Recommendations for Decontamination
All mannequins should be decontaminated at the end of each training session. If more than one student is using a mannequin, the appropriate steps should be taken to clean the mannequin between students.
Please consult with your local CPR agency (Heart & Stroke Foundation, Red Cross, St. John Ambulance) for more information on mannequin decontamination.
All Instructors should be available after the course to assist with the cleaning of the mannequins used in the course. Protective gloves should be worn during the disassembly and decontamination procedures. The guidelines for decontamination of mannequins as outlined by the Heart and Stroke Foundation of Canada should be followed.
Update 1983: Centers for Disease Control, 1978 Hepatitis Surveillance report No.42, Pages 34-36
Members of the Multidisciplinary Ad Hoc Committee for Evaluation of Sanitary Practices in Cardiopulmonary Resuscitation Training representing the following organizations:
- American Heart Association: Subcommittee on Emergency Cardiac Care
- American Red Cross: First Aid and CPR Programs
- Centers for Disease Control: Center for Infectious Diseases
- Centers for Disease Control: Laboratory Program Office
- In the past years, we have received numerous inquiries concerning the possible role of cardiopulmonary resuscitation (CPR) training mannequins in transmitting viral hepatitis type B. Recently, inquiries have been received about the potential for transmission of not only hepatitis B but Acquired Immunodeficiency Syndrome (AIDS), herpes viruses and various upper and lower respiratory infections (influenza, infectious mononucleosis, tuberculosis, etc.). The use of CPR mannequins has increased rapidly because of expanded training programs sponsored by medical emergency organizations. To date, it is estimated that over 40 million people have had direct contact with mannequins during training courses. In the United States, a number of companies distribute multiple model lines of mannequins for training programs in hospitals, police and fire department, service organizations, lay groups, and schools as part of health, first aid, and physical education courses. Since practicing with a mannequin is an integral part of CPR training, the care and maintenance of the mannequins is of utmost importance. Instructors and training agencies rely heavily on manufacturer’s recommendations for mannequin use and maintenance, and these recommendations should be examined carefully before purchasing mannequins.
- To our knowledge, the use of CPR training mannequins has never been documented as being responsible for an outbreak or even an isolated case of bacterial, fungal, or viral disease. It is our opinion, however, that mannequin surfaces may present a risk of disease transmission under certain circumstances and that these surfaces should be cleaned and disinfected consistently to minimize the risk. Although the major portion of the following discussion was written in 1978 pertaining only to sanitary practices that should be followed to prevent transmission of hepatitis type B, the current revision by the Ad Hoc Committee for Evaluation of Sanitary Practices in Cardiopulmonary Resuscitation Training is applicable to lessening the risks of transmitting a wide variety of infectious diseases.
- There are several important control considerations in CPR training. First, the act of mouth-to-mouth or mouth-to-nose artificial respiration obviously requires close physical contacting which a potential rescuer must ignore his or her concerns for personal protection or aesthetic apprehensions to save the life of a victim. Accordingly, in training sessions, students are urged to overcome such hesitations, and they may practice on mannequins contaminated by the hands and oral fluids of previous students. This situation becomes especially obvious during the practice of two rescuers in which the mannequin cannot be adequately cleaned between uses by the two students. Also, the practice of removing upper airway obstruction involves sweeping the back of the mannequin throat with a finger, and in this situation, contamination from previous students may be smeared on the mannequin face. In practice, there is usually no pause at this point to decontaminate the face before beginning mouth-to-mouth breathing. Additionally, the valve mechanisms and lungs in mannequin airway invariably become contaminated during use, and if they are not appropriately dismantled and cleaned after class, they may serve as contamination sources for subsequent classes. There is no recognized evidence, however, that the mannequin valve mechanisms produce aerosols even when air is forcibly expelled during chest compression exercises.
- Some manufacturers have provided protective face shields for mannequins to improve hygienic conditions during training sessions, but it is unlikely that students learning the two-rescuer resuscitation method would change such shields after each use. Protective shields and detailed instructions for sanitizing the mannequins between uses by students and classes are available from several manufacturers.
- When dealing with potential contamination by microorganisms having either unknown chemical resistance levels (e.g. AIDS) or resistance levels that have not been fully characterized (e.g. hepatitis and herpes viruses), the mannequins pose a difficult disinfection program. Although there are several intermediate-to-high level disinfectants recommended for use in instances of contamination such as hepatitis B, the majority would meet with objection because of either material incompatibility with the mannequin (e.g. staining or other damage of plastic materials by iodine compounds) or undesirable residues, odors, or toxicities may affect students (e.g. formaldehyde, glutaraldehyde) when used during the training sessions. Alcohol’s, quaternary ammonium compounds, and phenolics are not generally recommended since proper contact times for effective action are difficult to achieve (e.g. alcohol’s evaporate rapidly) or the compounds have limited actions against certain viruses and bacterial).
These guidelines for mannequin decontamination appear with permission from the Heart & Stroke Foundation of Canada. This information appears in the “HSFS BLS Instructors Handbook – 1996.”
- Purchases of training mannequins should thoroughly examine the manufacturers’ recommendations and provisions for sanitary practices.
- Students should be told in advance that the training sessions will involve “close physical contact” with their fellow students.
- Students should not actively participate in training sessions (hands-on training with mannequins) if they have dermatological lesions on hands or in oral or circumoral areas, if they are known to be seropositive for hepatitis B surface antigen (HbsAq), if they have upper respiratory tract infections, if they have Acquired Immunodeficiency Syndrome (AIDS), or if the student has reason to believe that he or she has been exposed to or is in the active stage of an infectious process.
- If more one mannequin is used in a particular training class, students should preferably be assigned in pairs, with each pair having contact with only one mannequin. This would lessen the possible contamination of several mannequins by one individual and therefore limit possible exposures or other class members.
- All persons responsible for CPR training should be thoroughly familiar with hygienic concepts (e.g. thorough hand washing prior to mannequin contact, not eating during class to avoid contamination of mannequins with food particles, etc.) as well as the procedures for cleaning and maintaining mannequins and accessories (e.g. face shield). Mannequins should be inspected routinely for signs of physical deterioration, such as cracks or tears in plastic surfaces, which make thorough cleaning difficult or impossible. The clothes and hair of mannequins should be washed periodically e.g. monthly or whenever visibly soiled.
- During the training of two-rescuer CPR, there is no opportunity to disinfect the mannequin between students when “switching procedure” is practiced. In order to limit the potential for disease transmission during this exercise, the second student taking over ventilation on the mannequin should simulate ventilation instead of blowing into the mannequin. This recommendation is consistent with current training recommendations of the American Red Cross and the American Heart Association.
- Training of the “obstructed airway procedure” involves the student using his or her finger to sweep foreign matter out of mannequin’s mouth. This action could contaminate the student’s finger with exhaled moisture and saliva from previous students in the same class and/or contaminate the mannequin with material from the student’s finger. When practicing this procedure, the finger sweep should either be simulated or done on a mannequin whose airway was decontaminated after the procedure.
- At the end of each class, the procedures listed below should be followed as soon as possible to avoid drying of contamination on mannequin surfaces:
- Disassemble mannequin as directed by manufacturer;
- As indicated, thoroughly wash all external and internal surfaces (also reusable protective face shields) with warm soapy water and brushes;
- Rinse all surfaces with fresh water;
- Wet all surfaces with a sodium hypochlorite having at least 500 ppm free available chlorine (1/4 cup liquid household bleach per gallon tap water for 10 minutes). This solution must be made fresh at each class and discarded after each use;
- Rinse with fresh water and immediately dry all external and internal surfaces, rinsing with alcohol will aid drying of internal surfaces, and this drying will prevent the survival and growth of bacterial or fungal pathogens.
