ATTACHMENT_A_OVAMC_Policy_No._00Q-16.docx

Non-Critical Reusable Medical Equipment Cleaning and Disinfection Expires: 1/20/2020

1. PURPOSE: To establish a standardized process for the cleaning and disinfection of non-critical, reusable medical equipment used in the Medical Center, Acute Care, Community Living Center, ambulatory care, outpatient clinics and community-based outpatient clinics, collectively called “OVAMC”.

2. POLICY: In accordance with existing infection prevention and control policies, Non-Critical reusable medical equipment (NCRME) is cleaned by staff according to manufacturers’ instructions and local guidelines/procedures.

3. DEFINITIONS:

a. Cleaning: The act of removing visible debris. Meticulous mechanical cleaning of visible debris must always precede disinfection. Any adhesive residue must be removed prior to disinfection

b. Personal Protective Equipment (PPE): Specialized clothing or equipment worn by an employee for protection against a hazard (e.g., gowns, lab coats, gloves, masks, and face shields provided to prevent exposure to blood and body fluids) is always worn to protect from exposure to a hazard (e.g., chemicals or microorganisms on contaminated items). It is worn when such hazardous exposure is likely to occur to the skin, eyes, nose or mouth. PPE may include gown, gloves, mask, eye glasses, or face shield.

c. Non-Critical Reusable Medical Equipment: Those items that come in contact with intact skin but not mucous membranes. Intact skin acts as an effective barrier to most microorganisms; therefore, the sterility of items coming in contact with intact skin is “not critical.”

d. Disinfectants: Antimicrobial product applied t inanimate objects only. Low level disinfectants can kill most vegetative bacteria, some fungi, and viruses. All disinfectants used must be Environmental Protection Agency (EPA) approved for hospital use. Bottles containing liquid disinfectants should not be left where easily accessible to patients or visitors. Facility approved disinfectant wipe containers may be mounted in approved patient care locations and on certain carts and equipment, as needed.

(1) Examples of disinfectants that are EPA approved include:

(a) 1:10 Bleach Solution

(b) Cavicide 1™ Spray

(c) Chlorox Healthcare Bleach Germicidal Spray

(d) Germicidal wipes such as:

1 Caviwipes 1™

2 Dispatch® Hospital Cleaner Disinfectant Towels with Bleach.

(2) Storing of Equipment. After equipment items have been cleaned and disinfected they are stored in a manner that prevents contamination before reuse.

4. RESPONSIBILITIES:

5. PROCEDURES:

a. NOTE: SPS is only responsible for ensuring that Critical and Semi-Critical medical equipment is properly cleaned according to the manufacturer’s instructions. Specific instructions are contained in SPS procedures.

b. EMS is primarily responsible for ensuring that non critical medical equipment (NCRME) is properly cleaned and sanitized according to guidelines and manufacturer’s instructions. Examples of NCRME cleaned by EMS staff or their contracted designee include but are not limited to, furniture items and rolling stock such as wheelchairs and IV Poles. Cleaned and sanitized items are then labeled with a tag stating SANITIZED and placed in the designated storage area. EMS is responsible for ensuring that all NCRME inside acute care and CLC patient rooms is cleaned and sanitized during the discharge terminal cleaning process of patient rooms, therefore individual items that remain in the patient room are not labeled with sanitized tags. In the event that nursing staff remove a cleaned & sanitized item from the patient room because it is not needed for a specific patient and it is removed prior to patient entry into the room, said staff member will place a SANTIIZEDSANITIZED tag on the item and place it in the clean storage area. Specific instructions are contained in EMS procedures.

c. All Clinical Services end users will be primarily responsible for cleaning medical equipment physically located in their areas, including, but not limited to those items listed in Clinical Personnel and End User Responsibility for Cleaning Non-Critical RME (attachment #1) which contains special cleaning instructions for specific equipment. Examples of NCRMEof NCRME cleaned by clinical staff include glucometers, stethoscopes, i-Stats, etc.

d. Instructions for the cleaning of medical equipment located in Surgical Suites, Endoscopy and Urology Procedure rooms and minor surgical procedure rooms are addressed in a separate policy.

e. Gloves must be worn during the cleaning of equipment. After glove removal, proper hand hygiene must follow.

f. As designated on product labels, equipment surfaces will be cleaned and disinfected with a facility approved disinfectant spray or wipe (e.g.Caviwipes 1 ™) Use a two steptwo-step process- one cloth to clean heavy soil and one cloth to disinfect. Ensure that the surface being cleaned remains wet for the manufacturers designated wet time. See attachment # 3 for facility approved disinfectants and wet times. Some examples are below:

(1) Items disinfected with Caviwipes 1™ wipes or spray must remain wet on surface for one (1) minute and allowed to dry before equipment use.

