Infection prevention surgical rounds checklist
Operating::Procedure room observational tool
What does this form include?
This form contains 16 sections:
I. Operating/Procedure Room Environment
- Operating/procedure room, halls, equipment/carts, vents appear clean, dust free, uncluttered. Floors clean and free of debris/dust.
- Operating/procedure room facility in good repair (e.g., no holes in walls, floors or ceiling)
- Solid ceiling; no tiles
- Interim EVS cleaning performed directionally, top to bottom
II. Sterile Supplies and Equipment
- Are non-essential items stored uncovered in operating rooms?
- All equipment clean and OR bed mattress pads/arm boards intact?
- Flexible scopes
- Sterile supplies protected from contamination/dust?
- No expired supplies
III. Room Procedure Observation
- Is floor mopped in between cases?
- Doors closed, not propped open; traffic in and out of room kept to minimum during case
IV. Perioperative Patient Care
- Pre-op antibiotic given by anesthesia personnel within 60 minutes prior to incision (Note: 120 minutes for Vancomycin /Fluoquinolines)
- IV injection ports swabbed prior to access
- Hair removal performed before entering operating/procedure room (planned hair removal only; occasionally additional hair must be clipped or done in the operating/procedure room)
- Pre-op skin prep: was op-site cleaned prior to scrub?
- Dual agent prep used (i.e., Chloraprep or Duraprep)
- Is application technique appropriate for product used? [Side to side (Chloraprep)] [In concentric circles, from middle out to periphery (Betadine)]
- Perineal area prepped and covered with impervious drape?
- Is operative site allowed to air dry prior to incision? How long did site dry prior to incision?_________________
- Is operative site dried with a towel or 4x4s prior to incision?
- Is adhesive incise drape used?
V. Attire (for anyone entering semi-restricted and restricted surgical site areas)
- Surgical caps/hood cover all hair
- Nursing
- Anesthesia
- Surgeons
- Body hair (ex: chest, facial) fully covered
- Do any operating/procedure room staff members appear to have long or artificial fingernails?
- Dress code followed: No rings; other jewelry (e.g. watches, earrings, bracelets, necklaces, piercing) should be removed or totally confined within scrub attire
- Dress code followed: Shirts of scrub suit tucked in or close fitting
- Dress code followed: All non-scrubbed personnel wearing long sleeved jackets (hospital approved) that are buttoned or snapped
- Dress code followed: No fanny packs, backpacks, totes
- Dress code followed: Clean (not visibly wet or soiled) operating/procedure room scrub suit
- Dress code followed: Undergarments completely covered, no turtlenecks or fleece
- Dress code followed: Shoe covers worn when dedicated shoe ware not in use.
VI. Sterile Field
- Mask covers nose and mouth and is tied securely
- Mask in place when entering OR with open sterile packs and in sterile core
- Sterile items left open no more than 60 minutes prior to patient entering room and should be constantly monitored during that time period
- Scrubbed persons maintain sterility of sterile gown, gloves, supplies (e.g., while waiting for procedures to be done such as X-Rays?)
- Chemical indicators must be checked when instruments are opened, before they are placed on the sterile field
- Items introduced into sterile field are opened, dispensed, and transferred by methods to maintain sterility/integrity
- Items/devices dropped below level of the operating/procedure room table are considered contaminated
- Is drape between anesthesia and pt. above the level of anesthesiologist’s nose/mouth? Does anesthesia lean over drape during procedure?
- Surgical equip (e.g. cables, tubing) secured to sterile field with non-perforating devices
- Nonsterile equip. (mayo stands, C arms) should be covered w/sterile barrier materials; only sterile items touch sterile surfaces; sterile barrier material should be applied to any equip adjacent to the sterile field
- All personnel moving in/around sterile field do so in manner to maintain sterility, for example:a. Staff do not turn back to sterile field, hands above waistb. Scrubbed personnel pass front to front or back to backc. Separation of sterile team from non-sterile team maintainedd. Unscrubbed personnel do not pass between two sterile fields
VII. Anesthesiology
- Drainage bags (e.g., foley) kept off the floor
- Aseptic practice used for IV tubing, fluids, medications – injection ports swabbed prior to access
- Sterile equip. – IV solution/tubing assembled immediately prior to use
- Aseptic practice used for all invasive procedures (e.g., epidurals, blocks, IV insertion)
- Was antibiotic infusion mentioned/checked prior to incision?
