10 May IS IT PRACTICE TO ALLOW THE ACCESS POINT TO DRY PRIOR TO ACCESSING THE CATHETER?
Unsterile tray
j. Checklist to observe for adherence to practice
k. Observer to watch for breech in maintaining sterility
l. Other (please specify)
39. Which of the following are used when accessing a femoral catheter (e.g. for medications)?
(select all that apply)
a. Sterile glove
b. Non--sterile gloves
c. Hat
d. Gown
e. Mask
f. Full body sterile drapes
g. Dressing trolley
h. Sterile dressing pack / tray
i. Unsterile tray
j. Checklist to observe for adherence to practice
k. Observer to watch for breech in maintaining sterility
l. Other (please specify)
40. Which of the following are used when accessing a Tunnelled catheter for medications?
(select all that apply)
a. Sterile glove
b. Non--sterile gloves
c. Hat
d. Gown
e. Mask
f. Full body sterile drapes
g. Dressing trolley
h. Sterile dressing pack / tray
i. Unsterile tray
j. Insertion checklist to observe for adherence to practice
k. Observer to watch for breech in maintaining sterility
l. Other (please specify)
41. When accessing the CVC which solution is used to clean the access point? a. 70% alcohol / Alcohol swab
b. > 0.5% Chlorhexidine gluconate with alcohol
c. Tincture of iodine
d. Povidone--iodine
e. Other (please specify)
42. Which technique is used to clean the access point?
a. Wipe gently for a period of time or rubs
b. Vigorous rubbing for a period of time or rubs
c. Other (please specify)
43. What is the duration of time the access point is cleaned for? a. < 5 seconds
b. <10 seconds
c. 11-- 14 seconds
d. > 15 seconds
e. Not timed
44. How many rubs of the access point is performed?
a. <5
b. <10
c. 11--19
d. > 20
e. Not counted
45. Is it practice to allow the access point to dry prior to accessing the catheter?
YES/NO
46. Do you routinely use in--line filters for clear fluids?
YES/NO
47. Do you routinely use in--line filters for Lipids?
YES/NO
48. How often are the following infusion lines changed?
a. lipid / fat emulsion lines (daily, 48 hourly, 72 hourly, 96 hourly, weekly)
b. TPN (excluding lipid) (daily, 48 hourly, 72 hourly, 96 hourly, weekly)
c. Clear fluids daily (48 hourly, 72 hourly, 96 hourly, weekly)
d. Blood / blood products (daily, 48 hourly, 72 hourly, 96 hourly, weekly, after infusion)
49. How often are the following fluids changed?
a. Pre--package with no additives (i.e. 10% Dextrose) (daily, 48 hourly, 72 hourly, 96 hourly, weekly)
b. Pre--package with additives added on the ward (i.e. extra sodium chloride) (daily, 48 hourly, 72 hourly, 96 hourly, weekly)
c. Pharmacy prepared (i.e. TPN) (daily, 48 hourly, 72 hourly, 96 hourly, weekly)
d. Lipid / fat emulsion (daily, 48 hourly, 72 hourly, 96 hourly, weekly)
50. What time are fluids and lines routinely changed?
a. Between 0800--1200
b. Between 1200--1600
c. Between 1600--2100
d. Between 2100--0000
e. Between 0000--0600
f. No set time
g. Other (please specify)
51. Are stopcocks (three way taps) routinely used?
YES/NO
52. Are multi lumen extension tubing’s (octopus systems) routinely used? YES/NO
53. When using stopcocks (3 way taps) on CVC’s how are they capped when not in use? a. Left open
b. A needle--less access point is attached
c. A cap
d. Never use
54. Are needle--less intravascular devices ( e.g. Smart Site) routinely used on all access points? YES/NO
55. How often are needle--less intravascular devices changed? a. Daily
b. 48 hourly
c. 72 hourly
d. 96 hourly
e. Weekly
f. Not routinely changed
g. Don’t use
56. How often are dressings changed on the following? (select all that apply)
a. PICC lines (long line) (not routinely, daily,2nd daily, weekly, visibly soiled or loose)
b. Femoral lines (not routinely, daily,2nd daily, weekly, visibly soiled or loose)
c. Tunnelled catheters (unhealed insertion site) (i.e. Broviac / Hickman) (not routinely, daily,2nd daily, weekly, visibly soiled or loose)
d. Tunnelled catheters (healed insertion site) (i.e. Broviac / Hickman) (not routinely, daily,2nd daily, weekly, visibly soiled or loose, dressing not used)
57. Which of the following are used when accessing a CVC to change a dressings? (select all that
apply)
a. Sterile glove
b. Non--sterile gloves
c. Hat
d. Gown
e. Mask
f. Full body sterile drapes
g. Dressing trolley
h. Sterile dressing pack / tray
i. Unsterile tray
j. Checklist to observe for adherence to practice
k. Observer to watch for breech in maintaining sterility
l. Other (please specify)
58. Do you use positive pressure displacement valves (e.g. CLC) on the follow CVCs? a. PICC (YES/NO)
b. UVC (YES/NO)
c. Femoral catheters (YES/NO)
d. Tunnelled catheters (YES/NO)
59. How often is the insertion site physically examined by the nurse? a. Hourly
b. At care times
c. Each shift
d. Daily
e. Other (please specify)
60. Do nursing staff responsible for CVC management receive annual education on CVC management, including infection prevention?
YES/NO
61. Do nursing staff responsible for CVC management have their knowledge assessed on CVC management, including infection prevention? YES/NO
62. Do nursing staff receive feedback on the number of catheter related blood stream infections?
LOW RISK APPLICATION FORM-HUMAN RESEARCH ETHICS.
Please do not print this form. To complete this application form, save a blank copy to your computer and open the form in the
free Adobe Reader software (version 9.0 or later). Complete the form, save it and attach it to an email from your La Trobe
University email account addressed to the relevant Faculty Human Ethics Committee (FHEC) Secretary.
If you do not have this software installed, or are using an older version of Adobe Reader, the latest version can be downloaded
from the Adobe website.
Please be advised that expedited review does not absolve the researcher(s) from adherence to acceptable ethical standards as
outlined in the NHMRC National Statement and the La Trobe University Human Research Ethics Guidelines.
Please note that this application needs to be submitted with the following supporting documentation:
· Participant Information Statement
· Consent Form
· Withdrawal of Consent Form (use the template provided on the La Trobe University Human Research Ethics website).
· Other documents related to your project including advertisements, flyers, questionnaires, interview schedules etc
Section 1. Project Details
1.1 Core Project Details
Project Title
Title/Full Name of Chief Investigator/
Supervisor
Must be an academic staff member of La
Trobe University or affiliated institute
School/Institute Phone
Position Staff ID
Email
Title/Full Name of Principal Research
Student (if applicable)
Enter contact details in Section 12
Proposed commencement date Proposed conclusion date
Please provide a summary in lay terms
of what this research project involves
with particular reference to the
participants
(Please ensure the description is 50
words or less and in plain language)
1.2 Type of Project
Research by Academic Staff Member Postgraduate Research Contract Research
Masters by Coursework Undergraduate Research Honours Research
Clinical Trial
Other
1.3 Is this project part of a larger project?
No Yes
1.4 Does this project involve multi-centre research?
No Yes
1.5 Project Description
Aims
Research design / approach
Methodology / data
collection techniques &
analysis
Section 2. Participant Details
Does your research project involve:
Human participants
Use of data banks only
Section 3. Research Using Existing Databases
Please refer to the Victorian Privacy Impact Assessment Guide.
https://www.privacy.vic.gov.au/privacy/web2.nsf/files/privacy-impact-assessments-guide
3.1 If the research involves access to existing database provided by an institution(s), please indicate:
Source(s) and number of records
Whether data to be used will be de-identified,
potentially identifiable (e.g. coded), or identified
Whether permission has been granted by donors
to use these data for research purposes
Whether formal permission/clearance has been
sought or obtained from the relevant institution(s)
(see also Section 5 below)
Updated December 2013 Page 3 of 7
Section 4. Location of Study
4.1 Please identify the precise location of the study
If permission is required to use the location, indicate how permission will be obtained. See also Section 5.
