Title Page

  • Conducted on

  • Prepared by

  • Location
  • This checklist is derived from the Hospital Preparedness Assessment Tool by the Centers for Disease Control and Prevention (CDC).

Elements to be assessed

1. Infection prevention and control policies and training for healthcare personnel (HCP):

  • Facility leadership including the Chief Medical Officer, quality officers, hospital epidemiologist, and heads of services (e.g., infection control, emergency department, environmental services, pediatrics, critical care) has reviewed the Centers for Disease Control and Prevention’s COVID-19 guidance.<br>https://www.cdc.gov/coronavirus/2019-nCoV/guidance-hcp.html

  • Facility provides education and job-specific training to HCP regarding COVID-19 including:<br>• Signs and symptoms of infection<br>• How to safely collect a specimen<br>• Correct infection control practices and personal protective equipment (PPE) use<br>• Triage procedures including patient placement<br>• HCP sick leave policies and recommended actions for unprotected exposures (e.g., not using recommended PPE, an unrecognized infectious patient contact)<br>• How and to whom COVID-19 cases should be reported

2. Process for rapidly identifying and isolating patients with confirmed or suspected COVID-19:

  • Signs are posted at entrances with instructions to individuals 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.

  • Facemasks are provided to coughing patients and other symptomatic individuals upon entry to the facility.

  • Signs are posted in triage areas (e.g. ED entrances) advising patients with fever or symptoms of respiratory infection to immediately notify triage personnel so appropriate precautions can be put in place.

  • Alcohol based hand sanitizer for hand hygiene is available at each entrance and in all common areas.

  • Facility provides tissues and no-touch receptacles for disposal of tissues in waiting rooms and in common areas.

  • Facility has a separate well-ventilated space that allows waiting patients to be separated by 6 or more feet, with easy access to respiratory hygiene and cough etiquette supplies.

  • Facility has a process to ensure patients with confirmed or suspected COVID-19 are rapidly moved to an Airborne Infection Isolation Room (AIIR).

  • Alternatively, for patients that cannot be immediately placed in a room for further evaluation, a system is provided that allows them to wait in a personal vehicle or outside the facility (if medically appropriate) and be notified by phone or other remote methods when it is their turn to be evaluated.

  • Triage personnel are trained on appropriate processes (e.g., questions to ask and actions to take) to rapidly identify and isolate suspect cases.

  • Facility has a process that occurs after a suspect case is identified to include immediate notification of facility leadership/infection control.

  • Facility has a process to notify local or state health department of a suspect case soon after arrival.

  • Facility has a process for receiving suspect cases arriving by ambulance.

3. Patient placement:

  • Confirm the number and location of Airborne Infection Isolation Rooms (AIIRs) available in the facility (ideally AIIRs will be available in the emergency department and on inpatient units).

  • Document that each AIIR has been tested and is effective (e.g., sufficient air exchanges, negative pressure, exhaust handling) within the last month. The AIIR should be checked for negative pressure before occupancy.

  • Verify each AIIR meets the following criteria:<br>• Minimum of 6 air changes per hour (12 air changes per hour are recommended for new construction or renovation).<br>• Air from these rooms should be exhausted directly to the outside or be filtered through a high-efficiency particulate air (HEPA) filter before recirculation.<br>• Room doors should be kept closed except when entering or leaving the room, and entry and exit should be minimized.<br>• When occupied by a patient, the AIIR is checked daily for negative pressure.

  • A protocol is established, which specifies that aerosol-generating procedures that are likely to induce coughing (e.g., sputum induction, open suctioning of airways) are to be performed in an AIIR using appropriate PPE.

  • Facility has plans to minimize the number of HCP who enter the room. Only essential personnel enter the AIIR. Facilities should consider caring for these patients with dedicated HCP to minimize risk of transmission and exposure to other patients and HCP.

  • Facility has a process (e.g., a log, electronic tracking) for documenting HCP entering and exiting the patient room.

  • Facility has policies for dedicating noncritical patient-care equipment to the patient.

4. Transmission-Based Precautions (use Standard, Contact, Airborne Precautions plus eye protection for patients with confirmed or suspected COVID-19 cases):

  • Personal protective equipment (PPE) and other infection prevention and control supplies (e.g., hand hygiene supplies) that would be used for both healthcare personnel (HCP) protection and source control for infected patients (e.g., facemask on the patient) are located in sufficient supply including at patient arrival, triage, and assessment locations.

  • Facility has a respiratory protection program. Appropriate HCP have been medically cleared, fit-tested, and trained for respirator use.

  • HCP receive appropriate training, including “just in time” training on selection and proper use of (including putting on and removing) PPE, with a required demonstration of competency.

  • Facility has a process for auditing adherence to recommended PPE use by HCP.

5. Movement of patients with confirmed or suspected COVID-19 within the facility:

  • Patient movement outside of the AIIR will be limited to medically-essential purposes.

  • A protocol is in place to ensure that, if the patient is being transported outside of the room, HCP in the receiving area are notified in advance.

  • Patients transported outside of their AIIR will be asked to wear a facemask and be covered with a clean sheet during transport.

6. Hand hygiene (HH):

  • HH supplies, including alcohol-based hand sanitizer are readily accessible in patient care areas, including areas where HCP remove PPE.

  • Facility has a process for auditing adherence to recommended hand hygiene practices by HCP.

7. Environmental cleaning:

  • Facility has a plan to ensure proper cleaning and disinfection of environmental surfaces and equipment in the patient room.

  • If environmental services personnel are given this responsibility, they should be appropriately trained and fit-tested.

  • All HCP with cleaning responsibilities understand the contact time for selected products.

  • Facility has a process to ensure shared or non-dedicated equipment is cleaned and disinfected after use according to manufacturer’s recommendations.

  • Facility uses an EPA-registered hospital-grade disinfectant with EPA-approved emerging viral pathogens claims on hard non-porous surfaces.<br>• If there are no available EPA-registered products that have an approved emerging viral pathogen claim for COVID-19, products with label claims against human coronaviruses should be used according to label instructions.

8. Monitoring and managing HCP:

  • The facility follows the local/state public health authority’s policies and procedures for monitoring and managing

  • HCP with potential for exposure to COVID-19, including ensuring that HCP have ready access, including via telephone, to medical consultation.

  • Facility has a process to track exposures and conduct active- and/or self-monitoring of HCP if required by public health.

  • Facility has a process to conduct symptom and temperature checks prior to the start of any shift of asymptomatic, exposed HCP that are not work restricted.

9. Visitor access and movement within the facility:

  • Plans for visitor access and movement within the facility have been reviewed and updated within the last 12 months.

  • Visitors are screened for symptoms of acute respiratory illness before entering the hospital.

  • Facility has a plan to restrict visitation to rooms of patients with confirmed or suspected COVID-19.

  • If visitors are allowed to enter the room of a confirmed or suspected COVID-19 patient, the facility will:<br>• Enact a policy defining what PPE should be used by visitors.<br>• Provide instruction to visitors before they enter a patient room, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy. <br>• Maintain a record (e.g., a log with contact information) of all visitors who enter and exit the room.<br>• Ensure that visitors limit their movement within facility (e.g. avoid the cafeteria).

  • 10. Facility regularly monitors the situation on CDC's coronavirus disease (COVID-19) web page. www.cdc.gov/COVID19


  • Comments/Recommendations

  • Name & Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.