INFECTION CONTROL ROUND CHECKLIST- WARD/ICU

DATE: DEPARTMENT:
SR.NO SITE/ITEMS & POINTS TO BE NOTED YES NO REMARKS
HOUSE KEEPING SERVICES/GENERAL
1 CLEANING/DUSTING
1.
2. FLOOR (USE
NURSING OF DISINFECTION
STATION SOLUTIONS)
(USE OF DISINFECTION
SOLUTIONS)
3. TOILETS/WASHROOMS (USE OF DISINFECTION
SOLUTIONS)
4. DRESSING TROLLEY/EMERGENCY TROLLEY (USE OF
DISINFECTION SOLUTIONS)
5.BEDSIDE LOCKER/CARDIAC TABLE(WET & DRY)
6.PATIENT BED( NEAT & CLEAN)
7.AVAILIBILITY OF DISINFECTANT SOLUTIONS
2 HAND HYGIENE COMPLIANCE
1.TOTAL OPPORTUNITY
2.AVAILABILLITY OF HANDWASHING LIQUID
3.TOTAL MISSING OPPORTUNITIY
4.AVAILABILITY OF HAND RUBING SOLUTION
3 PERSONAL PROTECTIVE EQUIPMENTS USAGE
1.DONNING (PRACTICES AND AWARENESS)
2.DOFFING (PRACTICES AND AWARENESS)
4 INDWELLING DEVICE CARE
1. FOLEY'S CARE
2.CVC CARE
3. ET/TRACHEOSTOM CARE
4.ORAL CARE
5. IV LINE OBSERVED FOR ANY SIGNS OF INFECTION
6.ADMINISTRATION SET CHANGE
7.SAFE INJECTION PRACTICES: AS PER
SIGLE PROTOCOLS
NEEDLE SINGLE
SYRINGE
8.MULTIUSE VIAL,
9.IV SET MANAGEMENT
5 CLEANING/DISINFECTION & STERILIZATION PRACTICES
1.SUCTION BOTTLE & SUCTION BULB DISINFECTION
PRACTICES
2.O2 HUMIDIFIER BOTTLE DISINFECTION
3. O2 MASK , NABULIZER MASK DISINFECTION
4.BAINES CIRCUIT
5.VENTILATOR MACHINE DISINFECTION
6.BIOMEDICAL EQUIPMENTS CLEANING & DISINFECTION
PRACTICES
6 BIOMEDICAL WASTE MANAGEMENT:
1: SEGREGATION
2.AVAILIBILITY OF BMW BINS
3.AVAILABILITY OF BMW BAGS
4. COLLECTION
5.TRANSPORTATION
7 LINEN MANAGEMENT:
1.DAILY BASE CHANGING PROTOCOL
2.COLLECTION
3.PROPER TRANSPORTATION
4. PRIMARY WASHING OF LINEN IF SOILED WITH BLOOD
AND BODY FLUID
 8 DOCUMENTATION: BUNDLE CARE
9 EXPIRY OF CSSD ITEMS
10 IMPROPER USAGE OF ICU/OT FOOTWARES

SIGN OF ICN: SIGN OF INCHARGE:

 INFECTION CONTROL ROUND CHECKLIST- OPD
DATE: DEPARTMENT:
SR.NO HOUSE
SITE/ITEMS & POINTS TO BE NOTED
KEEPING SERVICES/GENERAL YES NO REMARKS
1 CLEANING/DUSTING
1. FLOOR (USE OF DISINFECTION SOLUTIONS)
2. DRESSING TROLLEY/EMERGENCY TROLLEY
(USE OF DISINFECTION SOLUTIONS)
3.AVAILIBILITY OF DISINFECTANT SOLUTIONS
2 HAND HYGIENE COMPLIANCE
1.TOTAL OPPORTUNITY
2.AVAILABILLITY OF HANDWASHING LIQUID
3.TOTAL MISSING OPPORTUNITIY
4.AVAILABILITY OF HAND RUBING SOLUTION
3 PERSONAL PROTECTIVE EQUIPMENTS USAGE
CLEANING/DISINFECTION & STERILIZATION
4
PRACTICES
1.SUCTION BOTTLE & SUCTION BULB
DISINFECTION PRACTICES
2.O2 HUMIDIFIER BOTTLE DISINFECTION
6.BIOMEDICAL EQUIPMENTS CLEANING &
DISINFECTION PRACTICES
5 BIOMEDICAL WASTE MANAGEMENT:
1: SEGREGATION
2.AVAILIBILITY OF BMW BINS
3.AVAILABILITY OF BMW BAGS
4. COLLECTION
5.TRANSPORTATION
6 EXPIRY OF CSSD ITEMS

SIGN OF ICN: SIGN OF INCHARGE:

SARDAR VALLABHHAI PATEL INSTITUTE OF MEDICALSCIENCES AND RESEARCH
 PERSONAL PROTECTIVE EQUIPMENT AUDIT CHECKLIST- INFECTION CONTROL D

DEPARTMENT
SIGN OF ICN:
INFECTION CONTROL DEPARTMENT
SARDAR VALLABHHAI PATEL INSTITUTE OF MEDICALSCIENCES AND RESEARCH
 PERSONAL PROTECTIVE EQUIPMENT AUDIT CHECKLIST- INFECTION CONTROL DATE:

HEALTH CARE
DEFINED DEFINED
STAFF ARE TRAINED WORKERS USED SIGN OF
AVAILABILITY OF PPE DONNING DOFFING
FOR USING PPE PPE IN EXPOSED INCHARGE
AREA AREA
AREA
INFECTION CONTROL DEPARTMENT
ATE:

REMARKS
 SARDAR VALLABHHAI PATEL INSTITUTE OF MEDICALSCIENCES AND RESEARCH

SUCTION JAR DISINFECTION AUDIT CHECKLIST DATE:

NURSING STAFF
SODIUM
SUCTION JAR AWARE PCA STAFF AWARE SUCTION JAR
HYPOCHLORITE
DEPARTMEN SUCTION JAR DISINFECTION DOCUMENTATIO REGARDING REGARDING SUCTION STORED AT DRY SIGN OF
SOLUTION RECEIVED REMARKS
T AVAILABILITY SOLUTION N MAINTAINED SUCTION JAR JAR DISINFECTION AND CLEAN PLACE INCHARGE
RECORD
AVAILABLE DISINFECTION PRACTICES (IF NOT IN USE)
MAINTAINED
PRACTICES

SIGN OF ICN:

INFECTION CONTROL DEPARTMENT

 OPERATION THEATER AUDIT CHECKLIST- INFECTION CONTROL
DEPARTMENT:

NOT
SR.No. DISCRIPTION YES NO
APPLICABLE
COMMENTS

1 Cleaning and Disinfection Practices

OT Sleeper/Shoe Kept at entering
OT footware easily accessible
Restricted entry to cleaned zone and beyond
OT complex including Floor, Lobby, changing room, Doctor's room and OT
Rooms are clean
OT Complex Deep cleaning/Disinfection is taking place on regular time
( Weekly) & Documented for the same)
Minimum 30 minutes time period is given between 2 surgeries
Deep Cleaning is taking place at the end of the OT
OT Shoes is washed on daily basis after OT
2 Changing room and OT Attire of OT staff
Changing room available prior to OT enterance

Space for changing, shower and personal storage of staff and doctors

Clean OT dressed/scrub suit available and stored in separate clean

rack/cupbord
Separate storage area for clean and dirty items
All OT staff properly in OT scrubb suit/Surgical gown
Nails cut of staff
Staff wear any jewellry/thread/watch on hands
3 Patient Enterance
Defined patient enterance to the OT
All OT doors working properly and Close
4 CSSD Items
CSSD items kept in separate clean area above the floor
FIFO system maintained
All CSSD Instrument sets and Trays including linen are checked sterile and
unexpired & Documented
Arrangement of quick availabilty of sterile items. for e.g. a flash sterilizer within
OT complex.
5 Hand Hygiene
Total Opportunity
Availability of Hand Washing/Scrubbing solution
Total Missing Opportunity
6 Operation Room
Humidity
Temperature
Pressure
Doors are remained closed while ongoing Surgery
Hepa Filter Validation done on regular basis
7 Instrument Cleaning
All used Instruments are pre washed before sending to CSSD
Drying is taking place after before sending CSSD
Regular Instrument polishing taking place
8 Linen Management
OT linen stored in defined and clean area
Linen clean and stain free
Pre washing taking place after surgery
9 Biomedical Waste Management
Segreagtion
Availability of BMW Bins
Availability of BMW Bags
Collection
Transportation
10 Staff Awareness
NSI management
O2 Flow Meter and Suction Jar Disinfection
Instrument Cleaning/Disinfection/sterilization
CSSD Recall
Hand Hygiene
Linen Policy

