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PRINCIPLES OF DECONTAMINATION 10 Medical Director’s Directorate Date of production/Last update Date of last review Date of next review Lead reviewer Infection Control Manual 1 January 2009 January 2011 January 2012 Ann Jack ICN 10 PRINCIPLES OF DECONTAMINATION CONTENTS Page 10.1 Decontamination overview 3 10.2 Cleaning 7 10.3 Disinfection 24 10.4 Sterilisation 28 10.5 Documents 33 Appendix 1 35 Page 2 Chapter 10 – Decontamination 10.1 Decontamination Overview 10.1.1 Introduction Micro-organisms can be transmitted to people from instruments, equipment and/or the environment. Where a piece of equipment is used for more than one patient it must be decontaminated following each and every episode of use and prior to being sent for service or repair, to ensure the safety of both patients and staff. The decontamination process makes medical devices safe for healthcare staff to handle and for use on patients The level of decontamination required is dependent on what the equipment is used for and the level to which it has been contaminated. The term decontamination refers to a process, which removes or destroys contamination. Consequently micro-organisms (or other contaminants) are prevented from reaching a susceptible site, in sufficient numbers necessary to initiate infection or any harmful response. These are the process to be followed to initiate correct steps in performing decontamination: • Cleaning: physical removal of contaminants including dust, soil and organic matter, along with a large proportion of micro organisms. (Drying will cause a further reduction). This Process is essential prior to disinfection and sterilisation (refer to section10.2) • Disinfection: Utilising heat or chemicals to reduce the number of viable micro- organisms to a level which is not harmful to health (but not all viruses and/or bacterial spores). (Refer to section10.3) • Sterilisation: Renders the object free from viable micro-organisms, including bacterial spores and viruses (refer to section 10.4) The purpose of this section of the manual is to ensure a quality service which takes into account a safe method of decontamination of equipment and items used in patient care, thereby helping to provide and maintain a safe, healthy working environment Important Note: All decontamination procedures should be undertaken by a qualified trained and equipped member of staff, wearing personal protective equipment. Responsibilities The NHS Scotland Code of Practice for the Local Management of Hygiene and Healthcare Associated Infection (Scottish Executive, 2004) supports action to reduce the risk of healthcare associated infection (HAI) for patients, staff, visitors and wider public at local level. Success is dependent on a change in culture where infection control is truly everybody’s business with a clear focus on the importance of good hygiene, infection control practice and education. Page 3 Service Users, staff and visitors each have an individual responsibility to ensure a safe, effective and clean medical and surgical devices that are to be used on patients within the healthcare setting. All staff have a responsibility within the organisation and must support its commitment to HAI control and reduction. See NHS Fife Infection Control Manual – Introduction: Responsibilities Incident reporting Where there has been a potential or actual risk in relation to the decontamination of surgical instruments and other patient associated equipment which exposes staff or others to infection or injury, the NHS Fife Incident Management Policy – G9 should be followed and an NHS Fife Incident/Near Miss Report Form completed. Staff should report any issues arising in relation to the use of cleaning solutions, e.g. skin reactions The decontamination process required is commonly specified as one of three levels (based on the classification system first proposed by Dr E H Spaulding). Risk Application High Item in close contact with a break in the skin or mucous membrane or introduced into a sterile body cavity Item in contact with intact mucous membranes, body fluids and particularly after use on infected patients or prior to use on immuno-compromised patients. Items in contact with healthy skin or mucous membranes or not in contact with patient. Medium Low Recommendatio n Sterilisation Sterilisation or disinfection cleaning Some high-risk or intermediate-risk medical devices are not able to be heat sterilised and require high level disinfection between patients use i.e. fibre-optic endoscopes. Refer to section? 10.1.2 Single Use Equipment Single use means that the manufacturer: Intends the item to be used once and then discarded Considers the item unsuitable for use on more than one occasion. Has insufficient evidence to confirm that re-use would be safe. It is essential that equipment intended for single use is not reprocessed. If a single use item is reused/reprocessed then NHS Fife and the user is legally liable for that particular product. Single use items/products are denoted by: Page 4 10.1.3 The Decontamination of invasive medical healthcare equipment prior to inspection, service or repair Equipment being sent for maintenance or repair must be correctly decontaminated to remove or minimise the risk of infection to staff subsequently involved in handling the equipment. A declaration of decontamination status certificate should be completed before sending items for repair or maintenance. See Operational policy E10 and Appendix 1 (page 35). Good practice points The decontamination process chosen must be effective for the device being re- processed and the procedure that will be undertaken. Ensure the decontamination agents used are compatible with both the devices and the reprocessing equipment. Decontaminate devices in accordance with the manufacturers instructions Ensure appropriate decontamination facilities are available for the process to be undertaken Ensure any decontamination equipment used is fit for purpose and regularly maintained, validated and tested. Appropriate Personal Protective Equipment (PPE) must be worn when undertaking decontamination activities. Staff undertaking decontamination activities should be trained for the tasks they undertake. Never re use single use equipment Standard infection control precautions should be adhered to at all times. Workflow should proceed from dirty to clean Sterile and sterilised devices must be segregated and stored in clean dry conditions, outwith the decontamination area. Page 5 10.1.4 Choosing a Decontamination Process Choosing the Appropriate Decontamination Process In accordance with “Spaulding” Risk Classification Are disposables available? NO YES Choose level of decontamination required:- Level of Infection Risk HIGH Level of Infection Risk MEDIUM Sterilisation (or high level disinfection if heat labile) Disinfection or Sterilisation Is item able to withstand heat sterilisation? YES sterilise NO – High Level chemical disinfection Can equipment withstand heat disinfection? YES – Washer Disinfect or Non- Chemical Disinfection Use disposables Level of Infection Risk LOW Clean Can equipment withstand automated cleaning? YES – use automated cleaning if available. NO – Can item be immersed? If not available then → YES – use immersion cleaning method NO – use non immersion cleaning method Always ensure that the