/policies/,/policies/administrative/,/policies/administrative/uw-health-administrative/,/policies/administrative/uw-health-administrative/material-management/,

/policies/administrative/uw-health-administrative/material-management/518.policy

201711317

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100

UWHC,UWMF,

Policies,Administrative,UW Health Administrative,Material Management

Environmental Responsibilities on the Inpatient Care Units (5.18)

Environmental Responsibilities on the Inpatient Care Units (5.18) - Policies, Administrative, UW Health Administrative, Material Management

5.18

Page 1 of 3



Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Foundation (UWMF).


Policy Title: Environmental Responsibilities on the Inpatient Care Units
Policy Number: 5.18
Effective Date: August 10, 2017
Chapter: Materials Management
Version: Revision


I. PURPOSE

To identify responsibilities performed by the Environmental Services (ES) personnel to provide
maintenance of a clean and safe environment for inpatient care and to delineate some supportive
responsibilities for clinical staff within their own areas of responsibility and when the ES program is not
available.

II. POLICY ELEMENTS

A. ES has primary responsibility for cleaning on the inpatient care units, including daily cleaning
and discharge cleaning in the patient rooms, routine cleaning of all other areas on the unit, and
non-routine or emergency cleaning on the unit as needed.

B. All staff has responsibility for keeping their own work areas neat and orderly, for keeping the
patient rooms safe and neat, and for ensuring that non-routine cleaning needs are addressed by the
appropriate means.

C. ES and clinical staff have a joint responsibility to communicate with the patient to ensure access
to the patient room for timely and thorough cleaning and to ensure that all patient concerns are
addressed.

D. Environmental Services Technicians and clinical staff communicate throughout the day to ensure
ES responsibilities in the patient room and on the unit are met. Patient care equipment, patient
room and spaces adjacent to patient rooms shall be cleaned according to standards established by
ES.

III. PROCEDURES AND RESPONSIBILITIES

A. Environmental Services
1. Daily Cleaning of Patient Rooms. Attempts will be made on a daily basis to clean every
occupied inpatient room and restroom. The following cleaning will be performed on a daily
basis based on accessibility to the room:

Page 2 of 3

a. Empty waste receptacles, replace Sharps needle box if necessary, wipe all high-touch
surfaces with hospital grade disinfectant, check and fill dispensers, and mop floors.
b. If room is marked for neutropenic precautions, use appropriate protocols.
c. Detail cleaning such as high dusting is scheduled weekly, or more as needed.
d. The Environmental Services Technician signs and places the Environmental Services
calling card in each patient room to signify to the patient that the room has been cleaned.
e. Unoccupied rooms are checked daily and re-cleaned as necessary to ensure that they are
ready for admission of a patient.

2. Cleaning of non-patient rooms
a. Empty waste receptacles, wipe high-touch surfaces with hospital grade disinfectant, and
mop floors as needed.
b. Clean rest rooms, tubs and showers daily.
c. Hall sinks are cleaned and stocked daily.
d. Hall desk areas are cleaned daily.
e. Hall floors are auto-scrubbed daily; other floor care on hall floors is scheduled as
needed. Restorative floor care in rooms is scheduled as needed.
f. Lobbies, lounges, and other public areas are policed and cleaned often throughout the day
as needed.
g. Note: non-patient rooms that do not have direct patient care activity may be on a
cleaning schedule that only involves daily trash removal and weekly cleaning.

3. Patient room discharge
a. Once nursing enters a room as a discharge for cleaning, ES will be contacted via pager.
ES can also be contacted at pager #7548 at any time if the bed tracking system is down.
b. ES will respond to discharges as quickly as possible. Priority will be dictated by the
need for the room with guidance from nursing coordinators.
c. ES will remove all patient care equipment in the room and take to designated location for
cleaning. In addition to the regular cleaning completed each day, ES will also:
i. Empty waste receptacles, wipe all horizontal surfaces with hospital grade
disinfectant, check and fill dispensers, and mop floors.
ii. The Environmental Services Technician will take note of any repairs that
may be needed and communicate these to the Environmental Services
supervisor and enter a service request via U-Connect for Facilities and
Engineering Services.
iii. If the room is designated an Isolation, ES Technicians will follow appropriate
PPE protocols and remove the isolation sign after all areas of the room are clean.
iv. Mark the room as “Clean” in Health Link following the completion of the
discharge clean - this will alert the ACCESS Center that the room is ready for
a patient admission.

4. Cleaning of Infusion Center
a. See Administrative Policy 5.18 - Attachment 2 for procedures for daily and weekly
cleaning of the Infusion Center.

B. Clinical Staff
1. Daily Tasks
a. Remove all extra and un-used patient care equipment and supplies from the patient room.
b. Place soiled linen generated between Environmental Services pick-ups in the soiled linen
hamper located in the holding area directly outside the patient room.
c. Report spots or stains on carpets and furniture to Environmental Services as soon as
possible to facilitate cleaning.

Page 3 of 3

d. Remove specimens from the urine/stool collectors prior to ES cleaning.
e. Clean, or have cleaned, any equipment that belongs to the unit.

2. Patient Room Discharge
a. Nursing should enter rooms for discharge cleaning into the bed tracking system as soon
as the room is able to be cleaned. Signs for isolations that have not been discontinued
should remain on the door. ES will remove isolation signs when the room is clean.
b. If time allows, or if area/unit dictates, clinical staff should assist in getting the discharge
room ready for cleaning by ES by doing the following:
i. Remove any patient belongings that may have been left in the room. Take to
nurse station for labeling.
ii. Remove all patient care equipment; take equipment for reprocessing to the
ACCO, return unit-owned items to the proper location.
iii. Strip bed and bag linen.

3. Refrigerators
a. Area nursing staff is responsible for cleaning staff refrigerators.

C. All Staff
1. Ensure that all patient concerns about cleaning are immediately communicated to the
Environmental Services Department.
2. All personnel are responsible for communicating with ES if a cleaning issue is observed in
patient rooms or public areas.
3. Remove broken or malfunctioning equipment or unit fixtures and enter a service request via
U-Connect for Facilities and Engineering Services.

IV. COORDINATION

Sr. Management Sponsor: VP, Facilities & Support Services
Author: Director, Environmental Services

Approval Committee: UW Health Administrative Policy & Procedure Committee


SIGNED BY

Elizabeth Bolt
UW Health Chief Administrative Officer

Page 1 of 3
Administrative Policy 5.18 - Attachment 1
UW Health Cleaning Standards for Patient Care Equipment in Inpatient Areas









Revised
June 28, 2017








Items to be Cleaned
Individual Responsible
for Cleaning
Frequency
of Cleaning
Products Used to Clean

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* Product recommendations in this table reflect available UW
Health products capable of providing adequate disinfection
when properly applied. Check equipment manufacturer's
cleaning recommendations to ensure compatibility with UW
Health products.
** For large items, use spray quat disinfectant or multiple
caviwipes to ensure the surface is adequately visibly wet.
Bed Rail Pads

X X

X

X X

Bladder scanner

X X

X

X X Wipe down the console and probe
Blood glucose meters -Nova Stat
Strip

X X

X X X

Clean the meter using Caviwipes or bleach wipes. Do not spray
hospital disinfectant directly on the meter. Do not get cleaning
solution inside of the test strip port. The meter should dry
completely before returning it to the re-charging base.
• Enter the Operator ID# outside the patient's room.
• A vial of test strips should be left in a patient's room if testing
frequently or if extended length of stay with persistent isolation
precautions is expected. Otherwise, single test strips should be
taken into each patient's room to minimize waste.
• Once testing is completed, clean the meter using Caviwipes or
bleach towelettes as noted above.
If soiled with blood or other body fluids: Follow Policy #13.10:
Cleaning of All Blood and Body Fluid Spills
Blood pressure cuffs (portable,
stationary)

X X X

X

X X

Defibrillators and code cart equipment

X X

X

X X

EKG machines, portable

X X

X

X X

Electric Razors

X X

X

X X Wipe razor base and discard razor head.
High chairs (AFCH)

X X X

Soft pads washed by NAs, ES staff or Child Life personnel
IV poles and pumps not being
returned to CS or OR/PACU

X

X

X X

X X Also wiped down with Caviwipes by NA at AFCH
Medication scanners (Intermec
handheld devices)

X X

X X X X All components (case, screen, bar code reader lens, etc.) can be
cleaned with alcohol or Caviwipes.
Bleach wipes should not be used on the screens or bar code
reader lens.
No liquid should be directly sprayed or poured onto the device.
Occupational therapy equipment

X

X X

X X Occupational Therapy is responsible for:
1) Evaluation equipment: Hand-held dynamometers, pinch meter
= After patient use
2) Therapeutic exercise equipment: Dumbbells, dowels, pulleys,
cuff weights = Weekly
Phlebotomy Handheld Devices X

X

X

X X For isolation patients, cover handheld device with a Ziploc plastic
bag.

Page 2 of 3
Administrative Policy 5.18 - Attachment 1
UW Health Cleaning Standards for Patient Care Equipment in Inpatient Areas









Revised
June 28, 2017








Items to be Cleaned
Individual Responsible
for Cleaning
Frequency
of Cleaning
Products Used to Clean

P
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* Product recommendations in this table reflect available UW
Health products capable of providing adequate disinfection
when properly applied. Check equipment manufacturer's
cleaning recommendations to ensure compatibility with UW
Health products.
** For large items, use spray quat disinfectant or multiple
caviwipes to ensure the surface is adequately visibly wet.
Physical therapy equipment

X

X

X X Physical Therapy is responsible for:
Basketball stand & balls are cleaned by PT after each patient use
Portable lift equipment (sit to stand,
Hoyer)

X X

X

X X

Pulse Oximeters

X X

X

X X

Reusable Patient lifts/slings

X X

Disposable lifts/slings are discarded if soiled and after discharge
Reusable slings are washed by Nursing using laundry detergent.
Scales

X X

X

X X Hand rails are wiped down.
Seizure pads

X X

X

X X

Stethoscope: Personal and Retained
in Room

X X

X

X

X X

Stretchers**

X X

X X

X X

Telemetry boxes and cables (GE
Monitoring Equipment)

X X X

X X

X X

Thermometers, docking station (TLC)

X X

X

X X NA wipes down with Caviwipes before returning it to the docking
station.
Thermometers, electronic

X

X

X X

Thermometers, rectal (AFCH)

X X

X

X X

Transfer Devices (e.g., slide boards,
maxislides, reusable hovermats) **

X X

X X

X X

Ultrasound machine, LogiQ GE
ultrasound

X* X

X

X X

Ultrasound machine, portable

MD X

X

X X

Ultrasound machine, Sonosite

X* X

Ventilator

X

X

X X Respiratory Therapy is responsible for cleaning/disinfection.
Vital Signs monitors

X

X

X X

X X

Wheelchairs **

X X

X

X X Wipe down high-touch areas including the arms, seat and back of
chairs.
X-ray machines, CT Scan, MRI-
Stationary

X

X

X X Cleaned by Radiology Technicians
X-ray machines-Portable

X

X

X X Cleaned by Radiology Technicians

Page 3 of 3
Administrative Policy 5.18 - Attachment 1
UW Health Cleaning Standards for Patient Care Equipment in Inpatient Areas









Revised
June 28, 2017








Items to be Cleaned
Individual Responsible
for Cleaning
Frequency
of Cleaning
Products Used to Clean

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* Product recommendations in this table reflect available UW
Health products capable of providing adequate disinfection
when properly applied. Check equipment manufacturer's
cleaning recommendations to ensure compatibility with UW
Health products.
** For large items, use spray quat disinfectant or multiple
caviwipes to ensure the surface is adequately visibly wet.
Cleaning of specialized nursing care equipment in ICU, PACU, orthopedics, oncology, when the equipment is removed from the patient and NOT in use:
Bair huggers

X

X

X X

IV poles and pumps

X

Env Services takes them ACCO for return to CS
Neurological reusable drainage
equipment

X

Portable sequential compression
sleeve devices

X

X

X X They are cleaned at each discharge unless they are too heavily
soiled with blood - if too soiled to effectively cleaned, they are
thrown away
Monitors and blood pressure cables

X

X

X X Cleaned at every discharge
Mounted compression sleeve devices

X

X

X X If they are present in the room, ES staff cleans - not always
present
Disposable Items:
Blood pressure cuffs (disposable -
Critikon Soft-Cuf)

Carpuject Cartridges
Tourniquets
*** If a patient is in enhanced contact precautions for C. difficile, bleach wipes or OxyCide should be used to disinfect all patient care equipment
exiting the patient room.
Please see "Clinical Mobile Device Cleaning" on UConnect for information on cleaning laptops, Workstations on Wheels and Handheld devices

Attachment 2
UW Health Cleaning Standards for the UWHC Infusion Center
Administrative Policy 5.18 - Attachment 2 Effective Date August 10, 2017
Purpose
Thorough daily cleaning of this highly used area is essential because of the susceptibility of the patients
served, and because of the high possibility of the presence of infectious organisms.
Attire
Gloves should always be worn when cleaning this area. Good hand washing technique is essential.
Use Purell. If soiling of clothing is likely, a gown should also be worn.
Equipment

Standard cart set up for patient area cleaning

Standard bed make up
Procedure
A. Daily:
1. Police all rooms - this will include emptying all trash containers, removing linen from
hampers, emptying full recycling containers and spot mopping the floor. Check and fill,
as needed, paper and soap dispensers.
2. Dialysis tubing is placed in a red bag. This waste is removed at the end of each day.
Check and remove full sharps containers.
3. Clean all rooms nightly, using "Daily Patient Room Cleaning" procedures.
A. Clean all areas except beds, including counter tops, sinks, bathrooms, floors. Dust
mop and wet mop all floors.
B. Dust all televisions nightly.
C. Move all items except lab equipment and specimens.
D. Wash chairs and platforms that can be reached.
E. Check paper towels and soap dispensers and refill as needed.
4. Cleaning Principles:
Any surface contaminated with blood, blood products or other body fluids must be cleaned
using a two-step cleaning process with a disinfectant detergent that is EPA registered and
labeled as effective against the HIV virus (AIDS) at the correct diluted ratio. The surface
will be first cleaned with the disinfectant cleaner. After the initial cleaning, the affected
surfaces will be sprayed with the disinfectant cleaner. The disinfectant solution is wiped
over the surface with a clean rag and then allowed to air dry.
EXCEPTION: Full strength sodium hypochlorite (bleach) is recommended as the second
step when cleaning and disinfecting blood and body fluids from patients in isolation.
A. Whenever encountering blood, blood products or other body fluids the wearing of
protective gloves will be mandatory. If gross amounts of blood or blood products
are encountered and soiling is likely, you should wear a gown while cleaning the
surface(s).
B. Hands and other skin surfaces should be washed immediately after gloves are
removed.
B. Weekly:
1. High dust all areas.
2. Detail clean all rooms, including windows, walls, and baseboards.
Reference

OSHA Instruction CPL 2-2.44B, pg: 15 and 16, #2, 29CFR 1910.22(a)(1) and (a)(2)

CDC, June 24, 1988; Morbidity and Mortality Weekly Report, page B-9