Cleaning and Decontamination of
Equipment, Medical Devices and the
Environment,
(Including the management of blood and
body fluid spillages) policy
Infection Prevention and Control
Description: This policy describes the processes and
procedures for cleaning and decontamination of equipment
and devices within the healthcare setting.
Key Words:
Infection Prevention & Control, Cleaning,
Decontamination
Version:
8
Adopted by:
Quality Assurance Committee
Date Adopted
Main author:
July 2015
Amanda Hemsley
Name of
responsible
committee:
Date issued:
Infection Control Committee
Quality Assurance Committee
Review date:
August 2017
Expiry date:
February 2018
Target audience:
All LPT Staff
Type of Policy:
Clinical
August 2016

Non Clinical
Contribution List
Key individuals involved in developing the document
Name
Designation
Amanda Hemsley
Senior Nurse Advisor, Infection Prevention and Control
Antonia Garfoot, Fiona Infection Prevention and Control Team
Drew, Mel Hutchings
Circulated to the following individuals for consultation
Name
Diane Postle
Emma Wallis
Neil Hemstock
Emma Wallis
Dr. Margaret
Leverment
Kathy Feltham
Claire Armitage
Michelle Churchard
Smith
Bernadette Keavney
Kerry Palmer
Janet McNally
Sarah Clements
Linda Bull
Jo Bale
Katie Willetts
Paul Williams
Francisco Guerra
Louise Carpenter
1
Designation
Head of Professional Practice and Education
Lead Nurse, CHS
Lead Nurse, FYPC
Lead Nurse, Physical Health – CHS Division
Occupational Health Physician
Lead Nurse, MHSOP, CHS Division
Lead Nurse, AMH&LD, community
Lead Nurse, AMH&LD, Inpatient
Head of Trust Health and Safety Compliance
Medical Devices Manager
Team Manager
Matron Loughborough & Hinckley
Matron Coalville Community Hospital
Nursing Operational Lead
Senior Nurse, Specialist Nursing FYPC
Team Manager, Langley Ward
Senior Matron, Oakham House
Inpatient Lead, AMH
Contents
Definitions that apply to this policy…………………………………………………
4
1.0
Summary …………………………………………………………………………………
5
2.0
Introduction……………………………………………………………………………….
5
3.0
Purpose…………………………………………………………………………………...
5
4.0
Justification for the document…………………………………………………………...
5
5.0
Cleaning and Decontamination of Equipment, Medical Devices and the
Environment (including the management of blood and body fluid spillages) ……
6
5.1 Cleaning……………........................................................................................
6
5.2 Decontamination of Medical Devices……………………..………………………
7
5.3 Classification of Infection Risk Associated with the decontamination of the
Medical device……………………………………………………………………….
8
5.4 Methods of Decontamination……………………………………………………….. 8
5.5 Selecting a Chemical Disinfectant……………………………….………………… 10
5.6 Sterilisation methods…………………..……………………………………………. 10
5.7 Benchtop Steam Sterilisers………………………………………………………… 10
5.8 Decontamination of equipment prior to maintenance/service request/
Decontamination status certificate………………………………………………… 11
5.9 Medical equipment in patients own homes……………………………………… 11
5.10 Toys……………………………………..………………………………………….
11
5.11 Procedure following a spillage of blood, other body fluid and known
contaminated material……………………………………………………………... 14
5.12 Management of body fluid spillage..……………………………………………… 14
5.13 Cleaning and Disinfection Methods…………………………….……………….
16
5.14 Cleaning and Decontamination procedures……………………………………
16
6.0
Training …………………………………………..………………………………………
22
7.0
References and Associated documents………………………………………………
22
Appendix 1
Appendix 2
Appendix 3
Appendix 4
2
National Colour Coding Scheme for Cleaning………………………...
Safe System of Work……………………………………………………..
Declaration of Contamination Status Certificate……………………….
Management of Body Fluid Spillages Poster….……………………….
24
25
26
27
Version Control and Summary of Changes
Version
number
Date
Comment
s
Replaces K027
(description
V1 and K028
change
V1
and
amendments)
Version 2.0
16Sept 09
Version 3,
Oct 09
Review by A. Howell;
Version 4
Nov 09
Version 5
Nov 09
Version 5
Draft 1
Version 5
Draft 2
Version 5
Draft 3
Version 5
Final
Version 6
Nov 09
Changed from guideline to a policy and associated
CQC requirement changes made
CDT Core pathway incorporated into overall
policy document
Further changes made following consultation with
LCCHS staff and external specialists
Revisions to incorporate requirements of the NHSLA
standards
Further changes made following consultation with
LCCHS staff
Policy approved at the Clinical Governance
Committee.
Harmonised in line with LCRCHS, LCCHS, LPT
(Historical organisations)
Version 7
November 2014
Review of document in line with changes to products
used and the management of blood and body fluid
spillages
Version 8
August 2016
Updated to reflect disposable hoist slings for single
patient use
Nov 09
Nov 09
May 10
Aug 10
For further information contact: Infection Prevention and Control Team
3
Definitions that apply to this policy
Autoclave
Biological
agent
Cleaning
A piece of equipment used for sterilisation, which uses steam
Under pressure. (Heat is commonly used in sterilisation;
moisture and especially high-pressure steam increase
the susceptibility of vegetative bacteria and spores).
Any bacteria, virus or toxin
A process, which physically removes micro-organisms and
Organic matter but does not necessarily destroy infectious
agents. Cleaning is an essential prerequisite to disinfection
or sterilisation.
