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 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 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 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 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