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Cleaning (in the healthcare setting) refers to the removal of visible dirt, dust and debris. Cleaning alone results in large reductions in environmental contamination, including the removal of many pathogens.
A clean patient environment contributes to prevention of healthcare-associated infection. Cleaning in healthcare facilities aims to remove visible dirt and dust, reducing levels of harmful micro-organisms in the patients’ surroundings. Dust contains skin scales and micro-organisms, which can be spread in the environment and air by sweeping or dry dusting.
A clean patient environment contributes to prevention of healthcare-associated infection.
Most areas of a healthcare facility will require at least daily cleaning. Other specialised clinical areas may require twice daily (outpatient areas) or more frequent cleaning (operating theatres).
Any cleaning method that generates movement of dust, e.g. sweeping or dry dusting, should not be used. Damp dusting of surface and mopping of floors are the preferred method as these techniques do not generate dust movement. The routine use of disinfectants for all clinical areas is unnecessary and strongly discouraged as it contributes to the development of antimicrobial resistance.
The cleaning tasks assigned to the domestic staff may vary between institutions, but in most instances include the following:
It is, however, critical to establish who is responsible for cleaning what (between domestic and nursing staff) to ensure there are no items or areas that are overlooked.
For routine environmental cleaning staff should wear:
Items such as door handles, light switches, patient monitors and medical equipment buttons/knobs are frequently touched by healthcare workers and patients. These are high-risk surfaces for cross-transmission because they hold the micro-organisms that are transferred from people’s hands. Domestic staff should be specifically alerted to give extra attention to these frequently touched surfaces during their routine cleaning.
Frequently touched surfaces are a high risk for cross-transmission because they hold the pathogens that are transferred from people’s hands.
Routine cleaning is the standard, everyday procedure for cleaning of clinical areas, including mopping of floors, damp dusting of surfaces with detergent, etc. Terminal cleaning is performed when a patient with a transmissible illness is discharged (usually for isolation rooms), e.g. MRSA and other drug-resistant bacteria, tuberculosis, Clostridium difficile. The terminal cleaning process requires:
Terminal cleaning is required when a patient with a transmissible illness is discharged (usually from an isolation room).
The following principles should be applied:
All healthcare facilities require a written, easily understandable and accessible standard operating procedure (SOP) for managing blood spills.
This is generally defined as waste from a healthcare facility that may contain hazardous pathogens. Examples include:
Other special types of waste are generated from healthcare facilities including expired medication, chemicals and oils. These are also potentially hazardous and require a programme for disposal, separate from management of clinical and general waste.
Clinical waste is waste that may contain hazardous pathogens; non-clinical healthcare waste includes general rubbish, expired medications and chemicals.
Waste management is the handling and safe disposal of infectious and non-infectious waste. The aims of waste management are to ensure safe and environmentally friendly destruction or reprocessing of healthcare waste.
Most countries have legislation governing the disposal of healthcare waste. Ultimately the head of each healthcare facility is responsible for ensuring that proper policies and processes are in place for waste management. Each facility or group of facilities should have a designated waste manager responsible for implementation of the waste policy and procedures for protection of staff working with waste. Compliance monitoring for waste management is usually performed by the IPC practitioner. Training in healthcare waste management is required for all facility staff, including clinical staff, domestic staff, porters, radiographers, pharmacists and other allied health professionals.
The healthcare facility manager is responsible for ensuring that proper waste management policies and processes are in place.
This is simply the separation of healthcare-associated waste at source into clinical (infectious waste) or non-clinical (domestic) waste. Waste segregation takes place at the point of generation (source) into different (colour-coded) plastic bags or containers for disposal. Separation of waste at source (i.e. at ward or clinic room level) saves time, cost and eliminates the risk attached with sorting medical waste. Many healthcare facilities use colour-coded waste bags and posters/signs to indicate to healthcare workers and visitors where the disposal of different types of waste must take place. For example, red bags for clinical waste and black or clear bags for non-clinical waste and general rubbish. Sharps are disposed of at source in robust solid containers to avoid accidental injuries.
Waste segregation is the separation of healthcare-associated waste into clinical (infectious waste) or non-clinical (domestic) waste.
