Att G8_Dialysis Event

NHSN Dialysis Event Manual
Dialysis Event Surveillance 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, 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: 1) arteriovenous fistulas created from the patient’s own blood vessels; 2) arteriovenous
grafts typically constructed from synthetic materials; 3) tunneled central lines; and 4) nontunneled
central lines. Other access devices, such as catheter-graft hybrid devices, fall in between grafts and
tunneled central lines in terms of risk. Because of frequent hospitalizations and receipt of
antimicrobial drugs, hemodialysis patients are also at high risk for infection with antimicrobialresistant 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
Dialysis Event Surveillance form. This count is called the denominator and 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. These include: 1) IV antimicrobial starts; 2) positive blood cultures; and 3) evidence of
local access site infection. Facilities use a Dialysis Event Surveillance form to report the details of
each dialysis event that occurred among these patients. Dialysis events are also known as
numerators. Before data can be reported, facilities must indicate that they are reporting according
to protocol by saving a Dialysis Monthly Reporting Plan. Completion of an Outpatient Dialysis
Center Practices Survey is also 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 or peritoneal dialysis patients) are present, exclude them from Dialysis Event
numerator and denominator reporting, unless they are receiving outpatient hemodialysis in lieu
of their regular dialysis modality, on a temporary basis.
Population: Hemodialysis outpatients.
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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


Include transient patients
Include peritoneal dialysis patients or transplant patients undergoing temporary,
outpatient hemodialysis.

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: 1) intravenous (IV) antimicrobial
start; 2) positive blood culture; and 3) 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 pass 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, should not be reported. The 21 day rule
applies across calendar months. Refer to each dialysis event definition for instructions on applying
the 21 day rule for each specific event type.
IV antimicrobial start: An IV antimicrobial start is defined as a single outpatient dose or the first
outpatient dose of an antibiotic or antifungal course. Report all starts of 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 administered at a
hospital or physician’s office.


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

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antimicrobial is continued, the second facility would report the IV antimicrobial start in
their facility as well.

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 should not be reported. If different
organisms grow from these subsequent positive blood cultures, add the new organisms to
the first positive blood culture 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
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expected swelling at any vascular access site, regardless of whether the patient received treatment
for infection. Report pus, redness, or increased swelling of the central line site even if the central line
has already been removed at the time of symptom onset. 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.


21 day rule: There must be 21 or more days between the onset of the first episode and the
onset of the second episode of pus, redness, or increased swelling at a vascular access site for
both dialysis events to be considered separate. 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 should not be 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 abandoned/non-functional and even
if they are not used for dialysis (i.e., PICC lines and chemotherapy ports). Exception: If reporting pus,
redness, or increased swelling of a central line site that occurred after the central line was removed,
report that central line even if it was no longer in place at the time of the event.

14



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).

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

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

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 (i.e.,
Gore Acuseal®15).



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



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 how a
patient is primarily cannulated.

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 device16).

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 Dialysis Monthly Reporting Plans: The Dialysis 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 Dialysis 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 Dialysis Monthly
Reporting Plan with the “DE” checkbox selected for the ‘outpatient hemodialysis clinic’ location, for
each month of participation in Dialysis Event surveillance.
Report Denominator Data Monthly: The denominator is the count of patients by their highest
risk vascular access type and is reported on the Denominators for Dialysis Event Surveillance
form (CDC 57.503). The denominator is used to estimate the number of patient-months
considered at risk for dialysis events. To report denominator data each month, report the

16

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

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number of unique hemodialysis outpatients, by their highest risk vascular access type, who
received hemodialysis at the center during the first two working days of the month.
Report all hemodialysis outpatients, including transient patients. Exclude non-hemodialysis
patients (e.g., peritoneal dialysis patients) and exclude inpatients. Report denominator data
every 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

Nontunneled
Central
Lines

Tunneled
Central
Lines

Other
Access
Devices

Grafts

LOWER
INFECTION
RISK

Fistulas

See tables of instructions for an explanation of each field of the Denominators for Dialysis Event
Surveillance form.
First two “working days”: The first two “working days” of the month represent the first two days of
the month when the facility is open to patients during all regularly scheduled shifts. Sundays are
not considered one of the first two “working days” of the month. Reporting the number of
hemodialysis outpatients dialyzed on the first two “working days” of the month provides the
opportunity to realistically capture all patients expected to be dialyzed during all regularly
scheduled shifts.


