Policy Title:

Cleaning, disinfection and Sterilisation

Executive Summary:

Details the differences between cleaning, disinfection and
sterilisation and how these are achieved and most appropriately
used within the Trust.

Supersedes:

V2 2007

Description of
Amendment(s):

Minor Wording

This policy will impact on:

clinical practices, employees and health & safety

Financial Implications:

None

Policy Area:

Infection Control Trust
Wide

Document
Reference:

CDSv3.09

Version Number:

Effective Date:

2009

Issued By:

Director of Infection

Prevention and Control

Review Date:

12.2011

Author:

Service Manager

Infection Prevention

and Control

Impact Assessment
Date:

06.09

APPROVAL RECORD

Committees / Group

Date

Consultation:

Infection Control Committee

06.09

Health Protection Unit

06.09

Approved by Director:

Director of Nursing & Patient

Care Standards

06.09

Received for information:

CONTENTS

Page

Policy Statement including Single Use Items

1. Introduction

2. Principles

3. Definitions

4. Risk Assessment for the Decontamination of Reusable Medical Devices

4.1 High Risk

4.2 Medium Risk

4.3 Low Risk

5. Methods of Disinfection and Sterilisation for Reusable Medical Devices

5.1 Heat Sterilisation

5.2 Chemical Sterilisation

5.3 Heat Disinfection Methods

5.4 Chemical Disinfection

6. Bench Top Steam Sterilisers

7. Endoscope Washer Disinfectors

7.1 Decontamination

8. Prion Disease

8.1 Prions

8.2 Creutzfeldt-Jacob Disease (CJD)

8.3 Identification and Tracing of Instruments

Legislation, Guidance and References

Appendices

I Risk Categories for the Decontamination of Reusable Medical Devices

II Quarantine of Surgical Instruments

III Disinfection Methods

Equality and Human Rights Policy Screening Tool

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POLICY STATEMENT FOR REPROCESSING MEDICAL DEVICES

The Trust has a responsibility to have a system in place to ensure that, as far as is
reasonably practicable, all re-usable medical devices are properly decontaminated prior to
use and that the risks associated with decontamination facilities and processes are
adequately managed.

In this policy the term

re-usable medical device applies to all such devices whether owned

by the organisation, rented, on loan or acquired by any other means.

SINGLE-USE DEVICES MUST NOT BE REPROCESSED

Single-use devices

must not be reprocessed and single patient use devices must not be

re-used outside the manufacturers guidance.

The processing and re-use of single-use devices has inherent risks such as safety,
performance and effectiveness, thereby exposing patients and staff to unnecessary risk and
represents a substantial litigation risk to the Trust.

All equipment purchased must comply with the European Union (EU) and United Kingdom
(UK) standards for reprocessing, packaging and ensuring the equipment is still suitable for
its intended use.

Guidance within this policy is provided for disinfection and sterilisation using heat and cold
chemical methods and advice for single-use items and guidance for CJD is also included.
Further detailed advice can be obtained from the Medical Devices Agency MDA DB2002
(05) July 2002 “Decontamination of endoscopes” and MDA DB2002 (06) October 2002
“Benchtop steam sterilisers – Guidance on Purchase, Operation and Maintenance”.  These
documents should be available to all users of endoscope washer disinfectors and benchtop
sterilisers.  Copies of the documents can be obtained from the Infection Prevention &
Control Team or

www.mhra.gov.uk

. Also refer to the Trust policy on single-use Medical

Devices: Implications and consequences of re-use.

1. INTRODUCTION

The choice of decontamination method depends on a number of factors, which include
the type of material to be treated, the organisms involved, the time available for
decontamination and the risks to staff and patients.

Disinfection, sterilisation and cleaning are necessary to prevent cross infection from
equipment, surfaces and skin of patients and health care staff (for skin decontamination
refer to the Good Practices policy). This policy relates to all areas.

Guidance is provided for disinfection and sterilisation using heat and cold chemical
methods and advice for single-use items and CJD is also included, refer also to the
Single-used Medical Devices: Implications and Consequences of Reuse policy.

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2. PRINCIPLES

2.1 The re-usable medical device life cycle, shown in figure 1 comprises the following

processes – acquisition, cleaning, disinfection, inspection, packaging, sterilisation,
transportation, and storage before use. This cycle is used to render a re-usable
item safe for use. It is important that the Infection Prevention & Control Team is
involved at all stages including pre-purchasing.

