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Routine and Scheduled Cleaning

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Infectious agents can be widely found in pre-hospital setting. Transmission of infectious agents from the environment to patients may occur through direct contact with contaminated equipment, or indirectly, for example, via hands that are in contact with contaminated equipment or the environment and then touch a patient. Cleaning is a process which intends to remove foreign material (e.g. dust, soil, blood, secretions, excretions and micro-organisms) from a surface or an object using water, detergent and mechanical action/ friction. Although cleaning is known to successfully reduce the microbial load on surfaces there are some circumstances where disinfection is also required to be performed. Disinfection is a process that eliminates many or all micro-organisms except bacterial spores. Disinfection is necessary when body fluids are spilled, when a multi-resistant organisms (MRO) is present or there is an outbreak of an infection. Cleaning of ambulance interiors, ambulance equipment, office environments or stations should be done routinely and anytime they become soiled with dirt or debris. It is an essential part of the standard precautions in infection control. Therefore keeping the ambulance clean is an important part of infection prevention and should be done in accordance with the Routine Cleaning and the Scheduled Cleaning procedures.

Procedure – Scheduled Cleaning [PRO-252]

Procedure – Routine cleaning [PRO-118]

Ambulance interior and equipment

High-touch areas in ambulances and shared patient equipment are considered high risk and should have a high frequency of clean. This is the responsibility of operational staff after each patient, refer to the Routine Cleaning Procedure. Low-touch surfaces such as floor, walls, steering wheel, locker doors, etc., in ambulances and light fleet, are considered a moderate risk and should have a frequent scheduled clean. This is the responsibility of operational staff using the vehicles and should occur once per shift whenever operationally possible. Spot cleaning of surfaces that are visibly soiled should be completed as required by staff using the vehicles. Fleet Cleaning and Stock Expiry Register

Level 1 clean – standard precaution (after every patient)

Cleaning of all high touch surfaces, all equipment which has had a direct or indirect patient or clinician contact or any surface/item that is visibly soiled must occur after each patient attended. High touch surfaces and equipment includes ambulance grab rails, handles, drawers, stretcher mattress, belts, handles and rails, response kits, ECG monitor, ECG leads, pulse oximetry probe, BP cuff. Use appropriate standard precaution PPE as required: • Detergent and water are adequate for a level 1 routine clean: - Use buckets and mops designated for ambulance cleaning. - With clean disposable cloths, mop and the detergent solution (diluted to the manufacturer’s instructions, wipe/ mop over surfaces and equipment: ○ Empty buckets after use, rinse with a fresh detergent solution and store upside down to allow for draining and drying. ○ Dispose of cloths after use. ○ Rinse mop after use and store upside down to allow for draining and drying. Mop heads should be replaced regularly and when visibly soiled. • Where this is not practical, all-in-one detergent/disinfectant wipes (e.g. Clinell® wipes) are a suitable alternative:

- Use more than one wipe for larger surface areas; sufficient to ensure the whole surface is wet (e.g. 4 to 6 wipes may be required to clean a stretcher). - Allow the surfaces to air dry. • Alcohol based wipes (e.g. Isowipes®) can be used for cleaning electronic equipment and screens. - Disinfectant wipes (e.g. Clinell®) and alcohol wipes (e.g. Isowipes®) should be available at all ambulance stations and in all ambulances. - Use detergent and water with disposable cloths and bucket and/or mop and bucket (as described in section 3.1 of the Routine Cleaning Procedure) for grossly soiled surfaces that are too large to be managed with detergent/disinfectant wipes, such as the ambulance floor. - For re-usable ambulance items that are grossly soiled or require specialised cleaning, refer to the following procedure.

Procedure – Reprocessing of Used or Soiled Ambulance Equipment [PRO-112]

Level 2 decontamination – after a patient with transmission-based precautions (contact or droplet)

In addition to a level 1 clean, all surfaces and equipment that have been in contact with a patient requiring transmission-based precautions or indirectly via the clinician must be cleaned with a disinfectant. A disinfectant is a chemical agent that rapidly kills or inactivates most infectious agents. Disinfectants are not to be used as general cleaning agents, unless combined with a detergent, as a combination cleaning agent (detergent-disinfectant). Where a 2 in 1 detergent and disinfectant has been used, (e.g. Actichlor Plus or Clinell wipes in the level 1 clean), there is no need to repeat, as the decontamination step has already been completed. Use appropriate transmission-based precaution PPE as required. Procedure - COVID-19 Clean using Actichlor Plus

Actichlor Plus solution must be prepared with a ratio of 1 tablet to 1 litre of cool water to ensure 1000ppm concentration.

