# Presentation: 673528

## Patient Safety Component – Outpatient Dialysis Center Practices Survey

| Facility ID#:____________________________ | *Survey Year:_____________ |
| --- | --- |
| A. Facility Information |  |
| *1.	Ownership of your dialysis center (choose one): □ Government     □ Not for profit     □ For Profit         

*2.	Location/hospital affiliation of your dialysis center: 
              □ Freestanding        □ Freestanding but owned by a hospital       □ Hospital based

*3.	Types of dialysis services offered (check all that apply): 
              □ In-center hemodialysis
              □ Peritoneal dialysis
              □ Home hemodialysis

*4.	Number of in-center hemodialysis stations: _______ |  |
| *5.	Is your facility part of a group or chain of dialysis centers?     Yes       No
                         If Yes, name of group or chain: 
                  □ Da Vita            □ Dialysis Clinic Inc. (DCI)            □ Fresenius Medical Care
                         □ Other (specify): ___________________________________________

*6.	Primary person responsible for collecting data for this survey:
              □ Administrator
              □ Infection Control Practitioner
              □ Dialysis Nurse
              □ Dialysis Technician 
              □ Other (specify): ________________________________

*7	Is there someone at your unit in charge of infection control?      Yes     No
                           If Yes, which best describes this person? 
                            □ Hospital-affiliated or other infection control practitioner comes to our unit
                            □ Dialysis staff member
                       □ Other (specify): ________________________________

*8.	In general at your facility, are hemodialysis patients treated in discrete shifts (e.g., morning shift separate from afternoon shift) or are dialysis treatments initiated as soon as a machine is available? 
              □ Discrete shifts                    □ Overlapping or mixed shifts
 |  |

**Patient Safety Component – ****Outpatient Dialysis Center Practices Survey**

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**Assurance of Confidentiality:**  The information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).
- Public reporting burden of this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN:  PRA (0920-0666).
- CDC 57.104 (Front)  Rev. 1, v1.3.5

- OMB No. 0920-0666
- Exp. Date:  03-31-2011

- * required

## Patient Safety Component – Outpatient Dialysis Center Practices Survey

| A. Facility Information (continued) |
| --- |
| *9.         At a typical hemodialysis station, how much time separates the removal of one patient who has just completed treatment from the initiation of the next patient on the same machine? 
              ____ hours    ____ minutes

*10.	Please select the types of records available to staff or an administrator in your unit (check all that apply): 
 |
| Please respond to the following questions based on records from your facility for the first week of December (applies to most recent December relative to current date). |
| B. Patient and staff census |
| *11.	How many CHRONIC, NON-TRANSIENT dialysis PATIENTS were assigned to your center during the first week of December? _______
              Of these, please indicate the number who received: 
              a. in-center hemodialysis:         _______
              b. home hemodialysis:              _______
              c. peritoneal dialysis:                _______
*12.       How many full-time and part-time PATIENT CARE staff were employed in your facility during the first week of December? Include only staff who had direct contact with hemodialysis patients or equipment.: ______
              Specify the number of these clinical staff by category: 
              a. nurse/nurse assistant: _____                          e. dietician: _____
              b. dialysis patient-care technician: _____             f. physicians/physician assistant: _____
              c. dialysis biomedical technician: _____               g. nurse practitioner: _____
              d. social worker: _____ |
| C. Vaccines |
| *13.       Of the patients counted in question 11, how many received: 
               a. at least 3 does of hepatitis B vaccine (ever)?: _____
               b. the influenza (flu) vaccine for this flu season (October or later)?: _____
               c. the pneumococcal pneumonia vaccine (ever)? _____ |
| *14.       Does your facility use standing orders to allow nurses to administer vaccines to patients without a     specific physician order?
              □ Yes, for hepatitis B and other vaccines
              □ Yes, only for hepatitis B vaccine
              □ No, not for any vaccines |
| *15.        Of the patient care staff members counted in question 12, how many received: 
               a. at least 3 doses of hepatitis B vaccine (ever)?: _____
               b. the influenza (flu) vaccine for this flu season (October or later)?: _____ |
| CDC57.104(Back) Rev.1 |

**Patient Safety Component – ****O****utpatient Dialysis Center Practices Survey**

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|  | Paper copies | Electronic records | None |
| --- | --- | --- | --- |
| Microbiology lab culture & antimicrobial sensitivity results | □ | □ | □ |
| Hospitalization and patient discharge summary | □ | □ | □ |
| Hemodialysis machine assignment | □ | □ | □ |
| Patient immunizations | □ | □ | □ |
| Staff immunizations | □ | □ | □ |

- OMB No. 0920-0666
- Exp. Date:  03-31-2011

## Patient Safety Component – Outpatient Dialysis Center Practices Survey

- Page 3 of 4

| *16.  | Please indicate whether your facility offers the following immunizations:

influenza vaccine offered to patients
influenza vaccine offered to patient care staff
pneumococcal vaccine offered to patients
 |
| --- | --- |
| D. Hepatitis B and C |  |
| *17. | Of your CHRONIC, NON-TRANSIENT in-center hemodialysis PATIENTS from question 11: 
How many converted from hepatitis B surface ANTIGEN (HBsAg) negative to positive in the past 12 months (i.e., had newly acquired hepatitis B virus infection, not as a result of vaccination)? Do not include patients who were antigen positive before they were first dialyzed in your center: _____

How many were hepatitis B surface antigen (HBsAg) positive on arrival to your center? _____          |
| *18. | Of the patients counted in question 11a., were all or almost all tested for hepatitis B surface ANTIBODY (anti-HBs) in the past 12 months?       Yes       No
                If Yes, how many were positive? _____ |
| *19.  | Of the patients counted in question 11a., were all or almost all tested for hepatitis C antibody in the past 12 months? (Note: This is NOT hepatitis B core antibody)?        Yes         No
                If Yes, how many were positive for hepatitis C antibody? _____ |
| E. Dialysis Policies and Practices |  |
| *20.  | Does your facility reuse dialyzers for some or all patients?       Yes         No
                If Yes, 
                a. What method is used to disinfect the majority of these dialyzers?
                   □ Amuchina          □ Glutaraldehyde (e.g., Diacide®)    □ Peracetic acide (e.g., Renalin®) 
                   □ Formaldehyde    □ Heat                                             □ Other
                b. Is bleach also used to clean the inside of these dialyzers?       Yes        No
                c. Where are dialyzers reprocessed? 
                   □ Dialyzers are reprocessed at our facility
                   □ Dialyzers are transported to an off-site facility for reprocessing
                   □ Both at our facility and off-site
                d. Are dialyzers refrigerated before reprocessing?     Yes       No |
|  *21. | Where are medications from multidose vials most commonly drawn into syringes to prepare for patient administration? 
□ On a mobile medication cart within the treatment area or at the individual dialysis stations
□ In a separate medication room or in a medication area separate from the patient treatment area
□ At a fixed location within the dialysis unit, not separated by walls from the rest of the patient                          treatment area
□ Other (specify): _______________________________________________________ |
| 
CDC57.104(Back)  Rev.1 |  |

| Yes | No |
| --- | --- |
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- OMB No. 0920-0666
- Exp. Date:  03-31-2011

## Patient Safety Component – Outpatient Dialysis Center Practices Survey

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| *22. | Does your facility generally use erythopoietin from single-dose or multiple-dose vials? 
□ Multiple-dose              □ Single-dose 
                If single-dose, is erythropoietin from a single-dose vial administered to more than one patient?
                Yes       No |
| --- | --- |
| *23. | Please indicate whether your facility uses any of the following means of restricting or ensuring appropriate antibiotic use?

have a written policy on antibiotic use
formulary restrictions
antibiotic use approval process
automatic stop orders for antibiotics
other (specify): __________ |
| F. Vascular Access |  |
| *24. | Job classification of staff members primarily responsible for providing hemodialysis catheter care (access catheters or change dressing) (Check all that apply): 
□ Nurse         □ Technician           □ Other (specify): __________________________________ |
| *25. | Before prepping a graft or fistula for puncture, is the area commonly washed with soap and water? 
Yes       No |
| *26. | Before puncture of a graft or fistula, the area is most often prepped with: 
□ Alcohol        □ Chlorhexidine         □ Povidone-iodine       □ Other (specify): ____________ |
| *27.  | The most common connector-device on hemodialysis catheters used in your center are:
□ Blunt needle systems     □ Needleless luer-lock devices     □ Sharp needle systems |
| *28.  | Before access of hemodialysis catheters, the catheter port site (usually a rubber diaphragm) is prepped with (check the one most commonly used): 
□ Alcohol      □ Chlorhexidine     □  Nothing      □ Povidone-iodine      □ Other (specify): __________ |
|  *29. | When a hemodialysis catheter dressing is changed, the exit site (i.e., place where the catheter enters the skin) is cleaned with (check the one most commonly used): 
□ Alcohol      □ Chlorhexidine     □  Nothing      □ Povidone-iodine      □ Other (specify): __________ |
| *30. | For hemodialysis catheters, is antibacterial ointment routinely applied to exit site during dressing change? 
Yes       No
                  If Yes, what type of ointment? 
              □ Bacitracin/polymixin (polysporin) □ Povidone-iodine 
                 □ Mupirocin                                   □ Other (specify): ______________________ |
| *31. | For peritoneal dialysis catheters, is antibacterial ointment routinely applied to exit site during dressing change?      Yes       No       N/A
                  If Yes, what type of ointment? 
                  □ Bacitracin/polymixin (polysporin)     □ Gentamicin       □ Povidone-iodine 
                  □ Ciprofloxacin                                  □ Mupirocin          □ Other (specify):______ |
| *32. | Specify the most common type of dressing used over hemodialysis catheters:
□ Bandage (e.g., Band aid ®) □ None                                              □ Transparent      
□ Gauze                          □ Chlorhexidine patch (e.g., Biopatch®)       □ Other (specify): |
| CDC57.104(Back) Rev.1 |  |

| Yes | No |
| --- | --- |
| □ | □ |
| □ | □ |
| □ | □ |
| □ | □ |
| □ | □ |

- OMB No. 0920-0666
- Exp. Date:  03-31-2011