Infection Prevention & Control Audit

Infection Prevention & Control Audit

Infection Prevention & Control (IPC) Audit is a tool that enables healthcare professionals find gaps in IPC practice. So that, appropriate Corrective & Preventive action can be taken. A complete IPC Audit tool cover all aspects of Standard & Additional Precautions.

Standard Precautions includes

1.       Hand Hygiene

2.       Personal Protective Equipment

3.       Bio-Medical Waste Managements

4.       Safe Handling of Sharps

5.       Safe Handling of Instruments

6.       Sterilization of Instruments

7.       Safe injection Practices

8.       Spill Management

9.       Environmental Cleaning & Sanitation

10.   Linen Safety

11.   Microbiological Culture & Surveillance

12.   Disinfection of Operation Theatre

Additional Precautions includes

1.       Droplet Precautions

2.       Airborne Precautions

3.       Contact Precautions

IPC Audit tool developed below covers all dimension of each precaution. This can be implemented in all areas of hospital like Out-Patient Department, In-Patient Department, Operation Theatres, High Risk Areas like Intensive Care Unit, Newborn Care Unit, Post Operative Ward, Labour Room, Blood Bank etc.

IPC Audit Scoring Method

It is very simple. Scoring is planned based on compliance of Attributes.

Full Compliance- 02 Marks

Partial Compliance- 01 Mark

Non-Compliance- 0 Mark

Total Compliance= Score Obtained/Total Score X 100

The below Model IPC Audit Format is given below. It is prepared as per NQAS, Kayakalp, LAQSHYA, MUSQAN quality programme guidelines. It will be very much helpful for Public Health Facilities like PHC, CHC, SDH, DH and Medical Colleges.

HAND HYGIENE

• Is wide enough Hand Washing Sink available?
• Is water Supply available 24x7?
• Is Elbow Tap available?
• Is Antiseptic Liquid/Soap/ABHR available?
• Are Hand Hygiene Moments and Steps signages displayed?
• Do the Staffs Adhere to Hand Hygiene Protocol (5 moments, Surgical Hand Washing Steps, Duration)?

PERSONAL PROTECTIVE EQUIPMENTS

• Is supply of PPE adequate?
• Are PPE Donning & Doffing Signage displayed?
• Do Staffs wear PPE according to indication while patient care?
• Do Staffs follow correct order of Donning & Doffing of PPE?
• No Reuse of disposable PPE?

BIO-MEDICAL WASTE MANAGEMENT

• Are availability of Color coded Bins and Liners adequate as per BMW Rules 2016?
• Is Biomedical Waste Management Protocol displayed?
• Are BMW segregated at the site of generation as per Protocol?
• Are BMW removed from the department within 24 hours?
• Are BMW Bins not over filled and covers removed once (3/4th) filled?
• Are BMW covers labelled (Ward Name, Date) before transport?
• Are BMW collected using Closed Trolley?
• Do staffs wear PPE while handling BMW?
• Are Daily BMW records updated regularly?

SAFE HANDLING OF SHARPS

• Are Needles not recapped?
• Is Functional Needle Cutter and Puncture proof container available?
• Are Syringes mutilated before disposal?
• Are sharp wastes discarded in Puncture proof container?
• While handling sharps, Are the Staffs aware that sharp end of instruments should be positioned away From oneself and others?
• Is Needle Stick Injury protocol signage displayed?
• Are the staffs aware of Needle Stick Injury Protocol?

SAFE HANDLING OF INSTRUMENTS

• Are staffs aware of splauding’s classification of instruments?
• Are staffs aware of disinfection policy (appropriate disinfectant agent and contact time?
• Are staffs aware of 3 major categories of disinfection (Low, Intermediate, and High Level)?
• Whether Disinfection Policy is displayed at point of use?
• Are Instruments and Equipments disinfected before each patient use?
• Whether Heavy duty or Utility Gloves are used during disinfection?
• Are Availability of 0.5%, 1% Hypochloride Solution and High Level Disinfectant (2% glutaraldehyde) ensured?
• Are Staffs aware of appropriate disinfectants for instruments, equipments, procedures, objects?
• Are Staffs aware of contact time for disinfection?

STERILIZATION OF INSTRUMENTS

• Are all critical care instruments Autoclaved before use?
• Are the instruments cleaned and dried thoroughly before sterilization?
• Are Bins’ & Trays’ packed with before sterilization?
• Are Chemical Indicators Containing Department Name, Type of Bin or Tray, Date of Autoclaving, Date of Expiry, Machine Number, and Lot Number?
• Are Chemical Indicators pasted in appropriate places (Inside the bin, on the lid, over the package)
• Are sterilized bins, trays stored in a clean & dry area?
• Are records of sterilization and CSSD Recall maintained?
• Are sterile bins, trays used before expiration date (72 hours)?
• Are bins, trays sent for sterilization again in 24 hours if opened?

