{"text_format":"1","workbook":"xlsx","n_sheets":20,"sheets":["Drop Down","Results","Home","Contents","Instructions","Assessment Tool","Patient Washing","Hair Removal","Skin Disinfection","Preventing Skin Recolonisation","Prophylactic antibiotics","Warming Intravenous","Pre-Operative Patient Warming","Intra-Operative Patient Warming","Post-Operative Patient Warming","Maintaining asepsis","Maintaining asepsis instrument","Surgical environment","Wound Management","SSI"],"not_rendered":{"charts":0,"images":49,"macros":1,"external_links":0,"defined_names":1,"comments":2,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

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[null,null,null,null,"     Assessment Selection:"]
["MENU"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Assessment","Score","Out of"]
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[null,null,null,null,null,null,{"$f":"'Patient Washing'!$Y$1","v":"Incomplete"},null,null,null,{"$f":"'Hair Removal'!$Y$1","v":"Incomplete"},null,null,null,{"$f":"'Skin Disinfection'!$Y$1","v":"Incomplete"},null,null,null,{"$f":"'Preventing Skin Recolonisation'!$Y$1","v":"Incomplete"},null,null,null,{"$f":"'Prophylactic antibiotics'!$Y$1","v":"Incomplete"},null,null,null,null,null,null,null,1.2,{"$f":"'Hair Removal'!$Z$1","v":""},20,{"$f":"IF(AF14=\"\",\"\",AG14)","v":""}]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,{"$f":"'Prophylactic antibiotics'!$Z$1","v":""},16,""]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,3.1,{"$f":"'Warming Intravenous'!$Z$1","v":""},20,""]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,3.2,{"$f":"'Pre-Operative Patient Warming'!$Z$1","v":""},24,""]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,3.3,{"$f":"'Intra-Operative Patient Warming'!$Z$1","v":""},28,""]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,3.4,{"$f":"'Post-Operative Patient Warming'!$Z$1","v":""},20,""]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,4.0999999999999996,{"$f":"'Maintaining asepsis'!$Z$1","v":""},16,""]
[null,null,null,null,null,null,{"$f":"'Warming Intravenous'!$Y$1","v":"Incomplete"},null,null,null,{"$f":"'Pre-Operative Patient Warming'!$Y$1","v":"Incomplete"},null,null,null,{"$f":"'Intra-Operative Patient Warming'!$Y$1","v":"Incomplete"},null,null,null,{"$f":"'Post-Operative Patient Warming'!$Y$1","v":"Incomplete"},null,null,null,{"$f":"'Maintaining asepsis'!$Y$1","v":"Incomplete"},null,null,null,null,null,null,null,4.2,{"$f":"'Maintaining asepsis instrument'!$Z$1","v":""},32,""]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,5,{"$f":"'Surgical environment'!$Z$1","v":""},20,""]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,6,{"$f":"'Wound Management'!$Z$1","v":""},16,""]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,7,{"$f":"SSI!$Z$1","v":""},24,""]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(AF13:AF26)","v":0},null,{"$f":"SUM(AH13:AH26)","v":0}]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Overall Compliance Score"]
[]
[]
[null,null,null,null,null,null,{"$f":"'Maintaining asepsis instrument'!$Y$1","v":"Incomplete"},null,null,null,{"$f":"'Surgical environment'!$Y$1","v":"Incomplete"},null,null,null,{"$f":"'Wound Management'!$Y$1","v":"Incomplete"},null,null,null,{"$f":"SSI!$Y$1","v":"Incomplete"},null,{"$f":"IFERROR(SUM(AF27/AH27),\"Incomplete\")","v":"Incomplete"}]

{"sheet":"Home","index":2,"n_rows":30,"n_cols":5,"rows_kept":30,"cut":false,"hidden":false,"merged":[[21,4,22,6],[23,4,24,6],[6,0,7,2],[29,7,30,17],[25,4,26,6],[27,4,28,6],[29,4,30,6],[15,7,16,17],[17,7,18,17],[19,7,20,17],[21,7,22,17],[23,7,24,17],[25,7,26,17],[27,7,28,17],[15,4,16,6],[17,4,18,6],[19,4,20,6]]}
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[]
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["MENU"]
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[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,"HOSPITAL OR TRUST"]
[]
[null,null,null,null,"THEATRE SPECIALITY"]
[]
[null,null,null,null,"PERSONNEL CONDUCTING\nASSESSMENT"]
[]
[null,null,null,null,"Name and job title"]
[]
[null,null,null,null,"Name and job title"]
[]
[null,null,null,null,"Name and job title"]
[]
[null,null,null,null,"Name and job title"]
[]
[null,null,null,null,"DATE(S) OF ASSESSMENT"]

{"sheet":"Contents","index":3,"n_rows":7,"n_cols":1,"rows_kept":7,"cut":false,"hidden":false,"merged":[[6,0,7,2]]}
[]
[]
[]
[]
[]
[]
["MENU"]

{"sheet":"Instructions","index":4,"n_rows":7,"n_cols":1,"rows_kept":7,"cut":false,"hidden":false,"merged":[[6,0,7,2]]}
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[]
[]
[]
[]
[]
["MENU"]

{"sheet":"Assessment Tool","index":5,"n_rows":7,"n_cols":1,"rows_kept":7,"cut":false,"hidden":false,"merged":[[6,0,7,2]]}
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[]
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[]
[]
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["MENU"]

{"sheet":"Patient Washing","index":6,"n_rows":29,"n_cols":26,"rows_kept":29,"cut":false,"hidden":false,"merged":[[6,0,7,2],[27,18,27,20],[28,18,31,20],[27,15,31,17],[27,12,31,14],[19,18,21,20],[22,12,24,14],[22,15,24,17],[22,18,24,20],[25,12,26,14],[25,15,26,17],[25,18,26,20],[22,5,24,11],[22,4,24,4],[25,5,26,11],[25,4,26,4],[15,12,18,14],[15,15,18,17],[19,12,21,14],[19,15,21,17],[7,4,8,20],[15,4,18,4],[15,5,18,11],[19,5,21,11],[19,4,21,4],[15,18,18,20]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"S29","v":"Incomplete"},{"$f":"IF(M16=\"\",\"\",SUM(M16:R27))","v":""}]
[]
[]
[]
[]
[]
["MENU"]
[null,null,null,null,"1.1 PATIENT WASHING"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"Defined standard",null,null,"Standard is applied",null,null,"Comments"]
[null,null,null,null,"NICE recommends that patients should shower or have a bath (or be",null,null,null,null,null,null,null,"Present in local policy",null,null,"Evidence that element is"]
[null,null,null,null,"assisted to shower, bath or bed bath) using soap, either the day before, or",null,null,null,null,null,null,null,null,null,null,"performed"]
[null,null,null,null,"on the day of surgery.",null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,null,null,null,"If ‘partial’ – specify where"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,"non-compliant"]
[]
[null,null,null,null,1,"Prior to elective admission: Patients are given verbal and written information on washing. This includes what they should do, why this is important and how to ask for help."]
[]
[]
[]
[null,null,null,null,2,"There is a defined process to assist patients unable to wash by themselves."]
[]
[]
[null,null,null,null,3,"There is a defined process for assisting patients undergoing emergency\nprocedures to wash wherever this is possible."]
[]
[]
[null,null,null,null,4,"The patient wash is recorded in the pre-operative checklist."]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(M16:O27)/(8)","v":0},null,null,{"$f":"SUM(P16:R27)/(8)","v":0},null,null,"Overall % Compliance"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(M16=\"\",\"Incomplete\",SUM(M16:R27)/(16))","v":"Incomplete"}]

{"sheet":"Hair Removal","index":7,"n_rows":29,"n_cols":26,"rows_kept":29,"cut":false,"hidden":false,"merged":[[6,0,7,2],[7,4,8,20],[15,4,18,4],[15,5,18,11],[15,12,18,14],[15,15,18,17],[15,18,18,20],[27,12,31,14],[27,15,31,17],[27,18,27,20],[28,18,31,20],[21,4,22,4],[21,5,22,11],[21,12,22,14],[21,15,22,17],[21,18,22,20],[25,4,26,4],[25,5,26,11],[25,12,26,14],[25,15,26,17],[25,18,26,20],[23,4,24,4],[23,5,24,11],[23,12,24,14],[23,15,24,17],[23,18,24,20],[19,4,20,4],[19,5,20,11],[19,12,20,14],[19,15,20,17],[19,18,20,20]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"S29","v":"Incomplete"},{"$f":"IF(M16=\"\",\"\",SUM(M16:R27))","v":""}]
[]
[]
[]
[]
[]
["MENU"]
[null,null,null,null,"1.2 HAIR REMOVAL"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"Defined standard",null,null,"Standard is applied",null,null,"Comments"]
[null,null,null,null,"NICE recommends that razors should not be used for hair removal",null,null,null,null,null,null,null,"Present in local policy",null,null,"Evidence that element is"]
[null,null,null,null,"because they increase the risk of SSI. If hair must be removed, then",null,null,null,null,null,null,null,null,null,null,"performed"]
[null,null,null,null,"clippers with disposable heads are recommended.",null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,null,null,null,"If ‘partial’ – specify where"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,"non-compliant"]
[]
[null,null,null,null,1,"Prior to elective admission: patients are given verbal and written information not to shave or remove hair from operative site. This includes why this is important and how to ask for help."]
[]
[]
[]
[null,null,null,null,2,"Hair removal is only undertaken where it is necessary to visualise the\noperative site."]
[]
[null,null,null,null,3,"Hair is removed as near to time of incision as possible."]
[]
[null,null,null,null,4,"Hair is removed using clippers with single-use disposable head."]
[]
[null,null,null,null,5,"Staff who are responsible for hair removal have been trained and are\ncompetent in performing the procedure."]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(M16:O27)/(10)","v":0},null,null,{"$f":"SUM(P16:R27)/(10)","v":0},null,null,"Overall % Compliance"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(M16=\"\",\"Incomplete\",SUM(M16:R27)/(20))","v":"Incomplete"}]

{"sheet":"Skin Disinfection","index":8,"n_rows":25,"n_cols":26,"rows_kept":25,"cut":false,"hidden":false,"merged":[[6,0,7,2],[7,4,8,20],[15,4,18,4],[15,5,18,11],[15,12,18,14],[15,15,18,17],[15,18,18,20],[23,12,27,14],[23,15,27,17],[23,18,23,20],[24,18,27,20],[19,4,22,4],[19,5,22,11],[19,12,22,14],[19,15,22,17],[19,18,22,20],[23,4,24,4],[23,5,24,11]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"S25","v":"Incomplete"},{"$f":"IF(M16=\"\",\"\",SUM(M16:R23))","v":""}]
[]
[]
[]
[]
[]
["MENU"]
[null,null,null,null,"1.3 SKIN DISINFECTION"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"Defined standard",null,null,"Standard is applied",null,null,"Comments"]
[null,null,null,null,"NICE recommends that the skin should be disinfected immediately",null,null,null,null,null,null,null,"Present in local policy",null,null,"Evidence that element is"]
[null,null,null,null,"prior to the incision with chlorhexidine or providence-iodine",null,null,null,null,null,null,null,null,null,null,"performed"]
[null,null,null,null,"(alcoholic or aqueous)",null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,null,null,null,"If ‘partial’ – specify where"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,"non-compliant"]
[]
[null,null,null,null,1,"There is a defined skin disinfection process agreed by a multi-disciplinary team that states the specific agent, application method, timing and person responsible."]
[]
[]
[]
[null,null,null,null,2,"All products used for skin disinfection are intended for use as a surgical skin disinfectant and must have an associated management protocol.\nE.g. multi-dose bottles: date of opening and use by date."]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(M16:O23)/(4)","v":0},null,null,{"$f":"SUM(P16:R23)/(4)","v":0},null,null,"Overall % Compliance"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(M16=\"\",\"Incomplete\",SUM(M16:R23)/(8))","v":"Incomplete"}]

