Download View - Infection Prevention Tools

2007 Northern California
Infection Prevention and Control Program Template and
Appendices
Copyright 2007
Kaiser Foundation Hospitals
Page 1 of 22
GOALS
Goals of Infection Prevention and
Control Programs:
Goals of this IC Program
Template:





To intervene directly to prevent infections
To educate and train HCWs, patients, and
non-medical caregivers
To obtain and manage critical data and
information, including surveillance for
infections
To develop and recommend policies and
procedures

To support standardization of IC
Program content (not format) region
wide
To provide guidance for IC staff with
limited experience
Page 2 of 22
TABLE OF CONTENTS
1. Infection Prevention and Control Program Template
Components
Page 4 – 6
2. Infection Prevention and Control Committee Tools
 Agenda
 Attendance Grid
 Topic Tracker
 Ancillary Department Report
Page 8 - 12
3. Infection Prevention and Control Departmental
Assessment Tools
 Home Care
 Cardiac Cath/IR
 Lab
 Multidisciplinary ICU Rounds
 Nutritional Services
 Operating Room
 Pharmacy
 Inpatient Nursing
Page 14 - 23
Page 3 of 22
IC PROGRAM TEMPLATE COMPONENTS
1. PREVENTION AND CONTROL OF INFECTIONS
A. PATIENT SAFETY - CLINICAL PREVENTION AND CONTROL INTERVENTIONS
1. Ensure implementation of staff/MD compliance with:
 Universal/Standard Precautions
 Transmission Based Precautions
2. Performance improvement projects planned and implemented annually
3. Participation in regular environmental rounds review IC practices and compliance with policies
4. Participation in ICU rounds providing IC consultation on patient care provided to reduce risk of HAI,
prevent and control transmission of infection
5. Ongoing review and consultation regarding environmental services practices and products
6. Collaboration with Employee Health in implementation and support of Respiratory Etiquette, Flu
Prevention
7. Ensure implementation of appropriate staff and physician Hand Hygiene practices
8. Provision of IC input in process of selection and use of products designed to decrease the risk of
healthcare associated infections
9. Support of appropriate instrument/equipment disinfection and sterilization practices
10. Support of appropriate environmental cleaning/disinfection processes and practices including
equipment which is part of the patient environment such as computer keyboards.
11. Support compliance with disposal of biohazardous waste according to Medical Waste Management
Act and OSHA Bloodborne Pathogen Standard.
12. In collaboration with Construction Services/Operations performs Infection Control Risk Assessment
on construction, renovation, and demolition projects.
13. In collaboration with Construction Services/Operations assess construction areas that have
sustained water damage for bacteria and mold exposure risk to health plan members, visitors and
employees.
B. CONSULTATION
Consultation to inpatient and outpatient clinical departments including Employee Health regarding IC
issues, significant event follow-up, risk assessment, prevention and control strategies - examples
include:
 Skilled Nursing Facilities associated with KP (and KP SNF in San Leandro)
 Dialysis
 Home Care
 Special Procedures
 Disinfection and sterilization processes: vaginal probes, scopes
 Waste Management
 General Infection Control policies including aseptic technique
 Hand Hygiene
 Vascular Access Devices
 Outbreak Management
 Regulatory Compliance
 Development of competencies
 Integrated Safety Committee
 Emergency Preparedness
C. OUTBREAK INVESTIGATION
 Lead communicable disease exposure incident follow-up in collaboration with local leadership,
Infectious Disease physicians, Employee Health
 Lead investigation of outbreaks in collaboration with local leadership, Infectious Disease physicians,
Employee Health and Public Health Department staff
 Ensure appropriate control measures are implemented in collaboration with Employee Health
