PICU Catheter-related Blood Stream Infection
Care Team Checklist
Purpose: To work as a team to decrease patient harm from catheter-related blood stream infections
When: During all central venous or central arterial line insertions, with one form for each new site attempted
per line
By whom: Bedside nurse

If there is an observed deviation of infection control practices, line placement should stop immediately and
the deviation should be corrected. If a correction is required, mark yes to question #7 and explain deviation
at the bottom of the page and what corrections were made
If there are any concerns, the bedside nurse should contact the ICU attending directly.

1.
Today’s date
2.
Patient Name/History Number:
3.
Is the procedure:
Please answer these questions with respect to the
healthcare provider(s) inserting the line
_____ / _____ / ________
month day
year
____________________________________
 Elective
 Emergent
Yes
Yes, after
prompting by nurse
Yes
No
1. Hands washed with Purell or soap before procedure?
2. Was this hand washing directly observed?
3. Do all individuals participating in line placement at
bedside have on mask, hair cover with all hair under cap,
sterile gown, and sterile gloves?
4. Is insertion site prepared with chlorhexidine?
5. Is patient covered head-to-toe with sterile drape?
6. After procedure, was a sterile dressing immediately
applied to site?
7. Was a correction required to ensure compliance with
above infection control practices? (explain below)
COMMENTS:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
*****Please place completed checklist in envelope on central line cart*****