F O R M A T
SURVEY TERHADAP PELAKSANAAN PENCEGAHAN DAN PENGENDALIAN INFEKSI
DI RSUD dr. SOEDONO
MADIUN
SURVEY KPPI
2014
/
Formulir model No.03
INDIKATOR PENCEGAHAN DAN PENGENDALIAN INFEKSI
DI RUMAH SAKIT
Rumah Sakit : RSUD Dr. Soedono Madiun
Jenis/type/kelas :
"NO "INDIKATOR-INDIKATOR "PENJELASAN "OBS/ "YA/ "TDK "TK "TERKAIT "
" " " "BKT "ADA " "RESIKO/ " "
" " " " " " "DAMPAK " "
"1.2."Apakah organisasi " " " " " "KPPI "
" "Komite PPI langsung " "B " " " " "
" "dibawah Direktur " " " " " " "
"1.3."Apakah anggota " " " " " "KPPI "
" "Komite/Tim terdiri " "B " " " " "
" "dari bagian-Instalasi" " " " " " "
" "terkait ?: (sebutkan)" " " " " " "
" " - Pimpinan " Beri tanda yang " " " " " "
" "/Managemen RS. "ada " " " " " "
" " - Dokter wakil dari" " " " " " "
" "tiap SMF " " " " " " "
" " - Dokter ahli " " " " " " "
" "epidemiologi " " " " " " "
" " - Dokter " " " " " " "
" "Mikrobiologi / PK " " " " " " "
" " - Laboratorium " " " " " " "
" " - Farmasi " " " " " " "
" " - Sterilisasi " " " " " " "
" " - Perawat PPI " " " " " " "
" " - Gizi " " " " " " "
" " - Sanitasi " " " " " " "
" " - Loundry/rumah " " " " " " "
" "tangga " " " " " " "
" " - Pemeliharaan " " " " " " "
" "sarana " " " " " " "
" " - House keeping " " " " " " "
" " -K3 " " " " " " "
" " -Petugas Kamar "(sebutkan) " " " " " "
" "Jenazah " " " " " " "
"1.4."Apakah Tugas & "Sebutkan jenis SPO " " " " "KPPI "
" "kewenangan nya "PPI (kriteria IN; "B " " " " "
" "termasuk: "tehnik aseptis; " " " " " "
" "Pembuatan SPO PPI "sterilisasi;laundry" " " " " "
" " "; sanitasi dll) " " " " " "
" " "SK/lainnya " " " " " "
" " - SPO Kejadian" " " " " " "
" "Luar biasa " " " " " " "
" "penggunaan " " " " " "FarmasiIPCO"
" "Antibiotika " " " " " " "
" "Penggunaan " " " " " "IPCO, "
" "Antisetik-disinfektan" " " " " "Farmasi "
" " - Masukkan " " " " " "Perlengkapa"
" "untuk design , " " " " " "n, IPL, K3 "
" "renovasi, perombakan " " " " " " "
" "gedung tu. OK; " " " " " " "
" "ICU;R.Isolasi " " " " " " "
"1.5."Apakah anggota "Bila ya berapa% " " " " "KPPI, "
" "Komite/Tim pernah "jumlah anggota yang"B " " " "Diklit "
" "mendapatkan "dilatih; dimana? " " " " " "
" "pendidikan & "Oleh siapa? Materi " " " " " "
" "pelatihan? "pelatihan ? " " " " " "
"1.6."Apakah mempunyai "Lihat jadwal " " " " "KPPI "
" "Program Pengendalian "rencana kerja dan "B&O " " " " "
" "Infeksi yang antara "hasil Infection " " " " " "
" "lain meliputi : "Rate/ angka " " " " " "
" "Revisi SPO berkala "kejadian Infeksi " " " " " "
" "(3th 1X misalnya " " " " " " "
" "Survailan hasil: "Sebutkan frekuensi " " " " "IPCN, IPCO "
" "IDO "& format pelaporan "B " " " " "
" "Bakteriemia/IADP " " " " " " "
" "Phemonia " " " " " " "
" "ISK " " " " " " "
" "Mikrobiologi " " " " " " "
" "Lain-lain (sebutkan)?" " " " " " "
" " - lain-lain "sebutkan "B " " " " "
"1.7."Apakah telah "Sebutkan penyediaan" " " " "IPCN, IPCO "
" "melakukan "APD dimana? Apakah "B&O " " " " "
" "Survailan Proses ? "mudah digunakan " " " " " "
" "Antara lain "bila diperlukan? " " " " " "
" "pengetahuan petugas, "Ditanyakan kapan " " " " " "
" "Perilaku petugas : "menggunakan APD- " " " " " "
" "Cuci tangan-APD "cuci tangan " " " " " "
" "Tehnis asepsis " "B&O " " " " "
" "Penggunaan "Penggunaan AB lihat" " " " "IPCO, Komed"
" "Antibiotika "dokumen medik atau "B " " " " "
" " "apakah pernah " " " " " "
" " "dilakukan Drug " " " " " "
" " "Utilization Study? " " " " " "
" "Waste disposal "Cara penanganan "B&O " " " "IPL "
" "Lingkungan * "Diamati di " " " " "KPPI, IPL, "
" " "ICU-NICU- OK- "B&O " " " "ruang "
" " "R.Isolasi " " " " "terkait "
" "Tindakan invasif "idem "B&O " " " "KPPI, IPL, "
" " " " " " " "ruang "
" " " " " " " "terkait "
"1.8."Apakah pernah "Sebutkan diskusi "B&O " " " "KPPI "
" "dilakukan diskusi "dalam kasus apa? " " " " " "
" "dari hasil "Pemecahan masalah ?" " " " " "
" "survailans/kasus PPI "tintak lanjut? " " " " " "
" "/KLB? Apakah ada " " " " " " "
" "tindak lanjut? " " " " " " "
"1.9."Apakah Komite/Tim "Bila sudah sebutkan"B&O " " " "KPPI, "
" "pernah memberikan ": (Dr.: Farmasis: " " " " "Personalia,"
" "Dik-Lat kepada "Radiologis:Lab:Gizi" " " " "Diklit "
" "personil RS.? "; sanitasi; " " " " " "
" "Jelaskan! "cleaning service; " " " " " "
" "Petugas OK "pencucian;kamar " " " " " "
" " "mayat; ambulan; " " " " " "
" " "pemeliharaan " " " " " "
" " "sarana) " " " " " "
" "Petugas ICU " "B&O " " " " "
" "R.Isolasi " "B&O " " " " "
" "Tenaga Medik " "B&O " " " " "
" "Tenaga keperawatan " "B&O " " " " "
" "Tenaga non medik " "B&O " " " " "
" "terkait " " " " " " "
" "Tenaga baru " "B&O " " " " "
"1.10"Apaka melakukan "(sebutkan: "B " " " "KPPI,IPL, "
". "pencatatan pelaporan "Prevalen/IR; peta " " " " "IPCN, IPCLN"
" "mengenai : "kuman; kualitas " " " " " "
" "Hasil survailan "air; udara; " " " " " "
" "/monitoring "KLB;dll. " " " " " "
" "Umpan balik " "B " " " " "
" "Tindak " "B " " " " "
" "lanjut/pemecahan " " " " " " "
" "masalah ? " " " " " " "
" " " " " " " " "
"1.11"Penanggung jawab " "B&O " " " "KPPI & "
". "pelaksanaan PPI ? " " " " " "Direktur, "
" " " " " " " "unit "
" " " " " " " "terkait "
" " - IPCN "(sebut kantor, jml " " " " " "
" "- IPCO "tenaga & " " " " " "
" " "kualifikasi tenaga)" " " " " "
" " - Bagian sesuai "(sebutkan " " " " " "
" "dengan fungsi: "kualifikasi tenaga " " " " " "
" " "& DIK terkait PPI) " " " " " "
" " "jumlah " " " " " "
" " * Rawat Jalan " " " " " " "
" " * Rawat Inap "Medik: Bedah: " " " " " "
" "(+isolasi) "isolasi dll " " " " " "
" " "sebutkan " " " " " "
" " * Kamar Operasi" " " " " " "
" " * ICU-NICU " " " " " " "
" " * Gawat Darurat" " " " " " "
" " * Laboratorium " " " " " " "
" " * Radiologi " " " " " " "
" " * Sterilisasi " " " " " " "
" " * Gizi " " " " " " "
" " * " " " " " " "
" "Sanitasi–Lingkungan " " " " " " "
" " * Kamar mayat "Lihat poin 10 " " " " " "
" " * Ambulan " " " " " " "
" " * Cleaning " " " " " " "
" "service " " " " " " "
" " *HD " " " " " " "
" " " " " " " " "
" "*Endoscopy " " " " " " "
" " *VK " " " " " " "
" " " " " " " " "
" "*Laundry " " " " " " "
"1.1."Apakah pernah "(sebutkan kasus dan"B&O " " " "KPPI "
"2 "menangani Kejadian "frekuensi & lama " " " " " "
" "Luar Biasa ? "KLB; keberhasilan)" " " " " "
" "Apakah dalam "Sebutkan bantuan "B&O " " " "KPPI, "
" "menangani KLB "dari mana? " " " " "Komite lain"
