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Table 2 APSIC central line insertion checklist

From: APSIC guide for prevention of Central Line Associated Bloodstream Infections (CLABSI)

Name of patient   Age   Sex   Unique ID  
Name of Insertor   Date   Time   Unit  
Is the Indication for insertion appropriate? Yes No
Type of Central Venous Catheter Tunneled   Non-Tunneled   PICC line   Chemoport   Any other:  
Emergency Procedure Yes No   
The Insertion Procedure
Was sublclavian or IJ vein the site for insertion - Y/N  
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 70 % alcohol and >0.5 % 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: