Download ASC Environmental Rounds Survey Tool

ASC ENVIRONMENTAL ROUNDS
SURVEY TOOL
Date (s) of observation: __________________________________________________________
Observer: ________________________________
Any answer that is in a RED box requires an action plan
Compliant:
YES
STANDARDS
Compliant:
NO
NA
DESCRIPTION/COMMENTS
I. Infection Control Policies and Procedures
1. Staff has access to ASC Infection Control policies
2. Staff can articulate the procedure for reportable diseases
3. Staff can articulate the procedure for reporting infections related to
procedures performed at their facility or at any other facility
4. Staff can articulate symptoms of illness that should keep them from
coming to work, as reflected in the ASCs “Personnel Illness
Restriction” Policy
5. Staff can articulate what should be done if two or more employees or
patients in their unit or department have developed influenza-like
illness or gastrointestinal illness
6. Staff can articulate the procedure to follow after blood, body fluid
exposure
YES
YES
NO
NO
YES
NO
YES
NO
YES
NO
YES
NO
II. Handwashing Facilities
1. Artificial fingernails are not allowed on healthcare direct patient
care providers
2. Soap dispensers accessible, operating correctly and dispensing
appropriate antimicrobial agent?
3. Paper towels available and adequately dispensed
4. Antimicrobial waterless hand agents available, especially where
hand washing sinks are unavailable
5. Staff can explain and/or staff is observed complying with the hand
hygiene policy
6. Staff dons and removes gloves at appropriate opportunities
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
1.01 ASC ENVIRONMENTAL ROUNDS SURVEY TOOL
1
Compliant:
YES
YES
STANDARDS
7. Lotions are used appropriately in clinical areas
Compliant:
NO
NO
NA
DESCRIPTION/COMMENTS
III. Storage of Supplies
1. Clean and sterile supplies and equipment are stored appropriately
2. Items stored at least 12”-18” from a sink or there is a protective
barrier (splash guard) to prevent splash contamination; storage
under sinks of patient care supplies is prohibited and storage of
other items is discouraged.
3. Supplies stored on shelves and off floors
4. Supplies are within expiration date
5. There is clear separation of clean and dirty activities
6. Items labeled as "single use only" (SUDs) are not reused
YES
NO
YES
NO
YES
YES
YES
NO
NO
NO
YES
NO
Exception for approved third-party reprocessor
VI. Medication Management
1. Medications must be separated by type and dosage
YES
NO
2. Requirements for storage and use of OR state-supplied vaccines are
YES
NO
met
3. Open irrigation solutions are labeled with date and time
YES
NO
4. IV fluids spiked at time of use
YES
NO
5. Medications are within date
YES
NO
6. Medications are stored appropriately
YES
NO
7. Medications requiring special care after initial use are
YES
NO
stored/labeled appropriately
8. Medications are prepared safely
YES
NO
V. Safe Injection Practices
ONE NEEDLE: ONE SYRINGE: ONE PATIENT: ONE TIME
1. Single-dose vials are never used as multi-dose vials
YES
NO
2. Fluid infusion and administration sets (IV bags, tubing, and
YES
NO
connectors) are used for one patient only and discarded after use
3. Patient's skin is prepped with an approved prep before IV placement
YES
NO
4. Single dose medications or infusates are used for only one patient
and not collected or combined (bags of IV fluids are ALWAYS single
YES
NO
use)
5. Medication vials used for more than one (1) patient are always
YES
NO
entered with a new needle and new syringe
6. The rubber septum on a medication/infusate vial is disinfected with
YES
NO
1.01 ASC ENVIRONMENTAL ROUNDS SURVEY TOOL
2
STANDARDS
Compliant:
YES
Compliant:
NO
YES
NO
YES
NO
YES
YES
NO
NO
YES
NO
YES
NO
YES
YES
NO
NO
alcohol or antiseptic prior to piercing
7. Needles and syringes are used for only one patient
8. Medications or infusates that are packaged as prefilled syringes are
used for only one patient
9. Hand hygiene is performed before preparing medications
10. Medications or infusates are drawn up at start of each procedure
11. Needles and syringes are discarded intact in an appropriate sharps
container after use
12. Flushes are not drawn from a bulk container
NA
DESCRIPTION/COMMENTS
VI. Linens
1. Linens are stored appropriately and kept covered until use
2. Clean and soiled linens are kept separated
VII. Surface Disinfection
1. Toys are disinfected per policy
2. Non-critical items are cleaned per policy
3. Point of care devices are cleaned according to policy
YES
YES
YES
NO
NO
NO
VIII. Instrument Decontamination/Cleaning
Items are thoroughly pre-cleaned and decontaminated with enzymatic
detergent according to manufacturer instructions, evidence-based
guidelines and ASC policy prior to high level disinfection or
sterilization.