Contamination
This term refers to the soiling of inanimate objects or living
Material with harmful, potentially infectious or unwanted matter.
Decontamination 1. The process of cleansing an object or substance to remove
contaminants such as micro-organisms or hazardous
materials, including chemicals, radioactive substances, and
infectious diseases.
Disinfectant
Impervious
Infectious
Infection
LPT
Organisms
Personal
Protective
Equipment
(PPE)
Sanitiser
Sterilisation
4
A chemical agent, which destroys vegetative micro-organisms,
but not necessarily spores.
Incapable of being penetrated, a material impervious to liquid
Caused by a pathogenic micro-organism or agent that has the
capability of causing infection
This is an organism present at a site and causes an
inflammatory response or where the organism is present in
a normally sterile site.
Leicestershire Partnership Trust
This is defined as any living thing, in medical terms we refer to
bacteria and viruses as organisms
Specialised clothing or equipment worn by employees for
Protection against health and safety hazards. Gloves,
aprons, gowns, masks and eye protection
A chemical that both cleans and disinfects.
Refers to the killing or removal of all viable micro-organisms,
including spores. Prions are not affected. This may be
achieved by heat, chemical means, Gamma-irradiation or ultraviolet light.
1.0
Summary
This policy provides Trust–wide guidance for cleaning and decontamination of
equipment, medical devices and the environment used by healthcare workers. It
contains specific information on what type of products to use on the equipment in
relation to potential or real infections that patients may be experiencing; it also
encompasses information in relation to aspects of decontamination.
Further guidance for healthcare workers and other staff who work in Prisons and
places of detention can be found in ‘Prevention of infection and communicable
disease control in prisons and places of detention – A manual for healthcare workers
and other staff’
2.0
Introduction
The provision of healthcare carries with it inherent risks to the healthcare worker
and the patient. The purpose of the document is to ensure that all staff is aware of
their responsibilities with respect to reducing the risk of health care associated
infections. This will support the provision of appropriate precautionary measures
to protect themselves, their co-workers and their patients. This policy identifies staff
member’s responsibilities and provides them with the information they require to
enable them to minimise the risk of health care associated infections. It identifies
the principles, responsibilities and methods associated with cleaning and
decontamination of equipment and the environment. This policy also includes
information regarding the cleaning and decontamination of equipment used or
taken into a patient’s own home/environment.
The general public and staff have a right to expect that any potential hazards in a
healthcare environment are adequately controlled. All staff must possess an
appropriate awareness of their role in cleaning and decontamination. Not only is
this part of their professional duty of care to the patients with whom they are
involved, but it is also their responsibility to themselves, to other patients and
members of staff under the Health and Safety at Work Act (1974). The Control of
Substances Hazardous to Health (COSHH) Regulations (2002), require actions to
be taken to control the risk of hazardous substances, including biological agents.
3.0
Purpose
The purpose of this policy is to inform healthcare workers of the different processes
for cleaning and decontamination for both equipment and the environment in
relation to health care delivery. It includes the products that should be used and the
correct procedure when dealing with a blood or body fluid spillage.
4.0
Justification for the Document
Infection prevention and control safety is a legal requirement under the Health and
Safety at Work Act 1974. This document provides information on the processes
required for the cleaning and decontamination of equipment and the environment
for patients receiving healthcare. This will support the prevention of cross infection
within the organisation and ensure equipment used by/on patients identified with
suspected or confirmed vomiting and / or diarrhoea is cleaned appropriately This
5
information is relevant for all areas where care delivery is provided and is not
restricted to health buildings. The document has been produced in accordance with
published evidence and national best practice guidelines. As a duty of care LPT
must ensure that staff is given guidance as to the appropriate steps they need to
undertake to ensure that they can protect the patients within their care.
5.0
5.1
Cleaning and Decontamination of Equipment, Medical Devices and the
Environment (Including the management of blood and body fluid
spillages)
Cleaning
The Trust has adopted the National Patient Safety Agency (NPSA) National
Colour coding for Safer Practice Notice 15, Appendix 1
Environmental cleaning
Good environmental hygiene is an integral and important component of a policy
for preventing healthcare-associated infections in community hospitals and other
healthcare settings. The environment must be visibly clean, free from dust and
soil and acceptable to patients, their visitors and staff. A clean environment
reflects the overall appearance, structure and efficient function of Leicestershire
Partnership NHS Trust.
The environment is known to play an important role in cross infection during
increased incidents or outbreaks of infection. Door handles, flush handles, taps,
toilet rolls etc. have all been implicated at some point in this potential risk.
Therefore accumulation of dust, dirt and liquid residues may increase the risks and
must be reduced to the minimum. This can be achieved by regular cleaning and by
good design features in buildings, fittings and fixtures. A programme for monitoring
the standard of hygiene is in place across all clinical settings via the environmental
audits, top ten markers and cleaning audit programme.
Cleaning Equipment
Cleaning equipment must be stored clean and dry in a designated area.
Colour coding of cleaning equipment with materials (mop heads, gloves and cloths)
should be in accordance with NPSA National Colour coding Safer Practice.
(Appendix 1).
Mop-heads should be laundered or replaced daily following use or be disposable.
All equipment used for wet cleaning should be washed, dried and stored inverted
after use. Items should not be left soaking. Gram negative micro-organisms can
quickly contaminate solutions and wet residues.
Cleaning Schedule
A written cleaning schedule should be displayed, which includes the regular
removal of dust by damp dusting high and low horizontal surfaces. This should
specify the persons responsible for cleaning, the frequency of cleaning and the
6
methods used.
