Cleaning and Disinfection Procedure - Newcastle Hospitals Control... · Page 2 of 15 The Infection...

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The Newcastle upon Tyne Hospitals NHS Foundation Trust

Cleaning and Disinfection Procedure

Version No.: 13.4

Effective From: 23 December 2015

Expiry date: 23 December 2018

Date Ratified: 10th December 2015

Ratified By: IPCC

1. Introduction Healthcare Associated Infections (HCAI) are a major concern both in the acute and community setting. The situation is further worsened by the increasing resistance of microorganisms to common antimicrobial agents. The cost of HCAI is huge and includes both the financial costs to the NHS and the direct effects on the patient and their carers in terms of increased morbidity/mortality and also the psychosocial aspects of some of the HCAI. Not all HCAI can be avoided but a significant proportion can be prevented by the adoption of evidenced-based Infection Prevention and Control (IPC) standards. Using preventative measures that are based on reliable evidence of efficacy is a core component of an effective strategy designed to protect patients from the risk of infection. 2. Scope This procedure applies to all healthcare professionals working across acute and community services within Newcastle upon Tyne Hospitals NHS Foundation Trust. This includes medical staff, nurses, allied health professionals and students. 3. Aim

The aim of this procedure is to minimize exposure to and transmission of potentially pathogenic microorganisms and clearly defines how to clean and disinfect patient equipment. It should be read in conjunction with Guidelines for the Management of Patients with Blood-borne Viral Infections, the Cleaning and Disinfection of Endoscopes Policy, Waste Management Policy and Procedures, Decontamination of healthcare equipment following patient use and prior to service and/or repair, Decontamination of the Patient Environment (including Terminal and Deep Cleaning) 4. Duties (Roles and Responsibilities)

The Chief Executive has overall responsibility for the implementation, monitoring and review of this procedure

This responsibility is delegated to the Director of Infection Prevention and Control (DIPC)

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The Infection Prevention and Control Committee (IPCC) will review the procedure and any new evidence base within the time frame set out in the procedure

It is the responsibility of the Trust to ensure that policies, education, training and procedures are in place to minimize the risk of infection

It is the responsibility of the Trust/line managers and service heads to ensure that policies, procedures and access to education and training are made available to all staff

It is the responsibility of all staff to ensure that they understand and implement this policy and attend training sessions as specified in their role

The responsibility for delegation of decontamination lies with the nurse in charge of the ward/department

The nurse in charge must ensure that staff are educated/trained to an appropriate level in their assigned cleaning tasks

Community staff have an individual responsibility to ensure any items of equipment are decontaminated in line with this policy

5. Definitions

Infection Prevention and Control (IPC)

Director of Infection Prevention and Control (DIPC)

Infection Prevention and Control Committee (IPCC)

Healthcare Associated Infections (HCAI)

Control of Substances Hazardous to Health (C.O.S.H.H.)

Personal Protective Equipment (PPE)

Clinical Assurance Tool (CAT)

Community Environment Action Team (CEAT)

6. Decontamination

6.1 Effective Hand Hygiene

The most simple and effective way to prevent HCAIs is by undertaking effective hand hygiene. The Trust recommends that hands are decontaminated in accordance with the ‘5 Moments for Hand Hygiene’. (Refer to the Trust Hand Hygiene Policy).

6.2 Glossary of terms

Table 1

DECONTAMINATION The combination of processes (including cleaning, disinfection and sterilisation) used to render a re-usable item safe for further use on patients and handling by staff. Effective decontamination is essential in reducing the risk of transmission of infectious agents

CONTAMINATION The soiling or pollution of inanimate objects or living material with harmful, potentially infectious or unwanted material


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CLEANING The process that physically reduces the level of contamination (organic matter, dirt, grease) but does not destroy all organisms

DISINFECTION The partial removal or destruction of organisms except spores

STERILISATION The process used to render an object free from all organisms including spores

SINGLE PATIENT USE

Any device deemed unsuitable for re-processing and so stated by the manufacturers. Equipment so labelled may be used a number of times by the same patient only

