From: APSIC guide for prevention of Central Line Associated Bloodstream Infections (CLABSI)
Name of patient | Â | Age | Â | Sex | Â | Unique ID | Â | |||
Name of Insertor | Â | Date | Â | Time | Â | Unit | Â | |||
Is the Indication for insertion appropriate? | Yes | No | ||||||||
Type of Central Venous Catheter | Tunneled | Â | Non-Tunneled | Â | PICC line | Â | Chemoport | Â | Any other: | Â |
Emergency Procedure | Yes | No | Â | Â | ||||||
The Insertion Procedure | ||||||||||
Was sublclavian or IJ vein the site for insertion - Y/N | Â | |||||||||
Has insertor and assistant performed hand hygiene procedures, either by washing hands with liquid soap and water or with alcohol-based hand rubs (ABHR)? | Yes | No | ||||||||
Was 70Â % alcohol and >0.5Â % CHG used in cleaning site of insertion? | Yes | No | ||||||||
Have both the operator and assistant practised maximal sterile barrier precautions (wearing a sterile gown, sterile gloves, and cap and using a full body drape for patient)? | Yes | No | ||||||||
Signature of person in-charge: | Â |