Central Line-Associated Bloodstream Infections (CLABSI) ImplementationGuide: Links to Resources*

*Disclaimer:Thelinksin thedomainsbelowarenotmutuallyexclusive nordo theyrepresent anexhaustive listof all thepossibleresourcesavailable. Furthermore,the linkspresenteddonotconstitute anendorsementof theseorganizationsor theirprogramsbythe CentersforDiseaseControlandPrevention (CDC)or thefederalgovernment,andnoneshould beinferred.

SeealsotheCDC 2011Guidelinesforthe PreventionofIntravascularCatheter-RelatedInfections at:

Example Resources / Websites
I.GeneralInfrastructure, Capacity,andProcesses
ENGAGEMENTOFLEADERSHIP,CHAMPIONS,ANDHEALTHCAREPERSONNEL
ComprehensiveUnit-basedSafetyProgram(CUSP)Board Checklist
ChecklistofCUSPactivitiesforboardmembersandseniorleaderstopreventhealthcare-associatedinfections(HAI),fromtheArmstrongInstituteforPatientSafetyandQualityatJohnsHopkinsMedicine /
_toolkit_new/board-checklist.pdf
Engage the SeniorExecutive Module - CUSPToolkit
ModulewithmultipletoolsforengagementofseniorexecutivesinCUSPactivities,fromtheAgencyforHealthcareResearchandQuality(AHRQ) /
tools/cusptoolkit/modules/engage/index.html
AccountabilityofHealth Care Personnelin PreventingCLABSIs
Frameworkofpersonnelaccountabilityandresponsibilitiesinprevention ofCLABSIs,fromtheJointCommission /
_4- 4_Accountability_of_Health_Care_Personnel_in_Preventing_CLAB SIs.pdf
Back toBasics: 12Tenetsto Reduce CLABSIs
Listof12tenetsofcollaborationtoreduceCLABSIs,fromtheAgencyforHealthcareResearchandQuality(AHRQ) /
tools/clabsitools/clabsitoolsap9.html
Steps in Developing aBusinessCaseAnalysis
AframeworklistingninestepsthathealthcarepersonnelcanusetobuildabusinesscaseforCLABSIprevention,fromtheJointCommission /
_6-4_Steps_in_Developing_a_Business_Case_Analysis.pdf
HAI CostCalculator
DownloadableExcelfilesthatallowhospitalstocalculatefacilityspecificcostsofhealthcare-associatedinfectionsandsavingsrealizedbypreventingthem,fromtheAssociationforProfessionalsinInfectionControlandEpidemiology(APIC) /
IndividualSelf-Assessment
Self-assessmentforindividualswhomaychampionCLABSIpreventioneffortstoensurefoundationalknowledgewithlinkstomanytools,fromtheJointCommission /
_3-25_Individual_Self_Assessment.pdf
Comprehensive Unit-based SafetyProgram(CUSP)Tools
ToolstoEngage,Educate,Execute,andEvaluateCLABSIpreventionefforts,fromtheAgencyforHealthcareResearchandQuality(AHRQ) /
tools/clabsitools/index.html
I.GeneralInfrastructure, Capacity,andProcesses,Continued
LessonsLearned fromKeystone ICUProject
Guidanceforlarge-scaleimprovementprojectsbasedonlessonslearnedfromasuccessfulICUcollaborativetoreduceCLABSIrates,fromtheJointCommission /
_4-6_Lessons_Learned_from_Keystone_ICU_Project.pdf
TOOLS FORTHECLABSIWORKGROUP
APICImplementationGuide to PreventingCentralLine-AssociatedBloodstreamInfectionsCompilationofguidanceontopicsincludinggeneralinformation,CLABSIsurveillance,ensuringadherencetothecentrallinebundle,preventinginfectionsduringcathetermaintenance,preventinginfectionsamongthepediatricpopulationandintherenalsetting,fromtheAssociationforProfessionalsinInfectionControlandEpidemiology /
AssessmentofProgramforPrevention ofCentralLine-AssociatedBloodstreamInfectionsWorksheetthatprovidesamethodtomeasurethelevelofimplementationofanorganization’sCLABSIpreventionprogram,fromthePennsylvaniaPatientSafetyAuthority /
OrganizationalSelf-Assessment
Tooltoconductaself-assessmentoforganizationalinfrastructurerelatedtoCLABSIpreventionwithlinkstoimprovementtools,fromtheJointCommission /
_3-26_Organizational_Assessment.pdf
FailureModesEffectAnalysis (FMEA)forCLABSI
AsuiteoftoolsthatassistinconductingassessmentstoidentifyhighestriskfailuresleadingtoCLABSIsandthemostimportantareasforprocessimprovements,fromtheUtahHospitalAssociation /
EliminateHarmAcrossthe Board
ChecklistofCLABSIPreventionStrategies,fromtheHospitalQualityInstitute,inpartnershipwiththeAmericanHospitalAssociation,PartnershipforPatients,andtheHealthResearchEducationalTrust /
CLABSI EventReportTemplateforDefectAnalysis
TemplatereportforthereviewofincidentCLABSI,fromthe HospitalQualityInstitute /
