IPAC Audit Tool _ Outpatient Clinics

• Hospital Site conducted

• undefined

• Conducted on

  Date

• Prepared by

Location

• undefined

• Clinic/Area:

• Date:

  Date

• ICP

• Unit Manager:

• Unit Supervisor:

Element

Policies and Procedures

• There is a process to triage clients/patients/residents with a communicable disease, e.g.: Screening takes place when booking appointments

  Yes

  No

  N/A

• Appointments are scheduled at end of day

• A segregated waiting area or private room is provided

  Yes

  No

  N/A

• Risk reduction strategies to reduce exposure to communicable diseases are in place:

  Yes

  No

  N/A

• Reception staff can maintain a two metre distance with clients/patients or there is plexiglass barrier at reception to protect staff

  Yes

  No

  N/A

• There is signage relating to hand hygiene and respiratory screening

  Yes

  No

  N/A

• Alcohol-based hand rub (ABHR) is available to clients/patients and staff

  Yes

  No

  N/A

• ABHR is the preferred method of hand hygiene if hands are not visibly soiled

  Yes

  No

  N/A

• Personal protective equipment (PPE) is available for staff

  Yes

  No

  N/A

• Masks are available for individuals with a respiratory infection

  Yes

  No

  N/A

• Tissue boxes are available in the waiting room

  Yes

  No

  N/A

• Toys are cleanable (smooth, nonporous and able to withstand rigorous mechanical cleaning (e.g., no plush toys)

  Yes

  No

  N/A

• Toys are cleaned between patients, when soiled and on an assigned, scheduled basis

  Yes

  No

  N/A

• Toy cleaning and disinfection is documented

  Yes

  No

  N/A

Education

• Staff receive training in Infection Prevention and Control (IPAC) core competencies including Routine Practices and hand hygiene

  Yes

  No

  N/A

• Staff receive job specific IPAC education at time of hire or transfer

  Yes

  No

  N/A

• Staff education is documented

  Yes

  No

  N/A

Routine Practices

• There is a dedicated hand hygiene sink, located at least one metre from where sterile or clean supplies are stored

  Yes

  No

  N/A

• A splash guard is in place if the hand hygiene sink is less than one metre from counter

  Yes

  No

  N/A

• Liquid soap is available for hand washing

  Yes

  No

  N/A

• ABHR dispensers are located at point-of-care

  Yes

  No

  N/A

• ABHR dispensers are located at entrances to examination rooms

  Yes

  No

  N/A

• Soap and ABHR containers are disposable and are not topped-up

  Yes

  No

  N/A

• Hand towels are single-use

  Yes

  No

  N/A

• There is a puncture-resistant sharps container accessible at point-of-use

  Yes

  No

  N/A

• Sharps containers are not over-filled

  Yes

  No

  N/A

• Sharps containers are changed when contents reach the fill line and are not overfilled

  Yes

  No

  N/A

• Gloves are worn for contact with blood and body fluids

  Yes

  No

  N/A

• PPE supplies are readily available and easily accessible in appropriate sizes

  Yes

  No

  N/A

• There is clear separation between the location where clean PPE is put on and soiled PPE is removed

  Yes

  No

  N/A

• PPE is removed immediately following the activity for which it was put on

  Yes

  No

  N/A

• Sterile medical gloves are worn for procedures involving contact with sterile body sites

  Yes

  No

  N/A

• Gloves are removed immediately after completion of the procedure before touching clean items and surfaces

  Yes

  No

  N/A

• Single-use disposable gloves are not re-used or washed

  Yes

  No

  N/A

• Hand hygiene is performed before donning and after removal of PPE

  Yes

  No

  N/A

• Facial protection (well-fitted mask and eye protection) worn for procedures that are likely to result in sprays or splashes of blood or other body fluids. Prescription eyeglasses are not acceptable as eye protection

  Yes

  No

  N/A

• If N95 respirators are used, previous fit-testing has occurred

  Yes

  No

  N/A

• Masks/respirators are discarded after use and are not re-used

  Yes

  No

  N/A

• Equipment is cleaned and disinfected between each patient use

  Yes

  No

  N/A

• Patients are encouraged to practice respiratory etiquette

  Yes

  No

  N/A

Additional Precautions

• Staff select the appropriate PPE based on route of transmission and nature of interaction with Patient/Client

  Yes

  No

  N/A

• Staff select and use appropriate IPAC signage when a patient is under additional precautions

  Yes

  No

  N/A

Exam/Procedure Rooms

• Hand hygiene dispenser at entrance to exam rooms

  Yes

  No

  N/A

• Hand hygiene at point of care

  Yes

  No

  N/A

• Examination table is intact; no tears or cracks in cover

  Yes

  No

  N/A

• Exam room chairs are intact; no tears or cracks in chairs

  Yes

  No

  N/A

• There is a dedicated hand hygiene sink

  Yes

  No

  N/A

• A splash guard is in place if the hand hygiene sink is less than one metre from counter

