Att G.18_Surveys- Hospital, IRF, and LTAC

Plan and Annual Surveys

Instructions for Completion of the Patient Safety Component-Annual
Hospital Survey (CDC 57.103)
Instructions for Form Completion

Data Field
Facility ID #
Survey Year

Required. The NHSN-assigned facility ID will be auto-entered by the computer.
Required. Select the calendar year for which this survey was completed.
The survey year should represent the last full calendar year. For example, in 2014,
a facility would complete a 2013 survey.

Facility Characteristics
Ownership (check one)

Required. Select the appropriate ownership of this facility:
 P - For profit
 NP - Not for profit, including church
 GOV - Government
 MIL - Military
 VA- Veterans Affairs
 PHY - Physician owned
If facility is a Hospital: Section required if facility is enrolled in NHSN as a hospital (e.g., HOSP-GEN, HOSPONC, etc.); otherwise, optional.
Number of patient days
Required. Enter the total number of patient days from inpatient locations in your
hospital during the last full calendar year. Newborns should be included in this
count.
Number of admissions
Required. Enter the total number of inpatient admissions, including newborns, for
your hospital during the last full calendar year.
Is your hospital a teaching
Required. If a teaching hospital, select ‘Yes'. Otherwise, select 'No'.
hospital for physicians and/or
physicians in training?
If Yes, what type?

January 2015

Conditionally Required. If a teaching hospital, select the type from the options
listed:
(Note: There is no minimum requirement for the number of students in training to
meet these definitions.)
 Major: Facility has a program for medical students and post-graduate
medical training.
 Graduate: Facility has a program for post-graduate medical training (i.e.,
residency and/or fellowships).
 Undergraduate: Facility has a program for medical students only.

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Plan and Annual Surveys

Facility Characteristics (continued)
Number of beds set up and
Required. Record the maximum number of beds set up and staffed for the last full
staffed in the following location calendar year for the bed types listed below. If any bed type is new or has not
types (as defined by NHSN)
been available long enough to have a full calendar year’s worth of data from
which to obtain the maximum number, indicate the maximum number from the
number of months available. For definitions of CDC location types, see CDC
Locations and Descriptions chapter.
a. ICU

Enter the number of beds in locations designated as intensive care units (ICUs) in
the facility. This includes all adult, pediatric, and neonatal levels II/III and III.

Enter the number of beds set up and staffed in all other inpatient locations used
for overnight stay patients in this hospital. This includes all inpatient beds in the
facility, and not just those that are subject to NHSN surveillance.
If facility is an Ambulatory Surgery Center (ASC): Section required only if facility is enrolled in NHSN as an
ASC (known as AMB-SURG in NHSN); otherwise, select ‘No ASC or not operational in this survey year’.
Setting
Select the physical setting of this ambulatory surgery center: Within a hospital or
Free-standing.
Total number of procedures
Enter the total number of procedures performed in your ambulatory surgery center
during the last full calendar year; includes surgical and non-surgical procedures.
Procedures are defined as any patient care event that is assigned a CPT code.
Percent of procedures that was Of the total procedures performed, enter the percentage that was surgical. Surgical
surgical
procedures are defined using the full definition of an NHSN operative procedure,
found in the NHSN SSI Protocol.
What percentage of your
For each place listed, enter the percentage of patients that were discharged or
ambulatory surgery patients were transferred to these places following their procedure(s): Home/Customary
discharged or transferred to the residence; Recovery care center (facility other than this one); Acute care hospital
following places
(emergency or inpatient). The total of all three should equal 100%.
Facility Microbiology Laboratory Practices. Completion of this section requires the assistance from the
microbiology laboratory. Questions should be answered based on the testing methods that were used for the
majority of the last full calendar year.
1. Does your facility have its Required. Select 'Yes' if your laboratory performs antimicrobial susceptibility
own laboratory that
testing; otherwise, select 'No'.
performs antimicrobial
susceptibility testing? If No, Conditionally Required. If ‘No’, select the location where your facility's
where is the facility's
antimicrobial susceptibility testing is performed: Affiliated medical center,
antimicrobial susceptibility Commercial referral laboratory, or Other local/regional, non-affiliated reference
testing performed? (check laboratory. If multiple laboratories are used indicate the laboratory which
one)
performs the majority of the bacterial susceptibility testing. You must complete
the remainder of this survey with assistance from your outside laboratory.
2. Does the laboratory use
Required. Select 'Yes' if your laboratory uses CLSI antimicrobial susceptibility
CLSI (formerly NCCLS)
standards; otherwise, select 'No'.
antimicrobial susceptibility
standards? If Yes, specify Conditionally Required. If ‘Yes’, specify the version used by your laboratory or
which version of the M100 the referral laboratory.
document the laboratory
uses.
b. All other inpatient
locations

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Plan and Annual Surveys

Facility Microbiology Laboratory Practices (continued)
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)

Required. Select from the choices listed the appropriate (1) primary susceptibility
testing and (2) secondary, supplemental, or confirmatory testing method (if
performed) for each organism.
Note: Repeat tests using the primary method should not be indicated as secondary
methods; instead indicate in the ‘Comments’ column the number of times repeat
testing is done using the same primary method.
If your laboratory does not perform susceptibility testing, please indicate the
methods used at the referral laboratory. If ‘Other’ is selected as the method for any
pathogen, use the ‘Comments’ column to describe the method used.
Required. Select 'Yes' if your laboratory has implemented the revised
cephalosporin and monobactam breakpoints for Enterobacteriaceae recommended
by CLSI as of 2010; otherwise, select 'No'.

4. Has your laboratory
implemented the revised
cephalosporin and
monobactam breakpoints for
Enterobacteriaceae
recommended by CLSI as of
2010?
5. Has your laboratory
Required. Select 'Yes' if your laboratory has implemented the revised carbapenem
implemented the revised
breakpoints for Enterobacteriaceae recommended by CLSI as of 2010; otherwise,
carbapenem breakpoints for select 'No'.
Enterobacteriaceae
recommended by CLSI as of
2010?
6. Does your laboratory
Required. Select 'Yes' if your laboratory performs a special test for carbapenemase
perform a special test for
production; otherwise, select 'No'.
carbapenemase production?
If Yes, please indicate what Conditionally Required. If ‘Yes’, specify what is done if carbapenemase
is done if carbapenemase
production is detected.
production is detected
(check one).
Conditionally Required. If ‘Yes’, specify which test is performed to detect
If Yes, which test is
carbapenemase.
routinely performed to
detect carbapenemase (check
all that apply).
7. Does your laboratory
Required. Select 'Yes' if your laboratory performs colistin or polymyxin B
perform colistin or
susceptibility testing for drug-resistant gram negative bacilli; otherwise, select
polymyxin B susceptibility 'No'.
testing for drug-resistant
gram negative bacilli?
Conditionally Required. If ‘Yes’, select the method(s) used from the choices
If Yes, indicate methods
provided. If ‘Other’ is selected, please specify.
(check all that apply).

January 2015

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Plan and Annual Surveys

Facility Microbiology Laboratory Practices (continued)
8. Does your facility have its Required. Select 'Yes' if your laboratory performs antifungal susceptibility testing
own laboratory that
for Candida species; otherwise, select 'No'.
performs antifungal
susceptibility testing for
Conditionally Required. If ‘No”, select one of the choices provided.
Candida species? If No,
where your facility's
antifungal susceptibility
testing is performed? (check
one).
9. If antifungal susceptibility Required. Select from the choices listed the method(s) of antifungal susceptibility
testing is performed at your testing performed at your facility or an outside laboratory. If ‘Other’ is selected,
facility or an outside
please specify.
laboratory, what methods
are used? (check all that
apply)
10. Is antifungal susceptibility Required. Select 'Yes' if your laboratory or outside laboratory
testing performed
automatically/reflexively performs antifungal susceptibility testing for Candida
automatically/reflexively for species which are from normally sterile body sites (such as blood), without
Candida spp. cultured from needing a specific order or request for susceptibility testing from the clinician;
normally sterile body sites otherwise, select 'No'.
(such as blood), without
needing a specific order or Conditionally Required. If ‘Yes’, select from the choices listed the antifungal
request for susceptibility
drugs which are tested automatically/reflexively. If ‘Other’ is selected, please
testing from the clinician? If specify.
Yes, what antifungal drugs
are tested automatically/
reflexively? (check all that
apply)
11. What is the primary testing Required. Select from the choices listed the testing methods used to perform C.
method for C. difficile used difficile testing by your facility’s laboratory or the outside laboratory where your
most often by your facility’s facility’s testing is done. If ‘Other’ is selected, please specify.
laboratory or the outside
laboratory where your
Note: “Other” should not be used to name specific laboratories, reference
facility’s testing is
laboratories, or the brand names of C. difficile tests; most methods can be
performed? (check one)
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.

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Plan and Annual Surveys

Facility Microbiology Laboratory Practices (continued)
12. Does your facility produce
an antibiogram (i.e.,
cumulative antimicrobial
susceptibility report)?
If Yes, is the antibiogram
produced at least annually?
If Yes, are data stratified by
hospital location?
If No, please identify any
obstacle(s) to producing an
antibiogram. (Check all that
apply)

Required. Select ‘Yes’ if your facility produces an antibiogram; otherwise select
‘No’.
Conditionally Required. If ‘Yes’, indicate whether the antibiogram is produced at
least annually.
Conditionally Required. If ‘Yes’, indicate whether antibiogram data are stratified
by hospital location.
Conditionally Required. If ‘No’, indicate the obstacle(s) to producing an
antibiogram at your facility. If ‘Other’ is selected, please specify.

Infection Control Practices. Completion of this section may require assistance from the Infection Preventionist,
Hospital Epidemiologist, other infection control personnel, and/or Quality Improvement Coordinator. Questions
should be answered based on the policies and practices that were in place for the majority of the last full calendar
year.
13. Number of infection
preventionists (IPs) in
facility

Required. Enter the number of individuals (full-time employees) who work in the
infection prevention department of the hospital as infection prevention
professionals. Certification in infection control, the CIC credential, is not required
to be considered an “IP” on this survey.
a. Total hours per week
Enter the number of hours per week engaged in activities designed to find and
performing surveillance report healthcare-associated infections (in the hospital) and the appropriate
denominators. Total should include time to analyze data and disseminate results.
b. Total hours per week for Enter the number of hours per week spent on infection prevention and control
infection control
activities other than surveillance. These activities include, but are not limited to,
activities other than
education, prevention, meetings, etc.
surveillance
For detailed description about the use of Contact Precautions, please refer to the CDC/HICPAC 2007 Guideline
for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
(http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf).
14. Does the facility routinely Required. Select ‘No’ if your facility does not routinely place any patient infected
place patients infected or
or colonized with MRSA in Contact Precautions; otherwise, select the single best
colonized with MRSA in
choice from the choices listed that most accurately describes the primary
contact precautions? (check indication for placing patients with MRSA on Contact Precautions at your facility.
one)
15. Does the facility routinely Required. Select ‘No’ if your facility does not routinely place any patient infected
place patients infected or
or colonized with VRE in Contact Precautions; otherwise, select the single best
colonized with VRE in
choice from the choices listed that most accurately describes the primary
contact precautions? (check indication for placing patients with VRE on Contact Precautions at your facility.
one)
16. Does the facility routinely Required. Select ‘No’ if your facility does not routinely place any patient infected
place patients infected or
or colonized with CRE in Contact Precautions; otherwise, select the single best
colonized with CRE in
choice from the choices listed that most accurately describes the primary
contact precautions? (check indication for placing patients with CRE on Contact Precautions at your facility.
one)

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Plan and Annual Surveys

Infection Control Practices (continued)
17. Does the facility routinely
place patients infected or
colonized with ESBLproducing or extended
spectrum cephalosporin
resistant Enterobacteriaceae
in contact precautions?
(check one)
18. Does the facility routinely
perform screening cultures
for CRE?
If Yes, in which situations
does the facility routinely
perform screening cultures
for CRE? (check all that
apply)

19. Does the facility use
chlorhexidine bathing on
any patient to prevent
transmission of MDROs in
your hospital?
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?
If Yes, for which MDROs?
(check all that apply)
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?

January 2015

Required. Select ‘No’ if your facility does not routinely place any patient infected
or colonized with ESBL-producing or extended spectrum cephalosporin-resistant
Enterobacteriaceae in Contact Precautions; otherwise, select the single best choice
from the choices listed that most accurately describes the primary indication for
placing patients with ESBL-producing or extended spectrum cephalosporinresistant Enterobacteriaceae on Contact Precautions at your facility.
Required. Select ‘Yes’ if your facility routinely obtains screening cultures from
patients for CRE (e.g., rectal, perirectal, or stool cultures); otherwise, select ‘No.’
Conditionally required. If ‘Yes’, select all the situations in which your facility
would routinely obtain screening cultures from patients for CRE. If ‘Other’ is
selected, please specify the situation(s) in which CRE screening is performed.
Note: ‘Epidemiologically-linked’ patients refer to contacts of the patient with
newly identified CRE. This might include current or prior roommates or patients
who shared the same healthcare personnel or patients who are located on the same
unit or ward.
Required. Select ‘Yes’ if your facility routinely uses chlorhexidine bathing on
any patient in any ward or unit as an intervention to prevent the transmission of
any MDRO; otherwise, select ‘No’.
Required. Select ‘Yes’ if the laboratory that performs clinical culture testing for
your facility routinely notifies relevant staff (either the Infection Prevention staff
and/or clinical staff) in a timely manner (e.g., within 4 hours) when an MDRO is
identified from clinical or surveillance cultures; otherwise, select ‘No.’
Conditionally required. If ‘Yes’, select all the MDROs for which timely
notification of relevant staff is performed by the laboratory. If ‘Other’ is selected,
please specify the MDRO(s) for which this would apply.
Required. Select ‘Yes’ if your facility routinely communicates the MDRO status
of a patient known to be colonized or infected with an MDRO to the receiving
facility at the time of patient transfer; otherwise, select ‘No’.

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Plan and Annual Surveys

Infection Control Practices (continued)
22. Among patients with an
Required. Enter the estimated percentage of the time that your facility receives
MDRO admitted to your
information from a transferring facility about the MDRO status of a patient
facility from another
known to be colonized or infected with an MDRO.
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. Completion of this by section may require assistance from the pharmacy and/or
physicians who focus on Antibiotic Stewardship or Infectious Diseases, where available, and/or members of the
Pharmacy and Therapeutic Committee. Antibiotic Stewardship refers to a coordinated, multidisciplinary approach
to optimize and measure antibiotic use. For further information, refer to Core Elements of Hospital Antibiotic
Stewardship Programs (http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html). Questions
should be answered based on the policies and practices that were in place for the majority of the last full calendar
year.
23. Does your facility have a
written statement of support
from leadership that
supports efforts to improve
antibiotic use (antibiotic
stewardship)?
24. Is there a leader responsible
for outcomes of stewardship
activities at your facility?
If Yes, what is the position
of this leader? (check one)

25. Is there at least one
pharmacist responsible for
improving antibiotic use at
your facility?
26. Does your facility provide
any salary support for
dedicated time for antibiotic
stewardship activities?

January 2015

Required. Select 'Yes' if there is written evidence of senior-level management
support focused on antibiotic use prescribing (e.g., formal letter of support for
efforts to improve antibiotic use, written communication to hospital staff that
encourages optimal antibiotic prescribing, communication of support that reaches
staff beyond those who receive executive-level meeting notes); otherwise, select
'No'.
Required. Select 'Yes' if any individual has been identified as a lead to antibiotic
stewardship activities as evidenced by responsibility for improving antibiotic use
in the job description or performance review, authority to coordinate activities of
staff from multiple departments (e.g. laboratory, pharmacy, information
technology), and/or responsibility to report to senior level management on
program planning and outcomes.
Conditionally Required. If ‘Yes’, specify the qualification or job title of the
leader(s). More than choice one may be selected. If ‘Other’ is selected, please
specify the position.
Required. Select 'Yes' if your facility has at least one pharmacist who dedicates
time distinct from general pharmacy duties to educate staff, and track or monitor
antibiotic use to ensure optimal prescribing practices; otherwise, select 'No'.
Required. Select 'Yes' if any individual was given salary support at least 4 hours
per week (0.1 full-time employees) to engage in duties to improve or monitor
antibiotic use that are not part of their general clinical duties; otherwise, select
'No'.