PREVENTIONBUNDLES
CDCChecklistforPrevention ofCLABSI
Checklistbasedon2011CDCGuidelineforPreventionofIntravascularCatheter-AssociatedBloodstreamInfections,fromCentersforDiseaseControlandPrevention /
HowtoGuide: PreventCentralLine-AssociatedBloodstreamInfections
Guidedescribingkeyevidence-basedcarecomponentsofaCLABSIPreventionBundle,fromtheInstituteforHealthcareImprovement(IHI).Log-inRequired /
CLABSIPrevention ToolkitsResources
ToolkitofCLABSIpreventionresources,fromtheArmstrongInstituteforPatientSafetyandQualityatJohnsHopkinsMedicine /
JointCommission CLABSI Toolkit
MonographandaccompanyingtoolkitofCLABSIpreventionresources,fromtheJointCommission /
I.GeneralInfrastructure, Capacity,andProcesses,Continued
STAFFTRAININGANDCOMPETENCYASSESSMENTS - INSERTION
Certification forthe Insertion ofCentralVenousAccessDevices
Samplepolicyrelatedtocertificationofgraduatemedicalstudentstoinsertcentrallines,fromStonyBrookUniversityHospital /
BaystateHealthCentralLine Insertion PrivilegingforAttendingPhysicians
Samplepolicyrelatedtocentrallineinsertioncredentialingandprivilegingforphysicians,fromBaystateMedicalCenter /
StaffRequirementsforPlacingPICCand Midline VascularAccessDevices
Samplepolicydetailingrequirementsfor staffwhoplacePICCormidlinevascularaccessdevices,fromUniversityofKentuckyHealthCare /
VascularCatheterInsertion Checklist
Checklisttobecompletedbytheinserterandassistanttodocumentstepsbefore,during,andaftercentrallineinsertion,fromBJCHealthcare /
_3-16_BJC_Vascular_Catheter_Insertion_Cklst_Final.pdf
Central Line InsertionStandard Workand SafetyChecklist
Checklistforstandardworkbefore,during,andaftercentrallineinsertionprocedure,fromKaiserPermanente /
JohnsHopkinsHospitalCentralLine InsertionChecklist
Acentrallineinsertionchecklistforthecareteam,fromJohnsHopkinsHealthSystem /
CentralLine Insertion Care TeamChecklist
Checklistprovidingsequentialcriticalstepsthathaveshowntoreduceinfections;fromtheAgencyforHealthcareResearchandQuality(AHRQ) /
VideosinClinicalMedicine: CentralVenousCatheterization
Videodemonstratingpropertechniqueduringtheplacementofaninternaljugularcentralvenouscatheter,fromtheNewEnglandJournalofMedicine /
Videos inClinicalMedicine: PICCPlacementin theNeonate
Videodemonstratingpropertechniqueduringtheplacementofaperipherallyinsertedcentralcatheterinaneonate,fromtheNewEnglandJournalofMedicine /
VideosinClinicalMedicine: PulmonaryArteryCatheterization
Videodemonstratingpropertechniqueduringtheplacementofpulmonaryarterycatheter,fromtheNewEnglandJournalofMedicine /
I.GeneralInfrastructure,Capacity,andProcesses,Continued
DOCUMENTATIONOFINSERTION
Physician ProcedureNoteforInvasive Line Insertion
Sampleprocedurenotefordocumentationofcentrallineinsertion,fromHealthEastCareSystemandtheCollaborativeHealthcare-AssociatedInfectionNetwork:PreventingHAIsinMinnesota /
CentralLine Insertion Procedure Note
Sampleprocedurenotefordocumentationofcentrallineinsertion,fromRoxboroughMemorialHospitalandthePennsylvaniaPatientSafetyAuthority /
VascularAccessProcedureNote
Sampleprocedurenotefordocumentationofcentrallineinsertion,fromBethIsraelMedicalCenter /
_3-15_Beth_Israel_Checklist.pdf
STAFFTRAININGANDCOMPETENCYASSESSMENTS - MAINTENANCE
CentralLineDressingChange
Videoforstaffeducationoncentrallinedressingchanges,fromtheArmstrongInstituteforPatientSafetyandQualityatJohnsHopkinsMedicine / ls/central_line_dressing_change.html
"Be a life SAVER" Online EducationalModule
Educationalmoduleoncentrallinedressingchangesprovidinginteractivevignettesandtestmaterialsforuseasastand-aloneeducationalmodule,fromUtahHospitalAssociation /
VascularAccessDeviceQuizforthe Prevention ofCLABSI
QuizdesignedtotesthealthcarepersonnelknowledgeonCLABSIpreventiontechniques,fromJohnsHopkinsUniversity,QualityandSafetyResearchGroup /
Clean ItLikeYou Mean It
Overviewandexamplesfromthe“CleanItLikeYouMeanIt”campaigncollaborativethatusesevidence-basedbestpracticesandnurseeducationtoreduceCLABSIs,preparedbyMorganStanleyChildren’sHospitalatNewYorkPresbyterianHospitalandpostedbytheAmericanAssociationofCriticalCareNurses /
-NYPMorganStanleyChildHosp-NY-Presentation.pdf
