Audit

Staff Interview

What populations are served at this location:

Do you know how to contact infection prevention?

Staff know how to access Institutional Infection Prevention Policies?

Do you have any departmental infection prevention policies?

When was the last time departmental policies were reviewed?

Staff know the location of the Exposure Control Plan / Tuberculosis Control Plan

Influenza vaccination status is known (ex. appropriate colored heart)

Non-vaccinated staff wear mask appropriately

Staff know how to access IFU

Manager uses the Sick Call log

What is done when you identify an empty hand sanitizer dispenser

What is done when you identify a full sharp disposal container

How is water taken from the ice/water machine to the patient's room

Staff can explain what is "biohazardous waste"

What items are disposed of in the red biohazard containers

Staff know how to transport clean/dirty reusable items

Staff can describe process for pre-cleaning items to be sent for sterilization or HLD

State communicable disease list available. Staff can verbalize how to report.

Hand Hygiene
Hand hygiene locations readily available

Trained observer

Observations done and recorded each month

Rates posted

Trained validator

Competency validation done every other year

Hand hygiene education done annually

Able to show individual's compliance

No artificial nails, bracelets, thumb-hole tops, hand splints or braces

Hand hygiene is done prior to donning gloves

Hand hygiene is done after removing gloves

Hand hygiene is done prior to having contact with the patient even if not wearing gloves

MMP locations

Waiting areas neat and clean.

Patient scheduling: illness triage? What is response if positive for illness?

Potentially infectious patient (PIP) is moved into exam room/procedure room/patient room asap

Communication to provider about PIP?

Horizontal and high-touch surfaces of exam rooms cleaned between patients.

What procedures are done at this location?

Appropriate procedures in place for patient and staff safety (i.e. PPE, smoke evacuation, positive pressure procedure room?)

Department Rounds

Cough etiquette supplies available at entrance to location?

Employee can verbalize when hand hygiene is expected.

Stretchers and wheel chairs are cleaned after use with appropriate disinfectant

No non-intact stretchers, wheel chairs, beds, chairs, etc.

Clean linen is covered and maintained in a clean/dry area

Disposable blood pressure cuffs not re-used for routine patient care

Reusable blood pressure cuffs cleaned between patients

No under sink storage except for cleaning products

Environment and equipment is clean and dust free

All storage containers are cleanable (i.e. no wicker, cardboard boxes etc.)

Emergency supplies - high level disinfected items intact packages, no outdates

No food or drink in the patient care area. Labeled hydration station.

Clean equipment is covered with a clear bag/clean tag is present

Alcohol dispensers readily available

General appearance of the area is clean and uncluttered

Ceiling tiles are clean and dry

Cleaning supplies are labeled (if in secondary container) and approved for use in the hospital

IV bags are not pre-spiked

Medication Room

When are refrigerator(s) defrosted/cleaned

Refrigerator is labeled as "medication" refrigerator

Thermometer present - temps are tracked

Staff can describe what to do if temperature out of range

Multi-dose vials are dated when they are first opened and discarded within 28 days.

Multi-dose vials that are used for more than one patient are stored appropriately and do not enter the immediate patient zone.

What is the process for expired medication?

Safety devices are used for all injections, phelbotomy, venipuncture, & IV therapy. Describe any exceptions to safety devices and rationale.

Sharps containers are accessible, secured to wall/counter and emptied when reach "full" line

Glass is disposed of in rigid sharps containers

Hands are washed prior to preparing medications

Aseptic technique used to enter medication vials

Single use medication vials discarded

Staff can verbalize vaccine storage policy

There is a 3 foot splash zone from the sink where medications are not prepared or stored or splash guard is available

Patient Care

Staff use and can explain standard precautions

Staff use and can explain transmission based precautions

Gloves not worn in the hallway

Communication to ancillary departments or clinicians about potentially communicable patient (Ticket/tag to ride, verbal report, etc.)

Appropriate mouth, nose, and eye protection is worn for aerosol-generating procedures

Inspect patient rooms and bathrooms for inappropriate supplies or outdated supplies

Staff understand cohorting

Appropriate skin disinfection prior to injection/blood draw

Scrub the hub prior to accessing IVs

All medications are prepared in a clean preparation area

All point of care devices are cleaned and disinfected after every use according to IFU.

Patient Zone

PPE available gloves, gowns, eye protection, masks

Staff know how to don and doff PPE - competency validated?

Transmission based precaution signs available?

Appropriate use of transmission based precaution signs?

Appropriate order entered into EMR?

Sharps container less than 3/4 full

Sterile irrigation fluid is opened for same day use only (<24hr). Date noted.

Soiled linen is placed in designated covered hampers and is marked with biohazard symbol

Ultrasound gel is single use packets or bottle is dated.

Hampers used appropriately- ie. no bags on the floor, no overflowing linen

If bed is unmade- mattress intact?

Staff know wet contact time for disinfectants

Staff know which disinfectant to use for each item

Precaution Room

Precaution bag is present or cubby is stocked with supplies

Correct sign on door

Adequate amount of supplies available

Hand sanitizer available and full

Hand sanitizer covered in Enteric Precaution room

Soap and water is used to disinfect hands as leaving Enteric Precaution room

Wastebasket inside doorway - not overflowing

Hamper available inside room - not overflowing

PPE worn correctly

PPE removed prior to leaving patient room

If negative pressure- PAPR hood or N95 utilized

If negative pressure- check logbook in maintenance- when needed, pressure to be checked/documented every shift

Food handling

Thermometer present

Temperatures logs maintained

Food/ containers dated

Clean

No expired food

Clean Supply Room

Clean utility is separate from dirty utility

Outer shipping boxes not stored with supplies/ removed from clean areas

Clean items only

Bottom of storage racks must have solid surface shelving

No medical supplies on floor

Storage of sterile supplies 8-10" above the floor, 2" away from exterior walls

All sterile supplies are dry with intact packaging, not stored on the floor

Nothing stored under the sinks

18 inches of clearance from ceiling in clean utility room or other clean areas

No outdated supplies

Door closed

Positive pressure

Temperature and humidity monitored if MMC processed sterile supplies are stored

Staff can explain even related sterility

Dirty Utility Room

Dirty items only

Door closed on soiled utility room

No storage of drinking cups, tissues, paper towels, toilet tissue

PPE available

Negative pressure maintained and monitored

Items waiting for processing are stored open and remain wet

Sterile Procedure safety

Room appropriate temperature, humidity and pressurization

Sterile trays are not set up ahead of time and covered for future use

All hair covered when sterile field is open and during procedure

No unattended sterile field

Lead aprons cleaned between uses

Masks worn covering nose and mouth - both ties tied

Appropriate surgical scrub is done prior to sterile procedure

All surfaces appropriately cleaned between cases

Principles of asepsis are maintained for the sterile field and surgical incision

Reprocessing onsite or transport?

Visible bioburden removed at point of use

Items are kept moist

Reprocessing

Appropriate temperature, humidity and pressure?

Appropriate PPE worn?

Staff can speak to IFU

Instruments not visibly dry prior to manual cleaning

Instruments unhinged and open

No processing of single use items

Biologicals used appropriately

Area is clean and dust free

Separation of clean and dirty, function and workflow

Endoscopes logged to trace to patient

Endoscopes manual cleaning begins within 1 hour of end of use

Endoscope reprocessing competency validated

Flexible endoscopes are inspected for damage and leak tested as part of each reprocessing cycle

After high-level disinfection, devices are stored in a manner to protect from damage or contamination (Note endoscopes must be hung in a vertical position)

All high level disinfection processes have competency

All cleaning brushes are single-use, disposable or if, reusable, cleaned and either high-level disinfected or sterilized (per IFU).

Chemical and biological indicators are used as required.

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.