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					 Title: Decontamination Policy
 Scope: Trust wide                              Classification: Policy
 Identification No: ICM 03                      Version No: 2
 Replaces: Sefton PCT Decontamination Policy
 Author/Originator: Martin Jones Infection Control Specialist Nurse
 In consultation with: Infection Control Committee
 Accountable Director: Director of NHS Sefton Provider Services and Director of Public Health
 Authorised by: Governance Committee            Date: November 2009
 To be read in conjunction with: Infection Control Policies
 Equality Impact Assessment carried out         Date: 14th April 2009
 Issue Date: 1 June 2009                        Review Date: 1 June 2011

In considering the application of this policy, procedure or function the PCT will ensure that
staff or patients will not be discriminated against or treated differently on account of any
subjective bias in relation to the six pillars of equality and diversity: race, disability,
gender, age, sexual orientation, religion/belief.

This document can only be considered valid when viewed via the Sefton PCT website or
Department Policy Folder. If this document is printed into hard copy or saved to another
location, you must check that the version number on your copy matches that of the one

This document is available in other formats on request
Decontamination Policy


Section                                                                   Page

1.             Introduction                                                  3

2.             Purpose                                                       3

3.             Roles and responsibilities                                    3

4.             Definitions                                                   3

5.             Consultation, approval and ratification process               3

6.             Review and revision arrangements                              3

7.             Dissemination and Implementation                              3

8.             Document Control                                              4

9.             Monitoring compliance with and effectiveness of policy        4

10.            Categories of Medical Devices and Equipment                   4

11.            Methods of Decontamination                                    5

12.            Facilities required for Decontamination                       7

13.            Legislation related to Decontamination                        7

14.            Management of Medical Devices Prior to repair, Service        8
               and Investigation

15.            Transport of Contaminated Devices / Equipment to the          8
               Decontamination Area

16.            Purchase and Decommissioning of Medical Devices               8
               and Equipment

17.            Preparations / Agents Currently Available in the PCT          9

18.            A-Z of Equipment Decontamination                             11

19.            References                                                   17


A              Handling of Equipment Prior to Inspection, Service,          19
               Repair, Return to Lending Organisation, or Investigation
               of an Adverse Incident. (MHRA, 2003)

B              Declaration of Contamination Status (MHRA, 2003)             20

C              Implementation Plan                                          21

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Decontamination Policy

1.     Introduction

       All medical devices and equipment used in healthcare environments may become
       contaminated with biological / microbiological material and thus can present a risk to
       patients, as well as those subsequently handling or using them. Safe and effective
       decontamination of all re-usable equipment between uses is therefore an essential part of
       routine infection control practice. Inadequate decontamination has frequently been
       responsible for outbreaks of infection in healthcare establishments, and can result in the
       transmission of a broad range of micro-organisms from variant Creutzfeldt-Jakob Disease
       (vCJD) to blood borne viruses such as Human Immunodeficiency Virus (HIV) or hepatitis B,
       to fungal and common bacterial infections.

       This policy therefore demonstrates the Primary Care Trust (PCT) commitment to ensuring a
       high standard of decontamination, and provides a basic code of practice for cleaning,
       disinfection and sterilisation of medical devices and equipment throughout the organisation.
       It outlines the systems required for safe decontamination of devices and equipment and as
       well as the legislative requirements and national guidance associated with decontamination

2.     Purpose

       The purpose of this policy is to reduce the risk of cross contamination from contaminated
       medical devices for staff and patients

3.     Roles and Responsibilities

       Sefton PCT provider services reusable instruments are reprocessed by fully accredited
       CSD (Central Sterilising Department). Any commissioned service carrying out
       decontamination, including sterilisation using local methods i.e. benchtop sterilisers, must
       adhere to legislation set out under section 13.

       Line managers
       It is the responsibility of line managers to ensure all staff undertaking decontamination
       procedures are aware of this policy and ensure risk assessments are carried out where
       necessary and reported to the infection control team.

       All employees undertaking decontamination duties have a responsibility to adhere to this

       Community Equipment Store Personnel.
       Equipment decontaminated, handled and transported to and from Sefton Community
       Equipment store will be managed specifically in accordance with the Infection Control
       Guidelines for the Community Equipment Service – ICM 15.

       Infection Prevention and Control Team (IPCT)
       The IPCT will monitor effectiveness of the procedures set out in this policy as defined
       below in section 9 and ensure any amendments are incorporated in agreement with the
       Infection Control Committee (I.C.C).

4.     Definitions

                                           Page 3 of 24
Decontamination Policy

       These are made within policy document

5.     Consultation, Approval and Ratification Process

       This policy has been approved and produced in consultation by Infection Control
       Committee and Health Protection Committee, approved by the Governance Committee and
       ratified by Trust Board.

6.     Review and Revision Arrangements

       This policy will be reviewed every two years or earlier if there is a requirement to do so,
       such as new legislation; changes in national guidelines or changes in clinical practice.

7.     Dissemination and Implementation

       Dissemination and implementation will be in line with trust policy and procedure for the
       development, implementation and control of policies and organisation wide procedures.
       Implementation of this policy is detailed in attached implementation plan – see appendix C.

8.     Document Control

       Document control will be in line with trust policy and procedure for the development,
       implementation and control of policies and organisation wide procedures.

9.     Monitoring Compliance with and Effectiveness of the Policy

       Compliance with the policy shall be monitored via the trust annual infection control audit.
       Summary of Infection Control Audit Results are presented to the Infection Control
       Committee. This shall be the responsibility of the service leads who will also be responsible
       for ensuring that any issues of non-compliance identified are addressed via an action plan.

10.    Categories Of Medical Devices and Equipment

       All medical devices / items of equipment can be divided into three categories:

       i)      Single Use

               The medical device is intended to be used once on an individual patient during a
               single procedure and then discarded. It is not intended to be reprocessed or used
               on another patient. The following symbol indicates that a medical device is “single

                                           Page 4 of 24
Decontamination Policy

       ii)        Single Patient Use

                  The medical device can be used for more than one episode of use on one patient
                  only. The device will need to undergo some form of reprocessing / decontamination
                  between each use. The manufacturer must state for how many uses the device can
                  be used prior to disposal.

       iii)       Re-usable

                  The medical device can be used for repeated episodes of use on different patients,
                  but will need to undergo some form of reprocessing / decontamination between
                  each episode.

                  „Any re-use of a single use device is likely to be associated with significant risk.
                  Potential risks include that of cross-infection through inadequate decontamination,
                  mechanical failure due to exposure of the item to chemical agents, material
                  alteration, and finally reactions of patients to residues from chemical
                  decontamination agents. All equipment must always therefore be used according to
                  the manufacturers instructions‟ (MDA, 2000).

11.    Methods of Decontamination

       Any devices stated by the manufacturer as being “single patient use” or “re-usable” must
       therefore undergo some form of decontamination between uses. There are three levels of

             Cleaning
             Disinfection
             Sterilisation


       Cleaning is a process that physically removes contaminants e.g. dust, dirt, grease and
       body fluids, using a general purpose detergent (e.g. washing up liquid) and warm water.

       Cleaning is important for two reasons:

             As a method of decontaminating low risk items

             As an essential pre-requisite to any disinfection or sterilisation process. Organic matter
              must first be removed in order for heat or chemicals to be able to penetrate and
              therefore disinfect or sterilise effectively.

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Decontamination Policy

       Detergent is essential for breaking down grease and dirt. It therefore improves the ability of
       water to remove soiling. Approximately 80% of micro-organisms will be removed by
       thorough cleaning. Careful drying is also essential to prevent any remaining bacteria from
       multiplying. Protective clothing must be worn for all cleaning procedures ie. gloves and
       aprons as a minimum, and where there is a risk of splashing – goggles must be worn (see
       ICM 7 “Standard Precautions Policy”). Wherever possible a mechanical method of
       instrument cleaning must always be used.

       Organisms such as Streptococci, Staphylococci, hepatitis B and Mycobacterium
       tuberculosis can survive in the environment for weeks or even months, hence the
       importance of thorough and regular cleaning and dust removal.

       Disinfection :

       Disinfection is a process which reduces the number of micro-organisms to a level at which
       they are not harmful (it will not affect bacterial spores). Disinfection can be achieved either
       by heat, or via chemical disinfectants. Wherever possible, disinfection should always be
       achieved via heat as it is more reliable. Examples of heat disinfection are bedpan
       washer/disinfectors, laundry washing machines, and dishwashers. In order to achieve heat
       disinfection, the item must be heated to 81ºC for at least 1 minute, 71ºC for at least 3
       minutes, or 65ºC for at least 10 minutes. Where heat disinfection is used, the process must
       be regularly monitored to ensure that the correct parameters of temperature and time are
       being met.

       However, where heat is not appropriate (i.e. for heat labile items), chemical disinfectants
       may need to be used. However, there are many problems inherent in the use of chemical
       disinfectants such as:

          Many are unstable for long periods of time
          Their effectiveness is dependent on correct chemical concentration and exposure time
          They have no value as cleaning agents
          They have varying levels of activity against bacteria, viruses and fungi
          They should only be used on clean surfaces, as they are inactivated by organic matter
           and cannot therefore penetrate effectively

       Disinfectants must only be used where heat disinfection is not possible e.g. for dealing with
       environmental contamination such as a blood spillage, or the decontamination of heat
       sensitive items.

       All disinfectants must be stored, reconstituted and used in accordance with manufacturers
       instructions and COSHH (Control of Substances Hazardous to Health) regulations


       Sterilisation is a process that removes or destroys all micro-organisms, including spores.
       On-site sterilisation can only be achieved by steam sterilisation (autoclaving). Wherever
       possible, re-usable devices should be sterilised by a Central Sterilising Supply Department
       (MDA 2002). These services have the equipment and expertise to clean and sterilise re-
       usable medical devices effectively and consistently. They are also able to track surgical
       instruments through the decontamination process and retrospectively trace them back to
       the individual patient on whom they have been used. In the unlikely event of a sterilisation
       cycle failure, products can then be recalled (Department of Health, 2000)

       Choosing an Appropriate Method of Decontamination:

                                            Page 6 of 24
Decontamination Policy

        The manufacturer of a medical device or item of equipment is required to provide advice on
        how that item should be decontaminated. Where available, their guidance must always be

        The level of decontamination required depends on the risk of the item transmitting micro-
        organisms. Any item can therefore be categorised into one of three levels of risk:

 Risk               Application of Item                      Recommendation

 HIGH                   Penetrates skin or mucus CLEANING      FOLLOWED                       BY
                         membranes                STERILISATION
                        In contact with broken skin
                         or mucus membranes
                        Enters sterile body areas

 MEDIUM                 In contact with intact mucus CLEANING                FOLLOWED         BY
                         membranes                    DISINFECTION
                        Contaminated with any body (Except for instruments used in the vagina
                         fluid                      or cervix e.g. vaginal speculae. These
                                                    must be sterile or have been sterilised
                                                    prior to use, single use instruments must
                                                    be used unless directed by infection
                                                    control nurse)

 LOW                    In contact with intact skin         CLEANING ONLY
                        Not in contact with the patient

                                              Page 7 of 24
Decontamination Policy

12.     Facilities Required for Decontamination:

       Wherever possible, the decontamination process should take place in a dedicated non-
       patient area. Any decontamination area will have specific design requirements (i.e. floors /
       wall finishes / sanitary ware etc). Advice must always be sought from the Infection Control
       Team when designing such facilities. Contaminated and clean items must always be
       segregated and stored separately. Where possible, medical devices and items of
       equipment must only be stored clean. However, if storage of contaminated items is
       necessary, these items must be segregated and clearly labelled as contaminated. Within
       the decontamination area there must be a clear one-way flow of equipment, from entry of
       dirty items into the area, to removal of the clean equipment following decontamination.

13.    Legislation related to Decontamination:

       Consumer Protection Act, 1987 – There may be exposure to civil liability with payments
       for damages for any injuries caused to another person by a defective product. This could
       include an inadequately decontaminated item which causes an infection.

       Control of Substances Hazardous to Health (COSHH) Regulations, 1999 - Staff must
       be aware of these regulations that relate to biological and chemical risks, including risks
       from disinfectants. These regulations require a risk assessment to be carried out for all
       potentially hazardous substances.

       General Product Safety Regulations, 1994 – apply when a product is intended for
       consumers. The regulations apply to both producers and distributors of a product. A
       producer includes those who recondition / decontaminate products.

       Health & Safety at Work Act, 1974 – establishes the employer’s responsibility for the
       health and safety of employees and visitors to their premises, for providing safe equipment,
       safe systems of work and training for staff e.g. how to handle contaminated equipment.

       Management of Health & Safety at Work Regulations, 1992 – expand on the Health &
       Safety at Work Act, requiring employers to make a systematic assessment of all the risks to
       the health & safety of their employees and others, arising from work activities e.g. in the
       case of autoclaves, hazards from heat, steam, and pressure should be addressed.

       Medical Devices Directive (MDD) 93/42 EC – this sets out essential requirements to
       ensure reprocessed medical devices are safe and fit for purpose.

       Medical Devices Regulations, 1994 – Medical devices put on the market within the UK
       are subject to specific regulation and must carry a CE marking if placed on the market after
       June 1998. This denotes compliance with a number of essential requirements covering the
       safety and performance of the medical device.

       Medical Devices Regulations, (MDR) 2002, adopts MDD into UK law

       Pressure Systems and Transportable Gas Containers Regulations, 1992 – covers
       safety issues relating to the autoclave as a pressure vessel.

       Workplace (Health, Safety and Welfare) Regulations, 1992 – deals with the physical
       requirements of the workplace.

                                           Page 8 of 24
Decontamination Policy

14.    Management of Medical Devices prior to Repair, Service and Investigation:
       Occasions may arise when medical devices or equipment require repair, service or
       investigation. However, anyone who handles any medical equipment has a right to expect
       that these medical devices or other equipment have been appropriately treated so as to
       remove or minimize the risk of infection or other hazards. Any staff handling used medical
       devices and equipment should however assume that they are contaminated and take
       appropriate precautions to reduce the risk to themselves and others. Items subject to
       service, repair or investigation should therefore be decontaminated prior to these activities
       taking place. This also applies to any loaned items being returned to a manufacturer or
       supplier (see Appendix A).

       In order to identify contamination status, a written declaration must accompany any item of
       medical equipment when being transported within the PCT or outside of the PCT for
       inspection, service or repair (see appendix B). Where decontamination of the equipment
       could remove evidence of a fault or hinder any subsequent investigation (see appendix A),
       advice on transportation arrangements should be sought from the manufacturer, repair
       organisation or investigating body as it may require the use of a specialist courier. In this

              the device must be double wrapped in appropriate packaging
              prior warning must be given to the intended recipient
              the equipment must be clearly labelled to indicate that it is contaminated
              the packaging should be sufficiently robust to withstand transport
              the inner packaging should be suitable to ensure that the outer packaging does not
               become contaminated or breached during transit

15.    Transport of Contaminated Devices / Equipment to the Decontamination Area
       Some re-usable medical instruments and equipment used within the home setting will
       require returning to the Primary Care site for decontamination purposes.
       In these circumstances, the used items must be transported as soon as possible in
       containers that are:

              Leak-proof
              Easy to clean
              Rigid (in order to prevent the instruments becoming a sharps hazard and to protect
               the items from damage)
              Capable of being closed securely
              Lockable where appropriate (to prevent tampering)
              Clearly labelled to identify the user and the contents
              Robust enough to prevent damage of the instruments in transit

       Any transportation container must allow segregation of contaminated and clean
       instruments. Risk assessments must be carried out by the Infection Control Team before
       any contaminated items are transported.

16.    Purchase and Decommissioning of Medical Devices and Equipment:

       Those involved in the purchasing of medical devices and equipment must always consider
       the suitability and compatibility of the item with the decontamination processes available
       within the PCT. The following issues should be taken into account:

                                           Page 9 of 24
Decontamination Policy

              How easily can the item be cleaned?
              Does the item need dismantling before decontamination? If so, can this be
               performed by the clinician?
              Does the item have electrical components? If yes, does the PCT have the ability to
               decontaminate these?
              Does the product have a limited life / number of times that it can be reprocessed?
              Are the recommended cleaning methods available within the PCT?
              What cleaning agents / disinfectants are recommended and does this comply with
               the PCT’s Infection Control Policies and Health & Safety requirements?
              Is the item heat labile? If so, does the PCT have the appropriate equipment to
               disinfect / sterilise at low temperatures?
              How long will the decontamination process take?
              Has a risk assessment process been undertaken to determine whether a single-use
               or a re-usable product is more appropriate for the circumstances (ie. would an
               alternative pose significantly less risk of cross-infection or be more cost effective?)

       Where necessary, advice should be sought from the Infection Control Team.

       The Buying Department and Estates Department must be contacted for advise regarding
       the disposal / decommissioning of any clinical equipment. All items must be appropriately
       decontaminated prior to disposal.

17.    Preparations / Agents currently available in the PCT:

       To provide a standard approach across the PCT, a limited number of products are
       recommended by the Infection Control Team and Facilities Dept. No additional products
       should be introduced. Protective gloves should be worn when using / handling any of the
       following agents. Decontamination products must never be mixed or decanted into other

Products to be used for Cleaning:

 Product or Chemical           Concentration                    Use

 General         Purpose Dilute in warm water.        General cleaning of surfaces,
 Detergent (GPD)                                      environment, furniture, trolleys
                         Concentration:    as     per
                                                      and wheelchairs etc. Must be
 e.g. Hospec             manufacturers’ instructions.
                                                      used with disposable cloths/paper
                                                      towels.      Solution must be
                                                      changed      frequently;     hence
                                                      detergent wipes are preferred and
                                                      are more practical.      Following
                                                      cleaning, all equipment must be
                                                      stored dry.

 Detergent wipes               Impregnated wipe:               General cleaning of surfaces,
                                                               environment and furniture. As
 E.g. Vernacare tuffie or Use as dispensed                  as
                                                               detergent wipes are preferred,
 Sani cloth detergent wipes single-use wipe
                                                               they are described as method of
                                                               cleaning under point 18 below.

                                            Page 10 of 24
Decontamination Policy

Products to be used for Disinfection:

 Product or Chemical    Concentration                          Use
 Chlorine         based

 NaDCC          (Sodium                                        (Under local COSHH Assessment)

 NB. These are chlorine
 releasing agents and are
 therefore   corrosive  to
 metals and inactivated by
 organic matter.

 e.g Presept Tablets or Haz Dilute to 10,000 parts per         Decontamination of spillages of
 tabs                       million      (ppm)    (See         blood and blood stained body fluids
                            manufacturers      dilution        only. (Refer to ICC 03 “Policy for
                            instructions)                      the Management of Spillages of
                                                               Blood and Other Body Fluids”)

                                                         Surface decontamination              e.g.
                             Dilute to 1,000 ppm. (See commodes.
                             manufacturers      dilution

                                                               Decontamination of blood spills
 e.g Presept Granules        As supplied                       only. (Refer to ICC 07 Standard
                                                               Precautions policy)

                                                               NB. Chlorine releasing agents must
                                                               not be used on urine or mixed with
                                                               hot water or other cleaning agents,
                                                               as toxic chlorine fumes are


 NB. Flammable. Does not
 penetrate organic matter.

 70% Isopropyl Alcohol       Impregnated wipe:                Surface disinfection of specific
 e.g. Azowipe or tuffie hard Use as dispensed              as items or surfaces on clean
 surface disinfectant wipes single-use wipe                   surfaces, please consult ICT prior
                                                              to use.

                                           Page 11 of 24
Decontamination Policy

PLEASE NOTE : Chlorhexidine based products must never be used for environment or
equipment cleaning. Chlorhexidine is only to be used for skin disinfection.

18.     A-Z of Equipment Decontamination:

       This is not intended to be an exhaustive list of all items of medical equipment used within
       the Trust. Services, practical working arrangements, situations and environments vary.
       Manufacturers instructions must always be followed in regards to decontamination of any
       product. Where manufacturers decontamination instructions are unclear, or alternative
       disinfection agents are recommended, the Infection Control Nurse should be contacted.

Item                                     Recommended Method

Airways and Endotracheal Tubes           Disposable – single use only

Ambu-bag / Re-breathing bag              Dispose of filter and mask between uses

Auroscope Ear Piece                      Disposable single use only.

Baby Changing Mats                       Cover with disposable paper roll and change between
                                         each baby. Wipe over with detergent wipe and after
                                         each use and dry with paper towel or air dry.

Baby Scales                              Line with disposable paper roll and change between
                                         each baby. Wipe over with detergent wipe after each
                                         use and dry with paper towel or air dry.

Baths, Shower Chairs & Seats and Clean with warm water and general purpose detergent
Non-Slip Mats.                   or detergent wipe after each patient. Hang bath mats
                                 up to dry

Bed Cradles                              Clean with warm water and general purpose detergent
                                         between use by different patients, and dry with paper
                                         towel or air dry.

Bedpans and Urinals (only disposables Wearing disposable gloves, place bedpan / urinal and
recommended)                          contents in macerator.

                                         NB. Ensure contents contain only body fluids and
                                         toilet paper.
                                         In the event of machine failure inform Estates
                                         Department immediately and dispose of contents of
                                         bedpan / urinal down toilet or sluice. Disgard empty

                                          Page 12 of 24
Decontamination Policy

Item                                  Recommended Method
                                      bedpan / urinal as infectious waste after use.

                                     Disinfect in a washer/ disinfector if available.
Bedpan Holders (for       use   with Alternatively, wearing disposable gloves and plastic
disposable bed pans)                 apron, dispose of contents down toilet, sluice or
                                     macerator. Clean with warm water and general
                                     purpose detergent and if soiled with a body fluid follow
                                     this by using a solution of 1,000ppm Presept. Dry
                                     thoroughly and store dry. Do not soak.

Blood Glucose Monitoring Pen          Single patient use only – only use for one patient and
                                      then discard. Alternatively, use single use retracting

Blood Pressure Sphygmomanometer Cuff must be impermeable. After use wipe with
and Cuff                        detergent wipe and dry with paper towel or air dry.

Bowls (washing)                       Patients must have their own individual wash bowl.
                                      After each use clean with warm water and general
                                      purpose detergent and store dry in or behind patients’
                                      locker (not on the floor). Spare wash bowls must be
                                      stored inverted in a clean area (not in the sluice).

Buckets for Leg Ulcers                Line with a single use plastic bag. After each use
                                      dispose of bag, clean with warm water and general
                                      purpose detergent. Rinse and dry thoroughly. Store
                                      dry and inverted.

Catheter Bag Holders                  Clean with detergent wipes between patients ensure

                                      Patients must have their own individual comb. When
                                      visibly soiled, clean with detergent.

Commodes                              Clean with detergent wipe between uses, plus at least
                                      weekly. If contaminated with body fluid follow this by
                                      using an 1,000ppm solution of Presept.
                                      NB. Ensure commodes are in a good state of repair
                                      with no tears to covering.

Dressing Trolley                      Clean whole trolley with detergent wipe at the

                                       Page 13 of 24
Decontamination Policy

Item                                Recommended Method
                                    beginning of the session and when visibly soiled. Wipe
                                    with top surface with detergent wipe between use. NB.
                                    Ensure no items are left on the trolley when not in use.

Dressing Scissors                   For sterile or high and medium procedures – use
                                    sterile disposable scissors.

                                    For non-sterile, low risk procedures – clean with warm
                                    water and general purpose detergent.

Ear Syringing Equipment             Each day before use, the Propulse must be disinfected
                                    using a 1,000ppm solution of Presept. Fill the water
                                    tank with the solution, and run the machine to allow the
                                    solution to fill the pump and flexible tubing. Leave to
                                    stand for 10 minutes, then empty the water tank and
                                    rinse the system through with tap water before use.

                                    At the end of the session disinfect as above. Rinse the
                                    machine by running sterile water through it and dry it
                                    prior to leaving it unused.

                                    Jet Tip – single patient use only.

                                    Jobson Horne Probe – Place in general purpose
                                    detergent and warm water to remove wax. Rinse under
                                    hot water. Dry thoroughly. Follow this by either
                                    autoclaving or soak in 70% alcohol for 10 minutes then
                                    allow to dry.

                                    (Primary Ear Care Centre, 2007)

ECG Equipment (machine and leads)   Wipe machine with detergent wipes and               dry.
                                    Electrodes must be disposed of after each use.

Endotracheal Tubes                  Disposable only – use once and discard.

Enteral Feeding Equipment           See manufacturers instructions for each product.

Examination Couches                 Cover with disposable paper roll. (paper
                                    roll should be attached to either a holder on couch or a
                                    wall mounted dispenser). Change paper between each
                                    patient. Wipe with detergent wipe between each use.
                                    If the cover becomes torn or damaged, the couch
                                    should be re-upholstered or replaced.
                                    NB alcohol wipes (e.g. azo wipes) must be avoided as
                                    long term use of these will damage the exam cover.

