Cleaning and Disinfection Policy - NHS Gateshead · disinfection or sterilisation (if appropriate)...

Cleaning and Disinfection Policy V 8.0

Policy No: IC15

Version: 8.0

Name of Policy: Cleaning and Disinfection Policy

Effective From: 11/06/2018

Date Ratified 17/04/2018

Ratified Infection Prevention & Control Committee

Review Date 01/04/2020

Sponsor Director of Nursing, Midwifery & Quality / Joint Director of

Infection Prevention & Control

Expiry Date 18/04/2021

Withdrawn Date

Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no assurance that

this is the most up to date version

This policy supersedes all previous issues.

Cleaning and Disinfection Policy V 8.0 2

Version Control

Version Release Author/Reviewer Ratified

by/Authorised

by

Date Changes

(Please identify page no.)

1.0

Feb 2002 February

2002

2.0

3.0

K Melling Control of

Infection

Committee

TPF

21/10/05

11/10/06

4.0

Feb 2006 K Melling Control of

Infection

Committee

Trust Policy

Forum

21/10/05

11/01/06

5.0 Nov 2008 E Flude

RIPD Meeting

November

2008

6.0 22/11/2011

E Flude IPCC 28/09/11 Summary of changes

6.1 28/08/2012

E Flude IPCC 27/07/12 Audit revision

7.0 05/06/2015 E Flude

IPCC 17/04/15 See summary of changes

8.0

11/06/2018 R Green - reviewer IPCC 17/04/2018 No changes on review


Contents

Section Page

1 Introduction .......................................................................................................................... 4

2. Policy scope ........................................................................................................................... 4

3. Aim of policy ......................................................................................................................... 4

4 Duties (roles and responsibilities) ......................................................................................... 4

5 Definitions ............................................................................................................................. 5

6 Main Body of the policy ........................................................................................................ 6

6.1 Spillage management .............................................................................................. 6

6.2 Risk Assessment of Medical Devices ....................................................................... 7

6.3 Domestic Services / Equipment ............................................................................... 8

6.4 Responsibilities For Cleaning at Ward & Department Level ................................... 9

6.5 Terminal Enhance Cleaning ................................................................................... 10

6.6 Enhanced Cleaning ................................................................................................ 10

6.7 Deep Clean Programme ........................................................................................ 11

7. Training ............................................................................................................................... 11

8. Equality and diversity .......................................................................................................... 11

9. Monitoring compliance with the policy .............................................................................. 12

10. Consultation and review .................................................................................................... 12

11 Implementation of policy (including raising awareness) .................................................... 12

12 References .......................................................................................................................... 12

13 Associated documentation (policies) .................................................................................. 12

Appendices

Appendix 1 Equipment Cleaning Guide.. ..................................................................................... 13-19

Appendix 2 Enhanced Cleaning Guide .............................................................................................. 20

Appendix 3 Chlorclean Domestic Guide ........................................................................................... 21

Appendix 3 Chlorclean Nursing Guide .............................................................................................. 22

Appendix 4 National Colour Coding Scheme .................................................................................... 23

Appendix 5 Cleaning Procedure for Bedside Entertainment System .......................................... 24-27

Appendix 6 Single Use Medical Devices Guide ................................................................................. 28

Appendix 7 Clinell Sporicidal Wipe Guide ................................................................................... 29-30


Cleaning & Disinfection Policy

1 Introduction

This policy follows current national evidence based guidance as stated within the Epic3 guidelines

(2014), The Revised Healthcare Cleaning Manual (2009) and The Health & Social Care Act (DOH

2008).

Hospital hygiene is important for the prevention of healthcare-associated infections in hospitals. All

health care workers must be able to identify the most appropriate method of cleaning and

disinfection or sterilisation (if appropriate) for all equipment and the patient environment.

2 Policy scope

This Policy applies to all healthcare professionals within Gateshead Health NHS Foundation trust.

All health care workers have a responsibility to adhere to Trust policy and ensure that appropriate

measures are taken to reduce the risks associated with infection.

3 Aim of policy

This policy outlines precautions within Gateshead Health NHS Foundation Trust to minimise the risk

of infection to patients, visitors and staff. The aim of this policy is to enable healthcare workers to

identify and decontaminate equipment safely and effectively and sets out cleaning and disinfection

requirements within this trust.

4 Duties (Roles and responsibilities)

Those listed all have a duty to assist the Trust in the achievement of national standards for infection

prevention and control by compliance with this and all other Infection Prevention and Control

policies. All staff have a responsibility to disseminate good practice.

Specific responsibilities are outlined as follows:

Chief Executive - The Chief Executive has ultimate responsibility for ensuring that effective systems

and processes are in place to minimise the risk of infection to patients, staff and visitors.

All Staff - All Trust staff have a responsibility to adhere to Trust policy and ensure that appropriate

measures are taken to reduce risks associated with infection. All Trust Staff have a responsibility to

ensure they receive annual training in Infection Prevention and Control.