Section 5. External Approvals
If a project requires approval from other institutions or ethics committees, next of kin or guardian, or representative or authority in the
case of special groups, copies of such approvals must be provided to the UHEC at the time of application or be made available as soon as
possible thereafter.
Please indicate as appropriate if formal clearance/permission has been sought or obtained.
5.1 Institutional
Name(s) of institution/ethics committee/authority:
Yes, details below Yes, to follow (estimate when likely to be obtained below) No, please explain below N/A
Section 6. Informed Consent
6.1 How will consent be obtained?
Written consent form Other – explain below how consent will be recorded
6.2 How will competence to give consent be determined and who will make this determination?
Please provide details below:
6.3 Will Participant Information Statement and Consent Forms be used?
Yes (copies attached) No (please explain below) An alternative method of obtaining consent
will be used (please specify below)
6.4 Will Participant Information Statement and Consent Forms be translated into the participants’ first language?
Yes (please provide copies of translations) No (please explain below) N/A
Updated December 2013 Page 4 of 7
6.5 Will all participants have the capacity to give voluntary and informed consent?
Yes No
Section 7. Description of Procedures
7.1 Describe in detail below exactly what you will be asking of participants and emphasise anything that may have
adverse consequences.
7.2 Will questionnaire(s) (including those that are published or commercially available) be used in the project?
Please attach a copy to this application.
No Yes (please attach a copy to this application)
7.3 If interviews or focus groups are to be held, please indicate the kinds of questions to be asked below or attach
the interview schedule in the case of structured interviews.
7.4 Will participants at any time be photographed, video recorded, or audio recorded?
No Yes
Section 8. Risk and Indemnity
8.1 Is there any risk of physical, psychological, social, legal or financial and/or community, employment and/or
professional harm to the participant or organisation?
No Yes
Section 9. Recording and Security of Project Documentation
9.1 How will data be recorded? (e.g. written questionnaires, interview notes, photographs, audio/video recording,
direct electronic data entry)
9.2 How will confidentiality of results be maintained?
If you cannot ensure the confidentiality of results, your project may be above low risk and require full ethical review.
Updated December 2013 Page 5 of 7
9.3 Indicate how the security of project documentation will be maintained and specify the precise location of the
storage place(s):
9.3.1 During the study
9.3.2 Following completion of the study
Project documentation should be stored in secure, lockable locations, preferably on campus. Computer files should be password protected. Data, de-identified
where appropriate, and consent forms should normally be kept for a period consistent with the Public Records Office of Victoria Standard (02/01) (normally 5 years
for non clinical trial data and 15 years for clinical trial data following publication).
9.4 Will any data (including samples) be preserved for possible future use in another project either by yourself or
another researcher?
No Yes
Section 10. Dissemination of Results
10.1 Will participants be informed that results from the study may appear in publications, be included in a thesis or
report, or be presented at conferences? (If relevant, this information should be included in the Participant
Information Statement and given to participants prior to obtaining informed consent).
No Yes
Please provide details
10.2 Will participants be informed that results from the study will be available to them on request? (If relevant, this
information should be included in the Participant Information Statement and given to participants prior to
obtaining informed consent).
No Yes
10.3 Will participants be informed that their personal data collected in the course of the research will be available to
them on request? (If relevant, this information should be included in the Participant Information Statement and
given to participants prior to obtaining informed consent).
No Yes
Please explain
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