A CLEANLINESS GUIDELINE FOR HEALTH WORKERS

MARCH 2015

Draft

FOREWORD

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CONTENTS

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ABBREVIATIONS

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DEFINITIONS

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• Anti microbial resistance: Resistance of micro organisms to an antibiotic, antifungal, antiviral or antiseptic that are designed to destroy or inhibit their growth.

• Antiseptic: A chemical substance which is used to reduce bacteria from the skin surface. These are not interchangeable with surface disinfectants that should never be used on the skin. There are two antiseptics which have a sustained anti-microbial action, i.e. chlorhexidine and povidone iodine.

• Biohazard: A potentially dangerous infectious agent that may be found in clinical health care settings and clinical microbiology laboratories.

• Cleaning: The physical removal of soiling/contamination or pollutant from surfaces or objects thereby making them safe for use.

• Contamination: The soiling or pollution by inferior material such as micro-organisms or radioactive material on areas or equipment that is not desired and where its presence is harmful or constitutes a hazard.

• Detergent: An agent that possesses ability to purify or cleanse. They are composed of both hydrophilic and lipophilic parts and can be divided into four groups: anionic, cationic, amphoteric, and nonionic detergents. Although products used for hand washing or antiseptic hand wash in health-care settings represent various types of detergents, any form of “soap” as used in this guideline refers to “a detergent”.

• Disinfectant: An agent that destroys or inhibits replication of some or most micro-organisms. It is commonly used for cleaning of surfaces of equipment and operational surfaces. These exclude human skin.

• Disinfection: A process of destroying pathogenic organisms or rendering them inert especially as applied to the treatment of inanimate (inactive) materials to reduce or eliminate infectious organisms.

• Fomites: An object that in itself is not harmful but is able to harbour pathogenic micro-organisms and thus may serve as an agent for transmission of an infection.

• Hand antisepsis: Agents that are used to cleanse hands.

• Hand decontamination (also known as hand hygiene): It is achieved by effective hand washing through the use of running water and antiseptic hand wash or alcohol hand rub agents and drying, to remove visible or non-visible contaminating agents on hands.

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• Hand hygiene: Personal maintenance of cleanliness of hands using clean, running water and antiseptic hand wash or hand rub agents.

• Hand rub agent: An alcohol-containing preparation designed for application to the hands to reduce the number of viable microorganisms on the hands. In most instances such preparations usually contain 60%–95% ethanol or isopropanol.

• Healthcare waste: Refers to waste that is generated from any health care organisation and has the potential to pose a health risk to the public and the environment e.g. radio-active substances, gas, flammable liquids and solids, used fomites and other equipment.

• Infested linen: Linen that has been exposed to ecto-parasites such as ticks, lice, bed bugs, fleas, rodents, etc.

• Micro-organisms: A group of micro-organisms that include bacteria, fungi, viruses and parasites. Not all micro-organisms can cause diseases or infections.

• Nosocomial infection: An infection that is acquired by the patient from the hospital (health establishment) which the patient did not have when coming to the hospital (health establishment) in the first place.

• Pathogen: An infectious organism such as bacteria, viruses and fungi that causes disease.

• Resident micro-organisms: Micro-organisms that live on the skin and protect the skin against invasion by harmful bacteria/transient micro-organisms. They are not easily removed by friction of hand washing but their removal is desirable before performing invasive procedures like surgery.

• Soiled / Dirty linen: Linen that has been used in patient care irrespective of visibility or non-visibility of soiling agents such as infected or non-infected blood, body fluids and other human excreta on it.

• Standard Precaution: A universal activity that is embarked on as a way of preventing an unwanted happening regardless of the presumed or potential presence of a risk, for example washing of hands with antiseptic and the wearing of a plastic apron before and after interacting with the patient.

• Surgical scrub: Thorough washing of hands, forearms and nails such as before surgery, using a soft, non-abrasive brush as well as an implement.

• Terminal disinfection: A process of destroying pathogenic organisms or rendering them inert especially as applied to the treatment of inanimate materials to reduce or eliminate infectious organisms at the end of patient stay in a specified area or room. This process of cleaning usually happens after the patient is removed from the room/ward after being cured from an infectious disease, discharged, transferred out or died.

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• Theatre linen: Cotton drapes that are used in sterile fields in the operating theatre and are sterilized by the Central Sterilizing Services Department (CSSD) after it has been laundered.

• Transient micro-organisms: are not constantly on the skin but are acquired by direct contact with infected patient, equipment or the environment. Such micro-organisms can however, survive on the hands and are easily cross-transmitted to others. Removal of transient micro- organisms in particular, through effective hand hygiene is essential in preventing cross infection.

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REGULATORY AND POLICY FRAMEWORK

The following regulatory and policy frameworks govern this guideline:

National Health Act, 2003 (Act No. 61 of 2003)

Occupational Health and Safety Act, 1993 (Act No. 85 of 1993)

National Environment Management: Waste Act, 2008 (Act No. 59 of 2008)

Environment Conservation Act, 1989 (Act No. 73 of 1989)

Foodstuff, Cosmetic and Disinfectants Act, 1972 (Act No. 54 of 1972)

Fertilizers, Farm Feeds, Agricultural Remedies Act, 1947 (Act No. 36 of 1947)

Biological Hazard Regulation No R 1390:27, December 2001

The National Infection Prevention and Control Policy and Strategy, 2007 (NDOH)

Infection Control Assessment Tool: A Standardized Approach for Improving Hospital Infection Control Practices, March 2014 (NDOH)

National Core Standards for Health Establishments in South Africa, 2011 (NDOH)

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Scope of the Guideline

This guideline shall apply to all healthcare providers in public health establishment of South Africa.

CHAPTER 1: PERSONAL HYGIENE

1.1 Hand Hygiene Hand hygiene is a general term that applies to personal maintenance of cleanliness of hands using

clean, running water and antiseptic hand wash or hand-rub agents. Hand hygiene substantially

reduces potential pathogens on the hands and is considered a primary measure for reducing the

risk of transmitting pathogens to patients and staff members. Various studies have demonstrated

that poor hand hygiene practices are associated with health care-associated cross-infections,

the spread of multi-resistant organisms e.g. methicilin-resistant Staphylococcus aureus (MRSA),

Acinetobacter spp and other antibiotic resistant Gram negative bacteria and viruses. Some common micro-

organisms that are carried by hands can be diagrammatically depicted as follows:

Figure1: Germs that are found on the hands7

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The figure above demonstrates that hands are the main sources of transmission and spread of

bacteria, fungi and viruses that cause various diseases. Poor hand hygiene therefore has the

possibility of causing outbreak of many infections and diseases. It is in this regard that high

mortality and morbidity, as well as increasing litigations related to health associated infections in

healthcare establishments, is partially associated with poor hand hygiene practices. Studies have

also shown that the prevalence of health care-associated infections decreased as hand hygiene

measures improved1&2.

Proper hand hygiene in a health establishment is possible only where the necessary resources

for hand washing are readily available. These include:

i) Designated and dedicated hand wash basins (open plug) equipped with constant clean,

running water. It should be noted that the basin must never be used for disposing any other

liquid waste.

ii) Elbow or foot-operated water mixer taps.

iii) Wall-mounted liquid pumped soap dispenser or bottle pump above the hand wash basin.

Liquid soap dispensers are designed in such a way that contamination of the dispenser’s nipple

is not easy.

iv) Plain liquid soap for routine hand washing. While plain soaps have little or no antimicrobial

activity, antimicrobial agents are sometimes added to soaps to give them limited germicidal

properties. Soap can become contaminated with resistant organisms and can increase the

microorganisms on the hands after washing. It is in this regard that use of soap bars for general

hand washing is avoided because they are exposed to the air, remain moist after lathering and

carry debris from previously washed hands, making them readily contaminated.

v) Antibacterial liquid hand washing soap to be used in high risk areas such as ICU, high care,

operating theatres and neonatal units.

vi) Disposable paper towels.

vii) Functional pedal waste bins (foot operated). However, foot (pedal) operated bins should

preferably not to be used in isolation areas due to the difficulty in disinfecting the hinge

mechanism parts of the bin.

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viii)Various cleansing liquids with alcohol used for hand rub. Alcohol-based cleansing products are

supplemented with additives to increase the germicidal activity of the product. Different

additives have different germicidal properties. Some of the commonly used additives are

described below.

- Quaternary ammonium compounds have proven to be as effective as soap and water.

They have a low germicidal activity against gram-negative bacteria, rendering them

susceptible to contamination with these organisms. These products should not be used for

antiseptic hand hygiene.

- Chlorohexidine is added to soaps and alcohol-based products to give them increased

antimicrobial activity. It also provides some residual activity which may reduce

multiplication of organisms that might have been left behind. Instances have been

recorded where chlorohexidine products have become infected by chlorohexidine-resistant

microbes, resulting in hospital-acquired infections / nosocomial infections.

- Hexachlorophene (sometimes also known as Nabac) is a topical antibacterial cleanser. It

works like a detergent to cleanse skin and to prevent the growth of certain bacteria.

Hexachlorophene is absorbed through the skin and should therefore not be used to bathe

patients with burns or sensitive skin areas. Being absorbed through the skin can lead to

neurotoxicity especially in newborns, and should therefore not be used to bath babies.

- Chloroxylenol has a combined antibacterial and anesthetic action. It kills sensitive bacteria

and fungi while at the same time it numbs the treated area. It is absorbed through the

skin, but less effectively than hexachlorophene.

- Iodophors are active against a wide spectrum of microorganisms, but are known to cause

skin irritation more often than other preparations. It has largely replaced iodine in health

care settings because of the skin discolouration and irritation that is caused by iodine.

Iodophors contain iodine with a polymer carrier to make them less irritating.

The efficacy of these alcohol based hand washing liquids is determined by the amount being used

to wash as well the amount of time they spend on the individual’s skin. It is therefore important

to ensure that hands are dry when the product is applied since water dilutes the washing liquids.

Enough of the product must be applied to thoroughly moisten the entire hand, including the wrists

and the finger tips at the space under the fingernails (subungual space). If hands feel dry after 10-

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15 seconds, it is likely that too little product was applied therefore a need to pour more liquid on

the hands.

Staff members should obey the following principles for hand hygiene at all times so as to reduce

the risk of storing and transmitting pathogens:

Fingernails should be kept short and clean, because in many instances the space under

fingernails harbours more types of bacteria than the rest of the hand.

No nail polish or acrylic nails (artificial nails), because microscopic cracks in the nail polish

or acryl also carry the potential of harbouring unwanted bacteria.

No jewellery on hands and forearms. Rings with gemstones interfere with proper hand

washing and donning of gloves.

No jewellery that hangs from the ears and chest of staff members as it poses risk of cross

infection.

.1.1 When to wash hands

1.1.1 When to wash hands

Hand washing while in a health care establishment is informed by the risk of cross infection of

pathogens from one person to another especially on direct contact. Hand washing should

therefore be performed3.

• Before every contact with a patient.

• After exposure / contact with any body fluids or even if there is no noticeable contact.

Body fluids include urine, faeces, mucus, wound exudates, saliva and blood.

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Understanding critical times for hand washing and following proper

hand washing techniques that are in line with intended purpose

should always be observed.

• Before and after performance of any aseptic procedure e.g. insertion of indwelling

catheters that includes urinary catheters, central and peripheral intravascular catheters

and other invasive procedures that require wearing of gloves. Hands should also be washed

immediately after removal of gloves.

• After having had contact with a patient e.g. position changing, measuring vital signs,

changing of clothes or linen, etc.

• After contact with patient surroundings. Hands should be cleaned even if a patient has not

been touched, e.g. after touching inanimate objects (including medical equipment, patient

files) that are in the immediate vicinity of the patient.

