A quality improvement project to standardise decontamination procedures in a single NHS board in Scotland

Review of decontamination protocols for shared non-critical objects in 35 policies of UK NHS Acute Care Organisations

BACKGROUND

Decontamination of non-critical objects shared by patients is key in reducing HAIs, but it is a complex process that needs precise guidance from UK NHS Acute Care Organisations (ACOs).

AIM

To review the indications given by NHS ACOs' policies regarding the decontamination of shared non-critical devices.

METHODS

Detailed lists of decontamination protocols for shared non-critical objects were retrieved from cleaning, disinfection, and decontamination policies of 35 NHS ACOs. Three parameters were considered for each object: decontamination method, decontamination frequency and person responsible for decontamination.

FINDINGS

1279 decontamination protocols regarding 283 different shared non-critical objects were retrieved. 689 (54%) did not indicate the person responsible for decontamination, while only 425 (33%), were complete, giving indications for all three parameters analysed. Only 2.5% (32/1279) decontamination protocols were complete and identical in two policies. In policies where cleaning represented the major decontamination method, chemical disinfection was rarely mentioned and vice versa. A general agreement among policies can be found for four main decontamination methods (detergent and water, detergent wipes, disinfectant wipes, use of disposable items), two decontamination frequencies (between events, daily) and two responsible person designations (nurses, domestic staff).

CONCLUSIONS

Decontamination protocol policies for shared non-critical objects had some similarities but did not concur on how each individual object should be decontaminated. The lack of clear indications regarding the person responsible for the decontamination process put at risk the ability of policies to serve as guidance.