Sign
Sign Of OT Incharge: of
ICN:
 SARDAR VALLABHHAI PATEL INSTITUTE OF MEDICALSCIENCES AND RESEARCH

DISINFECTION AUDIT CHECKLIST DATE:

BIOMEDICAL ALL NURSING STAFF PCA STAFF DISINFECTION

ALL REQUIRED FLOOR SURFACE ALL SOLUTION
EQUIPMENT DISINFECTANT WERE AWARE WERE AWARE CHEMICAL RECEIVED
DISINFECTION DISINFECTION DISINFECTION RECEIVED SIGN OF
DEPARTMENT DISINFECTION S HAVING REGARDING REGARDING DOCUMENTATION
SOLUTION CHEMICAL CHEMICAL UNDILUTED & INCHARGE
SPRAY PROPER DISINFECTION DISINFECTION AVAILABLE (SODIUM
AVAILABILITY AVAILABILITY AVAILABILITY SEALED
AVAILABLITY LABELING POLICY POLICY HYPOCHLORITE)

SIGN OF ICN:
INFECTION CONTROL DEPARTMENT
REMARKS
 SARDAR VALLABHHAI PATEL INSTITUTE OF MEDICALSCIENCES AND RESEARCH
CSSD AUDIT CHECKLIST- INFECTION CONTROL DATE:
NOT
SR.No. DISCRIPTION YES NO COMMENTS
APPLICABLE

Location Of Department for central sterilization has a separate area

1
for decontamination, clean processing, sterilization and distribution.
Adequate facilities and equipment for cleaning ,
2
disinfection, drying , packing and sterilization are available.
Traffic flow in the area proceed from dirty to clean with
3
separate entrances/ exists for each.
4 Gowning area is available prior to entry to clean area
Appropriate documentation for the HVAC (Heat Ventilation air
Conditioning system) for (temperature, humidity ,positive pressure
5
in clean areas / negative pressure for decontamination area, air
changes /hour) is available.
Hand washing and disinfection facilities are available and being
6
properly used as required by staff and visitors
Each sterilization process is properly validated (Bowie Dick test -
7
Biological test - Physical parameters-Chemical indicators)
8 Linen & instrument packing are done separately
9 All staff is putting on clean uniforms and proper protective attire
10 Potentially contaminated equipment handled & transported safely
11 The trolleys used for different area are clean and labeled
All chemical solution used in the washer disinfectors are within the
12
expiry dates
Enzymatic detergents are used in the manual cleaning with the use
13
of soft brush & cold water
 Surgical instruments are being disinfected, dried and arranged in
14
the proper way
Instruments are being properly packed with indicator tape placed
15 outside each pack, expiry date is clearly and properly printed on
each pack
16 Sterile packs are being stored in clean dust free store
17 Dumb Elevator in Use
Cleanliness and tidiness well observed in :
18 a. Equipment and instruments
19 b. Receiving area
20 c. Packing area
21 d. Sterile area
22 e. Sterile store
23 f. Un-sterile store (raw material store)
24 g.Transportation carts
25 h.Dumb Elevator

Sign of
Sign Of CSSD Incharge:
ICN:
 SARDAR VALLABHHAI PATEL INSTITUTE OF MEDICALSCIENCES AND RESEARCH

BIOMEDICAL WASTE MANAGEMENT AUDIT CHECKLIST

DATE :