{"sheet":"Preventing Skin Recolonisation","index":9,"n_rows":23,"n_cols":26,"rows_kept":23,"cut":false,"hidden":false,"merged":[[21,18,21,20],[7,4,8,20],[18,18,20,20],[22,18,25,20],[15,4,17,4],[15,5,17,11],[15,12,17,14],[15,15,17,17],[15,18,17,20],[18,4,20,4],[18,5,20,11],[18,12,20,14],[18,15,20,17],[23,4,24,4],[23,5,24,11],[6,0,7,2],[21,12,25,14],[21,15,25,17]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"S23","v":"Incomplete"},{"$f":"IF(M16=\"\",\"\",SUM(M16:R21))","v":""}]
[]
[]
[]
[]
[]
["MENU"]
[null,null,null,null,"1.4 PREVENTING SKIN RECOLONISATION"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"Defined standard",null,null,"Standard is applied",null,null,"Comments"]
[null,null,null,null,"NICE recommends that if an incise drape is used, this should be",null,null,null,null,null,null,null,"Present in local policy",null,null,"Evidence that element is"]
[null,null,null,null,"iodophore impregnated unless the patient has an iodine allergy.",null,null,null,null,null,null,null,null,null,null,"performed"]
[null,null,null,null,null,null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,null,null,null,"If ‘partial’ – specify where"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,"non-compliant"]
[]
[null,null,null,null,1,"For surgical procedures where an incise drape is required an iodophore\nimpregnated drape is used (unless the patient has an iodine allergy)."]
[]
[]
[null,null,null,null,2,"The manufacturers guidance on incise drape size selection and method of application is adhered to."]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(M16:O21)/(4)","v":0},null,null,{"$f":"SUM(P16:R21)/(4)","v":0},null,null,"Overall % Compliance"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(M16=\"\",\"Incomplete\",SUM(M16:R21)/(8))","v":"Incomplete"}]

{"sheet":"Prophylactic antibiotics","index":10,"n_rows":29,"n_cols":26,"rows_kept":29,"cut":false,"hidden":false,"merged":[[6,0,7,2],[24,4,26,4],[15,5,17,11],[18,5,20,11],[21,5,23,11],[24,5,26,11],[7,4,8,20],[15,12,17,14],[15,15,17,17],[15,18,17,20],[15,4,17,4],[18,4,20,4],[21,4,23,4],[18,12,20,14],[21,12,23,14],[21,18,23,20],[18,15,20,17],[18,18,20,20],[21,15,23,17],[27,12,31,14],[27,15,31,17],[27,18,27,20],[28,18,31,20],[24,12,26,14],[24,15,26,17],[24,18,26,20]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"S29","v":"Incomplete"},{"$f":"IF(M16=\"\",\"\",SUM(M16:R27))","v":""}]
[]
[]
[]
[]
[]
["MENU"]
[null,null,null,null,"2 PROPHYLACTIC ANTIBIOTICS"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"Defined standard",null,null,"Standard is applied",null,null,"Comments"]
[null,null,null,null,"Antibiotics are given as indicated to minimise the risk of infection and",null,null,null,null,null,null,null,"Present in local policy",null,null,"Evidence that element is"]
[null,null,null,null,"reduce the emergence of antibiotic resistance.",null,null,null,null,null,null,null,null,null,null,"performed"]
[null,null,null,null,null,null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,null,null,null,"If ‘partial’ – specify where"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,"non-compliant"]
[]
[null,null,null,null,1,"There is a defined list of surgical procedures where prophylactic antibiotics may be required."]
[]
[]
[null,null,null,null,2,"For surgical procedures where prophylactic antibiotics are indicated the\nrecommended agents and dose and are identified."]
[]
[]
[null,null,null,null,3,"Prophylactic antibiotics are administered within 60 minutes before the incision."]
[]
[]
[null,null,null,null,4,"A single dose of prophylactic antibiotics is administered unless surgery is prolonged or there is another specific indication for a repeat dose."]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(M16:O27)/(8)","v":0},null,null,{"$f":"SUM(P16:R27)/(8)","v":0},null,null,"Overall % Compliance"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(M16=\"\",\"Incomplete\",SUM(M16:R27)/(16))","v":"Incomplete"}]

