AHS - Dialysis - Inpatient

• Conducted on

  Date

• Prepared by

• Location
  Address

• Date of observations

  Date

• Dialysis Nurse:

• Dialysis Tech:

• Nephrologist

• Location of treatment:

  Critical Care Unit

  Dialysis Room

  Other

Documentation

• Patient Number (MRN or Encounter):

• There is consent to place a vascular access device.

  Yes

  No

  N/A

• There is a consent for hemodialysis (according to organization policy).

  Yes

  No

  N/A

• Hepatitis profile performed prior to dialysis or at time of first treatment.

  Yes

  No

  N/A

• Pre-dialysis weight is documented.

  Yes

  No

  N/A

• The order for dialysis includes all of the following:

  Select Access (AVF, Catheter, etc.) Lenth of Treatment Blood flow rate Dialysate flow rate Dialyzer to be used Dialysate bath (k+, Ca++) Ultrafiltration Medications (heparin, other) Blood (if indicated)

  • Access (AVF, Catheter, etc.)
  • Lenth of Treatment
  • Blood flow rate
  • Dialysate flow rate
  • Dialyzer to be used
  • Dialysate bath (k+, Ca++)
  • Ultrafiltration
  • Medications (heparin, other)
  • Blood (if indicated)

• There is a consent for blood (if ordered).

  Yes

  No

  N/A

• Protocols are documented on the record (i.e. if a hypotension protocol is ordered PRN, a copy of it is on the record or described in the order).

  Yes

  No

  N/A

• Completed dialysis flow sheet.

  Yes

  No

  N/A

• Yes

  No

  N/A

• Care plans address dialysis.

  Yes

  No

  N/A

• All entries are timed, dated and authenticated.

  Yes

  No

  N/A

• Handoff communications are documented (if required by policy).

  Yes

  No

  N/A

• There is patient education documented regarding dialysis.

  Yes

  No

  N/A

• Comments:

Blood Administration Safety

• The blood or blood product is matched to the order.

  Yes

  No

  N/A

• The blood or blood product is matched to the patient.

  Yes

  No

  N/A

• There is a 2 person verification process (or one person if accompanied by automated identification technology such as bar coding).

  Yes

  No

  N/A

• One individual conducting the ID verification in the 2 person verification process is the qualified person administering the blood.

  Yes

  No

  N/A

• The second person in the verification process is qualified to participate in the process as determined by the hospital.

  Yes

  No

  N/A

• The blood tag is completed and returned to the blood bank at the conclusion of the transfusion.

  Yes

  No

  N/A

• Vital signs during transfusion are monitored according to hospital policy.

  Yes

  No

  N/A

• There is a policy addressing reactions to blood and blood products.

  Yes

  No

  N/A

• Comments:

Arteriovenous fistula/graft (dis)cannulation

• Mask worn properly.

  Yes

  No

  N/A

• Hand hygiene performed (staff).

  Yes

  No

  N/A

• Don new clean gloves.

  Yes

  No

  N/A

• Apply skin antiseptic and allow it to dry. (No contact with site after antiseptic)

  Yes

  No

  N/A

• Insert needles aseptically (mask/PPE).

  Yes

  No

  N/A

• Connect blood lines aseptically.

  Yes

  No

  N/A

• Remove gloves and perform hand hygiene.

  Yes

  No

  N/A

• To discannulate:<br>Mask worn properly.

  Yes

  No

  N/A

• Perform hand hygiene and don clean gloves.

  Yes

  No

  N/A

• Disconnect from blood lines aseptically and activate needle retraction device.

  Yes

  No

  N/A

• Clean gloves worn to compress site.

  Yes

  No

  N/A

• Clean bandage applied.

  Yes

  No

  N/A

• Gloves removed and hand hygiene performed.

  Yes

  No

  N/A

Catheter connection and disconnection

• Mask / PPE appropriately donned.

  Yes

  No

  N/A

• Hand hygiene performed.

  Yes

  No

  N/A

• New clean gloves donned,

  Yes

  No

  N/A

• Catheter hub scrubbed with antiseptic.

  Yes

  No

  N/A

• Hub allowed to dry.

  Yes

  No

  N/A

• Blood tubes connected aseptically.

  Yes

  No

  N/A

• Disconnection:<br>- Hand hygiene performed and clean gloves donned<br>- aseptically disconnect blood tubings from catheter<br>- new caps placed on catheter aseptically<br>- gloves removed<br>- hand hygiene performed.

  Yes

  No

  N/A

Environmental Considerations

• Quality controls performed (water - RO/DI)

  Yes

  No

  N/A

• Machines are cultured.

  Yes

  No

  N/A

• Appropriate cleaning process between patients (machines and environment)

  Yes

  No

  N/A

• Patient privacy observed.

  Yes

  No

  N/A

• Dialysis machines listed in hospital biomedical equipment inventory (even if owned by contractor).

  Yes

  No

  N/A

• Dialysis machines risk rated as critical in inventory (failure in use is potentially life threatening)

  Yes

  No

  N/A

• Dialysis machines PM'd on schedule

  Yes

  No

  N/A

• Dialysis machine repair records shared with hospital.

  Yes

  No

  N/A

• Appropriate storage used in the assigned dialysis area.

  Yes

  No

  N/A

• Comments:

Oversight & PI

• Dialysis contractor reports quality controls to infection preventionist.

  Yes

  No

  N/A

• Outcome metrics reported to the hospital.

  Yes

  No

  N/A