2.2 Prior to purchasing equipment Trust staff must ensure that the item can be

decontaminated effectively and that the suppliers offers clear instructions on the
cleaning, disinfection and sterilisation methods suitable for individual pieces of
equipment, the Infection Prevention & Control Team can also provide advice.

2.3 Routine decontamination of equipment and the environment can be undertaken by

cleaning with soap/detergent. This same process must also be used for the
preparation of equipment prior to the appropriate disinfection/sterilisation method if
required.

Heat disinfection/sterilisation methods can be used on all heat-stable equipment.
Heat-sensitive equipment such as fireoptic scopes must be sterilised/disinfected
using cold chemical processes or gas sterilisation with ethylene oxide.

Re-Usable Medical Device Life Cycle

At all stages:

Location

Facilities

Equipment

Management

Policies/Procedures

CLEANING

DISINFECTION

INSPECTION

PACKAGING

STERILIZATION

TRANSPORT

STORAGE

USE

TRANSPORT

DISPOSAL
1. Scrap
2. Return to lender

ACQUISITION

1. Purchase
2. Loan

Figure 1

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3. DEFINITIONS

Decontamination: is the combination of processes, including cleaning, disinfection
and/or sterilisation, used to render a reusable item safe for further use.

Cleaning: is the process which physically removes large numbers of micro-organisms
and the organic material on which they survive.

Disinfection: is described as a process used to reduce the number of viable micro-
organisms but which may not necessarily inactivate some microbial agents, such as
viruses and bacterial spores.

Sterilisation: the removal of viable micro-organisms and spore on an object.

4. RISK ASSESSMENT FOR THE DECONTAMINATION OF RE-USABLE MEDICAL

DEVICES

The choice of appropriate decontamination methods is undertaken on a risk assessment
basis, with three categories, high, medium and low risk. A description of these
categories is given below and also summarised in Appendix I.

4.1 High Risk

These devices penetrate skin or mucous membranes, enter the vascular system or
sterile spaces, for example surgical instruments, and require sterilisation prior to
their use. Other sterile devices such as cardiac or urinary catheters, implants,
needles, etc, are single use (and sterilised by the manufacturer) and

must not be

reprocessed.

4.2 Medium

Risk

These devices come into contact with intact mucous membranes or may be
contaminated with particularly virulent (pathogenic) or readily transmissible
organisms. They require high-level disinfection to remove vegetative bacteria.
These items have the potential to be in contact with mucous membranes, damaged
skin, infected lesions, blood/body fluids. This category also applies to items used
on immuno-compromised patients. These items are made safe by a disinfection
process.

4.3 Low

Risk

These devices either come into contact with intact skin or do not come into contact
with the patient. Whilst this policy focuses mainly on the high and medium risk
devices, it is equally applicable to the lower risk devices, which are frequently
decontaminated locally in a clinical unit.

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5. METHODS OF DISINFECTION AND STERILISATION AVAILABLE FOR RE-USABLE

DEVICES

The method of decontamination will depend largely on the nature of potential pathogens
present and the infection risk associated with the device (Appendix I). To prevent
damage to a device, other factors such as the heat, pressure and chemical tolerance as
well as the manufacturers advice, must be taken into account before reprocessing
devices, there must be compliance with each of the stages identified in figure 1.

5.1 Heat

Sterilisation

Heat sterilisation – using autoclaves with steam under pressure either in the
Hospital Sterilisation and Disinfection Unit (HSDU) or bench top steam sterilisers,
which are covered in detail in section 6.

The following are the temperatures and cycle times for autoclaves in HSDU or
bench top steam sterilisers in clinical areas:

Porous load (wrapped)

134 - 138

for 3 minutes

Unwrapped instruments

121 - 124

for 15 minutes or 115

c for 15 minutes

5.2 Chemical

Sterilisation

Cold sterilisation – using chemicals such as chlorine dioxide for heat labile
equipment. For sterilisation, immersion in chlorine dioxide is required for 5
minutes.

Gas Sterilisation – can be used for the sterilisation of heat sensitive equipment
(ethylene oxide is used, although not available in HSDU – for further advice contact
the HSDU manager ext. 1920).

