Understanding the Dialysis Event Protocol and
Avoiding Common Reporting Mistakes
Alicia Shugart, MA
Public Health Analyst
Topics
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Dialysis Event Protocol
Collecting data
Reporting a numerator and denominator each month
Selecting “DE” on the Monthly Reporting Plan
Running reports
Using help resources
Avoiding common reporting errors
DIALYSIS EVENT PROTOCOL
Read the Dialysis Event Protocol

The Dialysis Event Protocol
is a document that provides
instructions for reporting

All users are required to
read the Dialysis Event
Protocol to become familiar
with instructions,
definitions and procedures
Data Reporting Requirements
1.
Outpatient Dialysis Center Practices Survey

2.
Monthly Reporting Plan

3.
Indicate what NHSN surveillance your facility will do each month
Denominators for Outpatient Dialysis form

4.
Completed upon enrollment and annually thereafter
Completed once monthly
Dialysis Event form

Completed monthly, one for each dialysis event that occurs
Outpatient Dialysis Center Practices Survey

Completed during enrollment in NHSN and annually
thereafter

Survey includes questions about staff and patients
during the first week of January
 It is recommended to complete the survey in January each year
 This is the best time to complete the survey, even if you plan to
enroll later this year

Print from the Dialysis Event homepage:
http://www.cdc.gov/nhsn/forms/57.104_PSOutptDialysisSurv_BLANK.pdf
Outpatient Dialysis Center Practices Survey

Example of questions about patients and staff in the
first week of January
Vascular Access Definitions
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Fistula: A surgically created connection between an artery
and a vein
Graft: A surgically created connection between an artery
and a vein created with implanted synthetic tubing
Tunneled Central Line: Central venous catheter that travels
a distance under the skin from the point of insertion before
terminating at or close to the heart or one of the great
vessels
Nontunneled Central Line: Central venous catheter fixed in
place at the point of insertion and travels directly from the
skin entry site to a vein and terminates close to the heart or
one of the great vessels
Other Access Device: Includes hybrid access devices (e.g.,
HeROTM vascular access device), ports, and any other
access devices not meeting above definitions
Use of trade names and commercial sources is for identification only and does not imply endorsement.
Infection Risk by Vascular Access

Risk of infection varies by vascular access type:
LOW RISK
HIGH RISK

Arteriovenous fistulas
Arteriovenous grafts
Other access devices (e.g., hybrids)
Tunneled central lines
Nontunneled central lines
NHSN data are stratified by vascular access type
Denominators for Outpatient Dialysis form

Report all maintenance hemodialysis outpatients
treated at your facility on the first 2 working days of
the month, stratified by 5 vascular access types

Count each patient only once
 If they have more than 1 vascular access, count that patient
under their highest infection risk access only
 Consider ALL vascular accesses present, not just those being
used for dialysis
 If a patient is present on both working days (e.g., for a make-up
appointment) do not count them twice

Complete this form once per month
Dialysis Events

Dialysis events reported to NHSN by users
 IV antimicrobial starts
 Positive blood cultures
 Pus, redness or increased swelling at the vascular access site

Dialysis events calculated in NHSN from reported
data
 Local access site infection
 Access-related bloodstream infection
 Vascular access infection
Dialysis Event Form

Monitor all maintenance hemodialysis outpatients
who are treated at your facility at any time during the
month for dialysis events:
 IV antimicrobial start
 Positive blood culture
 Pus, redness, or increased swelling at the vascular access site

Complete a Dialysis Event form for each patient that
has a dialysis event
Dialysis Event Form

Any patient who receives maintenance hemodialysis
treatment at your facility is included in dialysis event
reporting
 Even if they were not counted on the denominator form
 Include transient patients who have a dialysis event while
receiving hemodialysis treatment at your facility
Dialysis Event Form
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Patient
demographics

Risk Factors

Dialysis Event
type(s) &
details
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Problems/
symptoms
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Outcomes
Dialysis Event Date
Dialysis Event
Date Criteria
IV antimicrobial start
Date of first outpatient administration
Positive blood culture
Date specimen was collected
Pus, redness, or increased
swelling at vascular access site
Sign/symptom onset date
Combination
Earliest date of the three types
Dialysis Event Type: IV Antimicrobial Start

Report all outpatient IV antimicrobial starts
 Include all IV antibiotics and antifungals, not just vancomycin
 Include starts that occur for any reason and duration, not just
vascular access problems
 Exclude antivirals

IV antimicrobials must be stopped for more than 21
days and then restarted to be considered a new
event
 If IV antimicrobials are stopped for ≤ 21 days it is still the same
event
Dialysis Event Type: Positive Blood Culture

Include all positive blood cultures from specimens
taken as an outpatient or within one (1) day after a
hospital admission
 Even if the patient does not receive treatment
 Even if the infection is not related to dialysis treatment

If you have > 1 positive blood culture, they must be
more than 21 days apart to be considered separate
dialysis events
Suspected Source of Positive Blood Culture
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“Vascular access” if there is objective evidence of
vascular access infection and it is thought to be the
source
“A source other than the vascular access” if another
source is thought to be the source and either:
 culture from another site has the same organism as the blood
 clinical evidence of infection at the site, but site is not cultured
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“Contamination” if organism is thought by the
physician, Infection Preventionist, or nurse manager
to be a contaminant
“Uncertain” only if there is insufficient evidence to
decide among the 3 previous categories
Positive Blood Culture Microorganisms

On the back of the Dialysis Event form, report the
microorganisms for positive blood cultures
 Suggestion: attach microbiology lab report to paper form

List up to 3 microorganisms (in order of importance)
 Usually order of importance is indicated on the laboratory report

For each microorganism, include antimicrobial
susceptibility information
 i.e., susceptible, resistant, intermediate, or not tested
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Only certain bug/drug combinations are required
Dialysis Event Type: Pus, Redness or
Increased Swelling at the Vascular Access Site

Report all episodes of one or more symptoms of
pus, redness or increased swelling at a vascular
access site
 Even if the patient does not receive treatment
 Always report pus
 Report redness or swelling if they are more than expected and
suspicious for infection at the time of onset

There must be 21 or more days between the onset of
a first and second episode of pus, redness, or
increased swelling at a vascular access site to be
considered separate dialysis events
21 Day Rule

There must be 21 or more days between dialysis
events of the same type

Purpose of the rule is prevent over-reporting of what
is likely the same patient problem
21 Day Rule Example

A patient has two positive blood cultures within 21
days as a result of a bloodstream infection on
January 1st and January 9th
 Report 1 dialysis event
 Event date is January 1st

The patient has a third positive blood culture on
February 20th
 Report a second dialysis event
 Because event date of this new positive blood culture is 21 or
more days after the last reported positive blood culture
Dialysis Event Problems & Outcomes

Specify problems associated with the dialysis event
 Fever, chills or rigors, drop in blood pressure
 Wound (not related to the vascular access) with pus or increased
redness
 Cellulitis
 Pneumonia or respiratory infection
 Other problem

Specify outcomes associated with either the dialysis
event or problems
 Hospitalization
 Death
Dialysis Event Combinations

1 Dialysis Event report may have multiple parts,
combining:
 IV antimicrobial start
 Positive blood culture
 Pus, redness or increased swelling at vascular access site
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For example, if a positive blood culture is the reason
that a patient is treated with IV antimicrobials, this is
part of the same group of events and they are
reported together
CREATE A SYSTEM TO COLLECT
DATA
Data Collection System

Determine how will you capture all dialysis events:
 IV antimicrobial starts
 Positive blood cultures
 Onsets of pus, redness or increased swelling at the vascular
access site
 And problem and outcome information for the form
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If frontline staff are aware of the dialysis event
definitions, they can inform the primary data
collector/reporter when an event occurs
Follow-up on hospitalizations to determine if a
positive blood culture resulted from a specimen
collected within 1 calendar day after admission
Data Collection

All resources are
available on the public
NHSN website:
www.cdc.gov/nhsn/
 Protocol & forms
Data Reporting

NHSN is accessed
through a secure
website:
https://sdn.cdc.gov
 Data entry/reporting
Using NHSN Forms

Data are collected on forms according to the
protocol
 Report Monthly Patient Census (denominator data) within 30
days of the end of the month
 Report Dialysis Events (numerator data) if they occur, within 30
days of the end of the month
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Using forms ensures all the required information
needed is ready for data entry
 Saves time – an incomplete event can’t be saved, so if data are
missing, it may be necessary to start over with data entry
 Improves data quality
REPORT A NUMERATOR AND A
DENOMINATOR EACH MONTH
Numerator, Denominator and Rates

Rates are used to standardize data and make them
comparable across settings of different size

To calculate a rate, you require a numerator and a
denominator for each month
 Number of dialysis events over number of patient-months
Rate =
Dialysis Events (numerator)
Patient Census (denominator)
x 100
Monthly Reporting Plan Generates Alerts if
Data are Not Reported on Time

If a reporting plan is saved with “DE” selected for the
outpatient hemodialysis clinic location, but either a
numerator (events) or denominator (census) are not
reported, an alert appears upon login after 30 days
from the end of the month

E.g., data for December should be reported before
the end of January. Beginning February 1, any time a
user logs in, they will see an alert for missing data
Reporting Zero Dialysis Events
(Numerator is Equal to Zero)

If no dialysis events occurred during a month, select
“Report No Events” on the Denominators for
Outpatient Dialysis form in NHSN
 No IV antimicrobial starts
 No positive blood cultures
 No pus, redness, or swelling at the vascular access site

This indicates that the numerator (dialysis events) is
equal to zero for this month/year

The denominator (patient census information) is still
reported for that month
Select
“Report No Events”
to report zero dialysis
events for the month
“Missing Summary Data” Alert for Missing
Denominator
Alert for Missing Numerator

If no dialysis events are reported and the “Report No
Events” checkbox has not been selected, there are two
alerts for that month:
 “Missing Events”
 “Incomplete Summary Data”

NHSN does not know if events need to be reported (so it
alerts you that there are “Missing Events”) or if “Report
No Events” needs to be checked (so it also alerts you
that there is “Incomplete Summary Data”)

If either an event is reported or if “Report No Events” is
selected, a numerator for that month has been reported,
so both alerts will disappear for that month
“Missing Events” Alert for Missing Numerator
“Incomplete Summary Data” Alert for Missing
Numerator
ADD “DE” TO YOUR MONTHLY
REPORTING PLAN BEFORE
ADDING DATA
Monthly Reporting Plan

Indicates what Patient Safety Component
surveillance modules your facility intends to do:
 Device-Associated Module >> Dialysis Event “DE”
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If not doing surveillance for a specific month, select
‘No NHSN Patient Safety Modules Followed this
Month’ on the Monthly Reporting Plan
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You can submit up to one year of Monthly Reporting
Plans in advance
Choose only if your facility is NOT
doing any surveillance this month
Indicating “DE” on your reporting plan each
month helps you to report correctly.
RUN REPORTS
Reviewing Your Data

Monthly review is recommended to:
 Ensure all data have been reported and are accurate

Review of quarterly data is recommended to:
 Detect problems in your facility
 Provide feedback to your staff
 Get staff engaged in quality improvement

Allows for a better understanding of your facility’s
performance by comparing your facility’s rates
against NHSN aggregate rates
Creating Reports

Experiment with the analysis
function – you can’t break anything!

Allow pop-ups from http://*.cdc.gov
Three Steps to Create a Report
1. Generate new data sets
2. Select a report (“output option”) from the list of
templates

Modify the report, if desired
3. Press “Run” button to create the report
You can create a report with just a few clicks!
Step 1 – Generate Data Sets

First step: generate new data sets

Generating data sets captures all of your facility’s
NHSN data so that reports will be created using
complete, up-to-date information

Each user has their own analysis data sets
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They may take several minutes to generate, but you
can work elsewhere in NHSN while you wait
Step 1 – Generate Data Sets
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From the navigation bar, select ‘Analysis’, then
‘Generate Data Sets’
Select ‘Generate New’ and ‘OK’, then wait for update
Step 2 –
Select a Report
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Once data sets are
generated, select
‘Output Options’ from
the navigation bar
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Open folders to find
dialysis event templates
1. ‘Device-Associated
Module’ folder
2. ‘Dialysis Events’ folder
3. ‘CDC Defined Output’
folder
Step 3 – Run the Report

Press “Run” button next to the report you want
USE HELP RESOURCES
Use Help Resources

Refer to the Protocol and Tables of Instructions
 These can be found along with other reporting resources on the
Dialysis Event Homepage
http://www.cdc.gov/nhsn/psc_da_de.html

Use the “Help” link to search the NHSN Online Manual

Ask the NHSN Helpdesk at [email protected]
AVOID COMMON REPORTING
ERRORS
Population

Dialysis event surveillance population includes
pediatric patients
 Date of birth is a required event field, so age is captured for each
dialysis event

Dialysis event surveillance population does not
include peritoneal dialysis patients
 Dialysis event surveillance population includes only maintenance
hemodialysis outpatients
Vascular Accesses

Include all central lines in Dialysis Event reporting,
even those not being used for hemodialysis (e.g., a
port for chemotherapy)
 Dialysis Event form: indicate all of the patient’s vascular
accesses
 Denominators for Outpatient Dialysis form: count the patient
under the highest infection risk vascular access type that he has
Denominators for Outpatient Dialysis form

Patients must be physically present for maintenance
hemodialysis treatment on the first two working days
of the month to be counted on the denominator form:
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Include transient patients
Include pediatric patients
Exclude acute/hospitalized patients
Exclude peritoneal dialysis patients
Exclude patients that miss their treatment appointment
Report dialysis events that occur in patients receiving
maintenance hemodialysis at your facility, regardless
of whether or not the patient was counted in the
denominator for that month
Report Dialysis Events Only

A Dialysis Event form is completed only if a dialysis
event occurs:
 IV antimicrobial starts
 Positive blood cultures
 Pus, redness, or increased swelling at the vascular access site

Problems and outcomes on the Dialysis Event form
are not reportable by themselves:
 Fever, chills or rigors, drop in blood pressure, wound, cellulitis,
pneumonia, hospitalization and death are only reported if a
dialysis event also occurs
CMS ESRD QIP NHSN Reporting Requirements

In 2012, requires a minimum of 3 consecutive
months of Dialysis Event reporting as defined in the
Dialysis Event Protocol:
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Annual Dialysis Survey
Monthly Reporting Plan with “DE” selected
Dialysis denominator reported – patient census information
Dialysis numerator reported – at least one dialysis event
reported or “Report No Events” to indicate numerator is zero
See our FAQs about NHSN and CMS ESRD QIP at
http://www.cdc.gov/nhsn/dialysis/faq-ESRD-QIP.html
Questions?
NHSN Helpdesk
[email protected]
For more information please contact Centers for Disease Control and
Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: [email protected] Web: www.cdc.gov