Page 4 of 22
IC PROGRAM TEMPLATE COMPONENTS continued
TRAINING – STAFF AND PHYSICIANS
1. Provides new hire and annual IC training provided in an interactive venue that facilitates active
learning and provides an opportunity for HCWs to have their questions answered, addressing topics
including
 hand hygiene
 sharps safety
 BBP and Tuberculosis (TB) Exposure Control Plan, etc.
 product selections, changes and evaluations
 updates on policy changes
 surveillance outcomes, outbreak or cluster protocols
 complicated patients with high healthcare associated infection risks
2. Provides dept specific training programs as requested
3. Ensures periodic evaluation and updating of programs
E. SURVEILLANCE – MANAGING CRITICAL DATA
1. Monitors defined population(s) at risk as identified by local IC Committee – examples:
 Central Line Related Bloodstream Infection (BSI) including dialysis population
 Ventilator Associated Pneumonia (VAP)
 Unusual organisms
 Orthopedic Surgical Site Infections (SSI)
 Multi Drug Resistant Organisms (MDRO)
 Interventional radiology
 Construction associated infections (e.g. aspergillus)
2. Tracks and trends patient cultures to determine trends, clusters, unusual organisms, etc in
ambulatory care setting and inpatient settings
3. Supports Risk Management in IC related sentinel event tracking and trending
4. Reports and Analyzes Data by
 selection of appropriate methods of measurement selection and use of appropriate nationally
available aggregate comparative data (benchmarks)
 statistical tools
 risk stratification
 statistical analysis
5. Preparation and distribution of reports on all identified indicators to appropriate/designated groups
6. Targeting of opportunities for performance improvement
For information only: Following is the number of hours spent in surveillance activities according to
hospital size per CDC survey 2005:
< 200 bed = 13 hr/wk
200-500 = 23 hr/wk
500-1000 = 16 hr/wk
>1000
= 24 hr/wk
D.
2. IC COMMITTEE
1. In collaboration with P&T Committee, IC Committee should provide oversight for Antibiotic Stewardship
program implementation (by Pharmacy and ID physicians) NOTE: Antibiotic stewardship is a new
initiative for ID and Pharmacy and is not yet in place in all medical centers. The goals of this initiative
are focused in large part on infection prevention and control including reduction of Clostridium difficile
infections, appropriate treatment of infections as well as continuing emergence of antibiotic resistance.
2. IC Committee receives/analyzes BI (biological indicator) monitoring reports from Sterile Processing
department.
3. IC Committee receives/analyzes dialysis water/dialysate cultures from dialysis services.
4. IC Committee performs annual committee evaluation to optimize ongoing functioning.
5. IC Committee conducts the annual IC Program Risk Assessment, Plan/Goals and Evaluation.
6. Approval of any change in surveillance indicators during the calendar year (different from annual
program plan)
7. Ensure reports from departments as detailed in 3A below
8. IC committee membership should conform with Title 22 requirements: i.e. Representatives from
Physicians, IC, Administration and Nursing
Page 5 of 22
IC PROGRAM TEMPLATE COMPONENTS continued
3. PROGRAM PLANNING/EVALUATION AND DATA SHARING
A. DATA SHARING/ANALYSIS
1. Committee Informs Others:
 Quarterly: Local Board Report Data and Action Plan as indicated shared with Regional IC
 Quarterly: Local IC surveillance data shared with Regional IC for collation
 Annual IC Program update and outstanding issues shared with Integrated Safety
Committee
 Quarterly IC Committee report to local Executive Committee per Title 22 requirement
2. Committee Receives Information:
 Antibiotic utilization reports (in addition to P&T Committee)
 IC surveillance data and analysis from local IC staff