" "dilakukan sendiri " " " " " " "
" "atau dengan bantuan " " " " " " "
" "pihak luar RS.? " " " " " " "
" " " " " " " " "
" " " " " " " " "
" " " " " " " " "
" " " " " " " " "
" " " " " " " " "
" " " " " " " " "
"2. "LINGKUNGAN " " " " " "Direktur "
" " " " " " " "KPPI "
" " " " " " " "Bidang "
" " " " " " " "Perencanaan"
" " " " " " " "Subbag "
" " " " " " " "Perlengkapa"
" " " " " " " "n "
" " " " " " " "IPAL "
" " * Tandon berasal" " " " " " "
" "dari PDAM " " " " " " "
" " * Tandon berasal"(sebutkan) " " " " " "
" "bukan PDAM " " " " " " "
" " * Tanpa Tandon " " " " " " "
" "langsung PDAM " " " " " " "
"2.2." Apakah dilakukan "Sebutkan frekuensi "B " " " " "
"2. "klorinasi pada air " " " " " " "
" "yang digunakan? " " " " " " "
"2.2."Bila ya! Apakah "Sebut alatnya dan "B " " " " "
"3. "proses klorinasi "pernah divalidasi? " " " " " "
" "tersebut menggunakan " " " " " " "
" "alat ? sebutkan! " " " " " " "
" " - Nama alat " " " " " " "
" " - pernah " " " " " " "
" "divalidasi " " " " " " "
" " - Kapan terakhir " " " " " " "
" "divalidasi " " " " " " "
"2.2."Pada tahap mana "Sebutkan : tandon –"B " " " " "
"4. "klorinasi dilakukan? "pipa distribusi " " " " " "
" " "atau lain-lain " " " " " "
" " - tandon " " " " " " "
" " - pipa distribusi " " " " " " "
" " - lain-lain " " " " " " "
"2.2."Apakah pernah "Sebutkan frekuensi "B " " " " "
"5. "dilakukan Pemeriksaan"& tempat " " " " " "
" "bakteriologis ? "pengambilan sampel " " " " " "
" "Berapa kali ? dan " " " " " " "
" "pengambilan sampel " " " " " " "
" "dari tahapan yang " " " " " " "
" "mana " " " " " " "
" " * Tandon " " " " " " "
" " * Unit " " " " " " "
" "Sterilisasi " " " " " " "
" " * Kamar operasi " " " " " " "
" " * ICU-NICU " " " " " " "
" " * Dialisis " " " " " " "
" " * Ruangan " " " " " " "
" "isolasi " " " " " " "
" " * Laboratorium " " " " " " "
" " * Gizi " " " " " " "
" " * Ruangan : " " " " " " "
" " * Pencucian " " " " " " "
"2.2."Apakah dilakukan "Lihat proses dan "B&O " " " " "
"6. "treatment Waste "peralatan water " " " " " "
" "water/ air buangan ? "treatment " " " " " "
"2.3."Udara " " " " " "IPL, IPAM, "
" " " " " " " "unit "
" " " " " " " "terkait "
" " * semua ruangan " " " " " " "
" " * Kamar operasi " " " " " " "
" "rutin " " " " " " "
" " * Kamar operasi " " " " " " "
" "setelah operasi " " " " " " "
" "Px dengan TB " " " " " " "
" " * Kamar operasi " " " " " " "
" "bila KLB " " " " " " "
" " * Ruangan isolasi " " " " " " "
" "(Airbone) " " " " " " "
" " * Ruangan isolasi " " " " " " "
" "seluruhnya " " " " " " "
" " * ICU-NICU " " " " " " "
" " * R. khusus " " " " " " "
" "imunologi rdh " " " " " " "
" " * R. penyimpana " " " " " " "
" "barang steril " " " " " " "
" " * Unit sterilisasi " " " " " " "
" " * GIZI " " " " " " "
" " * lain-lain " " " " " " "
"2.3."Setelah dilakukan " "B " " " " "
"2. "pemeriksaan & " " " " " " "
" "mengetahui hasilnya, " " " " " " "
" "Apa yang dilakukan? " " " " " " "
"2.4."Sampah " " " " " "IPL "
"2.4."Bagaimana cara " "B&O " " " " "
"2. "mengenali perbedaan " " " " " " "
" "sampah-sampah " " " " " " "
" "tersebut? " " " " " " "
"2.4."Bagaimana cara "Dengan alat yang "B&O " " " " "
