Form CDC 57.127 CDC 57.127 MDRO and CDI Prevention Process and Outcome Measures Mon

*required for saving          **conditionally required based upon monitoring selection in Monthly Reporting Plan Facility ID #: __________   *Month:_______  *Year:________  *Location Code:_______
Setting: Inpatient **Total Patient Days: __________ **Total Admissions: __________ Setting: Outpatient (or Emergency Room)  **Total Encounters: ___________   If monitoring C. difficile in a FACWIDE location, then subtract NICU & Well Baby counts from Totals: **§Patient Days:_______ **§Admissions:_______ **§Encounters:_______
MDRO & CDI Infection Surveillance or LabID Event Reporting
Specific Organism Type	MRSA		VRE		CephR- Klebsiella		CRE- Ecoli	CRE-Klebsiella	MDR- Acinetobacter		C. difficile
Infection Surveillance											
LabID Event (All specimens)											
LabID Event (Blood specimens only)									
Process Measures (Optional)
Hand Hygiene **Performed:_____ **Indicated:_____						Gown and Gloves **Used:_____ **Indicated:_____
Active Surveillance Testing (AST)
**Active Surveillance Testing performed				
**Timing of AST † (circle one)		Adm Both		Adm Both
**AST Eligible Patients ‡ (circle one)		All NHx		All NHx
Admission AST
**Performed
**Eligible
Discharge/Transfer AST
**Performed
**Eligible

 

Outcome Measures (Optional)
Prevalent Cases
(Specific Organism Type)	MRSA	VRE
**AST/Clinical Positive
**Known Positive
Incident Cases
**AST/Clinical Positive
Custom Fields
Label _________   _________   _________   _________   _________ Data  _________   _________   _________   _________   _________

 

File Type	application/vnd.ms-powerpoint
File Title	Slide 1
Author	Jasie L. Jackson
Last Modified By	ano3
File Modified	2010-12-12
File Created	2006-12-04

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