 Employee Health report to IC Committee including sharps injury data, other employee
illness reports, flu vaccination rates and reasons for declination, employee health screening
issues, status of immunization programs such as Pertussis, Mumps
 Ancillary department reports such as: Environmental Services (EVS) (e.g. monitoring of
cleaning of frequently touched surfaces especially in high risk areas such as OR, L&D,
ICU), SPD Scope Processing
 Home Care – Annual Program Plan, Risk Assessment, and Evaluation and ongoing issues
 Regional and national surveillance data and analysis
 National single use Reprocessing Program Savings and Quality Reports
B. PROGRAM PLANNING AND EVALUATION
 Per The Joint Commission IC Standard 1.10 EP 9, development of annual Risk
Assessment and Plan/Goals based on: Significant Events, Surveillance Data, Needs
Assessments, other
 Completion of annual evaluation of IC Program Plan and Goals based on performance
improvement, surveillance data, other
4. REGULATORY ACCREDITATION AND COMPLIANCE
1. Ongoing assessment of medical center compliance with regulatory standards relating to IC including
The Joint Commission Core Measures, OSHA, DHS – Title 22, Medicare Conditions of Participation
2. Implementation of IC related changes mandated by regulatory and licensing agencies
3. Facilitation of IC related patient/system tracers to ensure readiness for The Joint Commission survey
4. Participation in mandatory regional initiatives as indicated, such as IHI infection prevention bundle
implementation
5. Policy and procedure review and update: Written infection prevention and control policies and
procedures are established, implemented, maintained and updated periodically in response to new
clinical procedures and technologies, and remediation of significant event findings
6. Review of local EH (Employee Health) guidelines related to IC to ensure consistency
7. IC Staff participates on appropriate medical center, which may include: Infection Control Committee,
OR, Critical Care, Manager or Dept Head meetings, Product Evaluation, Safety Committee
8. IC Staff participates in Regional and National IC staff meetings
9. IC collaborates with, and provides info as requested to, appropriate local and state health departments
for reporting of communicable disease and related conditions, to assist with control of infectious
diseases and Community/State-wide infectious disease disaster preparedness.
References:
1. APIC Text of Infection Control and Hospital Epidemiology. January 2005. Association for Professionals in
Infection Control and Epidemiology, Inc.
2. Hale, RW et al. “Efficacy of Infection Surveillance and Control Programs in Preventing Nosocomial Infections in
US Hospitals”. American Journal of Epidemiology. 1990 Vol. 121, No. 2: 182-205.
3. Scheckler, W et al. “Requirements for infrastructure and essential activities of infection control and
epidemiology in hospitals: A Consensus Panel report”. American Journal of Infection Control Feb 1998 pp 4760.
Page 6 of 22
IC COMMITTEE TOOLS
Page 7 of 22
IC COMMITTEE TOOLS: AGENDA (note: none of the content below is required from a regulatory perspective – but
instead based on best practice models throughout the region)
Infection Prevention and Control Committee Agenda
Date/location:
Intent (e.g. approve,
Topic
I.
Review/Approval of Minutes
Announcements
II.
Standing Reports:
Presenter
information only,
discussion, etc.
A. Antibiotic Stewardship
B. Ancillary Departments
(recommend quarterly reporting schedule – no
regulatory requirement regarding frequency):
 Construction
 Nutritional Services
 Dialysis
 Laboratory
 Employee
 Pharmacy
Health
 Sterile Processing
 Engineering
 EVS
 Home Care
C. IC Related Community Involvement
(e.g. education provided to schools, community flu fairs,
etc)
D. Public Health Department Report
E. IC Related Sentinel Events/Product Recalls
F. SCIP/IHI Compliance Reports
G. Surveillance

