Form CDC 57.500 CDC 57.500 Outpatient Dialysis Center Practices Survey

Form Approved

Outpatient Dialysis Center

Practices Survey

OMB No. 0920-0666

Exp. Date:

www.cdc.gov/nhsn

Complete this survey as described in the Dialysis Event Protocol.

Instructions: This survey is only for dialysis centers that provide in-center hemodialysis. If your center offers only home dialysis, please complete the Home 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. Please submit your responses to the questions in this survey electronically by logging into your NHSN facility.

*required to save as complete
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.	a. What is the location/hospital affiliation of your dialysis center? (choose one)
	 Freestanding	 Hospital based		 Freestanding but owned by a hospital
*3.	b. If hospital-based or hospital-owned, is your center affiliated with a teaching hospital? Is your facility accredited by an organization other than CMS? If yes, specify (choose one- drop down)					 Yes  No  Yes  No
	 Joint Commission		 National Dialysis Accreditation Committee (NDAC)	 Other (specify)________
*4.	a. What types of dialysis services does your center offer? (select all that apply)
	 In-center daytime hemodialysis	 In-center nocturnal hemodialysis		 Peritoneal dialysis	 Home hemodialysis
	b. What patient population does your center serve? (select one)
	 Adult only	 Pediatric only		 Mixed: adult and pediatric
*5.	How many in-center hemodialysis stations does your center have? _______
*6.	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? ____________________________
*7.	Do you (the person primarily responsible for collecting data for this survey) perform patient care in the dialysis center?						 Yes	 No
*8.	Is there someone at your dialysis center in charge of infection control?						 Yes	 No
	If yes, which best describes this person? (if >1 person in charge, select all that apply)
	 Hospital-affiliated or other infection control practitioner comes to our unit
	 Dialysis nurse or nurse manager
	 Dialysis center administrator or director
	 Dialysis education specialist
	 Patient care technician
	 Other, specify: _________________
*9.	Does your center provide dialysis services with Long Term Care Facilities (e.g., staff-assisted dialysis in nursing homes, skilled nursing facilities; not long-term acute care hospitals)?						 Yes	 No
	If yes, how many facilities?______________________
*10.	Is there a dedicated vascular access nurse/coordinator (either full or part-time) at your center?						 Yes	 No
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 1.75 hours 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 57.500 (Front) Rev 7, V 8.6 Page 1 of 9

A.2. Isolation and Screening

*11.

Does your center have capacity to isolate patients with hepatitis B?

 Yes, use hepatitis B isolation room

 Yes, use hepatitis B isolation area

 No hepatitis B isolation

*12.

Are patients routinely isolated or cohorted for treatment within your center for any of the following conditions? (if yes, select all that apply)

 No, none

 Hepatitis C

 Active tuberculosis (TB disease)

 Vancomycin-resistant Enterococcus (VRE)

 Clostridioides difficile (C. diff.)

 Methicillin-resistant Staphylococcus aureus (MRSA)

 Other, specify: _________________

*13.

Are patients routinely assessed for conditions that might warrant additional infection control precautions, such as infected wounds with drainage, fecal incontinence or diarrhea? If yes, when does this assessment most often occur? (select one)  Before the patient enters the treatment area (e.g., at check-in or in the waiting room)  Once the patient is seated in the treatment station  Other (specify)________________  Other (specify)________

 Yes

 No

*14.

Does your center routinely screen patients for latent tuberculosis infection (LTBI) on admission to your center?

 Yes

 No

A.3. Patient Records and Surveillance

*15.

Does your center maintain records of the station where each patient received their hemodialysis treatment for every treatment session?

 Yes

 No

*16.

Does your center maintain records of the machine used for each patient’s hemodialysis treatment for every treatment session?

 Yes

 No

*17.

If a patient from your center was hospitalized, how often is your center able to determine if a bloodstream infection contributed to their hospital admission?

 Always

 Often

 Sometimes

 Rarely

 Never

 N/A – not pursued

*18.

How often is your center able to obtain a patient’s microbiology lab records from a hospitalization?

 Always

 Often

 Sometimes

 Rarely

 Never

 N/A – not pursued

*19.

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)_______________

*20.

Which of the following infections and adverse events in your home hemodialysis patients does your center routinely track? (select all that apply)

 Bloodstream infection  Vascular access site infection

 needle/access dislodgment  air embolism  catheter breakage or disconnection

 Other (specify)_______________

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

*21.

Was your center operational during the first week of February?

 Yes

 No

*22.

How many MAINTENANCE, NON-TRANSIENT dialysis PATIENTS were assigned to your center during the first week of February? ________

Of these, indicate the number who received:

In-center hemodialysis:

_________

Home hemodialysis:

_________

Peritoneal dialysis:

_________

*23.

How many acute kidney injury (AKI) patients received hemodialysis in your center during the first week of February? ________

*24.

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:

_________

Dietitian:

_________

Dialysis patient-care technician:

_________

Physicians/physician assistant:

_________

Dialysis biomedical technician:

_________

Nurse practitioner:

_________

Social worker:

_________

Other:

_________

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C. Vaccines
*25.	Of the dialysis patients counted in question 22, 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)? ________
*26.	Of the in-center hemodialysis patients counted in question 22a, 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)? ________
*27.	Of the patient care staff members counted in question 24, how many received:
	At least 3 doses of hepatitis B vaccine (ever)? ________
	The influenza (flu) vaccine for the current/most recent flu season? ________
*28.	Does your center use standing orders to allow nurses to administer any of the vaccines mentioned above to patients without a specific physician order?				 Yes	 No
*29.	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. Hepatitis B and C
D.1. Hepatitis B
*30.	Of the MAINTENANCE, NON-TRANSIENT in-center hemodialysis PATIENTS from question 22a:
	How many were hepatitis B surface ANTIGEN (HBsAg) positive in the first week of February? _______
	Of these patients who were hepatitis B surface ANTIGEN (HBsAg) positive in the first week of February, how many were positive when first admitted to your center? _______
	How many patients converted from hepatitis B surface ANTIGEN (HBsAg) negative to positive during the prior 12 months (i.e., in the past year, how many patients 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: _______
*31.	In the past year, has your center had ≥1 hemodialysis patient who reverse seroconverted (i.e., had evidence of resolved hepatitis B infection followed by reappearance of hepatitis B surface antigen)?				 Yes	 No
D.2. Hepatitis C
*32.	Does your center routinely screen hemodialysis patients for hepatitis C antibody (anti-HCV) on admission to your center? (Note: This is NOT hepatitis B core antibody)				 Yes	 No
*33.	Does your center routinely screen hemodialysis patients for hepatitis C antibody (anti-HCV) at any other time?				 Yes	 No
	If yes, how frequently?
	 Twice annually		 Annually	 Other, specify: _________________
*34.	Of the MAINTENANCE, NON-TRANSIENT in-center hemodialysis patients counted in question 22a,
	How many were hepatitis C antibody positive in the first week of February? _______
	Of these patients who were hepatitis C antibody positive in the first week of February, how many were positive when first admitted to your center? _______
	How many patients converted from hepatitis C antibody negative to positive during the prior 12 months (i.e., in the past year, how many patients had newly acquired hepatitis C infection)? Do not include patients who were anti-HCV positive before they were first dialyzed in your center: _______

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E. Dialysis Policies and Practices
E.1. Dialyzer Reuse
*35.	Does your center reuse dialyzers for any patients?								 Yes	 No
	If yes,
	Of the MAINTENANCE, NON-TRANSIENT in-center hemodialysis patients counted in 22a, how many of them participate in dialyzer reuse? _______
	Does your center routinely test reverse osmosis (R.O.) water from the reuse room for culture and endotoxin whenever a reuse patient has a pyrogenic reaction?								 Yes	 No
	Of all reused dialyzers at your center, how many undergo refrigeration prior to reprocessing?
	 All	 Most		 Some		 Few		 None
	Is there a limit to the number of times a dialyzer is used?
	 Yes (indicate number): _______
	 No limit as long as dialyzer meets certain criteria (e.g., passes pressure leak test, etc.)
	Of all reused dialyzers in your center, how many of them have sealed (non-removable) header caps?
	 All		 Most		 Some	 Few	 None
	Where are dialyzers reprocessed?
	 Dialyzers are reprocessed at our center only
	 Dialyzers are transported to an off-site facility for reprocessing only
	 Both at our center and off-site
	If any dialyzers are reprocessed at the facility,
	How is dialyzer header cleaning performed? (select all that apply)
	 Automated machine (e.g., RenaClear® System)
	 Spray device (e.g., ASSIST® header cleaner)
	 Insertion of twist-tie or other instrument to break up clots
	 Disassemble dialyzer to manually clean
	 Other, specify: _________________
	 No separate header cleaning step performed
	How are dialyzers reprocessed?
	 Automated reprocessing equipment
	 Manual reprocessing
E.2. Water/Dialysate
*36.	What type of dialysate is used for in-center hemodialysis patients at your center? (choose one)
	 Conventional
	 Ultrapure
*37.	Does your center routinely test the following whenever a patient has a pyrogenic reaction?
	Patient blood culture								 Yes	 No
	Dialysate from the patient’s dialysis machine								 Yes	 No
E.3. Priming Practices
*38.	Does your center use hemodialysis machine Waste Handling Option (WHO) ports?								 Yes	 No
*39.	Are any patients in your center “bled onto the machine” (i.e., where blood is allowed to reach or almost reach the prime waste receptacle or WHO port)?								 Yes	 No