Couches, work surfaces and floors in clinical rooms must be made of materials that
are impermeable to fluids, easy to clean and kept in good condition i.e. not torn or
split
Carpets are not supported for use in clinical areas or areas that are a
potential risk of being contaminated with body fluids. Where carpets are
provided there should be procedures (or contracts) in place for steam cleaning and
for dealing with spillages. (If it is a large spill that cannot be cleaned adequately
then consider the removal of the carpet).
Curtains (including disposable curtains) should be changed: when soiled
 after an outbreak or increased incident
 when a patient is discharged and has a known or suspected infection
 routinely every six months in clinical areas and yearly in non-clinical areas.
An adequate supply of curtains should be purchased to facilitate this and changes
following an outbreak of infection. Certain window dressings may not meet infection
prevention and control cleaning requirements, and advice must be sort when
replacing such items. Where blinds are already in place, then these must be part
of an identified cleaning schedule and should be on a rota (as per curtains).
5.2
Decontamination of Medical Devices
Decontamination must always be carried out in line with manufacturer’s instructions
and LPT’s Infection Prevention and Control Policy. Decontamination must be
appropriately documented for assurance purposes via an identified system.
The term medical device covers all products except medicines used in health care
for the diagnosis, prevention, monitoring or treatment of illness or disability. Further
information can be located within LPT’s Medical Devices Policy.
Three Types of Equipment
a. Single use only which means that the manufacturer intends the item to be used
once, then discarded. Re-use of single use devices can affect safety,
performance and effectiveness, exposing staff and patients to unnecessary
risks. Therefore the re-use of single use medical devices has legal, technical and
economic implications for the user and may render them liable to prosecution. If
in doubt, refer to the manufacturers recommendations.
Single use symbol:
7
b. Single patient use which means that the item can be reused if re-processed
using an appropriate method and is used on the same patient only (equipment
must be checked to ensure that it can be used as single patient use prior
to cleaning).
c. Re-usable equipment, which should be appropriately decontaminated between
patients.
5.3
Classification of Infection Risk Associated with the Decontamination
of Medical Devices
Patients can be protected against infection by ensuring that disease-producing
microbes are removed from potential sources of infection. This involves the
cleaning, disinfection and sterilisation of contaminated materials, equipment and
surfaces. The choice of method can be based on the infection risks to the
patient, which can be classified as high, intermediate and minimal risks (Ayliffe et al
2002).
Risk
Application of Term
High
Items in close contact with Non intact skin, Non
intact mucous membranes or entering a sterile
body cavity
Recommendation
Sterilisation
E.g. surgical instruments
Intermediate
Items in contact with intact mucous
membranes, body fluids, Virulent or readily
transmissible organisms or items used for
highly susceptible patients or sites
Cleaning followed
by Disinfection
e.g. respiratory equipment such as
laryngoscopes nasal specula, laryngeal mirrors
and other equipment such as vaginal specula
(for vaginal examination)
Minimal
(Low)
Items in contact with healthy skin, or not in
contact with the patient
Cleaning
e.g. tables, bedside tables, chairs
5.4
Methods of Decontamination
Cleaning is a process, which physically removes visible contamination but does
not destroy micro-organisms; is an essential pre-requisite to disinfection and
sterilisation.
Disinfection is a process that uses heat or chemical agents to reduce the number
of viable micro-organisms but does not necessarily inactivate viruses or bacterial
spores.
8
Sterilisation is a process used to render objects free from viable microorganisms, including spores and viruses but excluding prions.
NB: Manufacturers guidance for decontamination must be adhered to at all times.
Cleaning Methods
The recommended method of cleaning surgical instruments is by using an
automated system such as a washer-disinfector or ultrasonic cleaning bath.
Cleaning agents used for medical devices must be ‘CE’ marked, as they are
classified as an accessory to a medical device. ‘CE’ is an abbreviation of the
French phase ‘Conformite Europeene’, which literally means ‘European
Conformity’.
Dish washing detergents are designed for washing dishes and not surgical
instruments and may leave soil residues that cannot be seen by the naked
eye.
The cleaning agent also needs to be compatible with both the device and
reprocessing equipment. Damage to the medical device, their components or
reprocessing equipment may occur following contact with incompatible
decontamination agents. Manufacturers of reusable medical devices are required
to provide information on how to decontaminate their devices and these
instructions must be adhered to.
The preferred method of cleaning instruments is by using an automated system
such as a washer-disinfector or ultrasonic cleaning bath. Cleaning standards can
be more easily measured and controlled using automated methods. They also
have the advantage of reducing exposure of the user and environment to microorganisms and chemicals.
Disinfection Methods
Cleaning is an essential requirement prior to disinfection; disinfection should not
be used as a substitute for sterilisation.
Chemical Disinfection
a. Chemical disinfectants can be toxic, flammable, corrosive or have other
material incompatibilities, so their use should be avoided wherever
possible. Chemical disinfection is not as effective as disinfection by heat
and should never be used as a substitute for sterilisation or when
alternatives such as single use items are available
b. Chemical disinfectants may be ineffective if: used on items which have not been cleaned adequately
 not freshly made up
 made up to the wrong concentrations
 mixed with incompatible substances or materials
c. Chemical disinfectants must be stored, reconstituted and used in
accordance with the Control of Substances Hazardous to health (COSHH)
9
Regulations. A written task risk assessment must be made on each
chemical in use.