ROUTINEAUDITS
CentralLine Insertion Practices(CLIP)TrainingModule
NationalHealthcareSafetyNetwork(NSHN)trainingcourse onthecollectionofdataaboutcentrallineinsertionpractices,fromtheCentersforDiseaseControlandPrevention(CDC) /
CentralLine MaintenanceAuditForm
Auditformtoassesscentrallinemaintenancepractices,fromtheAgencyforHealthcareQualityandPromotion(AHRQ) /
CentralLine MaintenanceBundle
Checklist/auditformtoassesscentrallinemaintenancepractices,fromIPRO,theMedicareQualityImprovementOrganizationforNewYorkState /
I.GeneralInfrastructure, Capacity,andProcesses,Continued
DressingIntegrityObservation AuditForm
Audittoolforcentrallinedressingsandappropriatechangesofadministrationsets,fromtheUniversityofRochester /
NursingPractice Observation AuditForm
Audittooltocollectobservationswhennursesarechangingcentrallinedressings,fromtheUniversityofRochester /
CentralLine Outcomeand ProcessMeasuresWorksheet
Worksheettoassistwithcalculationofoutcomeandprocessmeasuresrelated tocentrallineinsertion,care,andmaintenance,fromthePennsylvaniaPatientSafetyAuthority /
BloodstreamInfection Event,Device-associatedModule
SurveillanceguidancewiththecurrentNationalHealthcareSafetyNetwork(NHSN)CLABSIdefinition(revisedJanuary2015),fromtheCentersforDiseaseControlandPrevention /
CLABSI ReviewForm
FillableworksheetforthereviewofincidentCLABSI, fromtheUniversityofRochester /
CLABSI AuditTool
AdownloadableExcelfilethatcalculatescompliancewithguidelinesforthemaintenanceofcentrallines,fromIPRO,theQualityimprovementOrganizationfortheStateofNewYork /
FEEDBACK FORPROVIDERS
CLABSI InvestigationNurse Letter
LetterTemplatetoassistininvestigationofbreachesthatmaybeassociatedwithCLABSI,fromtheAgencyforHealthcareResearchandQuality(AHRQ) /
WeeksWithoutCLABSI Banner
DownloadablePowerPointslidetoinformstaffofnumberofweekssincelastCLABSI,fromtheAgencyforHealthcareResearchandQuality(AHRQ) /
EliminateHarmAcrossthe Board:DaysSinceLastCLABSIChecklistand Poster
PostertoinformstaffofthedayssincethelastCLABSI,includingalistofpreventionmeasures, fromtheHospitalQualityInstitute /
II.AppropriateUse
CentralLineNecessityTrackingTool
Atoolthatcanbeusedasaremindertoreview centrallinenecessitywiththephysician,fromNewYorkStatePartnershipforPatients /
DailyCentralLine Maintenance Checklist
Achecklistformaintenancethatbeginsby assessingnecessity,fromtheJointCommission /
_3-23_Daily_Central_Line_Maintenance_Checklist_-
_Template.pdf
Central Line RemovalConsiderations
Listofquestionstodeterminethepresenceofanindicationtoremoveacentralline,fromtheJointCommission /
_3-24_CVC_Removal_Considerations.pdf
III.ProperInsertion
VascularCatheterInsertion Checklist
Checklisttobecompletedbytheinserterandassistanttodocumentstepsbefore,duringandaftercentrallineinsertion,fromBJCHealthcare /
_3-16_BJC_Vascular_Catheter_Insertion_Cklst_Final.pdf
CentralLine Insertion Standard Workand SafetyChecklist
Checklistforstandardworkbefore,during,andaftercentrallineinsertionprocedure,fromKaiserPermanente /
JohnsHopkinsHospitalCentralLine InsertionChecklist
Acentrallineinsertionchecklistforthecareteam,fromJohnsHopkinsHealthSystem /
CentralLine Insertion CareTeamChecklist
Checklistprovidingsequentialcriticalstepsthathaveshowntoreduceinfections;fromtheAgencyforHealthcareResearchandQuality(AHRQ) /
CatheterChoiceGuide
Aflowcharttoguidethechoiceofvascularaccessdevicesaccordingtotherapeuticindicationandexpecteddurationofnecessity,fromJohnsHopkinsMedicine /
EMPOWERINGSTAFF TOSTOPTHELINE
Stop the Line forPatientSafety
Videofromthe“StoptheLine”initiativeempoweringhealthcare personnelinwaystospeakupwhensafetyconcernsareobserved,fromtheVeteran’sAdministration /
ModelStop the Line Policy
Asamplepolicythatrequiresstafftospeakupifunsafeconditionsareobserved,fromtheMinnesotaHospitalAssociation /
Prevention ofCentralLine-AssociatedBlood StreamInfections at MassachusettsGeneralHospitalResidentCLABSItrainingpresentation;slides15-17includeexamplesofhowpotentialbreachesinthesterilefieldshouldbehandlediftheyoccur,fromMassachusettsGeneralHospital /
_CentralLineInsertion_ResidentTrainin_0911.pdf

