Appendix 6: Central Line Maintenance Audit Form

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.

 

Audit Date: ____/____/20____                    Addressograph Here

1. Was the need for a central line for this patient discussed on patient rounds?

[  ] Yes                    [  ] Yes, as part of Daily Goals                   [  ] No

2. Was proper hand hygiene used by all personnel involved in line care for this patient (i.e., hand washing with soap and water or with alcohol-based hand sanitizer)?

[  ] Yes        [  ] No, not during:_ _Dressing change_ _Accessing the line_ _Port/clave change __Other

3. If the line was percutaneously placed, was this line placed in a recommended site?

[  ] Yes (IJ, SC)          [  ] No (femoral)

4. Was the dressing changed during this shift?

[  ] Yes, changed because:
     [  ] Dressing soiled, damp or non-occlusive
     [  ] Due to be changed (7 days for transparent OR 1 day for gauze)
     [  ] Changed by specific team (e.g., PICC, TNA)
     [  ] Dressing was overdue to be changed?
     ____ days for transparent
     ____ days for gauze

[  ] No, not changed because:
     [  ] It was intact and not due
     [  ] It was due but could not be completed.
     Explain:

5. Was Chloraprep© or 2% chlorhexidine in 70% Isopropyl alcohol used for skin antisepsis?

[  ] Yes:
     Was it used appropriately?
     [  ] Scrub vigorously back and forth for 30 seconds
     [  ] Groin sites 2 minutes
     [  ] Air dry up to 2 minutes
     [  ] No – Explain:

[  ] No, Povidone iodine used
     Secondary to allergy?
     [  ] Yes     [  ] No – Explain:

Did scrub comply with recommendations?

  1. Clean with soap and water or alcohol, air dry
  2. Povidone iodine air dry 2 minutes
    [  ] Yes     [  ] No – Explain:

6. Were central line tubing and all additions (secondary tubing, etc.) changed during this shift?

[  ] Yes, completed because:
     [  ] Tubing due to be changed
     [  ] 72 hours since last change
     [  ] 24 hours for intralipids
     [  ] Medication tubing expired

[  ] No, not completed because
     [  ] Not due to be changed
     [  ] Due but could not be completed – Explain:

7. Was there blood return from each lumen?       [  ] Yes           [  ] No        [  ] Unable to assess
                                                                                                                           (infusion can't be stopped)

Please specify lumen:

Use of Advanced Technology

8. Was a chlorhexidine impregnated BioPatch used?                            [  ] Yes              [  ] No

9. Was a chlorhexidine impregnated occlusive dressing used?          [  ] Yes              [  ] No

10. Was an antibiotic coated catheter used at insertion?                      [  ] Yes              [  ] No

11. What will you change to improve line maintenance practices?

 

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Current as of January 2012
Internet Citation: Appendix 6: Central Line Maintenance Audit Form: 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/clabsitoolsap6.html