Director of Nursing, Midwifery and Quality, Joint Director of Infection Prevention and Control -

The Director of Nursing, Midwifery and Infection Prevention and Control has delegated

responsibility for ensuring that effective systems and processes are in place to minimise the risk of

infection to patients, staff and visitors.

Trust Board - The Trust Board has a responsibility to ensure that the risk of infection to patients,

staff and visitors is minimised to its lowest potential and therefore supports the full

implementation of this policy.

Medical Director/Joint Director of Infection Prevention & Control - The Medical Director has a

shared responsibility with the Director of Nursing, Midwifery & Quality and Infection Prevention

and Control for ensuring effective Clinical Governance within the organisation.

Director of Operational Services - Leads on Decontamination for the Trust and provides an annual

report to the Trust board.


Hotel Services Manager – is responsible for ensuring a proactive cost effective service, with

sufficient staff with the right skills to meet the needs of the organisation.

Provide advice regarding cleaning & disinfection and product use where required.

Consultant Microbiologist - Provide expert advice in line with Trust infection prevention & control

needs and national policy to the Infection Prevention & Control Team, Joint Directors of Infection

Prevention & Control and service users.

Head of Infection Prevention and Control - Has a duty to provide expert infection control advice

and support to the Director of Infection Prevention and Control, the Infection Prevention & Control

Team and other service users. Ensure that Education and Training programmes are appropriate to

meet national guidelines and the local needs of service users.

Infection Prevention and Control Team - Have a duty to provide expert advice, education and

training to service users. Deliver Mandatory Education and Training to service users. Participate in

daily surveillance and patient management for actual and potential infection. Validate the Ward

Quality Measures in-conjunction with the Modern Matrons and Ward Managers to monitor

compliance of practice.

Divisional Director/ Manager/Clinical Lead - Divisional Managers and identified leads within

departments/directorates have a duty to ensure compliance with Trust policy.

Divisional Managers - are responsible for ensuring all staff attend mandatory training on Infection

Prevention and Control and that those non-attendees are followed up in accordance with the Trust

Mandatory Training Policy (PP25).

Modern Matron - Matrons are responsible for the reduction of healthcare associated infection.

They monitor adherence to Infection Prevention & Control policy via clinical presence/expertise

and the Ward Quality Measure audit tools. Ensure that Infection Prevention and Control Link staff

are released to attend study sessions and perform audits for their areas which will provide the

Trust with evidence of compliance in infection control.

5 Definition

The essence of good cleaning is that things not only look clean afterwards, but that they are clean.

All users of healthcare premises have a right to assume that the environment is one where

infection hazards are adequately controlled. (The Revised Healthcare Cleaning Manual 2009)

The hospital environment must be visibly clean, free from non-essential items and equipment, dust

and dirt. The hospital environment must also be acceptable to patients, visitors and staff. (epic3

2014)

Hospital environmental hygiene encompasses a wide range of routine activities included within:

• Cleaning the general hospital environment

• Cleaning items of shared clinical and patient equipment

The term cleaning is used to describe the physical removal of soil, dirt or dust from surfaces.

Conventionally, this is achieved in healthcare settings using cloths and mops. Disposable paper

cloths and microfibre mops are used within this trust predominantly. Detergent and water is used

for cleaning of soiled or contaminated surfaces.

Enhanced cleaning describes the use of methods in addition to standard cleaning specifications.

This may include increased cleaning frequency for all or some surfaces, or the use of additional


cleaning equipment. Enhanced cleaning may be applied to all areas of the healthcare environment

or in specific circumstances, such as cleaning of bed spaces or rooms following the transfer or

discharge of patients who are colonised or infected with a pathogenic microorganism. This is

referred to as enhanced terminal cleaning (TEC).

Disinfection is the use of chemical or physical methods to reduce the number of pathogenic

microorganisms on surfaces. These methods need to be used in combination with cleaning as they

have limited ability to penetrate organic material.

The term decontamination is used for the process that results in the removal of hazardous

substances, such as microorganisms or chemicals, and therefore, may apply to cleaning or

disinfection.

6 Cleaning and Disinfection

Please refer to Appendix 1 for a comprehensive Equipment Cleaning Guide

6.1 Spillage Management

1. Ensure the environment is made safe for patients, visitors and staff.

2. Appropriate aprons and gloves (facial protection if appropriate) should be worn.

Please refer to IPC Personal Protective Equipment Policy No. 2

3. Clean up spillage with a disposable paper towel and then wash area with detergent

and water and disposable paper towels if appropriate. Dispose into black household

waste bags.

4. For spills involving BODY FLUIDS clean up spillage using disposable paper towels as

described above & then use a chlorine solution as in table below to disinfect.

The trust currently uses a combined detergent and disinfectant product Chlorclean

for those spillages requiring 1,000ppm disinfection. Refer to Appendix 3 for product

information. Dispose of into orange clinical waste bags if known or suspected

infection otherwise use the offensive waste stream.