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

 If a facility dialyzes patients 3 days a week on a Monday/Wednesday/Friday schedule, the facility
should count patients on both of the first 2 working days of the month, but only count new
patients on the second day.
Sun
Facility
closed



Mon
1

2
Working
day 1
(count all
patients)

Tues

Wed
3

4
Working
day 2
(count
new
patients)

Thurs

Fri
5

Sat
6

7

For facilities that provide nocturnal hemodialysis, working days should include nocturnal
hemodialysis patients. However, all Sunday shifts should be excluded from working days.

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

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



Select “No NHSN Reporting this Month” on a month’s Dialysis Monthly Reporting Plan and do not
complete a denominator form if:
1. the facility was closed or non-operational for the entire month;
2. the individual in charge of dialysis event surveillance is out of the office for a given
month and no surveillance can be conducted;
3. the facility will not be adhering to the Dialysis Event Protocol for a given month.



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

Report Numerator Data Monthly: The numerator is 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 dialysis event among all outpatients 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, greater than expected redness or greater than expected swelling at a 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, even if the events occur in
different months. For example, if a patient has a positive blood culture and begins IV antimicrobials
the next day, 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.

Event Type

IV antimicrobial start
Positive blood culture

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

Pus, redness or increased swelling at
vascular access site

Date of onset

Combination

Earliest date of the three types

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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 Dialysis Event Surveillance form to confirm no events
of that type occurred during the month.
Three options for "report no events" are now available on the Denominators for Dialysis Event
Surveillance form:
- No IV antimicrobial start events
- No Positive blood culture events
- No Pus, redness or increased swelling at vascular access site events
During months when dialysis events are not reported for a specific event type or combination of
event types, the three "report no events" fields will become accessible on the first day of the
proceeding month. For example, the "report no events" check boxes on the March 2014
denominator form will remain greyed out until April 1, 2014.
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.
𝑟𝑎𝑡𝑒 =

𝐷𝑖𝑎𝑙𝑦𝑠𝑖𝑠 𝐸𝑣𝑒𝑛𝑡𝑠 (𝑛𝑢𝑚𝑒𝑟𝑎𝑡𝑜𝑟)
× 100
𝑃𝑎𝑡𝑖𝑒𝑛𝑡-𝑀𝑜𝑛𝑡ℎ𝑠 (𝑑𝑒𝑛𝑜𝑚𝑖𝑛𝑎𝑡𝑜𝑟)

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 Surveillance 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
^ = conditionally required field
Patient Data
Data Fields
Facility ID #
Event ID #
*Patient ID #

Instructions for Completion
NHSN-assigned facility ID will auto-populate in this field.
Event ID# will auto-populate in this field.
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 the patient is “Hispanic or Latino,” or “Not
Hispanic or Not 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

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.
 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.

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Instructions for the Dialysis Event Form

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

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).
Required. Select “Yes” if this patient was temporarily admitted for treatment
at your facility for a short time at the time of the event (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

Other vascular access
device - specify

February 2014

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 needle (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.
Optional. Specify the type of “other vascular access.”

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Instructions for the Dialysis Event Form

^Is this a cathetergraft hybrid?

*Access Placement
Date

Vascular access
comment
Is this patient’s dialyzer
reused?

