Appendix 7. Central Venous Catheter-Associated Laboratory-Confirmed Blood Stream Infection Event Report Template for Defect Analysis
Tools for Reducing Central Line-Associated Blood Stream Infections
These tools will help your unit implement evidence-based practices and eliminate central line-associated blood stream infections (CLABSI). When used with the CUSP (Comprehensive Unit-based Safety Program) Toolkit, these tools dramatically reduced CLABSI rates in more than 1,000 hospitals across the country.
| Patient: | MR No: | Admit Date: |
| Diagnosis: | Infection Date: | Criteria: Organism: |
CVC Insertion Info
| Date: | Type: |
| Location: | Who Inserted: |
| Insertion Site:
Date CVC Removed: |
Was insertion bundle used? [ ] Yes [ ] No If no, explain: Were all elements complied with when CVC inserted?[ ] Yes [ ] No If no, explain: |
| 1 | Patient's location/room number(s) | |
| 2 | Did all personnel involved in line care for this patient use proper hand hygiene? | [ ] Yes [ ] No If no, explain: |
| 3 | Date of last CVC dressing change and skin condition at insertion site at that time | |
| 4 | Was a 2 percent chlorhexidine/70 percent alcohol scrub followed by air dry used during last CVC dressing change? | [ ] Yes [ ] No If no, explain: |
| 5 | Was a 70 percent alcohol or 2 percent chlorhexidine/70 percent alcohol followed by air dry used prior to accessing the CVC hub/port? (Use facility's protocol.) | [ ] Yes [ ] No If no, explain: |
| 6 | Who accessed the CVC system 48-72 hours before infection date? (Check all that apply) | [ ] Floor nurse [ ] Nurse from other unit [ ] Attending MD [ ] Resident/Fellow [ ] Anesthesia [ ] Radiology [ ] Other |
| 7 | Estimated number of CVC system entries for each 24-hour period for 72 hours prior to infection date | |
| 8 | What are compliance rates for “scrubbing the hub” before accessing line on this unit? | |
| 9 | Date of last IV administration set change(s) | Lipid and/or blood products (q24h): All other sets (q72-96h): |
| 10 | Estimated hang time for parenteral fluid(s) over last 72 hours prior to infection | Lipids (q24h): All other fluids: |
| 11 | Was central line removal discussed daily? | [ ] Yes [ ] No If no, explain: |
| 12 | Describe any mechanical problems with CVC prior to the infection date | |
| 13 | Have there been any problems with the CVC or IV equipment or supplies? | [ ] Yes If yes, explain: [ ] No |
| 14 | Did the person who inserted the catheter have documented competency to insert? | [ ] Yes [ ] No If no, explain: |
| 15 | What is hand hygiene compliance like for all units the patient was in where patient had a CVC? | |
| 16 | How did workload/unit activity affect insertion and care of the CVC? | |
| 17 | Can each staff member involved in this patient's care verbalize correct strategies to prevent CLABSI? | [ ] Yes [ ] No If no, explain: |
| 18 | Are there any significant patient factors that may have contributed to this infection? | [ ] Yes If yes, explain: [ ] No |
| 19 | After your assessment, do you believe this infection was potentially preventable? | [ ] Yes Explain: [ ] No Explain: |
If defects are identified, use the Learning from Defects Tool in the CUSP Toolkit to prevent future defect(s).
