Att G.7_Dialysis Event

NHSN Dialysis Event Manual
Dialysis Event Protocol

Dialysis Event Protocol
Introduction
In 2011, more than 395,000 patients were treated with maintenance hemodialysis in the United
States.13 Hemodialysis patients require a vascular access, which can be a catheter, or a graft or an
enlarged blood vessel that can be punctured to remove and replace blood. Bloodstream infections
and localized infections of the vascular access site cause substantial morbidity and mortality in
hemodialysis patients. Hemodialysis vascular access types, in order of increasing risk of infection,
include arteriovenous fistulas created from the patient’s own blood vessels; arteriovenous grafts
typically constructed from synthetic materials; tunneled central lines; and nontunneled central
lines. Other access devices, such as catheter-graft hybrid devices, also exist. Because of frequent
hospitalizations and receipt of antimicrobial drugs, hemodialysis patients are also at high risk for
infection with antimicrobial-resistant bacteria. Measuring and tracking rates of infection and
utilizing this information is an important part of prevention.
Infection prevention information is located at http://www.cdc.gov/dialysis/
Dialysis Event Surveillance
Overview: Each month, facilities report the number of hemodialysis outpatients who were
dialyzed in the facility on the first two working days of the month, using the Denominators for
Outpatient Dialysis form. This count is used to estimate the number of patient-months that there is
risk of healthcare-associated infection. At the facility, throughout the entire month, any and all
outpatients who receive maintenance hemodialysis at the facility are monitored for three
National Healthcare Safety Network (NHSN)-defined dialysis events, which include IV
antimicrobial starts, positive blood cultures, and evidence of local access site infection. Facilities
use a Dialysis Event form to report the details of each dialysis event that occurred among these
patients. Before data can be reported, facilities must indicate that they are reporting according to
protocol by saving a Patient Safety Monthly Reporting Plan. Completion of an Outpatient Dialysis
Center Practices Survey is required annually.
Setting: Surveillance occurs in outpatient hemodialysis centers. These centers may be attached to
or affiliated with a hospital, but should serve hemodialysis outpatients. If other patients (e.g.,
inpatients, peritoneal dialysis patients) are present, exclude them from Dialysis Event numerator
and denominator reporting.
Population: Hemodialysis outpatients.
 Include transient patients
 Include peritoneal dialysis patients or transplant patients undergoing temporary
hemodialysis
U.S. Renal Data System, USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage
Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and
Kidney Diseases, Bethesda, MD, 2013. (http://www.usrds.org/adr.htm)
13

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Dialysis Event Protocol

Requirements: Participating facilities are required to report data according to this protocol,
using the NHSN definitions described herein, to ensure data are uniformly reported across
participating facilities. Report available data to NHSN within 30 days to 60 days of the end of the
month for which they were collected. If additional data become available after that period, users
are expected to report the additional information retrospectively to ensure NHSN data are
complete and accurate. This may involve reporting additional dialysis events and/or editing
existing event records.
Event Definitions and Key Terms
Dialysis Event: Three types of dialysis events are reported by users: IV antimicrobial start; positive
blood culture; and pus, redness, or increased swelling at the vascular access site. The following
measures are also generated from the reported data: bloodstream infection (BSI), local access site
infection (LASI), access-related bloodstream infection (ARB), and vascular access infection (VAI).
21 day rule: An event reporting rule which reduces reporting of events that are likely to be related
to the same patient problem. The rule is that 21 or more days must exist between two dialysis
events of the same type for the second occurrence to be reported as a separate dialysis event. If
fewer than 21 days have passed since the last reported event of the same type, the subsequent
event of the same type is NOT considered a new dialysis event and therefore, it is not reported. The
21 day rule applies across calendar months. Refer to each event definition for instructions on
applying the 21 day rule for each specific event type.
IV antimicrobial start: Report all starts of intravenous (IV) antibiotics or antifungals administered
in an outpatient setting, regardless of the reason for administration (i.e., include IV antimicrobial
starts unrelated to vascular access problems) and regardless of the duration of treatment. A start is
defined as a single outpatient dose or first outpatient dose of a course. Report all IV antibiotic starts,
not just vancomycin. Do not report IV antiviral starts. Report outpatient starts that are
continuations of inpatient antimicrobial treatment.


21 day rule: There must be 21 or more days from the end of one IV antimicrobial course to
the beginning of a second IV antimicrobial start for two starts to be reported as separate
dialysis events, even if different antimicrobials are used. If IV antimicrobials are stopped for
fewer than 21 days and then restarted, the second start is NOT considered a new dialysis
event and therefore, is not reported.



For outpatient IV antimicrobial starts that are continuations of inpatient antimicrobial
treatment, consider the start day to be the first day of outpatient administration.



Inter-facility patient transfers: If a patient at a dialysis facility has an IV antimicrobial start
and then transfers to another facility (as a transient or permanent patient) where the
antimicrobial is continued, the second facility would report the IV antimicrobial start in
their facility as well.

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Positive blood culture: Report all positive blood cultures from specimens collected as an outpatient
or collected within one calendar day after a hospital admission. One calendar day after hospital
admission includes positive blood cultures collected on the day of or the day following admission to
the hospital. Positive blood cultures meeting the criteria above should be reported regardless of
whether or not a true infection is suspected or whether the infection is thought to be related to
hemodialysis.


21 day rule: There must be 21 or more days between positive blood cultures for each
positive blood culture to be considered a separate dialysis event, even if organisms are
different. If positive blood cultures occur less than 21 days apart, the second positive blood
culture is NOT considered a new dialysis event and therefore, is not reported. However, if
different organisms grow from these subsequent positive blood cultures, add the new
organisms to the reported event.



Suspected source of the positive blood culture: indicating one of four suspected sources of a
positive blood culture is required.
o

Vascular access: Choose “Vascular access” if there is objective evidence of vascular
access infection and the vascular access is thought to be the source of the positive
blood culture.

o

A source other than the vascular access: Choose “A source other than the vascular
access” if either (a) or (b) is true:
a) a culture from another site (e.g., infected leg wound, urine) shows the same
organism found in the blood and the site is thought to be the source of the
positive blood culture.
b) there is clinical evidence of infection at another site which is thought to be the
source of the positive blood culture, but the site was not sampled for culture.

o

Contamination: Choose “Contamination” if the organism isolated from the blood
culture is thought by the physician, infection preventionist, or nurse manager to be a
contaminant. Contamination is more likely if the organism is a common commensal
and is isolated from only one of several blood cultures. Examples of common
commensals include: diphtheroids [Corynebacterium spp., not C. diphtheriae];
Bacillus spp. [not B. anthracis]; Propionibacterium spp.; coagulase-negative
staphylococci [including S. epidermidis]; viridans group streptococci; Aerococcus
spp.; and Micrococcus spp.

o

Uncertain: Choose “Uncertain” only if there is insufficient evidence to decide among
the three previous suspected source categories.

Pus, redness, or increased swelling at the vascular access site: Report each new outpatient episode
where the patient has one or more symptoms of pus, greater than expected redness or greater than
expected swelling at any vascular access site, regardless of whether the patient received treatment
for infection. Pus is always reportable. Report redness or swelling if it is greater than expected and
suspicious for infection. Indicate the vascular access site(s) where the symptom(s) occurred.

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Dialysis Event Protocol



21 day rule: There must be 21 or more days between the onset of one episode and the
onset of a second episode of pus, redness, or increased swelling at a vascular access site to
be considered separate dialysis events. If an episode of pus, redness, or increased swelling
at a vascular access site resolves and then recurs within 21 days of the first onset, the
recurrence is NOT considered a new dialysis event and therefore, is not reported.

Measure Definitions
o

Bloodstream infection (BSI): Any positive blood culture.

o

Access-related bloodstream infection (ARB): Positive blood culture with the suspected
source reported as the vascular access or uncertain.

o

Local access site infection (LASI): Pus, redness, or increased swelling of the vascular access
site and access-related bloodstream infection is not present.

o

Vascular access infection (VAI): Either a local access site infection or an access-related
bloodstream infection.

Vascular Access Types
Consider all vascular accesses for hemodialysis and all central venous catheters that are present at
the time of the event in Dialysis Event reporting, even if they are not used for dialysis and even if
they are abandoned/non-functional.


Nontunneled central line: a central venous catheter that is fixed in place at the point of
insertion and travels directly from the skin entry site to a vein and terminates close to the
heart or one of the great vessels, typically intended for short term use.



Tunneled central line: a central venous catheter that travels a distance under the skin from
the point of insertion before entering a vein, and terminates at or close to the heart or one
of the great vessels (e.g., Hickman® or Broviac® catheters14).



Graft: a surgically created connection between an artery and a vein using implanted
material (typically synthetic tubing) to provide a permanent vascular access for
hemodialysis.



Fistula: a surgically created direct connection between an artery and a vein to provide
vascular access for hemodialysis.
o

14

Buttonhole: a cannulation technique where a blunt needle (cannula) is inserted into
the fistula at the same location each time using an established track. Report the way
in which a patient is primarily cannulated.

Use of trade names and commercial sources is for identification only and does not imply endorsement.

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

Other access device: includes catheter-graft hybrid vascular access devices, ports, and any
other vascular access devices that do not meet the above definitions. Do not use this field to
report vascular accesses that are grafts, central venous catheters or fistulas. Do not use this
field to report peritoneal dialysis accesses.
o

Catheter-graft hybrid: a subcutaneous surgical implant with both a catheter and a
graft component that provides blood flow directly from the target artery to the
heart, bypassing the patient’s central venous system (e.g., HeRO® vascular access
device15).

REPORTING INSTRUCTIONS
NHSN forms and/or the definitions in this protocol should be used to collect required data. Each
form has a corresponding table of instructions.
Complete a Survey Annually: Upon enrollment and annually thereafter, complete the Outpatient
Dialysis Center Practices Survey (CDC 57.500). After enrollment, the data for the dialysis survey
should be collected and reported in February.
Complete Patient Safety Monthly Reporting Plans: The Patient Safety Monthly Reporting Plan
(CDC 57.106) is used by NHSN facilities to inform CDC that they are committed to following the
NHSN surveillance protocol, in its entirety, for each data type specified on the plan. These data are
referred to as “in-plan.” A Monthly Reporting Plan must be completed before data can be entered
into NHSN for that month.
To indicate the facility is reporting in accordance with this protocol, save a Monthly Reporting Plan
with the “DE” checkbox selected for the ‘outpatient hemodialysis clinic’ location, under the DeviceAssociated section, for each month of participation in Dialysis Event surveillance.
Report Denominator Data Monthly: The denominators are counts of patients by vascular
access type used to estimate the number of patient-months considered at risk for dialysis
events. To report denominator data, each month, report the number of hemodialysis
outpatients with each vascular access type who received hemodialysis at the center during the
first two working days of the month on the Denominators for Outpatient Dialysis form (CDC
57.503).
Report all hemodialysis outpatients, including transient patients. Exclude non-hemodialysis
patients and exclude inpatients. Report denominator data each month, regardless of whether
any dialysis events occur. Count each patient only once; if the patient has multiple vascular
accesses, record that patient once, reporting only their vascular access with the highest risk of
infection (note: this might not be the vascular access currently in use for dialysis).
HIGHER
INFECTION
RISK
15

Nontunneled
Central
Lines

Tunneled
Central
Lines

Other
Access
Devices

Grafts

Fistulas

LOWER
INFECTION
RISK

Use of trade names and commercial sources is for identification only and does not imply endorsement.

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Dialysis Event Protocol

See tables of instructions for an explanation of each field of the Denominators for Outpatient Dialysis
form.
Working Days: The first two “working days” of the month should provide the opportunity to
capture all regularly scheduled shifts and patients.


For example, if a facility dialyzes patients 6 days a week, Monday through Saturday, and the
first day of the month falls on a Sunday, then Monday and Tuesday would be the first two
working days of the month for that facility.
Sun
Mon
Tues
Wed
Thurs
Fri
Sat
1
2
3
4
5
6
7
Facility
Working
Working
closed
day 1
day 2



For facilities that provide nocturnal hemodialysis, working days should include nocturnal
hemodialysis patients.



Working days are shift/schedule dependent – the actual patient census is not a criterion for
determining a working day.



If the facility was closed the entire month, do not complete a denominator form. Instead,
select “No NHSN Patient SafetyModules Followed this Month” on that month’s Monthly Reporting Plan.

Report Numerator Data Monthly: The numerators are the number of dialysis events that occur
during a defined time period. To report numerator data, complete one Dialysis Event form (CDC
57.502) per occurrence of event(s) among all patients who received hemodialysis at the facility
during that month.
Any patient who receives outpatient hemodialysis treatment at your facility is monitored for
dialysis events, even if they were not counted on the denominator form. Include transient patients
at your facility who have a dialysis event. Complete a Dialysis Event form only if a hemodialysis
outpatient has one or more of the following:
 IV antimicrobial start
 Positive blood culture
 Pus, redness or increased swelling at the vascular access site
See tables of instructions for an explanation of each field of the Dialysis Event form.
Multiple Dialysis Events: If multiple dialysis events occur together, as a part of the same patient
problem, they should be reported on the same Dialysis Event form. For example, if a patient has a
positive blood culture and begins IV antimicrobials, these two events would be recorded together
on one form. When reporting multiple dialysis events together, the “date of event” is always the
date that the first event occurred. Refer to dialysis event definitions for the 21 day rule. Do not
report unrelated dialysis events on the same form.

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Dialysis Event Protocol

Event Type
IV antimicrobial start

Date of Event Criterion
Date of first outpatient dose of an antimicrobial course

Positive blood culture

Date of specimen collection

Pus, redness or increased swelling at
vascular access site

Date of onset

Combination

Earliest date of the three types

Report No Events: Each dialysis event type needs to be accounted for every month. Either the event
type is reported on one or more Dialysis Event forms, or the “report no events” box for that event
type must be checked on the Denominators for Outpatient Dialysis form to confirm no events of that
type occurred during the month.
Data Analyses
Dialysis event rates are stratified by vascular access type and expressed per 100 patient-months.
Rates are calculated by dividing the number of events by the number of patient-months and
multiplying the result by 100. CDC calculates aggregate pooled mean rates for each event type by
combining rates from all participating facilities. Facilities can compare their rates with the
aggregate rates using NHSN analysis rate table or run chart output options. Facilities are strongly
encouraged to analyze the data they report and provide regular feedback to staff about patient
outcome event rates.

Reporting Resources
Data collection and reporting resources are available on the NHSN Dialysis Event website:
http://www.cdc.gov/nhsn/dialysis/dialysis-event.html.
Please direct questions to the NHSN Helpdesk at [email protected] and include “dialysis” in the subject
line.

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Instructions for the Dialysis Event Form

Instructions for the Dialysis Event Form
(CDC 57.502)

Complete a dialysis event form for IV antimicrobial starts; positive blood cultures; and
onsets of pus, redness or increased swelling at vascular access sites, according to
definitions and reporting instructions in the Dialysis Event Protocol.
* = required field when reporting in-plan
Patient Data
Data Fields
Facility ID #
Event ID #
*Patient ID #

Instructions for Completion
NHSN-assigned facility ID will be auto-entered by the computer.
Event ID# will be auto-entered by the computer.
Required. Enter the alphanumeric patient ID number. This is the patient
identifier assigned by the healthcare facility and may consist of any
combination of numbers and/or letters.

Social Security #
Secondary ID #
Medicare #
Patient Name
*Gender

Optional. Enter the 9-digit numeric patient Social Security Number.
Optional. Enter the alphanumeric ID number assigned by the facility.
Optional. Enter the patient’s Medicare number.
Optional. Enter last, first and middle name of the patient.
Required. Select “Female,” “Male,” or “Other” to indicate the patient’s
gender.
Required. Enter the patient’s date of birth (format: mm/dd/yyyy).
Optional. Specify whether patient is Hispanic or Latino.
Optional. Specify all of the following that identify the patient’s race: American
Indian/Alaska Native; Asian; Black or African American; Native
Hawaiian/Other Pacific Islander; and White.

*Date of Birth
Ethnicity (specify)
Race (specify)

General Event Information
*Event Type
*Date of Event

*Location
Was the patient
admitted/readmitted
to the dialysis facility
on this dialysis event
date?

February 2014

Required. Select “DE – Dialysis Event”.
Required. Date (format: mm/dd/yyyy ) depends on event type:
 For IV antimicrobial starts, enter the date the outpatient IV
antimicrobial administration was started.
 For positive blood cultures, enter the date the blood specimen was
collected, not the date the laboratory reported the result.
 For pus, redness, or increased swelling at the vascular access site,
enter the onset date.
 If reporting more than one type of dialysis event, using the above
criteria select the earliest event date.
Required. Enter the location code of the “outpatient hemodialysis clinic” that
is collecting Dialysis Event information.
Required. Select ‘yes’ if the dialysis event occurred on the same date the
patient was admitted or readmitted to your facility (e.g., upon admission or
immediately following a hospital discharge).

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Instructions for the Dialysis Event Form

*Transient Patient

Required. Select “Yes” if this patient was temporarily admitted for treatment
at your facility for a short time (fewer than 30 days or 13 treatments) due to
vacation, emergency, or other short-term displacement.
Select “No” if this patient is part of your regular patient census.

Data Fields
*Vascular accesses
Fistula
Buttonhole

Graft
Tunneled central line
Nontunneled central
line
Other vascular access
device

Is this a catheter-graft
hybrid?

Risk Factors
Instructions for Completion
Required. Select all vascular accesses that the patient had present at the
time of the dialysis event, even if they are not used for dialysis and even if
they are abandoned/non-functional.
Indicate if the patient has a surgically created direct connection between an
artery and a vein for hemodialysis.
Conditionally required for patients with fistulas. Select “yes” if the patient’s
fistula is primarily accessed via buttonhole cannulation technique (i.e., a
procedure in which a blunt needed (cannula) is inserted into the fistula at the
same location each time using an established track).
Select “no” if the patient’s fistula is primarily accessed by conventional or
rope ladder method.
Indicate if the patient has a connection between an artery and a vein created
with surgically implanted material (typically synthetic tubing) for
hemodialysis.
Indicate if the patient has a central venous catheter that travels a distance
under the skin from the point of insertion before entering a vein, and
terminates at or close to the heart or one of the great vessels.
Indicate if the patient has a central venous catheter that is fixed in place at
the point of insertion and travels directly from the skin entry site to a vein
and terminates close to the heart or one of the great vessels.
Indicate if the patient has a hybrid vascular access device (e.g., HeRO®
vascular access device14), port, or any other vascular access device that does
not meet the above definitions. Do not use this field to report vascular
accesses that are grafts, central venous catheters or fistulas. Do not use this
field to report peritoneal dialysis accesses.
Conditionally required for patients with an ‘other access device.’ Select ‘yes’
if the patient has a catheter-graft hybrid access device: a subcutaneous
surgical implant with both a catheter and a graft component that provides
blood flow directly from the target artery to the heart, bypassing the
patient’s central venous system (e.g., HeRO® vascular access device4).
Select ‘no’ if the patient’s other access device is not a catheter-graft hybrid.

4

Use of trade names and commercial sources is for identification only and does not imply endorsement.

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Instructions for the Dialysis Event Form

*Access Placement
Date

Vascular access
comment

Required. For each access type present, indicate the date (mm/yyyy) the
access was placed or check the box if placement date is unknown. If the
patient has more than one access of the same type (e.g., two grafts), indicate
the access placement date of the access in use, or most recently in use, at the
time of the event.
Optional. Use this field to add any additional information about the patient’s
vascular access(es) that would help you to interpret your surveillance data,
such as recent surgical revisions, etc. CDC typically does not analyze these
data.

Event Details
Specify Dialysis Event
IV antimicrobial start

Required. Select all that apply:
Report all starts of intravenous (IV) antibiotics or antifungals administered
in an outpatient setting, regardless of the reason for administration (i.e.,
include IV antimicrobial starts unrelated to vascular access problems) and
regardless of the duration of treatment. Report all IV antibiotic starts, not
just vancomycin. Do not report IV antiviral starts. Report outpatient starts
that are continuations of inpatient antimicrobial treatment. A start is defined
as a single outpatient dose or first outpatient dose of a course.
21 day rule: There must be 21 or more days from the end of one IV
antimicrobial course to the beginning of a second IV antimicrobial start for
two starts to be reported as separate dialysis events, even if different
antimicrobials are used. If IV antimicrobials are stopped for fewer than 21
days and then restarted, the second start is NOT considered a new dialysis
event and therefore is not reported.
For outpatient IV antimicrobial starts that are continuations of inpatient
antimicrobial treatment, consider the start day to be the first day of
outpatient administration.

Was vancomycin the
antimicrobial used for
this start?
Positive blood culture

Conditionally required for IV antimicrobial start dialysis events. Indicate
whether IV vancomycin was started by selecting “Yes” or “No.” If multiple IV
antimicrobials were used, select “Yes” if any of them were vancomycin.
Report all positive blood cultures from specimens collected as an outpatient
or collected within one calendar day after a hospital admission. Positive
blood cultures meeting this definition should be reported regardless of
whether or not the patient was treated for bloodstream infection.
21 day rule: There must be 21 or more days between positive blood cultures
for each positive blood culture to be considered a separate dialysis event,
even if organisms are different. If positive blood cultures occur less than 21
days apart, the second positive blood culture is NOT considered a new
dialysis event and therefore, is not reported. However, if different organisms
grow from these subsequent positive blood cultures, add the new organisms
to the first report.

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Instructions for the Dialysis Event Form

Specify pathogen(s)
and antimicrobial
susceptibilities
Where was the
positive blood culture
collected

Data Fields
Pathogens

Antimicrobial agent
and susceptibility
results

Antimicrobial agent
and susceptibility
results (continued)

Conditionally required for a positive blood culture. See the following section
for additional instructions.
Indicate the location where the blood was drawn for the positive blood
culture.

Pathogens and Antimicrobial Susceptibilities
Instructions for Completion
Select each organism identified in the positive blood culture from a pathogen
dropdown menu (up to three organisms can be selected). No specific order of
microorganisms is required for dialysis event positive blood cultures.
The species should be entered once it becomes available on the final lab
report. Do not report preliminary results (such as Gram stain). If the species
is not indicated on the final lab report or is not listed in the NHSN pathogen
dropdown list, then select the “spp” choice for the genus (e.g., Bacillus natto
is not on the list so it would be reported as Bacillus spp.). Note that the
pathogen dropdown menu opens to display an abbreviated list of the most
common pathogens. A more complete list can be accessed by scrolling to the
bottom of the menu and selecting “(All Pathogens…)”
Conditionally required if ≥1 pathogen is identified.
 For organisms shown on the back of the event form, susceptibility
results are required only for the antimicrobial agents listed.
 For organisms that are not listed on the back of an event form,
susceptibility results are optional.
 (Optional) Report up to a maximum of 20 additional antimicrobials
and susceptibility results, per microorganism.
Select the organism’s susceptibility result code for each antimicrobial agent.
S – Susceptible
For gentamicin and streptomycin
I – Intermediate
high level tests only, use:
R – Resistant
S – Susceptible/Synergistic
N – Not Tested
R – Resistant/Not Synergistic
NS- Non-susceptible
S-DD- Susceptible-dose dependent

Antimicrobial Drug Code Table
AMK = amikacin
AMP = ampicillin
AMPSUL = ampicillin/sulbactam
AMXCLV = amoxicillin/clavulanic acid
ANID = anidulafungin
AZT = aztreonam
CASPO = caspofungin
CEFAZ= cefazolin
CEFEP = cefepime
February 2014

COL = colistin
DAPTO = daptomycin
DORI = doripenem
DOXY = doxycycline
ERTA = ertapenem
ERYTH = erythromycin
FLUCO = fluconazole
FLUCY = flucytosine
GENT = gentamicin

MOXI = moxifloxacin
OX = oxacillin
PB = polymyxin B
PIP = piperacillin
PIPTAZ = piperacillin/tazobactam
QUIDAL = quinupristin/dalfopristin
RIF = rifampin
STREPHL = streptomycin-high level
test
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Instructions for the Dialysis Event Form

CEFOT = cefotaxime
CEFOX= cefoxitin
CEFTAZ = ceftazidime
CEFTRX = ceftriaxone
CEFUR= cefuroxime
CTET= cefotetan
CHLOR= chloramphenicol
CIPRO = ciprofloxacin
CLIND = clindamycin

Data Fields

GENTHL = gentamicin-high level test
IMI = imipenem
ITRA = itraconazole
LEVO = levofloxacin
LNZ = linezolid
MERO = meropenem
METH = methicillin
MICA = micafungin
MINO = minocycline

TETRA = tetracycline
TICLAV = ticarcillin/clavulanic acid
TIG = tigecycline
TMZ =
trimethoprim/sulfamethoxazole
TOBRA = tobramycin
VANC = vancomycin
VORI = voriconazole

Event Details (continued)
Instructions for Completion

Suspected source of Conditionally required for positive blood culture dialysis events. Select one
positive blood suspected source of the positive blood culture:
culture
 Vascular access: Choose “Vascular access” if there is objective
evidence of vascular access infection and the vascular access is
thought to be the source of the positive blood culture.
 A source other than the vascular access: Choose “A source other than
the vascular access” if either (a) or (b) is true:
a) a culture from another site (e.g., infected leg wound) shows the
same organism found in the blood and is thought to be the source
of the positive blood culture.
b) there is clinical evidence of infection at another site which is
thought to be the source of the positive blood culture, but the site
was not sampled for culture.
 Contamination: Choose “Contamination” if the organism isolated
from the blood culture is thought by the physician, infection
preventionist, or nurse manager to be a contaminant. Contamination
is more likely if the organism is a common commensal and is isolated
from only one of several blood cultures. Examples of some common
commensals include: diphtheroids [Corynebacterium spp., not C.
diphtheriae], Bacillus spp. [not B. anthracis], Propionibacterium spp.,
coagulase-negative staphylococci [including S. epidermidis], viridians
group streptococci, Aerococcus spp., and Micrococcus spp.
 Uncertain: Choose “Uncertain” only if there is insufficient evidence to
decide among the three previous categories.

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Instructions for the Dialysis Event Form

Pus, redness, or
increased swelling at
the vascular access
site

Report each new outpatient episode where the patient has one or more
symptoms of pus, greater than expected redness or greater than expected
swelling at any vascular access site, regardless of whether the patient
received treatment for infection. Pus is always reportable. Report redness or
swelling if it is greater than expected and suspicious for infection.
21 day rule: There must be 21 or more days between the onset of one
episode and the onset of a second episode of pus, redness, or increased
swelling at a vascular access site to be considered separate dialysis events. If
an episode of pus, redness, or increased swelling at a vascular access site
resolves and then recurs within 21 days of the first onset, the recurrence is
NOT considered a new dialysis event and therefore, is not reported.

Check the access
site(s) with pus,
redness, or increased
swelling:

Data Fields
*Specify Problem(s)
Fever
Chills or rigors
Drop in Blood Pressure
Wound with pus or
increased redness
Cellulitis
Pneumonia or
respiratory infection
Urinary Tract Infection
Other Problem
None
*Outcome(s)
Loss of vascular access

Hospitalization

February 2014

Conditionally required if there is pus, redness, or increased swelling at the
vascular access site. Select vascular access site(s) with these findings.

Event Details (continued)
Instructions for Completion
Required. Indicate which problems are present.
Select if fever ≥37.8°C (100°F) oral is present.
Select if chills or rigors are present.
Select if abnormal drop in blood pressure is present.
Select if a wound that is unrelated to the vascular access site has pus or
increased redness is present.
Select if cellulitis is present at a site other than the vascular access and
without open wound.
Select if pneumonia or other respiratory tract infection is present.
Select if urinary tract infection is present.
Select if other problem related to the IV antimicrobial start; positive blood
culture; and/or pus, redness, or increased swelling at vascular access site is
present. Specify the problem.
Select “none” if there are no problems.
Required.
Select “Yes” if the event(s) or problem(s) contributed to a loss of the
patient’s vascular access (i.e., the vascular access required removal or
became unusable).
Examples of vascular access loss: infection necessitating the removal of a
central venous catheter or graft, or rendering a fistula or graft unusable for
≥1 treatment. Select “No” if there was no loss of vascular access. Check
“Unknown” if uncertain about whether there was loss of vascular access.
Select “Yes” if the event(s) or problem(s) contributed to the patient’s
hospitalization.
Select “No” if patient was not admitted to a hospital. Select “Unknown” if
uncertain about whether or not the patient was hospitalized.
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Instructions for the Dialysis Event Form

Death

Select “Yes” if the event(s) or problem(s) contributed to the patient’s death.
Select “No” if patient did not die. Select “Unknown” if uncertain about
whether or not the patient died or if cause of death was unknown.

Custom Fields
Custom fields

Optional. Up to 50 alphanumeric, numeric, and/or date fields may be added
to this form for local use.
NOTE: Each custom field must be added in advance. Within NHSN, select
“Facility,” then “Customize Forms,” and then follow on-screen instructions.
The Form Type is “CDC-Defined – PS – Event” and form is “DE – Dialysis
Event.”

Comments
Comments

February 2014

Optional. Use this field to add any additional information about the dialysis
event that would help you to interpret your surveillance data. CDC typically
does not analyze these data.

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NHSN Dialysis Event Manual
Instructions for the Denominators for Dialysis Event Form

Instructions for the Denominators for Dialysis Event Form
(CDC 57.503)

* Indicates a required field when reporting in-plan.
Data Field
Instructions for Data Collection
Facility ID #
*Location code
*Month
*Year
*Number of Maintenance
Hemodialysis Patients by
Vascular Access Type

The NHSN-assigned facility ID will be auto-entered by the computer.
Required. Enter the location code for the outpatient hemodialysis clinic
location from which you will collect data about dialysis events.
Required. Enter the month during which the data were collected for this
location.
Required. Enter the 4-digit year during which the data were collected for
this location.
Required. For each type of vascular access listed, enter the number of
patients who received maintenance hemodialysis at this location on the first
two working days of the month, including transient patients. Consider all
vascular accesses the patient has, even if they are not used for dialysis and
even if they are abandoned and/or are non-functional. A patient must be
physically present for in-center maintenance hemodialysis on one of these
days to be counted on this form (exclude patients who are hospitalized).
Record each patient only once. If a patient has more than one vascular
access, record the access type with highest risk for infection, using the
following hierarchy:
Lower Risk
- Fistula
- Graft
- Other vascular access device (e.g., catheter-graft hybrid access)
- Tunneled Central Line
- Nontunneled Central Line
Higher Risk

For example, if a patient has a fistula and a tunneled central line, count this
patient under the category of tunneled central line. If the patient has a
fistula and a “jump graft” record the patient as having a graft. If the patient
has only a catheter-graft hybrid or a port, record as “other access device”.
umber of these Fistula Conditionally required. Out of the fistula patients counted above, how many
Patients who undergo are primarily cannulated with buttonhole cannulation technique, where a
Buttonhole Cannulation blunt needle (cannula) is inserted into the fistula at the same location each
time using an established track.
*Total patients
Required. The sum of all patients listed above will enter automatically.
Custom fields
Optional. Up to 50 alphanumeric, numeric, and/or date fields may be added
to this form for local use.
NOTE: Each custom field must be added in advance. Within NHSN, select
“Facility,” then “Customize Forms,” and then follow on-screen instructions.
The Form Type is “CDC-Defined – DIAL – Summary Data” and form is “DIAL
– Denominators for Dialysis Event form.”

NHSN Dialysis Event Manual
Instructions for the Denominators for Dialysis Event Form

Instructions for the Outpatient Dialysis Center Practices Survey
(CDC 57.500)
A complete survey is an annual reporting requirement specified in the NHSN Dialysis Event Protocol. Users
cannot create Monthly Reporting Plans or submit monthly data for May through December until a survey
for that year is completed.
Print a blank survey from: http://www.cdc.gov/nhsn/forms/57.104_PSOutpatientDialysisSurv_BLANK.pdf
A worksheet is available to calculate answers for patient- and staff-specific questions. Click here to access
the worksheet: http://www.....
Complete one survey per center. Surveys are completed for the current year. It is strongly recommended that
the survey is completed in February of each year by someone who works in the center and is familiar with
current practices within the center. Complete the survey based on the actual practices at the center, not
necessarily the center policy, if there are differences.
Survey Question
Instructions for Data Collection
Facility ID #
The NHSN-assigned facility ID will be auto-entered by the computer.
Survey Year
Required. Enter the 4-digit year that the data were collected for this facility.
A.
Dialysis Center Information
A.1. General
1. Ownership
Required. Select the ownership of your dialysis center: Government, Not for profit,
or For profit.
2. Hospital affiliation
Required. Select the location/hospital affiliation of your dialysis center:
o Freestanding: the dialysis center is not hospital affiliated.
o Hospital based: the dialysis center is affiliated with a hospital and the building
is attached to, or part of, the hospital.
o Freestanding, but owned by a hospital: the dialysis center is affiliated with a
hospital, but the building is not attached to the hospital.
3. Dialysis services
Required. Indicate all dialysis service types that are offered by your facility:
o In-center daytime hemodialysis
o In-center nocturnal hemodialysis
o Peritoneal dialysis
o Home hemodialysis (includes home, home-assisted, and NxStage®5 patients)
4. Stations
Conditionally required if for question 3, in-center hemodialysis was selected. Enter
the number of useable in-center hemodialysis stations in your facility.
5. Group/chain
Required. Select “Yes” if your facility is part of a group or chain of dialysis centers.
If owned and managed by two different groups, then indicate the managing
company.
Select “No” if your facility is not owned by a group or chain of dialysis centers.
a. Group/chain
Conditionally required. Enter the name of the dialysis facility group or chain.
name

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NHSN Dialysis Event Manual
Instructions for the Denominators for Dialysis Event Form

Survey Question
6. Data collector

7.

8.

Person in charge of
infection control
a. Person in charge
of infection control
description
Vascular access
nurse/coordinator

Instructions for Data Collection
Required. Select “Yes” if the person who is primarily responsible for collecting the
NHSN survey data performs patient care in the facility. Select “No” if the person
who is primarily responsible for collecting these survey data does not perform
patient care in the facility.
Required. Select “Yes” if there is at least one person at your dialysis facility who is
designated as in charge of infection control. Select “No” if no one is designated as
in charge of infection control.
Conditionally required. Select the description(s) that best describe the person(s) in
charge of infection control in your dialysis facility.
Required. Select “Yes” if there is a dedicated vascular access nurse or coordinator,
either full or part-time, at your facility. Select “No” if there is no dedicated vascular
access nurse or coordinator.

A.2. Isolation and Screening
9. Capacity to isolate
Required. Select “Yes, use hepatitis B isolation room” if a separate room exists
hepatitis B patients
where patients positive for hepatitis B virus infection receive hemodialysis. Select
“Yes, use hepatitis B isolation area” if a specific section of the hemodialysis clinic is
designated as an area for patients positive for hepatitis B virus infection to receive
hemodialysis. Select “No hepatitis B isolation” if your facility does not have the
capacity to isolate patients who are positive for hepatitis B virus infection.
10. Conditions
Required. Select all of the conditions for which patients are routinely isolated or
isolated/cohorted
cohorted for treatment within your facility.
 Select only those conditions that are admitted and isolated by your facility.
If your facility would refer the patient with the condition (e.g., active TB)
elsewhere for dialysis, do not select that condition on the survey.
 Select only those conditions for which all patients that are positive for the
condition are isolated. If additional criteria are used to isolate some
positive patients (e.g., active diarrhea, draining wound), but not all, do not
select this condition for the survey.
If no other conditions are routinely isolated or cohorted for treatment within your
facility, select “None.”
11. TB screening
Required. Select “Yes” if your center routinely screens patients for tuberculosis (TB
disease) upon admission. Select “No” if patients are not routinely screened for TB
upon admission.
A.3. Patient Records
12. Station assignment
Required. Select “Yes” if your facility maintains records of patients’ hemodialysis
station assignment. Select “No” if these records are not maintained.
13. Machine assignment Required. Select “Yes” if your facility maintains records of patients’ hemodialysis
machine assignment. Select “No” if these records are not maintained.
14. BSI hospitalizations
Required. Following a hospitalization, indicate the frequency with which your
facility is able to determine whether a bloodstream infection contributed to the
patient’s hospital admission. Select “N/A – not pursued” only if your facility does
not routinely try to determine the cause of hospitalizations.

NHSN Dialysis Event Manual
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Survey Question
15. Hospital lab records

Instructions for Data Collection
Required. Following a hospitalization, indicate the frequency with which your
facility is able to obtain the patient’s hospital microbiology lab records. Select “N/A
– not pursued” only if your facility does not routinely request microbiology lab
records for patient hospitalizations.