Product

Type of Product Actichlor Plus Neutral Detergent AND TGA approved disinfectant 1 tablet (1.7g) dissolved 1 litre water cool/cold water 1000 ppm

Ensure any exposed linen not stored in the overhead locker is disposed of in a linen skip. Remove any rubbish and empty rubbish bins. Clean all vehicle surfaces and equipment with the following: • USE Clinell wipes for equipment (ECG cable, BP cuffs, stethoscopes, etc.) • USE Actichlor Plus on all other surfaces and larger equipment (stretcher, walls, floor, ceiling and driver/ passenger foot well etc.) • USE 70% Isopropyl Alcohol wipes for sensitive medical equipment (ECG electrode, MDT/Monitor screens). Allow all surfaces to dry or, dry electronic equipment with a clean dry cloth, if required. Empty bucket(s) after use, rinse with clean water or solution and store upside down to allow draining and drying. Dispose of cloth(s) and/or mop head after use. Spills of Actichlor Plus or bleach Contain any bleach solution spills with disposable cloths. If unprotected skin or eyes become contaminated, wash with copious amounts of water and seek assistance. For reusable ambulance items that are grossly soiled or require specialised cleaning, refer to the following procedure.

Dilution Concentration

Procedure – Reprocessing of Used or Soiled Ambulance Equipment [PRO-112]

Level 3 air – after a patient with transmission-based precautions (airborne)

In addition to a level 1 and level 2 clean, air the ambulance and equipment by leaving all doors open and equipment exposed to air for 10 minutes. Scheduled cleaning of ambulance vehicles

Scheduled three monthly cleaning of metropolitan ambulances (stretcher carrying vehicles) and stretchers is managed by SAAS Fleet Services. Scheduled cleaning of country ambulances will occur as per local arrangements.

Ambulance Stations

Ambulance station sluice rooms or equipment reprocessing areas are considered moderate risk and should have a frequent clean. All other areas of ambulance stations are considered low risk and should have a regular scheduled clean. Routine cleaning

Staff on shift/on station are responsible for: • Maintaining all station areas free from clutter to not inhibit any external providers from performing contracted cleaning. • Ensure refrigerators, freezers, kitchens, storage rooms, and personal areas such as lockers, drawers, and cupboards are maintained in a manner that does not put the health and safety of others at risk. • Wiping benches, storage containers and spaces in clinical areas (clinical storerooms and sluice rooms) and mop floors with detergent and water. Scheduled cleaning

Scheduled cleaning of ambulance stations is managed by SAAS Building Services, who will inform the relevant workgroup or worksite regional Operations Manager when and what type of cleaning is scheduled. • Managers should ensure any staff who have known allergies or reactions to scheduled cleaning are accommodated at an alternative worksite for an appropriate pre-determined exclusion period. Spot cleaning of surfaces that are visibly soiled should be completed as required by staff using the area. All staff will be required to ensure the station area is tidy and free from obstruction in time to allow access for any scheduled cleaning to occur. It is the responsibility of staff to ensure any outside facilities e.g. sheds or alfresco common areas are maintained in a manner that does not present a risk of health or safety to others.

Office Environments

SAAS office/administration areas are considered low risk as there is minimal patient contact or indirect patient contact. There is still a risk that infectious agents causing common illnesses can spread easily in a workplace if routine cleaning is not done. Routine cleaning

Staff are responsible for: • Regular hand hygiene, particularly after a break away from their workstation. • Cleaning their workstations, particular attention needs to be paid to ‘hot desks’, which should be cleaned prior to and after each use using all-in-one detergent/disinfectant wipes. • Cleaning of electronic equipment, with particular attention to telephones and computer keyboards and mice using alcohol wipes at the start of every day/shift. • Maintaining the office area free from clutter so as to not inhibit any external providers from performing contractual cleaning. • Ensuring refrigerators, freezers, kitchen, storage rooms, and personal areas such as lockers, drawers and cupboards are maintained in a manner that does not put the health and safety of others at risk. Scheduled cleaning

Scheduled cleaning of office environments is managed by SAAS Building Services, who will inform the relevant workgroup when and what type of cleaning is scheduled.

Managing a blood or body fluid spill

For all body fluid spills the following process must be followed: • Don appropriate PPE including eye protection and gowns. • Contain the fluid using hand towels or blankets.

• As soon as practicable soak up as much of the fluid as possible using absorbent disposable material and dispose of in a medical waste bin. • Clean the area with detergent and warm water. • Remove all visible signs of the spill. This may require more than one attempt, changing the water and cleaning material often. • Wipe a large spill with bleach after cleaning and drying using 25ml of bleach per 1 Litre of water or

Actichlor Plus.

Cleaning equipment

Most cleaning procedures require the use of some equipment including spray bottles, cloths, sponges, mops and buckets. The following guidelines should be followed when using cleaning equipment: • Cleaning cloths should be disposable. • Mops and buckets must be cleaned with detergent and warm water after use and then stored upside down to dry. • Refillable spray bottles must be cleaned and dried thoroughly before re-use. Bleach solutions should NOT be put in spray bottles. Cleaning equipment should always be stored in a manner that ensures a safe work environment and should be put away in a way that minimises the risk of injury.

Re-processing of equipment

All ambulance equipment can be sorted into three categories relating to the level of risk it poses. The categories are: • Critical items which enter or penetrate into tissue, a body cavity or the bloodstream. • Semi-critical items which have contact with intact mucous membranes or non-intact skin. • Non-critical items are those which have contact with intact skin only. In SAAS, all critical and semi-critical items, are single patient use only. They are marked with the following symbol or the words ‘single-use only’ printed on them. These must be disposed of in an appropriate receptacle after single use or single patient use. The reuse of single-use items is not approved by SAAS and is regulated by the Therapeutic Goods Administration (TGA). The level of reprocessing required for non-critical items depends on the item, its intended use, manufacturer’s instructions and SAAS procedures. After use on a patient, any reusable medical equipment must not be used for the care of another patient until it has been cleaned and reprocessed appropriately. Cleaning reusable items is the first step and should occur as soon as practicable. This should be done in accordance with the ‘Level 1 Clean’ as detailed in the Routine Cleaning Procedure. If the equipment has been exposed to a known or suspected multi-resistant organism (MRO) or other infectious agents requiring contact, droplet or airborne transmission based precautions, the cleaning step should be followed by a disinfection step. This should be completed in accordance with the ‘Level 2 Decontamination’ steps in the Routine Cleaning Procedure. Items that have been heavily soiled may require specialised cleaning (e.g. Posey Restraint Net). This should be done in accordance with the Reprocessing of Used or Soiled Ambulance Equipment Procedure.Uniforms, stretchers and ambulance interiors which are grossly soiled should be managed according to the Reprocessing of Used Soiled Ambulance Equipment Procedure.

Procedure – Reprocessing of Used or Soiled Ambulance Equipment [PRO-112]

Procedure – Soiled and/or Broken Ambulance Stretchers [PRO-258]

Safe handling and disposal of sharps waste and linen

The safe handling of sharps, waste and linen is essential to protect you, your work colleagues and patients. This procedure outlines safe work practices for the handling and disposal of sharps, waste and linen. Safe handling and disposal of sharps

It is important that all staff are aware of the inherent risk of injury associated with the use of sharps such as needles, scalpels and lancets. When handling sharps the following principles apply: • The person using the sharp is responsible for its safe disposal • Dispose of the sharp immediately following its use and at the point of care

• Dispose of all sharps in designated puncture resistant containers that conform to relevant Australian Standards (AS/NZS 4261:1994 reusable;

AS 4031:1992 non-reusable) • Dispose of sharps disposal containers when they are ¾ full or reach the specified fill line, seal appropriately and place in the clinical waste stream • Never pass sharps by hand between health care workers • Never recap used needles unless an approved recapping device is used • Never bend, break or otherwise manipulate by hand a needle from a syringe. Linen management

The correct handling of linen is vital, it can be contaminated with blood and any other body fluids as well as through improper handling and storage. Clean linen does not need to be sterile (free from all microbes), but correct handling will prevent the growth of micro-organisms that can develop under poor conditions. Clean linen Clean linen must be stored in a clean dry place that prevents contamination by aerosols, dust, moisture and vermin. It should be transported and stored separately from soiled lined. Clean linen should only be handled by staff who have used proper hand hygiene procedures. Clean linen in Ambulances should be re-stocked with supplies at metropolitan public emergency departments and most ambulance stations, or as per local arrangements. Soiled linen All used linen should be handled with care to avoid dispersal of microorganisms into the environment and to avoid contact with staff clothing. The following principles apply for linen used by all patients regardless of their infectious status:

• All used linen is considered contaminated therefore minimal handling is recommended • Appropriate PPE must be worn during the handling of soiled linen to prevent skin and mucous membrane exposure to blood and body fluids • Dispose of all linen into an appropriate linen container at the point of care • Linen which is heavily contaminated with blood and/or other body fluids which could leak must be contained by a leak-proof bag and secured prior to transport • Hand hygiene must be performed following the handling of all used linen. • Placed in linen bags which are no more then three-quarters full. Once a linen bag is three-quarters full the top should be tied. • Collected by a contractor or taken to a contractor and laundered as per SA Health standards.

Hand hygiene must be performed following the handling of any used linen.

Linen is not to be rinsed or sorted by SAAS staff once used and must NOT to be washed in a domestic washing machine.

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