Form 57.507 Home Dialysis Center Practices Survey

Form Approved

Home Dialysis Center Practices Survey

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Complete this survey as described in the Dialysis Event Protocol.

Instructions: This survey is only for dialysis centers that do not provide in-center hemodialysis. If your center performs in-center hemodialysis, please complete the Outpatient Dialysis Center Practices Survey. Complete one survey per center. Surveys are completed for the current year. It is strongly recommended that the survey is completed in February of each year by someone who works in the center and is familiar with current practices within the center. Complete the survey based on the actual practices at the center, not necessarily the center policy, if there are differences. Contact the NHSN Helpdesk (nhsn@cdc.gov) with questions.

*required to save as complete
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Facility ID #: ____________________________				*Survey Year: ______________
*ESRD Network #: ______________
A. Dialysis Center Information
A.1. General
*1.	What is the ownership of your dialysis center? (choose one)
	 Government		 Not for profit	 For profit
*2.	What is the location/hospital affiliation of your dialysis center? (choose one)
	 Freestanding		 Hospital based	 Freestanding but owned by a hospital
*3.	a. What types of dialysis services does your center offer? (select all that apply)
	 Peritoneal dialysis		 Home hemodialysis
	b. What patient population does your center serve? (select one)
	 Adult only		 Pediatric only	 Mixed: adult and pediatric
*4.	Is your center part of a group or chain of dialysis centers?						 Yes	 No
	If yes, what is the name of the group or chain? ____________________________
*5.	Do you (the person primarily responsible for completing this survey) perform patient care in the dialysis center or in the homes of patients cared for by this center?						 Yes	 No
A.2. Surveillance
*6.	Which of the following infections in your peritoneal dialysis patients does your center routinely track? (select all that apply)
	 Peritonitis	 Peritoneal dialysis catheter site infection			 Other (specify)_______________
*7.	Which of the following infections in your home hemodialysis patients does your center routinely track? (select all that apply)
	 Bloodstream infection	 Vascular access site infection			 Other (specify)_______________
Assurance of Confidentiality: The voluntarily provided 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 30 minutes 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 57.507 (Front) Rev 1, V8.8

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Please respond to the following questions based on information from your center for the first week of February (applies to current or most recent February relative to current date).
B. Patient and staff census
*8.	Was your center operational during the first week of February?					 Yes	 No
*9.	How many dialysis PATIENTS were assigned to your center during the first week of February? ________
	Of these, indicate the number who received:
	Peritoneal dialysis:	_________
	Home hemodialysis:	_________
*10.	How many PATIENT CARE staff (full time, part time, or affiliated with) worked in your center during the first week of February? Include only staff who had direct contact with dialysis patients or equipment: _________
	Of these, how many were in each of the following categories?
	Nurse/nurse assistant:			_________
	Dialysis patient-care technician:			_________
	Dialysis biomedical technician:			_________
	Social worker:			_________
	Dietitian:			_________
	Physicians/physician assistant:			_________
	Nurse practitioner:			_________
	Other:			_________
C. Vaccines
*11.	Of the dialysis patients counted in question 9, how many received:
	At least 3 doses of hepatitis B vaccine (ever)? ________
	The influenza (flu) vaccine for the current/most recent flu season? ________
	At least one dose of pneumococcal vaccine (ever)? ________
*12.	Of the patient care staff members counted in question 10, how many received:
	At least 3 doses of hepatitis B vaccine (ever)? ________
	The influenza (flu) vaccine for the current/most recent flu season? ________
*13.	Which type of pneumococcal vaccine does your center offer to patients? (choose one)
	 Polysaccharide (i.e., PPSV23) only
	 Conjugate (e.g., PCV13) only
	 Both polysaccharide & conjugate
	 Neither offered
D. Screening
*14.	Does your center routinely screen patients for hepatitis B surface antigen (HBsAg) upon admission to your center?
	Peritoneal patients		 Yes		 No
	Home hemodialysis patients		 Yes		 No
*15.	Does your center routinely screen patients for latent tuberculosis infection (LTBI) upon admission to your center?
	Peritoneal patients		 Yes		 No
	Home hemodialysis patients		 Yes		 No

