Enhanced Droplet/Contact PPE Audit ToolUNIT: Room # Room # Room # Room # Room # Room # Donning PPE ....

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April 3 2020 Enhanced Droplet Contact Audit Tool 1 DATE: AUDITORS NAME: UNIT: Room # Room # Room # Room # Room # Room # Donning PPE Yes No Yes No Yes No Yes No Yes No Yes No Was alcohol based hand rub or soap and water used prior to putting on PPE? Was the gown the first PPE put on? Does the gown: • Open to the back? • Tie at the neck and waist? • Cover the skin and clothing? Was a surgical/procedure mask or N95 (if aerosol generating procedure) put on? Is the mask secured by loops or ties? Is the metal piece on the mask shaped to the bridge of nose? For N95 – was a seal check performed? Mark N/A if no N95 respirator worn Was eye protection put on? Mark yes if eye protection in place (i.e., combined mask and eye protection or separate eye protection). Note: eye glasses do not count as eye protection Were gloves put on last? Gloves were put on and pulled over gown cuffs? Enhanced Droplet/Contact PPE Audit Tool

Transcript of Enhanced Droplet/Contact PPE Audit ToolUNIT: Room # Room # Room # Room # Room # Room # Donning PPE ....

Page 1: Enhanced Droplet/Contact PPE Audit ToolUNIT: Room # Room # Room # Room # Room # Room # Donning PPE . Yes . No : Yes : No . Yes : No . Yes : No . Yes : No . Yes : No . Was alcohol based

April 3 2020 Enhanced Droplet Contact Audit Tool 1

DATE:

AUDITORS NAME:

UNIT:

Room

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Room

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Room

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Room

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Room

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Room

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Donning PPE Yes No Yes No Yes No Yes No Yes No Yes No

Was alcohol based hand rub or soap and water used prior to putting on PPE?

Was the gown the first PPE put on?

Does the gown: • Open to the back?

• Tie at the neck and waist?

• Cover the skin and clothing?

Was a surgical/procedure mask or N95 (if aerosol generating procedure) put on?

Is the mask secured by loops or ties?

Is the metal piece on the mask shaped to the bridge of nose?

For N95 – was a seal check performed? Mark N/A if no N95 respirator worn

Was eye protection put on? Mark yes if eye protection in place (i.e., combined mask and eye protection or separate eye protection). Note: eye glasses do not count as eye protection

Were gloves put on last?

Gloves were put on and pulled over gown cuffs?

Enhanced Droplet/Contact PPE Audit Tool

Page 2: Enhanced Droplet/Contact PPE Audit ToolUNIT: Room # Room # Room # Room # Room # Room # Donning PPE . Yes . No : Yes : No . Yes : No . Yes : No . Yes : No . Yes : No . Was alcohol based

April 3 2020 Enhanced Droplet Contact Audit Tool 2

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Room #

Room #

Room #

Doffing PPE Yes No Yes No Yes No Yes No Yes No Yes No

Were gloves removed first?

When gloves removed did they: • Grasped at the palm and remove the first glove,

pulling the glove inside out?

• Scooped under the second glove with a bare finger and remove the second glove?

• Placed in garbage?

Was the gown removed as the next step?

When gown removed did they: • Untie neck, then waist

• Scoop fingers under cuff; then pull sleeve over one hand

• Use gown covered hand to pull gown over other hand

• Pull gown off without touching the outside

• Roll gown inside out

• Place in laundry hamper or garbage as appropriate

Was hand hygiene performed after the gown was removed?

HCW left the patient/resident/client environment (i.e., room/bed space) before removing face protection?

If eye protection NOT connected to mask: Eye protection was removed using the handles and placed in a reprocessing bin or garbage? Note: leave blank if connected to mask

Surgical/procedure mask or N95 respirator (for aerosol generating procedures) was:

• Removed using the loops or ties?

• Placed in the garbage bin while not touching anything but the loops or ties?

Was hand hygiene performed after removing face protection?

‘Personal Protective’ tips: Do not dangle a mask around the neck when not in use.

Do not reuse mask

Change mask if it becomes wet or soiled

Do not double glove

Do not use same pair of gloves for more than one patient

Do not clean gloves for reuse

Remove gloves and perform hand hygiene immediately after patient care activities. If gloves are still indicated, replace with a clean pair


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