Healthcare waste should be segregated at source (point of generation)
|Category||Recommended colour coding||Examples of items|
|Anatomical tissues and clinical waste, any material which is visibly contaminated with blood or body fluid or infectious agents||●
Red: Clinical waste
|Placentae, human limbs and tissue, excision products, used bandages and dressings, urinary catheter and drainage bags*, intravenous administration sets, abdominal swabs, theatre dressings, Infectious disease isolation area: gloves and aprons, linen savers with blood or body fluids|
|Sharps, sharp objects that are contaminated with blood or body fluid||●
|Hypodermic needles, stylets, vials, syringes containing blood or body fluids, insertion ends of intravenous administration sets, trochars, cannulae, rigid guidewires|
|Non-clinical waste generated by patients but not contaminated with blood or body fluids, paper and packaging, packaging or wrapping, office and administration||●
|Items used by patients but not contaminated with blood or body fluids, e.g. used gloves, linen savers, tissues, paper towels, packaging or wrapping from sterile items or processed items, babies' nappies, sanitary towels, Office paper, wrapping paper from SSD, surgical masks, overshoes, surgical disposable caps and gowns|
|SSD equipment, used single items sent to SSD for sterilization or high-level disinfection||○
Clear: For sterilization
|Surgical instruments, vaginal speculae, respiratory equipment, masks, etc.|
|Storage of patient articles||○
Clear: For storage
|Storage of patient articles|
* IV fluid and wound drainage bags containing residual fluid should be emptied in the sluice room.
This is the risk management programme (part of standard precautions) that is implemented to reduce the risk of sharps (or needlestick) injuries. The following recommendations apply to waste management of sharps:
When removing waste from clinical areas, the domestic staff should ensure that:
Medical waste is often stored in a holding area in the wards/clinical area, until collected by the domestic staff for disposal. This area should be kept clean, dry, well-ventilated and secured. Depending on the clinical area concerned, waste may need to be collected as often as twice daily. Collected waste from the clinical areas is then transported to the facility’s wasteholding area, to await collection for final disposal at an incineration or waste destruction site. Similar to the requirements mentioned above, this wasteholding area should be securely locked, clean, dry, well ventilated and free from pests/rodents. The area should be inspected by IPC staff intermittently.
There are several different methods available for destruction and disposal of medical waste. Non-clinical waste (e.g. paper towels, rubbish) is usually buried at a local municipal dumpsite or landfill. Clinical waste and sharps are ideally destroyed by incineration. This is the best way to ensure that there is no remaining risk for needlestick injury and no viable micro-organisms. The heat generated by this process is often ‘re-cycled’ to generate steam or produce heat for the healthcare facility. Other newer technologies for waste disposal are available for example microwave or heat sterilization, and shredding. If third parties are used for waste disposal, the facility must draw up contracts for this purpose. In parts of Africa, leftover food and/or kitchen waste are disposed of in compost heaps, which in turn produce compost for fertilising food crops.
Decontamination is the process followed to ensure that re-usable medical devices are safe to use on the next patient. Examples are the decontamination of a vaginal speculum between patients or the decontamination of surgical instruments between operations.
Decontamination is a process that ensures that medical devices are safe to use on another patient.
Decontamination is required to destroy and remove micro-organisms before a medical device or piece of equipment is used on another patient. Micro-organisms can be transferred to patients (through direct or indirect contact with inadequately decontaminated devices/equipment) resulting in healthcare-associated infection.
Decontamination includes some or all of the following steps:
The decontamination process involves cleaning, disinfection and/or sterilization.
Different micro-organisms have differing levels of susceptibility to destruction. Some, like viruses, most bacteria and fungi are relatively easy to kill. Others, like mycobacteria (TB) and spores (Clostridium difficile) are relatively resistant to killing. That is why it is important to know which micro-organisms need to be destroyed when selecting the appropriate method for decontaminating a particular device.
Figure 6-1: Most resistant to least resistant micro-organisms
Any medical device or piece of equipment that comes into direct contact with a patient or patient’s body fluids, can potentially be contaminated with micro-organisms. For example blood pressure cuffs, thermometers and saturation probes all pose a risk of infection transmission if not adequately decontaminated between patients.
The method of decontamination is determined by the level of risk for infection transmission. For example, devices that will be in contact with the patient’s bloodstream or sterile tissue/sterile body cavities must be sterilized. Items that will only be in contact with intact skin, can undergo low-level disinfection, which should remove most pathogens. The Spaulding classification gives guidance on how to determine the type of decontamination processes required.
