Private facilities
Name of hospital:
Category: Clinic/Polyclinic/Nursing Home/Multi speciality Hospital
Address:
District:
Division:
State:
Facility Nodal officer-
Name –
Designation-
Contact number –
Whether entire hospital/ Block(s) within hospital is dedicated for COVID care/non-COVID (Tick as Applicable)
Whether the facility is functional/being made functional (for COVID)/NA (Tick as Applicable)
Numbers/Quantity of :
• Isolation Beds (excluding ICUs):
o Isolation Beds for Confirmed Cases – _______ Separate Area – Yes/No
o Isolation Beds for Suspect Cases – _______ Separate Area – Yes/No
• O2 supported Beds :
o No. of Beds Supported with Central Supply : __________
o No. of Beds Supported with Bed-side Cylinder/ O2 concentrator :_______
• ICU Beds
• Ventilators
• Suction Machine/Centralized Suction point
• Pulse Oxymeter/Monitor
• O2 Manifold (Yes/No)
• Nebulizer Machine
• Thermal Scanner
• PPEs
• Spill/Mercury spill kit
• Apron/Lab coat(for clinicians)
• Waste management bins & polybag
• Heavy Duty gloves & Gumboot (for waste handlers)
• N95 masks
• Three bucket system for Mopping
• 1% Hypochlorite Solution(lit)
• Alcohol based hand rub (lit)
• Liquid Soap(lit)
• Others disinfectants with quantity
S No
Particulars
Indicator
Assessment
Remarks
1.
GENERAL
A
In case of dedicated block, does it have a separate entry/exit?
Y / N
B
Whether the facility has admitted COVID patients?
Y / N
C
If answer to B is yes, whether other hospitals identified for shifting of non COVID patients?
Y / N
2
INFRASTRUCTURE
A
Designated Emergency Area with provision for:
• Holding and Screening
• Triage and treatment
With adequate space for physical distancing
Y / N
B
Whether ICU has:
a. 2 meter space between beds
Y / N
b. Ventilators for each bed
Y / N
c. Air Handling Unit in the room
Y / N
d. If AHU n/a, Negative Pressure?
Y / N
C
Whether wards for confirmed cases have:
a.1meter space between beds
Y / N
b. Negative Pressure
Y / N
D
Whether wards for Suspect cases have:
a.1meter space between beds
Y / N
b. Negative Pressure
Y / N
E
Availability of 24/7 Electricity & Water supply, with back up
Y / N
F
Hand washing facility
Y / N
G
Number of separate toilets for patients of all genders
12 per 100 beds
H
Whether there is a dedicated space for parking and disinfecting ambulances?
Y / N
I
Provision of Isolation ward for confirmed and suspected COVID patient
Y/N
J
Availability of shoes rack(restriction of external foot wear in the ward)
Y/N
3
DRUGS
A
Availability of Essential Drugs for treatment of COVID patients as per protocols.
HCQ
Y / N
Antivirals
Y / N
Azithromycin
Y / N
Others
Y / N
4
SUPPORT SERVICES (Availability of/linkages with)
A
Laboratory and diagnostics services
Routine laboratory tests for co-morbidities
Y / N
B
Availability of VTM / Swabs for sample collection
Y / N
C
Facility for disinfection & sterilization of patient linen & equipment
CSSD
Y / N
Mechanized Laundry
Y / N
D
Dietary Services
–
Y / N
E
Blood bank / Storage Unit
–
Y / N
F
Radiology
X-Ray – Static
Y / N
X- Ray – Mobile
Y / N
Ultrasound
Y / N
CT Scan
Y / N
G
Ambulance services
Available or linked
Y / N
H
Availability of Medical Gas Pipelines for:
Medical Air
Y / N
Suction
Y / N
Oxygen
Y / N
I
Oxygen Source Capacity (mention numbers with buffer stock)
a)
Generation Plant Capacity (m3)(liters divided by 1000 equals m3)
b)
Liquid Oxygen Tank (m3)
c)
Manifold with Cylinder–
1. No of type D (7 m3) cylinders connected
d)
2. Noof type D (7 m3) backup cylinders
e)
Availability of O2 Cylinder (excluding Manifold Cylinders)
a.
Number of Cylinder D type (7 m3)
b.
Number of Cylinder B type (1.5 m3)
f)
Number of bed side concentrators
J
AMC/CMC/Calibration for equipment as per requirement
Manifold & Other sources of oxygen supply
Y / N
Ventilators
Y / N
Other critical equipment.
Y / N
5
INFECTION PREVENTION AND CONTROL
A
COVID Infection Control Committee Costituted and regular monitoring at the facility
Y / N
B
COVID treatment guideline communicated and implemented
Y/N
C
Regular Medical Checkup and Quarantine of staff as per guideline
Y/N
D
Culture Surveillance (Bed/Ward/Equipment)
Y/N
E
Waste management(Segregation, Collection & Transportation) and disinfection of waste as per guideline
Y/N
F
Waste Management bins(covered)Trolleys(closed), demarcated storage area with handwashing facility and consumables(non-chlorinated polybag) for management of biomedical waste& ETP (Effluent Treatment Plant)
Y/N
G
All waste daily lifted by CWTF van
Y/N
6
HUMAN RESOURCES
Numbers
A
Doctors including specialists available
Physician
Anesthetist
Surgeon
Any other ( please specify)
GDMO
B
Nurses available
C
Technicians (Lab, Radiology, Dialysis) available
Laboratory
Radiology
Dialysis
D
Dedicated Staff accommodation and transport available
Y / N
E
Are service providers using PPE as per protocols?
Y / N
7
CAPACITY BUILDING
i.
All personnel trained on COVID-19 management.
Y / N
ii.
Moment & Steps of Hand Washing
Y/N
iii.
Wearing and Removing of PPE
Y/N
iiii.
Standard Precautions
Y/N
v.
Spill/Mercury spill management
Y/N
vi.
Preparation of 1% Hypochlorite solution
Y/N
vii.
Decontamination/Disinfection of surfaces (operating, examination, floors, walls, table, dressing table), Instruments/Equipment, O2 cylinder, Ambulance etc
Y/N
viii.
Autoclaving/Chemical sterilization/High level disinfections of instrument as per protocols
Y/N
ix.
Waste management (General & Bio-Medical)
Y/Y
x.
Clinicians trained on ventilator management/CPR
Y / N
xi.
Staff trained on sample collection, packaging, storage and transportation
Y / N
xii.
Doctors, nurses and support staff trained on IPC.
Y / N
xiii.
Unidirectional Mopping
Y/N
8
Availability of protocols
i.
Treatment
Y / N
ii.
Ventilator management
Y / N
iii.
IPC
Y / N
iiii.
Rational use of PPE
Y / N
v.
Moment & 6-step of Hand washing
Y/N
vi.
Disinfection/Autoclaving protocols
Y/N
vii.
Sample collection, collection/lab testing
Y / N
viii.
Spill/Mercury spill management
Y/N
ix.
Handling Dead Bodies/ Mortuary
Y / N
x.
Safety awareness regarding COVID
Y/ N
xi.
Bio-Medical work instruction (segregation, handling & transportation)
Y/N
9
Data Management & Reporting
A
Total No. of Admission till Date (Cumulative)
B
Total No. of Discharge till Date (Cumulative)
C
Total No. of Positive Case till Date (Cumulative)
D
Total No. of Negative till Date (Cumulative)
E
Whether reporting COVID patients data regularly to DSO
Y / N
B
Availability of Broadband Internet connectivity + Computers + DEOs
Y / N
Name and Designation of SSV Team Member:
Date of SSV:
deemagclinic
deemagclinic 