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Plan and Annual Surveys

Antibiotic Stewardship Practices (continued)
27. Does your facility have a
Required. Select 'Yes' if your facility has a policy requiring documentation of
policy that requires
dose, duration and indication for all antibiotics in the medical record or during
prescribers to document in order entry; otherwise, select 'No'.
the medical record or during
order entry, a dose, duration, Conditionally Required. If ‘Yes’ to question 5, select ‘Yes’ if charts have been
and indication for all
audited to confirm documentation of dose, duration, and indication in patient
antibiotics?
medical records; otherwise, select ‘No’.

28.

29.

30.

31.

If Yes, has adherence to this
documentation policy (dose,
duration, and indication)
been monitored?
Does your facility have
Required. Select 'Yes' if there are facility-specific recommendations for antibiotic
facility-specific treatment treatment selection based on national guidelines and local susceptibility reports
recommendations, based on for ANY common clinical conditions (e.g., community required pneumonia,
national guidelines and local urinary tract infections, or skin and soft tissue infections); otherwise, select 'No'.
susceptibility, to assist with
antibiotic selection for
Conditionally Required. If ‘Yes’ to question 6,
common clinical conditions? a. Select ‘Yes’ charts have been audited to confirm adherence to facility-specific
treatment guidelines for ANY of the common clinical conditions listed above;
If Yes, has adherence to
otherwise, select ‘No’.
facility-specific treatment
recommendations been
monitored?
Is there a formal procedure Required. Select 'Yes' if your facility has developed a standardized way for
for all clinicians to review clinicians on the treating team (or attending physician? or physician of record?) to
the appropriateness of all
reassess the continuing need and choice of antibiotics at or after 48 hours after the
antibiotics at or after 48
initial orders (to confirm indication, review microbiology results, and review
hours from the initial orders antibiotic choice, dose, and duration); otherwise, select 'No'.
(e.g. antibiotic time out)?
Do any specified antibiotic Required. Select 'Yes' if your facility has at least one antibiotic agent that requires
agents need to be approved a physician or pharmacist to review and approve administration of the drug due to
by a physician or pharmacist its spectrum of activity, cost, or associated toxicities; otherwise, select 'No'.
prior to dispensing (i.e., preauthorization) at your
facility?
Does a physician or
Required. Select 'Yes' if your facility had physicians or pharmacists
pharmacist review courses knowledgeable in antibiotic use, and not part of the treating team, review courses
of therapy for specified
of therapy for specified antibiotic agents and communicate the results to
antibiotic agents and
prescribers (such as audit with feedback); otherwise, select 'No'.
communicate results with
prescribers (i.e., audit with
feedback) at your facility?

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Plan and Annual Surveys

Antibiotic Stewardship Practices (continued)
32. Does your facility monitor Required. Select 'Yes' if your facility monitors antibiotic use or consumption at
antibiotic use (consumption) the unit, service, and/or facility wide level at least quarterly; otherwise, select
at the unit, service, and/or 'No'.
facility wide?
Conditionally Required. If ‘Yes’, select from the choices of listed antibiotic use
If Yes, by which metrics
metrics. Days of Therapy (also known as Antimicrobial Days) is defined by any
(Check all that apply)
amount of a specific antimicrobial agent administered in a calendar day to a
particular patient (i.e., each antimicrobial agent administered to a patient counted
If Yes, are facility- and/or as one day of therapy). The Defined Daily Dose is the assumed average
unit-specific reports on
maintenance dose per day for a drug used for its main indication in adults and is
antibiotic use shared with derived from the total number of grams of each antibiotic purchased, dispensed,
prescribers?
or administered. If ‘Other’ is selected, please specify the method(s) or metric(s)
used.
Conditionally Required. Select 'Yes' if facility and/or unit-specific reports on
antibiotic use are shared with prescribers (individually, by service line, by
medical group, etc.); otherwise, select 'No'.
33. Do prescribers ever receive Required. Select 'Yes' if prescribers (individually, by service line, by medical
feedback by the stewardship group, etc.) have received feedback based on observed practices through inprogram about how they can person, telephone, written or electronic communication about how they can
improve their antibiotic
improve their antibiotic prescribing; otherwise, select 'No'.
prescribing?
34. Has your stewardship
Required. Select 'Yes' if your facility stewardship program has provided
program provided education education on how to improve antibiotic use to clinicians and other relevant staff
to clinicians and other
(e.g. Grand Rounds, in-service training, or direct instruction); otherwise, select
relevant staff on improving 'No'.
antibiotic use?

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Plan and Annual Surveys

Instructions for Completion of the Patient Safety Annual Facility Survey
for LTAC (CDC 57.150)
Data Field
Facility ID #
Survey Year

Facility Characteristics
Ownership (check one)

Affiliation (check one)

Setting/Classification:
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)

Instructions for Form Completion
Required. The NHSN-assigned facility ID will be auto-entered by the computer.
Required. Select the calendar year for which this survey was completed.
The survey year should represent the last full calendar year. For example, in 2014,
a facility would complete a 2013 survey.
Required. Select the appropriate ownership of this facility:
 For profit
 Not for profit, including church
 Government
 Veterans Affairs
Required. Select the appropriate affiliation for this facility:
 Independent – The facility is a stand-alone facility that does not share a
building, staff, or policies (such as infection control) with any other
healthcare institution.
 Hospital system – The facility is affiliated with a local healthcare system.
Facility shares policies (such as infection control) with other institutions
within the hospital system. Facility may or may not share staff as well as a
building with other facilities that are part of that hospital system.
 Multi-facility organization (specialty network) – The facility is part of a
regional or national network of specialty facilities. Facilities share policies
(such as infection control), corporate leadership, and a common business
structure.
Required. Select the physical setting of the facility: free-standing or within a
hospital.
Conditionally required. If facility is classified as free-standing, select one or more
of the following facility or unit types that share physical housing with your
LTAC:
 No (none)
 Skilled nursing facility (SNF)/nursing home
 Residential facility (assisted living)
 Inpatient rehabilitation facility
 Neuro-behavioral unit or facility
 Other: specify

Conditionally required. If facility is classified as within a hospital, indicate ‘Yes’
If classified as “Within a
or ‘No’ if it is:
hospital”, is your LTAC hospital  In a building that does not provide acute care services (e.g., psychiatric
located:
hospital)
 Near (but not within) an acute care hospital

January 2014

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Plan and Annual Surveys

Instructions for Form Completion

Data Field

Note: These questions are to clarify the physical set-up of each HOSP-LTAC. All
separately licensed LTAC hospitals should be enrolled within NHSN as a separate
LTAC facility type regardless of the physical setting of the facility.
Number of Patient Days
Required. Enter the total number of patient days for your hospital during the last
full calendar year.
Number of Admissions
Required. Enter the total number of inpatient admissions for your hospital during
the last full calendar year.
Average daily census
Required. Enter the average number of patients housed each day during the last
full calendar year. Please round to the nearest whole number.
Numbers of LTAC beds in the Required. Enter the total number of LTAC beds in each on the following
following categories (categories categories during the last full calendar year:
should equal total number of
 Intensive care unit (ICU) or critical care beds
beds)
 High observation/special care/high acuity beds (not ICU)
 Other LTAC beds

Total number of LTAC beds
Required. The total number of LTAC beds in the facility during the last full
(licensed capacity)
calendar year will be automatically summed based on the above counts.
Number of single occupancy
Required. Enter the total number of single occupancy rooms during the last full
rooms
calendar year.
Facility Microbiology Laboratory Practices. Completion of this section requires the assistance from the
microbiology laboratory. Questions should be answered based on the testing methods that were used for the
majority of the last full calendar year.
35. Does your facility have its Required. Select 'Yes' if your laboratory performs antimicrobial susceptibility
own laboratory that
testing; otherwise, select 'No'.
performs antimicrobial
susceptibility testing? If No, Conditionally Required. If ‘No’, select the location where your facility's
where is the facility's
antimicrobial susceptibility testing is performed: Affiliated medical center,
antimicrobial susceptibility Commercial referral laboratory, or Other local/regional, non-affiliated reference
testing performed? (check laboratory. If multiple laboratories are used indicate the laboratory which
one)
performs the majority of the bacterial susceptibility testing. You must complete
the remainder of this survey with assistance from your outside laboratory.
36. Does the laboratory use
Required. Select 'Yes' if your laboratory uses CLSI antimicrobial susceptibility
CLSI (formerly NCCLS)
standards; otherwise, select 'No'.
antimicrobial susceptibility
standards? If Yes, specify Conditionally Required. If ‘Yes’, specify the version used by your laboratory or
which version of the M100 the referral laboratory.
document the laboratory
uses.
37. For the following organisms Required. Select from the choices listed the appropriate (1) primary susceptibility
please indicate which
testing and (2) secondary, supplemental, or confirmatory testing method (if
methods are used for (1)
performed) for each organism.
primary susceptibility

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Plan and Annual Surveys

Data Field
testing and (2) secondary,
supplemental, or
confirmatory testing (if
performed)

Instructions for Form Completion
Note: Repeat tests using the primary method should not be indicated as secondary
methods; instead indicate in the ‘Comments’ column the number of times repeat
testing is done using the same primary method.
If your laboratory does not perform susceptibility testing, please indicate the
methods used at the referral laboratory. If ‘Other’ is selected as the method for any
pathogen, use the ‘Comments’ column to describe the method used.
Required. Select 'Yes' if your laboratory has implemented the revised
cephalosporin and monobactam breakpoints for Enterobacteriaceae recommended
by CLSI as of 2010; otherwise, select 'No'.

38. Has your laboratory
implemented the revised
cephalosporin and
monobactam breakpoints for
Enterobacteriaceae
recommended by CLSI as of
2010?
39. Has your laboratory
Required. Select 'Yes' if your laboratory has implemented the revised carbapenem
implemented the revised
breakpoints for Enterobacteriaceae recommended by CLSI as of 2010; otherwise,
carbapenem breakpoints for select 'No'.
Enterobacteriaceae
recommended by CLSI as of
2010?
40. Does your laboratory
Required. Select 'Yes' if your laboratory performs a special test for carbapenemase
perform a special test for
production; otherwise, select 'No'.
carbapenemase production?
If Yes, please indicate what Conditionally Required. If ‘Yes’, specify what is done if carbapenemase
is done if carbapenemase
production is detected.
production is detected
(check one).
Conditionally Required. If ‘Yes’, specify which test is performed to detect
If Yes, which test is
carbapenemase.
routinely performed to
detect carbapenemase (check
all that apply)?
41. Does your laboratory
Required. Select 'Yes' if your laboratory performs colistin or polymyxin B
perform colistin or
susceptibility testing for drug-resistant gram negative bacilli; otherwise, select
polymyxin B susceptibility 'No'.
testing for drug-resistant
gram negative bacilli?
If Yes, indicate methods
Conditionally Required. If ‘Yes’, select the method(s) used from the choices
(check all that apply).
provided. If ‘Other’ is selected, please specify.

January 2015

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Plan and Annual Surveys

42.

43.

44.

45.

46.

Instructions for Form Completion
Data Field
Does your facility have its Required. Select 'Yes' if your laboratory performs antifungal susceptibility testing
own laboratory that
for Candida species; otherwise, select 'No'.
performs antifungal
susceptibility testing for
Conditionally Required. If ‘No”, select one of the choices provided.
Candida species? If No,
where your facility's
antifungal susceptibility
testing is performed? (check
one).
If antifungal susceptibility Conditionally Required. Select from the choices listed the method(s) of antifungal
testing is performed at your susceptibility testing performed at your facility or an outside laboratory. If ‘Other’
facility or an outside
is selected, please specify.
laboratory, what methods
are used? (check all that
apply)
Is antifungal susceptibility Required. Select 'Yes' if your laboratory or outside laboratory
testing performed
automatically/reflexively performs antifungal susceptibility testing for Candida
automatically/reflexively for species which are from normally sterile body sites (such as blood), without
Candida spp. cultured from needing a specific order or request for susceptibility testing from the clinician;
normally sterile body sites otherwise, select 'No'.
(such as blood), without
needing a specific order or Conditionally Required. If ‘Yes’, select from the choices listed the antifungal
request for susceptibility
drugs which are tested automatically/reflexively. If ‘Other’ is selected, please
testing from the clinician? If specify.
Yes, what antifungal drugs
are tested automatically/
reflexively? (check all that
apply)
What is the primary testing Required. Select from the choices listed the testing methods used to perform C.
method for C. difficile used difficile testing by your facility’s laboratory or the outside laboratory where your
most often by your facility’s facility’s testing is done. If ‘Other’ is selected, please specify.
laboratory or the outside
laboratory where your
Note: “Other” should not be used to name specific laboratories, reference
facility’s testing is
laboratories, or the brand names of C. difficile tests; most methods can be
performed? (check one)
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.
Does your facility produce Required. Select ‘Yes’ if your facility produces an antibiogram; otherwise select
an antibiogram (i.e.,
‘No’.
cumulative antimicrobial
susceptibility report)?
Conditionally Required. If ‘Yes’, indicate whether the antibiogram is produced at
If Yes, is the antibiogram
least annually.
produced at least annually?
If Yes, are data stratified by Conditionally Required. If ‘Yes’, indicate whether antibiogram data are stratified
hospital location?
If No, please identify any

January 2015

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Plan and Annual Surveys

Instructions for Form Completion
Data Field
obstacle(s) to producing an by hospital location.
antibiogram. (Check all that
apply)
Conditionally Required. If ‘No’, indicate the obstacle(s) to producing an
antibiogram at your facility. If ‘Other’ is selected, please specify.
Infection Control Practices. Completion of this section may require assistance from the Infection Preventionist,
Hospital Epidemiologist, other infection control personnel, and/or Quality Improvement Coordinator. Questions
should be answered based on the policies and practices that were in place for the majority of the last full calendar
year.
47. Number of infection
Required. Enter the number of individuals (full-time employees) who work in the
preventionists (IPs) in
infection prevention department of the hospital as infection prevention
facility
professionals. Certification in infection control, the CIC credential, is not required
to be considered an “IP” on this survey.
c. Total hours per week
Enter the number of hours per week engaged in activities designed to find and
performing surveillance report healthcare-associated infections (in the hospital) and the appropriate
denominators. Total should include time to analyze data and disseminate results.
d. Total hours per week for Enter the number of hours per week spent on infection prevention and control
infection control
activities other than surveillance. These activities include, but are not limited to,
activities other than
education, prevention, meetings, etc.
surveillance
48. Does your facility perform Required. Select from the choices listed, all MDRO(s) for which newly-admitted
active surveillance testing patients are tested for colonization:
(culturing) of new patients  Methicillin-resistant Staphylococcus aureus (MRSA)
on admission for
 Vancomycin-resistant Enterococcus (VRE)
colonization with any of the  Carbapenem-resistant Enterobacteriaceae (CRE)
following multidrug Other multidrug-resistant gram-negative rods
resistant organisms
 We do not screen new admissions for MDROs
(MDROs)? (check all that
apply)
For detailed description about the use of Contact Precautions, please refer to the CDC/HICPAC 2007 Guideline
for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
(http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf).
49. Does the facility routinely Required. Select ‘No’ if your facility does not routinely place any patient infected
place patients infected or
or colonized with MRSA in Contact Precautions; otherwise, select the single best
colonized with MRSA in
choice from the choices listed that most accurately describes the primary
contact precautions? (check indication for placing patients with MRSA on Contact Precautions at your facility.
one)
50. Does the facility routinely Required. Select ‘No’ if your facility does not routinely place any patient infected
place patients infected or
or colonized with VRE in Contact Precautions; otherwise, select the single best
colonized with VRE in
choice from the choices listed that most accurately describes the primary
contact precautions? (check indication for placing patients with VRE on Contact Precautions at your facility.
one)
51. Does the facility routinely Required. Select ‘No’ if your facility does not routinely place any patient infected
place patients infected or
or colonized with CRE in Contact Precautions; otherwise, select the single best
colonized with CRE in
choice from the choices listed that most accurately describes the primary
contact precautions? (check indication for placing patients with CRE on Contact Precautions at your facility.

January 2015

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Plan and Annual Surveys

Data Field

Instructions for Form Completion

52. Does the facility routinely
place patients infected or
colonized with ESBLproducing or extended
spectrum cephalosporin
resistant Enterobacteriaceae
in contact precautions?
(check one)
53. Does the facility routinely
perform screening cultures
for CRE?

Required. Select ‘No’ if your facility does not routinely place any patient infected
or colonized with ESBL-producing or extended spectrum cephalosporin-resistant
Enterobacteriaceae in Contact Precautions; otherwise, select the single best choice
from the choices listed that most accurately describes the primary indication for
placing patients with ESBL-producing or extended spectrum cephalosporinresistant Enterobacteriaceae on Contact Precautions at your facility.

one)

If Yes, in which situations
does the facility routinely
perform screening cultures
for CRE? (check all that
apply)

54. Does the facility use
chlorhexidine bathing on
any patient to prevent
transmission of MDROs in
your hospital?
55. 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?
If Yes, for which MDROs?
(check all that apply)
56. 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?
57. Among patients with an
MDRO admitted to your
facility from another

January 2015

Required. Select ‘Yes’ if your facility routinely obtains screening cultures from
patients for CRE (e.g., rectal, perirectal, or stool cultures); otherwise, select ‘No.’
Conditionally required. If ‘Yes’, select all the situations in which your facility
would routinely obtain screening cultures from patients for CRE. If ‘Other’ is
selected, please specify the situation(s) in which CRE screening is performed.
Note: ‘Epidemiologically-linked’ patients refer to contacts of the patient with
newly identified CRE. This might include current or prior roommates or patients
who shared the same healthcare personnel or patients who are located on the same
unit or ward.
Required. Select ‘Yes’ if your facility routinely uses chlorhexidine bathing on
any patient in any ward or unit as an intervention to prevent the transmission of
any MDRO; otherwise, select ‘No’.
Required. Select ‘Yes’ if the laboratory that performs clinical culture testing for
your facility routinely notifies relevant staff (either the Infection Prevention staff
and/or clinical staff) in a timely manner (e.g., within 4 hours) when an MDRO is
identified from clinical or surveillance cultures; otherwise, select ‘No.’
Conditionally required. If ‘Yes’, select all the MDROs for which timely
notification of relevant staff is performed by the laboratory. If ‘Other’ is selected,
please specify the MDRO(s) for which this would apply.
Required. Select ‘Yes’ if your facility routinely communicates the MDRO status
of a patient known to be colonized or infected with an MDRO to the receiving
facility at the time of patient transfer; otherwise, select ‘No’.

Required. Enter the estimated percentage of the time that your facility receives
information from a transferring facility about the MDRO status of a patient known
to be colonized or infected with an MDRO.

6

Plan and Annual Surveys

Instructions for Form Completion
Data Field
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. Completion of this by section may require assistance from the pharmacy and/or
physicians who focus on Antibiotic Stewardship or Infectious Diseases, where available, and/or members of the
Pharmacy and Therapeutic Committee. Antibiotic Stewardship refers to a coordinated, multidisciplinary approach
to optimize and measure antibiotic use. For further information, refer to Core Elements of Hospital Antibiotic
Stewardship Programs (http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html). Questions
should be answered based on the policies and practices that were in place for the majority of the last full calendar
year.
58. Does your facility have a
Required. Select 'Yes' if there is written evidence of senior-level management
written statement of support support focused on antibiotic use prescribing (e.g., formal letter of support for
from leadership that
efforts to improve antibiotic use, written communication to hospital staff that
supports efforts to improve encourages optimal antibiotic prescribing, communication of support that reaches
antibiotic use (antibiotic
staff beyond those who receive executive-level meeting notes); otherwise, select
stewardship)?
'No'.
59. Is there a leader responsible Required. Select 'Yes' if any individual has been identified as a lead to antibiotic
for outcomes of stewardship stewardship activities as evidenced by responsibility for improving antibiotic use
activities at your facility?
in the job description or performance review, authority to coordinate activities of
staff from multiple departments (e.g. laboratory, pharmacy, information
If Yes, what is the position technology), and/or responsibility to report to senior level management on
of this leader? (check one) program planning and outcomes.
Conditionally Required. If ‘Yes’, specify the qualification or job title of the
leader(s). More than choice one may be selected. If ‘Other’ is selected, please
specify the position.
Required. Select 'Yes' if your facility has at least one pharmacist who dedicates
time distinct from general pharmacy duties to educate staff, and track or monitor
antibiotic use to ensure optimal prescribing practices; otherwise, select 'No'.

60. Is there at least one
pharmacist responsible for
improving antibiotic use at
your facility?
61. Does your facility provide Required. Select 'Yes' if any individual was given salary support at least 4 hours
any salary support for
per week (0.1 full-time employees) to engage in duties to improve or monitor
dedicated time for antibiotic antibiotic use that are not part of their general clinical duties; otherwise, select
stewardship activities?
'No'.
62. Does your facility have a
Required. Select 'Yes' if your facility has a policy requiring documentation of
policy that requires
dose, duration and indication for all antibiotics in the medical record or during
prescribers to document in order entry; otherwise, select 'No'.
the medical record or during
order entry, a dose, duration, Conditionally Required. If ‘Yes’ to question 5, select ‘Yes’ if charts have been
and indication for all
audited to confirm documentation of dose, duration, and indication in patient
antibiotics?
medical records; otherwise, select ‘No’.

January 2015

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Plan and Annual Surveys

63.

64.

65.

66.

67.

Instructions for Form Completion
Data Field
If Yes, has adherence to this
documentation policy (dose,
duration, and indication)
been monitored?
Does your facility have
Required. Select 'Yes' if there are facility-specific recommendations for antibiotic
facility-specific treatment treatment selection based on national guidelines and local susceptibility reports
recommendations, based on for ANY common clinical conditions (e.g., community required pneumonia,
national guidelines and local urinary tract infections, or skin and soft tissue infections); otherwise, select 'No'.
susceptibility, to assist with
antibiotic selection for
Conditionally Required. If ‘Yes’ to question 6,
common clinical conditions? a. Select ‘Yes’ charts have been audited to confirm adherence to facility-specific
treatment guidelines for ANY of the common clinical conditions listed above;
If Yes, has adherence to
otherwise, select ‘No’.
facility-specific treatment
recommendations been
monitored?
Is there a formal procedure Required. Select 'Yes' if your facility has developed a standardized way for
for all clinicians to review clinicians on the treating team (or attending physician? or physician of record?) to
the appropriateness of all
reassess the continuing need and choice of antibiotics at or after 48 hours after the
antibiotics at or after 48
initial orders (to confirm indication, review microbiology results, and review
hours from the initial orders antibiotic choice, dose, and duration); otherwise, select 'No'.
(e.g. antibiotic time out)?
Do any specified antibiotic Required. Select 'Yes' if your facility has at least one antibiotic agent that requires
agents need to be approved a physician or pharmacist to review and approve administration of the drug due to
by a physician or pharmacist its spectrum of activity, cost, or associated toxicities; otherwise, select 'No'.
prior to dispensing (i.e., preauthorization) at your
facility?
Does a physician or
Required. Select 'Yes' if your facility had physicians or pharmacists
pharmacist review courses knowledgeable in antibiotic use, and not part of the treating team, review courses
of therapy for specified
of therapy for specified antibiotic agents and communicate the results to
antibiotic agents and
prescribers (such as audit with feedback); otherwise, select 'No'.
communicate results with
prescribers (i.e., audit with
feedback) at your facility?
Does your facility monitor Required. Select 'Yes' if your facility monitors antibiotic use or consumption at
antibiotic use (consumption) the unit, service, and/or facility wide level at least quarterly; otherwise, select 'No'.
at the unit, service, and/or
facility wide?
Conditionally Required. If ‘Yes’, select from the choices of listed antibiotic use
metrics. Days of Therapy (also known as Antimicrobial Days) is defined by any
If Yes, by which metrics
amount of a specific antimicrobial agent administered in a calendar day to a
(Check all that apply)
particular patient (i.e., each antimicrobial agent administered to a patient counted
as one day of therapy). The Defined Daily Dose is the assumed average
If Yes, are facility- and/or maintenance dose per day for a drug used for its main indication in adults and is
unit-specific reports on
derived from the total number of grams of each antibiotic purchased, dispensed, or
antibiotic use shared with administered. If ‘Other’ is selected, please specify the method(s) or metric(s)

