ISPT ICU, NICU, SICU, PICU

• Conducted on

  Date

• Prepared by

• Location
  Address

I. STANDARD PRECAUTIONS

• Yes

  No

  N/A

A, HAND HYGEINE

• a. Frequency of handwashing per HCW ( actual numbers/ shift )

• i.e. 5 moments of moments of hand hygiene and the 7 steps of hand washing

  Yes

  No

  N/A

• b. Proportion of HCW who performs handwashing (%) – CCTV Monitored

• c. Access to sink, soap and alcohol

  Yes

  No

  N/A

B. PERSONAL PROTECTIVE EQUIPMENT (PPE'S)

• a. Correct donning and doffing

  Yes

  No

  N/A

• b. Storage of clean and new PPE’s

  Yes

  No

  N/A

II. TRANSMISSION BASED PRECAUTIONS

CONTACT

• Adequate PPE worn

  Yes

  No

  N/A

• Regular Handwashing

  Yes

  No

  N/A

DROPLET

• Mask worn at all times ?

  Yes

  No

  N/A

• Correct PPE’s worn?

  Yes

  No

  N/A

• Room cleaning done regularly?

  Yes

  No

  N/A

AIRBORNE

• Adequate ventilation ?

  Yes

  No

  N/A

• Negative pressure room ?

  Yes

  No

  N/A

III. ENVIRONMENTAL CONTROLS

CLEANING

• Frequency of cleaning the unit/s ( check availability of SOI ) ( actual cleaning / day )

• Adequacy/ availability of cleaning materials including housekeeping carts

  Yes

  No

  N/A

DISINFECTIING

• Adequacy and availability of disinfectants ( check availability of SOI )

  Yes

  No

  N/A

• Frequency of disinfecting the unit/s ( actual number/ day )

WASTE DISPOSAL

• Correct segregation, handling, collection and disposal of waste ( check availability of SOI )

  Yes

  No

  N/A

AIRFLOW AND VENTILATION MANAGEMENT

• Laminar flow air is present and working?

  Yes

  No

  N/A

• Exhaust ducts is present and functioning?

  Yes

  No

  N/A

• Is ventilation adequate?

  Yes

  No

  N/A