Att G10_Dialysis Prevention Process Measures

Dialysis Prevention Process Measures Module

Dialysis Prevention Process Measures (PPM) Protocol
Infections are the second most common cause of death in end-stage renal disease patients,
and they account for nearly 14% of deaths.1 NHSN prevention process measure
surveillance tracks staff adherence to CDC’s recommended practices that are shown to
prevent infections in dialysis settings.2
Audit adherence to recommended practices to:
 Ensure complete and correct implementation.
 Promote and reinforce recommended practices among staff.
 Track practice adherence over time
 Help inform where quality improvements should be directed
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. Facilities can participate in any combination of the
six PPM options. When a PPM surveillance option is selected on the Dialysis Monthly
Reporting Plan, users must complete a minimum number of observations that month.
Report data to NHSN within 30 days of the end of the month in which they were collected
(e.g., data from September 2015 should be reported no later than October 30, 2015).

Data Collection Instructions:
For each PPM followed in-plan, use the corresponding audit tool to collect the minimum
number of observations each month:
Observations
Audit Tool
per Month
Hand Hygiene Audit Tool
30
Hemodialysis Catheter Connection/Disconnection Audit Tool
10
Hemodialysis Catheter Exit Site Care Audit Tool
5
Arteriovenous Fistula and Graft Cannulation/Decannulation Audit Tool
10
Dialysis Station Routine Disinfection Audit Tool (coming soon)
10
Injection Safety Audit Tool (coming soon)
5

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Dialysis Prevention Process Measures Module

Please see the CDC’s Dialysis Safety website: http://www.cdc.gov/dialysis/preventiontools/index.html for additional resources and updates.
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 staff members at
particularly busy times, when staff may be less attentive to proper practices.

NHSN Reporting Instructions
Complete Dialysis Monthly Reporting Plans
The Monthly Reporting Plan (CDC 57.501) is used by NHSN facilities to inform CDC that
they are committed to following the NHSN surveillance protocol, in its entirety, for each
monitoring selection 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 PPM checkbox(es) selected for the ‘outpatient hemodialysis clinic’
location for each month of participation.
Report Summary Data Monthly
Results of each audit tool are summarized into two numbers:
1. The number of successful observations (instances where adherence to each audit
tool step was observed).
2. The total number of observations performed.
Report these summary numbers to NHSN using the Prevention Process Measures form
(NHSN 57.504). In NHSN, this form is accessed via “Summary Data,” then “Add,” and then
“Prevention Process Measures.”
NHSN Data Analysis
Feedback to staff on the adherence to recommended practices is crucial to improvement.
Facilities should consider regularly posting and/or reporting aggregate data to staff. In
addition, feedback (positive or negative) to individuals can be useful.
Percent adherence is calculated by dividing the number of successful observations by the
total number of observations and multiplying the result by 100:
𝑃𝑒𝑟𝑐𝑒𝑛𝑡 𝐴𝑑ℎ𝑒𝑟𝑒𝑛𝑐𝑒 =

March 2015

𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑆𝑢𝑐𝑐𝑒𝑠𝑠𝑓𝑢𝑙 𝑂𝑏𝑠𝑒𝑟𝑣𝑎𝑡𝑖𝑜𝑛𝑠
𝑥 100
𝑇𝑜𝑡𝑎𝑙 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑂𝑏𝑠𝑒𝑟𝑣𝑎𝑡𝑖𝑜𝑛𝑠

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Dialysis Prevention Process Measures Module

Effective April 2015, NHSN analysis includes output options (reports) that calculate
percent adherence for each measure.
Additional Resources:
CDC’s Dialysis Safety website
Hand Hygiene:
 Hand Hygiene and Glove Use Observation Protocol
 World Health Organization’s My 5 Moments for Hand Hygiene
Dialysis Station Disinfection
 Environmental Surface Disinfection in Dialysis Facilities: Notes for Clinical Managers
Injection Safety
 Protect Patients Against Preventable Harm from Improper Use of Single–Dose/Single–
Use Vials
 Injection Safety Checklist
References
1. NIH: United States Renal Data System, 2014 Annual Data Report: Epidemiology of
Kidney Disease in the United State. National Institute of Diabetes and Digestive and
Kidney Diseases, Bethesda, MD, 2014.
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

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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 auto-populate in this field.
*Location code
Required. Select the location code from the dropdown menu for the
outpatient hemodialysis clinic location at which data were collected.
*Month
Required. Select the month during which the data were collected for this
location.
*Year
Required. Select the 4-digit year during which the data were collected
for this location.
*Total # of Successful Required. Enter the total number of observations made throughout the
Hand Hygiene month when staff hand hygiene was indicated and was successfully
Opportunities performed.
*Total # of Hand Hygiene Required. Enter the total number of hand hygiene observations made
Opportunities throughout the month when staff hand hygiene was indicated.
Note: When reporting in-plan, a minimum of 30 observations is required
each month. Individual observations can be collected using a hand
hygiene audit tool such as the CDC Hemodialysis Hand Hygiene
Observations Audit Tool.
Required. Enter the total number of catheter connection and/or catheter
disconnection observations made throughout the month during which all
CDC-recommended infection prevention best practices for this procedure
were successfully performed.

*Total # of Successful
Hemodialysis Catheter
Connection/
Disconnection
Observations
*Total # of Hemodialysis Required. Enter the total number of catheter connection and/or catheter
Catheter Connection/ disconnection observations made throughout the month.
Disconnection
Observations Note: When reporting in-plan, a minimum of 10 observations is required
each month. Individual observations can be collected using an audit tool
such as the CDC Hemodialysis Catheter Connection & Disconnection
Observations Audit Tool.
*Total # of Successful Required. Enter the total number of hemodialysis catheter exit site care
Hemodialysis Catheter observations made throughout the month during which all CDCExit Site Care recommended infection prevention best practices for this procedure were
Observations successfully performed.
*Total # of Hemodialysis Required. Enter the total number of hemodialysis catheter exit site care
Catheter Exit Site Care observations made throughout the month.
Observations

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NHSN Dialysis Manual
Instructions for the Prevention Process Measures Form

Data Field

*Total # of Successful
Arteriovenous Fistula and
Graft Cannulation/
Decannulation
Observations
*Total # of Arteriovenous
Fistula and Graft
Cannulation/
Decannulation
Observations

*Total # of Successful
Dialysis Station Routine
Disinfection Observations
*Total # of Dialysis
Station Routine
Disinfection Observations

*Total # of Successful
Injection Safety
(Medication Preparation)
Observations
*Total # of Injection
Safety (Medication
Preparation) Observations

Instructions for Data Collection
Note: When reporting in-plan, a minimum of 5 observations is required
each month. Individual observations can be collected using an audit tool
such as the CDC Hemodialysis Catheter Exit Site Care Observations
Audit Tool.
Required. Enter the total number of arteriovenous fistula and graft
cannulation and/or decannulation observations made throughout the
month during which all CDC-recommended infection prevention best
practices for this procedure were successfully performed.
Required. Enter the total number of arteriovenous fistula and graft
cannulation and/or decannulation observations made throughout the
month.
Note: When reporting 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. Enter the total number of dialysis station routine disinfection
observations made throughout the month during which all CDCrecommended infection prevention best practices for this procedure were
successfully performed.
Required. Enter the total number of dialysis station routine disinfection
observations made throughout the month.
Note: When reporting in-plan, a minimum of 10 observations is required
each month. Individual observations can be collected using an audit tool
that includes all elements of the CDC Dialysis Station Routine
Disinfection Checklist.
Required. Enter the total number of medication preparation injection
safety observations made throughout the month during which all CDCrecommended infection prevention best practices for this procedure were
successfully performed.
Required. Enter the total number of medication preparation injection
safety observations made throughout the month.

Note: When reporting in-plan, a minimum of 5 observations is required
each month. Individual observations can be collected using an injection
safety audit tool that includes all elements of the CDC Outpatient
Injection Safety Checklist.
*Total # of Successful Required. Enter the total number of medication administration injection
Injection Safety safety observations made throughout the month during which all CDC(Medication recommended infection prevention best practices for this procedure were
successfully performed.
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NHSN Dialysis Manual
Instructions for the Prevention Process Measures Form

Data Field
Instructions for Data Collection
Administration)
Observations
*Total # of Injection Required. Enter the total number of medication administration injection
Safety (Medication safety observations made throughout the month.
Administration)
Observations Note: When reporting in-plan, a minimum of 5 observations is required
each month. Individual observations can be collected using an injection
safety audit tool that includes all elements of the CDC Outpatient
Injection Safety Checklist.
Custom fields
Optional. Add up to 50 alphanumeric, numeric, and/or date fields to this
form for local use.

Comments

March 2015

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 the form is “PPM – Prevention Process Measures.”
Optional. Use this field to add any additional information about the
Prevention Process Measures that would help you to interpret your
surveillance data. CDC typically does not analyze these data.