B. Patient and staff census
16. Operational during
Required. Select “Yes” if your facility was open for hemodialysis treatment during
first week of
the first week of February (the first seven calendar days of the month) of the
February
survey year.
Select “No” if your facility was closed for hemodialysis treatment during the first
week of February of the survey year.
 If you select “No,” answer subsequent questions about the first week of
February based on policy and enter zeros for quantitative questions.
17. Number of dialysis
Required. Indicate the total number of all the maintenance, non-transient, dialysis
patients in 1st week
patients assigned to your facility during the first week of February (the first seven
of February
calendar days of the month) of the survey year (include in-center hemodialysis,
home hemodialysis, and peritoneal dialysis patients). The sum of 17.a., 17.b., and
17.c., must be less than or equal to the answer to question 17.
a. In-center
Conditionally required if in-center hemodialysis services were indicated for
hemodialysis
question 3. Of the patients specified in question 17, indicate how many underwent
in-center hemodialysis during the first week of February.
b. Home
Conditionally required if home hemodialysis services were indicated for question
hemodialysis
3. Of the patients specified in question 17, indicate how many underwent home
hemodialysis during the first week of February. Include home, home-assisted, and
NxStage®6 patients.
c. Peritoneal dialysis. Conditionally required if peritoneal dialysis services were indicated for question 3.
Of the patients specified in question 17, indicate how many underwent peritoneal
dialysis during the first week of February.
18. Number of staff in
Required. Indicate the total number of patient care staff persons (including full
1st week of February time, part time, and affiliated with) who worked in your facility during the first
week of February (the first seven calendar days of the month) of the survey year.
Include only those staff persons whose role involves direct contact with dialysis
patients or equipment.
 Count each person as 1, even if they work part-time.
 If a person works at more than one facility, they are counted as 1 at each
facility.
 Include physicians who see patients in the facility.
 Include patient care staff who are normally present during the year, but
were absent this week due to vacation or other leave.
 Include per diem staff only if they are consistently part of facility staffing.
 If your facility was not operational during the 1st week of February, enter 0.

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NHSN Dialysis Event Manual
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Survey Question
a.-h. Occupational
categories

C. Vaccines
19. a. Patients received
hepatitis B vaccine

b. All hemodialysis
patients who
received influenza
vaccine

c. In-center
hemodialysis
patients received
influenza vaccine

d. Patients received
pneumococcal
vaccine

Instructions for Data Collection
Conditionally required if answer to question 18 is equal to 1 or more. Of the total
number of patient care staff specified in question 18, indicate the number per
occupational category. The sum of the occupational categories 18.a. – 18.h. must
equal the number of patient care staff indicated in question 18.
Conditionally required if answer to question 17 is equal to 1 or more. Of all
maintenance, non-transient patients indicated in question 17 (a.-c.), indicate how
many have ever received at least 3 doses of hepatitis B vaccine.
 Do not count patients who are in the process of completing the hepatitis B
vaccine series.
 Include all patients who have received 3 or more doses, even if the brand of
hepatitis B vaccine being used requires four doses to complete the series.
 Include patients with documentation of having received 3 or more doses,
even if they were not vaccinated at your facility.
Conditionally required if answer to question 17 is equal to 1 or more. Of all
maintenance, non-transient patients indicated in question 17 (a.-c.), indicate how
many received the influenza (flu) vaccine for this flu season (September or later).
 This question refers to the flu season that began in the year preceding the
survey year. For example, if the survey year is 2014, count flu vaccinations
for the 2014-2015 flu season.
 Include patients who report having received a flu vaccination for this season
(or for whom there is documentation) even if they were not vaccinated at
your facility.
Conditionally required if answer to question 17 is equal to 1 or more. Of all
maintenance, non-transient in-center patients indicated in question 17a. only,
indicate how many received the influenza (flu) vaccine for this flu season
(September or later).
 This question refers to the flu season that began in the year preceding the
survey year. For example, if the survey year is 2014, count flu vaccinations
for the 2014-2015 flu season.
 Include patients who report having received a flu vaccination for this season
(or for whom there is documentation) even if they were not vaccinated at
your facility.
Conditionally required if answer to question 17 is equal to 1 or more. Of the total
number of maintenance, non-transient patients indicated in question 17, indicate
how many have ever received the pneumococcal vaccine, even if they were not
vaccinated at your facility.

NHSN Dialysis Event Manual
Instructions for the Denominators for Dialysis Event Form

Survey Question
20. Number of in-center
hemodialysis
patients vaccinated
against hepatitis B

a. Number of home
hemodialysis
patients
vaccinated against
hepatitis B

21. a. Patient care staff
who received
hepatitis B vaccine

b. Patient care staff
who received
influenza vaccine

Instructions for Data Collection
Conditionally required. Of the total number of maintenance, non-transient
hemodialysis patients indicated in question 17a, indicate how many ever received
at least 3 doses of hepatitis B vaccine.
 Do not count patients who are in the process of completing the series.
 Include all hemodialysis patients who received 3 or more doses, even if the
brand of hepatitis B vaccine being used requires four doses.
 Include patients who have documentation of having a complete hepatitis B
vaccine series, even if not received at your facility.
Conditionally required. Of the total number of maintenance, non-transient
hemodialysis patients indicated in question 17b, indicate how many ever received
at least 3 doses of hepatitis B vaccine.
 Do not count patients who are in the process of completing the series.
 Include all hemodialysis patients who received 3 or more doses, even if the
brand of hepatitis B vaccine being used requires four doses.
 Include patients who have documentation of having a complete hepatitis B
vaccine series, even if not received at your facility.
Conditionally required. Of the patient care staff members counted in question 18,
indicate how many have ever received at least 3 doses of hepatitis B vaccine.
 Do not count staff members who are in the process of completing the
series.
 Include all staff members who received 3 or more doses, even if the brand
of hepatitis B vaccine being used requires four doses.
 Include patient care staff members who report having received at least 3
doses of hepatitis B vaccine (or for whom there is documentation) even if
not received at your facility.
Conditionally required. Of the patient care staff members counted in question 18,
indicate how many received the flu vaccine for the current/most recent flu season.
 This refers to the flu season that began in the year preceding the survey
year. For example, if the survey year is 2014, count flu vaccinations for the
2014-2015 flu season.
 Include patient care staff members who report having received a flu
vaccination for this season (or for whom there is documentation) even if
they were not vaccinated at your facility.

NHSN Dialysis Event Manual
Instructions for the Denominators for Dialysis Event Form

Survey Question
22. Vaccine standing
orders
23. Type of
pneumococcal
vaccine(s)

Instructions for Data Collection
Required. Select “Yes” if your facility uses standing orders to allow nurses to
administer some or all vaccines to patients without a specific physician order.
Select “No” if there are no standing orders for any vaccines.
Required. Indicate the type(s) of pneumococcal vaccine offered to your facility’s
patients:
o Polysaccharide: pneumococcal polysaccharide vaccine, called PPSV23 or
Pneumovax®.7
o Conjugate: pneumococcal conjugate vaccine, called PCV13 or Prevnar® 13.3
If type of vaccine offered is unknown, select “Offered, but type unknown.” If
pneumococcal vaccine is not offered, select “Not offered.”

D. Hepatitis B and C
D.1. Hepatitis B - Complete this section even if your facility does not treat hepatitis B surface antigen (HBsAg)
positive patients.
24. a. In-center HD
Required. Of the maintenance, non-transient, in-center hemodialysis patients
patients with HBV
specified in question 17.a., indicate how many were hepatitis B virus surface
infection during 1st
antigen (i.e., HBsAg) positive in the first week of February (i.e., the first seven
week of February
calendar days of the month). This is a measure of prevalence of hepatitis B virus
infection among patients in your facility during this period.
a.i. In-center HD
Required. Of the maintenance, non-transient, in-center hemodialysis patients
patients with HBV
specified in question 24.a., indicate how many were hepatitis B virus surface
infection upon
antigen (i.e., HBsAg) positive when they were first admitted to your facility (i.e.,
admission
they had hepatitis B virus infection upon admission). This is a measure of
prevalence of hepatitis B virus infection among your incoming patients.
b. In-center HD
Required. Of the maintenance, non-transient, in-center hemodialysis patients
patients acquired
specified in question 17.a., indicate how many converted from hepatitis B virus
HBV infection in 12
surface antigen (i.e., HBsAg) negative to positive during the 12 months prior to
months prior to
February (i.e., they acquired HBV infection in the past year). Do not include
February
patients who were antigen positive before they were first dialyzed in your center
(i.e., patients specified in question 24.a.i.). This is a measure of annual incidence of
hepatitis B virus infection among patients in you facility.
D.2. Hepatitis C
25. Hepatitis C antibody Required. Select “Yes” if your facility screens hemodialysis patients for hepatitis C
admission screening antibody (anti-HCV) upon admission. Select “No” if your facility does not screen
hemodialysis patients for hepatitis C antibody (anti-HCV) upon admission.

