Cleaning Health Care Facilities: CDC's Procedures for Low-Resource Settings

This CDC guidance is written for health care facilities with limited resources, especially in low- and middle-income countries. U.S. facilities should use CDC's U.S. infection prevention resources.

Risk decides how often and how thoroughly

How often, with what method and by what process an area is cleaned should depend on the risk of spreading germs, which combines three things:

• Probability of contamination — heavily contaminated surfaces need more frequent, thorough cleaning than lightly contaminated ones.
• Vulnerability of patients — areas with vulnerable patients, such as the immunosuppressed, need more.
• Potential for exposure — high-touch surfaces (bed rails) need more than low-touch ones (walls).

Every facility should set cleaning schedules naming the person responsible, the frequency, the method (product and process) and detailed standard operating procedures for every type of patient area and for noncritical equipment, backed by checklists and other job aids.

Basic technique

• Look first. Check whether the patient's condition, a spill, isolation precautions or clutter calls for extra care or protective equipment, and report damaged furniture.
• Cleaner to dirtier. Clean low-touch before high-touch surfaces; patient areas before toilets; areas not under isolation before those that are. In a room, start with shared equipment and common surfaces, then items touched during care outside the patient zone, and finally what the patient touches directly.

Cleaning from cleaner to dirtier areas, toward the patient zone. CDC figure.

• High to low. Clean bed rails before bed legs, surfaces before floors, and the floor last, so falling dirt doesn't land on cleaned areas.
• Systematically. Work in one direction — say, clockwise from the foot of the bed — the same way in every patient zone.

A systematic path around the patient care area. CDC figure.

• Spills first. Deal with blood or body fluid spills immediately (below).

Wiping surfaces: soak a fresh cloth in cleaning solution, fold it in half and in half again to about the size of your hand (giving 8 sides), wipe with firm mechanical action, leave surfaces wet long enough for disinfectants to work, turn the cloth to use every side, and replace it when all sides are used or it's no longer saturated.

Always: start each session with fresh cloths, and in higher-risk areas use a new cloth for each patient bed; never double-dip cloths into solution containers; never shake mop heads or cloths; and never leave dirty mops or cloths soaking in buckets.

High-touch surfaces differ by room, so identify them with clinical staff and list them in checklists — typically bed rails, IV poles, sink handles, bedside tables, call bells, doorknobs and light switches, among others.

General patient areas

These carry lower risk, so need less frequent and rigorous cleaning than specialized units.

Terminal cleaning aims to leave nothing for the next patient: remove used personal items and linens, check window treatments, reprocess all reusable noncritical equipment, clean and disinfect every surface — including those hard to reach while the room was occupied, such as the mattress, bed frame, tops of shelves and vents — and the floor, and scrub and disinfect sinks. Cleaning, infection prevention and clinical staff should agree who does what, in checklists, so nothing is missed.

Toilets are frequently contaminated high-touch areas: clean and disinfect private toilets at least once a day and shared ones at least twice a day — more often if local toilet types and habits call for it; dedicated cleaners at shared toilets can help.

Floors carry low risk and usually need daily cleaning without disinfectant, always last. Mop in a figure-8 with overlapping strokes, turning the mop every 5–6 strokes, rinsing it after each small area (about 3m x 3m), working from the far end toward the exit, with wet-floor signs. Change mop heads and solutions when soiled, after every isolation room, every 1–2 hours, and at the end of each session.

Mopping toward the exit. CDC figure.

Blood and body fluid spills

In any area, clean and disinfect spills immediately, in two steps:

1. Wear the right protective equipment; contain the spill and soak it up with absorbent towels, cloths or granules, disposed of as infectious waste; then clean with neutral detergent and warm water.
2. Disinfect with an approved intermediate-level disinfectant — typically chlorine at 500–5000ppm free chlorine (a 1:100 or 1:10 dilution of 5% bleach, depending on the spill's size), but not on urine. Leave it wet for the required contact time (for example 10 minutes), rinse if needed, and send reusable cloths and mops for reprocessing.

Don't use a combined detergent-disinfectant for spills.

Specialized areas

Intensive care units, operating rooms, burn units, labor and delivery, dialysis and others serve vulnerable patients where contamination is likely, so surfaces and floors are cleaned and disinfected unless stated otherwise, and who cleans what — nurses often share the work — must be spelled out.

Isolation and precaution rooms

Rooms for patients under airborne, contact or droplet precautions are high-risk, especially for hardy or multidrug-resistant germs. Clean them after other areas, wear the protective equipment posted on the door, change supplies and equipment afterward (or dedicate them), and leave the cart outside.

• Airborne: routine cleaning at least daily and a terminal clean with curtains laundered — keeping the door closed throughout.
• Contact and droplet: high-touch surfaces and floors at least twice a day. For spore-forming C. difficile, a two-step process: rigorous mechanical cleaning, then a sporicidal disinfectant such as sodium hypochlorite (1,000ppm or 5,000ppm) or enhanced hydrogen peroxide at 4.5%.
• Carbapenem-resistant gram-negative bacteria (CRE-CRAB-CRPsA): the World Health Organization's 2017 guidelines make cleaning and disinfection a key measure; see its 2019 implementation manual.
• Viral hemorrhagic fevers such as Ebola: special procedures, dedicated training and strict protective equipment apply.

Shared patient equipment

Noncritical equipment — IV poles, commode chairs, blood pressure cuffs, stethoscopes — touches patients or is handled often, and is frequently shared. (Critical and semi-critical equipment needs specialized reprocessing and is never cleaning staff's job.)

Noncritical equipment with high-touch surfaces. CDC figure.

• Keep a schedule saying who cleans each item, how and how often.
• Clean and disinfect shared equipment before and after each use; dedicated equipment with the room's routine cleaning; everything at terminal cleaning.
• Don't buy or use equipment that can't be cleaned, unless it can be covered; get the manufacturer's instructions and train staff before use.
• Disinfectant compatibility: chlorine corrodes metal — keep it to 1000 ppm (0.1%) and rinse afterward; alcohols (60-80%) can damage glues, plastic tubing, silicone and rubber, but suit small items such as stethoscopes and thermometers.
• Clean heavily soiled items such as bedpans in a sluice room near the ward, disinfecting bedpans with a washer-disinfector or boiling water rather than chemicals.

Sources

Based on "Environmental Cleaning Procedures," Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings, Centers for Disease Control and Prevention; a work of the United States government in the public domain.