Appendix 5: Central Line Insertion Care Team Checklist

Tools for Reducing Central Line-Associated Blood Stream Infections

These tools will help your unit implement evidence-based practices and eliminate central line-associated blood stream infections (CLABSI). When used with the CUSP (Comprehensive Unit-based Safety Program) Toolkit, these tools dramatically reduced CLABSI rates in more than 1,000 hospitals across the country.

 

Patient Name: ______________________________ Hx#:____________ Unit: ____________ Date/Time:____________

A minimum of 5 supervised successful procedures in both the chest and femoral sites is required (10 total). If a physician successfully performs 5 supervised lines in one site, he or she is independent for that site only. A total of 3 supervised rewires is required prior to performing a rewire independently.

Supervisor Role: 2nd year resident and above (approved for line placement). Assistant Role: RN, ClinTech, MD, NP, PA (responsible for completing checklist).

If there is a deviation in any of the critical steps, immediately notify the operator and stop the procedure. If a correction is required, make a check mark in the “Yes With Reminder” column and note the correction in the comment space. Report uncorrected deviations and complications of line placement. Contact the attending if any item on the checklist is not adhered to or if there are any concerns. Return this completed form to the designated person in your area.

Critical StepsYesYes With ReminderProcedure Deviation: Complete ReportComments
Before the procedure, did the operator    
Obtain informed consent    
Obtain supervision if needed (see roles, above)    
Perform a time-out/briefing    
Confirm hand washing/sanitizing immediately prior    
Use full-barrier precautions
  • Operator(s): Cap, mask, sterile gown and gloves, eye protection
    
  • Supervisor: Cap, mask, sterile gown and gloves, eye protection
    
  • Assistant: Cap, mask, isolation gown and gloves, eye protection (if at risk for entering sterile field, use sterile gown and gloves)
    
Properly position to prevent air embolism
  • For chest/EJ: Trendelenburg (HOB<0 degrees)
  • For femoral: supine
    
Sterilize procedure site (chlorhexidine)    
Allow site to dry    
Use sterile technique to drape patient from head to toe    
Use local anesthetic and/or sedation    
During the procedure, did the operator    
Maintain a sterile field    
Monitor that lumens were not cut    
Clamp any ports not used during insertion (to avoid air embolism, clamp all but distal port)    
Obtain qualified second operator after 3 unsuccessful sticks (except if emergent)    
Aspirate blood from each lumen (to avoid air embolism and ensure intravascular placement)    
Transduce central venous pressure or estimate central venous pressure by fluid column (to avoid arterial placement)    
After the procedure, did the operator    
Clean blood from the site using antiseptic agent (chlorhexidine) and apply sterile dressing    
Verify placement by x-ray (tip in SVC/RA junction)    

 

Operator: ________________________ Supervisor: ________________________ 

Assistant: ________________________

 

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Page last reviewed January 2012
Internet Citation: Appendix 5: Central Line Insertion Care Team Checklist: Tools for Reducing Central Line-Associated Blood Stream Infections. January 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/clabsitools/clabsitoolsap5.html