TAP Central Line-Associated Bloodstream Infections (CLABSI) Implementation Guide: Links to Example Resources

Engagement of Leadership, Champions, and Healthcare Personnel

• Comprehensive Unit-based Safety Program (CUSP) Board Checklist pdf icon[PDF – 589 KB]external icon
  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 Toolkitexternal icon
  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 icon[PDF – 81 KB]external icon
  Framework of personnel accountability and responsibilities in prevention of CLABSIs, from The Joint Commission
• Back to Basics: 12 Tenets to Reduce CLABSIsexternal icon
  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 icon[PDF – 38 KB]external icon
  A framework listing nine steps that healthcare personnel can use to build a business case for CLABSI prevention, from The Joint Commission
• HAI Cost Calculatorexternal icon
  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 icon[PDF – KB]external icon
  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) Toolsexternal icon
  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 icon[PDF – 68 KB]external icon
  Guidance for large-scale improvement projects based on lessons learned from a successful ICU collaborative to reduce CLABSI rates, from The Joint Commission
• Infection Prevention Champion
  Informational webpage and accompanying PDF to aid partners in the identification and guidance of infection prevention champions, from CDC

Tools for the CLABSI Workgroup

• APIC Implementation Guide to Preventing Central Line-Associated Bloodstream Infections pdf icon[PDF – 2.2 MB]external icon
  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 Infectionsexternal icon
  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 icon[PDF – 182 KB]external icon
  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 CLABSIexternal icon
  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 icon[PDF – 329 KB]external icon
  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 word icon[DOC – 53 KB]external icon
  Template report for the review of incident CLABSI, from the Hospital Quality Institute
• Toolkit for Reducing Central Line-Associated Blood Stream Infectionsexternal icon
  Resources include “Weeks without CLABSI Banner”, fact sheet, guidelines, cart inventory, insertion checklist, maintenance audit, event report template, investigation nurse letter, and tenets for reducing CLABSIs, from the Agency for Health Research and Quality (AHRQ)
• Quick Observation Tools (QUOTS)external icon
  Easy, quick tools arranged by themes (e.g. transmission-based precautions, device-associated infections, high-level disinfection, etc.)for infection prevention that can be used by healthcare providers primarily responsible at the location being assessed, from APIC

Prevention Bundles

• CDC Checklist for Prevention of CLABSI pdf icon[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 Infectionsexternal icon
  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 & Resourcesexternal icon
  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 icon[PDF – 44 KB]external icon
  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 icon[PDF – 1 page]external icon
  Sample policy related to central line insertion credentialing and privileging for physicians, from Baystate Medical Center
• Vascular Catheter Insertion Checklist pdf icon[PDF – 552 KB]external icon
  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 Checklistword icon[DOC – 65 KB]external icon
  Checklist for standard work before, during, and after central line insertion procedure, from Kaiser Permanente
• Johns Hopkins Hospital Central Line Insertion Checklist pdf icon[PDF – 28 KB]external icon
  A central line insertion checklist for the care team, from Johns Hopkins Health System
• Central Line Insertion Care Team Checklistexternal icon
  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 Catheterizationexternal icon
  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 Neonateexternal icon
  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

• Central Line Insertion Procedure Note pdf icon[PDF – 1 page]external icon
  Sample procedure note for documentation of central line insertion, from Roxborough Memorial Hospital and the Pennsylvania Patient Safety Authority
• Vascular Access Procedure Note pdf icon[PDF – 118 KB]external icon
  Sample procedure note for documentation of central line insertion, from Beth Israel Medical Center

Staff Training and Competency Assessments – Maintenance

• Central Line Dressing Changeexternal icon
  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 Moduleexternal icon
  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 word icon[DOC – 51 KB]external icon
  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 icon[PDF – 1.8 MB]external icon
  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 icon[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 Formexternal icon
  Audit form to assess central line maintenance practices, from the Agency for Healthcare Quality and Promotion (AHRQ)
• Central Line Maintenance Bundle pdf icon[PDF – 1 page]external icon
  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 icon[PDF – 21 KB]external icon
  Audit tool for central line dressings and appropriate changes of administration sets, from the University of Rochester
• Nursing Practice Observation Audit Formpdf icon[PDF – 21 KB]external icon
  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 icon[PDF – 2 pages]external icon
  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 icon[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 icon[PDF – 235 KB]external icon
  Fillable worksheet for the review of incident CLABSIs, from the University of Rochester
• CLABSI Audit Tool pdf icon[PDF – 4 pages]external icon
  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 Letterexternal icon
  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 Bannerexternal icon
  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 icon[PDF – 329 KB]external icon
  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 excel icon[XLSX – 32 KB]external icon
  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 icon[PDF – 44 KB]external icon
  A checklist for maintenance that begins by assessing necessity of central line, from The Joint Commission
• Central Line Removal Considerations pdf icon[PDF – 22 KB]external icon
  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 icon[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 icon[PDF – 552 KB]external icon
  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 word icon[PDF – 65 KB]external icon
  Checklist for standard work before, during, and after central line insertion procedure, from Kaiser Permanente
• Johns Hopkins Hospital Central Line Insertion Checklist pdf icon[PDF – 28 KB]external icon
  A central line insertion checklist for the care team, from Johns Hopkins Health System
• Central Line Insertion Care Team Checklistexternal icon
  Checklist providing sequential critical steps that have shown to reduce infections, from the Agency for Healthcare Research and Quality (AHRQ)
• Catheter Choice Guide pdf icon[PDF – 19 KB]external icon
  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 Safetyexternal icon
  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 word icon[DOC – 589 KB]external icon
  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 icon[PDF – 77 KB]external icon
  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 icon[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 icon[PDF – 144 KB]external icon
  Guidelines and components of a central line maintenance bundle, from The Joint Commission
• Scrub The Hub! pdf icon[PDF – 89 KB]external icon
  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 icon[PDF – 40 KB]external icon
  A policy for ordering, procurement, and transport of blood cultures, from the Johns Hopkins Hospital
• Blood Culture Procedure pdf icon[PDF – 12 KB]external icon
  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)

Education of Patients and Families

• American Thoracic Society: Central Venous Catheter pdf icon[PDF – 2 pages]external icon
  Patient information about central line indications and symptoms to report to care givers, from the American Thoracic Society.
• FAQs about “Catheter-Associated Bloodstream Infections” pdf icon[PDF – 1 page]
  Answers to frequently asked questions about CLABSIs and how hospitals and patients can prevent them, from the Centers for Disease Control and Prevention (CDC). The Spanish version of this tool is located here pdf icon[PDF – 2 pages]

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