SINGLE USE/ DISPOSABLE

Any device deemed unsuitable for re-processing and so stated by the manufacturers. Dispose of after each use

N.B. The terms sterilisation and disinfection are often used incorrectly, for example: it is not correct to refer to the immersion of baby bottles in a hypochlorite solution as sterilisation. In fact, this is a disinfection procedure that destroys some but not all organisms present. No new item of equipment intended for disinfection or sterilisation prior to re-use should be purchased without consulting a member of the Infection Prevention and Control Team before purchase. The conscientious application of decontamination procedures and policies are of utmost importance in the prevention of cross-infection to individual patients and staff. Always refer to the manufacturer’s instructions in the first instance. If further advice or clarification is required, then contact a member of the Infection Prevention and Control Team. The thoroughness of cleaning/disinfection is as important as the agent used. It is important to emphasise that thorough physical cleaning must be the first step in decontamination. Failure to achieve this will subsequently render applied methods such as chemical disinfection ineffective. Heat disinfection is preferable to chemical disinfection and therefore should always be considered in the first instance.

6.3 Control of Substances Hazardous to Health (C.O.S.H.H. 1989)

The C.O.S.H.H. Regulations require employers to evaluate and control the risks to health for all their employees from exposure to hazardous substances at work. This includes microbiological agents and chemicals hazardous to health. A C.O.S.H.H. assessment should be undertaken by a competent person, e.g. appropriately trained individual If in doubt about situations not specifically mentioned in this document please contact a member of Health and Safety or Infection Prevention and Control Team.

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6.4 National Categories of Decontamination (Department of Health2004a) Table 2

INDICATION LEVEL OF DECONTAMINATION

METHOD

HIGH RISK Items that come into contact with or penetrate skin/mucous membranes or enter a sterile body area

Sterilisation Autoclave; Ethylene Oxide

MEDIUM RISK Items that have contact with mucous membranes or are contaminated with organisms that are easily transmitted

Disinfection; Sterilisation

Autoclave; Heat disinfection; Chemical disinfection

LOW RISK Items used on intact skin

Clean Wash with detergent, hot water/universal sanitising wipes

6.5 Cleaning Standards and Principles for Healthcare Staff

6.5.1 Standards

• Equipment is free from all dirt e.g. soiling, smudges, dust, fingerprints and grease

• Equipment is free of tape/plastic etc., which may compromise cleaning

• Equipment legs, wheels and castors are free from mop strings, dust, soiling, etc.

6.5.2 Principles

Clean hands

Risk assess the requirement for PPE for the task to be performed e.g. gloves, apron, visor

Select correct cleaning materials (refer to Table 3 or manufacturers guidance)

If using Actichlor plus solution dispense into a bowl and only dip clean, unused cloths into the solution once throughout the process (i.e. do not dip used cloths into the solution)

Remove heavy soiling prior to cleaning as this will reduce the effectiveness of the disinfectant

Use new wipe / solution soaked cloth

Wipe all surfaces including underneath, paying particular attention to ‘high touch’ points

Wipe from top to bottom and from clean to dirty, going from clean to

dirty area using an ‘S’ shaped motion for surfaces. (Overlap slightly and

return outside the surface, to avoid missing areas)

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Avoid transferring microorganisms, dispose of wipe / cloth between each separate surface or if it becomes dry or soiled

If using Actichlor plus ensure contact time of 5 minutes for routine cleaning and 10 minutes if for sporicidal cleaning e.g. in cases of Clostridium difficile; rinse with water

If using Actichlor plus dry surface with clean cloth if very wet, after rinsing

Leave to air dry if using Clinell universal sanitising wipes

Once complete, remove PPE and wash hands with liquid soap and water

Apply Clinell indicator tape for commodes

Report any damage to equipment – may need replacing

All equipment MUST clean and ready for patient use before being placed in storage areas

Where universal sanitising wipes are recommended for routine cleaning of clinical equipment, this should be replaced by disinfection with combined detergent/chlorine releasing agent 1000ppm following use in an isolation area if in accordance with manufacturer’s guidance.

The table below gives general guidance on how to decontaminate patient equipment. However, this list is not exhaustive therefore if necessary advice should be sought from the Infection Prevention and Control Team.

