Facility ID:________________
| Event#_________________________
|
*Patient ID:_____________________ Social Security#: __ __ __ - __ __ - __ __ __ __
|
Secondary ID: __________________
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Patient Name, Last: ___________________ First: ________________________ Middle:_____________
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*Gender: □ F □ M □ Other *Date of Birth: ____/_____/________ (mm/dd/yyyy)
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Ethnicity (specify): ___________________ Race (specify): __________________________
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*Event Type: CLIP *Location:______________ *Date of Insertion: ____/_____/________ (mm/dd/yyyy)
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*Person recording insertion practice data: □ Inserter □ Observer
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Central line inserter ID: ____________ Name, Last: ___________________ First: ______________
|
*Occupation of inserter:
|
□ Fellow □ Medical student □ Other student □ Other medical staff □ Physician assistant □ Attending physician □ Intern/Resident □ Nurse □ Advanced practice nurse □ Other (specify)___________________
*Was inserter a member of PICC/IV Team? □ Y □ N
|
*Was this central line placed emergently (i.e., during a medical emergency to address an immediately life- threatening condition)? □ Y □ N
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*Reason for insertion:
□ New indication for central line (e.g., hemodynamic monitoring, fluid/medication administration, etc.)
□ Replace malfunctioning central line □ Suspected central line-associated infection □ Other (specify)__________________________ If Suspected central line-associated infection, was the central line exchanged over a guidewire? □ Y □ N
|
*Was ultrasound guidance used to place this central line? □ Y □ N
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*Inserter performed hand hygiene prior to central line insertion: □ Y □ N (if not observed directly, ask inserter)
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*Maximal sterile barriers used: Mask □ Y □ N Sterile gown □ Y □ N Large sterile drape □ Y □ N Sterile gloves □ Y □ N Cap □ Y □ N
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*Skin preparation (check all that apply): □ Chlorhexidine gluconate □ Povidone iodine □ Alcohol □ Other (specify): ______________________ If skin prep choice was not chlorhexidine, was there a contraindication to chlorhexidine? □ Y □ N
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*Was skin prep agent completely dry at time of first skin puncture? □ Y □ N (if not observed directly, ask inserter)
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*Insertion site: □ Femoral □ Jugular □ Lower extremity □ Scalp □ Subclavian □ Umbilical □ Upper extremity
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Antimicrobial coated catheter used: □ Y □ N
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*Central line catheter type:
|
□ Non-tunneled (other than dialysis)
| □ PICC
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□ Tunneled (other than dialysis)
| □ Umbilical
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□ Dialysis non-tunneled
| □ Other (specify): _____________________________
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□ Dialysis tunneled
| (‘Other’ should not specify brand names or number of lumens; most lines can be categorized accurately by selecting from options provided.)
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*Did this insertion attempt result in a successful central line placement? □ Y □ N
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Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.125 (Front) Rev 4, v6.5
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