DISINFECTION AND DECONTAMINATION POLICY
(PATIENT CARE EQUIPMENT)
December 2015
1
Title:
Disinfection and Decontamination Policy (Patient Care Equipment)
Author(s):
Karen Martin, Infection Prevention and Control Nurse
Ownership:
Fiona Hughes, Head of Infection Prevention and Control
Approval By:
Chief Executive HCAI
Accountability Forum
Original
Operational
Date:
February 2011
Revised Date:
Approval
Date:
04 November 2015
December 2015
Next
Review:
December 2019
Version No.:
1.0
Disinfection and Decontamination
Policy (Patient Care Equipment and
Immediate Patient Environment)
(June 2013)
Reference
Number:
Med11/001
Links to other
policies,
Procedures,
Guidelines or
Protocols
 Policy for the Management of Decontamination
 Policy for Decontamination of Reusable Invasive Medical Devices
 Policy for the Management of Medical Devices available at
www.mhra.gov.uk.
 Regional Infection Prevention & Control Guidelines, including
those for MRSA and Cleaning and Disinfection
www.infectioncontrolmanual.co.ni
 Support Services Infection Prevention Cleaning Procedures
 Laundry Handling Guidelines
 Waste Manual
 Guidelines for Use and Decontamination of Infant Feeding
Equipment in Hospital
Supersedes:
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 2 of 36
CONTENTS
Section
1.0 Introduction
1.1 Background
1.2 Purpose
Page
5
5
5
2.0 Scope of the Policy
5
3.0 Roles and Responsibilities
3.1 Trust Board and Chief Executive
3.2 Seniors Managers/ Ward Managers
3.3 All Healthcare Employees within the WHSCT
5
5
6
6
4.0 Key Principles
6
5.0 Patient Care Equipment/ Medical Devices
5.1 Single Use and Single Patient Use
5.2 Classification of Risk
5.3 Medical Devices
5.4 Personal Protective Equipment
7
7
7
8
8
6.0 Methods Of Decontamination
6.1 Cleaning and Drying
6.2 Disinfection
6.3 Antiseptic
6.4 Sterilisation
6.5 Choosing a Method
6.6 When Should Reusable Medical Equipment be Cleaned
6.7 Cleaning Schedules
8
8
8
9
9
9
9
9
7.0 Chemical Disinfectants and Their Uses
7.1 Chlorine-Based Disinfectants/ Non-Chlorine Based Disinfectants
7.2 Alcohol
7.3 Chlorhexidine
7.4 0.2% Chlorhexidine Gluconate & 70% Isopropyl Alcohol
7.5 Iodine and Iodophors
9
9
10
10
11
11
8.0 Treatment of Infectious/ Potentially Infectious Spillages
11
9.0 Cleaning of an Isolation Room
12
10.0 Equipment Sent for Service or Repair, Including Use of Decontamination
Certificate
12
11.0 Cleaning of Vehicles
13
12.0 Implementation
12.1 Dissemination
12.2 Exceptions
13
13
13
13.0 Monitoring
13
14.0 References
14
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 3 of 36
15.0 Consultation Process
14
16.0 Equality Statement
14
17.0 Appendices
14
18.0 Signatories
15
Appendix 1 Disinfection Procedures for Individual Items and Equipment
16
Appendix 2 Cleaning and Disinfection of Beds Poster
32
Appendix 3 Recommendations with Regard to Ultrasound Probes
33
Appendix 4 Actichlor Plus Poster
34
Appendix 5 Difficil-S Poster
35
Appendix 6 Bedpan Washer-Disinfectors
36
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 4 of 36
1.0
INTRODUCTION
1.1
Background
Patient equipment may serve as a reservoir for the transmission of
infectious agents to susceptible hosts. In order to ensure safe systems of
work and to prevent transmission of infectious agents, it is essential that
the decontamination of reusable patient equipment is carried out.
Decontamination is a combination of processes used to make a reusable
item safe for further use on patients and handling by staff. It is achieved
at three levels:



Cleaning
Disinfection
Sterilisation
This policy contains information for staff involved in decontaminating
equipment, instruments and surfaces at ward or department level.
1.2
Purpose
The purpose of this policy is to ensure a system is in place for effective
decontamination of all equipment used before and between each patient
and that risks associated with decontamination facilities and processes
are properly managed across the Trust
2. 0
SCOPE OF THE POLICY



That the Trust will continually review and develop practices in order
to comply with all present and future medical device legislation within
resources available.
That equipment will be adequately cleaned, disinfected or sterilised
according to its function so as to protect as far as reasonably
practical the health, safety and welfare of staff, patients and those
who are involved in inspection, service, repair or transportation of
medical devices or equipment.
That the Trust will ensure adequate provision of disinfectants,
cleaning agents and the equipment necessary to achieve the
required standard of decontamination.
3.0
ROLES AND RESPONSIBILITIES
3.1
Trust Board and Chief Executive
Have an overall governance role in Infection Prevention and Control in
relation to staff, patients and visitors.
Disinfection and Decontamination Policy (Patient Care Equipment)
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3.2
3.3
4.0
Senior Managers/ Ward Managers
 When purchasing new equipment, a pre-approval questionnaire must
be completed and accompany the requisition to the Procurement
Sub-Group for Medical Devices & Decontamination. The WHSCT
Non-stock Requisition Pre-approval Questionnaire is available on the
Trust intranet, located under P in the Useful Documents section.

Each head of department should ensure that new items of
equipment have a written decontamination protocol, which complies
both with the manufacturer's recommendations for decontamination
and Infection Prevention and Control guidance.

Department managers are responsible for all aspects of
environmental cleanliness within their clinical area, including the
cleanliness of reusable medical equipment.

Equipment used for sterilisation or disinfection must be
commissioned on installation, regularly serviced, maintained and
tested in accordance with the manufacturer's instructions and current
advice from the DHSSPNI.

All reusable surgical instruments and devices MUST BE SENT TO
HSDU for processing. These instruments MUST NOT BE WASHED
AT WARD OR DEPARTMENT LEVEL.

Equipment should be disposed of when effective cleaning can no
longer be achieved.
All Healthcare Employees within the WHSCT
 Staff involved in decontaminating medical equipment must ensure
they are appropriately trained in the use and decontamination of
patient equipment.

Educate families and their carers in relation to decontamination of
equipment within the home.

Encourage colleagues, patients/ client and visitors to comply with
IPC precautions within this guideline.

Cleaning products should be used in accordance with Control of
Substances Hazardous to Health (COSHH) Regulations and
manufacturers’ instructions.
KEY PRINCIPLES
The overarching principle/ statement for this policy is to ensure that staff
are informed and instructed in the management of disinfection and
decontamination of patient equipment and patients’ environment, thus
reducing the risk of transmission.
Disinfection and Decontamination Policy (Patient Care Equipment)
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5.0
PATIENT CARE EQUIPMENT/ MEDICAL DEVICES
5.1
Single Use and Single Patient Use
Patient care equipment is classified as:
All single use items carry the single use logo.
Single use medical devices must only be
used once.
Single Use
DO NOT REMOVE STERILISED ITEMS FROM
PACKAGEING UNTIL IMMEDIATELY BEFORE USE.
Single Patient Use
5.2
Single patient use means equipment may be
used more than once on one patient only.
The device will require cleaning/
decontamination between each use following
the manufacturer’s instructions.
Classification of Risk
Equipment can also be categorised according to the infection risk (Low,
Medium or High).
The following table classifies the risk of infection associated with
equipment.
Risk
Application
Recommendation
High
Items in close contact with a break
in the skin or mucous membrane or
introduced into a sterile body area/
invasive procedure.
Disinfection and sterilisation
processing within HSDU.
Intermediate
Items in contact with intact skin,
mucous membranes or body fluids,
particularly after use on infected
patients or prior to use on immunocompromised patients.
Sterilisation or disinfection required
using appropriate disinfectant.
Cleaning may be acceptable in
some agreed situations.
Low
Items in contact with healthy skin or
mucous membranes or not in
contact with patients.
Cleaning.
Disinfection and Decontamination Policy (Patient Care Equipment)
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5.3
Medical Devices
A medical device may be defined as any instrument, apparatus,
appliance, software, material or other article, whether used alone or in
combination, including the software intended by its manufacturer to be
used specifically for diagnostic and/ or therapeutic purposes and
necessary for its proper application, intended by the manufacturer to be
used on human beings for the purpose of:




Diagnosis, prevention, monitoring, treatment or alleviation of disease
Diagnosis, monitoring, treatment alleviation or compensation for an
injury or handicap
investigation, replacement or modification of the anatomy or
physiological process
control of conception
The Medicines and Healthcare products Regulatory Agency (MHRA)
regulates medical devices in the UK under European legislation. Medical
devices must not be mistaken for medicinal products.
5.4
Personal Protective Equipment
Personal protective equipment (PPE) should be worn when carrying out
cleaning, e.g. apron or gown and gloves and eye/ face protection if
splashing is likely to occur, and this should be disposed of into the
orange clinical waste bin.
6.0
METHODS OF DECONTAMINATION
6.1
Cleaning and Drying
Thorough cleaning with detergent and hot water is adequate for most
surfaces in the healthcare environment. Cleaning is essential before
disinfection or sterilisation of any equipment or instrument can take
place. Cleaning is a process which removes soil, e.g. dust, dirt and
organic matter, along with a large proportion of micro-organisms. A
further reduction will occur on drying as many micro-organisms cannot
multiply on a clean dry surface.
6.2
Disinfection
Disinfection by either heat or chemicals will destroy micro-organisms, but
not bacterial spores. Chemical disinfection does not necessarily kill all
micro-organisms present, but reduces them to a level not harmful to
health. Heat treatment should always be chosen in preference to
chemical disinfection if the equipment can withstand it. Some
disinfectants, if used under strictly controlled conditions, may be
considered sterilants, although this process may be more accurately
described as high level disinfection.
Disinfection and Decontamination Policy (Patient Care Equipment)
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6.3
Antiseptic
Antiseptic is the term usually employed to indicate that a particular nontoxic disinfectant may be used on skin or living tissues. An antiseptic
solution should not be used to disinfect instruments or the environment.
6.4
Sterilisation
Sterilisation is a process which achieves the complete destruction or
removal of all micro-organisms, including bacterial spores, but with the
exception of prion proteins. Equipment and materials used in procedures
involving a break in the skin or mucous membranes should be sterilised,
e.g. surgical instruments.
6.5
Choosing a Method
The choice of method of disinfection or sterilisation depends on a
number of factors, which include:






6.6
risk to patients and healthcare workers from equipment
micro-organisms involved
type of material to be disinfected
level of decontamination required for the procedure
facilities for decontamination
manufacturers recommendation
When Should Reusable Medical Equipment Be Cleaned?
Cleaning should take place:






between each patient use
at regular predefined intervals as part of an equipment cleaning
schedule
immediately after contamination with blood or body fluids
before disinfection or sterilisation
before inspection, servicing or repair
prior to disposal.
6.7
Cleaning Schedules
Local schedules should be established to indicate the frequency of
regular cleaning. Cleaning should be documented by the person who
cleaned the equipment and cleaning schedules should be audited. Clean
indicator tape should be applied, signed and dated.
7.0
CHEMICAL DISINFECTANTS AND THEIR USES
7.1
Chlorine-Based Disinfectants/ Non-Chlorine Based Disinfectant
Chlorine-based disinfectants are available from pharmacy in tablet form
for dilution at Ward/ Department level.


They act rapidly by the release of available chlorine.
Diluted solutions are unstable and should be freshly prepared.
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 9 of 36

Chlorine-based disinfectants discolour fabrics, carpets or soft
furnishings and are corrosive against metals.
Uses
 Dealing with viruses/ bacteria.
 All environmental decontamination, including blood spillages.
Precautions
 Refer to manufacturers’/ COSHH instructions/ assessments and
Health and Safety Manual when handling disinfectants.
 Disposable nitrile gloves must be worn when handling disinfectants.
7.2
Alcohol
Do not penetrate well into organic matter, especially protein-based and
should, therefore, be used only on physically clean surfaces.
Uses
 Alcohol impregnated swabs are used for disinfection of skin prior to
venepuncture.
 Can be used as a base for other bactericides, such as chlorhexidine
and iodine for pre-operative skin disinfecting, e.g. 70% alcohol with
2% chlorhexidine.
 Alcohol may be used for disinfecting physically clean equipment or
hard surfaces as specified in these guidelines or following
consultation with the Infection Prevention & Control Nurse and
according to manufacturer’s recommendations.
 Hand decontamination – for further information see appropriate
section in the Northern Ireland Regional Infection Prevention and
Control Manual, available either via the WHSCT Intranet or
www.infectioncontrolmanual.co.uk.
Precautions
 Refer to manufacturers’/ COSHH instructions/ assessments and
Health and Safety Manual when dealing with disinfectants.
7.3
Chlorhexidine
Inactivated by soap, organic matter and by some emollients. Only
emollients supplied by Pharmacy should be used.
Uses
 To be used exclusively as an antiseptic for decontamination of skin
and mucous membranes.
 Chlorhexidine solutions combined with detergent are used for hand
disinfection.
 Combined with alcohol for rapid disinfection of physically clean
hands.
 Combined with alcohol for skin disinfection.
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 10 of 36
Precautions
 Refer to manufacturers’/ COSHH assessments and Health and
Safety Manual when dealing with disinfectants/ antiseptics.
 DO NOT USE FOR CLEANING ANY TYPE OF INSTRUMENTS OR
EQUIPMENT.
7.4
2% Chlorhexidine Gluconate & 70% Isopropyl Alcohol
Formulated to work against skin microbes.



Broad spectrum – Gram positive micro-organisms, Gram negative
micro-organisms as well as most viruses and fungi.
Rapid – Good reduction in level of organisms within 30 seconds.
Has residual effect for 48 hours.
Uses
 Decontaminate the skin site prior to the insertion of venous access
devices or prior to surgical procedures
 Should be used to clean venous access device insertion site during
dressing changes and allowed to air dry. An aqueous solution of
chlorhexidine gluconate should be used if the manufacturer’s
recommendations prohibit the use of alcohol with their products.
Precautions
 Refer to manufacturers’/ COSHH instructions/ assessments and
Health and Safety Manual when dealing with antiseptics.
 Not licensed for paediatric use.
7.5
Iodine and Iodophors
 Inactivated by organic matter.
 May corrode metals.
Uses
 Alcoholic preparations containing iodine and iodophors can be used
for pre-operative skin preparation.
 Povidone iodine detergent preparations are suitable for surgical
hand-disinfection
8.0
TREATMENT OF INFECTIOUS/ POTENTIALLY INFECTIOUS
SPILLAGES




All blood and body fluid spillages should be treated as potentially
infectious regardless of their source
Wear disposable gloves and apron. If there is a risk of splashing
wear eye protection.
Remove gross contamination with paper towel before washing with
neutral detergent solution diluted with water.
Decontaminate with an Actichlor Plus/ Difficil-S solution. Allow to air
dry for at least 5 minutes before rinsing the area with fresh water.
Disinfection and Decontamination Policy (Patient Care Equipment)
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



9.0
Refer to Appendix 2 and 3 for correct dilution and precautions when
using Actichlor Plus/ Difficil-S.
If using chlorine granules leave for 3 minutes.
Place all disposable equipment, including protective equipment in an
orange clinical waste bag.
Tightly seal and tag the bag and leave in designated area for
collection.
CLEANING OF AN ISOLATION ROOM
Instructions for Night Staff:

For additional information refer to the:
Support Services Infection Prevention Cleaning Procedures, which
can be accessed via the Trust Intranet, in the Infection Prevention &
Control Guidelines section.

A room that is vacated after 8pm and is not required until the
morning should be left closed. The Support Services supervisor
should be informed at 8am the following day.

If the room is required before 8am a Nursing Assistant/ Auxiliary
should carry out terminal cleaning.

The nurse in charge of the ward should instruct the Nursing
Assistant/ Auxiliary regarding correct procedures.

The nurse in charge should inspect the room and sign the terminal
clean audit sheet. The room should be allowed to air dry before use.

Isolation cleaning equipment should be stored dry until the following
morning when Support Services should be informed.
10.0 EQUIPMENT SENT FOR SERVICE OR REPAIR, INCLUDING USE OF
DECONTAMINATION CERTIFICATE
A wide range of equipment is in use within the Trust. It is essential to
keep equipment clean, disinfected or sterilised (depending on the type of
equipment) before patient use. This is also necessary when equipment
requires repair.
It is the Head of Department's ultimate responsibility to ensure that
Technicians/ Engineers who are asked to service, inspect or repair
equipment are not put at risk by doing so. There is a legal requirement to
carry out decontamination prior to inspection/ service or repair (Health
and Safety at Work Act 1974).
A Decontamination Certificate MUST be filled in and attached to
EVERY piece of equipment which is sent for inspection, service or
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 12 of 36
repair, before returning equipment to an equipment library or if
equipment is loaned to another ward/ department. A
Decontamination Certificate must be completed before the loaned
equipment is returned to its original ward.
11.0
CLEANING OF VEHICLES
Used for the:




Transportation of dirty laundry
Transportation of hospital waste
Delivery/ pick up of surgical instruments
Transportation of equipment to Central Equipment Stores
The above mentioned transport vehicles should be cleaned as per
Transport Policy Guidelines which may be obtained by contacting the
Transport Department, Altnagelvin Hospital, Tel: 028 71345171 ext.
214609.
12.0
IMPLEMENTATION
12.1
Dissemination
This policy is relevant to all healthcare staff employed by the WHSCT
and those employed by external agencies providing healthcare for
patients/ clients on behalf of the Trust.
The policy will be posted on the Trust Intranet under the Infection
Prevention and Control Guidelines section.
A Trust Communication will be issued to highlight that the policy has
been updated.
12.2
Exceptions
There are no exceptions.
13.0
MONITORING
Compliance with this policy shall be monitored by individual managers
and overall responsibility will lie with the director of their service.
Multi-disciplinary teams monitor clinical areas on a regular basis as part
of the environmental cleanliness strategy.
Disinfection and Decontamination Policy (Patient Care Equipment)
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14.0
REFERENCES
Infection Control Team. (2012). Standard Infection Control Precautions,
Literature Review: Management of patient care equipment in the hospital
setting. Health Protection Scotland [Online] Available at:
http://www.documents.hps.scot.nhs.uk/hai/infection-control/icmanual/sicp-lr-equipment-v1.0.pdf [Accessed: January 2014].
NHS Estates (1997). Washer-Disinfectors, Validation and Verification,
Health Technical Memorandum 2030. London: The Stationery Office
[Online] Available at:
http://www.publications.spaceforhealth.nhs.uk/stream.php?id=04s9Zn92
oGq344R1qpn1nos5npq5pn8482pp [Accessed: January 2014]
Pratt, R.J., Pellowe, C. M., Wilson, J.A., Loveday, H.P., Harper, P.J.,
Jones, S.R.L.J., McDougall, C., & Willcox, M.H. (2007). epic2: National
evidence based guidelines for preventing healthcare-associated
infections in NHS hospitals in England. Journal of Hospital Infection,
65(S), pp.S1-64.
15.0 CONSULTATION PROCESS
Infection Prevention and Control Team
Consultant Microbiologists
Support Services
Members of IP&C Policies & Guidelines Working Group
Members of Chief Executive HCAI Accountability Forum
16.0 EQUALITY STATEMENT
In line with duties under the equality legislation (Section 75 of the
Northern Ireland Act 1998), Targeting Social Need Initiative, Disability
discrimination and the Human Rights Act 1998, an initial screening
exercise to ascertain if this policy should be subject to a full impact
assessment has been carried out. The outcome of the equality
screening for this policy is: PENDING
Major impact
Minor impact
No impact
17.0
APPENDICES
Appendices to this policy are as follows:
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 14 of 36






18.0
Appendix 1 – Disinfection Procedures for Individual Items and
Equipment
Appendix 2 – Cleaning and Disinfection of Beds Poster
Appendix 3 – Recommendations with Regard to Ultrasound Probes
Appendix 4 – Actichlor Plus Poster
Appendix 5 – Difficil-S Poster
Appendix 6 – Bedpan Washer-Disinfectors
SIGNATORIES
Signed for and on behalf of the Western Health & Social Care Trust:
Karen Martin
Infection Prevention & Control Nurse
Date
Fiona Hughes
Head of Infection Prevention & Control
Date
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 15 of 36
Appendix 1
DISINFECTION PROCEDURES FOR INDIVIDUAL ITEMS AND EQUIPMENT
Below is a list of equipment in alphabetical order. This list is not exhaustive. If
the information you require is not included, use the procedure for a similar item.
Alternatively, refer to the manufacturer’s recommendations, particularly for
complicated and unusual pieces of equipment.
Equipment or Site
Routine or Preferred Method
Airways and
Endotracheal tubes
Single-use/ disposable only.
Alcohol Gel/ Hand
Rub Wall Dispensers
Nursing assistants/ auxiliaries daily
clean outside of dispensers with
warm water and neutral detergent
and dry with a paper towel.
Acceptable Alternative or
Additional
Recommendations
N/A
Weekly clean inside.
Ampoules
Wipe neck with a 70% isopropyl
alcohol impregnated swab and
allow drying before opening or
piercing (if ampoule has a rubber
bung scrub for 30 seconds and
allow 30 seconds to dry).
N/A
Anaesthetic
Equipment
Tubing should be single use /
disposable
N/A
Auroscopes
Wipe over handle with 70%
isopropyl alcohol wipe after each
use.
N/A
Disposable auroscope speculae to
be used.
Baby Changing Mats
Cover with a disposable paper
towel roll and discard towel roll
afterwards.
Then wash with warm water and
neutral detergent. Dry thoroughly
with a paper towel.
N/A
Discard mat if cracked or torn.
Babies Feeding
Refer to the Guidelines for Use and
Decontamination of Infant Feeding
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 16 of 36
Equipment or Site
Routine or Preferred Method
Acceptable Alternative or
Additional
Recommendations
Bottles, Teats and
Dummies
Equipment in Hospital, which may
be accessed via the WHSCT
intranet, Infection Prevention and
Control Guidelines section.
Baby Weighing
Scales
Clean with warm water, neutral
detergent or a neutral detergent
impregnated wipe after every use
then dry.
Infected patients following
clean with neutral detergent.
Decontaminate with a 70%
isopropyl alcohol wipe
Baths
Non-infected patients:
Clean with neutral detergent /
cream cleanser and warm water
then rinse after use by each
patient.
Infected patients and for
patients with unhealed wounds
and those who are
immunocompromised, disinfect
the bath before and after use
as outlined in Actichlor Plus
Dilution Chart (Appendix 4) or
Difficil-S (Appendix 5).
Bath Hoists
Non-infected patients:
Clean after each patient with warm
water and neutral detergent and
rinse.
Disassemble hoist weekly for
thorough clean.
Infected patients:
Disinfect as outlined in
Actichlor Plus Dilution Chart
(Appendix 4) or Difficil-S
(Appendix 5)
Bath Water
Medicated bath additives only on
prescription.
Beds and Cots
Wash with warm water and neutral
detergent and dry with a paper
towel.
Mattresses should be cleaned and
checked following discharge.
Unzip cover and inspect for signs
of damage/ contamination. Report
to Nurse in charge. Mattresses
should be replaced when
damaged.
Infected patients:
Disinfect as outlined in
Actichlor Plus Dilution
Chart (Appendix 4) or Difficil-S
(Appendix 5).
Beds (Pressure
Relieving)
Refer to manufacturer instructions.
Must be included in Nursing
Assistants/ Auxiliary cleaning
schedules.
Clean between each patient use.
Unzip cover and inspect inner cells
for signs of damage/
Refer to manufacturers
instructions about suitable
disinfectants.
Ensure that untrained staff is
aware of manufacturer’s
instructions. If manufacturer’s
instructions are at variance with
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 17 of 36
Equipment or Site
Routine or Preferred Method
contamination.
Report same to nurse in charge.
Mattresses should be replaced
whenever damaged.
Acceptable Alternative or
Additional
Recommendations
these guidelines seek advice
from the Infection Prevention &
Control Staff.
Bed Frames/ cradles
Clean with warm water and neutral
detergent and dry following every
patient use.
Infected patients:
Disinfect as outlined in
Actichlor Plus Dilution
Chart (Appendix 4) or Difficil-S
(Appendix 5).
Bedpans/ Urinals
The washer-disinfector is for the
emptying, cleaning and
disinfection of bedpans,
commode buckets, their lids,
urine bottles, urine collection
jugs and kidney bowls.
Heat disinfection in a washerdisinfector (80C for 1 min). Select
the correct cleaning programme
depending on the degree of soiling
i.e. short/ normal/ intensive. After
removal from the machine, ensure
that there is no visible soiling. If
soiling persists re-process. Store
dry and inverted.
Alternatively, single-use disposable
items may be used. These should
always be disposed of into a
macerator unit. Ensure the lid is
kept closed for 1 minute after cycle
has ended.
The user must complete a daily
automatic control test as specified
in HTM 2030 (see Appendix 6).
Infected patients:
Patients with enteric infections
should preferably have en suite
facilities.
Enteric illness: Enhanced
cleans will be required.
Particular attention should be
paid to the cleaning and
decontamination of door
handles, lavatory handle and
taps.
Same should be requested
from Support Services.
Wash with warm water and neutral
detergent after use. Followed by an
acticlor clean
Liner should always be used.
Manufacturer’s recommendations
to be followed.
Manufacturer’s
recommendations to be
followed.
Birthing Pool
If en suite facilities are not
available supply the patient
with a clean commode and
ensure that bedpans are
removed immediately following
use.
Commodes should be cleaned
and disinfected as outlined in
Actichlor Plus Dilution Chart
(Appendix 4) or Difficil-S.
(Appendix 5).
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 18 of 36
Equipment or Site
Routine or Preferred Method
Acceptable Alternative or
Additional
Recommendations
Blood Gas Analysers
(at ward/ department
level)
Refer to manufacturers
instructions. A written protocol
must be in place with clear
guidance about who is responsible
for decontaminating the machine
and how it should be carried out.
Bowls (Washing)
For All Patients
Individual washbowls should be
available for each patient. After
each use, clean with Actichlor Plus
used as per dilution chart
(Appendix 4) or Difficil-S (Appendix
5) and dry and store inverted.
Bowls (Surgical,
Sterile)
Return to HSDU.
Bowls (Vomit)
Single use/ Disposable
Non-disposable
Where racks are available use
bedpan washer or send to the
HSDU.
Breast Pumps
Machine
Clean after use with neutral
detergent and dry with paper towel
Use Single use disposable kits.
Breast pump machine for use
at home by mothers when baby
remain in hospital. On return to
ward decontaminate with
Actichlor Plus see (Appendix 4)
use single use disposable kit
Carpets
Carpets should be avoided in
clinical areas.
Where they already exist:
Vacuum clean or when soiled clean
by hot water extraction.
Scheduled rota for cleaning to be in
place
For known contaminated spills:
Disinfect with an agent that
does not damage carpet then
clean with a detergent.
Seek advice from Support
Services.
Following an outbreak, steam
cleaning may be required,
consult Infection Prevention &
Control Team.
Catheter drainage
Bags
Single use (disposable)
N/A
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 19 of 36
Equipment or Site
Routine or Preferred Method
Computer Monitor
and keyboard
Clean weekly with detergent wipe
(do not use alcohol based product
on touch sensitive screens)
Crockery and Cutlery
Machine wash with rinse
temperature above 80C and dry or
hand wash in detergent and hot
water (approx. 60C), rinse and dry
thoroughly. Household gloves will
be required at this temperature.
Cleaning Equipment
Colour coded cleaning equipment
should be used for each area i.e.
Red - bathroom and toilet area
Blue - general areas ward
Green - catering department and
food service areas
Yellow - isolation
Acceptable Alternative or
Additional
Recommendations
NB. Patients on isolation
should all have separate
equipment should be disposed
of in orange bag after use.
Buffer machine: drain reservoir
after use and store dry.
Commodes
Wash after each use with warm
water and neutral detergent, dry
with a disposable paper towel.
Always leave clean and ready for
use.
Infected patients and / or if
faecal contamination has
occurred clean and disinfect as
outlined in Actichlor Plus
Dilution Chart (Appendix 4).
Place clean indicator tape
across the front and over the
arms ensure signature by staff
member.
Couches (Treatment)
Wash with warm water and neutral
detergent and dry after each
patient.
Change paper towel/ roll between
each patient.
Infected patients and/ or if
contaminated with body fluids
i.e. blood, urine or faeces;
disinfect as outlined in Actichlor
Plus Dilution Chart (Appendix