Table 3

EQUIPMENT FREQUENCY DECONTAMINATION REGIMEN

Anaesthetic Equipment

Following patient use Single use or return to SSD for reprocessing, in accordance with manufacture’s guidance

Anaesthetic Machines

Following each patient use

Disinfect with combined detergent/chlorine releasing agent 1000 ppm and dry thoroughly

ED Trolleys (including mattresses)


Wash with detergent and hand hot water, dry thoroughly or decontaminate with universal sanitising wipes, (except in case of known/suspected infectious diarrhoea, use a combined detergent/chlorine releasing agent 1000ppm)

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Baby Feeding Equipment


Pre sterilised, single use bottles OR single patient use – rinse in cold water, wash thoroughly in hand hot water and detergent. Rinse thoroughly again, then immerse in hypochlorite solution of 125 ppm available chlorine for 30 minutes (minimum). Air bubbles must be expelled and items must be fully submersed. Dispose of at discharge or after 7 days, whichever is soonest. Breast feeding equipment, wash with hand hot water, rinse and dry thoroughly

Baths Following each patient use

Disinfect with combined detergent/chlorine releasing agent 1000 ppm and rinse thoroughly

Baths, Arjo Following each patient use

As per manufacturer’s instructions

Bed Pan Holders Following each patient use


Bed Pan Macerators/Washers (external body only)

Daily/following contamination

Disinfect with combined detergent/chlorine releasing agent 1000ppm

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Beds, including mattresses, crash mats, sensor mats, pillows, bed frames and duvets

Following each patient use / discharge

Whilst patient is occupying bed space

Disinfect with combined detergent/chlorine releasing agent 1000ppm and dry thoroughly. Mattress must be rinsed with cold water and dried thoroughly

Decontaminate with universal sanitising wipes

Community - returned to Loan equipment for decontamination/servicing when no longer required

Bowls (Washing) Following each patient use

Wash with detergent and hand hot water after each use. Rinse and dry thoroughly. Store separately and inverted (pyramid style)

Blood Warmers Following each patient use


BP Cuffs Following each patient use


Commodes Following each patient use

Disinfect with sporicidal product e.g. combined detergent/chlorine releasing agent 1000 ppm and dry thoroughly

Community – returned to Loan equipment for decontamination when no longer required

Computers/Computer keyboards/External surfaces of computer trolleys and carts

Daily or when keyboard cleaning indicator flashes


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Cots Following each patient use

Whilst patient is occupying bed space

Disinfect with combined detergent/chlorine releasing agent 1000ppm and dry thoroughly. Mattress and bed frame must be rinsed with cold water and dried thoroughly


Dressing Trolleys Following each patient use

Decontaminate with universal sanitising wipes at start of day when visibly soiled, and between each use

Drip Stands Weekly/following patient use


Drug Fridge Weekly Wash with detergent and hand hot water

Ear syringing equipment

Single patient use

Examination Couches/Podiatry chairs


Daily decontamination with universal sanitising wipes

Weekly clean with combined detergent /chlorine releasing agent 1000ppm, rinse with cold water and dry thoroughly

Fans Weekly/when visibly dusty

Decontaminate with universal sanitising wipes externally. When dusty internally contact the Estates Department

Flower Containers Weekly or following patient use

Wash with hand hot water and detergent, rinse, dry and store inverted

Fridge (Specimen) Weekly Wash with hand hot water and detergent

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Hoists (Frame) Following each patient use


Community – returned to loan equipment when no longer required

Humidifiers (equipment)

Following each use Single patient use. Clean mask with hot water and detergent, rinse with hot water and dry thoroughly after each use with the same patient N.B. Fluids, including water used for inhalation therapy MUST BE STERILE

Humidifiers (machine)

Daily Wash with detergent and hand hot water or universal sanitising wipes

Incubators Following each patient/weekly

Wash with hand hot water and detergent, rinse and dry

IV Pumps Following each patient use/weekly


Linen Skips Daily Decontaminate with universal sanitising wipes

Medicine Pots Following each patient use

Disposable OR wash with hand hot water and detergent, dry thoroughly. DO NOT WASH IN HAND WASH BASIN

