3. Environmental Cleaning Supplies and Equipment
Best Practices for Environmental Cleaning in Global Healthcare Facilities with Limited Resources
The materials on this page were created for use in global healthcare facilities with limited resources, particularly in low- and middle-income countries. Environmental cleaning resources designed for U.S. healthcare facilities can be found at Healthcare Environment Infection Prevention.
The selection and appropriate use of supplies and equipment is critical for effective environmental cleaning. This chapter provides overall best practices for selection, preparation, and care of environmental cleaning supplies and cleaning equipment, including:
- cleaning and disinfectant products
- reusable/disposable supplies and equipment
- PPE used by cleaning staff for performing cleaning procedures
3.1 Products for environmental cleaning
There are different kinds of products available for environmental cleaning, which all have distinct properties and advantages and disadvantages to their potential use in healthcare.
Ideal Properties
For all products used for healthcare environmental cleaning:
Nontoxic: it should not be irritating to the skin or mucus membranes of the user, visitors, and patients. Everything being equal, choose products with the lowest toxicity rating.
Easy to use: directions for preparation and use should be simple and contain information about PPE as required.
Acceptable odor: it should not have offensive odors to users and patients.
Solubility: it should be easily soluble in water (warm and cold).
Economical/Low cost: it should be affordable.
Additional Ideal Properties
For cleaning products:
- Efficacious: should remove dirt, soil, and various organic substances.
- Environmentally friendly: should not cause environmental pollution upon disposal; biodegradable.
For disinfectants:
- Broad spectrum: it should have a wide antimicrobial range, including those pathogens that are common causes of HAIs and outbreaks.
- Rapid action: it should be fast acting and have a short contact time.
- Remains wet: it should keep surfaces wet long enough to meet recommended contact times with a single application.
- Not affected by environmental factors: it should be active in the presence of trace quantities of organic matter (e.g., blood) and compatible with cleaning supplies (e.g., cloths) and products (e.g., detergents) and other chemicals encountered in use.
- Material compatibility: it should be proven compatible with common healthcare surfaces and equipment.
- Persistence: it should have residual antimicrobial effect on the treated surface.
- Cleaner: it should have some cleaning properties.
- Nonflammable: it should have flash point of more than 65°C (150°F).
- Stability: it should be stable in concentration and use dilution.
These are the best practices for environmental cleaning products (e.g., detergents, disinfectants):
- Develop and maintain a master list of facility-approved environmental cleaning products in the facility cleaning policy, as well as a list of approved suppliers (i.e., manufacturers, distributors).
- Minimize the number of different environmental cleaning products in use at the facility. Clearly stating this in the facility cleaning policy will:
- simplify the environmental cleaning process
- minimize the training requirements for cleaning staff
- reduce the potential for errors in preparation and use
- Store environmental cleaning products in a manner that:
- eliminates contamination risk and degradation
- minimizes contact with personnel (e.g., inhalation, skin contact)
- Manage environmental cleaning products according to the product’s safety data sheet (SDS). Display the SDS where these products are stored and prepared.
- Prepare cleaning and disinfectant solutions according to manufacturer’s instructions. Preparing higher-strength concentrations or diluting beyond recommendations may pose unnecessary risk to patients, staff, visitors, and the environment.
- Ensure that environmental cleaning products are selected that do not damage the surfaces and equipment to be cleaned and disinfected.
- Ensure that standard operating procedures or instructions are available for the preparation, use, and disposal of environmental cleaning products.
3.1.1 Cleaning products
Cleaning products include liquid soap, enzymatic cleaners, and detergents. They remove organic material (e.g., dirt, body fluids) and suspend grease or oil. This is done by combining the cleaning product with water and using mechanical action (i.e., scrubbing and friction).
For most environmental cleaning procedures, select neutral detergents (pH between 6 and 8) that are easily soluble (in warm and cold water).
There are also specialized cleaning products, which may provide advantages for specific areas or materials within the healthcare facility (e.g., bathroom/toilet cleaners, floor polishers, glass cleaners). However, consider specialized products on a case-by-case basis, weighing the advantages and disadvantages (e.g., additional cost) and ability of the facility to ensure the correct storage, preparation, and use.
3.1.2 Disinfectants
Disinfectants are only for disinfecting after cleaning and are not substitutes for cleaning, unless they are a combined detergent-disinfectant product. See 3.1.3. Combined detergent-disinfectants. Before disinfecting, use a cleaning product to remove all organic material and soil.
Low-level disinfection is generally adequate for environmental cleaning procedures, but there are specific cases where intermediate-level disinfection with sporicidal properties (e.g., C. difficile) is required. See 4.6.8 Transmission-based precaution/Isolation wards.
Common low- and intermediate-level disinfectants that can be used for environmental surfaces in healthcare settings include:
- quaternary ammonium compounds
- alcohol (ethyl or isopropyl)
- chlorine releasing agents (e.g., bleach)
- improved hydrogen peroxide
Table 4 shows the main advantages and disadvantages of each of these disinfectants. In practice, the advantages and disadvantages of each product will have to be weighed with other factors, including availability and cost.
Do not use these products for disinfection of environmental surfaces and noncritical patient care equipment:
liquid chemical sterilant or high-level disinfectants (e.g., glutaraldehyde, peracetic acid, orthophthaldehyde)
antiseptics (e.g., chlorhexidine, iodophors)
phenolics (due to high toxicity)
Low-level disinfectant:
Quaternary ammonium compounds such as:
- alkyl dimethyl benzyl ammonium chloride
- alkyl dimethyl ethylbenzyl ammonium chloride
Spectrum of activity:
- Bactericidal
- Virucidal (only enveloped viruses)
- Fungicidal
| Advantages | Disadvantages |
|---|---|
Toxicity:
Wide material compatibility:
Detergent properties, with good cleaning ability Low cost |
Toxicity:
Narrow microbiocidal spectrum:
Affected by environmental factors:
|
Intermediate-level disinfectant:
Alcohols (60-80%) such as
- isopropyl alcohol,
- ethyl alcohol
- methylated spirits
Spectrum of activity:
- Bactericidal
- Virucidal
- Fungicidal
| Advantages | Disadvantages |
|---|---|
| Broad spectrum (but not sporicidal)
Rapid action Nontoxic Non-staining, no residue Noncorrosive Low cost Good for disinfecting small equipment or devices that can be immersed |
Slow acting against non-enveloped viruses
Does not remain wet.
Affected by environmental factors:
Material compatibility:
Flammable |
Intermediate-level disinfectant:
Chlorine releasing agents such as
- bleach/sodium or calcium hypochlorite
- sodium dichloroisocyanurate (NaDCC)
Spectrum of activity:
- Bactericidal
- Virucidal
- Fungicidal
- Mycobactericidal
- Sporicidal (hypochlorites only at 5000ppm or 0.5%)
| Advantages | Disadvantages |
|---|---|
| Hypochlorites are broad spectrum (sporicidal)
Rapid action Nonflammable Low cost Widely available Can reduce biofilms |
Affected by environmental factors:
High toxicity:
Material compatibility:
Leaves residue, requires rinsing or neutralization. Offensive odors Poor stability:
|
Intermediate-level disinfectant:
Improved hydrogen peroxide such as:
- 5% enhanced action formulation hydrogen peroxide
- 3% hydrogen peroxide
Spectrum of activity:
- Bactericidal
- Virucidal
- Fungicidal
- Mycobactericidal
- Sporicidal (only at 4-5%)
| Advantages | Disadvantages |
|---|---|
| Rapid action
Nontoxic Detergent properties, with good cleaning ability Not affected by environmental factors
Safe for environment Can reduce biofilms |
Material compatibility:
High cost |
24. Rutala WA, Weber DJ. 2016. Monitoring and improving the effectiveness of surface cleaning and disinfection. American Journal of Infection Control 44: e69-e76.
3.1.3 Combined detergent-disinfectants
Combined (one-step) detergent-disinfectant products can generally be used in place of a two-step (separate detergent and disinfectant product) process when disinfection is indicated for specific environmental cleaning procedures. See 4. Environmental Cleaning Procedures.
Do not use a combined (one-step) detergent-disinfectant product (instead use a two-step process) when performing environmental cleaning for:
- C. difficile—see 4.6.8 Transmission-based precaution/Isolation wards.
- spills of blood or bodily fluids—see 4.5 Spills of blood or body fluids.
When using a combined product for environmental cleaning, it is recommended to periodically (i.e., on a scheduled basis) use a rinse step to remove residues from surfaces. Additionally, care should be taken to ensure that the combined product stays wetted on the surface for the required contact time (to complete the disinfection process). Consult the product label to get the correct contact time.
3.2 Preparation of environmental cleaning products
Environmental cleaning products are often sold as concentrated formulas that are diluted (i.e., combined with water) to make a solution.
These are the best practices for preparation of environmental cleaning products:
- Always prepare solutions according to the manufacturer’s instructions. Most chemicals (including cleaning products) work at an optimum dilution—too diluted or too concentrated impacts the effectiveness of the product and may pose unnecessary risk to staff, patients, visitors, and the environment.
- Always prepare environmental cleaning products in designated environmental cleaning services areas (i.e., a dedicated, secured space not used for any other purposes). See 3.5 Care and storage of supplies, equipment, and personal protective equipment.
- Provide training and simple instructions (e.g., standard operating procedures (SOPs)) for preparing solutions according to manufacturer’s instructions.
- Personal protective equipment (PPE) might be required for preparation of solutions, particularly for disinfectants (e.g., sodium hypochlorite). Consult the product’s SDS for the required PPE.
- Standardized containers (for measuring solutions) and easy to use pictorial job aids (e.g., posters) should be used for preparation of solutions.
If feasible, it is highly recommended to:
- Prepare solutions with an automatic dispensing system that is calibrated regularly. Manual dilution and mixing are more subject to error.
- Use test strips to confirm correct concentrations of solutions (e.g., for chlorine-based products).
Solutions are generally batch prepared in large containers, which are then transferred to smaller, portable containers (e.g., bottles, buckets) for daily cleaning procedures. See 3.3 Supplies and equipment for environmental cleaning. Solutions can also be prepared directly into buckets for environmental cleaning of floors, if a standard-sized bucket is available.
All containers used for storing solutions of environmental cleaning products should:
- be clean, clearly labeled, and have an expiration date based on the manufacturer’s instructions for stability
- be thoroughly cleaned and dried before refilling
- never be topped up—use them until the indicated expiration date (after which it should be disposed) or until the container is empty, whichever comes first
3.3 Supplies and equipment for environmental cleaning
Essential supplies and equipment for environmental cleaning include:
Surface cleaning supplies:
- portable containers (e.g., bottles, small buckets) for storing environmental cleaning products (or solutions)
- surface cleaning cloths.
Floor cleaning supplies:
- mops or cleaning squeegee with floor cloth
- Buckets
- wet floor/caution signs.
Do not use these cleaning supplies and equipment for disinfection of environmental surfaces and noncritical patient care equipment:
- brooms and dry mops
- fumigators (and fumigation) and disinfectant fogging
- spray bottles: use squeeze bottles instead
In general, all the essential environmental cleaning supplies and equipment are reusable, but facilities can also choose to use disposable supplies (e.g., cloths) for certain cleaning tasks or where resources allow. Cleaning equipment should be:
- fit for the intended purpose
- cleaned and stored dry between uses
- properly used
- well maintained; see 3.5 Care and storage of supplies, equipment, and personal protective equipment.
Consider purchasing supplemental supplies and equipment such as toilet brushes or abrasive pads for cleaning certain surfaces or areas. Some facilities might also have access to more sophisticated equipment such as floor scrubbers or vacuum cleaners with high-efficiency particulate air (HEPA) filters. If the use of HEPA filters is part of the facility policy, provide an SOP on its cleaning and maintenance.
Surface cleaning supplies
Portable containers for environmental cleaning products (or solutions) should be clean, dry, appropriately-sized, labelled, and dated.
- Narrow-necked bottles are preferred over buckets to prevent the “double-dipping” of cleaning cloths, which can contaminate solutions.
- Squeeze bottles are preferred over spray bottles for applying cleaning or disinfectant solutions directly to cleaning cloths before application to a surface.
Surface cleaning cloths should be cotton or microfiber (disposable wipes can be used if resources allow). Have a supply of different colored cloths to allow color-coding: for example, one color for cleaning and a second color for disinfecting. Color-coding also prevents cross-contamination between areas, like from toilets to patient areas, or isolation areas to general patient areas. For example, red cloths could be used specifically for toilet areas, blue for general patient areas, and yellow for isolation areas.
Floor cleaning supplies
Mop heads or floor cloths should be cotton or microfiber.
- Use a cart or trolley with two or three buckets for the mopping process—see 3.3.1 Preparation of supplies and equipment.
- It is highly recommended to display a wet floor/caution sign before starting mopping activities.
Figure 3. Portable squeeze bottle
Figure 4. Color-coded cleaning cloths
Figure 5. Cotton mop (left), microfiber floor cloth (right) and a floor safety sign
Microfiber Versus Cotton
Give careful consideration to the type of material before purchasing cleaning cloths.
Microfiber cloths are often preferred over cotton for both cleaning cloths and mop heads because microfiber absorb more dirt and microorganisms than cotton. However, microfiber cloths can be damaged by high pH and therefore not compatible with all disinfectant products (especially chlorine-based). They need to be laundered separately from cotton cloths/linens, which could be expensive.
Disinfectant or Detergent-Disinfectant Wipes
Prepared (ready-to-use) wipes that are saturated with an appropriate disinfectant or detergent-disinfectant product can be used as an alternative to cotton or microfiber cleaning cloths. Take care to evaluate the appropriateness of the product, considering the recommended properties. It is also important to ensure that they are stored appropriately with the lid closed, so the wipes remain wet. Discard wipes if they are no longer saturated. Follow manufacturer’s instructions for storing wipes and reprocessing containers, as well as instructions for use (e.g., recommended contact times).
3.3.1 Preparation of supplies and equipment
Daily preparation of supplies and equipment for a given cleaning staff member or location will depend on local factors, including the size of patient care areas and number and type of patient zones to be cleaned.
Cleaning carts and trolleys
Figure 6. Cleaning cart setup, including color-coded buckets for different environmental cleaning solutions (e.g., disinfectants, detergents)
- Cleaning carts and trolleys provide several benefits, such as the ability to carry and safely manage all the essential cleaning supplies and equipment and increased occupational safety for cleaning staff.
- Stock cleaning carts with sufficient quantities of supplies (e.g., cleaning cloths, cleaning solutions) to avoid the need to return for more supplies in the middle of cleaning in a particular patient care area.
These are the best practices for cleaning carts and trolleys:
- Separate clean and soiled items (e.g., cleaning cloths)
- Never put personal items, food, or beverages in them.
- Equip them with a lockable compartment for containers of cleaning and disinfectant solutions.
- Thoroughly clean them at the end of each day or shift—see 3.5 Care and storage of supplies, equipment, and personal protective equipment.
- While in use, never leave them unattended or out of your sight.
- When not in use, store them in a designated environmental cleaning services area.
Surface cleaning supplies
Portable containers of environmental cleaning products (or solutions) and cleaning cloths can be carried directly on the cleaning cart or on a caddie kit, if a full cleaning cart is not available.
The cart should have enough cleaning cloths to complete the required cleaning session, with a clean cloth for each patient zone to prevent cross-contamination. Keep clean and soiled cloths separate. Place clean clothes in one container or section of the caddie and soiled cloths in another.
Floor cleaning supplies
It is best practice to use a two- or three-bucket system for mopping. This can be facilitated on the cleaning cart or on a separate trolley, if a full cleaning cart is not available.
- Two-bucket system (routine cleaning):
one bucket contains a detergent or cleaning solution and the other contains rinse water (Figure 7). - Three-bucket system (for disinfection):
one bucket contains the detergent or cleaning solution, one contains rinse water and one the disinfectant or disinfectant solution (Figure 8).