January 2015

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Plan and Annual Surveys

Data Field
prescribers?

Instructions for Form Completion
used.

Conditionally Required. Select 'Yes' if facility and/or unit-specific reports on
antibiotic use are shared with prescribers (individually, by service line, by medical
group, etc.); otherwise, select 'No'.
68. Do prescribers ever receive Required. Select 'Yes' if prescribers (individually, by service line, by medical
feedback by the stewardship group, etc.) have received feedback based on observed practices through inprogram about how they can person, telephone, written or electronic communication about how they can
improve their antibiotic
improve their antibiotic prescribing; otherwise, select 'No'.
prescribing?
69. Has your stewardship
Required. Select 'Yes' if your facility stewardship program has provided
program provided education education on how to improve antibiotic use to clinicians and other relevant staff
to clinicians and other
(e.g. Grand Rounds, in-service training, or direct instruction); otherwise, select
relevant staff on improving 'No'.
antibiotic use?

January 2015

9

Plan and Annual Surveys

Instructions for Completion of the Patient Safety Annual Facility Survey
for IRF (CDC 57.151)
Data Field
Facility ID #
Survey Year

Instructions for Form Completion
Required. The NHSN-assigned facility ID will be auto-entered by the computer.
Required. Select the calendar year for which this survey was completed.
The survey year should represent the last full calendar year. For example, in 2014,
a facility would complete a 2013 survey.

Facility Characteristics
Ownership (check one)

Required. Select the appropriate ownership of this facility:
 For profit
 Not for profit, including church
 Government
 Veterans Affairs
Affiliation (check one)
Required. Select the appropriate affiliation for this facility:
 Independent – The facility is a stand-alone facility that does not share a
building, staff, or policies (such as infection control) with any other
healthcare institution.
 Hospital system – The facility is affiliated with a local healthcare system.
Facility shares policies (such as infection control) with other institutions
within the hospital system. Facility may or may not share staff as well as a
building with other facilities that are part of that hospital system.
 Multi-facility organization (specialty network) – The facility is part of a
regional or national network of specialty facilities. Facilities share policies
(such as infection control), corporate leadership, and a common business
structure.
How would you describe your Required. Select the appropriate classification of your inpatient rehabilitation
licensed inpatient rehabilitation facility:
facility? (check one)
 Free-standing - The rehabilitation facility functions as a stand-alone facility.
Patients receive all required care within the constructs of this facility. The
facility may share a building with another healthcare facility, but does not
share staff, patients, or policies (such as infection control) with the other
healthcare facility.
 Healthcare facility based - The rehabilitation facility functions as part of a
larger healthcare facility. Patients can be transported from the rehabilitation
area to the healthcare facility area on a regular/daily basis for procedures or
therapy. The facility may share staff and policies (such as infection control)
with the affiliated healthcare facility.
Total number of beds
Required. Enter the total number of beds in your facility during the last full
calendar year.
Average daily census
Required. Enter the average number of patients housed each day in your facility
during the last full calendar year. Please round to the nearest whole number.
Number of patient days
Required. Enter the total number of patient days for your facility during the last
full calendar year.

January 2014

1

Plan and Annual Surveys

Instructions for Form Completion
Required. Enter the average length of stay of patients in your facility during the
last full calendar year. Please round to the nearest whole number.
Indicate the number of
Required. For your facility during the last full calendar year, enter the number of
admissions with the primary
admissions with the primary diagnosis for each of the categories listed.
diagnosis for each of the
 Traumatic spinal cord dysfunction
following rehabilitation
 Non-traumatic spinal cord dysfunction
categories (must sum to the total  Stroke
number of admissions listed
 Brain dysfunction (non-traumatic or traumatic)
below)
 Other neurologic conditions (e.g. multiple sclerosis, Parkinson’s disease, etc)
 Orthopedic conditions (incl. fracture, joint replacement, other)
 All other admissions
Total number of admissions
Required. The total number of admissions will be automatically summed from the
categories above.
Additionally, enter the total number of admissions that were patients on a
ventilator as well as the number that were pediatric admissions.
Facility Microbiology Laboratory Practices. Completion of this section requires the assistance from the
microbiology laboratory. Questions should be answered based on the testing methods that were used for the
majority of the last full calendar year.
70. Does your facility have its Required. Select 'Yes' if your laboratory performs antimicrobial susceptibility
own laboratory that
testing; otherwise, select 'No'.
performs antimicrobial
susceptibility testing? If No, Conditionally Required. If ‘No’, select the location where your facility's
where is the facility's
antimicrobial susceptibility testing is performed: Affiliated medical center,
antimicrobial susceptibility Commercial referral laboratory, or Other local/regional, non-affiliated reference
testing performed? (check laboratory. If multiple laboratories are used indicate the laboratory which
one)
performs the majority of the bacterial susceptibility testing. You must complete
the remainder of this survey with assistance from your outside laboratory.
71. Does the laboratory use
Required. Select 'Yes' if your laboratory uses CLSI antimicrobial susceptibility
CLSI (formerly NCCLS)
standards; otherwise, select 'No'.
antimicrobial susceptibility
standards? If Yes, specify Conditionally Required. If ‘Yes’, specify the version used by your laboratory or
which version of the M100 the referral laboratory.
document the laboratory
uses.
72. For the following organisms Required. Select from the choices listed the appropriate (1) primary susceptibility
please indicate which
testing and (2) secondary, supplemental, or confirmatory testing method (if
methods are used for (1)
performed) for each organism.
primary susceptibility
testing and (2) secondary, Note: Repeat tests using the primary method should not be indicated as secondary
supplemental, or
methods; instead indicate in the ‘Comments’ column the number of times repeat
confirmatory testing (if
testing is done using the same primary method.
performed)
If your laboratory does not perform susceptibility testing, please indicate the
methods used at the referral laboratory. If ‘Other’ is selected as the method for any
pathogen, use the ‘Comments’ column to describe the method used.
Data Field
Average length of stay

January 2015

2

Plan and Annual Surveys

73.

74.

75.

76.

77.

78.