Medicine Trolley Weekly Wash with detergent and hand hot water or universal sanitising wipes

Monitors Daily Decontaminate with universal sanitising wipes

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Nebulisers Following each use In most circumstances they are single use (refer to manufacturer’s guidelines). For single patient use wash in a clean sink with hot water and detergent, completely immerse, rinse with hot water and dry thoroughly. See Critical Care Bedside Disposable Guidelines for drying procedure

Notes Trolleys Weekly Wash with detergent and hand hot water or universal sanitising wipes

Nurse Call System Following patient discharge/transfer from bed area


Outpatient Trolleys At the end of each day - if trolley is used in conjunction with paper roll

Daily decontamination with universal sanitising wipes

Weekly clean with combined detergent /chlorine releasing agent 1000ppm, rinse with cold water and dry thoroughly

Oxygen Point Daily Decontaminate with universal sanitising wipes

Oxygen Saturation Probe

Following each patient use.


Patient Chart Holders Weekly/following patient discharge

Decontaminate with universal sanitising wipes. Disinfect with combined detergent/chlorine releasing agent 1000 ppm on patient discharge

Pendants Daily/following patient discharge.

Disinfect with combined detergent/chlorine releasing agent 1000 ppm

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Plastic Storage Containers and Shelves in clinical areas

Weekly Wash with detergent and hand hot water, dry thoroughly or universal sanitising wipes

Plastic IV Trays Following each patient use


Polyprophylene urinals


See Trust guidelines for using Polyprophylene Urinals

Polyprophylene urinal bed holders

Daily See Trust guidelines for using Polyprophylene Urinals

Pressure Bags (reusable)

Following each patient use. Theatres - prior to and following each patient use

Disinfect with combined detergent/chlorine releasing agent 1000 ppm (See Appendix 1)

Pumps (IV)/Syringe Drivers

Daily/following each patient use


Pulse Oximeters Following each patient use


Resus Trolley Weekly Decontaminate with universal sanitising wipes

Scales/baby scales Following each patient use/weekly


Slings Following patient discharge

Single use/single patient use OR return to Laundry on discharge/if visibly contaminated

Stethoscopes Following each patient use


Storage cupboards e.g. pharmacy, SSD

Weekly Wash with detergent and hand hot water, dry thoroughly or decontaminate with universal sanitising wipes

Suction Units Weekly/following each patient use

Decontaminated with universal sanitising wipes









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Syringe drivers After each patient use Decontaminate with universal sanitising wipe. If contaminated follow manufactures instructions.

Theatre Table, Procedure Stool, Lights

Table and stools, following each patient, lights at the beginning and end of the day

Wash with detergent and hand hot water, dry thoroughly or decontaminate with universal sanitising wipes in between patients. At the end of the list or after an infected case disinfect with combined detergent/chlorine releasing agent 1000 ppm

Theatre Trolleys Following each patient use

Wash with detergent and hand hot water, dry thoroughly or decontaminate with universal sanitising wipes in between patients. At the end of the list or after an infected case disinfect with combined detergent/chlorine releasing agent 1000 ppm

Toys Weekly/following individual patient use

Refer to Trust Toy Cleaning Guidelines on intranet

Tracheostomy – inner cannula

Minimum twice per shift or more frequently as clinically indicated

Acute - Cleaned at bedside using a disposable plastic bowl and bottled sterile water. Where required, disposable sponges in accordance with manufacturers guidance, can be used. Inner cannula must be dried and stored in a screw-top container, labelled with the patient’s details. Water used for cleaning to be disposed of in dirty utility. Refer to Trust Tracheostomy Workbook and Competency Pack 2015. Community – refer to manufacturers guidance



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Tympanic Thermometers


Decontaminate thermometer body, between patients, with universal sanitising wipes. Decontaminate tip and lens on a daily basis (provided lens cover is used) using isopropyl alcohol 70% wipe

Ventilators/Non invasive ventilators

Daily/following each patient use

Clean daily with universal sanitising wipes. Between patients disinfect with combined detergent/chlorine releasing agent 1000 ppm

Walking Frame/Walking sticks


Wash with detergent and hand hot water or universal sanitising wipes.

Community - returned to Loan equipment for decontamination when no longer required

Wheelchairs, ward/department owned



Community- returned to loan equipment for decontamination when no longer required

Frequency of cleaning activity may alter if/when contamination has occurred

All stored equipment must be cleaned weekly. All stored equipment is considered clean and therefore indicative labelling is not required (except commodes)

Trolleys/wheelchairs not belonging to a particular ward/department must

be cleaned/decontaminated by the regular users, e.g. porters

Cleaning regimens must be documented and available

For specific anaesthetic/ventilation equipment refer to manufacturer’s

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guidance

Toys used on the SCIDS Unit, RVI are designated single patient use only

For patients nursed in isolation, equipment should be cleaned/decontaminated according to Trust policy for Decontamination of the Patient Environment (including Terminal and Deep Cleaning)

Any items of equipment used for patient care in the community which are to

be returned to Loan equipment for decontamination, must be thoroughly cleaned with a universal sanitising wipe prior to collection by the Loan equipment Service

All static/dynamic mattresses used for patients in the community are returned

to Loan equipment for decontamination when no longer required. Further advice on the decontamination of mattresses can be found in Decontamination of the Patient Environment (including Terminal and Deep Cleaning)

Single use items must NEVER be re-used

All spillages must be regarded as potentially hazardous and be dealt

with immediately

All appropriate PPE must be provided and worn when dealing with any spillages

Responsibility for spillages: Clinical Area – member of ward staff Non-clinical Area – member of staff During Transit – porter or driver

If equipment is contaminated with blood or blood stained body fluids it must be cleaned with 10,000ppm chlorine releasing agent, rinsed and dried thoroughly. For further information on the management of blood spillages please refer to the information in the spill kits on wards/departments and Trust Standard Precautions Policy.

7. Training

IPC e-Learning packages, available on the Trust intranet, are mandatory for all Trust staff on induction and annually thereafter as outlined in the Mandatory Training Policy. This programme contains hand hygiene training which all Trust staff must access, complete and pass. The training is recorded through the e-Learning completion software and reported to the Trust Education Group, Trust Board and Executive.

8. Equality and Diversity The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their

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individual needs and does not discriminate against individuals or groups on any grounds. This policy has been appropriately assessed.

9. Monitoring

Standard/process/issue Monitoring and audit

Method By Committee Frequency

Acute setting Clinical Assurance Tool (CAT)

Sister/ Charge Nurse/ Department Manager/ Matron

IPCC Monthly

Community setting Community Environment Action Team

Clinical Lead/ IPCN

IPCC Quarterly

Clinical Assurance Tool (CAT) incorporating Matrons monthly cleanliness checks monitors standards of environmental cleanliness. The CAT scorecard is reported to Trust Board, IPCC and Directorate Managers on a monthly basis. Community Environmental Action Team (CEAT) inspections monitor standards of environmental cleanliness and the results are reported to IPCC on a quarterly basis.

10. Consultation and review

The policy will be formally reviewed every three years, or more frequently if national or local policy or procedural change.

11. Implementation (including raising awareness)

Matrons/Sisters/Charge Nurses and Clinical Leads should ensure that staff are aware of this procedure. This procedure is available for staff to access via NUTH intranet. 12. References

COSHH 1989 National Categories of Decontamination

National Standards for Cleanliness

Health and Safety Executive (2005) COSHH: a brief guide to the Regulations: What you need to know about the Control of Substances Hazardous to Health Regulations

2002 (COSHH). London: HSE. Available from : www.hse.gov.uk/pubns/indg136.pdf

The NHS Cleaning Manual, National Patient Safety Agency (2009)

Decontamination of Healthcare Equipment following Patient Use and Prior to Service and/or Repair

Decontamination of the Patient Environment (including Terminal and Deep Cleaning) Cleaning and Environmental Strategy