5. Chlorine solution is to be made up fresh, as it will not be effective if stored. The

concentration used should be appropriate for patients where infection is suspected

or confirmed. (See table below)

6. A chlorine solution should not be used for prolonged metal and rubber contact – an

alternative product should be available for use (follow manufacturers guidelines

where appropriate or discuss with infection prevention and control team).

However, where the use of chlorine on stainless steel or rubber is unavoidable, it

must be allowed to dry and then rinsed off.

Type of spillage Disinfection solution Personal protective

equipment

Urine*, faeces, vomit,

sputum

*Always clean up urine

first with disposable

towel to avoid

generation of chlorine

gas

1000 parts per million

(0.1%) Chlorine / Sodium

Dichloroisocyanurate

Solution (Chlorclean)

Disposable Gloves and

Apron

Blue gown for suspected or

known C. diff

Facial protection where

potential of splash/spray


Type of spillage Disinfection solution Personal protective

equipment

Tuberculosis 5000 parts per million

(0.5%) chlorine/ Sodium


solution. (HAZ tabs)

Gloves and Apron

Facial protection (FFP3)

where potential of

splash/spray

Blood/blood stained

fluids

Use Hypochlorite

granules/Spill kit or

10,000 parts per million

(1%) chlorine/Sodium


solution. (HAZ tabs)

Gloves and Apron

Facial protection (surgical

mask) where potential of

splash/spray

Known/suspected CJD

patients

20,000 ppm (2%)

Hypochlorite solution

Emergency Drug

cupboard (Milton

Sterilising Fluid)

Gloves and Apron

Facial protection where

potential of splash/spray

ppm = the strength in parts per million

Please refer to Appendix 3 for Chlorclean protocol

6.2 Risk Assessment of Medical Devices

Devices designated for single use (see symbol) must not be re-used under any

circumstances.

If a device is re-processed the user may be committing an offence under any or all of the

following acts:

• Health and Safety at Work Act 1974

• Part 1 of the Consumer Protection Act 1987

• The General Product Safety Regulations 1994

• The Medical Devices Regulations 1994

Any item, which is single use, must be disposed of after single use.

Please refer to Appendix 6

All devices borrowed from the Medical Devices Library need to be cleaned, decontaminated

then placed into clear plastic bag and the decontamination form signed prior to them

leaving your ward/department for return.

The risk associated with a re-usable device/equipment depends on the degree of patient

contact, the part of the body in contact with the device and the potential or actual body

fluids present. (See table overleaf)


RISK Level of contamination /

contact

Clean Disinfect Sterilise

LOW Healthy intact skin Yes Only if known or

suspected

colonisation/

infection or if

contaminated

with body fluids

MEDIUM Mucous membranes,

broken skin, patients with

known

infection/colonisation

or

Manufacturer

recommendation

Yes Yes Yes

HIGH Into sterile body cavities,

(Equipment used for CJD

patients see policy no.22)

Yes Yes

See Appendix 1 for Cleaning Guide for equipment.

6.3 Domestic Services /Equipment

The Domestic Service provides for cleaning of the general hospital environment – floors,

sanitary areas, furniture and fittings. A scheduled service is provided between 7am – 9pm

each day. An Emergency Response Team is available 24 hours via bleep 2096 for terminal

enhanced cleans.

Domestic cleaning schedules should be available and displayed in every ward and

department.

This Trust follows the guidance of the National Patient Safety Agency National Colour

Coding Scheme for hospital cleaning materials and equipment. Colour coding of hospital

cleaning materials and equipment ensures these items are not used in multiple areas and

reduce the risks of cross-infection. Please see Appendix 4.


Non-domestic staff have access to disposable mops and mop buckets in the ward sluice

rooms. It is their responsibility and NOT the responsibility of the Domestic Staff to ensure

the buckets are emptied and cleaned and mop heads disposed after each use.

Please refer to Trust Cleaning Strategy and individual department Domestic Cleaning

Schedules for more detailed information.

6.4 Responsibilities for Cleaning Ward and Department Level

Domestic Staff Non Domestic staff

Furniture and non-technical fittings

Technical equipment / Specialist patient

equipment e.g. monitors, pumps,

commodes.

Beds – Head/foot/hand set daily Between

patients during 7am – 8.30pm

Beds during hours 9pm – 7am unless

terminal enhanced clean is required when

need to bleep the Domestic Response Team.

Floors Patient accessories

Curtains Disposal of Sharps

Hospedia Patient Line bedside equipment Disposal of equipment


Domestic Staff Non Domestic staff

Terminal clean (Standard Seven) Computer equipment & phones

Telephones Work clothing and Work Shoes

6.5 Terminal Enhanced Cleaning

Terminal Enhanced Cleaning is necessary following vacation of a room/bed space by a

patient with a known or suspected infection/colonisation. A thorough or terminal enhanced

clean is recommended for infections such as multi resistant organisms (MRO) in sputum,

exudate from wounds or drains, Tuberculosis and Clostridium difficile.

