*Specify Event: (check one or more)
IV antimicrobial start. Was IV vancomycin started? Yes No
Patient with a positive blood culture:
* Suspected source of positive blood culture (check one):
Vascular access A source other than the vascular access Contamination Uncertain
If positive blood culture, specify pathogen on pages 2-3.
Pus, redness, or increased swelling at vascular access site
Check the access site(s) with pus, redness, or increased swelling:
fistula graft tunneled central line nontunneled central line hybrid access
*Problem(s): (check one or more)
Fever >37.8°C (100°F) oral Chills or rigors Drop in blood pressure
Wound (NOT related to vascular access) with pus or increased redness
Cellulitis (skin redness, heat, or pain without open wound)
Pneumonia or respiratory infection
Other (specify) ___________________________________________________
