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{"sheet":"Operating Room","index":0,"n_rows":186,"n_cols":5,"rows_kept":186,"cut":false,"hidden":false,"merged":[[129,0,129,4],[135,0,135,4],[141,0,141,4],[154,0,154,4],[147,0,148,4],[125,0,128,0],[150,0,153,0],[100,0,103,0],[138,1,140,4],[143,0,146,0],[143,1,143,4],[144,1,146,4],[137,1,137,4],[150,1,150,4],[101,1,103,4],[98,0,98,4],[111,0,111,4],[117,0,117,4],[123,0,123,4],[100,1,100,4],[67,0,68,4],[74,0,76,4],[119,0,122,0],[119,1,119,4],[120,1,122,4],[104,0,105,4],[107,0,110,0],[107,1,107,4],[108,1,110,4],[71,1,73,4],[8,0,8,4],[27,0,28,4],[46,0,47,4],[156,0,159,0],[156,1,156,4],[157,1,159,4],[113,0,116,0],[113,1,113,4],[114,1,116,4],[65,0,65,4],[137,0,140,0],[181,0,184,0],[181,1,181,4],[182,1,184,4],[175,0,178,0],[175,1,175,4],[176,1,178,4],[160,0,160,4],[166,0,166,4],[179,0,179,4],[94,1,94,4],[162,0,165,0],[162,1,162,4],[163,1,165,4],[125,1,125,4],[126,1,128,4],[131,0,134,0],[131,1,131,4],[132,1,134,4],[151,1,153,4],[172,0,173,4],[70,1,70,4],[95,1,97,4],[168,0,171,0],[168,1,168,4],[169,1,171,4],[87,1,87,4],[88,1,90,4],[91,0,92,4],[94,0,97,0],[42,0,45,0],[53,0,53,4],[36,0,39,0],[185,0,187,3],[185,4,187,4],[70,0,73,0],[78,0,81,0],[78,1,78,4],[79,1,81,4],[87,0,90,0],[20,0,20,3],[26,0,26,4],[61,1,61,4],[23,1,25,4],[30,0,33,0],[34,0,34,4],[40,0,40,4],[59,0,59,4],[37,1,39,4],[43,1,45,4],[62,1,64,4],[36,1,36,3],[30,1,30,3],[22,1,22,3],[49,1,49,3],[3,0,4,3],[55,0,58,0],[55,1,55,3],[49,0,52,0],[31,1,33,4],[42,1,42,3],[50,1,52,4],[56,1,58,4],[11,1,13,4],[17,1,19,4],[83,1,83,4],[14,0,14,4],[5,0,5,1],[6,0,6,1],[61,0,64,0],[23,0,25,0],[17,0,19,0],[10,0,10,3],[11,0,13,0],[16,1,16,3]],"flags":["formulas_cached_only"]}
[]
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[]
["Infection Prevention and Control Assessment Tool\n Operating Room"]
[]
["[Insert Date Here]"]
["[Insert Medical Center Name Here]"]
[]
["Pre-operative"]
[1,"Existing infections must be treated before surgery.\n",null,null,false]
[]
[null,"Comments:"]
[]
[]
[]
[2,"Hair Removal:  None unless absolutely needed – then via clipping - use of disposable clipper head and process for sterilization of clipper hand piece b/w patients. REMOVE HAIR BEFORE BRINGING PATIENT INTO OR.",null,null,false]
[]
[null,"Comments:"]
[]
[]
[]
[3,"Pre-op shower/bath: Chlorhexidine bath cloths must be used to bathe the patient the night before and morning of surgery with special attention to the planned site of incision.\n\n",null,null,false]
[]
[null,"Comments:"]
[]
[]
[]
["Pre-op Shower"]
[]
[4,"Gross contamination must be removed from the patient's skin prior to surgical skin prep.\n",null,null,false]
[]
[null,"Comments:"]
[]
[]
[]
[5,"Chloraprep or Duraprep should be used for surgical skin prep.  Technicare should be used for surgical mucous membrane prep.\n",null,null,false]
[]
[null,"Comments:"]
[]
[]
[]
[6,"Skin prep technique should involve moving from center to outside and beyond planned site of incision.\n",null,null,false]
[]
[null,"Comments:"]
[]
[]
["Hand/forearm antisepsis for surgical team "]
[]
[7,"Surgical team members must clean underneath each fingernail prior to performing first scrub of day.",null,null,false]
[]
[null,"Comments:"]
[]
[]
[]
[8," No hand or arm jewelry is permitted for surgical team.\n",null,null,false]
[]
[null,"Comments:"]
[]
[]
[]
[9,"Surgical team must have short, natural nails - artificial nails not permitted.",null,null,false]
[]
[null,"Comments:"]
[]
[]
[]