"3. "pengangkutan sampah "bagaimana? " " " " " "
" "dari tempat pelayanan" " " " " " "
" "ke tempat pembuangan " " " " " " "
" "akhir ? " " " " " " "
" " - kereta tertutup " " " " " " "
" " - kereta terbuka " " " " " " "
"2.4."Apakah petugas "Sarung tangan karet"B&O " " " " "
"4. "pengangkut/ pengelola"Masker " " " " " "
" "sampah menggunakan "Sepatu karet " " " " " "
" "APD (Alat Pelindung "apron " " " " " "
" "Diri) dalam " " " " " " "
" "menjalankan tugas ? " " " " " " "
" " - Sarung tangan " " " " " " "
" "karet " " " " " " "
" " - Masker " " " " " " "
" " - Sepatu karet " " " " " " "
" " - Apron " " " " " " "
"2.4."Apakah di ruangan "Tempat sampah "O " " " " "
"5. "pelayanan disediakan "tertutup/terbuka. " " " " " "
" "tempat sampah? "Dibedakan ! " " " " " "
" "Sebutkan lokasi "Penempatan TS. " " " " " "
" " - tempat sampah "Sebutkan jumlah "O " " " " "
" "terbuka " " " " " " "
" " - tempat sampah "Sebutkan jumlah "O " " " " "
" "tertutup " " " " " " "
" " - tempat sampah "Untuk barang tajam "O " " " " "
" "khusus " " " " " " "
"2.4."Berapa kali " Perhatikan apa "B&O " " " " "
"6. "sampah-sampah di "nunggu penuh baru " " " " " "
" "tempat pelayanan "dibuang ? " " " " " "
" "dibuang ? " " " " " " "
"2.4."Bagaimana pembuangan "Cara & frekuensi "B&O " " " " "
"7. "sampah-sampah setelah"pembuangan " " " " " "
" "dikumpulkan dari " " " " " " "
" "ruang pelayanan " " " " " " "
"2.4."Apakah ada "Keadaan: terbuka – "B&O " " " " "
"6. "penampungan sampah "tertutup. " " " " " "
" "sementara ? bila ada "Keamanan / safety " " " " " "
" "sebutkan lokasi, " " " " " " "
" "keadaan nya " " " " " " "
"2.4."Apakah di RS ini " "B&O " " " " "
"7. "mempunyai alat " " " " " " "
" "Pembakaran sampah " " " " " " "
" "/incinarator? " " " " " " "
"2.4."Bila tidak, dimana "Bersama sampah "B " " " " "
"8. "sampah-sampah dibuang"masyarakat ? " " " " " "
" "? " " " " " " "
" " - Diangkut khusus " " " " " " "
" "ke insinarator tempat" " " " " " "
" "lain " " " " " " "
" " - dibuang bersama " " " " " " "
" "sampah masyarakat " " " " " " "
"2.4."Bila ada, apa saja "sebutkan "B&O " " " " "
"9. "yang dimasukkan " " " " " " "
" "kedalam incinarator? " " " " " " "
"3. "Kamar Operasi " " " " " "IBS, OKM "
" " - dinding "- dinding (jenis, " " " " " "
" " "letak almari) " " " " " "
" " - lantai (keramik; "Jenis, keadaan " " " " " "
" "vinyl dll) " " " " " " "
" " - langit-langit "Jenis, keadaan " " " " " "
" " - AC/filter udara – "Jenis-letak : " " " " " "
" "hepa "AC window – " " " " " "
" " "split-central-siste" " " " " "
" " "m filter. " " " " " "
"3.2."Apakah ada Pembagian " "O " " " " "
" "zona/ area gedung " " " " " " "
" "kamar operasi? " " " " " " "
"3.3."Babaimana system "15 X per jam "B&O " " " " "
" "udara kamar operasi "bergantian/3X per " " " " " "
" "?: "jam udara segar " " " " " "
" " "mengalir dari atas " " " " " "
" " "kebawah " " " " " "
" " "(rekomendasi " " " " " "
" " "–pabrik) " " " " " "
"3.4."Apakah menggunaan " "O " " " " "
" "lampu U.V. untuk " " " " " " "
" "sterilisasi K.O.? " " " " " " "
"3.5."Bagaimana Tekanan " "O " " " " "
" "ruangan kamar operasi" " " " " " "
" "? " " " " " " "
