed shelves. Mattresses Specialist, General Purpose Detergent Rented mattresses should be returned to including Alpha x-cell; (GPD) the rental company after cleaning, with a Nimbus Pumps & carry decontamination certificate. Mattresses bags, Pegasus owned by the Community Trust should be returned to the issuing Equipment Loan Store for cleaning before being loaned again. Prior to removal from the client’s home mattresses should be washed with GPD and hot water. If visibly soiled treat as a spillage (see Spillages page 7-C). Cracked/damaged equipment should be removed from service. Report any malfunction immediately to the Facilities Department. I C Guidelines 19 - C September 2000 Equipment Agent/Method Comments and Instruction for Use Manufacturer’s guidelines must always be checked prior to carrying out the decontamination process Mouth pieces General Purpose Detergent Wash with GPD. Dry. Wipe over with (GPD) then 70% alcohol wipe. 70% alcohol wipe. Store dry. - for use with placebo inhalers - if not disposable Manual handling equipment - Arm resters General Purpose Detergent (GPD) Wipe with detergent and water and dry. Use hard surface wipe if soiled or used by infected patient. Send to on site hospital laundry to be washed between patients use and when soiled or in local/ward washing machine. Allocated for individual patient use unless patient is fully dressed and a low infection risk. - Bath hoist - Banana board and immoturn - Handling belts (fabric) - Hoist sling - Sliding sheet and easislide - Stand aid slings Launder Remove cover and send to on site hospital laundry to be washed when soiled. - Supine transfer boards (Pat slide) General Purpose Detergent (GPD) Wipe with detergent and water and dry if in direct patient contact. Use alcohol wipe if soiled or used by infected patient. Ward dishwasher. Wash in detergent and warm water. Do not wash at handwash sink. None. Vacuum after each use. Do not use for more than 2 days without washing or reprocessing. Launder after use. Rinse after each use, wring and store with mop head uppermost to allow head to dry. Launder daily in high risk areas. Disposable slings may be used and should be allocated for use on one patient only. Medicine cups General Purpose Detergent (GPD) Mops (dish/dolly) Mops (dry dust attracting) Do not use. Mops (wet) flat Mops wet General Purpose Detergent (GPD) Mop (bucket) General Purpose Detergent (GPD) Clean with detergent and warm water inside and out, at the end of the day and evening shift. Cracked/damaged equipment should be removed from service. Report any malfunction immediately to the Facilities Department. I C Guidelines 20 - C September 2000 Equipment Agent/Method Comments and Instruction for Use Manufacturer’s guidelines must always be checked prior to carrying out the decontamination process Nail brushes (surgeons’ Single use disposable Use only if essential. A sterile nail brush hands) should be used. Nail brushes (ward Single use disposable Avoid use if possible. areas) Nasal atomizer Single use disposable None. Nebulisers General Purpose Detergent Nebuliser masks and tubing can be re(GPD) used for the same patient. Wash mask with hot water and GPD. Store mask and tubing dry in a designated container (NB container should be clearly marked with the patient’s name if not for use in his/her home). Neurological testing Single use disposable Never improvise, eg name badges etc due to the risk of blood borne infection. Pillows General Purpose Detergent Must be completely covered with water (GPD) impermeable cover. Wash cover with detergent and warm water and dry between patient use. Proctoscopes Disposable. Autoclave for non disposables. Raised toilet seat General Purpose Detergent Wash with GPD. Excessive scratching, cracks etc will make adequate cleaning difficult. In this instance seats should be discarded. Razors (safety and Use disposables – single patient None. Must be disposed of as a “sharp” open) use immediately after use Razors (electric) Use disposable heads – single None patient use Receivers General Purpose Detergent Wash with GPD. Dry. Wipe over with - if not disposable (GPD) then 70% alcohol wipe. 70% alcohol wipe. Resuscitation Equipment For silicone or black bags, ensure - Ambubag they are physically clean then - Face mask wipe with 70% isopropyl alcohol. Scissors (General use nursing) Sheepskins Showers Isopropyl Alcohol 70% Disposable masks/ampubags are available as an alternative and can be used for infectious conditions but are a single use item. Use sterile scissors for aseptic procedures. Send to laundry Cream Cleanser or General Purpose Detergent (GPD) To be cleaned and dried once daily by domestic staff and by nursing staff between patients. Slings Refer to Manual Handling Equipment - for use with hoists listed on page 20-C. Cracked/damaged equipment should be removed from service. Report any malfunction immediately to the Facilities Department. I C Guidelines 21 - C September 2000 Equipment Agent/Method Comments and Instruction for Use Manufacturer’s guidelines must always be checked prior to carrying out the decontamination process Specula vaginal Autoclave Return to Sterile Services Department or - if not disposable use a bench-top autoclave (see Use of Bench-to Autoclaves page 10-C). Prior to autoclaving wash with general purpose detergent to remove visible organic matter. Avoid splashing during this procedure. (See Auriscopes) Specula - aural Spillages Spoons Hypochlorite - used for administration of oral poliomyelitis vaccine – if not disposable Sputum Pots Disposable Stethoscope Isopropyl Alcohol Swab (See Spillages page 7-C) Wash with hot water and GPD. Place in 1000 ppm hypochlorite solution for 30 minutes. Rinse. Remove and store dry. Stools General Purpose Detergent (GPD) Suction machines Hard surface wipes Thermometers - digital Disposable sleeve - tympanic Disposable cover - mercury not recommended None Wipe head with 70% isopropyl alcohol and leave to dry Wash with GPD and hot water. Damaged coverings should be replaced immediately. Pay particular attention to horizontal surfaces and/or grooves where dust may collect. All suction machines, where possible, should be fitted with a closed disposable liner system. Used suction liners and tubing should be disposed of as clinical waste. Machines should be wiped over with hard surface wipes. Glass jars – wear protective clothing (aprons, visor/spectacles and gloves). Empty contents down sluice, wash with detergent and warm water. Dry thoroughly. Catheters and tubing must be changed between each patient/client daily when in constant use (see page 2-E) Wipe handle with 70% isopropyl alcohol. Single use. Wipe with 70% isopropyl alcohol swab and allow to dry Cracked/damaged equipment should be removed from service. Report any malfunction immediately to the Facilities Department. I C Guidelines 22 - C September 2000 Equipment Agent/Method Comments and Instruction for Use Manufacturer’s guidelines must always be checked prior to carrying out the decontamination process Tourniquet General Purpose Detergent Wash with GPD and warm water if (GPD) soiled. Use disposables for patients with Disposable single use infectious disease. Toys - soft Machine washable Heavily contaminated toys may have to be destroyed. - hard General Purpose Detergent Wash with GPD and warm water. Rinse (GPD) and dry thoroughly. If contaminated with blood treat as a spillage. Trolleys General Purpose Detergent Prior to carrying out a procedure within (GPD) the clinic setting at the start/end of clinic and when trolley visibly soiled, use of hard surface wipes is satisfactory for use if trolley visibly clean. These should be used in accordance with Ultrasonic baths Detergent solution the manufacturer’s instructions. A detergent solution should be used in the baths. The detergent solution should be changed according to manufacturers instruction. On removal from ultrasonic baths instruments should be rinsed in water and inspected for residual debris. The baths should be emptied, cleaned and left dry at the end of each day. Uniforms These should be laundered separately to - staff avoid contaminating non-work clothes. Urine bag/bottle General Purpose Detergent Wash with GPD and warm water holders/stands (GPD) between patients Vaccine Spillage (See Vaccines page 21-E). Vacutainer barrels Single use (Re use of barrels not Discard as a single unit with needle acceptable attached immediately after use into a sharps bin. Vaginal Cones Autoclave Return to Sterile Services Department or - if not for individual use a bench-top autoclave (see section of client use the use of Bench-top Autoclaves page 10-C). Prior to autoclaving wash with general purpose detergent to remove visible organic matter. Avoid splashing during this procedure. Vaginal Diaphragms (See Diaphragms) Vaginal Speculae (See Speculae) Walking aids General Purpose Detergent Wash with GPD and hot water. Store (GPD) dry. Cracked/damaged equipment should be removed from service. Report any malfunction immediately to the Facilities Department. I C Guidelines 23 - C September 2000 Equipment Agent/Method Comments and Instruction for Use Manufacturer’s guidelines must always be checked prior to carrying out the decontamination process Wheelchairs General Purpose Detergent Wash with GPD and hot water. Pay (GPD) particular attention to grooves/crevices where dust may collect. If visibly soiled treat as a spillage (see Spillages of Blood or Body Fluids page 7-C). I C Guidelines 24 - C September 2000 REFERENCES AYLIFFE G.A.J, E.J.L. LOWBURY, J.D. WILLIAMS, A.M. GEDDES. 1992. Control of Hospital Infection. A Practical Handbook. Third edition. Chapman and Hall. London. AYLIFFE G.A.J, D. COATES, P.N. HOFFMAN. 1993. Chemical Disinfection in Hospitals. PHLS. London. COATES D, D.N. HUTCHINSON. 1993. How to produce a hospital disinfection policy. Journal of Hospital Infection. 26. 57 - 68. CONTROL OF SUBSTANCES HAZARDOUS TO HEALTH. 1988. Statutory Instrument No. 1657. HMSO. London. DAMANI N. 1997. Manual of Infection Control Procedures. Oxford University Press. Oxford. DEPARTMENT OF HEALTH. 1994. Health Technical Memorandum 2010. Sterilization. Parts 1 – 4. HMSO. London. DEPARTMENT OF HEALTH. 1998. Health Technical Memorandum. 2031. Clean Steam. HMSO. London. HEALTH AND SAFETY AT WORK ACT. 1974. HEALTH SERVICE CIRCULAR HSC 1999/123 - Controls Assurance Statements 1999/2000: Risk Management and Organisational Controls HEALTH SERVICE CIRCULAR HSC 1999/179. Decontamination of medical devices. Controls Assurance in infection control. HEALTH SERVICE GUIDELINES. 1993. Decontamination of Equipment prior to Inspection, Service or Repair. HSG (93) 26. LEWIS J, D. MEESE. 1997. Promoting Public Health - Infection Control in the Community. ICNA/RCN. MEDICAL DEVICES AGENCY. 1995. MDA DB9501. Supplied for Single use only. MDA. London. The re-use of Medical Devices MEDICAL DEVICES AGENCY. 1996. MDA DB9605. The purchase, operation and maintenance of Bench top Steam Sterilisers. MDA. London. MEDICAL DEVICES AGENCY. 1998. MDA DB9804. The validation and periodic testing of Bench top Vacuum Steam Sterilisers. MDA. London. MEDICAL DEVICES AGENCY. 1998a. Medical Device and Equipment Management for Hospital and Community-based Organisations. Department of Health. London. I C Guidelines 25 - C September 2000 MEDICAL DEVICES AGENCY 2000. Equipped to Care – The safe use of medical devices in the 21st Century. MDA. London. PERSONAL PROTECTIVE EQUIPMENT AT WORK REGULATIONS. 1992. Health and Safety Regulations. WILSON J. 1995. Infection Control in Clinical Practice. Baillierre Tindall. London. WORCESTERSHIRE COMMUNITY AND MENTAL HEALTH NHS TRUST. 1997. Health and Safety policies and procedures. Health and Safety: Glutaraldehyde.* NB * Until review is completed staff working in Wyre Forest and Tenbury should refer to the equivalent policies approved by the former Kidderminster Health Care NHS Trust. I C Guidelines 26 - C September 2000