Form #4 Form #4 Culture Questionnaire

MRSA Prevention Initiative Survey Hospital Name: _______________ Unit Name: _________

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Indianapolis ACTION Collaborative Staff Survey

MRSA Prevention Initiative

Thank you for taking the time to complete this survey. We are asking everyone who has contact with patients or patient rooms at participating Community East units to complete the survey.

Although doing the survey is not required as part of your job (i.e., voluntary), your answers are very important to us. Your answers are anonymous and will not be shared with co-workers, managers, or other facility staff. The survey results will be used for research purposes only. Completing and returning the survey acts as your consent for us to use your results in our research.

The questions ask about what you think and do at your job regarding the spread of a germ that doesn’t respond to medicines. The bacteria (germ) is called Methicillin Resistant Staphylococcus aureus or MRSA. There are also a set of questions about your opinions about your unit(s).

The survey results will be helpful for both patients and staff. Your answers will be used to help us understand how to decrease infections in your hospital system and other hospitals as successful results are disseminated.

Public reporting burden for this collection of information is estimated to average XX minutes per response, the estimated time required to complete the survey. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

The following questions ask about how MRSA is spread and prevented:

How is MRSA most often spread to patients?

(1) Overuse of antibiotics

(2) Through the air

(3) Bedside equipment

(4) Healthcare worker hands

How long can MRSA live outside the body on surfaces?

(1) Seconds

(2) Minutes

(3) Hours

(4) Days

Which hand hygiene method is MOST EFFECTIVE in killing MRSA?

(1) Alcohol hand rub

(2) Plain soap and water

(3) Antimicrobial soap and water

(4) None of the above

Which of the following precautions should be taken before contact with MRSA patients or items in their room?

(1) Cleaning hands

(2) Gloving

(3) Gowning

(4) All of the above

People who have MRSA but do NOT have symptoms can spread MRSA.

(0) False

(1) True

The following questions ask about what you think and do regarding MRSA:

What percent of the time have you cleaned your hands (washed hands or used alcohol hand rub) when entering and exiting a patient room in the past 30 days?

% (0-100%)

What percent of the time have you gowned and gloved before contact with a MRSA patients or items in their room in the past 30 days?

% (0-100%)

In the past 30 days, when you cleaned your hands when entering and exiting a patient room, which product do you use most often? (Please check one)

(1) Soap and water

(2) Alcohol hand rub (gel or foam)

There are many reasons why you might not always clean your hands using alcohol hand rub or soap. How often is each of the following the reason for not cleaning your hands?

For each item below, please check the answer that best applies on a scale from Never to Always.	Never (1)	Rarely (2)	Sometimes (3)	Often (4)	Always (5)
Too busy
Forget
Lack of alcohol hand rub or soap
Alcohol hand rub or soap not easy to get to
Using alcohol hand rub or soap damages my skin (causes skin dryness, redness, or cracking)
Alcohol hand rub or soap smells bad
Other (please specify) ___________________________

Please note: ‘staff’ refers to an employee who has contact with patients or patient rooms and ‘unit(s)’ refers to your unit. Please think of the unit that you spend the most time on when answering these questions.

For each item below, please check the answer that best applies on a scale from Strongly Disagree to Strongly Agree.	Strongly Disagree (1)	Disagree (2)	Unsure (3)	Agree (4)	Strongly Agree (5)
MRSA is a national problem.
MRSA is a problem in this unit(s).
If I clean my hands as recommended, I will decrease my patients’ risk of getting MRSA.
If I clean my hands as recommended, I will decrease my risk of getting MRSA.
If I wear gowns and gloves as recommended, I will decrease my patients’ risk of getting MRSA.
If I wear gowns and gloves as recommended, I will decrease my risk of getting MRSA.
When other staff in this unit(s) do not clean their hands, I feel comfortable reminding them.
When other staff in this unit(s) do not gown and glove before touching a MRSA patient, I feel comfortable reminding them.
Staffing shortages contribute to MRSA transmission in this unit(s).
The way patients are transported contributes to MRSA transmission in this unit(s).
It takes me too much time to clean my hands before contact with a MRSA patient or items in their room.
It takes me too much time to gown and glove before contact with a MRSA patient or items in their room.
Too much attention is being placed on MRSA prevention in this unit(s).
I am satisfied with my job in this unit(s).

These next questions ask about your opinions regarding CICU. Please think of the unit that you spend the most time on when answering these questions.

For each item below, please check the answer that best applies on a scale from Strongly Disagree to Strongly Agree.	Strongly Disagree (1)	Disagree (2)	Unsure (3)	Agree (4)	Strongly Agree (5)
This unit(s) encourages staff input for making changes and improvements.
It's hard to make any changes in this unit(s) because we're so busy seeing patients.
The leadership in this unit(s) is available for consultation on problems.
When there is a conflict in this unit(s), the people involved talk it out and resolve the problem successfully.
The staff in this unit(s) are involved in initiating plans for improving quality.
The staff in this unit(s) feel overwhelmed by the work demands.
I’m optimistic that the staff in this unit(s) can make positive changes in the way we relate to each other.
The staff in this unit(s) have constructive work relationships.
There is tension between the staff in this unit(s).
Unit(s) leadership discourages staff in this unit(s) from taking initiative.
This unit(s) is stressful.
The decisions in this unit(s) are made at the top with little input from those doing the work.
The staff in this unit(s) operate as a real team.
This unit(s) is in chaos.
I’m optimistic that the staff in this unit(s) can take the initiative to improve patient care.
This unit(s) defines success as teamwork and concern for people.
This unit(s) is not open to making changes in the way we deliver patient care.
Things have been changing so fast in this unit(s) that it is hard to keep up with what is going on.
I’m optimistic that the staff in this unit(s) can prevent MRSA.
Hospital leaders visit this unit(s) regularly to help improve the quality of patient care.
Hospital leaders help us implement our own solutions to improve the quality of patient care.
For each item below, please check the answer that best applies on a scale from Strongly Disagree to Strongly Agree.	Strongly Disagree (1)	Disagree (2)	Unsure (3)	Agree (4)	Strongly Agree (5)
Ideas coming from staff working on this unit(s) have been implemented to improve the quality of patient care.
This unit promptly reports significant changes in antimicrobial resistance
This unit provides appropriate resources to prevent antimicrobial resistance
This unit provides appropriate resources to control antimicrobial resistance
Nurse Managers reinforce infection control policies on this unit
Chiefs of Service (Directors) reinforce infection control policies on this unit
Top-level administrators actively support infection control activities on this unit

This last set of questions asks about you and your role within your hospital:

What is your current job title?

(1) Nursing Assistant (NA or Patient Care Technician) (9) Speech Therapist

(2) Licensed practical nurse (LPN) (10) Physical/Occupational Therapist

(3) Registered nurse (RN) (11) Phlebotomist

(4) Certified nurse practitioner (CRNP) (12) Radiology (X-ray) Technician

(5) Physician’s Assistant (13) Pharmacist

(6) Intern/Resident/Fellow (MD) (14) Clinical Dietician

(7) Attending or Staff Physician (MD) (15) Environmental Management

(8) Respiratory Therapist (16) Escort

(17) Other (please specify) _________________________________

In the past 30 days, what percentage of your work time was spent on this unit(s)?

% (0-100%)

In the past 30 days, which shift did you work most often?

(1) Day (2) Evening (3) Night

On average, how many hours do you currently spend in direct patient care per week?

(1) 0 (2) 1-10 (3) 11-20

(4) 21-30 (5) 31-40 (6) More than 40 hours

How many total years have you worked in the healthcare field?

(1) Less than 6 months (2) 6 months -1 year (3) 1-3 years

(4) 3-5 years (5) 5-10 years (6) 10-20 years

(7) More than 20 years

How old are you now?

(1) Less than 20 years old (2) 20-29 years old (3) 30-39 years old

(4) 40-49 years old (5) 50-59 years old (6) More than 59 years old

++++Thank you for completing this survey. Your answers are very important to the success of this MRSA program at your facility and other hospital systems.++++

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