Environmental Cleaning in Healthcare Facilities:

CS314156-A

Best Practices for

Environmental Cleaning

in Healthcare Facilities:

in Resource-Limited Settings

Division of Healthcare Quality Promotion

VERSION 2

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

CS295875-A

This document provides guidance on best practices for environmental cleaning procedures and

programs in healthcare facilities in resource-limited settings. It was developed as a collaboration

between the Centers for Disease Control and Prevention (CDC) and the Infection Control Africa

Network (ICAN).

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings is a

publication of the Division of Healthcare Quality Promotion in the National Center for Emerging and

Zoonotic Infectious Diseases within CDC and the Education Working Group of the Infection Control

Africa Network.

Centers for Disease Control and Prevention

Robert Redﬁeld, MD, Director

National Center for Emerging and Zoonotic Infectious Diseases

Rima Khabbaz, MD, Director

Division of Healthcare Quality Promotion

Denise Cardo, MD, Director

Infection Control Africa Network

Sade Ogunsola, PhD, Chair

Education Working Group

Shaheen Mehtar, MBBS, Chair (Past Chair ICAN)

Photo Credit:

Cover page photo features Ms. De Bruin, a dedicated and passionate environmental cleaning staff

member for over 40 years at a hospital in Cape Town, South Africa.

Suggested citation:

CDC and ICAN. Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings. Atlanta,

GA: US Department of Health and Human Services, CDC; Cape Town, South Africa: Infection Control Africa Network; 2019.

Available at:

https://www.cdc.gov/hai/prevent/resource-limited/index.html

and

http://www.icanetwork.co.za/icanguideline2019/

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

iii

Acknowledgements

Overall coordination and writing of the best practices:

Molly Patrick (International Infection Control Program, Division of Healthcare Quality Promotion, CDC, Atlanta, Georgia, USA) jointly

coordinated the development and led the writing of the best practices. Shaheen Mehtar (Education Working Group, Infection Control

Africa Network, Cape Town, South Africa) jointly coordinated the development and contributed signiﬁcantly to the structure and content

of the best practices. Danielle Carter, Joyce Thomas and Sonya Arundar (Division of Healthcare Quality Promotion, CDC) provided

professional editing (plain language and usability) assistance.

Expert Committee:

The following experts participated in technical consultations to guide the development and provided technical review of the best practices:

Benedetta Allegranzi, Nathalie Tremblay (Department of Service Delivery and Safety, World Health Organization (WHO), Switzerland); Margaret

Montgomery (Water, Sanitation, Hygiene and Health Unit, WHO, Switzerland); Claire Kilpatrick (Soapbox Collaborative, UK); Joost Hopman

(Consultant Microbiologist, Radboud University Medical Center, The Netherlands); Nkwan Jacob Gobte (Infection Control Africa Network,

Cameroon); Matt Arduino, Michael Bell, Bryan Christensen, Denise Kirley, Cliff McDonald, Sujan Reddy, Rachel Smith, Amy Valderrama (Division

of Healthcare Quality Promotion, CDC).

External Peer Review Group:

The following experts provided technical expertise on infection prevention and control (IPC) in resource-limited settings: Nizam Damani

(IPC Consultant, WHO and Southern Health & Social Care Trust, UK); Briette du Toit (Infection Prevention and Control Ofﬁcer, Mediclinic

Southern Africa, South Africa); Nagwa Khamis (CEO Consultant and Head of IPC Department, Children Cancer Hospital of Egypt, Egypt);

Linus Kirimi Ndegwa (Program Manager, IPC/AMR, Division of Global Health Protection, CDC and IPNET-K Secretary General, Kenya);

Robert M Njee (Senior Research Scientist, National Institute for Medical Research, Tanzania); Marcelyn Magwenzi (Microbiologist/

IPC Trainer, Infection Control Association of Zimbabwe, Zimbabwe); Ana Maruta (IPC Team Lead, WHO, Sierra Leone); Apurba S Sastry

(Infection Control Ofﬁcer, Antimicrobial Stewardship Lead, Associate Professor of Microbiology, Jawaharlal Institute of Postgraduate

Medical Education and Research, India); Yolanda Van Zyl (Infection Control Practitioner/Chairperson Infection Control Society South Africa,

Paarl Hospital, Western Capt Department of Health, South Africa).

TABLE OF CONTENTS

Acknowledgements ........................................................................................................................................................................................................... iii

Abbreviations

.............................................................................................................................................................................................................................viii

Key deﬁnitions

Icon Legends

1. Introduction .......................................................................................................................................................................................................................................5

1.1 Environmental transmission of HAIs

.............................................................................................................................................................5

1.2 Environmental cleaning and IPC

......................................................................................................................................................................6

1.3 Environmental cleaning and WASH infrastructure

...........................................................................................................................7

1.4 Basis and evidence for proposed best practices

..............................................................................................................................8

1.5 Purpose and scope of the document

..........................................................................................................................................................8

1.6 Intended audience of the document

............................................................................................................................................................9

1.7 Overview of the document

....................................................................................................................................................................................9

2. Cleaning Programs

2.1 Organizational elements

..................................................................................................................................................................................... 12

2.1.1 Administrative support

.................................................................................................................................................................... 12

2.1.2 Communication

..................................................................................................................................................................................... 13

2.1.3 Management and supervision

.................................................................................................................................................. 14

2.2 Stafﬁng elements

2.2.1 Stafﬁng levels

.......................................................................................................................................................................................... 15

2.2.2 Training and education

.................................................................................................................................................................... 16

2.3 Supporting infrastructure and supply elements

............................................................................................................................. 17

2.3.1 Designated space

................................................................................................................................................................................ 17

2.3.2 Water and wastewater services

.............................................................................................................................................. 17

2.3.3 Supplies and equipment procurement and management

................................................................................ 19

2.3.4 Finishes, furnishings and other considerations

......................................................................................................... 19

2.4 Policies and procedural elements

.............................................................................................................................................................. 20

2.4.1 Cleaning policies

.................................................................................................................................................................................. 20

2.4.2 Standard operating procedure

................................................................................................................................................. 21

2.4.3 Cleaning checklists, logs, and job aids

............................................................................................................................. 22

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

2.5 Monitoring, feedback and audit elements ...........................................................................................................................................23

2.5.1 Routine monitoring

............................................................................................................................................................................. 24

2.5.2 Feedback mechanisms

................................................................................................................................................................... 25

2.5.3 Program audits

...................................................................................................................................................................................... 26

3. Environmental Cleaning Supplies and Equipment

....................................................................................................................................... 27

3.1 Products for environmental cleaning

....................................................................................................................................................... 27

3.1.1 Cleaning products

............................................................................................................................................................................... 28

3.1.2 Disinfectants

............................................................................................................................................................................................ 28

3.1.3 Combined detergent-disinfectants

....................................................................................................................................... 30

3.2 Preparation of environmental cleaning products

.......................................................................................................................... 31

3.3 Supplies and equipment for environmental cleaning

................................................................................................................ 31

3.3.1 Preparation of supplies and equipment

........................................................................................................................... 33

3.4 Personal protective equipment for environmental cleaning

................................................................................................ 34

3.5 Care and storage of supplies, equipment, and personal protective equipment

................................................. 37

4. Environmental Cleaning Procedures

....................................................................................................................................................................... 41

4.1 General environmental cleaning techniques

..................................................................................................................................... 42

4.2 General patient areas

............................................................................................................................................................................................ 44

4.2.1 Outpatient wards

.................................................................................................................................................................................. 45

4.2.2 Routine cleaning of inpatient wards

.................................................................................................................................... 45

4.2.3 Terminal or discharge cleaning of inpatient wards

................................................................................................. 45

4.2.4 Scheduled cleaning

........................................................................................................................................................................... 46

4.3 Patient area toilets

................................................................................................................................................................................................... 47

4.4 Patient area ﬂoors

.................................................................................................................................................................................................... 47

4.5 Spills of blood or body ﬂuids

........................................................................................................................................................................... 48

4.6 Specialized patient areas

................................................................................................................................................................................... 49

4.6.1 Operating rooms

................................................................................................................................................................................... 50

4.6.2 Medication preparation areas

................................................................................................................................................... 52

4.6.3 Sterile service departments (SSD)

........................................................................................................................................ 53

4.6.4 Intensive care units

............................................................................................................................................................................ 54

4.6.5 Emergency departments

............................................................................................................................................................... 54

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

vii

2.5 Monitoring, feedback and audit elements ...........................................................................................................................................23

2.5.1 Routine monitoring

............................................................................................................................................................................. 24

2.5.2 Feedback mechanisms

................................................................................................................................................................... 25

2.5.3 Program audits

...................................................................................................................................................................................... 26

3. Environmental Cleaning Supplies and Equipment

....................................................................................................................................... 27

3.1 Products for environmental cleaning

....................................................................................................................................................... 27

3.1.1 Cleaning products

............................................................................................................................................................................... 28

3.1.2 Disinfectants

............................................................................................................................................................................................ 28

3.1.3 Combined detergent-disinfectants

....................................................................................................................................... 30

3.2 Preparation of environmental cleaning products

.......................................................................................................................... 31

3.3 Supplies and equipment for environmental cleaning

................................................................................................................ 31

3.3.1 Preparation of supplies and equipment

........................................................................................................................... 33

3.4 Personal protective equipment for environmental cleaning

................................................................................................ 34

3.5 Care and storage of supplies, equipment, and personal protective equipment

................................................. 37

4. Environmental Cleaning Procedures

....................................................................................................................................................................... 41

4.1 General environmental cleaning techniques

..................................................................................................................................... 42

4.2 General patient areas

............................................................................................................................................................................................ 44

4.2.1 Outpatient wards

.................................................................................................................................................................................. 45

4.2.2 Routine cleaning of inpatient wards

.................................................................................................................................... 45

4.2.3 Terminal or discharge cleaning of inpatient wards

................................................................................................. 45

4.2.4 Scheduled cleaning

........................................................................................................................................................................... 46

4.3 Patient area toilets

................................................................................................................................................................................................... 47

4.4 Patient area ﬂoors

.................................................................................................................................................................................................... 47

4.5 Spills of blood or body ﬂuids

........................................................................................................................................................................... 48

4.6 Specialized patient areas

................................................................................................................................................................................... 49

4.6.1 Operating rooms

................................................................................................................................................................................... 50

4.6.2 Medication preparation areas

................................................................................................................................................... 52

4.6.3 Sterile service departments (SSD)

........................................................................................................................................ 53

4.6.4 Intensive care units

............................................................................................................................................................................ 54

4.6.5 Emergency departments

............................................................................................................................................................... 54

4.6.6 Labor and delivery wards ............................................................................................................................................................. 55

4.6.7 Other specialized areas

.................................................................................................................................................................. 56

4.6.8 Transmission-based precaution / Isolation wards

................................................................................................... 59

4.7 Noncritical patient care equipment

........................................................................................................................................................... 61

4.7.1 Material compatibility considerations

................................................................................................................................. 63

4.7.2 Sluice rooms

............................................................................................................................................................................................ 63

4.8 Methods for assessment of cleaning and cleanliness

.............................................................................................................. 64

5. Conclusion and way forward

.......................................................................................................................................................................................... 67

Further reading

(page 67).

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

2.2 Stafﬁng elements

Appropriate number of staff (stafﬁng levels) and training and education are key program elements.

Cleaning staff should always be paid positions that have:

• written job descriptions or terms of reference

• structured, targeted training (e.g., pre-service, annual, when new equipment is introduced)

• deﬁned performance standards or competencies

• access to an on-site supervisor to ensure they can safely perform their work (e.g., address supply shortage,

safety concerns)

According to best practices, cleaning staff should:

• be familiar with their job descriptions and performance standards

• perform duties only for which they were trained (e.g., cleaning staff should not be asked to clean high-risk wards (e.g.,

operating room), unless they have received speciﬁc training for that patient care area)

• know the identities and hazards of the chemicals that they could be exposed to in the workplace

• have supplies and equipment, including PPE, to perform their duties

• have working shifts consistent with acceptable norms for the given context

2.2.1 Stafﬁng levels

Adequate stafﬁng is one of the most important factors for an effective environmental cleaning program.

In small primary care facilities with limited inpatient services, cleaning staff might be part-time

positions or have other responsibilities, such as laundry services, but most hospitals require full-time,

dedicated cleaning staff.

Determining adequate stafﬁng levels

The required number of cleaning staff will vary based on several of factors, including:

• number of patient beds

• occupancy level

• type of cleaning (e.g., routine or terminal)

• types of patient care areas (e.g., specialized care areas such as ICUs and ORs)

Stafﬁng levels should include consideration of reasonable shift length, and the need for

breaks, as well as extra staff for contingencies, such as outbreaks and other emergencies.

There are a variety of methods for estimating stafﬁng needs, ranging from time studies to

workload software, but there is no one single best-practice method.

Facilities should consult available expertise to determine resources (e.g., workload software)

and existing data (e.g., from other similar facilities) for estimating their cleaning staff needs.

In the absence of existing data, stafﬁng levels should be estimated empirically, based on

performing cleaning according to facility policy, and reﬁned over time. See

Policies and

procedural elements

(page 20).

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

2.2.2 Training and education

Training for cleaning staff should be based on national or facility environmental cleaning guidelines and

policies. It should be mandatory, structured, targeted, and delivered in the right style (e.g., participatory)

and conducted before staff can work independently within the healthcare facility.

• Training content should include, at a minimum:

Ð general introduction to the principles of IPC, including:

x transmission of pathogens

x the key role cleaning staff play in keeping patients, staff and visitors safe

x how cleaning staff can protect themselves from pathogens

Ð detailed review of the speciﬁc environmental cleaning tasks for which they are responsible,

including review of SOPs, checklists, and other job aids

Ð when and how to safely prepare and use different detergents, disinfectants, and cleaning solutions

Ð how to prepare, use, reprocess, and store cleaning supplies and equipment (including PPE)

Ð participatory training methods, hands-on component with demonstration and practice

Ð easy-to-use visual reminders that show the cleaning procedures (i.e., without the need for a

lot of reading)

Ð orientation to the facility layout and key areas for the cleaning program (e.g., environmental

cleaning services areas)

Ð other health and safety aspects, as appropriate

• Develop the training program according to the intended audience, in terms of education and

literacy level.

• Develop training content speciﬁcally for cleaning staff who could be responsible for cleaning

procedures in specialized patient areas—particularly high-risk areas, such as intensive care units,

operating rooms, and maternity units.

• Maintain training records, including dates, training content, and names of trainers and trainees.

• Select appropriate, qualiﬁed trainers at a facility or district level—generally, staff with IPC training

who have been involved in the development of environmental cleaning policy are best qualiﬁed. They

could be members of existing IPC or hygiene committees, the cleaning program manager, or local or

district-level Ministry of Health staff.

• Conduct periodic competency assessments and refresher trainings as needed (e.g., at least annually,

before introduction of new environmental cleaning supplies or equipment).

Ð Focus refresher trainings on gaps identiﬁed during competency assessments and routine

monitoring activities.

If cleaning services are contracted out, the training requirements and content should be

speciﬁed in the service level agreement.

Promptly address supplemental training needs identiﬁed by facility staff (e.g., cleaning

program manager) within the scope of the contract.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

2.3 Supporting infrastructure and supply elements

The facility infrastructure is critical for an effective environmental cleaning program. The main areas of needed

infrastructure include

• designated physical space

• access to adequate water and wastewater services/systems

• systems to procure and manage environmental cleaning supplies and equipment

• appropriate selection of ﬁnishes, furnishings and patient care equipment

These areas must be available within the facility itself, regardless of whether the program

is managed in-house or by an external company.

The recommended layout and location of these areas according to best practices are included in

Care and storage of supplies, equipment, and personal protective equipment

(page 37) and

Sluice rooms

(page 63), respectively.

2.3.2 Water and wastewater services

Environmental cleaning requires large quantities of water and produces almost as much wastewater,

which must be disposed of safely and appropriately to prevent contamination of the environment and

surrounding community.

The Water and Sanitation for Health Facility Improvement Tool (WASH FIT) facilitates a comprehensive

process to assess, prioritize, and improve basic water, sanitation, and hygiene services at healthcare

facilities according to the deﬁned indicators. See

Environmental cleaning and WASH

(page 7). Table 1

(below) uses these indicators to describe, the additional water and wastewater services needed to perform

environmental cleaning according to best practices.

These services must be available within the facility itself, regardless of whether the program is

managed in-house or by an external company.

Many of the supporting infrastructure and supply elements needed for environmental cleaning programs are also addressed within the Facility

level assessment tool (IPCAF) from

WHO | Core components for IPC - Implementation tools and resources

(https://www.who.int/infection-

prevention/tools/core-components/en/) and the

WHO publication Minimum requirements for infection prevention and control in health care

facilities

(https://www.who.int/infection-prevention/tools/core-components/en/).

2.3.1 Designated space

For the implementation of effective environmental cleaning programs, it’s important that the facility has:

• designated physical space for storage, preparation, and care of cleaning supplies and equipment

• separated sluice rooms or areas (soiled and clean) for reprocessing of noncritical patient care equipment

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Table 1. Water, sanitation, and hygiene services needed for environmental cleaning programs,

expanded from WASH FIT indicators

WHO WASH FIT Indicator Elements needed for environmental cleaning programs

Improved water supply piped into the facility

or on premises and available (i.e., functional)

Access to an improved water source on premises will generally meet the water

quality needs for environmental cleaning.

Water for cleaning does not need to be potable or treated to drinking water

standards, but it is important that the water is free from turbidity (i.e.,

cloudiness due to suspended particles or dirt) because this can reduce the

effectiveness of detergents and disinfectant solutions.

Note: some non-turbid waters can have higher organic content, so when

using chlorine as a disinfectant, monitor the concentration to ensure the target

was reached.

Water services are available at all times and

of sufﬁcient quantity for all uses

Water supply should be continuously available from the water source or on-site

storage and the available daily quantity (i.e., yield) should be sufﬁcient to meet

the cleaning needs of the facility.

All endpoints (i.e., taps) are connected to

an available and functioning water supply

Access points (piped to taps, or within large water storage containers) should

be available inside the facility in designated environmental cleaning services

areas and sluice areas.

For large facilities, there should be a functional tap available in these areas on

every ﬂoor and every major ward or wing of the facility.

Functioning hand hygiene stations are available in

service areas

and points of care

Cleaning staff should have access to dedicated hand hygiene stations (i.e., not

used for cleaning of equipment), with soap and water before and after:

• cleaning and disinfectant solution preparation

• equipment reprocessing

• performing environmental cleaning in patient care areas

• donning and dofﬁng personal protective equipment (PPE)

Graywater (i.e. rainwater or wash water) drainage

system diverts water away from the facility (i.e. no

standing water) and also protects nearby households

Utility sinks or drains (i.e., not sinks used for hand hygiene) should be

available inside the facility in designated environmental cleaning services

areas and sluice areas.

Drains should lead either to on-site wastewater systems (e.g., soakaway

system) or to a functioning sewer system.

WHO Essential Environmental Health Standards for Healthcare Facilities have deﬁned quantities of water for speciﬁc services, including cleaning (e.g., 40-60L per general

inpatient per day). However, facilities should determine this amount at a facility level because it will vary depending on a number of factors (e.g., level of dilution required for

cleaning and disinfectant products).

For the purpose of environmental cleaning, “service areas” are the environmental cleaning services area and sluice areas.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

2.3.3 Supplies and equipment procurement and management

The selection and appropriate use of environmental cleaning supplies and equipment is critical for effective

environmental cleaning programs. These aspects are covered in

Environmental Cleaning Supplies and

Equipment

(page 27).

To prevent stock-outs, it is important to effectively manage the procurement, upkeep, and maintenance

of environmental cleaning supplies and equipment. This requires establishing systems and processes in

multiple departments within the facility.

If an external company manages the cleaning program, the contract or service level agreement

should include:

• approved environmental cleaning products and supplies

• equipment speciﬁcations

• maintenance schedule

The best practices for supplies and equipment management for in-house managed programs are as follows:

• A master list of the supplies and equipment (i.e., detailed speciﬁcations and supplier information) and

required quantities (e.g., annual basis) developed by the cleaning program manager, facility procurement

team and facility IPC or hygiene committee.

• The results of routine inspections and maintenance activities should determine the required quantities of

supplies and equipment.

• Regular (e.g. monthly) inventories and inspections of supplies and equipment will:

Ð prevent stock-outs

Ð anticipate supply needs

Ð ensure availability of additional materials for contingencies such as outbreaks

• Large facilities might have a central store that receives supplies and equipment after inventory reports and

distributes them to designated environmental cleaning services areas throughout the facility on a regular

basis.

Ð The cleaning program manager should manage the inspections and restocking of the environmental

cleaning services areas.

Ð The facility procurement team should manage supplies at the central store.

2.3.4 Finishes, furnishings and other considerations

It’s important to ensure that all ﬁnishes, furniture, and patient care equipment can be effectively cleaned

and are compatible with the facility disinfectant(s). The facility procurement team, the cleaning program

manager, and the IPC or hygiene committee should collaboratively develop a decision-making process and

policy to guide selection and procurement and selection of ﬁnishes (e.g., ﬂooring for new construction of

patient care areas).

The recommended characteristics for ﬁnishes and furniture are summarized in Table 2 (below). For direct

patient care equipment, there are often fewer options for material composition. Therefore, ﬁnding compatible

disinfectants could be the main driver rather than the equipment type itself—see

Material compatibility

considerations

(page 63).

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Table 2. Ideal characteristics of ﬁnishes, furnishings, and other surfaces (e.g., ﬂoors)

Characteristic Selection guidance

Cleanable Avoid items with hard-to-clean features (e.g., crevasses).

Do not use carpet in patient care areas.

Select material that can withstand repeated cleaning.

Easy to maintain and repair Avoid materials that are prone to cracks, scratches, or chips, and quickly patch/

repair if they occur.

Select materials that are durable or easy to repair.

Resistant to microbial growth Avoid materials that hold moisture, such as wood or cloth, because these

facilitate microbial growth.

Select metals and hard plastics.

Nonporous Avoid items with porous surfaces, such as cotton, wood and nylon.

Avoid porous plastics, such as polypropylene, in patient care areas.

Seamless Avoid items with seams.

Avoid upholstered furniture in patient care areas.

2.4 Policies and procedural elements

The development of facility cleaning policy, SOPs, checklists, and other job aids are key elements for implementing an

effective environmental cleaning program according to best practices.

2.4.1 Cleaning policies

The facility-speciﬁc environmental cleaning policy provides the standard to which the facility will perform to

meet best practices and enables a common understanding among staff of the required program elements.

If an external company manages the cleaning program, the facility policy can be used to develop

the contract or service level agreement.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Facility Environmental Cleaning Policies

Should always include the following elements:

• deﬁned lines of accountability and functional reporting lines and responsibilities for all

implicated staff

• cleaning schedules for every patient care area and noncritical patient care equipment, specifying the

frequency, method, and staff responsible

• contingency plans and required cleaning procedures for environmentally hardy organisms and for

outbreak management

• training requirements and performance standards for cleaning staff

• monitoring methods, frequency, and staff responsible

• list of approved cleaning products, supplies, and equipment and any required speciﬁcations

on their use

• list of necessary PPE and when hand hygiene action is recommended for staff and patient safety

It is best practice to consult national or subnational (e.g., provincial) governmental policies during the

development of facility policies, to ensure that governmental standards for healthcare environmental

cleaning are incorporated into the document. For example, governmental bodies might have lists of

environmental cleaning products that are approved for use in healthcare. There could also be national

accreditation bodies for hospitals that have requirements for healthcare cleaning programs and policy.

Cleaning Schedules

Provide details on key technical requirements for environmental cleaning, including:

• frequency

• method (product, process)

• staff responsible for speciﬁc cleaning tasks

These requirements affect stafﬁng and scheduling needs, oversight, and monitoring needs and have

implications for supply and equipment needs (particularly consumable materials).

• Use facility-speciﬁc risk assessments to develop cleaning schedules. See

Appendix A – Risk-

assessment for determining environmental cleaning method and frequency

(page 71).

• In the early stages of cleaning program development, use the results of this risk assessment to prioritize

the development of SOPs and other job aids for higher-risk areas.

•

Environmental Cleaning Procedures

(page 41) can also be consulted as a reference for developing

cleaning schedules.

2.4.2 Standard operating procedures

Facility-speciﬁc SOPs for each environmental cleaning task are essential to guide cleaning staff practices.

The SOPs should be readily available to cleaning staff, cleaning supervisors and other ward staff as needed

for reference.

If an external company manages the cleaning program, the facility should provide their SOPs to

the contracting company or, at a minimum, internally validate the company SOPs to ensure they

are in line with the facility policy.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Standard Operating Procedures (SOP)

Environmental cleaning SOPs should always include the following elements:

• the speciﬁc supplies and equipment needed for the cleaning session; refer to

Environmental Cleaning Supplies

and Equipment

(page 27).

• preparatory steps, including hand hygiene and required PPE session; refer to

Personal protective equipment for

environmental cleaning

(page 34).

• step-by-step instructions on the cleaning process, in the order they should be performed; refer to

General environmental cleaning techniques

(page 42).

• ﬁnal steps, including collection of soiled cleaning supplies for reprocessing or disposal, safe removal of

PPE, and hand hygiene; refer to

Care and storage of supplies, equipment and personal protective equipment

(page 37).

Use manufacturer’s instructions to develop SOP and include:

• preparation of environmental cleaning products (i.e., dilution, if applicable)

• reprocessing of reusable cleaning supplies, equipment and personal protective equipment

• reprocessing (i.e., cleaning and disinfection) of noncritical patient care equipment

These are additional best practices for SOPS:

• Always develop SOPs and other written or pictorial job aids with careful consideration of literacy levels and

preferred language of cleaning staff.

Ð Use infographics to present a clear message.

• A manual with all the facility SOPs should be available with the cleaning program manager.

• Individual SOPs should also be available in a central location(s) within each ward or service area, as close as

possible to where they are needed.

2.4.3 Cleaning checklists, logs, and job aids

It is best practice to develop supplemental materials to assist with the implementation of SOPs.

Cleaning checklists are an interactive tool that can help ensure that all steps of an

SOP are completed. For example, a checklist with the individual high-touch surfaces can

supplement a SOP for routine cleaning in a speciﬁc patient care area.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Cleaning logs are job aids that can help guide the daily workﬂow for cleaning staff and

ultimately become records.

They specify the location (i.e., room, ward), cleaning session (e.g., routine cleaning, terminal

cleaning), date, and name/signature of cleaning staff. They are typically developed using

occupancy records, where clinical staff (e.g., ward in-charge) record the occupied beds/areas.

They are also important as records that environmental cleaning is occurring as speciﬁed in

facility policy and accountability and tracking mechanisms.

• Make logs available in central locations or where the cleaning task occurs so that

supervisory staff can manage them on a daily basis, along with staff (e.g., IPC focal person)

responsible for periodic monitoring activities.

• Also develop logs for required periodic or scheduled cleaning tasks (e.g., weekly, monthly),

such as replacement of window coverings (e.g., curtains).

Cleaning job aids include posters, pictorial guides, and other visual reminders for key

cleaning tasks.

For monitoring environmental cleaning supplies and equipment:

• Use checklists and logs to facilitate routine inspection and maintenance of these items.

• To prevent stock-outs, keep checklists and logs in the designated environmental cleaning

services closet, and the cleaning program manager should periodically review them (e.g.,

weekly, monthly) to inform the procurement staff or contracting company of supply needs.

• Post job aids (e.g., pictorial guides) in the designated environmental cleaning services

closet for the preparation of environmental cleaning products, supplies, and equipment

(e.g., cleaning cart, if applicable).

2.5 Monitoring, feedback, and audit elements

Structured monitoring programs ensure that environmental cleaning is conducted according to best practices. There

must be organizational support and resources to address deﬁciencies identiﬁed during monitoring activities. Use a

standardized methodology for monitoring, apply it on a routine basis, and provide timely feedback to cleaning staff

and program leadership.

If an external company manages the cleaning program, facility staff such as the cleaning program

manager or focal person or a member of the IPC committee should still periodically conduct

monitoring activities.

Common monitoring methods are summarized in Table 3 (below) and described in detail in

Methods for assessment of

cleaning and cleanliness

(page 64).

Given the advantages and disadvantages of these methods, it is best practice to:

• Use both direct (e.g., performance observation) and indirect methods (e.g., environmental marking).

• Use objective (e.g., ATP bioluminescence) over subjective methods (e.g., assessments of cleanliness), if resources allow.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Table 3. Suggested monitoring staff and frequency for common routine monitoring methods

Monitoring method Monitoring staff

Monitoring frequency

Performance

observations

Cleaning supervisors At least weekly

Might be more frequent with new cleaning staff and eventually reduce

in frequency after a deﬁned time or target score has been reached

Visual assessments

of cleanliness

Cleaning supervisors

Cleaning program manager or

focal person

IPC or hygiene committee staff

Developed at facility level, based on local policy and context

(e.g., resources)

See

Methods for assessment of cleaning and cleanliness

(page 64)

Fluorescent markers

(e.g., UV visible)

Cleaning supervisors

Cleaning program manager or

focal person

IPC or hygiene committee staff

Developed at facility level, based on local policy and context

(e.g., resources)

See

Methods for assessment of cleaning and cleanliness

. (page 64)

2.5.1 Routine monitoring

In the inpatient setting, it is best practice to routinely (e.g., weekly) monitor; see

Options for Evaluating

Environmental Cleaning

, CDC (https://www.cdc.gov/hai/toolkits/appendices-evaluating-environ-cleaning.html):

• At least 5% of beds (≥150 bed facilities) or a minimum of 15 patient care beds/areas (for hospitals with

less than 150 beds).

Ð for facilities with less than 15 beds, this can be increased to 25%

• If resources allow, 10-15% of beds should be monitored on a weekly basis during the ﬁrst year of the

monitoring program.

It is important that the agreed-upon frequency (e.g., weekly) can be consistently maintained in order to

establish benchmarks and track changes in practice and performance over time.

In the outpatient setting, it is best practice to monitor at least 10-15% of examination or procedural areas

on a weekly basis. If resources allow, this can be increased to 25% weekly, allowing every examination or

procedural area to be monitored on a monthly basis.

Set up processes so that staff external to the environmental cleaning program conduct periodic monitoring activities to validate ﬁndings. For example, IPC or hygiene

committee staff not directly involved in day-to-day oversight and management of the cleaning program should periodically conduct monitoring in order to validate the

results generated internally by cleaning supervisors

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

2.5.2 Feedback mechanisms

Promptly return monitoring results to cleaning staff, so they can make immediate improvements to practice,

and management (e.g., cleaning program manager), to make more general improvements to the cleaning

program. Feedback mechanisms should include:

• direct feedback to staff

• reporting to management

Direct feedback to staff:

Provide multiple types of direct feedback to cleaning staff, including:

• real-time feedback and coaching, during or following performance observations

• a regular verbal debrief (e.g., monthly), usually during a one-on-one meeting between the

cleaning staff and their direct supervisors

• performance reviews (written or verbal), usually on an annual basis

Reporting to management:

Share monitoring results with the cleaning program manager and the facility IPC or hygiene committee

so they can present summary or aggregate reports—both at facility level and stratiﬁed by patient care

area (e.g., ward) or type of clean (e.g., terminal vs routine)—to administration and management. This

analysis will identify trends and program-level gaps that require corrective action. For example, there may

be consistently lower clean scores for terminal cleans or within a particular patient care area, identifying a

need to further understand the barriers and gaps for these cleaning procedures. Generally, these high-level

trend reports will be more useful over time when there is more data available from the program.

During early stages of cleaning program development, the most valuable form of feedback is

directly “coaching” cleaning staff and supervisors in a non-punitive manner so they can make

prompt improvements to practice.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Audit results can also inform needed modiﬁcations to contracts or service level

agreements, if the cleaning program is managed by an external company.

2.5.3 Program audits

In environmental cleaning programs with functional routine monitoring programs, it is best practice to

periodically perform a comprehensive program audit to review the major program elements and identify areas

for improvement at the programmatic level.

• Program audits should review all the key program elements.

• Perform them annually or every two years.

• Auditors should not be facility staff or at least should not be directly involved with the program

implementation.

• Options for auditors will be context-speciﬁc, but some potential options include auditors from an external

company, Ministry of Health or subnational (e.g., district/provincial) health ofﬁcers, or staff from another

healthcare facility in the same network.

• File program audit reports and records on-site at the facility to allow benchmarking and to inform the

development of remedial action plans and quality improvement projects.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

3. Environmental Cleaning Supplies and Equipment

The selection and appropriate use of supplies and equipment is critical for effective environmental cleaning. This chapter provides

overall best practices for selection, preparation, and care of environmental cleaning supplies and cleaning equipment, including:

• cleaning and disinfectant products

• reusable/disposable supplies and equipment

• PPE used by cleaning staff for performing cleaning procedures

Ideal Properties

For all products used for healthcare environmental cleaning:

• Nontoxic: it should not be irritating to the skin or mucus membranes of the user, visitors, and patients.

Everything being equal, choose products with the lowest toxicity rating.

• Easy to use: directions for preparation and use should be simple and contain information about

PPE as required.

• Acceptable odor: it should not have offensive odors to users and patients.

• Solubility: it should be easily soluble in water (warm and cold).

• Economical/Low cost: it should be affordable.

Additional Ideal Properties

For cleaning products:

• Efﬁcacious: should remove dirt, soil, and various organic substances.

• Environmentally friendly: should not cause environmental pollution upon disposal; biodegradable.

For disinfectants:

• Broad spectrum: it should have a wide antimicrobial range, including those pathogens that are common c

auses of HAIs and outbreaks.

• Rapid action: it should be fast acting and have a short contact time.

• Remains wet: it should keep surfaces wet long enough to meet recommended contact times with a

single application.

• Not affected by environmental factors: it should be active in the presence of trace quantities of organic

matter (e.g., blood) and compatible with cleaning supplies (e.g., cloths) and products (e.g., detergents)

and other chemicals encountered in use.

• Material compatibility: it should be proven compatible with common healthcare surfaces and equipment.

• Persistence: it should have residual antimicrobial effect on the treated surface.

• Cleaner: it should have some cleaning properties.

• Nonﬂammable: it should have ﬂash point of more than 65°C (150°F).

• Stability: it should be stable in concentration and use dilution.

3.1 Products for environmental cleaning

There are different kinds of products available for environmental cleaning, which all have distinct properties and

advantages and disadvantages to their potential use in healthcare.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

These are the best practices for environmental cleaning products (e.g., detergents, disinfectants):

• Develop and maintain a master list of facility-approved environmental cleaning products in the facility cleaning policy, as

well as a list of approved suppliers (i.e., manufacturers, distributors).

• Minimize the number of different environmental cleaning products in use at the facility. Clearly stating this in the facility

cleaning policy will:

Ð simplify the environmental cleaning process

Ð minimize the training requirements for cleaning staff

Ð reduce the potential for errors in preparation and use

• Store environmental cleaning products in a manner that:

Ð eliminates contamination risk and degradation

Ð minimizes contact with personnel (e.g., inhalation, skin contact)

• Manage environmental cleaning products according to the product’s safety data sheet (SDS). Display the SDS where

these products are stored and prepared.

• Prepare cleaning and disinfectant solutions according to manufacturer’s instructions. Preparing higher-strength

concentrations or diluting beyond recommendations may pose unnecessary risk to patients, staff, visitors, and the

environment.

• Ensure that environmental cleaning products are selected that do not damage the surfaces and equipment to be

cleaned and disinfected.

• Ensure that standard operating procedures or instructions are available for the preparation, use, and disposal of

environmental cleaning products.

3.1.1 Cleaning products

Cleaning products include liquid soap, enzymatic cleaners, and detergents. They remove organic material

(e.g., dirt, body ﬂuids) and suspend grease or oil. This is done by combining the cleaning product with water

and using mechanical action (i.e., scrubbing and friction).

For most environmental cleaning procedures, select neutral detergents (pH between 6 and 8) that are

easily soluble (in warm and cold water).

There are also specialized cleaning products, which may provide advantages for speciﬁc areas or materials

within the healthcare facility (e.g., bathroom/toilet cleaners, ﬂoor polishers, glass cleaners). However, consider

specialized products on a case-by-case basis, weighing the advantages and disadvantages (e.g., additional

cost) and ability of the facility to ensure the correct storage, preparation, and use.

3.1.2 Disinfectants

Disinfectants are only for disinfecting after cleaning and are not substitutes for cleaning, unless they

are a combined detergent-disinfectant product. See

Combined detergent-disinfectants

(page 30). Before

disinfecting, use a cleaning product to remove all organic material and soil.

Low-level disinfection is generally adequate for environmental cleaning procedures, but there are speciﬁc

cases where intermediate-level disinfection with sporicidal properties (e.g., C. difﬁcile) is required. See

Transmission-based precaution / Isolation wards

(page 59).

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Common low- and intermediate-level disinfectants that can be used for environmental surfaces in healthcare

settings include:

• quaternary ammonium compounds

• alcohol (ethyl or isopropyl)

• chlorine releasing agents (e.g., bleach)

• improved hydrogen peroxide

Table 4 (below) shows the main advantages and disadvantages of each of these disinfectants. In practice,

the advantages and disadvantages of each product will have to be weighed with other factors, including

availability and cost.

