Appendix 6: Central Line Maintenance Audit Form
Tools for Reducing Central Line-Associated Blood Stream Infections
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:
[ ] No, not changed because:
5. Was Chloraprep© or 2% chlorhexidine in 70% Isopropyl alcohol used for skin antisepsis?
[ ] Yes:
[ ] No, Povidone iodine used
Did scrub comply with recommendations?
6. Were central line tubing and all additions (secondary tubing, etc.) changed during this shift?
[ ] Yes, completed because:
[ ] No, not completed because
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?
Page originally created January 2012