DIALYSIS SPECIFIC EOC OBSERVATION
Data Definition Tool
This audit is to be completed by the manager or designee on a monthly basis. "Dialysis Specific EOC Observation" audits are due by the last day of the month.
Instructions: Indicate Yes, No, NA (Not Applicable) for each question below.
Submit 1 "Dialysis Specific EOC Observation" audit per month using the "Dialysis Specific EOC Observation" audit tool.
Updated: 3/01/2015
QUESTION
STANDARD
LOCATION
YES
DIALYSIS - BUILDING INTERIOR PHYSICAL ENVIRONMENT INSPECTION
1 Date of Observation
2 Name of Observer
3 Are floors clean, intact, and free from damage?
observed in clinic
4 Are ceiling tiles free of stains, cracks, or missing tiles?
5 Grids are secure and free from rust?
observed in clinic
observed in clinic
Is the interior lighting clean, illuminated, intact, and free
6 from damage?
7 Is door clearance adequate?
8 Do Fire Doors remain closed?
observed in clinic
observed in clinic
observed in clinic
9 Are walls and baseboards intact and free from damage?
10 Are windows and window blinds clean?
Are the lobby/waiting room chairs clean and in good
11 repair?
12 Are Emergency Call Systems fully operational?
Are countertops intact and free from damage allowing
13 cleaning and disinfection?
Floors are clean, intact, and free from damage
Ceiling tiles are free of stains, cracks, or
missing tiles
Grids are secure and free from rust
The interior lighting is clean, illuminated,
intact, and free from damage
The door clearance is adequate
Fire doors are closed
Walls and baseboards are intact and free from
damage.
observed in clinic
observed in clinic
Windows and window blinds are clean.
The lobby/waiting room chairs are clean and
Observed in Lobby in good repair.
Observed in Lobby
restroom
Emergency Call System is fully operational
observed in clinic
Countertops are intact and free from damage
to allow cleaning and disinfection.
DIALYSIS - CLEANING AND DISINFECTION OF THE DIALYSIS STATION
14 Date of Observation
15 Staff Observed
Were gloves, gown, protective eyewear and mask or
faceshield worn during the cleaning and disinfection
16 procedure?
Were all blood lines and disposables discarded in the
17 biohazardous waste?
18 Was the prime waste receptacle emptied and disinfected?
observed at
chairside
observed at
chairside
observed at
chairside
Were gloves removed following the disposal and
19 disinfection part of the procedure?
Was hand hygiene performed before putting on new
20 gloves?
Were clean gloves put on before beginning the next
21 cleaning step?
observed at
chairside
observed at
chairside
observed at
chairside
Were the internal and external surfaces of the prime waste
22 receptacle wiped and allowed to dry?
observed at
chairside
Was a disinfectant-soaked cloth used to wipe the top,
23 front, and side surfaces of the machine?
Was a disinfectant-soaked cloth used to wipe the dialysate
24 hoses of the machine?
Was a disinfectant-soaked cloth used to wipe the Hansen
connectors of the machine?
25
Was a disinfectant-soaked cloth used to wipe the BP cuff
26 and tubing?
observed at
chairside
observed at
chairside
Was a disinfectant-soaked cloth used to wipe the outside
27 surfaces of the dialysate concentrate containers?
observed at
chairside
observed at
chairside
observed at
chairside
Gloves, gown, protective eyewear and mask
or faceshield were worn during the cleaning
and disinfection procedure
All blood lines and disposables were discarded
in the biohazardous waste
The prime waste receptacle was emptied and
disinfected
Gloves were removed following the disposal
and disinfection part of the procedure
Hand hygiene was performed before putting
on new gloves
Clean gloves were put on before beginning
the next cleaning step
The internal and external surfaces of the
prime waste receptacle were wiped and
allowed to dry
A disinfectant-soaked cloth was used to wipe
the top, front, and side surfaces of the
machine
A disinfectant-soaked cloth was used to wipe
the dialysate hoses of the machine
A disinfectant-soaked cloth was used to wipe
the Hansen connectors of the machine
A disinfectant-soaked cloth was used to wipe
the BP cuff and tubing
A disinfectant-soaked cloth was used to wipe
the outside surfaces of the dialysate
concentrate containers
Was a disinfectant-soaked cloth used to wipe the data
28 entry station?
observed at
chairside
A disinfectant-soaked cloth was used to wipe
the data entry station
Were any unused disposable supplies removed from the
29 dialysis chair and disposed ?
observed at
chairside
Was a disinfectant-soaked cloth used to wipe all external
30 front-facing and side surfaces of the fully reclined chair?
observed at
chairside
Was a disinfectant-soaked cloth used to wipe the sides of
31 the seat cushion of the fully reclined chair?
observed at
chairside
Was a disinfectant-soaked cloth used to wipe the tops of
32 the side tables beside the fully-reclined chair?
Was a disinfectant-soaked cloth used to wipe the TV
33 controls?
Was a disinfectant-soaked cloth used to wipe the call
34 button?
observed at
chairside
observed at
chairside
observed at
chairside
observed at
chairside
observed at
chairside
Any unused disposable supplies were
removed from the dialysis chair and disposed
A disinfectant-soaked cloth was used to wipe
all external front-facing and side surfaces of
the fully reclined chair
A disinfectant-soaked cloth was used to wipe
the sides of the seat cushion of the fully
reclined chair?
A disinfectant-soaked cloth was used to wipe
the tops of the side tables beside the fullyreclined chair
A disinfectant-soaked cloth was used to wipe
the TV controls
A disinfectant-soaked cloth was used to wipe
the call button?
A disinfectant-soaked cloth was used to wipe
the IV poles
A disinfectant-soaked cloth was used to wipe
the O2 concentrators
35 Was a disinfectant-soaked cloth used to wipe the IV poles?
Was a disinfectant-soaked cloth used to wipe the O2
36 concentrators?
Was a disinfectant-soaked cloth used to wipe the counters
37 around the dialysis station?
39 Were all cloths and wipes discarded properly?
observed at
chairside
observed at
chairside
observed at
chairside
Was hand hygiene performed immediately after cleaning
40 and disinfecting the Dialysis Station?
observed at
chairside
38 Were all clamps cleaned?
A disinfectant-soaked cloth was used to wipe
the counters around the dialysis station
All clamps were cleaned
Aall cloths and wipes were discarded properly
Hand hygiene was performed immediately
after cleaning and disinfecting the Dialysis
Station
DIALYSIS - HOME TRAINING TREATMENT AREA AUDIT
There is a documented method in place to
summon immediate assistance for a patient
or solitary staff
The emergency resuscitation equipment is
immediately available
Is there a documented method in place to summon
41 immediate assistance for a patient or solitary staff?
Is emergency resuscitation equipment immediately
42 available?
observed at
chairside
observed at
chairside
Did staff respond to a TEST emergency call for assistance in
43 < 4 minutes?
observed at
chairside
Is the treatment space adequate to prevent cross44 contamination when multiple patients are training?
Does the treatment space provide adequate patient
45 privacy?
There is no visible evidence of dry or wet blood on the
46 equipment or surfaces?
observed at
chairside
observed at
chairside
observed at
chairside
The staff responded to a TEST emergency call
for assistance in < 4 minutes
The treatment space is adequate to prevent
cross-contamination when multiple patients
are training
The treatment space provide adequate
patient privacy
There is visible evidence of dry or wet blood
on the equipment or surfaces
There is no visible evidence of dry or wet PD effluent on
47 the equipment or surfaces?
observed at
chairside
There is visible evidence of dry or wet PD
effluent on the equipment or surfaces
Is the patient treatment area (including floors, countertops,
48 and ceiling tiles) in good repair?
observed at
chairside
observed at
chairside
The patient treatment area (including floors,
countertops, and ceiling tiles) is in good repair
Treatment chairs are in good repair and
functional
49 Are treatment chairs in good repair and functional?
DIALYSIS - ISOLATION PRACTICES
Is the Isolation room or area equipped with dedicated
equipment and supplies for use by only HBsAG+ positive
50 patients?
observed at
chairside
Is the door to the Isolation room closed during initiation
51 and discontinuation of dialysis treatment?
observed at
chairside
Do staff caring for HBVsAG positive ANTIGEN+ patients only
provide care for HBsAG positive V ANTIBODY+ patients in
close proximity during the same shift maintaining a proper
52 buffer zone?
observed at
chairside
Do all patients seated in the "Buffer Zone" have a
53 documented HBsABy titer of > 10 in the past 12 months?
observed at
chairside
The Isolation room or area equipped with
dedicated equipment and supplies for use by
only HBsAG+ positive patients
The door to the Isolation room is closed
during initiation and discontinuation of
dialysis treatment
Staff caring for HBVsAG positive ANTIGEN+
patients only provide care for HBsAG positive
V ANTIBODY+ patients in close proximity
during the same shift maintaining a proper
buffer zone.
All patients seated in the "Buffer Zone" have a
documented HBsABy titer of > 10 in the past
12 months
Are staff providing medications to isolation patients
prohibited from caring for susceptible patients during the
54 same shift?
observed at
chairside
Is Isolation equipment labeled and dedicated for use for
55 HBsAG positive V+ patients only?
observed at
chairside
Is the Isolation room used for HBsAg positive V+ patients
56 when the census includes any HBsAg positive V+ patients?
observed at
chairside
Staff providing medications to isolation
patients are prohibited from caring for
susceptible patients during the same shift
The Isolation equipment is labeled and
dedicated for use for HBsAG positive V+
patients only
The Isolation room is used for HBsAg positive
V+ patients when the census includes any
HBsAg positive V+ patient
Does staff wear gloves, gown, protective eyewear and
mask or faceshield when entering the isolation room during
57 treatment?
observed at
chairside
The staff wears gloves, gown, protective
eyewear and mask or faceshield when
entering the isolation room during treatment
Does staff remove gloves, gown, protective eyewear and
mask or faceshield when entering the isolation room during
58 treatment?
observed at
chairside
The staff removes gloves, gown, protective
eyewear and mask or faceshield when leaving
the isolation room during treatment
Does staff perform hand hygiene immediately after leaving
59 the isolation room?
Does the isolation room or area have equipment,
instruments, and supplies desginated to be used only for
60 patients with MRSA?
Does the isolation room or area have equipment,
instruments, and supplies desginated to be used only for
61 patients with VRE?
DIALYSIS - PATIENT TREATMENT AREA AUDIT
62 Are there dummy drip chambers in the patient care area?
63 Is the patient care area in good repair?
64 Are the patient chairs in good repair?
65 Emergency supplies include: AED?
66 Emergency supplies include: O2?
67 Emergency supplies include: Suction?
68 Emergency supplies include: Ambu bag with face mask?
69 Emergency supplies include: IV solutions?
70 Emergency supplies include: Back board?
71 Emergency supplies include: Oral airway?
72 Emergency supplies include: Emergency medications?
observed at
chairside
The staff performs hand hygiene immediately
after leaving the isolation room
observed at
chairside
The isolation room or area has equipment,
instruments, and supplies desginated to be
used only for patients with MRSA
observed at
chairside
The isolation room or area has equipment,
instruments, and supplies desginated to be
used only for patients with VRE
observed at
chairside
observed at
chairside
observed at
chairside
Observed on
emergency cart
Observed on
emergency cart
Observed on
emergency cart
Observed in
emergency cart
Observed in
emergency cart
Observed in
emergency cart
Observed in
emergency cart
Observed in
medication room
No Dummy drip chambers are present in the
patient care area
The patient care area is in good repair
The patient chairs are in good repair
Emergency supplies include: AED
Emergency supplies include: O2
Emergency supplies include: Suction
Emergency supplies include: Ambu bag with
face mask
Emergency supplies include: IV solutions
Emergency supplies include: Back board
Emergency supplies include: Oral airway
Emergency supplies include: Emergency
medications
73 Are AED checks performed daily?
Are emergency supplies checked monthly or after use for
74 expiration dates, cleanliness, and proper function?
DIALYSIS - SUPPLY CONTAMINATION PREVENTION
75 Date of Observation
76 Staff Observed
documented in AED
log
AED checks were performed daily.
The emergency supplies are checked monthly
Observed in
or after use for expiration dates, cleanliness,
medication room
and proper function
Were all supplies stored in designated clean areas at a safe
77 distance from the dialysis stations?
observed at
chairside
Was the staff member compliant with never keeping
78 patient care supplies in pockets or on their person?
observed at
chairside
All supplies were stored in designated clean
areas at a safe distance from the dialysis
stations.
The staff member was compliant with never
keeping patient care supplies in pockets or on
their person.
observed at
chairside
All non-disposable equipment (thermometers,
IV poles, pH/conductivity meters, O2
concentrators, glucometers, stethoscopes)
were disinfected when removed from the
used dialysis station BEFORE is was returned
to a common area or another dialysis station.
Was all non-disposable equipment disinfected by wiping all
surfaces with EPA-registered hospital disinfectant and
80 allowed to dry?
observed at
chairside
All non-disposable equipment was disinfected
by wiping all surfaces with EPA-registered
hospital disinfectant and allowed to dry.
Were all unused disposable supplies discarded or dedicated
81 to the patient and not returned to the common supplies?
observed at
chairside
All unused disposable supplies were discarded
or dedicated to the patient and not returned
to the common supplies.
Was all non-disposable equipment (thermometers, IV
poles, pH/conductivity meters, O2 concentrators,
glucometers, stethoscopes) disinfected when removed
from the used dialysis station BEFORE is was returned to a
79 common area or another dialysis station?