ISOLATION CASE WORKFLOW CHECKLIST (OR + PACU)
Hospital: ________________________ | OR/PACU/Anesthesia	Form Code: F-28 | Version: ___ | Effective: ___ | PAGE 1 of 1

SECTION 1 — PATIENT / PRECAUTIONS
Date: ________________     Time: ________________ Patient MRN: ___________________________________ Procedure: _____________________________________	Precautions required: ☐ Standard    ☐ Contact    ☐ Droplet    ☐ Airborne ☐ Other: ________________________________ IPC notified:    ☐ Yes    ☐ No Name: ______________________    Time: _________

SECTION 2 — PRE-CASE PLANNING

☐ Case scheduled with isolation considerations (end of list if feasible) ☐ PPE available outside room (correct sizes) ☐ Signage placed (precautions) ☐ Transport route planned (minimize exposure)    Route: _________________________________________ ☐ Receiving areas informed (PACU/ICU/ward) ☐ Minimal essential equipment prepared only (avoid extra supplies) ☐ Dedicated/disposable items prepared as per policy (if applicable)

SECTION 3 — OR / PROCEDURE ROOM SETUP

☐ Doors closed plan / minimize entry-exit ☐ Anesthesia machine and high-touch surfaces protected/covered as approved ☐ Suction/oxygen/monitors ready ☐ Waste bins + sharps bin available at point of use ☐ Closed container ready for contaminated reusable devices to CSSD/HLD (use F-28)

SECTION 4 — INTRA-CASE PRACTICE

☐ Hand hygiene performed per moments ☐ Safe injection / hub disinfection performed ☐ Contaminated items contained immediately (no open transport) Notes: _________________________________________________________________________________________________

SECTION 5 — PACU / RECOVERY PLAN

Recovery location:    ☐ Main PACU (isolation bay/room)    ☐ PACU-equivalent area    ☐ ICU    ☐ Ward Handover method:    ☐ Face-to-face in PPE    ☐ SBAR with isolation reminders PPE availability confirmed in recovery area:    ☐ Yes    ☐ No Transport monitoring plan confirmed:    ☐ Yes    ☐ No

SECTION 6 — POST-CASE CLEANING & RELEASE

☐ Anesthesia work area between-case cleaning done (F-28) (if next case same room)    ☐ N/A ☐ Anesthesia machine cleaning per policy done (F-28)    ☐ N/A ☐ Reusables sent for reprocessing (F-28)    ☐ Yes    ☐ No ☐ Waste disposed per regulated pathway ☐ Terminal cleaning completed by EVS (sign-off below)

TERMINAL CLEANING SIGN-OFF
EVS Name/Sign: ____________________________________ Time: _________	OR Charge Nurse verification: ____________________________________ Time: _________	Anesthesia verification (anesthesia zone complete): ____________________________________ Time: _________