Draft Example - Primary Team Instructions

Emerging Infections Program
Healthcare-Associated Infections & Antimicrobial Use
Prevalence Survey

Operational Manual
Version 1, June 20, 2013

Primary Team Instructions*

*NOTE: This document contains only the sections of the complete Operational Manual that are
relevant to the Primary Team’s responsiblities in this survey. Some sections, appendices, and
forms have been removed as they are not relevant to the major activities of the Primary Team. If
you have questions about the complete Operational Manual, please contact your EIP Team.

TABLE OF CONTENTS
Prevalence survey design overview ……………………..…………………………................
Prevalence survey teams …………………………………...…………………………………..
Patient population ………………………………………………………………………………..
Overview of survey procedures for Primary Teams ...…………………………...................
Data collection ………………………………………………………………………………........
Data validation ……………………………………………………………………......................
Detailed instructions for completing survey forms……………………………..……………..
What to do with completed forms …………………………………………………………..
Appendix 1: CDC Patient Locations ……………………………………………………………
Appendix 2: Antimicrobial Agent List……………………….. .………………………………..

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References used in preparing this manual:
1) The National Healthcare Safety Network (NHSN) Manual: Patient Safety Component
Protocol, available at http://www.cdc.gov/nhsn/PDFs/pscManual/PSC-Manual-portfolio.pdf.
2) Operational manual for the Four Country (England, Wales, Northern Ireland, Republic of
Ireland) Healthcare Associated Infection Prevalence Survey 2006, Hospital Infection Society
and Infection Control Nurses Association. Survey results presented in: Smyth ETM,
McIlvenny G, Enstone JE, et al. Four Country Healthcare Associated Infection Prevalence
Survey 2006: overview of the results. J Hosp Infect 2008;69:230-48.
3) Operational manual for the Jacksonville Healthcare-Associated Infections Prevalence Survey
Pilot 2009, Jacksonville, FL, Version 6, June 29, 2009.
4) Operational manual for the Emerging Infections Program Phase 3 Healthcare-Associated
Infections and Antimicrobial Use Prevalence Survey, Version 2a, May 6, 2011.
5) Emerging Infections Program Phase 3 Healthcare-Associated Infections and Antimicrobial
Use Prevalence Survey protocol, Version 4a, March 22, 2011.
PREVALENCE SURVEY DESIGN OVERVIEW
This manual contains instructions for performing the Emerging Infections Program (EIP)
Healthcare-Associated Infections (HAI)/Antimicrobial Use Prevalence Survey and completing
the data collection forms.
The project has been designed as a point prevalence survey, to be conducted on a single day in
each participating hospital. Hospital types included in the survey are general, acute care
hospitals, including general, acute care, pediatric hospitals. Hospitals were randomly selected
and recruited for participation in each EIP site from 3 bed size strata: small, medium, and large.
The numbers of hospitals recruited in each of these strata attempted to approximate the
distribution of hospitals in these bed size categories across the entire EIP catchment area
(combined catchment areas of the 10 EIP sites).
Each participating hospital will select its own survey date. Where possible, all hospital survey
dates will occur during the same 4-month period (e.g., May through August).
Prior to the survey date, participating hospitals will assemble a team of hospital staff to perform
survey-related activities. This team is called the Primary Team, or PT. During the month prior to
the survey, a member of the PT will complete a Healthcare Facility Assessment (HFA). On the
survey date, the PT will perform medical record review on a random sample of hospital
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inpatients to collect a limited amount of basic information. This basic information includes patient
demographic data (e.g., age, gender, etc.), hospitalization dates, height and weight information,
presence of selected medical devices, and antimicrobial drug administration. Because this is a
point prevalence survey, all data collection will remain restricted to information present (or
cultures collected) on or prior to the survey date.
Each EIP site will have a trained team of survey personnel (the EIP Team, or EIPT) that may
assist the PT with its data collection, where needed. In some cases, where resources do not
permit collection of data on the survey date itself, the PT and/or EIPT may collect the
information retrospectively, according to the specific approach developed by the CDC and EIP
survey personnel. Information collected on the survey date by the PT will be transmitted to
EIPTs within 30 days following the survey date.
The EIPT will identify those patients for whom additional medical record review is needed (i.e.
those patients identified as being on antimicrobial drugs or scheduled to receive antimicrobial
drugs on the day of the survey or the day prior to the survey). The EIPT will request and review
medical records of this subset of patients to collect additional antimicrobial use data and make
HAI determinations. EIPTs will enter all survey data into a web-based electronic data
management system developed by CDC.
PREVALENCE SURVEY TEAMS
As noted above, primary data collection for the prevalence survey will be conducted by 2 teams:
Primary Teams (PTs) and EIP Teams (EIPTs).
The PT is the team that each participating hospital assembles for the purposes of conducting
prevalence survey activities. The number, experience, and expertise of team members will vary
from hospital to hospital, although it is recommended that the PT leader be an infection
preventionist. Other team members will be determined by the PT leader. These individuals may
be Registered Nurses or other hospital personnel without specific infection prevention
experience, as long as these team members: 1) possess appropriate credentials and
permissions to review patient medical records as required by the facility; 2) have participated in
prevalence survey training conducted by EIP sites and/or CDC; and 3) receive adequate
supervision by the PT leader. The PT will complete the HFA and collect basic demographic and
limited clinical data on patients selected for inclusion in the survey. The EIPT may assist the PT
in these survey date activities, to the extent determined upon by the PT and EIPT, by providing
support or participating in data collection.
The EIPT is the team composed of EIP epidemiologists/surveillance officers and led by the EIP
survey coordinator. In some EIP sites, this team may also include other designated, qualified
individuals, as deemed appropriate by the EIP survey coordinator. EIPT members will
participate in prevalence survey training conducted by CDC. The EIPT will assist the PT with
acute care unit mapping to NHSN location codes, patient selection activities, and will also
perform retrospective medical record review of patients surveyed by the PT to identify HAIs and
to assess antimicrobial use.
PATIENT POPULATION
The prevalence survey will include patients of any age admitted to acute care areas of
participating hospitals. Acute care areas of participating hospitals include labor and delivery (LD)
units, labor-delivery-recovery-postpartum (LDRP) units, and newborn nurseries housing well
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newborns. Newborns rooming in with mothers on LDRP or postpartum (PP) units are also
included. There is no required duration of hospitalization for a patient to be included in the study
(except in the case of patients on observation status, who are eligible for inclusion in the survey
if they have been in the hospital for ≥ 24 hours at the time of the survey).
Do not include patients in the following categories:
 Patients in non-acute care areas of the hospital.
 Patients in non-admission areas of the hospital.
 Patients in skilled nursing care units.
 Patients undergoing same-day treatment or surgery.
 Patients seen as outpatients, whether for 23-hour observation, diagnosis, or therapy (e.g.
chemotherapy, dialysis, or cardiac catheterization).
 Patients in the Emergency Department.
 Patients in hospice units.
Ideally, all acute care patients in participating hospitals would be included the survey. However,
in many instances this is not practical. Therefore, a random sample of acute care patients from
each participating hospital will be included. The process for selecting the random sample of
patients is described below. The size of the random sample will depend on the staffed bed size
of the hospital:




Small hospitals will have a target sample size of 75 patients (or all acute care inpatients
in circumstances where the acute care patient census on the survey date is <75).
Medium hospitals will have a target sample size of 75 patients.
Large hospitals will have a target sample size of 100 patients.

OVERVIEW OF SURVEY PROCEDURES FOR PRIMARY TEAMS
1) Each hospital should designate a PT leader in advance of the survey date. The PT leader
is responsible for coordinating all prevalence survey activities at that facility and for
supervising and organizing the efforts of the PT.
2) Approximately one month prior to the survey date, the PT leader or designee will
complete the HFA; this assessment gathers information on hospital characteristics (such
as bed size) and infection control and antimicrobial stewardship practices, policies and
resources. The PT leader or designee will be responsible for completing the assessment
and submitting it to the EIPT, but the PT leader or designee is expected and encouraged
to consult with other hospital colleagues/departments to collect all information needed to
complete the HFA. The HFA should be completed within 1-2 weeks.
3) In advance of the survey date (e.g., approximately one month prior to the survey date),
the PT leader will send a list of the participating facility’s acute care inpatient units to the
EIPT. The EIPT will work with staff at CDC to map each acute care inpatient unit to the
correct NHSN location code (see Appendix 1).
4) The PT leader will submit a list of acute care bed numbers to the EIPT approximately 2-3
weeks in advance of the survey date. This bed number list should, whenever possible, be
formatted in Microsoft Excel, with columns for acute care unit name, CDC location code,
and bed number. Bed numbers should represent unique hospital beds (and, therefore, in
most cases unique patients).
5) Approximately one week prior to the survey, the PT leader will receive a randomly-sorted
acute care bed number list from the EIPT. This list should include the following
information for each acute care bed number: the hospital unit on which the bed is located,
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the CDC location code for that unit, and the CDC ID code assigned to that bed number.
The list should also make note of the target sample size for that hospital, based on the
hospital’s bed size category.
Note for small hospitals: If the number of staffed beds in a small hospital is less than 75,
then the goal will be for the PT to survey all patients in that hospital on the survey date.
For example, if Hospital CC has 50 staffed beds, Hospital CC would have a sample size
goal of 50 patients on the survey date. If 45 eligible acute care patients were in Hospital
CC on the morning of the survey date (i.e. 5 beds were empty), the PT should attempt to
survey all 45 patients. Also, in hospitals where the number of staffed beds may be
greater than 75 but the number of eligible patients on the survey date turns out to be less
than 75, the PT should attempt to survey all eligible patients.
6) CDC ID codes should be pre-assigned to bed numbers prior to the survey by the EIPT or
the PT. Each code will be a 7-digit, alpha-numeric code starting with the state’s two-letter
abbreviation, followed by a two-letter facility identifier and 3 numbers (example, CAAA001). The two-letter facility identifier will be assigned by the EIPT.
Example of CDC ID code assignment: Hospital AA in CA is a small hospital with a target
sample size of 75 patients. The CA EIPT member assigned to Hospital AA provides the
PT leader with the hospital two-letter code (AA), and patient numbers from 1 to 75.
Therefore, CDC ID codes in Hospital AA will be CA-AA001 through CA-AA075. Hospital
BB, also in CA, is a large hospital and therefore has a target sample size of 100. The CA
EIPT member gives the Hospital BB PT leader the hospital two-letter code (BB) and
patient numbers from 1 to 100. Therefore, Hospital BB’s CDC ID codes will be CA-BB001
through CA-BB100.
7) Between 12:00 am and 8:00 am on the morning of the survey date, the PT leader will
print out the hospital census for that day. The PT will match the randomly-sorted acute
care bed number list with the morning census to identify the patients to be surveyed. For
example, if the first bed number on the randomly-sorted bed number list is bed 100 on
the 2 North patient care unit, then the PT will use the morning census to identify the
patient occupying bed 100 on the 2 North unit. That patient will be included in the survey,
unless initial review of the patient’s record reveals that the patient is not an acute care
patient eligible for inclusion in the survey. Once the randomly-sorted bed numbers are
matched to the morning census, the CDC ID codes are used as unique identifiers for the
patients occupying those acute care bed numbers randomly selected for inclusion in the
survey.
8) The PT and/or EIPT must complete a Patient Information Form (PIF) for each patient
included in the minimum sample size goal. The PIF is a 2-page form. Only the first page
needs to be completed on the survey date; the second page of the PIF consists of follow
up information (e.g., hospital discharge date and outcome date) that will be collected at a
later date (and filled out, in most cases, by the EIPT). In the Hospital AA example, a small
hospital, the PT needs to complete a PIF for each patient occupying one of the first 75
bed numbers on the randomly-sorted acute care bed number list on the morning of the
survey, assuming that each of the patients occupying those 75 bed numbers is eligible for
the survey (i.e. are eligible acute care inpatients) and their medical records are available.
9) Special circumstances that may arise include the following: (1) a patient occupying a bed
selected for inclusion in the survey is not eligible for the survey; (2) the patient’s medical
record is unavailable at the time of the survey; and (3) a bed selected for inclusion in the
survey is empty at the time of the survey. Circumstance (2) is likely to be a problem
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primarily in facilities where PTs need to review paper medical records to complete PIFs.
Several special circumstances are addressed below:
a) What if I go to review the medical record of a patient occupying a bed selected for
inclusion in the survey, and I discover that the patient is actually a patient on
observation status?
Answer: If the patient is an observation-status patient who has been in the hospital for
at least 24 hours, include that patient in the survey. If the patient is an observationstatus patient who has been in the hospital for < 24 hours, exclude that patient and
move on to the next patient/bed number on your list.
b) What should I do if I travel to a unit to review a patient selected for inclusion in the
survey, but the patient is off the floor and the medical record is not available?
Answer: In these cases, the PT should make a second attempt to review that patient’s
chart at a later time on the survey date. If the patient record is still not available on the
second attempt, then the PT can skip that patient and not include that patient in the
survey.
c) What should I do if a patient selected for inclusion in the survey dies or is discharged
from the hospital between the time the morning census was generated and the time I
travel to the unit to review the medical record?
Answer: If a patient selected for inclusion in the survey has been discharged or has
died between the time the morning census list is generated and the time the PT
reviews that patient’s medical record on the survey date, the PT may skip that patient
and not include that patient in the survey if the medical record is not available. If,
however, the patient’s record is still available, and it can be confirmed that the patient
was in the hospital, was an eligible acute care inpatient, and occupied the selected
acute care bed number for some period of time on the survey date, the patient should
be included in the survey and a PIF should be completed.
d) What should I do if a patient selected for inclusion in the survey is transferred to
another bed in my hospital between the time the morning census was generated and
the time I travel to the unit to review the medical record?
Answer: In this circumstance, you will need to skip that patient. Do not “follow” the
patient to their new location in the hospital. Also, if the patient’s original bed number
(the bed number selected for inclusion in the survey) is now occupied by a different
patient than the patient on the morning census list, DO NOT review the record of the
patient who is now occupying the bed. You should move to the next acute care bed
number and patient on your randomly-sorted bed number list.
e) What should I do if I discover that a bed number selected for inclusion in the survey is
empty at the time of the survey?
Answer: You should simply skip that bed number and move on to the next bed
number on your list. Of course, you will need to replace that empty bed number with
another bed number on your randomly-sorted list, and the process for doing this is
described in the answer to the next question.
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f) What should I do if I get to my minimum goal sample size on my list, but I realize that I
have had to skip a few patients for the reasons noted above (e.g., medical records
were not available, beds were empty, etc.), and so I haven’t actually completed my
minimum goal number of PIFs?
Answer: Let’s consider an example, You are a PT member in Hospital BB, considered
a large hospital for the purposes of the prevalence survey. You know that your
minimum sample size goal for the prevalence survey is 100 patients. You have
reached the 100th acute care bed number on your randomly-sorted bed number list,
and you realize that you have only been able to complete 95 PIFs, since 3 patients’
medical records were not available and 2 bed numbers were empty. In this case, you
should simply continue in order down your randomly-sorted acute care bed number
list until you are able to complete 5 more PIFs. That will give you your minimum goal
sample size of 100. It is very important to continue down your randomly-sorted list in
order—do not skip around on your list to select the replacement bed numbers.
10) The PT leader should ensure that all PIFs are completed, ideally on the day of the survey
whenever possible. If the form is completed on the survey date, the PT leader should
ensure that the time of data collection is recorded in the appropriate space at the top of
the PIF. If the PIFs cannot be completed on the survey date, it is acceptable for PTs
