Attachment C - CLABSI Monthly Device Rounds Checklist

A ttachment C: CLABSI Device Rounds Checklist

CLABSI Device Rounds Checklist (Device Checklist Form)

CLABSI device rounds are an opportunity to directly observe patients’ central venous catheters (CVCs) to ensure evidence-based best practices are followed to prevent device-associated infections. The device rounds incorporate data collection and real-time discussion, education, and problem-solving to optimize CVC care measures. You may want to invite the unit CUSP Executive to attend these rounds. Of note, smaller groups tend to be most effective for CVC rounds.

Complete this checklist one day per month for each patient’s central-line device present in the participating unit at the time of assessment. The assessment may be completed by frontline personnel, infection preventionists, CUSP members, vascular device experts, or others in the unit. Once the month’s assessments are complete, combine the data from each patient’s device checklist form and enter the total count for each of the following items in the data collection program portal (Monthly Aggregated Checklist Form).

For each CVC, confirm each of the following elements are in place (if the patient has more than one CVC, complete one checklist for each CVC):

• Is the dressing within date?

Transparent dressing changed every 7 days. Gauze dressing changed every 48 hours.

• Yes

• No

• No date

• N/A

• Is the dressing clean and dry?

No dressing discoloration, no blood at site, etc.

• Yes

• No

• Is the dressing intact?

Transparent window intact, etc.

• Yes

• No

• Is the dressing appropriately applied and maintained?

Reverse used, no tape used to re-enforce, Catheter hub and sutures inside of dressing, tegaderms not overlapping, appropriately sized, adhered into skin folds, electrode not stuck on dressing. If heavy tubing is pulling off the dressing and a tubing securement should be recommended, select No.

• Yes

• No

• Are IV fluids and medication bags within date?

This is an all or nothing measure and includes high risk medications. If any IV fluid or medication bag is not in date, select “No”. Medication bags infused less than 6 hours do not require a label. CPN changed every 24 hours. Lipids every 24 hours. Propofol glass vial every 12 hours. Propofol in a syringe every 6 hours.

• Yes

• No

• Not dated/labeled

• N/A

• Is IV fluid/medication tubing within date?

This is an all or nothing measure and includes high risk tubing. If any IV fluid or medication tubing is not in date, select “No”. Continuous tubing every 96 hours, intermittent/disconnected tubing every 24 hours, CPN every 24 hours, lipids every 24 hours, propofol glass vial every 12 hours, propofol syringe every 6 hours.

• Yes

• No

• Not dated/labeled

• N/A

• Does a disconnected administration set have a sterile cap attached?

• Yes

• No Sterile Cap

• N/A

• Was daily chlorhexidine gluconate (CHG) bathing completed within the past calendar day?

Documented in “LDA” flowsheet within the last calendar day

Note: “Not Appropriate for the Patient = If line is less than 24 hours, Burn patients, Dermatitis, Neonates, Allergy”

• Yes, CHG performed

• No, CHG not performed

• No, Patient refused despite follow up or escalation

• Not Applicable/Appropriate for Patient (approved contraindication)

• Were the linens changed (including bedding and gown/clothing) within an hour of the last CHG treatment?

• Yes

• No

• N/A

CLABSI Device Rounds Checklist (Monthly Aggregated Checklist Form)

CLABSI device rounds are an opportunity to directly observe patients’ central venous catheters (CVCs) to ensure evidence-based best practices are followed to prevent device-associated infections. The device rounds incorporate data collection and real-time discussion, education, and problem-solving to optimize CVC care measures.

Aggregate data from your monthly CLABSI Device Rounds Checklists by totaling the number of “Yes” responses and enter the total count in the spaces provided below.

Provide the total count for the following with respect to your unit for the month of [MONTH].
	Total count
Total number of central lines assessed
Count of CVCs for which the following CLABSI prevention elements were in place. Total number of times where:
Dressings were within date
Dressings were clean and dry
Dressings were intact
Dressings were appropriately applied and maintained
IV fluids and medication bags were within date
IV fluid/medication tubing were within date
Disconnected administration sets had sterile caps attached
Daily chlorhexidine gluconate (CHG) baths were completed within the past calendar day
Linens were changed (including bedding and gown/clothing) within an hour of the last CHG treatment
Public reporting burden for the collection of information is estimated to average 90 minutes per response, the estimated time required to complete this assessment. 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: AHRQ Reports Clearance Officer, Attention: PRA, Paperwork Reduction Project (0935-XXXX), AHRQ, 5600 Fishers Lane, MS 0741A, Rockville, MD 20857. The confidentiality of your responses is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure.