Title Page

  • Conducted on

  • Prepared by

  • Location

  • Modalities observed:

  • If other, specify:

Observations

Hand Hygiene

  • Alcohol based hand rub (ABHR) available

  • Soap and water available

  • Staff know when the use Soap versus ABHR

  • Performed before patient contact

  • Performed after patient contact

  • Other:

Transmission Based Precautions

  • Gloves readily available

  • Gowns readily available

  • Masks readily available

  • Eye protection available

  • Appropriate use of PPE demonstrated

  • Don PPE appropriately

  • Doff PPE appropriately

  • Universal masking

  • Respiratory etiquette signage in place

  • Standard precautions observed for all patients

  • Appropriate precautions implemented for indicated precautions (.e. enteric, neutropenic, airborne, droplet, etc.)

  • Process for potential/confirmed respiratory infectious disease

  • Staff can state what to do for accidental exposure to transmissible pathogens

  • Other:

Environment

  • Patient care surfaces disinfected between patients

  • Appropriate surface disinfectants are used

  • Wet times appropriate for disinfectant

  • Patient care area free of dust accumulation

  • Care areas free of clutter

  • Air vents free of dust accumulation

  • Clean rooms positively pressured

  • Soiled rooms negatively pressured

  • Aerosolizing procedures conducted in negative pressure room

  • Biohazardous waste is managed appropriately

  • Pharmaceutical waste is managed appropriately

  • Sharps disposal management appropriately

  • Battery disposal managed appropriately

  • Hazardous materials are managed appropriately

  • Mainstream trash is managed appropriately

  • Clean linens are covered

  • Biomedical Equipment has a current Preventive Maintenance (PM) Sticker date

  • Equipment is clean (free of dust and debris)

  • Other:

Point of Care Testing

  • There should be no evidence of grime, dirt, adhesive marks, or blood left on the device, case or supplies

  • Devices and cases are cleaned after every use

  • Reagents dated per manufacturer's instructions for use

  • Other:

Procedure Rooms / Instruments

  • Appropriately "restricted" or "semirestricted"

  • Traffic controlled during procedures

  • Temperature and humidity monitored & documented

  • Surgical attire, if required, managed appropriately

  • Appropriately turnedover between patients

  • Terminally cleaned/logged

  • Positively pressured (unless bronchoscopy or other aerosolizing procedure)

  • Instruments for reprocessing rinsed at point of use

  • Instruments for reprocessing kept moist with enzymatic spray until transported to SPD

  • Instruments for reprocessing transported in rigid, covered biohazardous labelled container

  • Sharps discarded prior to transport

  • Other:

HighLevel Disinfection

  • Instruments for HLD are processed initially at point of use

  • Instruments are transported for HLD appropriately

  • HLD quality controls are documented for the sterilants used

  • HLD lot numbers and indicators are documented (logged) as applicable

  • Bidirectional traceability documentation is present as applicable

  • After HLD, instruments are stored in a manner that protects their disinfection

  • Other:

Clean Storage

  • Temperature and humidity monitored & documented

  • Room is positively pressured

  • Pouched sterilized instruments are stored appropriately

  • Processed scopes (TEEs) are stored appropriately; and storage cabinet is free of dust and debris

  • Only clean items/equipment are stored in this area

  • The room is free of dust, dirt, grime, etc

  • Scopes are labeled with process date. Per hospital procedure, are reprocessed at least every 14 days

  • No expired supplies

  • Other:

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