02/04/2008
Primary Care Division
Infection Control Audit Tool
Site :
Location :
Speciality :
Head of Department (or nominee):
Audit Date :
Completed By : Accompanied By (if applicable) :
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Index Introduction Section 10
Waste Disposal
Section 11
Sharps Handling & Disposal
Section 12
Linen Storage, Bagging & Laundering
Section 13
Clinical Practice
Section 14
Cleaning & Disinfection
Section 15
Care of Equipment
Section 16
Staff Facilities
Section 17
Vaccine Storage
Section 18
Minor Surgery
Section 19
Baby Changing Facilities
How to use this audit tool Section 1
General
Section 2
Toilet Area
Section 3
Shower Area
Section 4
Sluice Room (Disposal)
Section 5
Domestic Services Room
Section 6
Consulting Room / Treatment Room
Section 7 Section 8a
Local decontamination (contact Infection Control Team for information) Kitchens – General
Section 8b
Kitchens - Refrigerator
Section 8c
Kitchens - Cookers / Microwaves
Section 8d
Kitchens - Dishwashing
Section 8e
Kitchens - Training
Section 9
Handwashing Facilities
Scoring Summary Action Plan Example Audit Calendars Recommended Reading
Version 2 Revised may2004
Review Date: April 2006
Introduction In recent years there has been an increase in concern about the risks to health from receiving treatment and care. The Clinical Standards Board for Scotland published standards for Healthcare Associated Infection (HAI) Infection Control, December 2001 (Ref: ISBN 1-903766-12-5), a copy of which can be obtained from Trust Clinical Standards Facilitator (0141 211 3916). These standards are used by the NHS Quality Improvement Scotland, to assess the quality of Infection Control provided in both the Primary Care and hospital settings throughout Scotland.
02/04/2008 It is anticipated that the relevant sections of the audit tool are completed at least once a year by staff at local level, As hand washing is the single most important means of preventing the spread of infection, section 9 hand washing facilities should be completed on a monthly basis. It is advised that the section on how to use this audit tool is read, prior to undertaking the audit. Further information in relation to the self assessment process or audit tool can be obtained by contacting a member of the Prevention and Control of Infection Team by: Email
[email protected] Lesley
[email protected] [email protected] [email protected] [email protected]
Telephone
0141 211 3568
As part of the process of ensuring that these standards are met, as well as ensuring that the quality of the infection control practice within the Trust is of a high standard, the Prevention and Control of Infection Team has developed an Infection Control Environmental Audit Tool. This audit tool defines the acceptable standards for a managed environment which minimises the risk of infection to patients, staff and relatives. These standards reflect current legislation, national guidelines and good practice of infection control within a healthcare environment. To ensure that staff at a local level has ownership of the standards, the Head of Department or nominee should demonstrate compliance through self assessment using the audit tool provided. The Environmental Audit tool is divided into sections containing the relevant standard and criteria, not all sections may be applicable to your area.
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
How to use this audit tool 1. Inpatient areas; Heads of Department or nominated member of staff should identify and complete all sections relevant to their area. Outpatient areas (i.e. Health Centres, Resource Centres) For ease of collation and reporting an identified person within the locality should be responsible for distribution of relevant sections of audit tool to areas and in collating the return of completed action plans and scores to the Infection Control Team (ICT) within the required time frame. 2. Section 9 ‘Handwashing Facilities’’ should be completed on a monthly basis locally, however score and action plan need only be returned to ICT as indicated by timeframe identified by score. 3. Other relevant sections should be completed at least yearly, or as indicated by scoring achieved (see scoring sheet for more details) or by the Infection Control Team in the returned summary report 4. It is suggested that an audit calendar (enclosed) should be completed to chart the relevant sections indicating when re-audit is required 5. To each criterion within the relevant sections, place a cross in the appropriate box (Yes, No or Not Applicable) 6. All criteria which are not fully met require action. However, there are some criteria that require immediate action. These criteria are clearly marked.
7. An action plan, available at the back of the document, should be completed for all actions, indicating realistic timeframes (Immediate actions should be included). To assist in completing your action plan a copy of the Infection Control Team action plan for all sections and criteria is available within the intranet and Public Folder- infection control. For any further advice, contact a member of the Infection Control Team. A Copy of the action plan, score and copies of Infection Control audit reports should be retained at ward/department level as evidence of compliance with these standards, which will be reviewed by the Infection Control Team as part of their planned audit programme.