YES
NO
IX. High Level Disinfection (HLD)
1. Medical instrument and devices are visually inspected for residual
soil and re-cleaned as needed before high-level disinfection
2. HLD equipment is maintained according to manufacturer
instructions or evidence-based guidelines
3. Chemicals used for HLD are prepared according to manufacturer
instructions or evidence-based guidelines
4. Chemicals used for HLD are tested for appropriate concentration
(MEC) according to manufacturer instructions or evidence-based
guidelines, and are replaced before they expire
5. Chemicals used for HLD are documented to have been prepared and
replaced according to manufacturer's instructions or evidence-based
guidelines
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
1.01 ASC ENVIRONMENTAL ROUNDS SURVEY TOOL
3
STANDARDS
Compliant:
YES
Compliant:
NO
YES
NO
YES
YES
YES
NO
NO
NO
YES
NO
YES
NO
YES
YES
NO
NO
YES
NO
6. Equipment is high-level disinfected according to manufacturer's
instructions or evidence-based guidelines and according to the ASC
Infection Control Cleaning, Disinfection and Sterilization policy
7. Items that undergo HLD are dried before re-use
8. HLD logs are in order
9. Test strips are properly dated
NA
DESCRIPTION/COMMENTS
X. Sterilization
1. Autoclaves: chemical and biological indicators are used
appropriately
2. Biological indicators run at least weekly or with each load with an
implantable
3. Sterilization logs accurate and up to date
4. Process is in place for embargo of instruments until BI is read
5. Sterile packages are inspected for integrity and compromised
packages are reprocessed
XI. General Decontamination/HLD/Sterilization
1. Proper PPE is worn when processing dirty equipment
2. Competencies are maintained for cleaning, disinfection and
sterilization processes
3. HLD, decontamination, and /or sterilization is performed in
appropriate environment
4. Areas used for cleaning or disinfection flow from dirty to clean
5. There is a procedure in place for identification and recall of
inadequately sterilized or high level disinfected instruments
6. After sterilization or high level disinfection, devices and instruments
are stored in a designated clean area so sterility/cleanliness is not
compromised
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
XII. Isolation
1. Staff are able to articulate isolation policies (such as for TB,
chickenpox, “Respiratory Etiquette”)
2. Staff are able to state how patients should be managed that have a
known resistant organism (e.g. MRSA, VRE, C. difficile, draining
wound or rash)
3. Personal protective equipment (PPE) is available
1.01 ASC ENVIRONMENTAL ROUNDS SURVEY TOOL
4
Compliant:
YES
STANDARDS
Compliant:
NO
NA
DESCRIPTION/COMMENTS
XIII. General Issues
1. Areas free of dust, dirt, soil, trash, odors, clutter and hazards
(fixtures, walls, ceilings, floors)
2. Areas and furnishings are in good repair
3. Objects and environmental surfaces that are touched frequently in
patient care areas (stretchers, IV pumps and poles, medication prep
areas, procedure tables, toilet surfaces, waiting area surfaces) are
disinfected with an EPA-registered, ASC designated and approved
disinfectant.
4. Environmental cleaning contracts follow ASC Infection Control
Policy
5. For ASCs with an IV treatment room or procedure room-IV pumps,
chairs and procedure tables are cleaned between each pt.
6. Areas identified as nursing responsibility are cleaned appropriately
7. Staff food and drinks are placed in appropriate areas
8. Regulated waste containers are in appropriate locations and covered
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
YES
YES
NO
NO
NO
XIV. Refrigerators, Freezers, Ice Machines, Ice Chests
1. Refrigerators and freezers are large enough to properly store
medications.
2. Refrigerators and freezers well maintained and clean
3. Medication refrigerator temperatures maintained between 36-46
degrees F (between 2-8 degrees Celsius) Temperatures checked
minimum of daily. Twice a day if storing state-supplied vaccines.
4. Medication freezer maintained below 5 degrees F (below -15
degrees Celsius)
5. An appropriate means to check medication in event of a power
outage is in place
6. Food and medications are stored separately
7. Food and/or medications are within date
8. Specimens and culture media are stored separately from food and
medications
9. Specimens and lab reagents are stored appropriately
10. Ice chests and ice machines are maintained according to ASC policy
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
YES
NO
NO
YES
NO
YES
YES
NO
NO
1.01 ASC ENVIRONMENTAL ROUNDS SURVEY TOOL
5
REFERENCE
Developed by the Oregon Patient Safety Commission; adapted from tools by Duke University, BJC Healthcare, Kaiser Permanente, University
Hospital North Carolina, and Oregon Health and Sciences University.
DISCLAIMER: All data and information provided by the Oregon Patient Safety Commission is for informational purposes only. The Oregon Patient Safety
Commission makes no representations that the patient safety recommendations will protect you from litigation or regulatory action if the recommendations
are followed. The Oregon Patient Safety Commission is not liable for any errors, omissions, losses, injuries, or damages arising from the use of these
recommendations.
1.01 ASC ENVIRONMENTAL ROUNDS SURVEY TOOL
6