57.125 Central Line Insertion Practices Adherence Monitoring Form

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Central Line Insertion Practices Adherence Monitoring
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*required for saving
Facility ID: _____________________
Event #: ________________________________
*Patient ID: _____________________
Social Security #: __ __ __ - __ __ - __ __ __ __
Secondary ID: ____________________
Medicare #: _______________________
Patient Name, Last: _____________________
First: __________________
Middle: __________________
*Gender: □ F    □ M     □ Other
*Date of Birth: ___ /___ /______ (mm/dd/yyyy)
Ethnicity (specify): ____________________________
Race (specify): ________________________________
*Event Type: CLIP
*Location: ________________________
*Date of Insertion: ___ /___ /_____ (mm/dd/yyyy)
*Person recording insertion practice data:
□ Inserter
□ Observer
Central line inserter ID: _________
Name, Last: ____________________
First: ______________________
*Occupation of inserter:
□ Fellow
□ Medical student
□ Other student
□ Other medical staff
□ Physician assistant
□ Attending physician
□ Intern/resident
□ Registered nurse
□ Advanced practice nurse
□ Other (specify): ______________________
*Was inserter a member of PICC/IV Team?
□ Y
□ N
*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 
*Inserter performed hand hygiene prior to central line insertion:
□ Y
□ N
(if not observed directly, ask inserter)
*Maximal sterile barriers used:
Mask  □ Y   □ N
Sterile gown □ Y   □ N 


Large sterile drape  □ Y   □ N
Sterile gloves □ Y   □ N
Cap □ Y   □ N
*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
□ U
*Was skin prep agent completely dry at time of first skin puncture?
□ Y
□ N
(if not observed directly, ask inserter)
*Insertion site:
□ Femoral
□ Jugular
□ Lower extremity
□ Scalp
□ Subclavian
□ Umbilical 
□ Upper extremity
Antimicrobial coated catheter used:
□ Y
□ N
*Central line catheter type:
□ Non-tunneled (other than dialysis)
□ PICC
□ Tunneled (other than dialysis)
□ Umbilical
□ Dialysis non-tunneled
□ Other (specify): _______________________________
□ Dialysis tunneled
(“Other” should not specify brand names or number of lumens; most lines can be categorized accurately by selecting from options provided.)
*Did this insertion attempt result in a successful central line placement?
□ Y
□ N
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, v6.6 
Central Line Insertion Practices Adherence Monitoring
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