Transmission based precautions

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Facility / Ward and Bed number

Patient MRN

• MRN:

Airbourne precautions

• Is the patient on Airborne precautions?

  Yes

  No

• Is the patient in an single room with ensuite facilities, separate air conditioning unit and the door closed

  Yes

  No

• What was the reason this question failed. E.G. Door open

• Is the correct precaution sign on patients door

  Yes

  No

• Prior to entering room is PPE station available outside room with N95/P2 masks available?

  Yes

  No

• Are Catering entering patients room to deliver or collect meal trays to patient?

  Yes

  No

  N/A

• If able, can staff demonstrate correct donning and doffing of PPE

  Yes

  No

  N/A

Contact precautions

• Is the patient on Contact precautions?

  Yes

  No

• Does the Patient require Contact PLUS precautions? Pt identified with C-Diff, Noro or Rotavirus

  Yes

  No

  N/a

• Are staff and visitors demonstrating or educated to wash hands prior to exiting room with soap and water?

  Yes

  No

  N/A

• Appropiate room with door open if desired

  Yes

  No

• Is the correct precaution sign on patients door?

  Yes

  No

• Prior to entering room is PPE station available outside room with Apron and/or impervious gowns and gloves available?

  Yes

  No

• Staff can demonstrate correct donning and doffing of PPE

  Yes

  No

  N/A

Droplet precautions

• Is the patient on droplet precautions?

  Yes

  No

• Is the patient in an appropiate room with door closed?

  Yes

  No

• Is the correct precaution signage on patients door?

  Yes

  No

• Prior to entering room is PPE station available outside room with Level 2 or 3 masks available?

  Yes

  No

• Correct donning and doffing of PPE is demonstrated by staff

  Yes

  No

  N/A

• Is PPE being worn by patient when leaving room

  Yes

  No

  N/A

General Requirements

• Hand Hygiene - ABHR readily available on PPE station AND in room

  Select Yes No

  • Yes
  • No

• Swabbing completed on admission if previous flagged

  Yes

  No

  N/A

• Is there documentation such as a note for Infectious disease in progress notes or safety alert form

  Yes

  No

  N/A

• Is there a PPE station in easy access to the MRO room?

  Yes

  No

• Is there disinfectant wipes available

  Yes

  No

• Ask the patient if a Information leaflet was provided (if appropiate)

  Yes

  No

  N/A

• All clinical waste bin is disposed of in a Clinical waste bin (ideally a C64 bin)

  Yes

  No

• Appropiate cleaning procedures in place (Ask enviromental staff if available)

  Yes

  No

  N/A

• Housekeeping not aware of MRO

• MRN: