Ambulance Service Full Name:
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Street Address (1):
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City:
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State:
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Zip code:
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Date of Assessment:
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Today D-M-Y
Medical Director Name:
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Ambulance Service Supervisor or Point of Contact Name:
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Ambulance Supervisor or Point of Contact Email Address:
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Ambulance Supervisor Phone Number:
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Is the ambulance service accredited?
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Yes
No
Please list the accreditation organization:
Which procedures are performed by the ambulance service? Select all that apply.
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Number of staff for this ambulance service (include volunteer, paid, full-time, and part-time):
Average number of calls per week:
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Average number of transports per week:
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Does the ambulance service have a Designated Infection Control Officer (DICO)?
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Yes
No
Please check DICO infection control duties/activities within the organization. Select all that apply.
Frequency of contact with DICO:
Monthly
Quarterly
Annually
Only as needed
Does the ambulance service have a representative that regularly attends health care coalition meetings?
* must provide value
Yes
No
1. Written infection control policies and procedures are available and incorporate evidence-based guidelines (e.g., CDC/HICPAC, OSHA), regulations, or standards.
Yes
No
2. An annual risk assessment that includes infection prevention and control is conducted.
Yes
No
3. Infection control policies and procedures are reassessed at least annually or according to state or federal requirements, and updated as necessary.
Yes
No
4. Ambulance service has a screening process to identify potentially infectious persons at initial point of patient encounter (e.g., fever, respiratory symptoms, new rash, and travel).
Yes
No
1.
Yes
No
2. Personnel are trained on the BBP exposure control plan.
Yes
No
Training includes the following:
a. What a BBP is (e.g., hepatitis B, HIV).
Yes
No
b.
Yes
No
c. What to do if a BBP exposure occurs.
Yes
No
d. Training occurs upon hire.
Yes
No
e. Training occurs annually.
Yes
No
3.
Yes
No
4. Ambulance service tracks exposure events and evaluates event data and develops/implements corrective action plans to reduce incidence of such events.
Yes
No
5. A process is in place with hospital or local public health to notify ambulance service if an infectious patient diagnosis is confirmed and there is potential personnel exposure (e.g., meningitis, tuberculosis, etc.).
Yes
No
6. A process is in place for transport of a patient in transmission based precautions (e.g., contact precautions for Clostridioides difficile, MRSA).
Yes
No
7. a.
Yes
No
b.
Yes
No
c. Measles, Mumps, Rubella (MMR):
Yes
No
d.
Yes
No
e.
Yes
No
8. All health care personnel receive baseline tuberculosis (TB) screening upon hire.
Yes
No
9. Ambulance service has a plan for personnel follow-up if exposure to TB or annual screening if in high-risk area.
Yes
No
10. If respirators are used, the ambulance service has a respiratory protection program that details required worksite-specific procedures and elements for required respirator use, including provision of medical clearance, training, and fit testing as appropriate.
Yes
No
11. Ambulance service has policies/procedures concerning personnel who have potentially transmissible conditions.
Yes
No
a. Work-exclusion policies that encourage reporting of illnesses.
Yes
No
b. Education of personnel on prompt reporting of illness to supervisor.
Yes
No
12. While in the field, who would ambulance personnel contact with questions or concerns about an infectious disease/condition of a patient?
First Name, Last Name, Job Title
1a. All personnel are educated regarding appropriate indications for hand hygiene upon hire.
Yes
No
b. All personnel are educated regarding appropriate indications for hand hygiene annually.
Yes
No
2a. Personnel are required to demonstrate hand hygiene competency upon hire.
Yes
No
b. Personnel are required to demonstrate hand hygiene competency annually.
Yes
No
3. Ambulance service regularly audits (monitors and documents) personnel hand hygiene compliance.
Yes
No
4. Ambulance service provides feedback from audits to personnel regarding their hand hygiene performance.
Yes
No
5. Supplies necessary for adherence to hand hygiene are readily accessible to personnel in and out of the ambulance.
Yes
No
1. The following PPE is available and readily accessible in various sizes:
a.
Yes
No
b. Clothing cover (e.g., gown):
Yes
No
c. Facial protection (goggles or face shield):
Yes
No
d.
Yes
No
e.
Yes
No
f. Powered air purifying respirator (PAPR):
Yes
No
2. Personnel have access to as second uniform if contamination with blood or bodily fluids occur.
Yes
No
3a. Personnel receive training on proper selection and use of PPE upon hire.
Yes
No
b. Personnel receive training on proper selection and use of PPE annually.
Yes
No
c. Personnel receive training on proper selection and use of PPE when new equipment or protocols are introduced.
Yes
No
4a. Personnel receive education on standard precautions upon hire.
Yes
No
b. Personnel receive education on standard precautions annually.
Yes
No
5a. Personnel receive education on transmission-based precautions upon hire.
Yes
No
b. Personnel receive education on transmission-based precautions annually.
Yes
No
6. Personnel are required to demonstrate competency with selection and use of PPE following each training.
Yes
No
7. Ambulance service regularly audits (monitors and documents) adherence to proper PPE selection and use.
Yes
No
8. Ambulance service provides feedback from audits to personnel regarding their performance with selection and use of PPE.
Yes
No
9. Ambulance service evaluates PPE for design, fit, comfort, and feedback from frontline staff regarding performance.
Yes
No
Check the box below if your ambulance service offers BLS service only.
1. Safety devices are used for all injectable medications and procedures.
Yes
No
2a. Personnel who prepare and/or administer medications receive training on safe injection practices upon hire.
Yes
No
b. Personnel who prepare and/or administer medications receive training on safe injection practices annually.
Yes
No
c. Personnel who prepare and/or administer medications receive training on safe injection practices when new equipment or protocols are introduced.
Yes
No
3. Personnel are required to demonstrate competency with safe injection practices following each training.
Yes
No
4. Ambulance service regularly audits (monitors and documents) adherence to safe injection practices.
Yes
No
5. Ambulance service provides feedback from audits to personnel regarding their adherence to safe injection practices.
Yes
No
6. Ambulance service has policies and procedures to track personnel access to controlled substances to prevent narcotics theft/diversion.
Yes
No
7. Ambulance services utilize single-dose vials in the care of patients whenever possible.
Yes
No
a. Are any multi-dose vials currently used by the ambulance service?
Yes
No
8. All sharps containers are disposed of in a puncture-resistant sharps container.
Yes
No
1. Ambulance service has a policy and/or procedure to contain respiratory secretions in patients who have symptoms of a respiratory infection.
Yes
No
a. Process includes placing a facemask on a coughing patient upon scene arrival and through the duration of the ambulance transport.
Yes
No
b. If a patient cannot tolerate a mask, ambulance personnel wear a mask.
Yes
No
2. Ambulance service educates personnel on the importance of infection prevention measures to contain respiratory secretions to prevent the spread of respiratory pathogens.
Yes
No
Check the box below if your ambulance service offers BLS service only.
1. Single-use, safety device lancets available and used for blood glucose testing.
Yes
No
2a. Personnel who perform point-of-care testing receive training on recommended practices upon hire.
Yes
No
b. Personnel who perform point-of-care testing receive training on recommended practices annually.
Yes
No
c. Personnel who perform point-of-care testing receive training on recommended practices when new equipment or protocols are introduced.
Yes
No
3. Personnel are required to demonstrate competency with recommended practices for point-of-care testing following each training.
Yes
No
4. Ambulance regularly audits (monitors and documents) adherence to recommended practices during point-of-care testing.
Yes
No
5. Ambulance service provides feedback from audits to personnel regarding their adherence to recommended practices.
Yes
No
6. Blood glucose meters are cleaned and disinfected after each patient use per manufacture recommendations.
Yes
No
1a. Ambulance service has written policies and procedures for ROUTINE cleaning and disinfection of environmental surfaces in the ambulance.
Yes
No
b. Ambulance service has written policies and procedures for ROUTINE cleaning and disinfection of equipment such as gurneys, spinal boards, and blood pressure cuffs.
Yes
No
2. Supplies necessary for appropriate cleaning and disinfection procedures are easily accessible (e.g., EPA-registered disinfectants).
Yes
No
3. Policies and procedures are in place for the use of the medical bag.
Yes
No
a. Where to set bag down at the scene.
Yes
No
b. Not going into the bag with dirty hands.
Yes
No
c. Specific area for putting dirty equipment into the bag (i.e., keep clean and dirty area separate).
Yes
No
4a. Personnel who clean and disinfect the ambulance and equipment receive training on cleaning procedures upon hire.
Yes
No
b. Personnel who clean and disinfect the ambulance and equipment receive training on cleaning procedures annually.
Yes
No
c. Personnel who clean and disinfect the ambulance and equipment receive training on cleaning procedures when new equipment or protocols are introduced.
Yes
No
5. Ambulance service regularly audits (monitors and documents) adherence to cleaning and disinfection procedures, including using products in accordance with manufacturer's instructions (e.g., dilution, storage, shelf-life, contact time).
Yes
No
6. Ambulance service provides feedback from audits to personnel regarding their adherence to cleaning and disinfection procedures.
Yes
No
7. Ambulance has a policy and/or procedure for decontamination of spills of blood or other bodily fluids.
Yes
No
8. Ambulance service has policies and/or procedures for containment/disposal of human waste (i.e., urine, stool, vomit).
Yes
No
9. Ambulance service has trained staff on handling and disposal of regulated medical waste (e.e., items to place in red bag).
Yes
No
Check the box below if the ambulance service DOES NOT reprocess devices.
1. Ambulance service has policies and procedures to ensure that reusable medical devices are cleaned, high-level disinfected, or sterilized according to the Spaulding Criteria prior to use on another patient.
Yes
No
2. Policies and procedures are in place for transport of contaminated reusable medical devices for cleaning, high-level disinfection, or sterilization.
Yes
No
3. Ambulance service regularly audits (monitors and documents) adherence to reprocessing procedures.
Yes
No
4. Ambulance service provides feedback from audits to personnel regarding their adherence to reprocessing procedures.
Yes
No
5. Protocols are in place to ensure that personnel can readily identify devices that have been properly reprocessed and are ready for use.
Yes
No
1. Personnel receive training on care of urinary catheters. Training includes: emptying bag aseptically, maintain closed system, no pulling/tugging, maintain unobstructed urine flow, and bag below level of bladder.
Yes
No
2. Personnel receive training on care of central lines. Training includes: scrub the hub, accessing the catheter, dressing intact. no pulling on line, importance of proper technique with accessing, clamps on if not in use.
Yes
No
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