*required for saving **required for completion Facility ID:
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Event #:
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*Patient ID:
| Social Security #:
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Secondary ID:
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Patient Name, Last: First: Middle:
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*Gender: F M Other
| *Date of Birth:
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Ethnicity (specify):
| Race (specify):
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*Event Type: BSI
| *Date of Event:
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Post-procedure BSI: Yes No
| Date of Procedure:
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NHSN Procedure Code:
| ICD-9-CM Procedure Code:
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*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
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*Date Admitted to Facility:
| *Location:
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Risk Factors
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*If ICU/Other locations, Central line: Yes No *If Specialty Care Area, Permanent central line: Yes No Temporary central line: Yes No *If NICU, Non-umbilical Central line: Yes No Umbilical catheter: Yes No Birth weight (grams):
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Location of Device Insertion: __________
Date of Device Insertion: ___/___/______
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Event Details
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*Specific Event: Laboratory-confirmed
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*Specify Criteria Used: Signs & Symptoms (check all that apply) Any patient
□ Fever □ Chills □ Hypotension
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Laboratory (check one)
□ Recognized pathogen from one or more blood cultures □ Common skin contaminant from ≥2 blood cultures
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**Died: Yes No
| BSI Contributed to Death: Yes No
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Discharge Date:
| *Pathogens Identified: Yes No *If Yes, specify on pages 2-3.
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Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 32 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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 CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.108 (Front) Rev. 4 v6.4
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