NC Point Prevalence Assessment HAI Solutions · LLUMC Pilot · adapted from Ryder Science, Inc. NC Utilization Point Prevalence Assessment Pre-pilot feasibility tool — sampling frame for QIKcap vs. IPA cap comparison Assessment Session Date Unit Investigator Connector Record NC No. 1 Patient No. coded, no identifiers VAD Type Select… Non-tunneled CVC (CVC) Tunneled CVC (CVC-Tun) Subcutaneous Implanted Port (Port) PICC Midline (MID) Hemodialysis (HD) Pulmonary Artery Catheter (PA) Peripheral Arterial Catheter (PAC) Peripheral IV Catheter (PIV) Insertion Site Select… Subclavian Vein (SCV) Jugular Vein (IJ/EJ) Femoral (Fem) Upper Extremity (UE) Radial/Ulnar (RA/UA) Hand (H) Wrist (W) Forearm (F) # Lumens Connector Location Select… Catheter Hub, direct (Hub) Extension Set (Ext) Stopcock (SC) Manifold Port (Man) Add-on / Y-site Device (AOD) Administration Set Port (AS) Connector Configuration Select… Administration Set (AS) Extension Tubing (ET) Manifold (MF) Stopcock (SC) Multi-lumen Device (ML) Clinical Purpose Select… Continuous Infusion (CI) Intermittent Medication (IM) Blood Sampling (BS) Infusion Manifold Access (IMA) Not Currently Accessed (NA) Passive Disinfection Cap Select… Not Present (NP) IPA Cap Present (IPA) QIKcap Present (QC) Other Cap Present (O) Eligible for Micro. Sampling Select… Yes — accessible septum, ≥24 hrs (Y) No — not accessible/eligible (N) Unit / Care Area if different from session unit above Notes Save NC Record