5.3 Heat Disinfection Methods

Disinfection by low temperature steam –this is moist head disinfection/

pasteurisation process (73

c for 10 minutes).

Washer disinfection – the use of washer/disinfectors uses two principles of
disinfection (thermal disinfection and chemical disinfection), although the main
emphasis is on the mechanical/physical removal of tissue and debris prior to
disinfection (see also HTM 2030 washer-disinfector).

Temperature ranges and time periods

c for 10 minutes

c for 3 minutes

c for 1 minute

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5.4 Chemical

Disinfection

Chemical disinfection – Chemical disinfectants are used when alternatives are
required for heat-sensitive items. The microbicidal activity of the chemical and the
contact time are important considerations when choosing chemical disinfectants,
for example, hypochlorite or chlorine dioxide.

IMPORTANT DOS AND DON’TS OF CHEMICAL DISINFECTION

DON’T

Take care to measure your disinfectant
correctly

Use a disinfectant for sterilisation

Add the disinfectant to the right amount
of water, to make a solution for use

Add detergent to a disinfectant; this
may inactivate both

Use a clean, dry container for the
solution

Store instruments or cleaning tools in a
disinfectant

Wash away dirt, where you can, before
using disinfectant

Top up solution: make up a fresh one
when expiry time reached, e.g. Virkon 7
days shelf life

Remember that if disinfectants are used
carelessly, they may grow microbes

Use two disinfectants together

Check expiry dates

Bring in your own disinfectant to the
hospital

Give adequate time for disinfectant to
work

Disinfect if cleaning is sufficient

6. BENCH TOP STEAM STERILISERS



Wherever possible, all instruments and other equipment should be sterilised in
HSDU. Benchtop steam sterilisers are intended for the sterilisation of unwrapped
instruments for use in the immediate environment and have the following features:



Fully automated pre-determined sterilisation cycle



Steam generated internally



Single manually operated door



Electrically heated



Before purchase advice should be sought from an Authorised Person for sterilisers
(Contact Estates Department, at MDGH ext 1616) regarding the use, ranges of
sterilisers available and installation and commissioning. HTM 2010 contains detailed
advice on specification, purchase, installation, maintenance and operation. Validation
is also required prior to the use of the steriliser and all records of the validation
process retained by the owner/user.



Periodic testing of benchtop steam sterilisers and maintenance tasks must be
undertaken and retrospective testing is not recommended. Routine monitoring of the
process and periodic testing on a daily basis, weekly, quarterly and annually must be
undertaken and recorded (HTM 2010 part 4).

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

Owners of benchtop steam sterilisers should ensure that the steriliser is subject to a
planned and documented schedule of preventative maintenance. Guidance is
provided in HTM 2010.



The user should follow the recommendations for the use and quality of the water to
fill the reservoir, the frequency of changing the water and routine maintenance of the
reservoir (HTM 2010, 2030, 2031). The quality of steam is also an important factor in
the sterilisation process and should be assessed regularly in line with HTM 2031.



In order to comply with HTM standards benchtop steam sterilisers must only be used
in association with an automatic washer disinfector and benchtop steam sterilisers
must have an automatic water cycle (filling and emptying).



All forms of wrapping material, including pouches, are considered as being
inappropriate for use with benchtop steam sterilisers. Benchtop steam sterilisers
are also

not suitable for processing porous loads such as swabs, towel dressings,

gowns and drapes.

Therefore, only those benchtop steam sterilisers equipped with a vacuum stage
(porous load) are only suitable for processing wrapped instrument and instruments
with lumens, and then only they have a pre-sterilising vacuum cycle.

7. ENDOSCOPE WASHER DISINFECTORS

Endoscopes can be categorised by their design into rigid or flexible, and all flexible and
most rigid scopes are meant to be re-used. When purchasing endoscopes or
accessories, consideration must be given to the ease of decontamination of reusable
equipment and alternative single use items. Flexible scopes contain a wide range of
materials which render them heat sensitive, and chemical disinfection is the choice of
reprocessing method.

The diverse range of materials incorporated into scopes and their accessories, including
automated endoscopes reprocessors (AERs) make it essential to obtain advice from
manufacturers on chemical compatibility and decontamination methods (detailed
information can be found in MDA DB2002 05).