manufacturers’ guidance is considered before purchasing equipment. Page 6 Chapter 10– Decontamination 10.2.1 Cleaning Definition CLEANING is a dirt removing process, using liquid detergent and warm water. This process removes a high proportion of all micro-organisms. It is essential for the removal of organic matter, grease and lubricants, which might otherwise protect organisms from additional decontamination processes such as disinfection and sterilisation. Good Practice Points When carrying out any decontamination process personal protective equipment must be worn. Cleaning is the first and most important step in any decontamination process and is an essential prerequisite to ensure effective disinfection or sterilization of equipment. Follow the manufacturer’s recommendations or guidance provided with regard to the amount to be used, dilution and contact time and to always make cleaning solutions at time of use. Wherever available, the use of mechanical cleaners such as washer disinfectors and ultrasonic washers is preferred to the manual cleaning of items. The cleaning method used should be assessed to ensure the effectiveness of the cleaning process without damage to equipment. Cleaning can be achieved by either manual or automated methods. Decontaminate hands prior to commencing the process and donning PPE Wear the correct PPE for the task being undertaken i.e. gloves, aprons and eye protection Ensure cleaning solutions are made up freshly when they are required and not preprepared in advance If disinfection is required, this must be carried out after thorough cleaning rinsing and drying has been undertaken Dispose of cleaning materials and PPE as per NHS Fife Waste Policy. Decontaminate hands following the cleaning process. All documentation to record item being reprocessed and the method used is completed at the time reprocessing has occurred. General principles: Cleaning and thorough rinsing should always precede any attempt to disinfect or sterilise Cleaning can be achieved by either manual or automated methods. Cleaning should be carried out using a validated cleaning process wherever possible. 10.2.2 Manual Cleaning (see flowchart page 10) 10.2.3 Automated Cleaning (see flowchart page 11) Effective cleaning is an essential prerequisite to all subsequent methods of decontamination. Automated cleaning is a controlled process that will provide more consistent results and therefore manual cleaning of items should only be undertaken when automated methods are inappropriate or unavailable. Automated or mechanical cleaning can be undertaken by means of ultrasonic washers or thermal washer disinfectors. Page 7 List of automated cleaners o o o Ultrasonic cleaner – this is not a disinfection processes Washer disinfector Thermal washer disinfector - The use of an automated thermal washer-disinfector provides disinfection using moist heat. Good practice points for ultrasonic cleaners Staffs are trained and competent in the use of the ultrasonic cleaner Staff must wear PPE at all times when performing decontamination processes Ensure joints and hinges are fully open Fully immerse in cleaning solution to ensure all surfaces come into contact with the solution Do not overload the basket Do not overlap instruments Do not place instruments on the floor of the ultrasonic cleaner Do not operate with the lid off Do not put hands into the tank of the ultrasonic cleaner while the machine is in use Good practice points for washer disinfectors Staffs are trained and competent in the correct use of the WD, (including testing of the equipment) Decontaminate hands prior to commencing the process Wear PPE for the task being undertaken Decontaminate hands following the cleaning process and removal of PPE. Check instruments thoroughly for cleanliness and functionality and dispose of any that are damaged, blunt or show signs of corrosion. Maintain good housekeeping by cleaning the area as you go. Ensure decontamination equipment is kept clean. Page 8 Approved Agents for Automated Cleaning Product (Recommended Name) Proprietary Name Usage General purpose (neutral) Hospec For manual immersion and nonimmersion cleaning, environmental cleaning and patient associated equipment cleaning. Detergent impregnated wipes Tuffie detergent wipes For horizontal surfaces, nonimmersion cleaning and patient associated equipment Bactericidal detergent Johnson Diversity D2 For dishwashing by hand. Enzymatic detergent Ultraclean Used in ultrasonic washers for cleaning of medical instruments detergent Sonozyme Used in washer disinfector for endoscopes Page 9 10.2.2 Manual cleaning flowchart Cleaning Manual Immersion Equipment Required: o A sink/receptacle (not a hand wash basin) to ensure full immersion of the equipment o A warm detergent solution as per manufacturer’s instructions o Disposable clean cloths o A clean non-shedding cloth or disposable paper towels o Personal Protective Equipment (PPE) i.e. disposable gloves, aprons and goggles/face visors Procedure: o Decontaminate hands prior to donning PPE o o Fill sink/receptacle with warm water (<35 C) and detergent o Immerse the item ensure to displace trapped air o Brush, wipe, agitate or irrigate the items to dislodge and remove visible dirt o Remove items and drain them over the detergent solution o Rinse items in clean water o Remove items to drain o Carefully hand dry using absorbent non-shedding cloth o PPE should be removed and disposed of in clinical waste. Hands must be washed after this procedure Non-Immersion Equipment Required: o o A warm water (<35 C) detergent solution o Disposable clean cloths o A clean disposable non-shedding cloth o PPE, disposable gloves and aprons Procedure: o If equipment is electrical ensure that it has been disconnected from the mains supply before cleaning o Decontaminate hands prior to the donning of PPE o Immerse the clean cloth in the detergent solution and wring out thoroughly o Commence with the upper surface of the item, wipe thoroughly ensuring that detergent solution does not enter electrical components o Periodically rinse the cloth in clean water and repeat as above o Surfaces should be hand dried. o NB the above procedure may be performed using detergent impregnated wipes, however, check with the manufacturer’s instructions o PPE should be removed and disposed of in clinical waste. Hands must be washed after this procedure Page 10 10.2.3 Automated cleaning flowchart Automated Cleaning Thermal Washer Disinfectors (WD) This process incorporates both cleaning and disinfection. Procedure: o Decontaminate hands prior to donning PPE. o Follow manufacturer’s instruction for details on operating the WD. o Ensure instruments, bedpans and other equipment is compatible with the process and detergents used. o Ensure items are loaded correctly and any hinged or jointed items are open. o Items that require irrigation must be attached correctly to the irrigator. o Ensure the action spray is not being obstructed by items needing cleaned. o After the cycle is completed check items thoroughly for visible soiling. Reprocess any item that remains contaminated. o Complete the documentation recording the items that have been processed. o PPE to be disposed of in clinical waste. o Hand decontamination must be performed after removal of PPE. Ultrasonic cleaners Equipment requirements: - preliminary essentials prior to using the