{"sheet":"Warming Intravenous","index":11,"n_rows":31,"n_cols":26,"rows_kept":31,"cut":false,"hidden":false,"merged":[[6,0,7,2],[21,4,23,4],[21,5,23,11],[21,12,23,14],[21,15,23,17],[18,5,20,11],[18,12,20,14],[18,15,20,17],[29,12,33,14],[29,15,33,17],[29,18,29,20],[30,18,33,20],[15,4,17,4],[15,5,17,11],[15,12,17,14],[15,15,17,17],[15,18,17,20],[27,4,28,4],[27,5,28,11],[27,12,28,14],[27,15,28,17],[24,4,26,4],[24,5,26,11],[24,12,26,14],[27,18,28,20],[18,4,20,4],[18,18,20,20],[21,18,23,20],[7,4,8,20],[24,15,26,17],[24,18,26,20]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"S31","v":"Incomplete"},{"$f":"IF(M16=\"\",\"\",SUM(M16:R29))","v":""}]
[]
[]
[]
[]
[]
["MENU"]
[null,null,null,null,"3.1 WARMING INTRAVENOUS AND IRRIGATION FLUIDS"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"Defined standard",null,null,"Standard is applied",null,null,"Comments"]
[null,null,null,null,"Intravenous fluids (500 ml or more) and blood products should be",null,null,null,null,null,null,null,"Present in local policy",null,null,"Evidence that element is"]
[null,null,null,null,"warmed to 37°C using a fluid warming device following manufacturer’s",null,null,null,null,null,null,null,null,null,null,"performed"]
[null,null,null,null,"instructions. All irrigation fluids used intra-operatively should be warmed",null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,null,null,null,"If ‘partial’ – specify where"]
[null,null,null,null,"in a thermostatically controlled cabinet to a temperature of 38–40°C.",null,null,null,null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,"non-compliant"]
[]
[null,null,null,null,1,"All intravenous fluids (500 ml or more) and blood products are warmed\nduring operative procedures."]
[]
[]
[null,null,null,null,2,"All irrigation fluids used intra-operatively should be warmed in a\nthermostatically controlled cabinet to a temperature of 38–40°C."]
[]
[]
[null,null,null,null,3,"There is sufficient and the appropriate equipment available for warming intravenous and irrigation fluids."]
[]
[]
[null,null,null,null,4,"The temperature of warmed irrigation fluids is measured to ensure the\ntemperature is within the recommended temperature range 38-40°C."]
[]
[]
[null,null,null,null,5,"Staff are trained in the use of fluid warming devices."]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(M16:O29)/(10)","v":0},null,null,{"$f":"SUM(P16:R29)/(10)","v":0},null,null,"Overall % Compliance"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(M16=\"\",\"Incomplete\",SUM(M16:R29)/(20))","v":"Incomplete"}]

{"sheet":"Pre-Operative Patient Warming","index":12,"n_rows":51,"n_cols":26,"rows_kept":51,"cut":false,"hidden":false,"merged":[[9,4,14,11],[6,0,7,2],[25,4,28,4],[25,5,28,11],[25,12,28,14],[25,15,28,17],[19,4,21,4],[19,5,21,11],[19,12,21,14],[19,15,21,17],[7,4,8,20],[15,4,18,4],[15,5,18,11],[15,12,18,14],[15,15,18,17],[15,18,18,20],[25,18,28,20],[35,12,39,14],[35,15,39,17],[35,18,35,20],[36,18,39,20],[29,4,31,4],[29,5,31,11],[29,12,31,14],[29,15,31,17],[29,18,31,20],[32,4,34,4],[32,5,34,11],[32,12,34,14],[32,15,34,17],[32,18,34,20],[19,18,21,20],[22,4,24,4],[22,5,24,11],[22,12,24,14],[22,15,24,17],[22,18,24,20]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"S37","v":"Incomplete"},{"$f":"IF(M16=\"\",\"\",SUM(M16:R35))","v":""}]
[]
[]
[]
[]
[]
["MENU"]
[null,null,null,null,"3.2 PRE-OPERATIVE PATIENT WARMING"]
[]
[null,null,null,null,"NICE recommends all patients should be assessed for their risk of perioperative hyopthermia. All patients should be actively warmed on the ward/emergancy department at least 30 minutes prior to induction of anaesthesia If the patients temperature is below 36°C or at risk of hypothermia, they should be warmed immediately. The patients core temperature should be 36°C or above before being transferred to theatre, unless there is a need to expedite surgery. ",null,null,null,null,null,null,null,"Defined standard",null,null,"Standard is applied",null,null,"Comments"]
[null,null,null,null,null,null,null,null,null,null,null,null,"Present in local policy",null,null,"Evidence that element is"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"performed"]
[null,null,null,null,null,null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,null,null,null,"If ‘partial’ – specify where"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,"non-compliant"]
[]
[null,null,null,null,1,"Prior to elective admission: Patients are given verbal and written information on the importance of keeping warm. This includes what they should do, why this is important and how to ask for help."]
[]
[]
[]
[null,null,null,null,2,"The patients’ risk of hypothermia is assessed pre-operatively and recorded."]
[]
[]
[null,null,null,null,3,"Measure the patient’s temperature using a site that produces a direct measure or direct estimate of core temperature, within one hour before transfer to theatre."]
[]
[]
[null,null,null,null,4,"All patients should be actively warmed for at least 30 minutes prior to induction of anaesthesia. If the patient’s temperature is below 36°C or are at high risk of hypothermia they are warmed immediately."]
[]
[]
[]
[null,null,null,null,5,"All patients are kept warm and comfortable before and during transfer to theatre and active warming should be continued or restarted as soon as possible."]
[]
[]
[null,null,null,null,6,"Preoperative staff are trained in the use of temperature monitoring equipment and warming devices. "]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(M16:O35)/(12)","v":0},null,null,{"$f":"SUM(P16:R35)/(12)","v":0},null,null,"Overall % Compliance"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(M16=\"\",\"Incomplete\",SUM(M16:R35)/(24))","v":"Incomplete"}]
[]
[]
[null,null,null,null,"GUIDANCE ON COMPLETING 3.2 PRE-OPERATIVE  "]
[null,null,null,null,"1 a) Check what written and verbal information patients are given at pre-assessment clinic. This should include informing patients about the consequences of perioperative hypothermia and that remaining adequately covered and staying warm will reduce these risks."]
[null,null,null,null,"b) Ask ﬁve patients waiting for surgery if they were given advice about keeping warm."]
[null,null,null,null,"2a) Check if theatre/pre-assessment clinic/ward protocols include this standard."]
[null,null,null,null,"b) Review ﬁve patient records to check that risk of hypothermia is assessed and documented at pre-assessment clinic and/or anesthetic assessment."]
[null,null,null,null,"[The presence of two or more of the following factors increases the risk of perioperative hypothermia and indicates need for forced air warming: ASA grade 2 – 5 (higher grade > risk);undergoing combined general and regional anaesthesia; major or intermediate surgery; risk of cardiovascular complications; temperature below 36°C]."]
[null,null,null,null,"3a) Check if ward protocols include procedures for checking a patient’s temperature preoperatively using a site that measures either a direct measurement of core temperature or a direct estimate of core temperature. These sites are: pulmonary artery, distal oesophagus, urinary bladder, zero heat-ﬂux (deep forehead), sublingual, axilla or rectum. Devices that provide an indirect measure or estimate of core temperature, (e.g. infrared tympanic, infrared temporal, infrared forehead & forehead strips) are not recommended."]
[null,null,null,null,"b) Query ward staff to establish if the patient’s temperature is taken within an hour of surgery and what they do if a patient’s temperature is below 36°C."]
[null,null,null,null,"4a) Check if ward protocols include procedures for actively warming patients preoperatively. Active warming is a process that transfers heat to the patient rather than passively keeping them warm. This can be achieved using forced-air warming or conductive fabric devices."]
[null,null,null,null,"b) Query ward staff to establish what action is taken if a patient’s temperature is below 36°C and if appropriate equipment to deliver active warming is available on the ward/unit."]
[null,null,null,null,"5) Query the ward staff about how they ensure that patients are kept warm prior to going to theatre. For example: blankets are provided and patients use dressing gown/slippers if walking."]
[null,null,null,null,"6) Check with ward staff if they are trained in the use of temperature monitoring equipment and warming devices."]

{"sheet":"Intra-Operative Patient Warming","index":13,"n_rows":56,"n_cols":26,"rows_kept":56,"cut":false,"hidden":false,"merged":[[38,5,40,11],[6,0,7,2],[38,12,42,14],[38,15,42,17],[38,18,38,20],[39,18,42,20],[7,4,8,20],[9,4,14,11],[15,4,17,4],[15,5,17,11],[15,12,17,14],[15,15,17,17],[15,18,17,20],[18,4,20,4],[18,5,20,11],[18,12,20,14],[18,15,20,17],[18,18,20,20],[25,4,28,4],[25,5,28,11],[25,12,28,14],[25,15,28,17],[25,18,28,20],[21,4,24,4],[21,5,24,11],[21,12,24,14],[21,15,24,17],[21,18,24,20],[32,4,34,4],[32,5,34,11],[32,12,34,14],[32,15,34,17],[32,18,34,20],[29,4,31,4],[29,5,31,11],[29,12,31,14],[29,15,31,17],[29,18,31,20],[35,4,37,4],[35,5,37,11],[35,12,37,14],[35,15,37,17],[35,18,37,20]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"S40","v":"Incomplete"},{"$f":"IF(M16=\"\",\"\",SUM(M16:R38))","v":""}]
[]
[]
[]
[]
[]
["MENU"]
[null,null,null,null,"3.3 INTRA-OPERATIVE PATIENT WARMING"]
[]
[null,null,null,null,"NICE recommends that patients having anaesthesia for longer than 30 minutes, or at a higher risk of perioperative hypothermia are warmed from induction of anaesthesia using forced-air warming.",null,null,null,null,null,null,null,"Defined standard",null,null,"Standard is applied",null,null,"Comments"]
[null,null,null,null,null,null,null,null,null,null,null,null,"Present in local policy",null,null,"Evidence that element is"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"performed"]
[null,null,null,null,null,null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,null,null,null,"If ‘partial’ – specify where"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,"non-compliant"]
[]
[null,null,null,null,1,"The patient should be adequately covered to conserve heat and only\nexposed during surgical preparation."]
[]
[]
[null,null,null,null,2,"There is sufficient and appropriate equipment available to measure patient’s temperature using a site that produces either a direct measure or direct estimate of core temperature. "]
[]
[]
[null,null,null,null,3,"The patient’s core temperature should be measured and recorded before induction of anaesthesia. If less than 36°C, then anaesthesia should not commence, unless there is a need to expedite surgery."]
[]
[]
[]
[null,null,null,null,4,"The patient's temperature should be measured and recorded every 30 minutes, using a site that produces either a direct measure or direct estimate of core temperature. "]
[]
[]
[]
[null,null,null,null,5,"All patients are actively warmed using forced-air warming* throughout the intraoperative phase, except those identified as low risk of hypothermia and whose surgery will last less than 30 minutes. "]
[]
[]
[null,null,null,null,6,"There is sufficient and appropriate equipment to administer active warming using forced air* within the theatre."]
[]
[]
[null,null,null,null,7,"Intraoperative staff are trained in the use of temperature monitoring equipment and warming devices. "]
[]
[]
[null,null,null,null,null,"* A resistive heating mattress or blanket may be considered if a forced-air warming device is unsuitable.",null,null,null,null,null,null,{"$f":"SUM(M16:O38)/(14)","v":0},null,null,{"$f":"SUM(P16:R38)/(14)","v":0},null,null,"Overall % Compliance"]
[null,null,null,null,null,"* A resistive heating mattress or blanket may be considered if a forced-air warming device is unsuitable.",null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(M16=\"\",\"Incomplete\",SUM(M16:R38)/(28))","v":"Incomplete"}]
[]
[]
[null,null,null,null,"GUIDANCE ON COMPLETING 3.3 INTRA-OPERATIVE WARMING  "]
[null,null,null,null,"1 a) Check if theatre protocol includes this standard."]
[null,null,null,null,"   b) Observe ﬁve patients on a list to establish if the standard is adhered to."]
[null,null,null,null,"2 a) Check if suitable equipment is available to measure patient temperature."]
[null,null,null,null,"   b) Query theatre staff to establish if there is sufﬁcient equipment to do this when required."]
[null,null,null,null,"3  a) Check if theatre protocol includes this standard."]
[null,null,null,null,"   b) Observe ﬁve patients on a list to establish if the standard is adhered to."]
[null,null,null,null,"4 a) Check if theatre protocol includes this standard."]
[null,null,null,null,"   b) Observe ﬁve patients on a list to establish if the standard is adhered to."]
[null,null,null,null,"5 a) Check if theatre protocol includes this standard."]
[null,null,null,null,"  b) Observe ﬁve patients on a list to establish if the standard is adhered to."]
[null,null,null,null,"6 a) Check if suitable equipment is available to deliver forced-air warming."]
[null,null,null,null,"  b) Query theatre staff to establish if there is sufﬁcient equipment to do this when required."]
[null,null,null,null,"7   Check with theatre staff if they are trained in the use of temperature monitoring equipment and warming devices."]

