• Write in black or blue pen, using block letters and legible by alendar


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									                                Central Line Insertion Checklist – Guidelines for Completion

• 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
                                                                                •   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
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
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.

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