Information

  • Surgical Services Infection Prevention Audit

  • 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 OR

Cleaning

  • Ceiling tiles are in place, dry and free from stains, cracks, and holes

  • High level dusting has been done.

  • Air supply grills are clean and free of dust.

  • Return grills are clean, dust free and are not blocked by equipment.

  • All surfaces free of dust and debris.

  • All equipment are clean.

  • Equipment does not have rust.

  • Equipment with current inspection stickers

  • Equipment cleaned according to manufacturer's recommendations

  • All appliances for prep/storage of medications are visibly clean

  • OR is cleaned between patients and at the end of the day per policy

  • Patient table clean, no dirt, bodily fluids, rust... found when broken down

  • Mattresses /cushions are clean with no holes / cracks / tears

  • Anesthesia cart is clean.

  • Sterilizers in the Core are clean

  • EVS closet is clean, organized and secure

Storage

  • Clean utility room is clean and organized

  • Dirty utility room is labeled, clean and secured

  • Clean equipment is stored separately from soiled equipment

  • Storage units/shelves have solid bottoms

  • Storage units /bins/shelving are clean and organized

  • Storage of supplies is clean and organized

  • Supplies > or = to 18" from ceiling and 10" above floor on lined shelving

  • No items stored on the floor

  • No expired supplies

  • Items are stored in a manner that will not compromise sterility (compressed, crushed, susceptible to tears, away from sources of moisture)

  • No torn or compromised supplies

  • Sterilized trays are free of dust, unopened, no tears

  • Inappropriate or unnecessary equipment and supplies are not present in the area

  • 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

  • Linen carts/ room are clean and organized

  • Linen carts in hallways or combined storage rooms are covered.

  • Items are stored in appropriate or safe locations (nothing on top of trash containers, shred bins, blocking hallways, doors or exits)

  • Supplies are not stored where food/ drinks are consumed. (or no food /drinks in supply room)

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

  • Free of clutter

  • No food or drink nor personal belongings.<br>

  • No laboratory samples at desk

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

  • Nothing on top of sharps boxes

  • Sharps boxes <2/3 full

  • 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

  • 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

  • Lead aprons clean, stored properly. Staff able to articulate cleaning and disinfection after use.<br>

  • Radiology equipment clean and properly stickered (PM).

Staff and Space / Work Flow

  • Appropriate attire is worn<br>

  • Doors are not propped open

  • Hallways are clean and uncluttered.

  • Egress corridors are free from obstruction

  • Temperature in OR rooms is according to standards and documented.<br>

  • Humidity in OR rooms is according to standards and documented.<br>

  • Each OR room has appropriate number of air exchanges per standards. (at least 20 /hr)

  • Anesthesia cart where meds are stored is clean and secured.

  • Medication carts/meds are clean and secured.

  • Laryngoscope blades are sealed in peel packs.<br>

  • Compressed gas is secured (Ultane)

  • Yankauer suction tip is not open or left from previous case.

  • Soiled linen is collected and transported to designated dirty utility area in a covered leak proof container

  • Sterilization records are filled out completely (Immediate Use Sterilization done in the OR)

  • Sterilizers in the Core are not allowed free flow of steam to Core

  • Fans are not present in the OP or in the Core.

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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