Resistant Organisms

Healthcare Associated Infection statistics
H. Unresolved CPA (continuous performance
assessment) site visit/The Joint Commission survey
findings
III.
Policy and Procedure Review
IV.
IC Education Provided
IV.
Old Business
V.
New Business
VII.
Adjourn
Next Infection Control Committee Meeting Date and
Time:
Page 8 of 22
Time
IC COMMITTEE TOOLS: ATTENDANCE GRID
Infection Prevention and Control Committee Attendance Grid
Year:
COMMITTEE
MEMBER
Total
Attendance
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
CORE MEMBERS (required by Title 22*)
Infection Control
Infectious
Disease
Physician
Nursing
Representative
Administrative
Representative
AD HOC MEMBERS
Engineering/Faci
lity Services
Dialysis
Employee Health
Service
Home Care
Laboratory
Nutritional
Services
Pharmacy
Sterile
Processing
Perioperative
Services
Ambulatory Care
* Reference:
Barclays Official California Code of Regulations, Title 22. Social Security, Division 3. Health Care Services, 6/15/07, Register 2007, No. 24.
Page 9 of 22
IC COMMITTEE TOOLS: TOPIC TRACKER (note: none of the content below except quarterly report to Med Exec
Committee and Integrated Safety Committee is required from a regulatory perspective – but instead based on best
practice models throughout the region)
Infection Prevention and Control Committee Topic Tracker/Scheduler
Year:
TOPIC
RESPONSIBLE
GROUP OR
PERSON
SCHEDULED EVENTS
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
REPORTS/PLANS
Annual IC Program
Plan and Goals
Quarterly Report to
Executive
Committee
(required by Title
22)
Annual Committee
Evaluation
Policy and
Procedure
Review/Approval
SURVEILLANCE
ICU BSI
Ventilator
Associated
Pneumonia-ICU
Total Hip
Replacement,
Revision and
Hemiarthroplasty
MRSA/VREHospital AcquiredCommunity
Acquired.
Hemodialysis Line
Associated Blood
Stream Infections
Bariatric Surgery
(Laparoscopic
Gastroenteroscopy)
LOCAL COMMITTEE REPORTS
SCIP/IHI Work
Groups
Scope Reprocessing
Committee
Integrated Safety
Committee
Page 10 of 22
Nov
Dec
REPORT
FREQUENCY
TOPIC
RESPONSIBLE
GROUP OR
PERSON
SCHEDULED EVENTS
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
(Required by JC)
Emergency
Preparedness
Committee
O.R. Committee
ANCILLARY DEPARTMENT REPORTS
Construction
Dialysis
Employee Health
Service
Engineering
Home Care
Laboratory
Nutritional Services
Pharmacy
Sterile Processing
Patient Care
Services
Respiratory Care
Page 11 of 22
Nov
Dec
REPORT
FREQUENCY
IC COMMITTEE TOOLS: ANCILLARY DEPARTMENT REPORT
Ancillary Department Report
To Infection Prevention and Control Committee
Date:
Department:
Presenter:
TOPIC
DEPARTMENTAL SUMMARY AND PLAN OF
ACTION
Strategies for improving/maintaining IC prevention in
your department (e.g. hand hygiene)
 Engineering include: assessment of negative
pressure in TB isolation rooms, automated scope
reprocessor preventative maintenance report
 EVS include: biological indicator results for
Sanipak if applicable, update regarding any
performance improvement projects (e.g. cleaning
of frequently touched surfaces in occupied
patient rooms) and annual summary of cleaning
products used
 SPD include: sterilizer biological indicator
results, recalls, reprocessing program overview
and savings, scope reprocessing assessments
 Dialysis include: dialysate and water culture
reports
 Employee Health: use separate standard form
or include fit testing, PPD conversions and
communicable disease/BBP exposures, flu rates
and reasons for declination (flu season)
 Periop Services: Flash sterilization summary
and action plan to minimize, compliance with
SCIP measures
Your departmental assessment of the adequacy of
the human, information, physical and financial
resources allocated to support infection prevention
and control activities in this medical center.
Your departmental assessment of the overall failure
or success of key processes for preventing and
controlling infection
Please provide overview:
Your department’s suggested changes or approval of
the current IC program.
Please list if any:
Any sentinel events or concerns relating to Infection
Prevention and Control during current reporting
period.
Please list if any:
Identify any barriers and a plan of action for each.
Identify any barriers and a plan of action for each.
Page 12 of 22
INFECTION PREVENTION AND CONTROL
DEPARTMENTAL ASSESSMENT TOOLS
Page 13 of 22
Infection Prevention and Control Assessment Tool
Home Care Visit
PROCESS/AREA TO ASSESS
Yes, No, N/A,
COMMENTS
Aseptic technique used to change central line dressings and
Chloraprep/Biopatch used for site care.
Staff carries and uses required PPE (CPR mask, face shield,
gloves, mask, gown)
Staff has no expired supplies in car trunk
Staff follows proper bag technique
Staff follows proper hand hygiene procedure (degermer before
and after all patient contact and between tasks except if hands
are soiled – then soap and water)
Staff encourages proper hand hygiene in patients and family per
policy.
Staff reports deaths or injury that may be related to infection
Staff can describe/demonstrate immediate action for a
blood/body fluid exposure (needle stick or splash): Flush with
soap and water for needle stick, flush with water for splash to
eyes, nose or mouth
Lap top cleaned/disinfected between patients (keyboard and
external).
Patient care equipment cleaned/disinfected between patients
(e.g. glucometer)
Lab specimens are transported in clean, closed container (zip
lock bag or tote box – biohazard label if unable to view content
of container); separation of clean & dirty areas in the trunk
Single dose vials are used once and tossed
Multi-dose vials are discarded by manufacturers out date
Page 14 of 22
Infection Prevention and Control Assessment Tool
Cardiac Cath Lab/Interventional Radiology
Yes, No, N/A,
COMMENTS
PROCESS/AREA TO ASSESS
Hair removal: Avoid; If necessary, clipper or depilatory on day of procedure
Hand Hygiene
Surgical Scrub for procedures involving incisions (e.g. pacemaker insertions)
1. Clean under nails before scrub
2. Hand scrub for 2 – 3 min @ start of day or use waterless alcohol based scrub
product
3. Rings / bracelets removed before scrub; fingernails short, no polish, no artificial nails
Hand washing/degerming for percutaneous procedures: Use antimicrobial soap and water
or waterless alcohol degermer or brushless scrub:
1. Before and after procedures
2. Before and after palpating cath insertion sites
3. Before and after inserting, replacing, accessing, repairing or dressing an
intravascular catheter
Medications:
 Prefilled syringes on and off the sterile field prepared for upcoming cases must have
expiration date if not used within 24 hours, and expiration time if used in less than 24
hours (MM 4.30 EP3 and NPSG 3D)
Vascular Access/Skin Prep (Cut down, puncture site, incision)
 Thoroughly clean with Chloraprep
 Do not swab excess; allow to dry before insertion
PPE/Barriers
 Caps, masks, eye protection, non porous gown for: surgeons, assistants, circulators
 Shoe covers optional to protect shoe soiling
 Large non porous surgical drapes
Sterile field
 Avoid back to sterile field, crossing behind assistant back when reaching
Traffic – for procedures with incision only
 Dorr closed during procedure
 Efforts made to reduce traffic during procedures such as locking door during procedure,
walkie talkie or phone
Wound dressings
 Gauze preferred, with semi-permeable covering
 Avoid occlusive dressings
 (IR): Biopatch for any lines left in place (e.g. temporary pacer wires)
Environmental Cleaning
 Complete clean once per day & spot clean between cases
 Trash removed after each case
Ventilation
 Air vents cleaned monthly
For procedures with incision only (such as pacemaker insertion):
 15 AEX per hr /positive air pressure
Reference: Chambers CE, Eisenhauer MD et al. Infection Control Guidelines for the Cardiac Catheterization
Laboratory: Society Guidelines Revisited. Published in Wiley- Liss, Inc. 2005
Page 15 of 22
Infection Prevention and Control Assessment Tool
Laboratory
Yes, No, N/A,
COMMENTS
PROCESS/AREA TO ASSESS
PPE/Barriers
 Gloves, gown, masks are used per protocol to protect healthcare
workers from communicable disease, and to prevent transmission of
infection from patient to patient.
Hand hygiene
 Alcohol degermer is used before donning gloves to draw blood, and
after glove removal in inpatient areas.
 Gloves are changed between patients in outpatient lab – degerming
is optional.
 Hands should be washed in the event of visible soiling.
Cleaning of environment
 Blood spills are cleaned and then the area of spill is disinfected with
bleach wipes or diluted bleach solution.
Blood Bank Tissue
Policies should address:
 Acceptable temperature range for tissues stored at room
temperature and method of recording daily temperatures for
these storage areas.
 Description of the use of the manufacturer’s package instruction
for preparation of tissue for implant.
 A tissue log which includes column for documenting whether
package integrity upon receipt is acceptable or not and also the
initials of the individual performing the assessment.
Standard PC 17.10: the hospital uses standardized procedures to
acquire, receive, store, and issue tissues.
 EP 7: Maintain daily records to show that tissues were stored at the
required temperatures. Note: Main types of tissue storage used
are “ambient” room temperature (for example, freeze-dried
bone), refrigerated, frozen (for example, deep freezing colder
than -40 degrees C), and liquid nitrogen.
 EP 10: Verify at receipt that package integrity is met and transport
temperature was controlled and acceptable.
Page 16 of 22
Infection Prevention and Control Assessment Tool
ICU Multidisciplinary Rounds
PROCESS TO ASSESS
Yes, No, N/A, COMMENTS
1. Hand Hygiene
 Alcohol degermer and lotion dispensers mounted and
being used
 CDC guidelines followed
2. PPE/Isolation
 PPE easily accessible to staff
 Staff removes PPE at point of use
 Isolation initiated and discontinued appropriately
3. Vascular Access
 Arrowgard antiseptic impregnated central catheters
being used
 Biopatch used for a-lines and central lines (at least
non-impregnated)
 Chloraprep used for central and peripheral line prep
and site care