Lake Superior Quality Innovation Network serves Michigan, Minnesota, and Wisconsin, under the
Centers for Medicare & Medicaid Services Quality Improvement Organization Program.

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IV.Proper Maintenance
CVCMaintenanceBundles
Guidelinesandcomponentsofacentrallinemaintenancebundle,fromtheJointCommission /
_3-22_CVC_Maintenance_Bundles.pdf
Scrub The Hub!
Flyerthatinstructspersonnelchargedwithmaintainingcentrallinesinproperdisinfectionbeforeaccessingthehub,fromtheJointCommission /
_3-21_Scrub_the_Hub.pdf
Blood Cultures: Ordering,Procurementand Transport
Apolicyforordering,procurement,andtransportofbloodcultures,fromtheJohnsHopkinsHospital /
Blood Culture Procedure
Procedurelistingthestepsforthecollectionofbloodculturesfromperipheralveinsorcentrallines,fromJohnsHopkinsMedicine /
Basic Infection ControlPlan forOutpatientOncologySettings
Proceduresfortheaccessandmaintenanceoflongtermcentralvenouscatheters,applicabletopermanentcentrallines,fromtheCentersforDiseaseControlandPrevention (CDC) /
V.SupplementalStrategies
Antimicrobial-orAntiseptic-ImpregnatedCathetersUtilization Algorithm
Algorithmtoassistindeterminingwhentouseantimicrobialorantisepticcatheters,fromtheJointCommission /
_3-10_Antimicrobial-Antiseptic- Impregnated_Catheters_Utilization_Algorithm.pdf

Lake Superior Quality Innovation Network serves Michigan, Minnesota, and Wisconsin, under the
Centers for Medicare & Medicaid Services Quality Improvement Organization Program.

| Follow us on social media @LakeSuperiorQIN

This material was prepared by Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MI/MN/WI-C310-17-33 032717