Policies Cleaning Disinfecting Drying Packaging and Sterilizing of Equipment

DESERET SurgiMed HOSPITAL
Nat’l Highway, Kabacan, North Cotabato

Contact no. (064) 248 24 94/ email add: deseretsurgimed@gmail.com
Area: Central sterile supply unit, wards, laboratory, ER, OR Document code # : _________________
Process owner: CSR Officer, Nurses Revision #.:_______________________
Title: POLICIES AND PROCEDURE ON CLEANING, Effectivity Date: August 29, 2017
DISINFECTING, DRYING, PACKAGING AND Number of Pages: 9
STERILIZING OF EQUIPMENT, INSTRUMENTS
AND SUPPLIES.
Sound Cleaning, Disinfection and Sterilization procedures are one of the

most effective ways in combating the spread of diseases. An effective infection
control program includes an awareness of sterilization procedures for the various
hospital departments.
Well-trained staffs of the Central Supply Room have great responsibility

for ensuring sterilization and helping to prevent the spread of infection within the
hospital. Proper procedures for decontamination, sterilization and post-
sterilization storage should be practiced.
POLICY:
• DSMH personnel should know the proper procedure for cleaning,

disinfecting, packaging, and sterilizing of equipments, instruments and
supplies.
• DSMH personnel in charge of cleaning, disinfecting, drying, packaging,

and sterilizing of equipment and supplies should be properly attired (Using
PPE’s) before handling the above procedures.
• DSMH personnel in charge of cleaning, disinfecting, drying, packaging

and sterilizing of equipments, instruments and supplies should have
undergone proper orientation of the above procedures before they are
allowed to handle them.
Prepared by: Reviewed by: Approved by:
MANOLITO C. RIVERA, RN, MAN DR. EDWIN JOHN C. LIMJUCO, MHcA DR. IRECSON S. CASTEEL,MD ,DPBO,FPOA,MAHA
Nurse Supervisor Chief of Clinics Medical Director

1
AND SUPPLIES.
PURPOSE:
To give guidance to staff to ensure that all re-useable equipment is

decontaminated safely after use to reduce the risk of cross infection. To ensure
staff awareness of the requirements for equipment to be cleaned, disinfected or
sterilize. To ensure staff have appropriate guidance on the process of
decontamination of equipment. To raise staff awareness of the healthcare and
cross contamination risks associated with used equipment.
Procedures/ Guidelines in the implementation of the above policy:
1. The Medical Director of DSMH has overall responsibility to ensure that the
requirements of the Department of Health for the decontamination of
medical equipment are met.
2. Personal protective equipment should be worn when undertaking

decontamination. Strict hand hygiene protocols must be adhered to when
carrying out decontamination. All patient related equipment must be
cleaned wherever possible in the patient area where it is used.
Manufacturer guidelines for decontamination must be followed. Soiled
equipment should not be sent to any third party for inspection,
maintenance, repair or storage prior to cleaning.
3. Low risk items– items; which come into contact only with intact skin or
have no direct patient contact, e.g. washing bowls, crutches, furniture,
floors, etc. These items should be cleaned and dried. If they become

2
AND SUPPLIES.
contaminated with blood or body fluids they should be cleaned and

disinfected.
4. Medium risk items– items; which have contact with intact mucous
membranes, damaged skin or body fluids, e.g. thermometers, bedpans,
commodes, etc. These items MUST be cleaned and disinfected.
5. High risk items – items, which directly or indirectly come into contact with
sterile tissues/fluids, e.g. surgical instruments, catheters, implants, etc.
These items MUST be sterilized.
6. General measures include staff hand hygiene. Skin preparation for

patients: Prior to aseptic procedure, e.g. Biopsy, Lumbar Puncture, etc., if
physically dirty wash and dry, then swab the area with 70% Isopropyl
Alcohol. Prior to parenteral administration of drugs, if site is physically
dirty, wash dry, swab area with alcohol, air dry.
7. The decontamination of most items of equipment and the environment

involves thorough cleaning with detergent and hot water, rinsing and
drying.
Equipment Product Procedure

BATHING & SANITATION EQUIPMENT
Baths, bath seats, 0.1% chlorine release After each use
commodes detergent disinfect/wash, rinse and
wipe.

