Form CDC 57.103 CDC 57.103 Patient Safety Component--Annual Hospital Survey

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Patient Safety Component—Annual Hospital Survey

Instructions for this form are available at: http://www.cdc.gov/nhsn/forms/instr/57_103-TOI.pdf

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*required for saving

Tracking #:

Facility ID:

*Survey Year:

Facility Characteristics (completed by Infection Preventionist)

*Ownership (check one):

□ For profit

□ Not for profit, including church

□ Government

□ Military

□ Veterans Affairs

□ Physician owned

If facility is a Hospital:

*Number of patient days: _________

*Number of admissions: __________

For any Hospital:

*Is your hospital a teaching hospital for physicians and/or physicians-in-training?

Yes

No

If Yes, what type:

____ Major

____ Graduate

____ Undergraduate

*Number of beds set up and staffed in the following location types (as defined by NHSN):

a. ICU (including adult, pediatric, and neonatal levels II/III and III):

___________

b. All other inpatient locations:

___________

If facility is an Ambulatory Surgery Center (ASC): (i.e., enrolled in NHSN as an AMB-SURG facility):

□ No ASC or not operational in this survey year

Setting:

___Within a hospital

___Free-standing

Total number of procedures: __________

Percent of procedures that were 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):

_______%

Facility Microbiology Laboratory Practices (completed with input from Microbiology Laboratory Lead)

*1. Does your facility have its own on-site 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

□ Other local/regional, non-affiliated reference laboratory

Continued >>

Assurance of Confidentiality: The 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 50 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. 7, Release 8.3

Patient Safety Component—Annual Hospital Survey

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Facility Microbiology Laboratory Practices (continued)
*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 outside laboratory.
Please use the testing codes listed below the table.
Pathogen				(1) Primary	(2) Secondary				Comments
Staphylococcus aureus				_______________	______________				______________
Enterococcus spp.				_______________	______________				______________
Enterobacteriaceae				_______________	______________				______________
Pseudomonas aeruginosa				_______________	______________				______________
Acinetobacter spp.				_______________	______________				______________
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. Has the laboratory implemented the revised cephalosporin and monobactam breakpoints for Enterobacteriaceae recommended by CLSI as of 2010?								□ Yes			□ No
*5. Has the laboratory implemented the revised carbapenem breakpoints for Enterobacteriaceae recommended by CLSI as of 2010?								□ Yes			□ No
*6. Does the laboratory perform a special test for presence of carbapenemase?							□ 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
If Yes, which test is routinely performed to detect carbapenemase: (check all that apply)
□ PCR			□ MBL screen
□ Modified Hodge Test			□ Carba NP
□ E test			□ Other (specify): _________________
Continued >>

Patient Safety Component—Annual Hospital Survey

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Facility Microbiology Laboratory Practices (continued)

*7. Does the 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)

□ Vitek (Legacy)

□ MicroScan walkaway rapid

□ Agar dilution method

□ Vitek 2

□ MicroScan walkaway conventional

□ E test

□ BD Phoenix

□ MicroScan auto or touchscan

□ Other (specify): _____________________

□ Sensititre

□ Other micro-broth dilution method

*8. 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

□ Other local/regional, non-affiliated reference laboratory

□ Not offered by my facility

9. 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 (specify): ________________

*10. 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

Continued >>

Patient Safety Component—Annual Hospital Survey

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Facility Microbiology Laboratory Practices (continued)
*11. 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 or conduct a search for further guidance on selecting the correct option to report.)
*12. Does your facility produce an antibiogram (i.e., cumulative antimicrobial susceptibility report)?
□ Yes	□ No
If Yes, is the antibiogram produced at least annually?
□ Yes		□ No
If Yes, are data stratified by hospital location?
□ Yes		□ No
If No, please identify any obstacle(s) to producing an antibiogram. (Check all that apply)
□ The laboratory data are difficult to access
□ Limited or no information technology tool for data analysis
□ Limited personnel time for data analysis
□ Limited personnel skills for data analysis
□ Limited interest in an antibiogram from staff who prescribe antibiotics
□ Our institution does not have enough isolates of any or most species (i.e., < 30 isolates per species) to produce an antibiogram
□ Other (please specify): ___________________________________________
Continued >>

