Amerimed SOP
< All Topics

3.04.03 Decontamination

3.04.03 Decontamination (Revised 10/2022)


The following are the best strategies for minimizing and/or eliminating the possibility of contracting or transmitting of infectious agents in the event of exposure or contamination.


Personal Contamination

If you are stuck by a needle or other sharp or get blood or other potentially infectious materials in your eyes, nose, mouth, or on broken skin, immediately flood the exposed area with water and clean any wound with soap and water or a skin disinfectant if available. Report this immediately to your supervisor and seek immediate medical attention.


Environmental Surfaces and Equipment

All blood, body fluids, and tissue must be regarded as potentially infectious. Universal precautions or body substance isolation precautions will therefore be required any time an employee has direct contact with blood, body fluids, tissue, or any other suspected potentially infectious material.

The preferred decontamination solution for ambulance units are any EPA registered, hospital grade germicidal wipes and they should be used according to manufacturer’s guidelines.

In unusual circumstances if bleach is used as a disinfectant, it MUST be freshly mixed in a 1:10 dilution with water every 24 hours to retain its effectiveness.

Any portion of equipment, supplies, or environmental surfaces which cannot be adequately disinfected, must be labeled as biohazardous using an adhesive biohazard label or a securely attached biohazard tag.



Absorb the spill then use the provided germicidal wipes according the manufacturer’s guidelines.

In the unusual circumstance that bleach is used, the entire exposed surface will be saturated with a 1:10 dilution of bleach. The bleach must be allowed sufficient time to penetrate the surface prior to removal. Do not wipe the surface completely dry. Bleach is only effective when it is in prolonged contact with the surface..


Medical Equipment

Medical equipment may be defined as critical, semi-critical, or non-critical.


Such equipment enters normally sterile tissue, the vascular system, or permits blood to flow through it.

Sterilization Methods

Critical or high level sterilization methods include autoclaving and cold sterilization, if autoclaving is not available. All critical medical equipment must be effectively sterilized between each patient use.


This equipment may contact mucous membranes or non-intact skin. Although most respiratory equipment is considered semi-critical, it requires high level disinfection/sterilization. Thermometers, however, require only intermediate level disinfection.

Disinfection Methods

Thermometers-Oral, Tympanic and/or Temporal:

  • a) With oral and tympanic thermometers, disposable sheaths are to be used.
  • b) Temporal thermometers will be cleaned between each patient with an alcohol pad and/or per manufacturer’s guidelines.
  • c) Other semi-critical equipment is to be disinfected using an approved EPA registered disinfectant.
  • d) Equipment that cannot be appropriately disinfected following contamination must be replaced.


This type of equipment contacts intact skin and includes otoscopes, stethoscopes, and blood pressure cuffs.

Disinfection Methods

All non-critical medical equipment must be cleaned when visibly soiled. Any portion of equipment contaminated with blood or body fluids must be thoroughly cleansed with a disinfectant solution in accordance with decontamination protocols.


Syringe and Needle System

  • a) The syringe and needle system should only be used when a vacutainer system is unavailable.
  • b) Discard the complete unit into a sharps collector.
  • c) Do not remove, recap, or otherwise manually manipulate the needle. Use safety needles when available.
  • d) Automatic spring-loaded lancet release devices should be avoided where possible.

Resuscitator Bags

All resuscitator ambu-bags and pocket masks must be cleaned after use according to the manufacturer’s recommendations for cold sterilization.

Airways, Oxygen Masks and Tubing

All such equipment will be disposable single use items and be discarded after each use.

CPR Training

All persons responsible for conducting CPR training should follow the requirements of the instructor course for decontamination.

Decontamination of Housekeeping Surfaces

Cleaners with germicidal activity are appropriate for use on these surfaces.


Hazardous Materials

All hazardous and/or biohazardous materials should be contained and/or disposed of properly and as quickly as possible:

  • a) Storage containers for biohazard waste items are provided by the contracted biohazard waste disposal service company.
  • b) All biohazard wastes are to be stored in a specifically designated, separate, and contained area with the international biohazard symbol posted prominently on entrance to this area. The area must be access controlled therefore preventing entry to unauthorized persons.
  • c) All storage areas must be kept clean and in good repair while maintaining the integrity of the stored containers.