Infection Control
upon entering & exiting tx floor, before and after touch patient
What is hand hygiene?
greater than 60
What is DQI goal?
Conducted every 6 months; V110, V0122, V0130, V0147
What is MCS Safety Audit?
pre / post tx
What is washing AV Access?
10% or greater for the Division
What is the Home goal?
< / = 1/4 length
What are artificial nails?
Adequacy, CVC in Use, Optimal Fluid, Missed Treatments, Flu
What are components of DQI?
Key Personnel, 3 mth pt lab trend, Hospitalizations, 30 day Readmission, Infection Control, Vaccinations, IVDs, Water, QUAPI
What is Core Survey Document?
16% or <
What is CVC goal?
3 Steps in this process
What is Modality Choice Pathway?
Gowns, mask, face shield, gloves
What is adequate PPE?
85% or >
What is goal for FLU
BFR, Artificial nails, Pre / Post Assessment, Infection Control, Access prep, Scrub the Hub
What is most commonly cited deficiencies?
68% or greater
What is goal for AVF?
Nsg Assessment, Pt Data, RX, Machine settings, Intradialytic, Pre / Post Data collection, Abnormal Findings
What is Policy #1-03-08
chair opened up, fully reclined, dialysis machine, prime buckets, tv, chase boxes
What is disinfection of dialysis station?
75% or greater
What is goal for Optimal Fluid?
Total #of dialysis stations; #of FTE, isolation room, Reprocessing, Organization
What is 3427?
Steps 1 thru 7
What is CVC Pathway?
CVC / AVF to PD or HHD
What is conversion?
Look, listen, feel, raise arm, collapse of AVF
What is 10 second access check?
PW > TW, TW < PW, UFR > 13mL/kg/hr
What is Optimal Fluid?
Fire, Bomb, tornado, Severe Weather, Earthquake, Flood, HVA, Annual Letters, Annual GB
What is Incident Management Tool / Emergency Preparedness?
15 seconds or greater
What is scrub the hub for CVC care?
Hypertensive, Hypotensive, F/U, Documentation, Call MD
What are abnormal findings / actions?