Whole-house surveillance
Q. Must we perform surveillance on all central lines, or is targeted surveillance okay?
A. Infection surveillance must be performed on all central lines; these lines carry significant risk of morbidity and mortality regardless of circumstances. Limiting surveillance to certain types of lines, patient care units or service lines is not allowable under NPSG.07.04.01.
Documentation
Q. Please explain the documentation icons for EPs 6 and 12. What will surveyors expect to see?
A. EP 6 requires use of “a catheter checklist and a standardized protocol for central venous catheter insertion” The checklist or protocol is not required to be a part of the patient’s medical record. A simple indication that the checklist or protocol was completed, perhaps via a checkbox or brief note, is sufficient.
EP 12 requires use of a “standardized protocol to disinfect catheter hubs and injection ports before accessing the ports”. This is not a patient-specific documentation requirement. Surveyors will ask to see each organization’s protocol; this may be in the form of a policy, protocol, etc.