8. A copy of each completed section score and action plan should be returned via identified person (if applicable) i.e. HAI lead, to the Infection Control Team within given timeframe by email to Sarah.Caulfield@gartnavel,glacomen.scot.nhs.uk, or by post to Sarah Caulfield, Secretary to Risk Management Department, Ward 4, Risk Management department, 1055 Great Western Road, Glasgow, G12 OXH. 9. Your Department will be given a summary report and advice on when to re-audit by the Infection Control Team 10. The ICT will collate a response for overall Primary Care Division Performance to NHS Quality Improvement Scotland (Clinical Standards Board Scotland) Healthcare Associated Infection (HAI) Infection Control, reporting any common themes, challenges, good practice through the Infection Control Committee and Risk Management Advisory Group
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 1 Standard:
General
The general environment will be maintained appropriately to negate the risk of cross infection
Criteria
Yes
No
N/A
Action
1.1 Chairs/tables/trolleys and lockers are clean and in a good state of repair.
Immediate
1.2 All floor coverings are clean and in good state of repair.
Immediate
1.3 Dust is not present on high horizontal surfaces. 1.4 Low level surfaces are clean and free from dust 1.5 Where extractor fans are in operation, they must be clean and free from dust. 1.6 Curtains and blinds are clean and in good repair 1.7 If toys are available, they are clean, in a good state of repair and capable of being cleaned and withstanding chemical disinfectants.
Immediate
1.8 There is a cleaning schedule available within the ward/department Total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 2 Standard:
Toilet Area The toilet area will be maintained appropriately to negate the risk of cross infection.
Criteria 2.1 The toilet area and fixtures are clean and dry
Yes
No
N/A
Action Immediate
2.2 The toilet area is free of extraneous items 2.3 The fixtures and fittings are in good repair 2.4 Handwashing sinks are fitted with mixer taps 2.5 Handwashing sink is clean
Immediate
2.6 Liquid soap is available at all Handwashing sinks
Immediate
2.7 Liquid soap dispensers are clean
Immediate
2.8 Disposable paper towels are available in a wall mounted dispenser. 2.9 Waste disposal facilities are appropriate See Section 10 Waste Disposal 2.10 Toilet seats and toilet aids are clean and dry
Immediate
2.11 Sanitary disposal is available in female toilets 2.12 There is a cleaning schedule available Total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 3 Standard:
Shower Area The shower area will be maintained appropriately to negate the risk of cross infection.
Criteria 3.1 Shower areas are clean and dry and in good state of repair
Yes
No
N/A
Action Immediate
3.2 The area is free of extraneous items i.e. creams, bedpans 3.3 The shower area furnishings/fittings are in good repair e.g. tiles, flooring 3.4 Shower curtains are clean
Immediate
3.5 Shower chairs are clean and dry
Immediate
3.6 Waste disposal facilities are appropriate i.e. foot operated sack holders with domestic waste sack 3.7 Showers are run daily prior to use 3.8 Anti-slip bath/shower mats are clean and hung dry over the bath rail between use 3.9 There is a cleaning/replacement schedule for shower curtains Total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 4 Standard:
Sluice Room (Disposal) The sluice room will be maintained appropriately to negate the risk of cross infection.
Criteria
Yes
No
N/A
Action
4.1 Surfaces and fittings are clean, dry and free from spillages
Immediate
4.2 All surfaces and fittings are in good repair and free from extraneous items
Immediate
4.3 There is a sink for washing equipment e.g. bedpan shells, suction jars. 4.4 There is a dedicated handwashing sink 4.5 Handwashing sinks are fitted with mixer, elbow/wrist operated taps 4.6 There is a wall mounted antiseptic scrub/liquid soap dispenser
Immediate
4.7 Disposable paper towels are available in wall mounted dispenser
Immediate
4.8 Waste disposal facilities are appropriate See Section 10 waste disposal 4.9 The macerator is clean and functioning 4.10 Bedpan racks are clean Sub-total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 4 (cont’d) Criteria
Sluice Room (Disposal) Yes
No
N/A
Action
Sub-total (from previous page) 4.11 Commodes are clean, ready for use and in a good state of repair
Immediate
4.12 Bedpan holders and jugs are stored clean, inverted or on racks 4.13 Wash bowls are stored clean and dry and inverted, or patients own are stored in locker
Immediate
4.14 Sterile packs/equipment are not stored in the sluice
Immediate
4.15 Chemical reagents are kept in a locked cupboard
Immediate
4.16 If ‘nurses’ green sluice mops and buckets are available – mop and bucket is correctly colour coded (green). – buckets are stored clean, dry and inverted – mop heads laundered after each individual use. Total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 5 Standard:
Domestic Services Room The domestic services room will be maintained appropriately to negate the risk of cross infection.
Criteria
Yes
No
N/A
Action
5.1 Surfaces and fittings are clean and in good repair
Immediate
5.2 The floor is clean, dust free and free from spillages
Immediate
5.3 There is a Belfast sink or deep sink available for cleaning equipment 5.4 There is a dedicated handwashing sink 5.5 Handwashing sinks are fitted with mixer, elbow/wrist operated taps 5.6 Liquid soap is available and dispenser is clean
Immediate
5.7 Disposable paper hand towels are available in wall mounted dispensers
Immediate
5.8 Only items used for the purpose of cleaning are stored in the room 5.9 Protective clothing is available i.e. plastic aprons, gloves 5.10 Cleaning agents are suitably stored in a locked cupboard
Immediate
5.11 The equipment used by the Domestic staff is clean, well maintained and stored securely. 5.12 Mopheads are laundered daily
Immediate
5.13 Mopheads are stored upright
Immediate
5.14 Rubber gloves are stored clean and dry
Immediate
Sub-total
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 5 (cont'd) Criteria
Domestic Services Room Yes
No
N/A
Action
Sub-total (from previous page) 5.15 Buckets are stored clean, dry and inverted
Immediate
5.16 Colour coded mops, heavy duty gloves, disposable cloths are used appropriately: Red for Yellow for Blue for
Toilet Kitchen General
5.17 There is no evidence of used disposable cloths
Immediate
5.18 Spray cleaners are stored clean, empty and dry
Immediate
5.19 Cleaning schedule is available Total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 6 Standard:
Consulting Room / Treatment Room The consulting room/treatment room will be maintained appropriately to negate the risk of cross infection.
Criteria 6.1 Surfaces/fixtures are visibly clean, dry and in good repair
Yes
No
N/A
Action Immediate
6.2 Room is free from extraneous items 6.3 Sterile packs, dressings etc are stored off the floor in closed cupboards 6.4 Items are stored above floor level
Immediate
6.5 There is an effective stock rotation system 6.6 Items of sterile equipment are in date (randomly select 2 items and check date) 6.7 There is a dedicated handwashing sink
Immediate
6.8 Handwashing sinks are fitted with mixer, wrist/elbow operated taps
Immediate
6.9 There is a wall mounted antiseptic soap/ liquid soap dispenser
Immediate
6.10 An alcohol hand rub is available for use when recommended by Infection Control Staff Sub-total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 6 (cont'd)
Consulting Room / Treatment Room
Criteria
Yes
No
N/A
Action
Sub-total (from previous page) 6.11 Waste disposal facilities are appropriate. See section 10 Waste Disposal 6.12 Sharps container is available and stored safely
Immediate
6.13 Equipment is stored clean and dry
Immediate
6.14 Medicine trolleys are clean
Immediate
6.15 Dressing trolleys are cleaned with detergent and water before each session and whenever contaminated
Immediate
6.16 Dressing trolleys are wiped with 70% alcohol or detergent wipes between cases 6.17 Examination couch is clean, surface intact with wipeable surfaces
Immediate
6.18 Disposable paper towel is used to protect the couch and changed between patients
Immediate
6.19 Cover blankets are laundered weekly or after contamination 6.20 Drug fridge is clean, free of extraneous items and is defrosted regularly
Immediate
Sub-total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 6 (cont'd)
Consulting Room / Treatment Room
Criteria
Yes
No
N/A
Action
Sub-total (from previous page) 6.21 Drug fridge temperature is recorded daily and is within safe zone (2-8°C)
Immediate
6.22 Suitable protective clothing is available i.e. plastic aprons, disposable gloves, protective eyewear
Immediate
6.23 Lotions in lotion cupboard are stored appropriately and identified for individual patient use when required
Immediate
6.24 NHS Greater Glasgow Management of needlestick injuries flipchart is available
Immediate
6.25 Specimens are stored in suitable washable container before transporting to the lab.
Immediate
Total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 7 Standard:
Local Decontamination
Contact Infection Control Team.
Re usable instruments are effectively and safely decontaminated after each use to negate the risk of cross infection
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 8a Standard:
Kitchens – General
The kitchen will be maintained appropriately to negate the risk of cross infection.
Criteria
Yes
No
N/A
Action
8a.1 An identified handwashing sinks, liquid bactericidal soap and paper towels are available.
Immediate
8a.2 All work surfaces are clean, intact and impervious
Immediate
8a.3 All work surfaces are cleaned after each meal with bactericidal detergent and hot water and dried
Immediate
8a.4 A bactericidal detergent is used for cleaning the kitchen surfaces and crockery
Immediate
8a.5 A disposable cloth is used for cleaning the kitchen surfaces and crockery and is discarded after use.
Immediate
8a.6 Hands are washed and a clean plastic apron is worn to serve patient meals/beverages
Immediate
8a.7 Kitchen surfaces (walls, ceilings, work surfaces and floors) are intact and washable. 8a.8 Inappropriate items are not stored on the work surfaces
Immediate
8a.9 Disposable paper towelling is used to dry surface areas after cleaning.
