CVC Insertion Risk Factors:
|Patient: |MR No: |Admit Date: |
|Diagnosis:. | |Infection Date: |
| | |Criteria: |
[pic]
| |CVC Insertion (date, type, where inserted) |Date CVC |Insertion Site |Maximum sterile barriers, full length drape, 2-minute skin|
| | |Removed | |prep with 2% Chlorhexidine/70% alcohol followed by air |
| | | | |drying |
| | | | | |
| | | | | |
| | | | | |
| |Patient Information and CVC Care Practices | |
|1 |Patient’s location/room number(s) | |
|2 |Proper hand hygiene was used by all personnel involved in line |Yes: __________ |
| |care for this patient? |No: ___________ If no, please explain why:_________________________________________ |
|3 |Date of last CVC dressing change and skin condition at | |
| |insertion site at that time | |
|4 |A 2% Chlorhexidine/70% alcohol scrub followed by air dry used |Yes: __________ |
| |during last CVC dressing change |No: ___________ If no, please explain why:_________________________________________ |
|5 |A 70% alcohol or 2% Chlorhexidine/70% alcohol followed by air |Yes: __________ |
| |dry used prior to accessing the CVC hub/port |No: ___________ If no, please explain why:_________________________________________ |
|6 |48-72 hours before infection date, who accessed the CVC system |____Floor Nurse ___Nurse from Other Unit ____ Attending MD ____Resident/Fellow ____Anesthesia |
| |(check all that apply)? |___ Radiology Personnel ___ Other |
| | |(specify)_____________________________________________________________ |
|7 |Estimated number of CVC system entries for each 24-hour period | |
| |for 72-hours prior to infection date | |
|8 |Date of last IV administration set change(s) |Lipid and/or blood products (q24h) _________________ |
| | |All other sets (q72-96h) __________________________ |
|9 |Estimated hang time for parenteral fluid(s) over last 72 hours |Lipids (q24h) ________________________ |
| |prior to infection |All other fluids _______________________ |
|10 |Central line removal discussed daily |Yes: __________ |
| | |No: ___________ If no, please explain why:_________________________________________ |
|11 |Describe any mechanical problems with CVC prior to the | |
| |infection date | |
|12 |Have there been any problems with the CVC or IV equipment or | |
| |supplies? | |
|13 |Are there any significant patient factors that may have | |
| |contributed to this infection? | |
|14 |After your assessment, do you believe this infection was | |
| |potentially preventable? |Yes: _______ Please explain why: |
| | | |
| | | |
| | | |
| | |No: ________ Please explain why: |
| | | |
| | | |
| | | |
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