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Cleaning of Blood and Body Fluid Spills (4.1.4)

Cleaning of Blood and Body Fluid Spills (4.1.4) - Policies, Clinical, UW Health Clinical, Infection Control

4.1.4


UW HEALTH CLINICAL POLICY 1
Policy Title: Cleaning of Blood and Body Fluid Spills
Policy Number: 4.1.4
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: December 18, 2015

I. PURPOSE

To prevent transmission of infection due to environmental contamination w ith blood or body f luids, and w hen
cleaning spills of such materials.

II. GENERAL CONSIDERATIONS

Under the provisions of Standard Precautions, all moist body substances except sw eat are considered
potentially infectious. Pathogens may be harbored in blood, body f luids, tissues, secretions and excretions
(e.g., respiratory secretions, stool, urine, w ound drainage, etc.). Precautions are w arranted for cleaning and
disinfecting the environment after spills of such body substances, w hether or not the patient has a
recognized infection.

III. POLICY ELEMENTS

A. Blood and body f luid soilage and spills w ill be cleaned up immediately, or as soon as feasible, to minimize
the risk of exposure to persons in the hospital environment.
B. Blood and body f luid soilage and spills w ill be cleaned using a tw o step procedure w ith the hospital
disinfecting detergent, w hich must be EPA registered as tuberculocidal, or as effective against both human
immunodeficiency virus and hepatitis B virus, at the in-use dilution.
C. Work areas having a potential for blood and body f luid soilage must have hospital disinfecting detergent
readily available.
D. Selected w ork areas (e.g., hemodialysis, clinical laboratories) may elect to sanitize surfaces w ith diluted
household bleach, after f irst cleaning the soiled surface w ith hospital disinfecting detergent. If household
bleach (5.25% sodium hypochlorite) is used, it should be diluted in w ater at a ratio of 1:10 to 1:100, and
must be made up fresh daily. An alternative to freshly diluted household bleach in these settings is an EPA
registered hospital disinfectant containing stabilized sodium hypochlorite at a concentration of at least
0.0525%.
E. For surfaces soiled w ith brain, spinal cord, optic nerve or cerebrospinal f luid from a patient w ith know n or
suspected spongiform encephalopathy (e.g., Creutzfeldt-Jacob disease, variant Creutzfeldt-Jacob disease,
fatal familial insomnia, Gerstmann-Straussler-Sheinker syndrome), full-strength 5.25% sodium hypochlorite
(household bleach) w ith 15 minutes exposure time is recommended as the second step, after cleaning w ith
hospital disinfecting detergent.

IV. PROCEDURE

A. Blood or body f luid spills or soilage must be cleaned up immediately, or as soon as feasible, to minimize the
risk of exposure. All healthcare w orkers share in the responsibility to minimize such exposures.
B. The follow ing sequence w ill be used to clean spills of blood and body f luids.
i. The spill w ill be visually inspected for the presence of sharp materials.
a. If the spill contains broken glass, needles or any other sharp item, a device or spill kit
w hich w ill prevent sharp injury must be used for cleanup.
b. For spills accompanied by larger amounts of glass or other sharps, a dust pan or other
impervious implement of suff icient size to minimize potential for sharp injury must be used.
c. If the spill may contain sharps w hich are not visually discernible, or the potential for the
presence of sharps cannot be excluded, a spill kit or dust pan must be used for cleanup.
ii. The individual cleaning the spill w ill put on appropriate personal protective equipment (PPE).
a. For small spills, w earing gloves is typically suff icient to avoid skin contact w ith the
material.
b. For larger spills, and under conditions in w hich cleaning of the spill may result in splashing
or spattering of the individual's mucosa, skin or clothing, additional PPE must be w orn.
1. A faceshield or eyew ear plus a mask w ill prevent splashes to the mucosa (moist
areas of the eyes, nose and mouth).
2. An isolation gow n w ill prevent small splashes from reaching skin and clothing.



