Att G11_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 Observations
30
Hemodialysis Catheter Connection/Disconnection Observations
10
Hemodialysis Catheter Exit Site Care Observations
5
Arteriovenous Fistula and Graft Cannulation/Decannulation
10
Observations
Dialysis Station Routine Disinfection Observations
10
Injection Safety Medication Preparation Observations
10
Injection Safety Medication Administration Observations
20
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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:
𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃𝑃 𝐴𝐴𝐴𝐴ℎ𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒𝑒 =

February 2016

𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁 𝑜𝑜𝑜𝑜 𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆𝑆 𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂
𝑥𝑥 100
𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇𝑇 𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁 𝑜𝑜𝑜𝑜 𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂𝑂

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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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