Facility Name Date Start timeAM PM Day M W F Tu Th Sa Shift 1 Observer Location within unit Discipli ID: 937070
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Audit Tool: Arteriovenous stula/graft decannulation observations(Use a “ ” if action performed correctly, a “ ” if not performed. If not observed, leave blank)CDC Dialysis Collaborative Facility Name: ____________________ Date: Start time:_________AM / PM Day: M W F Tu Th Sa Shift: 1 Observer: ______________________ Location within unit:__________________ Discipline hygiene performed (sta )Newgloves wornDisconnect from blood removed Clean gloves worn (by patient/sta ) to compress siteClean gauze applied to site If other activitiesperformed between needle removals, hand hygiene is performed and new, clean gloves are worn Sta gloves removed Sta hygiene performedPatient gloves removed and hand hygiene performedComments=physician, =nurse, =technician, =student, Duration of observation period = minutes Number of procedures performed correctly = Total number of procedures observed during audit = ADDITIONAL COMMENTS/OBSERVATIONS: National Center fo
r Emerging and Zoonotic Infectious DiseasesDivision of Healthcare Quality Promotion CDC Dialysis Collaborative Facility Name: ____________________ Date: Start time:_________AM / PM Day: M W F Tu Th Sa Shift: 1 Observer: ______________________ Location within unit:__________________ Audit Tool: Arteriovenous stula/graft cannulation observations(Use a “ ” if action performed correctly, a “ ” if not performed. If not observed, leave blank)DisciplineSite cleaned and water hygiene performed (sta )New, clean gloveswornSkinantiseptic appropriatelySkinantiseptic allowedto dryNo contact graft site(after blood lines Glovesremovhygiene performedComments=physician, =nurse, =technician, =student, 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 DiseasesDivision of Healthcare Quality Promotio