disinfection policy and procedure

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Disinfection
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Authors Name & Title: Nicola Best- Infection Prevention Nurse
Scope: Trust Wide Classification: Clinical
Replaces: v2.0
To be read in conjunction with the following documents:
Medical equipment policy
Infection prevention & control standard arrangements
Hand hygiene policy
Endoscope decontamination policy
Other protocols pertinent to specific areas or procedures
Document for public display? Yes
Unique Identifier: TC43(08) Review Date: 1
st
June 2015
Issue Status: Approved Version No: 2.1 Issue Date: 11
th
July 2013
Authorised by: Infection Prevention Committee Authorisation Date: 1
st
June 2013
After this document is withdrawn from use it must be kept in an archive for 10 years
Archive: Document Control Date added to Archive:
Officer responsible for archive: Document Control Administrator
Has the document undergone Equality Analysis? Yes/No
Has Endorsement been completed? Yes
Disinfection
Policy &
Procedure

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POLICY STATEMENT
In order to protect patients and staff from the transmission of infection from medical devices
or other equipment, all equipment must be decontaminated appropriately.
1. Roles and Responsibilities
Trust board
 Has a duty to ensure that appropriate arrangements and management systems
are in place for infection prevention and control (The Health Act 2006).
Director of Infection Prevention and Control
 Is responsible for implementation of this policy.
The Infection Prevention Committee
 Is responsible for development and approval of this policy and for its review.
Ward/departmental managers
 Have responsibility for decontamination of equipment in their area and also a
responsibility to ensure that staff working in their area e.g. nursing staff and
housekeepers are aware of this policy and that staff involved with
decontamination have adequate and suitable training.
All staff
 Have a responsibility to ensure that they comply with this policy, that they use
equipment provided appropriately and that they report any concerns or seek
further advice as necessary from their manager or the Infection prevention team.
Temporary or agency staff, contractors, students or others will be expected to comply with
the requirements of this policy, applicable to their area of operation.
2. Standards
Staff will be expected to adhere to the standard precautions policy for infection prevention
& control and to the Control of Substances Hazardous to Health regulations.
3. Protocol
3.1 Cleaning, disinfection and sterilisation -definitions
Decontamination is the process of rendering an article safe to handle by cleaning with or
without disinfection or sterilisation.
Cleaning is the physical removal of dust, grease or organic matter that will reduce the
number of micro-organisms present and remove medium supporting the growth of micro-
organisms.
Cleaning is necessary prior to disinfection and sterilisation.

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Disinfection is the process of reducing the number of micro-organisms to a level at which
they are not harmful, with the exception of bacterial spores and prions.
Sterilisation is the process of removing or destroying all micro-organisms, including
spores.
3.2 Choice of decontamination method
All reusable equipment will require cleaning. Some equipment will also require
disinfection or sterilisation.
The choice of method will depend on the purpose of the equipment and other risk factors
as follows:
Risk Application Method of
decontamination
High Items that penetrate the
skin/mucous membranes or
enter sterile body cavities
Sterilisation or use of
sterile single use items
Medium Items that have contact with
mucous membranes or are
contaminated with pathogenic
readily transmissible micro-
organisms
Sterilisation or
disinfection or use of
sterile single use item
Low Items in contact with intact skin Cleaning
3.3 General principles for decontamination of equipment
3.3.1 Cleaning – the general environment and any equipment classified as low risk will
not usually require disinfection. Water and a neutral detergent can be used or suitable
disposable impregnated cloths.
Equipment should be dismantled if necessary in line with manufacturer’s guidelines prior
to cleaning.
See appendix 1 for procedure for cleaning equipment and also for blood and body fluid
spillages.
3.3.2 Disinfection - chemical disinfectants must always be used at the correct strength
and for the correct length of time as specified by the manufacturer. Disinfectants should
always be stored in the appropriate, labelled container.
Staff in the theatre department will undergo local training prior to using automated washer
disinfectors for flexible endoscopes and records of each disinfection cycle will be kept in
the theatre department. Endoscope reprocessing is addressed in more detail in the
Endoscope Decontamination policy.
See appendix 2 for disinfectant list.

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3.3.3 Sterilisation - most equipment requiring sterilisation will be packaged and sent off-
site to an approved sterile services department. Records of surgical trays and equipment
re-processed in this way will be recorded in the theatre records to ensure traceability.
Some equipment will be purchased pre-sterilised.
3.4 Standard infection control precautions
3.4.1 Hand hygiene is the single most important measure in preventing infection and
hand hygiene should be performed after all exposure to potentially contaminated
equipment (see hand hygiene policy for further details).
3.4.2 Protective clothing should be worn when decontaminating equipment on the basis
of a risk of transmission of the healthcare practitioners clothing and skin by blood,
secretions or other fluids. A disposable apron and gloves should be worn and also face
protection if a risk of splash to the eyes and mouth.
3.5 Decontamination Certificates –prior to service, inspection or repair
3.5.1 If equipment is to be returned to the medical engineering department or to the
supplier because of a fault or for routine service/inspection then a decontamination
certificate label must then be completed correctly, signed and attached to the equipment.
3.5.2 Supplies of these labels are available on each ward/department and further
supplies can be obtained from the medical engineering department.
If the equipment is visibly unclean or the label has not been completed satisfactorily the
medical engineering department will not accept the equipment and ensure that it is
returned to the relevant ward/department for cleaning and correct completion of the label.
3.5.3 If the exterior of the equipment cannot be decontaminated for any reason this
should be noted on the decontamination form and the equipment should be packaged in
a clear plastic bag and prior warning given to the intended recipient.
3.5.4 If the internal mechanism has been contaminated with blood or body fluids it may
not be possible to safely clean the equipment on the ward.
This should be noted on a decontamination form and prior warning given to medical
engineering before it is returned.
3.6 Single use devices.
3.6.1 Devices designated for ‘single-use’ must not be reused under any circumstances.
The reuse of ‘single-use’ devices can affect their safety, performance and effectiveness,
thereby exposing patients and staff to unnecessary risk. The reuse of ‘single-use’ devices
has legal implications.
3.6.2 Anyone who reprocesses or reuses a device intended by the manufacturer for use
on a single occasion, bears full responsibility for its safety and effectiveness.

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3.6.3 For further guidance, reference should be made to MDA (Medical Devices Agency)
Device Bulletin DB2000 (04), which deals with the implications and consequences of
reuse of single-use medical devices.
3.7 COSHH (Control of Substances Hazardous to Health) Regulations
3.7.1 COSHH regulations require that an assessment is made of any health risks that
may arise from exposure to hazardous substances and that appropriate control measures
must be provided to minimise the risks.
3.7.2 Most disinfectants are hazardous to some degree and are therefore subject to
COSHH regulations. Information should therefore be available in all places of use.
Managers are required to ensure that staff are properly trained and aware of the proper
use of cleaning agents and disinfectants.
4 Policy Implementation Plan
4.1 The infection prevention committee is responsible for implementing this policy.
4.2 This policy will be available on the intranet and the contents will be made known to
link staff during link staff meetings and also staff will be made aware of the policy during
annual mandatory updates.
4.3 Domestic staff will be made aware of the requirements in this policy during their
induction process and during annual updates.
4.4 Relevant theatre staff will undergo training in disinfection and sterilisation processes
and will also use a self-assessment competency programme.
5. Monitoring of Compliance
5.1 General decontamination of equipment will be monitored as part of the infection
control audit tool (performed at least 6 monthly)and results will be feedback to each
individual area, with an action plan to be completed by that ward/department.
5.2 Decontamination of equipment will also be monitored by the matrons as part of the
weekly cleaning schedules.
5.3 Theatre staff will monitor the washer – disinfection and sterilisation processes by
using protein residue testing system weekly on instruments selected at random. An audit
of endoscope decontamination processes will be performed at least annually. Results will
be fed back to the theatre manager and the decontamination group and any action plans
will be monitored by this group.
5.4 Decontamination of equipment prior to service, repair and inspection will be
monitored by the medical engineering department and they will do an audit at least
annually to monitor compliance with this policy, results of which will be fedback to the
infection prevention committee
References

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Sterilisation, disinfection & cleaning of medical equipment: Guidance on decontamination
from the microbiology advisory committee to the Department of Health, medicines and
healthcare products regulatory agency.2005
MDA DB 2000 (04) Single use medical devices: implications and consequences of re-
use. Medical Devices Agency 2000
MHRA DB 2003 (03) Management of medical devices prior to repair, service or
investigation.
Pratt RJ et al and the epic guideline development team (2007). National Evidence Based
Guidelines for preventing healthcare associated infections in NHS hospitals. Journal of
Hospital Infection. 65S (supplement) S1-S64
APPENDIX 1
1. General protocol for decontamination of medical equipment
All reusable equipment should be cleaned following every episode of care.

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If the manufacturer’s instructions for decontamination of the equipment are available then
these must be followed.
If no instructions are available the general guidelines below should be followed for
external cleaning of the equipment:
 If the equipment is electrical then disconnect/unplug from the electrical power source
 Clean with a disposable cloth lightly dampened with water and a general purpose
detergent e.g. Hospec or alternatively use a disposable multi-surface wipe and clean
until all visible traces of soiling has been removed
 Care must be taken to ensure water does not get inside any electrical equipment so
the cloth must be only lightly dampened
 Wipe with dry cloth
Alcohol/alcohol wipes should not be used generally unless it has been confirmed by the
manufacturer that the alcohol will not damage the surfaces of the equipment.
If the equipment is contaminated with blood/body fluids:
 Standard/universal precautions must be adhered to when handling and cleaning the
equipment. Gloves and aprons should be worn and eye protection if there is a risk of
splashing.
 The equipment should be disinfected following the manufacturer’s instructions or if no
instructions are available by cleaning and then using a cloth lightly dampened with a
1000ppm chlorine solution (e.g. antichlor solution).
2. Procedure for Blood Spillages
- Wear plastic apron and gloves
- Cover the blood spill with actichlor granules (or suitable alternative)
- Leave for 2 minutes, to allow granules to absorb spillage
- Clear up granules with a disposable cloth and discard into a yellow clinical waste bag
- Clean area with detergent and water
DO NOT USE ABOVE METHOD ON URINE SPILLAGES AS THE HYPOCHLORITE
MAY REACT WITH THE URINE
3. 3. Procedure for Body Fluid eg Urine/Faeces Spillages
- Wear plastic apron and gloves
- Soak up the spillage with disposable paper towels
- Discard into a yellow waste disposal bag
- Clean area with detergent and water
- Wipe area with actichlor solution and disposable cloth
APPENDIX 2
Disinfectant Reason for Use Examples

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Products
Chlorine Disinfectant
tablets
e.g. Actichlor
1 tablet in 1 litre of
water = 1000pm
chlorine for surfaces
 For disinfection of
surfaces and
equipment
 For environmental
cleaning when patients
are in isolation or
during outbreaks or
deep cleaning
 Mattresses, commodes,
fixtures and fittings in
isolation rooms
Disinfectant
granules e.g.
actichlor
 For disinfection of
surfaces following
spillages of body fluids
 Blood spillage
Peracetic acid e.g.
Aperlan
 For disinfection in
automated
washer/disinfector
 Bronchoscopes
Chlorine Dioxide
e.g.Tristel wipes
 For disinfection of
probes
 TOE probes
Isopropyl Alcohol
solution
 For disinfection of
suitable hard surfaces
if visibly clean
 Metal trolleys
Isopropyl
impregnated wipes
with chlorhexidine
 For disinfection of
suitable equipment if
visibly clean
 Needleless connectors on
intravenous lines
Chlorhexidine
acetate 0.015% and
cetrimide 0.15%
solution
 Disinfection in aseptic
suite in pharmacy
 Work surfaces in aseptic
suite
Denatured ethanol
70% + hydrogen
peroxide 0.125%
 Disinfection in aseptic
suite in pharmacy
 Equipment in aseptic suite
Sterile denatured
ethanol 70%
 Disinfection in
pharmacy
 Equipment in isolator
room and isolator
1% hypochlorite
solution
 Disinfection in aseptic
suite
 Equipment and surfaces
in aseptic suite
Proceine
Qceine
 Impregnated mopping
system for cleaning in
aseptic suite
 Floors ,walls, ceilings in
aseptic suite

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Endorsed by:
Name of Lead Clinician/Manager
or Committee Chair
Position of Endorser or Name of
Endorsing Committee
Date
Director of Infection prevention and Control Infection Prevention Committee June 2013

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Record of Changes to Document - Issue number:
Changes approved in this document: Date:
Section
Number
Amendment
(shown in bold italics)
Deletion Addition Reason
Appendix
2
Actichlor replaces Haz tab Appendix 2
Appendix
2
Tristel wipes Appendix 2
Appendix
2
Examples column Appendix 2
3.3.3 Some fine instruments will be
sterilised in a dedicated area within
the theatre complex. Only staff
trained and competent to do so will
process this equipment and all
records of sterilisation cycles and
instrument swill be kept in the
theatre department.
3.3.3