Appendix 5: Central Line Insertion Care Team Checklist
Tools for Reducing Central Line-Associated Blood Stream Infections
Patient Name: ______________________________ Hx#:____________ Unit: ____________ Date/Time:____________
A minimum of 5 supervised successful procedures in both the chest and femoral sites is required (10 total). If a physician successfully performs 5 supervised lines in one site, he or she is independent for that site only. A total of 3 supervised rewires is required prior to performing a rewire independently.
Supervisor Role: 2nd year resident and above (approved for line placement). Assistant Role: RN, ClinTech, MD, NP, PA (responsible for completing checklist).
If there is a deviation in any of the critical steps, immediately notify the operator and stop the procedure. If a correction is required, make a check mark in the “Yes With Reminder” column and note the correction in the comment space. Report uncorrected deviations and complications of line placement. Contact the attending if any item on the checklist is not adhered to or if there are any concerns. Return this completed form to the designated person in your area.
| Critical Steps | Yes | Yes With Reminder | Procedure Deviation: Complete Report | Comments |
|---|---|---|---|---|
| Before the procedure, did the operator | ||||
| Obtain informed consent | ||||
| Obtain supervision if needed (see roles, above) | ||||
| Perform a time-out/briefing | ||||
| Confirm hand washing/sanitizing immediately prior | ||||
Use full-barrier precautions
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Properly position to prevent air embolism
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| Sterilize procedure site (chlorhexidine) | ||||
| Allow site to dry | ||||
| Use sterile technique to drape patient from head to toe | ||||
| Use local anesthetic and/or sedation | ||||
| During the procedure, did the operator | ||||
| Maintain a sterile field | ||||
| Monitor that lumens were not cut | ||||
| Clamp any ports not used during insertion (to avoid air embolism, clamp all but distal port) | ||||
| Obtain qualified second operator after 3 unsuccessful sticks (except if emergent) | ||||
| Aspirate blood from each lumen (to avoid air embolism and ensure intravascular placement) | ||||
| Transduce central venous pressure or estimate central venous pressure by fluid column (to avoid arterial placement) | ||||
| After the procedure, did the operator | ||||
| Clean blood from the site using antiseptic agent (chlorhexidine) and apply sterile dressing | ||||
| Verify placement by x-ray (tip in SVC/RA junction) |
Operator: ________________________ Supervisor: ________________________
Assistant: ________________________