Immediate
8a.10 Dishes are left to air dry or dried with disposable paper towels
Immediate
8a.11 Correct cleaning materials used in the kitchen are stored separately from other ward cleaning equipment, and away from food.
Immediate
8a.12 All opened food (e.g. cereals) is stored in pest proof containers or packets are appropriately sealed.
Immediate
Sub-total
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 8a (cont’d) Criteria
Kitchens – General Yes
No
N/A
Action
Sub-total (from previous page) 8a.13 All food waste is removed from the kitchen after each meal e.g. via food disposal unit within the sink or double black bags.
Immediate
8a.14 Extractor fans are clean and in good working order.
Immediate
8a.15 Open windows must have a mesh screen or Insecta flash, to prevent insects entering the kitchen. 8a.16 Bread is stored in a clean bread bin or covered container
Immediate
8a.17 Stocks of any foods are within date and there is a system of stock rotation
Immediate
8a.18 Access to the kitchen should be restricted and not used as a thoroughfare.
Immediate
8a.19 There are no inappropriate items or equipment in the kitchen e.g. staff hand bag/personal belongings.
Immediate
8a.20 There is no evidence of infestation or animals in the kitchen.
Immediate
8a.21 Wooden boards, spoons and rolling pins are only used in rehabilitation departments under supervision.
Immediate
8a.22 Notices within the kitchen are kept to a minimum, laminated and are in date.
Immediate
8a.23 Colour coded yellow mops, rubber gloves etc are used
Immediate
8a 24 There is a clean, functioning foot operated waste bin Total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 8b Criteria
Kitchens – Refrigerator Yes
No
N/A
Action
8b.1 The temperature of the refrigerator is recorded daily and is between 0 – 4ºC
Immediate
8b.2 Freezer temperature is recorded daily and is below minus 18ºC
Immediate
8b.3 Patient food in the fridge is labelled with name/date as per Trust/local policy.
Immediate
8b.4 Items stored in the refrigerator are covered
Immediate
8b.5 Food is properly stored and marked with use by date
Immediate
8b.6 There is no food past the expiry date in the fridge.
Immediate
8b.7 Milk is stored under refrigerated conditions, with outer polythene wrapping removed
Immediate
8b.8 All dairy products are refrigerated and within expiry date
Immediate
8b.9 Raw food is absent from ward refrigerator e.g. eggs, meat or fish
Immediate
8b.10 Where indicated on the label, sauces and preserves are stored in the refrigerator after opening.
Immediate
8b.11 Non food items are absent from the refrigerator i.e. drugs or specimens
Immediate
8b.12 All refrigerators are externally clean and door seals intact.
Immediate
8b.13 Refrigerator is clean internally and defrosted weekly
Immediate
Total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 8c Criteria
Kitchens – Cookers / Microwaves Yes
No
N/A
Action
8c.1 The cooker is clean and free from food stuffs
Immediate
8c.2 Microwave ovens, if present, are clean and used for staff food only
Immediate
8c.3 Microwave ovens, if present, interior and exterior is clean and free from spillages
Immediate
Total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 8d Criteria
Kitchens – Dishwashing Yes
No
N/A
Action
8d.1 All crockery and cutlery is thermally disinfected or washed with bactericidal detergent
Immediate
8d.2 There is a functioning dishwasher or double sink designated to wash crockery and cutlery.
Immediate
8d.3 Dishwasher is clean, appropriate solutions are used and the machine reaches 80°C or above for the final rinse
Immediate
8d.4 A disposable cloth is used for washing dishes only and disposed of after use. 8d.5 Green scourers are not used Total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 8e Criteria
Kitchens – Training Yes
No
N/A
Action
8e.1 All staff designated as food handlers have received food hygiene training.
Immediate
8e.2 Patients are supervised when involved in the preparation of food.
Immediate
8e.3 If used, food temperature probes are maintained and cleaned in between uses with approved bactericidal wipes.
Immediate
Total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 9 Standard:
Handwashing Facilities Handwashing facilities should be appropriate to negate the risk of cross infection.
Criteria
Yes
No
N/A
Action
9.1 Wash hand basins are fitted with mixer taps with single pillar and no plug
Immediate
9.2 Wash hand basins are fitted with wrist/elbow operated taps
Immediate
9.3 Basins are suitably situated to encourage use 9.4 Basins are clean and intact
Immediate
9.5 Liquid soap is available
Immediate
9.6 Liquid soap dispensers are available at all wash hand basins
Immediate
9.7 Liquid soap dispensers are clean and dry
Immediate
9.8 Paper towel dispensers and towels are available at all sinks
Immediate
Sub-total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 9 (cont’d) Criteria
Handwashing Facilities Yes
No
N/A
Action
Sub-total (from previous page) 9.9 Foot operated waste bins with appropriate liner is provided for paper waste. See section 10 Waste Disposal
Immediate
9.10 Handcream, if it is available, is in pump dispenser
Immediate
9.11 No fabric towels are seen at handwashing sinks
Immediate
9.12 The sinks are free from used equipment e.g. medicine pots
Immediate
9.13 Alcohol hand gel is available for use when specified by the Infection Control Staff 9.14 Laminated posters demonstrating a good handwashing technique are available at sinks 9.15 Hands are washed/decontaminated as hand hygiene technique described in the Prevention and Control of Infection Manual (observe 2 members of staff) Total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 10 Standard:
Waste Disposal
Waste is disposed of safely without the risk of contamination or injury.
Criteria
Yes
No
N/A
Action
10.1 Black bags are available for the disposal of domestic waste
Immediate
10.2 Yellow bags are available for the disposal of clinical waste
Immediate
10.3 Waste is segregated according to Waste Policy
Immediate
10.4 An adequate number of bins are available for use 10.5 Pedal operated bins are in use
Immediate
10.6 Pedal operated bins are functioning 10.7 Pedal operated bins are clean
Immediate
10.8 Bags are sealed securely
Immediate
10.9 Bags are no more than 3/4 full
Immediate
10.10 Identification tape and label are available and in use
Immediate
10.11 Waste is stored in a suitable designated area prior to uplift
Immediate
10.12 The storage area is kept clean
Immediate
10.13 Waste bags are stored safely from the public
Immediate
10.14 The disposal area is locked and inaccessible to unauthorised persons
Immediate
Sub-total
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 10 (cont’d) Criteria
Waste Disposal Yes
No
N/A
Action
Sub-total (from previous page) 10.15 Clinical and domestic waste is stored separately
Immediate
10.16 All staff who handle waste bags and containers have received appropriate training
Immediate
10.17 Cytotoxic waste is disposed through the approved channel (ask 2 staff)
Immediate
Total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 11 Standard:
Sharps Handling & Disposal
Sharps will be handled safely to negate the risk of sharps injury.
Criteria
Yes
No
N/A
Action
11.1 Sharps containers in use comply with BS7320/UN3291
Immediate
11.2 Sharps containers are assembled correctly.
Immediate
11.3 Sharps containers are labelled and dated following Waste policy.
Immediate
11.4 Sharps containers are less than 2/3rds full.
Immediate
11.5 Sharps container is free from protruding sharps.
Immediate
11.6 Sharps are disposed of directly into a sharps box.
Immediate
11.7 When administrating medication via injection, a sharps container (of suitable size) is taken to the point of administration (ask two members of staff).
Immediate
11.8 Needles are discarded without being re-sheathed
Immediate
11.9 NHS Greater Glasgow Management of needlestick injury flipchart is available and accessible. 11.10 Sharps containers are safely stored and do not present a risk to patients.
Immediate
11.11 Sharps containers are safely stored in a designated area prior to uplift.
Immediate
Total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 12 Standard:
Linen Storage, Bagging & Laundering
Linen is handled appropriately to prevent cross infection.
Criteria
Yes
No
N/A
Action
12.1 Clean linen is suitably stored, above floor level in a clean area, protected from contamination
Immediate
12.2 White laundry bags are available for used linen
Immediate
12.3 Red alginate bags are available for fouled/infected linen
Immediate
12.4 Blue laundry bags are available for personalised clothing
Immediate
12.5 Used linen is segregated according to Laundry Policy.(Ask 2 members of staff)
Immediate
12.6 Linen bags are less than 2/3rds full and capable of being secured
Immediate
12.7 Linen buggies are available and in use 12.8 Used linen is stored in a designated area
Immediate
12.9 Used linen is regularly uplifted 12.10 Staff wear disposable plastic aprons and gloves when handling soiled/infected linen
Immediate
Sub-total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 12 (cont’d)
Linen Storage, Bagging & Laundering
Criteria
Yes
No
N/A
Action
Sub-total (from previous page) 12.11 If laundry facilities at ward level; washing machine is situated in a designated area and guidance for use is complied with 12.12 There is evidence that washing machine is maintained and serviced 12.13 Handwashing Facilities are available in the laundry room
Immediate
Total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 13 Standard:
Clinical Practice
Clinical Practice will reflect Infection Control guidelines and negate the risks of cross infection to patients whilst providing appropriate protection to staff
Criteria
Yes
No
N/A
Action
13.1 Staff can locate the Prevention and Control of Infection Manual.
Immediate
13.2 Powder free non-sterile gloves are available.
Immediate
13.3 Powder free sterile gloves are available if required.
Immediate
13.4 Disposable plastic aprons are available.
Immediate
13.5 Eye protection is available (shatter proof may be required in some areas).
Immediate
13.6 Specimens are collected following Standard Precautions 13.7 Specimens are well secured in re-sealable clear plastic bags 13.8 Specimens and form are clearly labelled 13.9 Specimens are stored in a secure separate designated washable container 13.10 Waterproof plasters are available for use to cover cuts and abrasions
Immediate
Sub-total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 13 (cont’d) Criteria
Clinical Practice Yes
No
N/A
Action
Sub-total (from previous page) 13.11 Non sterile gloves are worn for emptying urinary catheter bags.
Immediate
13.12 A disposable receptacle is used for emptying urinary catheter bags.
Immediate
13.13 Catheter stands are in use, there are no catheters/bags touching the floor.
Immediate
Total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 14 Standard:
Cleaning & Disinfection
Disinfectants are available and used correctly to prevent cross infection.
Criteria
Yes
No
N/A
Action
14.1 General purpose neutral detergent is available
Immediate
14.2 Chlorine releasing disinfectants are available e.g. chlorine spillage kit, Titan Sanitizer, Actichlor
Immediate
14.3 Disinfectants are used in accordance with manufacturers instructions 14.4 Impervious flooring such as vinyl is used whenever body fluid spillage is frequent and predictable 14.5 Carpets are impervious and bleach resistant 14.6 All furniture/equipment is capable of being cleaned/ decontaminated 14.7 Cleaning and disinfectant agents are stored appropriately
Immediate
14.8 Spillages of blood and other body fluids are appropriately cleaned and disinfected (ask two staff members) 14.9 Medical devices marked as single use are not re-used
Immediate
14.10 Single patient use devices are used only for individual patient and destroyed on completion of treatment Sub-total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 14 (cont’d) Criteria
Cleaning & Disinfection Yes
No
N/A
Action
Sub-total (from previous page) 14.11 Decontamination guidelines are available and staff are able to resource this information (Ask two staff)
Immediate
14.12 COSHH Data sheets are available for disinfectants/detergents
Immediate
14.13 Non sterile gloves are available when disinfectants are used
Immediate
14.14 Disposable waterproof aprons and eye protection are available when there is risk of splashing
Immediate
14.15 Staff are aware that a decontamination certificate should be completed prior to sending equipment for maintenance and repair
Immediate
Total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 15 Standard:
Care of Equipment
Equipment is cleaned/ decontaminated/ stored correctly to negate the risk of infection.
Criteria
Yes
No
N/A
Action
15.1 Re-usable equipment is decontaminated as manufacturers instructions 15.2 Suction equipment is clean and dry with a bacterial/viral hydrophobic filter in situ.
Immediate
15.3 Suction tubing and catheters are kept within plastic bags.
Immediate
15.4 Thermometers are stored dry.
Immediate
15.5 Mattresses and wipeable duvets are cleaned between patients with detergent and water and dried (Ask two staff members)
Immediate
15.6 All surfaces such as mattresses and pillows are protected from body fluids contamination with wipeable or disposable waterproof covers 15.7 Oxygen cylinders are clean. Masks are available, but not open to contamination by dust or condensation.
Immediate
15.8 Nebulisers are stored clean and dry after individual patient use following therapeutic use of humidifiers and nebulisers
Immediate
15.9 Treatment trolleys are routinely cleaned, and are free from extraneous items. 15.10 Lifting aids undergo a suitable decontamination procedure between patients (Ask two members of staff)
Immediate
Total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 16 Standard:
Staff Facilities
Staff facilities are maintained appropriately to negate the risk of cross infection.
Criteria
Yes
No
N/A
Action
16.1 There are facilities available for staff to change. 16.2 There are clean wash/shower areas available for staff to use. 16.3 Staff have a designated toilet See section 2 Toilet area 16.4 If cooking facilities are available, the area where the facilities are situated must be clean and all surfaces intact.
Immediate
16.5 If a fridge is in use, it must be clean and food stored in a container and labelled.
Immediate
16.6 The fridge must have a thermometer present and a daily record of temperature is kept (temperature range 0 – 4ºC).
Immediate
16.7 If a freezer is in use, the temperature must be recorded daily (temperature below minus 18ºC).
Immediate
16.8 There is a designated sink/dishwasher for staff to wash their cutlery and crockery.
Immediate
16.9 There is a designated handwashing sink within the area.
Immediate
16.10 Liquid soap is available.
Immediate
Total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 16 Criteria
Staff Facilities Yes
No
N/A
Action
Sub-total (from previous page) 16.11 Disposable paper towels are available.
Immediate
16.12 There is a pedal operated domestic waste bin within the area. See section 10 Waste Disposal 16.13 When a microwave is in use, it must be kept clean.
Immediate
Total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 17 Standard:
Vaccine Storage
Vaccines are stored safely to ensure efficacy of the drug.
Criteria
Yes
No
N/A
Action
17.1 Vaccines are stored in a designated, lockable drug fridge
Immediate
17.2 Vaccine/drug fridges temperatures are recorded daily or before starting a vaccine session (must be between 2 – 8ºC)
Immediate
17.3 Vaccines are not stored in the fridge door
Immediate
17.4 Vaccines are rotated to avoid accidental usage of expired vaccines
Immediate
17.5 Vaccine/drug fridges are not overstocked
Immediate
17.6 Vaccine/drug fridge is fitted with a minimum / maximum thermometer
Immediate
17.7 Vaccines are placed in the vaccine/drug fridge immediately following delivery
Immediate
Total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 18 Standard:
Minor Surgery
The environment is maintained appropriately to negate the risk of cross infection.
Criteria
Yes
No
N/A
Action
18.1 There is a room designated for minor surgery 18.2 The floor covering is intact, washable, non-slip with coved edges 18.3 The walls have smooth, washable surfaces ( no ceramic tiles) 18.4 The walls can withstand chemical disinfectants 18.5 The ceiling have smooth washable surfaces, able to withstand chemical disinfection 18.6 The window is fully closed during surgical procedures
Immediate
18.7 The window ensures privacy with opaque glass (no curtains)
Immediate
18.8 The ceiling light is covered 18.9 There is an anglepoise lamp 18.10 There is adequate ventilation by natural or mechanical means Sub-total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 18 (cont’d) Criteria
Minor Surgery Yes
No
N/A
Action
Sub-total (from previous page) 18.11 The work surfaces are smooth, intact, impervious and able to withstand chemical disinfectants 18.12 The work surfaces have a coved edge 18.13 The work surfaces are free from extraneous items 18.14 Storage cupboards are lockable for chemicals 18.15 There is no open shelving in the room 18.16 The treatment couch is intact with a washable, impervious surface 18.17 The treatment couch is regularly maintained, height adjustable and accessible from both sides 18.18 The couch is protected with disposable paper towel, changed between patients.
Immediate
18.19 The electric sockets are accessible and sufficient for requirements 18.20 There are splash proof sockets, placed approx. 1 m from the floor 18.21 Curtain screens are ceiling mounted on rails Sub-total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 18 (cont’d) Criteria
Minor Surgery Yes
No
N/A
Action
Sub-total (from previous page) 18.22
Curtains should be laundered at least 6 monthly and when visibly soiled
18.23 There is a designated hand washing basin with elbow /wrist operated mixer taps with single pillar and no plug See section 9
Immediate
18.24 There is a wall mounted disposable paper hand towels and liquid soap dispenser
Immediate
18.25 There are single use disposable nail brushes available (if used)
Immediate
18.26 There is an antiseptic skin cleanser
Immediate
18.27 There are detergent skin preparations available i.e. chlorhexidine, iodine
Immediate
18.28 There is the necessary personal protective equipment. See section 13.
Immediate
18.29 There are disposable sterile drapes available Sub-total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 18 (cont’d) Criteria
Minor Surgery Yes
No
N/A
Action
Sub-total (from previous page) 18.30 There is a designated procedure trolley 18.31 There is a foot operated clinical waste bin, with yellow bag See section 10
Immediate
18.32 There is a foot operated domestic waste bin. See section 10
Immediate
18.33 There is a sharps container which conforms to BS 7320, securely stored
Immediate
18.34 There is an up to date Prevention and Control of Infection Manual 18.35 There is a protocol for spillages of blood /body fluids
Immediate
18.36 There is a domestic cleaning schedule which is sufficient to prevent the accumulation of dust or debris on horizontal surfaces 18.37 Staff have received Hepatitis B vaccination 18.38 Single use items are disposed of after individual use
immediate
18.39 Re-usable instruments are sterilised at CSSD
Immediate
18.40 Re-usable instruments being decontaminated on site
ImmediateContract Infection Control Team for standards
18.41
Immediate
If, available on site steriliser conforms to HTM2010,
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Section 19 Standard:
Baby Changing Facilities
Baby changing facilities are maintained appropriately to negate the risk of cross infection
Criteria
Yes
No
N/A
Action
19.1 The environment is clean 19.2 There are appropriate handwashing facilities. See Section 9 19.3 There are appropriate waste disposal facilities. See Section 10 19.4 There is a flat surface for baby changing which is smooth, intact, impervious and able to withstand chemical disinfectants 19.5 The baby changing surface is clean and intact Total
Comments
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Scoring Summary To complete the scoring for each section
1
Points for every Yes
0
Points for every No
This will give a Total Score for that section Possible Score = (Number of questions) [D] Maximum Score [E] = Possible Score [D] minus Total Not Applicable Score [C] Percentage =Total Yes Score divided by Maximum Score x 100
It is recommended that section 9 Handwashing is audited monthly. The timescales for the other sections relevant to your area will be dependant on the percentage received. It is recommended that if a score of 60% or less is obtained, an audit of the section is repeated in 3 months time; if between 60-75% re-audit in 6 months; if greater than 75% re-audit in 1 year.
