Infection Control Audit Check List PDF, Free Download

Infection Control Audit: Health care associated infection is an adverse event that increases length of Stay, Cost of treatment, more utilization of hospital resources etc. These results in dissatisfaction for patients & their relatives, risk of infection transmission to other patients and health care workers.

Implementing Infection Prevention and control activities should be schematic and comprehensive. After framing a Standard Operative Procedure for IPC Activities, It needs to be audited periodically. Audit outcomes will be very helpful to find the gaps in practice hence corrective action can be taken.

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Infection control Audit should focus on all aspects of health care practices, environment, microbiological surveillance etc. It is ideal to include Standard and additional Precautions. Various check points should be set under each element with scoring system.

Interpretation of Infection control Audit Data is much important to identify poorly performing element and to address it through feedback.

The below Model Infection Control 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.

Scoring System

Scoring followed by data interpretation is very important to find gaps. Compliance Score is given as below

  1. Full Compliance – 2
  2. Partial Compliance- 1
  3. Non-Compliance- 0

Score should be calculated for each element and expressed in percentage. At the end, mean percentage of all elements should be calculated.

Scoring Infection Control Audit

Scoring followed by data interpretation is very important to find gaps. Compliance Score (CS) is given as below

  1. Full Compliance – 2
  2. Partial Compliance- 1
  3. Non-Compliance- 0

Score should be calculated for each element and expressed in percentage. At the end, mean percentage of all elements should be calculated for Infection Control Audit Score.

INFECTION CONTROL AUDIT ELEMENTS AND CHECK POINTS

ELEMENT- I) HAND HYGIENE          

  1. Is Hand Washing Sink available?
  2. Is water Supply available 24x7?
  3. Is Elbow Tap available?
  4. Is Antiseptic Liquid/Soap/ABHR available?
  5. Are Hand Hygiene Moments and Steps signages displayed?
  6. Do the Staffs Adhere to Hand Hygiene Protocol (5 moments, 6steps of Hand washing)?

ELEMENT- II) PPE  

  1. Is supply of PPE adequate?
  2. Are PPE Donning & Doffing Signage displayed?
  3. Do Staffs wear PPE according to indication while patient care?
  4. Do Staffs follow correct order of Donning & Doffing of PPE?
  5. No Reuse of disposable PPE?

ELEMENT- III) BIOMEDICAL WASTE (BMW) MANAGEMENT                

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

ELEMENT- IV) SAFE HANDLING OF SHARPS

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

ELEMENT- V) SAFE HANDLING OF INSTRUMENTS   

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

ELEMENT- VI) STERILIZATION OF INSTRUMENTS      

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

ELEMENT- VII) SAFE INJECTION PRACTICES  

  1. Do Staffs use new injection for each procedure, including reconstitution of medication and vaccine?
  2. Do Staffs check injection packaging to ensure that it is not punctured, torn, moisture and exposed to moisture?
  3. Do Staffs use sterile needle for reconstitution of medicines?
  4. Are Staffs aware of Multi dose vials Policy?
  5. 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?
  6. Do Staffs adhere to Multidose vial policy (i.e. medicine to be discarded after 10 pricks or 28 days whichever is earlier)
  7. Are heat sensitive drugs and vaccines stored in refrigerator at appropriate temperature (e.g. insulin, vaccines are stored at 2 to 80C)
  8. Do Staffs check the Multidose vial for turbidity, particulate matter or discoloration before use?
  9. Do Staffs wipe the access diaphragm of the rubber vial before inserting needle?
  10. Do Staffs never leave a needle or cannula inserted into rubber stopper after use?

ELEMENT- VIII) LINEN SAFETY              

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

ELEMENT- IX) MICROBIOLOGICAL SURVEILLANCE   

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

ELEMENT- X) DISINFECTION OF OPERATION THEATRE       

  1. Are there Air Handling Unit (HEPA or Laminar Airflow) in OT?
  2. Is the temperature of OT maintained between 18-240C?
  3. Is the Humidity of OT maintainted between 30%-60%?
  4. Are Zoning of OT done and unidirectional flow maintained to prevent cross infection?
  5. Is the Operation table placed away from entrance?
  6. Are daily cleaning procedures followed (before, between, after cases)?
  7. Is weekly general washing/cleaning procedure followed?
  8. Whether fogging is done on daily basis?
  9. Are chemical bound formaldehyde solution (e.g. Bacillocid) used for fogging?
  10. Are staffs aware of steps of fumigation?

Download Infection Control Audit PDF Forms for various areas of health facilities

Infection Control Audit For Operation Theatre

Infection Control Audit for High Risk Areas

Infection Control Audit for Wards