57.150 Patient Safety Component -- Annual Facility Survey for LTAC

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Patient Safety Component—Annual Facility Survey for LTAC

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*required for saving								Tracking #:
*Facility ID:								*Survey Year:
Facility Characteristics
*Ownership (check one):
□ For profit	□ Not for profit, including church				□ Government		□ Veterans Affairs
*Affiliation (check one):			□ Independent		□ Multi-facility organization (specialty hospital network)
□ Hospital system
*Setting/classification:		____ Free-standing		____ Within a hospital
If classified as “Free-standing,” does your LTAC hospital share physical housing with one or more of the following on-site facilities or units (check all that apply)?
□ No
□ Skilled nursing facility (SNF)/nursing home
□ Residential facility (assisted living)
□ Inpatient rehabilitation facility
□ Neuro-behavioral unit or facility
□ Other (please specify: _______________________________________)
If classified as “Within a hospital,” is your LTAC hospital located: In a building that does not provide acute care services (e.g., psychiatric hospital)?										□ Yes	□ No
Near (but not within) an acute care hospital?										□ Yes	□ No
In the previous calendar year, indicate:
*Number of patient days: ___________
*Number of admissions: ___________
*Average daily census: ___________
*Numbers of LTAC beds in the following categories (categories should equal total):
a. Intensive care unit (ICU) or critical care beds:									_________
b. High observation/special care/high acuity beds (not ICU):									_________
c. General LTAC beds:									_________
*Total number of LTAC beds (licensed capacity):									_________
*Number of single occupancy rooms:									_________
*Number of trained or certified infection preventionists (IPs) in facility:									_________
a. Total hours per week performing surveillance:									_________
b. Total hours per week for infection control activities other than surveillance:									_________
*Does you facility perform active surveillance testing (culturing) of new patients on admission for colonization with any of the following multi-drug resistant organisms (MDROs)? (check all that apply)
□ Methicillin-resistant Staphylococcus aureus (MRSA)
□ Vancomycin-resistant Enterococcus (VRE)
□ Carbapenem-resistant Enterobacteriaceae (CRE)
□ Other multidrug-resistant gram-negative rods
□ We do not screen new admissions for MDROs
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 30 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 57.150 (Front) Rev. 1 , v7.1

Patient Safety Component—Annual Facility Survey for LTAC

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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)

□ On-site, host hospital

□ Off-site, within same hospital system

□ Off-site, contracted hospital

□ Commercial referral laboratory

□ Other (specify): _________________________________

*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: M100- S________

*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

5.1 = MicroScan walkaway rapid

10 = E test

2 = Vitek (Legacy)

5.2 = MicroScan walkaway conventional

12 = Vancomycin agar screen (BHI + vancomycin)

2.1 = Vitek 2

5.3 = MicroScan auto or touchscan

13 = Other (describe in Comments section)

3.1 = BD Phoenix

6 = Other micro-broth dilution method

4 = Sensititre

7 = Agar dilution method

*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

□ MicroScan walkaway rapid

□ E test

□ Vitek (Legacy)

□ MicroScan walkaway conventional

□ Vancomycin agar screen (BHI + vancomycin)

□ Vitek 2

□ MicroScan auto or touchscan

□ Other (specify): _________________

□ BD Phoenix

□ Other micro-broth dilution method

□ Sensititre

□ Agar dilution method

*5. Has your laboratory implemented the revised cephalosporin and monobactam breakpoints for Enterobacteriaceae recommended by CLSI as of 2010?

□ Yes

□ No

Patient Safety Component—Annual Facility Survey for LTAC

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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

□ MicroScan walkaway rapid

□ E test

□ Vitek (Legacy)

□ MicroScan walkaway conventional

□ Vancomycin agar screen (BHI + vancomycin)

□ Vitek 2

□ MicroScan auto or touchscan

□ Other (specify): ______________________

□ BD Phoenix

□ Other micro-broth dilution method

□ Sensititre

□ Agar dilution method

*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: ________________

Patient Safety Component—Annual Facility Survey for LTAC

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Facility Microbiology Laboratory Practices
*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	□ Caspofungin
□ Micafungin		□ Anidulafungin	□ Flucytosine	□ Other
*13. What is the primary testing method for C. difficile used most often by your facility’s laboratory or the outside laboratory where your facility’s testing is performed? (check one)
□ Enzyme immunoassay (EIA) for toxin
□ Cell cytotoxicity neutralization assay
□ Nucleic acid amplification test (NAAT) (e.g., PCR, LAMP)
□ Glutamate dehydrogenase (GDH) antigen plus EIA for toxin (2-step algorithm)
□ GDH plus NAAT (2-step algorithm)
□ GDH plus EIA for toxin, followed by NAAT for discrepant results
□ Toxigenic culture (C. difficile culture followed by detection of toxins)
□ Other (specify): ______________________ (“Other” should not be used to name specific laboratories, reference laboratories, or the brand names of C. difficile tests; most methods can be categorized accurately by selecting from the options provided. Please ask your laboratory, refer to the Tables of Instructions for this form, or conduct a search for further guidance on selecting the correct option to report.)