The cleaning of a room /bed space and the furniture must be undertaken in a methodical

manner. Unnecessary equipment should not have been allowed to accumulate in the bed

area or room. The antechamber/airlock should only house a small working stock of items

specific to the treatment of that patient, including PPE.

The nurse in charge/department manager will:

1. Inform Domestic Services Office, or bleep if out of hours, of cleaning requirements

as soon as possible.

2. Rooms with a negative pressure setting should be left on this system when clean is

in progress.

3. It is the responsibility of the Nursing or Housekeeping Staff to remove all

equipment and dispose of it or decontaminate it away from patient area as

appropriate. Paper rolls/toilet rolls/ pads and other open packets should be

discarded. Wear an apron and gloves and dispose of items as clinical waste or as

sharps. Laminated notices may be cleaned and restored following terminal

cleaning.

4. Equipment, which requires repair, will need decontamination and a certificate

attached for the estates department.

5. Hire equipment must have a verification certificate of cleaning attached before it is

accepted for patient use.

6. Domestic staff will then remove window/bed curtains as appropriate. The walls,

bed, chair, light fitting, bed frame, mattress, & bed controls will all then be cleaned

using Chlorine/hypochlorite solution. (See chart in section 6.1 for strengths of

cleaning solution)

7. Before patient use new curtains must be hung.

6.6 Enhanced Cleaning

During outbreaks/suspected outbreaks of infection it is necessary to increase the frequency

of cleaning provided within a ward/department. The infection prevention and control team

in conjunction with Hotel and Domestic Services initiates this process (Appendix 2).

Please see the Outbreak policy IC no. 24 for guidance on outbreak management. Currently

enhanced cleaning with Chlorclean solution is continuous on EAU, CCD, CCU, SCBU and

Theatres.


Symptomatic GDH and C. diff toxin patients will have enhanced cleaning with Chlorclean

solution twice daily. Clinell sporacidal wipes may be used in between for cleaning the

commode and patient equipment. Please refer to appendix 7.

Long sleeve gowns and gloves are to be used for all patient care and cleaning activities.

They should have dedicated equipment such as commodes and BP machines allocated and

cleaned with Chlorclean solution or Clinell sporacidal wipes after each use.

Please refer to Trust Clostridium difficile policy IC26.

6.7 Deep Clean Programme

Deep clean programme is a concentrated programme of cleaning over and above the

routine day-to-day activities. There will be an annual schedule/timetable for deep cleans

throughout in-patient clinical areas. This currently includes steam cleaning of equipment

and fittings.

7 Training

All healthcare workers need to be aware of their individual responsibility for maintaining a safe

environment for patients and staff and be clear about their specific responsibilities for the cleaning

of equipment and clinical areas. They must receive training about the importance of ensuring the

clean hospital environment and minimising the risks of microbial contamination. (epic3 2014).

ALL STAFF on induction and thereafter at annual mandatory training should receive education in

the following:

• Cleaning equipment

• Cleaning method

• Concentration of chemical – COSHH sheet

• Protective equipment/clothing

• Safe disposal of used products and equipment

• Documentation (if applicable)

• Spillage management

• How to access Domestic Services/equipment

• Single use items

• Responsibilities prior to request for terminal cleaning of a room/bed space

An appropriately qualified member of staff should provide induction training at local level to all

healthcare workers. A register should be kept in the work place to document training provided.

All healthcare workers will attend a mandatory training session provided by the infection

prevention & control team on an annual basis covering:

• Epic3 guidelines – The hospital environment, hand hygiene, personal protective equipment,

Sharps disposal.

• Records of attendance will be maintained in the work place and with OD and Training

Department.

Ad hoc training on cleaning methods may be arranged with Infection Prevention & Control Nurses if

required in individual ward or department areas.

8 Equality and diversity

The Trust is committed to ensuring that, as far as reasonably practicable, the way we provide

services to the public and the way we treat our staff reflects their individual needs and does not


discriminate against individuals or groups on any grounds. The policy has been appropriately

assessed.

9 Monitoring compliance with the policy

Audit will enable evaluation of cleaning and disinfection programmes. This will include:

• Joint Matron & IPCN Environmental inspections

• Weekly/Monthly Domestic Maximiser reports to Ward Managers

• Weekly Ward Quality Measures audits which incorporate 5 common patient contact

equipment items, results centralised via Safecare dashboard

• Environmental A.T.P (Adenosine triphosphate) swabbing, following Domestic Terminal

cleans

• Environmental swabbing performed by Infection Prevention & Control Team reported to

the Infection Prevention & Control Committee

• Ongoing improvement programmes towards achieving of MRSA bacteraemia and C. difficile

targets

• Patient Exit Card reports and feedback from patient forums

The standards outlined provide a framework for audit of policy at user (ward/department) and

infection prevention and control team levels.

