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 Treating physician/Surgeon | Â | Â | Â | Â | Â | Unit | Â | ||||||||||||||
Type of Central Venous Catheter | Tunneled | Â | Non-Tunneled | Â | PICC line | Â | Chemoport | Â | Any other: | Â | |||||||||||
Days | 1 | 2 | 3 | 4 | 5 | 6 | 7 | ||||||||||||||
Date | Â | Â | Â | Â | Â | Â | Â | ||||||||||||||
The maintenance procedure | Y | N | Comment: | Y | N | Comment: | Y | N | Comment: | Y | N | Comment: | Y | N | Comment: | Y | N | Comment: | Y | N | Comment: |
date for change in dressing, date of IV set change | date for change in dressing, date of IV set change | date for change in dressing, date of IV set change | date for change in dressing, date of IV set change | date for change in dressing, date of IV set change | date for change in dressing, date of IV set change | date for change in dressing, date of IV set change | |||||||||||||||
Is review done for need for central line use? | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â |
Was hand hygiene practised before all line maintenance/access procedures? | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â |
Was alcohol used to disinfect hub before each access? | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â |
Was dressing changed using aseptic technique? | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â |
Were administration sets replaced every 4-7 days? | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â |
Signature of person in-charge: | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â | Â |