4).
Defibrillator
Clean after use
Damp dust weekly or if visibly
dusty.
Refer to Manufacturer’s
recommendations.
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 20 of 36
Equipment or Site
Routine or Preferred Method
Acceptable Alternative or
Additional
Recommendations
Denture Tubs
Disposable/ single patient use.
Mugs to be washed with warm
water and neutral detergent daily.
Diabetic Blood
Glucose Monitors
Clean with neutral detergent wipe
after every use - should be
included in cleaning schedule.
DO NOT LET LIQUID DRIP INTO
THE METER.
Infected patients:
Use patients own if possible.
If not, contact the diabetic
nurse practitioner to who will
supply an individual monitor for
the patient.
Following discharge of the
patient disinfect as outlined in
Actichlor Plus Dilution Chart
(Appendix 4).
Cleaning should include the
nylon carrying case.
DO NOT LET LIQUID DRIP
INTO THE METER.
External Drains
(not sink wastes)
Clean regularly. Chemical
disinfection is not required.
When blockage occurs, contact
Inter service (Help desk No
258888).
Dressing Trays/
Trolleys
Clean daily with warm water and
neutral detergent including the
wheels and dry with paper towel.
Decontaminate with alcohol prior to
and after use.
Disinfect as outlined in
Actichlor Plus Dilution Chart
(Appendix 4). Rinse, dry or use
70% alcohol if no organic
material is present.
Drip Stands/
Counters
Clean daily with neutral detergent
wipe while in use or if visibly dirty.
Clean weekly if not in use,
including wheels.
Refer to manufacturers instructions
Clean daily with neutral
detergent wipe whilst in use.
Disinfect as outlined in
Actichlor Plus Dilution Chart
(Appendix 4), rinse and dry or
use 70% alcohol if no organic
material is present.
Refer to manufacturers
instructions.
Drug Fridge
Wash with warm water, neutral
detergent and dry.
Clean weekly or if visibly dirty.
Scheduled rota for cleaning to be in
place.
A record of cleaning frequency/
maintenance should be retained.
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 21 of 36
Equipment or Site
Routine or Preferred Method
Acceptable Alternative or
Additional
Recommendations
Send to laundry as infected
linen for decontamination,
follow manufacturer’s
instructions.
Duvets
Water-impermeable cover:
Wash with warm water, neutral
detergent and dry.
Non water-proof duvets:
Launder regularly or if soiled.
ECG Machine
Clean after use with neutral
detergent wipes or if visibly dirty
and dry with paper towel. Include in
weekly schedule.
Refer to manufacturers instructions
Disinfect as outlined in
Actichlor Plus Dilution Chart
(Appendix 4) or use 70%
alcohol if no organic material
present.
Refer to manufacturers
instructions.
ECT Machine
Clean after use with neutral
detergent wipes or if visibly dirty
and dry with paper towel. Include in
weekly schedule.
Refer to manufacturer’s instructions
Disinfect as outlined in
Actichlor Plus Dilution Chart
(Appendix 4) or use 70%
alcohol if no organic material
present.
Refer to manufacturer’s
instructions.
Emergency Trolley/
Equipment
Clean after use with neutral
detergent and include in cleaning
schedule
Decontaminate after use as
outlined in Actichlor Plus
Dilution Chart (Appendix 4).
Dry or use 70% alcohol if no
organic material is present.
Endoscopes
Manual cleaning, disinfection and
storage of endoscopes according
to unit’s protocol and in accordance
with manufacturers and AER
(automated endoscope
reprocessors) instructions.
ALL FLEXIBLE ENDOSCOPES
MUST BE REPROCESSED
WITHIN THE CENRALISED
ENDOSCOPY DECONTAMINAION
UNIT AT EACH HOSPITAL SITE
ADVICE ON THE
DECONTAMINATION OF
ENDOSCOPES CAN BE SOUGHT
FROM THE DECONTAMINATION
MANAGER WHSCT
All staff must receive training in
the safe use, decontamination
and storage of endoscopes in
line with departmental policies,
manufacturers and the relevant
regulatory body’s
recommendations.
Advice on the decontamination
of endoscopes can be sought
from the Decontamination
Manager, Western Health &
Social Care Trust.
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 22 of 36
Equipment or Site
Routine or Preferred Method
Enteral Feeding Lines Follow manufacturer’s instructions
Fans
NB: fans are not
advised for use in
areas where patients
have/ are suspected
of having infection
Acceptable Alternative or
Additional
Recommendations
Disinfect as outlined in
Actichlor Plus Dilution Chart
(Appendix 4) or use 70%
alcohol if no organic material
present.
Refer to manufacturer’s
instructions.
Remove front grill and clean at
least weekly with neutral detergent
or if visibly dirty. Allow to dry before
returning to use. A regular cleaning
schedule for fans that cannot be
opened is essential and must be
agreed with Estate Services. When
purchasing new fans a removable
front cover is essential.
Floors (Dry Cleaning)
Vacuum or use a dust-attracting
dry mop.
Never use brooms in patient areas.
Non-disposable dust mops must be
vacuumed after each use.
Floors (Wet)
Microfibre Mop System/ traditional
lay flat mopping system to be used
An isolation pack must be
obtained from Support
Services. It must be returned
after use for decontamination.
Separate packs are required
for each patient in isolation.
Following discharge of an
infected patient, disinfect mop
bucket, handle etc as outlined
in Actichlor Plus Dilution Chart
(Appendix 4) or Difficil-S
(Appendix 5). Mop heads must
be removed for laundering
daily.
Fixtures and Fittings
In clinical areas damp dust daily
with warm water and neutral
detergent or if visibly dirty.
In known contaminated areas,
disinfect as outlined in Actichlor
Plus Dilution Chart (Appendix
4).
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 23 of 36
Equipment or Site
Routine or Preferred Method
Furniture and Ledges
In clinical areas damp dust daily
with warm water and neutral
detergent or if visibly dirty.
Haemodialysis
Equipment
Follow units/ manufacturers
protocol for decontamination of
haemodialysis machine/ dispose of
used lines and dialyser in clinical
waste.
Hair Rollers
Patients own to be used.
Wash with warm water and neutral
detergent and dry.
Rollers must not be
shared
Acceptable Alternative or
Additional
Recommendations
Following discharge of an
infected patient, refer to the
Support Services Infection
Control Cleaning Procedures,
which can be accessed via the
Trust Intranet, under the
Infection Prevention & Control
Guidelines section.
Humidifiers
(O2 Therapy)
Use single patient use/ disposable.
Wash with warm water and neutral
detergent if soiled between uses.
Humidifiers must only be filled
with sterile water which must
be changed every 24 hours or
sooner if necessary.
Ice machines
A regular maintenance programme
compatible with the manufactures
instructions should be in place.
Exterior/ interior clean weekly or as
per manufacturer’s instructions.
Ice scoops must be washed daily in
a dishwasher or wash in warm
water and neutral detergent. Store
in a container outside the ice
machine.
Requirements will vary with the
make/ model of machine.
Infant Incubators
Follow protocol available in each
unit.
Follow protocol available in
each unit.
Surgical Instruments
Send to HSDU for reprocessing.
DO NOT DECONTAMINATE AT
WARD/ DEPARTMENT LEVEL.
(Not recommended
for human
consumption)
A record of cleaning frequency/
maintenance should be
retained.
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 24 of 36
Equipment or Site
Routine or Preferred Method
Acceptable Alternative or
Additional
Recommendations
*Patients with unhealed
wounds, who are
immunocompromised or those
who have a known infection
should not use Jacuzzi/
whirlpool baths.
Jacuzzi/ Whirlpool
Baths
Wash with warm water and neutral
detergent after use.
Manufacturer’s recommendations
to be followed regarding cleaning,
maintenance and servicing. Baths
not regularly used must be flushed
as per legionella controls.
Jugs (for measuring
urine/ emptying urine
bags)
After each use decontaminate in
bedpan washer-disinfector, return
to HSDU or single use.
Laryngoscope
Blade
Disposable blades should be used.
Reusable blades: Send to HSDU
for reprocessing after each use.
Handle
Neutral detergent wipe then wipe
over handle with 70% isopropyl
alcohol wipe after each use.
Lifting/ Hoist Slings
Launder as per protocol/
manufacturer’s instructions.
Use disposable slings if lifting
equipment is compatible,
otherwise reserve sling for
patient and send to laundry
following discharge.
Mattresses/ Pressure
Relieving Devices
To be protected by a waterproof
cover. Wash with warm water and
neutral detergent and dry.
Maintenance to be carried out as
per protocol/ manufacturer’s
recommendations. Inspect
regularly for signs of damage to
mattress/ cover. Report same to
nurse in charge. Mattresses should
be replaced whenever damaged or
every 4 years.
Infected patients:
Disinfect as outlined in
Actichlor Plus Dilution Chart
(Appendix 4). Allow 5 minutes
contact time then rinse and dry.
Follow any specific instructions
advised by the manufacturer.
Medicine Cups
Single use only
Nail Brushes
(surgeon's hand)
Use sterile pre-packed single-use
disposable. Should not be routinely
available at ward level.
Nebuliser
Nebuliser tubing and mask are
single patient use only.
