Form 57.103 Patient Safety Component -- Annual Facility Survey

* required for saving	Tracking #:
Facility ID:	*Survey Year:
Facility Characteristics
*Ownership (check one):       □ For profit         □ Not for profit, including church                 □ Government □ Military               □ Veteran’s Affairs                                     □ Physician owned             □ Managed Care Organization
If facility is a Hospital: *Number of Patient Days: _________ *Number of Admissions:  _________
For any Hospital except Long Term Acute Care Hospitals:
*Is your hospital affiliated with a medical school? :     Yes        No
If Yes, what type of affiliation:        ____ MAJOR         ____ GRADUATE           ____ LIMITED
Number of beds set up and staffed:           a. ICU beds (including adult, pediatric, and               neonatal levels II/III and III):                                         ___________           b. Specialty care beds (including hematology/oncology,               bone marrow transplant, solid organ transplant,               inpatient dialysis, and long term acute care [LTAC]):         ___________           c. All other beds:                                                                ___________
For Hospitals that are Long Term Acute Care (LTAC):          No LTAC or not operational in this survey year Setting: ___ Within a hospital         ___ Free-standing Number of beds set up and staffed:           a. Ventilator beds:                                                              ___________           b. High-observation beds:                                                   ___________           c. All other beds:                                                                ___________
If facility is an Ambulatory Surgery Center (ASC):        No ASC or not operational in this survey year Setting: ___ Within a hospital        ___ Free-standing Total number of procedures: ________       Percent of procedures that are surgical: ________ % What percentage of your ambulatory surgery patients were discharged or transferred to the following places: Home/Customary residence:                                 _______% Recovery care center (facility other than this one): _______ % Acute care hospital (Emergency or inpatient):        _______ %
If facility is a Long Term Care (LTC) Facility:          No LTC or not operational in this survey year Number of resident days: ______                        Average length of stay: ___________
Infection Control Practices *Number of infection  preventionists (IPs) in facility:                        __________            a. Total hours per week performing surveillance:                   __________            b. Total hours per week for infection control activities                other than surveillance:                                                   __________                            Continued  >>
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 40 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 57.103 (Front)  Rev 3, v6.4

 

Facility Microbiology Laboratory Practices
*1.  Does your facility have its own laboratory that performs antimicrobial susceptibility testing?            □ Yes        □ No        If No, where is your facility's antimicrobial susceptibility testing performed?  (check one)  □ Affiliated medical center        □ Commercial referral laboratory *2.  Does the laboratory use CLSI (formerly NCCLS) antimicrobial susceptibility standards?        □ Yes      □ No         If Yes, specify the version of the M100 document that the laboratory uses: (check one) □ M100-S20     □ M100-S19     □ M100-S18     □ M100-S17     □ M100-S16     □ Earlier Version *3.  For the following organisms please indicate which methods are used for: (1) primary susceptibility testing and (2) secondary, supplemental, or confirmatory testing (if performed). If your laboratory does not perform susceptibility testing, please indicate the methods used at the referral laboratory. Please use the testing codes listed below the table.
Pathogen		(1) Primary	(2) Secondary		Comments
Coagulase-negative staphylococci Staphylococcus aureus Enterococcus spp.                                         Enterobacteriaceae                                            Pseudomonas aeruginosa Acinetobacter spp. Stenotrophomonas maltophilia
1 = Kirby-Bauer disk diffusion 2 = Vitek (Legacy) 2.1 = Vitek 2 3.1 = BD Phoenix 4 = Sensititre	5.1 = MicroScan walkaway rapid 5.2= MicroScan walkaway conventional 5.3 = MicroScan auto or touchscan 6 = Other micro-broth dilution method 7 = Agar dilution method			10 = E test 12 = Vancomycin agar screen (BHI + vancomycin) 13 = Other (describe in Comments column)
*4.  Does the laboratory confirm vancomycin-resistant staphylococci using a second method?       □ Yes     □ No        If Yes, please indicate methods:  (check all that apply)
□ Kirby-Bauer disk diffusion   □ Vitek (Legacy)   □ Vitek 2   □ BD Phoenix   □ Sensititre	□ MicroScan walkaway rapid □ MicroScan walkaway conventional □ MicroScan auto or touchscan □ Other micro-broth dilution method □ Agar dilution method			□ E test □ Vancomycin agar screen (BHI + vancomycin) □ Other (specify) ____________________
*5.  Has your laboratory implemented the revised cephalosporin and monobactam breakpoints for        Enterobacteriaceae recommended by CLSI as of 2010?                   □ Yes     □ No

 

Facility Microbiology Laboratory Practices
*6. Does the laboratory perform a special test for ESBL production?  □ Yes     □ No        If Yes, please indicate what is done if ESBL production is detected: (check one)         □ Change susceptible and intermediate interpretations for third generation cephalosporins and aztreonam to resistant         □ Suppress the results for third generation cephalosporins and aztreonam for the report         □ No changes are made in the interpretation of cephalosporins and aztreonam, the test is used for epidemiological or infection control purposes *7. Has your laboratory implemented the revised carbapenem breakpoints for Enterobacteriaceae recommended by CLSI as of 2010?       □ Yes    □ No *8. Does your laboratory perform a special test for carbapenemase production?      □ Yes    □ No        If Yes, please indicate what is done if carbapenemase production is detected: (check one)         □ Change susceptible carbapenem results to resistant         □ Report carbapenem MIC results without an interpretation         □ No changes are made in the interpretation of carbapenems, the test is used for epidemiological or                       infection control purposes *9. Does your laboratory perform colistin or polymyxin B susceptibility testing for drug-resistant gram negative      bacilli?         □ Yes    □ No        If Yes, please indicate methods: (check all that apply)
□ Kirby-Bauer disk diffusion         □ Vitek (Legacy)         □ Vitek 2         □ BD Phoenix         □ Sensititre	□ MicroScan walkaway rapid □ MicroScan walkaway conventional □ MicroScan auto or touchscan □ Other micro-broth dilution method □ Agar dilution method	□ E test □ Vancomycin agar screen (BHI + vancomycin) □ Other (specify) ____________________
*10. Does your facility have its own laboratory that performs antifungal susceptibility testing for Candida species?         □ Yes   □ No           If No, where is your facility's antifungal susceptibility testing performed? (check one)         □ Affiliated medical center    □ Commercial referral laboratory     □ Not offered by my facility           11. If antifungal susceptibility testing is performed at your facility or an outside laboratory, what methods are used?  (check all that apply)          □ Broth macrodilution     □ Broth microdilution     □ YeastOne colorimetric microdilution     □ E test         □ Vitek 2 card     □ Disk diffusion     □ Other ________________________

 

1. Facility Microbiology Laboratory Practices

1. *12. Is antifungal susceptibility testing performed automatically/reflexively for Candida spp. cultured from  

            normally sterile body sites (such as blood), without needing a specific order or request for susceptibility testing from the clinician?    □ Yes   □ No

            If Yes, what antifungal drugs are tested automatically/reflexively? (check all that apply)

            □ Fluconazole     □ Itraconazole      □ Voriconazole         □ Posaconazole  □ Caspofungin

            □ Micafungin      □ Anidulafungin    □ Amphotericin B     □ Flucytosine      □ Other ______________

1. *13. Which C. difficile testing method is used at your facility’s laboratory or the outside laboratory where your facility’s testing is performed?  (check all that apply and confirm with the laboratory that conducts the testing)        

            □ EIA for toxin       □ Cytotoxin assay            □ Stool antigen       □ Culture

            □ Nucleic acid amplification (e.g., PCR)        □ Other  (specify) __________________________

 

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File Title	Slide 1
Author	CDC
Last Modified By	ano3
File Modified	2010-08-17
File Created	2004-07-27

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