ultrasonic washer. Follow manufacturer’s instructions. o Ensure that the ultrasonic washer is clean and dry prior to use. o Fill the reservoir with potable water (drinking quality) to the designated line and replace the lid. o Switch on and leave for the required time to de-gas the water adhering to the manufacturer’s instructions. o Switch off Procedure: o Decontaminate hands prior to donning PPE. o Follow the preliminary essentials as above. o Remove the lid and add a suitable enzymatic detergent that is effective at low temperatures. o Set the timer control to the specified time. o Carefully immerse the item ensuring displacement of any air. o Irrigate lumened/cannulated devices. o Replace lid and switch on for the recommended duration. o Switch off, open lid and remove the items and drain. o Transfer to a clean rinse receptacle. o Rinse thoroughly with clean potable water ensuring irrigation of lumened/cannulated areas, drain. o Carefully hand dry using absorbent, non-shedding cloth. o Inspect item(s) for visible contamination, reprocess if this is evident. o After use the ultrasonic cleaner should be drained, cleaned, dried, covered and stored dry until required for re-use. o Complete the documentation recording the items that have been processed. o PPE to be disposed of in clinical waste. o Hand decontamination must be performed after removal of PPE. Page 11 Chapter 10– Decontamination 10.2.4 Equipment cleaning table All equipment used for patient care must be adequately decontaminated and stored correctly between uses. Selection of the appropriate decontamination procedure demands an understanding of the level of decontamination required. The principles of decontamination can be found in chapter 10.1. Page 12 DECONTAMINATION OF COMMONLY USED PATIENT EQUIPMENT THIS LIST IS NOT EXHAUSTIVE CLEANING: Use a solution of neutral liquid detergent and warm water, rinse and dry. For smaller items, a pre-impregnated detergent wipe may be used. EQUIPMENT OR SITE PROCEDURE COMMENT RESPONSIBILITY Airway/ endotracheal tube Single use. Ambu-lifts Clean between patients and when visibly soiled. Infected/immunosupressed patients or patients with Clinical staff blood/open wounds present; Clean then disinfect with 0.1% Hypochlorite solution. Ampoules single dose Wipe neck with 70% alcohol prior to opening. Ampoules to be handled by scrubbed-up staff must Clinical staff be sterile. Do not store in disinfectant or alcohol. Clinical staff Ampoules multi dose Before use, check that the cap and bung are intact and that the solution is clear. Disinfect the rubber diaphragm with 70% isopropyl alcohol before use. Discard any vial 4 weeks after its first use. Also Clinical staff discard any vial after the bung has been pierced 5 times. Auroscope specula (ear piece) Single use disposable preferred. Clean between each patient use. Aprons Single use disposable. White for clean work eg serving meals, administering Clinical staff undertaking medications. Coloured for potentially contaminating cleaning procedure activities eg wound dressings, decontaminating equipment etc. Domestic Staff in accordance (See local protocol for colour coding of aprons In with National Colour Coding ITU). Policy When injections are being made into a body cavity eg local anaesthetic into the epidural space, use a single dose vial. Clinical staff Page 13 EQUIPMENT OR SITE PROCEDURE COMMENT RESPONSIBILITY Baby Bottles/teats Pre-packed single use. Baby scales Protect from soiling with paper roll. If soiled or baby is known infected, clean then Clinical staff Renew between each use and clean disinfect. daily. Sanitary ware Clean after each patient use. If mothers wish to use their own bottles etc, then the Clinical staff bottles and teats should be rinsed in cold water to get rid of all traces of milk. Bottles should then be washed in neutral liquid detergent and warm water, rinsed and totally immersed in a solution of Hypochlorite 0.015% (140 ppm available chlorine) for 30 minutes and allowed to dry inverted. The tank should be emptied daily, washed in warm water and neutral liquid detergent, rinsed, and dried thoroughly with a paper towel before refilling. Infected/immunosupressed patients or patients with Domestic staff - daily, Nursing blood/open wounds present- clean then disinfect. staff - between patient use Taps and appliances which are not used at least Department Managers once per week are identified and flushed once per week for a period of 5 minutes (see Legionella Policy). Routine Cleaning Domestic Staff – in accordance with local work schedules Infected/immunosupressed patients or patients with Clinical staff blood/open wounds present - clean then disinfect. Bath Hoists Clean after each use. Bath water Antiseptics should not be added routinely to bath water. Bed Frames (back rest, foot rest) Clean after each use, when soiled and Infected/immunosupressed patients or patients with Domestic staff bed frames daily on patient discharge. blood/open wounds present - clean then disinfect. Nursing staff, when soiled and on discharge of patient. Only use when prescribed. Clinical staff Page 14 EQUIPMENT OR SITE Bed base & wheels Including cots PROCEDURE Clean weekly, when soiled and on patient discharge. COMMENT RESPONSIBILITY Infected/immunosupressed patients - clean then Underside downwards of bed disinfect with 0.1% hypochlorite solution. base domestic staff weekly. Top side of bed base, (below mattress) clinical staff weekly, when soiled and on discharge of patient. (Note in the absence of domestic service availability, the bed in its entirety should be decontaminated by clinical staff) Bed tables and underside of table Clean. Infected/immunosupressed patients - clean then Domestic staff daily disinfect with 0.1% hypochlorite solution. Nursing staff, when soiled and on discharge of patient Bed Pans (disposable) Use macerator as instructed. If not available, empty contents down sluice or toilet Clinical staff and dispose of as clinical waste. Bed pans (re-usable) Use bed pan washer disinfector. If not available, empty contents down sluice or toilet, Clinical staff clean then disinfect with 0.1% hypochlorite solution. Bed pan Carriers Clean and store in designated racks. Bins Clean with detergent and warm water, rinse and dry. Infected/immunosupressed patients - clean then Clinical staff disinfect with 0.1% hypochlorite solution. If used within isolation room, clean then disinfect with Domestic staff 0.1% hypochlorite solution. Bowls (patient wash) Use washer disinfector where available. Manually clean where unavailable Store dry and inverted above floor level. Infected/immunosupressed patients - clean then Clinical staff disinfect with 0.1% hypochlorite solution. (Discard disposable basins after each use and single patient use basins on patient discharge.) Page 15 EQUIPMENT OR SITE PROCEDURE COMMENT RESPONSIBILITY Bowls (surgical) Single use preferred. Birthing pools Follow manufacturers’ advice on Dispose of any single use accessories/hosing Clinical staff between patients. cleaning and maintenance. Use single use disposable liners. Clean then disinfect all surfaces and outlets with a 0.1% hypochlorite solution. Breast Pumps Single use disposable or treat as for baby bottles. Clinical staff Carpets Vacuum daily and wash by hot water extraction method at least once every six months. Domestic staff (Clinical staff should deal