7.1 Decontamination

The effective decontamination of equipment requires input from the following areas
of expertise:



Manufacturers of scopes and accessories



Manufacturers of AERs



Infection Prevention & Control Team



Endoscopy Department



Authorised persons for decontamination



Clinicians



Manufacturers of chemical disinfectants

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All procedures for the purchase, cleaning, disinfection/sterilisation, maintenance
and storage of scopes and AERs should be undertaken following expert guidance
from the above list of people and appropriate MDA Bulletins and HTM’s listed in the
reference section. Advice on the validation, maintenance and the periodic testing
is provided in HTM 2030.

Traceability of devices during their life cycle is also important, therefore, systems
have to be put in place to ensure all equipment used including AERs can be
identified to individual patients and recorded. (see also section 8.3 and Appendix II)

The use of mains water of appropriate quality can be a contributory factor to the
contamination of the scopes and AERs. Some machines have a pre-programmed
self-disinfection cycle. Which ever disinfection regime is chosen, it is essential that
all parts of the machine that come into contact with the water is accessed during
the self-disinfection cycle of the AER. It is also essential that water tanks and fluid
pathways of the machine are drained and left dry when not in use. Detailed advice
can be sought from the HTM 2031 on the required water quality for endoscopes
and AERs.

For information on disinfection methods see Appendix III.

8. PRION DISEASES

The abnormal proteins associated with prion disease are very resistant to all
conventional methods of decontamination.

8.1 Prions

Prions are infectious agents smaller than viruses and unlike any other pathogens.
Their only known component is an abnormal conformed protein. These abnormal
proteins then accumulate in the central nervous system. Prion diseases are fatal,
infectious, neuro-degenerative disorders with no known immunisation or treatment.
Currently there are four known human prion diseases:



Kuru



Gerstmann-straussler-scheinker-syndrome (GSS)



Fatal Familial Insomnia



Creutzfeldt-Jakob disease (CJD) and variant Creutzfeldt-Jakob disease (vCJD)

Most chemical and physical means of cleaning, disinfection and sterilisation are
only partially effective in inactivating prion disease.

8.2 Creutzfeldt-Jacob Disease (CJD)

For all patients irrespective of known or suspected prion disease: single use
devices must be used for lumber punctures and surgery relating to the eye, tonsils,
brain or spinal cord.

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LEGISLATION, GUIDANCE AND REFERENCES

ACDP (1998)

Transmittable Spongiform Encephalopathy Agents: Safe Working and

the Prevention of Infections

Advisory Committee on Dangerous

Pathogens Protection Against Bloodborne Infections

in the Workplace – HIV & Hepatitis

Ayliffe G.A.J., Coates D. and Hoffman P.N. (1986)

Chemical Disinfection in Hospitals

PHLS LONDON

Ayliffe G.A.J., Lowbury E.J.L., Geddes A.M. and Williams J.D. (1992)

Control of Hospital

Infection – A Practical Handbook (3

Edition) Chapman and Hall Medical, LONDON

British Medical Association (1989)
A Code of Practice for the Sterilisation of Instruments and Control of Cross Infection
BMA LONDON

Control of Substances Hazardous to Health Regulations 1999 (COSHH)

Department of Health and Public Health Laboratory Service (1995)

Hospital Infection

Control – Guidance on the Control of Infection in Hospital Department of Health,
LONDON

Department of Health

The Health & Social Care Act 2008 – Code of Practice for the

Prevention and Control of Health Care Associated Infection

Horton R., Parker L. (1997)

Informed Infection Control Practice Churchill Livingstone

DOH (2000)

Control Assurance Standards – Decontamination of re-usable devices

DOH (1999)

Decontamination Guidance (CD Rom Version 1.0) NHS Estates

MDA DB 9605 (1996)

The Purchase Operation and Maintenance of Benchtop Steam

Sterilisers

MDA DB 2000 (04)

Single-use Medical Devices: Implications and Consequences of

Re-Use

MDA DB 2002 (05)

Decontamination of Endoscopes

MDA DB 2002 (6)

Benchtop Steam Sterilisers – Guidance to the Purchase, Operation

and Maintenance

WHC (99) 157

Decontamination of Medical Devices

WHC (99) 158

Variant Creutzfeldt-Jakob Disease (vCJD)

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RISK CATEGORIES FOR THE DECONTAMINATION

OF REUSABLE MEDICAL DEVICES

Appendix I

Items in close contact with a break in skin or
mucous membrane or introduced into a normally
sterile body area

Definition

Examples

Surgical instruments
Syringes and needles
Intrauterine devices
Dressings

High Risk

Suitable methods

Sterilisation required
Items in contact with mucous membranes or other
items contaminated with particularly virulent or
readily transmissible organisms; or items to be used
on highly susceptible people

Definition

Examples

Respiratory equipment
Gastroscopes

Intermediate
Risk

Suitable methods

Disinfection required, by heat where possible
Items in contact with normal and intact skin

Definition
Examples

Washing bowls
Floors

Low Risk

Suitable method

Cleaning and drying usually adequate

APPENDIX II

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QUARANTINING OF SURGICAL INSTRUMENTS

Paragraph 4.28 of the Advisory Committee on Dangerous Pathogens (ACDP) Spongiform
Encephalopathy Advisory Committee (SEAC) guidance on “Transmissible spongiform
encephalopathy agents: Safe working and the prevention of infection” allows for instruments
that have been used on a patient suspected of having CJD of any type to be quarantined
pending a confirmation of diagnosis. Although it is not expected that this facility will need to
be used widely, the following supplementary advice has been prepared for reference in
those instances where such quarantining may be appropriate.

At the completion of a surgical procedure undertaken on a patient suspected of suffering
with CJD of any type, single-use instruments should be separated and disposed of by
incineration, re-usable instruments should be washed to remove gross soil.  Care should be
taken to avoid splashing and generating aerosols by holding instruments below the surface
of the water in a sink into which water is running and draining out continuously.

Instruments should not be held directly under a flowing tap, as this is likely to generate
splashes. Operatives should wear protective gloves and either a visor or goggles and care
must be taken to avoid penetrating injuries.

Instruments should be placed in a disposable instrument tray and allowed to air dry.  They
should then be placed in an impervious rigid plastic container with a close fitting lid. The lid
should be sealed with heavy-duty tape (e.g. autoclavable tape) and labelled with the
patient’s identification (i.e. hospital number, name and date of birth, the surgical procedure in
which the instruments were used and the name of the responsible person (e.g. the theatre
manager).

The sealed box should be stored indefinitely in a suitable designated place (within main
theatre) until the outcome of any further investigation is known. The instrument tray should
be disposed of by incineration.

If the patient is confirmed as suffering from CJD of any type, the box and its contents should
be incinerated without further examination. If an alternative, definitive diagnosis is
confirmed, the instruments may be removed from the box by the responsible person
(Theatre Manager or a deputy) and sent to the HSDU for processing in the usual way.

Records must be kept of all decisions, and the HSDU must be told of the decision before the
instruments are sent for routine processing.

Prolonged autoclaving or supplemental disinfection is not necessary for instruments
removed from quarantine, which had been used on a patient

not suffering from CJD of any

type.

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DISINFECTION METHODS APPENDIX III

Disinfection is the removal of most pathogenic organisms from an object. (Disinfectants

cannot sterilise. Where sterility is required heat treatment is

always preferable.) Simple cleaning with detergent will remove the majority of micro-organisms and is an essential first step in disinfection. There
are several types of disinfectant.

DISINFECTANTS

TYPE

EXAMPLE
(Brand may be changed from time to time)

NOTES

Alcohol

Industrial methylated spirits (70%).
70% Alcohol impregnated swabs and wipes
e.g. Mediswab, Azowipes.

Alcohol used for soaking items must be
disposed of at the end of each day.

Chlorine Dioxide

Tristel

Must only be used in specified areas.

Hypochlorite

Haztabs, Haztab Granules and Titan 500 mg
Hypochlorite sanitising powder e.g. Endbac

Neutralised by organic material.
Corrosive to metal.
Effective against viruses.

Phenolic –

only for use prior to

macerator repair – available from
Pharmacy on request

Hycolin (dilute to 2% solution in water)

Toxic and corrosive to skin.
Kills bacteria and fungi.

For specific infections the Infection Prevention & Control Team may offer individual advice on the choice and use of disinfectant.

Don't Forget -

C.O.S.H.H. regulations apply to all Disinfectants.

Always follow manufacturers instructions regarding dilutions.

Ensure adequate ventilation (especially for Hypochlorites and Aldehydes).

Always wear gloves and apron.

