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Best practice: decontaminating to reduce cross-infection

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Author Shila Patel, MSc, BSc, RGN, is clinical nurse specialist, infection control, Epsom and St Helier University Hospitals NHS Trust.
Patel, S. (2007) Decontaminating to reduce cross-infection. Nursing Times; 103: 38, 50–51.

A wide variety of equipment is routinely used during the delivery of healthcare and much of it – including blood-pressure cuffs, commodes, bedpans and pressure-relieving mattresses – is used for multiple patients. Shila Patel explains the principles of decontamination.

Outbreaks of infection have been associated with inadequately decontaminated equipment (Rampling et al, 2001; Catalano et al, 1999). The level of risk posed by equipment is variable (ranging from low to high) and depends on:

  • The equipment;
  • Its use and purpose;
  • The type and degree of patient contact;
  • The type and degree of microbial contamination;l Individual susceptibility to infection.

For example, surgical instruments pose a high risk of cross-infection if they are inadequately decontaminated between use with each patient. These instruments become contaminated with blood and other high-risk bodily fluids, posing a risk of cross-infection with bloodborne viruses such as hepatitis B and HIV.

In contrast, wash-bowls pose a low risk of cross-infection as they have only indirect contact with patients’ skin. In order to reduce the risk of cross-contamination and the potential for infection via equipment used by multiple patients it is important to have strict protocols in place for equipment decontamination, including details regarding method, frequency and responsibility for undertaking the decontamination procedure.

Selecting decontamination method

A number of factors should be considered before selecting a method of decontamination, including the manufacturers’ recommendations, the extent of contamination and the associated level of risk for transmitting infection or acting as a source of infection (Wilson, 2001).

Manufacturers’ recommendations

Where manufacturers’ recommendations are available, these should be followed. Failure to do so may invalidate the manufacturer’s warranty in the event of equipment malfunction or breakdown.

Staff should also be aware of single-use or single-patient instructions. A piece of equipment marked by the manufacturer as single use can
only be used on one patient during a single episode and must be discarded afterwards. It cannot be decontaminated and reused, even on the same patient. The Medicines and Healthcare products Regulatory Agency (2006) issued this advice as reuse of single-use devices may encourage the spread of infection and compromise the function or performance of the device.

Single-patient use devices, on the other hand, may be used more than once for the same patient. However, these – such as nebuliser masks – must be adequately decontaminated between each use.

Extent of contamination

Blood and/or bodily fluids are a potential source of contamination and it is vital to remove such substances from equipment using water and detergent or detergent-impregnated wipes, as appropriate. This removes approximately 80% of micro-organisms (Ayliffe et al, 1967).
Equipment must be dried after it has been cleaned to prevent any remaining micro-organisms from multiplying (Wilson, 2001).

Risk associated with equipment

Most low-risk equipment – for example commodes, mattresses and plastic wash-bowls –can be decontaminated by thorough cleaning.

Disinfection may be required in certain situations, for instance if blood contamination is present. In this case, the blood spillage must be cleaned using a suitable disinfectant such as sodium hypochlorite providing 10,000 parts per million available chlorine.

During an outbreak of infection, the infection-control team may advise that a disinfectant, such as sodium hypochlorite providing 1,000 ppm available chlorine is used for environmental cleaning.

For medium or high-risk items, cleaning and disinfection/sterilisation will always be necessary as these are likely to be heavily contaminated
with micro-organisms.

It is important to note that, as disinfection and sterilisation will be less effective in the presence of blood and bodily fluids, cleaning is an essential prerequisite before undertaking these higher levels of decontamination (Finn, 2000).

Chemical disinfectants, such as hypochlorite, may be inactivated by organic material. Sterilisation, usually achieved by steam under pressure, is also less efficient in the presence of organic soiling, as steam cannot readily penetrate blood and bodily fluids, making microbial destruction harder to achieve.

Decontamination frequency

Shared clinical equipment should be decontaminated appropriately following each and every use (Pratt et al, 2007). Regular and thorough cleaning of equipment, including that which is used infrequently, should be undertaken.

Dust poses a potential cross-infection risk as it is largely composed of shed skin squames (flat flakes of dead skin), some 10% of which carry micro-organisms (Wilson, 2001). Large dust particles will settle onto any horizontal surface, including equipment. Although many micro-organisms do not survive for very long in dust, some micro-organisms – such as the spores of C. difficile – can survive for anything from a few days to months.

It is important to have a system in place for thorough cleaning of equipment – including equipment that is used infrequently. There is no specific national guidance about how often this regular cleaning should be undertaken but doing it weekly helps minimise dust levels. These duties may be undertaken over the weekend (referred to as ‘weekend cleaning’ in the past) or at any point during the week when there is an opportunity. To aid this process, equipment should be itemised and a record kept of when each piece was cleaned.

If equipment is used for an extensive period by a single patient, regular cleaning should be undertaken even if there is no visible contamination. O’Connor (2000) advocates that beds should be cleaned once a week if used by a single patient for an extended period, in order to minimise dust and the accumulation of microbes.

Equipment may also require cleaning during patient use if it becomes contaminated, for example an IV fluid stand that becomes contaminated with blood.

Responsibility for equipment cleaning

All healthcare workers have a responsibility to clean the equipment that they use as part of their healthcare delivery (Pratt et al, 2007). Decontamination protocols should clearly identify whose responsibility it is to clean individual pieces of equipment.

Conclusion

Equipment that is used for multiple patients during the delivery of healthcare may act as a vehicle for transmitting micro-organisms from one patient to another and potentially lead to a healthcare-associated infection. Equipment cleanliness is therefore integral to reducing this risk.
It is important to have in place clear and simple protocols for decontaminating equipment, including details of frequency, method and designated responsibility. Failure to incorporate all three elements will result in inadequately decontaminated equipment and a continued cross-infection risk.

Key points for practice

  • Equipment acts as an indirect vehicle for the transmission of micro-organisms
  • The level of risk posed by equipment must be assessed – it is important to consider the type of equipment, how and when it is used, the type and degree of patient contact and the type and degree of microbial contamination
  • Manufacturers’ recommendations for decontamination must be followed
  • Single-use items must not be reused
  • Shared clinical equipment must be decontaminated appropriately following each use
  • All healthcare workers have a responsibility to clean the equipment that they use
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