10 Consultation and review

Members of Infection Prevention and Control Team (IPCT) and Infection Prevention and Control

Committee (IPCC)

11 Implementation of policy (including raising awareness)

All members of staff will be informed via trust wide e mail and individual team meetings when due

for review.

12 References

Epic3 Guidelines (H.P. Loveday, J.A. Wilson, R.J. Pratt et al, Journal of Hospital Infection 2014)

The Health & Social Care Act 2008 & Code of Practice (DoH 2008)

The Revised Healthcare Cleaning Manual (NHS, NPSA June 2009)

Health and Safety at Work Act 1974

Part 1 of the Consumer Protection Act 1987

The General Product Safety Regulations 1994

The Medical Devices Regulations 1994

13 Associated documentation

IC 2 Personal Protective Clothing in Clinical Practice Policy

IC 4 Hand Hygiene Policy

IC 6 Isolation Policy

IC 22 Creutzfeldt-Jakob Disease (CJD) and any other Transmissible Spongiform Encephalopathy

Policy

IC 24 Outbreak Management Policy

IC 26 Clostridium difficile and infective diarrhoeal Policy


Appendix 1

Equipment Cleaning Guide

Equipment/site Routine Method Additional information

AIRWAYS Disposable, single use only

Do not re-use

ANAESTHETIC TUBING,

AMBUBAG, FACE MASKS

Disposable single use only

AMPOULES Wipe the neck with 70% isopropyl 2%

Chlorhexidine (PDI sani cloth) wipe

BABIES BOTTLES/TEATS Single use only

Do not re-use

BABY SCALES Wash in hot water and detergent, dry

thoroughly and wipe over with a Clinell

Universal wipe.

If grossly soiled/ infected

immerse in Chlorclean solution

1,000ppm.

BATHS/HOISTS Non-infected patients – clean with

detergent solution rinse and dry

thoroughly after use

Infected patients and patients

with open wounds use Chlorclean

diluted to 1,000 ppm, rinse and

dry thoroughly after each use.

BED FRAMES Non-infected patients – clean with

detergent solution rinse and dry

thoroughly after use

Infected patients and patients

with open wounds use Chlorclean

diluted to 1,000ppm, rinse and

dry thoroughly after each use

BEDPAN Liners – single use only

Slipper pan wash & disinfect with

Chlorclean solution 1,000ppm, rinse and

dry thoroughly. Store away from sluice

master disposal units.

BEDPAN HOLDERS Wash & disinfect with Chlorclean solution

1,000ppm, rinse and dry thoroughly. Store

away from sluice master disposal units.

BIDET Following each use, wash & disinfect with

Chlorclean solution 1,000ppm, rinse and

dry thoroughly or wipe with a Clinell

Universal wipe and allow to dry

BLOOD/BODILY FLUID

SPILLAGE

Disposable apron and gloves must be

worn.

Absorb spillage with disposable paper

towels and discard in orange clinical waste

bag.

Any residual fluid should be wiped away

using Chlorclean solution 1,000ppm for

body fluid spillage OR detergent solution

followed by 10,000ppm HAZ tab solution

for blood spillages.

If broken glass or any other sharp is

included in the spill, it should be picked up

using forceps and disposed of in a sharps

container before the Chlorclean or HAZ tab

solution is used.



BLOOD WARMERS Use disposable circuit and discard after

use.

Wash & disinfect outer casing with

Chlorclean solution 1,000ppm rinse and

dry thoroughly.

A Clinell universal wipe may also be used

and allowed to dry.

Disposable blood warmers are

advised for theatre use.

BOWL (SURGICAL) Autoclave

BOWLS(WASHING) Disposable wash bowls are single use

BREAST PUMP Breast pump is designated to mother,

rinse and wash in hot water and detergent

solution, rinse and dry thoroughly.

Wipe with Clinell Universal wipe

Disconnect machine from electricity supply

Clean machine casing with hot water and

detergent and dry with disposable paper

towel.

Wipe over with Clinell Universal wipe

BUCKETS Clean after use, clean with Chlorclean

1,000ppm solution and dry thoroughly

with disposable paper towel

CARPETS Vacuum daily

Scheduled cleaning programme using hot

water extraction.

Contaminated spillage use hot

water extraction and seek advice

from IPC Team.

Steam clean

CATHETERS

CARDIAC INTRAVENOUS.

PERIPHRAL

SUCTION

URETHRAL

All single use do not re-use

CLIP REMOVERS All single use do not re-use

COMMODES After every use wash down with

Chlorclean 1,000ppm solution or wipe with

Clinell universal wipe all over ensuring

underneath commode seat and arms are

clean.

Use green tape around commode seat or

arm to indicate it has been cleaned with

date, time and signature.

Infected patient ensure

commode is designated to

infected patient only

GDH or C. diff patients’

commodes and bedside use

Clinell sporacidal wipes.

