Information
Interventional Radiology / Cath Lab
-
Conducted on
-
Prepared by
-
Personnel Attending the Rounds:
General Infection Control Practices & Safety
-
Staff can locate Infection Prevention Policies
-
Staff can articulate and locate the Bloodborne Pathogen Exposure Policy
-
Staff can locate the SDS
-
Appropriate PPE available
-
Staff is observed using PPE appropriately
-
PPE is disposed at point of use
-
Sinks properly located and functioning
-
Hand washing stations/ scrub sinks are stocked with towels, soap, surgical hand scrub, nail cleaners and brushes
-
Waterless surgical scrub available
-
Hand Hygiene before and after patient care
-
Hospital approved hand lotion is available
-
No artificial nails/products worn by direct patient care staff
-
No staff food, drinks, cosmetics, applying of contact lenses, use of personal lotions, or storing of personal items in patient care areas
-
Hospital approved disinfectant is available
-
Staff correctly observe isolation precautions posted for patients
-
Single use items (scissors, tweezers) not re-used
-
Enzymatic cleaner available in each IR
CLEANING
No High Dust Present
-
Supply cabinets are clean and dust/rust free
-
Air vents/ air supply grills are clean and dust free
No dust or rust on equipment or supplies. No damaged equipment or supplies
-
Patient monitors
-
IV Poles and pumps
-
Head Lights
-
Medical gas gauge
-
Mayo stands
-
Hampers (if any)
-
Exam table, including bottom of table
-
Computer and keyboards dust free and clean
-
Equipment is cleaned according to manufacturer's recommendations
-
Equipment is with current inspection stickers
-
All appliances for prep/storage of medications are visibly clean
-
No tape residue on equipment or on table
-
No tape residue anywhere in the IR
-
Anesthesia cart is clean. All drawers free of dust and clutter.
-
All other carts in the IR: clean and no tape residues on the inside. All drawers are free of dust and clutter.
-
IR suite properly stocked without clutter
-
Patient table clean, no dirt, bodily fluids, rust... found when broken down
-
Stands, kick buckets clean (if applicable)
-
Wheels, furniture, lights clean (no rusty wheels)
-
Door handles are clean
-
All other surfaces free of dust and debris
-
Ceiling tiles are in place, dry and free from stains, cracks, and holes
-
Hallways are clean and free of clutter
-
Walls free of breaks and penetrations, tape residue, dried bodily fluids
-
IR is cleaned between patients and at the end of the day per policy
-
Mattresses /cushions are clean with no holes / cracks / tears
-
EVS closet is clean, organized and secure
Storage
-
Clean utility room is clean and organized
-
Storage units /bins/shelving are clean and organized
-
Sterilized trays are free of dust, unopened, no tears
-
Supplies > or = to 18" from ceiling and 10" above floor on lined shelving
-
Storage of supplies is clean and organized
-
No items stored on the floor
-
No expired supplies
-
No torn or compromised supplies
-
Items are stored in a manner that will not compromise sterility (compressed, crushed, susceptible to tears, away from sources of moisture)
-
Supplies are not stored where food/ drinks are consumed. (or no food /drinks in supply room)
-
Linen carts/ room are clean and organized
-
Linen carts in hallways or combines storage rooms are covered.
-
Clean equipment is stored separately from soiled equipment
-
Dirty Utility Room is labeled, clean and organized.
-
Inappropriate or unnecessary equipment and supplies are not present in the area
-
Items are stored in appropriate or safe locations (nothing on top of trash containers, shred bins, blocking hallways, doors or exits)
-
All medications are secured with access only to authorized hospital personnel. narcotics are secured and stored separate from other medications
-
All open vials of medications have an expiration date from the manufacturers with no obvious signs of contamination, and are dated when opened. Multi-dose vials expire within 28 days of opening (USP 797)
-
Refrigerator thermometers reads 36-45 degrees Fahrenheit
-
Refrigerator and freezer logs are read at least twice a day (twice if used to store vaccines) (CDC)
-
Refrigerator and freezer temperature logs are dated and signed by the person performing the check and are readily available if requested (CDC)
-
Staff able to articulate the action taken if temperature is out of range
-
Corrective action is documented if temperature is out of range
Anesthesia Cart
-
When unlocked by appropriate staff, no expired medications found
-
No evidence of reuse of single dose vials
-
Intubation equipment sealed in unopened peel packs, clean and sterilized
IR Desk / Work Room
-
Free of clutter
-
No food or drink
-
No laboratory samples at desk
Supply Cabinets in the IR
-
Supply cabinets: No high dust
-
Bottom of all shelves lined
-
No expired equipment during spot check
-
No expired supplies during spot check
-
Cabinets kept closed at all times
Waste Management
-
Biohazardous waste containers do not hold regular trash
-
No biohazardous waste in the regular trash containers
-
Waste holding areas and carts are clean
-
Sharps containers are secured
-
ONLY sharps in sharps box
-
Sharps boxes <2/3 full
-
Nothing on top of sharps boxes
-
Dirty linen hamper is no more than 3/4 full
-
Dirty linen is covered and transported in leak resistant container
Soiled Utility Rooms
-
Cleaning products stored properly
-
Mop water and buckets clean
-
Cleaning tools clean
-
Adequate supply of cleaning materials
-
Soiled materials segregated
-
Floors clean
-
PPE available
-
Red bags tied properly
-
Trash bins clean
Hallways/Scrub areas
-
All storage to one side of hall
-
No unlabeled and unattended cleaning products in the hall
-
Scrub sinks, foot pads clean and free of rust
-
Staff able to articulate correct storage of lead aprons (according to policy/ manufacturer's recommendation.)
-
Staff able to articulate cleaning and disinfection of lead aprons in between use.
-
Radiology equipment clean and properly stickered (PM).
Staff and Space / Work Flow
-
Hand hygiene before and after procedure done.
-
Hair covered: scalp and facial hair
-
Ears covered with scrub cap
-
PPE worn as appropriate
-
IR staff at bedside in proper sterile attire
-
Scrub top tucked in for all IR staff scrubbed in for a procedure
-
No fleece sweaters, warm up clothing
-
No obvious signs of infection (ex. respiratory, skin) noted
-
Doors are not propped open
-
Egress corridors are free from obstruction
Staff Knowledge
-
Staff able to articulate the 5 moments of hand hygiene
-
Staff able to articulate the care of instruments at point of care.
-
Staff able to articulate how isolation patients are identified.
Other Findings
-
Add media
