19 decontamination policy

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HOSPITAL INFECTION CONTROLPOLICY

Document No: HIC19*All Sites

DECONTAMINATION

TITLE Decontamination policySUMMARY This document provides instruction and guidance

to managers and others on how to manageInfection Control in their department

All Chiefs of Service, Clinical Directors andDivisional / Departmental Managers throughoutthe Trust are required to instigate action toensure the successful implementation of thepolicy within their area(s) of control.

DATE OF REVIEW June 2007APPROVED VIA Hospital Infection Control Group 20

thApril 2005

Clinical Effectiveness Sub-Committee 7th June2005

DISTRIBUTION For distribution to all wards and departments viaCNST Team Ext 2505

RELATED DOCUMENTS HIC01

AUTHOR(S) / FURTHERINFORMATION

Infection Control Team

THIS DOCUMENT REPLACES

ISSUED BY:

Chief Executive

ISSUE DATE:June 2007


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HIC 19: DECONTAMINATION

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19: DECONTAMINATION POLICY

19.1 INTRODUCTION AND CORPORATE FRAMEWORK

19.2 PRINCIPLES

19.3 DECONTAMINATION OF MEDICAL DEVICES AND EQUIPMENT

19. 4 DECONTAMINATION OF THE ENVIRONMENT AND SPILLAGES

19. 5 DECONTAMINATION OF GENERAL EQUIPMENT(A TO Z)

19. 6 DECONTAMINATION OF SPECIALISED DEPARTMENTAL EQUIPMENT

19.7 REFERENCE DOCUMENTS

APPENDIX A - GUIDE TO DECONTAMINATION OF EQUIPMENT AND THEENVIRONMENT

APPENDIX B - DECONTAMINATION OF MEDICAL DEVICES PRIOR TOINSPECTION, SERVICE, REPAIR OR TRANSPORTATION

Infection control policies are being constantly developed and revised. If a policy isreferred to and is either not available or not current, please contact the Infection ControlTeam for advice


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19.1 INTRODUCTION AND CORPORATE FRAMEWORK

The purpose of this policy is to prevent and control the spread of infection by theprovision of sound decontamination guidelines. The trust board has agreed thatdecontamination in the trust must comply with the guidelines and standards included in

the references at the end of this policy relating to decontamination.

19.2 PRINCIPLES

Medical devices may serve as vehicles for the transmission of infection tosusceptible hosts. Decontamination is the combination of processes(including cleaning, disinfection and sterilization) used to make a re-usablemedical device safe for further use on patients and handling by staff. Theeffective decontamination of re-usable medical devices is essential inreducing the risk of transmission of infectious agents.

19.2.2 HEALTH AND SAFETY LEGISLATION AND GUIDANCE

Failure to comply with legislative requirements leaves the Trust or a Trustemployee liable to prosecution.

19.2.3 DEFINITION OF A MEDICAL DEVICE

The Department of Health defines a medical device as any instrument,apparatus, appliance, material or other article whether used alone or incombination, intended by the manufacturer to be used for human beings forthe purpose of: control of conception; diagnosis, prevention, monitoring,treatment or alleviation of disease; diagnosis, monitoring, treatment,alleviation of or compensation for an injury or handicap; investigation,replacement or modification of the anatomy or physiological process. Surgicalinstruments are medical devices.

Therefore medical devices include, for example, commode chairs, dripstands, dressing trolleys, BP cuffs, bedpans as well as surgical instruments.

19.2.4 PROCESSING AND REPROCESSING OF MEDICAL DEVICES INTENDEDFOR CLINICAL RE-USE

It is essential to maintain adequate records demonstrating how a medicaldevice was processed. Current Department of Health guidance advises thatcleaning (see section 19.2.7a) is of the utmost importance in minimising thepotential risk of transmitting infectious agents between patients via surgicalinstruments.


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c. Sterilization Sterilization is a process that kills or removes all typesof microorganisms, including resistant spores. It is impossible toguarantee that every microorganism exposed to a particular treatmenthas been killed. It is therefore realistic to define sterilization as a processthat provides an acceptably low probability that any microorganism will

survive the treatment. Autoclaving (intense heat under pressure) orgamma irradiation are common methods of sterilisation.

Risk Application Examples Recommendation

High For invasive items, those in

contact with a break in theskin or mucous membraneor introduced into a bodyarea

Surgical instruments,dressings, catheters,prosthetic devices

Sterilisation orHigh LevelDisinfection

Intermediate For items in contact withintact mucous membranes,body fluids, orcontaminated withparticularly virulent orreadily transmissibleorganisms, or items to beused on highly susceptiblepatients or sites.

Gastrointestinalendoscopes,respiratory equipment,reusable bedpans,cutlery, reusable facemasks, bed linen,auriscope ear pieces

Disinfection

Low For items in contact withnormal and intact skin, ornot in contact with patient

at all

Drip stands, monitors,blood pressure cuffs,wash bowls, bath

hoists, disposablebedpan holders,commodes, furniturefloors,

Cleaning andDrying

All procedures involving substances used in the decontamination of MedicalDevices must be subject to COSHH Risk Assessment.

NB: None of the above can reliably inactivate the risk from medical devicescontaminated with Prions (The infectious agents in transmissible spongiformencephalopathy such as CJD, vCJD). Please refer to HIC13 Creutzfeldt-Jakob Disease Policy for further information.

19.3 DECONTAMINATION OF MEDICAL DEVICES AND EQUIPMENT

19.3.1 SURGICAL INSTRUMENTS

Although there are no nationally agreed definitions of surgical instruments, forthe purpose of this policy the following definition will apply:


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any instrument that comes into contact with mucous menbrane, penetratesintact skin or is in contact with non-intact skin

All surgical instruments must be decontaminated using a validated automated

system.

Instruments must NOT be washed in any way at a local level. All instrumentsmust be placed immediately following use, into the appropriate container fortransport to Sterile Services Department.

19.3.2 MANUFACTURERS RECOMMENDATIONS

Manufacturers of CE marked reusable medical devices are required toprovide information on the appropriate process to allow reuse, includingcleaning, disinfection, and packaging and where appropriate the method of

sterilization of the device to be re-sterilized.

This may on occasions be contrary to the advice of the Medical DevicesAgency, or advice given in Health Technical Memoranda, etc. In this caseseek advice from the Infection Control Team.

19.3.3 BENCH TOP AUTOCLAVES

Apart from the bench top autoclave in the Radiotherapy department at JCUH,it is Trust policy that no bench-top downward displacement autoclaves shouldbe used.

19.3.4 TRANSPORTATION

All items being transported to the SSD for decontamination should be placedin a leak proof rigid container that has a secure lid.

19.3.5 EQUIPMENT

19.3.5.1 Decontamination Prior To Inspection, Service, Loan Or Repair

All equipment that is going for inspection, service or loan must be adequatelydecontaminated, according to manufacturers guidelines and accompanied bya decontamination certificate. The procedure and example certificate can befound in Appendix A and in MHRA DB 2003(05).

19.3.5.2 Purchasing New Equipment


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It is the users responsibility that prior to the purchase of any equipment,manufacturers guidance on decontamination must be sought and discussedwith the Infection Control Team.

19.4 DECONTAMINATION OF THE ENVIRONMENT

The Infection Control Team must be involved if any alterations to DomesticService Level Agreements are necessary. Any alterations must be in linewith the National Cleaning Standards.

19.4.1 Management of spillages

The appropriate protective clothing must be worn at all times when dealingwith spillages. This consists of disposable aprons and gloves, with theadditional protection of masks and eye protection. Eye protection must beavailable in all clinical areas.

NB. Blood spillages are especially hazardous in the presence of sharps(eg broken glass, sharp edges and needles). Such spillages requireextra care in avoiding injury to staff.

19.4.1.2 Blood or blood-stained body fluids

It is the responsibility of clinical staff to clean up spillages of body fluids inclinical areas. If blood is spilled either from a container or as a result of anoperative procedure the spillage must be dealt with as soon as possible.

The spilled fluid should be completely covered, either by sodiumdichloroisocyanurate granules or by disposable towels, which are then treatedwith a solution containing 10,000ppm available chlorine. At least threeminutes must elapse before the towels etc. are cleared and disposed of asclinical waste. If the blood spillage is dried, a solution of 10000ppm availablechlorine is to be applied. Blood spilled onto linen or curtains is to be sent to thelaundry as infected linen.

Spillages of body fluids from patients with Creutzfeldt-Jakob Disease or known,suspected or at risk of transmissible spongiform encephalopathy should betreated as in CJD Disease Policy, HIC 13 Para 13.8.

19.4.1.3 Non blood-stained body fluids (excluding urine)

The spillage should be wiped up using paper towels and discarded in a yellowplastic bag as clinical waste. The area should be cleaned and disinfected withhot water and detergent, followed by a rinse of 1000ppm available chlorinesolution.


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All other pertinent documents from NHS Estates and Medicines and Healthcareproducts Regulatory Agency (MHRA) also apply


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Appendix A: Guide to decontamination of equipment and the environment

This table is intended as a guide only. Regulations regarding decontamination of hospitaenvironment are constantly developing. It is essential that the user consults the manufacuse of any piece of medical equipment. In the event of uncertainty contact the infection c

Key:Alc = Alcohol (70% isopropyl alcohol wipe)GPD = GPD (general purpose detergent or detergent wipe)TD = Thermal disinfection

WARNING: All electrical equipment should be disconnected from the mains prior to any procedures.

Table 19.1 A guide to cleaning and decontamination of equipment in general use

Item Method Instructions

Ambulift GPD Clean after each use with GPD use alcohol wipe after us

material slings should be laundered. Dedicate a sling folaunder as infected linen on completion of isolation

Baby scales GPD Clean if visibly soiled. Wipe between babies

Baths GPDSAN

Domestic staff: clean daily using green cloth and sanitizeclean after each use with GPD.

Bath hoist GPD Clean after each use with GPD.

Bladder scanner

a) Machine casing

b) Probe

GPD

GPD

Wipe with a cloth moistened with GPD solution. Store dry

Wipe with a cloth moistened with GPD solution. For exteuse on broken skin.


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Face shield GPD,Hypo

Wearing PPE, remove face shield window by releasing cstar and holes are aligned. Wash any visible contaminatpurpose detergent.

If face shield become contaminated with blood or body fshould be washed in a hypochlorite (dichloroisocyanuratppm available chlorine), the face shield should then be r

storage.Flower vases TD, GPD FHN: Place flower vases and contents straight into wash

operate as per manufactures instructions

JCUH: Wash in hot water containing GPD Store dry and

Foam troughs/ wedges(orthopaedic)

GPD, Clean using a cloth moistened with GPD solution and drIf any of these items are damaged or torn and the underlcontaminated they should be replaced

Furniture and fittings GPD Damp dust between patients and more regularly in long-likelihood of contamination is greater

Goggles GPD Wash with hot water and GPD. Store dry. Discard if contbody fluids

Ice making machine GPD Machine casing should damp dusted with a cloth and GPschedule according to mftrs guidance.

Infusion pumps(Machine casings)

BaxterGraesbyIvacEpidural

GPD These items should be cleaned using a cloth moistened

Infusion stand GPD Clean using a cloth moistened with GPD solution and dry

Mattresses, mattresscovers and pillows

GPD Wash and dry with GPD thoroughly between patients Discontaminated or used for patients in isolation. Inspect cotime


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Medicine trolley GPD Damp dust with a cloth moistened with GPD weekly or wcontaminated

Patient warmingsystem

GPD Clean using a cloth moistened with GPD solution an

Pulse oximiter GPD Clean using a cloth moistened with GPD solution and dry

Stethoscopes GPD Clean earpieces and diaphragm with cloth moiste

Telemetry equipment GPD Clean using a cloth moistened with GPD solution and dry

Telephones GPD Damp dust with a cloth moistened with GPD solution dai

Vitalographs

(a) Machine casing GPD Clean using a cloth moistened with GPD solution and dry

Vital sign monitors GPD Clean using a cloth moistened with GPD solution and dr

Weighing machines(standing and sitting)

GPD,Hypo

Clean using a cloth moistened with GPD solution and dry

Wheel chairs GPD Clean using a cloth moistened with GPD solution and dry


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Appendix B: Decontamination of Medical Devices prior to Inspection, Service,Repair or Transportation

Equipment that has been in contact with patients or their body fluids may transmitinfection to those required to service, repair or transport it.

Anyone who inspects, services, repairs or transports medical devices and equipmenthas a right to expect that the devices have been appropriately treated so as to removeor minimise the risk of infection.

Wherever possible such equipment should be thoroughly cleaned and decontaminatedbefore each reuse and all devices presented for service or repair must be provided witha certificate documenting the method of decontamination or the reason whydecontamination was not possible. A copy of the certificate must accompany the itemand be requested by the person carrying out the service or repair prior to thishappening.

Responsibilities

It is the responsibility of the nurse in charge of the ward or department to ensure thatequipment handed over for repair or servicing is in a clean condition and the relevantdocumentation is completed.

It is the responsibility of the Estates or Medical Engineering Department to ensure thenecessary documentation has been completed prior to them taking charge of theequipment.

This also applies to any equipment that is returned to the manufacturer or collected,serviced or repaired by any person authorised to do so from outside of the Trust.

Other issues

A copy of the certificate must remain in the ward or department book for future referenceshould a look back into maintenance and repair of the equipment be necessary.

All decontamination and repair should be carried out in an appropriate area andadequate protective clothing should be worn as appropriate for the department andpersonnel concerned.

References:.

Department of Health (1993) Decontamination of equipment prior to inspection, serviceor repair. HSG (93)26Medical Devices Agency DB2003(05)NHS Estates (2004) The NHS Healthcare Cleaning Manual


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Certificate of Decontamination

To be completed (in duplicate) by person in charge of ward / department or an authorisedperson.

Ward / Department:

Description of equipment:..

Model / Serial number

Tick one of the following

This equipment has not been in contact with blood, other bodily fluids or

pathological samples. It has been cleaned using

This equipment has or may have been in contact with blood, other bodyfluids or pathology samples. It has subsequently been correctlydecontaminated using....and work can be carried out safely.

This equipment could not be decontaminated. Standard precautions are

necessary.

Signed:. Date:...

Position Held:..

To be completed by the person carrying out the decontamination

This equipment has been dealt with according to instructions contained in the policy forthe decontamination of medical devices prior to service or repair.

Signed:.... Date.

(Top copy to be affixed to equipment.Second copy to be retained in Decontamination Certificate Book)

19 decontamination policy

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