and/or EIPTs to complete the PIFs retrospectively, as long as data collection is restricted
to information present up until 5:00 pm (17:00 hours) on the survey date. For example, if
the PT is completing Patient X’s PIF two weeks after the survey date, and the PT
determines that a urinary catheter was not present until 7 pm on the survey date, the PIF
“Urinary catheter” item within the “Devices” section of the form would be checked “No,”
since the catheter was not in place until after 5 pm. In circumstances where data
collection is performed retrospectively, this should be indicated at the top of the PIF by
checking the “Data collection done retrospectively” box.
11) The PT leader should maintain the linkages between CDC ID codes and patient
identifiers until the EIPT notifies the PT leader that project activities are complete and the
linkages can be destroyed. The PT leader can maintain the linkages by making sure to fill
out the top portion of the Data Collection Form (the “Identifiers” section), making a copy
of each PIF, and storing these PIF copies in a secure location at the participating facility,
according to local institutional review board (IRB) and/or facility regulations.
12) The PT leader should submit all original, completed PIFs to the EIPT within 30 days after
the survey date, keeping in mind that PIFs contain patient identifiers. All necessary
precautions, according to each participating facility’s and/or state’s requirements, should
be taken to ensure patient privacy and confidentiality.
DATA COLLECTION
NOTE regarding sources of data: This project relies on existing data sources (e.g.,
medical records, nursing records, and laboratory reports). There is no direct interaction
with patients. Patients will not be interviewed. Acceptable sources of data include:
electronic or paper medical records, radiology or laboratory reports, census lists, lists of
patients with selected medical devices, etc. It is acceptable to consult with healthcare
providers (such as the Charge Nurse) on inpatient units to obtain information regarding
patients with selected medical devices.
There is one healthcare facility information form completed by the PTs:
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1) Healthcare Facility Assessment (HFA), completed one time by the PT leader or designee
approximately one month before the survey date.
There is one patient-level survey form completed by the PTs (and/or the EIPTs in some cases):
2) Patient Information Form (PIF), completed by PTs and/or EIPTs for all surveyed patients.
The first page is completed by the PTs and/or EIPTs, ideally on the survey date; the
second page (follow up information) will in most cases be completed by EIPTs through a
retrospective medical record review process.
There are additional forms completed by the EIPTs:
3) Antimicrobial Use Form, completed by EIPTs for patients identified on PIFs as being on
antimicrobial agent(s) or scheduled to receive antimicrobial agents;
4) HAI Form, completed by EIPTs for patients identified on PIFs as being on antimicrobial
agent(s), and identified on Antimicrobial Use Forms as receiving antimicrobial agent(s)
for treatment of active infection or for unknown rationale.
5) Antimicrobial use assessment/audit forms, completed by EIPTs to gather information
regarding the appropriate use of antimicrobial agents.
The PT role in survey data collection is described in more detail below.
Primary Teams
Data Collection Tools
Hospital characteristics will be collected on the HFA; the HFA should be completed using blue
or black ink. Patient data collection should be completed using the PIF, using black or blue ink.
Record dates, identification numbers, and codes where indicated. When making a selection(s)
among two or more answer choices, place an “X” in the appropriate box(es).
Timeline for Completing HFA and PIFs
Each hospital will select a single survey date. Ideally, all participating hospitals will conduct their
surveys during the same 4-month period (e.g., May through August). The HFA should be
completed and submitted to the EIPT during the month prior to the survey date. Surveys should
be conducted on a weekday, Monday through Friday, during normal working hours. The PT is
strongly encouraged to complete its patient-level data collection activities on the survey date;
however, when necessary data collection by the PT can be completed retrospectively, following
a standard approach developed by CDC and EIP staff. ALL data collection must remain
restricted to information present (or cultures collected) on or prior to the survey date. PTs will
provide their completed PIFs to the EIPT within 30 days of the survey date.
Data Collected
The HFA is completed once, prior to the survey. It is divided into several sections. The person
completing the HFA is asked to record the date on which the HFA was started, and his/her role
in the hospital. There is a section about hospital characteristics, a section about infection
control, and a section about antimicrobial stewardship. No hospital identifiers should be
recorded on the form. The EIPT will provide each hospital with a unique code to record at the
top of each form. This code will be submitted to the CDC, along with information recorded on the
HFA.
The PTs (and/or EIPTs) will complete the PIF (first page) for every patient included in the
survey. The PIF is divided into 5 sections: Identifiers, Demographic information, Height and
weight, Devices, and Antimicrobials. Identifiers are collected and kept at the local hospital.
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Identifiers are also provided to the EIPT so that the EIPT can complete its data collection
activities. Patient identifiers such as name, date of birth, and medical record number are not
transmitted to CDC. Dates such as admission date and survey date are transmitted to CDC.
Detailed instructions about how to answer each item in the PIF are provided below.
Patient Confidentiality Protection
All eligible patients included in the study will be assigned a unique study identification code
(called the “CDC ID”). This code does not incorporate personally identifying information. Each
code will be a 7-digit, alpha-numeric code starting with the state’s two-letter abbreviation,
followed by a two-letter facility identifier and 3 numbers (example, CA-AA001). The two-letter
facility identifier will be assigned by the EIPT. CDC ID codes will be assigned prior to review of
medical records. If bed numbers included in the random sample are not occupied, or patients
are subsequently found to be ineligible for inclusion in the study, CDC ID codes will not be reused or re-assigned to other patients.
The linkages between patient identifiers and CDC ID codes will be maintained at the appropriate
participating hospitals and EIP sites until the conclusion of project activities, at which time the
linkages should be destroyed. Data collected during the course of the study, whether identifiable
or de-identified, must be stored in secure locations according to local and/or state regulations.
Participating hospitals and EIP sites will obtain institutional review board (IRB) approval to
perform the prevalence survey, where such approval is necessary.
DATA VALIDATION
Data validation may be conducted by an Evaluation Team (EVALT) of independent, expert
infection preventionists. Whether or not validation is performed will depend upon the availability
of resources. The EVALT will retrospectively review a 10-20% random sample of surveyed
patients in each EIP site. The EIPT, with input from CDC, will determine the random sample of
patients to be reviewed by the EVALT. The EVALT will review patients’ medical records on site
in each hospital, although in some cases hospitals may choose to grant EVALT members
remote access to electronic health record systems. The EVALT will fulfill all requirements
mandated by participating institutions related to HIPAA, confidentiality and other special
requirements for access to hospitals and to patients’ medical records. In some instances the
EVALT members may require the assistance of EIPTs to fulfill specific hospital requirements
and conduct survey activities. In other instances it is possible that the EVALT will work directly
with PTs in hospitals to meet requirements and conduct survey activities. The EVALT will record
CDC ID codes and admission dates on data collection forms, but will not record identifiers such
as names or medical record numbers on forms. The EVALT will collect data using the PIF, the
Antimicrobial Use Form, the HAI Form, and the antimicrobial use assessment/audit forms. The
EVALT will enter its data into the electronic data management system. The timeline for EVALT
activities may begin after and/or extend beyond the timeline for EIPT data collection and entry
activities.
DETAILED INSTRUCTIONS FOR COMPLETING SURVEY FORMS
General points:
The Healthcare Facility Assessment (HFA) consists of 10 pages, divided into Sections 1
through 4. Instructions for completion of the assessment are provided on the HFA. EIPTs
may be consulted for clarification of any items included in the HFA.
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The Patient Information Form (PIF) consists of 2 pages. Data collection on the first page
is divided into 5 sections: Identifiers (Section I), Demographic information (Section II),
Weight and height (Section III), Devices (Section IV), and Antimicrobials (Section V).
Identifiers are at the top of page 1. The information in Section I will be shared with the
EIP site but not with CDC. Data entered in Sections II through V will be entered into the
electronic data management system and shared with CDC. Data collection on the second
page consists of one follow-up information section (Section VI). The information in this
section will be collected in most cases by EIPTs through retrospective medical record
review, although PTs may also be contacted to assist in providing information on
discharge dates and outcome for surveyed patients. This information will be entered into
the electronic data management system and shared with CDC.
INSTRUCTIONS FOR COMPLETING THE PATIENT INFORMATION FORM
Page 1
Data Field
CDC ID
Survey Date
Data collector initials
If data collected on
survey date, enter data
collection time:
Data collection done
retrospectively

Instructions
Record CDC identification code.
Enter the date in mm/dd/yyyy format.
Enter data collector’s initials.
For PIFs completed on the survey date (this is the ideal
approach), the data collector should record the time of day on the
survey date when the patient’s data were reviewed and the form
completed.
Check this box only in those circumstances where the PIF is NOT
completed on the survey date. If this box is checked, then all data
entered onto the first page of this form should be based on
information present up until 5 pm on the survey date. No
information present after 5 pm should be used in completing the
first page of the form.

Page 1, Section I. Identifiers – information in Section I is not submitted to CDC
Data Field
Instructions
Patient name
Enter last name, first name, middle initial.
Date of birth
Enter in mm/dd/yyyy format.
Hospital name
Enter the name of the hospital.
Hospital unit name
Enter the name of the hospital unit on which the patient is housed
at the time of the survey.
Room no.
Enter the number of the room occupied by the patient at the time
of the survey.
Medical record no.
Enter the medical record number.
Page 1, Section II. Demographic information
Data Field
Instructions
Age
Record the patient’s age on the survey date. Age may be noted
on the medical record “face sheet.” If patient’s age less than 30
days, indicate age in days. If patient’s age is 30 days to 11
months, indicate age in months. If patient is 12 months or older,
indicate age in years. Examples: 34 days of age should be coded
as Age=1 and the box for “months” should be checked. 14
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Admission date

Gender

CDC location code

Race

months of age should be coded as Age=1 and the box for “years”
should be checked.
Enter the date the patient was admitted to the hospital. Use
mm/dd/yyyy format. Admission date may be noted on the medical
record “face sheet.”
Check the appropriate box. M=male. F=female. Gender may be
noted on the medical record “face sheet.” An “Unknown” box is
provided for rare instances where gender is not known.
The CDC location code identifies the type of inpatient unit on
which the patient is housed on the survey date. CDC location
codes appear in Appendix 1. Hospital units should be mapped to
the appropriate CDC location codes in advance of the survey
date. The CDC location code for the unit of each bed number
selected for inclusion in the survey should appear on the
randomly-sorted bed number list that the EIPT provides to the PT
to use on the survey date. Record this code on the PIF. Only one
CDC location should be recorded on the PIF. If bed numbers
from heterogeneous units (those units with multiple patient types,
and with no single patient type comprising 80% or more of the
unit’s population) are included on the randomly sorted bed
number list, and there are multiple possible CDC location codes
that could potentially be assigned, depending upon the type of
patient occupying the bed on the day of the survey, you should
select the single most appropriate code based on the type of
patient or the clinical service to which the patient was admitted.
For example, Bed 100 on Unit 6 East is included in the survey. 6
East is a unit with the following patient types: 30% general
medicine, 40% orthopedic surgery, 30% hematology/oncology.
On the randomly-sorted bed number list, the CDC location
column has the following entry: “W-M or W-ORT or SCA-HONC.”
You should evaluate the medical record for the patient in Bed 100
on the day of the survey and record ONE CDC location code
based on the patient type or clinical service. If the patient is
admitted to the medical service for treatment of pneumonia, for
example, you would record only “W-M” on the PIF.
Race of patient as noted in the medical record. Race may be
noted on the medical record “face sheet.” Multiple boxes can be
checked. Do not make assumptions based on name or native
language. If race is unknown, please check “unknown”.
The minimum categories for the Federal statistics of race data
are defined as follows:
 American Indian or Alaskan Native: A person having origins
in any of the original peoples of North and South America
(including Central America) and who maintain tribal affiliation
or community attachment.
 Asian: A person having origins in any of the original people of
the Far East, Southeast Asia, or the Indian subcontinent. Can
include the following: Cambodia, China, Japan, Korea,

