Attachment D. MR review form for Case and Control

Case Screening Form HACO MRSA Study Based on Medical Record Review and ABCs Form
Case Study ID (stateid):___________________
Case Patient ID:_____________________
This form should be used as a guide to determine if iMRSA patient is eligible for the study and should be contacted for a
telephone interview. Sites are not required to transfer these data to CDC
PERSONAL INDENTIFIERS
Last Name:___________________

First Name:________________

Address :____________________________________________
State:____________

Zip Code:_________________

Phone No: (

)_______________

City:____________________
Medical Record Number:__________________

Screening Questions for Identification of Eligible CASE-PATIENTS:
Please refer to the study line list to answer questions below
1. Is this patient already enrolled in the HACO study during another encounter (only the earliest HACO infection identified
during the study should be included)?
 Yes (EXCLUDE patient)

 No (Go to Q.2)

Please use the ABCs MRSA CRF to answer questions below
2. Initial Invasive MRSA culture (Please use Question 10b on the 2011 ABCs MRSA CRF): Date collected____/____/____
(MM/DD/YY)
3. Was this patient ≥18 years of age at the time of initial culture (Please use question 7a on the 2011 ABCs MRSA CRF)?

 Yes (Go to Q.4)

 No (EXCLUDE patient)

4. Was the initial invasive MRSA culture collected > 3 calendar days after current hospital admission (Please use
question 17 on the 2011 ABCs MRSA CRF)?
 Yes (EXCLUDE patient)

 No (Go to Q.5)

5. Was this patient discharged from a study facility in the 12 weeks prior to initial culture (question 17 on the 2011 ABCs
MRSA CRF can be used to answer this question)?
 Yes (Go to Q.6)

 No (EXCLUDE patient)

Use the medical record from patient’s most recent prior hospitalization (Hospitalization of Interest) or patient’s
list of encounters to answer the following questions.
Hospitalization is defined as admission to the hospital and do not include same-day treatment/surgery, 23-hour
observation, or emergency room visit
6. What was the length of the patient’s hospital stay during the hospitalization of interest? _____________
 4 or more calendar days (Admit=Day 1) (Go to Q.7)

 less than 4 calendar days (EXCLUDE patient)

7. Was the patient’s medical record, for the hospitalization of interest, unavailable for review after 3 attempts?
 Yes (EXCLUDE patient)

 No (Go to Q.8)

8. Was the patient admitted from or discharged to a prison?

 Yes (EXCLUDE patient)

 No (Go to Q.9)

9. Was this patient admitted initially to a non-acute ward during hospitalization of interest (e.g. psychiatric units,
rehabilitative or skilled nursing units – see descriptions in table 1)?
 Yes (EXCLUDE patient)

 No (Go to Q.10)

10. Was this patient ≥ 18 years of age at the time of discharge from the hospitalization of interest?
 Yes (Go to Q.11)  No (EXCLUDE patient)
11. Was MRSA isolated from a normally sterile site during the hospitalization of interest?
 Yes (EXCLUDE patient)

 No (Go to Q. 12)

12. Did this patient have additional encounters, at this study facility, between discharge from hospitalization of interest and
date of initial culture?
 Yes (Go to Q.12a)

 No (Please proceeded to interview or LTCF form)

12a. If yes, was this encounter a hospitalization lasting > 3 days?
 Yes (Then this hospitalization will become the NEW hospitalization of interest and the responses for the
above questions should be disregarded
 No (Please proceed to interview)
13. Does this patient have a history of MRSA infection or colonization in the previous year (You can use Q.17 on the CRF
to answer this question OR the medical record review)?
 Yes (Eligible for the MAIN and the SUB-STUDY)

 No (Only Eligible for the MAIN STUDY)

14. Where was this patient discharge to from hospitalization of interest?
 Long-term care facility (please complete LTCF form)

 Home (Proceed to telephone interview)

Name of LTCF patient was discharged to:________________________________________________
IF YOU HAVE CHOSEN “EXCLUDE PATIENT” FOR ANY QUESTION ABOVE, THIS CASE DOES NOT QUALIFY
FOR THE MAIN RISK FACTOR STUDY.
Table 1: EXAMPLES OF NON-ACUTE CARE WARDS:
Unit Type

Description

Inpatient Hospice

Area where palliative care is provided to dying patients

Long Term Care Unit

Area where care is provided for persons with chronic
disease for extended periods of time