5.5
Selecting a Chemical disinfectant
Chlorine preparations
These contain Sodium hypochlorite and Sodium Dichloroisocyanurate (NaDCC),
which have good activity against viruses. They usually present in the form of
tablets, powders or granules, which can be reconstituted into the required
concentration. Solutions should be changed within 12 hours. In liquid form they
are less stable and have a shorter shelf life. NaDCC releases chlorine slowly and
has a more prolonged effect than Sodium hypochlorite. Chlorine preparations are
corrosive to metals and are inactivated by organic matter (NaDCC) to a lesser
extent). Large amounts of Chlorine solution products are not advised for direct use
on urine/vomit as they may release hazardous vapour, care must be taken when
using this product and safe systems of work must be put into place. (Appendix 2
and 4).
Alcohol preparations
Alcohol preparations are useful chemical disinfectants because they are ready
diluted and can be used immediately. They are effective against most bacteria
and viruses, but have poor penetration so should only be used on physically clean
surfaces. They are also flammable and must not be used near a naked flame.
Store in a cool dry place, most commonly used is 70% isopropyl alcohol.
Combined Detergent-Disinfectants (e.g. chlorclean, Actichlor plus)
Products are available that combine a detergent and a chlorine-based disinfectant
for use when cleaning the environment including sanitary equipment. This product
cleans and disinfects, negating the need to clean prior to disinfection.
5.6
Sterilisation Methods
Cleaning is an essential pre-requisite to effective sterilisation, as sterilisers
are not designed to wash or clean equipment. Dirty instruments placed in an
autoclave may not be sterilised as the contaminant may coagulate and form a
barrier through which the steam may not penetrate. Such instruments must be
regarded as non-sterile and they must not be used until they have been cleaned
thoroughly and re-sterilised.
The Medicines and Healthcare Regulatory Agency (MHRA) recommends the use
of a Sterile Services Department (SSD) or Hospital Sterilisation and Disinfection
Units (HSDU) wherever possible as they have the expertise, equipment and
economy of scale, they have also established methods of tracing instruments,
which is now a requirement in health care.
5.7
Benchtop Steam Sterilisers
Autoclaving (steam under pressure) is the most reliable way of sterilising
equipment i.e. instruments.
Use of bench top sterilisers applies to Podiatry services within Leicestershire
10
Partnership Trust, and dental services within the healthcare service provision
provided under contract with HMP Leicestershire. They must not be used by any
other services within LPT unless an agreed service delivery model has been
identified through the formal service development route.
5.8
Decontamination of Equipment Prior to Maintenance/ Service
Request/Decontamination Status Certificate
(including equipment moved between locations for any reason including
loan)
a. Infection can be transmitted from contaminated medical equipment and
devices that come into contact with patient or their blood/body fluids.
b. All equipment must be cleaned and properly decontaminated in
accordance with these procedures, prior to maintenance, repair, lending or
returning a loan or any other reason for movement.
c. The items must be accompanied by a Declaration of Contamination Status
Certificate to ensure that procedures have been followed to manage and
decontaminate the instruments/equipment ( Appendix 3)
5.9
Medical Equipment in patients own home
This refers to equipment the patient may use including clinical equipment i.e.
walking aids, moving and handling equipment, thermometers stethoscopes,
sphygmomanometer, blood glucose monitoring and INR monitoring etc.
If the equipment is owned by the patient and becomes contaminated the relatives
and carers should be advised to clean with detergent and water. If the equipment is
contaminated with blood it should be cleaned with detergent and water and
disinfected with non-diluted bleach providing the equipment can withstand bleach.
(As the equipment belongs to the patient they may choose to use an alternative
product). This does not refer to patients own furnishings.
Equipment provided by the Integrated Community Equipment Services (ICES)
contract currently with NRS will be cleaned and disinfected by the NRS in
accordance with this policy.
If LPT owned equipment is to be brought back to LPT premises and is contaminated
with blood or body fluids it should be cleaned in the patient’s own home with a chlor
clean wipe. the equipment cannot be used on another a patient until it has been
cleaned and disinfected appropriately. Clean and Dirty equipment must be
transferred or stored separately.
5.10 Toys
To reduce the risk of cross infection, all toys must be made of a material that where
possible allows for effective cleaning and decontamination.
All toys must be cleaned, on a weekly basis if not in use. For toys in use they
should be cleaned after each child has used it if visibly contaminated or has been
used by a child with a known or suspected infection. If not used by a child with a
known or suspected infection or visibly soiled they can cleaned after each session.
11
Toys used by staff away from their base should be transported in plastic lidded
containers, (‘dirty’ or used toys should never be placed in container with ‘clean’ toys).
After cleaning check all toys and equipment to ensure they remain fit for purpose!
Should any toy or pieces of equipment become contaminated with blood or body
fluids or used by a child with known infection these will require cleaning and
disinfecting with a chlor clean wipe.
All toys must be CE marked to ensure they are safe for use.
Staff employed by LPT are not expected to clean toys belonging to other
organisation’s, however it is the responsibility of the staff to ensure that they are
clean and fit for purpose prior to using them, however if toys become contaminated
during activities it is the responsibility of LPT employees to bring this to the attention
of that organisation to prompt decontamination, and should not be used further until
this process has taken place and assurance should be sought prior to using the toy.
Soft Toys
Soft toys must not be kept for general use in healthcare settings because they are
porous, support microbial growth and can be difficult to decontaminate.
There may be occasions when soft toys form an essential part of a therapy
session; where this is the case soft toys must be subject to machine washing
after each episode of care and thorough air/tumble drying (according to
manufacturer’s instructions). These toys should be single patient use and
laundered between patients. Any soft toys that are contaminated with blood or
body fluids must be disposed of. Repeated decontamination of soft toys can
compromise the integrity of the fabric and crate a choking hazard, therefore
ensure thorough checking takes place before and after use. Industrial washing
machines and industrial dryers must be used.
Hard Surface Toys
All toys must have a smooth, non-porous surface that is easy to clean. Toys with
moving parts or openings can harbour dirt and germs in the crevices; they must
be washed and scrubbed using detergent and warm water or a detergent wipe.
The utensil used to scrub/clean the toy with; must be single use and discarded
after use.
Mechanical/Electrical Toys
Mechanical/Electrical toys must have the surfaced wiped weekly using detergent
wipe. These must be PAT tested if they are able to be connected to the electrical
supply.
Note: Do not submerge electronic / battery operated toys / equipment in water.
Books
Books must be inspected weekly and the surfaces wiped using a disposable
detergent wipe. As they may have a potential of soaking up liquid, books with
12
signs of dampness or mildew must be discarded. They may require frequent
replacement.
Ball Pools
They should be inspected daily for cleanliness, debris and foreign items. Routine
cleaning for the balls and pool must be carried out on a monthly basis using warm
water and neutral detergent and then dried thoroughly.
Dressing up Clothing
Dressing up can form an important part of a child’s therapy or rehabilitation,
however, only use when necessary for therapy the following should be taken into
consideration
 All clothes must be washable and washed at a temperature of 60
degrees centigrade for 10 minutes. Clothes must be washed and
dried after use. Clothes should be inspected on a monthly basis and
laundered if required, the storage bins must also be washed at the
same time using a detergent wipe or detergent and warm water. An
industrial washing machine and industrial tumble dryer must be used.
Distraction boxes
These are the responsibility of all staff and should be checked and cleaned
following each individual use or on a weekly basis (if not in use). These should not
be stored with general toys.
Preparation Toys
These toys must be regularly inspected and cleaned using an appropriate cleaning
method as described above.
Second Hand Toys
Second hand toys must not be accepted by services within LPT
Individual Play Therapy
Prior to use; children’s or patients hands must be cleaned before and after use and
skin lesions must be covered.
Play Dough
This must be single patient use only and must not be shared with other children or
patients.
Play Sand
Sand pits are not to be used for general play purposes, however, for individual play
therapy; sand may be used for that child and discarded after use.
Staff undertaking home visits
Staff undertaking home visits or working in premises where cleaning of toys cannot
be carried out on premises should work in line with the follow guidance:
 On arrival of the visit, only remove those toys likely to be used for the
session. Where possible staff should use the toys that are available to
13
them in the family home. (these must be clean and free from blood
and body fluids)
 Any toy or piece of equipment contaminated with blood or body fluids
or used by a child/young person with a known infection must be
cleaned and/or decontaminated using chlor clean wipes before it is re
used with another child/ young person. If it is not possible to do this
immediately bag the toy and return to base for effective cleaning
before re use.
 Containers used for transportation must be cleaned on a weekly basis
or when the container becomes contaminated.
 Clean and dirty toys must be transported separately. The container
carrying the dirty toys must be cleaned and decontaminated at the
same time as the toys.
5.11
Procedure following a spillage of blood, other body fluids
or known contaminated material
In clinical areas it is the responsibility of the clinical staff to ensure that spillages of
blood, vomit, urine, faeces and other body fluids are cleaned up immediately and
effectively. It is vital that all staff take all reasonable precautions to protect
themselves and patients from transmission of infections.
Non-clinical areas – are the responsibility of domestics who have undergone an
appropriate level of training.
Disposable non-latex gloves and disposable plastic aprons must be worn for all
cleaning and decontamination procedures. Appropriate face protection must be worn
if there is a risk of splashing into the eyes or mouth. Where applicable the correct
colour coding of equipment should be adhered to in line with the NHS Cleaning
Manual and NPSA National Colour Coding Safer Practice (Appendix 3).
5.12
Management of Body Fluid Spillages
ALL spilled blood or body fluids should be regarded as potentially infectious, and
should be treated accordingly, for patients and staff. The Management of Body fluid
spillages poster should be followed (Appendix 4).
When treating a spillage, staff must wear disposable nitrile gloves and a disposable
plastic apron. Eye/face protection is required if there is a risk of splashing.
Always improve the ventilation in an area where you are clearing a body fluid
spillage (where possible).
Refer to COSHH note on the product label and check the expiry date.
14
Blood spillages of any size and all blood-stained body fluid spills (i.e. where
there is visible blood):
Step 1
 Following the manufacturer’s instructions, use a DRY Chlor-Clean Wipe to
absorb the spill
 If one wipe is not enough use more dry wipes to completely absorb the
spill: each wipe will absorb approximately 30ml of liquid
 Discard used wipes as clinical waste.
Step 2
 Moisten a NEW Chlor-Clean Wipe with cold tap water and gently squeeze
any excess water out over the sink
 Use the moistened wipe to clean and disinfect the area of the spillage
 Dispose into clinical waste
All body fluid spillages where there is no visible blood:
Warn any persons in the area that in the case of urine there will be an
unpleasant smell whilst the spill is treated; in the case of vomit there will be a
slightly stronger smell of chlorine.
Step 1
 Remove any solid matter using disposable paper towels. Absorb any
remaining liquid using either paper towels or a mop depending on the size
of the spill.
 Dispose of all waste in clinical waste bags and remove the washable mop
head for laundering. The mop head must be sent for laundering in the
appropriate colour coded bag.
Step 2
 Clean and disinfect the area using either a Chlor-clean solution and a
clean mop head or a moistened chlor-clean Wipe (as above)
 Dispose of any waste in a clinical waste bag and if a washable mop head
has been used, bag for laundering.
Blood Spillage on Absorbent Surfaces (Carpets/Soft Furnishings) owned by
LPT
Disposable nitrile gloves and a plastic apron must be worn. If blood is splashed or
spilled onto soft furnishings the item must be condemned after being disinfected with
Chlor-clean. Gloves, apron and all paper towels must be discarded into a clinical
waste bag for disposal.
If blood is spilled onto clothes, treat as infected linen.
15
Blood Spilled on Staff
Intact skin
The spilled blood should be washed off with copious warm running water and liquid
soap, paying particular attention to the fingernails. No further action is necessary.
Broken skin
The spilled blood should be washed off with copious warm running water and soap.
The incident must then be reported to the line manager and occupational health and
an incident form completed. The LPT Management of Sharps and Exposure to
Blood Borne Virus Policy must be followed.
Mucous membranes
Splashes of blood or body fluids entering the eye should be removed by immediate
irrigation. Ideally sterile saline "eye-wash" packs should be used if available, but if
not, running mains water (drinking water) can be used instead. Irrigation should be
continued until all traces of the contaminating material have been removed. The
incident must then be reported immediately to the line manager and Occupational
Health; an incident form must be completed. The LPT Management of Exposure to
Blood Borne Virus Policy must be followed.
5.13
Cleaning and disinfection methods
Clean
Use hot water and neutral detergent or detergent wipe
Rinse
Use clean water
Disinfect
Use Chlor-clean solution
NB: Chlor clean solution cleans and disinfects so
negates the need to clean prior to disinfection
Disinfect
(blood and body fluids
Chlor Clean wipes
(Appendix 4)
Dry
Use disposable paper towels
5.14
Cleaning and Disinfection procedures
This is not an exhaustive list; if the equipment is not listed here and you need
advice please contact the infection control team. All equipment must be cleaned
between each patient use. Please always refer to manufacturer’s instructions.
Cleaning for each piece of equipment is identified in the table below.
Unless otherwise stated:


16
If used with a patient with a known or suspected infection, clean and
decontaminate using chlor clean solution.
If visibly soiled with blood or body fluids clean and decontaminate
using chlor clean wipes

On discharge of the patient/terminal clean; clean and decontaminate
with chlor-clean solution
Manufacturer’s instructions should always be followed, if further advice is required
please contact the Infection prevention and control team.
Equipment
Recommended Action
AUROSCOPE
Clean external surface with detergent and
water or detergent wipes following use.
Ear pieces
BABY SCALES
Disposable single use, discard following use
Line the scales with disposable paper towel
before each use. After use discard paper
and clean with detergent wipe
Line the mat with disposable paper towel
before each use. After use discard paper
and clean with detergent wipe
Clean external surface with detergent and
water or detergent wipes following use.
BABY CHANGING MATS
Must be made of a material that is
wipeable and impervious to liquid
TRANSFER BOARD
BASIN – clinical hand wash
BEAN BAGS
Must be wipeable and impervious to
liquid
BED TABLES
If provided as single patient use to be
cleaned and decontaminated using chlor
clean solution on discharge or the patient or
when the patient no longer requires it.
Clean with hot water and neutral detergent,
rinse and dry.
Clean external surface with detergent and
water or detergent wipes following use.
Clean external surface with detergent and
water or detergent wipes following use.
Clean external surface with detergent wipes
following use.
Clean and decontaminate with chlor clean
solution.
BLOOD GLUCOSE MONITORING
EQUIPMENT
BUCKETS (Plastic – used for the
immersion of legs i.e. leg ulcer
treatment)
CHAIRS
Clean surface with detergent wipes
Wipeable and impervious to liquid following use.
Must be condemned and dispose of if
surface is not intact
CLIPPERS (Hair)
Clean external surface with detergent and
water or detergent wipes following use.
Head pieces
COMMODES
17
Disposable single use, discard following use
Clean and decontaminate with Chlor-clean
after every use, ensuring all surfaces
including the frame are cleaned. This
involves removing the seat from the frame
to enable access to all areas of the
commode.
If a commode is used at the bed side and
allocated to a specific patient whilst they are
receiving source isolation precautions, then
the commode must have a full clean after
each use. Once source isolation
precautions have been discontinued the
commode must be completely dismantled
and cleaned and decontaminated before
going back into general circulation.
DRESSING TROLLEY
DRUG FRIDGE
Outside (weekly)
Inside (weekly)
DYNAMAP
ECG LEADS AND MACHINE
ECG Electrodes
ENTERAL FEEDING PUMP
Check manufacturer’s instructions
EQUIPMENT (moving and
handling)
Including but not limited to:
Chair/Scales
Pat Slide
Rotunder
Standing Aids
Walking stick
Wheelchair
Zimmer Frame
EXAMINATION COUCHES
Material must be wipeable and
impervious to liquid
Must be condemned and dispose of if
18
If a commode is used at the bed side, but
not allocated to a specific patient whilst they
are receiving source isolation precautions,
then the commode needs to be completely
dismantled and cleaned and
decontaminated between each use.
Clean with hot water and detergent, rinse
and dry. Clean and disinfect with chlorclean
solution and place single use paper towel
across the flat surfaces during storage.
Clean with detergent wipes
After emptying clean using chlor-clean
Clean surface with detergent wipes
following use.
Clean surface with detergent wipes
following use.
