Isolation Rounds

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Unit Name:

• Room Number:

• Observer Name:

• Isolation Type:

  Contact Isolation

  Enhanced Contact Isolation

  Droplet Isolation

  Airborne Isolation

Entering Isolation Room

• Is appropriate signage displayed by/on the door?

  Yes

  No

  N/A

• Were gloves applied?

  Yes

  No

  N/A

• Did staff wash hands?

  Yes

  No

  N/A

• Were gowns applied?

  Yes

  No

  N/A

• Were gowns tied after being applied?

  Before

  After

  N/A

• If applicable, were masks applied?

  Surgical (Standard) Mask for Droplet Isolation

  N95 Mask for Airborne Isolation

• Were gloves pulled over the cuff of the gown sleeve?

  Yes

  No

  N/A

Exiting the Isolation Room

• Were gloves removed?

  Yes

  No

  N/A

• Were gowns removed?

  Yes

  No

  N/A

• Was appropriate Hand Hygiene used upon exiting the room?

  Select Alcohol Rinse Soap and Water (for Enhanced Contact Isolation) No Hand Hygiene Used

  • Alcohol Rinse
  • Soap and Water (for Enhanced Contact Isolation)
  • No Hand Hygiene Used

• Was the sink area clear for usage?

  Yes

  No

  N/A

• If a mask was required, was it removed last?

  Yes

  No

  N/A

• Was the equipment wiped off when staff exited the room?

  Yes

  No

  N/A

• If the patient was being transported, were appropriate barriers in place?

  Yes

  No

  N/A

Isolation Cart

• Are there adequate supplies? (Gloves, gowns, etc.)

  Yes

  No

  N/A

• Is disinfectant available? (CaviWipes and/or Clorox)

  Yes

  No

  N/A

• Are the appropriate masks for Airborne and Droplet Isolation well stocked?

  Yes

  No

  N/A

Neutropenic Precautions

• Is the door being kept closed?

  Yes

  No

  N/A

• Is the patient masked when they leave the room?

  Yes

  No

  N/A

Airborne Isolation Room

• Is the door being kept closed?

  Yes

  No

  N/A

• Are negative airflow checks being done?

  Yes

  No

  N/A

• Are N95 Airborne Isolation masks being consistently used?

  Yes

  No

  N/A