SHARP
CONTAINER INCHARGE
DEPARTEMNT RED YELLOW BLUE WHITE GREEN REMARKS
AVAILABILIT SIGN
Y

1- Compliance , 0 - Non compliance , NA- Not Applicable

SIGN OF ICN:
INFECTION CONTROL DEPARTMENT
 Date: SARDAR VALLABHHAI PATEL INSTITUTE OF
Department:
MEDICALSCIENCES AND RESEARCH
Patient Name: MRN:
SR.NO CAUTI ( Catheter Associated Urinary Tract Infection) YES NO Remark

1 Hand Hygiene
2 Catheter In situ required according to clinical indicaions?
3 Routine daily meatal hygiene ( Catheter Care) done?
4 Hand hygiene & gloves prior to catheter care/insertion/maintainance?
5 Indwelling catheter secured?
6 Sterile, Continuosly closed drainage system used?
7 Catheter and drainage tube connected?
8 Unobstructed urine flow present?
9 Collecting bag regularly emptied?
10 Collecting bag below the bladder level?

CLABSI (Central Line associated Blood Stream Infection) YES NO Remark

1 Hand Hygiene
2 Maximum sterile barrier precaution used?
3 Best insertion site to minimize infection chosen
4 Insertion site prepared with CHG with alcohol?
Sterile gauze dressing or sterile transparent, semioermiable dressing over the insertion site
5 used?
6 Gauze dressing changed every 2 days or semipermiable dressing changed every 7 days?
Assessed port/hub disinfected with appropriate antiseptic (CHG, Povidine-iodine, IPA-70%)
7 immediately prior to each use?
8 Wet/soiled/dislodge dressing replaced immediately?
9 Administration set for continuous infusion changed not more frequently than every 4 days?
10 If Blood/blood products/fat emulsion are administred, change tubing after 24 hyrs.
If propofol is administered, whether changed tubing after every 6-12 hrs or when the vial is
11 changed.
12 Daily audit performed to assess whether each central line is still needed?

VAP (Ventilator Associated Pneumonia) Prophylaxis: YES NO Remark

1 Hand Hygiene
2 Daily interruption of sedation & assessment of readiness to wean?
3 Head end elevated at 30-45 degrees?
4 Regular Antiseptic oral care given with Chlorhexidine Q4H?
5 Continuous subglottic suctioning done?
6 Intermittent closed ET suctioning done?
7 Stress ulcer prophylaxis done?
8 DVT prophylaxis done?

SSI (Surgical Site Infection) YES NO Remark

1 Hand Hygiene
2 Appropriate PPE worn while handling of surgical wound?
3 All sterile item used while dressing surgical wound
4 Controlled blood glucose level during the immidiate post-operative period?
5 Dry surgical dressing done with aseptic precaution?
6 Disconitinued antibiotic with in 24 hrs after surgery and time (48 hrs for cardiac)?
Surgical Site Assessment
7 Any discharge from incision site?
8 Any redness at incision site?

Staff Name: Employee ID:

Signature of ICN:
 KITCHEN AUDIT CHECKLIST

Date:

