ICU Safety Rounds Checklist

• Patient Name

• ICU Room No.

• Conducted on

  Date

• Prepared by

Central line bundle

• Does the patient have a central line?<br>

  Yes

  No

  N/A

• Were maximum barrier precautions used when central line was placed?<br>

  Yes

  No

  N/A

• Should the central line remain in place?

  Yes

  No

  N/A

• Is the central line dressing clean/dry/intact?

  Yes

  No

  N/A

Ventilator bundle

• Is the HOB at or above 30 Degrees?

  Yes

  No

  N/A

• Is the patient receiving PUD prophylaxis?

  Yes

  No

  N/A

• Is the patient receiving DVT Prophylaxis?

  Yes

  No

  N/A

• Has the patient received oral care ever 4 hours?

  Yes

  No

  N/A

• Did the patient receive oral rinse with CHG and toothbrushing every 12 hours?

  Yes

  No

  N/A

• DId the patient undergo a spontaneous breathing trial?

  Yes

  No

  N/A

• If spontaneous breathing trial completed, did the patient pass?

  Yes

  No

  N/A

• If extubation criterion met, was the patient extubated? <br>

  Yes

  No

  N/A

Completion

• Full Name and Signature of Attending Nurse

  Sign