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Table 3 APSIC central line maintenance checklist

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

Name of patient   Age   Sex   Unique ID  
Name of Treating physician/Surgeon       Unit  
Type of Central Venous Catheter Tunneled   Non-Tunneled   PICC line   Chemoport   Any other:  
Days 1 2 3 4 5 6 7
Date        
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?                      
Was hand hygiene practised before all line maintenance/access procedures?                      
Was alcohol used to disinfect hub before each access?                      
Was dressing changed using aseptic technique?                      
Were administration sets replaced every 4-7 days?                      
Signature of person in-charge: