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


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


  • 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

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