PT Instructions_v1_20130620 Page 10 of 30






Malaysia, Pakistan, the Philippine Islands, Thailand, and
Vietnam.
Black or African American: A person having origins in any of
the black racial groups of Africa. Terms such as “Haitian” or
“Negro” can be used in addition to “Black or African
American”.
Native Hawaiian or other Pacific Islander: A person having
origins in any of the original peoples of Hawaii, Guam,
Samoa, or other Pacific Islands.
White: A person having origins in any of the original peoples
of Europe, the Middle East, or North Asia.

Note: “Race” instructions modified from 2010 EIP 2010 MRSA
Case Report Form Instructions, revised 4/13/2010.

Ethnicity

(see OMB Standards for Data on Race and Ethnicity, as
published in 1997 Federal Register,
http://www.whitehouse.gov/omb/fedreg_1997standards/)
Ethnicity of patient as noted in medical record. Ethnicity may be
indicated on the medical record “face sheet.” Indicate ethnicity
EVEN IF race is already indicated. Hispanic or Latino ethnicity
indicates a person of Cuban, Mexican, Puerto Rican, South or
Central American, or other Spanish culture or origin, regardless
of race. For example, many whites are also Hispanic or Latino.
Do not make assumptions based on name or native language. If
not noted or unsure, check "unknown."
*Note: Some institutions combine race/ethnic coding. For
example, they might define a person’s race as “Hispanic or
Latino”. In this case race would be coded “unknown” on the DCF,
and ethnicity would be “Hispanic or Latino”.
Note: “Ethnicity” instructions modified from 2010 EIP 2010 MRSA
Case Report Form Instructions, revised 4/13/2010.
(see OMB Standards for Data on Race and Ethnicity, as
published in 1997 Federal Register,
http://www.whitehouse.gov/omb/fedreg_1997standards/)

Page 1, Section III. Weight and height
Data Field
Instructions
For infants in neonatal
For infants in locations that typically house newborns (including
locations (e.g.,
those listed on the form), record the birthweight in pounds and
CC:NURS, CCS:NURS,
ounces or in grams. If the birthweight is not known, check the
S:NURS, W:NURS,
“Birthweight unknown” box.
W:LDRP):
Birthweight
For other patients:
For patients who are not infants in neonatal locations, record the
BMI OR Height and
Body Mass Index (BMI, if available) during the 7 days prior to the
Weight
survey date or on the survey date. If multiple BMIs are available
PT Instructions_v1_20130620 Page 11 of 30

during the 7 days prior to the survey date or on the survey date,
record the BMI that is closest to the survey date. If BMI is not
available during the 7 days prior to the survey date or on the
survey date, record the patient’s height and weight. You may use
any height measurement available in the medical record from the
date of admission through the survey date. For weight, record
weight during the 7 days prior to the survey date or on the survey
date, using the weight value closest to the survey date. Height
may be recorded in feet and inches, or in centimeters (or “Height
unknown” may be checked if no height is available from
admission through the survey date). Weight may be recorded in
pounds and ounces, or in grams (or “Weight unknown” may be
checked if no weight is available during the 7 days prior to the
survey date or on the survey date).
Page 1, Section IV. Devices (in place on the survey date)
NOTE: Information on devices (urinary catheters, ventilators and central lines) may be found in
nursing notes and patients’ daily flowsheets (e.g., sheets that include information on vital signs,
fluid balance, nursing assessments, etc.). Progress notes and procedure notes may also contain
information on device use. Ventilator information may be found in respiratory therapy notes and
in intensive care unit flowsheets in sections documenting the patient’s respiratory status. Finally,
some record systems (particularly electronic record systems) may have a specific location
where information on the presence and status of medical devices is recorded.
Data Field
Urinary catheter

Ventilator

Central line

Instructions
Check “yes” if the patient has an indwelling urethral catheter (also
called a Foley catheter) on the survey date. Otherwise, check
“no.” Check “no” for patients who receive intermittent
catheterization or “straight” catheterization. Check “no” for
patients with nephrostomy tubes or suprapubic catheters. A
urinary catheter is defined in Appendix 3 as “A drainage tube that
is inserted into the urinary bladder through the urethra, is left in
place, and is connected to a closed collection system; also called
a Foley catheter; does not include straight in-and-out catheters.”
Check “yes” if the patient has a device to assist or control
respiration continuously through a tracheostomy or by
endotracheal intubation on the survey date. A ventilator is defined
in Appendix 3 as “A device to assist or control respiration
continuously, inclusive of the weaning period, through a
tracheostomy or by endotracheal intubation. NOTE: Lung
expansion devices such as intermittent positive pressure
breathing (IPPB); nasal positive end-expiratory pressure (PEEP);
continuous nasal positive airway pressure (CPAP, hypoCPAP)
are not considered ventilators unless delivered via tracheostomy
or endotracheal intubation (e.g., ET-CPAP).”
Check “yes” if the patient has a central line in place on the survey
date. A central line is defined as follows in Appendix 3 as:
“An intravascular catheter that terminates at or close to the

PT Instructions_v1_20130620 Page 12 of 30

heart or in one of the great vessels which is used for infusion,
withdrawal of blood, or hemodynamic monitoring. The following
are considered great vessels for the purpose of reporting
central-line infections: aorta, pulmonary artery, superior vena
cava, inferior vena cava, brachiocephalic veins, internal jugular
veins, subclavian veins, external iliac veins, and femoral veins.
NOTE: Neither the location of the insertion site nor the type of
device may be used to determine if a line qualifies as a central
line. The device must terminate in one of these vessels or in or
near the heart to qualify as a central line.
NOTE: An introducer is considered an intravascular catheter, and
depending on the location of its tip, may be a central line.
NOTE: Pacemaker wires and other nonlumened devices inserted
into central blood vessels or the heart are not considered central
lines, because fluids are not infused, pushed, nor withdrawn
through such devices.
NOTE: In neonates, the umbilical artery/vein is considered a
great vessel.
NOTE: The following devices are not considered central lines:
extracorporeal membrane oxygenation (ECMO), femoral arterial
catheters, and intraaortic balloon pump (IABP) devices.
If the patient has a central line, check “yes,” and indicate using
the check boxes provided whether the patient has a Peripherally
Inserted Central Catheter (PICC) in place, whether the patient
has a femoral line in place, whether the patient has another type
of central line in place, or whether the patient has a central line in
place for which the type is unknown (central line noted but type
not documented in the medical record). If the patient has more
than one line type, check as many boxes as apply. For example,
if a patient has a PICC inserted in the left upper extremity and a
triple lumen catheter in the right internal jugular vein, you would
check the “PICC” box and the “Other central line” box.
Page 1, Section V. Antimicrobials
Data field
Instructions
Antimicrobials administered
See Appendix 2 for the definition of “antimicrobial agent” for
or scheduled to be
the purposes of this survey. This question should be
administered on the survey
answered for every patient included in the survey. Use the
date:
Medication Administration Record (MAR) (including the
Emergency Department MAR and the inpatient MAR) and
operating room flow sheets (on which surgical prophylaxis
antibiotics may be recorded) to determine whether patients
are on antimicrobials or not. Check “yes” if the patient was
administered or was scheduled to be administered at least
one dose of an antimicrobial agent on the survey date.
Acceptable antimicrobial agents are those that appear in
Appendix 4 that are administered (or are scheduled to be
administered) by any of the following routes: IV, IM, orally,
enterally, or via inhalation. See Appendix 3 for a description
PT Instructions_v1_20130620 Page 13 of 30

Antimicrobials administered
or scheduled to be
administered on the day
before the survey date:

of antimicrobial agents and routes of administration that are
excluded from this survey.
See Appendix 2 for the definition of “antimicrobial agent” for
the purposes of this survey. This question should be
answered for every patient included in the survey. Use the
Medication Administration Record (MAR) (including the
Emergency Department MAR and the inpatient MAR) and
operating room flow sheets (on which surgical prophylaxis
antibiotics may be recorded) to determine whether patients
are on antimicrobials or not. Check “yes” if the patient was
administered or was scheduled to be administered at least
one dose of an antimicrobial agent on the day before the
survey date. Acceptable antimicrobial agents are those that
appear in Appendix 2 that are administered (or are
scheduled to be administered) by any of the following
routes: IV, IM, orally, enterally, or via inhalation. See
Appendix 2 for a description of antimicrobial agents and
routes of administration that are excluded from this survey.

Page 2: Keep in mind that this page is typically completed by the EIPTs during a
retrospective medical record review process in the weeks and months following the
survey dates. The PTs may be asked to assist in gathering hospital discharge and
outcome information.
Record the CDC ID and data collector initials at the top of the form.
Page 2, Section VI. Follow up information
Data field
Instructions
Enter date of follow-up data
This should be the date on which the discharge date and
collection
outcome was assessed. For example, if the PT gathers this
information and transmits it to the EIPT, then the date
recorded here should be the date on which the PT
determined the discharge date and outcome (not the date
on which the EIPT recorded that information on the PIF).
Hospital discharge date
The date of discharge from the survey hospitalization,
entered as mm/dd/yyyy. This should be assessed up to 90
days following the survey date. If the date is unknown,
chedck “Unknown.” If the patient is still in the hospital 90
days following the survey date, check “Still in hospital.”
Patient outcome at time of
Indicate whether the patient was alive at discharge
hospital discharge
(“Survived”), dead (“Died”), or if the outcome is unknown or
the patient is still in the hospital 90 days after the survey
date.
WHAT TO DO WITH COMPLETED FORMS
Primary Teams:
1) Copy each PIF.
2) Submit the original PIFs to the EIPT according to arrangements made with the EIPT, in
accordance with local and/or state guidelines and with all necessary precautions taken to
protect patient identifiers.
PT Instructions_v1_20130620 Page 14 of 30

3) Store copies of PIFs in a secure location at the survey hospital in the care of the PT, in
accordance with local and/or state guidelines.
4) Once the EIPT has been notified by CDC that project activities are complete, the forms
may be destroyed as long as this is in accordance with local guidelines. In some
instances, IRBs may require that forms be maintained for longer periods of time. Check
with your IRB for further information.
Note: Section I “Identifiers” of the PIF will not be shared with CDC or entered into the
CDC data management system.

PT Instructions_v1_20130620 Page 15 of 30

APPENDIX 1: CDC PATIENT LOCATIONS
Note: Location list, codes and descriptions are subject to change to maintain
consistency with locations defined in the National Healthcare Safety Network. Here is the
link to current NHSN location types:
http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf.
Note: Instructions for location mapping may be found at:
http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf.
CDC Patient Location/Service
Inpatient Adult Critical Care
Burn Critical Care

Code

Description

CC-B

Critical care area specializing in the care
of patients with significant/major burns.

Medical Cardiac Critical Care

CC-C

Medical Critical Care

CC-M

Medical/Surgical Critical Care

CC-MS

Neurologic Critical Care

CC-N

Critical care area specializing in the care
of patients with serious heart problems
that do not require heart surgery.
Critical care area for patients who are
being treated for nonsurgical conditions.
An area where critically ill patients with
medical and/or surgical conditions are
managed.
Critical care area specializing in treating
life-threatening neurological diseases.

Neurosurgical Critical Care

CC-NS

ONC Medical Critical Care

CC-ONC-M

ONC Surgical Critical Care

CC-ONC-S

Critical care area for the evaluation and
management of oncology patients with
serious illness before and/or after
cancer-related surgery.

ONC Medical-Surgical Critical Care

CC-ONC-MS

Critical care area for the care of
oncology patients with medical and/or
surgical conditions related to their
malignancy.

Prenatal Critical Care

CC-PNATL

Critical care area specializing in the
management of the pregnant patient with
complex medical or obstetric problems
requiring a high level of care to prevent
the loss of the fetus and to protect the

PT Instructions_v1_20130620 Page 16 of 30

Critical care area specializing in the
surgical management of patients with
severe neurological diseases or those at
risk for neurological injury as a result of
surgery.
Critical care area for the care of
oncology patients who are being treated
for nonsurgical conditions related to their
malignancy.

life of the mother.

Respiratory Critical Care

CC-R

Critical care area for the evaluation and
treatment of the patient with severe
respiratory conditions.
Critical care area specializing in the care
of patients following cardiac and thoracic
surgery.
Critical care area for the evaluation and
management of patients with serious
illness before and/or after surgery.
Critical care area specializing in the care
of patients who require a high level of
monitoring and/or intervention following
trauma or during critical illness related to
trauma.

Surgical Cardiothoracic Critical Care

CC-CT

Surgical Critical Care

CC-S

Trauma Critical Care

CC-T

Neonatal Unitsi
Well Baby Nursery (Level I)

W-NURS

Hospital area for evaluation and
postnatal care of healthy newborns. May
include neonatal resuscitation and
stabilization of ill newborns until transfer
to a facility at which specialty neonatal
care is provided.