{"sheet":"Post-Operative Patient Warming","index":14,"n_rows":44,"n_cols":26,"rows_kept":44,"cut":false,"hidden":false,"merged":[[6,0,7,2],[7,4,8,20],[18,5,20,11],[18,12,20,14],[18,15,20,17],[18,18,20,20],[30,12,34,14],[30,15,34,17],[30,18,30,20],[31,18,34,20],[15,4,17,4],[15,5,17,11],[15,12,17,14],[15,15,17,17],[15,18,17,20],[18,4,20,4],[24,4,26,4],[24,5,26,11],[24,12,26,14],[24,15,26,17],[24,18,26,20],[21,4,23,4],[21,5,23,11],[21,12,23,14],[21,15,23,17],[21,18,23,20],[27,4,29,4],[27,5,29,11],[27,12,29,14],[27,15,29,17],[27,18,29,20]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"S32","v":"Incomplete"},{"$f":"IF(M16=\"\",\"\",SUM(M16:R30))","v":""}]
[]
[]
[]
[]
[]
["MENU"]
[null,null,null,null,"3.4 POST-OPERATIVE PATIENT WARMING"]
[]
[null,null,null,null,"The postoperative period is defined as 24 hours after the patient enters",null,null,null,null,null,null,null,"Defined standard",null,null,"Standard is applied",null,null,"Comments"]
[null,null,null,null,"the recovery area. The patient’s temperature should be monitored and",null,null,null,null,null,null,null,"Present in local policy",null,null,"Evidence that element is"]
[null,null,null,null,"documented every 15 minutes in recovery. The patient should not be",null,null,null,null,null,null,null,null,null,null,"performed"]
[null,null,null,null,"transferred to the ward, until their temperature is 36°C or above.",null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,null,null,null,"If ‘partial’ – specify where"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,"non-compliant"]
[]
[null,null,null,null,1,"The patient’s core temperature is measured and recorded every 15 minutes in recovery."]
[]
[]
[null,null,null,null,2,"Patients with a core temperature less then 36°C are actively warmed with forced air, until their temperature reaches a normothermic level."]
[]
[]
[null,null,null,null,3,"Patients should not be returned to the ward if their temperature is less than 36°C."]
[]
[]
[null,null,null,null,4,"There is sufficient and appropriate equipment to administer forced air\nwarming within recovery if required."]
[]
[]
[null,null,null,null,5,"Post-operative staff are trained in the use of temperatue warming devices. "]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(M16:O30)/(10)","v":0},null,null,{"$f":"SUM(P16:R30)/(10)","v":0},null,null,"Overall % Compliance"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(M16=\"\",\"Incomplete\",SUM(M16:R30)/(20))","v":"Incomplete"}]
[]
[]
[null,null,null,null,"GUIDANCE ON COMPLETING 3.4 POST-OPERATIVE. "]
[null,null,null,null,"1 a) Check if recovery protocol includes this standard."]
[null,null,null,null,"   b) Observeﬁvepatients in recovery to establish if the standard is adhered to."]
[null,null,null,null,"2 a) Check if recovery protocol includes this standard."]
[null,null,null,null,"   b )Observe ﬁvepatients in recovery to establish if the standard is adhered to."]
[null,null,null,null,"3  a) Check if recovery protocol includes this standard."]
[null,null,null,null,"   b) Observe ﬁvepatients in recovery to establish if the standard is adhered to."]
[null,null,null,null,"4  a) Check if suitable equipment is available to deliver forced air warming."]
[null,null,null,null,"   b) Query theatre staff to establish if there is sufﬁcient equipment to do this when required."]
[null,null,null,null,"5     Check with recovery staff if they are trained in the use of temperature monitoring equipment and warming devices"]

{"sheet":"Maintaining asepsis","index":15,"n_rows":28,"n_cols":26,"rows_kept":28,"cut":false,"hidden":false,"merged":[[6,0,7,2],[24,4,25,4],[24,5,25,11],[7,4,8,20],[15,4,17,4],[15,5,17,11],[15,12,17,14],[15,15,17,17],[15,18,17,20],[21,4,23,4],[21,5,23,11],[21,12,23,14],[21,15,23,17],[21,18,23,20],[18,4,20,4],[18,5,20,11],[18,12,20,14],[26,12,30,14],[26,15,30,17],[26,18,26,20],[27,18,30,20],[18,15,20,17],[18,18,20,20],[24,12,25,14],[24,15,25,17],[24,18,25,20]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"S28","v":"Incomplete"},{"$f":"IF(M16=\"\",\"\",SUM(M16:R26))","v":""}]
[]
[]
[]
[]
[]
["MENU"]
[null,null,null,null,"4.1 MAINTAINING ASEPSIS - SURGICAL PRACTICE"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"Defined standard",null,null,"Standard is applied",null,null,"Comments"]
[null,null,null,null,"The principles of aseptic technique must be adhered to by staff involved",null,null,null,null,null,null,null,"Present in local policy",null,null,"Evidence that element is"]
[null,null,null,null,"in the surgical procedure.",null,null,null,null,null,null,null,null,null,null,"performed"]
[null,null,null,null,null,null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,null,null,null,"If ‘partial’ – specify where"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,"non-compliant"]
[]
[null,null,null,null,1,"Operating staff are trained and assessed as competent in performing\nsurgical hand antisepsis, gowning and gloving scrub."]
[]
[]
[null,null,null,null,2,"Operating staff performing surgical hand antisepsis, gowning and gloving correctly immediately prior to commencing surgery."]
[]
[]
[null,null,null,null,3,"Operating staff are trained and assessed as competent in the maintenance and management of the sterile field."]
[]
[]
[null,null,null,null,4,"Operating staff maintain and manage sterile field correctly."]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(M16:O26)/(8)","v":0},null,null,{"$f":"SUM(P16:R26)/(8)","v":0},null,null,"Overall % Compliance"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(M16=\"\",\"Incomplete\",SUM(M16:R26)/(16))","v":"Incomplete"}]

