FINAL – June 02 16

HEMODIALYSIS INFECTION PREVENTION & CONTROL AUDIT

Facility: ____________________________ Name of Unit: __________________________________

ITEM COMPLIANCE COMMENTS

YES NO N/A

FIRST AUDIT SESSION DATE:___________________________ AUDITORS:_________________________________________

HEMODIALYSIS INFECTION PREVENTION & CONTROL AUDIT INSTRUCTIONS
1. The audit is to be conducted in collaboration between the site ICP and a dialysis CRN. It is understood this may not be
possible in all geographic locations.
2. The audit tool is divided into four sections, with the intent that one section will be completed each quarter.
3. Complete each question/assessment item.

GENERAL
The Infection Prevention and Control Manual (IP&C) is easily
accessible

There is 4 feet (1.22m) between beds or loungers, totaling 80

square feet (7.44 square m) per station

Adverse events related to IP&C are reported according to facility

policy

Staff do not eat, drink, smoke, handle contact lenses, or apply

cosmetics in patient care areas

There is a routine schedule for cleaning refrigerators and ice

machines according to manufacturers’ guidelines

Refrigerators are clean and clear of frost

There is a routine schedule for cleaning blanket warmers

according to manufacturers’ guidelines

EQUIPMENT
There are written policies and procedures/protocols for
cleaning and disinfecting surfaces and equipment in the unit

Single-use equipment is not reused

Staff wear PPE during cleaning/disinfecting procedures

Patient bed spaces, including all machine surfaces are cleaned &
disinfected between patients with facility approved disinfectant

Non-critical patient equipment is disinfected between patients

with facility-approved disinfectant. This includes

• Glucometers

• Pulse oximeters

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• Stethoscopes

• BP cuffs

• Commodes

• Thermometers

• Scales

• Sharps containers

Patient equipment having contact with vascular access must

undergo at least high-level disinfection, or is disposed after use

Equipment to be repaired/serviced is cleaned and sterilized/

disinfected prior to being serviced or leaving the facility

Service and maintenance is performed with gloves, masks and

eye/face protection when contamination is likely

PATIENT EDUCATION
There is evidence of an ongoing education program for patients
and families reviewing:

• Personal hygiene

• Hand hygiene

• Respiratory hygiene

• Foot care

• Care of fistula or Central Line

• Blood borne pathogens

• Antibiotic Resistant Organisms (ARO)

• Early indicators of infection

• Who to report to regarding complications

STAFF EDUCATION
All staff members receive orientation and education in:

• Hand Hygiene

• Personal Protective Equipment

• Routine Practices

• Accessing catheters and fistulas

• Water treatment and distribution systems

All staff receive re-education regarding IP&C practices

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according to outlined facility IP& C Guidelines

All staff receive education and training when new equipment or

processes are instituted

Staff education and training regarding IP&C practices (hand

hygiene, RP, etc.) are documented and tracked

All staff receive education and training in management of

blood/body fluid exposures (focus: workplace exposure)

All staff are educated regarding cleaning and disinfection of

blood and body fluid spills (focus: environment)

HAND HYGIENE
There are adequate hand hygiene sinks present: 1 sink/3
patients with no more than 6 m between any patient station and
the nearest sink

Hand hygiene sinks are dedicated to hand hygiene

Antimicrobial soap is available for hand hygiene

There is a dedicated hand hygiene sink in each procedure room

Alcohol based hand rub (ABHR) is readily available

ABHR is available at point-of-care

ABHR available for patients/visitors in public areas of the unit

PERSONAL PROTECTIVE EQUIPMENT (PPE)

PPE is readily available when needed (long- sleeved gowns,
gloves, masks, eye/face protection)

Clean PPE is located away from sinks and other splash areas

There is a supply of non-sterile gloves placed at each station

PPE applied, removed, & disposed of according to facility policy

Gloves are single use and are not reused

PPE is available and accessible in appropriate sizes

Staff do not leave procedure room wearing used PPE

Gloves are worn when splattering of blood or soiling of hands is

likely (e.g., during initiation and termination of dialysis,
centrifugation of blood, accessing fistula, contact with
contaminated items/equipment)

Gloves are used for one task only, and removed after contact
with a patient and/or equipment

Gown and facial protection are worn when splattering of blood

or soiling of clothing is likely (e.g., during dialysis initiation/
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termination, centrifugation of blood, accessing fistula)

PPE is not worn outside the treatment area

RESPIRATORY AND GASTROINTESTINAL

Patients are screened for Influenza-like Illness and GI
symptoms at each visit to the dialysis unit

Patients likely to contaminate the environment (e.g., diarrhea,

vomiting) are managed with Contact Precautions per facility
guidelines

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 ITEM COMPLIANCE COMMENTS
YES NO N/A

SECOND AUDIT SESSION DATE:________________________ AUDITORS:__________________________________________

HEMODIALYSIS INFECTION PREVENTION & CONTROL AUDIT INSTRUCTIONS
1. The audit is to be conducted in collaboration between the site ICP and a dialysis CRN. It is understood this may not be
possible in all geographic locations.
2. The audit tool is divided into four sections, with the intent that one section will be completed each quarter.
3. Complete each question/assessment item.

HEPATITIS
All patients are screened for Hepatitis B and Hepatitis C prior to
start of the 1st dialysis treatment

All patients’ Hepatitis screening results are recorded in:

• The patient’s hemodialysis patient record

• A designated logbook

HbsAg susceptible patients are vaccinated for HBV and reported

to WRHA Public Health/CDC

All susceptible chronic hemodialysis patients are routinely

tested for HBV every 6 months, including unvaccinated patients
and non-responders

Annual testing of HbsAg-positive patients is done to determine

the patient’s ongoing Hepatitis B virus status

HbsAg-positive patients:

• Undergo dialysis in a separate room and

• Use separate machines, equipment, instruments,

supplies and medications

Staff members caring for HbsAg-positive patients do not care

for susceptible patients during the same shift

Staff caring for Hbs-Ag positive patients gown and glove prior to
entering isolation area

Anti-HCV negative patients are tested monthly for ALTs

Anti-HCV negative patients are tested every 6 months for anti-

HCV

HCV positive patients are not segregated or isolated during

hemodialysis. Routine Practices are used

HBV susceptible patients who return from travel to countries

where HBV is highly endemic are tested for HBV on their return
at 0, 3 and 6 months post-return

Staff are aware of the Blood and Body Fluid Exposure Protocol

All staff are offered Hepatitis B vaccine

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AROs
All new patients to the hemodialysis program are screened for
MRSA

Patients known to be positive for MRSA or C. difficile are

managed on Contact Precautions

TB
Known positive/suspect TB patients are managed on Airborne
Precautions in an area separate from the main treatment area

Known positive/suspect TB patients wear a procedure or

surgical mask if Airborne Infection Isolation Room (AIIR) is not
available while receiving their treatment

Staff are aware of MRP Policy # 60.30.07 re: management of

isolation rooms

Mantoux testing is completed for all patients:

• On admission to program
• Annually
• Two-step testing used

IMMUNIZATION
Influenza vaccine is offered to all patients annually

Pneumococcal vaccine is offered to all patients

INFECTION SURVEILLANCE
There is an active surveillance program for infections

Surveillance performed for:

• Blood stream infections

• Vascular access related infections

RECORD-KEEPING
There is centralized record-keeping for:

Patient vaccination status

• Hepatitis B vaccination

• Influenza

• Pneumococcal

Results of serological testing:

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• HIV

• HBV

• HCV

• HBV AND HCV co-infection

Results of diagnostic tests:

• TB Mantoux Testing

• AFB

Results of monthly ALT testing

Episodes of bacteremia

Loss of vascular access caused by infection

Adverse events, e.g., blood leaks and spills, machine

malfunctions

Calculate the percentage of each access device based on the

total number of dialysis patients in the unit:

• Total number of dialysis patients

• Number of patients with temporary central venous

catheters

• Number of patients with permanent tunneled

central venous catheters

• Number of patients with AV fistula

• Number of patients with AV graft

Number of Patients Number Percent

HBV +

HCV +

HBV & HCV co-infection

HIV +

MRSA +

CPE +

AMR GNB +

Other
There is Dialysis patient health record-keeping for: Auditor is to randomly choose ___# of charts to review

Status of vascular assess including

• Insertion of access
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• Location of access

• Change of site and reason for change

• Change of access type and reason for change

The location of each treatment including:

