Fillable Printable 57.125 Clip Blank
Fillable Printable 57.125 Clip Blank
57.125 Clip Blank
Form Approved
OMB No. 0920-0666
Exp. Date: 11/30/2019
www.cdc.gov/nhsn
Central Line Insertion Practic es Adherence Monitoring
Page 1 of 2
*required for saving
Facility ID: _____________________Event #: ________________________________
*Patient ID: _____ ________________Social Security #: __ __ __ - __ __ - __ __ __ __
Secondary ID: __________________ __Medicare #: _______________________
Patient Name, Last: ________________ _____First: __________ ________Middle: ________ __________
*Gender: □F □M □Other
*Date of Birth: ___ / ___ / ______ (mm/dd/ yyyy)
Ethnicity(specify): _____________________ _______Race (specify): ________________________________
*Event Type: CLIP*Location: ______ __________________*Date of Insertion: ___ /___ /_____ (mm/dd/yyyy)
*Person recording insertion practi ce dat a:
□Inserter□Observer
Centralline inserter ID: _________ Name, Last: ____________________First: __________ ____________
*Occupation of inserter:
□Fellow□Medical student□Other student□Other medical staff
□Physician assistant □Attending physician □Intern/resident□Registered nurse
□Advanced practice nurse □Other (specify): __________ ____ ___ _____
*Was inserter a m em ber of PICC/IV Team?
□Y □N
*Reason for insert i on:
□New indication for central line (e.g., hemodynamic monitoring, fluid/medi cat i on administration, etc.)
□Replace malfunctioning central line
□Suspected central line-associat ed i nf ection
□Other (specify): ______ ________ ___ ____ ___
If Suspected central l ine-associated infection, was the cent ral l i ne exchanged over aguidewire?□Y □N
*Inserter performed hand hygiene prior to central line inserti on:
□Y □N
(if not observed directly, ask inserter)
*Maximal steri le barriers used:
Mask
□Y□N Sterile gown □Y □N
Large sterile drape
□Y □N Sterile gloves □Y □N Cap □Y □N
*Skin preparation (ch eck all that apply)
□Chlorhexidine gluconate□Povidone iodine□Alcohol
□Other (specify): ______ ________ ___ ____
If skin prep choice wa s notchlorhexidin e, was there a contraindication to chlorhexidine?
□Y □N □U
If there was a contraindication to chlorhexidine, indicat e the type of contraindication:
□Patient is less than 2 m onths of age - chlorhexidine is to be use d with caution in pati ents less than 2
months of age
□Patient has a docume nted/known allergy /reaction to CHG based products that would preclude its use
□Facility restrictions or safety concerns for CHG use in prem ature infants precludes its use
*Was skin prep age nt completely dry at time of first skin punctu re?
□Y □N
(if not observed directly, ask inserter)
*Insertion site:
□Femoral□Jugular□Lower extremity□ Scalp □Subclavian□Umbilical □Upper extremity
Antimicrobial coat ed catheter used:
□Y □N
Assurance of Confide nt iality:The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is
collected with a guarantee that it will be held in strict confidence, will be usedonly for the purposes stated, and will not otherwise be disclosed or released without the
consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).
Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a
person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate
or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74,
Atlanta, GA 30333, ATTN: PRA (0920-0666).
CDC 57.125 (Front) Rev 5, v8.5
Form Approved
OMB No. 0920-0666
Exp. Date: 11/30/2019
www.cdc.gov/nhsn
CDC 57.125 (Back) Rev 5, v8.5
Central Line Insertion Practices Adherence Monitoring
Page 2 of 2
*Central line catheter type:
□Non-tunneled (other than dialysis)□PICC
□Tunneled (other than di alysis)□Umbilical
□Dialysis non-tunneled□Other (specify): ______ ________ ___ ____ _______ ___
□Dialysis tunneled
(“Other” should not specify brand names or number of lumens; most
lines can be categorized accurately by selecting from options provided.)
*Did this insertion attempt result in a successful central line placement?
□Y □N
Custom Fields
LabelLabel
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