{"sheet":"Maintaining asepsis instrument","index":16,"n_rows":38,"n_cols":26,"rows_kept":38,"cut":false,"hidden":false,"merged":[[6,0,7,2],[7,4,8,20],[15,4,18,4],[15,5,18,11],[15,12,18,14],[15,15,18,17],[15,18,18,20],[21,4,23,4],[21,5,23,11],[21,12,23,14],[21,15,23,17],[21,18,23,20],[36,12,40,14],[36,15,40,17],[36,18,36,20],[37,18,40,20],[26,4,27,4],[26,5,27,11],[26,12,27,14],[26,15,27,17],[26,18,27,20],[31,4,32,4],[31,5,32,11],[31,12,32,14],[31,15,32,17],[31,18,32,20],[28,4,30,4],[28,5,30,11],[24,4,25,4],[24,5,25,11],[24,12,25,14],[24,15,25,17],[24,18,25,20],[19,4,20,4],[19,5,20,11],[19,12,20,14],[19,15,20,17],[19,18,20,20],[28,12,30,14],[28,15,30,17],[28,18,30,20],[33,4,35,4],[33,5,35,11],[33,12,35,14],[33,15,35,17],[33,18,35,20]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"S38","v":"Incomplete"},{"$f":"IF(M16=\"\",\"\",SUM(M16:R36))","v":""}]
[]
[]
[]
[]
[]
["MENU"]
[null,null,null,null,"4.2 MAINTAINING ASEPSIS - INSTRUMENT MANAGEMENT"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"Defined standard",null,null,"Standard is applied",null,null,"Comments"]
[null,null,null,null,"All instrumentation should be suitably decontaminated and sterilised prior",null,null,null,null,null,null,null,"Present in local policy",null,null,"Evidence that element is"]
[null,null,null,null,"to surgical use.",null,null,null,null,null,null,null,null,null,null,"performed"]
[null,null,null,null,null,null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,null,null,null,"If ‘partial’ – specify where"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,"non-compliant"]
[]
[null,null,null,null,1,"Instruments should be decontaminated and sterilised in a credited central sterilisation unit which is compliant to quality management systems."]
[]
[]
[]
[null,null,null,null,2,"An instrument traceability system is in use."]
[]
[null,null,null,null,3,"There are defined mechanisms in place for recognising sterile integrity of instrumentation."]
[]
[]
[null,null,null,null,4,"Sterile instruments are stored in a clean, dry, dust free environment."]
[]
[null,null,null,null,5,"All sterile items have an identifiable event related shelf–life."]
[]
[null,null,null,null,6,"All perioperative staff are competent in the handling of sterile instruments."]
[]
[]
[null,null,null,null,7,"Instrumentation is set up immediately prior to surgical use."]
[]
[null,null,null,null,8,"There is a defined process to change instrumentation if contamination is identified."]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(M16:O36)/(16)","v":0},null,null,{"$f":"SUM(P16:R36)/(16)","v":0},null,null,"Overall % Compliance"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(M16=\"\",\"Incomplete\",SUM(M16:R36)/(32))","v":"Incomplete"}]

{"sheet":"Surgical environment","index":17,"n_rows":32,"n_cols":26,"rows_kept":32,"cut":false,"hidden":false,"merged":[[6,0,7,2],[7,4,8,20],[18,5,20,11],[18,12,20,14],[18,15,20,17],[18,18,20,20],[30,12,34,14],[30,15,34,17],[30,18,30,20],[31,18,34,20],[15,4,17,4],[15,5,17,11],[15,12,17,14],[15,15,17,17],[15,18,17,20],[18,4,20,4],[24,4,26,4],[24,5,26,11],[24,12,26,14],[24,15,26,17],[24,18,26,20],[21,4,23,4],[21,5,23,11],[21,12,23,14],[21,15,23,17],[21,18,23,20],[27,4,29,4],[27,5,29,11],[27,12,29,14],[27,15,29,17],[27,18,29,20]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"S32","v":"Incomplete"},{"$f":"IF(M16=\"\",\"\",SUM(M16:R30))","v":""}]
[]
[]
[]
[]
[]
["MENU"]
[null,null,null,null,"5 SURGICAL ENVIRONMENT"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"Defined standard",null,null,"Standard is applied",null,null,"Comments"]
[null,null,null,null,"Ensuring that the risk of airborne contamination entering the operative",null,null,null,null,null,null,null,"Present in local policy",null,null,"Evidence that element is"]
[null,null,null,null,"site is kept to a minimum.",null,null,null,null,null,null,null,null,null,null,"performed"]
[null,null,null,null,null,null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,null,null,null,"If ‘partial’ – specify where"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,"non-compliant"]
[]
[null,null,null,null,1,"The required air pressure and ventilation systems across the operating\ntheatre (including anaesthetic and scrub rooms) is defined."]
[]
[]
[null,null,null,null,2,"There is a defined process to ensure that the doors to the operating theatre remain closed while an operation is in progress."]
[]
[]
[null,null,null,null,3,"There is a defined number of staff that may be present within the operating theatre for each procedure."]
[]
[]
[null,null,null,null,4,"There is a defined process to monitor traffic in and out of the operating\ntheatre to ensure it is kept within agreed limits."]
[]
[]
[null,null,null,null,5,"There is a defined process to ensure that equipment is cleaned to remove all dust prior to it being brought into the operating theatre."]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(M16:O30)/(10)","v":0},null,null,{"$f":"SUM(P16:R30)/(10)","v":0},null,null,"Overall % Compliance"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(M16=\"\",\"Incomplete\",SUM(M16:R30)/(20))","v":"Incomplete"}]

