Att G.9_Dialysis Prevention Process Measures

Dialysis Prevention Process Measures Module

Dialysis Prevention Process Measures
Hand Hygiene Surveillance
Background
Infections are the second most common cause of death in end-stage renal disease patients,
and they account for nearly 14% of deaths (1). Hand hygiene is considered the cornerstone
of infection prevention. CDC guidelines to prevent intravascular catheter-related infections
recommend tracking hand hygiene adherence to inform healthcare personnel practice (2).
This surveillance option allows facilities to monitor adherence to hand hygiene among
healthcare personnel.
Setting: Surveillance occurs in outpatient hemodialysis centers. These centers may be
attached to or affiliated with a hospital, but should serve hemodialysis outpatients.
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. When hand hygiene (“HH”) surveillance is selected
on the Monthly Reporting Plan, a minimum of 30 hand hygiene adherence observations are
required per month. Report data to NHSN within 30 days of the end of the month in which
they were collected (e.g., hand hygiene adherence data from September must be reported
no later than October 30).
Use of the CDC Hemodialysis Hand Hygiene Observations Audit Tool to collect individual
observations is encouraged. Access the audit tool at:
http://www.cdc.gov/dialysis/PDFs/collaborative/Hemodialysis-Hand-HygieneObservations.pdf. If the CDC audit tool is not used, another tool employing the same
methods can be used. See additional information on conducting hand hygiene observations
at http://www.cdc.gov/dialysis/prevention-tools/Protocol-hand-hygiene-gloveobservations.html. Hand hygiene surveillance summary data are collected on the Dialysis
Prevention Process Measures form (CDC 57.504).
Definitions
Antiseptic handwashing: Washing hands with water and soap or other detergents
containing an antiseptic agent.
Antiseptic hand-rubbing: Applying an antiseptic hand-rub product to all surfaces of the
hands to reduce the number of microorganisms present.

Dialysis Prevention Process Measures Module

Handwashing: Washing hands with plain (i.e., non-antimicrobial) soap and water.
Hand hygiene: A general term that applies to: handwashing, use of an antiseptic hand
wash or antiseptic hand-rub, or surgical hand antisepsis.
Reporting Instructions
Perform at least 30 unannounced observations of hand hygiene opportunities each month.
Observers should try to ensure that observations are as representative as possible of
normal practice at the facility. This might include observing many different staff members
on different days and shifts. Observers should also consider observing at particularly busy
times, such as during shift change, when staff are sometimes less attentive to proper
practices. Observers should focus on an area of the unit where staff interactions with
patients are clearly visible. This may include observation of several staff members.
In general, hand hygiene should be performed according to the World Health
Organization’s “5-Moments”: 1. before touching a patient; 2. before performing
clean/aseptic procedures; 3. after body fluid exposure/risk; 4. after touching a patient; and
5. after touching patient surroundings (3). Specific examples of situations when hand
hygiene is indicated include after completing tasks at one patient station before moving to
another station, before and after contact with the patient’s vascular access, before and after
dressing changes, and after contact with items/surfaces at patient stations. Consider using
a tool that allows documentation of the professional category of staff who are observed,
along with space to document circumstances of successful or unsuccessful hand hygiene
opportunities.
See back of the CDC Hand Hygiene Observational tool for additional examples
(http://www.cdc.gov/dialysis/PDFs/collaborative/Hemodialysis-Hand-HygieneObservations.pdf).
*Note: Observations are made to first identify whether hand hygiene was indicated (i.e. an
opportunity) and then to determine whether hand hygiene was successfully performed for
that opportunity.
Although not reported for the purpose of this module, as part of hand hygiene
observations, observers should evaluate whether there are sufficient supplies of alcoholbased hand-rub, soap and paper towels and unrestricted access to sinks.

Dialysis Prevention Process Measures Module

Data Analysis
Feedback of rates of adherence with proper hand hygiene is crucial to improvement.
Facilities should consider posting and/or reporting aggregate rates to staff members
regularly so that they may track rates over time. In addition, feedback (positive or
negative) to individuals can be useful.
Numerator: Hand Hygiene Successes = Total number of observed opportunities when
hand hygiene was indicated and was successfully performed.
Denominator: Hand Hygiene Opportunities = Total number of observed opportunities
during which hand hygiene was indicated.

Locate reports in Analysis Output Options, under Prevention Process Measures folder.
References
1. NIH: U.S. Renal Data System, USRDS 2006 Annual Report. Bethesda, MD: National
Institute of Diabetes and Digestive and Kidney Diseases, 2006
2. CDC: Healthcare Infection Control Practices Advisory Committee (HICPAC)
Guidelines for the prevention of intravascular catheter-related infections,
http://www.cdc.gov/hicpac/bsi/bsi-guidelines-2011.html, 2011
3. WHO: About SAVE LIVES: Clean Your Hands.
http://www.who.int/gpsc/5may/background/5moments/en/, 2014

Dialysis Prevention Process Measures Module

Hemodialysis Catheter Connection/Disconnection Observation
Background
Setting: Surveillance occurs in outpatient hemodialysis centers. These centers may be
attached to or affiliated with a hospital, but should serve hemodialysis outpatients.
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. When hemodialysis catheter
connection/disconnection surveillance is selected on the Monthly Reporting Plan, a
minimum of 10 observations are required per month. Report data to NHSN within 30 days
of the end of the month in which they were collected (e.g., data from September must be
reported no later than October 30).
Use of the CDC Audit Tool to collect individual observations is encouraged. Access the audit
tool at: Hemodialysis Catheter Connection & Disconnection Observations Audit Tool.
If the CDC audit tool is not used, another tool employing the same methods can be used.
Summary data are collected on the Dialysis Prevention Process Measures form (CDC
57.504).
Definitions
Reporting Instructions
Perform at least 10 observations each month.
Data Analysis
Feedback of rates of adherence with best practices is crucial to improvement. Facilities
should consider posting and/or reporting aggregate rates to staff members regularly so
that they may track rates over time. In addition, feedback (positive or negative) to
individuals can be useful.
Numerator: The total number of observed catheter connections and/or catheter
disconnections when all CDC recommended infection prevention best practices were
successfully performed.
Denominator: The total number of observed catheter connections and/or catheter
disconnections.
References

Dialysis Prevention Process Measures Module

Hemodialysis Catheter Exit Site Care Observation
Background
Setting: Surveillance occurs in outpatient hemodialysis centers. These centers may be
attached to or affiliated with a hospital, but should serve hemodialysis outpatients.
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. When hemodialysis catheter exit site care
surveillance is selected on the Monthly Reporting Plan, a minimum of 10 observations are
required per month. Report data to NHSN within 30 days of the end of the month in which
they were collected (e.g., data from September must be reported no later than October 30).
Use of the CDC Audit Tool to collect individual observations is encouraged. Access the audit
tool at: Hemodialysis Catheter Exit Site Care Observations Audit Tool.
If the CDC audit tool is not used, another tool employing the same methods can be used.
Summary data are collected on the Dialysis Prevention Process Measures form (CDC
57.504).
Definitions
Reporting Instructions
Perform at least 10 observations each month.
Data Analysis
Feedback of rates of adherence with best practices is crucial to improvement. Facilities
should consider posting and/or reporting aggregate rates to staff members regularly so
that they may track rates over time. In addition, feedback (positive or negative) to
individuals can be useful.
Numerator: The total number of hemodialysis catheter exit site care observations when
all CDC recommended infection prevention best practices were successfully performed.
Denominator: The total number of hemodialysis catheter exit site care observations.
References

Dialysis Prevention Process Measures Module

Arteriovenous Fistula and Graft Cannulation/Decannulation
Background
Setting: Surveillance occurs in outpatient hemodialysis centers. These centers may be
attached to or affiliated with a hospital, but should serve hemodialysis outpatients.
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. When arteriovenous fistula and graft
cannulation/decannulation surveillance is selected on the Monthly Reporting Plan, a
minimum of 10 observations are required per month. Report data to NHSN within 30 days
of the end of the month in which they were collected (e.g., data from September must be
reported no later than October 30).
Use of the CDC Audit Tool to collect individual observations is encouraged. Access the audit
tool at: Arteriovenous Fistula & Graft Cannulation and Decannulation Observations Audit Tool
If the CDC audit tool is not used, another tool employing the same methods can be used.
Summary data are collected on the Dialysis Prevention Process Measures form (CDC
57.504).
Definitions
Reporting Instructions
Perform at least 10 observations each month.
Data Analysis
Feedback of rates of adherence with best practices is crucial to improvement. Facilities
should consider posting and/or reporting aggregate rates to staff members regularly so
that they may track rates over time. In addition, feedback (positive or negative) to
individuals can be useful.
Numerator: The total number of arteriovenous fistula and graft cannulation or
decannulation observations when all CDC recommended infection prevention best
practices were successfully performed.

Dialysis Prevention Process Measures Module

Denominator: The total number of arteriovenous fistula and graft cannulation or
decannulation observations. In-plan, a minimum of 10 observations is required each
month. Individual observations can be collected using an audit tool, such as the CDC.
References

Dialysis Station Routine Disinfection Observation
Background
Setting: Surveillance occurs in outpatient hemodialysis centers. These centers may be
attached to or affiliated with a hospital, but should serve hemodialysis outpatients.
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. When dialysis station routine disinfection
surveillance is selected on the Monthly Reporting Plan, a minimum of 10 observations are
required per month. Report data to NHSN within 30 days of the end of the month in which
they were collected (e.g., data from September must be reported no later than October 30).
Use of the CDC Audit Tool to collect individual observations is encouraged. Access the audit
tool at: Dialysis Station Routine Disinfection Checklist
If the CDC audit tool is not used, another tool employing the same methods can be used.
Summary data are collected on the Dialysis Prevention Process Measures form (CDC
57.504).
Definitions
Reporting Instructions
Perform at least 10 observations each month.
Data Analysis
Feedback of rates of adherence with best practices is crucial to improvement. Facilities
should consider posting and/or reporting aggregate rates to staff members regularly so

Dialysis Prevention Process Measures Module

that they may track rates over time. In addition, feedback (positive or negative) to
individuals can be useful.
Numerator: The total number of dialysis station routine disinfection observations when
all CDC recommended infection prevention best practices were successfully performed.
Denominator: The total number of dialysis station routine disinfection observations.
References

Injection Safety Observation
Background
Setting: Surveillance occurs in outpatient hemodialysis centers. These centers may be
attached to or affiliated with a hospital, but should serve hemodialysis outpatients.
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. When injection safety surveillance is selected on the
Monthly Reporting Plan, a minimum of 10 observations are required per month. Report
data to NHSN within 30 days of the end of the month in which they were collected (e.g.,
data from September must be reported no later than October 30).
Use of the CDC Audit Tool to collect individual observations is encouraged. Access the audit
tool at: CDC Outpatient Injection Safety Checklist.
If the CDC audit tool is not used, another tool employing the same methods can be used.
Summary data are collected on the Dialysis Prevention Process Measures form (CDC
57.504).
Definitions
Reporting Instructions
Perform at least 10 observations each month.
Data Analysis

Dialysis Prevention Process Measures Module

Feedback of rates of adherence with best practices is crucial to improvement. Facilities
should consider posting and/or reporting aggregate rates to staff members regularly so
that they may track rates over time. In addition, feedback (positive or negative) to
individuals can be useful.
Numerator: The total number of injection safety observations when all CDC
recommended infection prevention best practices were successfully performed.
Denominator: The total number of injection safety observations. In-plan, a minimum
of 10 observations is required each month.
References