  Yes

  No

  N/A

• Floor, walls and ceiling are intact and no evidence of water damage

  Yes

  No

  N/A

• Procedure room equipment is cleaned between patients

  Yes

  No

  N/A

• Gloves are readily available

  Yes

  No

  N/A

• Approved disinfectant wipes are available in every exam room

  Yes

  No

  N/A

• Paper cover over exam table, stretcher or bed is discarded after each patient

  Yes

  No

  N/A

• Linen and supply carts are not stored in exams/procedure rooms

  Yes

  No

  N/A

• Supplies are stored in cupboards and cabinets

  Yes

  No

  N/A

• Supplies and equipment are not stored on windowsills ledges or near sinks

  Yes

  No

  N/A

Medications and Medical Supplies

• Hand hygiene sink is available in medication room

  Yes

  No

  N/A

• Medication carts are routinely cleaned

  Yes

  No

  N/A

• Medication Refrigerators

  Yes

  No

  N/A

• Temperature of refrigerator is maintained at +2°C and +8°C or as recommended by manufacturer and temperature is monitored twice daily

  Yes

  No

  N/A

• Temperature of refrigerator containing vaccines is to be monitored and documented twice daily

  Yes

  No

  N/A

• Medication refrigerator temperature to be monitored and documented daily

  Yes

  No

  N/A

• Food is not stored in medication refrigerator

  Yes

  No

  N/A

• Hand hygiene is performed before handling and administering medication

  Yes

  No

  N/A

• Multi-dose medication containers are for single patient use only

  Yes

  No

  N/A

• Multi-dose medication, if used, is dated when they are first opened and disposed of in 28 days, when contaminated, or as specified by manufacturer

  Yes

  No

  N/A

• Diaphragm of medication vials are decontaminated before inserting needle

  Yes

  No

  N/A

• Medication vials are entered with a new needle and a new syringe, even when obtaining additional doses for the same patient

  Yes

  No

  N/A

• Ports of intravenous tubing is decontaminated before inserting needle

  Yes

  No

  N/A

• Medication administration tubing and connectors are used for only one patient

  Yes

  No

  N/A

• Bags of Intravenous (IV) solution is used for only one patient

  Yes

  No

  N/A

• Patient’s skin is cleaned with appropriate type of antiseptic before insertion of intravenous line

  Yes

  No

  N/A

• All sharps are disposed of in puncture-resistant sharps container

  Yes

  No

  N/A

• Ointments, eye drops, creams, and lotions are administered in a manner that prevents contamination of container

  Yes

  No

  N/A

Storage and Handling: Clean Utility Room

• Clean and sterile items are physically located separate from soil items

  Yes

  No

  N/A

• Sterile items are stored in their sterile packaging until time of use

  Yes

  No

  N/A

• Sterile items are handled in a manner that prevents contamination of the item

  Yes

  No

  N/A

• There is adequate shelving/storage available for clean and sterile supplies (supplies are not stored on floor)

  Yes

  No

  N/A

• Supplies are not stored in cardboard/shipping boxes

  Yes

  No

  N/A

• Supplies are stored away from public access

  Yes

  No

  N/A

• Soil items are not stored in the clean utility room

  Yes

  No

  N/A

• Sterile and clean items are stored in a manner that maintains the integrity of the packages as per event related sterility (e.g. not torn, wet, dusty)

  Yes

  No

  N/A

• Sterile supplies are stored 25 cm/10 inches from the floor, 45 cm/18 inches from the ceiling in at least 5 cm/2 inches from outside walls

  Yes

  No

  N/A

• Shelves: countertops cupboards are clean inside

  Yes

  No

  N/A

• Supplies and equipment packaging is intact and clean

  Yes

  No

  N/A

• There are no expired products

  Yes

  No

  N/A

• Clean linen is kept in clean storage room

  Yes

  No

  N/A

• Clean and sterile supplies are kept off of the floor

  Yes

  No

  N/A

• There is no sink or water supply in the clean utility

  Yes

  No

  N/A

• Staff and patient refrigerators used for storing food have a thermometer and are monitored daily

  Yes

  No

  N/A

• Supplies are not stored under sink

  Yes

  No

  N/A

• Air supply and exhaust outlets are visibly clean and free from dust

  Yes

  No

  N/A

Storage and Handling: Soil/Dirty Utility Room

• Cleaning supplies are not stored in the soil utility

  Yes

  No

  N/A

• There are label containers for general, biomedical and anatomical wastes, if appropriate

  Yes

  No

  N/A

• There is a dedicated hand hygiene sink in the room

  Yes

  No

  N/A

• The sink is free of debris and/or body fluids

  Yes

  No

  N/A

• PPE is availability in the room

  Yes

  No

  N/A

• The hopper/ VernaCare, if present, is free of debris, body fluids and excretions

  Yes

  No

  N/A

• The hopper/VernaCare, if present, has posted instructions for use

  Yes

  No

  N/A

• There is a covered, leak proof container for the purpose of containment and transportation of used, reusable medical devices that are to be decontaminated reprocessed in a centralized or off-site location

  Yes

  No

  N/A

• There is adequate workspace available to clean items

  Yes

  No

  N/A

• Work flows for the ability to clean

  Yes

  No

  N/A

• Disinfectants are clearly label and used according to manufacturer's instructions

  Yes

  No

  N/A

• Overall appearance of room is orderly and clean

  Yes

  No

  N/A

Environment

• Work surfaces (e.g., chairs, tables, equipment trays) used in the delivery of care are cleaned thoroughly and then disinfected between clients/patients/residents

  Yes

  No

  N/A

• Terminal cleaning of clinic space occurs at end of day

  Yes

  No

  N/A

• Waste containers are covered and are not over-filled

  Yes

  No

  N/A

• Single-use covers (e.g., paper table covers) are discarded after each client/patient/resident

  Yes

  No

  N/A

• Reusable linen is laundered after each use (i.e., single client/patient/resident use)

  Yes

  No

  N/A

• Soiled linen is contained in leak-proof bags that are not over-filled

  Yes

  No

  N/A

• All linen is bagged or otherwise contained at point of care

  Yes

  No

  N/A

• Clean linen is packaged by methods that ensure its cleanliness and protects from dust and soil

  Yes

  No

  N/A

• Clean surgical linen does not touch unclean surfaces

  Yes

  No

  N/A

• Sterile surgical linen is stored in a clean and dry area that is readily accessible from the area where they are used

  Yes

  No

  N/A

• Separate carts are used for soiled and clean linen

  Yes

  No

  N/A

• Clean and soiled linen are transported and stored separately

  Yes

  No

  N/A

• Clean linen is:

• physically separate from dirty linen

  Yes

  No

  N/A

• Linen is stored in a manner that prevents exposure to dust, moisture and soiling

  Yes

  No

  N/A

• Linen is stored in a manner that allows stock rotation (e.g., oldest stock is used first

  Yes

  No

  N/A

• Clean linen is unpacked on return from the laundry and stored in a designated area within each department (e.g., supply room, cart)

  Yes

  No

  N/A

• Clean linen is only stock-piled in designated areas

  Yes

  No

  N/A

• Clean linen is stored in an area away from housecleaning equipment

  Yes

  No

  N/A

• There is a process to prevent handling of clean linen by patients/residents

  Yes

  No

  N/A

• There is a mechanism for staff to report if clean linen is not of an adequate standard

  Yes

  No

  N/A

• Clean linen carts are dedicated for linen only

  Yes

  No

  N/A

• Linen carts are stocked with adequate supply to meet user needs until next scheduled delivery

  Yes

  No

  N/A

• There is a documented schedule to clean floors, walls, cupboards, shelving and other surfaces that are not routinely contacted during care delivery, and when visibly soiled

  Yes

  No

  N/A

• Washrooms are appropriately stocked with soap, toilet tissue and paper towel

  Yes

  No

  N/A

• Furniture is free of dust and dirt

  Yes

  No

  N/A

• Hand wash sinks with soap, paper towel and waste container is available in each examination/procedure room

  Yes

  No

  N/A

• Hand hygiene product is easily accessible

  Yes

  No

  N/A

• All patient related equipment is cleaned and disinfected after each patient use

  Yes

  No

  N/A

• Hallways are organized and free of clutter/equipment

  Yes

  No

  N/A

• Supplies are not stored adjacent to sinks (where they can be exposed to splash)

  Yes

  No

  N/A

• Ceiling tiles are intact and no evidence of water damage

  Yes

  No

  N/A

• Food and drinks are not present in any patient care areas

  Yes

  No

  N/A

• Products (e.g., creams, lotions, cotton balls, swabs) are single-use or are dispensed in a manner that does not contaminate the remaining portion (i.e., no double-dipping)

  Yes

  No

  N/A

• If bulk products are decanted into smaller containers for use, the containers are cleaned, disinfected and dried between uses (i.e., not topped-up)

  Yes

  No

  N/A

Waiting Room

• All furnishings made from non-porous, wipeable materials

  Yes

  No

  N/A

• ABHR available in waiting room

  Yes

  No

  N/A

• Room is clutter-free

  Yes

  No

  N/A

• Waste receptacles are provided in the room

  Yes

  No

  N/A

Equipment

• Shared, reusable non-critical equipment is cleaned and disinfected between clients/ patients/residents, including transporting equipment according to established standards

  Yes

  No

  N/A

• Clean and soiled equipment/devices are transported and stored separately

  Yes

  No

  N/A