Nebuliser chamber (ACORN) to be
Disposable single-use only.
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 25 of 36
Equipment or Site
Routine or Preferred Method
Acceptable Alternative or
Additional
Recommendations
changed after each treatment.
Peak Flow Meters
Use disposable mouth piece and
bacterial viral filter.
Single patient use.
Pillows
Use only with water impermeable
cover. Clean (warm water and
neutral detergent)/ change cover if
visibly soiled or following discharge
of each patient.
Pillows to be inspected routinely
and disposed of if found to be torn
or damaged.
Portanebs:
Inline Filters &
Inlet Filters
Refer to manufacturer’s
recommendations.
A written protocol must be in place
Refer to manufacturer’s
recommendations.
A written protocol must be in
place.
Pumps/ IV Infusion
Clean daily with neutral detergent
wipe while in use or if visibly dirty.
Clean weekly if not in use,
including wheels.
Refer to manufacturer’s
instructions.
Decontaminate after use with
Actichlor Plus (see Appendix 4)
Razors (Wet Shave)
For hygiene purposes - use
disposable.
Dispose of into a sharps container.
Razors (Electric)
Patient’s own razors must be used.
No sharing of razors permitted.
Rooms
Refer to Support Services Infection
Control Cleaning Procedures
Scales
Clean after use with neutral
detergent or if visibly dirty
include in weekly schedule.
Scissors
If scissors are not required to be
sterile: wipe before and after use
with a 70% alcohol impregnated
wipe.
Infected patients:
Disinfect as outlined in
Actichlor Plus Dilution Chart
(Appendix 4). Rinse and allow
drying.
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 26 of 36
Equipment or Site
Routine or Preferred Method
Acceptable Alternative or
Additional
Recommendations
Use disposable scissors, if there is
a possibility of contact with blood,
body fluids and sterile sites.
Shaving Brushes
Each patient should have their own
individual shaving equipment.
Brushes should be cleaned after
use and stored dry.
Slip/ Slide Sheets
Single patient use
Single patient use
Soap
Liquid soap: should be supplied in
a dispensing container. Do not topup. If hands are physically clean an
alcohol hand rub can be used
instead of soap and water.
Antiseptic hand wash must
always be available in patient
isolation rooms and for use
prior to aseptic procedures.
Tablet soap: is not acceptable in
public/ clinical areas.
Patients’ personal soap to be
stored dry.
Alcohol hand rubs must be
available at the end of every
bed and outside single rooms
unless contraindicated.
Chlorhexidine hand wash
should available in the clinical
area.
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 27 of 36
Equipment or Site
Routine or Preferred Method
Suction Equipment
Equipment:
Machines – after use clean outside
with neutral detergent wipes or
if visibly soiled.
Catheters – single use/disposable.
Do not leave open catheters
attached to tubing.
Tubing – single patient use /
disposable.
Filters – change in accordance with
manufacturers instructions.
Jars – preferably use disposable
liners, alternatively send to the
HSDU.
* Wear a plastic apron and nonsterile disposable nitrile gloves for
this procedure.
Disposable systems are discarded
to clinical waste bags if gelling
agent has been used. The reservoir
of the suction apparatus should be
kept empty and dry when not in
use. Suction tubing must be
changed following discharge/
transfer of every patient or more
frequently if necessary.
Specimen fridge
Wash with warm water, neutral
detergent and dry. Clean weekly or
if visibly dirty.
Speculae
Single use/ disposable
Sputum Containers
Disposable. Seal and discard as
clinical waste daily or sooner if
required.
Acceptable Alternative or
Additional
Recommendations
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 28 of 36
Equipment or Site
Sphygmomanometer
Sphygmomanometer
Cuff
Routine or Preferred Method
Acceptable Alternative or
Additional
Recommendations
Clean after use with neutral
Infected patients:
detergent wipe.
After cleaning with neutral
detergent, wipe with a 70%
alcohol impregnated wipe and
allow drying.
Wipe with a neutral detergent and
Follow manufacturer’s
allow drying. Ensure that cuff is dry recommendations.
prior to use.
Disposable cuffs can be ordered.
Disposable cuffs to be used –
These are single patient use only.
single patient use.
Stethoscope
Clean bell, ear pieces and
diaphragm after each use with a
70% alcohol impregnated wipe and
allow drying.
Syringe Drivers/
Pumps
After use surface clean with neutral
detergent wipe. If spillages occur
whilst in use, clean immediately.
Wipe over with 70% alcohol
impregnated wipe.
Refer to manufacturer’s
recommendations.
Syringe driver cloth covers to be
single patient use.
Infected patients:
After cleaning wipe with a 70%
alcohol impregnated wipe and
allow drying.
Refer to manufacturer’s
recommendations.
Thermometers
(Electronic)
Use a single-use sleeve and
change after each use.
Wipe thermometer tip with neutral
detergent wipe after use.
Ensure holder is cleaned at least
daily with warm water and neutral
detergent.
Refer to manufacturer’s
recommendations.
Infected patients:
Use a single-use sleeve.
Holder should be cleaned with
70% alcohol following each
use, or confined to the single
room only.
Refer to manufacturer’s
recommendations.
Thermometers
(Tympanic)
Use disposable cover for each
patient use and discard. Clean
holder as per manufacturer’s
recommendations.
Decontaminate immediately
following use as per
manufacturer’s
recommendations.
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 29 of 36
Equipment or Site
Routine or Preferred Method
Acceptable Alternative or
Additional
Recommendations
Infected patients/ faecal
stained toilets:
Disinfect as outlined in
Actichlor Plus Dilution
Chart (Appendix 4)/ Difficil-S
(Appendix 5). Rinse and dry.
Follow recommended
frequency cleaning.
Increased frequency for C.
difficile. Use appropriate PPE.
Toilet/ Toilet Seats
Wash as per schedule with warm
water and neutral detergent and
dry. More frequent cleans are
necessary in high usage areas.
Use cream cleaner for stubborn
stains. Use appropriate PPE
Refer to Support Services cleaning
schedules for frequencies in
individual departments.
Tonometer Prisms
Use disposable prisms
Tourniquet
Single use
Re-usable should be replaced
by single use
Trolleys
Wash trolley and wheels daily with
warm water and detergent, rinse
and dry with a paper towel.
Decontaminate prior to and after
dressings/ procedures using an
alcohol impregnated wipe.
Infected patients:
Disinfect as outlined in
Actichlor Plus Dilution
Chart (Appendix 4)/ Difficil-S
(Appendix 5) or if no organic
material present 70%
impregnated alcohol wipe
before and after use.
Tubing (Anaesthetic/
Ventilator)
Use disposables
Ultrasound Head/
Probe
(See Appendix 3)
Use a single patient use transducer
cover.
Refer to manufacturer’s
recommendations.
Avoid alcohol based products
Urinals
See Bedpans
Use a single patient use
transducer cover.
Refer to manufacturer’s
recommendations
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 30 of 36
Equipment or Site
Routine or Preferred Method
Ventilators
(Mechanical)
Refer to manufacturer’s
recommendations for
decontamination.
Single patient use disposable
tubing and filter must always be
changed between patients. Whilst
in use with a single patient change
disposable filters in accordance
with manufacturer’s
recommendations. Change
disposable tubing (circuit) every 7
days or more frequently if
contaminated.
Waterbed
Wash the mattress with warm
water and neutral detergent.
The removable cover can be
laundered to eliminate dust mites.
Refer to manufacturer’s
recommendations regarding
maintenance and water changing.
To be included in cleaning
schedule.
X-Ray Equipment
Refer to manufacturer’s
recommendations.
Damp dust with warm water and
neutral detergent. Do not over-wet
and allow surface to dry before
use.
Acceptable Alternative or
Additional
Recommendations
Refer to manufacturer’s
recommendations for
decontamination.
Clean with warm water and
neutral detergent and then
wipe with a 70% alcohol
impregnated wipe unless
contraindicated by the
manufacturer. For specialised
equipment, draw up local
protocol for cleaning and
disinfection, based on the
manufacturer's
recommendations.
Methods of decontamination are listed on the previous pages. This list is not
exhaustive and it must be remembered that a piece of equipment may require
different types of decontamination for various uses. If in doubt it is always
advisable to refer to the manufacturer’s recommendations, or contact the
Decontamination Manager or an Infection Prevention & Control Nurse. If it is
not possible to decontaminate a piece of equipment properly, this should be
stated on the Decontamination Certificate.
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 31 of 36
Appendix 2
CLEANING AND DISINFECTION OF BEDS
Poster may be accessed via Trust intranet – Infection Prevention & Control
Guidelines section.
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 32 of 36
Appendix 3
RECOMMENDATIONS WITH REGARD TO ULTRASOUND PROBES
Please note the following recommendations with regard to ultrasound probes:

