Medical Infection Control Audit Report

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

OPRP

• Health & safety protocols including SARS-CoV-2

  Yes

  No

  N/A

• Sanitation procedures SARS-CoV-2 specific

  Yes

  No

  N/A

• Availability of disinfectants for use against SARS-CoV-2

  Yes

  No

  N/A

• Third party validation of compliance with all health & safety protocols

  Yes

  No

  N/A

Healthcare Personnel Safety

• Medical facility has an exposure control plan that is tailored to the specific requirements of the facility

  Yes

  No

  N/A

• Is the medical staff trained on preventative measures for airborne, bloodborne pathogens periodically

  Yes

  No

  N/A

• Following an exposure event, post-exposure evaluation and follow-up, including prophylaxis as appropriate, are available to the staff and are supervised by the ship's doctor.

  Yes

  No

  N/A

• Medical facility tracks staff exposure events and evaluates event data and develops/implements corrective action plans to reduce incidence of such events.

  Yes

  No

  N/A

• Medical facility follows recommendations on Immunization Practices for immunization of the medical staff, including offering Hepatitis B and influenza vaccination.

  Yes

  No

  N/A

• All medical staff receive baseline tuberculosis (TB) screening prior to joining a vessel.

  Yes

  No

  N/A

• If respirators are used, the medical facility has a respiratory protection program that details required worksite-specific procedures and elements for required respirator use, including provision of medical clearance, training, and fit testing as appropriate.<br>

  Yes

  No

  N/A

• Medical facility has well-defined policies concerning contact of medical staff with patients when medical staff have potentially transmissible conditions.

  Yes

  No

  N/A

• Medical staff educated on the importance of infection prevention measures to contain respiratory secretions to prevent the spread of respiratory pathogens.

  Yes

  No

  N/A

Surveillance and Disease Reporting

• An updated list of diseases reportable to the public health authority is readily available.

  Yes

  No

  N/A

• Medical Staff can demonstrate knowledge of and compliance with mandatory reporting requirements for notifiable diseases, and for potential outbreaks.

  Yes

  No

  N/A

Hand Hygiene

• Medical staff is required to demonstrate competency with hand hygiene.

  Yes

  No

  N/A

• Medical facility routinely audits (monitors and documents) adherence to hand hygiene.

  Yes

  No

  N/A

• Medical facility provides feedback from audits to personnel regarding their hand hygiene performance.

  Yes

  No

  N/A

• Hand hygiene policies promote preferential use of soap and water over alcohol-based hand rub.

  Yes

  No

  N/A

Crew Pre-Embarkation Requirements

• PEME

  Yes

  No

  N/A

• Covid PCR test prior to departure from home

  Yes

  No

  N/A

Guest Health Screening Procedures

• Pre-embarkation Covid-19 testing

  Yes

  No

  N/A

• undefined

  Select RT-PCR PCR Antigen Antibody

  • RT-PCR
  • PCR
  • Antigen
  • Antibody

• Self-quarantine requirements at home

  Yes

  No

  N/A

• Health questionnaire at embarkation

  Yes

  No

  N/A

• Primary terminal health screening procedures

  Yes

  No

  N/A

• Secondary Medical Screening Procedures

  Yes

  No

  N/A

Crew Screening Procedures

• Pre-embarkation screening Covid-19 testing

  Select Yes No N/A

  • Yes
  • No
  • N/A

• undefined

  Select RT-PCR PCR Antigen Antibody

  • RT-PCR
  • PCR
  • Antigen
  • Antibody

• Self-quarantine requirements at home

  Yes

  No

  N/A

• Health questionnaire at embarkation

  Yes

  No

  N/A

• Primary terminal health screening procedures

  Yes

  No

  N/A

• Quarantine at embarkation/other quarantine setting

  Select 2 Days 4 Days 7 Days 10 Days 14 Days

  • 2 Days
  • 4 Days
  • 7 Days
  • 10 Days
  • 14 Days

Denial For Boarding Procedures & Disembarkation Scenarios

• Symptomatic cases

  Yes

  No

  N/A

• Positive findings during screening process

  Yes

  No

  N/A

• System in place to isolate/hospitalize cases off the ship

  Yes

  No

  N/A

• Repatriation procedures for suspected or confirmed cases once released

  Yes

  No

  N/A

• Hospital & hotels networking itinerary based

  Yes

  No

  N/A

Reporting System to the Public Health Authorities

• CDC

  Yes

  No

  N/A

• Local Authorities

  Yes

  No

  N/A

• Health Canada

  Yes

  No

  N/A

• Anvisa

  Yes

  No

  N/A

• Other

Terminals & On Board Procedures For Covid-19 Risk Mitigation

• Guest capacity reduction for cruising

  Yes

  No

  N/A

• Physical distancing procedures

  Yes

  No

  N/A

• Use of face masks (mandatory/optional)

  Yes

  No

  N/A

• Enough sanitation & disinfection stations in public areas

  Yes

  No

  N/A

• Touchless technology

  Yes

  No

  N/A

• Other technical measures or technology e.g. Pyure

Medical Facility

• Medical facility isolation ward for suspected/confirmed Covid-19 cases

  Yes

  No

  N/A

• Nurse with ICU training & skills

  Yes

  No

  N/A

• RT-PCR testing capability

  Yes

  No

  N/A

• Antigen Point of Care testing capability

  Yes

  No

  N/A

• Medical facility has written policies and procedures for routine cleaning and disinfection of environmental surfaces, including identification of responsible personnel.

  Select Upon Hire, prior to being allowed to perform environmental cleaning Periodically e.g., quarterly, annually When new equipment or protocols are introduced

  • Upon Hire, prior to being allowed to perform environmental cleaning
  • Periodically e.g., quarterly, annually
  • When new equipment or protocols are introduced

• Medical staff is required to demonstrate competency with environmental cleaning procedures following each training.

  Select Upon Hire, prior to being allowed to perform environmental cleaning Periodically e.g., quarterly, annually When new equipment or protocols are introduced

  • Upon Hire, prior to being allowed to perform environmental cleaning
  • Periodically e.g., quarterly, annually
  • When new equipment or protocols are introduced

• Medical facility routinely audits (monitors and documents) adherence to cleaning and disinfection procedures, including using products in accordance with manufacturer’s instructions (e.g., dilution, storage, shelf-life, contact time).

  Select Upon Hire, prior to being allowed to perform environmental cleaning Periodically e.g., quarterly, annually When new equipment or protocols are introduced

  • Upon Hire, prior to being allowed to perform environmental cleaning
  • Periodically e.g., quarterly, annually
  • When new equipment or protocols are introduced

• Medical facility provides feedback from audits to personnel regarding their adherence to cleaning and disinfection procedures.

  Select Upon Hire, prior to being allowed to perform environmental cleaning Periodically e.g., quarterly, annually When new equipment or protocols are introduced

  • Upon Hire, prior to being allowed to perform environmental cleaning
  • Periodically e.g., quarterly, annually
  • When new equipment or protocols are introduced

• Medical facility has a policy/procedure for decontamination of spills of blood or other body fluids.

  Select Upon Hire, prior to being allowed to perform environmental cleaning Periodically e.g., quarterly, annually When new equipment or protocols are introduced

  • Upon Hire, prior to being allowed to perform environmental cleaning
  • Periodically e.g., quarterly, annually
  • When new equipment or protocols are introduced

• Providing space in waiting rooms and encouraging persons with symptoms of respiratory infections to sit at least 2 feet away from others as possible.

  Yes

  No

  N/A

• Medical facility has policies and procedures to contain respiratory secretions in persons who have signs and symptoms of a respiratory infection, beginning at point of entry to the facility and continuing through the duration of the visit.

  Yes

  No

  N/A

• Offering facemasks to coughing patients and other symptomatic persons upon entry to the facility, at a minimum, during periods of increased respiratory infection activity in the community.

  Yes

  No

  N/A

PPE

• PPE stock quantities sufficient for an outbreak

  Yes

  No

  N/A

• Medical staff who use PPE receive training on proper selection and use of PPE

  Select Upon hire, prior to being allowed to perform point-of-care testing Periodically e.g., quarterly, annually When new equipment or protocols are introduced

  • Upon hire, prior to being allowed to perform point-of-care testing
  • Periodically e.g., quarterly, annually
  • When new equipment or protocols are introduced

• Medical facility provides feedback from audits to staff regarding their performance with selection and use of PPE.

  Yes

  No

  N/A

Point of Care Testing

• Medical staff who perform point-of-care testing receive training on recommended practices

  Select Upon hire, prior to being allowed to perform point-of-care testing Periodically e.g., quarterly, annually When new equipment or protocols are introduced

  • Upon hire, prior to being allowed to perform point-of-care testing
  • Periodically e.g., quarterly, annually
  • When new equipment or protocols are introduced

• Medical staff is required to demonstrate competency with recommended practices for point-of-care testing following each training.

  Yes

  No

  N/A

• Medical facility routinely audits (monitors and documents) adherence to recommended practices during point-of-care testing.

  Yes

  No

  N/A

• Medical facility provides feedback from audits to staff regarding their adherence to recommended practices.

  Yes

  No

  N/A

Isolation & Quarantine

• Designated cabins for isolation (single occupancy)

  Yes

  No

  N/A

• Designated cabins for quarantine

  Yes

  No

  N/A

Medical Equipment Cleaning

• Medical facility has policies and procedures to ensure that reusable medical devices are cleaned and reprocessed appropriately prior to use on another patient.<br>

  Yes

  No

  N/A

• Medical staff is required to demonstrate competency with reprocessing procedures (i.e., correct technique is observed by trainer) following each training

  Yes

  No

  N/A

• Medical facility routinely audits (monitors and documents) adherence to reprocessing procedures.

  Yes

  No

  N/A

• Medical facility provides feedback from audits to personnel regarding their adherence to reprocessing procedures.

  Yes

  No

  N/A

• Medical facility has protocols to ensure that staff can readily identify devices that have been properly reprocessed and are ready for use (e.g., tagging system, storage in designated area).

  Yes

  No

  N/A

• Medical facility has policies and procedures outlining facility response (i.e., risk assessment and recall of device) in the event of a reprocessing error or failure.

  Yes

  No

  N/A

• Routine maintenance for reprocessing equipment (e.g., steam autoclave) is performed by biomedical personnel in accordance with manufacturer instructions; confirm maintenance records are available.

  Yes

  No

  N/A

• Date of last biomedical preventative maintenance certification done

Sterilization of Reusable Devices

• Devices are thoroughly cleaned according to manufacturer instructions and visually inspected for residual soil prior to sterilization.

  Yes

  No

  N/A

• Cleaning is performed as soon as practical after use (e.g., at the point of use) to prevent soiled materials from becoming dried onto devices.

  Yes

  No

  N/A

• Enzymatic cleaner or detergent is used for cleaning and discarded according to manufacturer’s instructions (typically after each use)

  Yes

  No

  N/A

• After cleaning, instruments are appropriately wrapped/packaged for sterilization

  Yes

  No

  N/A

• A chemical indicator (process indicator) is placed correctly in the instrument packs in every load.

  Yes

  No

  N/A

• A biological indicator, intended specifically for the type and cycle parameters of the sterilizer, is used at least weekly for each sterilizer and with every load containing implantable items.

  Yes

  No

  N/A

• For dynamic air removal-type sterilizers (e.g., prevacuum steam sterilizer), an air removal test (Bowie-Dick test) is performed in an empty dynamic-air removal sterilizer each day the sterilizer is used to verify efficacy of air removal.

  Yes

  No

  N/A

• Sterile packs are labeled with a load number that indicates the sterilizer used, the cycle or load number, the date of sterilization, and, if applicable, the expiration date.

  Yes

  No

  N/A

• Sterilization logs are current and include results from each load.

  Yes

  No

  N/A

• After sterilization, medical devices are stored so that sterility is not compromised.

  Yes

  No

  N/A

• Sterile packages are inspected for integrity and compromised packages are reprocessed prior to use.

  Yes

  No

  N/A

• The medical facility has a process to perform initial cleaning of devices (to prevent soiled materials from becoming dried onto devices) prior to transport to the off-site reprocessing facility.

  Yes

  No

  N/A

Crew Training

• Stretcher team Covid-19 transport training & frequency

  Yes

  No

  N/A

• General crew Covid-19 training & frequency

  Yes

  No

  N/A