with body fluid spillage in the first instance) and report to Domestic Services. Catheter stands Clean between patients and when soiled. Chairs Clean with detergent and warm water, Wipe able fabrics should always be selected for use Domestic staff rinse and dry. in clinical areas. For contaminated spillages, follow NHS Fife spillage policy. Clinical staff should deal with body fluid spillage in the first instance and report to Domestic Services. Commodes Clean frame. The pan should be Infected/immunosupressed patients - clean then Clinical staff treated as for bedpans. disinfect with 0.1% hypochlorite solution. Computer and other IT equipment in clinical areas. Keep free from dust. Clean in Decontaminate hands after using the computer. accordance with manufacturers instructions. Use wipe able plastic keyboard covers where available. Re-usable, send to CSSD for Sterilisation. Clinical staff Infected/immunosupressed patients - clean then Clinical staff disinfect with 0.1% hypochlorite solution Clinical and/or administration staff Page 16 EQUIPMENT OR SITE PROCEDURE COMMENT RESPONSIBILITY Crockery/ cutlery Where possible, machine wash with a Where washing machine is not available, hand wash Kitchen staff, domestic staff or final rinse temperature of 80°C which with antibacterial detergent and warm water and clinical staff dependant on local allows air-drying of the contents. rinse in hot water. (The rinse water temperature policy. should be too hot for bare hands, necessitating the use of colour coded household rubber gloves) invert on racks and allow to air-dry or use disposable paper roll. Couches (examination) Cover with disposable paper roll to Infected/immunosupressed patients - clean then Clinical staff minimise contamination. Change disinfect with 0.1% hypochlorite solution. between patients. Clean daily or when soiled. Couch – frame & box Dentures Before overnight storage, clean with neutral liquid detergent and warm water or toothpaste, using patients own toothbrush. Plug holes and Overflows Clean regularly. Surgical Drains Single use disposable. Drip stands Clean. Duvets and Duvet Covers Domestic Staff Store overnight in fresh water in a clean sealed Clinical staff container (preferably disposable). Prior to use, brush again under running water. Clean pot and store dry. Do not pour disinfectant down the drain – it is of no Domestic Staff practical use. Ensure that taps are not run violently as this creates spray and aerosol. ‘Smelly’ drains should be reported to the C/N or Domestic Supervisor as applicable. Clinical Staff Infected/immunosupressed patients - clean then Clinical staff disinfect with 0.1% hypochlorite solution. Must be laundered after each patient (Ensure manufacturer’s instructions are consistent Clinical staff use and if soiled, in accordance with with GP/LS prior to purchase). Policy GP/LS Safe Handling of Laundry. Page 17 EQUIPMENT OR SITE Ear Syringe (Propulse) ECG Equipment Endoscopes Flower Vases Furniture - General PROCEDURE COMMENT Decontaminate in accordance with NHS Fife Ear Irrigation Policy NP4. Straps – clean between patient use. Use disposable electrodes. RESPONSIBILITY Clinical staff Clinical staff Machine – clean daily or when visibly soiled. Sterilisation or high level disinfection Refer to Endoscopy section of Infection Control Clinical staff required. Manual. Clean. Clean at least weekly or sooner when flowers are Clinical staff replaced. Change water daily. Clean. Domestic staff Infected/immunosupressed patients – clean then Clinical staff should deal with disinfect with 0.1% hypochlorite solution. body fluid spillage in the first instance Clinical staff Hair brushes/combs Clean and air dry (individual use). Hand Hygiene Refer to Infection Control Manual section 2.1 – Hand Hygiene. Headphones Use single patient use earpieces. Infected/immunosupressed patients – clean then Clinical staff Clean between patient use and if disinfect with 0.1% hypochlorite solution. soiled. Disposable or sterilise. Change daily Fill only with sterile distilled water. Clinical staff and between patients. Humidifiers Incubators When caring for patients with Clostridium Difficile All NHS Fife staff associated disease, always decontaminate hands with soap and water as alcohol gel has been proven non-effective in these cases. Non-infected patients – dismantle Infected/immunosupressed patients – clean then Clinical staff according to manufacturer’s disinfect with 0.1% hypochlorite solution. instructions and clean all parts including the motor unit and housing. Store dry. Reassemble and store dry. Do not top up reservoir but clean, dry and refill immediately before use with fresh sterile distilled water. Page 18 EQUIPMENT OR SITE Instruments PROCEDURE COMMENT Surgical instruments returned directly DISPOSABLE SHARPS RETURNED TO SSD. to the Sterile Services (SSD). MUST RESPONSIBILITY NEVER BE Clinical staff Do not clean instruments prior to return to SSD. Lancing Devices Single use only preferred. Where the patient has their own device, this should be used in accordance with the manufacturer’s guidance. Do not use on more than one patient. Laryngoscope Single use or returned directly to SSD Blades for sterilisation. Linen Refer to Infection Control Manual Chapter 2. Locker Tops and Clean daily or when spillage occurs. Bedside Tables Lockers (Interior) Mattresses Pillows Medicine Cups Clean weekly and on discharge. Clinical staff Clinical staff All staff Domestic staff daily. Clinical staff if spillage occurs and on discharge of patient. Clinical staff and Clean. Pillows should be enclosed in heat sealed plastic Clinical staff covers. Mattress and pillow integrity testing should Infected/immunosupressed patients – be carried out on a monthly basis. Contact your clean then disinfect with 0.1% Infection Control Nurse for instructions if required. hypochlorite solution. Single use disposable or treat as for Do not wash in handwashing sink in ward. crockery. Moving and handling Hoist – clean between patient use. equipment Slings and sliding sheets – should be allocated to each patient for their individual use and then sent to laundry for cleaning. Nailbrushes Single use disposable. Clinical staff All equipment should be cleaned between use on Clinical staff different patients and when soiled. If the patient has known Infected/immunocompromised, clean then disinfect with 0.1% hypochlorite. (Single use slings are available for certain makes of hoists). Not to be used in ward areas. If these are required All staff then they must be single use only. Do not leave at sink. Page 19 EQUIPMENT OR SITE Nebulisers PROCEDURE COMMENT Single patient use. Clean, rinse and between therapies. Oxygen Tubing Use only sterile water and medication. dry Rooms cleaning) Scissors Clinical staff thoroughly Change tubing and mask weekly. Single use. Clinical staff Patient equipment Clean between different patient use Infected/immunosupressed patients, clean stands eg IV and and when soiled. disinfect with 0.1% hypochlorite solution. monitor stands Proctoscopes RESPONSIBILITY then Clinical staff Single use. Clinical staff (terminal See Infection Control Manual Chapter In accordance with Terminal Cleaning work schedule 2 – ‘Control of the Environment’. For all dressings and sterile procedures, use sterile disposable or autoclavable scissors. Clinical and Domestic staff Clinical staff Shaving