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Device-associated Module
CLIP

Central Line Insertion Practices (CLIP) Adherence Monitoring
Introduction: Central line-associated bloodstream infections (CLABSIs) can be
prevented through proper placement and management of the central line. The CDC’s
Healthcare Infection Control Practices Advisory Committee (CDC/HICPAC) Guidelines
for the Prevention of Intravascular Catheter-Related Infections, 20111 recommends
evidence-based central line insertion practices known to reduce the risk of subsequent
central line-associated bloodstream infection. These include handwashing by inserters,
use of maximal sterile barriers during insertion, proper use of a skin antiseptic prior to
insertion, and allowing that skin antiseptic to dry before catheter insertion. Despite the
scientific evidence supporting these measures, several reports suggest that adherence to
these practices remains low in U.S. hospitals.
Several centers have found it useful to monitor adherence to evidence-based central line
insertion practices as a method for identifying quality improvement opportunities and
strategically targeting interventions. Feedback of adherence data has been a component of
multifaceted interventions that have successfully reduced CLABSI rates.
Participation in NHSN CLIP surveillance enables participating facilities and CDC to:
Monitor central line insertion practices in individual patient care units and facilities
and to provide aggregate adherence data for all participating facilities. Facilities have
the option of recording inserter-specific adherence data.
Facilitate quality improvement by identifying specific gaps in adherence to
recommended prevention practices, thereby helping to target intervention strategies
for reducing CLABSI rates.
Proposed future enhancements would allow facilities to link gaps in recommended
practice with the clinical outcome (i.e., CLABSI) both in individual facilities and for all
participating facilities.
Settings: Surveillance may occur in any type of patient care location where central lines
are inserted.
Requirements: Surveillance for central line insertion practices in at least one location in
the healthcare institution for at least one calendar month as indicated in the Patient Safety
Monthly Reporting Plan (CDC 57.106). Participating facilities may perform surveillance
for insertion practices during a month when concomitant CLABSI surveillance is being
conducted, or may collect insertion practice data during a month when no CLABSI
surveillance is being conducted or in locations where CLABSI are not monitored (e.g.,
emergency department, operating room, etc.). If participating facilities wish to identify
associations between insertion practices and outcomes (i.e., CLABSI), surveillance for
insertion practices and CLABSI must be done concomitantly.
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Numerator and Denominator Data: The Central Line Insertion Practices Adherence
Monitoring Form (CDC 57.125) is used to collect and report central line insertion
practices for every central line insertion occurring during the month in the unit(s) selected
for surveillance. The Instructions for Completion of the Central Line Insertion Practices
Adherence Monitoring Form (Tables of Instructions, Table 3) contains directions for
collection and entry of each data element on the form. The form can be completed at or
near the time of insertion either by the inserter or an observer present at the insertion
(e.g., nurse assisting with the catheter insertion), or the form can be completed from
documentation in the patient chart (e.g., if the elements of the monitoring form have been
incorporated into standard central-line insertion procedure notes). The form includes
information pertaining to demographics of the patient, information pertaining to the
inserter, information on maximal sterile barriers used, the reasons for central line
insertion, skin antisepsis, hand hygiene practice before insertion, type of central line and
insertion site, and use of a guidewire. Elements of these data will be used to calculate
adherence to recommended insertion practices.
Data Analyses: Adherence rates for specific insertion practices will be calculated by
dividing the number of central line insertions during which the recommended practice
was followed by the total number of central line insertions and multiplying the result by
100. Such calculations can also be done for a bundle of practices that have been shown
to reduce the incidence of CLABSI. In NHSN, adherence to the bundle requires a “Yes”
to all of the following:
Hand hygiene performed
Appropriate skin prep
o Chlorhexidene gluconate (CHG) for patients ≥ 2 months old
o Povidone iodine, alcohol, CHG, or other specified for children < 2 months
old
Skin prep agent has completely dried before insertion
All 5 maximal sterile barriers used
o Sterile gloves
o Sterile gown
o Cap
o Mask worn
o Large sterile drape
NOTE: CHG has not been labeled for use by the Food and Drug and Administration with
patients < 2 months of age. Acceptance of CHG use for adherence to the CLIP bundle in
this patient population does not reflect a recommendation of its use by the NHSN.
These calculations can be performed separately for different types of locations in the
institution. Participants have the option of calculating inserter-specific adherence rates.
Future enhancements to NSHN may allow the additional analysis option of generating a
line list of patients in whom a central line was inserted, the insertion practices followed

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Device-associated Module
CLIP

during the insertion, and information on any subsequent CLABSI associated with that
central line.

1

O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, Maki DG, et al. Guidelines
for the prevention of intravascular catheter-related infections, 2011. Clinical Infectious Diseases 2011; 52
(a):1087-99.

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