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 device5).
Select ‘no’ if the patient’s other access device is not a catheter-graft hybrid.
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) at the time of the event that would help you to interpret
your surveillance data, such as recent surgical revisions. CDC typically does
not analyze these data.
Optional. Select “yes” if this patient’s dialyzer is reprocessed for reuse. Select
“no” if a new dialyzer for each hemodialysis treatment.

Event Details
Specify Dialysis Event
IV antimicrobial start

Required. Select all that apply:
Report any starts of intravenous (IV) antibiotics or antifungals administered
in an outpatient setting, regardless of the reason for administration and
regardless of the duration of treatment. 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
both starts to be reported as separate dialysis events, even if different
antimicrobials are used. If IV antimicrobials are stopped and restarted within
21 days of each other, then the second IV antimicrobial start is NOT
considered a new dialysis event and should not be 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.

5

^Was vancomycin the
antimicrobial used for
this start?

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 one of them was vancomycin.

Was this a new
outpatient start or a
continuation of an
inpatient course?

Optional. Select “New antimicrobial start” if the first dose in a course of treatment
was administered in the dialysis facility.
Select “Continuation of antimicrobial” if the patient is continuing a course of IV
antimicrobials that were initiated in an inpatient setting.

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

Positive blood culture

Report any 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 determined to have a 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, should not be reported. However, if different
organisms grow from these subsequent positive blood cultures, add the new
organisms to the first dialysis event.

^Specify pathogen(s) Conditionally required for a positive blood culture. See the following
and antimicrobial section for additional instructions.
susceptibilities

Data Fields
^Pathogens

Pathogens and Antimicrobial Susceptibilities
Instructions for Completion
Conditionally required. Select each organism identified in the positive
blood culture from the pathogen dropdown menu (up to three organisms can
be selected). Microorganisms do not have to be listed in a specific order
when positive blood culture events are reported.
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.).

^Antimicrobial agent
and susceptibility
results

February 2014

Note that the pathogen dropdown menu opens to display an abbreviated list
of the most common pathogens. If the microorganism cannot be found in the
NHSN pathogen dropdown list, select “All Pathogens” at the top of the menu
to search through a more complete list of 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.

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Instructions for the Dialysis Event Form

Antimicrobial agent
and susceptibility
results (continued)

S – Susceptible
I – Intermediate
R – Resistant
N – Not Tested
NS- Non-susceptible
S-DD- Susceptible-dose dependent

For gentamicin and streptomycin
high level tests only, use:
S – Susceptible/Synergistic
R – Resistant/Not Synergistic

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

Data Fields

February 2014

COL = colistin
DAPTO = daptomycin
DORI = doripenem
DOXY = doxycycline
ERTA = ertapenem
ERYTH = erythromycin
FLUCO = fluconazole
FLUCY = flucytosine
GENT = gentamicin
GENTHL = gentamicin-high
level test
IMI = imipenem
ITRA = itraconazole
LEVO = levofloxacin
LNZ = linezolid
MERO = meropenem
METH = methicillin
MICA = micafungin

MINO = minocycline
MOXI = moxifloxacin
NITRO = nitrofurantoin
OX = oxacillin
PB = polymyxin B
PIP = piperacillin
PIPTAZ = piperacillin/tazobactam
QUIDAL = quinupristin/dalfopristin
RIF = rifampin
STREPHL = streptomycin-high level test
TETRA = tetracycline
TICLAV = ticarcillin/clavulanic acid
TIG = tigecycline
TMZ = trimethoprim/sulfamethoxazole
TOBRA = tobramycin
VANC = vancomycin
VORI = voriconazole

Event Details (continued)
Instructions for Completion

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Instructions for the Dialysis Event Form

^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.
Where was the
positive blood culture
collected?
Pus, redness, or
increased swelling at
the vascular access
site

Optional. Indicate the patient’s location when the blood culture was drawn.
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. Pus is always reportable. Cellulitis at the
vascular access site is also reportable as a pus, redness, or increased swelling
event. Report redness or swelling if it is greater than expected and suspicious
for infection.
21 day rule: 21 or more days must pass 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, should not be reported.

