Title Page
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Conducted on
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Shift
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Prepared by
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Campus
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Unit
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Unit
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Unit
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Unit
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Specify:
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Manager
Rounds
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1. Cough etiquette signs are visibly posted
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2. Respiratory stations are appropriately stocked (e.g tissue, hand sanitizer, etc).
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3. Covid19 signage is posted at the entrances of the facility.
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4. Staff are being screened upon entry to the facility for COVID19/upper respiratory symptoms.
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5. Patients are being screened upon entry to the facility for COVID19/upper respiratory symptoms.
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6. Visitation Restriction signs are visibly posted (if applicable)
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7. Did EVS staff provide appropriate environmental cleaning for known or suspected Covid-19 patients.
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8. Signs posted at entrances with instructions to individuals seeking medical care with symptoms of respiratory infection to immediately put on a mask and keep it on during their assessment, cover their mouth/nose when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after contact with respiratory secretions?
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9. Staff and Patients are following universal masking.
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10. Standard Precautions for All Patients are being observed.
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11. Admitted PUI/COVID-19+ patients are appropriately isolated in a negative pressure room, or private room with private bathroom and door closed.
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12. Transmission Based Precautions Applied Appropriately.
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13. Isolation carts appropriately stocked with PPE. Must contain ONLY PPE.
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14. Proper selection of PPE is appropriate for the task or transmission-based isolation precautions.
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15. PPE is worn appropriately.
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16. Donning and Doffing of selected PPE is performed appropriately.
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17.a. The following are being used appropriately for COVID-19: Masking.
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17.b. The following are being used appropriately for COVID-19: Gowns.
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17.c. The following are being used appropriately for COVID-19: Gloves.
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17.d. The following are being used appropriately for COVID-19: Eye protection or face shield.
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18. Aerosol Generating Procedures (AGP) are performed in negative pressure rooms.
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19. Staff knows who to contact to refill PPE supplies.
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20. Hand hygiene compliance performed when indicated (even after removal of gloves).
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21. Dedicated or disposable medical equipment is available in isolation carts/patient's room/or ante room for contact precautions.
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22 a. Hand hygiene supplies are available: Alcohol based hand sanitizer dispensers are filled.
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22 b. Hand hygiene supplies are available: Soap dispensers by hand hygiene sinks are filled.
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22 c. Hand hygiene supplies are available: Hand sanitizer delivers adequate amount of foam/gel.
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22 d. Hand hygiene supplies are available: Hand sanitizer dispenser is operating and has drip plate.
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23. Sani-wipes or Clorox wipes are available on each PPE cart or ante room.
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24. No eating or drinking in patient care areas.
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25. When transporting a patient on droplet/airborne precautions and movement is medically necessary outside of the patient room, the patient wears a face mask.
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26. Staff can state the importance of influenza vaccination for HCWs.
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27. Staff can state two instances when hand washing with soap and water is preferred to alcohol hand rub.
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28. Staff can state transmission-based precautions for COVID-19 PUI/+ patients.
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29. EPA registered and hospital approved disinfectants are used for cleaning and disinfection.
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Other COVID-19 related notes or observations.
