Attachment 5 - Revised questionnaire

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OMB Control No. 0920-0772

Expiration Date: 04/30/2011

RSA Infection Control Practices Survey Questionnaire

Your facility is one of approximately 200 nationwide that take part in the Emerging Infections Program/Active Bacterial Core Surveillance (ABCs) Invasive Methicillin Resistant Staphylococcus aureus (MRSA) project. This is a joint effort between the Centers for Disease Control and Prevention (CDC), your state health department and several academic medical centers. As part of this project, we are administering this survey to assess MRSA infection control practices at participating facilities. This is the second in a series of 3 planned surveys. The survey should be filled out by a member of your facility’s infection control program. It should not take longer than 20 minutes.

Data from this survey will be used to gauge the current state of MRSA control efforts at health-care facilities participating in this MRSA surveillance program. It will also help us understand how well the existing national guidelines for MRSA control are working. Your answers will provide important feedback for updating these guidelines.

You are free to choose to take part in this survey or not. Your choice will not affect your current or future participation in the Invasive MRSA project. All answers will be kept confidential at your local state ABCs site.

The survey has received ethical review at the CDC. Thank you for your time and help with this important public health activity.

If you have questions or concerns please feel free to contact the survey coordinator, Alex Kallen at 404-639-4275 ([email protected]) or your local ABCs Invasive MRSA project coordinator.

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-0772.

MRSA Infection Control Practices Survey Questionnaire

1. Date of survey completion:

Section 1: Background:

Please complete the following background information about your facility’s current status

2. State in which facility located:

3. Which of the following entities are found within your facility (check all that apply)?

 Acute (short-term) inpatient care facility (for example, acute care hospital)

 Post-acute inpatient care facility (for example, nursing home or rehabilitation facility)

 Ambulatory care facility (for example, urgent care center or doctor’s office)

 Other, describe ________________________________

4. What is the total number of staff currently working in infection control at your facility? Please describe using full-time equivalents of people working directly in infection control, do not include support staff (for example, if a facility had one full-time person and one half-time person, this would equal 1.5 staff members).

5. Currently, how many active acute care hospital beds does your facility have?

6. Currently, how many active adult Intensive Care Unit beds (ICU) does your facility have?

7. Currently, how many post-acute care (such as rehabilitation or assisted living) beds does your facility have?

8. Currently, how many active pediatric beds (including nursery, NICU beds, etc.) does your facility have?

9. Is your facility a teaching facility (for this survey that means your facility has physicians-in-training and/or nurses-in-training providing care to patients)?

 Yes

 No

Section 2: Institutional Culture

The following questions ask about general MRSA related activities at your facility.

10. Is your facility currently involved (in total or in part) in an external (one originating outside your facility) methicillin-resistant Staphylococcus aureus (MRSA) control initiative at that time? (check one)

 Yes

 No, please SKIP to question # 11

10a. Which ones? (please check all that apply).

 Institute for Healthcare Improvement’s Protecting 5 Million Lives from Harm Initiative for reducing MRSA infection

 VHA Inc. (Voluntary Hospital Association Initiative)

 Maryland Patient Safety Center MRSA Prevention Initiative

 Hospital Corporation of America MRSA Initiative

 Department of Veterans Affairs Initiative (Directive 2007-002)

 Other, please list ____________________________________________________

10b. What year was the program first instituted at your facility? If involved in more than one, please specify the year of the initiation of the first program. ________________

11. How great a priority is the control and prevention of MRSA at your facility? Please indicate how much you agree or disagree with the following statement: The control and prevention of MRSA infection is a priority at my facility.

 Strongly agree

 Agree

 Neither agree or disagree

 Disagree

 Strongly disagree

12. Considering the total amount of time all of your facility’s infection control practitioners have had to spend on all infection control activities in the last year, please indicate the approximate percentage of time they currently spend on MRSA control efforts.

 No time

 1 to 25%

 26 to 50%

 51 to 75%

 76 to 99%

 100%

13. Please indicate the degree to which you agree with the following statements on a scale of strongly agree to strongly disagree.

	Strongly agree	Agree	Neither agree or disagree	Disagree	Strongly disagree
Staff perceive that MRSA is a problem nationally					
Staff perceive that MRSA is a problem at my facility					
Front line patient-care staff are optimistic that they can prevent MRSA					
Staff have been asked to identify ways to control MRSA infections					
Staff ideas have been implemented in MRSA control efforts					
Physicians generally support MRSA control efforts at my facility					
Nurses generally support MRSA control efforts at my facility					
There are physicians who strongly advocate for MRSA control efforts					
There are nurses who strongly advocate for MRSA control efforts					
Leadership provides an environment that allows for creative approaches to MRSA control					
Leadership provides the resources (financial and human resources) necessary for MRSA control					

Section 3: Active Surveillance

The next set of questions will ask about use of MRSA active surveillance cultures.

