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Downloadable SOP for cleaning as approved by Cardiff and Vale NHS trust.

Do not perform the outlined procedure unless you have been tranined and evaluated as being copetent by an aushorised trainer.


On March the 12th 2020 the World Health Organisation declared Covid-19 a global pandemic. Within the Interventional Radiology department procedures such as Endoscopic Retrograde Cholangio Pancreatography (ERCP) are performed and are classified as an Aerosol Generating Procedure (AGP). The risk of transmission of Covid-19 is at its highest during AGP, therefore protecting staff during these procedures is paramount.
A shield to reduce the spread of COVID-19 during AGP has been designed.
Following the procedure strict infection prevention and control measures are required to ensure the shield is properly cleaned, disinfected and that staff are protected whilst performing this task. There is the potential to cause trauma during the intubation and blood splashes may occur, therefore the appropriate concentration of 10,000ppm/ 1% concentration of Acticlor plus is required.  


The purpose of this SOP is so that effective cleaning of the AGP shield takes place and that staff are protected whilst cleaning the shield. Further, cross contamination between patients should not occur.


The scope of this SOP is intended for staff groups involved in upper GI endoscopy procedures including ERCP and EUS. 


1. The shield is correctly cleaned and disinfected between cases

2. Staff are protected against contamination whilst carrying out the task of cleaning shield 

3. Staff are a aware of the control of substances hazardous to health guidelines COSHTH


  1. Metal trolley
  2. Actichlor Plus chlorine disinfectant tablets
  3. Actichlor Bottle
  4. Cleaning wipes/cloths
  5. Sterile gown
  6. Type 2 Surgical Mask
  7. Visor
  8. Appropriately sized gloves
  9. Surgical Hat



When the patient has left the procedure room, remove the transparent drapes. This must be done in a way that minimises shaking the drape. The drape should be carefully removed from box and the dirty side folded in on itself and discarded into an orange infectious waste bag


Following aerosol generating procedure (AGP) the Interventional Laboratory must not be entered for 1 hour post procedure, but this may depend on local IPC device, and in particular air exchange rates.


Gather the necessary cleaning equipment before entering laboratory. Dissolve 10 Actichlor Plus tablets into 1 L of water and allow sufficient time to dissolve prior to use.                


Don appropriate PPE prior to cleaning. Clean away any obvious contamination with Clinell Wipe.


Place box onto clean metal trolley and clean outer surfaces first (use one wipe per surface and discard wipes after use)                         


Remove box from the trolley, clean the top of trolley and place an absorbent pad onto it.                         


Turn box upside down and place onto trolley and clean all inside surfaces, again using one wipe per surface.                                                   


Allow a contact time of 2 minutes and then wipe off with water.


Allow box to air dry.                         

Actichlor Preparation

Video and instructions below


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