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
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
15. Transport of Contaminated Devices / Equipment to the 8
16. Purchase and Decommissioning of Medical Devices 8
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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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
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.
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).
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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
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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.
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
„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 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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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 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
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
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:
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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
In contact with broken skin
or mucus membranes
Enters sterile body areas
MEDIUM In contact with intact mucus CLEANING FOLLOWED BY
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
LOW In contact with intact skin CLEANING ONLY
Not in contact with the patient
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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.
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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:
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:
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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
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
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.
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Products to be used for Disinfection:
Product or Chemical Concentration Use
NaDCC (Sodium (Under local COSHH Assessment)
NB. These are chlorine
releasing agents and are
therefore corrosive to
metals and inactivated by
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.
Decontamination of blood spills
e.g Presept Granules As supplied only. (Refer to ICC 07 Standard
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
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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
In the event of machine failure inform Estates
Department immediately and dispose of contents of
bedpan / urinal down toilet or sluice. Disgard empty
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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
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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.
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Item Recommended Method
Examination Lamps (in Treatment Clean with detergent and dry daily, plus when visibly
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
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.
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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.
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
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
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.
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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
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
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
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.
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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)
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Medical Devices Directive 93/42 EC, (Annex 1 Essential requirements) EU Council
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
Handling of Equipment Prior to Inspection, Service, Repair, Return to Lending Organisation, or
Investigation of an Adverse Incident.
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 /
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 /
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Declaration of Contamination Status
From (consignor) : …………………….. To (consignee): ……………………….
Address …………………………………… Address…………………………...........
Reference …………………………………. Reference ………………………..........
Emergency Tel ……………………………
Type of Equipment ……………………… Manufacturer ………………………….
Description of equipment …………………………………………………………………..
Other identifying marks …………………………………………………………………….
Model Number …………………………… Serial Number…………………………
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
HAS THE ITEM BEEN DECONTAMINATED? Yes † No ‡
†What method of decontamination has been used? Please provide details :
‡ 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 …………………………
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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
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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
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.
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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.
Have arrangements been made with service
managers to enable staff to attend briefing and As training policy
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.
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