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NHSN Dialysis Event Manual
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26. Hepatitis C antibody
screening at times
other than
admission
a. Hepatitis C
antibody screening
frequency

27. a. In-center HD
patients with HCV
infection during 1st
week of February

Required. Select “Yes” if your facility screens hemodialysis patients for hepatitis C
antibody (anti-HCV) at any time other than upon admission. Select “No” if your
facility does not screen hemodialysis patients for hepatitis C antibody (anti-HCV) at
any other times than upon admission. Select “No” if hepatitis C testing is
diagnostic only.
Conditionally required. Indicate the frequency of non-admission hepatitis C
antibody (anti-HCV) screening.
o Twice annually: screening is two times per year, after admission.
o Annually: if screening is once per year, after admission.
Otherwise, select “Other” and specify the frequency of post-admission HCV
screening.

Required. Of the maintenance, non-transient, in-center hemodialysis patients
specified in question 17.a., indicate how many were hepatitis C virus antibody (i.e.,
anti-HCV) positive in the first week of February (the first seven calendar days of
the month). If your facility does not screen for hepatitis C antibody, respond to the
question counting patients with records of known history of HCV infection, if any.
This is a measure of prevalence of hepatitis C virus infection among your patients.
a.i. In-center HD
Required. Of the maintenance, non-transient, in-center hemodialysis patients
patients with HCV
specified in question 27.a., indicate how many were hepatitis C antibody (antiinfection upon
HCV) positive when they were first admitted to your facility (i.e., they had hepatitis
admission
C virus infection upon admission). If your facility does not screen for hepatitis C
antibody, respond to the question counting patients with records of known history
of HCV infection, if any. (Note: if your facility dos not screen for hepatitis C upon
admission, this will be the same response as 27.a.) This is a measure of prevalence
of hepatitis C virus infection among your patients.
b. In-center HD
Required. Of the maintenance, non-transient, in-center hemodialysis patients
patients acquired
specified in question 17.a., indicate how many converted from hepatitis C antibody
HCV infection in 12
(i.e., anti-HCV) negative to positive during the 12 months prior to February (i.e.,
months prior to
they acquired HCV infection in the past year). Do not include patients who were
February
antibody positive before they were first dialyzed in your center (i.e., patients
specified in question 27.a.i.). If your facility does not screen for hepatitis C
antibody, respond to the question counting patients with records of known history
of HCV infection, if any. This is a measure of annual incidence of hepatitis C virus
infection among your patients.
E. Dialysis Policies and Practices
E.1. Dialyzer Reuse
28. Dialyzer reuse
Required. Select “Yes” if dialyzers are reused for any patients. Select “No” if
dialyzers are never reused.
o Facilities that use non-disposable dialyzers for more than one patient
treatment should answer “Yes” to this question.
o All facilities with a dialyzer reuse program would answer “Yes” to this
question.
a. Dialyzer
Conditionally required. Indicate whether dialyzers are reprocessed at your facility,
reprocessing
if they are transported to an off-site facility for reprocessing, or if they are
location
reprocessed both at your facility and off-site.

NHSN Dialysis Event Manual
Instructions for the Denominators for Dialysis Event Form

b. Dialyzer
refrigeration
c. Dialyzer header
cleaning
d. Dialyzer reuse
limit
E.2. Dialysate
29. Type of dialysate

Conditionally required. Select “Yes” if dialyzers are refrigerated prior to being
reprocessed. Select “No” if dialyzers are not refrigerated prior to reprocessing.
Conditionally required. Select all dialyzer header cleaning methods in use. If there
is no header cleaning step, select “No separate header cleaning step performed.”
Conditionally required. If there is a number limit for the number of times the
dialyzer can be reused, select “Yes” and indicate the maximum number. Otherwise
select “No limit as long as dialyzer meets certain criteria.”
Required. Indicate the type of dialysate that is used for in-center hemodialysis
patients at your center.

o

30. Culture and
endotoxin tests after
pyrogenic reactions

E.3. Priming Practices
31. Waste Handling
Option (WHO) ports

32. Bled onto machine

E.4. Injection Practices
33. Form of
erythropoiesis
stimulating agent

a. ESA single-dose
vial or syringe
34. Medication
preparation location
35. Technician IV med
administration
E.5. Antibiotic Use

Ultrapure: dialysate with a viable microbial count less than 0.1 CFU/ml and an
endotoxin level less than 0.03 EU/ml.
o Conventional: dialysate that does not meet the ultrapure definition above.
Required. Select “Yes” only if your facility routinely tests a patient’s dialysate for
both culture and endotoxin whenever a patient has a pyrogenic reaction. Select
“No” if testing dialysate for both culture and toxin is not routine practice. If there
has never been a pyrogenic reaction among your patients, respond based on
facility policy.
Required. A waste handling option (WHO) port is a feature of some hemodialysis
machines that is designed to dispose of the saline that is flushed through the
dialyzer before the machine is used for a patient. Select “Yes” if your facility uses
WHO ports. Select “No” if the hemodialysis machines at your facility do not have
WHO ports or select “No” if the WHO ports are present, but not used.
Required. Select “Yes” if any patients in your facility are “bled onto the
hemodialysis machine,” a process where blood is allowed to reach or almost reach
the prime waste receptacle or WHO port. Select “No” if patients are not bled onto
their machines.
Required. Indicate the form of erythropoiesis stimulating agent (ESA) that is most
often used in your facility. “Single-dose” (also known as “single-use”) and “multidose” refer to specific manufacturer designations that are printed on the product
packaging/label, not the dosing practice in use. Please refer to the ESA’s label to
determine if the product most frequently used in your facility is labeled “singledose” or “multi-dose.” If ESA is not used, select “N/A.”
Conditionally required. Select “Yes” if ESA from a single-dose vial or syringe is ever
administered to more than one patient. Select “No” if ESA from a single-dose vial
or syringe is never administered to more than one patient.
Required. Indicate the location where medications are most commonly drawn into
syringes to prepare for patient administration.
Required. Select “Yes” if technicians ever administer any IV medications or
infusates, such as heparin or saline, to patients. Select “No” if technicians never
administer IV medications to patients.

