Form 1 2010 HAI & Antimicrobial Use Point Prevalence Survey: Pr

Prevalence Survey of Healthcare Associated Infections (HAIs) and Antimicrobial Use in U.S. Acute Care Hospitals

Attachment C_PrevSurveyForms (2)

Infection Control Practioners Prevalence Survey #2, Phase 3

OMB: 0920-0852

Document [docx]
Download: docx | pdf

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx



2

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

010 HAI & ANTIMICROBIAL USE POINT PREVALENCE SURVEY:

PRIMARY TEAM DATA COLLECTION FORM


CDC ID: - Survey date: //


I. Identifiers (for Primary Team and EIP Team use only; Identifiers are not transmitted to CDC)


Patient name: ___________________________________

(Last, First, MI)



Date of birth: //


Hospital name: __________________________________


Hospital unit name: ______________________________


Room number: __________________________________


Medical record no.: ______________________________



Data collector initials: ____________________________



II. Demographics




Age: _______ years months days



Admission date: //


Gender: M F Unknown


CDC location code: __________________________



III. Risk factors (in place on the survey date)

Urinary catheter:

No Yes Unknown


Ventilator:

No Yes Unknown

Central line:

No Yes


Unknown

If “Yes,” check all that apply:

PICC Femoral line Other central line



IV. Antimicrobials

On antimicrobials on the survey date or the calendar day prior to the survey date:

No Yes Unknown


**Qualification for hemodialysis and peritoneal dialysis patients ONLY**


On any of the following antimicrobials in the 4 calendar days prior to the survey date: vancomycin, amikacin, gentamicin, tobramycin, streptomycin, kanamycin



NA, not a dialysis patient



No Yes Unknown


F

Public reporting burden of this collection of information is estimated to average 5 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-xxxx.


ORM IS COMPLETE

2

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

010 HAI & ANTIMICROBIAL USE POINT PREVALENCE SURVEY:

EIP TEAM ANTIMICROBIAL USE FORM



Date: // Data collector initials: ________


CDC ID: -



Check here if no antimicrobials administered/scheduled to be administered. Otherwise, fill in table(s) below, for up to 6 antimicrobial agents.


Therapeutic site codes:

BJI = Bone or joint, BSI = Bloodstream infection, CNS = Central nervous system, CVI = Cardiovascular (other than BSI), DIS = Systemic, disseminated infection, ENT = Eyes, ears, nose, throat (includes upper respiratory infection, GTI = Gastrointestinal tract, HEB = hepatic and biliary system infections (including pancreas), IAB = intraabdominal infection other than GTI and HEB (e.g., spleen abscess), LRI = Lower respiratory infection, REP = Reproductive tract infection, SST = Skin or soft tissue infection (includes muscle infection), UTI = Urinary tract infection, UND = Undetermined, Other = specify other site.




C

Public reporting burden of this collection of information is estimated to average 15 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-xxxx.


ontinued on next page

CDC ID: -

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx







If Rationale for ANY drug listed above is “None documented” or “Treatment of active infection” GO TO HAI FORM.


If Rationale for ALL drugs listed above is “Medical prophylaxis” or “Surgical prophylaxis” DON’T fill out HAI Form. Data collection complete.




2

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

010 HAI & ANTIMICROBIAL USE POINT PREVALENCE SURVEY:

EIP TEAM HAI FORM


Date: // Data collector initials: ________


CDC ID: -


Does the patient have an HAI?

No data collection complete

Yes complete the table below.


Enter only one HAI on each HAI Form. This is HAI Form # _____ out of _____ total HAI Forms for this patient.

HAI

Specific Site

Device and Procedure Information

Comments


UTI

SUTI

ABUTI

OUTI

Catheter-associated?

No Yes


PNEU

PNU1

PNU2

PNU3

Ventilator-associated?

No Yes



BSI


LCBI

CSEP

Central line-associated?