Deciding on washing of hands can be depicted diagrammatically as follows:

Figure 2: Five moments for hand hygiene3

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The frequent washing of hands with soaps and antiseptic agents can cause a dryness of the skin

and a chronic irritant contact dermatitis. Damage to the skin changes skin flora, resulting in more

frequent colonisation by staphylococci and gram-negative bacteria. This by implication therefore

means that frequent hand washing becomes even that more important and good hand care thus a necessity. Lotions are often recommended to ease dryness of the skin and to prevent

contact dermatitis caused by frequent hand washing and excessive glove use. Lotions containing

petroleum or other oil emollients should only be used at the end of the workday, because

petroleum-based lotion formulation can weaken latex gloves and increase its permeability. If

using lotions during the workday, a water-based product should be selected. It is always advisable

to obtain from the manufacturer information regarding the interaction between gloves, lotions,

antimicrobial products, and dental materials6.

1.1.2 Hand washing techniques

While the majority of hands washing techniques require the presence of clean, running water and

liquid soap, various hand washing techniques are required for different purposes e.g. routine hand

washing, antiseptic hand washing, antiseptic hand scrub and surgical antisepsis. The basic

technique that is followed for hand washing takes 40-60 seconds and requires the following steps:

Step 1: Wet hands with water and apply enough soap to cover all hand surfaces.

Step 2: Rub hands palm to palm.

Step 3: Rub right palm over left dorsum with interlaced fingers and vice versa.

Step 4: Rub palm to palm with fingers interlaced.

Step 5: Backs of fingers to opposing palms with fingers interlocked.

Step 6: Rotational rubbing of left thumb clasped in right palm and vice versa.

Step 7: Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa.

Step 8: Rinse hands with water.

Step 9: Dry thoroughly with a disposable towel.

Step 10: Use the elbow or another piece of disposable towel to turn off the tap.

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Figure 3: Hand washing technique3

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1.1.2.1 Routine hand washing

Routine hand washing is the removal of transient micro-organisms, visible dirt or grime with plain

liquid soap (non-antimicrobial) and clean, running water and subsequent drying. Hand washing

thereof requires that one:

1) Wets hands with clean water and apply liquid soap liberally on the inside and outside of

the hand and between the fingers,

2) Rub palms together to scrub,

3) Rub in between fingers, the back of the hand and the wrist,

4) Rinse hands thoroughly with running water,

5) Dry hands with a clean disposable paper towel, and

6) Dispose the used paper towel in the waste bin.

This method of removal of micro-organisms and grime is sufficient for performing domestic

chores, after using the toilet or before eating and where one feels the need to clean hands.

Alcohol rub may be used if the hands are not visibly soiled and will serve the same purpose.

Alcohol rub should be practiced on commencing a work shift, contact with patients, after handling

fomites, removal of protective clothing and gloves.

1.1.2.2 Antiseptic hand wash

The routine antiseptic hand wash prevents skin abrasion that makes microbial entry

possible especially through defective gloves. Steps that are to be followed in

performing antiseptic hand wash require that:

1) All rings and hand jewellery be removed from fingers and arms,

2 ) H ands are wet with lukewarm water,

3) Three to five ml of soap or antimicrobial surgical h a n d scrub is dispensed (4 percent

chlorhexidine gluconate) into t h e palm of the right or left hand,

4 ) W a s h t h e right or left hand, carefully paying attention to t h e wrist, t h e knuckles, a n d

fingernails, for at least 15 seconds,

5) Steps 2 through to 4 are repeated for t h e other hand,

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6) Hands are rinsed with water, letting water run in t h e direction of t h e elbow,

7) Repeat steps 2 through to 6 twice,

8) Close the tap using elbows or foot (if the tap is foot operated), and

9) Dry t h e hands with a disposable paper towel or sterile cotton towel (one per hand).

1.1.2.3 Antiseptic hand rub

Alcohol hand rub is used for hands that are visibly clean but have been in contact with patients or

potentially contaminated surfaces. It should be noted that alcohol is inactivated by organic matter

and will not remove organic material or dirt from the hands. Antiseptic hand rubs contain 70%

isopropyl alcohol and emollients for hands only and is gentler on the skin. It should be noted that

this hand rub differs from surface disinfectant which contains 70% ethyl alcohol and contains no

glycerol and is harsh on the hands. The technique followed when conducting antiseptic hand rub

takes 20 – 30 seconds and is as follows:

1) A palm full (instead of a few drops) of alcohol hand rub is poured into a cupped hand,

2) The liquid is rubbed from one palm to another,

3) Right palm over left dorsum with interlaced fingers and vice versa,

4) Palm to palm with fingers interlaced,

5) Back of fingers to opposing palms with fingers interlocked,

6) Rotational rubbing of left thumb clasped in right palm and vice versa,

7) Rotational rubbing, backwards and forwards with clasped fingers of right hand and vice

versa,

8) Dip the fingertips of one hand into the hand rub that is cupped in one hand to

decontaminate under the nails and do likewise with the other hand, and

9) Allow drying and carry on with any intended activity – no need to wipe it off.

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The following diagram depicts the procedure for hand rub:

Figure 4: Antiseptic hand rubbing technique

1.1.2.4 Aseptic hand wash

Aseptic hand hygiene is aimed at destroying or removing transient micro-organisms by using

antiseptic liquid soap (such as chlorhexidine or povidone iodine) and running water. It is done

before carrying out aseptic procedures in the wards and procedure rooms where contaminated

surfaces are not supposed to be touched once the hands have been washed. Gloves should be

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worn after the hands are dried so to can perform the procedure. This type of hand washing is

intended for insertion of sterile device into patient cavities e.g. catheterization, insertion of

cannulae, lumber punctures, etc. Hands should always be washed immediately after removal of

gloves.

1.1.2.5 Surgical hand wash

Surgical hand washing is performed to reduce the number of resident microorganisms on the

surgeon‘s and scrub nurse’s hands prior to undertaking surgery or any cutting of body / skin or

performing any tissue penetrating procedure. Antiseptic agents such as chlorhexidine 2% to 4% (or

povidone iodine) remains under the epidermis (skin) for up to eight hours after application and

therefore helps to maintain a lowered count of microorganisms on the skin.

Surgical hand washing is done immediately before commencing with the surgical procedure and

also when the surgeon‘s skin has been exposed or has been in contact with the patient‘s bacteria

over a long period of time. It is also required that hand washing be done more frequent during

surgical operations that last for more than two to three hours.

Step 1:

(i) Remove all hand and wrist jewellery,

(ii) Use an antimicrobial soap, wash hands with the same technique as for routine hand

washing, and wash the wrists and forearms to the elbows. If a sponge is used, it must be

sterile. Sponges are to be discarded after a single use,

(iii) Clean nails, paying particular attention to the subungual space, and

(iv) Rinse hands and forearms with tepid (lukewarm) running water.

Step 2:

(i) Rub hands and forearms vigorously with an antiseptic agent for at least two minutes. This

step minimizes the number of microorganisms on the hands under the gloves and

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Note: Scrubbing with a nailbrush is no longer indicated for surgery since it stimulates and

increases the bacterial count on the surgeon’s skin.

minimizes growth during surgery. Gloves may have holes or may become nicked during

surgery, which could allow microorganisms from health care workers out of the gloves,

creating a risk for wound infection in the patient,

(ii) Rinse hands and forearms under clean, running tap water, holding the hands higher than

the elbows to avoid backflow of the rinsing water,

(iii) Holding the hands up and away from the body, dry them off with paper towel or air dry. Do

not touch anything, and

(iv) Put sterile surgical gloves on.

Selecting an appropriate hand wash chemical should be informed by the intended purpose of hand

wash. Better understanding of such chemicals and hand wash techniques is presented in Table 1

(see page 23).

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NB! Some chemicals that are sold under the premise that they carry antiseptic and

disinfectant properties may be harmful to living tissues of the skin. It is in this regard that

care should be taken before purchasing such chemicals.

Hand wash technique

Agent Purpose / Indication Area used on Duration of use

Routine hand wash Water and non-antimicrobial soap (i.e. plain soap1).

Remove soil and transient2 microorganisms.

All surfaces of the hands and fingers.

15 seconds3.

Antiseptic hand wash Water and antimicrobial soap e.g. Isopropyl alcohol- 60% to 70% with an emollient.

Remove or destroy transient microorganisms and reduce resident5 flora (persistent activity)8

Hand hygiene and it is recommended as hand sanitizers.

15 seconds3.

Povidone iodine: aqueous or in 70% isopropyl alcohol.

Skin preparation for surgery.

Chlorhexidine: 0.5% to 2% per water-volume; either in water or 70% isopropyl alcohol.

Aseptic procedures such as insertion of intra venous devices

Antiseptic hand rub Alcohol-based handrub4. Remove or destroy transient microorganisms and reduce resident5 flora (persistent activity)8

All surfaces of the hands and fingers.

Until the hands are dry.

Surgical antisepsis Water and antimicrobial soap e.g.Chlorhexidine: 0.5% to 2% per water volume; either in water or 70% isopropyl alcohol.Isopropyl alcohol- 60% to 70% with an emollient is recommended as hand sanitizers.

Remove or destroy transient microorganisms and reduce resident flora (persistent activity).

Hands and forearms6.

Aseptic procedures such as insertion of intra venous devices.

2–6 minutes.

Povidone iodine: aqueous or in 70% isopropyl alcohol.

Skin preparation for surgery.

Water and non-antimicrobial soap (i.e., plain soap1) followed by an alcohol-based surgical hand scrub product with persistent activity.

Follow manufacturer instructions for surgical hand scrub product with persistent activity7.

Table 1: Summary of hand hygiene antiseptic: indications and techniques

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1.2 Personal Protective Equipment

All cleaning staff must wear prescribed, clean protective equipment to fulfil their job expectations. Should the protective equipment (clothing) become unduly soiled or wet during the course of work, it must be replaced with clean equipment. Staff working in high care areas, such as operating theatres, must strictly adhere to the specified dress code for such areas. Appropriate personal protective equipment must be provided for cleaning staff that work in high risk areas of infection.

In addition to wearing prescribed protective equipment while working in high risk areas of infection, housekeeping staff is required to perform effective hand hygiene:

i) At the beginning and end of each work shift,

ii) After handling contaminated items,

iii) Before and after meals,

iv) After using the bathroom,

v) After removing gloves, and

vi) If hands are potentially contaminated.

Various pieces of personal protective equipment must be made available in health care facilities,

each with an own intended purpose. Table 2 below displays various pieces of personal protective

equipment (PPE) and their indications.

PERSONAL PROTECTIVE EQUIPMENT (PPE)

Domestic rubber gloves for normal cleaning duties

NB! Not the examination or clinical gloves worn by healthcare workers.

The gloves must reach up to mid arm and offer protection against chemicals

and direct contact with dirt. Gloves must be changed or washed thoroughly

with detergent after cleaning each bathroom, each patient room and

whenever soiled.

Domestic gloves are reusable and should be changed only if damaged

Heavy duty gloves for contact with chemicals which may harm the skin. These

gloves are reusable and should be changed only if damaged.

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Plastic aprons for any cleaning activity that may generate splashes. They must

be worn by covering the front part of a person as depicted in the picture on

the right column.

Eye Protection is not recommended routinely. It might, however, be

necessary in special circumstances, depending on the activity and the

anticipated risk of exposure to blood, body fluids or strong chemicals.

Face mask with visor protect against splashes and replace a goggle and mask

combination.

These are indicated in any risk prone procedure which involves light to

moderate splashes from blood or body fluids.

N95 respirators – without or without valves are air-purifying respirators that

have efficacy level of 95% or greater against particulate aerosols free of oil

and greater than 0.3microns in size such as dust, fumes, mists and microbial

agents.

N95 respirators should be worn when entering isolation rooms and when

performing other activities involving close contact with potentially infected

persons and areas.

It should be noted that N95 respirators cannot protect one from chemical

vapours / gases, oxygen deficient atmosphere and aerosol generating

procedures such as bronchoscopy, autopsy and asbestos handling.

The effectiveness of N95 respirators is ensured by the use of a model and size

that has fit-tested by OHS officer. Removal of other factors that may interfere

with correct fit and sealing surface of the respirator e.g. facial hair should be

done prior to wearing the respirator. Seal-check should be done evey time a

respirator is being put on at the entrance of the area concerned. It should be

replaced when damaged, soiled and on leaving the area of concern.

Table 2: Personal protective equipment (PPE)

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CHAPTER 2: ENVIRONMENTAL CLEANLINESSS

Although microbiologically contaminated surfaces can serve as reservoirs of potential pathogens,

these surfaces generally are not directly associated with transmission of infections to either staff

or patients. The transfer of microorganisms from environmental surfaces to patients is largely via

hand contact with the surface.

Environmental surfaces carry the least risk of disease transmission and can be safely

decontaminated using less rigorous methods than those used on medical instruments and devices.

The principles of cleaning and disinfecting environmental surfaces take into cognizance, the

intended use of the surface or item.

Cockroaches, flies and maggots, ants, mosquitoes, spiders, mites, midges, and mice are among the

typical arthropod and vertebrate pest populations found in poorly cleaned health-care facilities.

Insects and animals such as mosquitoes, flies and animals (e.g. stray animals, monkeys, etc) can

serve as agents of mechanical transmission of microorganisms, or as active participants (vectors) in

the disease transmission process.

2.1 Internal cleaning

Cleaning should be preceded assembling all relevant cleaning equipment as depicted in the

diagram:

A mop with a cotton string head which should be washed in very hot water and dried or sent to the laundry at the end of each cleaning session.

Static head mops for cleaning dry floors.

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Janitor Trolley allows for easy transportation of all cleaning equipment & consumables per ward rooms.

Electric operated floor polisher, scraper and buffer.

Colour – coded bucket for use as follows: Red plastic or stainless steel bucket for toilets,

urinals and sluice room. Green bucket for baths, basins and showers Blue bucket for furniture, doors, walls. Yellow bucket for isolation cubicles / rooms White bucket for kitchen / dining areasStainless steel buckets may be colour coded to inform their designated area of use.Clean coloured cloths for wiping surfaces to be used as follows: Red cloths for toilets, urinals and sluice Green cloths for baths, basins and showers Blue cloths for furniture, doors, walls and pictures Yellow cloths for isolation cubicles/ rooms White cloths for kitchen and any other food service

areas.

Specific detergents and cleaning disinfectants in pistol-grip spray container which contains spray chemicals for spray cleaning.

Table 3: Examples of cleaning equipment

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REMEMBER THE FOLLOWING!

Cleaning cloths must be segregated according to the approved colour coding system.

Change cleaning cloths and mop heads daily or more frequently when soiled.

Used cloths and mop heads must be washed with warm water and a detergent before reuse.

(If washed in a washing machine, the temperature should be at least 60°C.)

When solutions in pistol-grip spray containers have been completely used up, the reusable

containers must be first washed and dried before being refilled. DO NOT TOP UP! Liquid

products, including plain (non-antimicrobial) soap and antiseptic products can become

contaminated or support the growth of microorganisms, therefore topping up may result in

ultimate spread of contamination. It is in this regard that liquid products should be stored in

closed containers and dispensed from either disposable containers or containers that are

washed and dried thoroughly before refilling. Storage and use of cleaning products must be in

line with the manufacturer's instructions.

Cleaning carts and buckets must be constructed of rustproof material that is easily cleaned and

free of cracks and crevices.

All equipment, carts and accessories used by domestic cleaners must be cleaned at the end of

each day or if visibly soiled.

At the end of the day, the cleaned items must be stored dry in a designated storage area or

cleaning closet.

These closets must be kept neat, clean and free of clutter. All equipment must be routinely

maintained and kept in good order or be replaced if they are beyond repair.

Having assembled all cleaning materials, areas should be prepared for cleaning by:

i) Wearing appropriate protective clothing e.g. gloves, apron, goggles, boots, etc. before

commencing with cleaning.

ii) Placing hazard signs / notices in strategic positions during cleaning in all service areas.

iii) Diluting all solutions according to manufacturer’s instructions and ensure that detergent

are used for their intended areas and surfaces (see Annexure A).

iv) Paving (clearing) the area to be cleaned by removing all the light movable equipment,

furniture as well as any other possible obstructer.

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v) Cleaning should flow from the least soiled to the most soiled area, from the top to the

bottom and from the furthest area to the entrance.

vi) Floors cleaning should follow cleaning of areas above the floor(s).

vii) Wash mop head in a disinfectant, dry in a sunny area and store it in a safe place.

viii) The cleaning and proper storage of equipment should be done according to the

manufacturer’s recommendations.

ix) Hand washing needs to be done as explained in Chapter 1 after every cleaning is

completed.

Properties of cleaning chemical should be taken into consideration when deciding on the preferred

chemical to be used. The table below specifies considerations to be followed on deciding on the

chemicals to be used4.

Disinfectant Spectrum Stability Inactivation Corrosive/damagingGluteraldehyde Broad Moderate No NoAlcohol Not spores or

NE virusGood Yes Lens cement in endoscopes

Parasitic acid Broad No No SlightChlorine releasing agents

Broad No Yes Yes

Quaternary ammonium compounds (QAC)

Poor Yes Yes No

Peroxide compounds Variable Moderate Yes SlightTable 4: Properties of hand hygiene chemicals

Recommended dilution of chemicals for various uses is as follows4:

Product Chlorine available

How to diluteto 0.5%

How todilute to 1%

How todilute to 2%

Sodium hypochlorite - liquid bleach

3.5% 1 part bleach to 6 parts water

1 part bleach to 2.5 parts water

1 part bleach to 0.7 parts water

Sodium hypochlorite - liquid 5% 1 part bleach to 9 parts water

1 part bleach to 4 parts water

1 part bleach to 1.5 parts water

Sodium dichloroiso-cyanurate (NaDCC) powder

60% 8.5 grams to 1 litre water

17 grams to 1 litre water

34 grams to 1 litre water

NaDCC tablets (1.5g/tablet) 60% 6 tablets to 1 litre water

11 tablets to 1 litre water

23 tablets to 1 litre water

Chloramines - powder 25% 20 grams to 1 litre water

40 grams to 1 litre water

80 grams to 1 litre water

Table 5: Recommended dilution of chemical for various uses

Page | 25

Given that every service area requires a specific way of cleaning, the aim of the ensuing section is

to describe techniques to be followed while cleaning various service areas in a health organisation.

2.1.1 Routine cleaning

(a) Damp dusting

Damp dusting is carried out to trap dust against escaping into the air when it is removed from a

surface. The cleaner/house keeper has to assemble all necessary equipment e.g. damp dusting

bucket (see Table 3) with water, apron, gloves, biocide sachets (see Annexure: A) and

appropriately coloured cloth (see Table 3) and waste bag (see Table 7).

An apron and a pair of gloves are worn when one gets to the area that is to be cleaned. Damp

dusting should commence from the highest to the lowest working point and from the cleanest to

the dirtiest area. Surfaces are wiped in a horizontal line rinsing the dust cloth intermittently in an

appropriate solution as it turns dirty. Where paper is used instead of a cloth, the former must be

disposed of into the appropriate waste bag as soon as it becomes dirty. Once all the surfaces are

clean and thoroughly dried, equipment is cleaned and safely stored. Thereafter gloves and the

apron are removed, and hands are washed.

(b) High level dusting

High level dusting is done in the same way as damp dusting, but an extension pole is required to

reach the areas. It is not advisable to stand on chairs to carry out high level dusting. The wearing

of additional protective clothing such as head cover and goggles is recommended for high level

dusting. As with other cleaning methods, dusting is commenced from the highest point down and

continuously rinsing the duster / cloth when soiled. Proper cleaning and storage of equipment

must be done once cleaning is done.

(c) Suctioning and cleaning

Vacuum (suctioning) cleaning is used on carpeted floors to remove dust and dirt from the carpet

fibres. Unlike brushing or sweeping, vacuuming traps and removes dirt. Before commencing with

suction, (i) the functionality of the electrical cabling should be checked by running it through the

hands to check for cuts, damage or knots, and (ii) the machine must be checked whether it is

clean and dry and that the bag is empty or not more than half full. When in use, care should be

Page | 26

taken that the cable is always behind the housekeeper and that it is not a trip hazard. Suction

cleaning should start from the furthest point in the room and move backwards towards the door.

Having ensured that all areas are clean, the machine is cleaned and stored accordingly. It is

advisable to ensure that the suction machine is being serviced in line with the manufacturer’s

recommendations.

(d) Static head mopping

Static head mops and static rolls are used to trap the dust on hard floors in a similar way that

damp dusting does, however, water is not used in this type of floor cleaning. It is therefore to

appreciate that this type of mopping is indicated for removing dirt and dust on the floors before

commencing with wet mopping. It replaces the use of brooms (used for sweeping floors) whose

use is discouraged as they disperse dust into the air thereby promote air contamination and cross

infection. Starting from the furthest area to the door, the static head mop is run along the edges

of the floor using a figure of eight thus ensuring that all dust is trapped. Once all the mopping is

done, all the debris is collected into the appropriate bag. As a rule, clean and store the equipment

in a proper place once the mopping is finished.

(e) Wet mopping

Wet mopping is used on hard (slippery) floors where there is a need for decontamination or if

there is any material on the floor that cannot be removed by a dry static head mop. Having

assembled all the necessary equipment e.g. clean, properly colour coded mop, detergent, water

and waste bag, a hazard sign is placed on the floor to warn passersby against stepping on the wet

floor. Because wet mopping carries a high risk of injury caused by falling, oral warning of

passersby should always be communicated even if the notice is placed on the floor for all to see.

Having immersed the mop in the water with detergent, half the floor area is being mopped at a

time thus ensuring that there is always a dry area on which people can walk. The mop should be

run along the edges of the floor, ensuring that all areas of the floor are covered. It must be

intermittently rinsed off throughout the moping process. If the water becomes discoloured, it

must be emptied, washed and be refilled with clean water and detergent. Once mopping is

Page | 27

completed and the area is clean, the mop head is thoroughly washed and placed in a sunny area

to dry.

Rule of thumb! Cleaning equipment and machinery should always be tidied / cleaned and properly

stored once the cleaning is done.

(f) Floor scrubbing/stripping

Non slip floor surfaces need a special scrubbing machine to clean them as they may have ridges or

areas that will not be cleaned completely with either a static head mop or a wet mop. Large areas

of floor require a floor cleaning machine that is capable of cleaning large areas within an

acceptable time with minimum physical stress on the cleaner. The type of floor cleaning machine

on which a cleaner can sit, is usually the most suitable machine for scrubbing such large areas of

open flooring.

The following must be assembled prior to commencement of floor scrubbing or stripping so as to

save time once started:

(i) Scrub and water extraction machine,

(ii) Appropriate floor pad,

(iii) Hand held scouring pad,

(iv) Appropriate coloured damp dusting bucket,

(v) Hazard signs,

(vi) Mop handle and mop head or a static head mop handle and roll, and

(vii) Disposable gloves.

Once the scrubbing machine has been prepared in line with the manufacturer’s recommendations

on safety and use, it is plugged in so that the cable is behind the cleaner. Scrubbing / stripping

then commences from the furthest point and towards the cleaner / housekeeper.

As with wet mopping for corridors, scrubbing should be done first on one side of the corridor then

the other side so to ensure that there is a dry section for people to walk on. Excess water is

sucked by the extraction machine while any puddles that might have not been cleared by the

water extraction machine are removed with a mop that is continuously rinsed in clean detergent.

After scrubbing the main section of the floor, edges / seals are scrubbed with the gloved hand

scouring pad. The entire floor is then thoroughly mopped and allowed to dry.

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(g) Sealing floors

It is recommended that scrubbed floors be sealed to ensure that the floors remain clean and shiny

while not slippery. Floor sealing is commonly applied on vinyl floor rather than tiled floors. Having

had the floor correctly scrubbed, the floor is cleaned at least three times with clean water and be

allowed to dry thoroughly ensuring that no marks are visible.

A small amount of sealant is poured onto the floor starting from the furthest point and applied all

over from left to right using a dampened mop. The floor is then allowed to dry thoroughly. Whilst

the floor is drying the mop head is rinsed with clean water.

