Central Line Insertion Care Team Checklist

Form Template

A minimum of 5 supervised successful procedures in both the chest and femoral sites is required (10 total).

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If a physician successfully performs the 5 supervised lines in one site, they are independent for that site only. A total of 3 supervised rewires is required prior to performing a rewire independently. The Supervisor Role is a 2nd-year resident and above (approved for line placement). The Assistant Role is a RN, Clinical Technician, MD, NP, PA (responsible for completing checklist) using the Central Line Insertion Care Team Checklist mobile app. If there is any deviation from any of the critical steps, immediately notify the operator and stop the procedure until corrected. If a correction is required, make a check mark in the “yes with reminder” column and note what correction was made in the comment space, if applicable. Uncorrected deviations and complications of line placement are to be reported. Contact the Attending if any item on the checklist is not adhered to or if you have any concerns. Please submit the completed app to the designated person in your area.

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