 Statlock used to anchor central lines instead of sutures
 Central lines removed when no longer indicated
 PICC lines inserted instead of centrally inserted central
lines whenever possible
 Subclavian site used preferentially for central line
placement (#2 IJ and #3 femoral)
4. Silver Foley
 Silver foley used per Utilization Guidelines
5. Ventilator Care and Pneumonia Prevention
 HOB up 30 degrees unless circulatory compromise or
other contraindication
 Patient out of bed in chair routinely when clinical status
allows
 Patient receiving nutrition by NGT or other
 GI prophylaxis per protocol
 Sedation vacation
 Routine oral care/suctioning
6. Antibiotics
 Is the patient on the correct antibiotic(s) and dosage?
 Can the antibiotic be discontinued or changed from IV
to P.O.
Page 17 of 22
Infection Prevention and Control Assessment Tool
Nutritional Services
PROCESS/AREA TO ASSESS
Yes, No, N/A,
COMMENTS
A. Personnel
1. Manager or designee food safety certification current and posted (3yr)
3. All employees hair restrained, neat appearance
5. No evidence of personal food or belongings in work area
6. Current inspection report posted or availability of report signage posted
7. No evidence of skin lesions, and/or infections observed
8. Health screening process in place and all staff have current health screening
B. Storage of Food and Supplies
1. Storeroom is clean, dry, uncluttered at room temp (50-70º), delivery stocked
within 2-4 hours.
2. Supplies are 12” off floor and 18” below sprinklers.
3. Bins & packages are closed, labeled, scoops outside, bins clean.
4. Dented cans are removed or discarded.
5. All products with expiration dates are current
6. Storeroom floors, walls, vents, etc. are clean
7. Cold storage: raw meat below other food, stored food labeled and dated, no
outdated items
8. Cold storage: temperatures are recorded daily and follow up is documented
when out of range.
Refrigeration at 41º or below
Freezer at 0º or below
Internal thermometers
9. Cold storage: clean racks, walls, floors, vents, door gaskets, no air gaps, no
ice, no staff food
C. Food Handling
1. Manager & staff have (and use) thermometers
2. No evidence of improper thawing, i.e. not at room temperature
3. Cooking temperatures are posted and followed.
4. Hot food is held at 140º or above; Steam table pans with adequate moisture
5. No evidence of improper cooling*
6. Salad bar temps are documented. Follow up documented when out of range
7. Salad bar well maintained: crocks appear full, sneeze guard clean, free of
spills, ice bed covers exterior of crocks
8. Sandwich bar at or below 41º. Temps are documented. Follow up
documented if out of range
9. No evidence of poor food handling: gloves changed frequently, no bare hand
contact
10. Proper hand washing observed, procedures posted including waterless
method if applicable, well supplied
11. No evidence of food sitting at room temperature (exception: cooling)
Page 18 of 22
Infection Prevention and Control Assessment Tool
Operating Room
PROCESS/AREA TO ASSESS
Yes, No, N/A,
COMMENTS
Pre-operative
Existing infections treated
Hair removal
 None unless absolutely needed – then via clipping
Control of serum glucose
 Cardiac procedures
Pre-op shower
 Chlorhexidine – night before and morning of surgery
Patient skin prep
 Gross contamination removed prior to prep
 Appropriate antiseptic agent used – Chloraprep preferred
 Skin prep technique – center to outside, large area
Hand/forearm antisepsis for surgical team
 Clean underneath each fingernail prior to performing first scrub of day
 No hand or arm jewelry
 Nails short, no artificial nails
 Pre-op scrub for at least 2-5 minutes using appropriate antiseptic OR use
appropriate procedure for brushless scrub product
Antimicrobial prophylaxis
 Appropriate antibiotic within 1 hr of cut, adjustment in dosage for obesity, redosed if procedure over 4 hours
Intra-operative
Ventilation
 Keep doors closed, only necessary personnel in room, positive air pressure, 15
ACH
Normothermia
 For colon procedures
Sterilization of surgical instruments
 Indicators checked
 Limit flash sterilization
Traffic Flow and Surgical Attire
 Fresh scrubs
 Cover gowns to be determined by policy. The value of cover apparel within the
institution is unsubstantiated.
 Nonscrubbed personnel should wear long-sleeved jackets that are buttoned or
snapped closed during use. Complete closure of the jacket avoids accidental
contamination of the sterile field. Long-sleeved attire is advocated to prevent
bacterial shedding from bare arms and is included in the Occupational Safety
and Health Administration (OSHA) regulation for the use of personal protective
equipment (PPE).
 Other garments should be contained completely within or covered by the
surgical attire. Clothing that cannot be covered by the surgical attire should not
be worn.
 Surgical mask must fully cover mouth & nose
 Cap/hood must fully cover all hair on head
 Face protection must cover face, not just eye glasses
Page 19 of 22
Infection Prevention and Control Department Assessment Tools: Operating Room continued

