Central Line Insertion Checklist – Guidelines for Completion GENERAL NOTES • Write in black or blue pen, using block letters and legible writing in free text fields • One character per square • Colour in circles where indicated – or mark with a large ‘X’ through the middle of the circle • If a mistake is made , please scribble out the incorrect choice clearly and then place a tick beside the correct choice Data field Rationale Issues Facility Code This is the unique facility identifier as per • The CEC will provide each facility with their unique Department of Health listing. It will be used code to be entered on each form from your unit. to provide facility specific reports from the • Should this code inadvertently be left off your CLAB-ICU database. Each hospital has their faxed forms – do not be concerned – we can own facility code (alpha-numeric) manually correct this. Patient Label Patient identifier for patient record only. • MRN will be used during the data quality process to identify those patients with more than one CVC. • No other patient identifiers are read by the teleform software – only MRN • Form will be part of patient medical record and requires patient label to ensure correct filing. • Patient privacy must be ensured when faxing patient identifying information. In order to safeguard personal health information the NSW Health Privacy Manual recommends that regularly used fax numbers be stored in the fax machine memory ( Privacy Manual reference: Section 220.127.116.11) • PLEASE DO NOT PLACE PATIENT LABEL OVER THE SQAURE BLACK IDENTIFYING MARKER IN THE RIGHT TOP CORNER OF FORM. This interferes with the software’s ability to correctly identify and scan the form for data fields. If label is too large, let it protrude into/cover the facility code box – as hospital can be identified by the label. Data field Rationale Issues Date of Procedure Indicates when the CVC was inserted. • This is a mandatory field as it provides the data to determine the denominator rate for the CLAB rate • is important to calculate number of days line is in situ Procedure’s MO Name Proceduralist identifier. Name of person • Proceduralist identification is required for local inserting the CVC data collection and information. Data can be collated for training records such as registrar log books. If proceduralist does not want name to be identified, ensure that a key to the code used is maintained in the unit. For example a standard 2x2 code such as first two initials of first name and surname to be entered so that appropriate ad hoc reports can be generated from the database on request. Name of Assistant Assistant identifier. Determine who is • Required for local data collection. Assistant may be assisting with the insertion of the CVC and either the nurse caring for the patient or the completing the form. supervisor of the insertion • If the insertion of the CVC is completed without an assistant – leave blank Name of Supervisor Name of person supervising a trainee • Required for local data collection. (junior medical staff). • Data is collected for training records Where was the line inserted? Location where central venous catheter was • Where line is inserted outside of ICU only inserted information required is that relating to date of insertion: insertion site; date of line removal; date of discharge from ICU • When specifying ‘Other’ write the name of speciality unit eg HDU. Do not write ward information such as P3 Catheter Type The type of catheter that was used for the • If catheter is not amongst the selection – please procedure. specify catheter type in ‘other’ Data field Rationale Issues Catheter Gauge The gauge measurement of the catheter. • Please document line gauge in the boxes provided with use of the decimal point (see revised CVC Checklist_Aug_07). Please indicate outside of the boxes whether the catheter measurement is a plain’gauge’ or a ‘french’ gauge – the 2 represent different gauge sizes Insertion Site Note the insertion site of the CVC ie • Insertion site selection is an important feature of subclavian, internal jugular etc. the evidence for reduction of CLAB. • The evidence suggests that subclavian is the preferred site for reducing infection risk. However this is the least suitable site for patients with severe lung pathology or prolonged clotting times. • Clinical judgement should always be used to guide decision making . Position Where the catheter position is. Colour in • To ensure that multiple lines in the same patient one circle only (Right or Left). are differentiated note which side the line was inserted on. Procedure ‘type’ performed What type of procedure was performed – ie • May choose >1 type eg: elective AND ultrasound- was this an emergency, elective or guided repositioning of an existing catheter. Number of Lumens Indicate the number of lumens in the • Colour in one circle only. catheter inserted. Line Coating Note what sort of line coating is used on • Colour in one circle only. the catheter – i.e. antiseptic or antibiotic. Local Anaesthetic Only document if local anaesthetic is used. • If local anaesthetic is used, detail the type of local anaesthetic and the dose Sedation Only document if sedation is used. • If sedation is used, detail type of sedation, the dose given and the administration route. • Where patient is intubated and sedated – indicate only ANY ADDITIONAL SEDATION Data field Rationale Issues BEFORE THE PROCEDURE Undertake competency Note if the proceduralist has undertaken a • Many units do not have a formal competency assessment (if unsupervised)? competency assessment – particularly for assessment process. The project will assist in registrar or junior medical staff. developing a standardised model. • Where a Senior Medical Practitioner (SMP ie: Staff Specialist, Consultant, VMO) is the Proceduralist – then ‘competency should be assumed and ‘Yes’ should be indicated Cleanse hands (2 minute hand Appropriate hand hygiene is an important • Hand Hygiene protocol is described in the CLAB hygiene with approved factor in reducing central line associated Guideline (Section 8 ,Page 6) solution)? bacteraemia DURING THE PROCEDURE Prep procedure site with Appropriate skin preparation as detailed in • ICUs may be using other prep solutions as part of chlorhexidine/alcohol – 30 the guideline is considered optimal to their routine procedure. The skin prep on the seconds for dry sire; 2 minutes reducing central line associated checklist reflects current best practice (according for moist site (esp. femoral) bacteraemia. to the guideline) Use large sterile sheet to cover Maximal barrier precautions are required to • The drape must cover the length of the patient. patient? minimise the risk of infection at the time of insertion of the central line. Wear sterile gloves and sterile Maximal barrier precautions are required to • Evidenced based practice. gown during the line insertion? minimise the risk of infection at the time of insertion of the central line. Wear hat, mask, and protective Maximal barrier precautions are required to • Evidenced based practice. (Note: current eyewear (A YES answer requires minimise the risk of infection at the time of controversy exists around wearing of hats) all to be worn.) insertion of the central line. Maintain sterile technique during Maximal barrier precautions are required to • Evidenced based practice. procedure and dressing? minimise the risk of infection at the time of insertion of the central line. Data field Rationale Issues Undertake multiple passes (> 3) Increased passes increases risk of infection. • If less than 3 passes- choose NO. If more than 3 passes - choose YES. • If a line is inserted in the wrong place (malposition), removed and re-inserted iwith correct placement, then Only record the successful site insertion, and tick the malposition circle to indicate this to have been a complication AFTER THE PROCEDURE Was dressing dated or date Provides a quick check during daily • If not dated on dressing- staff will need to refer to documented on ICU care plan? inspection on the length of time the patient medical record. catheter has been in situ. Was catheter position confirmed Provides evidence that the catheter is in • If not performed, any complications will not be by fluroroscopy or CXR? the correct position. immediately identified. Was catheter position confirmed Provides evidence that the catheter is in • If not performed, any complications will not be by transducer? the correct position. immediately identified. Did any of the following Document immediate complications due to • Local data collection to inform education programs complications occur? insertion of catheter. and patient risk assessments. Date of Line Removal When the line was removed. • Important to calculate number of days line has been in situ CVC- related BSI detected Indicates if BSI has been detected. • See guideline for definition of CVC-BSI (CLAB) If yes- Date of Blood Culture Date in which the BSI was detected. Date Discharged from ICU When the patient was discharged from the • This includes patients who have died in ICU. ICU.