* required for saving *Facility ID:
| | Event #:
|
*Resident ID:
| | *Social Security #:
|
Medicare number (or comparable railroad insurance number):
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Resident Name, Last: First: Middle:
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*Gender: F M Other
| | | *Date of Birth:
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*Resident type: Short-stay (<90 days) Long-stay (>90 days)
|
*Date of Original Admission to Facility: ___/___/_____
|
Ethnicity (specify):
| | | Race (specify):
|
*Event Type: UTI
| | *Date of Event:
|
*MDRO Infection Surveillance:
□ Yes, this infection’s pathogen & location are in-plan for Infection Surveillance in the MDRO/CDI Module □ No, this infection’s pathogen & location are not in-plan for Infection Surveillance in the MDRO/CDI Module
|
*Resident Care Location:
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*Primary Resident Service Type: (Check one) Long-term general nursing Long-term dementia Long-term psychiatric Skilled nursing/Short-term rehab (subacute) Ventilator Bariatric Other
|
*Has resident been transferred from an acute care facility in the past 3 months? Yes No If Yes, date of last transfer from acute care to your facility: ___/___/_____
|
*Urinary Catheter status at time of specimen collection: In place Removed within 48 hours prior Not in place nor within 48 hours prior *Site where Device Inserted (Check one): Your facility Acute care Other facility Clinic/community *Device Type: Indwelling/Suprapubic Condom (males only) Date of Device Insertion: ___/___/_____
|
Event Details
|
*Specific Event: Symptomatic UTI (SUTI) Asymptomatic Bacteremic UTI (ABUTI)
|
*Specify Criteria Used: (check all that apply) Signs & Symptoms
>37.2C [> 99F] on repeated occasions, or an increase of >1.1oC (>2oF) over baseline
New onset confusion / functional decline
Acute pain, swelling, or tenderness of the testes, epididymis,
or prostate Acute dysuria Purulent drainage at catheter insertion site
New and/or marked increase in (check all that apply):
Incontinence Visible (gross) hematuria
|
Laboratory & Diagnostic Testing
Positive culture with ≥105CFU/ml with single predominant microorganism or 2 species of gram negative microorganisms from voided specimen Positive culture with ≥102 CFU/ml of any microorganisms from in/out catheter specimen Positive culture with ≥105 CFU/ml of any microorganisms from newly placed indwelling catheter specimen Leukocytosis (>14,000 cells/mm3), or
Left shift (>6% or 1,500 bands/mm3) Positive blood culture with 1 matching organism in urine culture
|
Secondary Bloodstream Infection: Yes No
| | |
*Transfer to acute care facility: Yes No If yes, date of transfer:___/___/_____
| Died: Yes No
| UTI Contributed to Death: Yes No
|
| | *Pathogens Identified: Yes No *If Yes, specify on pages 2-3.
|
| |