"3.6."Berapa Suhu kamar "tidak lebih dari "B&O " " " " "
" "operasi? "24(C " " " " " "
"3.7."Berapa Kelembaban "tidak lebih dari "B&O " " " " "
" "dari kamar operasi ? "50% " " " " " "
"3.8."Bagaimana keadaan "Design & keadaan "B&O " " " " "
" "pintu kamar operasi ?" " " " " " "
"3.9."Apakah mempunyai " "B&O " " " " "
" "SPO.alur Petugas? " " " " " " "
"3.10"Apakah mempunyai " "B&O " " " " "
". "SPO.alur Penderita ? " " " " " " "
"3.11"Apakah mempunyai SPO " "B&O " " " " "
". "penjadwalan operasi ?" " " " " " "
"3.12"Apakah mempunyai SPO "Termasuk "B&O " " " " "
". "alur barang "penyimpanan barang " " " " " "
" "steril-non steril ? "steril " " " " " "
"3.13"Apakah mempunyai SPO."- Lokasi "B&O " " " " "
". "penanganan disposal ?"- infeksi-non " " " " " "
" " "infeksi " " " " " "
" " "- kantung tertutup " " " " " "
"3.14"Dimana dilakukan "Lingkungan OK "O " " " " "
". "dekontaminasi "Unit " " " " " "
" "disposal ? "terilisasi/CSSD " " " " " "
" " "Pencucian " " " " " "
"3.15"Dimana dilakukan "OK "O " " " " "
". "sterilisasi peralatan"Unit " " " " " "
" "bedah? "terilisasi/CSSD " " " " " "
"3.16"Adakah SPO persiapan "- cuci tangan bedah"B&O " " " " "
". "operator? "- kesehatan " " " " " "
"3.17"Adakah SPO. Persiapan"- pencukuran "B&O " " " " "
" "Px ? "- Antibiotika " " " " " "
" " "profilaksis " " " " " "
"3.18"Adakah SPO. Peri "- tehnik asptis "B&O " " " "Bid. Keprwt"
" "operatif ? " " " " " "/yanmed "
"3.19"Adakah SPO perawatan "- peralatan yg "B&O " " " "Bid. Keprwt"
" "luka? "digunakan " " " " "/yanmed "
"3.20"Adalah SPO Pengecekan"frekuensi "B " " " "IPAM "
". "udara setelah operasi" " " " " " "
" "kasus TB.? " " " " " " "
"3.21"Adakah SPO Penggunaan" "B " " " "IBS, OKM "
". "masker N95 pada kasus" " " " " " "
" "TB? " " " " " " "
"3.22"Bagaimana keadaan "- kering "O " " " " "
". "Sikat untuk cuci "- kering " " " " " "
" "tangan bedah ? "disterilisasi " " " " " "
" " "- direndam " " " " " "
" " "disinfektan " " " " " "
"3.23"Adakah SPO untuk "Sebutkan frekuensi "B&O " " " " "
". "pembersihan kamar "& cara, bahan yg " " " " " "
" "operasi ? "digunakan (foging) " " " " " "
" " "- rutin setiap hari" " " " " "
" " "- besar : " " " " " "
" " "* 1minggu / kali " " " " " "
" " "* 2 minggu / kali " " " " " "
" " "* 1 bulan 1 kali " " " " " "
" " "* tidak pernah " " " " " "
" " " " " " " " "
"4. "Ruangan ISOLASI "Bila ada " " " " "Wadir Yan, "
" " " " " " " "Kabid "
" " " " " " " "Medik, "
" " " " " " " "Kabid "
" " " " " " " "Kprwt, WKB "
" " - Ruang ganti " " " " " " "
" "petugas " " " " " " "
" " - Ruang perawatan " " " " " " "
" "Px " " " " " " "
" " -Ruang cuci " " " " " " "
" "tangan/peralatan " " " " " " "
" " - ruang disposal " " " " " " "
" " - kamar mandi " " " " " " "
"4.2."Adakah SPO Pembagian "-airbone isolasi "B&O " " " " "
" "ruang Px menurut cara"-infeksi lain " " " " " "
" "penularan ? " " " " " " "
"4.3."Apakah Gedung "-tekanan negatif "B&O " " " " "
" "didisign dengan R.Px "Aliran udara >= 6X " " " " " "
" "tekanan negatif? "per jam (u/airbone)" " " " " "
" " " " " " " " "
" " "-dinding; pintu; " " " " " "
" " "langit-langit;lanta" " " " " "
" " "i " " " " " "
"4.4."Bagaimana system " "O " " " " "