Instructions for Form Completion
Data Field
Has your laboratory
Required. Select 'Yes' if your laboratory has implemented the revised
implemented the revised
cephalosporin and monobactam breakpoints for Enterobacteriaceae recommended
cephalosporin and
by CLSI as of 2010; otherwise, select 'No'.
monobactam breakpoints for
Enterobacteriaceae
recommended by CLSI as of
2010?
Has your laboratory
Required. Select 'Yes' if your laboratory has implemented the revised carbapenem
implemented the revised
breakpoints for Enterobacteriaceae recommended by CLSI as of 2010; otherwise,
carbapenem breakpoints for select 'No'.
Enterobacteriaceae
recommended by CLSI as of
2010?
Does your laboratory
Required. Select 'Yes' if your laboratory performs a special test for carbapenemase
perform a special test for
production; otherwise, select 'No'.
carbapenemase production?
If Yes, please indicate what Conditionally Required. If ‘Yes’, specify what is done if carbapenemase
is done if carbapenemase
production is detected.
production is detected
(check one).
Conditionally Required. If ‘Yes’, specify which test is performed to detect
If Yes, which test is
carbapenemase.
routinely performed to
detect carbapenemase (check
all that apply)?
Does your laboratory
Required. Select 'Yes' if your laboratory performs colistin or polymyxin B
perform colistin or
susceptibility testing for drug-resistant gram negative bacilli; otherwise, select
polymyxin B susceptibility 'No'.
testing for drug-resistant
gram negative bacilli?
If Yes, indicate methods
Conditionally Required. If ‘Yes’, select the method(s) used from the choices
(check all that apply).
provided. If ‘Other’ is selected, please specify.
Does your facility have its Required. Select 'Yes' if your laboratory performs antifungal susceptibility testing
own laboratory that
for Candida species; otherwise, select 'No'.
performs antifungal
susceptibility testing for
Conditionally Required. If ‘No”, select one of the choices provided.
Candida species? If No,
where your facility's
antifungal susceptibility
testing is performed? (check
one).
If antifungal susceptibility Conditionally Required. Select from the choices listed the method(s) of antifungal
testing is performed at your susceptibility testing performed at your facility or an outside laboratory. If ‘Other’
facility or an outside
is selected, please specify.
laboratory, what methods
are used? (check all that

January 2015

3

Plan and Annual Surveys

Instructions for Form Completion

Data Field
apply)

79. Is antifungal susceptibility Required. Select 'Yes' if your laboratory or outside laboratory
testing performed
automatically/reflexively performs antifungal susceptibility testing for Candida
automatically/reflexively for species which are from normally sterile body sites (such as blood), without
Candida spp. cultured from needing a specific order or request for susceptibility testing from the clinician;
normally sterile body sites otherwise, select 'No'.
(such as blood), without
needing a specific order or Conditionally Required. If ‘Yes’, select from the choices listed the antifungal
request for susceptibility
drugs which are tested automatically/reflexively. If ‘Other’ is selected, please
testing from the clinician? If specify.
Yes, what antifungal drugs
are tested automatically/
reflexively? (check all that
apply)
80. What is the primary testing Required. Select from the choices listed the testing methods used to perform C.
method for C. difficile used difficile testing by your facility’s laboratory or the outside laboratory where your
most often by your facility’s facility’s testing is done. If ‘Other’ is selected, please specify.
laboratory or the outside
laboratory where your
Note: “Other” should not be used to name specific laboratories, reference
facility’s testing is
laboratories, or the brand names of C. difficile tests; most methods can be
performed? (check one)
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.
81. Does your facility produce Required. Select ‘Yes’ if your facility produces an antibiogram; otherwise select
an antibiogram (i.e.,
‘No’.
cumulative antimicrobial
susceptibility report)?
Conditionally Required. If ‘Yes’, indicate whether the antibiogram is produced at
If Yes, is the antibiogram
least annually.
produced at least annually?
If Yes, are data stratified by Conditionally Required. If ‘Yes’, indicate whether antibiogram data are stratified
hospital location?
by hospital location.
If No, please identify any
obstacle(s) to producing an Conditionally Required. If ‘No’, indicate the obstacle(s) to producing an
antibiogram. (Check all that antibiogram at your facility. If ‘Other’ is selected, please specify.
apply)
Infection Control Practices. Completion of this section may require assistance from the Infection Preventionist,
Hospital Epidemiologist, other infection control personnel, and/or Quality Improvement Coordinator. Questions
should be answered based on the policies and practices that were in place for the majority of the last full calendar
year.
82. Number of infection
Required. Enter the number of individuals (full-time employees) who work in the
preventionists (IPs) in
infection prevention department of the hospital as infection prevention
facility
professionals. Certification in infection control, the CIC credential, is not required

January 2015

4

Plan and Annual Surveys

Instructions for Form Completion

Data Field

to be considered an “IP” on this survey.
e. Total hours per week
Enter the number of hours per week engaged in activities designed to find and
performing surveillance report healthcare-associated infections (in the hospital) and the appropriate
denominators. Total should include time to analyze data and disseminate results.
f. Total hours per week for Enter the number of hours per week spent on infection prevention and control
infection control
activities other than surveillance. These activities include, but are not limited to,
activities other than
education, prevention, meetings, etc.
surveillance
83. Does your facility perform Required. Select from the choices listed, all MDRO(s) for which newly-admitted
active surveillance testing patients are tested for colonization:
(culturing) of new patients  Methicillin-resistant Staphylococcus aureus (MRSA)
on admission for
 Vancomycin-resistant Enterococcus (VRE)
colonization with any of the  Carbapenem-resistant Enterobacteriaceae (CRE)
following multidrug Other multidrug-resistant gram-negative rods
resistant organisms
 We do not screen new admissions for MDROs
(MDROs)? (check all that
apply)
For detailed description about the use of Contact Precautions, please refer to the CDC/HICPAC 2007 Guideline
for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
(http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf).
84. Does the facility routinely Required. Select ‘No’ if your facility does not routinely place any patient infected
place patients infected or
or colonized with MRSA in Contact Precautions; otherwise, select the single best
colonized with MRSA in
choice from the choices listed that most accurately describes the primary
contact precautions? (check indication for placing patients with MRSA on Contact Precautions at your facility.
one)
85. Does the facility routinely Required. Select ‘No’ if your facility does not routinely place any patient infected
place patients infected or
or colonized with VRE in Contact Precautions; otherwise, select the single best
colonized with VRE in
choice from the choices listed that most accurately describes the primary
contact precautions? (check indication for placing patients with VRE on Contact Precautions at your facility.
one)
86. Does the facility routinely Required. Select ‘No’ if your facility does not routinely place any patient infected
place patients infected or
or colonized with CRE in Contact Precautions; otherwise, select the single best
colonized with CRE in
choice from the choices listed that most accurately describes the primary
contact precautions? (check indication for placing patients with CRE on Contact Precautions at your facility.
one)
87. Does the facility routinely Required. Select ‘No’ if your facility does not routinely place any patient infected
place patients infected or
or colonized with ESBL-producing or extended spectrum cephalosporin-resistant
colonized with ESBLEnterobacteriaceae in Contact Precautions; otherwise, select the single best choice
producing or extended
from the choices listed that most accurately describes the primary indication for
spectrum cephalosporin
placing patients with ESBL-producing or extended spectrum cephalosporinresistant Enterobacteriaceae resistant Enterobacteriaceae on Contact Precautions at your facility.
in contact precautions?
(check one)
88. Does the facility routinely Required. Select ‘Yes’ if your facility routinely obtains screening cultures from
perform screening cultures patients for CRE (e.g., rectal, perirectal, or stool cultures); otherwise, select ‘No.’

January 2015

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Plan and Annual Surveys

Instructions for Form Completion

Data Field
for CRE?
If Yes, in which situations
does the facility routinely
perform screening cultures
for CRE? (check all that
apply)

Conditionally required. If ‘Yes’, select all the situations in which your facility
would routinely obtain screening cultures from patients for CRE. If ‘Other’ is
selected, please specify the situation(s) in which CRE screening is performed.
Note: ‘Epidemiologically-linked’ patients refer to contacts of the patient with
newly identified CRE. This might include current or prior roommates or patients
who shared the same healthcare personnel or patients who are located on the same
unit or ward.
Required. Select ‘Yes’ if your facility routinely uses chlorhexidine bathing on
any patient in any ward or unit as an intervention to prevent the transmission of
any MDRO; otherwise, select ‘No’.

