Is there enough stock of PPE and drugs? |
Yes/No |
Are all HCW patients, attendants and caregivers wearing a three-layer surgical facemask inside the pre and post-transplant area? |
Yes/No |
Is training for use of PPE including donning, doffing and proper disposal is completed for HCW? |
Yes/No |
Have HCW received training in updated clinical knowledge of COVID-19 & guidelines from government, academic society, and hospital authority, cough etiquette, hand hygiene, social distancing, PPE and universal precautions? |
Yes/No |
Have HCW received training for clinical, epidemiology, laboratory screening of patients, donors, care takers and COVID consent process? |
Yes/No |
Have HCW self-monitored their symptoms and informed transplant program head in case they or their family members develop symptom(s) suggestive of COVID-19? |
Yes/No |
Is list of staff recorded and be retained by transplant team head? |
Yes/No |
Have HCW had meals at different times after washing hands with flowing water? |
Yes/No |
COVID FREE SAFE PATHWAY FOR TRANSPLANT |
Yes/No |
Is there a designated entry and exit for patients and HCW involved in transplant? |
Yes/No |
Is there a dedicated area for pre-transplant evaluation to maintain distance between patients, donors and health workers, and is it cleaned between sessions? |
Yes/No |
Is cleaning and disinfection time table of pre-transplant area displayed at entry gate? |
Yes/No |
PRE AND POST-TRANSPLANT OPD AND WARD |
Yes/No |
Is there an alcohol-based hand sanitizer at entry? |
Yes/No |
Are the following equipment either used separately for each patient OR disinfect between the shifts? |
Yes/No |
Stethoscopes (diaphragms and tubing cleaned with an alcohol based disinfectant) |
Yes/No |
BP cuffs (NIBP cuffs can be cleaned by alcohol or 1% sodium hypochlorite) |
Yes/No |
Oxygen saturation probes |
Yes/No |
No sharing of thermometers |
Yes/No |
Are posters displayed on education and preventions of COVID-19 (hand hygiene, social distancing, COVID-19 symptoms and testing and universal precautions)? |
Yes/No |
Transplant infectious disease assessment if required |
Yes/No |
Transplant psychiatry assessment if required |
Yes/No |
Are disinfection, environmental cleanliness, and good air conditioning & ventilation conditions instituted? |
Yes/No |
Is social distancing followed? |
Yes/No |
Are all frequently touched surfaces inside the transplant unit, cleaned and disinfected frequently and duty list maintained? |
Yes/No |
Transplant OT |
Yes/No |
Is there dedicated transplant OT and HCW for surgery? |
Yes/No |
Is there cleaning and disinfection of OT and timetable? |
Yes/No |
Post-Transplant |
Yes/No |
Post-transplant patient and donor in separate rooms with an attached bathroom |
Yes/No |
Are visitors limited to one visitor for 10 minutes with social distancing (2 meter), wearing a surgical mask and a gown? |
Yes/No |
Determine approaches to minimize exposure to the healthcare setting for non-essential services |
Yes/No |
Is telemedicine and emergency consultation contact number available? |
Yes/No |
Recipients should avoid travel to area with COVID-19 cases |
Yes/No |
Can patients find information about the latest developments regarding COVID-19 on the hospital and government website? visit https://www.mohfw.gov.in/ |
Yes/No |
Remark : Date: Name/Signature |