- Was antibiotic infusion repeated if surgery is longer than 4 hours?
- Anesthesia cart appears clean; hand sanitizer readily available
- Re-usable personal equipment (e.g., stethoscope) cleaned between cases
VIII. Medications/Solutions
- Are medications and solutions: single-dose or multi-dose? What solutions/medications are multi-dose?___________________________
- Are any medications or solutions expired?
- Is the wound irrigated? If yes, list solution used for irrigations.
- Are topical medications one time use?
- Are any solutions mixed in the operating/procedure room? If yes, list:_________________________________
- Manufacturer's IFU (solution, length of soak time) followed for reconstitutions?
- Are any containers refilled? If yes, list:_______________________________________________________
- Are any solutions supplied or used as a spray?
IX. OSHA/Bloodborne Pathogen Standard
- Appropriate eye protection used
- Sharps containers at point of use, secured from tipping, no more than ¾ full
- Sharps safety devices utilized where available
- Biohazard room labeled and locked
- Hoppers & biohazard containers accessible in soiled utility
X. General Infection Prevention and Control
- Do members of the surgical team appear to have upper respiratory infection (e.g., cough, sneezing)?
- Do any operating/procedure room staff appear to have hand/forearms/skin/fingernail open lesions or infections?
- Was conversation in sterile field limited to only necessary conversation?
- Sterile team removes gloves and washes hands at end of case
- Were gloves changed between dirty and clean procedures?
- Was hand hygiene performed when gloves changed?
- Is a hand antisepsis product available?
- Clean, sterile, and soiled items are kept separate
- Used sterile instruments pre-cleaned with enzymatic cleaner/equipment transported to CSR for decontamination and sterilization
- Were instruments transported in a closed container?
- Was the container labeled with the chemical used for the instruments?
XI. Sterilization
- Are instrument trays checked by nurse for breaks prior to placing on sterile field?
- Are biologicals performed and within normal limits for sterilizers?
- Do processes appear efficient in SPD with items/areas tidy and well labeled?
- Are instruments pre-cleaned or soaked soon after use?
- Were instruments sterilized using IUSS delivered to sterile field without contamination?
- Water was not splashed on the sterile field when instruments sterilized using IUSS were delivered?
- Were items sterilized using immediate-use steam sterilization? If yes, list reason for using IUSS: __________________________________
- Item that was sterilized using IUSS was not contaminated by circulating nurse?
- Was IFU followed and all required documentation completed?
XII. HVAC Systems (if not optimal, action plan required)
- Room humidity between 30-60%? Document humidity:__________________
- Room temperature between 68-73 degrees? Document temperature: ________________
- Air exchanges/hour at least 15/hour or between 20-25? Document AE/H: _________________
XIII. Hand Scrub (observe one individual scrubbing)
- Physician, Nurse, Tech, or SA
- Product used: _________________________________________
- Scrub brush used with product
- Does the healthcare worker clean under his/her fingernails?
- Is scrub accomplished from hand to forearm to elbow?
- Does the surgical scrub last 3-5 minutes?
- When the scrub is finished, are fingers held up so water runs down toward elbows?
- If waterless product is used as the first scrub of the day, is it a water aided scrub?
- If waterless product is used, does the staff member apply product to hand and then up arms to elbow?
- Hand scrub products are not "topped off?"
XIV. Refrigerator / Freezer Monitoring and Tissue Tracking
- Temperature Log or Temp Track complete
- Notification if temperature is out of range
- Contingency plan
- Separate refrigerators for tissue/medications
- Tissue is temperature monitored/documented from time delivered to storage
Additional Comments
- Are there any additional findings or comments?
Surveyor's Signature
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