HAP Resource Center

Guidelines: Audit Form for CDI/Contact Precaution Compliance

  • Review patients with diarrhea of unknown origin or who had a C. diff test ordered. Were they on appropriate isolation? Yes/No. This is for your own information and not reported in the data portal.
  • Audit at least ten rooms for compliance with enteric or contact precautions. These can be for C.diff or other MDROs. It is preferable to get a full observation (hand hygiene in and out) but if this is not possible, then be consistent in what you observe (i.e. all “ins” or “outs”). It is preferable to have trained observers (can be staff from environmental services or a patient advocate or respiratory staff) to alleviate the burden of data collection. If you have a very low volume of patients on isolation, please let the project manager know that you are unable to collect 10 observations.
  • Keep track of totals for precaution compliance results collected (hand hygiene, gowns, gloves). Total number of rooms observed is your denominator. Numerator is the number of “Yes” for each measure. These can be shared monthly with your coach.

Download the checklist to document patient room number, isolation (if applicable)_, hand hygiene before and after patient contact, and use of gloves and gowns during patient contact.


Topics: Population Health, Quality Initiatives

Revision Date: 9/1/2019

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