SAFE INJECTION PRACTICES

• Do Staffs use new injection for each procedure, including reconstitution of medication and vaccine?
• Do Staffs check injection packaging to ensure that it is not punctured, torn, moisture and exposed to moisture?
• Do Staffs use sterile needle for reconstitution of medicines?
• Are Staffs aware of Multi dose vials Policy?
• Do Multidose vials contain information on date and time of preparation (for medicine that require reconstitution), Date & Time of first piercing the vials, Staff Name and signature?
• Do Staffs adhere to Multidose vial policy (i.e. medicine to be discarded after 10 pricks or 28 days whichever is earlier)
• Are heat sensitive drugs and vaccines stored in refrigerator  at appropriate temperature (e.g. insulin, vaccines are stored at 2 to 80C)
• Do Staffs check the Multidose vial for turbidity, particulate matter or discoloration before use?
• Do Staffs wipe the access diaphragm of the rubber vial before inserting needle?
• Do Staffs never leave a needle or cannula inserted into rubber stopper after use?

SPILL MANAGEMENT

• Are Spill Management Tray available (Blood & Mercury & Acid, Base)?
• Whether list of articles in Tray is displayed?
• Whether adequate and appropriate PPE is available in the Tray?
• Whether Caution Board is available?
• Are Spill Management Protocol displayed prominently?
• Are Staffs able to demonstrate spill management procedure?
• Whether 1% Hypochloride Solution is available?

ENVIRONMENTAL CLEANING & SANITATION

• Is there Three bucket system available in the department?
• Is supply of cleaning solution adequate?
• Are 0.5% and 1% Hypochlorite solution available in the department?
• Is there no usage of broom stick?
• Do House-Keeping Staffs wear appropriate PPE while cleaning?
• Do House-Keeping staffs adhere to Standard Operating Procedure for cleaning (unidirectional movement) i.e. innermost to outermost or less contaminated area to more contaminated area and High Surfaces to Low Surfaces?
• Do House-keeping staffs adhere to not to ‘double dip’ in cleaning solution?
• Do House-keeping staffs adhere to mop an area of 120 square feet before re-dipping mop into cleaning solution?
• Do House-Keeping Staffs adhere to change the cleaning solution after cleaning an area of 240 square feet?
• Do House-Keeping Staffs adhere change the cleaning solution more frequently in highly contaminated areas and when visibly soiled?
• Do House-keeping staffs disinfect the mop after cleaning in 0.5% Hypochlorite solution for 30 mins?
• Is frequency of cleaning followed as per hospital policy?
• Are the High Touch Surfaces (i.e. doorknobs, bedrails, light switches, wall areas around the toilet in the patient’s room) cleaned 0.5% hypochlorite solution daily?
• Is there dedicated utility area for house-keeping items?
• Is there no bad odour from toilets and bathrooms?
• Whether toilets and bathrooms are cleaned every two hours?
• Is there no blockage in toilets?
• Is there no dirt and grease on the floor and corridors?
• Are there two buckets with waste covers (Green for Bio-degradable, Blue- for Non-Biodegradable) for general waste?
• Is signage for segregation of waste displayed?
• Are Cleaning checklists displayed and updated regularly in respective places i.e. Bathrooms, Toilets, Wash Basins?

LINEN SAFETY

• Whether the department has adequate linen stock to meet requirements of hospital policy?
• Are Bed Linen changed as per hospital policy?
• Are linens clean and odor free?
• Is there No sorting, rinsing or sluicing of linen done at Point of use/ patient care area?
• Are soiled and clean linen segregated at source?
• Are soiled linens collected in separate bags/bin and handed over to laundry?
• Are the used linens stored properly before transportation to laundry?
• Are records of linen sent and received from laundry maintained regularly?
• Are the clean linens stored properly in clean area?

MICROBIOLOGICAL SURVEILLANCE

• Whether Microbiological Surveillance is done atleast a month?
• Are Surface and environment samples (Delivery/ OT tables, doors, handles, procedure lights) taken for microbiological surveillance?
• Are the samples taken from floor, surface where sterilized bins are stored?
• Are water samples sent for Microbiological Surveillance?
• Are records of environmental surveillance being maintained?
• Are the reports of the microbiological surveillance reviewed and action taken appropriately?

DISINFECTION OF OPERATION THEATRE

• Are staffs adhere to wear OT dress and Surgical attire (Caps, Masks, Gowns according the OT Zones?
• Are there Air Handling Unit (HEPA or Laminar Airflow) in OT?
• Is the temperature of OT maintained between 18-240C?
• Is the Humidity of OT maintained between 30%-60%?
• Are Zoning of OT done and unidirectional flow maintained to prevent cross infection?
• Is the Operation table placed away from entrance?
• Are daily cleaning procedures followed (before, between, after cases)?
• Is weekly general washing/cleaning procedure followed?
• Whether fogging is done on daily basis?
• Are chemical bound formaldehyde solution (e.g. Bacillocid) used for fogging?
• Are staffs aware of steps of fumigation?