No Yes



SSI

SUP INC

DEEP INC

ORGAN/SPACE

(for ORGAN/SPACE, specify site : ___________ )

NHSN operative procedure category code :


OR (if operative procedure but not NHSN) check the following: OTH


BJ


BONE

JNT

DISC




CNS

IC

MEN

SA




CVS

VASC

ENDO

CARD

MED




EENT

CONJ

EYE

EAR

ORAL

SINU

UR



GI

GE

GIT

HEP

IAB

NEC



LRI

BRON

LUNG



REPR

EMET

EPIS

VCUF

OREP



SST

SKIN

ST

DECU

BURN

BRST

UMB

PUST

CIRC



SYS

DI






Was there a Secondary Bloodstream Infection associated with this HAI? No Yes Unknown



Enter up to three pathogen codes for this HAI: 1) ________ 2)________ 3) _________ OR No pathogen identified



Enter the CDC location of attribution for this HAI: _______________ Unknown Not applicable (i.e., SSI)

Date: // Data collector initials: ________

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx


CDC ID: -

Antimicrobial Susceptibility Testing—Instructions:

  1. Check the appropriate box(es) to indicate which of the pathogen(s) below (if any) caused this HAI. “E. coli”=Escherichia coli;E. faecium”=Enterococcus faecium; “E. faecalis”=Enterococcus faecalis; “P. aeruginosa”=Pseudomonas aeruginosa; “S. aureus”=Staphylococcus aureus.

  2. Check the appropriate susceptibility test results for the antimicrobial agents listed: S=sensitive/susceptible. I=intermediate, R=resistant, N=not tested.

  3. Antimicrobial agent abbreviations: AMK=amikacin, AMP=ampicillin, AMPSUL=ampicillin/sulbactam,CEFEP=cefepime, CEFOT=cefotetan, CEFTAZ=ceftazidime, CEFTRX=ceftriaxone, CIPRO=ciprofloxacin, CLINDA=clindamycin, DAPTO=daptomycin, DOXY=doxycycline, ERYTH=erythromycin, GENT=gentamicin, IMI=imipenem, LEVO=levofloxacin, LNZ=linezolid, MERO=meropenem, OX=oxacillin, PENG=penicillin G, PIP=piperacillin, PIPTAZ=piperacillin/tazobactam, QUIDAL=quinupristin/dalfopristin, RIF=rifampin, TETRA=tetracycline, TMZ=trimethoprim/sulfamethoxazole, VANC=vancomycin.


Check here if NONE of the organisms below are pathogens for this HAI (data collection is now complete).

Acinetobacter

baumannii

other

AMK

AMPSUL

CEFEP

CEFTAZ

CIPRO


COL/PB

GENT

IMI

LEVO

MERO

PIPTAZ

TOBRA

TIG

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N


E. coli

AMK

AZT

CEFEP

CEFOT

CEFTAZ

CEFTRX

CIPRO

GENT

IMI

LEVO

MERO

TOBRA

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

Positive test for extended-spectrum beta lactamase (ESBL) production?

Yes No Don’t know

Positive test for carbapenemase production?

Yes No Don’t know




E. faecium

AMP

DAPTO

LNZ

PENG

QUIDAL

VANC

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N


E. faecalis

AMP

DAPTO

LNZ

PENG

VANC

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N


Klebsiella

pneumoniae

oxytoca

other

AMK

AZT

CEFEP

CEFOT

CEFTAZ

CEFTRX

CIPRO

GENT

IMI

LEVO

MERO

TOBRA

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

Positive test for extended-spectrum beta lactamase (ESBL) production?

Yes No Don’t know

Positive test for carbapenemase production?

Yes No Don’t know




P. aeruginosa

AMK

AZT

CEFEP

CEFTAZ

CIPRO

GENT

IMI

LEVO

MERO

PIP

PIPTAZ

TOBRA

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N


S. aureus

CLIND

DAPTO

DOXY

ERYTH

GENT

LNZ

OX

QUIDAL

RIF

TETRA

TMZ

VANC

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N

S

I

R

N



FORM IS COMPLETE

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AuthorShelley Magill
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