Title Page

  • Document No.

  • Infection Control Theatre Premise Audit

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Theatre Environment

Theatre Environment

  • The changing areas are clean with adequate locker storage?

  • There is clean footwear for visitors to the unit?

  • Footwear is regularly decontaminated?

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

  • Opened food is stored in pest free containers?

  • There is no food past expiry date?

  • Milk is stored under refrigerated conditions?

  • Fridge temperature is between 0 - 5 degrees C?

  • The theatres are clean and free from dust?

  • Wall seals are clean and free from dust?

  • Theatre table mattresses are intact and clean?

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

  • Mops and buckets are stored dry and clean?

  • Mop heads are laundered daily?

  • Separate cleaning equipment is provided for each theatre?

  • The sluice is clean and free from spillage?

  • There is no evidence of infestation of animals?

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

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

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

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

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

Clinical Practices

Clinical Practices

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

  • Labels for specimens?

  • Infected linen bags?

  • HSDU autoclavable bags?

  • All specimens are handled, labelled and stored safely?

  • Sterile dressings are used to cover intravenous cannula sites?

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

  • Staff can locate the infection control policy manual?

  • Staff can name their link nurse?

  • There is a staff induction programme for infection control?

Protective Clothing

Protective Clothing

  • Masks are worn correctly when entering clean areas?

  • Masks are removed when leaving operating theatres?

  • All headgear is worn correctly?

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

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

  • Overshoes are not worn?

  • Disposable / waterproof gowns?

  • Eye protection?

  • Gloves are worn as required?

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

Hand Hygiene

Hand Hygiene

  • Soap / anaesthetic is available at all sinks?

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

  • Access to hand washing basins is clear?

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

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

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

  • The infection control team approves the antiseptic in use?

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

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

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

  • Hands are washed after removal of gloves?

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



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

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

  • Correct dilutions of hypochlorite are used for blood spillages?

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

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

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

Care of Equipment

Care of Equipment

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

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

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

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

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

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

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

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

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

Sharps Handling

Sharps Handling

  • Containers used comply with British Standard and UN 3291?

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

  • Sharps box is available on the anaesthetic trolley?

  • Sharps box is correctly assembled?

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

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

Linen Handling

Linen Handling

  • Linen is segregated in appropriate colour coded bags?

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

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

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

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

  • Infected linen is disposed of correctly?

Waste Disposal

Waste Disposal

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

  • Correct segregation of glass and clinical and household waste?

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

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

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

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

  • The storage areas ( trucks ) are cleaned regularly?

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