Guidelines for Global Healthcare Settings
This guide is designed for healthcare facilities worldwide, especially those with limited resources in low- and middle-income countries. Healthcare facilities in the U.S. should consult specific U.S. environmental cleaning resources.
U.S. Healthcare Environment Infection Prevention
This chapter outlines the most current best practices for environmental cleaning in patient care areas. It covers routine cleaning, cleaning in specific situations like blood spills, and cleaning noncritical patient care equipment. Summaries are available in Appendix B1 – Cleaning procedure summaries for general patient areas and Appendix B2 – Cleaning procedure summaries for specialized patient areas.
The specific environmental cleaning procedures for each patient care area, including how often, the methods, and the processes, should be determined by the risk of pathogen transmission.
This risk is based on:
- Probability of contamination: How likely is the area to be contaminated?
- Vulnerability of patients to infection: How susceptible are the patients in this area to infections?
- Potential for exposure: Are surfaces high-touch or low-touch?
These factors combine to define low, moderate, and high-risk levels. High-risk areas require more frequent and rigorous environmental cleaning using different methods and processes. Risk assessment is the key to determining cleaning frequency, method, and process in both routine and contingency cleaning schedules for all patient care areas. This risk-based approach is detailed in Appendix A – Risk-assessment for determining environmental cleaning method and frequency.
Risk-Based Principles for Environmental Cleaning Frequency
Contamination Probability: Surfaces with high contamination require more frequent and thorough cleaning than moderately contaminated surfaces. Moderately contaminated surfaces, in turn, need more rigorous cleaning than lightly contaminated or non-contaminated surfaces.
Patient Vulnerability: Areas caring for vulnerable patients (e.g., immunosuppressed) need more frequent and rigorous cleaning compared to areas with less vulnerable patients.
Pathogen Exposure Potential: High-touch surfaces (e.g., bed rails) must be cleaned more often and more thoroughly than low-touch surfaces (e.g., walls).
Every healthcare facility should create detailed cleaning schedules that include:
- Identifying the responsible person.
- Specifying the cleaning frequency.
- Defining the method (product, process).
- Detailed Standard Operating Procedures (SOPs) for cleaning surfaces and noncritical equipment in every patient care area.
Checklists and job aids are essential tools to ensure thorough and effective cleaning.
These aspects are further explained in 2.4.3 Cleaning checklists, logs, and job aids.
4.1 Essential Environmental Cleaning Techniques
For all environmental cleaning procedures, use these fundamental strategies:
Preliminary Visual Site Assessment
Before starting, perform a visual preliminary site assessment to check:
- If the patient’s condition might affect safe cleaning procedures.
- If extra Personal Protective Equipment (PPE) or supplies are needed (e.g., for blood/body fluid spills or if the patient is under transmission-based precautions).
- For obstacles (e.g., clutter) or issues that could impede safe cleaning.
- For any damaged or broken furniture or surfaces that need reporting to a supervisor.
Cleaning from Cleaner to Dirtier Areas
Always clean from cleaner to dirtier areas to prevent spreading dirt and microorganisms. Examples include:
- In terminal cleaning, clean low-touch surfaces before high-touch surfaces.
- Clean patient areas (e.g., patient zones) before patient toilets.
- Within a patient room, terminal cleaning should begin with shared equipment and common surfaces, then move to surfaces and items touched during patient care outside the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone (Figure 9). High-touch surfaces outside the patient zone should be cleaned before high-touch surfaces inside it.
- Clean general patient areas (not under transmission-based precautions) before areas under transmission-based precautions.
Figure 9. Best practice for cleaning strategy moving from cleaner zones to dirtier zones within a patient area.
Cleaning from High to Low (Top to Bottom)
Clean from high to low to prevent dirt and microorganisms from contaminating already cleaned areas by dripping or falling. For example:
- Clean bed rails before bed legs.
- Clean environmental surfaces before floors.
- Clean floors last to collect any fallen dirt and microorganisms.
Methodical and Systematic Cleaning Approach
Clean in a systematic manner to ensure no areas are missed—for instance, left to right or clockwise (Figure 10).
In multi-bed areas, clean each patient zone consistently, e.g., starting at the foot of the bed and moving clockwise.
Figure 10. Example of a systematic cleaning strategy for environmental surfaces, moving in a pattern around the patient care area.
Immediate Attention to Body Fluid Spills
Clean spills of blood or body fluids immediately, following the procedures in 4.5 Spills of blood or body fluids.
General Surface Cleaning Process:
- Thoroughly saturate a fresh cleaning cloth with environmental cleaning solution.
- Fold the cloth to a hand-size for efficient use of all surface areas (typically fold in half, then in half again to create 8 cleaning sides).
- Wipe surfaces using the strategies mentioned above (clean to dirty, high to low, systematic), using mechanical action for cleaning and ensuring surfaces remain wet for the required contact time for disinfection.
- Regularly rotate and unfold the cloth to use all sides.
- Dispose of the cloth or store for reprocessing when all sides are used or it’s no longer saturated.
- Repeat from step 1.
Best Practices for Surface Cleaning:
- Use fresh cloths at the start of each cleaning session (e.g., daily routine cleaning).
- Change cloths when they are no longer saturated, replacing with a new, wetted cloth. Store soiled cloths for reprocessing.
- In higher-risk areas, change cloths between each patient zone (i.e., new cloth per patient bed), especially in intensive care units (ICUs)—see 4.6 Specialized patient areas.
- Ensure sufficient cloths are available to complete the cleaning session.
- Never double-dip cloths into portable containers of cleaning solutions.
- Never shake mop heads or cloths, as this spreads dust and droplets containing microorganisms.
- Never leave soiled mop heads and cloths soaking in buckets.
High-Touch Surfaces
Identifying high-touch surfaces in each patient care area is essential for effective cleaning procedures, as these vary by room, ward, and facility. Refer to Appendix C – Example of high-touch surfaces in a specialized patient area. Consult clinical staff in each area to assess workflows and determine key high-touch surfaces.
Include identified high-touch surfaces in checklists and job aids to ensure thorough cleaning. See 2.4.3 Cleaning checklists, logs, and job aids.
Common High-Touch Surfaces:
- Bedrails
- IV poles
- Sink handles
- Bedside tables
- Counters for medication and supply preparation
- Edges of privacy curtains
- Patient monitoring equipment (keyboards, control panels)
- Transport equipment (wheelchair handles)
- Call bells
- Doorknobs
- Light switches
4.2 Cleaning Protocols for General Patient Areas
General patient areas include outpatient or ambulatory care wards and general inpatient wards for patients not requiring acute care.
These areas require three types of cleaning:
- Routine cleaning.
- Terminal cleaning.
- Scheduled cleaning.
Generally, the risk of contamination and patient vulnerability is lower in these areas, requiring less frequent and rigorous cleaning than specialized patient areas.
4.2.1 Outpatient Wards Cleaning
General outpatient or ambulatory care wards include waiting areas, consultation rooms, and minor procedural areas.
Table 6. Recommended Cleaning Frequency, Method, and Process for Outpatient Wards
| Area | Frequency | Method | Process |
|---|---|---|---|
| Waiting / Admission | At least once daily (per 24-hour period) | Clean | High-touch surfaces and floors |
| Consultation / Examination | At least twice daily | Clean | High-touch surfaces and floors |
| Procedural (minor operative) | Before and after each proceduree | Clean & Disinfect | High-touch surfaces and floors, focus on patient zone, procedure table |
| Procedural (minor operative) | End of day (terminal clean) | Clean & Disinfect | All surfaces and floors, handwashing sinks (scrub & disinfect), sluice areas/sinks |
| All | Scheduled basis (weekly, monthly), visibly soiled | Clean | Low-touch surfaces; see 4.2.4 Scheduled cleaning |
e If prolonged time between procedures or dust risk, re-wipe surfaces with disinfectant before next procedure.
4.2.2 Routine Cleaning of Inpatient Wards
Routine cleaning in inpatient areas occurs while patients are admitted, focusing on patient zones to remove organic material and reduce microbial contamination for a visually clean environment.
Note: This is done while the room is occupied, requiring systems to ensure cleaning staff access for routine cleaning.
Table 7. Recommended Cleaning Frequency, Method, and Process for Routine Cleaning of Inpatient Wards
| Frequency | Method | Process |
|---|---|---|
| At least once daily (per 24-hour period) | Clean | High-touch surfaces and floors, handwashing sinks |
| Scheduled basis (e.g., weekly), visibly soiled | Clean | Low-touch surfaces; see 4.2.4 Scheduled cleaning |
4.2.3 Terminal Cleaning of Inpatient Wards
Terminal cleaning in inpatient areas occurs after patient discharge/transfer. It includes the patient zone and wider area, aiming to eliminate microbial contamination transfer to the next patient.
Terminal cleaning requires collaboration between cleaning, IPC, and clinical staff to define responsibilities for every surface and item, including:
- Discarding disposable personal care items.
- Removing patient care equipment for reprocessing.
Checklists and SOPs should identify staff responsibilities to prevent overlooked items due to confusion.
Table 8. Recommended Cleaning Frequency, Method, and Process for Terminal Cleaning of Inpatient Wards
| Frequency | Method | Process |
|---|---|---|
| Patient transfer or discharge | Clean & Disinfect | See general terminal cleaning process below |
General Terminal Cleaning Process:
- Remove soiled/used personal care items (e.g., cups, dishes) for reprocessing or disposal.
- Remove facility linens for reprocessing or disposal. See Appendix D – Linen and laundry management.
- Inspect window treatments. Clean blinds on-site if soiled, and remove curtains for laundering.
- Reprocess all reusable noncritical patient care equipment; see 4.7 Noncritical patient care equipment.
- Clean and disinfect all low- and high-touch surfaces, including less accessible areas (e.g., mattress, bedframe, tops of shelves, vents), and floors.
- Clean (scrub) and disinfect handwashing sinks.
4.2.4 Scheduled Cleaning
Scheduled cleaning is done alongside routine or terminal cleaning to reduce dust and soiling on low-touch surfaces not typically soiled. Use neutral detergent and water for these surfaces. If visibly soiled with blood or body fluids, clean and disinfect immediately.
Table 9. Recommended Cleaning Frequency, Method, and Process for Scheduled Cleaning of Inpatient Wards
| Frequency | Method | Process |
|---|---|---|
| Weekly | Clean | High surfaces (above shoulder height) like cupboard tops, vents, walls, baseboards, corners |
| Monthly | Clean | Window blinds, bed curtains |
| Annually | Clean | Window curtains |
4.3 Cleaning Patient Area Toilets
Toilets in patient care areas, whether private or shared, have high patient exposure (high-touch surfaces) and are frequently contaminated, posing a higher pathogen transmission risk than general areas.
Cultural Considerations
Toileting practices vary, affecting cleaning and disinfection needs. More than twice daily cleaning and disinfection might be necessary in some cases.
Dedicated cleaning staff for shared toilets can reduce associated risks, depending on resources and staffing.
Table 10. Recommended Cleaning Frequency, Method, and Process for Patient Area Toilets
| Area | Frequency | Method | Process |
|---|---|---|---|
| Private toilets | At least once daily (per 24-hour period), after routine cleaning of patient area | Clean & Disinfect | High-touch and frequently contaminated surfaces (sinks, faucets, handles, toilet seat, door handles) and floors |
| Public or shared toilets | At least twice daily | Clean & Disinfect | High-touch and frequently contaminated surfaces (sinks, faucets, handles, toilet seat, door handles) and floors |
| Both (private & shared) | Scheduled basis (weekly), visibly soiled | Clean | Low-touch surfaces; see 4.2.4 Scheduled cleaning |
4.4 Cleaning Patient Area Floors
Floors generally have low patient exposure (low-touch surfaces) and pose a low pathogen transmission risk. Daily cleaning is usually sufficient, and disinfectant is not always needed under normal conditions.
Higher-risk situations may require floor disinfection. Refer to 4.2 General patient areas and 4.6 Specialized patient areas for guidance on floor cleaning frequency and when disinfection is necessary.
Table 11. Recommended Cleaning Frequency, Method, and Process for Patient Area Floors
| Area | Frequency | Method | Process |
|---|---|---|---|
| Floors in general inpatient and outpatient areas | At least once daily (per 24-hour period) or as specified for the area | Clean (unless specified otherwise) | See general mopping process below |
General Mopping Process:
- Immerse mop or floor cloth in cleaning solution and wring out.
- Mop in a figure-8 pattern with overlapping strokes, turning the mop head regularly (every 5-6 strokes).
- After cleaning a small area (e.g., 3m x 3m), rinse mop/cloth in rinse water and wring out.
- Repeat from step 1.
Figure 11. Illustration of effective mopping strategy, working towards the exit to avoid re-soiling cleaned areas.
Best Practices for Floor Cleaning:
- Use wet floor or caution signs to prevent injuries.
- Mop from cleaner to dirtier areas.
- Mop systematically, moving from farthest area from the exit towards the exit (Figure 11).
- Change mop heads/cloths and cleaning/disinfectant solutions as needed (visibly soiled, after isolation room, every 1-2 hours) and at the end of each session.
4.5 Managing Spills of Blood or Body Fluids
Regardless of the area’s risk level, blood or body fluid spills (e.g., vomitus) must be cleaned and disinfected immediately using a two-step process.
Table 12. Recommended Cleaning Frequency, Method, and Process for Spills of Blood or Body Fluids
| Area | Frequency | Method | Process |
|---|---|---|---|
| Any spill in any patient area | Immediately, ASAP | Clean and disinfect: – do not use combined detergent-disinfectant – use intermediate-level disinfectant | See general process for cleaning blood/body fluid spills below |
General Process for Cleaning Blood or Body Fluid Spills:
- Wear appropriate PPE. See Table 5 in 3.4 Cleaning Supplies and Equipment.
- Confine the spill and wipe it up immediately with absorbent materials (paper towels, cloths, or granules to solidify liquids). Dispose of materials as infectious waste.
- Clean thoroughly with neutral detergent and warm water solution.
- Disinfect using a facility-approved intermediate-level disinfectant.
- Chlorine-based disinfectants at 500-5000ppm free chlorine (1:100 or 1:10 dilution of 5% chlorine-bleach, depending on spill size) are usually adequate (avoid chlorine on urine spills). See Appendix E – Chlorine disinfectant solution preparation.
- Ensure disinfectant remains wet for the required contact time (e.g., 10 minutes), then rinse with clean water to remove residue (if required).
- Immediately send reusable supplies and equipment (cloths, mops) for reprocessing (cleaning and disinfection) after spill cleanup.
4.6 Specialized Patient Areas Cleaning Protocols
Specialized patient areas include units serving:
- High-dependency patients (ICUs).
- Immunosuppressed patients (bone marrow transplant, chemotherapy).
- Patients undergoing invasive procedures (operating rooms).
- Patients frequently exposed to blood or body fluids (labor and delivery, burn units).
Roles and Responsibilities
Clearly define roles and responsibilities for environmental cleaning in these high-risk areas.
This vulnerable population and high contamination probability make these areas higher risk than general patient areas.
Unless specified, environmental surfaces and floors in the following sections require cleaning and disinfection with a facility-approved disinfectant for all described cleaning procedures.
4.6.1 Operating Room Cleaning
Operating rooms are highly specialized, with controlled atmospheres for surgical procedures. They require cleaning at three distinct intervals:
- Before the first procedure.
- Between procedures.
- After the last procedure (terminal cleaning).
Responsible Staff
Surgery department clinical staff often manages operating room cleaning due to its specialized nature. Operating room nurses and assistants may perform cleaning duties alongside or instead of general cleaning staff.
Critical and semi-critical equipment reprocessing is not the responsibility of environmental cleaning staff. These procedures cover only environmental surfaces and noncritical equipment.
Clearly defined cleaning responsibilities are crucial for all surfaces and noncritical equipment (stationary and portable), using checklists and SOPs.
Table 13. Recommended Cleaning Frequency and Process for Operating Rooms
| Frequency | Process