[10,"Surgical team members must perform a pre-surgical hand scrub for at least 2  minutes using appropriate antiseptic solution OR use brushless alcohol based scrub product per manufacturer's recommendations.",null,null,false]
["Antimicrobial  prophylaxis"]
[]
[11,"Appropriate antibiotic must be administered within 1 hr of incision.  An adjustment in dosage must be made for obesity.  Antibiotic must be re-dosed if procedure lasts over 4 hours.",null,null,false]
[]
[null,"Comments:"]
[]
[]
["Intra-operative"]
[]
[]
[12,"Ventilation:   Doors must be kept closed, only necessary personnel in room, positive air pressure, 15 ACH.\n\n",null,null,false]
[]
[null,"Comments:"]
[]
[]
[13,"Smoke filter used for laparoscopic procedures (reduces risk of transmission viruses such as HIV/HPV via laser/electrocautery)",null,null,false]
[]
[null,"Comments:"]
[]
[14,"Normothermia must be maintained for patients undergoing colon procedures.\n\n",null,null,false]
[]
[null,"Comments:"]
[]
[]
["Sterilization of Surgical Instruments"]
[]
[14,"Biological and chemical indicators must be checked when instruments are opened.\n",null,null,false]
[]
[null,"Comments:"]
[]
[]
[]
[15,"Flash sterilization must be minimized and a flash log maintained.\n",null,null,false]
[]
[null,"Comments:"]
[]
[]
["Traffic Flow and Surgical Attire"]
[]
[16,"Surgical team must wear fresh, clean scrubs.\n",null,null,false]
[]
[null,"Comments:"]
[]
[]
[]
[17,"Use of cover gowns should be determined by department policy. The value of cover apparel within the institution is unsubstantiated.\n",null,null,false]
[]
[null,"Comments:"]
[]
[]
[]
[18,"Non-scrubbed personnel should wear long-sleeved jackets that are buttoned or snapped closed during use. Complete closure of the jacket avoids accidental contamination of the sterile field. Long-sleeved attire is advocated to prevent bacterial shedding from bare arms and is included in the Occupational Safety and Health Administration (OSHA) regulation for the use of personal protective equipment (PPE).\n",null,null,false]
[]
[null,"Comments:"]
[]
[]
[]
[19,"Under garments should be contained completely within or covered by the surgical attire. Clothing that cannot be covered by the surgical attire should not be worn.\n",null,null,false]
[]
[null,"Comments:"]
[]
[]
[]
[20,"The surgical mask must fully cover mouth & nose.\n",null,null,false]
[]
[null,"Comments:"]
[]
[]
[]
[21,"The surgical cap/hood must fully cover all hair on head; if wearing personal head cover, recommend wearing single use bouffant over the personal head cover when in the OR.\n",null,null,false]
[]
[null,"Comments:"]
[]
[]
[]
[22,"Face protection must completely protect eyes.  Eye glasses do not constitute sufficient eye protection.\n",null,null,false]
[]
[null,"Comments:"]
[]
[]
["OR Areas:  Unrestricted area, Transition zone, Semi restricted area and Restricted area"]
[]
[23,"Unrestricted area: Street clothes can be worn in this area.\n",null,null,false]
[]
[null,"Comments:"]
[]
[]
[]
[24,"Transition zone:  Only authorized staff are permitted - the changing rooms/lockers are included in this zone.\n",null,null,false]
[]
[null,"Comments:"]
[]
[]
[]
[25,"Semi restricted area: This includes the pre-op area, recovery room, storage room, corridors outside OR rooms.  This should be separate from equipment reprocessing.  Only authorized staff are permitted.  Storage should be enclosed in order to minimize dust and debris.  Surgical attire, cap and clean closed shoes are required.\n",null,null,false]
[]
[null,"Comments:"]
[]
[]
[]
