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dm2020 0202 PDF

This document provides an assessment form to guide hospital managers and healthcare professionals in adhering to infection prevention and control standards and protocols during the COVID-19 pandemic. The form covers areas like patient triage, placement and movement, use of personal protective equipment, environmental cleaning, visitor management, aerosol-generating procedures, monitoring, occupational health of staff, and training requirements. Completing the assessment helps ensure facilities have proper infection control measures in place to prevent the spread of COVID-19 among patients and staff.

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188 views6 pages

dm2020 0202 PDF

This document provides an assessment form to guide hospital managers and healthcare professionals in adhering to infection prevention and control standards and protocols during the COVID-19 pandemic. The form covers areas like patient triage, placement and movement, use of personal protective equipment, environmental cleaning, visitor management, aerosol-generating procedures, monitoring, occupational health of staff, and training requirements. Completing the assessment helps ensure facilities have proper infection control measures in place to prevent the spread of COVID-19 among patients and staff.

Uploaded by

code4sale
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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INFECTION PREVENTION AND CONTROL ASSESSMENT FORM FOR HOSPITAL

MANAGERS AND HEALTHCARE PROFESSIONALS

The purpose of
this Infection Prevention and Control (IPC) Assessment Form is to
provide guidance for Health Facility Managers and Healthcare Professionals to adhere with
IPC Standards and Protocols in light with the COVID-19 pandemic.

A. Assessment and Triage of Patient with Acute Respiratory Illness

Item YES NO Not


Applicable
A dedicated area to triage patients with respiratory
symptoms that is separate from other clinical triage and
evaluation area is provided

Patients in the waiting area are separated 6 feet apart

There is a separate entrance, exit, and foot traffic for


patients and staff
Alcohol-based hand sanitizer is available in the
assessment/ triage area and other patient care and
common areas
Facemasks are provided to patients with respiratory
symptoms at entrances
Specifically-trained healthcare personnel have been
assigned responsibility for overseeing the triage process
There is an alternative system to face-to-face triage
(telephone triaging)
Criteria for prioritizing admission of patients to those in
most critical need have been established

A process of ensuring that the receiving healthcare worker


is notified in advance
transported within the
is
in place when
facility
a patient is being

B. Source Control Measures and Patient Placement

Item YES NO Not


Applicable

Suspect, probable, and confirmed COVID-19 patients wear


a facemask while inside the facility premises
Suspect and probable COVID-19 patients are admitted in a
single-person, fully enclosed room, with a dedicated bathroom
Cohorting of patients in a ward is done only to confirmed
COVID-19 patients and are placed at least 3 feet apart

Suspect, probable, or confirmed COVID-19 cases remain in


their respective rooms duration of their stay in the facility.
Transferring rooms is prohibited.
Transport and movement of patients are limited to
medically essential purposes only

Procedures and tests are conducted in the patient’s room


There is a dedicated health personnel (or team) assigned
to care for suspect, probable, or confirmed COVID-19
cases during their shift.

Healthcare personnel and patient has appropriate PPE


when doing transfers between facilities

C. Implementation of Standard, Contact, and Droplet Precautions

{tem YES NO Not


Applicable

Sinks for handwashing are well stocked with soap and


towels

Availability of alcohal-based handrubs at point of care


Correct hand hygiene technique
healthcare workers
is practiced by
all
Use of WHO approach on My 5 Moments for Hand Hygiene

a. Before touching a patient

b. Before any aseptic or clean procedure is performed

c. After exposure to patient's body fluid


d. After touching a patient

e. After touching the patient's surroundings

PPE
and
is available immediately outside
in other areas where patient care
of the patient room
is provided.

Healthcare workers entering rooms of suspect, probable, or


confirmed COVID-19 patients wear proper PPE
a. Face shield/ goggles

b. Facemask (N95
procedures)
if doing aerosol-generating
c. Isolation gown

d. Clean non-sterile gloves

Correct donning of PPE is performed before entering


patient's room
Correct doffing of PPE is performed after doing patient care

Trash disposal bins are positioned near the exit outside


each patient room to make
after removal
it
easy for staff to discard PPE

Used PPE
are properly disposed
Dedicated equipment (stethoscope, BP cuff, thermometers,
etc.) are used for each patient. If this is not feasible, the
equipment is cleaned and disinfected between patients.
Regular disinfection and decontamination of environmental
surfaces, critical, and non-critical items are done using FDA
and facility-approved disinfectants

D. Visitor Management and Exclusion

Item YES NO Not


Applicabie

Policies on restricting visitors for suspect, probable, or


confirmed COVID-19 patients are in place

Limit points of entry to the facility and visitation hours


allow screening of all potential visitors
to
Instructions for visitors not to visit if they have fevertheor
symptoms of
a respiratory infection are posted
hospital entrances and common areas
at
Visitors are actively assessed for fever and COVID-19
symptoms upon entry to the facility. If present, the visitor is
not allowed to enter the facility.

The hospital has a process to


allow for remote
communication between the
patient and visitor (video calls
through cell phones or tablets)
\fvisitors are allowed to enter the room of a suspect,
probable, or confirmed COVID-19 patient, the facility:

a. has a policy defining what PPE should be used by


visitors

b. provides instruction to visitors before they enter a


patient room, on hand hygiene, limiting surfaces
touched, and use of PPE according to current
facility policy.

c. maintains a record (with contact information) of all


visitors who enter and exit the room.

d. ensure their movement within the


that visitors limit
facility (e.g. avoid the cafeteria).

E. Requirements for Performing Aerosol-Generating Procedures

Aerosol-generating procedures are performed


air
negative
hour and
in
pressure room with at least 12 exchanges per
controlled direction of airflow when using mechanical
ventilation

IF NOT AVAILABLE, procedures are done in


an adequately
ventilated room, with air flow of at least 160 L/s per patient

Healthcare worker use appropriate PPE when performing


aerosol-generating procedures
a. N95 respirator mask

b. Eye goggles or face shield

c. Clean, non-sterile gloves

d. Isolation gown

Persons in theandroom are limited minimum required for


procedure support
patient care

Room surfaces are cleaned and disinfected promptly after


the procedure

F. Monitoring and Reporting

The IPC team/ HESU


probable case of COVID-19
is in thewhen there
notified
facility
is a suspect or
Hospital Infection Prevention and Control Committee/ Nurse
monitors and reports breaks in IPC protocols

G. Occupational Health

Health facility uses the World Health Organization for the risk
assessment of healthcare workers as indicated in DM 2020-
0106, Interim Guidelines for Health Workers Exposure Risk
Assessment and Management in the Context of COVID-19
Virus.

Healthcare workers are actively screened for fever and


symptoms of COVID-19 before the start of the shift
Healthcare worker monitors themselves regularly for fever
and respiratory symptoms

a. When ill, healthcare worker is reminded to stay


home

b. Ifsymptoms consistent with COVID-19 develop while


in the facility, the healthcare worker keep their
facemask on, inform the supervisor, and leave the
workplace

Healthcare worker suspected to have COVID-19 are


prioritized for testing

Health facility implements the mandatory 14-day quarantine


of healthcare workers with high risk of exposure after their
last duty.

A return-to-work criteria is used for suspected or confirmed


COVID-19 healthcare workers

Job- or task-specific education and training on the following


Infection Prevention and Control practices are done:

a. Appropriate use of PPE

b. Donning and doffing of PPE

c. Proper handwashing

d. Prevention of contamination of clothing, skin, and


environment

e. Signs and symptoms of COVID-19 and how to


monitor patients with such

f. How to properly clean and disinfect environmental


surfaces and equipment
g. Staying home when ill
h. Recommended actions for unprotected exposures
(e.g., not using recommended PPE, an
unrecognized infectious patient contact)

Concrete action points to address gaps:

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