Information
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Infection Prevention Audit for Dialysis Service
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Conducted on
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Prepared by
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Location
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Personnel in Attendance
General appearance of the dialysis machines
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The hemodialysis machine appears clean and free of dust, rust, tapes and tape residue
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The machine has it's own Preventive Maintenance Log readily available for review
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The cart for the PD machines appear clean, free of dust, rust, tapes and tape residue
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The PD machine appears clean and free of dust, rust, tapes and tape residue
Dialysis Supply Storage Room
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Tools to perform hand hygiene are available: Hand Hygiene Sink (Soap & Water) or Alcohol Based Hand Sanitizer
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No supplies within 3 feet from the sink in the absence of a splash guard
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All supply cabinets/lockers inside the room appear clean and free of dust, rust, tapes and tape residue
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The room is free of clutter
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Dust / dust bunnies not observed on high surfaces
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The floor is clean
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No food or drinks found in the storage room
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The shelves are free of dust, rust, tapes and tape residue
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All carts or shelves have solid liners on the bottom shelf
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All supply carts are clean and free of dust, rust, tapes and tape residue.
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All supply bins are clean and free of dust
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All supplies are 18 inches from the ceiling and 10 inches from the floor
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There are no expired supplies in the room
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All chemical containers are labeled when it was opened and stored safely per policy
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All chemicals are stored in designated storage place and not left unattended.
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All personal items are placed inside the staff lockers
PROCESS OBSERVATION 1.0 Hemodialysis Catheter Connection
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1.1 Mask worn?
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1.2 Hand hygiene performed?
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1.3 Clean gloves applied?
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1.4 Catheter hub scrubbed with antiseptic?
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1.5 Aseptically connected catheter to blood lines?
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1.6 Gloves removed and hand hygiene performed?
PROCESS OBSERVATION 2.0 Disconnection of Hemodialysis Catheter
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2.1 Mask worn?
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2.2 Hand hygiene performed?
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2.3 Clean gloves applied?
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2.4 Aseptically disconnected catheter from blood lines?
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2.5 Catheter hub scrubbed with antiseptic?
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2.6 Aseptically attached new caps?
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2.7 Gloves removed and hand hygiene performed?
PROCESS OBSERVATION 3.0 Changing of Hemodialysis Dressing
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3.1 Dressing change performed aseptically?
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3.2 Mask worn?
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3.3 Hand hygiene performed and new gloves donned?
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3.4 Skin antiseptic applied and allowed to dry?
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3.5 Site not touched after antiseptic applied?
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3.6 Antimicrobial ointment applied per policy?
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3.7 Dressing applied aseptically?
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3.8 Gloves removed and hand hygiene performed?
PROCESS OBSERVATION 4.0 Reverse Osmosis (RO) Water Room
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4.1 Chlorine checks are documented every four hours?
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4.2 Is wand off of floor for bicarbonate tank?
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4.3 There is a water alarm on the floor to alert staff of flooding?
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4.4 Each water system component is clearly labeled with name and function?
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4.5 Written policies and procedures for water treatment system operation are utilized and current?
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4.6 Logbooks include parameters for each components operation and the action taken when a component is not within set parameters?
PROCESS OBSERVATION 5.0 Maintenance of Dialysis Machine
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5.1 Exterior of dialysis machines are wiped down at the end of each use with bleach?
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5.2 Machines are vinegar rinsed and heat disinfected daily, and the outside of the machine is wiped down with bleach?
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5.3 Machines have a weekly internal bleach clean documented?
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5.4 Dialysis personnel culture dialysate from all machines on a monthly basis?
6.0 Bicarbonate Jugs
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6.1 Jugs are bleached weekly (soaked for 15 minutes, rinsed with RO water, and allowed to air dry)?
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6.2 Space for jug bleaching is adequate to allow dirty to clean flow?
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6.3 Wands for bicarbonate jugs are bleach cleaned weekly?
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6.4 Wands for bicarbonate are soaked in RO water daily?
7.0 Staff Competency
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7.2 Dialysis management annually verifies competency of staff to perform connection, disconnection, and aseptic dressing changes?
8.0 Water
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8.1 Water testing results are reported and reviewed at dialysis steering committee meetings and Infection Prevention Committee?
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8.2 All water testing results are recorded in log sheets, reviewed, and corrective action indicated as applicable per policy?
9.0 Safety
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9.1 Eye wash stations are located in rooms where chemicals are used (within ten seconds of point of use OR per organizational policy)?
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9.2 PPE worn while within the splash zone (within four feet of dialyzer)
Staff Knowledge
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Able to articulate the 2 methods of hand hygiene
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Able to articulate at least 3 isolation precautions and site examples of infections/organisms requiring such precautions
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Able to articulate where to find the infection prevention & control policies and procedures
Comments
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