{"sheet":"Wound Management","index":18,"n_rows":30,"n_cols":26,"rows_kept":30,"cut":false,"hidden":false,"merged":[[6,0,7,2],[18,18,20,20],[7,4,8,20],[15,4,17,4],[15,5,17,11],[15,12,17,14],[15,15,17,17],[15,18,17,20],[18,4,20,4],[18,5,20,11],[18,12,20,14],[18,15,20,17],[21,18,24,20],[25,18,27,20],[25,4,27,4],[28,12,32,14],[28,15,32,17],[28,18,28,20],[29,18,32,20],[21,4,24,4],[21,5,24,11],[21,12,24,14],[21,15,24,17],[25,5,27,11],[25,12,27,14],[25,15,27,17]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"S30","v":"Incomplete"},{"$f":"IF(M16=\"\",\"\",SUM(M16:R28))","v":""}]
[]
[]
[]
[]
[]
["MENU"]
[null,null,null,null,"6 WOUND MANAGEMENT"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"Defined standard",null,null,"Standard is applied",null,null,"Comments"]
[null,null,null,null,"NICE recommends that surgical incisions should be covered with an",null,null,null,null,null,null,null,"Present in local policy",null,null,"Evidence that element is"]
[null,null,null,null,"appropriate interactive dressing at the end of the operation.",null,null,null,null,null,null,null,null,null,null,"performed"]
[null,null,null,null,null,null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,null,null,null,"If ‘partial’ – specify where"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,"non-compliant"]
[]
[null,null,null,null,1,"There is a defined range of interactive wound dressings available for all\nprocedures."]
[]
[]
[null,null,null,null,2,"There is a surgical wound management plan for all procedures that includes the use of any wound drain."]
[]
[]
[null,null,null,null,3,"Wound management information is provided to the patient verbally and in written form. This includes information on how to look after their wound, what to expect and how and when to ask for help."]
[]
[]
[]
[null,null,null,null,4,"There is access to a tissue viability expert for all in-patients with surgical wounds. "]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(M16:O28)/(8)","v":0},null,null,{"$f":"SUM(P16:R28)/(8)","v":0},null,null,"Overall % Compliance"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(M16=\"\",\"Incomplete\",SUM(M16:R28)/(16))","v":"Incomplete"}]

{"sheet":"SSI","index":19,"n_rows":38,"n_cols":26,"rows_kept":38,"cut":false,"hidden":false,"merged":[[6,0,7,2],[7,4,8,20],[15,4,18,4],[15,5,18,11],[15,12,18,14],[15,15,18,17],[15,18,18,20],[36,12,40,14],[36,15,40,17],[36,18,36,20],[37,18,40,20],[25,4,29,4],[25,5,29,11],[25,12,29,14],[25,15,29,17],[25,18,29,20],[30,4,32,4],[30,5,32,11],[30,12,32,14],[30,15,32,17],[30,18,32,20],[33,4,35,4],[33,5,35,11],[33,12,35,14],[33,15,35,17],[33,18,35,20],[19,4,21,4],[19,5,21,11],[19,12,21,14],[19,15,21,17],[19,18,21,20],[22,4,24,4],[22,5,24,11],[22,12,24,14],[22,15,24,17],[22,18,24,20]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"S38","v":"Incomplete"},{"$f":"IF(M16=\"\",\"\",SUM(M16:R36))","v":""}]
[]
[]
[]
[]
[]
["MENU"]
[null,null,null,null,"7 SURVEILLANCE OF SURGICAL SITE INFECTION (SSI)"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"Defined standard",null,null,"Standard is applied",null,null,"Comments"]
[null,null,null,null,"SSI is monitored using a standardised surveillance methodology to",null,null,null,null,null,null,null,"Present in local policy",null,null,"Evidence that element is"]
[null,null,null,null,"provide feedback to surgeons and the surgical team about the quality of",null,null,null,null,null,null,null,null,null,null,"performed"]
[null,null,null,null,"infection prevention in the operating theatre, and to provide patients with",null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,null,null,null,"If ‘partial’ – specify where"]
[null,null,null,null,"accurate information about the risk of SSI associated with the operation.",null,null,null,null,null,null,null,null,null,null,"N = 0; Partial = 1; Yes = 2",null,null,"non-compliant"]
[]
[null,null,null,null,1,"Patients are provided with verbal and written information about the risks of SSI associated with their operation. This includes how and when they should report problems with their wound."]
[]
[]
[]
[null,null,null,null,2,"There is a planned programme of SSI surveillance that covers major surgery over a defined period, e.g. 5 years."]
[]
[]
[null,null,null,null,3,"There is a robust process for data collection to assess rates of SSI based on a standardised surveillance methodology."]
[]
[]
[null,null,null,null,4,"There is a system in place to capture data on SSI that develop after the\npatient has been discharged from hospital. E.g. detection of patients\nreadmitted with SSI and/or post-discharge patient review or questionnaire."]
[]
[]
[]
[]
[null,null,null,null,5,"Results of surveillance are reviewed by the surgical teams, theatre staff and hospital Governance structures."]
[]
[]
[null,null,null,null,6,"High or increased rates (or unusually low rates) are investigated and\nappropriate action taken to address any problems identified."]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(M16:O36)/(12)","v":0},null,null,{"$f":"SUM(P16:R36)/(12)","v":0},null,null,"Overall % Compliance"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(M16=\"\",\"Incomplete\",SUM(M16:R36)/(24))","v":"Incomplete"}]