Isolation Policy

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Appendix 1

Guidelines for using Pressure Infusion Bags

The Trust has selected two types of pressure infusor bags. The Smiths Medex Clear Cuff Reusable Pressure Infusor and the Leonard Laing Disposable Single Use Pressure Infusor, both are available in 500ml and 1000ml. The re-usable bag is for general patient use. The disposable bag is for patients in isolation. Decontamination of the re-usable pressure bag: All parts of the re-usable pressure bag including the clear cuff, built in hook, stopcock, hand bulb and pressure gauge, can be decontaminated at the patient bed side following each patient use with a solution of 1000ppm available chlorine. In the event of contamination with blood/bodily fluids decontaminate with 10,000ppm available chlorine. They must not be soaked or immersed in chlorine solution and they must be thoroughly dried prior to storage in a dedicated equipment store. The following standard must be attained:

The single-use bag must never be re-used

The patients name must be written on the single-use bag using a permanent marker

If there is visible evidence of a breach in the integrity of the pressure bags then they must be discarded in accordance with the Trust Waste Policy

Pressure bags used in theatres must be decontaminated prior to and following each patient use

Single-use bags are restricted for patients in isolation. Upon cessation of isolation the bag must be discarded. If the patient requires ongoing invasive monitoring a re-usable bag should be used

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The Newcastle upon Tyne Hospitals NHS Foundation Trust

Equality Analysis Form A

This form must be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval.

PART 1 1. Assessment Date: 2. Name of policy / strategy / service:

Cleaning and Disinfection Procedure

3. Name and designation of Author:

Louise Hall, Matron IPC

4. Names & designations of those involved in the impact analysis screening process:

Dr Ashley Price, DIPC,

5. Is this a: Policy Strategy Service

Is this: New Revised

Who is affected Employees Service Users

Wider Community

6. What are the main aims, objectives of the policy, strategy, or service and the intended outcomes? (These can be cut and pasted from your policy)

7. Does this policy, strategy, or service have any equality implications? Yes No X

If No, state reasons and the information used to make this decision, please refer to paragraph 2.3 of the Equality Analysis Guidance before providing reasons:

The policy refers to processes for cleaning. There is no difference in how this is carried out for people with protected characteristics.

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8. Summary of evidence related to protected characteristics Protected Characteristic Evidence, i.e. What evidence do

you have that the Trust is meeting the needs of people in various protected Groups

Does evidence/engagement highlight areas of direct or indirect discrimination? If yes describe steps to be taken to address (by whom, completion date and review date)

Does the evidence highlight any areas to advance opportunities or foster good relations. If yes what steps will be taken? (by whom, completion date and review date)

Race / Ethnic origin (including gypsies and travellers)

None relevant to this policy None None

Sex (male/ female) None relevant to this policy None None Religion and Belief None relevant to this policy None None Sexual orientation including lesbian, gay and bisexual people

None relevant to this policy None None

Age None relevant to this policy None None Disability – learning difficulties, physical disability, sensory impairment and mental health. Consider the needs of carers in this section

Cleaning of patients equipment such as wheelchairs is referred to in the wheelchair policy.

None None

Gender Re-assignment None relevant to this policy None None Marriage and Civil Partnership None relevant to this policy None None Maternity / Pregnancy There are no identified

hazards for pregnant or breast feeding women related to the solutions used for cleaning

None None

9. Are there any gaps in the evidence outlined above? If ‘yes’ how will these be rectified?

No

10. Engagement has taken place with people who have protected characteristics and will continue through the Equality Delivery

System and the Equality Diversity and Human Rights Group. Please note you may require further engagement in respect of any significant changes to policies, new developments and or changes to service delivery. In such circumstances please contact the Equality and Diversity Lead or the Involvement and Equalities Officer.

Do you require further engagement? Yes No x

11. Could the policy, strategy or service have a negative impact on human rights? (E.g. the right to respect for private and family life, the right to a fair hearing and the right to education?

No

PART 2 Name:

Louise Hall

Date of completion:

26/11/2015

(If any reader of this procedural document identifies a potential discriminatory impact that has not been identified, please refer to the Policy Author identified above, together with any suggestions for action required to avoid/reduce the impact.)

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