Form 57.507 Home Dialysis Center Practices Survey

Form Approved

OMB No. 0920-0666

Exp. Date: 12/31/2026

www.cdc.gov/nhsn

January 2025

Home Dialysis Center Practice Survey

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. Please submit your responses to the questions in this survey electronically by logging into your NHSN facility.

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*Facility ID #:		*Survey Year:
*ESRD Network #:
Dialysis Center Information
*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.	Is your facility accredited by an organization other than CMS?  Yes  No If yes, specify (choose one)  National Dialysis Accreditation Commission (NDAC)  Accreditation Commission for Health Care (ACHC)  Other (specify) _______________
*4.	a. What types of dialysis services does your center offer? (select all that apply):  Home Peritoneal Dialysis  Home Hemodialysis b. What patient population does your center serve? (select one)  Adult only  Pediatric only  Mixed: adult and pediatric
*5.	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? ____________________________
*6.	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
*7	Within the last 3 years, has your facility/organization been surveyed by CMS or a CMS approved accrediting organization (i.e., state survey agency, Accreditation Commission for Health Care [ACHC], National Dialysis Accreditation Commission [NDAC])?  Yes  No
*8. 8a.	Does your center provide dialysis services within long-term care facilities (e.g., staff-assisted dialysis in nursing homes or skilled nursing facilities; not long-term acute care hospitals)?  Yes  No If yes, what types of dialysis services are provided within long-term care facilities? (check all that apply):  Hemodialysis in LTC  Peritoneal Dialysis in LTC
Surveillance
*9.	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
*10.	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
Patient Census
*11.	Was your center operational during the first week of February (2/1 through 2/7)?  Yes  No
*12.	How many ADULT MAINTENANCE, NON-TRANSIENT ESRD and AKI PATIENTS were assigned to your center during the first week of February (2/1 through 2/7)? ________ Of these, indicate the number who received: a. Home Hemodialysis: ________ b. Peritoneal Dialysis: _________
13 (new)	If MIXED Population or PEDIATRIC Population was selected in question 4, how many Maintenance, Non-Transient ESRD and AKI PEDIATRIC PATIENTS were assigned to your center the first week of February (2/1 through 2/7) _________ Home Hemodialysis __________ Peritoneal Dialysis: ___________
14.	Based on the number of patients that treated in the first week of February (2/1 through 2/7), please indicate the number of patients per Race: American Indian/Alaska Native: __________ Black or African American: ____________ Asian: _____________ Native Hawaiian/Other Pacific Islander: ____________ White: _____________ More than one Race: _________________ Unknown: ______________ Declined to response: ___________
15.	Based on the number of patients that were treated in the first week of February (2/1 through 2/7), please indicate the number of patients per Ethnicity: Hispanic or Latino: ________ Not Hispanic or Latino: _________ Unknown: ________ Declined to respond: _______
Staff Census
*16.	How many patient care STAFF (full time, part time, or affiliated with) worked in your center during the first week of February (2/1 through 2/7)? Include only staff who had direct contact with dialysis patients or equipment: _________ Of these, how many were in each of the following categories? a. Nurse/nurse assistant: __________ e. Dietitian: _________ b. Dialysis patient-care technician: __________ f. Physicians/physician assistant: _________ c. Dialysis biomedical technician: __________ g. Nurse practitioner: _________ d. Social worker: __________ h. Other: _________
*17.	Of the patient care staff members counted in question 15, how many received: a. A completed series of hepatitis B vaccine (ever)? ________ b. The influenza (flu) vaccine for the current/most recent flu season? ________
Please respond to the following questions based on your peritoneal dialysis patients in the first week of February (2/1 through 2/7).. This applies to current or most recent February relative to current date.
Peritoneal Dialysis (PD) Patients
*18.	Number of maintenance, non-transient ESRD and AKI Peritoneal Dialysis patients that were assigned to your center during the first week of February (2/1 through 2/7): _____
*19.	Of the Peritoneal Dialysis patients counted in question 18, how many received: a. A complete series of hepatitis B vaccine (ever) ________________ b. The influenza (flu) vaccine for the current/most recent flu season ______________ c. At least one dose of pneumococcal vaccine (ever) _________________ d. The annual COVID-19 vaccine __________
*20.	Which of the following infections in your Peritoneal Dialysis patients does your center routinely track? (select all that apply)  Peritonitis  Exit site infection  Tunnel infection  Other (specify)_______________
*21.	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: _______________
Please respond to the following questions based on your home dialysis patients in the first week of February (2/1 through 2/7).. This applies to current or most recent February relative to current date.
*22.	Number of maintenance, non-transient ESRD and AKI Home Hemodialysis patients that were assigned to your center during the first week of February (2/1 through 2/7): _____
*23.	Of the Home Hemodialysis patients in question 22, how many received dialysis through each of the following access types during the first week of February? a. AV fistula: _____________ b. AV graft: _____________ c. Tunneled central line: _____________ d. Non-tunneled central line: _____________ e. Other vascular access device (e.g., HeRO®): _____________
*24.	Does your dialysis facility utilize buttonhole cannulation techniques for Home Hemodialysis patients?  Yes  No a. Of the AV fistula patients from question #23a, how many had buttonhole cannulation? ________ b. When buttonhole cannulation is performed for home hemodialysis patients: i. Who most often performs it?  Nurse  Patient (self-cannulation)  Technician  Other, specify: ________________ ii. Before buttonhole 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., Chloraprep™, 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 iii. Is antimicrobial ointment (e.g., mupirocin) routinely used at buttonhole cannulation sites to prevent infection?  Yes  No
*25.	Of the Home Hemodialysis patients counted in question #22, how many received: a. A complete series of hepatitis B vaccine (ever) __________ b. The influenza (flu) vaccine for the current/most recent flu season ______________ c. At least one dose of pneumococcal vaccine (ever) ______________ d. The annual COVID-19 vaccine _________
*26.	Which of the following events in your Home Hemodialysis patients does your center routinely track? (select all that apply)  Bloodstream infection  Needle/access dislodgement  Vascular access site  Air embolism infection  Catheter breakage or bloodline separation  Other (specify): ____________
Patient Vaccine and Screening
*27.	Which type of pneumococcal vaccine does your center offer to patients? (choose one)  New Conjugate (PCV20) only  New Conjugate (PCV15) and Polysaccharide (PPSV23)  Both New Conjugate (Either PCV20 or PCV15) and Polysaccharide (PPSV23)  Other (please specify)  Neither offered
*28.	Does your center routinely screen patients for hepatitis B surface antigen (HBsAg) upon initiation of care? a. Peritoneal Dialysis patients:  Yes  No b. Home Hemodialysis patients:  Yes  No
*29.	Does your center routinely screen patients for hepatitis C antibody (anti-HCV) upon initiation of care? a. Peritoneal Dialysis patients:  Yes  No b. Home Hemodialysis patients:  Yes  No
*30.	Does your center routinely screen patients for latent tuberculosis infection (LTBI) upon initiation of care? a. Peritoneal Dialysis patients:  Yes  No b. Home Hemodialysis patients:  Yes  No
*31.	If your center does routinely screen patients for latent tuberculosis infections (LTBI), what method is used? (select all that apply): a. Peritoneal Dialysis patients  Tuberculin Skin Test (TST)  Blood Test  Other (specify) b. Home Hemodialysis patients  Tuberculin Skin Test (TST)  Blood Test  Other (specify)
Prevention Activities
*32.	Has your center participated in any national or regional infection prevention-related initiatives in the past year?  Yes  No a. 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: _________________________________________________ b. 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 End Stage Renal Disease (SCOPE) Collaborative Peritoneal Dialysis Catheter-related Infection Project  SCOPE Collaborative Hemodialysis Access-related Infection Project  None of the above  Other, specify
*33.	a. What education do you provide to patients in your center when they start dialysis? (check all that apply):  Vascular access care  Hand hygiene  Risks related to catheter use  Recognizing signs of infection  Instructions for access management when away from the dialysis unit  Different dialysis modalities (i.e., home dialysis or peritoneal dialysis)  Other, specify: ______________________________  None b. What education do you provide to your patients regularly (at least annually) (check all that apply):  Vascular access care  Hand hygiene  Risks related to catheter use  Recognizing signs of infection  Instructions for access management when away from the dialysis unit  Different dialysis modalities (i.e., home dialysis or peritoneal dialysis)  Other, specify: __________________  None
*34.	Does your center provide training for staff on infection prevention and control at least once annually?  Yes  No
*35.	Does your center perform staff knowledge assessments for infection prevention and control (select all that apply)  At least annually  One or more times each year  At least once a year  When new equipment or procedures are introduced
Arteriovenous (AV) Fistulas or Grafts
*36.	Before prepping the fistula or graft site for cannulation, what is the access site most often cleansed with (either by patients or staff upon entry to the clinic)?  Soap and water  Alcohol-based hand rub  Antiseptic wipes  Other, specify: ____________  Nothing
*37.	Before cannulation of a fistula or graft, what is the skin most often prepped with? (select one)  Alcohol  Chlorhexidine without alcohol  Chlorhexidine with alcohol (e.g., Chloraprep™, 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
Hemodialysis Catheters
*38.	Are patients who receive hemodialysis through a central venous catheter permitted in your Home Hemodialysis program?  Yes  No
*39.	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®, 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
*40.	Are hemodialysis 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)?
*41.	When the hemodialysis 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®, 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
*42.	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)  Gentamicin  Mupirocin  Bacitracin/gramicidin/polymyxin B (Polysporin® Triple)  Bacitracin/polymyxin B (e.g., Polysporin®)  Bacitracin/neomycin/polymyxin B (triple antibiotic)  Povidone-iodine  Other, specify: ____________
*43.	Are antimicrobial lock solutions used to prevent hemodialysis catheter infections?  Yes, for all catheter patients  Yes, for some catheter patients  No a. If yes, which lock solution is most commonly used? (select one)  Sodium citrate  Taurolidine  Gentamicin  Ethanol  Vancomycin  Multi-component lock solution or other, specify: __________  Taurolidine and heparin (DefencathTM)
*44.	Are needleless closed connector devices (e.g., Tego®, Q-Syte™) used on your patients’ hemodialysis catheters?
*45.	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
*46.	a. Does your center educate patients with hemodialysis 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 hemodialysis catheters are instructed against showering  No, education and instructions are not provided on this topic b. Does your center provide hemodialysis catheter patients with a protective catheter cover (e.g., Shower Shield®, Cath Dry™) to allow them to shower?  Yes, routinely for all or most patients with a catheter  Yes, only for select patients with a catheter  No
Comments:
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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 65 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 H21-8, Atlanta, GA 30333, ATTN:  PRA (0920-0666).