NHSN Dialysis Manual
Instructions for the Prevention Process Measures Form

Instructions for Prevention Process Measures Form
(CDC 57.504)
Complete a Prevention Process Measures form to summarize observations, according to
definitions and reporting instructions in the Prevention Process Measures Protocol.
* Indicates a required field when reporting in-plan.
Data Field
Instructions for Data Collection
Facility ID #
The NHSN-assigned facility ID will be auto-entered by the computer.
*Month
Required. Enter the month during which the data were collected for this
location.
*Year
Required. Enter the 4-digit year during which the data were collected for
this location.
*Location code
Required. Enter the location code for the outpatient hemodialysis clinic
location from which you will collect data about dialysis events.
*Observation Type
Total # of Successful Required. The total number of observed opportunities when staff hand
Hand Hygiene hygiene was indicated and was successfully performed.
Observations
Total # of Hand Hygiene Required. The total number of observed opportunities during which
Observations hand hygiene was indicated. In-plan, a minimum of 30 unannounced
observations of hand hygiene opportunities is required each month.
Individual observations can be collected using any hand hygiene audit
tool, such as the CDC Hemodialysis Hand Hygiene Observations Audit
Tool.
Total # of Hemodialysis Required. The total number of observed catheter connections and/or
Catheter Connection/ catheter disconnections when all CDC recommended infection prevention
Disconnection Successful best practices were successfully performed.
Observations
Total # of Hemodialysis Required. The total number of observed catheter connections and/or
Catheter Connection/ catheter disconnections. In-plan, a minimum of 10 observations is
Disconnection required each month. Individual observations can be collected using an
Observations audit tool, such as the CDC Hemodialysis Catheter Connection &
Disconnection Observations Audit Tool.
Total # of Hemodialysis Required. The total number of hemodialysis catheter exit site care
Catheter Exit Site Care observations when all CDC recommended infection prevention best
Successful Observations practices were successfully performed.
Total # of Hemodialysis Required. The total number of hemodialysis catheter exit site care
Catheter Exit Site Care observations. In-plan, a minimum of 10 observations is required each
Observations month. Individual observations can be collected using an audit tool, such
as the CDC Hemodialysis Catheter Exit Site Care Observations Audit
Tool.
Total # of Arteriovenous Required. The total number of arteriovenous fistula and graft
Fistula and Graft cannulation or decannulation observations when all CDC recommended
Cannulation/ infection prevention best practices were successfully performed.

NHSN Dialysis Manual
Instructions for the Prevention Process Measures Form

Data Field
Decannulation Successful
Observations
Total # of Arteriovenous
Fistula and Graft
Cannulation/
Decannulation
Observations
Total # of Dialysis
Station Routine
Disinfection Successful
Observations
Total # of Dialysis
Station Routine
Disinfection Observations

Total # of Injection
Safety Successful
Observations
Total # of Injection
Safety Observations

Custom fields

Comments

Instructions for Data Collection

Required. The total number of arteriovenous fistula and graft
cannulation or decannulation observations. In-plan, a minimum of 10
observations is required each month. Individual observations can be
collected using an audit tool, such as the CDC Arteriovenous Fistula &
Graft Cannulation and Decannulation Observations Audit Tool.
Required. The total number of dialysis station routine disinfection
observations when all CDC recommended infection prevention best
practices were successfully performed.
Required. The total number of dialysis station routine disinfection
observations. In-plan, a minimum of 10 observations is required each
month. Individual observations can be collected using any audit tool,
which includes all of the elements of the CDC Dialysis Station Routine
Disinfection Checklist.
Required. The total number of injection safety observations when all
CDC recommended infection prevention best practices were successfully
performed.
Required. The total number of injection safety observations. In-plan, a
minimum of 10 observations is required each month. Individual
observations can be collected using any hand hygiene audit tool, such as
the CDC Outpatient Injection Safety Checklist.
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 “PPM – Prevention Process Measures.”
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.