Long Term Care Alzheimer’s Unit

Area where care is provided to persons with Alzheimer’s
syndrome for extended periods of time

Behavioral Health/Psychiatric Unit
Area where care is provided to patients with mental
disorders

Control Screening From: HACO Risk Factor Study Based on Medical Record Review and
ABCs Form
Complete for Eligible Controls* ONLY:
Control Study ID:___________________

StateID of Matched Case :____________________

This form should be used as a guide to assist in determining if an eligible matched control* should be contacted for a
telephone interview. Sites are NOT required to transfer these data to CDC.
(*Eligible controls = controls matched with cases based on age group, hospital where hospitalization of interest occurred,
and month of discharge)
PERSONAL INDENTIFIERS
Last Name:___________________

First Name:________________

Address :____________________________________________
State:____________

Zip Code:_________________

Phone No: (

)_______________

City:____________________
Medical Record Number:__________________

Screening Questions:
1. Is this patient already enrolled in the HACO risk factor study as a control for another case OR as a case?
 Yes (EXCLUDE patient)

 No (Go to Q.2)

Please refer to the control list to answer the following questions
Hospitalization is defined as admission to the hospital and do not include same-day treatment/surgery, 23-hour
observation, or emergency room visit
2. What was the length of the patient’s hospital stay during the hospitalization of interest? _____________
 4 or more calendar days (admit=Day1)(Go to Q.3)

 less than 4 calendar days (EXCLUDE patient)

3. Was the patient discharged alive from the hospitalization of interest?
 Yes (Go to Q.3a)

 No (EXCLUDE patient)

3a. If yes, did the patient die between the date of discharge from the hospitalization of interest and the date of
matched-case initial invasive MRSA culture? (Please refer to the patient’s list of encounters – you may only find
this out during the health interview. Please refer telephone script Q1)
 Yes (EXCLUDE patient)
 No (Go to Q.4)
4. Was this patient admitted initially to a non-acute ward during the hospitalization of interest (e.g. psychiatric units,
rehabilitative or skilled nursing units- see descriptions in table 1)?
 Yes (EXCLUDE patient)

 No (Go to Q.5)

Please refer to the control line list, patient’s medical record or patient’s list of encounters to answer the following
questions.
5. Is the medical record from this patient unavailable after three attempts?
 Yes (EXCLUDE patient)

 No (Go to Q.6)

6. Was this patient admitted from or discharged to a prison?
 Yes (EXCLUDE patient)

 No (Go to Q.7)

7. Was MRSA isolated from a normally sterile site during the hospitalization of interest?
 Yes (EXCLUDE patient)

 No (Go to Q.7a)

7a. Was MRSA isolated from a normally sterile site in the 12 weeks post-discharge from the hospitalization of
interest? Please refer to the patient’s list of encounters -you may only find this out during interview (question 10
on interview form)
 Yes (EXCLUDE patient)

 No (Go to Q.8)

8. Did this patient have additional encounters, at this study facility, between discharge from hospitalization of interest and
date of initial culture for the matched case?
 Yes (Go to Q.8a)

 No (Please proceeded to interview or LTCF form – see Q.10)

8a. If yes, was this encounter a hospitalization lasting > 3 days?
 Yes (EXCLUDE patient)

 No (Please proceed to interview or LTCF form – see Q.10)

9. Does this patient have a history of MRSA infection or colonization in the previous year based on the medical record
review?
 Yes (Eligible for the MAIN and the SUB-STUDY)

 No (Only Eligible for the MAIN STUDY)

10. Where was this patient discharged to from hospitalization of interest?
 Long-term care facility (please complete LTCF form)

 Home (Proceed to telephone interview)

Name of LTCF patient was discharged to:_______________________________________________
IF YOU HAVE CHOSEN “EXCLUDE PATIENT” FOR ANY QUESTION ABOVE, THIS CONTROL DOES NOT QUALIFY
FOR THE MAIN RISK FACTOR STUDY, PLEASE CHOOSE ANOTHER CONTROL FROM YOUR CONTROL LIST.
Table 1: EXAMPLES OF NON-ACUTE CARE WARDS:
Unit Type

Description

Inpatient Hospice

Area where palliative care is provided to dying patients

Long Term Care Unit

Area where care is provided for persons with chronic
disease for extended periods of time

Long Term Care Alzheimer’s Unit

Area where care is provided to persons with Alzheimer’s
syndrome for extended periods of time

Behavioral Health/Psychiatric Unit

Area where care is provided to patients with mental
disorders