89. Does the facility use
chlorhexidine bathing on
any patient to prevent
transmission of MDROs in
your hospital?
90. Are results rapidly
Required. Select ‘Yes’ if the laboratory that performs clinical culture testing for
communicated (generally
your facility routinely notifies relevant staff (either the Infection Prevention staff
within 4 hours) to infection and/or clinical staff) in a timely manner (e.g., within 4 hours) when an MDRO is
prevention staff and/or
identified from clinical or surveillance cultures; otherwise, select ‘No.’
clinical staff when MDROs
are identified from clinical Conditionally required. If ‘Yes’, select all the MDROs for which timely
or screening cultures in the notification of relevant staff is performed by the laboratory. If ‘Other’ is selected,
laboratory?
please specify the MDRO(s) for which this would apply.
If Yes, for which MDROs?
(check all that apply)
91. When a patient with an
Required. Select ‘Yes’ if your facility routinely communicates the MDRO status
MDRO is transferred to
of a patient known to be colonized or infected with an MDRO to the receiving
another facility, does your facility at the time of patient transfer; otherwise, select ‘No’.
facility communicate the
patient’s MDRO status to
the receiving facility at the
time of transfer?
92. Among patients with an
Required. Enter the estimated percentage of the time that your facility receives
MDRO admitted to your
information from a transferring facility about the MDRO status of a patient known
facility from another
to be colonized or infected with an MDRO.
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. Completion of this by section may require assistance from the pharmacy and/or
physicians who focus on Antibiotic Stewardship or Infectious Diseases, where available, and/or members of the
Pharmacy and Therapeutic Committee. Antibiotic Stewardship refers to a coordinated, multidisciplinary approach
to optimize and measure antibiotic use. For further information, refer to Core Elements of Hospital Antibiotic
Stewardship Programs (http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html). Questions
should be answered based on the policies and practices that were in place for the majority of the last full calendar

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Data Field

Instructions for Form Completion

93. Does your facility have a
written statement of support
from leadership that
supports efforts to improve
antibiotic use (antibiotic
stewardship)?
94. Is there a leader responsible
for outcomes of stewardship
activities at your facility?

Required. Select 'Yes' if there is written evidence of senior-level management
support focused on antibiotic use prescribing (e.g., formal letter of support for
efforts to improve antibiotic use, written communication to hospital staff that
encourages optimal antibiotic prescribing, communication of support that reaches
staff beyond those who receive executive-level meeting notes); otherwise, select
'No'.
Required. Select 'Yes' if any individual has been identified as a lead to antibiotic
stewardship activities as evidenced by responsibility for improving antibiotic use
in the job description or performance review, authority to coordinate activities of
staff from multiple departments (e.g. laboratory, pharmacy, information
technology), and/or responsibility to report to senior level management on
program planning and outcomes.

year.

If Yes, what is the position
of this leader? (check one)

Conditionally Required. If ‘Yes’, specify the qualification or job title of the
leader(s). More than choice one may be selected. If ‘Other’ is selected, please
specify the position.
Required. Select 'Yes' if your facility has at least one pharmacist who dedicates
time distinct from general pharmacy duties to educate staff, and track or monitor
antibiotic use to ensure optimal prescribing practices; otherwise, select 'No'.

95. Is there at least one
pharmacist responsible for
improving antibiotic use at
your facility?
96. Does your facility provide Required. Select 'Yes' if any individual was given salary support at least 4 hours
any salary support for
per week (0.1 full-time employees) to engage in duties to improve or monitor
dedicated time for antibiotic antibiotic use that are not part of their general clinical duties; otherwise, select
stewardship activities?
'No'.
97. Does your facility have a
Required. Select 'Yes' if your facility has a policy requiring documentation of
policy that requires
dose, duration and indication for all antibiotics in the medical record or during
prescribers to document in order entry; otherwise, select 'No'.
the medical record or during
order entry, a dose, duration, Conditionally Required. If ‘Yes’ to question 5, select ‘Yes’ if charts have been
and indication for all
audited to confirm documentation of dose, duration, and indication in patient
antibiotics?
medical records; otherwise, select ‘No’.

If Yes, has adherence to this
documentation policy (dose,
duration, and indication)
been monitored?
98. Does your facility have
Required. Select 'Yes' if there are facility-specific recommendations for antibiotic
facility-specific treatment treatment selection based on national guidelines and local susceptibility reports
recommendations, based on for ANY common clinical conditions (e.g., community required pneumonia,
national guidelines and local urinary tract infections, or skin and soft tissue infections); otherwise, select 'No'.
susceptibility, to assist with
antibiotic selection for
Conditionally Required. If ‘Yes’ to question 6,
common clinical conditions? a. Select ‘Yes’ charts have been audited to confirm adherence to facility-specific
treatment guidelines for ANY of the common clinical conditions listed above;

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Plan and Annual Surveys

Instructions for Form Completion
Data Field
If Yes, has adherence to
otherwise, select ‘No’.
facility-specific treatment
recommendations been
monitored?
99. Is there a formal procedure Required. Select 'Yes' if your facility has developed a standardized way for
for all clinicians to review clinicians on the treating team (or attending physician? or physician of record?) to
the appropriateness of all
reassess the continuing need and choice of antibiotics at or after 48 hours after the
antibiotics at or after 48
initial orders (to confirm indication, review microbiology results, and review
hours from the initial orders antibiotic choice, dose, and duration); otherwise, select 'No'.
(e.g. antibiotic time out)?
100. Do any specified
Required. Select 'Yes' if your facility has at least one antibiotic agent that requires
antibiotic agents need to be a physician or pharmacist to review and approve administration of the drug due to
approved by a physician or its spectrum of activity, cost, or associated toxicities; otherwise, select 'No'.
pharmacist prior to
dispensing (i.e., preauthorization) at your
facility?
101. Does a physician or
Required. Select 'Yes' if your facility had physicians or pharmacists
pharmacist review courses knowledgeable in antibiotic use, and not part of the treating team, review courses
of therapy for specified
of therapy for specified antibiotic agents and communicate the results to
antibiotic agents and
prescribers (such as audit with feedback); otherwise, select 'No'.
communicate results with
prescribers (i.e., audit with
feedback) at your facility?
102. Does your facility
Required. Select 'Yes' if your facility monitors antibiotic use or consumption at
monitor antibiotic use
the unit, service, and/or facility wide level at least quarterly; otherwise, select 'No'.
(consumption) at the unit,
service, and/or facility wide? Conditionally Required. If ‘Yes’, select from the choices of listed antibiotic use
metrics. Days of Therapy (also known as Antimicrobial Days) is defined by any
If Yes, by which metrics
amount of a specific antimicrobial agent administered in a calendar day to a
(Check all that apply)
particular patient (i.e., each antimicrobial agent administered to a patient counted
as one day of therapy). The Defined Daily Dose is the assumed average
If Yes, are facility- and/or maintenance dose per day for a drug used for its main indication in adults and is
unit-specific reports on
derived from the total number of grams of each antibiotic purchased, dispensed, or
antibiotic use shared with administered. If ‘Other’ is selected, please specify the method(s) or metric(s)
prescribers?
used.
Conditionally Required. Select 'Yes' if facility and/or unit-specific reports on
antibiotic use are shared with prescribers (individually, by service line, by medical
group, etc.); otherwise, select 'No'.
103. Do prescribers ever
Required. Select 'Yes' if prescribers (individually, by service line, by medical
receive feedback by the
group, etc.) have received feedback based on observed practices through instewardship program about person, telephone, written or electronic communication about how they can
how they can improve their improve their antibiotic prescribing; otherwise, select 'No'.
antibiotic prescribing?

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Plan and Annual Surveys

Data Field
104. Has your stewardship
program provided education
to clinicians and other
relevant staff on improving
antibiotic use?

January 2015

Instructions for Form Completion
Required. Select 'Yes' if your facility stewardship program has provided
education on how to improve antibiotic use to clinicians and other relevant staff
(e.g. Grand Rounds, in-service training, or direct instruction); otherwise, select
'No'.

9