We are in strange times. COVID-19 has become a global pandemic. People are practicing social distancing to "flatten the curve", or as I like to say, we are practicing physical distancing with social cohesion to help stop the spread of COVID-19 and to ease the strain on overburdened healthcare systems. People are aware of the need for frequent hand-washing and the need for frequent cleaning of high contact surfaces. As health care professionals, we have always been aware of the need to practice infection prevention and control in our practice settings. Now is a good time to review best practices for cleaning and disinfecting seating and mobility equipment.
With respect to cleaning and disinfecting surfaces and COVID-19, the Government of Canada states "Coronaviruses are enveloped viruses. This means they are one of the easiest viruses to kill with the appropriate disinfectant product when used according to the label directions." (2020, paragraph 2) [Note: This reference contains a list of hard-surface disinfectants, including wipes, approved by Health Canada for use against COVID-19.]
Best Practices for Cleaning for Infection Prevention and Control
Let's begin by looking at the Best Practices for Environmental Cleaning for Prevention and Control of Infections in All Health Care Settings, 3rd Edition (Public Health Ontario, 2018). This document states that equipment that is used to transport individuals with limited mobility and is used with more than one patient, such as wheelchairs, "should be disinfected with a hospital disinfectant immediately after use, before use for another client/patient/resident, and when visibly soiled, paying particular attention to high-touch areas" (Public Health Ontario, 2018, p. 103). High touch areas include the arm supports, push handles, and wheel locks. Areas that may have padding, such as the arm supports, should be inspected for damage prior to cleaning. If the damage is such that the part cannot be cleaned adequately, the part should be removed and replaced. Best practice also includes having a schedule for regular cleaning and having clearly outlined responsibility (i.e., identifying the discipline or disciplines responsible for conducting the cleaning and disinfecting) (Public Health Ontario, 2018).
These same principles apply for mobility equipment that has been assigned to an individual for use during their stay in a healthcare setting. When wheelchairs are used for personal mobility, rather than for transport purposes, high touch areas may also include the handrims of the wheels. Wheelchairs must be cleaned and disinfected after they no longer are in use by one individual and before the equipment is assigned to anyone else. For individuals owning their own wheelchairs, schedules for regular cleaning and maintenance also should be considered.
Medical Devices and Levels of Disinfection
Let's look at how to conduct cleaning and disinfection. There are, in fact, two levels of disinfection for medical equipment. Low-level disinfection (LLD) is the "level of disinfection required when processing non-invasive medical equipment (i.e., non-critical equipment) and some environmental surfaces. Equipment and surfaces must be thoroughly cleaned prior to low-level disinfection." (Public Health Ontario, 2013, p. 4). High-Level Disinfection (HLD) is the "level of disinfection required when processing semicritical medical equipment/devices." (Public Health Ontario, 2013, p. 3). Non-critical medical equipment is a "device that either touches only intact skin (but not mucous membranes) or does not directly touch the client/patient/resident." (Public Health Ontario, 2013, p. 4). Semicritical medical equipment "comes in contact with nonintact skin or mucous membranes but ordinarily does not penetrate them (e.g., respiratory therapy equipment)" (Public Health Ontario, 2013, p. 5). Semicritical equipment requires cleaning followed by high-level disinfection at a minimum, while sterilization is preferred. Although wheelchairs are essential for mobility, for cleaning purposes wheelchairs are considered non-critical medical equipment requiring low-level disinfection (Public Health Ontario, 2013).
Check Owner's Manual
Let's look at the steps for cleaning and for disinfection. Before doing either, check with the Owner's Manual for the wheelchair to follow the cleaning instructions. For example, some owner's manuals may say to not use bleach when cleaning.
Some healthcare facilities have cleaning machines into which a manual wheelchair can be loaded and then cleaned/disinfected at the push of a button. The instructions for the wheelchair cleaning machine should be followed when using this device. It is important to note that some power wheelchairs should not be cleaned in such a machine due to the electrical components.
