Manager Review Date: ______
UBC Review Date: ______
Date due to IP Team: ______
CLABSI Prevention Case Review-Unit Level Assessment
Nurse Sensitive Outcome Indicators
Investigating Unit: ______Date admitted to Unit: ______Pt Account #: ______
Date Blood Culture collected (from IP report): ______Location of Patient 48 hrs prior to UA: ______
(NHSN tool for IP use to determine correct unit designation)
Date central line inserted: ______Dept where CL inserted:______
Number of days after insertion date infection was identified? ______Organism Identified: ______
Record the highest value from 2 days before specimen collection date to 2 days after (infection window)
Highest Temp: ______Highest WBC: ______
Same organism & same sensitivity identified from other site within 48 hr? Yes o No o
List other site(s): ______
Date CL removed: ______
Type of central line(CVAD Report):
o Multi lumen o o Tunneled Catheter o Implanted Port o PICC o Non-tunneled
o Other (Specify) ______
Location of CVAD (CVAD Report)
o Left chest o Left arm o Left femoral o Left internal jugular
o Right chest o Right arm o Right femoral o Right internal jugular
Line necessity reviewed with provider? o Yes o No Date last reviewed: ______
Dressing change in past 7 days? o Yes o No Date last reviewed: ______
Hub change in past 7 days? o Yes o No Date last reviewed: ______
Direct observation of patient (if still on unit) OR select another patient with a central line
o Scrub the hub done o Aseptic technique with dressing change o IV tubing labeled
Interview with (any) RN on date of investigation. Discuss knowledge of:
o Scrub the hub o Dressing changes and aseptic technique o Appropriate intervals for dressing change
o Appropriate intervals for hub change o Appropriate intervals for IV tubing change
What risk factors were present at the time of the CLABSI? o extended stay o >65yrs o immune suppressed
o multiple co-morbidities o Other: describe
CUSP Questions for UBC:
Was this event preventable? Did we do everything possible to prevent? (Yes or No is required)
o Yes: ______
______
o No: State what measures were implemented for prevention: ______
______
______
What can we do differently to improve patient safety and outcomes? ______
______
UBC action plan (must include measurable dates): ______
______
Date action plan reported/scheduled for staff meeting discussion (must be within 30 days of UBC meeting): ______
UBC Chair signature: ______Date: ______Manager signature: ______Date: ______
Fax to: Infection Prevention: 713-2471 Please submit on or prior to due date listed on this form