SEA-URCHIN Unit level practices – Measuring the progress of implementation

Note: When we ask if there is documentation of a decision, or if there are documented policies or goals; we mean that if you were asked, you could provide documents to show
these things.

Hand washing
Stage Yes No In your unit…
1. Awareness   Management is aware of the importance of increasing hand washing compliance in preventing infection
2. Adoption   There is documentation of a decision to increase hand-washing compliance
3. Mobilization   All nurses, doctors and other staff are aware of the benefit of the hand washing
  There is at least 1 sink for every 10 beds
  There are posters showing how to do hand washing effectively
  Alcohol based hand rubs are available at every bed space
4. In practice   Hand washing compliance is routinely observed and evaluated
  Training in hand washing has been delivered in the last 6 months
  Observed rates of hand washing compliance are 50% or greater
5. Routine and   There are documented policies that encourage or require staff to implement hand washing
integrated practice   All new staff receive training in hand washing
  Observed rates of hand washing compliance are 80% or greater
6. Sustainable practice   At least 6 months of audit data about hand-washing are available

Appropriate antibiotic use

Stage Yes No In your unit…
1. Awareness   Management is aware of importance of appropriate antibiotic use in preventing and treating infection
2. Adoption   There is documentation of a decision to improve antibiotic use
3. Mobilization   All nurses, doctors and other staff are aware of the importance of appropriate antibiotic use
  The laboratory facilities needed to determine appropriate antibiotics (for example blood culture) are available for all
patients
  The antibiotics needed are always available for all patients
4. In practice   Antibiotic use is documented in a way that enables monitoring
  Training in appropriate antibiotic use has been delivered in the last 6 months
  There are documented goals for antibiotic use to be achieved
5. Routine and   There are documented policies that encourage or require staff to implement appropriate antibiotic use
integrated practice   All new staff receive training in the appropriate antibiotic use
  The documented goals for antibiotic use are achieved more than 75% of the time
6. Sustainable practice   At least 6 months of audit data about antibiotic use are available
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Equipment cleaning (including decontamination, cleaning, high level disinfection and sterilisation of incubators, CPAP & ventilation equipment, etc)
Stage Yes No In your unit…
1. Awareness   Management is aware of the importance of equipment cleaning in preventing infection
2. Adoption   There is documentation of a decision to improve equipment cleaning
3. Mobilization   All nurses, doctors and other staff are aware of the importance of equipment cleaning
  A dedicated space is regularly available to clean equipment
  The equipment needed (for example continuous supply of cleaning running water, detergents, cloths, etc) to
undertake cleaning is always available
4. In practice   Equipment cleaning is documented in a way that enables monitoring of practice
  Training in equipment cleaning has been delivered in the last 6 months
  There are documented goals for levels of equipment cleaning
5. Routine and   There are documented policies that encourage or require staff to clean equipment
integrated practice   All new staff receive training in equipment cleaning
  The documented goals for levels of equipment cleaning are achieved more than 75% of the time
6. Sustainable practice   At least 6 months of audit data on equipment cleaning are available

Environmental cleaning (for example monitors, lights, benches, sinks and surrounds, floors, wards, air conditioning units)
Stage Yes No In your unit…
1. Awareness   Management is aware of the importance of environmental cleaning in preventing infection
2. Adoption   There is documentation of a decision to improve environmental cleaning
3. Mobilization   All nurses, doctors and other staff are aware of the importance of environmental cleaning
  The space needed to undertake environmental cleaning (for example to move equipment into) is available
  The equipment needed (for example continuous supply of cleaning running water, detergents, mops, etc) to
undertake environmental cleaning is always available
  There are dedicated, trained staff available to undertake environmental cleaning
4. In practice   Environmental cleaning is documented in a way that enables monitoring of practice
  Training in environmental cleaning has been delivered in the last 6 months
  There are documented goals for levels of environmental cleaning
  Environmental surveillance is undertaken at least once every 6 months
5. Routine and   There are documented policies that encourage or require staff to implement environmental cleaning
integrated practice   All new staff receive training in environmental cleaning
  The documented goals for levels of environmental cleaning are achieved more than 75% of the time
6. Sustainable practice   At least 6 months of audit data about environmental cleaning are available

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Intravascular catheter insertion and care
Stage Yes No In your unit…
1. Awareness   Management is aware of the importance of the intravascular catheter insertion and care in preventing infection
2. Adoption   There is documentation of a decision to improve intravascular catheter insertion and care
3. Mobilization   All nurses, doctors and other staff are aware of importance of intravascular catheter insertion and care
  The space needed to undertake intravascular catheter insertion and care is available
  The equipment needed to undertake intravascular catheter insertion and care is always available
4. In practice   Intravascular catheter care insertion and is documented in a way that enables monitoring of practice
  Training in intravascular catheter insertion and care has been delivered in the last 6 months
  There are documented goals for levels of intravascular catheter insertion success to be achieved
5. Routine and   There are documented policies that encourage or require staff to undertake appropriate intravascular catheter
integrated practice insertion and care
  All new staff receive training in intravascular catheter insertion and care
  The documented goals for levels of intravascular catheter insertion and care are achieved more than 75% of the
time
6. Sustainable practice   At least 6 months of documented audit of catheter related outcomes [catheter survival times, catheter occlusion
rates, catheter misplacement, catheter related vascular accidents, blood stream infections and catheter related
blood stream infections, phlebitis] are available

Early, exclusive and sustained breastmilk feeding

Stage Yes No In your unit…
1. Awareness   Management is aware of the importance of early, exclusive and sustained breastmilk feeding in preventing infection
2. Adoption   There is documentation of a decision to improve the implementation of early, exclusive and sustained breast
milkfeeding
3. Mobilization   All nurses, doctors and other staff are aware of the importance of early, exclusive and sustained breastmilk feeding
in preventing infection
  All nurses, doctors and other staff are aware of the importance of not separating mother and baby in preventing
infection
  The space needed (for example for mothers to be in the unit) for early, exclusive and sustained breastmilk feeding is
available
  The equipment needed (for example refrigeration, etc) for early, exclusive and sustained breast milk expression and
storage is always available
4. In practice   Breastfeeding is documented in the medical (or other) record in a way that enables monitoring of the practice
  Training in early and sustained breast milk expression, storage and safe administration has been delivered in the last
6 months
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   There are documented goals for levels of early, exclusive and sustained breastmilk feeding to be achieved
5. Routine and   There are documented policies that encourage or require staff to implement early, exclusive and sustained
integrated practice breastmilk feeding
  All new staff receive training in early, exclusive and sustained breastmilk feeding
  The documented goals for levels of early, exclusive and sustained breastmilk feeding are achieved more than 75% of
the time
6. Sustainable practice   At least 6 months of audit data about early, exclusive and sustained breastmilk feeding are available

Kangaroo mother care (KMC)*

Stage Yes No In your unit…
1. Awareness   Management is aware of the benefit of KMC
2. Adoption   There is documentation of a decision to implement KMC
3. Mobilization   All nurses, doctors and other staff are aware of the benefit of the KMC
  The space needed (for example for mothers to be in the unit)to undertake KMC is available on the unit
and/or a postnatal ward facility appropriate for KMC
  The equipment needed (pouches, accurate infant scales) for implementation and monitoring of KMC is always
available
  There is a documented definition of what KMC means
4. In practice   KMC is documented in the clinical record in a way that enables monitoring of practice
  Training in KMC has been delivered in the last 6 months
  There are documented goals for levels of KMC to be achieved in the unit
5. Routine and   There are documented policies that encourage or require staff to implement KMC
integrated practice   All new staff receive training in KMC
  The documented goals for levels of KMC in the unit are achieved more than 75% of the time
6. Sustainable practice   At least 6 months of audit data about KMC are available
*KMC was originally defined as “skin-to-skin contact between a mother and her newborn, frequent and exclusive or nearly exclusive breastfeeding, and early discharge from
hospital”. “The major component of KMC is skin-to-skin contact (SSC) in which infants are placed vertically between the mother's breasts firmly attached to the chest and below
her clothes.” Conde-Agudelo A, Belizán JM, Diaz-Rossello J. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database of Systematic
Reviews 2011, Issue 3. Art. No.: CD002771.

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