" "aliran udara pada " " " " " " "
" "r.Perawatan Px ? " " " " " " "
" "-AC window " " " " " " "
" "-AC splite " " " " " " "
" "-Udara keluar ke " " " " " " "
" "koridor " " " " " " "
" "-Udara keluar ke area" " " " " " "
" "publik " " " " " " "
" "- dengan menggunakan " " " " " " "
" "filter/Hepa " " " " " " "
"4.5."Apakah tersedia Alat " "B&O " " " " "
" "Pelindung Diri(APD) " " " " " " "
" "untuk petugas & Px? " " " " " " "
" "-sarung tangan " " " " " " "
" "-Masker bedah/N95 " " " " " " "
" "-Topi " " " " " " "
" "-Gaun " " " " " " "
" "-Apron " " " " " " "
" "-Bungkus sepatu " " " " " " "
"4.6."Apakah APD tersebut "- letak tempat "O " " " " "
" "mudah diperoleh bila "penyimpanan " " " " " "
" "diperlukan? "- kunci? " " " " " "
"4.7."Adakah SPO untuk "- pengetahuan "B&O " " " " "
" "penggunaan APD ? "petugas " " " " " "
" " "- dik-lat " " " " " "
"4.8."Adakah SPO pencegahan"Cara &Kepatuhan "B&O " " " " "
" "Baku ? " " " " " " "
" "- cuci tangan " " " " " " "
" "prosudural " " " " " " "
" "- penggunaan APD " " " " " " "
" "- alur petugas-Px " " " " " " "
" "- "Tempat sampah " " " " " "
" "pengelolaan-disposal " " " " " " "
"4.9."Adakah SPO penangan "- Penempatan "B&O " " " " "
" "disposal ? "- dekontaminasi " " " " " "
"4.10"Apakah dilakukan " "O " " " " "
" "dekontaminasi di " " " " " " "
" "area R. Isolasi ? " " " " " " "
" "Bila ya, Bagaimana " " " " " " "
" "cara melakukannya ? " " " " " " "
" "- dengan klorin, " " " " " " "
" "tempat terbuka " " " " " " "
" "- dengan klorin " " " " " " "
" "tempat tertutup " " " " " " "
" "- disinfektan lain " " " " " " "
"4.11"Bagaimana keadaan & "- dilapisi dengan "O " " " " "
". "cara pembersihan "plastik; " " " " " "
" "kasur yang digunakan "disposible/reuse " " " " " "
" "untuk merawat " " " " " " "
" "penderita? " " " " " " "
"4.12"Apakah disediakan " "O " " " " "
". "fortable X ray unit? " " " " " " "
" "- alat suction " " " " " " "
" "- ventilator " " " " " " "
"4.13"Adakah Monitoring "- pencatatan jadwal"B&O " " " " "
". "petugas selama "- bila terjadi IN " " " " " "
" "bertugas di "termonitor " " " " " "
" "R.isolasi? " " " " " " "
" " " " " " " " "
"5. "PENCUCIAN " " " " " "Laundry "
"5.2."Adakah SPO pembagian "- mesin cuci kasus "B&O " " " " "
" "penggunaan alat-alat "infeksi " " " " " "
" "? " " " " " " "
"5.3."Adakah SPO. " "B&O " " " " "
" "Penggunaan APD ? " " " " " " "
" "- Masker " " " " " " "
" "- Topi " " " " " " "
" "- Sarung tangan karet" " " " " " "
" "- Apron " " " " " " "
" "- Sepatu karet " " " " " " "
"5.4."Adakah SPO " "B&O " " " " "
" "Pengangkutan linen ? " " " " " " "
" "- alat pengangkut " " " " " " "
" "(trolly " " " " " " "
" "tertutup/terbuka) " " " " " " "
" "- infeksi-noninfeksi " " " " " " "
" "- linen bersih-kotor " " " " " " "
" "- pembersihan alat " " " " " " "
" "pengangkut " " " " " " "
"5.5."Adakah sarana cuci " "O " " " " "
" "tangan ? " " " " " " "
"5.6."Adakah SPO Kontrol " "B&O " " " "IPL "
" "kualitas linen " " " " " " "
" "bersih? t.u. linen " " " " " " "
" "untuk operasi " " " " " " "
" "- kebersihan "sampling " " " " " "
" "- keutuhan " " " " " " "
" "- mikrobiologi " " " " " "IPL "
" "2 minggu 1 kali " " " " " " "
" "1 bulan 1 kali " " " " " " "
" "3 bulan 1 kali " " " " " " "
" "tidak pernah " " " " " " "
"6. "CUCI TANGAN " " " " " "KPPI "
"6.2."Apakah telah "- dik-lat "B&O " " " " "
" "dilakukan "- cakupan petugas " " " " " "
" "sosialisasikan " " " " " " "
" "keseluruh petugas " " " " " " "
" "terkait di RS ? " " " " " " "
"6.3."Apakah ada monitor "- cuci tangan "B&O " " " " "
" "atau survailan "- pengeringan " " " " " "
" "tentang kepatuhan "APD " " " " " "
" "petugas ? "penanganan disposal" " " " " "
" " " "O " " " "Perlengkpan"
"6.4."Adakah sarana Cuci "- letak " " " " " "
" "tangan dengan air "- jumlah " " " " " "
" "mengalir di tempat "- sabun yang " " " " " "
" "pelayanan ? "digunakan " " " " " "
" " "alat pengering/ " " " " " "
" " "handuk " " " " " "
"7. "CLEANING SERVICE " " " " " "C S "
"7.2 "Apakah petugas "- masker "O " " " " "
" "menggunakan APD pada "- sarung tangan " " " " " "
" "saat bekerja ? "karet " " " " " "
" " "- sepatu karet " " " " " "
" " "- apron " " " " " "
"7.3 "Adakah SPO untuk "Cek SPO "B&O " " " " "
" "pembersihan "Cek ke petugas " " " " " "
" "tumpahan/percikan " " " " " " "
" "darah dan cairan " " " " " " "
" "tubuh ? Bagaimana " " " " " " "
" "pelaksanaannya? " " " " " " "
"7.4."Siapa yang melakukan " "B " " " "Perlengkpan"
" "supervisi untuk " " " " " " "
" "petugas CS ? " " " " " " "
" " " " " " " " "
" " " " " " " " "
"8. "KESEHATAN KESELAMATAN" " " " " "K3, "
" "KERJA " " " " " " "
"8.2."Bila pernah, Apa yang" "O " " " " "
" "saudara lakukan ? " " " " " " "
"8.3."Apakah saudara " "O " " " " "
" "melaporkan kejadian " " " " " " "
" "ini ? kepada siapa/ " " " " " " "
" "adakah tindak " " " " " " "
" "lanjutnya ? " " " " " " "
"8.4."Bagaimana cara "Ditanyakan pada "O " " " " "
" "saudara menangani "petugas di ruangan;" " " " " "
" "semprit yang telah "laboratorium " " " " " "
" "digunakan ? " " " " " " "
"8.5."Apakah saudara " "O " " " " "
" "melakukan " " " " " " "
" "dekontaminasi pada " " " " " " "
" "barang-barang " " " " " " "
" "setelah digunakan ? " " " " " " "
"8.6."Bila ya. Barang apa " "O " " " " "
" "saja? Dimana " " " " " " "
" "dilakukan? Bagaimana " " " " " " "
" "caranya? " " " " " " "
"9. "RUANGAN "Pengamatan " " " " "Terkait "
" " "dilakukan di " " " " " "
" " "ICU-NICU, R. " " " " " "
" " "isolasi,Lab. " " " " " "
"9.2."Bagaimana persediaan "Wadah, "O " " " " "
" "& penggunakan kapas "Cara menggunakan " " " " " "
" "alkohol ? " " " " " " "
" "-kapas dibasahi " " " " " " "
" "alcohol dalam wadah " " " " " " "
" "tertutup " " " " " " "
" "-kapas dibasahi " " " " " " "
" "alcohol dalam wadah " " " " " " "
" "terbuka " " " " " " "
" "-kapas diperas diatas" " " " " " "
" "wadah sebelum " " " " " " "
" "digunakan " " " " " " "
" "-kapas disemprot " " " " " " "
" "alcohol sebelum " " " " " " "
" "digunakan " " " " " " "
"9.3."Bagaimana pengobatan "Amati "O* " " " " "
" "luka dilakukan ? "- tehnik aseptis " " " " " "
" "- instrumen sebelum " " " " " " "
" "digunakan direndam " " " " " " "
" "disinfektan " " " " " " "
" "- Instrumen steril " " " " " " "
" "digunakan beberapa Px" " " " " " "
" "kasus sama " " " " " " "
" "- instrumen steril " " " " " " "
