Ltc Toi Uti

NHSN Long Term Care Facility Component

Tables of Instructions

Table XX . Instructions for Completion of the Urinary Tract Infection for LTCF form (CDC 57.140)

Data Field

Instructions for Form Completion

Facility ID

The NHSN-assigned facility ID number will be auto-entered by the computer.

Event #

Event ID number will be auto-entered by the computer.

Resident ID

Required. Enter the alphanumeric resident ID. This is the resident identifier assigned by the hospital and may consist of any combination of numbers and/or letters. This should be an ID that remains the same for the resident across all visits and admissions.

Social Security #

Required. Enter the 9-digit numeric resident Social Security Number.

Medicare number

Optional. Enter the resident Medicare number or comparable railroad insurance number

Resident Name, Last

First, Middle

Optional. Enter the name of the resident. If available, data will be auto-entered from Resident Form.

Gender

Required. Circle M (Male) or F (Female) to indicate the gender of the resident.

Date of Birth

Required. Record the date of the resident birth using this format: MM/DD/YYYY.

Resident type

Required. Circle short-stay (less than 90 days) or long-stay (greater than 90 days) to indicate the resident type

Date of first admission to Facility

Required. The date of first admission is the date the resident first entered the facility and stayed without a break greater than 15 consecutive months using this format: MM/DD/YYYY

Date of current admission

Required. Record the current (i.e. the most recent) date the resident was re-admitted to this LTCF using this format: MM/DD/YYYY

Example: If the resident was transferred to an acute care facility and then re-admitted to your facility 4 days later (a re-entry) the date of re-entry is considered the current admission date. If the resident has not been discharged or transferred out of your facility, then the date of current admission would be the same as the date of first admission to facility..

Ethnicity (specify)

Optional. Enter the resident’s ethnicity:

Hispanic or Latino

Not Hispanic or Not Latino

Race (specify)

Optional. Enter the resident’s race: Select all that apply.

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Event Type

Event Type

Required. UTI

Resident care location

Optional. Enter the resident care area where the resident was assigned when the laboratory-identified MDRO or C. difficile event specimen was collected

Primary resident service type

Required. Check just one of the primary resident services types that best represents the type of service the resident receives. Long-term general nursing, long-term dementia, long-term psychiatric, skilled nursing/short-term rehab (subacute), ventilator, bariatric, hospice/palliative

Has resident been transferred from an acute care facility in the past 3 months?

Required. Circle “Yes” if the resident has been an inpatient of an acute care facility and transferred to your facility in the past three months, otherwise circle “No”.

Urinary catheter status

Required. Check “In place” if urinary catheter was in place at time of urine specimen collection; Check “Removed within 48 hours prior “ if a urinary catheter was removed within the 48 hours before urine specimen was collected; Check “Not in place nor within 48 hours prior” if no urinary catheter was in place at the time of or within the 48 hours prior to urine specimen collection.

Site where Device Inserted

Required. Check “Your facility” if catheter placed in your LTCF; Check “acute care” if catheter placed in an acute care hospital prior to admission to your LTCF; Check “other facility” if catheter placed at another extended care facility prior to admission to your LTCF; Check “clinic/community” if catheter placed at on outpatient clinic or resident admitted to your LTCF from home with a catheter in place.

Device Type

Required. Check “indwelling” if the catheter is a temporary or permanent catheter placed either through the urethra, “suprapubic” if placed through the skin of the suprapubic region; Check “condom” if it is a condom catheter placed over the penis but not inserted through the urethra, appropriate for males only.

Date of device insertion

Optional. Enter the date the indwelling urethral catheter was inserted.

Event Details

Event details: Specific event: UTI

Will be determined by system

Event details: UTI Specify criteria used

Required. Check each of the elements of the criteria that were used to identify the specific type of UTI being reported.

Event Details:

Secondary Bloodstream infection

Required. Check Y if there is a culture-confirmed bloodstream infection (BSI) and a related healthcare-associated UTI, otherwise check N.

Event Details:

Transfer to acute care facility

Required. Check Y if resident transferred to acute care facility for any reason within 30 days of event, otherwise check N.

Event Details:

Transfer date

Conditionally required. If patient transferred, date patient transferred from the LTCF.

Event Details:

Died

Required. Check Y if patient died from any cause within 30 days of the event, otherwise check N.

Event Details:

Pathogens identified

Required. Enter Y if pathogen identified, N if otherwise. If Y, specify organism name on reverse. For SUTI with secondary BSI and ABUTI, enter only the matching organism(s) identified in both urine and blood cultures (See Table 2a for instructions).

Custom fields and labels

Optional. Up to two date fields, two numeric fields, and 10 alphanumeric fields that may be customized for local use.

NOTE: Each Custom Field must be set up in the Facility/Custom Options section of the application before the field can be selected for use.

Comments

Optional. Enter any information on the event.

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