CDC Dialysis Collaborative Day: M W F Tu Th Sa Shift: 1 2 st nd 3 rd Facility Name: ____________________ Date: _____________ Start time:_________AM / PM 4th Observer: ______________________ Location within unit:__________________ Audit Tool: Arteriovenous fistula/graft cannulation observations (Use a “√” if action performed correctly, a “Ф” if not performed. If not observed, leave blank) Hand Skin Site cleaned New, clean hygiene antiseptic Discipline with soap gloves performed applied and water worn (staff) appropriately Skin antiseptic allowed to dry No contact with fistula/ graft site (after antisepsis) Cannulation Connect to Hand Gloves performed blood lines hygiene Comments removed aseptically aseptically performed Discipline: P=physician, N=nurse, T=technician, S=student, O=other Duration of observation period = minutes Number of procedures performed correctly = Total number of procedures observed during audit = ADDITIONAL COMMENTS/OBSERVATIONS: National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion CDC Dialysis Collaborative Day: M W F Tu Th Sa Shift: 1 2 st nd Facility Name: ____________________ Date: _____________ Start time:_________AM / PM 4 Observer: ______________________ Location within unit:__________________ 3 rd th Audit Tool: Arteriovenous fistula/graft decannulation observations (Use a “√” if action performed correctly, a “Ф” if not performed. If not observed, leave blank) If other activities Disconnect Clean gloves performed between Patient gloves Hand Clean gauze Staff from blood Needles worn (by needle removals, Staff removed and hygiene New, clean /bandage hand Discipline line removed patient/staff) hand hygiene is gloves hand hygiene Comments performed gloves worn applied to hygiene aseptically aseptically to compress performed and removed performed (staff) site performed site new, clean gloves (if applicable) are worn Discipline: P=physician, N=nurse, T=technician, S=student, O=other Duration of observation period = minutes Number of procedures performed correctly = Total number of procedures observed during audit = ADDITIONAL COMMENTS/OBSERVATIONS: National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion
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