CLABSI Maintenance K-Card

HAC SPS Bundle Elements

Which department are you completing this survey for?

Name of the employee observed:

Was there a daily discussion of line necessity, functionality, and utilization among bedside and medical care team members during rounds?

  • Discuss with the medical team continued necessity of line.
  •  Discuss with the medical team the function of the line and any problems.
  • Discuss with the medical team the frequency of access and utilization of line. 
  • Consider bundling labs and line entries.
  • Consider best practice is documentation that the discussion occurred in the medical record.
Are regular assessments being performed and documented to assure dressing is clean/dry/occlusive?

  • Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled [CDC Reference].
  •  Replace dressings used on short-term central venous catheters sites every 2 days for gauze dressings and at least every 7 days for transparent dressings [CDC Reference].
  • For neonates, the dressing is changed PRN only.  Neonate is birth to 44-weeks corrected gestational age.
Is the standardized access procedure being upheld?
Was hand hygiene procedures performed, either by washing hands with conventional soap and water or with alcohol-based hand rubs (ABHR)?

  • Hand hygiene should be performed before and after palpating catheter insertion sites as well as before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter.
  • Palpation of the insertion site should not be performed after the application of antiseptic, unless aseptic technique is maintained [CDC Reference].
Were the caps disinfected before all line entries by scrubbing (10 full twists & 5 sec dry) with an appropriate antiseptic (CHG).
Was the port scrubbed with alcohol (15 second scrub and allowed to dry) or an alcohol / CHG containing product per manufacturers’ recommendations before accessing [CDC Reference]?
Were sterile gloves and mask used for needle access for all implanted permanent central lines?

Implanted permanent central line is a Portacath.
Was the port accessed using sterile technique? [CDC Reference].
Is the standardized dressing, cap, and tubing change procedures/timing being upheld?
Was the skin scrubbed around the site with CHG for 30 seconds (2 minutes for femoral site), followed by complete drying [CDC Reference]? If CHG is contraindicated see sub-text.

  • Chlorhexidine gluconate 2% with alcohol 70% swab-stick, sponge, or ampule is the antiseptic of choice.
  •  If a patient is intolerant to chlorhexidine, 10% Povidone Iodine is the preferred alternative for CVAD site cleaning.
  • For infants less than 1500 grams until two (2) weeks of life, or for patients with compromised skin integrity, chlorhexidine/alcohol is not used. Povidone iodine is used instead of chlorhexidine and is cleansed with sterile saline wipes after the povidone iodine is dry.
  • For patients less than 1500 grams and over two (2) weeks of life, chlorhexidine may be used but is cleansed off the skin with saline after the chlorhexidine has dried.
Was the crystalloid tubing changed no more frequently than every 96 hours [CDC Reference]?
Was the tubing used to administer blood products changed every 24 hours or more frequently per institutional standard [CDC Reference]?
Was the tubing used for lipid infusions changed within 24 hours of initiation the infusion [CDC Reference]?
Is the date and time for dressing/cap/tubing change documented [CDC Reference & SPS data]?

  • Check for change day sticker.
Was a mask worn when the hub of catheter or insertion site are exposed?

  • All individuals in room, including patient
  • If unable to mask patient, turn patient's head away from site
  • Shield patient’s face, ETT, or trach with mask or drape.
Were sterile gloves and mask used for dressing/tubing/cap changes?
Did the patient receive a CHG treatment in the last calendar day?

  • CHG only used for 48 weeks adjusted and greater
  • If contraindicated choose N/A
If any No is chosen above, please provide more details.