Using a dampened mop, a second coat of the sealant is applied all over the floor. This application

is continued until the required number of coats has been applied (as recommended by the

manufacturer). Once the floors are thoroughly dried and looks tidy, all equipment is cleaned and

appropriately stored.

(h) Floor polishing

Certain types of hard floors (e.g. vinyl and cement floors) require regular polishing to keep the

appearance looking best.

The floor should be cleaned using a wet mop and detergent. A small amount of polish is sprayed

and buffed onto the floor starting from the furthest point until the area has been all polished. The

area is then wiped clean with a static head mop. Any debris is disposed of into the appropriate

plastic bag and the rest of the equipment is cleaned and properly stored. Floor polishing should be

done as frequently and as necessary as possible to ensure that the floor retain their acceptable

appearance.

(i) Cleaning of glass

Glass needs to be cleaned with chemicals that are specially designed for glass surface to prevent

unsightly smears or streaks. Chemicals such as non-ammoniated, streak free glass cleaners are

recommended for cleaning glasses such as window-panes, whereas the cleaning of eating utensils

always merely requires simple dishwashing soap.

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Cleaning of glasses such as window-panes is best achieved when it is done by at least two people

standing on both sides of the glass and working simultaneously together. Where there is one

person only, cleaning will take time to finish since this person will be required to first clean one

side of the glass and then the other side. In doing so, it is found in many instances that cleaning

both sides need to be repeated to remove remaining streaks and wetness.

Whilst standing to the side of the glass (window-pane), a non-ammoniated, streak free glass

cleaner is sprayed or liberally applied onto the glass surface by using a paper or a cloth. Care

should be taken to ensure all edges and corners as well as the center of the window-pane are

cleaned. A clean paper towel is used for buffing and removing all smears and wetness. The paper

is disposed into appropriately coloured bags. It is important to remember that protective clothing

needs to be worn when cleaning window-panes (glass). Return equipment to the cleaning

cupboard and ensure it is clean, dry and safely stored.

2.1.2 Deep cleaning

Deep cleaning (often referred to as spring cleaning) is carried out at least twice a year by a

dedicated team of cleaners. It is undertaken in patient bay/ward areas, patient side rooms,

bathrooms, showers, sluice and utility rooms, patient toilets, treatment rooms, corridors, ward

kitchens, staff rooms, nursing bays and storage areas.

(i) Deep cleaning involves the cleaning of walls, ventilation shafts and storage areas, floors,

windows, ceilings, etc. In some situations, temporary closure of such areas is required

whilst deep cleaning is taking place.

(ii) Bearing in mind that care of medical equipment lies with the nursing staff, housekeeping

staff should carry out deep cleaning once the medical equipment have been

appropriately moved and or disconnected by nursing staff.

(iii) All other movable objects and curtains should be removed. Curtain hooks need to be

soaked in a detergent while curtain tracks are cleaned.

(iv) All deep cleaning is done by (a) using an approved chlorine-based cleaning product such

as Sodium hypochlorite (biocide) or an equivalent and by (b) using appropriate

disposable cloths.

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(v) Air vents and light fittings are cleaned and the walls are also cleaned starting from the

highest to the lowest areas. Bed frames, cot sides, soft foam mattresses, bedside lockers,

bedside tables, chairs and any other bed head appliances are cleaned using cleaning

cloths soaked in a detergent.

(vi) Hand wash basins, hand towel holders, alcohol and soap dispensers, door handles, lights

and flooring are also thoroughly cleaned. Floors are cleaned with wet mops and

scrubbed as described before.

(vii) On completion of deep cleaning, clean curtains are hanged and bed making is done with

clean bed linen.

Wards and treatment rooms

• Curtains are taken down for cleaning. Curtain hooks are soaked in a detergent while curtain

tracks are cleaned.

• Beds are pulled out, all parts of beds are cleaned with a clean cloth soaked in a detergent and

then left to dry.

• Wet mopping under the beds, particularly on difficult to reach areas, should be done whilst the

bed is pulled out.

• Patient mattresses are also thoroughly wiped clean with detergents, turned on their sides and

be left to dry.

• Patient lockers are washed with detergents (both inside and outside) and then dried before

anything is replaced inside or hanged.

• The hand wash basins are cleaned and soap grime is removed with scouring pad and

detergent.

• Floors are cleaned as described (see page 31).

• Once the floors and equipment are dry, ward furniture and equipment are pulled back to

place, repacking is done and bed-making is done with clean linen.

Page | 31

Cleaning of bathrooms, showers and toilets

• Before starting to clean, the functionality of all taps should be checked.

• Walls, tiles and ceilings are washed starting from the highest to the lowest areas using a red

coloured damp dusting bucket, red cloths and water that is mixed with a detergent.

• All surfaces, fixtures and fittings, including doors and door handles are also washed with a

detergent. Mirrors (glass) are washed with non-ammoniated, streak free glass cleaner thus

ensuring that all smears are removed.

• Plastic shower curtains should be thoroughly wiped down from top to bottom on both sides

using a red cloth and water that is mixed with a detergent.

• Floors are cleaned with a red coloured mop that has been soaked in a detergent.

• All dirt and soap grime are removed from sinks, basins and bath tubs with a scouring pad that

needs to be disposed of at the end of the shift when cleaning is completed.

• The inside of the sink, basin and bath are sprayed with the appropriate detergent / cleaning

chemical which is left for a few minutes to become activated. Also, clean under the sink

between the sink and the wall. The latter also applies to where there is a basin.

• The inside of the cistern is scrubbed and then the flush of toilet is pulled to allow entry of

clean, rust free water in the cistern.

• The rim and bowl of the toilet is sprayed with toilet cleaning chemical and left for few minutes

to activate. It is then cleaned with a toilet brush. A clean piece of paper roll is dampened with

a detergent and flush handle, toilet seat base and rim are wiped clean. The toilet brush and

holder is rinsed in running water and or detergent and thereafter dried.

• All waste bins are emptied and equipment is then replaced to their appropriate places.

Cleaning of utilities and sluice rooms

• The flush of the sluice pan is pulled to allow entry of clean water in the base. Spray with a

detergent around the area within the rim and bowl of the sluice pan and leave for a few

minutes to activate. All debris is removed using a scoure.

• The same procedure to clean bathrooms and toilets is followed to clean sluice rooms.

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Corridor Cleaning

Hazard signs are placed at entrances of corridors. All walls, fixtures, fitting and ledges are washed

starting from the highest to the lowest area and from the furthest to the nearby area. Half the

corridor is mopped at a time ensuring that there is a dry walkway for pedestrians to use. Once dry,

all remaining dirt is removed using static mop (see page 31 for static head and wet mopping).

Cleaning of food services

(i) Cleaning of kitchen areas

• Hazard signs are placed at entrances of corridors. As detailed in the preceding sections of

this guide, walls are washed starting from the highest to the lowest and furthest to nearby

areas. All edges, fixtures and fittings and surfaces, including door handles are washed with

detergent.

• All surfaces must be washed with warm, soapy water intermittently for various types of

food e.g. raw meat, vegetables and fish, because they should not be prepared on the same,

unwashed surfaces.

• All items inside the refrigerators and cupboards are removed. The inside of microwaves,

refrigerators and cupboards are cleaned with a white cloth soaked in water and soap

(detergent may be used where recommended by manufacturer). All the rubber seals

around the door and over the outside surface are wiped clean with wet cloth. Wipe outside

of microwaves, refrigerators and cupboards with a cloth soaked in a detergent (consider

manufacturer’s recommendation).

• Dishwashers/sterilizers should be emptied and the bottom base removed and cleaned daily.

• Floors are cleaned with white colour coded mops that is soaked in a detergent. Then, where

necessary a static head mob is used to remove dried out dirt.

(ii) Washing of plates and utensils

• At the end of meals and hot beverage / drink service, all the plates and utensils are collected

and thoroughly cleaned. Infectious utensils are left for last.

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• Leftover food is scraped into two doubled-up white plastic bags that should be kept in a

food waste bucket.

• Knives and forks are put into warm soapy water and detergent.

• Cups and plates are neatly piled onto the trolley.

• Paper waste is thrown into a black plastic bag.

• The trolley is wheeled into the main kitchen where all utensils are washed, dried and stored

for the next use.

• Immerse dirty cutlery and crockery into the sink filled with warm water, dish soap and

detergent. Wear rubber gloves if required.

• The cleaning of the cutlery and crockery commence with first the glasses, then the cups,

other crockery, cutlery, and ending off with the trays. Cleaning should be done by a

scouring pad that is specifically designed for kitchen use and be disposed of at the end of

the shift.

• Replace the water in the sink regularly as it gets too dirty or become cold. When all

crockery and cutlery are cleaned, rinse them in clean warm water, wipe them dry with clean

dish cloths and store them accordingly in cupboards.

• Pest control must be applied in the kitchen or anywhere where food is stored or served as

to ensure cockroaches and rodents are killed. Furthermore, domestic animals such as cats

and dogs are not allowed in the kitchen or where food is being stored or served.

(iii) Cleaning of food trolleys

• At the end of every meal service it must be ensured that food trolleys are returned to the

main kitchen where they are to be cleaned.

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REMEMBER!!!

• The appropriate colour coded apron (yellow) is worn when collecting utensils from

an infectious area / rooms. The apron is removed immediately when leaving the

infectious area and hands are washed at once.

• Any paper waste from an infectious patient must go into a red bag in the patient’s

room.

• Before commencing with the cleaning of the trolley, it should be ensured that the trolley is

unplugged.

• The trolley is cleaned with a clean, white cloth soaked in warm, soapy water and detergent.

Cleaning is from the inside outwards with special attention being paid to corners and areas

that are not readily accessible. Scouring pads may be used to remove dried in food

particles. Once trolleys are cleaned and dried, they are stored correctly for next use.

• Once a week trolleys must be turned upside down and cleaned with scouring pads. Special

attention should be paid to the cleaning of all the wheels and underneath bars. The inside of

the hand paper dispenser is also wiped clean and refilled where necessary.

2.1.3 Terminal disinfection

Terminal disinfection refers to a specialized cleaning technique of the room that is followed after a

patient with an infectious health condition has been removed from the room through discharge,

transfer out, death or has ceased to be a source of infection.

• The cleaning of the room is informed by the patient’s health condition e.g. if the patient

suffered from airborne infections such as MDR or XDR-TB, cleaning staff should wear N95

masks or any other face mask for any other respiratory condition. All other personal protective

equipment such as gloves, plastic aprons and goggles should be worn as guided by the nursing

staff. Gloves and aprons must be removed whenever leaving the room and subsequent hand

washing should be done by using antimicrobial soap.

• Bed-linen and curtains need to be carefully removed without shaking and be placed in a yellow

coloured bag, closed and directly sent to the laundry. Plastic mattresses and pillow covers

should be washed with soap and water or the recommended disinfectant as informed by the

type of disease, dried and wiped off with alcohol.

• The beds, over-bed tables, chairs, lamps and lockers must be wiped with soap and water or the

recommended disinfectant as informed by the type of disease, dried and wiped with alcohol.

The inside of the bedside cabinet and storage closet must be washed with a hospital-approved

detergent (see Annexure A).

• Medical equipment must be cleaned as recommended by their respective manufacturers.

These instructions / recommendations should include information about –

i) the equipment’s compatibility with chemical germicides,

Page | 35

ii) whether the equipment is water-resistant or can be safely immersed for cleaning, and

iii) how the equipment should be decontaminated if servicing is required.

• In the absence of manufacturers’ instructions, non-critical medical equipment such as

stethoscopes, blood pressure cuffs, dialysis machines, and equipment knobs and controls

usually require cleansing followed by low to intermediate-level disinfection, depending on the

nature and degree of contamination.

• Ethyl alcohol or isopropyl alcohol in concentrations of 60% to 90% (volume/volume) is often

used to disinfect small surfaces such as rubber stoppers of multiple-dose medication vials and

thermometers and occasionally external surfaces of equipment e.g. ventilators. However,

alcohol evaporates rapidly, which makes extended contact time difficult to achieve unless

items are immersed, a factor that precludes its practical use as a large-surface disinfectant.

Other equipment such as bedpans, urinals, bowls, jugs, etc require sterilisation more than

ordinary washing.

• All leftovers such as washing materials, containers and any other disposable materials must be

disposed into waste bags. Waste bags must be closed before leaving the room and be directly

sent to the waste storage area outside the ward for subsequent incineration.

• Floors and walls must be mopped and wiped with detergent. Windows, storage cupboards,

curtain rails, doors, door handles, hand wash basins must be washed with water and ammonia

based cleaning compounds.

eant to be used in both the teaching and research laboratory, this calculator (see below) can be

2.2 External cleaning

2.2.1 General environmental care

• Insects, birds, rodents and stray animals forage in and feed on substrates, including but not

limited to food scraps from kitchens/cafeteria, food in vending machines, wound exudates on

discarded dressing materials, other forms of human detritus, medical wastes, human wastes,

Page | 36

REMEMBER!!!

Alcohol may cause discolouration, swelling, hardening, and cracking of rubber and certain plastics after prolonged and repeated use and may damage the shellac mounting of lenses in medical equipment.

and routine household waste. Cockroaches, in particular, have been known to feed on fixed

sputum smears in laboratories. Insects carry a wide variety of pathogenic micro-organisms on

their body surfaces and in their gut; the direct association of insects with disease is

predominantly from vector transmission.

• The degree of pest infestation in an area is indicative of the standard of hygiene practices of a

health establishment. Apart from being a nuisance to have these species of insects, they pose a

serious health hazard. Implementing complete control measures regularly should be effected by

means of a continuous pest control programme.

• Modern approaches to institutional pest control focus on:

(a) eliminating food sources, indoor habitats, and other conditions that attract pests; and

(b) applying pesticides as needed.

• It should therefore be noted that pest control programmes must adopt integrated pest

management approaches which include (i) waste management, (ii) good housekeeping,

(iii) maintaining hygiene standards, (iv) the proper warehousing and storage of products, (v)

structural repairs, and (vi) general maintenance of premises.

• Sealing windows in health-care facilities and wire mesh screens helps to minimize insect

intrusion. Insects should be kept out of all areas of the healthcare establishment, especially

areas where immune suppressed patients are located.

• A licensed pest-control practitioner must enforce and maintain a regular documented pest

control program that is tailored to the needs of the health establishment. Any abnormal

incidence of pests should be reported immediately to the pest control practitioner at the

relevant Local Authority for his/her proper investigation.

• Industrial hygienists can provide information on possible adverse reactions of patients and staff

to pesticides and suggest alternative methods for pest control, as needed.

2.2.2 Routine cleaning of a health establishment (also see Section 2.1.1)

• All waste baskets must be emptied at least three times daily a n d more frequently as

necessary and be cleaned with a disinfectant then lined with impervious plastic bags.

Page | 37

• High dusting must be performed at least weekly using a clean damp duster. Walls must be

damp-wiped or spot-cleaned as needed. Horizontal surfaces such as window sills, chairs, over

bed tables and bedside cabinets must be damp-wiped daily and more frequently as necessary

with a hospital-approved detergent.

• Bathrooms must be cleaned daily and more frequently whenever they become dirty with a

hospital-approved detergent. Special attention must be given to the toilet, sink, fixtures and

the floor (see page 34). Dispensers for paper towels, toilet paper and liquid soap must be

refilled immediately when they become empty.

• All toilets and washbasins must be cleaned at least daily with ammonia based liquid, then

washed with water and wiped dry.

• All floors must be kept dry through frequent mopping during the day and night with water and

detergent; regular polishing of floors should be ensured to maintain their glossy appearance and

maintain good aesthetic appearance. Care must be taken to ensure that polishing of floors does

not render them slippery, as that has a high tendency of causing injury to patients, visitors and

staff.

• Cleaning and use of cleaning agents and techniques should be carried out in line with the level

of risk of the area as depicted in the table below:

Uses Examples Agents Cleaning technique or process

Low- risk area

Sluice roomsCorridorsAll wardsAblution blocksBeds & mattressesLockersFloors & surfaces

Detergent and clean water. Use clean, warm water with a neutral detergent.Apply with a clean cloth or mop, rinse and dry.

High risk area

Transplant unitsOperating theatresICUTrauma & EmergencyFood preparation areasMilk kitchenIsolation rooms or wards

Detergent and water.Wipe over with alcohol as recommended by Infection Prevention and Control (IPC) Team.

Chlorine releasing agents or other disinfectants may be used routinely in high risk areas.Consult IPC Team for use in terminal cleaning.

Stainless steel surfaces, enamel baths and basins.

Detergent and water or ammonia containing detergent e.g. Handy Andy®

Ensure the product is nonabrasive as scratches will retain

Page | 38

for removal of fatty deposits. dirt and bacteria.

Uses Examples Agents Cleaning technique or process

Blood spillages, other infected surfaces or spillages.

Detergent and water or Organic chlorine disinfectant (bleach).

Wipe over with alcohol wipe at beginning and end of treatment or wound dressing (ensures dryness).

Trolley surfaces. Detergent and water. Wipe over with alcohol wipe at beginning and end of treatment or wound dressing (ensures dryness).

Table 6: Cleaning technique for various areas

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CHAPTER 3: PATIENT LINEN

Clean linen is the linen that has been properly laundered and rendered safe for specified patient

use. Cotton drapes that have been sterilized by the Central Sterile Services Department (CSSD)

after they have been laundered are also regarded as clean linen.

3.1 Basic principles of linen management.

Since properly laundered linen is free from contamination, it should also be prevented from

becoming contaminated before being used on patients. To achieve this, the following principles

should be adhered to:

i) Clean linen is stored on shelves in a clean room that is designated for clean linen only or in

clean cupboards that are kept closed at all times.

ii) Clean linen is transported from the laundry to the user area in clean, closed containers

on trolleys that are solely designated for transporting clean linen.

iii) Clean linen is neatly stacked on a linen trolley during bed making times and also on the trolley

that is parked outside the patient room.

iv) Sluicing of soiled linen should be done at the laundry rather in the sluice room of the ward /

clinic.

v) Dirty linen must be stored in closed bags in a designated area (dirty linen room) for a

period not exceeding twenty four (24) hours, until it is collected from the unit /

ward / clinic / operating theatre to the laundry through the exit leading to the outside of the

room and never be transported within the ward.

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REMEMBER!!!

• Linen should never be placed on the floor.

• There must never be any contact between clean and soiled linen at any stage.

• The storage period of dirty linen must not exceed 24 hours.

• Hands must always be cleaned before handling clean linen.

vi) The door of the dirty linen room must be kept closed and access to the room must be

restricted. Dirty linen must be collected from the dirty linen room and transported to the

laundry in properly colour coded laundry bags.

vii) The reusable laundry bags and the linen trolleys must be disinfected and appropriately washed

before being returned to the wards or linen rooms.

Figure 5 below shows the movement of clean and dirty linen from the point of use to the

processing area and back. Green coloured circles depict clean linen while the red coloured circles

depict dirty linen.

Figure 5: Linen process

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3. Use of linen on patients

4. Storage of dirty linen in a

dedicated room for dirty linen separate from

clean linen

5. Removal os dirty linen from

temporary storage (ward

dirty linen room) through the outside exit.

6. Transportation of dirty linen

separate from clean linen

7. Washing and appropriate

disinfection of linen (at the

laundry)

1. Transportation of clean linen separate from

dirty linen

2. Storage of clean linen in

dedicated room for clean linen

viii) Since dirty linen is always heavily contaminated with a wide variety of micro-organisms, it

should always be handled with care to prevent cross contamination.

ix) The following standard operating procedure should be followed when handling dirty

linen:

a) Wear gloves and a plastic apron when handling soiled, infectious or infested linen.

However, there is no need to wear gloves when handling used, dry linen.

b) Move the canvass trolley for dirty linen to the foot end of the patient bed, examination

table or operating table.

c) With a gloved hand, remove foreign objects such as dressings, sticky tape, instruments,

sharps or food stuff on the linen and dispose them separate from the linen. Human excreta

and any other discharges may not be removed from the linen while in the ward or service

area, but are rather sent to the laundry in a separate properly labelled plastic bag e.g.

‘Sluice’.

d) Do not shake dirty linen.

e) Roll the linen inside out towards the foot end of the bed, bundle and place directly into the

appropriate coloured canvass bag on the trolley while ensuring that it does not come into

contact with your clothing.

f) Do not carry dirty linen to the dirty linen room or do not place it on any other surface as it

will contaminate the protective clothing or the surfaces onto which it is placed.

g) Close the bag when it is three quarter full. Then wheel it to the designated temporary

storage area, i.e. the dirty linen room. Infectious linen is placed in a yellow bag that is

closed immediately and directly sent to the laundry.

h) Label the canvass bag containing the linen with the date and the ward, unit or clinic name.

i) Where linen is infested, place it in a plastic bag which is additionally labelled i.e. ‘ infested

linen’ or ‘pest control’ and immediately call the pest control department to treat the linen

before sending it to the laundry.

j) Wash or spray hands with a disinfectant after handling dirty linen and when moving from

one patient‘s bed to another when making beds.

k) Bed linen and towels must both be changed daily irrespective of whether or not it is visibly

soiled and/or contaminated.

Page | 42

Figure 6 below illustrates how clean linen should be (i) neatly stacked on shelves in a clean room

that is designated for clean linen, (ii) neatly stacked on a linen trolley during bed making times, and

how dirty linen should be (iii) be bundled and placed directly into the appropriate coloured canvass

bag on the canvass trolley.

Clean linen storage Clean linen trolley

Removal of used lined at bedside Used linen transportation and storage

Figure 6: The management of patient linen in the ward

3.2 Bedside screens and curtains

• Bedside screens and curtains are considered part of patient linen, because i t is handled often

and can easily become contaminated.

• Being considered as part of patient linen, it is therefore also managed in similar fashion (see

Section 3.1 above, as well as Section 2.1.2 “Deep Cleaning” – p 35 and Section 2.1.3 “Terminal

disinfection” – p 39). Page | 43

• Bedside screens and curtains are replaced with clean ones:

i) after discharge of an infectious patient,

ii) immediately when they become visibly soiled, and

iii) every 4 (four) weeks if the patient(s) are non-infectious.

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CHAPTER 4: HEALTH CARE WASTE MANAGEMENT

In health establishments a wide range of waste such as used needles and syringes, soiled

dressings, body parts, diagnostic samples, blood, chemicals, pharmaceuticals, medical devices and

radioactive materials is generated. To managing such waste (solids and liquids) requires a process

whereby the said waste is collected, stored, transported, treated and disposed. Unfortunately, if

this process is poorly managed there is the potential of exposing health care workers, waste

handlers, patients and the community at large to infection, toxic effects and injuries, and the risks

of polluting the environment. It is therefore of the utmost importance that staff members

regularly undergo in-service education/training regarding waste management and that patients

are guided on how to go about waste generation and disposal thereof while they are within the

health establishment. In this regard special attention should be paid to them segregating the

waste they as patients generate.

4.1 National Core Standards requirements

The National Core Standards for Health Establishments in South Africa (2011) requires the

following:

1. Every health establishment must have a waste management policy and procedure. This

guideline suggests that the policy and procedure will at least detail the following:

i) The types of health care services provided.

ii) An estimation of out-patients treated.

iii) A monthly assessment of the quantity and characteristics of waste that is generated by the

health establishment.

iv) A contract and service level agreement with an external service provider as well as the

registration number, if the service of such a provider is being utilized.

v) The name and registration number of the waste treatment establishment that the waste

collector utilizes and any other third party involved.

vi) The roles and scope of duties of the designated health care waste officer.

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vii) A description of collection, storage and internal transportation systems that must be used.

viii) An in-service training programme that is designed for employees in the health

establishment.

ix) Any applicable recycling techniques that are employed by the health establishment.

2. Every health establishment has a designated and knowledgeable staff member responsible for

waste management. This guideline suggests the following functions for this incumbent:

i) The incumbent works very closely with staff members responsible for housekeeping,

gardening, infection prevention & control and environmental health services.

ii) He or she oversees compliance with the relevant legislation and standards.

iii) The staff member ensures constant supply of adequate PPE for all waste handlers in all

disciplines and constant supply of waste containers such as required bags and other

containers.

iv) He or she regularly monitor and ensure proper segregation of waste from areas of

generation to storage.

v) The incumbent keeps a log book record of waste classification.

4.2 The flow path of health care waste

The flow path of health care waste (HCW) within a health facility and beyond is as follows:

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Step 1

Generation

Step 2

Segregation at source

Step 3

Containerisation

Step 4

Intermediate storage

Step 5

Internal collection and transport

Step 6

Central storage

Step 7

External transport

Step 8

Health care risk waste treatment

Step 9

Residue collection

Step 10

Disposal

Figure 6: The flow path of health care waste

4.3 Waste classification

Waste generated in a health establishment is classified as follows:

4.3.1 Domestic waste (Category A)

Domestic waste consists of everyday household waste items that are discarded by the public. This

type of waste is any non-putrescent waste that consists of combustible materials such as paper,

cardboard, yard clippings, wood, fruit pills and food generated from a household. It excludes all

containers such as plastics, tins, bottles, cardboards and papers which should be segregated in line

with categorization of waste. This type of waste (Category A) is fairly non-toxic except for the

effect that expired or decayed substances has to people and animals on consumption.

4.3.2 Biomedical & health care waste (Category B)

Biomedical and healthcare waste is a waste that is generated from clinical activities. It is regarded

as hazardous waste since it poses substantial or potential threats to public health and the

environment, and it could damage or pollute land, air and water. Hazardous waste has the

potential to adversely affect the safety of the public, handlers or carriers throughout the lifecycle

of the waste, i.e. from generation, storage, disposal, transportation and up until destruction.

Hazardous waste usually displays the characteristics of transmitting infection, may be flammable,

corrosive, reactive or toxic. Some different wastes can often react to form explosions or dangerous

vapour that is risky to the wellbeing of people or animals.

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REMEMBER!!!

Recycling of packaging or paper waste – all paper and cardboard waste should be recycled

as this is perhaps where the greatest savings occurs.

a) CLINICAL WASTE is comprised of hazardous wastes that display varying characteristics that

require careful management. Such clinical wastes are as follows:

i) Human anatomical tissues, blood and bodily fluids, carcasses, body organs, laboratory

waste (including microbiological cultures and infectious waste from micro-biology and

pathology) and related swabs and dressing materials.

ii) Pharmaceutical waste such as cytotoxic pharmaceutical waste, expired pharmaceuticals,

and wastes containing heavy metal and non-hazardous pharmaceutical waste such as

cough syrups.

iii) Waste sharps such as scalpel blades, discarded syringes, needles, cartridges, broken vials,

blades and contaminated sharps.

Sharps containers – Sharps containers are used to discard needles, syringes and other used

sharp objects. It is a solid, usually yellow container with red writing and labels which is fixed

firmly to a surface, within arm‘s reach of its use. Sharps containers are specifically designed to be

visible, robust and strong to prevent accidental spillage and occupational injuries to people. They

should always be safely placed on procedure trolleys, be wall mounted or be fixed to a flat surface.

Sharps containers should therefore adhere to the following specifications:

i) Made of solid material which is puncture proof, tamper proof and leak proof. The latter is

of importance during handling or transportation.

ii) Designed in such a way that the container only has one way entry and no exit even during

accidental falling.

iii) Lids are tight fitting lids which do not open once closed and fastened into place.

iv) Withstand hot water wash up to 90 oC to maintain cleanliness.

v) Resistant to dropping (shock) or weights being placed on them.

vi) Able to withstand their recommended weight and volume of waste.

vii) Labelled with the words, “Danger Contaminated Sharps” and also display the international

infection waste hazard label on it.

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b) INFECTIOUS AND HIGHLY INFECTIOUS WASTE (Category C) includes the following:

• Infectious waste: (i) discarded materials, e.g. disposable gloves, linen and aprons, and (ii)

equipments contaminated with blood and other body fluids from patients with hazardous

communicable diseases and from patients with blood borne infections undergoing

haemodialysis.

• Highly infectious waste: (i) microbiological waste with any kind multiple pathogens, and (ii)

laboratory waste, e.g. cultures with viable biological agents.

• Other examples of waste: items used to dispose o f urine, faeces, and other bodily

secretions or excretions, e.g. (i) disposable bedpans, (ii) liners, (iii) sanitary pads, (iv)

disposable napkins, and (v) stoma bags.

c) OTHER HAZARDOUS WASTE (Category D) includes chemical waste such as empty aerosol cans,

heavy metal waste and discarded chemical disinfectants.

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REMEMBER!!!

• If waste meets the definition of “hazardous waste”, it has to be isolated from any domestic waste.

• Hazardous waste should never be allowed to enter a local authority’s waste management system.

• Sharp containers should only be filled up to three-quarters and then be sealed.

REMEMBER!!!

• Items containing intravenous infusions and human excreta should be disposed of into the sluice room before containers thereof are discarded.

• A red plastic bag minimum 60 micron thick and strong enough to hold the contents must be placed inside a robust container as liner. If the plastic bag is used as a standalone container, the thickness thereof should increase to 80 micron and be marked “infectious waste” with the appropriate waste hazard label.

d) RADIOACTIVE WASTE (Category E) is generated through the use of radioactive substances in

industry, research and medicine (non-nuclear applications), it is subject to regulatory control in

terms of the Hazardous Substances Act, 1973 (Act 15 of 1973), and it consists of a great

diversity of products in many physical and chemical forms

containing a wide variety of radioactive nuclides at different

concentration levels. Radioactive waste includes waste

contaminated with radio-nuclides whose ionizing radiation

has a detrimental effect on the genetic makeup of the human

body. The characteristics of the different waste types are

essential factors which determine the choice of a safe method

of waste management. Rules are therefore required for the grouping of waste into different

categories depending on the proposed waste management system.

4.4 Waste segregation and colour coding

A universal colour-coding system exists which emphasizes linkage of colour to the type and risk of

the waste contained or is expected to contain.

CATEGORY EXAMPLESCOLOUR/

PROPERTIESDESTINATION

Category A Paper, cardboard, yard clippings, wood or similar materials,

fruit and food containers, office & wrapping papers.

Black /

transparent

Recycling /

incineration.

Leftover food from patients and kitchens, including vegetable

& fruit peels, but not the containers thereof.White Landfill

Category B Discarded syringes, needles, cartridges, broken vials, blades,

rigid guide wires, trochars and cannulae.

Yellow

• Shatterproof.

• Penetration &

Incineration &

landfill

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PLEASE NOTE

The specific rules and prescripts for managing inactive, low, and/or high level radioactive waste in terms of segregation, sealing, labelling, temporary storage, the unlikely final disposal thereof, and the protection of health workers managing such waste, are not discussed in this Guideline. Further reading in this regard is therefore recommended.

leakage resistant.

Category C Human tissues; placentas; human organs; limbs; excision

products; used wound dressings, catheters and tubing;

intravenous infusions bags; abdominal swabs; gloves; masks;

linen savers; disposable caps; theatre cover shoes &

disposable gowns; sanitary towels; disposable baby napkins.

Red

• Leakage resistant

Incineration

Category D Empty aerosol cans, heavy metal waste and discarded

chemical disinfectants.

• Shatterproof.

• Penetration &

leakage resistant;

• Designated with

a “Flammable”

sign.

Incineration &

landfill

Category E Contaminated radio-nuclide’s whose ionizing radiation has

genotoxic effects. Also pharmaceutical products, chemical

waste, cytotoxics waste materials.

[NECSA: Nuclear Energy Corporation of South Africa, Pretoria]

• High lead density

material.

•Waterproof

•Designated with a

“Ionizing radiation”

warning sign.

• Sealed waste

disposed of at

NECSA waste

site.

• Other suitable

waste

incinerated and

then landfill.

Table 7: Colour coding of waste containers

With the use of the correct plastic bag colour, each container is automatically labelled as clinical waste,

non-clinical waste, kitchen waste, etc. When the bag is three quarters full, each bag or container must be

closed and secured, labelled with the name of the ward / service area and the name of the person who

closed and secured the bag, and it must be dated. Each new container or sharps container should be

labelled when replaced.

In every health facility there should be clearly visible charts showing what goes into which

colour bag or container. If a container and a plastic bag are used then both must be of the same

colour.

4.5 Waste storage

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• Domestic waste should be temporary stored separately from any other hazardous (biomedical

and clinical waste) waste as it is disposed at municipal waste areas.

i) Black plastic bags (domestic) are used for containing non-infectious, domestic waste. Once

the waste has been segregated it should be tied, labelled and stored in a clean, dry room

ready for collection.

ii) The sluice room is not recommended for temporary storage of waste. A secluded room

away from food services and where there is least movement of people should rather be

used.

iii) Temporary storage should preferably not exceed 24 hours.

iv) The containers for the temporary storage of non clinical waste should be leak proof,

intact, corrosive resistant, and have a close fitting lid.

v) From the temporary storage area, waste must be removed to a designated convenient

storage place until their collection by the municipality or waste management company.

vi) Domestic / non clinical waste can either be stored or dropped directly into a compactor

which will reduce the bulk of the domestic waste before it goes to land fill.

vii) Collection of waste should occur at least weekly or more frequently as the need arise so to

keep the health establishment free from scavengers and the bad smell of decaying

substance’s.

• Clinical waste should be locked and not be accessible to climatic conditions, rodents, stray

animals and the public or unauthorized personnel. The room should have adequate ventilation and

be washable with a water drainage point on the floor. There should also be proper lighting in the

room and the latter should be properly marked with a universal sign that signify “Hazard”.

4.6 Waste transportation

Waste should be collected everyday or more frequently depending on the need and be transported

on relevant (sufficient space), lockable wheeled trolleys, containers or carts. Trolleys should be

washed with detergent and water every day at the end of the collection cycle and allowed to dry.

All clinical waste must be registered and logged before transporting to a final disposal area. It is the

responsibility of the management of the health establishment to ensure that the final disposal of

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clinical waste is safe, permanent and not hazardous to the public. Clinical waste must be collected

by the contractor and transported safely in closed containers for final disposal.

4.7 Waste treatment and final disposal

Waste needs to be adequately treated to prevent contamination of receiving waters or land to a

degree which might interfere with their best or intended use, whether it is for water supply,

recreation, crop production, animal husbandry or human settlement.

Known technologies to improve or upgrade the quality of waste must be applied when treating

waste. This is done to ensure the waste is not detrimental to the environment and living

organisms that may subsequently come in to contact with the treated waste. It is recommended

that focused treatment of waste be considered and appropriate legislation be followed to treat

waste before actual disposal. Waste handlers must also be mindful of the fact that some waste

requires direct burning without treatment.

4.8 Protection of waste handlers

All waste handlers should be supplied with heavy duty domestic gloves, water resistant boots, full

length plastic overalls, full length heavy duty aprons and safety glasses (see Section 1.2, pages 24 -

25). There must be facilities for them to shower and to wash hands in their area of work.

Staff working in waste areas of a health establishment should be trained on how to handle and

identify the various types of waste and what precautions to take to prevent injury or spillage from

occurring. Additional in-service training regarding personal hygiene and infection control should

also be conducted. Safety precautions in cases of accidental exposure to hazardous waste such as

blood and all other body fluids, sharps injury, exposure to chemicals and other noxious substances

as well any other physical injury that emanates from waste management should be reported

immediately. Once reported, proper medical care should be provided and completion and

submission of relevant forms should also be done. Additional preventative mechanisms such as

regular medical examinations, treatment and alternative placement (in case a staff member is

found to be susceptible to disease or a complication of waste management) should be carried out

in line with the Occupational Health and Safety Act, Act 85 of 1993.