Initially refer to manufacturer’s guidelines

The use of Chlorine Dioxide Sporicidal Foam as a method of
decontamination should only be used if unable to process in an
endoscope washer disinfector.
The following guidelines are for equipment that cannot be processed through
HSDU.
Risk
Significant
Application
Recommendation
Probes in contact with non
intact skin, mucous
membranes or bodily fluids.
Clean with wipe system
which includes
traceability log book.
After use on intact skin of
infected/ colonised patients.
Continue to use sheath in
conjunction with above
cleaning system.
Product Codes
Prior to use on an immunocompromised patient
Low
Probes in contact with
healthy skin.
Clean with detergent and
hot water or detergent
impregnated wipes.
Continue to use sheath in
conjunction with above
cleaning system.
A written standard operating procedure (SOP) must be available, easy to read
and clearly visible to staff using the equipment. The SOP should be based on
the manufacturer’s instructions and this guidance.
Manufacturer’s instructions which contradict the principles outlined in the
guidance must be discussed with the IP&C Team.
Staff using the equipment must receive appropriate training in the agreed
decontamination procedure.
Traceability
The log book must be completed by the person who decontaminates each
device and the traceability labels must be sited in log book and Patient Notes.
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 33 of 36
Appendix 4
DISINFECTING YOUR GENERAL ENVIRONMENT &
BLOOD SPILLS WITH ACTICHLOR® PLUS TABLETS
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 34 of 36
WARNINGS
AND
PRECAUTIONS
Appendix 5
Disinfection and Decontamination Policy (Patient Care Equipment)
Page 35 of 36
Appendix 6
BEDPAN WASHER-DISINFECTORS
Automatic Control Test
This is completed weekly by Test Person from WHSCT to ensure that the
operating cycle functions correctly.
Daily Check
This is carried out by the user and recorded in the log book.
Use a normal cycle and record the result.
The test should be considered satisfactory if the following requirements are
met:




A visual display indicating ‘cycle complete’ occurs
The time for the disinfection temperature is maintained at that established
by the manufacturer or the performance qualification test.
The door cannot be opened until the cycle is complete
The person conducting the test does not observe any mechanical or other
anomaly
Disinfection and Decontamination Policy (Patient Care Equipment)
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