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E. Prevention Activities
*16.	Is your center actively participating in any of the following prevention initiatives (select all that apply):
	 CDC Making Dialysis Safer for Patients Coalition – facility-level participation
	 CDC Making Dialysis Safer for Patients Coalition – corporate- or other organization-level participation
	 The Standardizing Care to improve Outcomes in Pediatric Endstage Renal Disease (SCOPE) Collaborative Peritoneal Dialysis Catheter-related Infection Project
	 SCOPE Collaborative Hemodialysis Access-related Infection Project
	 None of the above
*17.	In the past year, has your center’s medical director participated in a leadership or educational activity as part of the American Society of Nephrology’s (ASN) Nephrologists Transforming Dialysis Safety (NTDS) Initiative?						 Yes			 No
F. Peritoneal Dialysis Catheters
*18.	For peritoneal dialysis catheters, is antimicrobial ointment routinely applied to the exit site during dressing change?					 Yes		 No
	If yes, what type of ointment is most commonly used? (select one)
	 Gentamicin		 Bacitracin/polymyxin B (e.g., Polysporin®)
	 Mupirocin		 Bacitracin/neomycin/polymyxin B (triple antibiotic)
	 Povidone-iodine		 Bacitracin/gramicidin/polymyxin B (Polysporin® Triple)
	 Other, specify: ___________________________
G. Vascular Access
G.1. General Vascular Access Information
*19.	Of the home hemodialysis patients from question 9b, how many received dialysis through each of the following access types during the first week of February?
	AV fistula: ________
	AV graft: ________
	Tunneled central line: ________
	Nontunneled central line: ________
	Other vascular access device (e.g., catheter-graft hybrid): ________
G.2. Arteriovenous (AV) Fistulas or Grafts
*20.	Before prepping the fistula or graft site for rope-ladder cannulation, what is the site most often cleansed with?
	 Soap and water	 Alcohol-based hand rub		 Antiseptic wipes	 Other, specify: ______				 Nothing
*21.	Before rope-ladder cannulation of a fistula or graft, what is the site most often prepped with? (select the one most commonly used)
	 Alcohol
	 Chlorhexidine without alcohol
	 Chlorhexidine with alcohol (e.g., Chloraprep®, ChlorascrubTM)
	 Povidone-iodine (or tincture of iodine)
	 Sodium hypochlorite solution (e.g., ExSept®, Alcavis) without alcohol
	 Sodium hypochlorite solution (e.g., ExSept®, Alcavis) followed by alcohol
	 Other, specify: _________________
	 Nothing
	What form of this skin antiseptic is used to prep fistula/graft sites?
	 Multiuse bottle (e.g., poured onto gauze)  Pre-packaged swabstick/spongestick
	 Pre-packaged pad  Other, specify: _________________
	 N/A

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G.2. Arteriovenous (AV) Fistulas or Grafts (continued)
*22.		How many of your fistula patients undergo buttonhole cannulation?
		 All	 Most	 Some	 None
*23.		Is antimicrobial ointment (e.g. mupirocin) routinely used at buttonhole cannulation sites to prevent infection?				 Yes		 No
G.3. Hemodialysis Catheters
*24.	Do any of your home hemodialysis patients receive hemodialysis through a central venous catheter?					 Yes		 No
*25.	Before accessing the hemodialysis catheter, what are the catheter hubs most commonly prepped with? (select the one most commonly used)
	 Alcohol
	 Chlorhexidine without alcohol
	 Chlorhexidine with alcohol (e.g., Chloraprep®, ChlorascrubTM)
	 Povidone-iodine (or tincture of iodine)
	 Sodium hypochlorite solution (e.g., ExSept®, Alcavis) without alcohol
	 Sodium hypochlorite solution (e.g., ExSept®, Alcavis) followed by alcohol
	 Other, specify: _________________
	 Nothing
	What form of this antiseptic/disinfectant is used to prep the catheter hubs?
	 Multiuse bottle (e.g., poured onto gauze)
	 Pre-packaged swabstick/spongestick
	 Pre-packaged pad
	 Other, specify: _________________
	 N/A
*26.	Are catheter hubs routinely scrubbed after the cap is removed and before accessing the catheter (or before accessing the catheter via a needleless connector device, if one is used)?						 Yes		 No
*27.	When the catheter dressing is changed, what is the exit site (i.e., place where the catheter enters the skin) most commonly prepped with? (select the one most commonly used)
	 Alcohol
	 Chlorhexidine without alcohol
	 Chlorhexidine with alcohol (e.g., Chloraprep®, ChlorascrubTM)
	 Povidone-iodine (or tincture of iodine)
	 Sodium hypochlorite solution (e.g., ExSept®, Alcavis) without alcohol
	 Sodium hypochlorite solution (e.g., ExSept®, Alcavis) followed by alcohol
	 Other, specify: _________________
	 Nothing
	What form of this antiseptic/disinfectant is used at the exit site?
	 Multiuse bottle (e.g., poured onto gauze)
	 Pre-packaged swabstick/spongestick
	 Pre-packaged pad
	 Other, specify: _________________
	 N/A

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G.3. Hemodialysis Catheters (continued)
*28.	For hemodialysis catheters, is antimicrobial ointment routinely applied to the exit site during dressing change?
	 Yes	No			 N/A – chlorohexidine-impregnated dressing is routinely used
	If yes, what type of ointment is most commonly used? (select one)
	 Bacitracin/gramicidin/polymyxin B (Polysporin® Triple)					 Gentamicin
	 Bacitracin/polymyxin B (e.g., Polysporin®)					 Mupirocin
	 Bacitracin/neomycin/polymyxin B (triple antibiotic)					 Povidone-iodine
	 Other, specify: _________________
*29.	Are antimicrobial lock solutions used to prevent hemodialysis catheter infections?
	 Yes, for all catheter patients			 Yes, for some catheter patients			 No
	If yes, which lock solution is most commonly used? (select one)
	 Sodium citrate		 Taurolidine
	 Gentamicin		 Ethanol
	 Vancomycin		 Multi-component lock solution or other, specify: _________________
*30.	Are needleless closed connector devices (e.g., Tego®, Q-Syte™) used on your patients’ hemodialysis catheters?							 Yes	No
*31.	Are any of the following routinely used for hemodialysis catheters in your center? (select all that apply)
	 Chlorhexidine dressing (e.g., Biopatch®, Tegaderm™ CHG)
	 Other antimicrobial dressing (e.g., silver-impregnated)
	Antiseptic-impregnated catheter cap/port protector:
	 3M™ Curos™ Disinfecting Port Protectors
	 ClearGuard® HD end caps
	 Antimicrobial-impregnated hemodialysis catheters
	 None of the above
Comments:
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