UW HEALTH CLINICAL POLICY 2
Policy Title: Cleaning of Blood and Body Fluid Spills
Policy Number: 4.1.4

3. For cleaning spills of unusually large volume, use of a f luid resistant gow n or
cover suit may be w arranted.
iii. If sharps are present in or immediately near the spill area, remove all sharp materials using the
disposable scoop or dust pan, as described in IV.B.i. above, and discard into a sharps container.
iv. Place paper tow els or cleaning rags on the spill to soak up excess liquid. When absorbed, discard
paper tow els or rags into an appropriate w aste container:
a. If the volume of blood or body f luids absorbed in the paper tow els or rags is suff iciently
large to drip, either spontaneously or w hen squeezed, the absorbent material must be
discarded in a red bag.
b. If the volume of blood or body f luids absorbed in the paper tow els or rags is small, such
that it w ill not drip either spontaneously or w hen squeezed, the absorbent material may be
discarded into a regular w aste container.
c. If there is any possibility that sharps may still be present (e.g., glass shards) the paper
tow els or rags must be picked up w ith a disposable scoop or dust pan, or other device
(e.g., hemostat) w hich precludes direct hand contact, for disposal into a sharps container.
v. Saturate the spill area w ith hospital disinfecting detergent and w ipe up w ith clean paper tow els or
cleaning rags.
a. If there is any possibility that sharps may still be present (e.g., glass shards) the paper
tow els or rags must be manipulated and picked up w ith a disposable scoop or dust pan, or
other device (e.g., hemostat) w hich precludes direct hand contact, for disposal into a
sharps container.
vi. Remove PPE and perform hand hygiene.
vii. Spray the spill area a second time w ith hospital disinfecting detergent, or bleach diluted as
described in III. D., and allow to air dry.
viii. Contaminated reusable housekeeping items such as a dust pan may be saturated w ith hospital
disinfecting detergent and w ashed off by rinsing into the sanitary sew er (e.g., slop sink, hopper)
prior to being put back into general service.

V. COORDINATION

Author: Infection Control Practitioner
Senior Management Sponsor: SVP, Patient Care Services and CNO
Approval committees: Infection Control Committee; UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: November 16, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Jeff Grossman, MD
UW Health CEO

Teresa Neely
SVP and CAAO

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES

-29 CFR Part 1910.1030 Occupational Exposure to Bloodborne Pathogens; Final Rule, December 6, 1991;
revised July 30, 1999.
-Siegel, J.D., Rhinehart, E., Jackson, M., Chiarello, L., and the Hospital Infection Control Practices
Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents



UW HEALTH CLINICAL POLICY 3
Policy Title: Cleaning of Blood and Body Fluid Spills
Policy Number: 4.1.4

in Healthcare Settings. Accessible at: http://w ww.cdc.gov/ncidod/dhqp/gl_isolation.html
-World Health Organization Infection Control Guidelines for Transmissible Spongiform Encephalopathies.
Report of a WHO Consultation. Geneva, Sw itzerland, 23-26 March 1999.
- Rutala, W.A., Weber, D.J., 2001. Creutzfeldt-Jakob Disease: Recommendations for Disinfection and
Sterilization. Clinical Infectious Diseases 32:1348-56.
-UW Health Bloodborne Pathogens Exposure Control Plan, accessible on the Infection Control Department
site on UConnect.
-UWHC policy #13.08, Hand Hygiene
-UWHC policy #13.07, Standard Precautions and Transmission Based Precautions (Isolation) for Inpatient
Settings
-UWHC policy #13.28, Standard Precautions and Transmission Based Precautions (Isolation) for
Ambulatory Settings
-UWHC policy #13.27, Precautions for Transmissible Spongiform Encephalopathy (CJD and other prion
diseases)
-UWHC policy #5.27, Waste Management

VIII. REVIEW DETAILS
Version: Revision
Next Revision Due: December 18, 2018
Formerly Know n as: Hospital Administrative policy 13.10