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

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.
Note, the corresponding access should be selected under “Risk Factors.”

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Instructions for the Dialysis Event Form

Exception: if reporting pus, redness, or increased swelling of a central line
site occurred after the central line was removed, report that central line,
even if it was no longer in place at the time of the event.

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

Event Details (continued)
Instructions for Completion
Required. Indicate all problems present at the time of the event.
Select if a fever of ≥37.8°C (100°F) (tested orally) is present.
Select if chills or rigors are present.
Select if abnormal drop in blood pressure occurs.
Select if a wound that is unrelated to the vascular access site has pus or
increased redness.
Select if cellulitis is present at a site other than the vascular access and
without open wound.
Select if pneumonia or another respiratory tract infection is present.
Select if a urinary tract infection is present.
Select if another problem related to the dialysis event (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 related problems.
Required.

Select “Yes” if the patient had a complete loss of the vascular access
(i.e., the vascular access became unusable and/or had to be removed)
and this outcome was either definitely or possibly related to the
event(s) or problem(s).

Select “No” if this outcome did not occur, or if loss of vascular access
occurred, but it was definitely not related to the event(s) or
problem(s). Also select “No” if there was only a partial loss of the
vascular access (i.e., the access needs revision or intervention to gain
patency).

Check “Unknown” if uncertain about whether or not loss of the
vascular access occurred (e.g., patient was lost to follow-up).
Hospitalization

February 2014

Select “Yes” if the patient was admitted to a hospital and this outcome
was either definitely or possibly related to the event(s) or
problem(s).

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Instructions for the Dialysis Event Form

Select “No” if this outcome did not occur, or the patient was
hospitalized, but it was definitely not related to the event(s) or
problem(s). Also select “No” if the patient only visited the emergency
department without admission and/or was placed under hospital
observation without admission.

Select “Unknown” if uncertain about whether or not the patient was
hospitalized (e.g., patient was lost to follow-up).
Death

Select “Yes” if the patient died and this outcome was either definitely
or possibly related to the event(s) or problem(s). Select “Yes” if cause
of death is unknown.

Select “No” if this outcome did not occur, or if the patient did die, but
it was definitely not related to the event(s) or problem(s).

Select “Unknown” if uncertain about whether or not the patient died
(e.g., patient was lost to follow-up).
Custom Fields
Custom fields

Optional. Add up to 50 alphanumeric, numeric, and/or date fields 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 – 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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Instructions for the Denominators for Dialysis Event Surveillance Form

Instructions for the Denominators for Dialysis Event Surveillance 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 auto-populate in this field.
Required. Select the location code for the outpatient hemodialysis clinic
location from which you will collect data about dialysis events.
Required. Select the month during which the data were collected for this
location from the dropdown menu.
Required. Select the 4-digit year during which the data were collected for
this location from the dropdown menu.
Required. For each type of vascular access listed, enter the number of
outpatients who received in-center 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 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:
Lowest Risk
- Fistula
- Graft
- Other vascular access device (e.g., catheter-graft hybrid access)
- Tunneled Central Line
- Nontunneled Central Line
Highest 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”.
Number of these Fistula Conditionally required. Out of the fistula patients counted above, count the
Patients who undergo number of patients who are primarily cannulated with buttonhole
Buttonhole Cannulation cannulation technique, where a 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 auto-populate in this
field.
Number of these patients
Optional. Of the “Total patients” counted above, count the number of
for whom dialyzers are
patients whose dialyzers are reprocessed for reused. If dialyzers are not
reused.
reused, enter 0.
Custom fields
Optional. Add up to 50 alphanumeric, numeric, and/or date fields to this
form for local use.

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Instructions for the Denominators for Dialysis Event Surveillance Form

Data Field

Instructions for Data Collection
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 Surveillance form.”

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