NHSN Dialysis Event Manual
Instructions for the Denominators for Dialysis Event Form

36. a.-d. Appropriate
antibiotic use

37. Infection prevention
initiatives
a. Initiative types
38. CDC-recommended
core interventions
for BSI prevention in
dialysis settings

39. Hand hygiene audits

40. Vascular access care
and catheter access
practice observation
41. Vascular access care
and catheter access
practice competency

E.7. Peritoneal Dialysis
42. Peritoneal dialysis
catheter
antimicrobial
ointment

Required. Select “Yes” only for those practices that have been implemented for
the purpose of appropriate antimicrobial use. If antimicrobials are restricted, but
for another purpose (e.g., cost management), select “No.” Select “No” if there are
no antimicrobial restrictions in your center.
o Have a written policy on antibiotic use: any written plan to guide and
determine the present and future decisions about appropriate antibiotic use.
o Formulary restrictions: the existence of rules that limit the use of certain types
of antimicrobials.
o Antibiotic use approval process: a mechanism exists to ensure specific criteria
are met before antibiotics are administered.
o Automatic stop orders for antibiotics: in the absence of a physician’s review
and order for continuation, antibiotics are automatically discontinued after a
specified period.
Required. Select “Yes” if your facility participates in any national or regional
infection prevention initiatives. This includes infection prevention initiatives
directed by your ESRD Network.
Conditionally required. Indicate the primary focus of the initiative. If involved in
more than one initiative, indicate the primary focus of each initiative.
Required. Select “Yes” if your facility follows all nine CDC-recommended core
interventions for BSI prevention in dialysis settings for all of your in-center
hemodialysis patients. Select “No” if your facility does not follow all nine CDCrecommended core interventions. Select “No” if all nine core interventions are not
implemented among all of your hemodialysis patients. Select “Don’t know” if you
are uncertain about whether all nine CDC-recommended core interventions are
followed for all of your facility’s hemodialysis patients.
Required. Select “Yes” if your facility performs hand hygiene audits monthly, or
more frequently. Select “No” if your facility does not perform hand hygiene audits,
or if the audits are performed less often than monthly.
Required. Select “Yes” if your facility performs vascular access care observations
and catheter access observations quarterly, or more frequently. Select “No” if your
facility does not perform vascular access care observations and catheter access
observations, or if the observations are performed less often than quarterly.
Required. Select “Yes” if your facility performs staff competency assessments for
vascular access care and catheter accessing annually, or more frequently. Select
“No” if your facility does not perform staff competency assessments for vascular
access care and catheter accessing, or if the assessments are performed less often
than yearly.
Required. Select “Yes” if antimicrobial ointment is routinely applied to peritoneal
dialysis catheter exit sites during dressing changes. Select “No” if antimicrobial
ointment is not routinely applied to the peritoneal dialysis catheter exit site during
dressing changes. Select “N/A” if your facility does not provide peritoneal dialysis
treatment.

NHSN Dialysis Event Manual
Instructions for the Denominators for Dialysis Event Form

F.
F.1.
43.

F.2.
44.

45.

46.

F.3.

47.

a. Peritoneal dialysis Conditionally required. Select the antimicrobial ointment that is most commonly
catheter
applied to the peritoneal dialysis catheter exit site during dressing changes.
antimicrobial
ointment type
Vascular Access
General Vascular Access Information
a.-e. Hemodialysis
Required. Of the total number of maintenance, non-transient hemodialysis
access types
patients indicated in question 17 (i.e., 17.a. in-center +17.b. home hemodialysis),
indicate how many patients received hemodialysis through each access type
during the first week of February (the first seven calendar days of the month).
 Note: this question requires a different counting process than the
Denominators for Outpatient Dialysis form: count all accesses that were
used for hemodialysis during the week.
Arteriovenous (AV) Fistulas or Grafts
Graft/fistula
Required. Indicate whether the graft/fistula site is most often cleansed with soap
cleanser used before and water, or alcohol-based hand rub, prior to prepping the area for puncture.
prep
Select “Other” and specify if a different cleanser is used. Select “Nothing” if a
cleanser is not used.
Graft/fistula
Required. To prep the graft or fistula for puncture, indicate the
puncture prep
antiseptic/disinfectant that is most often used to prep the area.
a. Graft/fistula
Conditionally required. Indicate the form of the antiseptic/disinfectant used to
puncture prep form
prep grafts or fistulas for puncture.
Buttonhole
Required. Buttonhole cannulation is a technique where a patient’s fistula is
cannulation
regularly accessed by inserting a blunt needle (cannula) into the fistula at the same
location each time using an established track. Indicate if “All,” “Most,” “Some,” or
“None” of your fistula patients undergo buttonhole cannulation.
a. Buttonhole
Conditionally required. Of the patients whose fistulae are accessed via the
patients
buttonhole cannulation technique, indicate whether they are in-center
hemodialysis patients only, home hemodialysis patients only, or both.
b. Buttonhole
Conditionally required. Select “Yes” if antimicrobial ointment is applied at the
antimicrobial
buttonhole cannulation site to prevent infections. Select “No” if antimicrobial
ointment
ointment is not used at the buttonhole cannulation site to prevent infections.
c. Buttonhole
Conditionally required. Among the in-center hemodialysis patients, indicate
cannulation
whether buttonhole cannulation is most often performed by a nurse, the patient,
performed by
or a technician. Otherwise, select “Other” and specify who most often performs
buttonhole cannulation.
Hemodialysis Catheters
If there are no patients with hemodialysis catheters, refer to facility policy to answer the following
questions.
Catheter hub prep
Required. Prior to accessing hemodialysis catheters, indicate what product is most
commonly used to prep the catheter hubs.
a. Catheter hub prep Conditionally required. Indicate the form of the antiseptic/disinfectant used to
form
prep catheter hubs prior to access.

NHSN Dialysis Event Manual
Instructions for the Denominators for Dialysis Event Form

48. Catheter hub scrub

49. Catheter exit site
prep
a. Catheter exit site
prep form
50. Catheter exit site
antimicrobial
ointment
a. Catheter exit site
antimicrobial
ointment type
51. Hemodialysis
catheter care staff
52. Antimicrobial lock
solutions to prevent
infection
a. Antimicrobial lock
solutions
53. Closed connector
luer access devices
a. Closed connector
luer access device
type
b. Closed connector
luer access device
patients
54. Other antimicrobial/
antiseptic products

Required. Select “Yes” if catheter hubs are routinely scrubbed after the cap is
removed, but before the catheter is accessed. Select “No” if scrubbing catheter
hubs is not routine practice.
Required. When a catheter exit site dressing is changed, indicate the
antiseptic/disinfectant that is most often used to prep the area.
Conditionally required. Indicate the form of the antiseptic/disinfectant used to
prep catheter exit sites when the dressing is changed.
Required. Select “Yes” if antimicrobial ointment is routinely applied to
hemodialysis catheters during dressing changes. Select “No” if antimicrobial
ointment is not routinely applied to hemodialysis catheters during dressing
changes.
Conditionally required. If antimicrobial ointment is routinely applied to
hemodialysis catheters during dressing changes, indicate the type of ointment that
is most commonly used.
Required. Indicate the job classification of the staff person who primarily performs
hemodialysis catheter care (i.e., accesses catheters or changes dressings).
Required. Indicate whether antimicrobial lock solutions are used to prevent
hemodialysis catheter infections for all catheter patients in your facility, for some
catheter patients in your facility, or for none of the catheter patients in your
facility.
Conditionally required. Indicate the type of antimicrobial lock solution that is most
commonly used in your facility.
Required. Select “Yes” if closed connector luer access devices are used on
hemodialysis catheters in your facility. Select “No” if closed connector luer access
devices are not used on hemodialysis catheters in your facility.
Conditionally required. If closed connector luer access devices are used on
hemodialysis catheters in your facility, indicate the type used.
Conditionally required. If closed connector luer access devices are used on
hemodialysis catheters in your facility, indicate if they are used for home
hemodialysis patients, in-center hemodialysis patients, or both.
Required. Indicate all of the applicable antimicrobial/antiseptic products that are
in use for hemodialysis catheters in your facility.

Comments

Optional. Use this field to add any additional information about the dialysis survey
necessary to interpret your responses. If the character limit is inadequate, please
email your comments to the NHSN Helpdesk at [email protected].

Save as …

A complete survey is an annual reporting requirement specified in the NHSN
Dialysis Event Protocol. Users are prevented from creating Monthly Reporting
Plans and submitting monthly data for April through December until a survey for
that year has been saved as complete. Surveys can be saved as complete as early
as February 8 each year.

NHSN Dialysis Event Manual
Instructions for the Denominators for Dialysis Event Form

For additional assistance, email the NHSN Helpdesk ([email protected]) and include “dialysis” in the subject
line.