TSDFT Infection Control Theatre Premise Audit Tool v1.1

• Document No.

• Infection Control Theatre Premise Audit

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Theatre Environment

• The changing areas are clean with adequate locker storage?

  Yes

  No

  N/A

• There is clean footwear for visitors to the unit?

  Yes

  No

  N/A

• Footwear is regularly decontaminated?

  Yes

  No

  N/A

• There are no drugs / blood transfusion or pathology specimens in the food fridge?

  Yes

  No

  N/A

• Opened food is stored in pest free containers?

  Yes

  No

  N/A

• There is no food past expiry date?

  Yes

  No

  N/A

• Milk is stored under refrigerated conditions?

  Yes

  No

  N/A

• Fridge temperature is between 0 - 5 degrees C?

  Yes

  No

  N/A

• The theatres are clean and free from dust?

  Yes

  No

  N/A

• Wall seals are clean and free from dust?

  Yes

  No

  N/A

• Theatre table mattresses are intact and clean?

  Yes

  No

  N/A

• There is a written policy for cleaning theatres on a seasonal basis, daily basis, 6 monthly basis for walls / ceilings etc?

  Yes

  No

  N/A

• Mops and buckets are stored dry and clean?

  Yes

  No

  N/A

• Mop heads are laundered daily?

  Yes

  No

  N/A

• Separate cleaning equipment is provided for each theatre?

  Yes

  No

  N/A

• The sluice is clean and free from spillage?

  Yes

  No

  N/A

• There is no evidence of infestation of animals?

  Yes

  No

  N/A

• Theatre ventilation system is monitored on a pre-planned maintenance programme by the works department and documented?

  Yes

  No

  N/A

• An ultraclean theatre is monitored on a regular basis ( minimum annually ) by the microbiology department contractor?

  Yes

  No

  N/A

• Visitors entering theatres ( past anaesthetic room ) change clothing and foot ware?

  Yes

  No

  N/A

• There is a sequence of increasingly clean zones for the entrance to the operating areas?

  Yes

  No

  N/A

• Patient beds brought into the operating theatre have clean linen removed and left outside theatre?

  Yes

  No

  N/A

Clinical Practices

• There is a policy for patients with known infections ( e.g. MRSA, HIV, HBV )?

  Yes

  No

  N/A

• Labels for specimens?

  Yes

  No

  N/A

• Infected linen bags?

  Yes

  No

  N/A

• HSDU autoclavable bags?

  Yes

  No

  N/A

• All specimens are handled, labelled and stored safely?

  Yes

  No

  N/A

• Sterile dressings are used to cover intravenous cannula sites?

  Yes

  No

  N/A

• The policies in the infection control manual are the most up-to-date versions?

  Yes

  No

  N/A

• Staff can locate the infection control policy manual?

  Yes

  No

  N/A

• Staff can name their link nurse?

  Yes

  No

  N/A

• There is a staff induction programme for infection control?

  Yes

  No

  N/A

Protective Clothing

• Masks are worn correctly when entering clean areas?

  Yes

  No

  N/A

• Masks are removed when leaving operating theatres?

  Yes

  No

  N/A

• All headgear is worn correctly?

  Yes

  No

  N/A

• Theatre clothing is not worn outside the theatre area ( minimum clean white coat to protect )?

  Yes

  No

  N/A

• All theatre clothing is intact and safe to use ( e.g. Charnley gowns intact )?

  Yes

  No

  N/A

• Overshoes are not worn?

  Yes

  No

  N/A

• Disposable / waterproof gowns?

  Yes

  No

  N/A

• Eye protection?

  Yes

  No

  N/A

• Gloves are worn as required?

  Yes

  No

  N/A

• Anaesthetic team do not handle equipment, notes or other articles with contaminated gloves?

  Yes

  No

  N/A

Hand Hygiene

• Soap / anaesthetic is available at all sinks?

  Yes

  No

  N/A

• Paper towels are available at all sinks in clinical areas?

  Yes

  No

  N/A

• Access to hand washing basins is clear?

  Yes

  No

  N/A

• The correct hand washing technique observed by circulating staff in at least one theatre?

  Yes

  No

  N/A

• A satisfactory scrub by medical staff is observed in at least one theatre?