SR.NO DISCRIPTION YES NO N/A REMARKS

Patient food preparation areas is located adjacent to delivery, interior
1
transportation, and storage facilities.
The receiving and control of incoming dietary supplies area is
2
- Separated from the general receiving area
- Contain a control station and a breakout area for loading and
3
weighing supplies.
Food preparation work spaces
4 -Spaces are provided for food preparation, cooking, and baking and close as possible to the
user (i.e., tray assembly and dining).
5 -The patient tray assembly area is close to the food preparation and distribution areas.
Food service carts
-The cart distribution system is provided, with spaces for storage, loading, distribution,
6
receiving, and sanitizing of the food service carts. The cart traffic is designed to eliminate any
danger of cross-circulation between
- Outgoing food carts and incoming, soiled carts, and the cleaning and sanitizing process not
7
to be through food processing areas.
Dining space(s) is provided for staff and separated from the food preparation and distribution
8
areas
Area for receiving, scraping, and sorting soiled tableware is adjacent to ware- washing and
9
separate from food preparation areas.
Designed to prevent contamination of clean wares with soiled wares through
10
cross-traffic.
The clean wares transferred for storage or use in the dining area without having
11
to pass through food preparation areas
Include multi-compartmented sinks of adequate size for the intended use, convenient to the
12
using service.
Hot water is supplemented to clean pots and pans by booster heater, steam jet,
13
or other appropriate means.
14 Mobile carts or other provisions are made for drying and storing pots and pans.
15 Hand wash basin, liquid soap and paper towels are available .
16 Disposable lent free towel is used for cleaning and drying the equipment and surfaces.
 Cleaning materials used in the kitchens are stored separate from other ward cleaning
17
equipment.
18 All opened food (e.g. cereal) is stored in pest proof containers in the dry store.
19 Food items in the store room are kept according to expiry date order on shelves.
Patient’s food sample kept in a separate fridge & labeled with name and date for
20
48hrs
21 Food in the refrigerator is within the expiry date.
Separate storage areas need to be provided for frozen raw meat- frozen raw fish- milk-
22
fruits & fresh vegetables-frozen vegetables-bread- canned and dehydrated foods.
Equipment in the preparation area (eg, mincers, mixers and blenders are properly
23
cleaned)
24 The refrigerator is used for food products only .
25 The refrigerator temperature is maintained as per protocol.
26 The kitchen is free from infestation.
27 Color coding for the knives & cutting board
Inaccessible areas (edges, corners and around furniture) are free of dust, grit, lint and
28
spots
29 Fly screens are in place where required
Fixtures, surfaces and appliances are free of grease, dirt, dust, deposits, marks, stains
30
and cobwebs
Shelves, cupboards and drawers are clean inside and out and are free from damage,
31
dust litter or stains and in a good state of repair
32 Kitchen trolleys are clean and in a good state of repair
33 Refrigerators/freezers are clean and free of ice build up
House keeper personal protective equipment is being used appropriately as mask-head
34
cap-plastic apron and gloves .
35 Valid health card for personnel
Food handlers maintain a high degree of personal hygiene and cleanliness with no
36
obvious infections eg. Skin infection
37 Floors always kept dry, free of dust, grit, litter, marks, water or other liquids.
38 Bathroom is cleaned ,equipped well with hand washing facilities
39 The drains are smooth and well covered
40 The dishwashers area are clean and well maintained.
Sign of Kitchen Authorities: Sign Of Infection Control Nurse:
SARDAR VALLABHHAI PATEL INSTITUTE OF MEDICALSCIENCES AND RESEARCH
 LAUNDRY AUDIT CHECKLIST- INFECTION CONTROL DATE:
NOT
SR.No. DISCRIPTION YES NO APPLICABL COMMENTS
E
Personnel
1 Clean, neat, untorn and tidy clothing is worn by staff
Good personal hygiene (including hair and body cleanliness) is
2
practiced
3 Finger nails are clean and trimmed
4 Usage of PPE as per requirenment
5 Injuries and suspected infections are reported immidiately
6 Personnel are screened for infectious diseases on hiring
Cleanliness
7 Floor is visibly cleaned
8 All machines are clean
9 All equipments are clean and in good condition

Washing/Folding/Cleaning/Storage
10 Zoning available for soiled and clean linen
11 Separate Zoning for soiled linen collection
Clean linens are transported in covered containers and stored in
12
covered areas
Hospital approved disinfection solution or detergent is use for linen
13
disinfection
14 Linen disinfection process is taking place on regular base
different process for infected linen which is contaminated with blood
15
and body fluid

Sign of
Sign Of Laundry Incharge:
ICN:
 SARDAR VALLABHHAI PATEL INSTITUTE OF MEDICALSCIENCES AND RESEARCH

CSSD EXPIRY TRAY AUDIT

DATE :

SR.NO. DEPARTEMNT TOTAL TRAYS EXPIRY TRAYS SEND TO CSSD INCHARGE SIGN ICN SIGN REMARKS

INFECTION CONTROL DEPARTMENT

 SARDAR VALLABHHAI PATEL INSTITUTE OF MEDICALSCIENCES AND RESEARCH

FRIDGE AUDIT

DATE :

SR.NO. DEPARTEMNT UNUSUAL ITEM FOUND ACTON TAKEN INCHARGE SIGN ICN SIGN REMARKS

INFECTION CONTROL DEPARTMENT