CVC Insertion Checklist

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* 1. Trainee

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* 2. Evaluator

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* 3. Date of Procedure

Date / Time

Date

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* 4. PROCEDURE PREPARATION

	Completed	Partially Completed	Not attempted
Review patient data (labs, anticoagulants/antipatelets, allergies to lidocaine/chlorhexadine)	Review patient data (labs, anticoagulants/antipatelets, allergies to lidocaine/chlorhexadine) Completed	Review patient data (labs, anticoagulants/antipatelets, allergies to lidocaine/chlorhexadine) Partially Completed	Review patient data (labs, anticoagulants/antipatelets, allergies to lidocaine/chlorhexadine) Not attempted
Obtain consent	Obtain consent Completed	Obtain consent Partially Completed	Obtain consent Not attempted
Obtain supplies	Obtain supplies Completed	Obtain supplies Partially Completed	Obtain supplies Not attempted
Position patient (Trendelenburg position if IJ or SC)	Position patient (Trendelenburg position if IJ or SC) Completed	Position patient (Trendelenburg position if IJ or SC) Partially Completed	Position patient (Trendelenburg position if IJ or SC) Not attempted
Identify site via US, capture image	Identify site via US, capture image Completed	Identify site via US, capture image Partially Completed	Identify site via US, capture image Not attempted
Perform Time Out with RN	Perform Time Out with RN Completed	Perform Time Out with RN Partially Completed	Perform Time Out with RN Not attempted
Clean hands	Clean hands Completed	Clean hands Partially Completed	Clean hands Not attempted
Clean site with chlorhexidine	Clean site with chlorhexidine Completed	Clean site with chlorhexidine Partially Completed	Clean site with chlorhexidine Not attempted
Put on sterile attire (hat, mask with face shield, gloves, gown)	Put on sterile attire (hat, mask with face shield, gloves, gown) Completed	Put on sterile attire (hat, mask with face shield, gloves, gown) Partially Completed	Put on sterile attire (hat, mask with face shield, gloves, gown) Not attempted
Drape patient and probe cover in sterile fashion	Drape patient and probe cover in sterile fashion Completed	Drape patient and probe cover in sterile fashion Partially Completed	Drape patient and probe cover in sterile fashion Not attempted

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* 5. PROCEDURE

	Completed	Partially Completed	Not attempted
Check and prepare kit (confirm needle, guide wire, scalpel, and catheter function and are not damaged; prep sterile flushes; clamp appropriate ports)	Check and prepare kit (confirm needle, guide wire, scalpel, and catheter function and are not damaged; prep sterile flushes; clamp appropriate ports) Completed	Check and prepare kit (confirm needle, guide wire, scalpel, and catheter function and are not damaged; prep sterile flushes; clamp appropriate ports) Partially Completed	Check and prepare kit (confirm needle, guide wire, scalpel, and catheter function and are not damaged; prep sterile flushes; clamp appropriate ports) Not attempted
Anesthetize entry and suture site with US guidance	Anesthetize entry and suture site with US guidance Completed	Anesthetize entry and suture site with US guidance Partially Completed	Anesthetize entry and suture site with US guidance Not attempted
Access vein with US guidance	Access vein with US guidance Completed	Access vein with US guidance Partially Completed	Access vein with US guidance Not attempted
Insert guide wire	Insert guide wire Completed	Insert guide wire Partially Completed	Insert guide wire Not attempted
Confirm guide wire placement with US (with or without needle in place), capture image	Confirm guide wire placement with US (with or without needle in place), capture image Completed	Confirm guide wire placement with US (with or without needle in place), capture image Partially Completed	Confirm guide wire placement with US (with or without needle in place), capture image Not attempted
Make superficial skin incision at location of guide wire (can be with needle in place)	Make superficial skin incision at location of guide wire (can be with needle in place) Completed	Make superficial skin incision at location of guide wire (can be with needle in place) Partially Completed	Make superficial skin incision at location of guide wire (can be with needle in place) Not attempted
Pass dilator while holding guide wire to the depth measured on US, minimize bleeding (small then large dilator for large bore CVC)	Pass dilator while holding guide wire to the depth measured on US, minimize bleeding (small then large dilator for large bore CVC) Completed	Pass dilator while holding guide wire to the depth measured on US, minimize bleeding (small then large dilator for large bore CVC) Partially Completed	Pass dilator while holding guide wire to the depth measured on US, minimize bleeding (small then large dilator for large bore CVC) Not attempted
Thread catheter over guide wire while holding guide wire securely	Thread catheter over guide wire while holding guide wire securely Completed	Thread catheter over guide wire while holding guide wire securely Partially Completed	Thread catheter over guide wire while holding guide wire securely Not attempted
Remove guide wire, clamping exit port immediately	Remove guide wire, clamping exit port immediately Completed	Remove guide wire, clamping exit port immediately Partially Completed	Remove guide wire, clamping exit port immediately Not attempted
Aspirate all ports, ensuring easy blood return, then flush, clamp, and cap all ports.	Aspirate all ports, ensuring easy blood return, then flush, clamp, and cap all ports. Completed	Aspirate all ports, ensuring easy blood return, then flush, clamp, and cap all ports. Partially Completed	Aspirate all ports, ensuring easy blood return, then flush, clamp, and cap all ports. Not attempted
Suture catheter in place	Suture catheter in place Completed	Suture catheter in place Partially Completed	Suture catheter in place Not attempted

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* 6. POST PROCEDURE

	Completed	Partially Completed	Not attempted
Clean site, apply skin prep, then seal site with biopatch / sterile dressing	Clean site, apply skin prep, then seal site with biopatch / sterile dressing Completed	Clean site, apply skin prep, then seal site with biopatch / sterile dressing Partially Completed	Clean site, apply skin prep, then seal site with biopatch / sterile dressing Not attempted
Dispose of all sharps and discard dirty material	Dispose of all sharps and discard dirty material Completed	Dispose of all sharps and discard dirty material Partially Completed	Dispose of all sharps and discard dirty material Not attempted
Obtain CXR (if IJ or SC)	Obtain CXR (if IJ or SC) Completed	Obtain CXR (if IJ or SC) Partially Completed	Obtain CXR (if IJ or SC) Not attempted
Document procedure using standardized template	Document procedure using standardized template Completed	Document procedure using standardized template Partially Completed	Document procedure using standardized template Not attempted