Active Bacterial Core Surveillance Neonatal Infection Ex

Active Bacterial Core Surveillance (ABCs)

Attachment 4_Ext GBS CRF 2009

Neonatal Group B Streptococcal Disease Prevention Tracking Form

OMB: 0920-0802

Document [pdf]
Download: pdf | pdf
NEONATAL INFECTION EXPANDED TRACKING FORM
Infant’s Name: _____________________________________________ 	

Infant’s Chart No.: _____________________

Mother’s Name: _____________________________________________ 	
(Last, First, M.I.)
	
Hospital Name: ______________________________­­­­­­­­­­_______________	

Mother’s Chart No.: ____________________

(Last, First, M.I.)

Culture date: _________________________

-Patient identifier information is NOT transmitted to CDCACTIVE BACTERIAL CORE SURVEILLANCE (ABCs)
NEONATAL INFECTION EXPANDED TRACKING FORM
STATEID __ __ __ __ __ __ __ 	

HOSPITAL ID (of birth; if home birth leave blank) __ __ __ __ __

Infant Information			

Were labor & delivery records available?

	

No (0)

2. 	Did this birth occur outside of the hospital?
	 Yes (1)
No (0)
Unknown (9)
IF
YES,
please
check
one:
	
Home Birth (1)	
Unknown (1)
En route to hospital (3)	
Other (4)
	

1. Date of Birth: __ __ /__ __ /__ __ __ __
month

day

year (4 digits)

Time of birth: ___ ___ ___ ___

(times in military format)

	

Birthing Center (2) 	
Unknown (9)

4. Birth weight: ___ lbs ___oz	 OR __ __ __ __ grams

3. Gestational age of infant at birth in completed weeks:
__ __ (do not round up)

	

Yes (1)

5. Date & time of newborn discharge from hospital of birth: __ __ /__ __ /__ __ __ __	­­__ __ __ __
month

6. Outcome:

Survived (1)

Died (2)

day

year (4 digits)

Unknown (9)

7. Was the infant discharged to home and readmitted to the birth hospital? (for GBS cases only):
IF YES, date & time of readmission: __ __ /__ __ /__ __ __ __		
month

	

Unknown (1)

time

day

year (4 digits)

No (0)

Yes (1)

No (0)

__ __ __ __
time

8. Was the infant admitted to a different hospital from home? (for GBS cases only):
IF YES, hospital ID: ___ ___ ___ ___ ___	

Yes (1)

AND date & time admission: __ __ /__ __ /__ __ __ __
month

9. 	 Infant discharge diagnosis (for GBS cases only):
	
ICD9-1 ­­­­­­­­­__ __ __.__ __	
ICD9-2 __ __ __.__ __	

day

year (4 digits)

__ __ __ __
time

ICD9-3 __ __ __.__ __

10. Did the baby receive breast milk from the mother? (for late-onset GBS cases only):
IF YES, did the baby receive breast milk before onset of GBS
infection (e.g., date of first positive neonatal culture):	

 

Yes (1)

No (0)

Unknown (9)

Yes (1)

No (0)

Unknown (9)

Maternal Information
  11. Maternal admission date & time: __ __ /__ __ /__ __ __ __	
month

day

year (4 digits)

12. Maternal age at delivery (years): __ __ years	

__ __ __ __ 	

13. Maternal blood type:

  14. Did mother have a prior history of penicillin allergy?
IF YES, was a previous maternal history of anaphylaxis noted?
  15. Date & time membrane rupture: __ __ /__ __ /__ __ __ __

	

month

day

year (4 digits)

Unknown (1)

time

A (1)

B (2)

Yes (1)	

No (0)	

Yes (1)

No (0)	

__ __ __ __	
time

AB (3)

O (4)

Unknown (1)

 16. Was duration of membrane rupture >18 hours?

Yes (1)

No (0)

Unknown (9)

 17. If membranes ruptured at <37 weeks, did membranes rupture
before onset of labor?

Yes (1)

No (0)

Unknown (9)

1/2009

Page 1 of 3

18. Type of rupture:

Spontaneous (1)	

Artificial (2)

19. Type of delivery: (Check all that apply)
Vaginal (1)

Vaginal after previous C-section (1)

Primary C-section (1)

Forceps (1)

Vacuum (1)

Unknown (1)

Repeat C-section (1)

If delivery was by C-section:	 Did labor or contractions begin before C-section?	

Yes (1)	

No (0)

Unknown (9)

Did membrane rupture happen before C-section?

Yes (1)	

No (0)

Unknown (9)

20. Intrapartum fever (T > 100.4 F or 38.0 C):

Yes (1)

	

No (0)

Unknown (9)

IF YES, 1st recorded T > 100.4 F or 38.0 C at: __ __ / __ __ /__ __ __ __
month

	

day

year (4 digits)

Yes (1)

No (0)

__ __ __ __
time

21.

Were antibiotics given to the mother intrapartum?	

	

IF YES, answer a-b and Questions 22-23
a)	 Date & time antibiotics 1st administered: (before delivery) __ __ /__ __ /__ __ __ __

	

b)	 Antibiotic 1: ___________________________

	

Start date: __ __ /__ __ /__ __ __ __

month

	

Start date: __ __ /__ __ /__ __ __ __

	

Start date: __ __ /__ __ /__ __ __ __

	

Start date: __ __ /__ __ /__ __ __ __

	

Start date: __ __ /__ __ /__ __ __ __

	

Start date: __ __ /__ __ /__ __ __ __

time

		

PO (3) # doses given before delivery: ______

IV (1)

IM (2)

PO (3) # doses given before delivery: ______

IV (1)

IM (2)

PO (3) # doses given before delivery: ______

IV (1)

IM (2)

PO (3) # doses given before delivery: ______

IV (1)

IM (2)

PO (3) # doses given before delivery: ______

Stop date (if applicable): __ __ /__ __ /__ __ __ __

Antibiotic 6: ___________________________

	

__ __ __ __

Stop date (if applicable): __ __ /__ __ /__ __ __ __

Antibiotic 5: ___________________________

	

	

Stop date (if applicable): __ __ /__ __ /__ __ __ __

Antibiotic 4: ___________________________

	

IM (2)

year (4 digits)

Stop date (if applicable): __ __ /__ __ /__ __ __ __

Antibiotic 3: ___________________________

	

day

Stop date (if applicable): __ __ /__ __ /__ __ __ __

Antibiotic 2: ___________________________

	

IV (1)

Unknown (9)

IV (1)

IM (2)

PO (3) # doses given before delivery: ______

Stop date (if applicable): __ __ /__ __ /__ __ __ __

22.	 Interval between receipt of 1st antibiotic and delivery: ___ ___ ___ (hours)

___ ___ (minutes)

23.	 What was the reason for administration of intrapartum antibiotics? (Check all that apply)
		

	
	

GBS prophylaxis (1)

C-section prophylaxis (1)

Mitral valve prolapse prophylaxis (1)	

Suspected amnionitis (1)

Other (1)

Unknown (1)

***Questions 24–32 should only be completed for early- and late-onset GBS cases***

Page 2 of 3

24. Did mother receive prenatal care?	

Yes (1)

No (0)

Unknown (9)

25. Was prenatal record (even partial information) in labor and delivery chart?	

Yes (1)

No (0)

Unknown (9)

IF YES: No. of visits: __ __ First visit: __ __ /__ __ /__ __ __ __ Last visit: __ __ /__ __ /__ __ __ __
month

day

year (4 digits)

month

day

year (4 digits)

26. Estimated gestational age (EGA) at last documented prenatal visit: ___ ___ . ___ ___ (weeks)
27. GBS
bacteriuria during this pregnancy?
Yes (1)
No (0) 	
	
IF YES, what order of magnitude was the colony count?
0 (1)
<10,000 (2)
10k–<25,000 (3)
25k–<50,000 (4)
50k–<75,000 (5)
>100,0000 (7)
Unknown (9)
28. Previous infant with invasive GBS disease?

Yes (1)

No (0)

29. Previous pregnancy with GBS colonization?

Yes (1)

No (0)

75k–<100,000 (6)

30a. Was maternal group B strep colonization screened for BEFORE admission (in prenatal care)?
Yes (1)
No (0)
Unknown (9)
IF YES, list dates, test type, and test results below:
Test date (list most recent first):
1. __ __ /__ __ /__ __ __ __

2. __ __ /__ __ /__ __ __ __

Test type:
Culture (1)

Rapid PCR (2)

Other (4)

Unknown (9)

Culture (1)

Rapid PCR (2)

Other (4)

Unknown (9)

	

Positive culture
(Do not include urine here!)

Rapid antigen (3)

Yes (1)

No (0)

Unknown (9)

Rapid antigen (3)

Yes (1)

No (0)

Unknown (9)

30b. If the most recent test was GBS positive was antimicrobial susceptibility performed BEFORE admission (in prenatal care)?
Yes (1)

No (0)

Unknown (9)

IF YES, Was the isolate resistant to clindamycin?
Was the isolate resistant to erythromycin?

Yes (1)

No (0)

Unknown (9)

Yes (1)

No (0)

Unknown (9)

31a.	Was maternal group B strep colonization screened for AFTER admission (before delivery)?

Yes (1)

No (0)

Unknown (9)	

IF YES, list date of most recent test, test type and test results below:
	
Test date (list most recent first):
__ __ /__ __ /__ __ __ __

Test type:
Culture (1)

Rapid PCR (2)

Other (4)

Unknown (9)

	
Rapid antigen (3)

Positive culture
(Do not include urine here!)
Yes (1)

No (0)

Unknown (9)

31b. If the most recent test was GBS positive, was antimicrobial susceptibility performed AFTER admission?
Yes (1)

No (0)

Unknown (9)

IF YES, Was the isolate resistant to clindamycin?
Was the isolate resistant to erythromycin?
32.

Yes (1)

No (0)

Unknown (9)

Yes (1)

No (0)

Unknown (9)

Were GBS test results available to care givers at the time of delivery?	

Yes (1)

No (0)

Unknown (9)

COMMENTS: ________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Page 3 of 3


File Typeapplication/pdf
File Modified2009-01-14
File Created2009-01-14

© 2024 OMB.report | Privacy Policy