Disposable single use, discard following use
Clean surface with detergent wipes
following use.
Clean surface with detergent wipes
following use.
Cover couch with single use paper towel
role, and change between each patient.
Clean after each session with a detergent
wipe.
surface is not intact
FANS
OUTER CASING
FINS
Couch covers must be replaced if not-intact.
If unable to replace the item must be
condemned and alternative couches must
be used.
Avoid blankets/linen unless these can be
changed between patients
Damp dust daily with detergent and hot
water or detergent wipes to remove dust,
dirt, debris and moisture.
Must be part of the cleaning schedule
(staff must not dismantle the fan)
Clean surface with detergent wipes
following use.
FOAM WEDGES
Must be heat sealed and
impervious to liquid
Must be condemned and dispose of if
surface is not intact
FOOT STOOLS
Clean surface with detergent wipes
following use.
Must be heat sealed and
impervious to liquid
Must be condemned and dispose of if
surface is not intact
GLUCOMETERS
Clean surface with detergent wipes
following use.
HAIR BRUSHES/COMBS
Single patient use only
HOIST
Clean surface with detergent wipes
following use.
Frame
Sling
Allocate to individual patient or use a On patients discharge send reusable
equipment to the laundry using the return to
disposable sling.
sender service
Disposable slings to stay with the
If contaminated with body fluids send to the
patient for the duration of the care
laundry in a red soluble bag and the blue
episode
outer bag using the return to sender service.
Note slings must not be tumble dried
as this can interfere with the integrity Single patient disposable slings must not
of the material and make it unsuitable be machine washed. The sling can be
spot cleaned with water and detergent for
to use
small stains, but must be disposed of if
there is significant blood or bodily fluid
contamination.
INR MONITORING EQUIPMENT
Clean surface with detergent wipes
following use.
INTRAVENOUS INFUSION PUMPS Clean surface with detergent wipes
following use.
INTRAVENOUS INFUSION STANDS Clean surface with detergent wipes
19
KEYBOARDS
LAMINATED PATIENT LEAFLETS
LARYNGOSCOPE
Hand piece
Blade
LIGHT CORD PULL
Must be covered with plastic outer
covering
LOCKERS
MATTRESSES AND BEDFRAMES
Mattress (Air) Owned by LPT
Mattress (Air) Rented
Mattress (Non-Air)
Bedframes (Rented or Owned)
following use.
Clean surface with detergent wipes
following use.
Clean surface with detergent wipes
following use.
Clean and disinfect with chlor clean
between uses.
Must be single patient use, dispose after
use.
Clean daily with detergent wipe
Clean daily with detergent wipe
If an air mattress is used for a patient who is
receiving source isolation precautions the
mattress will required sending for steam
cleaning and decontamination once the
precautions have been lifted.
For non-air mattresses used for a patient
who is receiving source isolation chlor clean
must be used to clean and decontaminate
the mattress once the precautions have
been lifted.
For mattresses where cleaning with chlor
clean is contra-indicated then an alternative
disinfectant must be used. For advice
contact the manufacturers or the infection
prevention and control team.
MEDICINE POTS
Single use recommended
Re-usable medicine pots
MOBILATOR
NAIL BRUSHES
Single use only
NEBULISER MASKS
Single patient use
NOTE HOLDERS
NURSING BAGS
Must be wipeable and impervious to
20
Dispose after use
Must be washed in a dishwasher between
uses. (ensure appropriate racks are used to
prevent obstructing the machine)
Clean after each use with detergent wipe
Dispose after use
Clean after each use and then dispose once
the patient has been discharged
Clean with detergent wipe
Clean daily with detergent wipe
liquid
OXYGEN CONDENSER
HUMIDIFIER
(concentrator) bottles
Oxygen sponge filter (at the back of
the machine) used with a humidifier.
Must be cleaned between patients
PEAK FLOW METRES
Digital or Manual machine
Single patient use (Salter E7600)
Wash with detergent and water and leave to
air dry.
Clean after each use with detergent wipe
Mouthpiece
PERCHING STOOL
PILLOWS
Must be wipeable and impervious to
liquid with heat sealed seams
PRESSURE RELIEVING CUSHION
Must be wipeable and impervious to
liquid with heat sealed seams
PULSE OXIMETERS
Single use, dispose after use
Clean after each use with detergent wipe
RAISED TOILET SEATS
SLIDING SHEETS
Allocate to individual patient
SYPHYGMAMOMANOTER
Clean and disinfect after each use with
Chlor clean solution
Must be stored on a rack or hook
On patient discharge send to the laundry
service, using the return to sender service.
Clean after each use with detergent wipe
STETHOSCOPE
Clean after each use with detergent wipe
Clean after each use with detergent wipe
Clean after each use with detergent wipe
Clean after each use with detergent wipe
In the event of soiling or used by a
patient with a known infection: clean with
chlor-clean solution
On discharge of the patient/terminal
clean: clean with chlor-clean solution
SUCTION EQUIPMENT
Suction equipment – outer
casing/machine
Tubing and suction catheters
SYRINGE DRIVER
Do not soak or immerse any part of
the equipment in water or any other
solution
21
Clean after each use with detergent wipe
single use only
Clean the unit in-between patients using a
lint free cloth lightly dampened with warm
water and mild detergent. Disinfect using
chlor clean solution. Turn off pump and
remove battery before cleaning. Once per
month (or as required) clean the lead screw
thread beneath the accuvator and guiding
rods with a small dry brush to remove
debris.