Know what action to take if you accidentally splash any on to your skin or into your eyes and mouth. See Good Practices
Policy for Infection Prevention & Control.

The following list is a guide for adequate disinfection. Additional information may be required by community staff working within the patient’s home environment. If
you have any problems or doubts about procedures, please contact either:

Infection Prevention & Control Nurses, Ext.

1597, 1417 or 1769, or Bleep 3034, or Consultant Microbiologist, Et 1810 or Bleep 3102

ITEM

ROUTINE

ADDITIONAL

RECOMMENDATIONS

Airways Disposable.

Ambubags

Detergent and hot water. Dry thoroughly.

Ambulift

Detergent and hot water. Dry thoroughly.

Hypochlorite if fouled, or after potentially infected patients.

Ampoules and Vials

Wipe neck with alcohol impregnated swab.

Auroscopes

Disposable single patient use

Baths

Clean at least daily, and between patients, with
detergent in hot water, rinse and dry.

After use by known or potentially infected patient, clean with
Hypochlorite sanitiser, rinse and allow to dry.

Bath Mats

Disposable single patient use

Bed Frames

Detergent in hot water between patients.

After patient with a specific infection, consult Infection Control Nursing
Plan.

Bed Pans

Non disposable.

Disposable

Bed/slipper pans, place directly into washer/disinfector.

Place directly into macerator.

Bed Pan Disposal Units
(Macerators)

Wash outside with detergent and hot water.

Report any leakage’s around the lid to the Nurse in Charge. Add 100
ml of Hycolin to machine prior to servicing and repairs.

Bed Pan Washer/Disinfectors

Wash outside with detergent and hot water.

Report any leakage’s to Nurse in Charge.

Bed Pan Holders

Wash in detergent and hot water, then rinse well and
store dry after each use.

ITEM

ROUTINE

ADDITIONAL

RECOMMENDATIONS

Bidets

Wash with detergent and hot water, rinse and dry
between patients.

Clean with hypochlorite sanitiser after use by known or potentially
infected patients and when any blood spillage’s are visible, rinse
and dry

Blood Glucose Meters

Wipe any blood contamination with alcohol impregnated
wipes.

Carpets

Vacuum clean daily.

Faeces & Vomit – Remove as much organic matter as possible
using paper towels, discard directly into yellow bag. Clean area
using a Hypochlorite solution and rinse with water.
Blood - Haztab granules and Hypochlorite, rinse well. (See
instructions in blood spillage pack)

Cleaning Cloths

Disposable.

Use different cloths in different areas, i.e.

Green

- Kitchens

Red

Bathrooms & Toilets

Blue

- General

Areas

Commodes (and Sanichairs)

Frame:

Approved cleaner e.g. Steri7 Wipes.

Bed pan: Disposable or bed pan washer.

Commodes must be labelled as clean

After patient with enteric infection wipe frame with Hypochlorite
sanitiser, rinse and dry.

Commodes must b e labelled as clean

Dressing Trolley

Clean with detergent and hot water before commencing
dressings. Disinfect top with alcohol impregnated wipes
between patients.

Emergency Pocket Masks

Wash with detergent and hot water, rinse and dry.
Replace disposable valve following each patient use.

Endoscope

See local guidelines.

Feeding Bottles

Send to HSDU.

Floors

Detergent only.

For blood contaminated spillage use hypochlorite 10,000 ppm, or
granules (see blood spillage pack). For other known or potentially
infected spillage use hypochlorite solution 10,000 ppm.

Flower Vases

Detergent in hot water, then rinse and dry.

Do not wash in the kitchen.

ITEM

ROUTINE

ADDITIONAL

RECOMMENDATIONS

Food Preparation Areas

Hypochlorite sanitiser solution and rinse with water.

Important to wipe dry, especially metal surfaces.

Food Trolleys

Detergent and hot water.

Disconnect heated trolley first!

Furniture

Detergent in hot water.

After Specific Infection Control Nursing, special arrangements will
be made.

Handbasins

Clean daily with hypochlorite sanitiser. Wash with detergent
in hot water and rinse and dry between patients.

After use by known or potentially infected patients, disinfect with
Hypochlorite sanitiser, rinse and allow to dry.

Hands

Soap and water, rinse and dry well or if appropriate use
alcohol hand sanitiser.

Antiseptic cleansing agent after contact with infected patients or
materials and prior to aseptic techniques ONLY. See hand
cleansing guidelines in Good Practices Policy.

Humidifiers

Wash daily with soap and water, then rinse and dry before
refilling with sterile water.

In between patient use send to HSDU.

Ice Making Machine

Defrost, wash inside with detergent and hot water, rinse and
dry, weekly.

Infant Incubator

Detergent and hot water, then Hypochlorite solution, 125
ppm available chlorine (one Haztabs tablet in 2.5 litres
water). Hypochlorite 125 ppm.

Important to wipe dry, especially metal parts.

Injection Trays/Kidney
Dishes

Disposable or detergent and hot water daily. Alcohol
impregnated wipes between patients.

Instruments

Autoclave or disposable.

Laryngoscope Blades

Disposable or wash in hot soapy water, rinse and dry. Wipe
blade with alcohol impregnated wipe.

Lavatory Brush

Rinse in last flush and store dry.

Linen

Launder.

Blood contaminated linen and linen from patients with specific
infections (isolation nursing) -

Red linen bag with soluble liner

Faecal contaminated linen -

White bag with red plastic liner

Soiled/dirty linen (including urine stained) -

White bag

ITEM

ROUTINE

ADDITIONAL

RECOMMENDATIONS

Mattress

Detergent in hot water, rinse and dry.

Hypochlorite sanitiser solution after contamination.

Measuring Jug (for use in
dirty utility room only)

Disposable

Medicine Pots

Disposable or detergent in hot water, rinse and dry.

Manual Handling Aids:

Machinery
Fabric Slings belts &

Slides

Detergent in hot water and dry. Launder unless single
patient use.

Must be identified per patient use with ID bracelet

Mops – Domestic

Wash mop head in detergent, rinse and squeeze dry. Store
dry – separate from other mop heads or launder detachable
mop heads daily if service available.

Use different coloured mops and buckets in different areas i.e.:

Green - Kitchen

Red

- Bathrooms

and

Toilets

Blue

- General

Areas

Mops – Isolation

For Domestic and Spillage use.

Yellow/Gold -

Isolation Nursing

Mops – Spillage

After use with disinfectants, rinse well and store dry.

White

Nailbrushes

Use not recommended.

Single use only.

Nappies Disposable.

Nebulisers & Volumatics

Wash daily with detergent in hot water, rinse and dry. For
single patient use only.

Must be stored dry when not in use.

Potties

Empty into sluice. If not available, empty down a toilet,
avoiding splashing. Clean in a designated sink using
disposable paper, detergent and hot water, rinse and store
dry. Ensure handles are also cleaned.

Use for individual patients only. Send to HSDU for disinfection once
no longer required by patient.

Razor – Electric

Should be patients own razor.

Razor – Wet

Disposable type only, unless patients own then wash with
detergent in hot water. Store dry.

Dispose of used blades and disposable razors in sharps disposal
box immediately after use.

Resuscitation Mask

Detergent in hot water. Store dry.

After infected patient dispose of appropriately.

ITEM

ROUTINE

ADDITIONAL

RECOMMENDATIONS

Razor – Wet

Disposable type only, unless patients own then wash with
detergent in hot water. Store dry.

Dispose of used blades and disposable razors in sharps disposal
box immediately after use.

Resuscitation Mask

Detergent in hot water. Store dry.

After infected patient dispose of appropriately.

Rooms
(cleaning after a patient
with a specific infection)

Scrubbing Machines

Detergent/ Hypochlorite sanitiser.

Detergent and hot water (including scouring pads). Store
dry.

After patient with specific infections special arrangements will be
made with the Domestic staff.

Discard pads after potentially or known infected area cleaned.

Sharps Boxes

Wipe any blood contamination with alcohol impregnated
wipe.

Shaving Brushes

Use not recommended. Use aerosol foam.

Shower Cubicle/Chairs

Wash with detergent in hot water, between patients.

After potentially or known infected patient use hypochlorite sanitiser,
rinse and allow to dry.

Stethoscope Heads

Wipe with alcohol impregnated swab.

Suction Jars

Detergent and hot water. Store dry.

Autoclave after use on infected patients.

Thermometer - Electronic

Disposable cover must be disposed of after use.

Tonometer Prisms

Soak in 70% alcohol for 15 minutes between patients and
store dry.

Toothglass

Disposable or dishwater (80

Toys

Vinyl/plastic toys wash in hot soapy water, rinse and dry,
weekly or when visibly soiled. Soft toys are not
recommended for general use.

Hospital toys must be washed with detergent and hot water, rinsed
and dried or cleaned immediately on removal from the room of a
child who has been isolated.

ITEM

ROUTINE

ADDITIONAL

RECOMMENDATIONS

Equality and Human Rights Policy Screening Tool

Policy Title: Cleaning, Disinfection & Sterilisation

Directorate: Nursing & Patient
Care Standards

Name of person/s auditing / authoring policy:

Service Manager Infection Prevention & Control & Infection Prevention & Control Committee

Policy Content:



For each of the following check whether the policy under consideration is sensitive to people of a

different age, ethnicity, gender, disability, religion or belief, and sexual orientation?



The checklist below will help you to identify any strengths and weaknesses of the policy and to

check whether it is compliant with equality legislation.

1. Check for DIRECT discrimination against any minority group of PATIENTS:

Response

Action

required

Resource

implication

Question: Does the policy contain any statements which
may disadvantage people from the following groups?

Yes

Yes No Yes No

1.0 Age?

√

1.1 Gender (Male, Female and Transsexual)?

√

1.2 Learning Difficulties / Disability or Cognitive

Impairment?

√

1.3 Mental Health Need?

√

1.4 Sensory Impairment?

√

1.5 Physical Disability?

√

1.6 Race or Ethnicity?

√

1.7 Religious Belief?

√

1.8 Sexual Orientation?

√

2. Check for DIRECT discrimination against any minority group relating to EMPLOYEES:

Response

Action

required

Resource

implication

Question: Does the policy contain any statements which
may disadvantage employees or potential employees from
any of the following groups?

Yes

Yes No Yes No

2.0 Age?

√

2.1 Gender (Male, Female and Transsexual)?

√

2.2 Learning Difficulties / Disability or Cognitive

Impairment?

√

2.3 Mental Health Need?

√

2.4 Sensory Impairment?

√

2.5 Physical Disability?

√

2.6 Race or Ethnicity?

√

2.7 Religious Belief?

√

2.8 Sexual Orientation?

√

TOTAL NUMBER OF ITEMS ANSWERED ‘YES’ INDICATING DIRECT DISCRIMINATION = 0

3. Check for INDIRECT discrimination against any minority group of PATIENTS:

Response

Action

required

Resource

implication

Question: Does the policy contain any conditions or
requirements which are applied equally to everyone, but
disadvantage particular people because they cannot
comply due to:

Yes

Yes No Yes No

3.0 Age?

√

3.1 Gender (Male, Female and Transsexual)?

√

3.2 Learning Difficulties / Disability or Cognitive

Impairment?

√

3.3 Mental Health Need?

√

3.4 Sensory Impairment?

√

3.5 Physical Disability?

√

3.6 Race or Ethnicity?

√

3.7 Religious, Spiritual belief (including other belief)?

√

3.8 Sexual Orientation?

√

4. Check for INDIRECT discrimination against any minority group relating to EMPLOYEES:

Response

Action

required

Resource

implication

Question: Does the policy contain any statements which
may disadvantage employees or potential employees from
any of the following groups?

Yes

Yes No Yes No

4.0 Age?

√

4.1 Gender (Male, Female and Transsexual)?

√

4.2 Learning Difficulties / Disability or Cognitive

Impairment?

√

4.3 Mental Health Need?

√

4.4 Sensory Impairment?

√

4.5 Physical Disability?

√

4.6 Race or Ethnicity?

√

4.7 Religious, Spiritual belief (including other belief)?

√

4.8 Sexual Orientation?

√

TOTAL NUMBER OF ITEMS ANSWERED ‘YES’ INDICATING INDIRECT DISCRIMINATION = 0

Signatures of authors / auditors:
Chris McGinley Service Manager Infection Prevention & Control
Dr Alan Wills DIPC, on behalf of the IPCC Date: 06.2009

Equality and Human Rights Compliance / Percentage Calculation

Number of ‘Yes’ answers for DIRECT discrimination.

Number of ‘Yes’ for INDIRECT discrimination.

Total answers for POLICY CONTENTS discrimination.

Percentage content non compliant

= 0%

Document Outline