TAP CLABSI Implementation Guide - Links to Example Resources

Engagement of Leadership, Champions, and Healthcare Personnel

• Comprehensive Unit-based Safety Program (CUSP) Board Checklist [PDF – 589 KB]
  Checklist of CUSP activities for board members and senior leaders to prevent healthcare-associated infections (HAI), from the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine
• Engage the Senior Executive Module – CUSP Toolkit
  Module with multiple tools for engagement of senior executives in CUSP activities, from the Agency for Healthcare Research and Quality (AHRQ)
• Accountability of Health Care Personnel in Preventing CLABSIs [PDF – 81 KB]
  Framework of personnel accountability and responsibilities in prevention of CLABSIs, from The Joint Commission
• Back to Basics: 12 Tenets to Reduce CLABSIs
  List of 12 tenets of collaboration to reduce CLABSIs, from the Agency for Healthcare Research and Quality (AHRQ)
• Steps in Developing a Business Case Analysis [PDF – 38 KB]
  A framework listing nine steps that healthcare personnel can use to build a business case for CLABSI prevention, from The Joint Commission
• HAI Cost Calculator
  Downloadable Excel files that allow hospitals to calculate facility specific costs of healthcare-associated infections and savings realized by preventing them, from the Association for Professionals in Infection Control and Epidemiology (APIC)
• Individual Self-Assessment for CLABSI Champions [PDF – KB]
  Self-assessment for individuals who may champion CLABSI prevention efforts to ensure foundational knowledge with links to many tools, from The Joint Commission
• Comprehensive Unit-based Safety Program (CUSP) Tools
  Tools to Engage, Educate, Execute, and Evaluate CLABSI prevention efforts, from the Agency for Healthcare Research and Quality (AHRQ)
• Lessons Learned from Keystone ICU Project [PDF – 68 KB]
  Guidance for large-scale improvement projects based on lessons learned from a successful ICU collaborative to reduce CLABSI rates, from The Joint Commission

Tools for the CLABSI Workgroup

• APIC Implementation Guide to Preventing Central Line-Associated Bloodstream Infections [PDF – 2.2 MB]
  Compilation of guidance on topics including CLABSI surveillance, central line bundle, catheter maintenance, and prevention of infections among the pediatric population and in the renal setting, from the Association for Professionals in Infection Control and Epidemiology (APIC)
• Assessment of Program for Prevention of Central Line-Associated Bloodstream Infections
  Worksheet that provides a method to measure the level of implementation of an organization’s CLABSI prevention program, from the Pennsylvania Patient Safety Authority
• Organizational Self-Assessment [PDF – 182 KB]
  Tool to conduct a self-assessment of organizational infrastructure related to CLABSI prevention with links to improvement tools, from The Joint Commission
• Failure Modes Effect Analysis (FMEA) for CLABSI
  A suite of tools that assist in conducting assessments to identify highest risk failures leading to CLABSIs and the most important areas for process improvements, from the Utah Hospital Association
• Eliminate Harm Across the Board [PDF – 329 KB]
  Checklist of CLABSI Prevention Strategies, from the Hospital Quality Institute, in partnership with the American Hospital Association, Partnership for Patients, and the Health Research & Educational Trust
• CLABSI Event Report Template for Defect Analysis [DOC – 53 KB]
  Template report for the review of incident CLABSI, from the Hospital Quality Institute

Prevention Bundles

• CDC Checklist for Prevention of CLABSI [PDF – 142 KB]
  Checklist based on 2011 CDC Guideline for Prevention of Intravascular Catheter-Associated Bloodstream Infections, from the Centers for Disease Control and Prevention
• How-to Guide: Prevent Central Line-Associated Bloodstream Infections
  Guide describing key evidence-based care components of a CLABSI Prevention Bundle, from the Institute for Healthcare Improvement (IHI). Log-in Required
• CLABSI Prevention Toolkits & Resources
  Toolkit of CLABSI prevention resources, from the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine

Staff Training and Competency Assessments – Insertion

• Certification for the Insertion of Central Venous Access Devices [PDF – 44 KB]
  Sample policy related to certification of graduate medical students to insert central lines, from Stony Brook University Hospital
• Baystate Health Central Line Insertion Privileging for Attending Physicians [PDF – 1 page][PDF – 66 KB]
  Sample policy related to central line insertion credentialing and privileging for physicians, from Baystate Medical Center
• Vascular Catheter Insertion Checklist [PDF – 552 KB]
  Checklist to be completed by the inserter and assistant to document steps before, during, and after central line insertion, from BJC Healthcare
• Central Line Insertion Standard Work and Safety Checklist[DOC – 65 KB]
  Checklist for standard work before, during, and after central line insertion procedure, from Kaiser Permanente
• Johns Hopkins Hospital Central Line Insertion Checklist [PDF – 28 KB]
  A central line insertion checklist for the care team, from Johns Hopkins Health System
• Central Line Insertion Care Team Checklist
  Checklist providing sequential critical steps that have shown to reduce infections; from the Agency for Healthcare Research and Quality (AHRQ)
• Videos in Clinical Medicine: Central Venous Catheterization
  Video demonstrating proper technique during the placement of an internal jugular central venous catheter, from the New England Journal of Medicine
• Videos in Clinical Medicine: PICC Placement in the Neonate
  Video demonstrating proper technique during the placement of a peripherally inserted central catheter in a neonate, from the New England Journal of Medicine

Documentation of Insertion

• Physician Procedure Note for Invasive Line Insertion [DOC – 55 KB]
  Sample procedure note for documentation of central line insertion, from HealthEast Care System and the Collaborative Healthcare-Associated Infection Network: Preventing HAIs in Minnesota
• Central Line Insertion Procedure Note [PDF – 1 page]
  Sample procedure note for documentation of central line insertion, from Roxborough Memorial Hospital and the Pennsylvania Patient Safety Authority
• Vascular Access Procedure Note [PDF – 118 KB]
  Sample procedure note for documentation of central line insertion, from Beth Israel Medical Center

Staff Training and Competency Assessments – Maintenance

• Central Line Dressing Change
  Video for staff education on central line dressing changes, from the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine
• “Be a life SAVER” Online Educational Module
  Educational module on central line dressing changes providing interactive vignettes and test materials for use as a stand-alone educational module, from Utah Hospital Association
• Vascular Access Device Quiz for the Prevention of CLABSI [DOC – 51 KB]
  Quiz designed to test healthcare personnel knowledge on CLABSI prevention techniques, from Johns Hopkins University, Quality and Safety Research Group
• Clean It Like You Mean It [PDF – 1.8 MB]
  Overview and examples from the “Clean It Like You Mean It” campaign collaborative that uses evidence-based best practices and nurse education to reduce CLABSIs, prepared by Morgan Stanley Children’s Hospital at New York Presbyterian Hospital and posted by the American Association of Critical Care Nurses

Routine Audits

• Central Line Insertion Practices (CLIP) Training Module [PDF – 161 KB]
  National Healthcare Safety Network (NSHN) training course on the collection of data about central line insertion practices, from the Centers for Disease Control and Prevention (CDC)
• Central Line Maintenance Audit Form
  Audit form to assess central line maintenance practices, from the Agency for Healthcare Quality and Promotion (AHRQ)
• Central Line Maintenance Bundle [PDF – 1 page]
  Checklist/audit form to assess central line maintenance practices, from IPRO, the Medicare Quality Improvement Organization for New York State
• Dressing Integrity Observation Audit Form [PDF – 21 KB]
  Audit tool for central line dressings and appropriate changes of administration sets, from the University of Rochester
• Nursing Practice Observation Audit Form[PDF – 21 KB]
  Audit tool to collect observations when nurses are changing central line dressings, from the University of Rochester
• Central Line Outcome and Process Measures Worksheet [PDF – 2 pages]
  Worksheet to assist with calculation of outcome and process measures related to central line insertion, care, and maintenance, from the Joint Commission
• Bloodstream Infection Event, Device-associated Module [PDF – 587 KB]
  Surveillance guidance with the current National Healthcare Safety Network (NHSN) CLABSI definition (revised January 2016), from the Centers for Disease Control and Prevention (CDC)
• CLABSI Review Form [PDF – 235 KB]
  Fillable worksheet for the review of incident CLABSIs, from the University of Rochester
• CLABSI Audit Tool [PDF – 4 pages]
  A downloadable Excel file that calculates compliance with guidelines for the maintenance of central lines, from IPRO, the Quality improvement Organization for the State of New York