The appropriate method of decontamination for a particular medical device is determined by the level of risk for infection transmission.
|Critical: enters directly into the bloodstream, sterile tissue or cavities||Surgical instruments, needles, intravenous catheters||Sterilization: no micro-organisms left, including spores|
|Semi-critical: contact with intact mucous membranes||Endoscopes, laryngoscopes, airway tubes, resuscitation masks and bags||High-level disinfection: no vegetative forms of bacteria left, few spores acceptable|
|Non-critical: Touches only intact skin||Blood pressure cuffs, stethoscopes, cervical collars, thermometers||Low-level disinfection: most pathogens removed|
Using the Spaulding classification as outlined above, non-critical devices and instruments can be decontaminated at ward level. This would include the cleaning and disinfection of commonly used items such as thermometers and stethoscopes. Other commonly used items such as urine jugs and bedpans are often cleaned at ward level. Cleaning of these items can be manual or automated. Staff responsible for manual cleaning should be provided with personal protective equipment including heavy-duty gloves, plastic aprons, and eye protection. The use of an automated washer-disinfector is ideal, as this minimises handling of bedpans/urinals, saves time and achieves better disinfection than manual methods.
Non-critical devices and instruments can be safely decontaminated at ward level.
|Items or site||Preferred method of decontamination||Alternative methods/comments|
|Airways and endotracheal tubes||Single-use disposable|
|Ambu bags||Send to SSD for heat disinfection.||Ethylene oxide|
|Ampoules||Wipe with 70% isopropyl alcohol and allow to dry before opening.||Do not immerse in disinfectant.|
|Baths||Clean with detergent and non-abrasive cream cleaner. Rinse and dry|
|Beds and cots||Wipe with warm water and detergent to remove all visible signs of dirt. Allow to dry.||Disinfection not necessary.|
|Bed lockers||Wipe with warm water and detergent. Dry.||Clean inside locker once patient has been discharged.|
|Bedpans and urinals||Wear non-sterile gloves. Empty contents directly into ward washer disinfector (80 °C × 1 min). Inspect for cleanliness after removal. Store inverted to dry.||Macerators: papier-mâché bedpans and urinals. Manual cleaning: wear gloves, empty bedpan into sluice and rinse. Clean thoroughly with a nylon scrubbing brush and detergent. Rinse. Invert to dry. Never soak bedpans.|
|Blankets and bed covers||Change after each patient has been discharged or when visibly soiled. Send to laundry to wash at 80 °C.||Do not allow bedding from home. These may be infected with bed bugs or carry scabies.|
|Bowls (patient wash)||Wash with detergent, rinse and store inverted to dry.||Modern ward washer disinfectors can also wash bowls.|
|Commodes||Wash seat daily with detergent and hot water and dry with disposable paper towel. Wipe the commode seat with a large alcohol wipe after each use.||If visibly contaminated, remove soil with tissue. Wash with warm water and detergent. Dry. For enteric diseases, wipe the commode with hypochlorite (1000 parts per million) after each use.|
|Computer and keyboards||Damp dust daily. Wipe keyboard carefully to remove visible dirt.||Use a keyboard cover which is changed frequently.|
|Crockery and cutlery||Wash at 80 °C in dishwasher. Manual cleaning: wear gloves and hand wash in detergent and hot water (60 °C), rinse and dry.||Wear domestic gloves for manual cleaning. Infected patients: unless as instructed by IPC team treat as routine. Disposable crockery is rarely indicated, e.g. rabies.|
|Curtains||Change curtains frequently. Isolation room curtains (infectious cases) should be changed with each terminal clean.||Blinds, both vertical and horizontal, are difficult to clean and wash regularly.|
|Dressing trolleys||Remove all items daily and wipe surface with warm water and detergent. Dry. Wipe over with 70–80% ethanol alcohol. Discard all previous contents of open jars and bottles. Replace with unopened containers.||If open jars are used, keep the volume small so that the containers can be heat disinfected when empty. Do not top up open disinfectant containers.|
|Endotracheal suction catheters||Disposable. Can be used for 24 hours on the same patient. Flush with sterile water after each use. Bowl is washed and dried after each suction and filled with sterile water only before use.||Decontaminate hands thoroughly before carrying out suction. Do not share suction catheters between patients. Do not recycle suction catheters.|
|Feeding bottles (baby)||Heat sterilized in SSD||Wash thoroughly. Rinse and soak in fresh hypochlorite solution (125 ppm available chlorine) for 30 minutes. Remove, rinse and dry.|
|Humidifiers||Empty daily and heat disinfect after each patient use. Clean with warm water and detergent. Dry. Fill with sterile water only.|
|Infant incubators||Wash all removable parts and clean thoroughly with detergent. Dry with paper towel.|
|Laryngoscope blades||Wash blade with detergent, rinse and dry. Wipe over with alcohol.|
|Mattresses||Use a water impermeable cover. Clean with warm water and detergent. Dry thoroughly. Never admit patients to soiled, stained or damaged mattresses.||Major source of cross-infection. Replace torn mattress covers immediately. Wet mattresses should be discarded.|
|Scissors||Wipe over with 70% alcohol before and after each use.|
|Thermometer (oral)||Wash and dry after each patient use. Wipe with 70% alcohol and store dry.||Never soak thermometers in disinfectant.|
|Ultrasound probe||Disinfect with 70% isopropyl alcohol between each patient use. Intravaginal: cover probe with a condom for each patient.|
|Ventilators||These are complex and should be cleaned and disinfected according to the manufacturer’s instructions. Sometimes there are technicians in the healthcare facility who do the maintenance.||Remove tubing and send to SSD for heat disinfection (80 °C × 3 min) or chemical disinfection. Clean all inspiratory and expiratory connections. Change both sets of filters. Check efficiency of air movement. Reassemble. Clean the outside of the ventilator. Register in logbook.|
|Wash basins||Clean with warm water and detergent. Disinfectants are not recommended.|
|X-ray equipment||Damp dust only.||Wipe with 70% alcohol if disinfection required.|
Cleaning is the first step towards disinfection, sterilization and making medical devices safe for re-use. Proper cleaning alone will remove approximately 80–90% of microbial contamination. It is vital that the cleaning process removes all visible organic matter such as blood, dirt or tissue. This then ensures effective disinfection or sterilization by allowing penetration of disinfectants and steam respectively.
Cleaning is the first step towards making medical devices safe for re-use, and will remove approximately 80–90% of microbial contamination.
For medical devices and instruments that can be safely immersed in water, the following steps apply:
Disinfection is the killing or destruction of most pathogens, and is applied to inanimate (non-living)surfaces or instruments. This process will not kill all pathogens (especially spore-forming pathogens), but reduces the level of contamination to one that is not harmful. Microbial killing by disinfection can be achieved using chemicals, heat or both.
The use of heat for either disinfection or sterilization is the preferred method for making items safe for re-use. However, for heat-sensitive items (endoscopes/electrical equipment) or surfaces (mattress covers, worktops, etc.), chemical disinfection is an acceptable alternative.
Disinfectants are generally inexpensive, have rapid action, can be used for processing at the point of use and are suitable for decontamination of heat-sensitive items. The negative aspects of disinfectants are that they are less effective than heat, require rinsing of items, may enhance antimicrobial resistance, may be harmful to the environment and can cause allergic reactions.
Disinfectants are cheap, act rapidly and can be used on heat-sensitive items, but are less effective than heat and can cause allergic reactions.
The following concepts about soaking are very important:
Soaking used medical devices in disinfectants is a waste because most disinfectants cannot penetrate organic matter.
Alcohol and chlorine-based disinfectants are the most widely available. Depending on the concentration used (see Table 6-4), these chemical disinfectants can achieve low to intermediate level disinfection. Chlorine may not be suitable for all types of disinfection, as it can be corrosive (causing damage to metal surfaces). Others types of disinfectants available include quaternary ammonium compounds (QACs) and phenolics. For semi-critical items like endoscopes, high-level disinfection is needed using aldehydes, peracetic acid or OPA.
Alcohol and chlorine-based disinfectants are the most widely used agents in low-resource settings.
|Item||Parts per million available chlorine|
|Blood spillage (HIV, HBV, HCV)||10 000|
|Pre-cleaned surfaces, cleaning equipment||1 000|
|Catering and infant feeding equipment||125|
Disinfectants are used for killing pathogens on inanimate surfaces or instruments. Antiseptics are chemicals used to kill pathogens on live tissue, for example alcohol hand-rub, chlorhexidine gluconate and povidone iodine for skin preparation prior to surgery.
Disinfectants kill pathogens on inanimate surfaces/instruments and antiseptics kill pathogens on live tissue/skin.
Any medical device or instrument that is re-usable should have a specified process for its decontamination, for example a standard operating procedure for re-processing of used vaginal speculae. Wherever possible, decontamination of devices/instruments should be performed in a dedicated sterile services department. This ensures that the items are handled by staff with the required skills, equipment and procedures to deliver safe medical devices. Most countries have legislation governing Patient and Occupational Health and Safety. In more developed settings, all decontamination processes require validation (a form of proof that the process was carried out to accepted standards).
Any re-usable medical device or instrument should have a specified process for decontamination. Wherever possible, decontamination should be performed in a dedicated sterile services department.
Any item that is designated by the manufacturer as single-use, or any item that cannot be thoroughly cleaned, e.g. hypodermic needles and syringes, should be discarded after use.
Any item designated by the manufacturer as single-use should be discarded after use, because the risk of infection transmission after inadequate reprocessing is high.
Ideally all critical and semi-critical items (see Spaulding classification under 6-25) should be decontaminated in the SSD. In certain instances, where items are needed urgently for re-use on other patients, decontamination may be carried out at point of care. In such circumstances it is even more important to ensure quality management and proper oversight of the decontamination process. Examples would include cleaning and high-level disinfection of bronchoscopes or endoscopes at point of care.
All critical and semi-critical items should be decontaminated in a sterile services department (SSD).
The SSD should be designed and laid out so as to streamline movement of items and to prevent contamination of processed, sterile items by ‘dirty’ items arriving in the ‘wash room’, cleaning area. Items and instruments for decontamination follow a specific flow or process through the SSD:
SSD staff should wear uniforms that cover their arms and neck area, to minimise skin contact with chemical products. Closed shoes should be worn. Industrial gloves and aprons are indicated for staff working in the ‘dirty’ areas or wash room. Eye protection may be needed where staff are rinsing items or using water jets through hollow bore instruments. All SSD staff should have received a full course of hepatitis B immunisation and 5-yearly tetanus boosters. Occupational health and safety training and access to an occupational health service is mandatory.
SSD staff require proper protective clothing/equipment, as well as hepatitis B and tetanus immunisations.
The most widely used method for the final step in decontamination of heat-stable items is steam sterilization. Steam is a reliable, non-toxic and cost-effective method of sterilization. The machines used for steam sterilization are known as autoclaves, and can be downward displacement (gravity) or high-vacuum autoclaves. Items to be autoclaved must be wrapped in materials (cloth or paper) that allow penetration of steam. There are several validation methods used to ensure that the sterilization process is effective. Biological indicators measure the effectiveness of the autoclave in killing bacterial spores. Chemical indicators are used to verify that the items have been exposed to heat (e.g. autoclave tape) and that steam has penetrated the packs (e.g. the ‘Bowie Dick’ test). Records of validation testing should be kept in SSD in a logbook for at least five years. There is a variety of other methods of sterilization including flash sterilizers, dry-heat sterilization, irradiation, ethylene oxide and hydrogen peroxide gas plasma.
Steam (autoclaving) is a reliable, non-toxic and cost-effective method of sterilization.
Endoscopy procedures are often performed in dedicated procedure rooms, with requirement of a rapid turnaround time for processing of equipment. For this reason, decontamination of endoscopes usually occurs at point of care. Several outbreaks and infections from poorly decontaminated endoscopes have been documented worldwide. Several pathogens can be transmitted by endoscopes including blood-borne viruses, gastro-intestinal bacteria and in some countries, intestinal parasites.
Reprocessing is the process followed to make a piece of shared equipment safe to use on the next patient. Endoscope reprocessing is a highly technical procedure and should only be undertaken by appropriately trained staff. The steps in endoscope reprocessing include: thorough cleaning of all channels, chemical disinfection, rinsing, drying and storage. Most endoscopes are heat-sensitive so cannot be autoclaved or heat sterilized. It is critical to follow the manufacturer’s recommendations at every stage of the decontamination process. As the risk for cross-infection is high, users must ensure cleaning and high-level disinfection of endoscopes are tightly regulated (validated) and monitored.
