*24.
| What type of erythropoietin vials are generally used in your facility? □ Single-dose □ Multiple-dose □ N/A Is erythropoietin from a single-dose vial administered to more than one patient? Yes No
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*25.
| Please indicate whether your facility uses any of the following means of restricting or ensuring appropriate antibiotic use?
a.have a written policy on antibiotic use b.formulary restrictions c.antibiotic use approval process d.automatic stop orders for antibiotics
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F. Vascular Access
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*26.
| For AV grafts or fistulas: a. Before prepping the area for puncture, is the area commonly washed with soap and water? Yes No b. Before puncture of a graft or fistula, the area is most often prepped with:
□ Alcohol □ Chlorhexidine (e.g., Chloraprep®) □ Povidone-iodine (or tincture of iodine) □ Sodium hypochlorite solution (e.g., ExSept®) □ Other (specify): ____________
c. Is buttonhole cannulation performed on any patients in your facility? Yes No
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*27.
| Job classification of staff members primarily responsible for providing hemodialysis catheter care (i.e., access catheters or change dressing) (select one): □ Nurse □ Technician
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*28.
| For hemodialysis catheters: a. Before access of the hemodialysis catheter, the catheter ports are prepped with (check the one most commonly used): □ Alcohol □ Chlorhexidine (e.g., Chloraprep®) □ Povidone-iodine (or tincture of iodine)
□ Sodium hypochlorite solution (e.g., ExSept®, Alcavis) □ Other (specify): __________ □ Nothing
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| b. When the catheter dressing is changed, the exit site (i.e. place where the catheter enters the skin) is cleansed with (check the one mostly commonly used):
□ Alcohol □ Chlorhexidine (e.g., Chloraprep®) □ Povidone-iodine (or tincture of iodine)
□ Sodium hypochlorite solution (e.g., ExSept®, Alcavis) □ Other (specify): __________ □ Nothing
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*29.
*30.
| Are antimicrobial lock solutions used to prevent hemodialysis catheter infections in your unit?
□ Yes, for all catheter patients □ Yes, for some catheter patients □ No
If yes, indicate the lock solutions used (check all that apply): □ Sodium citrate □ Gentamicin
□ Vancomycin □ Taurolidine □ Ethanol □ Other (specify): ________________
For hemodialysis catheters, is antibacterial ointment routinely applied to the exit site during dressing change? Yes No If Yes, what type of ointment? □ Bacitracin/polymixin (e.g., Polysporin®) □ Povidone-iodine
□ Mupirocin □ Other (specify): ______________________
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*31.
| For peritoneal dialysis catheters, is antibacterial ointment routinely applied to exit site during dressing change? Yes No N/A If Yes, what type of ointment? □ Bacitracin/polymixin (e.g., Polysporin®) □ Gentamicin
□ Mupirocin □ Other (specify): ______________________
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*32.
| Are any of the following used to prevent hemodialysis catheter-related infections in your unit (check all that apply): □ Antimicrobial-impregnated hemodialysis catheters □ Chlorhexidine dressing (e.g., Biopatch®, TegadermTM CHG) □ Closed connector luer access devices (e.g., Tego® or Q-SyteTM)
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CDC57.104(Back) Rev 2, v6.4
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