This standard operating procedure outlines the process for terminal cleaning in a healthcare setting. Terminal cleaning is carried out following ward/bay closure during an outbreak, when a patient in isolation no longer requires it, or after certain infectious patients vacate a room. The procedure involves cleaning the room and equipment with a combined detergent and chlorine agent. All areas, furnishings, and reusable equipment must be decontaminated before the room can be reused. The hotel services supervisor and nurse in charge must approve completion of terminal cleaning before new patients can be admitted.
This standard operating procedure outlines the process for terminal cleaning in a healthcare setting. Terminal cleaning is carried out following ward/bay closure during an outbreak, when a patient in isolation no longer requires it, or after certain infectious patients vacate a room. The procedure involves cleaning the room and equipment with a combined detergent and chlorine agent. All areas, furnishings, and reusable equipment must be decontaminated before the room can be reused. The hotel services supervisor and nurse in charge must approve completion of terminal cleaning before new patients can be admitted.
Original Description:
SOP for Terminal Cleaning in Hospital in order to control and prevent Infection
This standard operating procedure outlines the process for terminal cleaning in a healthcare setting. Terminal cleaning is carried out following ward/bay closure during an outbreak, when a patient in isolation no longer requires it, or after certain infectious patients vacate a room. The procedure involves cleaning the room and equipment with a combined detergent and chlorine agent. All areas, furnishings, and reusable equipment must be decontaminated before the room can be reused. The hotel services supervisor and nurse in charge must approve completion of terminal cleaning before new patients can be admitted.
This standard operating procedure outlines the process for terminal cleaning in a healthcare setting. Terminal cleaning is carried out following ward/bay closure during an outbreak, when a patient in isolation no longer requires it, or after certain infectious patients vacate a room. The procedure involves cleaning the room and equipment with a combined detergent and chlorine agent. All areas, furnishings, and reusable equipment must be decontaminated before the room can be reused. The hotel services supervisor and nurse in charge must approve completion of terminal cleaning before new patients can be admitted.
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Standard Operating Procedure (SOP) for Terminal Cleaning in a healthcare setting
v01.2, July 2018 Page 1 of 4 Document Control Sheet
Title: Standard Operating Procedure (SOP) for Terminal Cleaning in a
healthcare setting
Document Status: Approved
Document Type: SOP Version Number: v01.2, July 2018 Document location: Infection Prevention and Control (IPC) Athena Site Author: Frances Lafferty, Infection Control Nurse Owner: Infection Prevention and Control Policy Review Group Approved By: Robert Wilson, Infection Control Manager Date Effective July 2018 From:
Revision History: Version: Date: Summary of Changes: Responsible Officer: Issue 1 November 2016 Frances Lafferty
v01.1 May 2018 Minor changes to Actichlor Sharon Leitch
v01.2 July 2018 Hyperlinks and references Frances Lafferty
updated
Approvals: this document was formally approved by:
Name & Title / Group: Date: Version: Infection Prevention and Control Policy Review Group July 2018 v01.2
Dissemination Arrangements: Intended audience: Method: Date: Version: Throughout NHS Announcement on Daily Digest / July 2018 v01.2 A&A Weekly News Bulletin
Linked Documentation: Document Title: Document File Path: Terminal Cleaning Out of http://athena/execmed/inconprev/JBTestLibrary/Ward_staff Hours _remit_OOH_June_2013%5b1%5d.pdf
Actichlor TM Plus Poster http://athena/execmed/inconprev/JBTestLibrary/Forms/Pos
ters.aspx Mattress Care Policy http://athena/cgrmrd/ClinGov/DraftGuidance/G070%20- %20Mattress%20Care%20Policy.pdf HPS National Infection http://www.nipcm.hps.scot.nhs.uk/ Prevention and Control Manual
Standard Operating Procedure (SOP) for Terminal Cleaning in a healthcare setting
v01.2, July 2018 Page 2 of 4 Policy Statement
It is the responsibility of all staff to ensure that they consistently maintain a high standard of infection control practice.
NB. This document is uncontrolled when printed. The contents of this document are subject to change, any paper copy is only valid on the day of printing. To ensure you have the most up to date version of this document, please use the link to access the document directly from AthenA or contact the Author.
When to carry out a terminal clean
A terminal clean will be carried out following:
ward/bay closure in an outbreak situation
when a patient who was isolated for infection prevention and control reasons no longer requires isolation and vacates the room
▪ The room/ward should not be used until a complete terminal clean has been carried out in all areas. This includes the rooms, hard and soft furnishings and reusable patient care equipment (including the patient call system). Cleaning of patient care equipment is the responsibility of the clinical staff
Initiating a Terminal Clean
▪ Once isolation has been discontinued hotel services staff should be contacted to terminally clean the room. For Out of Hours cleaning when hotel services staff are not available refer to the agreement for terminal cleaning out of hours. Contact your Senior Charge Nurse or the night co-ordinator if you require further information
▪ In the case of an outbreak being declared over the senior charge nurse or the nurse in charge should discuss and agree the process for the terminal cleaning of the ward/department with the IPCT and hotel services staff
Note: During an outbreak situation, there will be occasions when patient numbers get to a level that some rooms will be empty. When this occurs, the ward area/room may be stripped and left ready for cleaning once the outbreak is declared over.
Terminal Cleaning Process
All staff involved in the terminal clean must ensure the following: Staff should wear the appropriate Personal Protective Equipment e.g. gloves and aprons and face protection if required
▪ The patient care environment should be cleaned with a combined detergent and chlorine releasing agent e.g. ActichlorTM Plus (check manufacturer’s guidelines). Domestic Staff should adhere to guidance on terminal cleaning which can be found in the ward/department DSR
▪ All patient associated equipment, e.g. blood pressure monitors, IV pumps, should be cleaned with a combined detergent and chlorine releasing agent e.g. ActichlorTM Plus (check manufacturer’s guidelines) Cleaning of patient care equipment is the responsibility of the clinical staff
Standard Operating Procedure (SOP) for Terminal Cleaning in a healthcare setting
v01.2, July 2018 Page 3 of 4 ▪ Once decontaminated, mattresses must be opened and inspected for any ingress of blood or body fluids and any issues addressed as per NHS Ayrshire and Arran Mattress Care Policy available on Athena
▪ Cleaning of Hospedia equipment must be included in the terminal clean. The
equipment must not be covered with a polythene bag. The room cannot be reoccupied until this equipment has been decontaminated
Following Completion of a terminal Clean
▪ The hotel services supervisor and the nurse in charge are responsible for checking all cleaning procedures are complete
▪ Once the terminal clean has been assessed as complete, patients can be admitted to that area right away
▪ Patient safety must always be the priority when a room/ward is reopened following a terminal clean
References 1. Health Protection Scotland (HPS) (2015). HPS Norovirus Outbreak Guidance 2015-16 and 2016-2017: Preparedness, control measures & practical considerations for optimal patient safety and service continuation in hospitals
2. Centre for Disease Control (CDC) (2007) The Healthcare Infection Control Practices Advisory Committee. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
3. HPS National Infection Prevention and Control Manual
4. NHS Ayrshire and Arran Infection Prevention and Control Athena Site (Posters) ▪ Actichlor Plus Blood Spills ▪ Actichlor Plus General Environment
Standard Operating Procedure (SOP) for Terminal Cleaning in a healthcare setting
