Deactivation, Decontamination, Cleaning, and Disinfection

Implementation Date: 11/2021

Date of Last Revision: 6/24/2023

Next Review Due: 6/23/2026

 

Reviewed by VTH Administrative Team: 11/2021

Reviewed by VTH Board: N/A

 

Reviewed & Approved by Hospital Director: 11/2021

Reviewed by Biosecurity Subcommittee: N/A

Subject to modification by the VTH Director without approval.

Policy

The intent of this policy is to provide the procedure for areas and materials (e.g., hazardous, chemotherapy) that involve decontamination, deactivating, cleaning, and for disinfecting and the definition of each. This refers to all personnel who perform decontamination, deactivating, cleaning, and disinfecting areas/activities in hazardous drug handling areas.

Personnel performing these activities must wear appropriate PPE resistant to the cleaning agents and the materials being cleaned, including two pairs of chemotherapy gloves and chemotherapy impermeable disposable gowns. Personnel will follow the proper cleaning process steps in order: deactivation, decontamination, cleaning, and disinfection (if applicable).

Guidelines

1. Personnel must be trained and must wear appropriate and required PPE. PPE and supplies must have sufficient inventory available for waste handling and disposal, and routine cleaning of surfaces.
   
   
2. Deactivation, decontamination, cleaning, and disinfecting protocols and methods must take into consideration such as the agents used for the surface material and type of HD and how to apply (do not spray and use wet wipes with appropriate solution). Make sure the area is well-ventilated.

Procedure (if applicable)

1. All personnel who perform deactivation, decontamination, cleaning, and disinfection activities in HD handling areas must be trained in appropriate procedures to protect themselves and the environment from contamination.
   
   
2. All areas where hazardous drugs are handled, and all reusable equipment and devices must be deactivated, decontaminated, and cleaned.
   
   
3. Personnel must wear appropriate PPE:
   1. Required: 2 pairs of chemotherapy gloves and an impermeable disposable gown
   2. If any chance of splashing, eye protection and face shields must also be used
   3. Respiratory protection must be used if warranted by the activity
      
      
4. Sterile compounding areas and devices must be subsequently disinfected.
   
   
5. Discard mats and cleaning disposables as hazardous waste. Disposable materials must be discarded in accordance with EPA regulations.
   
   
6. C-PEC must be contaminated at least daily when used, any time a spill occurs, before and after certification, and any time voluntary interruption occurs or if the ventilation tool is moved. Any areas under the work tray where contamination may build require deactivation, decontamination, and cleaning at least monthly.
   
   
7. Agents used in processes: Sterile Water, Sterile 70% Alcohol, Lysol
   
   
8. Individuals must document (date and initial) on the daily cleaning log when complete.

Definitions and Abbreviations (if applicable)

CTSD: Closed System Transfer Device

Drug transfer device that mechanically prohibits the transfer of environmental contaminants into the system and the escape of HD or vapor concentrations outside the system

PPE: Personal Protective Equipment

USP: United States Pharmacopeia

BSC: Biological Safety Cabinet

C-PEC: Containment Primary Engineering Control

CACI: Compounding Aseptic Containment Isolator

HD: Hazardous Drug

Deactivation: Renders a compound inert or inactive

Decontamination: Inactivating, neutralizing, or physically removing hazardous drug residue from non-disposable surfaces and transporting it to absorbent, disposable material

Cleaning: Removal of contaminants from objects and surfaces using water, detergents, surfactant, solvents, and/or other chemicals

1. 1. No cleaning step may be performed when compounding activities are occurring.

Disinfection: Destroying or inhibiting micro-organisms

1. 1. Disinfection is completed for areas intended to be sterile.

Veterinary Teaching Hospital (VTH): The collective clinical services of the Large Animal Clinic, Midwest Equine, the Small Animal Clinic, and the Veterinary Medicine South Clinic.