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CentralLineChecklist

Indicationtocompleteform:Toreviewproceduralpracticesrelatedtoinsertion,maintenanceandremovalofcentrallines includingCVPlines,PAC,dialysisaccessports,andPICC.*Ifthereisanobservedbreachofinfectioncontrolpractices,STOPtheline placementimmediatelyandcorrecttheissue.

PatientLabel

Date: SupervisingMD:

Present
ProcedureClinician: ProcedureRN: Insertedin: ED SICU

Notpresent

Privileged NotPrivileged
Unit M/SICU NSICU

Present Notpresent OR IR MICU CCU Bed# Other:

Typeofcatheter: CentralLine Pulmonaryartery DialysisCatheter DoesthepatientcurrentlyhaveaCVADinplace? Yes No Emergent Re wire Wastheprocedure Elective Insertionsite: Femoral RLReason: Subclavian RL Cephalic R L Brachial RL Other: # of catheters used to complete theinsertion ConsentDocumented? Indications to place the line: Yes

PICCline

Jugular RL Basilic R L

#ofattemptstoinsertthisline

YES NO

SAFEPRACTICES BeforeProcedure,assuminganonemergentsituation,didtheteam
1. Performatimeout&completethetimeoutform:Rightpatient,Rightsite,Rightprocedure? 2. Washhandsfor20secondsasrequired?

Duringtheprocedure:
1. Didprocedurephysicianfollowmaximumsterileprecautions? Didassistingphysicianfollowmaximumsterileprecautions? Handwashing,sterilegloves,gown,hat,largedrape&maskduringcatheterinsertion 2. Wasthesterilefieldmaintained? 3. WasthesitepreppedwithChloraprep/Chlorhexidine? 4. Wasultrasoundused? 5. Didallobservingstaffintheroomwearamask&cap?

Aftertheprocedure:
1. 2. 3. 4. 5. 6. 7. 8. Wassteriletechniquemaintainedwhenapplyingdressing? Wasdressinglabeledwithdateandtime? Werethereanyimmediatecomplications?List: Washandwashingdonepostprocedure?20secondsisrequired Wascatheterorguidewirecompletelyremoved,inspected&counted? WastheBiopatchappliedproperly? Wasthexrayreviewed? Wasthelineinsertiondocumented?

Comments:

SignatureofProcedureRN(ifpresent)/printname&date

SignatureofProcedureclinician/printorstampname&date

Ver.I2010 *ElementsofthechecklistinboldconstitutetheCentralLineBundle CCLW:OfficeofHealthcareImprovement

SAFEPRACTICES Removal:
1. 2. 3. 4. 5. 6. 7. Wastheneedforacatheterdocumenteddaily?(Required) Howmanydayswasthelineinplace? Wasthelineproperlylabeled? Wasthedressingdryandintact? Wasthesiteclean? WasthecentrallineusedforTPN? Wereallcomponentsoflineremovedandcatheterinspected?

YES NO

Comments:

TheCentralLineChecklistiscompletedbytheprocedureclinicianornurse.Theformiscollectedandmonitoredasperfacility protocol.

SignatureofProcedureRN(ifpresent)/printname&date

SignatureofProcedureclinician/printorstampname&date

Ver.I2010 *ElementsofthechecklistinboldconstitutetheCentralLineBundle CCLW:OfficeofHealthcareImprovement

CentralLineMaintenanceChecklist
Unit: Bed#: PatientsName: MR#: CatheterInsertionDate: LastDressingChangeDate: CatheterType: CentralVenousCatheter PulmonaryArteryCatheter DialysisCatheter PICCLine Arterial Catheter (Femoral site ONLY) Other: InsertionSite: RightJugular LeftJugular RightCephalic LeftCephalic Right Subclavian Left Subclavian Right Basilic LeftBasilic LeftFemoral RightBrachial LeftBrachial RightFemoral
PleasecircleeitherYforYesorNforNo Indicator Date Day# T1 T2 T3 Date Day# T1 Date Day# T1 Date Day# T1 T3 Date Day# T1 Date Day# T1 Date Day# T1 T3

T2 T3 DressingType (seebelow) Dressingclean,dry Y/N Y/N Y/N Y/N Y/N Y/N andintact Tendernessatthe Y/N Y/N Y/N Y/N Y/N Y/N site Unusedlumens capped,lockedand Y/N Y/N Y/N Y/N Y/N Y/N covered Dressingchanged Tubingchanged RNinitials Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N G=Gauze

T2

T3

T2

T2

T3

T2

T3

T2

Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

DressingType: S=Semipermeable

SignatureRecordonreverseside
OfficeofHealthcareImprovement

KeyPoints:
Assessthedressingeveryshiftandchangeifdamp,loosenedorsoiled. Changethetransparentdressingevery7daysorifdressingbecomesdamp,loosenedorsoiled. Changegauzedressingevery2daysorifdressingbecomesdamp,loosenedorsoiled. Catheteristobereplacedwithin24hourswheninsertedunderemergency,unsterileconditions. Catheteristobereplacedimmediatelyifsignsorsymptomsofinfection,infiltration,orcatheterdamagearepresent. Thefemoralveinistheleastpreferredinsertionsiteandshouldbereservedforemergencysituationsorwhennoothersitecanbeused. ChlorhexidineandBiopatchMAYNOTbeusedforinfantslessthan2monthsofage.UsePovidoneiodinebasedsolutionsforthesepatients. Centrallinetubingistobechangedevery72hoursorwhenitiscontaminated.Tubingmustbedated,timedandinitialedafterithasbeenchanged. Centrallinetubingistobechangedevery24hourswhenusedfor/withTPN,Propofolorintralipids.

DressingChangeChecklist
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Identifythepatientfordressingchange. Collectappropriateequipment(CentralLineMaintenanceKit). Washyourhands. ExplaintheproceduretothepatientandpositionthepatientsupineorsemiFowlerspositionwithheadturnedawayfromthedressingsite.Ifpatientisintubated, suctionthepatientpriortopositioning. Donprotectivewear,surgicalmask,cleangloves,sterilegowns,andcap. Carefullyloosenandremovetheolddressingdowntotheinsertionsite.Pullthedressingtowardstheexitsiteofalongtermcatheterortowardstheinsertionsiteofa shorttermcatheter(thishelpspreventpullingouttheline). Inspecttheareaaroundthesiteforanysignsofinfection(redness,swelling,drainage,tenderness,warmth,orodor). NotifyMDforanysignsorsymptomsofinfection. Deglove,washyourhandsadheretostricthandhygieneusingsoap. Openkit,createasterilefieldanddonsterileglove. Securecatheterfrommovement.Cleansethecatheterinsertionsiteusingappropriateantiseptictechnique;2%Chlorhexidinebasedpreparationispreferred.DONOT backswabtheinsertionsite.Donotfanorblowonthesite.Discardtheapplicatorafterasingleuse. Alwaysallowtheantiseptictoremainontheinsertionsiteandtodry. ApplyBiopatch(blueinthesky)andtransparentdressing.Applytapearoundtheedgesofthedressing. Labeldressingwithdate,timeandinitials. Discarduseditems,washhandsanddocumentinthepatientsmedicalrecordthefollowing:dateandtimeofdressingchanged,observationofsite,anysignsof complicationsandpatientsresponseandtoleranceoftheprocedure.

SignatureRecord
Initials

Signature

Initials

Signature

OfficeofHealthcareImprovement