Patient Safety Component—Annual Hospital Survey

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Infection Control Practices (completed with input from Hospital Epidemiologist and/or Quality Improvement Coordinator)
*13. 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:		_______
*14. Does the facility routinely place patients infected or colonized with MRSA in contact precautions? (check one)
□ Yes, all infected or colonized patients
□ Yes, only all infected patients
□ Yes, only those with certain characteristics that make them high-risk for transmission (e.g., wounds, diarrhea, presence of an indwelling device)
□ Yes, only those admitted to high-risk settings (e.g., ICU)
□ No
*15. Does the facility routinely place patients infected or colonized with VRE in contact precautions? (check one)
□ Yes, all infected or colonized patients
□ Yes, only all infected patients
□ Yes, only those with certain characteristics that make them high-risk for transmission (e.g., wounds, diarrhea, presence of an indwelling device)
□ Yes, only those admitted to high-risk settings (e.g., ICU)
□ No
*16. Does the facility routinely place patients infected or colonized with CRE in contact precautions? (check one)
□ Yes, all infected or colonized patients
□ Yes, only all infected patients
□ Yes, only those with certain characteristics that make them high-risk for transmission (e.g., wounds, diarrhea, presence of an indwelling device)
□ Yes, only those admitted to high-risk settings (e.g., ICU)
□ No
*17. Does the facility routinely place patients infected or colonized with ESBL-producing or extended spectrum cephalosporin resistant Enterobacteriaceae in contact precautions? (check one)
□ Yes, all infected or colonized patients
□ Yes, only all infected patients
□ Yes, only those with certain characteristics that make them high-risk for transmission (e.g., wounds, diarrhea, presence of an indwelling device)
□ Yes, only those admitted to high-risk settings (e.g., ICU)
□ No
Continued >>

Patient Safety Component—Annual Hospital Survey

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Infection Control Practices (continued)
*18. Does the facility routinely perform screening cultures for CRE?
□ Yes	□ No
If Yes, in which situations does the facility routinely perform screening cultures for CRE? (check all that apply)
□ Surveillance cultures of epidemiologically-linked patients of newly identified CRE patients (e.g., roommates)
□ Surveillance cultures at admission of all patients
□ Surveillance cultures at admission of high-risk patients (e.g., admitted from LTAC or LTCF)
□ Surveillance cultures at admission of patients admitted to high-risk settings (e.g. ICU)
□ Other (please specify): _________________
*19. Does the facility use chlorhexidine bathing on any patient to prevent transmission of MDROs in your hospital?
□ Yes	□ No
*20. Are results rapidly communicated (generally within 4 hours) to infection prevention staff and/or clinical staff when MDROs are identified from clinical or screening cultures in the laboratory?
□ Yes	□ No
If Yes, for which MDROs? (check all that apply)
□ MRSA
□ VRE
□ CRE
□ ESBL-producing Enterobacteriaceae
□ Other (please specify): _____________________
*21. When a patient with an MDRO is transferred to another facility, does your facility communicate the patient’s MDRO status to the receiving facility at the time of transfer?
□ Yes	□ No
*22. Among patients with an MDRO admitted to your facility from another healthcare facility, what percentage of the time does the facility receive information from the transferring facility about the patient’s MDRO status?
_____%
Antibiotic Stewardship Practices (completed with input from Physician and Pharmacist Stewardship Champions)
*23. Does your facility have a written statement of support from leadership that supports efforts to improve antibiotic use (antibiotic stewardship)?
□ Yes	□ No
*24. Is there a leader responsible for outcomes of stewardship activities at your facility?
□ Yes	□ No
If Yes, what is the position of this leader: (check one)
□ Physician		□ Pharmacist	□ Other (please specify): _______________________
Continued >>

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Antibiotic Stewardship Practices (continued)
*25. Is there at least one pharmacist responsible for improving antibiotic use at your facility?
□ Yes	□ No
*26. Does your facility provide any salary support for dedicated time for antibiotic stewardship activities?
□ Yes	□ No
*27. Does your facility have a policy that requires prescribers to document in the medical record or during order entry, a dose, duration, and indication for all antibiotics?
□ Yes	□ No
If Yes, has adherence to a documentation policy (dose, duration, and indication) been monitored?
□ Yes		□ No
*28. Does your facility have facility-specific treatment recommendations, based on national guidelines and local susceptibility, to assist with antibiotic selection for common clinical conditions?
□ Yes	□ No
If Yes, has adherence to facility-specific treatment recommendations been monitored?
□ Yes		□ No
*29. Is there a formal procedure for all clinicians to review the appropriateness of all antibiotics at or after 48 hours from the initial orders (e.g. antibiotic time out)?
□ Yes	□ No
*30. Do any specified antibiotic agents need to be approved by a physician or pharmacist prior to dispensing (i.e., pre-authorization) at your facility?
□ Yes	□ No
*31. Does a physician or pharmacist review courses of therapy for specified antibiotic agents and communicate results with prescribers (i.e., audit with feedback) at your facility?
□ Yes	□ No
*32. Does your facility monitor antibiotic use (consumption) at the unit, service, and/or facility wide?
□ Yes	□ No
If Yes, by which metrics? (Check all that apply)
□ Days of Therapy (DOT)			□ Purchasing Data
□ Defined Daily Dose (DDD)			□ Other (please specify): ________________________
If Yes, are facility- and/or unit- or service-specific reports on antibiotic use shared with prescribers?
□ Yes		□ No
Continued >>

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Antibiotic Stewardship Practices (continued)
*33. Do prescribers ever receive feedback by the stewardship program about how they can improve their antibiotic prescribing?
□ Yes	□ No
*34. Has your stewardship program provided education to clinicians and other relevant staff on improving antibiotic use?
□ Yes	□ No