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Scoring Summary Section
Total Yes [A]
Total No [B]
Total N/A [C]
Possible Score [D]
1
8
2
12
3
9
4
16
5
19
6
25
7
Contact ICT for advice
% Score [A] / [E] x 100
0
8a
24
8b
13
8c
3
8d
5
8e
3
Sub Total ()
137
Version 2 Revised may2004
Max Score [E] = [D] – [C]
Review Date: April 2006
02/04/2008
Scoring Summary (cont’d) Section
Total Yes [A]
Total No [B]
Total N/A [C]
Possible Score [D]
Sub Total ()
137
9
15
10
17
11
11
12
13
13
13
14
15
15
10
16
13
17
7
18
41
19
5
Total
301
Version 2 Revised may2004
Max Score [E] = [D] – [C]
% Score [A] / [E] x 100
Review Date: April 2006
02/04/2008
Action Plan Section
Version 2 Revised may2004
Problem(s) Identified
Recommendations
Action Taken
Review Date: April 2006
02/04/2008
Action Plan Section
Version 2 Revised may2004
Problem(s) Identified
Recommendations
Action Taken
Review Date: April 2006
02/04/2008
Action Plan Section
Version 2 Revised may2004
Problem(s) Identified
Recommendations
Action Taken
Review Date: April 2006
02/04/2008
Sample Audit Calendar 1 Sample audit calendar if all sections are relevant and greater than 75 % is achieved for all sections i.e. each section re-audited yearly. Please note, section 9 Hand washing should be audited locally monthly and results kept at a local level. A copy of score and action plan should only be returned to ICT as indicated by time frame determined by the score i.e. within 3, 6 or 12 months
January 9. Handwashing Facilities 2.Toliet area 3 Shower area 19 Baby changing.
February 9. Handwashing Facilities 1 General 6 Consulting/treatment room
March 9. Handwashing Facilities 4.Sluice 5 DSR
May
June
July
9. Handwashing Facilities 8 Kitchens
9. Handwashing Facilities 11 Sharps handling
9. Handwashing Facilities 12 linen storage 13 Clinical practice
September
October
November
9. Handwashing Facilities 16 Staff facilities
Version 2 Revised may2004
9. Handwashing Facilities 18 Minor Surgery
9. Handwashing Facilities 15 Care of equipment
April 9. Handwashing Facilities 7. local decontamination
August 9. Handwashing Facilities 14 Cleaning and disinfection
December 9. Handwashing Facilities 10 Waste disposal 17 Vaccine storage
Review Date: April 2006
02/04/2008
Blank Audit Calendar Please note, section 9 Hand washing should be audited locally monthly and results kept at a local level. A copy of score and action plan should only be returned to ICT as indicated by time frame determined by the score i.e. within 3, 6 or 12 months
January 9. Handwashing Facilities
February 9. Handwashing Facilities
March 9. Handwashing Facilities
April 9. Handwashing Facilities
May
June
July
August
9. Handwashing Facilities
9. Handwashing Facilities
9. Handwashing Facilities
9. Handwashing Facilities
September
October
November
December
9. Handwashing Facilities
9. Handwashing Facilities
9. Handwashing Facilities
9. Handwashing Facilities
Version 2 Revised may2004
Review Date: April 2006
02/04/2008
Recommended Reading th
Ayliffe G., Fraise A., Geddes A. and Mitchell K. (2000) Control of Hospital Infection 4 Edition Arnold Pratt R. et al (2001) The Epic Project: Developing National Evidence- based Guidelines for Preventing Healthcare associated Infections Journal of Hospital Infection 47 (supplement S3-S4) Greater Glasgow Primary Care NHS Trust Prevention and Control of Infection Manual NHS Estates (2001) Infection Control in the Built Environment Royal College of Nursing (2001) Good Practice in Infection Control; Guidance for nurses working in general practice NHSScotland Property and Environmental Forum (2002) Scottish Health Facilities Note 30 Infection Control in the built environment Scottish Consultants in Public Health Medicine (Communicable Disease/Environmental Health) Working Party (June 1995) Infection Control: A Purchasers Guide Specification Manual and Monitoring Protocol st
West Midlands ICNA (1995) Infection Control Audit Tool 1 Edition Wilson J. (2000). Infection Control in Clinical Practice Bailliere Tindall
Version 2 Revised may2004
Review Date: April 2006