Equipment Razors – Disposable, single patient Non-disposable (electric): Patients may only use Clinical staff – (wet shaving is use. their own personal electric razor. preferred) For cleaning of this product, refer to manufacturer’s instructions. Communal electric razors should not be used. Clippers. Single patient use (disposable heads). Page 20 EQUIPMENT OR SITE SKIN Sphygmomanometer Sphygmomanometer Cuffs PROCEDURE COMMENT RESPONSIBILITY Cord stumps – clean with cotton Clinical staff wool and warm water at every nappy change. Hands – Refer to NHS Fife’s Infection Control Manual Section 2.1. Injection Sites – clean skin with 70% Isopropyl alcohol (in single use swab) and allow to dry before injection. NB – Diabetic Patients – need not use alcohol for skin cleansing when injecting insulin. Operation Site – Chlorhexidine 0.5% in 70% alcohol OR Povidone iodine 10% alcoholic solution (Betadine). Pre-urinary catheterisation preparation – Clean with 0.9% sodium chloride – available in single use sachets. Venepuncture sites – Clean skin with 70% Isopropyl alcohol (in single use swab) and allow to dry before penetrating skin. Vulval area – Warm tap water for swabbing prior to childbirth. Clean. If patient has known infection/immunocompromised, Clinical Staff clean then disinfect with 0.1% hypochlorite. Single patient use preferred. Ensure electronic equipment is disconnected from mains prior to cleaning. Clean between each patient use. Clinical staff If reusable, should have waterproof If patient has known infection/immunocompromised, covers. clean then disinfect with 0.1% hypochlorite. Sputum Pots Use disposables clinical waste. and discard as Clinical staff Page 21 EQUIPMENT OR SITE Stethoscopes Suction Apparatus Syringes (1) Syringes (2) Toys Trolley (dressing) PROCEDURE COMMENT RESPONSIBILITY Diaphragm – Wipe with an alcoholClinical staff impregnated swab between each patient. Earpieces – Following disconnection, the earpieces should be cleaned. Catheters – Sterile single use. Do not open until needed. Do not connect until Clinical staff Tubing – Disposable. suction operating. Connectors – If contaminated, clean. Lids (where still in use) – clean. Change daily and between patients Filters – Refer to manufacturer’s instructions. Disposable Jars/Liners – Seal all connections, place in rigid leak proof container. Non-disposable – Take to sluice with lid attached and tip contents down sluice. Place in washer disinfector or send to SSD check. (Home care – if not available, clean then disinfect). Plastic (Sterile) – Disposable. Single use only. Baxa Syringes – reusable for Clean. administration of medication and enteral feeds. Refer to manufacturer’s instructions regarding frequency of use. Toys should be capable of being For patients with infectious diseases, the use of toys washed or wiped clean. should be discouraged or be destroyed after use. Toys in regular use must be cleaned daily. Visible soiled toys must be cleaned immediately. Soft toys are discouraged. Clean daily and when contaminated. Before and after each patient use, wipe over top surface with 70% alcohol and allow to dry before placing sterile pack on top. Clinical staff Clinical staff Clinical staff Clinical staff Page 22 EQUIPMENT OR SITE Tympanic thermometers Tourniquets Urine Bags PROCEDURE Handpiece – clean between patients. COMMENT RESPONSIBILITY If patient has known infection/immunocompromised, Clinical staff clean then disinfect with 0.1% hypochlorite. Earpiece – single use disposable sheath. Single patient use preferred. I patient has known infection/immunocompromised, Clinical staff clean then disinfect with 0.1% hypochlorite. Single patient use only. Urine bag holders/ stands Clean daily. Urine bottles Uniforms Vaginal specula See BEDPANS. Refer to NHS Fife’s Uniform Policy. Single use preferred. Night bags – Empty contents down the sluice or Clinical staff toilet avoiding splashing. Dispose of bag in orange clinical waste bag. Leg bags – Empty as required and replace 5-7 days in accordance with manufacturer’s instructions. If patient has known infection/immunocompromised, Clinical staff clean then disinfect with 0.1% hypochlorite. Where reusable devices are utilised, send to SSD for Clinical staff reprocessing. Walking aids Clean between patient use and when Dedicate for individual use. Clinical staff visibly dirty... Wheel chairs (patient Clean between patient use and when Dedicate for individual use. Clinical staff allocated) visibly dirty. Wheel chairs Clean as above Head of any department using common wheel chairs Head of Department (general department) must allocate responsibility to a relevant job holder for routine cleaning. Page 23 Chapter 10 – DECONTAMINATION 10.3 – Disinfection 10.3.1 Introduction Disinfection methods may be used to reduce the microbial flora of skin and mucous membranes i.e. hand decontamination and pre-operative skin preparation or to reduce the microbial flora of inanimate objects, where heat is inappropriate or cleaning alone is insufficient. Disinfection is an individual step in the decontamination cycle, used to reduce the number of microorganisms to a level that is considered safe, but which may not necessarily destroy some viruses or bacterial spores. It may be followed by sterilisation depending on the intended use of the device. It is generally used to decontaminate equipment which is in contact with intact mucous membranes, body fluids and particularly after use on infected patients or prior to use on immuno-compromised patients Some high-risk or intermediate-risk medical devices are not able to be heat sterilised and require high level disinfection between patients uses i.e. fibre-optic endoscopes. Practitioners who decontaminate endoscopes must have separate guidelines for the local reprocessing of endoscopes. Disinfection is achieved by either thermal or chemical methods (or a combination of both). Thermal disinfection must be used in preference to chemical disinfection. Chemical disinfection may only be used for items for which thermal disinfection methods are unsuitable. This process must not be used for items intended for single use only. Cleaning is a pre requisite to disinfection Heat disinfection (see flowchart page 27) Dishwashers, washing machines and washer-disinfectors are effective methods for disinfecting equipment because they clean the item and then expose the items to hot water for the required time to achieve thermal disinfection. Chemical Disinfection (see flowchart page 27) Physical cleaning of the device prior to chemical disinfection should always be carried out. When to use There should be very few reasons for using a chemical disinfectant. They can be toxic, flammable, corrosive or have other material incompatibilities so there use should be avoided wherever possible. The use of chemical disinfectants is only recommended for disinfection of heat sensitive instruments, decontamination of surfaces, making potentially infected items safe for handling If chemical disinfection is necessary, use the method recommended by the manufacturer. Chemical Disinfection can be of a high or a low level. a) High level chemical disinfection is used in specialist settings for items which cannot disinfection/sterilisation e.g. peracetic acid to reprocess endoscopes. b) Low level chemical disinfection e.g. chlorine releasing agents or alcohol withstand heat Page 24 Controls of Substances hazardous to Health (COSHH) Chemical disinfectants are often an irritant when in contact with the skin and mucous membranes or by vapour inhalation. They can also be corrosive and flammable. A risk assessment under the Controls of Substances hazardous to Health (COSHH) Regulations must be undertaken before a process using chemical disinfection can be used. There is a potential fire hazard associated with all chemical disinfectant products. It is advisable that these products are stored in an appropriate heat resistant cupboard. All staff using chemicals must undergo COSHH training, and must not handle the chemicals until training is complete. Safety data sheets for chemicals must be kept in each department Disinfectants must be stored, reconstituted and used in accordance with COSHH regulations. Good Practice Points Refer to NHS Fife disinfection policy to ensure correct agent is used (not available) Never use chemical disinfection when sterilisation is required or when cleaning alone is sufficient Physical cleaning of the device prior to disinfection is essential as organic material inactivate disinfectants. Check expiry date and storage conditions of disinfectants. Ensure disinfectants are used at the recommended concentration Do not mix disinfectants with each other or other chemicals as gases may be produced and can cause ill effects for the user. When chemically disinfecting large areas, ensure adequate ventilation Ensure that the disinfecting fluid penetrates into all crevices of the article being disinfected Deal with spillages promptly and in accordance with COSHH data sheet (see IC manual section 2.6) Equipment must never be stored in a chemical disinfectant. NEVER use alcohol based disinfectants in the presence of diathermy or other sources of ignition. Do not, under any circumstances, decant disinfectants/detergents/cleaning agents from one container to another Ensure all associated equipment is stored clean and dry Do not use chlorine preparations on urine as they may release chlorine vapour which is dangerous to the user Page 25 NHS Fife Approved Disinfectants Product name) (recommended Proprietary Name General purpose detergent Chlorine releasing agents Sodium hypochlorite solution Hospec Titan sanitizer Milton Sodium dichlorisocyanurate Actichlor Peracetic acid Isopropyl alcohol 70% Perasafe Isopropyl alcohol 70% Alco wipes, Mediswabs and Azowipes Virkon Isopropyl alcohol impregnated swabs 70% Peroxygen Compound (For Restricted Use) Chlorhexidine Iodine 2% Chlorhexidine Gluconate in 70% Isopropyl alcohol Triclosan Hibiscrub, Hibisol, Unisept and Hydrex Betadine, inadine and Povidine iodine ChloraPrep Skinsan Usage Pre-cleaning prior to disinfecting For toilet and sink use Infant feeding bottles and food preparation areas. Patient environment and associated equipment. (1,000 ppm 0.1%) Blood Spillages (10,000 ppm 1%) Heat labile endoscopy For hard horizontal surfaces Decontamination of the skin prior venepuncture and vascular cannulation to Laboratories and the mortuary This is used as a skin and hand disinfectant only For skin disinfection prior to surgery and for the treatment of small wounds. For skin disinfection prior to CVC insertion and aftercare Hand and skin disinfectant Page 26 10.3.2 Disinfection flowchart Disinfection Chemical Heat Equipment required: o Dishwashers, washing machines and washer- disinfectors o Ensure the items being disinfected in this manner will withstand repeated exposure to wet heat at o temperatures of 80 C Procedure: o Ensure the thermal disinfector that you are using is fit for purpose. o The disinfector must be able to clean the item and expose the item to hot water for the required time. o Decontaminate hands prior to donning PPE. o Where practicable ensure debris is removed from items before they are processed. o Complete documentation. o Remove PPE and dispose of into clinical waste. o Decontaminate hands after removing PPE. Full Immersion Method Equipment required following the cleaning process: o A solution of freshly prepared chemical disinfectant at the correct dilution. o PPE o Disposable absorbent nonshedding cloths Procedure: o Decontaminate hands prior to donning PPE o Fill the receptacle with the prepared chemical solution. o Carefully immerse the item fully to ensure displacement of trapped air. o Place lid on the receptacle and leave for the recommended time. o Remove the item from the solution drain into the solution. o Rinse thoroughly with sterile water, ensuring recontamination does not occur. o Carefully dry the item by hand using an absorbent non-shedding cloth. o Complete documentation. o Thoroughly wash and dry receptacle before storing in a clean area. o Remove PPE and dispose of into clinical waste. o Decontaminate hands after removing PPE. Non-Immersion Method Equipment required following the cleaning process: o A solution of freshly prepared chemical disinfectant at the correct dilution. o PPE o A clean disposable absorbent nonshedding cloths Procedure: o Decontaminate hands prior to donning PPE o Fill the receptacle with the prepared chemical solution. o Immerse the clean cloth into the disinfectant solution and wring thoroughly. o Wipe down the item followed, by rinsing the disinfectant residue from the item and the dry with an absorbent non-shedding disposable cloth. o Rinse thoroughly with sterile water, ensuring recontamination does not occur. o Carefully dry the item by hand using an absorbent non-shedding cloth. o Complete documentation. o Thoroughly wash and dry receptacle before storing in a clean area. o Remove PPE and dispose of into clinical waste. o Decontaminate hands after removing Page 27PPE. Chapter 10 – Decontamination 10.4.1 Sterilisation 10.4.2 Introduction Sterilisation is a process used to render an object free from all viable micro-organisms including viruses and bacterial spores, e.g. used for all equipment which is to be introduced into a sterile body area. It does not destroy prions. Moist heat sterilisation using steam under pressure is the preferred method and it should always be used in preference to other methods since it is more reliable, and the process can be effectively validated. Steam sterilisation is the established method of choice for sterilisation in healthcare services. For most reusable items this is usually done by heat using an autoclave. Use of a Central Sterilising Service Unit should be employed wherever possible. Where benchtop steam sterilisers are used this should only be carried out in accordance with national guidance. Care must be taken to use the type of steriliser which has been designed and validated for the particular load. At the end of the sterilisation process, a device can be considered either "sterile" or "sterilised" depending on the process undertaken. o o Vacuum sterilisers render the instrument(s) sterile. Benchtop ‘bowl and instrument(s)’ sterilisers render the processed products sterilised. There are 2 main types of steam sterilisers: 1. Vacuum sterilisers (wrapped instrument) Type B and some Type S. The device(s) are wrapped prior to sterilisation and after the process, the product remains wrapped until point of use. 2. Benchtop ‘bowl and instrument(s)’ sterilisers (unwrapped instruments) Type N. The device(s) are processed unwrapped however sterility is not maintained once the cycle is completed. Unless used immediately after sterilising the device(s) are only clean at point of use. Note: NHS Fife use only bench top bowl & instrument sterilisers. 10.4.3 Local Decontamination Unit Specific Responsibilities The NHS Scotland Code of Practice for the Local Management of Hygiene and Healthcare Associated Infection (Scottish Executive, 2004) supports action to reduce the risk of healthcare associated infection (HAI) for patients, staff, visitors and wider public at local level. Success is dependent on a change in culture where infection control is truly everybody’s business with a clear focus on the importance of good hygiene, infection control practice and education. Service Users, staff and visitors each have an individual responsibility to ensure a safe, effective and clean medical and surgical devices that are to be used on patients within the healthcare setting. All staff has a responsibility within the organisation and must Page 28 support its commitment to HAI control and reduction. Introduction: Responsibilities See NHS Fife Infection Control Manual – Senior Manager Decontamination (HDL (2001)10 Overall responsibility for risk assessment and management processes relating to decontamination of reusable medical devices Infection Control Team Provide advice and guidance too clinical and non-clinical staff on best practice in all aspects of infection control, including decontamination. The Microbiologist (Steriliser) The Microbiologist (Steriliser) advises on and audits microbiological aspects of decontamination including washer-disinfectors and sterilisation. Arranges for the culture of biological indicators where used. The Authorised Person (Sterilisers) Provide independent and impartial advice on purchasing and use of decontamination equipment (sterilisers/washer-disinfectors) Undertake audit of validation and periodic testing and maintenance of decontamination equipment. Estates and Facilities Manager Ensure organisation-wide facilities and services are compliant with national standards, statutory requirements and other guidance; Designs and commissions capital schemes which reflect best practice for decontamination Provides technical advice on purchase, installation and operation of decontamination equipment and engineering services. Test Person (Sterilisers) Performs the validation and periodic testing of sterilisers and washer disinfectors Maintenance Person (Sterilisers) Performs the planned and breakdown maintenance duties on sterilisers and washer disinfectors Competent Person (Pressure Vessels) Performs the statutory annual inspection of pressure vessels. User(s) have legal responsibilities (often departmental manager and may not be the person who operates the steriliser). Responsible for day to day operation of the steriliser Ensures all personnel receive training on decontamination equipment and processes commensurate with work activity Ensures that validation and periodic testing of equipment is carried out; Page 29 Is trained in decontamination Maintains staff training and decontamination equipment records Operator (must be trained and competent in the use of the steriliser) Prepares devices prior to processing in steriliser; Manually cleans devices where necessary Inspects devices for cleanliness Replenishes reservoir with sterile water (for irrigation) from unopened container Loads and operates steriliser; Checks sterilisation cycle is satisfactory; Performs the daily/ weekly checks of decontamination equipment Transfer cleaned and dried items from the inspection area. Completes records of loads processed, temperature checks and tracking of the processed equipment. Daily Checks (operator) Ensure steriliser is clean and free from dust/debris, inside and out. Carry out Automatic control tests, (Operate a normal cycle with an empty chamber. Record time, temperature and pressure to ensure they meet requirements) record any faults in the log book and report to User/Estates and Facility Managers. Weekly checks (operator) As for daily checks Clean door seal and examine to ensure it is undamaged Door interlock monthly, quarterly and annual testing will be carried out by Maintenance and test persons. Unwrapped Instruments and Utensil Steriliser (Bowl and Instrument Steriliser) This type of steriliser is used to process unwrapped surgical instruments and utensils intended for immediate use in a controlled medical environment and is achieved by direct contact of the product with saturated steam at a temperature of 134-137*C for a minimum holding time of 3 minutes. This type of steriliser is none as non-vacuumed and should not be used to process wrapped instruments and components, or unwrapped instruments / utensils with narrow lumens. Pre Sterilisation requirements Used devices must be transported safely from the clinical area to the decontamination room, in solid sided leak proof lidded containers, which are clearly marked “contaminated” If they are transported through public areas, they must also be secure. Used instruments generated from domiciliary visits must be transported in a solid sided leak proof container with fitted lid. This should be clearly labelled for those containers carrying separately clean and dirty instruments. Effective cleaning of devices prior to disinfection or sterilisation is essential in reducing the risk of transmission of infectious agents. If devices are not clean they cannot be sterilised (see section 10.2) Steam quality in the chamber is required to meet the specification for pyrogen free Page 30 “clean steam” (set out in HTM 2031) this can be achieved using either sterile water for irrigation (from a freshly opened container) or freshly produced reverse osmosis (RO) water. Water should be changed at a minimum of daily intervals and the reservoir should be drained rinsed with sterile water for irrigation and left dry overnight and when not in use. Maintenance, testing and Record Keeping In order to quality assure the process, the steriliser must be able to record pressure and temperature achieved during the sterilising cycle via a process verification recorder. This information should act as a permanent record. It is essential therefore that daily, weekly, quarterly and annual testing is performed and recorded in a steriliser log book to ensure all validated parameters for the steriliser are met. These records should remain with the steriliser at all times. keep a record of all testing, maintenance and repairs keep permanent records of every sterilisation cycle keep permanent records of each cycle load which is used to track medical devices through the decontamination process ensure that there is valid Pressure Vessel Insurance Certificate (this is a legal requirement. Storage and Transportation Device storage Storage facilities for sterile and sterilised products should be secure and out with the decontamination room. Sterile devices and sterilised devices must be stored separately to prevent the risk of confusion Only devices that were sterilised as wrapped items may be stored and used as a sterile device Immediately after sterilisation, unwrapped sterilised devices should be examined visually for dryness and, if necessary, should be dried. They should be wrapped/bagged to prevent gross contamination in clean, unused, sterilisation grade wrapping material and be clearly marked “sterilised only” Devices must be stored in dedicated clean, dry dust free containers, whether wrapped or bagged Stored devices should be used in strict date order i.e. ‘first in, first out’ Used devices should be stored safely in solid sided leak proof lidded containers and should be stored for the minimum possible time before being cleaned and disinfected. Transportation Sterile and sterilised devices must be transported in clean dry conditions which prevent damage to the devices and their packaging, and prevent contamination. Page 31 Good Practice Points Do not process wrapped, tubular or textile products in a non-vacuumed benchtop steam steriliser All items must be clean and dry before loading into the steriliser. Do not overload the steriliser Arrange load items to support the removal of air and the penetration of steam items such as bowls should be placed on their sides so that air will be displaced and condensation can drain out. Do not allow items to rest on the bottom of the chamber Drain and clean chamber and reservoir at the end of each day and leave dry All decontamination procedures should be undertaken by qualified trained competent staff, wearing the correct PPE for the process being performed. Care must be taken when handling loads as they may still be very hot Care must be taken when handling loads to prevent recontamination Unwrapped items are exposed to the air at the end of the cycle and subject to rapid recontamination. They should be used immediately (i.e. opening the steriliser door should be regarded as equivalent to opening a sterile pack). Do not sterilise single-use medical devices Do not operate equipment if you have not been trained Page 32 Chapter 10 – Decontamination 10.5 Documents The following list of NHS Fife policies should be should be seen as guidance and considered along with the specific policies and procedures for decontamination, Policy No. GP1 Policy No. GP5 Policy No. GP6 Policy No. GP7 Policy No. GP10 Policy No. GP15 Policy No. GP20 Policy No. GP22 Policy No. GP24 Policy No. GP26 Policy No. GP41 Policy No. E2 Policy No. E5 Policy No. E7 Policy No. E10 Policy No. E14 Policy No. GP/P4 Policy No. H2 Policy No. IC-02 Policy No. N4 Policy No. P1 Policy No. W8 Incident Management Policy Work Environment Hot Water Management Needlestick and Sharps (see N4) Electrical Safety Manual Handling Risk Assessment COSHH Safe and Effective Use of Benchtop Sterilisers Electro-Medical Equipment Management(see E2) Non NHS Fife Equipment Policy Electro Medical Equipment Management (see GP26) Electrical Safety Policy Policy for Environmental Audit – Infection Control Decontamination of Equipment prior to Inspection, Service or Repair Equipment Procurement Policy Personal Protective Equipment (PPE) Notification of Hazards Risk Assessment for TSE Agents including CJD and vCJD Needlestick & Sharps Policy (see GP7) Personal Protection Clothing Waste Management 1. REFERENCES • • • • • • • • • • • • • • Equipment Manufacturers Documentation with regards to operation including use of recommended chemical cleaning additives, testing and maintenance, and health and safety requirements. Control of Substances Hazardous to Health (COSHH) DB 2006(04) Single-use Medical Devices: Implications and Consequences of Reuse DB 2006(05) Managing Medical Devices HPS Endoscope Reprocessing: Guidance on the Requirements for Decontamination Equipment, Facilities and Management (2007) Health and Safety at Work Act (1974) HPS Local Decontamination Units: Guidance on the Requirements for Equipment, Facilities and Management (2007) Management of Health and Safety at Work Regulations (1999) The risk management of HAI: A methodology for NHSScotland (2008) MDA Device Bulletin 9605: The Purchase, Operation and Maintenance of Benchtop Sterilizers MDA Device Bulletin 9607: Decontamination of Endoscopes National Health Service in Scotland Decontamination Guidance version 1 (1999) NHS CMO (2007) 5 Important advice for dentists on re-use of endodontic instruments and variant Creutzfeldt-Jakob disease (vCJD) NHS HDL (2001)10 Decontamination of Medical Devices Page 33 • • • • • • • • • • • • • • • • • NHS HDL (2001)53 Managing the Risk of Healthcare Associated Infection in Scotland NHS HDL (2001)66 Healthcare Associated Infection: Review of Decontamination NHS HDL (2005)10 Decontamination – compliance in primary care NHS HDL (2006)45 Decontamination – treatment of patients in the independent healthcare sector NHS MEL (1998)47 Advisory Committee on Dangerous Pathogens (ACDP) / Spongiform Encephalopathy Advisory Committee (SEAC) NHS MEL (1999)65 Variant Creutzfeld Jakob Disease (vCJD): Minimising the Risk of Transmission NHSScotland: Sterile Services Provision Review Group: 1st Report (The Glennie Framework) (2001) Pressure Systems Safety Regulations (2000) Provision and Use of Work Equipment Regulations (1998) Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) (1995) Scottish Health Technical Memorandum 2010: Sterilisation (Parts 1 – 6) Scottish Health Technical Memorandum 2025: Ventilation in Healthcare Premises (Parts 1 – 4) Scottish Health Technical Memorandum 2030: Washer Disinfectors (Parts 1 – 3) Scottish Health Technical Memorandum 2031: Clean Steam for Sterilisation The Decontamination of Surgical Instruments and other Medical Devices (2001) Workplace (Health, Safety and Welfare) Regulations (1992) The Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2007 (SI 2007/1573) Page 34 0001234 DECLARATION OF DECONTAMINATION STATUS Prior to the Inspection, Servicing, Repair or Return of Medical and Laboratory Equipment Sent from: Sent to: I confirm receipt of this equipment in clean condition Signed………………………………………. Date………………………………………….. Recipient Job Card No: Sender Order No: Make and Description of Equipment: Model/Serial/Batch No: *Inspection/Servicing/Fault (please specify): PART A Initial box A if applicable otherwise complete all of part B This equipment has not been used in any invasive procedure or been in contact with blood, other body fluids, respired gases, or pathological samples. It has been cleaned in preparation for inspection, servicing, repair or transportation. PART B Has this equipment/item been exposed internally or externally to hazardous materials as indicated? If YES, provide details Blood, body fluids, respired gases *YES\NO Pathology samples *YES\NO Other Biohazards *YES\NO Chemical or substances hazardous to health *YES\NO Other hazards *YES\NO Has this equipment/item been cleaned and decontaminated, and all loose accessories removed? Indicate the methods and materials used (and methods to be used if further soiling is found) *YES\NO If the equipment/item could not be decontaminated please indicate why: Such equipment must not be sent without the prior agreement of the recipient whose reference or contact name is given above Has the equipment/item been suitably prepared to ensure safe handling/transportation? I declare that I have taken all reasonable steps to ensure the accuracy of the above information, in accordance with HSG (93) 26 Authorised signature ___________________________ Name (printed) ___________________________ Position __________________________ Unit __________________________ Dept __________________________ Phone Date __________________________ __________________________ * Delete where not applicable Top copy (White) attach to item/ Second copy (Yellow) send to recipient/Third copy (Pink) retain *YES\NO