Intensive Care Unit (ICU)

Central Venous Catheter: Observation ICU-1

Instructions: Observe patients with central lines in place. Observe each practice and record the observation. In the column on the right, sum (across) the total number of “Yes” and the total number of observations (“Yes” + “No”). Sum all categories (down) for overall performance.

Patient Patient Patient Patient Summary of Observations Central catheter: Observation Categories 1 2 3 4 Yes Total Observed Is the dressing adhesive intact over the catheter insertion site and drainage  Yes  Yes  Yes  Yes contained? (This question is for all 1  No  No  No  No dressings, including chlorhexidine gluconate -CHG dressings)

2 Is the dressing dated and timed  Yes  Yes  Yes  Yes according to facility policy?  No  No  No  No

3 Is the catheter secured to reduce  Yes  Yes  Yes  Yes movement or tension?  No  No  No  No

4 Are the administration tubing sets  Yes  Yes  Yes  Yes labeled with the start date and time?  No  No  No  No

If the tubing set is labeled, is it within  Yes  Yes  Yes  Yes 5 the specified date and time range for  No  No  No  No use?  N/A  N/A  N/A  N/A

    Are all inactive ports capped according Yes Yes Yes Yes  No  No  No  No 6 to facility policy?  N/A  N/A  N/A  N/A Total YES and TOTAL OBSERVED Central Catheter: Observation ICU-1

Date:______

Observer Role:  Nurse  Tech  Other______Initials:______

Location/Unit:______

Notes and comments: Urinary Catheter: Observation ICU-2

Instructions: Observe patients with urinary catheters in place. Observe each practice and record the observation. In the column on the right, sum (across) the total number of “Yes” and the total number of observations (“Yes” + “No”). Sum all categories (down) for overall performance.

Patient Patient Patient Patient Summary of Observations Urinary catheter: Observation Categories 1 2 3 4 Yes Total Observed

Is the catheter properly  Yes  Yes  Yes  Yes 1 secured to the patient?  No  No  No  No

Is there unobstructed flow  Yes  Yes  Yes  Yes 2 from the catheter into the bag?  No  No  No  No

Is the collection bag below the  Yes  Yes  Yes  Yes 3 level of the bladder?  No  No  No  No

Are the bag and tubing off of  Yes  Yes  Yes  Yes 4 the floor?  No  No  No  No Total YES and TOTAL OBSERVED Urinary Catheter: Observation ICU-2

Date:______

Observer Role:  Nurse  Tech  Other______Initials:______

Location/Unit:______

Notes and comments: Ventilator: Observation ICU-3

Instructions: Observe patients on ventilators. For each category, record the observation. In the column on the right, sum (across) the total number of “Yes” and the total number of observations (“Yes” + “No”). Sum all categories (down) for overall performance.

Summary of Patient Patient Patient Patient Ventilator: Observation Categories Observations 1 2 3 4 Yes Total Observed

Is the head of the bed elevated  Yes  Yes  Yes  Yes 1 >30 degrees?  No  No  No  No

Is the ventilator tubing free of  Yes  Yes  Yes  Yes 2 excessive condensation?  No  No  No  No

Are supplies needed for oral  Yes  Yes  Yes  Yes 3 care readily available?  No  No  No  No

Total YES and TOTAL OBSERVED Ventilator: Observation ICU-3

Date:______

Observer Role:  Nurse  Tech  Other______Initials:______

Location/Unit:______

Notes and comments: Standard Precautions: Observation of Hand Hygiene ICU-4 Provision of Supplies

Instructions: Observe patient care areas or areas outside of patient rooms. For each category, record the observation. In the column on the right, sum (across) the total number of “Yes” and the total number of observations (“Yes” + “No”). Sum all categories (down) for overall performance.

Room Room Room Room Room Summary of Observations Standard Precautions: Observation Categories 1 2 3 4 5 Yes Total Observed

Are functioning sinks readily  Yes  Yes  Yes  Yes  Yes 1 accessible in the patient care area?  No  No  No  No  No

Are all handwashing supplies, such  Yes  Yes  Yes  Yes  Yes 2 as soap and paper towels, available?  No  No  No  No  No

 Yes  Yes  Yes  Yes  Yes Is the sink area clean and dry? 3  No  No  No  No  No Are any clean patient care supplies  Yes  Yes  Yes  Yes  Yes on the counter within a splash-zone 4  No  No  No  No  No of the sink?

Are signs promoting hand hygiene  Yes  Yes  Yes  Yes  Yes 5 displayed in the area?  No  No  No  No  No

Are alcohol dispensers readily  Yes  Yes  Yes  Yes  Yes 6 accessible?  No  No  No  No  No

Are alcohol dispensers filled and  Yes  Yes  Yes  Yes  Yes 7 working properly?  No  No  No  No  No Total YES and TOTAL OBSERVED Standard Precautions: Observation of Hand Hygiene ICU-4 Provision of Supplies

Date:______

Observer Role:  Nurse  Tech  Other______Initials:______

Location/Unit:______

Notes and comments: Standard Precautions: Observation of ICU-5 Personal Protective Equipment Provision

Room Room Room Room Room Summary of Observations Standard Precautions: Observation Categories 1 2 3 4 5 Yes Total Observed Are gloves readily available  Yes  Yes  Yes  Yes  Yes outside each patient room or 1  No  No  No  No  No any point of care? Are cover gowns readily  Yes  Yes  Yes  Yes  Yes available near each patient 2  No  No  No  No  No room or point of care? Is eye protection (face shields or goggles) readily available near  Yes  Yes  Yes  Yes  Yes 3 each patient room or point of  No  No  No  No  No care? Are face masks readily available  Yes  Yes  Yes  Yes  Yes near each patient room or point 4  No  No  No  No  No of care?

Are alcohol dispensers readily  Yes  Yes  Yes  Yes  Yes 5 accessible and functioning?  No  No  No  No  No Total YES and TOTAL OBSERVED Standard Precautions: Observation of ICU-5 Personal Protective Equipment Provision

Date:______

Observer Role:  Nurse  Tech  Other______Initials:______

Location/Unit:______

Notes and comments: Isolation: Observation of Area Exterior to Contact Isolation Rooms ICU-6

Instructions: Observe areas outside of isolation rooms. Observe each practice and record the observation. In the column on the right, sum (across) the total number of “Yes” and the total number of observations (“Yes” + “No”). Sum all categories (down) for overall performance. Disregard not applicable categories. For example, cover gowns should be outside contact precautions rooms, but may not be required outside a room with airborne isolation precautions only.

Summary of Observations Room Room Room Isolation room: Observation Categories 1 2 3 Total Yes “Yes”& “No”

 Yes  Yes  Yes Is an isolation sign at the patient’s door? 1  No  No  No

 Yes  Yes  Yes Are gloves available outside of each patient room  No  No  No 2 or treatment area?  N/A  N/A  N/A

Are cover gowns available near each patient room  Yes  Yes  Yes 3 or treatment area?  No  No  No

Is other PPE for standard precautions (e.g., eye  Yes  Yes  Yes 4 protection, face masks) available near each patient  No  No  No room or treatment area?  N/A  N/A  N/A

 Yes  Yes  Yes Are surgical face masks or face shields or N95  No  No  No 5 respirators available near patient room?  N/A  N/A  N/A

Is dedicated patient equipment, such as stethoscopes  Yes  Yes  Yes 6 or blood pressure cuffs, available?  No  No  No TOTAL (Do not include N/A in totals) Isolation: Observation of Area Exterior to Isolation Rooms ICU-6

Date:______

Observer Role:  Nurse  Tech  Other______Initials:______

Location/Unit:______

Notes and comments: Isolation: Observation of Area Exterior to Airborne ICU-7 Infection Isolation Rooms

Instructions: If there are any patients requiring Airborne Infection Isolation on unit, observe area outside of each isolation room. Observe each practice and record the observation. In the column on the right, sum (across) the total number of “Yes” and the total number of observations (“Yes” + “No”). Sum all categories (down) for overall performance.

Room Room Room Summary of Observations Isolation room: Observation Categories 1 2 3 Yes Total Observed

Is an Airborne Infection Isolation sign at the  Yes  Yes  Yes 1 patient’s door?  No  No  No

 Yes  Yes  Yes Is the door to the room closed? 2  No  No  No Does a manometer or other measurement  Yes  Yes  Yes mechanism indicate negative pressure in the 3  No  No  No room? Are appropriate respirators, (N-95) in multiple sizes  Yes  Yes  Yes and/or charged, powered air purifying respirators 4  No  No  No (PAPR), available?

Are respirators stored outside the room or in an  Yes  Yes  Yes 5 anteroom?  No  No  No Total YES and TOTAL OBSERVED Isolation: Observation of Area Exterior to ICU-7 Airborne Infection Isolation Rooms

Date:______

Observer Role:  Nurse  Tech  Other______Initials:______

Location/Unit:______

Notes and comments: Standard Precautions: Observation of Needlestick Prevention ICU-8 and Care of Laundry

Room/ Room/ Room/ Room/ Room/ Summary of Standard Precautions: Observation Categories Area Area Area Area Area Observations 1 2 3 4 5 Yes Total Observed

 Yes  Yes  Yes  Yes  Yes Are sharps containers available? 1  No  No  No  No  No

Are sharps containers properly  Yes  Yes  Yes  Yes  Yes 2 secured and not full?  No  No  No  No  No

Are sharps containers positioned  Yes  Yes  Yes  Yes  Yes 3 at 52” to 56” above floor?  No  No  No  No  No

Are hampers for soiled laundry  Yes  Yes  Yes  Yes  Yes 4 labeled or color-coded?  No  No  No  No  No Are clean linen supplies spatially separated from soiled areas or  Yes  Yes  Yes  Yes  Yes 5 waste and covered or contained  No  No  No  No  No within a cabinet? Total YES and TOTAL OBSERVED Standard Precautions: Observation of Needlestick Prevention ICU-8 and Care of Laundry

Date:______

Observer Role:  Nurse  Tech  Other______Initials:______

Location/Unit:______

Notes and comments: Injection Safety: Observation of Centralized Medication Area ICU-9

Instructions: Observe medication preparation area. For each category, record the observation. Observe each practice below and answer Yes, No, or N/A. Sum all Yes and No responses. Divide by sum of “Yes”+”No”. Disregard not applicable categories.

Medication preparation room: Observation Categories

If multi-dose injectable medications are present, is the medication container  Yes  No  N/A 1 maintained in a dedicated medication preparation space? Is the medication preparation area free of opened single dose vials or opened  Yes  No 2 single use containers? If open multi-dose vials are present, are they dated and within the Beyond Use  Yes  No  N/A 3 Date (BUD) and the manufacturer’s expiration period? Medications are prepared in a clean area free from contamination or contact with  Yes  No 4 blood, body fluids, or contaminated equipment. Are splash guards installed at sinks that are located close to medication prep  Yes  No 5 areas?

6 Are sinks readily accessible to healthcare providers?  Yes  No

7 Are hand washing supplies, such as soap, and paper towels, available?  Yes  No

8 Are alcohol dispensers readily available, filled, and functioning properly?  Yes  No TOTAL (Total YES and No Only) Injection Safety: Observation of Centralized Medication Area ICU-9

Date:______

Observer Role:  Nurse  Tech  Other______Initials:______

Location/Unit:______

Notes and comments: Injection Safety: Observation of Portable Medication Systems ICU-10

Instructions: Observe three portable medication carts. For each category, record the observation as Yes, No, or N/A. In the column on the right, sum (across) the total number of “Yes” and the total number of observations (“Yes” + “No”). Divide by sum of “Yes”+”No”. Disregard not applicable categories.

Summary of Cart Cart Cart Observations Medication cart: Observation Categories 1 2 3 Total Yes “Yes” + “No”

 Yes  Yes  Yes If multi-dose injectable medications are present are they  No  No  No 1 maintained in a dedicated medication prep space?  N/A  N/A  N/A

Are alcohol dispensers readily accessible, filled, and  Yes  Yes  Yes 2 functioning properly?  No  No  No Is the medication cart free of opened single dose vials or  Yes  No 3 opened single use containers?

If open multi-dose vials are present, are they dated and  Yes  Yes  Yes 4 within the Beyond Use Date (BUD) and the manufacturer’s  No  No  No expiration period?  N/A  N/A  N/A

 Yes  Yes  Yes Are safety syringes available? 5  No  No  No

 Yes  Yes  Yes Are sharps containers available, secured, and not full? 6  No  No  No TOTAL (Total YES and No Only) Injection Safety: Observation of Portable Medication Systems ICU-10

Date:______

Observer Role:  Nurse  Tech  Other______Initials:______

Location/Unit:______

Notes and comments: Observation of Visitor area ICU-11

Instructions: Observe visitor area. Observe each practice below and answer Yes, No, or N/A. Sum all Yes and No responses. Divide by sum of “Yes” + ”No”.

Visitor area: Observation Categories

Are hand hygiene supplies readily accessible by visitors in the waiting  Yes  No  N/A 1 area?

2 Are face masks readily available?  Yes  No  N/A

Is there visible signage that clearly states that if visitors are ill,  Yes  No  N/A 3 they should report to the healthcare team? Is there visible signage that clearly states what, if any, visitor (children or  Yes  No  N/A 4 otherwise) restrictions are in place? TOTAL (Total YES and No Only) Observation of Visitor area ICU-11

Date:______

Observer Role:  Nurse  Tech  Other______Initials:______

Location/Unit:______

Notes and comments: