Form #7 Form #7 Nurse survey

ATTACHMENT I:

NURSE SURVEY

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

Standardizing Antibiotic Use in Long-Term Care, SAUL Study

Nurse Survey

The first set of survey questions provides background information about your training and your experience.

1. What is your title?

2. How long have you been in practice?

3. How long have you been working/providing care for residents in this facility?

4. What professional degree/s do you have, and in what year did you receive them?

5. How long have you worked in any long-term setting?

The following four questions refer to specific conditions under which an antibiotic is frequently ordered. For each type of infection (urinary tract, respiratory, skin and fever of unknown origin), please check the column that most appropriately describes the importance of the sign/symptom(s) in your decision to contact the physician. Please check column B, “Not relevant” if the sign/symptom is irrelevant to the decision to contact the physician; check column C, “Relevant by itself” if the sign/symptom is important enough by itself to merit calling the physician; check column number D, “Relevant in combination with other symptom(s)” if the sign/symptom is important in the decision to contact the physician only in combination with other signs/symptom(s). If column D is checked, please indicate the additional sign/symptom(s) (by number from column A) that are important in combination with the sign/symptom listed in column A for that row.

Public reporting burden for this collection of information is estimated to average 15 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

6. Please check the column that most appropriately describes the importance of the sign/symptom(s) in your decision to contact the physician regarding a resident who you suspect may have a urinary tract infection (UTI) who does not have an indwelling catheter.

A Sign/Symptom	B Not relevant	C Relevant by itself	D Relevant in combination with other symptom(s)
				Please note the sign/symptom number(s)
1. New or worsening urinary frequency or urgency
2. Burning or pain on urination
3. Incontinence in previously continent resident
4. Fever greater than 100°F or 2.4° increase above baseline temperature
5. Cloudy urine
6. Hematuria
7. Foul-smelling urine
8. Complaints of abdominal, back or flank pain
9. Change in mental status
10. New onset of delirium
11. Nausea and/or vomiting
12. Urinalysis positive for nitrites and/or leukocyte esterase
13. Urine culture showing a colony count  100,000/ml of a single organism

7. Please check the column that most appropriately describes the importance of the sign/symptom(s) in your decision to contact the physician regarding a resident who you suspect may have a urinary tract infection (UTI) who does have an indwelling catheter.

A Sign/Symptom	B Not relevant	C Relevant by itself	D Relevant in combination with other symptom(s)
				Please note the sign/symptom number(s)
1. New or worsening frequency or urgency
2. Burning or pain on urination
3. Incontinence in previously continent resident
4. Fever greater than 100°F or a 2.4°F increase above baseline temperature
5. Rigors (shaking chills)
6. Cloudy urine
7. Hematuria
8. Foul-smelling urine
9. Complaints of abdominal, back or flank pain
10. Change in mental status
11. New onset of delirium
12. Nausea and/or vomiting
13. Urinalysis positive for nitrites and/or leukocyte esterase
14. Urine culture showing a colony count  100,000/ml of a single organism

7. Please check the column that most appropriately describes the importance of the sign/symptom(s) in your decision to contact the physician regarding a resident who you suspect may have a respiratory infection?

A Sign/Symptom	B Not relevant	C Relevant by itself	D Relevant in combination with other symptom(s)
				Please note the sign/symptom number(s)
1. Fever greater than 102° F
2. Fever greater than 100°F, but less than or equal to 102°F.
3. Afebrile
4. Respiratory rate greater than 25 breaths/minute
5. Presence of a cough
6. Presence of a cough with sputum production
7. Pulse greater than 100 beats per minute
8. Change in cognition
9. New onset of delirium
10. Rigors (shaking chills)
11. Chest X-Ray positive for pneumonia
12. Leukocytosis (14,000 mm3)
13. COPD Diagnosis

7. Please check the column that most appropriately describes the importance of the sign/symptom(s) in your decision to contact the physician regarding a resident who you suspect may have a skin/soft tissue infection.

   A Sign/Symptom	B Not relevant	C Relevant by Itself	D Relevant in combination with other symptom(s)
   				Please note the sign/symptom number(s)
   1. New or increasing purulent drainage of a wound, skin or soft-tissue site
   2. Fever greater than 100°F or an increase of 2.4° F above baseline temperature
   3. Redness of affected site
   4. Tenderness at affected site
   5. Warmth at affected site
   6. Swelling that is new or increasing at affected site

8. Please check the column that most appropriately describes the importance of the sign/symptom(s) in your decision to contact the physician regarding a resident who you suspect may have a fever of unknown origin.

A Sign/Symptom	B Not relevant	C Relevant by itself	D Relevant in combination with other symptom(s)
				Please note the sign/symptom number(s)
1. Fever greater than 100°F or an increase of 2.4° F above baseline temperature
2. New onset of delirium