TELEPHONE
Staff
Clean daily with detergent wipe
Patient
THERMOMETERS (Digital)
Ear piece
Clean daily with detergent wipe
Hand Piece
TOILETS
Communal patients
Clean after use with a detergent wipe
URINALS/URINE JUGS
VAGINAL SPECULA
6.0
Single use only – dispose after use
Sanitise daily according to domestic
schedule
Single use only, dispose after use
Single use only, dispose after use
Training
There is a need for training identified within this policy. In accordance with the
classification of training outlined in the Trust Human Resources & Organisational
Development Strategy this training has been identified as mandatory and role
development training.
The course directory e source link below will identify: who the training applies to,
delivery method, the update frequency, learning outcomes and a list of available
dates to access the
raining.http://www.leicspart.nhs.uk/Library/AcademyCourseDirectory.pdf
A record of the event will be recorded on Ulearn as appropriate. The governance
group responsible for monitoring the training is the Infection Prevention and Control
Committee and Quality Assurance Committee.
7.0
References and Associated documents
LPT Documents
LPT Infection Prevention and Control Policies available via the intranet
References
BHTA British Healthcare Trades Association (2012) Protect, Rinse and Dry –
BHTA guidance on the care, cleaning and inspection of healthcare mattresses
BSI, PAS 5748(2014) Specification for the planning, application, measurement
and review of cleanliness services in hospitals.
DH (1993) HSG (93) 26 Decontamination of equipment prior to inspection, service
or repair.
DH (2010) The Health and Social Care Act 2008: Code of practice for health and
adult social care on the prevention and control of infections and related guidance.
22
DH (2006) Essential Steps to Safe, Clean Care: Reducing Healthcare Associated
Infections:
Great Britain (1974) the Health & Safety at Work Act 1974.
Great Britain (1999) The Control of Substances Hazardous to Health Regulations
1999.
HSC 1999/179 Controls Assurance in Infection Control: Decontamination of
Medical Devices Department of Health 1999
MDA DB 9501 The Reuse of Medical Devices Supplied for Single Use only
Medical Devices Agency. 1995
Merrimean E, Corwin P & Ikram R, (2002) Toys are a potential source of cross
infections in general practitioner’s waiting rooms. British Journal of General
Practice 52; 138 - 140
MDA SN 9619 (1996) Compatibility of medical devices and their accessories and
reprocessing units with cleaning, disinfecting and sterilising agents. Medical
Devices Agency Adverse Incident Centre.
Microbiology Advisory Committee to the Department of Health (1997)
Sterilisation, Disinfection and Cleaning of Medical Equipment: Guidance on
Decontamination Medical Devices Agency.
NHS National Patient Safety Agency, The NHS Cleaning Manual. 2009
Dept. of Health, Health Protection Agency. ‘Prevention of infection and
communicable disease control in prisons and places of detention – A manual for
healthcare workers and other staff’ July 2011. Gateway reference HPA 11-02,
DH16314
23
Appendix 1
24
Appendix 2
SAFE SYSTEM OF WORK
Substance: Chlor – clean tablets & water for dilution
Use: used for cleaning/disinfection of work surfaces, floors, equipment, walls and contact
areas e.g. door handles
Procedure to be followed: Making up the solution:
1. Put the minimum correct amount of cold water (from the cold tap) into designated
carrying/mixing receptacle depending on usage required either
1 litre or 2 litre quantity.
2. When adding the Chlor- clean tablet to the water ensure that any window and doors are
left open – DO NOT MIX SOLUTION IN AN UNVENTILATED AREA.
3. Put on gloves, apron and goggles prior to removing the Chlor- clean tablets from
tub, carefully remove lid and remove the required amount of tablets either 1 for 1litre of
water or 2 for 2 litre of water.
4. Carefully place the tablet into the water in the carrying/mixing receptacle.
The lid on the receptacle shouldn’t be fully closed until the tablets have finished
dissolving.
5. Replace lid securely on the Chlor-clean tablets and stow away in a locked, dry area.
6. The solution should not be used until the tablets have been completely dissolved into the
water.
Decanting of made up solution from mixing receptacle
1. Whilst still wearing your correct personal protective equipment (PPE), gloves apron
and goggles, carefully decant the solution into the cleaning bucket/bowl that you will be
using.
Usage of mixed solution
1. When using the solution you must ensure that you continue to wear the appropriate
PPE.
2. Depending on the surface cleaned, use a paper towel to rinse off and dry residual
solution e.g. table, chair
Disposal of mixed solution after use.
Discard solution into sluice or toilet and flush after disposal has taken place – you must
ensure that you are wearing your correct PPE when this task is undertaken.
25
Appendix 3
DECLARATION OF CONTAMINATION STATUS HSG (93) 26ANNEX
Prior to inspection, Repair or Return of Medical and Laboratory Equipment
To:
Make and Description of Equipment
Model/Serial Batch No:
Authority’s Ref or Order No:
Recipient Service or Terms Authorisation
Reference or Contact Name:
Tick box A if applicable. Otherwise complete all parts of B, providing further
Information as requested or appropriate.
A
B
This equipment/item 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
Has this equipment been exposed internally or
externally to hazardous materials as indicated below
Blood, body fluids, respired gases, pathological samples
Other biohazards
Chemicals or substances hazardous to health
Other hazards
Has this equipment/Item been cleaned and
decontaminated?
Indicate the methods and materials used:
YES
NO
YES
NO
If the equipment /item could not be decontaminated 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.
YES
NO
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
26
Authorised signature:
Unit:
Name (printed):
Position:
Dept.
Tel no:
Appendix 4
27