• Dialysis station and machine number used for each

dialysis treatment

• Names of staff members who connect and disconnect

the patient to and from a machine

Yes No Compliance Score:

Total number of ‘YES’

Total number of ‘NO’

Total number of items (‘YES’ and ‘NO’, exclude ‘N/A’)

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 ITEM COMPLIANCE COMMENTS
YES NO N/A

THIRD AUDIT SESSION DATE:_________________________ AUDITORS:__________________________________________

HEMODIALYSIS INFECTION PREVENTION & CONTROL AUDIT INSTRUCTIONS
1. The audit is to be conducted in collaboration between the site ICP and a dialysis CRN. It is understood this may not be
possible in all geographic locations.
2. The audit tool is divided into four sections, with the intent that one section will be completed each quarter.
3. Complete each question/assessment item.

DIALYSIS MACHINES
All dialysis machines are numbered, and the machine number
recorded for every dialysis treatment

There is an appropriate written procedure for rinsing and

disinfection of dialysis machines including:
• Disinfection agent used
• Contact time
• Frequency

Routine bacteriologic assays and endotoxins of dialysis fluids

are performed monthly and records are kept

There is an appropriate written procedure to be followed in the

event microbiologic assays are outside the normal range for
dialysate (i.e. >2000 cfu/ml)

Venous pressure transducer protectors are changed between

patients and not reused

If a transducer protector becomes wet, it is replaced

immediately and inspected for the source of contamination

Waste from dialysis machines is not permitted to back-flow into

the machine, e.g., drain hose and drain are not in contact with
each other

In the event of a blood leak, the dialysis machine is subject to

cleaning and disinfection for internal and external pathways
before use on another patient

There is an on-going preventative maintenance program for

each machine

There is an appropriate written procedure for the disinfection

of the wands outlining:

• Disinfection

• Agent used

• Contact time

• Frequency

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There is a protocol in place for dealing with a breach of the

transducer protector

List products used as well as cleaning/disinfection schedule for:

• External hemodialysis machine

• Internal hemodialysis machine

• Environmental surfaces

WATER TREATMENT- RO WATER

There are appropriate written procedures regarding the
cleaning and disinfection of the water treatment and
distribution system

The main RO water system is disinfected monthly and records

are kept

The portable RO water systems are disinfected at least weekly

RO water

• Is tested for bacteria and endotoxins monthly

• Records are kept

There is an appropriate written procedure to be followed:

• In the event microbiologic assays are outside the

normal range for water (i.e. >200 cfu/ml)

• When the RO water system is disrupted

WATER TREATMENT
Post water treatment is monitored and recorded through:

• Bacterial counts

• Endotoxin testing

PROCEDURE ROOM
General appearance is clean and tidy

Soiled linen bag is present

Appropriate biohazard receptacles are present if required

Appropriate sharps containers are readily available and not

over-filled

There are policies and procedures for cleanup of room

following invasive procedures

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Staff does not leave procedure room wearing PPE

Supplies in procedure room are limited to what is needed

There is clear separation between sterile, clean, and dirty

equipment/ items

CLEAN SUPPLIES/MEDICATIONS
Clean supplies and medications are stored away from waste or
soiled equipment and supplies

There is no evidence of dust or dampness in the clean area

Clean supplies and medications are only delivered to a cleaned

bed space after the patient has vacated space

Clean supplies are stored above the floor

Storage of medical equipment/devices (including boxes or totes

that contain medical equipment/devices) at least:

• 25 cm/10 inches off the floor (10 cm/4 inches if

shipping pallets used)

• 45 cm/18 inches from the ceiling

• 5 cm/2 inches from walls

Sterile supplies or opened trays are kept away from possible

sources of contamination

Soiled items are not brought into the clean area

Chemicals are stored separately & apart from food/drug items

Single-use items are not re-used

There is a refrigerator reserved for medication only

There is a refrigerator reserved for staff food

Refrigerators containing pharmaceuticals have temperature

recorded and maintained between 2°C and 8°C

There are documented procedures for how to deal with items

when temperatures are outside of the prescribed range (lower
than 2°C or greater than 8°C)

Unused supplies and medications taken to one patient’s station

are discarded or reprocessed before use on another patient

Carts and trays/bins used to transfer start-up equipment to

dialysis stations are cleaned and disinfected on a routine basis
(e.g., weekly)