- Each time a different student uses the mannequin in a training class, the individual protective face shield, if used, should be changed. Between students or after the instructor demonstrates a procedure such as clearing any obstruction from the airway, the mannequin face and inside the mouth should be wiped vigorously with clean absorbent material (e.g. 4” x 4” gauze pad) wet with either the hypochlorite solution described in recommendation #8 above or with 7% alcohol (isopropanol or ethanol). The surfaces should remain wet for at least 30 seconds before they are wiped dry with a second piece of clean absorbent material.
- We are somewhat reluctant to recommend use of alcohols in this instance and to do so only as an alternative, since some persons find the odor of hypochlorite objectionable. Although highly bactericidal, alcohols are not considered primarily as an aid in mechanical cleaning; also, in a short contact period alcohols may not be effective against bacteria or other pathogens. Nonetheless, in the context of vigorous cleaning with alcohol and absorbent material, little viable microbial contamination of any kind is likely after the cleaning procedure.
- People responsible for the use and maintenance of CPR mannequins should be encouraged not to rely totally on the mere presence of a disinfectant to protect them and their students from cross-infection during training programs. Emphasis should be placed on the necessity of thorough physical cleaning (scrubbing, wiping) as the first step in an effective decontamination protocol. Microbial contamination is easily removed from smooth, non-porous surfaces by using disposable cleaning cloths moistened with a detergent solution, and there is no evidence that a soaking procedure alone in any liquid is as effective as the same procedure accompanied by a vigorous scrubbing.
- With specific regard to recent concerns about potential for hepatitis B and AIDS transmission in CPR training, it has recently been shown that the hepatitis B virus is not as resistant to disinfectant chemicals as it was once thought to be. Current recommendations for strategies dealing with AIDS contamination are the same as those for viral hepatitis B.
- These guidelines for mannequin decontamination appear with permission from the Heart & Stroke Foundation of Canada. This information appears in the “HSFS BLS Instructors Handbook – 1996.”
The following cleaning tips were compiled with input from Ottawa high school teachers experienced in delivering the CPR course to their students, and the St. John Ambulance, Federal District. These tips do not attempt to teach the process of cleaning mannequins, which is covered in the Teacher Training Program by the CPR agency. Tips are meant to facilitate and ease the cleaning process in the school environment. Remember to ask students to remove any lipstick, gum, etc., before breathing into mannequins. Ink is hard to clean off as well!
- Need easy access to source of water and drainage.
- Usually done in a large room (e.g. shower, washroom, lunchroom, health room, kitchen, custodian’s room).
- Best if done over cement floors with drainage.
- Ensure adequate storage area for air drying (e.g. shelves, benches, drying racks).
- Plan location ahead of time so assistant teachers or student volunteers can start working right away.
- Some teachers submerge mannequin heads in a bathtub or shower.
- Assistance for cleaning is often found among student teachers, student volunteers (e.g. with spare periods), senior students, leadership students, and any other students who can acquire volunteer or leadership hours.
- In some schools, teachers clean their own mannequins. In others, the teaching staff works cooperatively to establish the most efficient method.
- Teachers indicate that up to one hour is usually needed to clean mannequins if they are alone, or ½ hour if volunteers help.
- One or two large garbage pails on wheels, plastic tubs (large enough to hold 10 heads and with plug in bottom to facilitate drainage), basins, large plastic pails (some schools install a spigot in the bottom of a pail which can be removed for drainage).
- Useful materials include: alcohol wipes, bleach, gauze wipes, scouring pads, disposable/rubber gloves, aprons, measuring cups, dish detergent, garbage bags, paper towels, towels, etc.
Protection for clothes and cleaning surfaces
- Since bleach is involved, protection for eyes, skin and clothing is important.
- In some schools, teachers and students use supplies from the Science Department (e.g. lab coats, latex gloves).
- Old clothes and aprons are also worn.