  Yes

  No

  N/A

• A satisfactory scrub by nursing staff is observed in at least one theatre?

  Yes

  No

  N/A

• The infection control team approves the antiseptic in use?

  Yes

  No

  N/A

• The plungers in the antiseptic containers are washed before reuse or new plungers are used each time?

  Yes

  No

  N/A

• Nailbrushes used for pre-operative scrubs are either single use or sterile?

  Yes

  No

  N/A

• No wrist watches / stoned rings worn by the staff carrying out hand washing technique?

  Yes

  No

  N/A

• Hands are washed after removal of gloves?

  Yes

  No

  N/A

• A good hand washing technique is included in new staff induction programme?

  Yes

  No

  N/A

Decontamination

• A disinfection policy is in place and known by staff?

  Yes

  No

  N/A

• Appropriate disinfectants and dilution charts are a available to deal with blood spillages?

  Yes

  No

  N/A

• Correct dilutions of hypochlorite are used for blood spillages?

  Yes

  No

  N/A

• Chemical disinfection is only used for heat liable equipment e.g. Flexible endoscopes?

  Yes

  No

  N/A

• Appropriate measures for compliance with COSHH are in place when using disinfectants e.g. Ventilation?

  Yes

  No

  N/A

• Data sheets are available for disinfectants used ( COSHH )?

  Yes

  No

  N/A

Care of Equipment

• Steve equipment is stored in a clean / dry condition?

  Yes

  No

  N/A

• Single use items are used in accordance with hospital policy?

  Yes

  No

  N/A

• Used instruments are stored in the sluice ( or dirty corridor ) in appropriate containers less than 3/4 full?

  Yes

  No

  N/A

• Staff can clearly state the procedure for handling biohazard equipment for return to sterile services?

  Yes

  No

  N/A

• Staff are aware of the need for decontamination and a certificate prior to sending equipment for maintenance / repair?

  Yes

  No

  N/A

• Suction equipment is clean and dry. Catheter is not attached ( clean cover accepted in some emergencies )?

  Yes

  No

  N/A

• Anaesthetic equipment is filtered and disinfected according to hospital policy I.e. LM's, Laryngoscopes?

  Yes

  No

  N/A

• Any manual handling / lifting aids are clean and in a good state of repair?

  Yes

  No

  N/A

• Manual handling aids are disinfected according to hospital policy after each patient use?

  Yes

  No

  N/A

Sharps Handling

• Containers used comply with British Standard and UN 3291?

  Yes

  No

  N/A

• Sharps box is less than 3/4 full and there are no pot ruling sharps?

  Yes

  No

  N/A

• Sharps box is available on the anaesthetic trolley?

  Yes

  No

  N/A

• Sharps box is correctly assembled?

  Yes

  No

  N/A

• Sharps box is labelled / signed according to hospital policy?

  Yes

  No

  N/A

• Staff are aware of appropriate action to take following an inoculation injury?

  Yes

  No

  N/A

Linen Handling

• Linen is segregated in appropriate colour coded bags?

  Yes

  No

  N/A

• Bags are less than 2/3 full and are capable of being secured?

  Yes

  No

  N/A

• Bags are stored in the dirty utility / linen disposal or sluice prior to disposal?

  Yes

  No

  N/A

• Clean linen is stored in a clean area ( not the sluice / bathroom )?

  Yes

  No

  N/A

• Linen coming from the wards on patients beds is clean?

  Yes

  No

  N/A

• Infected linen is disposed of correctly?

  Yes

  No

  N/A

Waste Disposal

• Waste disposal policy and / or chart is available to staff?

  Yes

  No

  N/A

• Correct segregation of glass and clinical and household waste?

  Yes

  No

  N/A

• Waste bags are less than 2/3 full, securely sealed and labelled ( as per local policy )?

  Yes

  No

  N/A

• There are foot operated bins in working order for clinical waste?

  Yes

  No

  N/A

• Waste bags are stored safely and away from the public?

  Yes

  No

  N/A

• The disposal area is locked and inaccessible to unauthorised persons?

  Yes

  No

  N/A

• The storage areas ( trucks ) are cleaned regularly?

  Yes

  No

  N/A

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