A wheelchair is considered an environmental surface, just as a bed is considered an environmental surface. Cleaning such surfaces involves "Physical removal of soil, dust or foreign material. Chemical, thermal or mechanical aids may be used. Cleaning usually involves soap and water, detergents or enzymatic cleaners. Thorough cleaning is required before disinfection … may take place" (Public Health Ontario, 2013, p.71). Equipment should be rinsed to ensure any residual detergent is removed as it may neutralize the disinfectant. The equipment should be dry to prevent the disinfectant from becoming diluted (Public Health Ontario, 2013, p. 30).
The next step is disinfecting. The disinfectant should be applied for the appropriate length of time, as indicated by the manufacturer of the disinfectant. Examples of low-level disinfectants include 3% hydrogen peroxide, 0.5% "enhanced action formulation" hydrogen peroxide, quaternary ammonium compounds (e.g., Lysol®), and bleach (1000 parts per million) (Public Health Ontario, 2013, p. 71) [Note: To make a bleach solution that is 1000 ppm (parts per million), add 20 ml (4 teaspoons) of undiluted household bleach to 1 litre (4 cups) of water. Bleach solutions should be properly labeled (York Region Community and Health Services Public Health, n.d.)] These "Low-level disinfectants kill most vegetative bacteria and some fungi as well as enveloped (lipid) viruses. Low-level disinfectants do not kill mycobacteria or bacterial spores" (Public Health Ontario, 2013, p. 71).
Disinfectant wipes may be used if the surface is not heavily soiled. Disinfectant wipes have a combination of cleaners and disinfectants in one solution. Should the wipes become dry due to their fast drying properties, the wipes should not be used (Public Health Ontario, 2020).
When working with cleaning solutions and disinfectants, personal protective equipment (PPE) should be used, in accordance with the manufacturer of the disinfectant.
The area where the cleaning/disinfecting occurs should be separate from the area where clean/disinfected wheelchair equipment is stored.
When cleaning a wheelchair, start with the area that is least visibly contaminated and then move to the more visibly dirty areas.
Ensure all parts of the wheelchair are cleaned/disinfected, including the cross brace, frame, back posts, arm supports, wheel locks, handrims, wheels, caster forks and casters.
Clean/disinfect the floor/surface where the wheelchair was positioned for cleaning.
Wheelchairs that are used in healthcare equipment pools must be cleaned/disinfected before they can be used by another individual. Health Canada has a list of approved disinfectants. The Owner's Manual from the equipment manufacturer also should be consulted to ensure the disinfectant is compatible with the equipment.
Look for Part Two to address the procedures to employ when cleaning/disinfecting wheelchair cushions and back supports.
As always, please provide your comments, questions and suggestions regarding Clinical Corner. Please email me at Sheilagh.Sherman@sunmed.com. I look forward to hearing from you!
Sheilagh Sherman, BA, BHScOT, MHM, OT Reg. (Ont.)
Clinical Education Manager
Sunrise Medical Canada
Note: The content of this article is not meant to be prescriptive; rather, it is meant as a general resource for clinicians to then use clinical reasoning skills to determine optimal solutions for individual clients. Sheilagh is unable to answer questions from members of the general public. Members of the general public are directed to their own therapists or other health care professionals to ask questions regarding needs.
This article is © Sunrise Medical, Inc., 2020 and cannot be copied, distributed, or otherwise reproduced in whole or in part without the express written permission of Sunrise Medical Canada.
- Government of Canada. (2020). List of hard-surface disinfectants for use against coronavirus (COVID-19). Retrieved from https://www.canada.ca/en/health-canada/services/drugs-health-products/disinfectants/covid-19/list.html
- Public Health Ontario. (2013). Best practices for cleaning, disinfection and sterilization of medical equipment/devices in all health care settings, 3rd edition. Retrieved from https://www.publichealthontario.ca