Do not use these products for disinfection of environmental surfaces and

noncritical patient care equipment:

• liquid chemical sterilant or high-level disinfectants (e.g., glutaraldehyde,

peracetic acid, orthophthaldehyde)

• antiseptics (e.g., chlorhexidine, iodophors)

• phenolics (due to high toxicity)

Table 4. Advantages and disadvantages of common healthcare disinfectants (modiﬁed from reference 24)

Disinfectant Advantages Disadvantages

Low-level disinfectant: Quaternary

ammonium compounds

e.g., alkyl dimethyl benzyl

ammonium chloride, alkyl dimethyl

ethylbenzyl ammonium chloride

Spectrum of activity

Bactericidal

Virucidal (only enveloped viruses)

Fungicidal

Toxicity:

• may be used on food contact

surfaces.

Wide material compatibility

• noncorrosive

Detergent properties, with good

cleaning ability

• low cost

Toxicity:

• skin irritant, can also cause respiratory irritation

Narrow microbiocidal spectrum

• not mycobactericidal or sporicidal, only limited activity

against non-enveloped viruses

• diluted solutions can support growth of microorganisms,

particularly gram negative organisms

Affected by environmental factors:

• activity reduced by various materials (e.g., cotton, water

hardness, microﬁber cloths, organic material)

• could induce cross resistance with antibiotics

• persists in the environment and waterways

Intermediate-level disinfectant:

Alcohols (60-80%)

e.g., isopropyl alcohol, ethyl alcohol,

and methylated spirits

Spectrum of activity

Bactericidal

Virucidal

Fungicidal

Mycobactericidal

Broad spectrum (but not

sporicidal)

Rapid action

Nontoxic

Non-staining, no residue

Noncorrosive

Low cost

Good for disinfecting small

equipment or devices that can be

immersed

Slow acting against non-enveloped viruses

Does not remain wet

• rapid evaporation makes contact time compliance difﬁcult

(on large environmental surfaces)

Affected by environmental factors:

• inactivated by organic material

Material compatibility:

• can damage materials (plastic tubing, silicone, rubber,

deteriorate glues)

Flammable

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Do not use a combined (one-step) detergent-disinfectant product (instead use a two-step

process) when performing environmental cleaning for:

• C. difﬁcile—see

Transmission-based precaution / Isolation wards

(page 59).

• spills of blood or bodily ﬂuids—see

Spills of blood or body ﬂuids

(page 48).

Disinfectant Advantages Disadvantages

Intermediate-level disinfectant:

Chlorine releasing agents

e.g., bleach/sodium or

calcium hypochlorite, sodium

dichloroisocyanurate (NaDCC)

Spectrum of activity

Bactericidal

Virucidal

Fungicidal

Mycobactericidal

Sporicidal (hypochlorites only at

5000ppm or 0.5%)

Hypochlorites are broad

spectrum (sporicidal)

Rapid action

Nonﬂammable

Low cost

Widely available

Can reduce bioﬁlms

Affected by environmental factors:

• inactivated by organic material

High toxicity:

• can release toxic chlorine if mixed with acids or ammonia

• skin and mucous membrane irritant

Material compatibility:

• damages fabrics, carpets

• corrosive

Leaves residue, requires rinsing or neutralization

Offensive odors

Poor stability:

• subject to deterioration if exposed to heat and UV

Intermediate-level disinfectant:

Improved hydrogen peroxide

e.g., 0.5% enhanced action

formulation hydrogen peroxide, 3%

hydrogen peroxide

Spectrum of activity

Bactericidal

Virucidal

Fungicidal

Mycobactericidal

Sporicidal (only at 4-5%)

Rapid action

Nontoxic

Detergent properties, with good

cleaning ability

Not affected by environmental

factors

• active in the presence of

organic material

Safe for environment

Material compatibility:

• contraindicated for use on copper, brass,

zinc, aluminum

High cost

3.1.3 Combined detergent-disinfectants

Combined (one-step) detergent-disinfectant products can generally be used in place of a two-step (separate

detergent and disinfectant product) process when disinfection is indicated for speciﬁc environmental cleaning

procedures. See

Environmental Cleaning Procedures

(page 41).

Table 4 (Continued)

When using a combined product for environmental cleaning, it is recommended to periodically (i.e., on a

scheduled basis) use a rinse step to remove residues from surfaces. Additionally, care should be taken to

ensure that the combined product stays wetted on the surface for the required contact time (to complete

the disinfection process). Consult the product label to get the correct contact time.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

3.2 Preparation of environmental cleaning products

Environmental cleaning products are often sold as concentrated formulas that are diluted (i.e., combined with water)

to make a solution.

These are the best practices for preparation of environmental cleaning products:

• Always prepare solutions according to the manufacturer’s instructions. Most chemicals (including cleaning products)

work at an optimum dilution—too diluted or too concentrated impacts the effectiveness of the product and may pose

unnecessary risk to staff, patients, visitors, and the environment.

• Always prepare environmental cleaning products in designated environmental cleaning services areas (i.e., a dedicated,

secured space not used for any other purposes). See

Care and storage of supplies, equipment, and personal protective

equipment

(page 37).

• Provide training and simple instructions (e.g., standard operating procedures (SOPs)) for preparing solutions according

to manufacturer’s instructions.

• Personal protective equipment (PPE) might be required for preparation of solutions, particularly for disinfectants (e.g.,

sodium hypochlorite). Consult the product’s SDS for the required PPE.

• Standardized containers (for measuring solutions) and easy to use pictorial job aids (e.g., posters) should be used for

preparation of solutions.

If feasible, it is highly recommended to:

• Prepare solutions with an automatic dispensing system that is calibrated regularly. Manual dilution and mixing are more

subject to error.

• Use test strips to conﬁrm correct concentrations of solutions (e.g., for chlorine-based products).

Solutions are generally batch prepared in large containers, which are then transferred to smaller, portable containers (e.g.,

bottles, buckets) for daily cleaning procedures. See

Supplies and equipment for environmental cleaning

below. Solutions

can also be prepared directly into buckets for environmental cleaning of ﬂoors, if a standard-sized bucket is available.

All containers used for storing solutions of environmental cleaning products should:

• be clean, clearly labeled, and have an expiration date based on the manufacturer’s instructions for stability

• be thoroughly cleaned and dried before reﬁlling

• never be topped up—use them until the indicated expiration date (after which it should be disposed) or until the

container is empty, whichever comes ﬁrst

3.3 Supplies and equipment for environmental cleaning

Essential supplies and equipment for environmental cleaning include:

• Surface cleaning supplies: portable containers (e.g., bottles, small buckets) for storing environmental cleaning

products (or solutions) and surface cleaning cloths.

• Floor cleaning supplies: mops or cleaning squeegee with ﬂoor cloths, buckets, and wet ﬂoor/caution signs.

Do not use these cleaning supplies and equipment for disinfection of environmental

surfaces and noncritical patient care equipment:

Ð brooms and dry mops

Ð fumigators (and fumigation) and disinfectant fogging

Ð spray bottles: use squeeze bottles instead

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

In general, all the essential environmental cleaning supplies and equipment are reusable, but facilities can also choose to

use disposable supplies (e.g., cloths) for certain cleaning tasks or where resources allow. Cleaning equipment should be:

• ﬁt for the intended purpose

• cleaned and stored dry between uses

• properly used

• well maintained. See

Care and storage of supplies, equipment, and personal protective equipment

(page 37).

Consider purchasing supplemental supplies and equipment such as toilet brushes or abrasive pads for cleaning certain

surfaces or areas. Some facilities might also have access to more sophisticated equipment such as ﬂoor scrubbers or

vacuum cleaners with high-efﬁciency particulate air (HEPA) ﬁlters. If the use of HEPA ﬁlters is part of the facility policy,

provide an SOP on its cleaning and maintenance.

Figure 3: Portable squeeze bottle

Figure 4: Color-coded cleaning cloths

Surface cleaning supplies

Portable containers for environmental cleaning products (or solutions) should be

clean, dry, appropriately-sized, labelled, and dated.

• Narrow-necked bottles are preferred over buckets to prevent the “double-

dipping” of cleaning cloths, which can contaminate solutions.

• Squeeze bottles are preferred over spray bottles for applying cleaning or

disinfectant solutions directly to cleaning cloths before application to a surface.

Surface cleaning cloths should be cotton or microﬁber (disposable wipes can be

used if resources allow). Have a supply of different colored cloths to allow color-

coding: for example, one color for cleaning and a second color for disinfecting.

Color-coding also prevents cross-contamination between areas, like from toilets to

patient areas, or isolation areas to general patient areas. For example, red cloths

could be used speciﬁcally for toilet areas, blue for general patient areas, and yellow

for isolation areas.

Floor cleaning supplies

Mop heads or ﬂoor cloths should be cotton or microﬁber.

• Use a cart or trolley with two or three buckets for the mopping process—

see the

Preparation of supplies and equipment section

(page 33).

• It is highly recommended to display a wet ﬂoor/caution sign before

starting mopping activities.

Figure 5: Cotton mop (left),

microﬁber ﬂoor cloth (right)

and a ﬂoor safety sign

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

These are the best practices for cleaning carts and trolleys:

• Separate clean and soiled items (e.g., cleaning cloths)

• Never put personal items, food, or beverages in them.

• Equip them with a lockable compartment for containers of cleaning and disinfectant solutions.

• Thoroughly clean them at the end of each day or shift—see

Care and storage of supplies, equipment, and personal

protective equipment

(page 37).

• While in use, never leave them unattended or out of your sight.

• When not in use, store them in a designated environmental cleaning services area.

Figure 6: Cleaning cart setup, including color-

coded buckets for different environmental cleaning

solutions (e.g., disinfectants, detergents)

Microﬁber Versus Cotton

Give careful consideration to the type of material before purchasing cleaning cloths.

Microﬁber cloths are often preferred over cotton for both cleaning cloths and mop heads because microﬁber

absorb more dirt and microorganisms than cotton. However, microﬁber cloths can be damaged by high pH

and therefore not compatible with all disinfectant products (especially chlorine-based). They need to be

laundered separately from cotton cloths/linens, which could be expensive.

Disinfectant or Detergent-Disinfectant Wipes

Prepared (ready-to-use) wipes that are saturated with an appropriate disinfectant or detergent-disinfectant

product can be used as an alternative to cotton or microﬁber cleaning cloths. Take care to evaluate the

appropriateness of the product, considering the recommended properties. It is also important to ensure

that they are stored appropriately with the lid closed, so the wipes remain wet. Discard wipes if they are no

longer saturated. Follow manufacturer’s instructions for storing wipes and reprocessing containers, as well

as instructions for use (e.g., recommended contact times).

3.3.1 Preparation of supplies and equipment

Daily preparation of supplies and equipment for a given cleaning staff member or location will depend on

local factors, including the size of patient care areas and number and type of patient zones to be cleaned.

Cleaning carts and trolleys

• Cleaning carts and trolleys provide several beneﬁts, such as the ability to

carry and safely manage all the essential cleaning supplies and equipment

and increased occupational safety for cleaning staff.

• Stock cleaning carts with sufﬁcient quantities of supplies (e.g., cleaning

cloths, cleaning solutions) to avoid the need to return for more supplies in the

middle of cleaning in a particular patient care area.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Surface cleaning supplies

Portable containers of environmental cleaning products (or solutions) and cleaning cloths can be carried directly on the

cleaning cart or on a caddie kit, if a full cleaning cart is not available.

The cart should have enough cleaning cloths to complete the required cleaning session, with a clean cloth for each patient

zone to prevent cross-contamination. Keep clean and soiled cloths separate. Place clean clothes in one container or

section of the caddie and soiled cloths in another.

Floor cleaning supplies

It is best practice to use a two- or three-bucket system for mopping.

This can be facilitated on the cleaning cart or on a separate trolley, if

a full cleaning cart is not available.

• Two-bucket system (routine cleaning): one bucket contains a

detergent or cleaning solution and the other contains rinse water

(Figure 7).

• Three-bucket system (for disinfection): one bucket contains the

detergent or cleaning solution, one contains rinse water and one

the disinfectant or disinfectant solution (Figure 8).

The rinse water bucket allows the mop to be rinsed and wrung out

before it is re-dipped into the prepared solution. This extends the life

of the solution (i.e., fewer changes are required), which saves both

time and material costs.

Figure 7: Two-bucket mopping system

Figure 8: Three-bucket mopping system

3.4 Personal protective equipment for environmental cleaning

Appropriate PPE for the cleaning staff for all environmental cleaning procedures should always be available and used

appropriately to reduce risk to both patients and staff.

PPE is required to prevent:

• exposure to microorganisms

• exposure to cleaning chemicals (e.g., disinfectants)

• the spread of microorganisms from one patient care area to another

The PPE required should be visibly marked or verbally communicated to cleaning staff by IPC

staff by cleaning supervisors, before starting every cleaning session.

IPC staff should either visibly mark or verbally communicate required PPE to staff or cleaning

supervisors before starting every cleaning session.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

These are the best practices for cleaning staff PPE:

• Always perform hand hygiene immediately before wearing gloves (donning) and immediately after removal (dofﬁng).

• Train cleaning staff on appropriate use, application, and removal of required PPE for all environmental cleaning

procedures and tasks for which they are responsible.

Table 5

(page 36) shows the general indications for PPE use, but always consult local IPC staff about location-

speciﬁc PPE requirements.

• Put on all required PPE before entering a patient care area and remove it (for disposal or reprocessing, if reusable)

before leaving that area.

Ð Exception: do not take off PPE in an airborne precaution area (e.g., TB ward) where a respirator (e.g., N95 or FPP2)

is required, until after departing that area.

• SOPs and pictorial job aids should list required PPE for speciﬁc tasks (including signage for isolation areas, preparation

of solutions).

• Use SDS to determine required PPE for preparing environmental cleaning products and solutions (e.g., manual

dilutions).

• Make sure all PPE (reusable and disposable) is:

Ð in good supply

Ð well maintained (good quality, appropriately stored)

Ð cleaned before use

Ð in good repair

• Reprocess (i.e., clean and disinfect) all reusable PPE at least once a day. See

Care and storage of supplies, equipment,

and personal protective equipment

(page 37).

• Conduct regular ﬁt-testing for cleaning staff who are required to wear respirators.

• Use reusable rubber gloves for cleaning.

• Use chemical-resistant gloves (e.g., nitrile, latex) for preparation of cleaning chemicals.

Best practices for glove usage for cleaning:

• Perform hand hygiene immediately before putting on gloves and directly after taking them off.

• Routine use of gloves is not recommended unless:

Ð the patients in the area are on transmission-based precautions

Ð there is risk of hand contact with blood or body ﬂuids (e.g., cleaning a spill, cleaning the bed of an

incontinent patient)

Ð there is prolonged contact with disinfectants (e.g., terminal cleaning)

• When use of gloves is indicated always change them (i.e., reprocess) between each cleaning session (e.g.,

routine cleaning of a patient zone under contact precautions, terminal cleaning of a general patient area).

See

Table 5

(page 36).

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Best practices for cleaning staff personal attire/grooming:

• Keep sleeves at or above the elbow to not interfere with glove use or hand hygiene.

• Wear rubber-soled closed toe shoes or boots (i.e., not sandals), to prevent accidental injury (e.g., slips and

falls) and exposure to cleaning chemicals, dirt, or bacteria.

• Remove wristwatches and hand jewelry before starting cleaning tasks—these items can tear gloves and

can also pick up microorganisms.

• Keep ﬁngernails short and free of nail varnish to prevent tearing of gloves and picking up dirt

and bacteria.

Table 5. Recommended personal protective equipment for environmental cleaning tasks / cleaning in

speciﬁc patient areas

Type of cleaning task Required personal protective equipment for cleaning staff

Routine cleaning (standard precautions)

None (unless spills or contamination risk—see below)

Terminal cleaning (standard precautions) Reusable rubber gloves

Blood and body ﬂuid spills and high contamination

risk areas (e.g., cleaning bed of an incontinent

patient, labor and delivery wards)

Gown and/or plastic apron

Reusable rubber gloves

Face mask with either goggles or face shield

Droplet precautions (routine and terminal cleaning) Gown and/or plastic apron

Reusable rubber gloves

Face mask with either goggles or face shield

Contact precautions (routine and terminal cleaning) Gown and/or plastic apron

Reusable rubber gloves

Airborne precautions (routine and terminal cleaning) Respirator (N95 or FPP2), ﬁt tested

Reusable rubber gloves

Preparation of disinfectant products and solutions According to speciﬁcations in SDS (manufacturer instructions)

If SDS not available, then:

• Chemical-resistant gloves (e.g., nitrile)

• Gown and/or apron

• Face mask with either goggles or face shield

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Reusable rubber gloves

Face Mask

Respirator (N95 or FPP2)

Goggles

Plastic apron

Face shield

Recommended personal protective equipment

3.5 Care and storage of supplies, equipment, and personal

protective equipment

Environmental cleaning supplies and equipment quickly become contaminated during their use. Regularly reprocess all

reusable items (i.e., thoroughly clean, disinfect, and dry).

These are the best practices for reprocessing reusable cleaning supplies and equipment:

• Send all reusable supplies and equipment (e.g., buckets, rubber gloves) for reprocessing:

Ð directly after use in a transmission-based precaution area

Ð when soiled with blood or body ﬂuids

• Thoroughly clean, disinfect, and rinse equipment such as buckets and containers whenever solution is replaced and

daily. Store them upside down to allow complete drying.

• Launder mop heads, ﬂoor cloths, and soiled cleaning cloths at least daily (e.g., at the end of the day) and allow them

to fully dry before storage and reuse.

• Reprocess all reusable supplies and equipment in a dedicated area that is not used for other purposes (i.e.,

reprocessing of cleaning equipment should never be conducted in handwashing sinks).

• Reprocess (e.g., launder) all reusable supplies and equipment according to manufacturer’s instructions.

Gown

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Do not use chlorine-based disinfectants to disinfect microﬁber cloths.

Use laundry services with hot water (70–80°C x 10 min) [158–176°F] to reprocess cloths and

mop heads, if they are available. Similarly, a commercial dryer can be used for these items, if

available (if not, these items are reprocessed as above).

Always launder mop heads and cleaning cloths separately from other soiled hospital textiles.

Manual reprocessing steps

If manufacturer’s instructions are not available, use this general process to manually reprocess reusable

supplies, equipment, and PPE:

1. Immerse in detergent solution and use mechanical action (e.g., scrubbing) to remove soil.

2. Disinfect by:

• fully immersing the items in boiling water or

• fully immersing the items in disinfectant solution for the required contact time and rinsing with clean water

to remove residue

3. Allow to fully dry

• Lay items to dry in a clean and dry area to prevent recontamination.

Ð Position mops with the head up to allow the mop head to fully dry.

All reusable supplies and equipment should be well maintained, clean, and in good repair. Regularly inspect and replace

or repair all reusable equipment when needed. Develop a facility monitoring and maintenance schedule that clearly

documents reusable supplies and equipment, frequency of inspection, and responsible staff.