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ANNEXURE A: LIST OF NON-NEGOTIABLE CLEANING MATERIALS FOR ALL PUBLIC HEALTH ESTABLISHMENTS

MATERIAL DESCRIPTION AND INDICATION1. Hand washing cleaning materials

Plain liquid soap or non-antimicrobial soap Detergent-based products containing esterified fatty acids and Sodium hydroxide (NaOH) or Potassium hydroxide

(KOH) that washes away dirt and bacteria on skin surface.

• Recommended for routine hand hygiene.

• Recommended for use in non-healthcare settings.

• Usually less expensive than antibacterial soaps.

Alcohol-based hand rub with emollient Contain 60-95% of isopropanol, ethanol, n-propanol or a combination of two of these products, and 1-3 glycerol or

propylene glycol. Intended for hand antisepsis.

• It is designed to effectively decontaminate visibly clean hands.

• Antiseptic hand-rub is formulated with enhanced emollients that add moisture to the skin after every use.

Antimicrobial soap Antimicrobial soaps / detergent contain antiseptic agent such as 4% Chlorhexidine gluconate (HiBiscrub®)

• Suitable as a surgical hand scrub, preoperative skin preparation, and personnel hand wash.

• Not needed in businesses or most homes (unless directed by your healthcare provider).

• Must be left on your hands for about two minutes in order to have any effect on bacteria.

• The bacteria they affect are mainly the gram-positives bacteria, e.g. Staphylococci.

• Surgical hand scrub, healthcare personnel hand wash.

• Skin wound and general cleansing.

Surgical scrub brush sponges These types of sponges are sterile and disposable. It contains a fingernail cleaner.

• Highly suitable for scrubbing hands and forearms prior to patient care or surgery.

• Bristles usually flexible and soft, thus gentle and soft on the skin.

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Paper towels For drying of hands.

• Paper towels have almost the same purposes as conventional towels, such as drying hands, wiping windows, dusting

and cleaning up spills.

• Paper towels soak up water because they are loosely woven which enables water to spread between them, even

against gravity. Manufacturers use the pattern of the material, microscopic spaces within the pattern, and a type of

cellulose in the fibres in order to maximize absorption.

2. Personal protective equipment

Gloves (non –sterile and sterile) Rubber gloves (sterile or unsterile) are intended for clinical purpose and are disposable after every use. Other gloves

such as heavy duty domestic gloves, are intended for use during households chores and are not sterile and are re-

usable, hence the need to wash them and have them dried after every use.

• If a medical/latex glove (sterile & unsterile) is torn, punctured, or injury occurs during an invasive procedure from a

sharp object, replace glove with a new one immediately or as soon as possible.

Long sleeve gowns/disposable aprons Hospital gowns are military green with higher dirt resistance. It is used as a direct contact barrier between a

healthcare provider’s body and the work area / patient.

• Medical surgical gowns offer a high level of protection without compromising comfort.

• Surgical gowns have a smooth texture that glides easily without catching or grabbing, thus allowing free movement.

• Gowns are worn during invasive procedures such as surgery and during bathing of patients. These gowns should not

be used for any other purposes other than that prescribed by the health establishment.

Surgical masks (face covers) Surgical masks are worn as a precaution to droplets (droplet precaution).

• Surgical masks are used as a physical barrier to protect the user’s face and eyes from hazards, for example splashes

of body fluids such as blood and any other fluids.

• Surgical masks also protect other people against infection from the person wearing the surgical mask.

• A surgical mask also known as a procedure mask is intended to be worn by health providers during surgery and at

other times to catch the bacteria shed in liquid droplets and aerosols from the wearer's mouth and nose. Such masks

trap large particles of body fluids that may contain bacteria or viruses expelled by the wearer when sneezing or

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coughing.

Particulate masks (N-95 respirator) Airborne precaution.

• These masks are suitable for use in surgical and clinical settings. They have a minimum 95% efficiency rating against

particulates which are 0.3 microns or larger, and they meet Communicable Disease Control guidelines for TB exposure.

• A proper seal between the user's face and the respirator forces inhaled air to be pulled through the respirator's filter

material and not through gaps between the face and respirator.

• N95 masks help protect against particulate contaminants, but they do not eliminate the risk of contracting any

disease or infection.

Goggles Eye protection.

• Goggles or safety glasses are forms of protective eyewear that usually enclose or protect the area surrounding the

eye in order to prevent particulates, water or chemicals from striking the eyes.

• One measure to reduce the risks of transmitting skin microorganisms from one person to another is in the use of

single use disposable blood pressure cuff covers.

• Goggles must be worn during risky procedures such as suctioning, intubation, vaginal examination during labour and

at delivery, theatre procedures, endoscopies and emptying portovacs.

Face shields (visors) Protect face, mouth, nose and eyes.

• Face shields offer optical-grade protection against the splash and splatter of blood-borne pathogens and other

potentially infectious materials, including H1N1 and other pandemic threats.

• A face shield can provide eye and face protection when and wherever there is the risk of exposure to blood-borne

pathogens, or the presence of other infectious disease-carrying materials is anticipated.

3. Environmental cleaning material

Chlorine compounds (Sodium-hypochlorite or

Sodium-dichloroisocyanurate)

(i) Clean up blood spills (0.5% or 0.05% of household bleach depending on the amount of organic materials i.e. blood

or mucus present on the surface.

(ii) To add to Laundry water (0.01%).

(iii) Sodium hypochlorite is a chemical compound with the formula NaClO. Sodium hypochlorite solution, commonly

known as bleach or Clorox, is frequently used as a disinfectant or a bleaching agent.

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(iv) Surface cleaning, soaking of glassware or plastic items (0.1%).

(v) A 1-in-5 dilution of household bleach with water (1 part bleach to 4 parts water) is effective against many bacteria

and some viruses, and is often the disinfectant of choice in cleaning surfaces in hospitals.

Glutaraldehydes (2% formulations) • High level disinfection for heat sensitive equipment i.e. endoscopes, respiratory therapy equipment, and anaesthesia

equipment)

• Glutaraldehyde is an organic compound a pungent colourless oily liquid, glutaraldehyde is used to disinfect medical

and dental equipment.

Sanitary all purpose cleaner For cleaning toilet bowls and other sanitary facilities e.g. Handy Andy®.

Cleans all washable surfaces. Power-packed-cuts through dirt, grime and grease build-up without rubbing. Dilution

Rate: Ready-to-use. Foam action cleaner.

Janitor trolley

Colour – coded bucket and cloths

• Enables cleaning personnel to easily identify the bucket to be used in specific areas.

• Red colour (for toilets, urinals and sluice) ,Green colour (for baths ,basins and showers) ,Blue colour ( for furniture,

doors, walls ,pictures).

• Red bucket and cloths for toilets, urinals and sluice.

• Green bucket and cloths for baths, basins and showers.

• Blue bucket and cloths for furniture, doors, walls and pictures.

• Yellow bucket and cloths for Isolation cubicles/ rooms.

Spray bottle (containing dish washing detergent

– disinfectant solution)

• Dishwashing liquid), also known as dishwashing soap and dish soap, is a detergent used to assist in dishwashing.

• It is usually a highly-foaming mixture of surfactant with low skin irritation, and is primarily used for hand washing of

glasses, plates, cutlery, and other cooking utensils in a sink or bowl.

Window cleaning squeegee • A squeegee is a tool with a flat, smooth rubber blade, used to remove or control the flow of liquid on a flat surface

such as a window pane.

• Some squeegees are backed with a sponge which can soak up soapy water from a bucket for application to a dirty

window.

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• The "swivel method", or "fan method" as it is referred to by professionals, uses a series of strokes combined with

turns that hold the water away from the leading edge of the squeegee.

• Simple squeegees are made in various shapes for household use, including the cleaning of shower doors, bathroom

tile, and garage floor.

Mop sweeper or soft-platform broom • General cleaning with detergent – based solutions.

• Sweep dust off hard floors with ease and effectiveness with the dust to control sweeper.

• These superb sweepers attract and hold dust without complication of chemical treatment.

• Synthetic sweeper heads are easy to launder and available in 3 sizes plus the option of the larger twin-headed V-

Sweeper.

Water and detergent-based solutions • A detergent is a surfactant or a mixture of surfactants with "cleaning properties” in dilute solutions.

• Detergents are commonly available as powders or concentrated solutions.

• A good all-purpose Cleaner will work on multiple surfaces and accomplish many types of cleaning needs in the home.

• The cleaner sprays evenly, removes grease and stuck-on debris, and leaves the area smelling fresh and clean.

Protective polymer(Strippers) • Polymers (floor strippers) are the components which give the polish its basic, wear and gloss properties.

• It makes the floors shine and give the floor polish or sealer the required resilience and ability to withstand wear.

• A high-performance antimicrobial flooring system consisting of a concrete pre-treatment, an antimicrobial and build

coat that is top-coated with an aliphatic, high performance antimicrobial polymer.

Wet vacuum pick up • Wet vacuums do not lose suction as they fill up with dirt. They use water for filtration of dirt so as more dirt is

suctioned, the water just gets dirty.

• Wet vacuum machines don't use a bag that would lose suction as it is filled up.

• NB! Ensure that the used water is being discarded as soon as cleaning is done.

4. Waste Containers

Puncture-resistant sharp containers Sharps container is a container that is filled with used injection needles (and other sharp medical instruments, such

as intravenous catheter).It is standard practice in developed and even underdeveloped countries for used needles to

be placed immediately into a sharps container after a single use, with only a few exceptions to the general rule.

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Needles are dropped into the container without touching the outside of the container.

Needles should never be pushed or forced into the container, as damage to the container and/or needle prick

injuries may result.

Proper use of a sharps container includes pick up by or delivery to an approved "red bag" or medical waste

treatment site.

Examples of sharps include:

i) Needles, syringes, lancets, broken glass with blood on it, clinical glasses.

Ii)Suture needles, scalpel blades, razors, Vacutainer tubes (both plastic and glass)

iii)Phlebotomy needles with vacutainer tube holder attached.

Iv)Contaminated glass i.e. pipettes, slides, cover slips, tubes & broken lab glass.

v)Disposable suture sets, biopsy forceps, broken instruments

vi)Capillary tubes (both plastic and glass)

vii)IV intravenous needles, catheters / administration sets

viii)Dental wires and endodontic files

ix)Any other sharp objects contaminated with blood of body flyids

x)Cutters and broken glass

Plastic bags Strong plastic bags used to line buckets and other containers for waste. Such plastic bags come in various sizes and

colours tailored for purpose. They carry waste as follows:

Red plastic bags:

• Clinical and infectious waste

• Isolation waste

• Spill clean-up items

Black / transparent plastic bags

Domestic waste is generated from the

• offices,

• kitchens,

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• rooms,

• bed linen,

• other disposable utensils e.g. paper towels paper, etc.

White plastic bags:

Leftover food from patients and kitchen and this includes peels from vegetables and fruits.

Sealed impervious containers Used for collecting highly hazardous materials and are to be stored in specially indicated refrigerators while awaiting

collection and incineration. Tissues / organs from individual patient should be placed in a transparent plastic bag

before they are stored in a sealed impervious container. Record of all tissues/organs that are stored in the refrigerator

should be readily available. Proof of handing and receiving such tissues / organs for incineration should be available in

both the health establishment and service provider’s records. Tissues and organs include but are not limited to:

Human tissues, organs, body parts

• Pathological: tissues,

• organs,

• body parts,

• human flesh,

• fetuses,

• blood

• body fluids

Pedal Bins lined with appropriate coloured

plastic bag

Washable, rust resistant containers with functional leads that are intended for collection of general waste such as

soiled bandages, discarded bandages, dressings, swabs or packaging, gloves or nappies. All bins should be lines with

appropriate colour coded plastic bags.

Drain Cleaner A drain cleaner is a device that unblocks sewer pipes or helps to prevent the occurrence of clogged drains

Alkaline drain openers primarily contain sodium hydroxide and some may contain potassium hydroxide. They may

appear in liquid or solid form.

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Acid drain cleaners usually contain concentrated sulphuric acid (sulphuric acid). It dissolves proteins and fats via

hydrolysis.