CONNECTORS All single use do not re-use

CROCKERY AND CUTLERY 1.Machine wash

2. Hot water and detergent solution, rinse

and dry thoroughly

DUVETS (PLASTIC

COVERED)

As per laundry policy Infected patient wash with

Chlorclean solution 1,000pppm

solution

DRAINAGE BOTTLES Single use do not re-use



ELECTRONIC DEVICES

Ie. INFUSION PUMPS

As per Medical Devices Policy.

Decontaminate prior to returning to

medical Devices Library, use paper towel

and Chlorclean solution 1,000ppm, rinse

and dry thoroughly.

Place in returns bag and seal to avoid cross

contamination.

Ensure decontamination document is

signed for and placed in bag with device.

Consumables ie. tubing, fluid

bags etc dispose in orange clinical

waste bag.

DRESSING TROLLEYS Prior and after each use, trolley should be

cleaned with hot water and detergent

solution, rinse and dry, then wiped over

with Clinell Universal wipe

Use of green tape dated time and

signature.

ENDOSCOPES See detailed departmental cleaning

protocols for washer disinfection

ENT INSTRUMENTS Please refer to ENT departmental

protocols for washer disinfection

FANS Switch off at electrical supply. Damp dust

with detergent solution and allow to dry

thoroughly.

Contaminated equipment use

Chlorclean 1,000ppm solution

FLOORS

(DRYCLEAN)

1.Vacuum clean

2.Use anti-static cloth

Brushes/brooms should not be

used in patient areas

FLOORS

(WET FLOOR)

Wash with hot water and detergent

solution with disposable microfibre/

cotton mop as appropriate, ensure

thoroughly dry.

Contaminated spillage use

Chlorclean 1,000ppm solution or

HAZ tab solution 10,000ppm for

blood spillages

FLOWER VASES Wash in hot soapy water, rinse and dry

thoroughly, store inverted.

FURNITURE/ FITTINGS Damp dust daily with hot water and

detergent solution, if contaminated or

after discharge of patient, use Chlorclean

1,000ppm solution, rinse and dry

thoroughly.

HANDS Refer to Hand Hygiene policy.

Soap and water if visibly soiled and for

patients with C. difficile infection or

gastroenteritis symptoms

Alcohol gel when hands are not visibly

soiled

HAIR BRUSHES/COMBS Single patient use only. Discard after

patient discharged.

HEADPHONES (PATIENT

LINE)

Earphone covers to be changed after each

patient.

Wipe down with Clinell Universal wipe .

HEARING AIDS Refer to ENT Department

recommendations.



HOISTS Wash thoroughly in hot water and

detergent solution, rinse and dry

thoroughly.

Wipe down with a Clinell Universal wipe

after each patient use.

Use green tape to indicate, date, time and

signature.

HUMIDIFIERS Single use only.

Wipe casement with Clinell Universal wipe

INFANT INCUBATORS Wash and disinfect with Chlorclean

solution 1,000ppm, wipe dry with

disposable paper towel.

Alternatively, wash down with hot soapy

water and then wipe with HAZ tab solution

1,000ppm, wipe dry with disposable paper

towel.

INSTRUMENTS (SURGICAL) Return to CSSD for autoclave.

IV STANDS/POLES Wash with hot water and detergent

solution, rinse and dry thoroughly with

disposable paper towel.

Wipe with Clinell Universal wipe.

LARYNGOSCOPES BLADES Single use only – do not re-use.

LINEN Refer to Laundry Policy.

LOCKERS See furniture and fittings.

MATTERESSES

WATER IMPERMEABLE

COVER.

Clean with hot water and detergent, rinse

and dry thoroughly with disposable paper

towels.

Use Chlorclean 1,000ppm solution if visibly

soiled and after every patient on

discharge.

MEDICINE MEASURES Disposable single use only

MICRO FIBRE/ COTTON

MOPS (WET)

Disposable single use

NAIL BRUSHES Disposable single patient use only

NEBULISER MACHINES Tubing single use only.

Dispose in orange clinical waste bag.

Decontaminate as per medical devices

Policy.

Between same patient use, wash measure

in hot soapy water, rinse and dry

thoroughly with paper towel.

OXYGEN TUBING Disposable single use only.



PATIENT’S OWN CLOTHING

(eg. CRAGSIDE UNIT)

The laundry area should be designated for

that purpose only and must not be

situated in an area where food is stored,

prepared, cooked or eaten. The washing

machine requires a sluice & hot wash

cycle. A dryer is recommended to ensure

that clothing is thoroughly dried. There

should be a yearly maintenance

programme and a record kept of these

checks.

The laundry room should be ventilated

with appropriate extraction devices. All

laundry areas must have impermeable

floor surfaces. Walls must be in sound

condition and easily cleaned as necessary.

Hand washing facilities must be available

for staff.

There should be a clear programme for

cleaning the laundry environment.