The rinse water bucket allows the mop to be rinsed and wrung out before it is re-dipped into the prepared solution. This extends the life of the solution (i.e., fewer changes are required), which saves both time and material costs.
Figure 7. Two-bucket mopping system
Figure 8. Three-bucket mopping system
3.4 Personal protective equipment for environmental cleaning
Appropriate PPE for the cleaning staff for all environmental cleaning procedures should always be available and used appropriately to reduce risk to both patients and staff.
PPE is required to prevent:
- exposure to microorganisms
- exposure to cleaning chemicals (e.g., disinfectants)
- the spread of microorganisms from one patient care area to another
The PPE required should be visibly marked or verbally communicated to cleaning staff by IPC staff by cleaning supervisors, before starting every cleaning session.
IPC staff should either visibly mark or verbally communicate required PPE to staff or cleaning supervisors before starting every cleaning session.
These are the best practices for cleaning staff PPE:
- Always perform hand hygiene immediately before wearing gloves (donning) and immediately after removal (doffing).
- Train cleaning staff on appropriate use, application, and removal of required PPE for all environmental cleaning procedures and tasks for which they are responsible.
- Table 5 shows the general indications for PPE use, but always consult local IPC staff about location-specific PPE requirements.
- Put on all required PPE before entering a patient care area and remove it (for disposal or reprocessing, if reusable) before leaving that area.
- Exception: do not take off PPE in an airborne precaution area (e.g., TB ward) where a respirator (e.g., N95 or FPP2) is required, until after departing that area.
- SOPs and pictorial job aids should list required PPE for specific tasks (including signage for isolation areas, preparation of solutions).
- Use SDS to determine required PPE for preparing environmental cleaning products and solutions (e.g., manual dilutions).
- Make sure all PPE (reusable and disposable) is:
- in good supply
- well maintained (good quality, appropriately stored)
- cleaned before use
- in good repair
- Reprocess (i.e., clean and disinfect) all reusable PPE at least once a day. See 3.5 Care and storage of supplies, equipment, and personal protective equipment.
- Conduct regular fit-testing for cleaning staff who are required to wear respirators.
- Use reusable rubber gloves for cleaning.
Use chemical-resistant gloves (e.g., nitrile, latex) for preparation of cleaning chemicals.
Best practices for glove usage for cleaning:
- Perform hand hygiene immediately before putting on gloves and directly after taking them off.
- Routine use of gloves is not recommended unless:
- the patients in the area are on transmission-based precautions
- there is risk of hand contact with blood or body fluids (e.g., cleaning a spill, cleaning the bed of an incontinent patient)
- there is prolonged contact with disinfectants (e.g., terminal cleaning)
- When use of gloves is indicated always change them (i.e., reprocess) between each cleaning session (e.g., routine cleaning of a patient zone under contact precautions, terminal cleaning of a general patient area). See Table 5.
Best practices for cleaning staff personal attire/grooming:
- Keep sleeves at or above the elbow to not interfere with glove use or hand hygiene.
- Wear rubber-soled closed toe shoes or boots (i.e., not sandals), to prevent accidental injury (e.g., slips and falls) and exposure to cleaning chemicals, dirt, or bacteria.
- Remove wristwatches and hand jewelry before starting cleaning tasks—these items can tear gloves and can also pick up microorganisms.
- Keep fingernails short and free of nail varnish to prevent tearing of gloves and picking up dirt and bacteria.
Table 5. Recommended personal protective equipment for environmental cleaning tasks / cleaning in specific patient areas
| Type of cleaning task | Required personal protective equipment for cleaning staff |
|---|---|
| Routine cleaning (standard precautions) | None (unless spills or contamination risk—see below) |
| Terminal cleaning (standard precautions) | Reusable rubber gloves |
| Blood and body fluid spills and high contamination risk areas (e.g., cleaning bed of an incontinent patient, labor and delivery wards) | Gown and/or plastic apron
Reusable rubber gloves Face mask with either goggles or face shield (if splash risk or large spill) |
| Droplet precautions (routine and terminal cleaning) | Gown and/or plastic apron
Reusable rubber gloves Face mask with either goggles or face shield |
| Contact precautions (routine and terminal cleaning) | Gown and/or plastic apron
Reusable rubber gloves |
| Airborne precautions (routine and terminal cleaning) | Respirator (N95 or FPP2), fit tested
Reusable rubber gloves |
| Preparation of disinfectant products and solutions | According to specifications in SDS (manufacturer instructions)
If SDS not available, then:
|
3.5 Care and storage of supplies, equipment, and personal protective equipment
Environmental cleaning supplies and equipment quickly become contaminated during their use. Regularly reprocess all reusable items (i.e., thoroughly clean, disinfect, and dry).
These are the best practices for reprocessing reusable cleaning supplies and equipment:
- Send all reusable supplies and equipment (e.g., buckets, rubber gloves) for reprocessing:
- directly after use in a transmission-based precaution area
- when soiled with blood or body fluids
- Thoroughly clean, disinfect, and rinse equipment such as buckets and containers whenever solution is replaced and daily. Store them upside down to allow complete drying.
- Launder mop heads, floor cloths, and soiled cleaning cloths at least daily (e.g., at the end of the day) and allow them to fully dry before storage and reuse.
- Reprocess all reusable supplies and equipment in a dedicated area that is not used for other purposes (i.e., reprocessing of cleaning equipment should never be conducted in handwashing sinks).
- Reprocess (e.g., launder) all reusable supplies and equipment according to manufacturer’s instructions.
Manual reprocessing steps
If manufacturer’s instructions are not available, use this general process to manually reprocess reusable supplies, equipment, and PPE:
- Immerse in detergent solution and use mechanical action (e.g., scrubbing) to remove soil.
- Disinfect by:
- fully immersing the items in boiling water or
- fully immersing the items in disinfectant solution for the required contact time and rinsing with clean water to remove residue
- Allow to fully dry
- Lay items to dry in a clean and dry area to prevent recontamination.
- Position mops with the head up to allow the mop head to fully dry.
Do not use chlorine-based disinfectants to disinfect microfiber cloths.
Use laundry services with hot water (70–80°C x 10 min) [158–176°F] to reprocess cloths and mop heads, if they are available. Similarly, a commercial dryer can be used for these items, if available (if not, these items are reprocessed as above).
Always launder mop heads and cleaning cloths separately from other soiled hospital textiles.
All reusable supplies and equipment should be well maintained, clean, and in good repair. Regularly inspect and replace or repair all reusable equipment when needed. Develop a facility monitoring and maintenance schedule that clearly documents reusable supplies and equipment, frequency of inspection, and responsible staff.
Certain equipment, such as floor polishers, might require maintenance checks by qualified people according to the manufacturer’s instructions. Keep a service record and make it available for inspection by the cleaning program manager and the IPC Team.
Environmental cleaning services area
Designate at least one environmental cleaning services area within the facility for preparation, storage, and reprocessing of reusable cleaning equipment and supplies. This area should not be used for any other purposes. For multistory facilities, it is best practice to have one of these areas on each floor.
The designated environmental cleaning services area should:
- be well-ventilated and illuminated (lighting or window access)
- be labeled with a biohazard sign on the door
- have an appropriate water supply (hot and cold water access, if feasible)
- have a utility sink/floor drain for safe disposal of used solutions
- be designed so that, whenever possible, buckets can be emptied into utility sink/floor drains without lifting them or creating splashes
- have a dedicated handwashing sink, used only for handwashing
- have access to an eyewash station
- have appropriate PPE available
- have enough space to keep reprocessing (dirty areas) separate from storage areas for cleaned equipment
- be easily accessible in relation to the areas it serves (i.e., easily accessible throughout the facility)
- be appropriately sized to the amount of materials, equipment, and chemicals stored in the room/area
- have printed copies of the SDS for all environmental cleaning products, manufacturer’s instructions, and job aids for preparation of cleaning and disinfectant solutions
- never contain personal clothing or grooming supplies, food or beverages
- there should be a separate area for cleaning staff to store these items
- have safe chemical storage and access
- have locks fitted to all doors to restrict access only to cleaning staff
- be free from clutter
- have washable surfaces (floors, walls, shelves)