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ANNEXURE B

GENERIC CLEANING SCHEDULE (for toilets, bathrooms and general service areas in a health care facility)

Name of a service area…………………………………… Names of housekeepers…………………………………………………………….…

Name of supervisor / manager…………………………................. Date………………………

DAILY DUTIES RECOMMENDED TIMES (may be more frequent as demanded by the condition of the area)6 8 10 11 12 13 14 15 16 18 20 22 02 04 05

• Replenish toilet and hand paper towels in toilets and hand washing areas respectively.

• Replenish liquid soap dispensers• Replenish air fresheners• Empty bedside waste bins / containers• Empty, clean and line waste bins elsewhere • Remove waste from all service areas to temporary

storage area.• Tie and close all the waste bags in the temporary storage

area.• Prepare tables for serving of tea and meals for patients• Clean door mats• Wash mirror, dirty wall surfaces and all work other

surfaces • Replace all notices as required• Wash hand basins and toilets (seats, urinals)• Fill male urinals with ice where possible• Scrub clean bed pans and urinals including sluice pans• Wash the floors including walk ways (wet mopping and

carpets suctioning)• Report any dysfunctional item immediately

Supervisor / Manager: …………………………………………………

Designation: ……………………………………………………………

Date: …………………………………………………………………….

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WEEKLY DUTIES Mon Tues Wed Thurs Fri Sat Sun Signature• Scrub all surfaces and polish all materials e.g. dispensers, taps,

outlets and trimmings.• Wash windows• Wash and wipe clean doors and their respective handles, walls

and hinges• Wash and wipe signage boards• Clean skirting

Supervisor / Manager: …………………………………………………

Designation: ……………………………………………………………

Date: …………………………………………………………………….

MONTHLY DUTIES JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC• Remove and replace all

curtains• Wash the walls, doors

and windows • Scrub patients’ lockers

and beds• Strip all floors and apply

polish

Supervisor / Manager: …………………………………………………

Designation: ……………………………………………………………

Date: …………………………………………………………………….

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ANNEXURE C: CLEANLINESS CHECKLIST FOR PHC FACILITIESThis cleanliness tool has been extracted and adapted from the National Core Standards Audit tool.

General appearance of the PHC EstablishmentInstructions: Observe the general environment using the following prompts in order to form a general impression of the hospitalNo Prompt Comments1. The appearance of the garden in terms of the grass

and flower beds around the premises (has it overgrown and not cut, and any presence of weeds)

2. The presence of dirt and litter around the hospital premises and along the corridors. The smell of the hospital

3. The state of the walls (is the paint peeling off or old and darkening walls, any dust on the walls)

4. The state of the fencing and gates. (Is the fence intact with no holes and the gates intact and functional)

5. The state of the windows, doors and roofs. (Cracked or intact; clean or dirty)

6. The presence of non-functional equipment standing along corridors or in other areas of the hospital

7. The appearance of the staff (Are they neatly dressed in uniform and wearing a name tag)

8. The encounter with the staff members (Are they helpful and friendly)

9. The availability and cleanliness of the blankets, linens and mattresses

10. There is a general impression of overcrowdingGeneral impression about the state of cleanliness?

Area assessed: Clinical care area/Consulting roomInstructions: Observe the environment for hygiene and cleanliness. The sampled clinical area will be assessed at three different points: patients’ care area, toilet and the kitchen/serving area. If the area complies tick Yes if not tick No

Patients care areaNo.

Question/Aspect Yes No Comments

11. The area is odour-free and clean, with clean linens, blankets and mattresses

12. Wash hand basin with functional taps, running water and proper drainage

13. Antimicrobial liquid soap and paper hand towels14. Medical waste is all contained in the appropriate

containers (all sharps such as needles, and syringes and blades in the sharps container; gloves and other medical waste in a red bags and non-medical waste in black bags)

15. The floor, countertops and door handles are clean

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and clear of spills and odoursActual Score (Sum of positive responses)Maximum possible score (Sum of all questions minus the not applicable responses)

Area assessed: Waiting areaInstructions: Observe the environment for hygiene and cleanliness. Assess the waiting area and if the area complies tick Yes if not tick NoNo.

Question/Aspect Yes No Comments

16. The area is odour-free and clean17. The floors are clean and clear of spills 18. There are waste bins visible in the waiting area19. The cleaning staff wear protective clothing while

carrying out their duties20. Records show that daily inspections of cleanliness are

carried out21. Are the walls clean and free of dust and web?22. Is the wall painting intact and well maintained with no

peeling and darkening?23. There is enough seats in the waiting area to

accommodate the patients waiting for service24. There are no broken windows and doors.25. There is no non-functional equipment stored/placed in

the waiting area.Actual Score (Sum of positive responses)Maximum possible score (Sum of all questions minus the not applicable responses)

Area assessed: Public toiletsInstructions: Observe the environment for hygiene and cleanliness. Assess the sampled area and if the area complies tick Yes if not tick NoNo.

Question/Aspect Yes No Comments

26. The area is odour-free and clean27. The floors are clean and clear of spills 28. The countertops and door handle are clean29. The cleaning staff wear protective clothing while

carrying out their duties30. There is a bin next to the wash hand basin31. Wash hand basin with functional taps, running water

and proper drainage32. Plain liquid soap33. Paper hand towels34. Toilet paper in each toilet cubicle35. Records show that daily inspections of cleanliness are

carried outActual Score (Sum of positive responses)Maximum possible score (Sum of all questions minus the not applicable responses)

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Area assessed: Tea roomNo Question/Aspect Yes No Comments 36. The area is odour-free and clean; and the floors

are clean and clear of spills37. The countertops and all working surfaces are

clean38. There are two wash hand basins with functional

taps, running water and proper drainage (one for hand washing and the other for dish washing)

39. Antimicrobial liquid soap and paper hand towels next to the hand washing basin

40. The bins are clean with well-fitting lids and lined with a bin bag

Actual Score (Sum of positive responses)Maximum possible score (Sum of all questions minus the not applicable responses)

Area assessed: Cleaning supervisor’s room/cleaning storage roomInstructions: Assess the selected area for their cleaning materials. Tick in the Yes column if THE ELEMENTS ARE PRESENT and in the No column if THEY ARE NOT. Mark N/A if item is not part of routine supplies in establishmentNo.

Question/Aspect Yes No Comments

41. Gloves (non-sterile and sterile)42. Long sleeve gowns/disposable aprons43. Surgical masks/face covers44. Goggles/Face shields45. Water and detergent-based solutions46. Janitor trolley47. Colour-coded bucket, mops and cloths48. Window cleaning squeegee49. Protective polymer

Wet vacuum pick up

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ANNEXURE D: CLEANLINESS CHECKLIST FOR HOSPITALSThis cleanliness tool has been extracted and adapted from the National Core Standards Audit tool.

General appearance of the hospitalInstructions: Observe the general environment using the following prompts in order to form a general impression of the hospitalNo

Prompt Comments

1) The appearance of the garden in terms of the grass and flower beds around the premises (has it overgrown and not cut, and any presence of weeds)

2) The presence of dirt and litter around the hospital premises and along the corridors. The smell of the hospital

3) The state of the walls (is the paint peeling off or old and darkening walls, any dust on the walls)

4) The state of the fencing and gates. (Is the fence intact with no holes and the gates intact and functional)

5) The state of the windows, doors and roofs. (Cracked or intact; clean or dirty)

6) The presence of non-functional equipment standing along corridors or in other areas of the hospital

7) The appearance of the staff (Are they neatly dressed in uniform and wearing a name tag)

8) The encounter with the staff members (Are they helpful and friendly)

9) The availability and cleanliness of the blankets, linens and mattresses

10) There is a general impression of overcrowdingWhat is your general impression about the hospital?

Area assessed: Clinical care area/WardInstructions: Observe the environment for hygiene and cleanliness. The sampled ward/clinical area will be assessed at three different points: patients’ care area, toilet and the kitchen/serving area. If the area complies tick Yes if not tick No

Patients care areaNo. Question/Aspect Yes No Comments11) The area is odour-free and clean, with clean linens,

blankets and mattresses12) Wash hand basin with functional taps, running water

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and proper drainage; antimicrobial liquid soap and paper handtowels

13) The cleaning staff wear protective clothing while carrying out their duties

14) Medical waste is all contained in the appropriate containers (all sharps such as needles, and syringes and blades in the sharps container; gloves and other medical waste in a red bags and non-medical waste in black bags)

Ward toilet and bathroom15) The floor, countertops and door handles are clean

and clear of spills and odours16) Toilet paper in each toilet cubicle17) Wash hand basin with functional taps, running water

and proper drainage; plain liquid soap and paper hand towels

18) Answer only one of the following question: In the female ward: Two waste bins for

sanitary pads and used paper hand towels In the male ward: at least one in male toilet

for used paper hand towels Kitchen/serving area in the ward

19) The area is odour-free and clean, with clean working surfaces

20) The bins are clean with well-fitting lids and lined with a proper bin bag

Actual Score (Sum of positive responses)Maximum possible score (Sum of all questions minus the not applicable responses)

Area assessed: Waiting area of …………………(Please specify the waiting area assessed)Instructions: Observe the environment for hygiene and cleanliness. Assess the sampled area and if the area complies tick Yes if not tick NoNo Question/Aspect Yes No Comments21) The area is odour-free and clean22) The floors are clean and clear of spills and litter.23) There are waste bins lined with an appropriate bin

bag visible in the waiting area.24) The cleaning staff wear personal protective

clothing while carrying out their duties25) Records show that daily inspections of cleanliness

are carried out26) Are the walls clean and free of dust and web?27) Is the wall painting intact and well maintained with

no peeling and darkening?28) There is enough seats in the waiting area to

accommodate the patients waiting for service29) There are no broken windows and doors.30) There is no non-functional equipment

stored/placed in the waiting area.

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Actual Score (Sum of positive responses)Maximum possible score (Sum of all questions minus the not applicable responses)

Area assessed: Public toiletsInstructions: Observe the environment for hygiene and cleanliness. Assess the sampled area and if the area complies tick Yes if not tick NoNo.

Question/Aspect Yes No Comments

31) The area is odour-free and clean32) The floors are clean and clear of spills 33) The countertops and door handle are clean34) The cleaning staff wear protective clothing while

carrying out their duties35) There is a bin with an appropriate bin bag next to

the wash hand basin36) Wash hand basin with functional taps, running

water and proper drainage37) Plain liquid soap38) Paper hand towels39) Toilet paper in each toilet cubicle40) Records show that daily inspections of cleanliness

are carried outActual Score (Sum of positive responses)Maximum possible score (Sum of all questions minus the not applicable responses)

Area assessed: Main kitchenNo Question/Aspect Yes No Comments 41) The area is odour-free and clean; and the floors

are clean and clear of spills42) The countertops and all working surfaces are

clean43) There are at least three wash hand basins with

functional taps, running water and proper drainage (one for hand washing, one for washing fruits and vegetables, and the other for dish washing)

44) Antimicrobial liquid soap and paper hand towels next to the hand washing basin

45) The bins are clean with well-fitting lids and lined with an appropriate bin bag

46) Are the staff members wearing clean personal protective clothing?

47) Are the walls clean and free of dust and webs?48) Is the wall painting intact and well maintained with

no peeling and darkening?49) There is no pest infestation (e.g. rats) 50) Is the cooking and serving utensils free of rust? Actual Score (Sum of positive responses)Maximum possible score (Sum of all questions minus the not applicable responses)

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Area assessed: Cleaning supervisor’s room/cleaning storage roomInstructions: Assess the selected area for their cleaning materials. Tick in the Yes column if THE ELEMENTS ARE PRESENT and in the No column if THEY ARE NOT. Mark N/A if item is not part of routine supplies in establishmentNo.

Question/Aspect Yes No Comments

51) Gloves (non-sterile and sterile)52) Long sleeve gowns/disposable aprons53) Surgical masks/face covers54) Goggles/Face shields55) Water and detergent-based solutions56) Janitor trolley57) Colour-coded bucket, mops and cloths58) Window cleaning squeegee59) Protective polymer60) Wet vacuum pick up

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SOURCES

Still to be written

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