All horizontal surfaces should be damp-

dusted on a daily basis. Sinks and taps

cleaned daily and when contaminated. A

record of cleaning should be maintained.

Foul or infected clothing should

immediately bagged & must not

be taken through other

patients/individuals rooms.

PATIENT ISOLATION ROOM Refer to Isolation Policy

PATIENT LINE EQUIPMENT Cleaned with Clinell Universal wipes.

Use green tape to indicate date, time and

signature.

See Appendix 6

PAT SLIDE Wash with hot water and detergent


paper towels.

Use Clinell Universal wipes after every

patient use.

Use Chlorclean 1,000ppm if

patient infected or visibly soiled.

PILLOWS As per Laundry Policy

PROCTOSCOPES Disposable single use only

RAZORS Disposable single use only

RESUSCITATION

EQUIPMENT

Disposable single use only

ROOMS For non-infected patients use detergent

solution and hot water, rinse and dry

thoroughly with paper towels.

For terminal enhance clean – use

Chlorclean 1,00ppm solution.

For TB use 5,000ppm HAZ tab

solution

For Blood borne virus HIV,

Hepatitis B & C use HAZ tab

solution 10,000ppm.



SURGICAL SKIN PREP

Chloraprep frepp and sepp solution or

Povidone iodine solution

The use of spirit based skin

disinfectant in conjunction with

diathermy has led to burns to

patients due to ignition of alcohol

vapour that has pooled under

drapes.

Thus if a diathermy is to be used

an alcohol based preparation

should be avoided.

If this is not possible, adequate

time for evaporation must be

allowed before draping the

patient.

SPECULAEUM Disposable preferred.

If reusable return to CSSD after every use

for autoclave.

SUCTION EQUIPMENT 1. Disposable liners

2. Outer carton wash in hot water and


with paper towel

3. Damp dust tops daily

SUCTION

TUBING/CANNULAE

Single use only.

Dispose in orange clinical waste bag.

SYRINGE PUMPS See Medical Devices Policy

THERMOMETERS Individual disposable sleeve discarded

after each patient use.

Wipe casing with Clinell Universal wipes.

TOILET SEATS Wash daily with hot water and detergent


paper towels.

Se Clinell wipe after each use.

If contaminated use Chlorclean

1,000ppm solution

DENTURE POTS Single use only - disposable

TOYS Clean with hot soapy water and dry

thoroughly with paper towels after use or

alternatively a Clinell Universal wipe

Children’s toys should be made

from wipeable/ cleanable

materials. Soft cuddly toys are

not suitable unless patient’s own

TROLLEYS (PORTERS) Clean with hot water and detergent

solution, rinse and dry with paper towels

at least daily.

Clean between each use with Clinell

Universal wipe

If contaminated or used for

infected patient use Chlorclean

solution 1,000ppm.

UNIFORM All uniforms/protective clothing should be

able to withstand a high temperature of

60C, separate from other laundry.

Tumble dried or hot ironed.

See hospital laundry

arrangements or used and fouled

infected linen.

URINALS Disposable single use preferred

Wash reusable in Chlorclean 1,000ppm


paper towels.



URINARY CATHETER BAG

STAND

Wash in hot water with detergent


paper towels.

Wipe with Clinell Universal wipe following

ach use and when visibly contaminated.

VENTILATORS Models with totally detachable, disposable

or Autoclavable circuits are recommended.

Ventilators should be protected by

bacterial filters and changed strictly in

accordance with manufacturer’s

instructions.

Patient’s circuits must be labelled

and dated. A policy for changing

circuits must be held in

department. Twice daily damp

dusting with Clinell Universal

wipes advised for CCD bedside

equipment.

VITALOGRAPH - (as on

CRITICAL CARE

DEPARTMENT)

Autoclave system.

Mouthpieces are disposable.

For tubing and bellows follow

manufacturer’s instructions.

WALL WASHING (also

known as terminal enhance

clean)

There is a wall washing programme for

trust.

Contact Domestic Response

Team via bleep

WASH HAND BASINS Clean with hot water and detergent

solution after use.

Chlorclean and titan sanitiser.

WALKING FRAMES Use hot water and detergent solution,

rinse and dry with paper towels

thoroughly.

Wipe over with Clinell Universal wipe after

each use if not patient’s own and when

visibly dirty.

WHEELCHAIRS Wash using hot water and wash using


thoroughly with paper towels.

Wipe over with Clinell Universal wipe

between each patient use.

WOUND CARE Refer to Nursing Procedures.

XRAY EQUIPMENT Switch off at electrical supply. Damp dust

with detergent solution and allow to dry

thoroughly.

Contaminated equipment use

Chlorclean 1,000ppm solution


Appendix 2

Enhanced Cleaning Guide

During outbreaks/suspected outbreaks of infection it is necessary to increase the frequency of cleaning

provided within a ward/department. The infection prevention and control team in conjunction with Hotel

and Domestic Services initiates this process.

