MMC Infection Control Rounds

Infection Prevention Site Survey and Risk Assessment

• Location name and address:
  Address

• Conducted on

  Date

• Contact

• Contact phone number

• Prepared by

Staff Interview

• What populations are served at this location:

• Do you know how to contact infection prevention?

  Yes

  No

  N/A

• Staff know how to access Institutional Infection Prevention Policies?

  Yes

  No

  N/A

• Do you have any departmental infection prevention policies?

  Yes

  No

  N/A

• When was the last time departmental policies were reviewed?

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Non-vaccinated staff wear mask appropriately

  Yes

  No

  N/A

• Staff know how to access IFU

  Yes

  No

  N/A

• Manager uses the Sick Call log

  Yes

  No

  N/A

• What is done when you identify an empty hand sanitizer dispenser

  Nurse Response

• What is done when you identify a full sharp disposal container

  Nurse Response

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

  Nurse Response

• Staff can explain what is "biohazardous waste"

  Yes

  No

  N/A

• What items are disposed of in the red biohazard containers

  Nurse Response

• Staff know how to transport clean/dirty reusable items

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Hand Hygiene

• Hand hygiene locations readily available

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Trained observer

  Yes

  No

  N/A

• Observations done and recorded each month

  Yes

  No

  N/A

• Rates posted

  Yes

  No

  N/A

• Trained validator

  Yes

  No

  N/A

• Competency validation done every other year

  Yes

  No

  N/A

• Hand hygiene education done annually

  Yes

  No

  N/A

• Able to show individual's compliance

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Hand hygiene is done prior to donning gloves

  Yes

  No

  N/A

• Hand hygiene is done after removing gloves

  Yes

  No

  N/A

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

  Yes

  No

  N/A

MMP locations

• Waiting areas neat and clean.

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

• Communication to provider about PIP?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

• Employee can verbalize when hand hygiene is expected.

  Yes

  No

  N/A

• Stretchers and wheel chairs are cleaned after use with appropriate disinfectant

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Disposable blood pressure cuffs not re-used for routine patient care<br>

  Yes

  No

  N/A

• Reusable blood pressure cuffs cleaned between patients

  Yes

  No

  N/A

• No under sink storage except for cleaning products

  Yes

  No

  N/A

• Environment and equipment is clean and dust free

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Alcohol dispensers readily available

  Yes

  No

  N/A

• General appearance of the area is clean and uncluttered

  Yes

  No

  N/A

• Ceiling tiles are clean and dry

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• IV bags are not pre-spiked

  Yes

  No

  N/A

Medication Room

• When are refrigerator(s) defrosted/cleaned

  Nurse Response

• Refrigerator is labeled as "medication" refrigerator

  Yes

  No

  N/A

• Thermometer present - temps are tracked

  Yes

  No

  N/A

• Staff can describe what to do if temperature out of range

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Glass is disposed of in rigid sharps containers

  Yes

  No

  N/A

• Hands are washed prior to preparing medications

  Yes

  No

  N/A

• Aseptic technique used to enter medication vials

  Yes

  No

  N/A

• Single use medication vials discarded

  Yes

  No

  N/A

• Staff can verbalize vaccine storage policy

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Patient Care

• Staff use and can explain standard precautions

  Yes

  No

  N/A

• Staff use and can explain transmission based precautions

  Yes

  No

  N/A

• Gloves not worn in the hallway

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Inspect patient rooms and bathrooms for inappropriate supplies or outdated supplies

  Yes

  No

  N/A

• Staff understand cohorting

  Yes

  No

  N/A

• Appropriate skin disinfection prior to injection/blood draw

  Yes

  No

  N/A

• Scrub the hub prior to accessing IVs

  Yes

  No

  N/A

• All medications are prepared in a clean preparation area

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Patient Zone

• PPE available gloves, gowns, eye protection, masks

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Transmission based precaution signs available?

  Yes

  No

  N/A

• Appropriate use of transmission based precaution signs?