[26,"Restricted area:  This includes the scrub sink areas and OR rooms.  The doors to this area should remain closed.  Complete surgical attire including a mask is required in this area when sterile supplies are open and/or operation in process.  Hair covering for patients must be provided.\n",null,null,false]
[]
[null,"Comments:"]
[]
[]
["Asepsis and Surgical Technique "]
[]
[27,"Adherence to principles of asepsis is required when placing intravascular devices or when administering IV drugs.\n",null,null,false]
[]
[null,"Comments:"]
[]
[]
[]
[28,"Assembly of sterile equipment and solutions must be done immediately prior to use.\n\n",null,null,false]
[]
[null,"Comments:"]
[]
[]
["Total Average Score (Avg %)",null,null,null,0]

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[]
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[]
["Infection Prevention and Control Assessment Tool\nSterile Processing Department Site Visit"]
[]
["[Insert Date Here]"]
["[Insert Medical Center Name Here]"]
["No.","Topic","Enter \"X\" if Yes or\nN/A        ","Enter \"X\" if No","Score"]
[]
[null,"DECONTAMINATION ROOM"]
[1,"Work flow in decontamination room is clean to dirty.",null,null,false]
[]
[null,"Comments:"]
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[]
[]
[2,"PPE (gloves, masks, gowns, eye/face shield) available.",null,null,false]
[]
[null,"Comments:"]
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[]
[3,"Hand hygiene dispensers (soap, degermer, lotion) placement:  For walls:  52-55 inches from floor to bottom of dispenser (Pedi = 54 inches).  At sinks: 48 inches.",null,null,false]
[]
[null,"Comments:"]
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[]
[]
[4,"Sharps containers:  less than 3/4 full, placement between 52-57 inches from floor; safety devices activated as appropriate.",null,null,false]
[]
[null,"Comments:"]
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[]
[2,"Cleaning brushes are reusable  and in good working condition; disinfected daily",null,null,false]
[]
[null,"Comments:"]
[3,"Environmental Services support is adequate - environment is clean and orderly.",null,null,false]
[]
[null,"Comments:"]
[]
[]
[4,"Hand hygiene supplies adequate and conveniently located (soap, water, lotion and degermer)",null,null,false]
[]
[null,"Comments:"]
[]
[]
[]
[5,"Used instruments are pre-soaked in enzymatic solution inside a closeable container at point of use and transported in manner preventing spilling/cross contamination during transport.",null,null,false]
[]
[null,"Comments:"]
[]
[]
[6,"Inspect a lumened instrument and a hinged instrument for presence of biomaterial.  For example a kerasin used in spine surgery has a lumen which can get easily plugged.",null,null,false]
[]
[null,"Comments:"]
[]
[]
[6,"Clean and dirty areas and processes separate and do not cross over.",null,null,false]
[]
[null,"Comments:"]
[]
[]
[7,"PPE readily accessible and worn as indicated.",null,null,false]
[]
[null,"Comments:"]
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[]
[8,"Supplies necessary for cleaning all instruments and devices are easily available, adequately stocked and in good condition.",null,null,false]
[]
[null,"Comments:"]
[]
[]
[11,"Soiled Utility Room:  PPE is available, sharps container less than 3/4 full, dirty sink for decontamination of instruments/equipment, enzymatic detergent solution available with container covered, labeled and changed as required, disinfectants labeled and",null,null,false]
[]
[null,"Comments:"]
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[]
[]
[]
[15,"Procedure Room:  no food/drink, hand hygiene supplies available, specimen transport bags available, linen enclosed/covered",null,null,false]
[]
[null,"Comments:"]
[]
[]
[9,"Staff can describe all processes related to decontamination.",null,null,false]
[null,"INSTRUMENT PREP"]
[]
[]
[]
[]
[10,"Supplies necessary for packaging and wrapping all instruments and devices are easily available, adequately stocked (integrators, packaging, wrapping, tape, protectors, markers, etc)"," ",null,false]
[]
[null,"Comments:"]
[11,"Hand hygiene dispenser present."," ",null,false]
[]
[null,"Comments:"]
[12,"Items are properly packaged, wrapped,and properly identified."," ",null,false]
[]
[null,"Comments:"]
[null,"STERILIZATION"]
[]
[13,"Cleaning schedule for sterilizers in place (Q week per Title 22).",null,null,false]
[]
[null,"Comments:"]
[]
[]
[14,"Instruments sterilized in open position (e.g. scissors).",null,null,false]
[]
[]
[null,"Comments:"]
[15,"Sterilization load record  consist of date; load #;  sterilizer #; initials; items; quantity of each item; biological indicator lot  # (if needed); biological control lot #( if needed); Verification of sterilization parameters.",null,null,false]
[]
[null,"Comments:"]
[]
[]
[16,"A process (policy and procedure) in place to ensure proper reprocessing of loaner instruments from vendors or other medical facilities.",null,null,false]
[]
[null,"Comments:"]
[]
[]
[]
[17,"Implantable devices are quarantine until BI results are negative; if implants are released early the incidence is documented on an Implantable/Non-implantable Device Early Release Record.",null,null,false]
[]
[null,"Comments:"]
[18,"Biological indicator failure equipment recall process in place - how frequent are recalls?",null,null,false]
[]
[null,"Comments:"]
[19,"Sterilization load records are properly completed (date, sterilizer number, load number, expiration labels, initials, quantity of each item, name of dept for each item).",null,null,false]
[]
[null,"Comments:"]
[]
[]
[20,"Every biological record is checked for result and properly recorded.",null,null,false]
[]
[null,"Comments:"]
[]
[]
[21,"Flash sterilizer cycles are checked daily to assure completeness.  Volume of flash sterilization is tracked to determine need for intervention to reduce.",null,null,false]
[]
[null,"Comments:"]
[]
[]
[null,"STERILE STORAGE"]
[22,"Sterile supplies stored at least 8-10 inches, 2 inches from the outside wall and 18 inches from ceiling fixture off floor to prevent contamination from floor dust and cleaning. ",null," ",false]
[]
[null,"Comments:"]
[]
[]
[23,"Bottom storage shelves of supply carts is solid to prevent contamination from floor dust and cleaning.",null," ",false]
[]
[null,"Comments: The AAMI ST79 standards for Sterilization in Healthcare Facilities section 8.9.2 Storage facilities (2006 version).  \"Shelving or carts used for sterile storage should be maintained in a clean and dry condition. For sterile and clean supplies stored on the bottom shelf of an open cart, there should be a physical barrier between the shelf and traffic or housekeeping activities.\""]
[]
[]
[24,"Sterilized items are stored and rotated with FIFO process (first in first out) by expiration date.",null," ",false]
[]
[null,"Comments:"]
[]
[]
[25,"Storage area is clean, dry adequate and integrity of packaging maintained.",null," ",false]
[]
[null,"Comments:"]
[]
[]
[26,"Staff can describe expiration dates and event related sterile storage.",null," ",false]
[]
[null,"Comments:"]
[]
[]
["Total Average Score (Avg %)",null,null,null,0]