Carts and trays/bins are stored in a clean area

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Medications are prepared in a clean, designated medication

area separated from the patient bed space

Medications are delivered separately to each patient (e.g., not

from a common cart/caddy)

Intravenous medication vials labeled for single use are not

punctured more than once

Pooling of residual medication from two or more vials does not

occur

Multi-dose vials are single-patient use & labeled with patient

name

Flush solutions used for each patient treatment are placed on a

clean surface at the patient bedside

Central lines and solutions are handled in an aseptic manner

WASTE & SHARPS DISPOSAL

There is a documented procedure for dealing with blood spills

Blood spills are cleaned immediately with a facility- approved

intermediate-level disinfectant

Waste is removed according to facility policy schedule:

• Lines are disposed of as regular waste

• Lines with large amounts of blood/body fluids are

disposed of as biomedical waste in appropriate
biomedical waste containers

The size and number of waste receptacles is adequate

Waste receptacles are not over-filled

Waste receptacles are emptied when 2/3 full

Large waste receptacles are covered (this does not include

bedside waste receptacles)

Leakage of body fluids from waste bags does not occur

Used needles are not re-capped

Sharps are discarded into puncture-resistant leak-proof

containers

Sharps are discarded at point of use

Sharps containers are not over-filled

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LINEN
Soiled linen is contained in leak-proof bags that are not
overfilled (e.g., closed off when 2/3 full)

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 ITEM COMPLIANCE COMMENTS
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FOURTH AUDIT SESSION DATE:________________________ AUDITORS:_________________________________________

HEMODIALYSIS INFECTION PREVENTION & CONTROL AUDIT INSTRUCTIONS
1. The audit is to be conducted in collaboration between the site ICP and a dialysis CRN. It is understood this may not be
possible in all geographic locations.
2. The audit tool is divided into four sections, with the intent that one section will be completed each quarter.
3. Complete each question/assessment item.

HEMODIALYSIS ACCESS MANAGEMENT

List antiseptic product used to clean:

• Skin prior to needling

• Skin around central line

• The catheter

CVC INSERTION AND CARE

There are written procedures for the care of hemodialysis
catheters

Staff receive annual training in care of hemodialysis catheters

Uncuffed catheters remain in place no longer than 4-6 weeks

before being replaced by a cuffed catheter or a fistula/graft

Catheter insertion site is prepared with 2% Chlorhexidine

gluconate (CHG) with 70% alcohol, or 10% povidone iodine if
CHG allergy and allowed to dry at least 2 minutes, or sterile
saline if povidone iodine allergy

The catheter exit site is:

• Examined at each treatment for signs of infection

• Documented in patient’s chart

Gauze dressings are:

• Only used if the exit site is bleeding or oozing

• Changed at every treatment

Transparent dressings are used and changed weekly

When dressing is changed, skin is cleansed with 2%

Chlorhexidine gluconate (CHG) with 70% alcohol, 2% aqueous
CHG or 10% povidone iodine if CHG allergy, and allowed to dry
at least 2 minutes

Breaks in technique are:

• Documented

• Reported according to facility policy

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Following treatment, an approved antibiotic ointment is

applied to the exit site (e.g., PI) if appropriate for the catheter
type (e.g., not to be used with Palindrome™ catheters)

FISTULA MANAGEMENT
The fistula exit site:

• Is examined at each treatment for signs of infection

• Results are noted in hemodialysis health record

Patient is instructed to wash fistula arm prior to treatment with

antimicrobial soap (2% CHG antimicrobial soap)

Fistula port is swabbed with 2% Chlorhexidine gluconate (CHG)

with 70% alcohol or 2% aqueous CHG prior to accessing

Breaks in technique are documented and reported in

hemodialysis health record

BLOOD CULTURES
There is a policy for blood culture collection

Blood culture policy indicates collection of 2 sets: one from the

central vascular catheter site, and one from a peripheral site

When collecting blood cultures, skin and site prep is done in

accordance with facility laboratory policy.

Breaks in technique are documented and reported according to

facility policy

ANTIBIOTIC USE
Nasal decolonization for Staphylococcus aureus or MRSA
carriage is not routinely done

Antimicrobial stewardship is practiced within the unit (e.g.,

vancomycin usage is minimal and monitored)

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