Post-Discharge Hospital Patients (Case Patients)- Telephone Interview

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Script continues from Attachment F “Screening Questions”

“Now that I know you are eligible to participate, I would like to share some additional details about the study and obtain your verbal permission for participation. Feel free to stop me and ask questions at any time.” [Interviewee GO TO Verbal Consent Form]

Section 1: Identifiers: Fill in BEFORE beginning telephone interview

Interview Date: _________________________ Interview Initials: ________________

1. Study ID: _________________________________

2. Hospital ID (hospitalization of interest): _______________________________

3. Enrollee Type: ___Case ___Control

4. County of Residence:________________________

5. Date of Hospital Discharge (from hospitalization of Interest): _____/_____/______

(mm/dd/yyyy)

6. Date of Invasive MRSA HACO culture (if control, used matched-case culture date): ____/____/_____

(mm/dd/yyyy)

7. Age ___

8. Sex ___Male ___Female

Public reporting burden of this collection of information is estimated to average 20 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/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

TIME CHECK:____________________

Section 2: medical history

“We now want to gather some information about your health, including treatments you may be receiving at home. Again, please remember if you do not feel comfortable answering any of these questions, we can skip the question.”

9. Did you have a healthcare worker such as a doctor, nurse, or physical therapist visiting you at home between the date you left [hospital name] on _____/_____/____ [date of discharge from hospitalization of interest] and ___/____/___[date of initial HACO MRSA culture]?

Yes 1 [Go to Q.9A]

No 2 [Go to Q.10]

Don’t know/Not sure 7 [Go to Q.10]

Refused 9 [Go to Q.10]

9A. While this healthcare worker was visiting you at home, did he/she do any of the following? [READ LIST AND CHECK ALL THAT APPLY]

___Intravenous medicines or fluids [If an interviewee doesn’t know what this is,

please say:“this is giving you medicines or fluids though your veins using a needle

or tube”]

___Wound care

___Physical therapy

___Don’t know/Not sure

___Refused

___Other (specify):______________________________________

10. Did you leave the hospital on ____/____/____ [date of discharge from hospitalization of interest] with a tube inserted into your vein? This type of tube is also known as an intravenous catheter.

Yes 1 [Go to 10B]

No 2

• [PROMPT:] “I just want to clarify that intravenous tube or catheter includes hemodialysis catheter, PICC line, Hickman, Port-A-Cath. So, you did not have any of those, correct?” [Go to Q.10A]

Don’t know/Not sure 7

• [PROMPT:] “Some examples of intravenous tube or catheter includes hemodialysis catheter, PICC line, Hickman, Port-A-Cath. Did you have any of those?” [Go to Q.10A]

Refused 9 [Go to Q.10A]

10A. [If no], Did you have a tube inserted into your vein anytime between the date you left ________________[hospital name] on _____/_____/____ [date of discharge from hospitalization of interest] and ___/____/____ [date of initial HACO MRSA culture]?

Yes 1 [Go to 10B]

No 2 [Go to Q.11]

Don’t know/Not sure 7 [Go to Q.11]

Refused 9 [Go to Q.11]

10B. Where was this intravenous tube located? [DO NOT READ LIST]

___Neck

___Chest

___Arm

___Don’t know/Not sure

___Refused

___Other (specify):______________________________________

10C. Do you remember what the healthcare worker called this intravenous tube? [DO NOT READ THE LIST]

___PICC line

___Port-A-Cath

___Hickman/Broviac

___PermCath

___Don’t remember/Not sure

___Refused

___Other (specify):______________________________________

1 0D. Was this tube placed into your vein surgically, in an operating room?

Yes 1

No 2

Don’t know/Not sure 7

Refused 9

10E. Was the part of the tube that went into your vein longer than 6 inches? [PROMPT: On average the length of the 4 fingers pressed closely together is about 3 inches]

Yes 1

No 2

Don’t know/Not sure 7

Refused 9

10F. For what reason did you have a tube inserted into your vein? [READ LIST]

Reason	YES	NO	Don’t Know/Not Sure	Refused
Antibiotic Treatment	1	2	7	9
Fluids	1	2	7	9
Blood products	1	2	7	9
Intravenous feeding	1	2	7	9
Dialysis	1	2	7	9
Chemotherapy	1	2	7	9
Pain medication	1	2	7	9
Other, Specify______________________________________________

10G. After you left the hospital on ____/____/____ [date of discharge from the hospitalization of interest], for how long did you have this tube in your vein?

______ days or _______weeks [Go to Q.10H] ___Don’t know/Not sure [Go to Q.10H]

___Still with the catheter[Go to Q. 11]

10H. For what reason was the tube removed? [READ LIST]

___End of intravenous medications as prescribed by your doctor

___Redness/pus/ or skin infection where the tube was located

___Fever

___Don’t know/Not sure

___Refused

___Other (specify):______________________________________

10I. After this tube was removed; did you have another tube inserted into your vein?

Yes 1 [Go to 10.I.i]

No 2 [Go to Q.11]

Don’t know/Not sure 7 [Go to Q.11]

Refused 9 [Go to Q.11]

10.I.i. [If yes], Was this tube inserted before ___/___/____ [date of initial HACO MRSA culture]?

Yes ………………………….1 [Go to 10.I.ii]

No ………………………….2 [Go to Q.11]

Don’t know/Not sure………………………....7 [Go to Q.11]

Refused ………………………….9 [Go to Q.11]

10.I.ii. What date was this second tube inserted?

____/_____/_____ (mm/dd/yyyy) ___Don’t know/Not sure

10.I.iii. How long was the second tube in you vein?

______ days or _______week ___Don’t know/Not sure ___Still with the catheter

“The next set of questions is about antibiotics you may have taken after you left the hospital on _____/_____/____ [date of discharge from hospitalization of interest]. Antibiotic bottles or prescriptions may help you remember about specific names. Would you like to gather this information before we go on?”

11. Did you take any antibiotic(s) by mouth or by vein between _____/_____/____ [date of discharge from hospitalization of interest] and ___/____/____ [date of initial HACO MRSA culture]? If you are someone who is receiving dialysis treatments, you might have gotten your antibiotics during a dialysis session.

Yes 1 [Go to Q.11A]

No 2 [Go to Q.12]

Don’t know/Not sure 7 [Go to Q.12]

Refused 9 [Go to Q.12]

11A. Did the doctor or nurse give you the antibiotic(s) to take at home when you left __________[hospital name] on ___/____/____ [date of discharge from hospitalization of interest]?

Yes ……………………. 1 [Go to Q.11C]

No …………………… 2 [Go to Q.11B]

Don’t know/Not sure………………….. 7 [Go to Q.11C]

Refused ……………………. 9 [Go to Q.11C]

11B. [If no] When were the antibiotic(s) prescribed to you?

____/____/____(mm/dd/yyyy)[Go to Q.11.C]

___Don’t know/Not sure [Go to Q.11.C] ___Refused [Go to Q.11.C]

11C. Why did you take the antibiotic(s)? [ONLY READ LIST IF PROMPT NEEDED]

___Ear, sinus, upper respiratory infections

___Bronchitis/pneumonia

___Urinary tract infection

___Skin Infection

___Dental/ oral surgery

___Surgery

___Other, specify:______________________________

___Don’t know/Not sure

___Refused

11D. For how long did you take antibiotic(s) between _____/_____/____ [date of discharge from hospitalization of interest] and ___/____/____ [date of initial HACO MRSA culture]? [NOTE: If the interviewee was discharged with antibiotics clarify you want to know the duration after he/she left the hospital or If interviewee took multiple course of antibiotics you want to know the total duration of antibiotic use]

______days or _____weeks [Go to Q.11.D.i] ___Don’t know/Not sure [Go to Q.11.D.i]

___Refused [Go to Q.11.D.i]

11.D.i. When did you stop taking antibiotics [NOTE: clarify to interviewee that you want to know the date he/she stopped prior to date of initial HACO MRSA culture on ___/____/____]?