" "satu Px satu set dan " " " " " " "
" "direused " " " " " " "
" "- instrumen steril " " " " " " "
" "disposible " " " " " " "
"9.4."Bagaimana pengelolaan"Pengamatan cara & "O " " " " "
" "obat injeksi multiple"penyimpanan " " " " " "
" "dose ? " " " " " " "
" "- jarum tetap diatas " " " " " " "
" "tutup karet " " " " " " "
"9.5."Apakah tersedia "- jumlah "O " " " " "
". "tempat sampah ? "- letak " " " " " "
" " "- jenis " " " " " "
"9.6."Apakah dilakukan " " " " " " "
" "reuse untuk " " " " " " "
" "barang-barang " " " " " " "
" "disposible ? " " " " " " "
"9.7."Bila ya. Sebutkan " "O " " " " "
" "jenis , cara & " " " " " " "
" "frekuensi, di mana " " " " " " "
" "dilakukan ? " " " " " " "
"9.8."Diamati tentang "- jumlah "O " " " " "
" "Termometer "- penempatan " " " " " "
" " "- cara pemakaian/ " " " " " "
" " "disinfeksi " " " " " "
"9.9."Diamati selang "- penggantian "O* " " " " "
" "oksigen, alat suction"- tehnik aseptis " " " " " "
"10 "KAMAR JENASAH " " " " " " "
" " " " " " " " "
" " " " " " " " "
" " " " " " " " "
"11 "GIZI " " " " " " "
"11.2"Sanitasi & "Pengelolaan alat " " " " " "
" "Pengontrolan "makan secara benar:" " " " " "
" "engineering "infeksius-noninfeks" " " " " "
" " "ius. " " " " " "
" " "Tersedia wastafel " " " " " "
" " "air panas utk " " " " " "
" " "sterilisasi " " " " " "
" " "peralatan makan dan" " " " " "
" " "dapur debngan 3 bak" " " " " "
" " "pencuci yang " " " " " "
" " "berbeda. " " " " " "
" " "Ventilasi positif " " " " " "
" " "Tudung biologis " " " " " "
" " "Thermostat pd unit " " " " " "
" " "pendingin " " " " " "
" " "penyimpanan bhn " " " " " "
" " "makanan " " " " " "
" " "Perabotan masak " " " " " "
" " "harus memenuhi " " " " " "
" " "persyaratan fisisk " " " " " "
" " "& bakteriologis " " " " " "
" " "(bebas kuman) & " " " " " "
" " "tidak dicampur " " " " " "
" " "adukkan " " " " " "
" " "penggunaannya " " " " " "
" " "(Pemisahan telenan " " " " " "
" " "utk pemotongan " " " " " "
" " "protein hewani) " " " " " "
"11.3"Penjamah makanan "Sesuai dgn " " " " " "
" " "Permenkes " " " " " "
" " "RI no 236/Menkes/IV" " " " " "
" " "/1997 " " " " " "
" " "APD " " " " " "
" " "Sceening petugas " " " " " "
" " " " " " " " "
Keterangan :
B = Bukti dokumen
O = Observasi- pengamatan
O* = Observasi dan simulasi/pertanyaan tahapan
Jumlah tempat tidur :
Jumlag dokter :
Jumlah perawat :
Kamar Operasi : terpisah Jumlah :
Unit Sterilisasi : terpusat
Ruangan yang diamati :
Kamar Operasi
ICU-NICU
R. Isolasi
Unit Sterilisasi
SINGKATAN :
"1 "TS: tidak significant ": tidak ada cidera "
"2 "R: resiko rendah / minor ": cidera ringan, misl luka lecet, dpt "
" " "diatasi dengan P3K "
"3 "M: resiko moderat ": Cidera sedang, misl luka robek, "
" " "berkurang fungsi "
" " "motorik/sensorik/psikologis/intelektual "
" " "(reversible). Tidak berhubungan dg "
" " "penyakit, setiap kasus yg memperpanjang "
" " "perawatan "
"4 "T: resiko tinggi / mayor ": cedera luas / berat, misl cacat "
" " "lumpuh, kehilangan fungsi "
" " "motorik/sensorik/psikologis/intelektual "
"5 "E: resiko ekstrim / ": kematian yg tidakberhubungan dgn "
" "katastropik "perjalanan penyakitnya "