                                     Page 14 of 24
Decontamination Policy

Item                                      Recommended Method

Examination    Lamps     (in   Treatment Clean with detergent and dry daily, plus when visibly
Rooms)                                   dirty.

Glucometer                                Wipe clean with detergent wipes and dry.
                                          Testing strips – single use only

Hoists, Pat Slides, Monkey Poles
                                          Clean with detergent wipe between patients ensure

Hoist Slings, Sliding Sheets (Fabric)     Patients should have their own sling and sliding sheet
                                          until discharge from hospital when these must be
                                          disposed of or laundered as appropriate.
                                          Any soiled items must be placed in a red soluble bag
                                          immediately and sent to the laundry (must not be
                                          washed manually).

Infusion Pumps (PEG feed etc)             Wipe before and after use with detergent wipe. Keep
                                          clean and dry.

Inhalation Compliance Devices             These should be used for individual patient use, and
Eg. Volumatic, Nebuhaler                  must not be shared. If dirty, wash with warm water and
                                          general purpose detergent. Rinse and dry thoroughly.

Jugs (for non-sterile procedures)         Disposable urinals can be used for emptying catheter
                                          bags. If fluid measurements are required, a plastic jug
                                          can be used for this purpose only (but must be kept in
                                          the sluice). A hot water disinfector should be used if
                                          available. Alternatively, the jug should be washed with
                                          warm water and detergent (washing up liquid) after
                                          use. It should then be
                                          rinsed with a 1,000 ppm Presept solution.

Laryngoscope Blades & Handles             Blades - disposable. Use once and discard.
                                          Handles - wipe detergent wipes, ensure dry.

Locker Tops and Tables                    Always ensure these are clean, dry and tidy. Clean
                                          with detergent wipes and ensure dry.

                                           Page 15 of 24
Decontamination Policy

Item                                  Recommended Method

Mattress                              Always ensure that mattresses are protected with an
                                      impermeable plastic cover. Wipe with detergent wipes
                                      between patients and dry. NB alcohol wipes (e.g. azo
                                      wipes) must be avoided as long term use of these will
                                      damage mattress covers

Medicine Pots + Medicine Spoons       Single use – discard after each use.

Nailbrushes (only for use prior to Single use – discard after each use.
surgical procedures)

Nebulisers - Masks + Tubing           Single patient use. Each individual patient must have
                                      his or her own nebuliser, mask and tubing, which is
                                      discarded on discharge from hospital. Clean with warm
                                      water and general purpose detergent, and store dry
                                      between therapies.

Oxygen Mask and Tubing                Single patient use. Each individual patient must have
                                      his or her own mask, which is discarded on discharge
                                      from hospital. Clean with warm water and general
                                      purpose detergent, or detergent wipe and store dry
                                      between therapies. Discard if soiled.

Pillows                               Always ensure that pillows are protected with an
                                      impermeable plastic cover. This can be covered by
                                      pillow case or blue roll, both must be replaced between
                                      patient use
                                      The plastic pillow cover must be wiped with detergent
                                      wipe between use.

Podiatry Chair                        Clean with detergent wipe between patient use
                                      NB alcohol wipes (e.g. azo wipes) must be avoided as
                                      long term use of these will damage the chair cover.

Podiatry Workstation / Trolley        Clean with detergent wipe before and after each

Podiatry Foot Tray                    Clean with detergent wipe before and after each
                                      session. Cover with disposable paper and change
                                      paper between each patient.

                                       Page 16 of 24
Decontamination Policy

Item                                   Recommended Method

Pulse Oximeter                         Wipe with detergent wipe between use, ensure dry
Pressure Relieving Aids                Clean with warm water and general purpose detergent
                                       or detergent wipes and dry thoroughly. If contaminated
e.g. mattresses, cushions and motors   with body fluid, refer to manufacturers instructions.

                                       Razors and brushes – Patients must have their own
Shaving Equipment                      individual equipment. Discard in sharps bin.

                                       Electric shavers – Patients must have their own
                                       individual shavers. They must not be shared. Clean as
                                       per manufacturers instructions.

Speculae (Vaginal)                     Disposable – single use. Discard as infectious waste
                                       after use.

Sputum Pots                            Disposable – change daily.
                                       Discard as infectious waste after use.

Stethoscopes                           Wipe bell with 70% alcohol between each use.
                                       Wipe ear pieces with 70% alcohol between staff use.

Sticks, Frames, Crutches               Clean with general purpose detergent or detergent
                                       wipes between use by different patients, or when dirty.

Surgical and Podiatry Instruments      Use disposable where possible. If re-usable send to
                                       contracted CSD.

Tens Machine                           Wipe machine with detergent wipes between uses by
                                       different patients, plus at least weekly and if dirty.

Thermometers                           Use disposable thermometers or those with a
                                       disposable sleeve
                                       Digital – use a new sleeve cover for each use. Wipe
                                       the thermometer with detergent wipes at least daily.

Toilet seats (raised)                  Wash with general purpose detergent and warm water.
                                       If soiled with a body fluid, follow this by wiping with a
                                       1,000 ppm solution of Presept. Rinse and dry.