Feedback for Providers

• CLABSI Investigation Nurse Letter
  Letter Template to assist in investigation of breaches that may be associated with CLABSIs, from the Agency for Healthcare Research and Quality (AHRQ)
• Weeks Without CLABSI Banner
  Downloadable PowerPoint slide to inform staff of number of weeks since last CLABSI, from the Agency for Healthcare Research and Quality (AHRQ)
• Eliminate Harm Across the Board: Days Since Last CLABSI Checklist and Poster [PDF – 329 KB]
  Poster to inform staff of the days since the last CLABSI, including a list of prevention measures, from the Hospital Quality Institute

• Central Line Necessity Tracking Tool [XLSX – 32 KB]
  A tool that can be used as a reminder to review central line necessity with the physician, from New York State Partnership for Patients
• Daily Central Line Maintenance Checklist [PDF – 44 KB]
  A checklist for maintenance that begins by assessing necessity of central line, from The Joint Commission
• Central Line Removal Considerations [PDF – 22 KB]
  List of questions to determine the presence of an indication to remove a central line, from The Joint Commission

• CDC Checklist for Prevention of CLABSI [PDF – 142 KB]
  Checklist based on 2011 CDC Guideline for Prevention of Intravascular Catheter-Associated Bloodstream Infections, from the Centers for Disease Control and Prevention
• Vascular Catheter Insertion Checklist [PDF – 552 KB]
  Checklist to be completed by the inserter and assistant to document steps before, during, and after central line insertion, from BJC Healthcare
• Central Line Insertion Standard Work and Safety Checklist [PDF – 65 KB]
  Checklist for standard work before, during, and after central line insertion procedure, from Kaiser Permanente
• Johns Hopkins Hospital Central Line Insertion Checklist [PDF – 28 KB]
  A central line insertion checklist for the care team, from Johns Hopkins Health System
• Central Line Insertion Care Team Checklist
  Checklist providing sequential critical steps that have shown to reduce infections, from the Agency for Healthcare Research and Quality (AHRQ)
• Catheter Choice Guide [PDF – 19 KB]
  A flow chart to guide the choice of vascular access devices according to therapeutic indication and expected duration of necessity, from Johns Hopkins Medicine

Empowering Staff to Stop the Line

• Stop the Line for Patient Safety
  Video from the “Stop the Line” initiative empowering healthcare personnel to speak up when safety concerns are observed, from the Veteran’s Administration
• Model Stop the Line Policy [DOC – 589 KB]
  A sample policy that requires staff to speak up if unsafe conditions are observed, from the Minnesota Hospital Association
• Prevention of Central Line-Associated Blood Stream Infections at Massachusetts General Hospital [PDF – 77 KB]
  Resident CLABSI training presentation; slides 15-17 include examples of how potential breaches in the sterile field should be handled if they occur, from Massachusetts General Hospital

• CDC Checklist for Prevention of CLABSI [PDF – 142 KB]
  Checklist based on 2011 CDC Guideline for Prevention of Intravascular Catheter-Associated Bloodstream Infections, from the Centers for Disease Control and Prevention
• CVC Maintenance Bundles [PDF – 144 KB]
  Guidelines and components of a central line maintenance bundle, from The Joint Commission
• Scrub The Hub! [PDF – 89 KB]
  Flyer that instructs personnel charged with maintaining central lines in proper disinfection before accessing the hub, from The Joint Commission
• Blood Cultures: Ordering, Procurement and Transport [PDF – 40 KB]
  A policy for ordering, procurement, and transport of blood cultures, from the Johns Hopkins Hospital
• Blood Culture Procedure [PDF – 12 KB]
  Procedure listing the steps for the collection of blood cultures from peripheral veins or central lines, from Johns Hopkins Medicine
• Basic Infection Control Plan for Outpatient Oncology Settings
  Procedures for the access and maintenance of long term central venous catheters, applicable to permanent central lines, from the Centers for Disease Control and Prevention (CDC)

• Antimicrobial- or Antiseptic-Impregnated Catheters Utilization Algorithm [PDF – 52 KB]
  Algorithm to assist in determining when to use antimicrobial or antiseptic catheters, from The Joint Commission
• Chlorhexidine Bathing Procedure
  A procedure that illustrates the use of chlorhexidine bathing, from the Agency for Healthcare Research and Quality (AHRQ)
• Chlorhexidine Bathing Skills Assessment
  A competency assessment to ensure appropriate implementation of chlorhexidine bathing, from the Agency for Healthcare Research and Quality (AHRQ)