A patient who has undergone a hernia repair presents to the outpatient’s department (OPD) after 14 days with a deep wound infection. The surgeon realises that this is the fifth case over the past eight weeks with an infected hernia repair. There is nothing out of the ordinary except that the operating theatre has been overloaded with work and has started decontaminating some surgical trays on site instead of sending them to the sterile services department (SSD) for reprocessing.
The operating theatre is not designed to reprocess a large number of surgical devices and only has equipment for reprocessing emergency instruments. Operating staff have not been adequately trained to clean and sterilize medical devices. They do not understand the validation process and how to deal with incorrect reprocessing cycles. There may not be adequate storage areas for the sterile packs.
Move the sterilization of surgical devices back to the SSD as soon as possible. If this is not possible, train the operating theatre staff to clean and reprocess surgical devices correctly. The reprocessing equipment must have validation systems in place to check each step of the cycle and there must be a visible record of each kept for a minimum of five years.
A young enthusiastic surgeon goes to a conference and comes back with a very sophisticated state of the art flexible hepatoscope (a type of endoscope). As an IPC practitioner you are asked to work out a way of reprocessing this item.
Find out more about the endoscope, contact the manufacturer and get the necessary guidelines on cleaning and disinfection. Since it is an expensive and delicate piece of equipment, the exact cleaning and disinfection method must be obtained from the manufacturer. Then set up a standard operating procedure (SOP) which includes absolutely every step and where possible validation of each step. Train the staff who will be dedicated to handle this device so that they are confident to deal with it and will recognise any shortfalls in the decontamination process. If none of this is possible, arrange for the manufacturer to recommend a private contractor who knows how to reprocess this equipment.
Consider blood-borne viruses, commonly HIV, hepatitis B and C but also other viruses that might affect the liver. In some countries parasitic diseases such as Echinococcus granulosis, liver fluke and others can be a problem. Healthcare-associated pathogens especially Pseudomonas, Acinetobacter, Staphylococcus aureus and enterococci must be considered. All these have to be dealt with in a clear and confident manner to make sure the equipment is safe to re-use.
The device can be dealt with by low temperature chemical disinfection methods, but never a sterilizer which reaches above 90°C. It has to be thoroughly cleaned; making sure each channel (including the biopsy channel) has been cleaned. The final stage would be to disinfect with the appropriate chemical as per manufacturer’s recommendations. Automated systems for reprocessing are preferable to manual ones but both can be equally effective if the endoscope is exposed for the correct time and thoroughly rinsed after exposure to chemicals.
You walk into a healthcare facility and are met with a strong smell of a disinfectant in the outpatient’s department (OPD). It was discovered that the cleaners were using hypochlorite for routine cleaning of the environment including the floors and all surfaces including the bedpans, because of ‘all the germs in the hospital’ and because ‘we have been doing it for years’.
No, by simply cleaning with warm water and detergent, 80-90% of organic matter will be removed and so will most pathogens. If the surfaces are visibly clean, then they are clean. No disinfectant is required for routine cleaning; only for terminal cleaning.
Hypochlorite is highly corrosive to metal and other materials, and therefore should not be used in these situations. It is also non-biodegradable and can lead to enhanced antimicrobial resistance. It is inactivated by organic matter and so becomes ineffectual in the presence of it.
There are very clear indications for the use of hypochlorite such as terminal cleaning after a Clostridium difficile infection or spillage of blood (wiped over after cleaning up).
The Department of Health is contacted after several patients at a dental practice are diagnosed with hepatitis C infection. Further testing of all dental practice patients reveals that 53 people have contracted hepatitis C (all shown to be the same strain). The dentist’s rooms are visited by an IPC practitioner to review the on-site decontamination and sterilization procedures and equipment.
She should perform a risk assessment to identify possible means by which blood-borne viruses could be transmitted. The following specific areas and procedures should be assessed:
It is not possible to adequately disinfect or sterilize rusty equipment. Any item that has rust on it should be condemned and replaced. It is essential that all critical medical equipment (like sterilizers) be maintained regularly, at least annually. This should be documented in a service logbook so that the facility has a record.
Inadequately decontaminated equipment can transmit blood-borne viruses and bacterial pathogens. Patients undergoing procedures with unsterile equipment are at very high risk of infection. Decontamination and sterilization procedures can be complicated and staff may be unfamiliar with the proper technique. Induction and regular in-service training are needed, especially if new instruments or new sterilization equipment is purchased.