Certain equipment, such as ﬂoor polishers, might require maintenance checks by qualiﬁed people according to the

manufacturer’s instructions. Keep a service record and make it available for inspection by the cleaning program manager

and the IPC Team.

Environmental cleaning services area

Designate at least one environmental cleaning services area within the facility for preparation, storage, and reprocessing

of reusable cleaning equipment and supplies. This area should not be used for any other purposes. For multistory

facilities, it is best practice to have one of these areas on each ﬂoor.

The designated environmental cleaning services area should:

• be well-ventilated and illuminated (lighting or window access)

• be labeled with a biohazard sign on the door

• have an appropriate water supply (hot and cold water access, if feasible)

• have a utility sink/ﬂoor drain for safe disposal of used solutions

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

• be designed so that, whenever possible, buckets can be emptied into utility sink/ﬂoor drains without lifting them or

creating splashes

• have a dedicated handwashing sink, used only for handwashing

• have access to an eyewash station

• have appropriate PPE available

• have enough space to keep reprocessing (dirty areas) separate from storage areas for cleaned equipment

• be easily accessible in relation to the areas it serves (i.e., easily accessible throughout the facility)

• be appropriately sized to the amount of materials, equipment, and chemicals stored in the room/area

• have printed copies of the SDS for all environmental cleaning products, manufacturer’s instructions, and job aids for

preparation of cleaning and disinfectant solutions

• never contain personal clothing or grooming supplies, food or beverages

• there should be a separate area for cleaning staff to store these items

• have safe chemical storage and access

• have locks ﬁtted to all doors to restrict access only to cleaning staff

• be free from clutter

• have washable surfaces (ﬂoors, walls, shelves)

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Checklists and other job aids are also required to ensure that cleaning is thorough and effective.

These aspects are covered in more detail in

Cleaning checklists, logs, and job aids

(page 22).

4. Environmental Cleaning Procedures

This chapter provides the current best practices for environmental cleaning procedures in patient care areas, as well as cleaning

for speciﬁc situations (e.g., blood spills) and for noncritical patient care equipment; see summary in

Appendix B1 – Cleaning

procedure summaries for general patient areas

(page 73) and

Appendix B2 – Cleaning procedure summaries for specialized

patient areas

(page 77).

The determination of environmental cleaning procedures for individual patient care areas, including frequency, method, and

process, should be based on the risk of pathogen transmission. This risk is a function of the:

• probability of contamination

• vulnerability of the patients to infection

• potential for exposure (i.e., high-touch vs low-touch surfaces)

These three elements combine to determine low, moderate, and high risk—more frequent and rigorous (with a different method

or process) environmental cleaning is required in areas with high risk. Risk determines cleaning frequency, method, and

process in routine and contingency cleaning schedules for all patient care areas. This risk-based approach is outlined in

Appendix A – Risk-assessment for determining environmental cleaning method and frequency

(page 71).

Risk-Based Environmental Cleaning Frequency Principles

Probability of contamination: Heavily contaminated surfaces and items require more frequent and thorough

environmental cleaning than moderately contaminated surfaces, which in turn require more frequent and rigorous

environmental cleaning than lightly or non-contaminated surfaces and items.

Vulnerability of patients to infection: Surfaces and items in care areas containing vulnerable patients (e.g.,

immunosuppressed) require more frequent and rigorous environmental cleaning than surface and items in areas with

less vulnerable patients.

Potential for exposure to pathogens: High-touch surfaces (e.g., bed rails) require more frequent and rigorous

environmental cleaning than low-touch surfaces (e.g., walls).

Every facility should develop cleaning schedules, including:

• identifying the person responsible

• the frequency

• the method (product, process)

• detailed SOPs for environmental cleaning of surfaces and noncritical equipment in every type of patient care area

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

4.1 General environmental cleaning techniques

For all environmental cleaning procedures, always use the following general strategies:

Conduct Visual Preliminary Site Assessment

Proceed only after a visual preliminary site assessment to determine if:

• patient status could pose a challenge to safe cleaning

• there is any need for additional PPE or supplies (e.g., if there are any spills of blood/body ﬂuids or if the patient

is on transmission-based precautions)

• there are any obstacles (e.g., clutter) or issues that could pose a challenge to safe cleaning

• there is any damaged or broken furniture or surfaces to be reported to supervisor/management

Proceed From Cleaner To Dirtier

Proceed from cleaner to dirtier areas to avoid spreading

dirt and microorganisms. Examples include:

• During terminal cleaning, clean low-touch

surfaces before high-touch surfaces.

• Clean patient areas (e.g., patient zones)

before patient toilets.

Patients &

direct

contact

items

• Within a speciﬁed patient room, terminal cleaning should start with shared equipment and common surfaces,

then proceed to surfaces and items touched during patient care that are outside of the patient zone, and ﬁnally

to surfaces and items directly touched by the patient inside the patient zone (Figure 9).

In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces

inside the patient zone.

• Clean general patient areas not under transmission-based precautions before those areas under transmission-

based precautions.

Proceed From High To Low (Top To Bottom)

Proceed from high to low to prevent dirt and microorganisms from dripping or falling and contaminating already

cleaned areas. Examples include:

• cleaning bed rails before bed legs

• cleaning environmental surfaces before cleaning ﬂoors

• cleaning ﬂoors last to allow collection of dirt and microorganisms that may have fallen

Figure 9. Example of a cleaning strategy from cleaner to dirtier areas

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Proceed in a Methodical, Systematic Manner

Proceed in a systematic manner to avoid missing

areas—for example, left to right or clockwise

(Figure 10).

In a multi-bed area, clean each patient zone in the same

manner—for example, starting at the foot of the bed and

moving clockwise.

Immediately Attend to Body Fluid Spills

• Clean spills of blood or body ﬂuids immediately, using the techniques in

Spills of blood or body ﬂuids

(page 48).

This is the general surface cleaning process:

1. Thoroughly wet (soak) a fresh cleaning cloth in the environmental cleaning solution.

2. Fold the cleaning cloth in half until it is about the size of your hand. This will ensure that you can use all of the

surface area efﬁciently (generally, fold them in half, then in half again, and this will create eight sides).

3. Wipe surfaces using the general strategies as above (e.g., clean to dirty, high to low, systematic manner), making

sure to use mechanical action (for cleaning steps) and making sure to that the surface is thoroughly wetted to allow

required contact time (for disinfection steps).

4. Regularly rotate and unfold the cleaning cloth to use all of the sides.

5. When all of the sides of the cloth have been used or when it is no longer saturated with solution, dispose of the

cleaning cloth or store it for reprocessing.

6. Repeat process from step 1.

For all environmental cleaning procedures, these are the best practices for environmental cleaning of surfaces:

• Use fresh cleaning cloths at the start of each cleaning session (e.g., routine daily cleaning in a general

inpatient ward).

• Change cleaning cloths when they are no longer saturated with solution, for a new, wetted cloth. Soiled cloths should

be stored for reprocessing.

• For higher-risk areas, change cleaning cloths between each patient zone (i.e., use a new cleaning cloth for each

patient bed). For example, in a multi-bed intensive unit, use a fresh cloth for every bed/incubator—see

Specialized

patient areas

(page 49) for more guidance.

• Ensure that there are enough cleaning cloths to complete the required cleaning session.

Figure 10. Example of a cleaning strategy for environmental surfaces,

moving in a systematic manner around the patient care area

• Never double-dip cleaning cloths into portable containers (e.g., bottles, small buckets) used for storing

environmental cleaning products (or solutions).

• Never shake mop heads and cleaning cloths—it disperses dust or droplets that could contain

microorganisms.

• Never leave soiled mop heads and cleaning cloths soaking in buckets.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

High-Touch Surfaces:

The identiﬁcation of high-touch surfaces and items in each patient care area is a necessary prerequisite to the

development of cleaning procedures, as these will often differ by room, ward and facility. See

Appendix C –

Example of high-touch surfaces in a specialized patient area

(page 91). Perform assessments and observations of

workﬂow in consultation with clinical staff in each patient care area to determine key high-touch surfaces.

Include identiﬁed high-touch surfaces and items in checklists and other job aids to facilitate

completing cleaning procedures. See

Cleaning checklists, logs, and job aids

(page 22).

Common high-touch surfaces include:

• bedrails

• IV poles

• sink handles

• bedside tables

• counters where medications

and supplies are prepared

• edges of privacy curtains

• patient monitoring equipment (e.g.,

keyboards, control panels)

• transport equipment (e.g.,

wheelchair handles)

• call bells

• doorknobs

• light switches

4.2 General patient areas

General patient areas include:

• outpatient or ambulatory care wards

• general inpatient wards with patients admitted for medical procedures, who are not receiving acute care (i.e.,

sudden, urgent or emergent episodes of injury and illness that require rapid intervention)

Three types of cleaning are required for these areas:

• routine cleaning

• terminal cleaning

• scheduled cleaning

Generally, the probability of contamination or the vulnerability of the patients to infection

is low, so these areas may require less frequent and rigorous (e.g., method, process)

ning than specialized patient areas.

4.2.1 Outpatient wards

General outpatient or ambulatory care wards include waiting areas, consultation areas, and minor

procedural areas.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Table 6. Recommended Frequency, Method and Process for Outpatient Wards

Area Frequency Method Process

Waiting / Admission At least once daily (e.g., per

24-hour period)

Clean High-touch surfaces and ﬂoors

Consultation / Examination At least twice daily Clean High-touch surfaces and ﬂoors

Procedural (minor

operative procedures; e.g.,

suturing wounds, draining

abscesses)

Before and after (i.e.,

between

) each procedure

Clean and disinfect High-touch surfaces and ﬂoors, with

an emphasis on the patient zone,

procedure table

Procedural (minor

operative procedures; e.g.,

suturing wounds, draining

abscesses)

End of the day (terminal

clean)

Clean and disinfect All surfaces and the entire ﬂoor

Handwashing sinks, thoroughly clean

(scrub) and disinfect

Sluice areas/sinks or scrub areas

All Scheduled basis (e.g.,

weekly, monthly) and when

visibly soiled

Clean

Low-touch surfaces; see

Scheduled

cleaning

(page 46)

If there is prolonged time between procedures or local conditions that create risk for dust generation/dispersal, re-wipe surfaces with disinfectant solution immediately

before the subsequent procedure.

4.2.2 Routine cleaning of inpatient wards

Routine cleaning of inpatient areas occurs while the patient is admitted, focuses on the patient zones and

aims to remove organic material and reduce microbial contamination to provide a visually clean environment.

Note: this occurs when the room is occupied, and systems should be established to ensure

that cleaning staff have reasonable access to perform routine cleaning.

Table 7. Recommended Frequency, Method and Process for Routine Cleaning of Inpatient Wards

Frequency Method Process

At least once daily (e.g.,

per 24-hour period)

Clean High-touch surfaces and ﬂoors

Handwashing sinks

Scheduled basis (e.g., weekly) and when

visibly soiled

Clean

Low-touch surfaces; see

Scheduled

cleaning

(page 46)

4.2.3 Terminal or discharge cleaning of inpatient wards

Terminal cleaning of inpatient areas, which occurs after the patient is discharged/transferred, includes the

patient zone and the wider patient care area and aims to remove organic material and signiﬁcantly

reduce and eliminate microbial contamination to ensure that there is no transfer of microorganisms to the

next patient.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Responsible Staff

Terminal cleaning requires collaboration between cleaning, IPC, and clinical staff, to delineate

responsibility for every surface and item, including ensuring that:

• disposable personal care items are discarded

• patient care equipment is removed for reprocessing

It is important that the staff responsible for these tasks are identiﬁed in checklists and SOPs to ensure

that items are not overlooked because of confusion in responsibility.

Table 8. Recommended Frequency, Method and Process for Terminal Cleaning of Inpatient Wards

Frequency Method Process

Patient transfer or discharge Clean and disinfect

See gnr rin ning r below

This is the general terminal cleaning process:

1. Remove soiled/used personal care items (e.g., cups, dishes) for reprocessing or disposal.

2. Remove facility-provided linens for reprocessing or disposal; see

Appendix D – Linen and laundry management

(page 92).

3. Inspect window treatments. If soiled, clean blinds on-site, and remove curtains for laundering.

4. Reprocess all reusable (noncritical) patient care equipment; see Noncritical patient care equipment (page 61).

5. Clean and disinfect all low- and high-touch surfaces, including those that may not be accessible when the room/area was

occupied (e.g., patient mattress, bedframe, tops of shelves, vents), and ﬂoors.

6. Clean (scrub) and disinfect handwashing sinks.

4.2.4 Scheduled cleaning

Scheduled cleaning occurs concurrently with routine or terminal cleaning and aims to reduce dust and soiling

on low touch items or surfaces. Perform scheduled cleaning on items or surfaces that are not at risk for

soiling under normal circumstances, using neutral detergent and water. But if they are visibly soiled with blood

or body ﬂuids, clean and disinfect these items as soon as possible.

Table 9. Recommended Frequency, Method and Process for Scheduled Cleaning of Inpatient Wards

Frequency Method Process

Weekly Clean

• High surfaces (above shoulder height) such as tops of

cupboards, vents

• Walls, baseboards and corners

Monthly

See

Appendix D – Linen and

laundry management

(page 92)

• Window blinds, bed curtains

Annually

See

Appendix D – Linen and

laundry management

(page 92)

• Window curtains

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

4.3 Patient area toilets

Toilets in patient care areas can be private (within a private patient room) or shared (among patients and visitors). They

have high patient exposure (i.e., high-touch surfaces) and are frequently contaminated. Therefore, they pose a higher risk

of pathogen transmission than in general patient areas.

Table 10. Recommended Frequency, Method and Process for Patient Area Toilets

Area Frequency Method Process

Private toilets At least once daily (e.g., per

24-hour period), after routine

cleaning of patient care area

Clean and

disinfect

• High-touch and frequently contaminated

surfaces in toilet areas (e.g.,

handwashing sinks, faucets, handles,

toilet seat, door handles) and ﬂoors

Public or shared toilets

(e.g., patients, visitors,

family members)

At least twice daily Clean and

disinfect

• High-touch and frequently contaminated

surfaces in toilet areas (e.g.,

handwashing sinks, faucets, handles,

toilet seat, door handles) and floors

Both (private and shared) Scheduled basis (e.g., weekly)

and when visibly soiled

Clean

• Low-touch surfaces; see

Scheduled

cleaning

(page 46)

4.4 Patient area ﬂoors

Floors generally have low patient exposure (i.e., are low-touch surfaces) and pose a low risk for pathogen transmission.

Therefore, under normal circumstances they should be cleaned daily, but the use of a disinfectant is not necessary.

Cultural considerations:

Toileting practices vary, in terms of both the types of toilets in use (e.g., squat or sit, wet or dry) and the adherence to

correct use. Therefore, needs for cleaning and disinfection vary. In some cases, more than twice daily cleaning and

disinfection may be warranted.

Depending on resource and stafﬁng levels, dedicated cleaning staff posted at shared toilets in healthcare facilities

could reduce risk associated with these areas.

There are situations where there is higher risk associated with ﬂoors (e.g., high probability of

contamination), so review the speciﬁc procedures in

General patient areas

(page 44) and

Specialized

patient areas

(page 49) for guidance on frequency of environmental cleaning of ﬂoors and when they

should also be disinfected.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Table 11. Recommended Frequency, Method and Process for Patient Area Floors

Area Frequency Method Process

Floors in general inpatient and

outpatient areas, always cleaned last

after other environmental surfaces

At least once daily (e.g., per 24-hour

period) or as often as speciﬁed in the

speciﬁc patient care area

• Clean (unless otherwise

speciﬁed within speciﬁc

patient care area)

See gnr

ing

r b

This is the general mopping process:

1. Immerse the mop or ﬂoor cloth in the bucket with

environmental cleaning solution and wring out.

2. Mop in a ﬁgure-eight pattern with overlapping strokes,

turning the mop head regularly (e.g., every 5-6 strokes).

3. After cleaning a small area (e.g., 3m x 3m), immerse

the mop or ﬂoor cloth in the bucket with rinse water

and wring out.

4. Repeat process from step 1.

These are the best practices for environmental

cleaning of general patient area ﬂoors:

• Use wet ﬂoor or caution signs to prevent injuries.

• Mop from cleaner to dirtier areas.

• Mop in a systematic manner, proceeding from area farthest from the exit and working towards the

exit (Figure 11).

• Change mop heads/ﬂoor cloths and buckets of cleaning and disinfectant solutions as often as needed (e.g.,

when visibly soiled, after every isolation room, every 1-2 hours) and at the end of each cleaning session.

Figure 11. Illustration of mopping

strategy, working toward the exit

4.5 Spills of blood or body ﬂuids

Regardless of the risk-level of an area, spills or contamination from blood or body ﬂuid (e.g., vomitus),

must be cleaned and disinfected immediately using a two-step process.

Table 12. Recommended Frequency, Method and Process for Spills of Blood or Body Fluids

Area Frequency Method Process

Any spill in any patient or

non-patient area

Immediately, as soon

as possible

Clean and disinfect:

• do not use combined detergent-

disinfectant product

• use intermediate-level disinfectant

See gnr r

r ning  i 

b r b i

below

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

4.6 Specialized patient areas

Specialized patient areas include those wards or units that provide service to:

• high-dependency patients, (e.g., ICUs)

• immunosuppressed patients (e.g., bone marrow transplant, chemotherapy)

• patients undergoing invasive procedures (e.g., operating theatres rooms)

• patients who are regularly exposed to blood or body ﬂuids (e.g., labor and delivery ward, burn units)

Pay special attention to roles and responsibilities for environmental cleaning.

This is the general process for cleaning of spills of blood or body ﬂuids:

1. Wear appropriate PPE. See

Table 5

(page 36).

2. Conﬁne the spill and wipe it up immediately with absorbent (paper) towels, cloths, or absorbent granules

(if available) that are spread over the spill to solidify the blood or body ﬂuid (all should then be disposed as

infectious waste).

3. Clean thoroughly, using neutral detergent and warm water solution.

4. Disinfect by using a facility-approved intermediate-level disinfectant.

• Typically, chlorine-based disinfectants at 500-5000ppm free chlorine (1:100 or 1:10 dilution of 5%

chlorine-bleach; depending on the size of the spill) are adequate for disinfecting spills (however, do

not use chlorine-based disinfectants on urine spills). See

Appendix E – Chlorine disinfectant solution

preparation

(page 94).

• Take care to allow the disinfectant to remain wet on the surface for the required contact time (e.g.,

10 minutes), and then rinse the area with clean water to remove the disinfectant residue (if required).

5. Immediately send all reusable supplies and equipment (e.g., cleaning cloths, mops) for reprocessing (i.e.,

cleaning and disinfection) after the spill is cleaned up.

This vulnerable population is more prone to infection and the probability of contamination is high, making

these areas higher-risk than general patient areas.