• All surfaces will be cleaned using Chlorclean solution 1,000ppm concentration

(Please use table in section 6.1 as a guide)

• Frequency of cleaning within toilet areas will increase

• Floor surfaces will be vacuumed cleaned, damp mopped and spot cleaned as necessary

• Enhanced cleaning will take place up to one week following the last symptomatic episode.

(This may be reviewed as appropriate by the infection prevention and control team and Hotel and

Domestic Services)

• Terminal Enhanced Cleaning of the whole area will then be systematically carried out

• The correct use of personal protective equipment must be considered following an appropriate risk

assessment.

(Please use IPC policy 2 Personal Protective Clothing in Clinical Practice as a guide)


Appendix 3

Chlorclean Domestic Guide


Appendix 3

Chlorclean Guide Nursing Staff


Appendix 4

NPSA National Colour Coding Scheme


Appendix 5

Cleaning Procedure for Bedside Entertainment System

GATESHEAD HEALTH NHS FOUNDATION TRUST

Procedure

Number

CLEANING PROCEDURES

Page

BEDSIDE ENTERTAINMENT SYSTEM

Revision

0

Weekly clean

Date

13/4/11

Purpose and Scope of Task To remove and collect all dust, dirt and deposits from the surface being

cleaned.

Responsibility Housekeeping Staff

Standard to be Achieved The surface being cleaned will be free from dust, dirt deposits and smears.

Equipment Work Trolley, disposable gloves and apron. Clinell clean label identification

Cleaning Materials Clinell wipes, white roll, orange clinical waste bag,

Environmental Controls Area to be well ventilated.

Floor areas to be maintained clean and dry.

Equipment to be cleaned and stored after use.

Ensure all cleaning products are safely stored away

Step

Procedure

1 Ensure all necessary supplies are placed onto the trolley

2 Move to area of work

3 Wash and dry hands put on a disposable apron and gloves

4 Remove disposable ear sponges and discard into clinical waste

bag

5 Clean the wall mounted box

Using a clinell wipe clean the top, front and sides of the wall

mounted box. Discard wipe into a clinical waste bag.

Using a piece of white roll, wipe over surfaces cleaned to dry

and finish.


6 Clean the wall mounted bracket

Using a clinell wipe, wipe and clean the arm canal bracket

attached to the wall mounted box, ensuring the ledges on the

inside of the bracket are cleaned and free from dust.

Discard wipe into a clinical waste bag.


and finish.

7 Clean the flexible arm

Using a clinell wipe, wipe and clean the arm working from the

top down to the main unit, ensuring all recessed areas are

cleaned and free from dust.



and finish.

8 Clean the monitor

Using a clinell wipe, wipe and clean the main unit back, edges

(sides, top and bottom) and front. Damp wipe clean the handle

pay attention the recessed area underneath the handle.



and finish.

Arm Canal Bracket

Flexible Arm +

Recessed area


9 Clean the Telephone handset

Lift the telephone handset from the receiver; clean the

telephone handset rest position on the monitor.

Continue cleaning the telephone handset cleaning the earpiece;

clean the telephone buttons, in-between the buttons and the

speaker, back, sides and front surfaces of the telephone.

Run the clinell wipe downwards along the telephone coil to the

telephone.



and finish.

10 Clean the TV/Radio Handset

Lift the TV/Radio handset from the receiver, clean the rest

position on the monitor.

Continue cleaning the handset buttons, in-between the

buttons, back, sides and front surfaces of the handset. Open to

hand set out and wipe clean the interior surfaces including the

area between the keyboard buttons.

Run the clinell wipe downwards along the coil to the handset


Using a piece of white roll, wipe over surfaces cleaned close the

handset and continue to dry and finish.

11 Clean the Earphones

Clean the attached headphones using a clinell wipe.

Discard wipe into a clinical waste bag

Dry with white roll

Replace the disposable headphone ear sponges

12 Remove apron and gloves and place into clinical waste bag

13 Wash and dry hand thoroughly

Telephone

Handset

TV Radio

Handset

Run clinell wipe

downwards along

telephone coil

Run clinell wipe downwards

along TV/ Radio handset coil


14 Mark a section of clinell green tape with the current date and

fix to the arm at the connection point to the monitor. This

indicates that the monitor has been fully cleaned ready for the

next user.

15 Update the log sheet recording the cleaning of the equipment.

16 Check stock levels of disposable headphone ear sponges.

Ensure there is sufficient stock for expected activity over

weekends and bank holiday periods.

Additional stocks of disposable headphone ear sponges can be

obtained during Monday – Fridays 9.30am – 7pm by calling:

Hospedia on Ext 3154 or 08454141063 (answer machine)

Clinell green tape

fixed to TV unit


Appendix 6

Single Use Medical Devices Guide


Appendix 7

Clinell Sporicidal Wipe Guide

Cleaning and Disinfection Policy - NHS Gateshead · disinfection or sterilisation (if appropriate)...

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