3
AND SUPPLIES.
Bed pans, urinals & Heat disinfection Place equipment in

potties bedpan washer/disinfector
and run cycle, store
inverted and dry.
Waste bins 0.15 chlorine releasing Wash, rinse and wipe dry.
detergent If blood or body fluids
present use 1% chlorine.
Sinks & Sluices 0.1% chlorine releasing Wash and rinse.

detergent
FEEDING EQUIPMENT
Bottles and infant feeding Hypochlorite solution/ Wash with detergent.
equipment Steam sterilization. Rinse and place into
sterilizer.
RESUSCITATION EQUIPMENT
Airways, ET Tubes Detergent. Single patient Place in bag and dispose.
use only.
Face masks rubber and Detergent Wash, rinse and dry.

plastic Single patient use only. Dispose
Ambubags Detergent (if valve is Wash, rinse and dry.

contaminated dismantles,
wash & wipe with alcohol
swab.

4
AND SUPPLIES.
GENERAL ITEMS OF EQUIPMENT

Surgical Instruments Sterilize Place in bag for
sterilization.
Nebulizers Detergent (if contaminated Wash, rinse and dry.
then place in hypochlorite)
Single patient use only.
Thermometers Isopropyl Alcohol Wipe with alcohol swab.

Dispose after use.
Scissors (nursing) Isopropyl Alcohol Wipe before and after

each procedure.
8. Any equipment which is to be sent for repair or storage must be cleaned

or decontaminated prior to being sent off the ward. The member of staff
who has been responsible for decontaminating the equipment must attach
a label to the equipment. The label should state on which
ward/department it has been used and the date and the name of the
person who cleaned or decontaminated.
9. Decontamination Methods: All equipment which fall into the high-risk

category should be sterilized between use or be single use items.
10. All equipment must be stored appropriately according to whether dirty or

clean; the two should never be stored or transported together.

5
AND SUPPLIES.
11. Use and decontamination of suction apparatus: Suction tubing and

catheters must be disposable and used in accordance with
manufacturer’s instructions. During use on the same patient, tubing must
be kept clean and jars emptied after use. Suction catheters must remain
sterile until connected.
12. Bacterial filters must be changed when wet and after known or suspected
respiratory infected cases.
13. Staff must empty the jars safely in order to prevent splashing. Appropriate
protective clothing must be worn i.e. disposable gloves, disposable plastic
aprons, and goggles if splashing into the face is likely.
14. Suction machines must be decontaminated prior to maintenance or repair.

Machines which may be contaminated internally must repaired/maintained
on a suitable waterproof surface and decontaminated if spillage occurs, or
the surface must be protected by a plastic sheet which must be discarded
into a clinical waste bin if contaminated with body fluids.
15. When not in use, suction machines must be stored clean and dry.
Catheters must remain in the sealed wrapper.
16. Cleaning of clinical waste disposal bins: Spillage – must be cleared

immediately when found. Wearing appropriate protective clothing i.e.
gloves and apron and if splashing is likely, eye protection. Remove debris
with grabbers or long handled dustpan or brush and discard into clinical
waste bag. Sharps must be discarded into an approved sharps box.

6
AND SUPPLIES.
17. Blood/body fluid spillage must be cleared using a long handled mop and
hot soapy water, followed by wiping over with Hypochlorite Solution. Mop
heads must be washed and rinsed in hot soapy water after use and stored
upright to dry. Buckets must be rinsed and stored dry. Non-disposable
gloves must be washed and dry before removal. Disposable gloves and
aprons must be discarded into the appropriate waste stream after use.
Eye protection must be washed in hot soapy water and dried after use.
Hands must be washed using the recommended six stage technique and
thoroughly dried immediately afterwards.
Procedures for the Sterilization of Hospital items and materials;
Methods of Sterilization Items/Materials Length of Exposure
1. Steam under pressure/ For heat and moisture 30 mins. at 250°F

Moist heat (Autoclave) resistant items such as
linen, surgical instruments, 15 mins. at 260°F
rubber goods (ex. gloves,
rubber suction tubings) 3 mins. at 270°F
2. Dry heat/Hot air (Oven) For anhydrous, oils, 1 hr. at 340°F

petroleum products and 2 hrs. at 320°F
bulk powders 6 hrs. at 250°F
3. Ionizing radiation Used in commercially 10-20hrs.

depending
Common source: available products such on the strength of
Cobalt 60 as sutures source
4. Activated For heat sensitive items 10 hrs. immersion

Glutaraldehyde(Cidex) such as sharps (ex. scissors, by thorough
blades) rinsing with

7
AND SUPPLIES.
sterile water.
ITEM PREPARATION FOR DISINFECTIONAND STERILIZATION BY

IMMERSION:
1. Items should be clean and free of organic debris and blood.
2. Items should be washed thoroughly in water and dried prior to immersion.
3. Items to be sterilized or disinfected should be placed in a container deep

enough to completely immerse them.
4. Be certain that items are dry before submerging so that the solution will not be
diluted.
5. Lumen of instrument or tubing must be completely filled with solution.
SHELF LIFE OF STERILE PACKAGES:
Determination of maximum shelf-life and time, a sterile package

may be kept in storage, depends on the following factors:
1. Condition of Storage
a. Storage areas must be clean, free of dust, dirt and vermin.
b. Closed cabinet prolong storage of muslin and paper-wrapped items to