(4) Items disinfected with bleach based product such as Chlorox Healthcare Bleach Germicidal solution or Dispatch® wipes must be remain wet for five minutes, and allowed to dry before use.

g. Cleaning of non-critical RME that is used for the care of patients with Clostridium difficile is managed with the use of a facility approved sporicidal disinfectant such as Dispatch wipes or Chlorox Healthcare Bleach Germicidal Spray.

4. REFERENCES

5. Centers for Disease Control and Prevention, Rutala, William A., Weber, David J. and the Healthcare Infection Control Practices Advisory Committee. Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008.

5. UPDATE TO: Policy 00Q-16 Non-Critical Reusable Medical Equipment Cleaning and Disinfection dated 8dated 8/28/2015

Timothy W. Liezert Medical Center Director

Attachments: (4) VA Medical Center MEDICAL CENTER Orlando, Florida POLICY NO. 00Q-16 Published: 1/20/2017

Attachment #1 Clinical Personnel and End User Responsibility for Cleaning Non-Critical RME Surfaces of equipment will be wiped / cleaned with designated cleaning agent.

Follow manufacturer’s instructions AT ALL TIMES

Per RT SOP

End user

X

Capsule endoscopy equipment - recorder belt

Antibacterial soap and warm water

Capsule endoscopy equipment - sensor array

X

End user

X

End user

Dopplers

X

End user EMS (inpatient rooms) X

End user

X

End user

X

Change table cover between patients

EMS

X

Finger and ear sensors (Sp02)

X

See special Instructions in separate attachment (#2)

Hover Matt inflatable mattress

Launder if multi use. Single use matts are discarded after use

Hydrocollator

Every 2 weeks using a soft cloth and low abrasive bathroom cleaner

See special Instructions in separate attachment (attachment (#3)

End user

X

Lift equipment - slings

X

Laundered

X

Cleaned by EMS (and end user as needed)

EMS

Specialty Beds

EMS

Refer to contractto contract

End user

As needed

Thermometer - oral temperature base

X

End user

X

Thermometer - temporal

X

End user

X

End user

X

T-spray; sanicloth HB wipe; Caviwipes 1 (refer to manufacturer's instructions)

T-spray; sanicloth HB wipe; Caviwipes 1 (refer to manufacturer's instructions)

Per RT SOP

Vital signs monitor screen

X

Use a lint free cloth

EMS or End User

Follow manufacturer instructions

*Cleaning of all items includes “as needed” in addition to assigned frequency

Attachment #2GLUCOMETER Cleaning Requirements:

· Clean the exterior surface of meter after control testing is done, between EACH patient testing, or daily, whichever is more frequent using a facility approved disinfectant wipe.

CLEANING STEPS:

1. Clean meter with one wipe first.

2. Use a second wipe to thoroughly disinfect/wet surface for the *total wet contact time recommended by manufacturer.

3. Allow to air dry, do NOT wipe dry.

*Caviwipes have a 1 minute “wet” time

Attachment #3 Port Protector Replacement on select models only

· Yellow or Blue port protector minimizes fluid from entering the meter

· Clean meter/area and replace port protector if blood or control solution comes into contact with it

· To replace a port protector, follow the instructions to the right

REPLACEMENT INSTRUCTIONS:

1. Clean the meter following policy.

2. Lift protector from its left or right edge.

3. Pull gently away until the protector separates from the meter.

4. Rest the flat bottom of the new port protector on the ledge of the test strip port.

5. Gently push both sides of the port protector until you hear the tabs snap into place. There should be no gap between the port protector and the meter around the edges.

Attachment #4*CaviWipes have a 1 minute “wet” time

CLEANING STEPS:

1. Clean i-STAT with one wipe first.

2. Use a second wipe to thoroughly disinfect/wet surface for the *total wet contact time recommended by manufacturer.

3. Allow to air dry, do NOT wipe dry.

· Clean the exterior surface aftersurface after control testing is done, between EACH patient testing, or daily, whichever is more frequent using a facility approved disinfectant wipe.

i-STAT Cleaning Requirements:

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