                                        Page 17 of 24
Decontamination Policy

Item                                   Recommended Method

Toys                                   Soft toys and those made of wood are not to be used.
                                       Only plastic toys that are in good condition and are
                                       easily wiped with general purpose detergent are
                                       suitable. All toys must be washed with hot water and
                                       general purpose detergent at the end of each clinic list.
                                       Those in waiting areas must be washed at least
                                       weekly, plus when soiled.

“Vacutainer” Needle Holders            Single-Use – discard after each procedure

Vomit Bowls/ Kidney Dishes             Disposable – single use. Discard of contents into
                                       macerator or toilet and then dispose of receptacle as
                                       infectious waste after use.

Weighing Scales                        Line with disposable paper towels.
                                       Wash with warm water and general purpose detergent
                                       or detergent wipe following use and ensure dry.

Work Surfaces                          Clean daily with warm water and general purpose
                                       detergent or detergent wipes.

19.    References / Bibliography

       Advisory Committee on Dangerous Pathogens / Spongiform Encephalopathy Advisory
       Committee (ACDP / SEAC). 2001. Transmissible Spongiform Encephalopathy Agents :
       safe working and the prevention of infection.

       AYLIFFE, G.A.J, D. COATES & P.N. HOFFMAN. 1993. Chemical Disinfection in Hospitals.
       Public Health Laboratory Service. London.

       Department of Health. 2003. Transmissible Spongiform Encephalopathy Agents : Safe
       Working and the Prevention of Infection.

       Department of Health. 2000. Decontamination of medical devices. HSC 2000/032

       Medical Devices Agency. 2000. ”Single – use Medical Devices : Implications and
       Consequences of Re-use”. MDA DB 2000(04)

       Medical Devices Agency. 2001. “Compatibility of medical devices and reprocessing units
       and decontamination agents”. MDA SN 2001 (28)

       Medical Devices Agency. 2002. Bench Top Steam Sterilisers – Guidance on Purchase,
       Operation and Maintenance. MDA DB 2002 (06)

                                        Page 18 of 24
Decontamination Policy

       Medical Devices Directive 93/42 EC, (Annex 1 Essential requirements) EU Council
       Directive 1995.

       Medicines and Healthcare Products Regulatory Agency. 2003. Management of Medical
       Devices Prior to Repair, Service or Investigation. MHRA DB2003 (05).

       Medicines and Healthcare Products Regulatory Agency. 2003. Community Equipment Loan
       Stores – Guidance on Decontamination. MHRA DB2003 (06).

       NHS Estates. 2003. A Guide to the decontamination of re-usable surgical instruments.

       Statutory Instrument 2002 No. 618, The Medical Devices Regulations 2002

                                         Page 19 of 24
    Decontamination Policy

                                        APPENDIX A

Handling of Equipment Prior to Inspection, Service, Repair, Return to Lending Organisation, or
                                Investigation of an Adverse Incident.
                                        (MHRA, 2003)

                                                               Decontaminate item
           Can the equipment
                    be                      Yes                   Label with
            decontaminated                                         contamination status
            without removing                                      Note fault / defect
           evidence important                                     For transport off –
            to a repair or an                                      site: pack and
              investigation?                                       despatch for service /
                                                                   repair / investigation
                              No                                  For transport on-site :
                                                                   store in preparation
              Inform repair                                        for service / repair /
              organisation                                         investigation

                                                                  Label with
                                           Yes                     contamination status
             organisation or                                      Note fault / defect
           investigating body                                     Pack and despatch for
           agrees despatch?                                        service / repair /


    Arrange visit by service / repair
     organisation or investigating

       Label with contamination
       Note fault / defect
       Quarantine in preparation
        for service / repair /

                                            Page 20 of 24
Decontamination Policy

                                    APPENDIX B

                         Declaration of Contamination Status
                                    (MHRA, 2003)

 From (consignor) : ……………………..                    To (consignee): ……………………….
 Address ……………………………………                           Address…………………………...........
 ……………………………………………….                              ……………………………………………
 ……………………………………………….                              ……………………………………………
 Reference ………………………………….                         Reference ………………………..........
 Emergency Tel ……………………………

 Type of Equipment ………………………       Manufacturer ………………………….
 Description of equipment …………………………………………………………………..
 Other identifying marks …………………………………………………………………….
 Model Number ……………………………          Serial Number…………………………
 Fault …………………………………………………………………………………………….

 IS THE ITEM CONTAMINATED?              Yes         No         Don’t know

 State type of contamination : blood, body fluids, respired gases, pathological
 samples, chemicals (including cytotoxic drugs), radioactive material or any other
 hazard ……………………………………

 HAS THE ITEM BEEN DECONTAMINATED?                  Yes †            No ‡

                                                        Don’t know

 †What method of decontamination has been used? Please provide details :
 Cleaning ………………………………………………………………………………………
 Disinfection ………………………………………………………………………………….
 Sterilisation ……………………………………………………………………….………….