Unless otherwise indicated, environmental surfaces and ﬂoors in the following sections require cleaning

and disinfection with a facility-approved disinfectant for all cleaning procedures described.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

4.6.1 Operating rooms

Operating rooms are highly specialized areas with a mechanically controlled atmosphere where

surgical procedures are performed. These require environmental cleaning at three distinct intervals

throughout the day:

• before the ﬁrst procedure

• between procedures

• after the last procedure (i.e., terminal cleaning)

Responsible Staff

Because operating rooms are highly specialized areas, the surgery department clinical staff

usually manages environmental cleaning. Operating room nurses and their assistants sometimes

perform cleaning duties along with, or sometimes instead of, general cleaning staff.

Critical and semi-critical equipment in the operating rooms require specialized reprocessing

procedures and are never the responsibility of environmental cleaning staff. The processes

described below pertain only to the cleaning and disinfection of environmental surfaces and the

surfaces of noncritical equipment.

Where multiple staff are involved, clearly deﬁned and delineated cleaning responsibilities must

be in place for cleaning of all environmental surfaces and noncritical patient care equipment

(stationary and portable). The use of checklists and SOPs is highly recommended.

Table 13. Recommended Frequency and Process for Operating Rooms

Frequency Process

Before the ﬁrst

procedure

Carefully inspect records and assess the operating space to ensure that the terminal clean was completed

the previous evening.

Wipe all horizontal surfaces in the room (e.g., furniture, surgical lights, operating bed, stationary

equipment) with a disinfectant to remove any dust accumulated overnight.

• Under normal circumstances, it is not necessary to perform the cleaning step in the morning if terminal

cleaning was conducted the evening before. This preliminary clean just utilizes a disinfectant to ensure

that the space is fully decontaminated before the ﬁrst procedure.

If there was no written confirmation or terminal cleaning on the previous day, do a full terminal clean

(see r  in rr i rin n n i b).

Thoroughly clean and disinfect portable patient-care equipment that is not stored within the operating

room, such as suction regulators, anesthesia trolley, compressed gas tanks, x-ray machines, and lead

gowns, before introduction into the operating room.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Frequency Process

Before and after

each procedure

Remove all used linen and surgical drapes, waste (including used suction canisters, ¾ ﬁlled sharps

containers), and kick buckets, for reprocessing or disposal.

Clean and disinfect:

• high-touch surfaces (e.g., light switches, doorknobs) outside of the surgical ﬁeld

• any visible blood or body ﬂuids outside of the surgical ﬁeld (e.g., walls, ﬂoors)

• all surfaces (high- and low-touch) and the ﬂoor inside of the surgical ﬁeld, including:

Ð tops of surgical lights

Ð reﬂective portion of surgical lights

Ð suction canisters

Ð tourniquet cuffs and leads

Ð anesthesia trolley

Ð operating table from top to bottom

After the ﬁnal

procedure

(i.e., terminal

clean)

Clean and disinfect:

• horizontal surfaces (high- and low-touch) and ﬁxed equipment in the room, including booms and wheels of any

equipment (e.g., carts)

• vertical surfaces such as walls and windows as needed to remove visible soiling

• ventilation (ducts)

• handwashing sinks, scrub and utility areas/sinks

• entire ﬂoor, including baseboards

Ð take care to move the operating table and any mobile equipment to make sure to reach the

ﬂoor areas underneath

Thoroughly clean and disinfect portable patient-care equipment that is not stored within the operating

room before removal from the operating room. Examples include:

• suction regulators

• anesthesia trolley

• compressed gas tanks

• x-ray machines

• lead gowns

Scheduled basis

(e.g., weekly)

At the same time as daily terminal cleaning, clean and disinfect:

• low-touch surfaces not cleaned every day (unless visibly soiled), including:

Ð ceilings

Ð walls

Ð insides of cupboards

Table 13. Recommended Frequency and Process for Operating Rooms (continued)

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Environmental Cleaning Supplies and Equipment for the Operating Room (OR):

Have dedicated supplies and equipment for the OR (e.g., mops, buckets).

Use fresh mops/ﬂoor cloths and mopping solutions for every cleaning session, including between procedures.

Use fresh cleaning cloths for every cleaning session, regularly replacing them during cleaning and never

double-dipping them into cleaning and disinfectant solutions.

4.6.2 Medication preparation areas

Departments or areas where medication is prepared (e.g., pharmacy or in clinical areas) often service

vulnerable patients in high-risk and critical care areas, in addition to other patient populations.

Responsible Staff

The staff who work in the medication preparation area might be responsible for cleaning and

disinfecting it, instead of the environmental cleaning staff.

Develop detailed SOPs and checklists for each facility to identify roles and responsibilities for

environmental cleaning in these areas.

Table 14. Recommended Frequency and Process for Medication Preparation Areas

Frequency Process

Before and after

every use

Countertops and portable carts used to prepare or transport medications

At least once

every 24 hours

All high-touch surfaces (e.g., light switches, countertops, handwashing sinks, cupboard doors) and ﬂoors

Scheduled basis

(e.g., weekly)

Low-touch surfaces, such as the tops of shelves, walls, vents

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Table 15. Recommended Frequency and Process for Sterile Service Departments (SSD)

Frequency Process

Before and after

every use

Utility sinks used for washing medical devices (e.g., endoscopes)

At least

twice daily

All high-touch surfaces (e.g., countertops, surfaces of washing equipment, handwashing sinks) and ﬂoors

Scheduled basis

(e.g., weekly)

Low-touch surfaces, such as the tops of shelves, walls, vents

Additional Best Practices for Sterile Service Departments (SSD)

SSDs have two distinct areas, the soiled area (also called dirty area or decontamination area) and the

clean area.

• Start daily environmental cleaning with the clean area and ﬁnish with the dirty area.

• Provide separate environmental cleaning supplies and equipment, including PPE for cleaning staff (e.g.,

reusable rubber gloves, gowns), to prevent cross-contamination between these areas.

• If resources permit, assign separate cleaning staff/teams to each area. If not, clean at different times of the

day depending on the workﬂow.

Find further guidance on environmental cleaning in SSDs here:

Decontamination and Reprocessing of Medical

Devices for Health-care Facilities

(https://www.who.int/infection-prevention/publications/decontamination/en/)

4.6.3 Sterile service departments (SSD)

Departments or areas where semi-critical and critical equipment is sterilized and stored (i.e., sterile services)

often service vulnerable patients in high-risk and critical care areas, in addition to other patient populations.

Responsible Staff

Staff who work in the SSD might be responsible for cleaning and disinfecting it, instead of

environmental cleaning staff. Alternatively, it is possible to train and assign a dedicated

cleaning staff member to this area

Develop detailed SOPs and checklists for each facility to identify roles and responsibilities for

environmental cleaning in these areas

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

4.6.4 Intensive care units

Intensive care units (ICUs) are high-risk areas due to the severity of disease and vulnerability of the

patients to develop infections.

Frequency and process is the same for adult, pediatric and neonatal units, but there are speciﬁc

considerations for neonatal areas. See Process / Additional guidance in the table below.

Table 16. Recommended Frequency and Process for Intensive Care Units

Frequency Process / Additional guidance

Twice daily and

as needed

Clean and disinfect high-touch surfaces.

Clean ﬂoors with neutral detergent and water.

If a neonatal incubator is occupied, clean and disinfect only the outside; only clean (neutral detergent)

on inside.

Ensure that cleaning schedules details responsible staff (e.g., nursing or cleaning staff) for environmental

cleaning of surfaces of noncritical patient care equipment.

Last clean of the day: also clean low-touch surfaces; see

Scheduled cleaning

(page 46)

Scheduled basis

(e.g., weekly)

and when visibly

soiled

Change ﬁlters in incubators according to manufacturer’s instructions, when wet or if neonate was on

contact precautions (during terminal clean).

After patient

transfer or

discharge (i.e.,

terminal cleaning)

See

Terminal or discharge cleaning of inpatient wards

(page 45).

Pay special attention to terminal cleaning of incubators.

Pay special attention to ensure reprocessing of noncritical patient care equipment.

Environmental Cleaning Supplies and Equipment for the ICU

Provide dedicated supplies and equipment for the ICU (e.g., mops, buckets) that are not used anywhere else.

Use fresh mops/ﬂoor cloths and mopping solutions for every cleaning session.

Use fresh cleaning cloths for surfaces for every cleaning session (at least two per day), regularly replacing

them during cleaning and never double-dipping into cleaning and disinfectant solutions.

4.6.5 Emergency departments

Emergency departments are moderate to high-risk areas because of the wide variability in the condition

of patients and admissions, which can:

• increase the probability of contamination of the environment from infectious agents or blood and

body ﬂuids

• make them more susceptible to infection (e.g., trauma patients)

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Table 17. Recommended Frequency and Process for Emergency Departments

Area Frequency Process

Waiting / Admission At least once daily (e.g., per 24-

hour period)

High-touch and low-touch surfaces and ﬂoors

Consultation /

Examination (low acuity)

After each event/case and at least

twice daily, and as needed

High-touch surfaces

End of the day: entire ﬂoor and low-touch surfaces

Procedural (trauma,

critical care)

Before and after (i.e., between

)

each procedure

High-touch surfaces, procedure table and ﬂoor, inside the

patient zone

Procedural (trauma,

critical care)

End of the day (terminal clean) All surfaces and the entire ﬂoor

Handwashing sinks (thoroughly clean (scrub) and disinfect)

Sluice areas/sinks or scrub areas

All Scheduled basis (e.g., weekly,

monthly) and when visibly soiled

See

Scheduled cleaning

(page 46)

Responsible Staff

Because emergency departments are specialized and high-throughput areas, clinical staff

(e.g., nurses) might play an active role in performing environmental cleaning, particularly in

examination and procedural areas.

Develop detailed SOPs, including checklists for each facility to identify roles and responsibilities

for environmental cleaning in these areas.

If there is prolonged time between procedures or local conditions that create risk for dust generation/dispersal, re-wipe surfaces with disinfectant solution immediately before

the subsequent procedure.

4.6.6 Labor and Delivery Wards

Labor and delivery wards are routinely contaminated and patients are vulnerable to infection.

Responsible Staff

Because labor and delivery wards are often high-throughput areas, clinical staff

(e.g., nurses) might play an active role in performing environmental cleaning, particularly

between procedures.

Develop detailed SOPs, including checklists, for each facility to identify roles and

responsibilities for environmental cleaning in these areas.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Table 18. Recommended Frequency and Process for Labor and Delivery Wards

Frequency Process

Before and after (i.e., between) every procedure

and at least daily

Remove soiled linens and waste containers for disposal/reprocessing; see

Appendix D – Linen and laundry management

(page 92).

Clean and disinfect:

• high-touch surfaces and ﬂoors with focus on the patient zone

• any surface (e.g., walls) that is visibly soiled with blood or body ﬂuids

After the last delivery (terminal clean) As above

• Clean and disinfect other high-touch surfaces (e.g., light switches, door

handles) outside of the patient zone and low-touch surfaces

• Clean (scrub) and disinfect handwashing sinks

• Clean and disinfect entire ﬂoor (move patient bed and other portable

equipment)

Scheduled basis (e.g., weekly, monthly)

See

Scheduled cleaning

(page 46)

4.6.7 Other specialized areas

The areas in this section are higher-risk because of:

• high probability of contamination

• high patient vulnerability to infection

Responsible Staff

Nursing and cleaning staff might be responsible for cleaning certain areas/items in these

areas, so there must be clearly deﬁned cleaning responsibilities for all surfaces and equipment

(stationary and portable).

Develop detailed SOPs, including checklists, for each facility to identify roles and

responsibilities for environmental cleaning in these areas.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Hemodialysis units include the dialysis stations (chair or bed, table and dialysis machine) for

dialysis treatment.

Table 19. Recommended Frequency and Process for Hemodialysis Units

Frequency Process

Before and after (i.e., between)

every patient

Remove disposable patient care items/waste and reprocess reusable noncritical

patient care equipment; see

“Shared Equipment” in Noncritical patient care

equipment

(page 61).

Clean and disinfect:

• all surfaces of the dialysis station/area (e.g., bed/chair, countertops, external

surfaces of the machine) and ﬂoors in the patient zone

• any surface (e.g., walls) that is visibly soiled with blood or body ﬂuids

After the last patient (terminal clean)

As above

• high-touch surfaces (e.g., light switches, door handles, handwashing sinks)

• entire ﬂoor (move procedure table and other portable equipment)

Scheduled basis (e.g.,

weekly, monthly)

Low-touch surfaces; see

Scheduled cleaning

(page 46).

Burn units house patients with signiﬁcant burn wounds.

Table 20. Recommended Frequency and Process for Burn Units

Frequency Process

Before and after (i.e., between)

every procedure and twice daily and

as needed

Remove soiled linens and waste containers for disposal/reprocessing; see

Appendix D – Linen and laundry management

(page 92).

Clean and disinfect:

• high-touch surfaces and ﬂoors with focus on the patient zone

• any surface (e.g., walls) that is visibly soiled with blood or body ﬂuids

Last clean of the day: clean and disinfect entire ﬂoor and low-touch surfaces

Scheduled basis

See

Scheduled cleaning

(page 46)

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Special isolation units house highly immunocompromised patients with speciﬁc conditions where white blood

cells are depleted (e.g., bone marrow transplant, leukemia).

Table 21. Recommended Frequency and Process for Special Isolation Units

Frequency Process

Daily, before cleaning any other

patient care area (i.e., ﬁrst cleaning

session of the day)

Clean and disinfect:

• high-touch and low-touch surfaces

• any surface (e.g., walls) that is visibly soiled with blood or body ﬂuids

Clean ﬂoors with neutral detergent and water

Scheduled basis (e.g., weekly, monthly)

See

Scheduled cleaning

(page 46)

Terminal cleaning

See

Terminal or discharge cleaning of inpatient wards

(page 45)

Pediatric wards (excludes pediatric intensive care units)

Table 22. Recommended Frequency and Process for Pediatric Wards

Area Frequency Process

Pediatric outpatient wards

(waiting/ admission area)

At least daily and as needed

(e.g., visibly soiled, blood/body

ﬂuid spills)

Clean and disinfect:

• high-touch and low-touch surfaces and ﬂoors

Pediatric outpatient wards

(consultation/examination

area)

After each event/case and

at least twice per day and as

needed

Clean and disinfect:

• high-touch surfaces

• last clean of day: entire ﬂoor and low-touch surfaces

Pediatric outpatient

wards (minor operative/

procedure rooms)

Before and after (i.e., between)

every procedure

Clean and disinfect:

• high-touch surfaces and ﬂoors in the patient zone/

procedure table; any surface visibly soiled with blood or

body ﬂuids

• last clean of the day: other high-touch surfaces and low-

touch surfaces, handwashing sinks and scrub/sluice areas

and the entire ﬂoor

Pediatric inpatient wards Same as adult inpatient wards

Same as adult inpatient wards; see

Routine cleaning of

inpatient wards

(page 45) and

Terminal or discharge cleaning

of inpatient wards

(page46)

All pediatric wards Scheduled basis

See

Scheduled cleaning

(page 46)

All pediatric wards After each use and at least daily Clean and disinfect:

toys; for toys that may be put into mouth of infant or

toddler ensure that they are cleaned, disinfected and

rinsed thoroughly after each use

•

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

General procedure rooms (e.g., radiology, endoscopy)

Table 23. Recommended Frequency and Process for General Procedure Rooms

Frequency

Before and after (i.e., between)

every patient

Process

Remove disposable equipment and reprocess reusable noncritical patient care

equipment; see “

Shared Equipment” in Noncritical patient care equipment

(page 61).

Clean and disinfect:

• high-touch surfaces (e.g., procedure table/station, countertops, external

surfaces of ﬁxed equipment) and ﬂoors with focus on the patient zone

any surface that is visibly soiled with blood or body ﬂuids

After the last patient (terminal clean) As above

Clean and disinfect:

• high-touch surfaces (e.g., light switches, door handles, handwashing sinks)

• entire ﬂoor (move procedure table and other portable equipment)

• low-touch surfaces

Scheduled basis (e.g., weekly, monthly)

See

Scheduled cleaning

(page 46).

4.6.8 Transmission-based precaution / Isolation wards

Isolation or cohorted areas with suspected or conﬁrmed cases of infections requiring transmission-based

precautions are considered high-risk areas, particularly for:

• environmentally hardy pathogens (e.g., resistant to disinfectants)

• multidrug-resistant pathogens that are highly transmissible and/or are associated with high morbidity

and mortality

The three types of transmission-based precautions are:

• airborne

• contact

• droplet

Transmission-specific PPE is required for all cleaning sessions in areas under transmission-

based precautions, according to ii policy or

Table 5

(page 36).

PPE should always be put on and removed following the indications posted /

recommended by IPC.

•

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

A full list of pathogens/infections requiring these precautions are included in CDC’s

Guideline for Isolation Precautions

(https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html).

These are the best practices for environmental cleaning in transmission-based precaution areas:

• Clean these areas after non-isolation areas.

• Change environmental cleaning supplies and equipment, including PPE, directly after cleaning these areas.

Ð If resources permit, dedicate supplies and equipment for these areas

• Post the type of precaution and required procedures, including required PPE, on visible signage outside the isolation

area, ensuring that these indications are understood by cleaning staff.

• Do not bring cleaning carts into the area—keep them at the door and only bring the equipment and supplies

needed for the cleaning process.

Table 24. Recommended Frequency and Process for Airborne Precautions

Frequency Process

At least once daily (e.g., per

24-hour period)

See

Routine cleaning of inpatient wards

(page 45) (only cleaning required)

Unit manager or shift leader should coordinate schedule

Take care to keep the door closed during the cleaning process (ventilation requirement)

After patient transfer or discharge

(terminal clean)

See

Terminal or discharge cleaning of inpatient wards

(page 45)

• remove privacy and window curtains for laundering

Unit manager or shift leader should coordinate schedule

Take care to keep the door closed during the cleaning process (ventilation requirement)

Table 25. Recommended Frequency and Process for Contact and Droplet Precautions

Frequency Process

At least twice daily and as needed High-touch surfaces and ﬂoors

Any surface (e.g., walls) that is visibly soiled with blood or body ﬂuids

See Cleaning for C. difﬁcile (spore-forming) (below)

Last clean of the day: clean and disinfect low-touch surfaces

After patient transfer or discharge

(terminal clean)

See

Terminal or discharge cleaning of inpatient wards

(page 45)

• remove privacy and window curtains for laundering

Cleaning for C. difﬁcile (spore-forming):

Two-step process required:

1. Rigorous mechanical cleaning process (e.g., using friction)

2. Disinfectant with sporicidal properties, for example:

Ð sodium hypochlorite solution (e.g., 1,000ppm or 5,000ppm). See

Appendix E – Chlorine disinfectant solution

preparation

(page 94).

Ð enhanced hydrogen peroxide at 4.5%

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Figure 12: Examples of noncritical patient

care equipment that are high-touch surfaces

Cleaning for Carbapenem-resistant Enterobacteriaceae, Acinetobacter baumannii and

Pseudomonas aeruginosa (CRE-CRAB-CRPsA):

These organisms belong to a group of carbapenem-resistant, gram-negative bacteria of

national and international concern because of their implication as an emerging cause of

severe healthcare-associated infections. In 2017, the World Health Organization published

the ﬁrst global guidelines for the prevention and control of CRE-CRAB-CRPsA in healthcare

facilities, which include environmental cleaning and disinfection as a key recommendation.

This implementation guide discusses the key elements of environmental cleaning needed for

prevention and control of these organisms:

WHO 2019: Implementation manual to prevent and

control the spread of carbapenem-resistant organisms at the national and health care facility

level [PDF – 98 pages]

(https://apps.who.int/iris/bitstream/handle/10665/312226/WHO-UHC-SDS-2019.6-eng.pdf)

Highly infectious pathogens of epidemic potential, such as those that cause viral hemorrhagic

fevers (e.g., Ebola):

There might be speciﬁc cleaning procedures for isolation areas of highly infectious pathogens.

Standalone training programs and strict adherence to required PPE is essential for conducting

effective environmental cleaning in these situations.

Find more information on developing context-speciﬁc protocols:

WHO: Infection prevention and control guidance for care of patients in health-care settings,

with focus on Ebola

(https://www.who.int/csr/resources/publications/ebola/ﬁlovirus_infection_

control/en/)

WHO | Ebola virus disease: Key questions and answers concerning water, sanitation and hygiene

(https://www.who.int/csr/resources/publications/ebola/water-sanitation-hygiene/en/)

4.7 Noncritical patient care equipment

Portable or stationary noncritical patient care equipment

incudes IV poles, commode chairs, blood pressure cuffs, and

stethoscopes. These high-touch items are:

• used by healthcare workers to touch patients

(i.e., stethoscopes)

• frequently touched by healthcare workers and patients

(i.e., IV poles)

• often shared between patients

Note: Critical and semi-critical equipment

requires specialized reprocessing procedures

and is never the responsibility of environmental

cleaning staff.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

These are the best practices for selection and care of noncritical patient care equipment:

• Clean all equipment using the methods and products available at the facility.

• All equipment should include detailed written instructions for cleaning and disinfection from the manufacturer,

including pictorial instructions if disassembly is required.

• Train the staff responsible for cleaning equipment on procedures before the equipment is placed into use.

• In patient care areas, do not purchase, install, or use equipment that cannot be cleaned and disinfected, unless they

can be ﬁtted with plastic (or other material) coverings.

• If plastic coverings are protecting difﬁcult-to-clean equipment, clean these items with the same frequency, inspect

coverings for damage on a regular basis, and repair or replace them as needed.

Table 26. Recommended Selection and Care of Noncritical Patient Care Equipment

Type of Equipment Frequency Method Additional Guidance

Shared (e.g., general

inpatient wards)

Before and after

each use

Clean and

disinfect

Select a compatible disinfectant; see

Material

compatibility considerations

(page 63).

Clean and disinfect heavily soiled items (e.g., bedpans)

outside of the patient care area in dedicated

Sluice

rooms

(page 63).

Disinfect bedpans with a washer-disinfector or boiling

water instead of a chemical disinfection process.

Dedicated (e.g.,

transmission-based

precautions, isolation

wards)

According to

frequency of patient

care area (at the

same time as routine

cleaning)

Method based

on the risk

level of the

patient care

area

Select a compatible disinfectant; see

Material

compatibility considerations

(page 63).

Clean and disinfect heavily soiled items (e.g., bedpans)

outside of the patient care area in dedicated

Sluice

rooms

(page 63).

Disinfect bedpans with a washer-disinfector or boiling

water instead of a chemical disinfection process

All After patient transfer

or discharge (i.e.,

terminal cleaning)

Clean and

disinfect

Conduct terminal cleaning of all noncritical patient care

equipment in

Sluice rooms

(page 63).

Responsible Staff

The responsibility for cleaning noncritical patient care equipment might be divided between

cleaning and clinical staff, so it is best practice to clearly deﬁne and delineate cleaning

responsibilities for all equipment (stationary and portable).

Develop a cleaning chart or schedule outlining the method, frequency, and staff responsible

for cleaning every piece of equipment in patient care areas and take care to ensure that

both cleaning and clinical staff (e.g., nursing) are informed of these procedures so that

items are not missed.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

4.7.1 Material compatibility considerations

A list of compatible cleaning and disinfectant products should be included in manufacturer’s instructions or

provided by the manufacturer upon request.

If manufacturer instructions are not available, here are the applicable material compatibility considerations

and best practices for use of common healthcare disinfectants:

Table 27. Recommended Material Cleaning and Disinfectant Compatibility Considerations

Disinfectant Material compatibility

considerations

Best practices for use on noncritical patient

care equipment

Chlorine/ hypochlorite-based Corrosive to metals • Concentration should not exceed 1000 ppm

or 0.1%

• Rinse equipment with clean water after disinfection

Alcohols (60-80%) Could deteriorate glues and

cause damage to plastic tubing,

silicone, and rubber

• Good for disinfecting small equipment or devices

that can be immersed (e.g., stethoscopes,

thermometers)

4.7.2 Sluice rooms

Each major patient care area should be equipped with a designated sluice room to reprocess soiled

noncritical patient care equipment (e.g., commode chairs, bedpans). Alternatively, there may be central

depots where these procedures are performed.

Sluice rooms should be as close as possible to the patient care areas that they serve and should have an

organized workﬂow from soiled (dirty) to clean.

The soiled area (used for reprocessing equipment) should be adequately sized and have:

• a door that is kept closed at all times and ideally has hands-free operation

• a work counter and sluice/utility sink with a hot and cold faucet

• a dedicated handwashing sink

• space for washers/disinfectors (if resources allow)

• PPE available to protect staff during cleaning and disinfecting procedures

The clean area (used for storing reprocessed equipment) should:

• be distinctly separate from (by workflow) soiled areas to prevent confusion regarding

reprocessing status

• have shelves that are smooth, non-porous and easy to clean

• be protected from water and soil, dirt, and dust

• be as close as possible to patient areas and easily available to staff

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Table 28. Recommended Frequency, Method and Process of Sluice Rooms

Type of Equipment Frequency Method Additional Guidance

Soiled areas At least once daily (e.g.,

per 24-hours period)

Clean and disinfect High-touch and frequently contaminated surfaces,

including work counters and sinks, and ﬂoors

(ﬂoors only require cleaning)

Clean area At least once daily (e.g.,

per 24-hours period)

Clean Horizontal surfaces and ﬂoors

Clean equipment should be covered or removed

during cleaning process

Both Scheduled basis (e.g.,

weekly) and when

visibly soiled

Clean Low-touch surfaces (e.g., vents, tops of cupboards)

4.8 Methods for assessment of cleaning and cleanliness

It is best practice to perform routine, standardized assessments of environmental cleaning (i.e., practices, level of

cleanliness) in order to:

• ensure that environmental cleaning procedures are being performed according to best practices and facility policy

• use results to inform program improvement (e.g., training, resource allocation)

This section includes an overview of the available methods, as well as their advantages and disadvantages. The best

practices for developing a system of routine monitoring, audit and feedback within environmental cleaning program

implementation are covered in

Monitoring, feedback, and audit elements

(page 23).

Methods for assessing cleaning practice include (

Table 29

below):

• direct performance observations

• visual assessment

• ﬂuorescent markers

Methods for assessing the level of cleanliness include (

Table 30

below):

• measuring the residual bioburden (i.e., ATP)

• taking a bacteriological culture of the surface itself using a swab or contact agar plate method

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Table 29. Advantages and Disadvantages of Monitoring Methods for Assessing Cleaning Practice:

Adherence to Cleaning Procedures

Method Advantages Disadvantages

Performance observations:

observers (e.g., cleaning

supervisors) use standardized

perform structured observations

using checklists that are speciﬁc to

individual patient care areas. The

goal is to rate the effectiveness of

cleaning staff and adherence to the

SOP (such as identifying the number

of steps performed correctly).

Can be used for large areas

(units, wards)

Easy to implement

Benchmarking is possible

Simple and inexpensive

Allows immediate and direct

feedback to individual staff

Encourages cleaning staff

engagement and input

Identiﬁes gaps for staff training/

job aid improvements

Subjective—difﬁculty in standardizing

methodology and assessment across observers

Labor-intensive

Results affected by Hawthorne bias (i.e., more of

an assessment of knowledge than actual practice)

Does not assess or correlate to bioburden

Visual assessment of cleanliness:

after an area has been cleaned,

observers check the cleanliness

of items. For example, using a

gloved hand, wipe surfaces to

inspect for dust.

Can be applied to entire facility or

speciﬁc units/wards

Easy to implement

Benchmarking is possible

Inexpensive

Allows immediate and direct

feedback to individual staff

Could be delay in feedback dependent on method

used to compile results

Subjective—based on individual determinations

of dust/debris levels

Does not assess or correlate to bioburden

Fluorescent markers (e.g., UV

visible): a tracing agent (e.g.,

ﬂuorescent material, chemical

tracer) marks predetermined items

and surfaces before cleaning. After

cleaning, a trained observer uses

a detecting agent (e.g., ultraviolet

light, enzymatic detector) to

determine if any tracing agent is

left. The observer counts the items

that still show tracing agent and

gives a score based on how many

were cleaned completely, partially,

or not at all.

Quick

Provides immediate feedback on

performance

Minimal training required to

perform

Objective

Benchmarking is possible

Relatively inexpensive

Does not assess or correlate to bioburden

Labor-intensive as surfaces should be marked

before cleaning and checked after cleaning has

been completed

Some difﬁculties documented in terms of removal

of markers from porous or rough surfaces (e.g.,

canvas straps)

Time-intensive

Need to vary frequency and objects to prevent

monitoring system from becoming known

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Table 30. Advantages and Disadvantages of Monitoring Methods for Assessing Cleanliness:

Effectiveness of Cleaning Procedures

Method Advantages Disadvantages

ATP bioluminescence:

detection of ATP indicates that

organic material (microbial or

biologic) is present on an object or

surface. Objects are tested before

and after cleaning to determine

the effectiveness of a cleaning

procedure. A numeric score can

be generated based on the

proportion of marked surfaces/

objects that were under the

pre-determined threshold.

Quick

Provides immediate feedback

Minimal training required to

perform

Objective

Expensive

Low sensitivity and speciﬁcity

Lacks a standardized threshold or benchmark

for determining the level or status of cleanliness

(i.e., “safe” post-cleaning ATL levels) for speciﬁc

surfaces or patient care areas

Variable benchmarks

Technology constantly changing

Interference of cleaning products, supplies and

in some cases surfaces, which can both reduce

or enhanced ATP levels (e.g., bleach, microﬁber,

stainless steel)

Environmental cultures:

the only direct measurement of

levels of microbial contamination

after cleaning. In this process,

cultures are taken (by swabbing

or use of RODAC or contact agar

plates) after an item is cleaned.

Swabbing can indicate the presence

of a speciﬁc bacteria on a surface.

Contact agar plates can show the

level of bacterial contamination

on an area of a large, ﬂat surface.

High sensitivity and speciﬁcity

Provides direct indication of

presence of speciﬁc pathogens

(direct swab cultures)

May be useful for identifying

source of outbreaks and/or

environmental reservoirs

Objective

Not recommended for routine use

Expensive

Prolonged time for results (>48hrs)

Requires access to laboratory resources and

trained personnel for interpreting results

Lack of deﬁned threshold or benchmark for

determining the level or status of cleanliness (e.g.,

colony-forming units per surface area)

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

5. Conclusion and Way Forward

The importance of environmental cleaning as a fundamental IPC intervention cannot be overstated. Environmental

contamination plays a role in transmission of HAIs, which are a signiﬁcant burden globally and disproportionately affect those in

resource-limited settings.

The best practices contained in this document provide the framework for implementing effective environmental cleaning

procedures and programs in healthcare facilities in resource-limited settings. While they are structured to be most relevant for

resource-limited settings, implementing all the best practices for cleaning supplies and equipment, cleaning procedures, and,

most importantly, for cleaning programs will require a strong and sustained commitment, including dedicated staff time and

resources. Strong leadership support for environmental cleaning and recognition of the important role that it plays in IPC is a

critical prerequisite to implementing these best practices.

It is important that environmental cleaning is implemented within the framework of a functional IPC program, while ensuring

that a multi-sectorial approach is taken to enable engagement and coordination across the various sectors (e.g., WASH) that

have a role to play to ensure a functional and effective cleaning program.

A toolkit for guiding the implementation of these best practices is currently under development. It will use the step-wise

approach that IPC improvement programs use extensively. It will also address the need to prioritize actions that target the

highest transmission risk based on environmental contamination and patient vulnerability, as well as the foundational program

elements which are needed ﬁrst in order to build an effective and robust environmental cleaning program over time.

Further reading

Best Practices from high-resource settings

1. Healthcare Infection Control Practices Advisory Committee (HICPAC).

Guidelines for Environmental Infection Control in

Health-Care Facilities

. 2003. Available from: https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html

2. Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory

Committee.

Best practices for environmental cleaning for prevention and control of infections in all health care settings. 3rd

ed. [PDF - 250 pages]

. Toronto, ON: Queen’s Printer for Ontario; 2018. Available from: https://www.publichealthontario.ca/

en/eRepository/Best_Practices_Environmental_Cleaning.pdf

3. The Provincial Infection Control Network of British Columbia (PICNet).

British Columbia Best Practices for Environmental

Cleaning for Prevention and Control of Infection in All Healthcare Settings and Programs [PDF - 158 pages]

. 2016. Available

from: https://www.picnet.ca/wp-content/uploads/British-Columbia-Best-Practices-for-Environmental-Cleaning-for-

Prevention-and-Control-of-Infections-in-All-Healthcare-Settings-and-Programs.pdf

4. National Patient Safety Agency (England and Wales) –

The revised health care cleaning manual 2009

. Available from:

https://www.hygiena.com/fr/doc_download/166-the-revised-healthcare-cleaning-manual

5. Government of South Australia.

Cleaning Standards for Healthcare Facilities

. 2017. Available from:

https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/resources/

cleaning+standard+for+south+australian+healthcare+facilities

Targeted training package for cleaning staff, generated for resource-limited settings

6. Soapbox Collaborative, UK.

TEACH CLEAN

. 2019. Available from: https://www.lshtm.ac.uk/research/centres/march-centre/

soapbox-collaborative/teach-clean

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

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health-care-associated infection in developing countries: systematic review and meta-analysis. The Lancet; 377:9761.

2. Weber DJ, Rutala WA, Miller MB, et al. 2010. Role of hospital surfaces in the transmission of emerging healthcare-

associated pathogens: norovirus, Clostridium difﬁcile, and Acinetobacter species. Am J Infect Control 38:S25–S33.

3. Otter JA, Yezlli S, Salkeld J, French G. 2013. Evidence that contaminated surfaces contribute to the transmission of

hospital pathogens and an overview of strategies to address contaminated surfaces in hospital settings. American Journal

of Infection Control; 41: S6-S11.

4. Huang SS, Datta R, Platt R. 2006. Risk of acquiring antibiotic-resistant bacteria from prior room occupants. Archs Intern

Med; 166:1945-1951.

5. Drees M, Snydman DR, Schmid CH, et al. 2008. Prior environmental contamination increases the risk of acquisition of

vancomycin-resistant enterococci. Clin Infect Dis; 46:678-685.

6. Nseir S, Blazejewski C, Lubret R, Wallet F, Courcol R, Durocher A. 2011. Risk of acquiring multidrug-resistant Gram-

negative bacilli from prior room occupants in the intensive care unit. Clin Microbiol Infect; 17:1201-1208.

7. Datta R, Platt R, Yokoe DS, Huang SS. 2011. Environmental cleaning intervention and risk of acquiring multidrug-resistant

organisms from prior room occupants. Archs Intern Med; 171:491-494.

8. Shaughnessy MK, Micielli RL, DePestel DD, et al. 2011. Evaluation of hospital room assignment and acquisition of

Clostridium difﬁcile infection. Infect Control Hosp Epidemiol; 32:201-206.

9. Ajao AO, Johnson K, Harris AD, et al. 2013. Risk of acquiring extended spectrum b-lactamase-producing Klebsiella

species and Escherichia coli from prior room occupants in the intensive care unit. Infect Control Hosp Epidemiol; 34:453-

458.

10. Mitchell BG, Digney W, Ferguson JK. 2014. Prior room occupancy increases risk of methicillin-resistant Staphylococcus

aureus acquisition. Healthcare Infect; 19:135-140.

11. Kramer A, Schwebke I, Kampf G. 2006. How long do nosocomial pathogens persist on inanimate surfaces? A systematic

review. BMC Infect Dis; 6:130.

12. Dancer SJ. 2014. Controlling hospital-acquired infection: focus on the role of the environment and new technologies for

decontamination. Clin Microbiol Rev; 27:665-690.

13. Falk PS, Winnike J, Woodmansee C, Desai M, Mayhall CG. 2000. Outbreak of vancomycin-resistant enterococci in a burn

unit. Infect Control Hosp Epidemiol 21:575-82.

14. Rampling A, Wiseman S, Davis L, Hyett AP, Walbridge AN, Payne GC, et al. 2001. Evidence that hospital hygiene is

important in the control of methicillin-resistant Staphylococcus aureus. J Hosp Infect 49:109-16.

15. Wilcox M., Fawley W., Wigglesworth N., Parnell P., Verity P., Freeman J. (2003) Comparison of the effect of detergent

versus hypochlorite cleaning on environmental contamination and incidence of Clostridium difﬁcile infection. J Hosp Infect

54: 109–114.

16. Denton M, Wilcox MH, Parnell P, Green D, Keer V, Hawkey PM, et al. 2004. Role of environmental cleaning in controlling

an outbreak of Acinetobacter baumannii on a neurosurgical intensive care unit. J Hosp Infect 56:106-10.

17. Hayden MK, Bonten MJ, Blom DW, Lyle EA, van de Vijver DA, Weinstein RA. 2006. Reduction in acquisition of

vancomycin-resistant enterococcus after enforcement of routine environmental cleaning measures. Clin Infect Dis

42:1552-60.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

18. McMullen K., Zack J., Coopersmith C., Kollef M., Dubberke E., Warren D. (2007) Use of hypochlorite solution to decrease

rates of Clostridium difﬁcile-associated diarrhea. Infect Control Hosp Epidemiol 28: 205–207.

19. Dancer SJ, White LF, Lamb J, Girvan EK, Robertson C. 2009. Measuring the effect of enhanced cleaning in a UK hospital:

a prospective cross-over study. BMC Med 7:28.