Date: ____/____/___(mm/dd/yyyy)

___Still taking antibiotics ___Don’t know/Not sure ___Refused

11E. We would like to know the name of the antibiotic(s) you were taking between ____/____/____ [date of discharge from the hospitalization of interest] and ___/____/____ [date of initial HACO MRSA culture]. If you have your pill bottles or prescription can you tell me the name(s) of the antibiotic(s) you were taking? If you do not have the pill bottles or prescription, can you remember the name of the antibiotic(s) you were taking?

[DO NOT READ LIST]

Antibiotic	Yes	Antibiotic	Yes
Amoxicillin	1	Floxin	1
Amoxicillin/Clavulanate	1	Keflex	1
Ampicillin	1	Keftab	1
Augmentin	1	Levofloxacin	1
Azithromycin	1	Monurol	1
Bactrim	1	Metronidazole	1
Biaxin	1	Norfloxacin or Norlox	1
Ceclor	1	Ofloxacin or Oflox	1
Cefaclor	1	Omnicef	1
Cefadroxil	1	Penicillin or Pen VK	1
Cefdinir	1	Pediazole	1
Ceftin	1	Septra	1
Cefixime	1	Suprax	1
Cefuorixime	1	Tetracyline	1
Cefzil	1	Tequin	1
Cefprozil	1	Trimox	1
Cephalexin	1	Trimethoprim/Sulfa	1
Cephradine	1	Vancomycin	1
Ciprofloxacin/Cipro	1	Zagam	1
Clarithromyc	1	Zithromax or Z-pak	1
Cleocin	1	Other, Specify
Clindamycin	1	Other, Specify
Dapsone	1	Other, Specify
Doxycycline	1	Other, Specify
Duricef	1	Other, Specify
Erythromycin	1	Other, Specify
Erythromycin/sulfa	1	Don’t Know/Not Sure	7
Flagyl	1	Refused	9

“I will now ask you questions about wounds or open places, such as a cuts or breaks in your skin. Please remember that many of the questions are going to refer to the time period after your left the hospital on _____/_____/____ [date of discharge from hospitalization of interest] and ___/_____/____” [date of initial HACO MRSA culture]

12. When you left the hospital on ___/___/____ [date of discharge from hospitalization of interest] did you have a wound such as a cut or break in your skin?

Yes 1 [Go to Q.12B]

No 2 [Go to Q.12A]

Don’t know/Not sure 7 [Go to Q.12A]

Refused 9 [Go to Q.12A]

12A. If you did not have a wound when you left the hospital, did you develop one between ___/____/____ [date of discharge from the hosptialzation of interest] and __/___/___ [date of initial HACO MRSA culture]?

Yes 1 [Go to Q.12B]

No 2 [Go to Q.13]

Don’t know/Not sure 7 [Go to Q.13]

Refused 9 [Go to Q.13]

12B. What type(s) of wound(s) was it? [READ LIST and CHECK ALL THAT APPLY]

___Pressure ulcer or bed sore

___Diabetic ulcer

___Surgical wound [If an interviewee doesn’t know what this is, Prompt: “a wound that

occurred from or after you had surgery”]

___Traumatic wound [If an interviewee doesn’t know what this is, Prompt: “a wound that occurs as a result of accidental injury or an accident”]

___Abscess/boil

___Don’t know/Not sure

___Refused

___Other (specify):______________________________________

12C. Where on your body was this wound? [DO NOT READ LIST; CHECK ALL THAT APPLY]

___Head/Neck

___Chest

___Shoulder

___Arm/hand

___Belly

___Sacral/buttock

___Leg

___Forefoot

___Heel

___Refused

___Other (specify):______________________________________

12D. Were you told by your doctor/nurse that you had MRSA or “MERSA" at any time between ___/____/____ [date of discharge from the hosptialzation of interest] and __/___/___ [date of initial HACO MRSA culture]?

Yes 1 –“when were you told you had it?” DATE:____/____/_____

No 2

Don’t know/Not sure 7

Refused 9

12E. Was your wound(s) cared for by a healthcare worker such as a doctor, nurse or physical therapist?

Yes 1 [Go to Q.12F]

No 2 [Go to Q.12I]

Don’t know/Not sure 7 [Go to Q.12I]

Refused 9 [Go to Q.12I]

12F. What type of healthcare worker was primarily responsible for caring for your wound? [Read List]

___Podiatrist [If an interviewee doesn’t know what this is, Prompt: “a doctor specialized in foot, ankle and lower leg care”]

___Surgeon [this can be a vascular or orthopedic surgeon]

Infectious disease doctor

___General Medicine doctor [If an interviewee doesn’t know what this is, Prompt: “your usual medical provider was responsible to examine the wound and provide treatment”]

___Nurse specialized in wound care

___Physical Therapist

___Don’t know/Not sure

___Refused

___Other, specify:__________________________________________________________

12G. When the healthcare worker was caring for your wound, did they remove the infected tissue away from your wound? This procedure is called “debridement”.

Yes 1

No 2

Don’t know/Not sure 7

Refused 9

12H. Did you receive whirlpool therapy for your wound?

Yes 1

No 2

Don’t know/Not sure 7

Refused 9

12I. Between _____/_____/____ [date of discharge from hospitalization of interest] and ___/____/____ [date of initial HACO MRSA culture], did your wound(s) close?

Yes 1

No 2

Don’t know/Not sure 7

Refused 9

Section 3: Healthcare exposures

“Now I will ask question about visits to medical buildings or facilities between _____/_____/____ [date of discharge from hospitalization of interest] and ___/____/____ [date of initial HACO MRSA culture].

13. Between _____/_____/____ [date of discharge from hospitalization of interest] and ___/____/____ [date of initial HACO MRSA culture], did you receive care in a doctor’s office, nursing home, or any other healthcare facility?

Yes 1 (Go to Q.13A)

No 2 (Go to Q.14)

Don’t know/Not sure 7 (Go to Q.14)

Refused 9 (Go to Q.14)

13A. In what type of facility did you receive care? [READ LIST]

Facility	Yes	[If Yes ask:]	No	DK/NS	Refused
Hospital	1	How many times did you visit the hospital between _____/_____/____ [date of discharge from hospitalization of interest] and _____/_____/____ [date of matched-case invasive HACO MRSA culture]?_____	2	7	9
Emergency Department	1	How many times did you visit the ED between _____/_____/____ [date of discharge from hospitalization of interest] and_____/_____/____ [date of matched-case invasive HACO MRSA culture]? _____	2	7	9
Doctor’s Office	1		2	7	9
Nursing Home	1	For how long did you stay in a nursing home? _____days or ____weeks	2	7	9
Dialysis Facility	1	What type of dialysis did you receive? __peritoneal __hemodialysis __don’t know/not sure	2	7	9
Assisted Living Facility	1		2	7	9
Outpatient Surgery Center	1		2	7	9
Other facility, specify:_____________________________________________________

13B. During any of the visits to a healthcare facility, did you have any surgical procedure that had to be performed in an operating room?

Yes 1 [Go to Q.13C]

No 2 [Go to Q.14]

Don’t know/Not sure 7 [Go to Q.14]

Refused 9 [Go to Q.14]

13C. [If yes], what was the name of the surgical procedure?

Type:______________________________________

13D. On what date did this occur? Date:_____/_____/_____

Section 4: Functional status

“Now I will ask you questions about your daily activities such as eating, dressing and bathing.”

14. On a scale of 1 to 5 - from 1 being completely independent (no help needed at all) to 5 being total dependence, how would you describe your level of performance in doing any of the following daily activities just prior to _____/_____/____ [date of case’s initial HACO MRSA culture]?

[READ LIST]

ADL	Independent	Supervision	Limited Assistance	Extensive Assistance	Total Dependence	Refused
Eating	1	2	3	4	5	9
Getting dressed	1	2	3	4	5	9
Taking a bath or shower	1	2	3	4	5	9
Getting in or out of bed	1	2	3	4	5	9
Walking inside your home	1	2	3	4	5	9

Coding

1. Independent- no help or staff oversight at any time.

2. Supervision- oversight, encouragement or cueing.

3. Limited assistance- resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance.

4. Extensive assistance- resident involved in activity, staff provide weight-bearing support.

5. Total dependence- full staff performance every time during entire 7-day period.

Section 5: History of MRSA Infection/Colonization

15. At any time in the 12 months PRIOR to ____/_____ [use month/year of iniale MRSA culture], did your doctor or a nurse tell you that you had MRSA or “MERSA”?

Yes 1 [Go to Q.15A]

No 2 [Go to Q.16]

Don’t know/Not sure 7 [Go to Q.16]

Refused 9 [Go to Q.16]

15A. Where in your body did you have MRSA? [DO NOT READ LIST; CHECK ALL THAT APPLY]

___Skin - [If yes], when did you have it? Date: _____/_____/_____

___Ulcer or Bed Sore – [If yes], when did you have it? Date:______/____/_____

___Blood - [If yes], when did you have it? Date:____/____/_____

___Lungs (Pneumonia) –[ If yes], when did you have it? Date:____/_____/_____

___Joint - [If yes], when did you have it? Date:____/____/_____

___Bone - [If yes], when did you have it? Date:____/____/_____

___Surgical Wound - [If yes], when did you have it? Date:____/____/_____

___Other (specify):_______________________________

[If yes], when did you have it? Date:____/____/_____

___Other (specify):______________________________

[If yes], when did you have it? Date:____/____/_____

Section 6: Level of education and income

“I would like to ask you a couple of questions about your level of education and income. Remember you may refuse to answer any of these questions.”

16. What is the highest grade or year of school you completed? [DO NOT READ LIST]

Never attended school or kindergarten only 1

Elementary or middle school; 1^st-8^th grade 2

Some high school; 9^th-11^th grade 3

High school graduate; 12^th grade or GED 4

Technical School 5

Some College 6

College graduate 7

Postgraduate/professional 8

Refused 9

17. In your home, what is the annual household income from all sources, including social security and pensions? Please stop me when I get to your level of income.

[READ EACH RESPONSE IN ORDER UNTIL RESPONDENT AGREES]

Dependent college student 1

Less than $15,000 2

Less than $25,000 3

Less than $35,000 4

Less than $50,000 5

Less than $70,000 6

$ 70,000 or more 7

Don’t know/Not sure ______ 8

Refused 9

Section 7: Demographics

“Now I would like to ask a few final questions about you.”

18. Are you of Hispanic or Latino origin?

___Yes

___No

19. How would you describe your race? [Read list]

[Respondent should be told that they can select one or more race]

___American Indian or Alaskan native

___Asian

___Black or African American

___Native Hawaiian or other Pacific Islander

___White

20. What is your height?

Height: __________feet ________inches OR ________meters ___Not known ___Refused

21. What was your weight when you left the hospital on _____/_____/____ [date of discharge from hospitalization of interest]?

Weight: _________ pounds OR ________Kg ___Not known ___Refused

“That was my last interview question. Do you have any questions for me? Thank you very much for your time and participation!”

STOP TIME:____________________

Section 8: After interview questions

22.Interview Completed? ___Yes ___No

23.Was a proxy used?

Yes 1 [Go to Q.23]

No 2

Don’t know/Not sure 7

23A. What was the reason for using proxy?

Deceased …………………………..1 Date of Death:____/_____/_____

Incapacitated or incompetent ……………..2

Enrollee preference…………………………….…3

Don’t know/Not sure……………………………..7

24.COMMENTS:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________