UCLA SMH CLABSI PREVENTION CHECKLIST

• UCLA SMH CLABSI PREVENTION CHECKLIST

• Client / Site

• Conducted on

  Date

• Prepared by

• Personnel

PHYSICIAN NECESSITY EVALUATION & DOCUMENTATION:

• Is there physician documentation of necessity for the line to remain in place daily for the past 7 days?

  Yes

  No

  N/A

NURSING LINE EVALUATION & DOCUMENTATION:

• Is the central line dressing occlusive and intact?

  Yes

  No

  N/A

• Is CVC insertion site healthy with no redness or drainage?

  Yes

  No

  N/A

• Is the CVC line labeled with date of insertion? For permanent intravascular devices inserted prior to admission, utilize N/A.

  Yes

  No

  N/A

• Date & time of last dressing change is less than 7 days for transparent or less than 48 hours for gauze dressing? (PICC dressing change 24 hours after insertion)

  Yes

  No

  N/A

• All the CVC tubing's are labeled with date & time? No tubing,Utilize N/A.

  Yes

  No

  N/A

• Do all the CVC tubing dates adhere to the policies (less than 96 hours for IV fluid/meds; less than 24 hours for TPN & lipids? No tubing, utilize N/A.

  Yes

  No

  N/A

• If stopcock present, is non-vented covering/cap present over unused port? No stop cock, utilize N/A.

  Yes

  No

  N/A

OTHER FINDINGS

• Add media

  Media