Form 57.104 Patient Safety Component--Outpatient Dialysis Center Pra

Facility ID#:____________________________	*Survey Year:_____________
A. Facility Information
*1.        Ownership of your dialysis center (choose one): □ Government     □ Not for profit     □ For Profit                                                   *2.        Location/hospital affiliation of your dialysis center:  □ Freestanding           □ Hospital based                                                                         □ Freestanding but owned by a hospital *3.        Types of dialysis services offered (check all that apply):               □ In-center hemodialysis          □ Peritoneal dialysis            □ Home hemodialysis                           *4.        Number of in-center hemodialysis stations: _______
*5.        Is your facility part of a group or chain of dialysis centers?     Yes       No                          If Yes, name of group or chain:                   □ Da Vita            □ Dialysis Clinic Inc. (DCI)            □ Fresenius Medical Care                     □ American Renal Assoc.     □ Nat’l Renal Alliance       □ Nat’l Renal Institutes                     □ Dialysis Corp. of America □ Renal Research Institute □ Satellite Healthcare                     □  Renal Advantage Inc      □ Liberty Dialysis       □ Renal Care Partners                     □ Other (specify): ___________________________________________ *6.        Do you (the person primarily responsible for collecting data for this survey) perform patient care in this dialysis unit?                                                                      Yes       No *7.        Is there someone at your unit in charge of infection control?      Yes     No                            If Yes, which best describes this person?                             □ Hospital-affiliated or other infection control practitioner comes to our unit                             □ Dialysis nurse or nurse manager                             □ Dialysis facility administrator or director                        □ Dialysis education specialist                        □ Other dialysis staff (specify): ________________________________ *8.        Is there a dedicated vascular access nurse/coordinator at your facility?     Yes     No *9.        Does your unit have capacity to isolate hepatitis B?     □ Yes, use hepatitis B isolation room               □ Yes, use hepatitis B isolation area   □ No hepatitis B isolation *10.      Indicate any other conditions that are isolated in your unit (check all that apply):   □ None             □ Hepatitis C   □ Tuberculosis (TB)  □ MRSA  □ Other (specify): ___________________________

 

1. A. Facility Information (continued)

1. *11.        Please indicate whether the following types of records are available to staff or an administrator in your unit (check all that apply):

1. Please respond to the following questions based on records from your facility for the first week of January (applies to current or most recent January relative to current date).

1. B. Patient and staff census

1. *12.        How many CHRONIC, NON-TRANSIENT dialysis PATIENTS were assigned to your center during the first week of January? _______

                 Of these, please indicate the number who received:

                 a. in-center hemodialysis:         _______

                 b. home hemodialysis:              _______

                 c. peritoneal dialysis:                _______

   *13.       How many full-time and part-time PATIENT CARE staff were employed in your facility during the first week of January? Include only staff who had direct contact with dialysis patients or equipment: ______

                 Specify the number of these clinical staff by category:

                 a. nurse/nurse assistant: _____                          e. dietician: _____

                 b. dialysis patient-care technician: _____             f. physicians/physician assistant: _____

                 c. dialysis biomedical technician: _____               g. nurse practitioner: _____

                 d. social worker: _____                                       h. other: _____

1. C. Vaccines

1. *14.       Of the patients counted in question 12, how many received:

                  a. at least 3 does of hepatitis B vaccine (ever)? _____

                  b. the influenza (flu) vaccine for this flu season (September or later)? _____

                  c. the pneumococcal vaccine (ever)? _____

1. *15.       Does your facility use standing orders to allow nurses to administer vaccines to patients without a     specific physician order?

                 □ Yes, for some or all vaccines

                 □ No, not for any vaccines

1. *16.        Of the patient care staff members counted in question 13, how many received:

                  a. at least 3 doses of hepatitis B vaccine (ever)?: _____

                  b. the influenza (flu) vaccine for this flu season (September or later)?: _____

   *17.        Please indicate whether your facility offers the following immunizations:

                            

                             a. influenza vaccine offered to patients

                             b. influenza vaccine offered to patient care staff

                             c. pneumococcal vaccine offered to patients

1. CDC57.104(Back) Rev 2, v6.4

	Yes, available	Yes, available electronically	Not available
Local hospital microbiology lab results (i.e., for cultures sent to hospital lab or patients during hospitalization) Hemodialysis station & machine assignment	□ □	□ □	□ □
Staff immunizations	□	□	□

Yes	No
□	□
□	□
□	□

 

*18.	Of your CHRONIC, NON-TRANSIENT hemodialysis patients from question 12 (12a + 12b), indicate the number with each of the following access types during the first week of January (patients with > 1 access type should be counted in each applicable category):                 AV fistula                      ______         Tunneled central line                  ______               AV graft                        ______         Nontunneled central line             ______               Hybrid access (e.g., graft-catheter) ______
D. Hepatitis B and C
*19.	Of your CHRONIC, NON-TRANSIENT in-center hemodialysis PATIENTS from question 12a: a. How many converted from hepatitis B surface ANTIGEN (HBsAg) negative to positive in the past 12 months (i.e., had newly acquired hepatitis B virus infection, not as a result of vaccination)? Do not include patients who were antigen positive before they were first dialyzed in your center: _____ b. How many were hepatitis B surface antigen (HBsAg) positive on arrival to your center? _____
*20.	Of the patients counted in question 12a., were all or almost all tested for hepatitis B surface ANTIBODY (anti-HBs) in the past 12 months?       Yes       No                 If Yes, how many were positive? _____
*21.	Does your facility routinely test hemodialysis patients for hepatitis C antibody (anti-HCV)? (Note: This is NOT hepatitis B core antibody)?     □ Yes, every 6 months □ Yes, every 12 months                                                      □ No (not done or less frequently than yearly)  If Yes, Of the patients counted in question 12a.,     a. How many converted from anti-HCV negative to positive during the past 12 months (i.e., had newly     acquired hepatitis C infection)? Do not include patients who were anti-HCV positive before  they were     first dialyzed in your center:_____     b. How many were positive for hepatitis C antibody on arrival to your center? _____
E. Dialysis Policies and Practices
*22.	Does your facility reuse dialyzers for some or all patients?       Yes         No                 If Yes,          a. What method is used to disinfect the majority of these dialyzers?                    □ Amuchina          □ Glutaraldehyde (e.g., Diacide®)    □ Peracetic acid (e.g., Renalin®)                    □ Formaldehyde    □ Heat                                           □ Other          b. Is bleach also used to clean the inside of these dialyzers?       Yes        No          c. Where are dialyzers reprocessed?      □ Dialyzers are reprocessed at our facility          □ Dialyzers are transported to an off-site facility for reprocessing            □ Both at our facility and off-site          d. Are dialyzers refrigerated before reprocessing?     Yes       No
*23.	Where are medications from multidose vials most commonly drawn into syringes to prepare for patient administration? □ On a mobile medication cart within the treatment area or at the individual dialysis stations □ In a separate medication room or in a medication area separate from the patient treatment area □ At a fixed location within the dialysis unit, not separated by walls from the rest of the patient treatment area □ Other (specify): _______________________________________________________
CDC57.104(Back)  Rev 2, v6.4

 

*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
*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
F. Vascular Access
*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
*27.	Job classification of staff members primarily responsible for providing hemodialysis catheter care (i.e., access catheters or change dressing) (select one):     □ Nurse       □ Technician
*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
	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
*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): ______________________
*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): ______________________
*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)
CDC57.104(Back) Rev 2, v6.4

Yes	No
□	□
□	□
□	□
□	□

 

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File Title	Slide 1
Author	CDC
Last Modified By	ano3
File Modified	2010-12-03
File Created	2004-07-27

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