OR Areas: unrestricted area, transition zone, semirestricted area and restricted
area
1. unrestricted – street clothes
2. transition – authorized staff only – changing rooms/lockers
3. semirestricted area – pre-op, recovery, storage, corridors outside OR
rooms: separate work area for equipment reprocessing, authorized
staff only, enclosed storage to minimize dust and debris, surgical attire
and cap required, clean closed shoes
restricted: scrub sink areas and OR rooms – door closed, complete surgical attire –
mask required when sterile supplies open and/or operation in process, hair
covering for patients
Asepsis and surgical technique
 Adhere to principles of asepsis when placing intravascular devices or when
administering IV drugs
 Assemble sterile equipment and solutions immediately prior to use
Page 20 of 22
Infection Prevention and Control Assessment Tool
Pharmacy
PROCESS/AREA TO ASSESS
Yes, No, N/A, COMMENTS
Sharps waste containers are no more than ¾ filled
Soap, towels, alcohol degermer, hand lotion - appropriate
hand hygiene is observed
EVS support for department is adequate
IV room (hood, counters, walls, ceilings, floor, sink area)
is clean
No shipping cardboard boxes used for storage of
supplies
Refrigerator/freezer temperature logs are complete/action
taken if not
Staff can describe procedure for cleaning/disinfecting of
IV hood and counters
Laminar flow hood used to compound sterile products is
certified (motor and HEPA filters changed)
PPE required for laminar flow hood used appropriately
and changed upon exit and re-entry
Page 21 of 22
Infection Prevention and Control Checklist
Inpatient Nursing Unit
Yes, No, N/A,
COMMENTS
PROCESS/AREA TO ASSESS
Hand hygiene per CDC guidelines
Frequently touched surfaces cleaned/disinfected daily in occupied patient rooms by EVS;
disinfectant wipes available; patient rooms/bathrooms clean (cubicle curtains, over bed tables,
shelves, sinks, shower, toilet, floor)
Computer keyboards and touchscreens clean and process for daily cleaning/disinfecting in place
Staff demonstrates appropriate handling of patients requiring expanded IC precautions
(appropriate PPE, practice, and signage for transmission based and/or standard precautions)
Negative pressure in isolation rooms “on” for patients in Airborne Precautions
Sharps containers are less than ¾ full; safety devices are activated (look in sharps containers for
activated devices)
Staff can describe/demonstrate immediate action for a blood/body fluid exposure (needle stick or
splash): Flush with soap and water for needle stick, flush with water for splash to eyes, nose or
mouth
Linen carts are covered and not overfilled
Items are stored 3” off floor to allow cleaning underneath; bottom shelf of clean storage carts is
solid or shelf liner in place to prevent contamination from dust and cleaning solutions
No external shipping cardboard boxes are used for storage
Medication and food refrigerator temp logs are complete and action taken noted when temp is
outside of parameters; all refrigerators are clean (including staff)
Patient care equipment clean (e.g. IV poles, Dynamap, wheelchairs, EKG machine, scales,
glucometers etc.) and staff can describe accountability and process
Lab specimens are transported in clean, closed container (zip lock bag or tote box – biohazard
label if unable to view content of container)
Toys in department are clean (if toy not able to be cleaned – it must be removed)
Single dose vials are used once and tossed; multi-dose vials are discarded by manufacturers
discard date
No food or drink noted in patient care areas or areas where there is a risk of blood/body fluid
exposure
Ice machines and drip trays are clean
Clean utility room:

Signage identifies as clean area

Hand washing or waterless degermer available

No contaminated items in area

Sterile and non-sterile items stored separately

Area is clean and orderly

No food or drink
Dirty utility room:

Signage identifies as dirty area

Hand washing or waterless degermer available

PPE is available

No food or drink

Medical waste container is covered

Regular waste container is covered

Area is clean and orderly
Page 22 of 22