20. Wilson AP, Smyth D, Moore G, Singleton J, Jackson R, Gant V, et al. 2011. The impact of enhanced cleaning within the

intensive care unit on contamination of the near-patient environment with hospital pathogens: a randomized crossover

study in critical care units in two hospitals. Crit Care Med 39:651-8.

21. Grabsch EA, Mahony AA, Cameron DR, Martin RD, Heland M, Davey P, et al. 2012. Signiﬁcant reduction in vancomycin-

resistant Enterococcus colonization and bacteraemia after introduction of a bleach-based cleaning-disinfection

programme. J Hosp Infect 82:234-42.

22. Mitchell BG, Hall L, White N, Barnett AG, Halton K, Paterson DL, Riley TV, Gardner A, Page K, Farrington A, Gericke

CA, Graves N. 2019. An environmental cleaning bundle and health-care-associated infections in hospitals (REACH):

a multicenter, randomized trial. The Lancet Infectious Diseases. Available from: https://doi.org/10.1016/S1473-

3099(18)30714-X.

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Facilities: Global Baseline Report 2019. WHO:Geneva. Available from: https://www.who.int/water_sanitation_health/

publications/wash-in-health-care-facilities-global-report/en/.

24. Rutala WA, Weber DJ. 2016. Monitoring and improving the effectiveness of surface cleaning and disinfection. American

Journal of Infection Control 44: e69-e76.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Appendix A – Risk-assessment for determining

environmental cleaning method and frequency

[Reproduced directly from PIDAC, 2018]

Step 1: Categorize the risk factors that determine the need for environmental cleaning:

Probability of Contamination with Pathogens

Heavy Contamination (score = 3)

An area is designated as being heavily contaminated if surfaces and equipment are routinely exposed to copious amounts of fresh

blood or other body ﬂuids (e.g., birthing suite, autopsy suite, cardiac catheterization laboratory, hemodialysis station, emergency

room, client/patient/resident bathroom if visibly soiled).

Moderate Contamination (score = 2)

An area is designated as being moderately contaminated if surfaces and equipment do not routinely (but may) become

contaminated with blood or other body ﬂuids and the contaminated substances are contained or removed (e.g., wet sheets). All

client/patient/resident rooms and bathrooms should be considered to be, at a minimum, moderately contaminated.

Light Contamination (score = 1)

An area is designated as being lightly contaminated if surfaces are not exposed to blood, other body ﬂuids or items that have

come into contact with blood or body ﬂuids (e.g., lounges, libraries, ofﬁces).

Vulnerability of Population to Infection

More Susceptible (score = 1)

Susceptible clients/patients/residents are most susceptible to infection because of their medical condition or lack of immunity.

These include those who are immunocompromised (oncology, transplant and chemotherapy units), neonates (level 2 and 3

nurseries), and those who have severe burns (i.e., requiring care in a burn unit).

Less Susceptible (score = 0)

For the purpose of risk stratiﬁcation for cleaning, all other individuals and areas are classiﬁed as less susceptible.

Potential for Exposure

High-touch surfaces (score = 3):

High-touch surfaces have frequent contact with hands. Examples include doorknobs, telephone, call bells, bedrails, light switches,

wall areas around the toilet and edges of privacy curtains.

Low-touch surfaces (score = 1):

Low-touch surfaces have minimal contact with hands. Examples include walls, ceilings, mirrors.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Step 2: Determine the total risk stratiﬁcation score:

The frequency of cleaning is based on the factors listed above. A score is given if the factors are present, and the frequency of

cleaning is based on the total score as derived in the following matrix:

Appendix A Table 1. Risk Stratiﬁcation Scores for High-Touch Surfaces (Score for Potential

for Exposure = 3)

Probability of contamination

with pathogens

More susceptible population

(score = 1)

Less susceptible population

(score = 0)

Heavy (score = 3) 7 (3+3+1) 6 (3+3+0)

Moderate (score = 2) 6 (3+2+1) 5 (3+2+0)

Light (score = 1) 5 (3+1+1) 4 (3+1+0)

Appendix A Table 2. Risk Stratiﬁcation Scores for Low-Touch Surfaces (Score for Potential

for Exposure = 1)

Probability of contamination

with pathogens

More susceptible population

(score = 1)

Less susceptible population

(score = 0)

Heavy (score = 3) 5 (1+3+1) 4 (1+3+0)

Moderate (score = 2) 4 (1+2+1) 3 (1+2+0)

Light (score = 1) 3 (1+1+1) 2 (1+1+0)

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Step 3: Determine the cleaning frequency based on the risk stratiﬁcation matrix:

Cleaning frequencies for each patient care area are derived from the total score that results from the risk stratiﬁcation matrix above.

Appendix A Table 3. Cleaning Frequencies Based on Total Risk Score

Total Risk Score Risk Type Minimum Cleaning Frequency

7 High Risk Clean after each case/event/procedure and clean additionally as required

4–6 Moderate Risk Clean at least once daily

Clean additionally as required (e.g., gross soiling)

2–3 Low Risk Clean according to a ﬁxed schedule

Clean additionally as required (e.g., gross soiling)

Appendix A Table 4. Patient Care Area Examples

Location

Probability of

Contamination

Potential for

Exposure

Vulnerability

of Population

Total

Score

Minimum Cleaning Frequency

Burn

Unit

2–3 3 1 6–7 Clean after each case/event/procedure,

at least twice daily and clean additionally

as required

General

inpatient

1–2 3 0 4–5 Clean at least once daily and clean

additionally as required

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Appendix B1 – Cleaning procedure summaries for

general patient areas

General outpatient area (Adult)

This is a low-risk area because the probability of contamination and the vulnerability of the patients to infection is low; however,

procedural areas are moderate risk and therefore require more frequent and rigorous environmental cleaning.

Appendix B Table 1. Cleaning Procedure Summaries for General Outpatient Areas (Adult)

Area Description Frequency Person / Staff

Responsible

Products/Technique Additional Guidance /

Description of Cleaning

Waiting/

admission areas

(Adult)

At least daily Cleaning staff Clean (neutral detergent

and water):

• high-touch surfaces

• ﬂoors

In addition, clean low-touch

surfaces on a scheduled basis

(e.g., weekly)

Consultation/

examination

areas (Adult)

At least twice

per day

Shared cleaning

possible: clinical and

cleaning staff

Clean (neutral detergent

and water):

• high-touch surfaces

Last clean of the day: clean

the entire ﬂoor with neutral

detergent and water

In addition, clean low-touch

surfaces on a scheduled basis

(e.g., weekly)

Minor operative

procedure rooms

Before and after

(i.e., between)

every procedure

Shared cleaning

possible: clinical and

cleaning staff

Clean and disinfect:

• any surface visibly soiled

with blood or body ﬂuids

• high-touch surfaces in

the patient zone

• ﬂoors in the patient zone

Last clean of the day

clean and disinfect:

• other high-touch surfaces

• low-touch surfaces

• handwashing sinks

• scrub/sluice areas

• the entire ﬂoor

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

General inpatient area (Adult)

This is a low-risk area because the probability of contamination and the vulnerability of the patients to infection is low.

Appendix B Table 2. Cleaning Procedure Summaries for General Inpatient Areas (Adult)

Type of Clean Frequency

Person / Staff

Responsible

Products/Technique

Additional Guidance / Description

of Cleaning

Routine clean At least daily Cleaning staff Clean (neutral detergent

and water):

• high-touch surfaces

in the patient zone

• handwashing sinks

• ﬂoors

In addition, clean low-touch surfaces

on a scheduled basis (e.g., weekly)

Terminal clean At patient

discharge or

transfer

Shared cleaning

possible: clinical

and cleaning staff

Clean and disinfect:

• high-touch surfaces

• low-touch surfaces

• ﬂoors

1. Remove soiled/used personal

care items (e.g., cups, dishes) for

reprocessing or disposal.

2. Remove facility-provided linens

for reprocessing or disposal; see

Appendix D – Linen and laundry

management

(page 92).

3. Inspect window treatments. If

soiled, clean blinds on-site, and

remove curtains for laundering.

4. Reprocess all reusable (noncritical)

patient care equipment; see

Noncritical patient care equipment

(page 61).

5. Clean and disinfect all low- and

high-touch surfaces, including

those that may not be accessible

when the room/area was occupied

(e.g., patient mattress, bedframe,

tops of shelves, vents), and ﬂoors.

6. Clean (scrub) and disinfect

handwashing sinks.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Patient area toilets

These are high-risk areas because they have high patient exposure, are frequently contaminated, and therefore pose a higher risk

of pathogen transmission than other general patient areas.

Appendix B Table 3. Cleaning Procedure Summaries for Patient Area Toilets

Area

Description

Frequency

Person / Staff

Responsible

Products/Technique

Additional Guidance / Description

of Cleaning

Toilets for

general inpatient

and outpatient

areas; frequently

used by visitors,

family members

At least once

daily (private

patient room)

At least twice

daily (public/

shared toilets)

and as needed

Cleaning staff Clean and disinfect:

• high-touch/frequently

contaminated surfaces

Ð handwashing sinks

Ð faucets

Ð handles

Ð toilet seat

Ð door handles

• ﬂoors

• any surface visibly

soiled with blood or

body ﬂuids

In addition, clean low-touch surfaces on

a scheduled basis (e.g., weekly).

Patient area ﬂoors

Floors in general inpatient and outpatient areas generally have low patient exposure (i.e., are low-touch surfaces) and pose a low

risk for pathogen transmission.

Appendix B Table 4. Cleaning Procedure Summaries for Patient Area Floors

Area

Description

Frequency

Person / Staff

Responsible

Products/Technique

Additional Guidance / Description

of Cleaning

Floors in general

inpatient and

outpatient areas,

always cleaned

last after other

environmental

surfaces

At least daily Cleaning staff Clean (neutral detergent

and water):

• clean to dirty, systematic

manner (figure-eight

pattern, regularly rinse

in rinse bucket)

Floors may require, depending on the

risk-level in a speciﬁc patient care area:

• more frequent cleaning

• use of a disinfectant

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Spills of blood or body ﬂuids

Regardless of the risk-level of an area, spills or contamination from blood or body ﬂuid (e.g., vomitus) must be cleaned and

disinfected immediately using a two-step process.

Appendix B Table 5. Cleaning Procedure Summaries for Spills of Blood or Body Fluids

Area

Description

Frequency

Person / Staff

Responsible

Products/Technique

Additional Guidance /

Description of Cleaning

Any spill in any

patient or non-

patient area

Immediately,

as soon as

possible

Cleaning staff

1. Wear appropriate PPE; see

Table 5

(page 36).

2. Conﬁne the spill and wipe it

up immediately with absorbent

(paper) towels, cloths, or absorbent

granules (if available) that are

spread over the spill to solidify the

blood or body ﬂuid (all should then

be disposed as infectious waste).

3. Clean (neutral detergent and water).

4. Disinfect using a facility-approved

intermediate-level disinfectant.

5. Immediately reprocess all reusable

supplies and equipment (e.g.,

cleaning cloths, mops) after the spill

is cleaned up.

Mark off spill area to prevent

contact,

as well as accidental

slips and falls

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Appendix B2 – Cleaning procedure summaries for

specialized patient areas

Operating room

These are high-risk specialized patient areas with a mechanically controlled atmosphere where surgical procedures are

performed. A high degree of asepsis is required because the vulnerability of the patients to infection is high.

Appendix B2 Table 1. Cleaning Procedure Summaries for Operating Room

Frequency Person / Staff

Responsible

Products/Technique Additional Guidance / Description

of Cleaning

Before ﬁrst

procedure

Shared cleaning

possible:

perioperative nursing

/ clinical staff and

cleaning staff

Disinfect:

• horizontal surfaces

Ð furniture

Ð surgical lights

Ð operating bed

Ð stationary equipment

See

Operating rooms

(page 50)

Records of previous evening terminal

clean required; if not or if no surgeries

on the day prior, perform terminal clean

(as below)

Before and after

every procedure

Shared cleaning

possible:

perioperative nursing

/ clinical staff and

cleaning staff

Clean and disinfect:

• high-touch surfaces (e.g., light

switches, door knobs) outside

surgical ﬁeld

• any surface visibly soiled with

blood or body ﬂuids

• all surfaces and noncritical

equipment and the ﬂoor inside

the surgical ﬁeld

See

Operating rooms

(page 50)

Remove all used linen and surgical

drapes, waste (including used suction

canisters, ¾ ﬁlled sharps containers),

and kick buckets, for reprocessing

or disposal

Portable noncritical (e.g., compressed

gas tanks, x-ray machine) equipment

should be thoroughly cleaned

and disinfected before and after

each procedure

After last procedure

(terminal clean)

Shared cleaning

possible:

perioperative nursing

/ clinical staff and

cleaning staff

Clean and disinfect:

• all surfaces and noncritical

equipment in the operating room

• the entire ﬂoor

• any surface visibly soiled with blood

or body ﬂuids

• scrub and utility areas/sinks

See

Operating rooms

(page 50)

Take care to move the operating table

and any mobile equipment to make

sure that the ﬂoor areas underneath are

thoroughly cleaned and disinfected

Clean and disinfect low-touch surfaces,

(e.g., the insides of cupboards and

ceilings/walls) on a scheduled basis

(e.g., weekly)

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Medication preparation areas

Areas where medication is prepared (including pharmacy or in clinical areas) are high-risk areas in which high degree

of asepsis is required.

Appendix B2 Table 2. Cleaning Procedure Summaries for Medication Preparation Areas

Frequency Person / Staff

Responsible

Products/Technique Additional Guidance / Description

of Cleaning

Between uses Clinical staff Clean and disinfect:

• countertops

• portable carts used to transport or

prepare medications

None

End of each day Shared cleaning

possible (clinical

staff and cleaning

staff)

Clean and disinfect:

• all high-touch surfaces

• ﬂoors

Clean and disinfect low-touch surfaces,

such as the tops of shelves and walls/

vents, on a scheduled basis (e.g.,

weekly)

Sterile services areas

Areas where semi-critical and critical equipment is sterilized and stored in which high degree of asepsis is required.

Appendix B2 Table 3. Cleaning Procedure Summaries for Sterile Services Areas

Frequency Person / Staff

Responsible

Products/Technique Additional Guidance / Description

of Cleaning

Before and after

every use

Clinical staff Clean and disinfect:

• utility sinks used for washing

• semi-critical equipment

(e.g., endoscopes)

None

Twice daily Shared cleaning

possible (clinical

staff and cleaning

staff)

Clean and disinfect:

• all high-touch surfaces

Ð countertops

Ð surfaces of washing equipment

Ð handwashing sinks

• ﬂoors

Clean and disinfect low-touch surfaces,

such as the tops of shelves and walls/

vents, on a scheduled basis (e.g.,

weekly) during the ﬁnal

daily clean

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

ICU (adult, pediatric, neonatal)

These are high-risk areas because patients may be immuno-compromised by underlying diseases, treatment modalities (e.g.,

invasive devices) and other life-threatening conditions (e.g., major trauma, stroke) and vulnerability to infection is high.

Appendix B2 Table 4. Cleaning Procedure Summaries for ICU (adult, pediatric, neonatal)

Frequency Person / Staff

Responsible

Products/Technique Additional Guidance / Description of

Cleaning

Twice daily and

as needed

Cleaning staff Clean and disinfect:

• high-touch surfaces (only

outside of neonatal incubator

when occupied)

Clean:

• ﬂoors with neutral detergent

and water

Last clean of the day: clean low-touch surfaces

At discharge/

transfer (terminal

clean)

Cleaning staff Clean and disinfect:

• high-touch surfaces

• low-touch surfaces

• ﬂoors

1. Remove soiled/used personal care items (e.g.,

cups, dishes) for reprocessing or disposal.

2. Remove facility-provided linens for

reprocessing or disposal.

3. Inspect window treatments. If soiled, clean

blinds on-site, and remove curtains for

laundering.

4. Reprocess all reusable (noncritical) patient

care equipment.

5. Clean and disinfect all low- and high-touch

surfaces, including those that may not be

accessible when the room/area was occupied

(e.g., patient mattress, bedframe, tops of

shelves, vents), and ﬂoors.

6. Clean (scrub) and disinfect handwashing

sinks.

Pay special attention to terminal cleaning of

incubators.

Change ﬁlters in incubators according to

manufacturer’s instructions, when wet or if neonate

was on contact precautions (during terminal clean).

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Special isolation units

These are high-risk areas in which patients are highly immunosuppressed (e.g., bone marrow transplant, leukemia) and

vulnerability to infection is high.

Appendix B2 Table 5. Cleaning Procedure Summaries for Special Isolation Units

Frequency Person / Staff

Responsible

Products/Technique Additional Guidance / Description of

Cleaning

Daily, before

cleaning any other

patient care area

(i.e., ﬁrst cleaning

session of the day)

Shared cleaning

possible (clinical

staff and cleaning

staff)

Clean and disinfect:

• high-touch surfaces, with focus on

the patient zone

Clean:

• ﬂoors with neutral detergent

and water

In addition, clean low-touch surfaces

At discharge/

transfer (terminal

clean)

Cleaning staff Clean and disinfect:

• high-touch surfaces

• low-touch surfaces

• ﬂoors

1. Remove soiled/used personal

care items (e.g., cups, dishes) for

reprocessing or disposal.

2. Remove facility-provided linens for

reprocessing or disposal.

3. Inspect window treatments. If soiled,

clean blinds on-site, and remove

curtains for laundering.

4. Reprocess all reusable (noncritical)

patient care equipment.

5. Clean and disinfect all low- and

high-touch surfaces, including those

that may not be accessible when the

room/area was occupied (e.g., patient

mattress, bedframe, tops of shelves,

vents), and ﬂoors.

6. Clean (scrub) and disinfect

handwashing sinks.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Burn units

These are high-risk units where vulnerability of the patients to infection (immunocompromised) and probability of contamination

(e.g., with blood and body ﬂuids) are high.

Appendix B2 Table 6. Cleaning Procedure Summaries for Burn Units

Frequency Person / Staff

Responsible

Products/Technique Additional Guidance / Description

of Cleaning

Before and after

(i.e., between) every

procedure and

twice daily and

as needed

Shared cleaning

possible (clinical

staff and cleaning

staff)

Clean and disinfect:

• high-touch surfaces and ﬂoors,

focus on the patient zone

• any surface visibly soiled with

blood or body ﬂuids

Remove soiled linens and waste containers

for disposal/reprocessing

Last clean of the day: clean and disinfect

entire ﬂoor and low-touch surfaces

At discharge/

transfer (terminal

clean)

Cleaning staff Clean and disinfect:

• high-touch surfaces

• low-touch surfaces

• entire ﬂoor

1. Remove soiled/used personal

care items (e.g., cups, dishes) for

reprocessing or disposal.

2. Remove facility-provided linens for

reprocessing or disposal.

3. Inspect window treatments. If soiled,

clean blinds on-site, and remove

curtains for laundering.

4. Reprocess all reusable (noncritical)

patient care equipment.

5. Clean and disinfect all low- and

high-touch surfaces, including those

that may not be accessible when the

room/area was occupied (e.g., patient

mattress, bedframe, tops of shelves,

vents), and the entire ﬂoor.

6. Clean (scrub) and disinfect

handwashing sinks.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

General procedure areas

These are high-risk areas (such as such as radiology and endoscopy services) because they often service patients with high

vulnerability to infection (e.g., immunosuppressed), in addition to other patient populations.

Appendix B2 Table 7. Cleaning Procedure Summaries for General Procedure Areas

Frequency Person / Staff

Responsible

Products/Technique Additional Guidance / Description

of Cleaning

Before and after

every procedure

Clinical staff Clean and disinfect:

• any surface that is visibly soiled

with blood or body ﬂuids

• high-touch surfaces inside the

patient zone

Ð procedure table/station

Ð counter tops

Ð external surfaces of

ﬁxed equipment

• ﬂoors inside the patient zone

Remove disposable equipment and

reprocess reusable noncritical patient

care equipment; see

Noncritical patient

care equipment

(page 61)

After last patient of

the day (terminal

clean)

Shared cleaning

possible (clinical

staff and cleaning

staff)

Clean and disinfect:

• all high-touch and low-touch

surfaces

• entire ﬂoor

Move the procedure table and other

portable equipment to clean and

disinfect the entire ﬂoor area

Handwashing sinks should be

thoroughly cleaned (scrubbed)

and disinfected

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Labor and delivery wards/rooms

These are high-risk areas because they are routinely contaminated and vulnerability of patients to infection is high.

Appendix B2 Table 8. Cleaning Procedure Summaries for Labor and Delivery Wards/Rooms

Frequency Person / Staff

Responsible

Products/Technique Additional Guidance / Description

of Cleaning

Before and after

(i.e., between) every

procedure

Shared cleaning

possible (clinical

staff and cleaning

staff)

Clean and disinfect:

• any surface that is visibly soiled with

blood or body ﬂuids

• high-touch surfaces inside the

patient zone

• ﬂoor inside the patient zone

Remove soiled linens and waste

containers for disposal/reprocessing

After last delivery

of the day (terminal

clean)

Cleaning staff Clean and disinfect:

• any surface that is visibly soiled

with blood or body ﬂuids

• all high-touch and low-touch

surfaces

• entire ﬂoor

Move the procedure table and other

portable equipment to clean and

disinfect the entire ﬂoor area

Handwashing sinks should be

thoroughly cleaned (scrubbed)

and disinfected

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Hemodialysis stations/areas

These are high-risk areas because they are routinely contaminated and vulnerability of patients to infection is high.

Appendix B2 Table 9. Cleaning Procedure Summaries for Hemodialysis Stations/Areas

Frequency Person / Staff

Responsible

Products/Technique Additional Guidance / Description

of Cleaning

After each event/

case

Shared cleaning

possible (clinical

staff and cleaning

staff)

Clean and disinfect:

• any surface that is visibly soiled with

blood or body ﬂuids

• all surfaces of the dialysis

station area

Ð bed

Ð chair

Ð countertops

Ð external surfaces of the machine

• ﬂoor inside the patient zone

Remove disposable patient care items/

waste and reprocess reusable patient

care equipment per below

Take care to allow enough contact time

before the next subsequent use of the

station/area

After last case of

the day (terminal

clean)

Cleaning staff Clean and disinfect:

• any surface that is visibly soiled with

blood or body ﬂuids

• all surfaces of the dialysis

station/area

• high-touch surfaces in the area/room

housing hemodialysis stations

• entire ﬂoor

Move the procedure table and other

portable equipment to clean and

disinfect the entire ﬂoor area

In addition, clean low-touch surfaces

on a scheduled basis (e.g., weekly)

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Pediatric outpatient area

These are high risk areas because they are frequently contaminated and pediatric patients are more vulnerable to infection due to

pathogens such as enteric viruses and inﬂuenza.

Appendix B2 Table 10. Cleaning Procedure Summaries for Pediatric Outpatient Area

Area

Description

Frequency Person / Staff

Responsible

Products/Technique Additional Guidance /

Description of Cleaning

Waiting /

admission areas

At least daily and

as needed (e.g.,

visibly soiled,

blood/body ﬂuid

spills)

Cleaning staff Clean and disinfect:

• high-touch and low-touch

surfaces

• ﬂoors

Toys that may be put into mouth of

infant or toddler must be cleaned,

disinfected and rinsed thoroughly

after each use

Consultation /

examination areas

After each event/

case and at least

twice per day and

as needed

Shared cleaning

possible (clinical

staff and

cleaning staff)

Clean and disinfect:

• high-touch surfaces

Last clean of the day: clean and

disinfect the entire ﬂoor and low-

touch surfaces

Minor operative

procedure rooms

Before and after

(i.e., between)

every procedure

Shared cleaning

possible (clinical

staff and

cleaning staff)

Clean and disinfect:

• any surface visibly soiled

with blood or body ﬂuids

• high-touch surfaces in the

patient zone

• ﬂoors in the patient zone

Last clean of the day:

clean and disinfect:

• other high-touch surfaces

and low-touch surfaces

• handwashing sinks

• scrub/sluice areas

• the entire ﬂoor

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Emergency department:

These are moderate to high-risk areas because of the number of people who could contaminate the environment and because

some patients may be more susceptible to infection (e.g., trauma patients).

Appendix B2 Table 11. Cleaning Procedure Summaries for Emergency Department

Area

Description

Frequency Person / Staff

Responsible

Products/Technique Additional Guidance /

Description of Cleaning

Waiting /

admission areas

At least daily and

as needed (e.g.,

visibly soiled,

blood/body ﬂuid

spills)

Cleaning staff Clean and disinfect:

• high-touch and low-touch

surfaces

• ﬂoors

None

Consultation/

examination

areas

After each event/

case and at least

twice per day and

as needed

Shared cleaning

possible (clinical

staff and

cleaning staff)

Clean and disinfect:

• high-touch surfaces

Last clean of the day: clean and

disinfect the entire ﬂoor and low-

touch surfaces

Procedure areas

include trauma

areas for high

acuity patients

Before and after

(i.e., between)

every procedure

Shared cleaning

possible (clinical

staff and

cleaning staff)

Clean and disinfect:

• any surface visibly soiled

with blood or body ﬂuids

• high-touch surfaces in the

patient zone

• ﬂoors in the patient zone

Last clean of the day:

clean and disinfect:

• other high-touch surfaces and

low-touch surfaces

• handwashing sinks

• scrub/sluice areas

• the entire ﬂoor

Transmission-based precaution / Isolation wards

These are high risk areas, especially for environmentally hardy pathogens (e.g., resistant to disinfectants) and for multidrug-

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

resistant pathogens that are highly transmissible or are associated with high morbidity and mortality.

Appendix B2 Table 12. Cleaning Procedure Summaries for Transmission-Based

Precaution / Isolation Wards

Area

Description

Frequency Person / Staff

Responsible

Products/Technique

Additional Guidance /

Description of Cleaning

Airborne

precautions

Daily and as

needed

Cleaning staff Clean (neutral detergent

and water):

• high-touch surfaces

• ﬂoors

Primary focus is adherence to

required PPE and additional entry/

exit procedures; see

Table 5

(page 36)

In addition, clean low-touch surfaces

on a scheduled basis

(e.g., weekly)

Droplet and/

or contact

precautions

Twice daily and

as needed

Cleaning staff Clean and disinfect:

• any surface visibly soiled

with blood or body ﬂuids

• high-touch surfaces

• ﬂoors

Cleaning staff must wear

required PPE

Table 5

(page 36)

Dispose of or reprocess cleaning

supplies and equipment

immediately after cleaning

Last clean of the day: clean and

disinfect the entire ﬂoor and low-

touch surfaces

Patient

diagnosed

with C. difﬁcile

on droplet

and contact

precautions

Twice daily and

as needed

Cleaning staff Clean and disinfect (two-

step process required and

sporicidal agent):

• any surface visibly soiled

with blood or body ﬂuids

• high-touch surfaces in the

patient zone

• ﬂoors

Two-step process required (do

not use combined detergent-

disinfectant):

1. Rigorous mechanical cleaning

process (e.g., using friction).

2. Disinfectant with sporicidal

properties, for example:

• sodium hypochlorite solution

(e.g., 1,000-5,000ppm)

• enhanced hydrogen peroxide

at 4.5%

Dedicated

noncritical

patient care

equipment for

patients on

transmission-

based

precautions

Consistent

with cleaning

frequency for

patient zone,

before and after

each use and as

needed

Shared cleaning

possible (clinical

staff and

cleaning staff)

Products based on the risk

level of the patient care

area

Select a compatible disinfectant;

see

Material compatibility

considerations

(page 63)

Reprocess (i.e., clean and disinfect)

dedicated equipment after patient

is discharged or transferred

(terminal clean)

Conduct terminal cleaning of all

noncritical patient care equipment in

Sluice rooms

(page 63)

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Area

Description

Frequency Person / Staff

Responsible

Products/Technique

Additional Guidance /

Description of Cleaning

All transmission-

based

precautions

At discharge/

transfer (terminal

clean)

Cleaning staff;

conducted

in close

collaboration

with clinical

staff, speciﬁcally

unit manager

or shift leader,

who should

coordinate

schedule

Clean and disinfect:

•

high-touch surfaces

• low-touch surfaces

• ﬂoors

1. Remove soiled/used personal

care items (e.g., cups, dishes) for

reprocessing or disposal.

2. Remove facility-provided linens for

reprocessing or disposal.

3. Always remove privacy curtains

and window coverings for

laundering (curtains, blinds).

4. Reprocess all reusable

(noncritical) patient care

equipment in sluice rooms.

5. Clean and disinfect all low- and

high-touch surfaces, including

those that may not be accessible

when the room/area was

occupied (e.g., patient mattress,

bedframe, tops of shelves, vents),

and ﬂoors.

6. Clean (scrub) and disinfect

handwashing sinks.

Airborne precautions:

Cleaning staff must wear required

PPE; see

Table 5

(page 36).

Keep the door closed during the

environmental cleaning process

(ventilation requirement).

Appendix B2 Table 12. Cleaning Procedure Summaries for Transmission-Based Precaution /

Isolation Wards (Continued)

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Noncritical patient care equipment

These items are high-touch surfaces that are touched by both patients and by healthcare workers and may be used on multiple

patients. They include portable or stationary noncritical patient care equipment such as IV poles, commode chairs, blood pressure

cuffs, wheel chairs and stethoscopes.

Appendix B2 Table 13. Cleaning Procedure Summaries for Noncritical Patient Care Equipment

Area

Description

Frequency Person / Staff

Responsible

Products/Technique Additional Guidance /

Description of Cleaning

Shared

equipment

(including

transport

equipment - e.g.,

wheelchairs)

-shared between

patients

Before and after

every patient, and

as needed

Shared cleaning

possible (clinical

staff and

cleaning staff)

Clean and disinfect:

Select a compatible

disinfectant; see Material

compatibility considerations

(page 63)

Ensure division of cleaning

responsibility between nursing

and cleaning staff

Clean and disinfect heavily soiled

items (e.g., bedpans) in

Sluice

rooms

(page 63)

• Disinfect bedpans with a

washer-disinfector or boiling

water instead of a chemical

disinfection process

Dedicated

equipment -

when dedicated

to a particular

patient during

their stay

Consistent

with cleaning

frequency for

patient area, and

as needed

Shared cleaning

possible (clinical

staff and

cleaning staff)

Products based on the risk

level of the patient care area

Ensure division of cleaning

responsibility between nursing

and cleaning staff

Shared and

dedicated

equipment

At patient

discharge/transfer

Shared cleaning

possible (clinical

staff and

cleaning staff)

Clean and disinfect:

Select a compatible

disinfectant; see Material

compatibility considerations

in (page 63)

Conduct terminal cleaning of all

noncritical patient care equipment

in dedicated Sluice rooms (page

63)

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Spills of blood or body ﬂuids

Regardless of the risk-level of an area, spills or contamination from blood or body ﬂuid (e.g., vomitus) must be cleaned and

disinfected immediately using a two-step process.

Appendix B2 Table 14. Cleaning Procedure Summaries for Spills of Blood or Body Fluids

Area

Description

Frequency Person / Staff

Responsible

Products/Technique Additional Guidance /

Description

of Cleaning

Any spill in any

patient or non-

patient area

Immediately, as

soon as possible

Cleaning staff

1. Wear appropriate PPE; see

Table 5

(page 36).

2. Conﬁne the spill and wipe it up

immediately with absorbent (paper)

towels, cloths, or absorbent granules

(if available) that are spread over

the spill to solidify the blood or body

ﬂuid (all should then be disposed as

infectious waste).

3. Clean (neutral detergent and water).

4. Disinfect using a facility-approved

intermediate-level disinfectant.

5. Immediately reprocess all reusable

supplies and equipment (e.g.,

cleaning cloths, mops) after the spill

is cleaned up.

Mark off spill area to

prevent contact

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Appendix C – Example of high-touch surfaces in a

specialized patient area

High touch surfaces include, but are not limited to:

bed rails • bed frames • moveable lamps • tray table • bedside table • handles • IV poles • blood-pressure cuff

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Appendix D – Linen and laundry management

Best practices for linen (and laundry) handling

• Always wear reusable rubber gloves before handling soiled linen (e.g., bed sheets, towels, curtains).

• Never carry soiled linen against the body. Always place it in the designated container.

• Carefully roll up soiled linen to prevent contamination of the air, surfaces, and cleaning staff. Do not shake linen.

• If there is any solid excrement on the linen, such as feces or vomit, scrape it off carefully with a ﬂat, ﬁrm object and put it in the

commode or designated toilet/latrine before putting linen in the designated container.

• Place soiled linen into a clearly labeled, leak-proof container (e.g., bag, bucket) in the patient care area. Do not transport soiled

linen by hand outside the speciﬁc patient care area from where it was removed.

• Reprocess (i.e., clean and disinfect) the designated container for soiled linen after each use.

• If reusable linen bags are used inside the designated container, do not overﬁll them, tie them securely, and launder after

each use.

Ð Soiled linen bags can be laundered with the soiled linen they contained.

The effectiveness of the laundering process depends on many factors, including:

• time and temperature

• mechanical action

• water quality (pH, hardness)

• volume of the load

• extent of soiling

• model/availability of commercial washers and dryers

Always use and maintain laundry equipment according to manufacturer’s instructions.

Always launder soiled linens from patient care areas in a designated area, which should:

• be a dedicated space for performing laundering of soiled linen

• not contain any food, beverage or personal items

• have ﬂoors and walls made of durable materials that can withstand the exposures of the area (e.g., large quantities of water

and steam)

• have a separation between the soiled linen and clean linen storage areas, and ideally should be at negative pressure relative to

other areas

• have handwashing facilities

• have SOPs and other job aids to assist laundry staff with procedures

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Best practices for personal protective equipment (PPE) for laundry staff:

• Practice hand hygiene before application and after removal of PPE.

• Wear tear-resistant reusable rubber gloves when handling and laundering soiled linens.

• If there is risk of splashing, for example, if laundry is washed by hand, laundry staff should always wear gowns or aprons and

face protection (e.g., face shield, goggles) when laundering soiled linens.

Best practices for laundering soiled linen:

• Follow instructions from the washer/dryer manufacturer.

• Use hot water (70–80°C X 10 min) [158–176°F]) and an approved laundry detergent.

Ð Disinfectant are generally not needed when soiling is at low levels.

Ð Use disinfectant on a case by case basis, depending on the origin of the soiled linen (e.g., linens from an area on contact

precautions).

• Dry linens completely in a commercial dryer.

Manual reprocessing steps

If laundry services with hot water are not available, reprocess soiled linens manually according to the following:

1. Immerse in detergent solution and use mechanical action (e.g., scrubbing) to remove soil.

2. Disinfect by one of these methods:

Ð Immersing the linen in boiling water or

Ð Immersing the linen in disinfectant solution for the required contact time and rinsing with

clean water to remove residue

3. Allowing to fully dry, ideally in the sun.

Best practices for management of clean linen:

• Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens or

other soiled items.

• Each ﬂoor/ward should have a designated room for sorting and storing clean linens.

• Transport clean linens to patient care areas on designated carts or within designated containers that are regularly (e.g., at least

once daily) cleaned with a neutral detergent and warm water solution.

Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings

Appendix E – Chlorine disinfectant solution preparation

Example 1 — Using Liquid Bleach

Chlorine in liquid bleach comes in different concentrations. Any concentration can be used to make a dilute chlorine solution

by applying the following formula:

[% chlorine in liquid bleach ∕ % chlorine desired] − 1 = Total parts of water for each part bleach

†

Example: To make a 0.5% chlorine solution from 3.5%

‡

bleach:

[3.5% ∕ 0.5%] − 1 = 7 − 1 = 6 parts water for each part bleach

Therefore, you must add 1 part 3.5% bleach to 6 parts water to make a 0.5% chlorine solution.

†

“Parts” can be used for any unit of measure (e.g. ounce, litre or gallon) or any container used for measuring, such as a pitcher.

‡

In countries where French products are available, the amount of active chlorine is usually expressed in degrees chlorum. One degree chlorum is equivalent to 0.3%

active chlorine.

Example 2 — Using Bleach Powder

If using bleach powder

†

, calculate the amount of bleach to be mixed with each litre of water by using the following formula:

[% chlorine desired ∕ % chlorine in bleach powder] × 1 000 = Grams of bleach powder for each litre of water

Example: To make a 0.5% chlorine solution from calcium hypochlorite (bleach) powder containing 35% active chlorine

[0.5% ∕ 35%] × 1 000 = 0.0143 × 1 000 = 14.3

Therefore, you must dissolve 14.3 grams of calcium hypochlorite (bleach) powder in each litre of water used to make a

0.5% chlorine solution.

†

When bleach powder is used; the resulting chlorine solution is likely to look cloudy (milky)

Example 3 — Formula for Making a Dilute Solution from a Concentrated Solution

Total Parts (TP) (H2O) = [% Concentrate ∕ % Dilute] − 1

Example: To make a 0.1% chlorine solution from 5% concentrated solution:

Calculate TP (H2O) = [5.0% ∕ 0.1%] − 1 = 50 − 1 = 49

Take 1 part concentrated solution and add to 49 parts boiled (ﬁltered if necessary) water.

Source: AVSC International (1999). Infection Prevention Curriculum. Teacher’s Manual. New York, p.267.

Interim Infection Prevention and Control Guidance for Care of Patients with Suspected or Conﬁrmed Filovirus Haemorrhagic Fever in Health-Care Settings, with

Focus on Ebola [PDF – 24 pages]

, p. 24. https://www.who.int/csr/resources/publications/who-ipc-guidance-ebolaﬁnal-09082014.pdf

CS314156-A

Division of Healthcare Quality Promotion