  Yes

  No

  N/A

• Appropriate order entered into EMR?

  Yes

  No

  N/A

• Sharps container less than 3/4 full

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Ultrasound gel is single use packets or bottle is dated.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• If bed is unmade- mattress intact?

  Yes

  No

  N/A

• Staff know wet contact time for disinfectants

  Yes

  No

  N/A

• Staff know which disinfectant to use for each item

  Yes

  No

  N/A

Precaution Room

• Precaution bag is present or cubby is stocked with supplies

  Yes

  No

  N/A

• Correct sign on door

  Yes

  No

  N/A

• Adequate amount of supplies available

  Yes

  No

  N/A

• Hand sanitizer available and full

  Yes

  No

  N/A

• Hand sanitizer covered in Enteric Precaution room

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Wastebasket inside doorway - not overflowing

  Yes

  No

  N/A

• Hamper available inside room - not overflowing

  Yes

  No

  N/A

• PPE worn correctly

  Yes

  No

  N/A

• PPE removed prior to leaving patient room

  Yes

  No

  N/A

• If negative pressure- PAPR hood or N95 utilized

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Food handling

• Thermometer present

  Yes

  No

  N/A

• Temperatures logs maintained

  Yes

  No

  N/A

• Food/ containers dated

  Yes

  No

  N/A

• Clean

  Yes

  No

  N/A

• No expired food

  Yes

  No

  N/A

Clean Supply Room

• Clean utility is separate from dirty utility

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Clean items only

  Yes

  No

  N/A

• Bottom of storage racks must have solid surface shelving

  Yes

  No

  N/A

• No medical supplies on floor

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Nothing stored under the sinks

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• No outdated supplies

  Yes

  No

  N/A

• Door closed

  Yes

  No

  N/A

• Positive pressure

  Yes

  No

  N/A

• Temperature and humidity monitored if MMC processed sterile supplies are stored

  Yes

  No

  N/A

• Staff can explain even related sterility

  Yes

  No

  N/A

Dirty Utility Room

• Dirty items only

  Yes

  No

  N/A

• Door closed on soiled utility room

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• PPE available

  Yes

  No

  N/A

• Negative pressure maintained and monitored

  Yes

  No

  N/A

• Items waiting for processing are stored open and remain wet

  Yes

  No

  N/A

Sterile Procedure safety

• Room appropriate temperature, humidity and pressurization

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• All hair covered when sterile field is open and during procedure

  Yes

  No

  N/A

• No unattended sterile field

  Yes

  No

  N/A

• Lead aprons cleaned between uses

  Yes

  No

  N/A

• Masks worn covering nose and mouth - both ties tied

  Yes

  No

  N/A

• Appropriate surgical scrub is done prior to sterile procedure

  Yes

  No

  N/A

• All surfaces appropriately cleaned between cases

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Reprocessing onsite or transport?

• Visible bioburden removed at point of use

  Yes

  No

  N/A

• Items are kept moist

  Yes

  No

  N/A

Reprocessing

• Appropriate temperature, humidity and pressure?

  Yes

  No

  N/A

• Appropriate PPE worn?

  Yes

  No

  N/A

• Staff can speak to IFU

  Yes

  No

  N/A

• Instruments not visibly dry prior to manual cleaning

  Yes

  No

  N/A

• Instruments unhinged and open

  Yes

  No

  N/A

• No processing of single use items

  Yes

  No

  N/A

• Biologicals used appropriately

  Yes

  No

  N/A

• Area is clean and dust free

  Yes

  No

  N/A

• Separation of clean and dirty, function and workflow

  Yes

  No

  N/A

• Endoscopes logged to trace to patient

  Yes

  No

  N/A

• Endoscopes manual cleaning begins within 1 hour of end of use

  Yes

  No

  N/A

• Endoscope reprocessing competency validated

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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)

  Yes

  No

  N/A

• All high level disinfection processes have competency

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Chemical and biological indicators are used as required.

  Yes

  No

  N/A

• Yes

  No

  N/A