CLABSI

• Patient Name

• Room Number

• MRN

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

EMR

• Type of Line

  Select CVC PICC TEMP HD CATH PERMCATH SWAN/ INTRODUCER UMBILICAL LINE PORT MIDLINE

  • CVC
  • PICC
  • TEMP HD CATH
  • PERMCATH
  • SWAN/ INTRODUCER
  • UMBILICAL LINE
  • PORT
  • MIDLINE

• Is order in EMR

  Yes

  No

  N/A

• Indications for use

  Select Peripheral venous administration contraindicated Hemodynamic support Alternate to repetitive cannulations TPN Inadequate peripheral venous access Replace dislodged central line Replace malfunctioning central line Suspected central line associated infection Other (see comments)

  • Peripheral venous administration contraindicated
  • Hemodynamic support
  • Alternate to repetitive cannulations
  • TPN
  • Inadequate peripheral venous access
  • Replace dislodged central line
  • Replace malfunctioning central line
  • Suspected central line associated infection
  • Other (see comments)

• CHG Bathing done

  Yes

  No

  N/A

• Does patient have documented allergy to CHG?

  Yes

  No

  N/A

• Documented Tubing changes every 96 hours

  Yes

  No

  N/A

Visualization of Line

• SwabCaps in place on all appropriate hubs

  Yes

  No

  N/A

• Biopatch appropriately placed at insertion site

  Yes

  No

  N/A

• Dressing clean/dry/intact

  Yes

  No

  N/A

• Is Line sutured appropriately?

  Yes

  No

  N/A

• Is all tubing labeled

  Yes

  No

  N/A

• Do all lumens have blood return, flush appropriately, or have an infusion currently active

  Yes

  No

  N/A

• Is dressing labeled with initials / date

  Yes

  No

  N/A

• If secured with securement device, is it used appropriately

  Yes

  No

  N/A

Observation of Nurse

• Did Nurse wash hands prior to accessing line

  Yes

  No

  N/A

• Is nurse proactive in getting line taken out when appropriate.

  Yes

  No

  N/A