30 days; open cabinet – 21 days

8
AND SUPPLIES.
2. Materials used for packaging
a. Commercially packaged, sterilized items are usually considered sterile

until the package is opened or damaged or becomes outdated.
b. The item is no longer considered sterile after accidental puncture, tear

or rupture due to crushing of a package.
c. Accidental wetting of a package contaminates the contents.
Shelf-life can be minimized by inventory control and rotation of sterile supplies.

Older supplies are always used first so that they do not become outdated.

9

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DESERET SurgiMed HOSPITAL

Nat’l Highway, Kabacan, North Cotabato

Sound Cleaning, Disinfection and Sterilization procedures are one of the

Well-trained staffs of the Central Supply Room have great responsibility

• DSMH personnel should know the proper procedure for cleaning,

• DSMH personnel in charge of cleaning, disinfecting, drying, packaging,

• DSMH personnel in charge of cleaning, disinfecting, drying, packaging

Prepared by: Reviewed by: Approved by:

Nurse Supervisor Chief of Clinics Medical Director

To give guidance to staff to ensure that all re-useable equipment is

Procedures/ Guidelines in the implementation of the above policy:

2. Personal protective equipment should be worn when undertaking

Prepared by: Reviewed by: Approved by:

Nurse Supervisor Chief of Clinics Medical Director

contaminated with blood or body fluids they should be cleaned and

6. General measures include staff hand hygiene. Skin preparation for

7. The decontamination of most items of equipment and the environment

Equipment Product Procedure

Prepared by: Reviewed by: Approved by:

Nurse Supervisor Chief of Clinics Medical Director

Bed pans, urinals & Heat disinfection Place equipment in

Sinks & Sluices 0.1% chlorine releasing Wash and rinse.

Face masks rubber and Detergent Wash, rinse and dry.

Ambubags Detergent (if valve is Wash, rinse and dry.

Prepared by: Reviewed by: Approved by:

Nurse Supervisor Chief of Clinics Medical Director

GENERAL ITEMS OF EQUIPMENT

Thermometers Isopropyl Alcohol Wipe with alcohol swab.

Scissors (nursing) Isopropyl Alcohol Wipe before and after

8. Any equipment which is to be sent for repair or storage must be cleaned

9. Decontamination Methods: All equipment which fall into the high-risk

10. All equipment must be stored appropriately according to whether dirty or

Prepared by: Reviewed by: Approved by:

Nurse Supervisor Chief of Clinics Medical Director

11. Use and decontamination of suction apparatus: Suction tubing and

14. Suction machines must be decontaminated prior to maintenance or repair.

16. Cleaning of clinical waste disposal bins: Spillage – must be cleared

Prepared by: Reviewed by: Approved by:

Nurse Supervisor Chief of Clinics Medical Director

Procedures for the Sterilization of Hospital items and materials;

Methods of Sterilization Items/Materials Length of Exposure

1. Steam under pressure/ For heat and moisture 30 mins. at 250°F

2. Dry heat/Hot air (Oven) For anhydrous, oils, 1 hr. at 340°F

3. Ionizing radiation Used in commercially 10-20hrs.

4. Activated For heat sensitive items 10 hrs. immersion

Prepared by: Reviewed by: Approved by:

Nurse Supervisor Chief of Clinics Medical Director

ITEM PREPARATION FOR DISINFECTIONAND STERILIZATION BY

1. Items should be clean and free of organic debris and blood.

2. Items should be washed thoroughly in water and dried prior to immersion.

3. Items to be sterilized or disinfected should be placed in a container deep

5. Lumen of instrument or tubing must be completely filled with solution.

SHELF LIFE OF STERILE PACKAGES:

Determination of maximum shelf-life and time, a sterile package

a. Storage areas must be clean, free of dust, dirt and vermin.

b. Closed cabinet prolong storage of muslin and paper-wrapped items to

Prepared by: Reviewed by: Approved by:

Nurse Supervisor Chief of Clinics Medical Director

2. Materials used for packaging

a. Commercially packaged, sterilized items are usually considered sterile

b. The item is no longer considered sterile after accidental puncture, tear

c. Accidental wetting of a package contaminates the contents.

Shelf-life can be minimized by inventory control and rotation of sterile supplies.