PD Catheter Insertion

Peritonitis prevention bundle compliance


Which department are you completing this survey for?

Name of the employee observed:

Patient MRN?


Antibiotic administration prior to placement?

Single dose of first generation Cephalosporin administered 0-60 minutes prior to placement
  OR 
Clindamycin or Vancomycin administered to those patients with +MRSA or Cephalosporin allergy


Catheter in a downward or lateral position?

Exit site free of sutures?

Beta cap (#23881) placed on catheter?

Transfer set (#19678) flushed with 10ml NS prior to attaching to catheter?

Transfer set attached to the catheter?

Minicap (#22984) securely attached to transfer set?

Exit site free of a Bio-Patch?

Exit site covered only with 2x3 Primapore Dressing (#17017)?

Exit site free of a tegaderm dressing covering?