14. Does your facility currently perform MRSA surveillance testing (culture or PCR) on any group of patients for the purpose of detecting MRSA colonization (active surveillance)? (check one)

 Yes

 No, please SKIP to question # 21

15. Please specify the test used for MRSA surveillance testing. (check one)

 Culture

 Polymerase chain reaction (PCR)

 Both – culture and PCR

 Other, please describe ______________________________

16. Is some form of active MRSA surveillance testing (culture or PCR) performed routinely on patients admitted to all units facility-wide? (check one)

 Yes, please SKIP to question #17

 No

16a. Please specify any specific settings where some form of active MRSA surveillance testing (culture or PCR) is routinely performed. (check all that apply)

 Patients admitted to ICU settings

 Patients admitted to acute care non-ICU settings

 Patients admitted to post-acute care settings

 Patients admitted to other settings, please describe: _____________________________

17. Please select any patient group for which you routinely perform active surveillance testing (culture or PCR). (check all that apply)

 Burn patients

 Bone marrow or stem cell transplant patients

 Oncology patients

 Patients transferred from outside acute-care facilities

 Patients transferred from long-term care facilities

 Roommates of patients with known MRSA colonization or infection

 Dialysis patients

 Patients with a history of MRSA

 Pre-operative patients

 Patients with open wounds

 Other patients, please describe _____________________________

17a. From which site(s) is active surveillance testing (culture or PCR) for MRSA routinely performed? (check all that apply)

 Nares

 Axillae

 Groin

 Pharynx

 Wounds

 Umbilicus

 Other, please describe: ______________________________________

17b. Do you currently routinely screen any healthcare workers for MRSA colonization? (check one)

 Yes

 No

18. Are patients placed in some form of isolation precautions in addition to standard precautions until active surveillance testing (culture or PCR) for MRSA is negative? (check one)

Yes

No

19. When is MRSA active surveillance testing (culture or PCR) currently performed? (check all that apply)

 At admission

 At discharge/transfer

 Periodically during hospital stay

20. Does your facility measure the percentage of eligible patients who actually have active surveillance testing (culture or PCR) performed? (check one)

 Yes

 No

Section 4: Isolation

The next set of questions will ask about the use of infection control precautions for MRSA colonized and infected patients

21. In your facility, are patients who are found to be infected or colonized with MRSA currently put in any isolation precautions in addition to standard precautions? (check one)

 Yes

 No, if no please SKIP to question # 25

22. Which MRSA precautions are currently included in these isolation precautions? (check all that apply)

 Place patient in private room or cohort patients with MRSA when private rooms are not available

 Gown worn by all prior to entering the room

 Gown worn prior to entering the room in some situations (for example, gown not required for those not anticipating patient contact)

 Gloves worn by all prior to entering room

 Gloves worn prior to entering the room in some situations (for example, gloves not required for those not anticipating patient contact)

 Masks worn by all prior to entering the room

 Masks worn prior to entering the room in some situations (not including situations when a mask is required to prevent transmission of a pathogen other than MRSA, i.e., tuberculosis)

 Removal of personal protective equipment (gowns, gloves, etc) prior to exiting the room

 Sign outside the room describing the isolation precautions that were in use

 Other, please describe: ___________________________________________________

23. Do you currently measure adherence to these isolation precautions among staff caring for these patients (meaning did you measure the percentage of those who actually comply with these isolation precautions)? (check one)

 Never

 Rarely

 Sporadically

 Frequently

 Very frequently

24. Does your facility currently have a policy that specifically addresses the discontinuation of isolation precautions that are used in addition to standard precautions for patients infected or colonized with MRSA? (select all that apply)

 Yes

 No, please SKIP to Question # 25

24a. Which best describes your facility’s policy that addresses the discontinuation of isolation precautions that are used in addition to contact precautions for patients colonized or infected with MRSA? (check all that apply)

 My facility never discontinues isolation precautions for a patient found to be infected or colonized with MRSA

 My facility discontinues isolation precautions at hospital discharge/transfer for a patient found to be infected or colonized with MRSA (patient not put into isolation precautions if readmitted)

 My facility discontinues isolation precautions after a patient has a single negative screening culture for MRSA from any site (either on or off antibiotics)

 My facility discontinues isolation precautions after a patient has multiple negative screening cultures for MRSA from any site (either on or off antibiotics)

 My facility discontinues isolation precautions after a patient completes antibiotics for MRSA

 My facility discontinues isolation precautions after a patient undergoes some form of decolonization procedure

 My facility discontinues isolation precautions after some other criteria have been fulfilled, please describe ____________________________________________________________

The next several questions ask about practices for patients who have a previous history of MRSA colonization or infection.

25. Does your facility currently have a mechanism to detect, at admission, patients previously infected or colonized with MRSA? (check one)

 Yes

 No, please SKIP to question # 26

25a. Are these patients (known to be previously colonized or infected with MRSA) put into isolation precautions in addition to standard precautions at admission? (check one)

Yes, all identified patients are put in isolation precautions

Yes, selected identified patients are put in isolation precautions

No, identified patients are not put in isolation precautions

Section 5: MRSA Measures

The next few questions will ask about measuring MRSA at your facility

26. For the following measures of MRSA, please indicate if your facility currently monitors (facility-wide or in targeted areas) each of the measures below over time . (check all that apply)

Measure	Yes	No
Overall proportion of S. aureus that is MRSA		
MRSA colonization and/or infection admission prevalence		
MRSA nosocomial bloodstream infection rate		
Any process measure for MRSA control programs (for example, percent of eligible patients put in isolation)		

If all no, please SKIP to question # 30

27. For any of the above selected measures of MRSA, please indicate to which stakeholders within your institution (groups with a direct interest) each measure(s) is reported. (check all that apply)

Reported to Infection Control Committee	Reported to other hospital committees	Reported to hospital leadership	Reported to unit directors	Reported to direct patient care providers (physicians and nurses)	Reported to other groups
					

28. What mechanisms are used to disseminate the information? (check all that apply)

 Periodic “report cards”

 Antibiogram

 Conferences/educational sessions

 Meetings with hospital/unit leadership

 Meetings with unit staff

 Newsletter or other publication

 Other, please describe ____________________________

29. Are any ward or service (for example, ICU or surgery service) specific MRSA measures reported? (check one)

 Yes

 No

Section 6: Environmental Measures

The next section deals with environmental measures taken to help control MRSA.

30. Does your facility currently use dedicated noncritical medical items (such as blood pressure cuffs or stethoscopes) for patients with MRSA colonization or infection? (check one)

 Yes

 No

31. At your facility, do cleaning procedures currently vary for rooms of patients colonized or infected with MRSA compared to those not colonized or infected? (check one)

 Yes

 No, please SKIP to question # 32

31a. Please indicate how cleaning procedures vary. (check all that apply)

 Terminal cleaning (cleaning after patient left room) differs

 Frequency of room cleaning differs (for other than terminal cleaning)

 Intensity of room cleaning differs (for other than terminal cleaning)

 Cleaning products differ

32. Are the cleaning practices at your facility monitored/observed regularly by infection control staff to ensure consistent cleaning and disinfection practices were followed? (check one)

 Yes

 No

Section 7: Antibiotic Utilization

This section asks about activities aimed at controlling the use of antibiotics.

33. Does your facility have a specific person (or people) responsible for reviewing antibiotic utilization with the goal of promoting the judicious use of antimicrobial agents? (check one)

 Yes

 No

34. Does your facility currently have a specific process in place that prompts clinicians to use the appropriate antibiotic for the appropriate duration for a specific clinical situation? (check one)

 Yes

 No

35. Does your facility currently restrict the use of any antibiotic? (check one)

 Yes

 No

36. Is vancomycin currently used as the preferred antibiotic for pre-operative prophylaxis for any surgical procedure? (check one)

 Yes, please list surgical procedures: ________________________

 No

Section 8: Other Activities

This last section asks about use of other infection control activities that may influence MRSA infections.

37. Does your facility have an education or training program for staff on reducing the transmission of MRSA? (the program may deal with other issues but must specifically review your facility’s program to control MRSA and include topics such as the transmission of MRSA and measures to prevent transmission)

 Yes

 No

38. Does your facility currently have access to expertise in MRSA specific infection control? (check all that apply)

 Yes, from facility staff members

 Yes, from experts outside of the facility

 No

39. Is adherence to hand hygiene policies measured periodically in at least one patient care area? (check one)

 Yes

 No

40. At your institution, is MRSA decolonization currently routinely offered to any specific group of people colonized or infected with MRSA?

 Yes

 No (if no SKIP to question #41)

40a. Which group(s) are offered decolonization (check all that apply)?

 Pre-surgical patients

 Patients on dialysis

 Immunocompromised patients

 Patients with recurrent MRSA infections

 ICU patients

 Staff members known to be colonized or infected

 Other groups, please describe: ___________________________

40b. What method is used for decolonization (check all that apply)?

 Nasal mupirocin,

 Chlorhexidine showers/baths or showers/baths with other skin cleansers (other than soap or detergent)

 Oral decontamination (e.g. chlorhexidine mouth wash)

 Systemic antibiotics (oral or intravenous)

 Other, please describe: _________________)

41. Does your facility currently have a laboratory based system that rapidly (within 24 hours) notifies infection control staff of new MRSA-colonized or MRSA-infected patients? (check one)

 Yes

 No

42. Has your facility implemented a “central line bundle” (full barrier precautions at insertion, chlorhexidine for skin cleansing, daily assessment of need for central line, subclavian as preferred site) for the prevention of central line-associated infections? (check one)

 Yes, the bundle has been implemented facility-wide

 Yes, the bundle has been implemented in specific units

 No

Thank you for your time!