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E.4. Injection Practices
*40.	What form of erythropoiesis stimulating agent (ESA) is most often used in your center?
	 Single-dose vial		 Multi-dose vial		 Pre-packaged syringe		 N/A
	Is ESA from one single-dose vial or syringe administered to more than one patient?							 Yes	 No
*41.	Where are medications most commonly drawn into syringes to prepare for patient administration? (choose one)
	At the individual dialysis stations
	On a mobile medication cart within the treatment area
	At a fixed location within the patient treatment area (e.g., at nurses’ station)
	At a fixed location removed from the patient treatment area (not a room)
	In a separate medication room
	In a pharmacy
	Other, specify: _____________________________________________________________________
*42.	Do technicians administer any IV medications or infusates (e.g., heparin, saline) in your center?							 Yes	 No
*43.	What form of saline flush is most commonly used?
	Manufacturer pre-filled saline syringes
	Flushes are drawn from single-use saline vials
	Flushes are drawn from multi-dose saline vials
	Flushes are drawn from the patient’s designated saline bag used for dialysis
	Flushes are drawn from the patient’s dialysis circuit
	Flushes are drawn from a common saline bag used for all patients
	Other (specify): _____________________________________________________________________
E.5. Antibiotic Use
*44.	Does your center use the following means to restrict or ensure appropriate antibiotic use?
	Have a written policy on antibiotic use							 Yes	 No
	Formulary restrictions							 Yes	 No
	Antibiotic use approval process							 Yes	 No
	Automatic stop orders for antibiotics							 Yes	 No
*45.	In your center, how often are antibiotics administered for a suspected bloodstream infection before blood cultures are drawn (or without performing blood cultures)?
	 Always	 Often		 Sometimes		 Rarely		 Never
E.6. Prevention Activities
*46.	Has your center participated in any national or regional infection prevention-related initiatives in the past year?							 Yes	 No
	If yes, what is the primary focus of the initiative(s)? (if >1 initiative, select all that apply)
	 Catheter reduction
	 Hand hygiene
	 Bloodstream infection prevention
	 Patient education/engagement for infection prevention
	 Increase vaccination rates
	 Decrease/improve use of antibiotics
	 Improve general infection control practices
	 Improve culture of safety
	 Other, specify: ____________________________________________________________________

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E.6. Prevention Activities (continued)
	If yes, 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
*47.	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
*48.	Does your center follow CDC-recommended Core Interventions to prevent bloodstream infections in hemodialysis patients?
	 Yes, all		 Yes, some	 No, none
*49.	Does your center perform hand hygiene audits of staff monthly (or more frequently)?						 Yes			 No
*50.	Does your center perform observations of staff vascular access care and catheter accessing practices quarterly (or more frequently)?						 Yes			 No
*51.	Does your center perform staff competency assessments for vascular access care and catheter accessing annually (or more frequently)?						 Yes			 No
E.7. Peritoneal Dialysis
*52.	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
	 Mupirocin
	 Povidone-iodine
	 Bacitracin/polymyxin B (e.g., Polysporin®)
	 Bacitracin/neomycin/polymyxin B (triple antibiotic)
	 Bacitracin/gramicidin/polymyxin B (Polysporin® Triple)
	 Other, specify: ___________________________
F. Vascular Access
F.1. General Vascular Access Information
*53.	Of the MAINTENANCE, NON-TRANSIENT hemodialysis patients from question 22 (22a + 22b), how many received hemodialysis 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): ________
F.2. Arteriovenous (AV) Fistulas or Grafts
*54.	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

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F.2. Arteriovenous (AV) Fistulas or Grafts (continued)
*55.	Before rope-ladder cannulation of a fistula or graft, what is the site most often prepped with? (select one)
	 Alcohol
	 Chlorhexidine without alcohol
	 Chlorhexidine with alcohol (e.g., Chloarprep™, PDI Prevantics®)
	 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
*56.	How many of the fistula patients in your center undergo buttonhole cannulation?
	 All	 Most	 Some	 None
	If any,
	Which fistula patients undergo buttonhole cannulation?
	In-center hemodialysis patients only
	Home hemodialysis patients only
	Both
	If any in-center hemodialysis patients undergo buttonhole cannulation,
	When buttonhole cannulation is performed for in-center hemodialysis patients:
	Who most often performs it?
	Nurse
	Patient (self-cannulation)
	Technician
	Other, specify: _________________
	Before cannulation, what is the buttonhole site most often prepped with? (select the one most commonly used)
	Alcohol
	Chlorhexidine without alcohol
	Chlorhexidine with alcohol (e.g., Chloarprep™, PDI Prevantics®)
	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
	Is antimicrobial ointment (e.g., mupirocin) routinely used at buttonhole cannulation sites to prevent infection?				 Yes	 No

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F.3. Hemodialysis Catheters
*57.	Before accessing the hemodialysis catheter, what are the catheter hubs most commonly prepped with? (select one)
	Alcohol
	Chlorhexidine without alcohol
	Chlorhexidine with alcohol (e.g., Chloarprep™, PDI Prevantics®)
	Povidone-iodine (or tincture of iodine)
	Sodium hypochlorite solution (e.g., Alcavis) without alcohol
	Sodium hypochlorite solution (e.g., 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
*58.	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
*59.	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 one)
	Alcohol
	Chlorhexidine without alcohol
	Chlorhexidine with alcohol (e.g., Chloarprep™, PDI Prevantics®)
	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
*60.	For hemodialysis catheters, is antimicrobial ointment routinely applied to the exit site during dressing change?
	 Yes		 No		 N/A – chlorhexidine-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: _________________
*61.	What is the job classification of staff members who most often perform hemodialysis catheter care (i.e., access catheters or perform exit site care) in your center? (select one)
	 Nurse	 Technician		 Other, specify: _________________

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F.3. Hemodialysis Catheters (continued)
*62.	Are antimicrobial lock solutions used to prevent hemodialysis catheter infections in your center?
	 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: _________________
*63.	Are needleless closed connector devices (e.g., Tego®, Q-Syte™) used on hemodialysis catheters in your center?						 Yes	 No
	If yes, for which patients:
	In-center hemodialysis patients only
	Home hemodialysis patients only
	 Both
*64.	Are any of the following routinely used for hemodialysis catheters in your center? (select all that apply)
	Chlorhexidine dressing (e.g., Biopatch®, Tegaderm™ CHG)						 Yes	 No
	Other antimicrobial dressing (e.g., silver-impregnated)						 Yes	 No
	Antiseptic-impregnated catheter cap/port protector:
	3M™ Curos™ Disinfecting Port Protectors						 Yes	 No
	ClearGuard® HD end caps						 Yes	 No
	Antimicrobial-impregnated hemodialysis catheters						 Yes	 No
*65.	a. Does your center provide catheter patients with supplies to allow for changing catheter dressings outside the dialysis center?
	 Yes, routinely	 Yes, only in certain circumstances			 No
	b. Does your center educate patients with catheters on how to shower with the catheter? (select the best response)  Yes, routinely for all or most patients with a catheter  Yes, only for select patients with a catheter  No, patients with catheters are instructed against showering  No, education and instructions are not provided on this topic  Other (specify)_____________________________________
	c. Does your center provide catheter patients with a protective catheter cover (e.g. Shower Shield®, Cath Dry™) to allow them to shower?
	 Yes, routinely	 Yes, only in certain circumstances			 No
Comments:
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