 ‡ Please   explain why the item has not been decontaminated :

Contaminated items should not be returned without prior agreement of the recipient

 This item has been prepared to ensure safe handling and transportation :
 Name …………………………………                  Position ………………………………………..
 Signature …………………………..              Date …………….. Tel …………………………

                                        Page 21 of 24
       Decontamination Policy

                                                                Appendix C: Implementation Plan

An implementation plan should be completed for all policies and organisation wide procedures. This will ensure that a systematic approach is taken to
       the introduction of policies in order to secure effective working practices.

The following evidence-based template provides a checklist to be used as a starting point for thinking about implementation in a systematic manner.

                                                            Issues identified        Risk of non compliance         Action to be taken          Timescale
 Coordination of implementation                          Provider                    Policy not implemented.    Policy implementation plan      March 2010
 How will the implementation plan be coordinated         Implementation plan to      Decontamination            to be taken to provider
 and by whom? Clear coordination is essential to         be developed by policy      processes not adequate     services committee.
 monitor and sustain progress against the                group.                      Non compliance with
 implementation plan and resolve any further issues                                  hygiene code               Compliance with the policy
 that may arise.                                         Infection control and                                  to be audited through
                                                         governance to raise                                    evidence based practice
                                                         awareness that the                                     group.
                                                         policy exists and where
                                                         to find.                                               Compliance then reported
                                                                                                                to provider services
                                                         Roles identified for                                   committee
                                                         implementation as per

 Engaging staff                                          All clinical staff to see   Risk of cross              Staff to be made aware of       Jan 2010
 Who is affected directly or indirectly by the policy?   policy and implement,       contamination, staff and   their responsibilities within
 Are the most influential staff involved in the                                      patients put at risk.      the policy. Managers to
 implementation?                                                                                                ensure compliance
 Engaging staff and developing strong working
 relationships will provide a solid foundation for
 changes to be made.
 Involving service users and carers                      All policies available to   Service users complaints   Follow policy on freedom        Jan 2010
 Is there a need to provide information to service       the public on request       if policy not available    of information. Policy to be
 users and carers regarding this policy?                 and able to be viewed                                  posted on infection control
 Are there service users, carers, representatives or     on the Sefton public                                   page on NHS Sefton web
 local organisations who could contribute to the         web site.                                              site

                                                                             Page 22 of 24
      Decontamination Policy

                                                            Issues identified        Risk of non compliance           Action to be taken        Timescale
Involving service users and carers will ensure that
any actions taken are in the best interest of service
users and carers and that they are better informed
about their care.
Communicating                                            The potential risk from     Risk of cross              All policies available to the   Jan 2010
What are the key messages to communicate to the          contaminated medical        contamination, staff and   public on request and able
different stakeholders?                                  devices.                    patients put at risk.      to be viewed on the Sefton
                                                                                                                public web site.
How will these messages be communicated?                 Communicated through
Effective communication will ensure that all those       dissemination of policy
affected by the policy are kept informed thus
smoothing the way for any changes. Promoting
achievements can also provide encouragement to
those involved.
Training                                                 Key issues formulate        Risk of cross              Deliver infection control       Jan 2010, training
What are the training needs related to this policy?      part of infection control   contamination, staff and   mandatory training.             ongoing
Are people available with the skills to deliver the      mandatory training,         patients put at risk.
training?                                                delivered by infection
All stakeholders need time to reflect on what the        control team.
policy means to their current practice and key           Guidance available in
groups may need specific training to be able to          policy
deliver the policy
Resources                                                Nil identified, to be       N/A                        N/A                             N/A
Have the financial impacts of any changes been           implemented with
established?                                             current budgets
Is it possible to set up process to reinvest any
Are other resources required to enable the
implementation of the policy, e.g., increased
staffing, new documentation?
Identification of resource impacts is essential at the
start of the process to ensure action can be taken
to address issues which may arise at a later stage.

                                                                             Page 23 of 24
      Decontamination Policy

                                                        Issues identified        Risk of non compliance         Action to be taken       Timescale
Securing and sustaining change                       None identified, to be      Risk of cross              Deliver induction training   Jan 2010, training
Have the likely barriers to change and realistic     monitored via annual        contamination, staff and   and disseminate policy       ongoing
ways to overcome them been identified?               infection control audit     patients put at risk.
Who needs to change and how do you plan to           programme.
approach them?
Have arrangements been made with service
managers to enable staff to attend briefing and      As training policy
training sessions?
Are arrangements in place to ensure the induction
of new staff reflects the policy?                    Infection control
Initial barriers to implementation need to be        training formulates
addressed as well as those that may affect the on-   corporate induction
going success of the policy.                         programme
Evaluating                                           More effective              Risk of cross              Through policy               Feb 2010, audit
What are the main changes in practice that should    decontamination             contamination, staff and   dissemination process.       ongoing
be seen from the policy?                             practices.                  patients put at risk.      Perform and report
How might these changes be evaluated?                Via Infection control                                  Infection control audit
How will lessons learnt from the implementation of   audit
this policy be fed back into the PCT?                Audit results to be
Evaluating and demonstrating the benefits of the     reported to appropriate
new policy is essential to promote the               PCT committee/s
achievements of those involved and justifying
changes that have been made.

                                                                          Page 24 of 24

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