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Administrative (Non-Clinical) Policy
UWHC only (Hospital Administrative-entity wide) UWMF only (entity wide)
UWHC Departmental (indicate name) UWMF Departmental (indicate name)
UWHC and UWMF (shared)
Policy Title: Disinfection of Hospital Owned/Rented Equipment Prior to
Servicing or Shipping
Policy Number: 13.31
Effective Date: June 1, 2015
Chapter: Infection Control
To establish procedures for cleaning and disinfecting hospital owned/rental equipment contaminated with
blood or other potentially infectious material prior to in house repairs or shipping to vendors for repairs.
Standard Precautions will be followed for cleaning and disinfecting hospital owned/rental equipment prior
to in-house repairs or shipping it to a vendor. Potentially infectious items will be rendered safe for
transport either by decontamination of external surfaces, or by containment within a container or bag
which identifies the contents as potentially biohazardous.
On-line Plant Engineering Service Request
A. Hospital owned/rental equipment servicing or repair must be completed by UWHC Clinical
Engineering, rental vendor, or other authorized repair vendor.
1. Patient equipment issued by Central Services (CS) will be returned to CS for
decontamination prior to servicing or repair.
2. Department owned equipment requiring repair will be transported to Clinical
3. Vendor owned/rental equipment will be returned to the vendor or rental facility under
terms of agreement with the respective entity.
B. All items transported within UWHC will be rendered safe for handling and transport prior to
being moved to CS, Clinical Engineering, or to shipping locations within UWHC in preparation
for offsite transit.
1. External surfaces of items too large to be contained within an impervious container or
bag which are contaminated with blood or body fluids will be properly disinfected with a
hospital-approved low level disinfectant product to render the item safe for handling and
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transport. After external surfaces are rendered safe for handling and transport, supporting
documentation needed to identify the piece of equipment or the service requested must be
affixed to the surface.
2. Smaller items may be placed into bins or other impervious containers or covered with a
clear plastic bag with a biohazard label or a red plastic bag, which is used to denote
biohazardous materials within UWHC. Supporting documentation needed to identify the
piece of equipment or the service requested will be affixed to the outside of the bag.
3. Carts used to transport multiple bins or containers of potentially infectious items must be
covered with a clear plastic bag with a biohazard label or a red plastic bag, which is used
to denote biohazardous materials within UWHC.
C. Central Services and Clinical Engineering will follow Standard Precautions for all repairs and
servicing of equipment which may be contaminated with blood or body fluids.
1. Sufficient Personal Protective Equipment (PPE) to prevent contamination of skin or
mucous membranes will be worn (e.g., gloves, gown, face shield).
2. For instruments with interior pathways or recessed areas which contain blood or body
fluids during normal operation of the instrument, PPE will be routinely worn when
accessing these areas with the assumption that these fluids are present.
3. For instruments with recessed internal areas which do not contain blood or body fluids
during the normal operation of the instrument, but which could become contaminated
under unusual circumstances, review of the supporting documentation and a visual
inspection will be made. If documentation indicates possibility that interior
contamination with blood or body fluids has occurred, or if there is visible indication of
such contamination, PPE must be worn as appropriate.
D. Equipment that will be shipped outside of UWHC for servicing must, at minimum, undergo
surface decontamination or impervious packaging to render the item safe for handling and
transport as described in IV.B.
1. Color coding of biohazards (e.g., red bags used strictly for biohazardous materials within
UWHC) is NOT an adequate means of conveying biohazard risk outside of UWHC.
Biohazardous materials being shipped outside of UWHC must have a biohazard sign
affixed to instrument or its container.
2. If an instrument is being shipped offsite for rental return or repair and is known to have
blood or body fluid contamination which has not been decontaminated (e.g., unexpected
blood leak into the interior of an instrument), this information must be conveyed in order
to ensure the safety of employees at the receiving facility. A biohazard label will be
affixed to the instrument and include notation of what portion of the instrument has not
E. If equipment is potentially contaminated and complete disinfection is not possible, appropriate
containment and warning labels are required on shipping containers. Refer to United States Postal
Service Publication #52 (Hazardous, Restricted and Perishable Mail) section 346, accessible on
the United States Postal Service website: USPS Publication 52
Occupational Safety and Health Administration. Occupational exposure to bloodborne pathogens: final
rule, 29 CFR 1910.1030. Accessible at: BBP Rule
VI. CROSS REFERENCE
Hospital Administrative Policy 13.10-Cleaning of Blood and Body Fluid Spills
Hospital Administrative Policy 13.07-Standard Precautions and Transmission-based Precautions
(Isolation) for Inpatient Settings
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Hospital Administrative Policy 13.28-Standard Precautions and Transmission-based Precautions
(Isolation) for Ambulatory Settings
UWHC Bloodborne Pathogens Exposure Control Plan, accessible on the Infection Control U-Connect
intranet site: Infection Control Department Site
Sr. Management Sponsor: VP, Dev, Nursing & Patient Care Services
Author: Sr. Clinical Infection Control Practitioner
Approval Committee: Administrative Policy and Procedures Committee
President & CEO
Previous revision: June 2012
Next revision: June 2018