Step down Neonatal ICU (Level II)

S-NURS

Special care nursery for care of preterm
infants with birth weight >1500g.
Includes resuscitation and stabilization of
preterm and/or ill infants before transfer
to a facility at which newborn intensive
care is provided.

Neonatal Critical Care(Level II/III)

CCS-NURS

Combined nursery housing both Level II
and III newborns and infants.

Neonatal Critical Care (Level III)

CC-NURS

A hospital neonatal intensive care unit
(NICU) organized with personnel and
equipment to provide continuous life
support and comprehensive care for
extremely high-risk newborn infants and
those with complex and critical illness.
Level III is subdivided into 3 levels
differentiated by the capability to provide
advanced medical and surgical care.
NOTE: The categories of Level III below
are classifications from the American
Academy of Pediatrics, Definitions of
hospital-based newborn services1.
These classifications are all considered
Level III nurseries in NHSN.

PT Instructions_v1_20130620 Page 17 of 30

Level IIIA – Hospital or state-mandated
restriction on type and/or duration of
mechanical ventilation.
Level IIIB – No restrictions on type or
duration of mechanical ventilation. No
major surgery.
Level IIIC – Major surgery performed on
site (e.g., omphalocele repair,
tracheoesophageal fistula or esophageal
atresia repair, bowel resection,
myelomeningocele repair,
ventriculoperitoneal shunt). No surgical
repair of serious congenital heart
anomalies that require cardiopulmonary
bypass and /or ECMO for medical
conditions.
Level IIID – Major surgery, surgical
repair of serious congenital heart
anomalies that require cardiopulmonary
bypass, and/or ECMO for medical
conditions.
Pediatric Critical Care
Pediatric Burn Critical Care

CC-BPED

Pediatric Cardiothoracic Critical Care

CC-CTPED

Pediatric Medical Critical Care

CC-MPED

Pediatric Medical/Surgical Critical Care

CC-MSPED

Pediatric Neurology Critical Care

CC-NPED

Pediatric Neurosurgical Critical Care

CC-NSPED

ONC Pediatric Critical Care

CC-ONCPED

PT Instructions_v1_20130620 Page 18 of 30

Critical care area specializing in the care
of patients ≤ 18 years old with
significant/major burns
Critical care area specializing in the care
of patients ≤ 18 years old following
cardiac and thoracic surgery.
Critical care area for patients ≤ 18 years
old who are being treated for nonsurgical
conditions. In the NNIS system, this was
called Pediatric ICU (PICU).
An area where critically ill patients ≤ 18
years old with medical and/or surgical
conditions are managed.
Critical care area for patients ≤ 18 years
old specializing in treating lifethreatening neurological diseases.
Critical care area specializing in the
surgical management of patients ≤ 18
years old with severe neurological
diseases or those at risk for neurological
injury as a result of surgery.
Critical care area for the care of
oncology patients ≤18 years old who are
being treated for surgical or nonsurgical
conditions related to their malignancy.

Pediatric Respiratory Critical Care

CC-RPED

Pediatric Surgical Critical Care

CC-SPED

Pediatric Trauma Critical Care

CC-TPED

Inpatient Specialty Care Areas
Inpatient Acute Dialysis Unit

SCA-DIAL

Solid Organ Transplant SCA

SCA-SOTP

Pediatric Dialysis SCA

SCA-DIALPED

Pediatric Solid Organ Transplant SCA

SCASOTPPED

Adult Wards
Antenatal Care Ward

W-ANT

Behavioral Health/Psych Ward

W-BHV

Inpatient Burn Ward

W-B

Inpatient Ear/Nose/Throat Ward

W-ENT

Inpatient Gastrointestinal Ward

W-GI

Inpatient Gerontology Ward

W-GNT

Inpatient Genitourinary Ward

W-GU

PT Instructions_v1_20130620 Page 19 of 30

Critical care area for the evaluation and
treatment of the patients ≤ 18 years old
with severe respiratory conditions.
Critical care area for the evaluation and
management of patients ≤ 18 years old
with serious illness before and/or after
surgery.
Critical care area specializing in the care
of patients ≤ 18 years old who require a
high level of monitoring and/or
intervention following trauma or during
critical illness related to trauma.
Hospital specialty care area for patients
who require acute dialysis as a
temporary measure.
Hospital specialty area for the
postoperative care of patients who have
had a solid organ transplant (e.g.,
heart/lung, kidney, liver, pancreas)
Hospital specialty care area for patients
≤ 18 years old who require acute dialysis
as a temporary measure.
Hospital specialty area for the
postoperative care of patients ≤ 18 years
old who have had a solid organ
transplant (e.g., heart/lung, kidney, liver,
pancreas).
Hospital area for observation, evaluation,
treatment or surgery of high risk
pregnancy patients.
Area for the evaluation and treatment of
patients with acute psychiatric or
behavioral disorders.
Hospital area for evaluation and
treatment of patients who have burns.
Hospital area for the evaluation,
treatment, or surgery of patients with
ear, nose, or throat disorders
Hospital area for evaluation, treatment or
surgery of patients with disorders of the
gastrointestinal tract.
Hospital area for the evaluation,
treatment or surgery of patients with
age-related diseases.
Hospital area for the evaluation,
treatment or surgery of patients with
disorders of the genitourinary system.

Inpatient Gynecology Ward

W-GYN

Inpatient Jail Unit

W-J

Labor and Delivery Ward

W-LD

Labor, Delivery, Recovery, Postpartum
Room (LDRP)

W-LDRP

Inpatient Medical Ward

W-M

Inpatient Medical/Surgical Ward

W-MS

Inpatient Neurology Ward

W-N

Inpatient Neurosurgical Ward

W-NS

ONC Leukemia Ward

W-ONC-LEUK

ONC Lymphoma Ward

W-ONCLYMPH

Area for the evaluation and treatment of
patients with lymphoma.

ONC Leukemia/Lymphoma Ward

W-ONC-LL

Area for the evaluation and treatment of
patients with leukemia and/or lymphoma.

ONC Solid Tumor Ward

W-ONC-ST

Area for the evaluation and treatment of
oncology patients with solid tumors.

ONC Hematopoietic Stem Cell
Transplant Ward

W-ONC-HSCT

Area for the care of patients who
undergo stem cell transplant for the
treatment of cancers and/or blood or
immune system disorders.

ONC General Hematology/Oncology
Ward

W-ONC-HONC

Area for the evaluation and treatment of
patients with cancer and/or blood
disorders.

PT Instructions_v1_20130620 Page 20 of 30

Hospital area for the evaluation,
treatment, or surgery of female patients
with reproductive tract disorders.
Overnight stay patient care area of a
hospital or correctional facility used only
for those who are in custody of law
enforcement during their treatment.
Hospital area where women labor and
give birth.
Hospital suite used for labor, delivery,
recovery and post partum (LDRP) – all
within the same suite.
Hospital area for the evaluation and
treatment of patients with medical
conditions or disorders.
Hospital area for the evaluation of
patients with medical and/or surgical
conditions.
Hospital inpatient area where patients
with neurological disorders are evaluated
and treated.
Hospital area for care of patients whose
primary reason for admission is to have
neurosurgery or to be cared for by a
neurosurgeon after head or spinal
trauma.
Area for the evaluation and treatment of
patients with leukemia.

Inpatient Ophthalmology Ward

W-OPH

Inpatient Orthopedic Trauma Ward

W-TORT

Inpatient Orthopedic Ward

W-ORT

Inpatient Plastic Surgery Ward

W-PLS

Inpatient Postpartum Ward

W-PP

Inpatient Pulmonary Ward

W-PULM

Inpatient Rehabilitation Ward

W-REHAB

Inpatient Surgical Ward

W-S

Stroke (Acute) Unit

W-STRK

Telemetry Unit

W-TELE

Inpatient Vascular Surgery Ward

W-VS

Pediatric Wards
Adolescent Behavioral Health Ward

W-BHV-ADOL

Hospital area for evaluation and
treatment of patients between the ages
of 13 and 18 with acute psychiatric or
behavioral disorders.

ONC Pediatric Hematopoietic Stem Cell
Transplant Ward

W-ONCHSCTPED

Area for the care of patients ≤18 years
old who undergo stem cell transplant for
the treatment of cancers and/or blood or
immune system disorders.

ONC Pediatric General
Hematology/Oncology Ward

W-ONCHONCPED

Area for the evaluation and treatment of
patients ≤18 years old with cancer

PT Instructions_v1_20130620 Page 21 of 30

Hospital area for care of patients whose
primary reason for admission is to have
eye surgery or to be cared for by an
ophthalmologist after eye trauma.
Hospital inpatient area where patients
with orthopedic injuries or disorders are
evaluated and treated.
Hospital area for evaluation, treatment or
surgery on bones, joints, and associated
structures by an orthopedist.
Hospital area for the care of patients
who have reconstructive surgery
performed by a plastic surgeon.
Hospital area for the patient who is
recovering from childbirth.
Hospital area where patients with
respiratory system conditions or
disorders are evaluated and treated.
Hospital area for evaluation and
restoration of function to patients who
have lost function due to acute or
chronic pain, musculoskeletal problems,
stroke, or catastrophic events resulting in
complete or partial paralysis.
Hospital area for evaluation and
treatment of patients who have
undergone a surgical procedure.
Hospital area for evaluation, stabilization
and treatment of patients who have
experienced an acute stroke.
Hospital area dedicated to providing
evaluation and treatment of patients
requiring continuous cardiac monitoring.
Hospital area for evaluation and
treatment of patients who have
undergone vascular surgery.

and/or blood disorders.
Pediatric Behavioral Health

W-BHVPED

Hospital area for evaluation and
management of patients ≤18 years old
with acute psychiatric or behavioral
disorders.

Inpatient Pediatric Burn Ward

W-BPED

Inpatient Pediatric Ear, Nose, Throat

W-ENTPED

Inpatient Pediatric Genitourinary

W-GUPED

Inpatient Medical Pediatric Ward

W-MPED

Inpatient Pediatric Med/Surg Ward

W-MSPED

Inpatient Pediatric Neurology Ward

W-NPED

Inpatient Pediatric Neurosurgical Ward

W-NSPED

Inpatient Pediatric Orthopedic Ward

W-ORTPED

Inpatient Pediatric Rehabilitation Ward

W-REHABPED

Hospital area specializing in the
evaluation and treatment of patients ≤18
years who have tissue injury caused by
burns.
Hospital area for evaluation and
management of patients ≤18 years old
with disorders of the ear, nose and/or
throat.
Hospital inpatient area where patients ≤
18 years old with disorders of the
genitourinary system are evaluated and
treated.
Hospital inpatient area where patients ≤
18 years old with medical conditions or
disorders are evaluated and treated.
Hospital inpatient area where patients ≤
18 years old with medical and/or surgical
conditions are managed.
Hospital inpatient area where patients ≤
18 years old with neurological disorders
are evaluated and treated.
Hospital area for care of patients ≤ 18
years old whose primary reason for
admission is to have neurosurgery or to
be cared for by a neurosurgeon after
head or spinal trauma.
Hospital area where patients ≤ 18 years
old with orthopedic injuries or disorders
are evaluated and treated.
Hospital area for evaluation and
restoration of function to patients ≤18
years old who have lost function due to
acute or chronic pain, musculoskeletal
problems, stroke, or catastrophic events
resulting in complete or partial paralysis.

Inpatient Pediatric Surgical Ward

W-SPED

Step Down Units

PT Instructions_v1_20130620 Page 22 of 30

Hospital area for evaluation and
treatment of patients ≤ 18 years old who
have undergone a surgical procedure.

Adult Step Down Unit

STEP

Pediatric Step Down Unit

STEP-PED

ONC Step Down Unit (all ages)

STEP-ONC

Hospital area for adult patients that are
hemodynamically stable who can benefit
from close supervision and monitoring,
such as frequent pulmonary toilet, vital
signs, and/or neurological and
neurovascular checks.
Patients ≤ 18 years old that are
hemodynamically stable who can benefit
from close supervision and monitoring,
such as frequent pulmonary toilet, vital
signs, and/or neurological and
neurovascular checks.
Area for oncology patients who are
hemodynamically stable and can benefit
from close supervision and monitoring,
such as frequent pulmonary toilet, vital
signs, and/or neurologic and
neurovascular checks.

Mixed Acuity Units
Mixed Acuity Unit

MIX-ADULT

Pediatric Mixed Acuity Unit (NOTE: If
patients are of mixed age, use Mixed
Age, Mixed Acuity Ward, designation
found in Inpatient Adult Ward section)

MIX-PED

Mixed Age, Mixed Acuity Unit

MIX-ALL

PT Instructions_v1_20130620 Page 23 of 30

Hospital area for the evaluation and
treatment of adult patients whose
conditions are of varying levels of acuity
(e.g., critical care, ward-level care, stepdown type care, etc.). Such a care area
may be comprised of patients followed
by different hospital services (e.g.,
coronary, medical, surgical, etc.). This
care area may or may not include ''acuity
adaptable'' or ''universal'' beds (i.e., this
model of patient care allows a patient to
stay in same bed during all phases of his
care, from critical care through lower
levels of care)
Hospital area for the evaluation and
treatment of patients ≤ 18 years old
whose conditions are of varying levels of
acuity (e.g., critical care, ward-level care,
step-down type care, etc.). Such a care
area may be comprised of patients
followed by different hospital services
(e.g., coronary, medical, surgical, etc.).
This care area may or may not include
''acuity adaptable'' or ''universal'' beds
(i.e., this model of patient care allows a
patient to stay in same bed during all
phases of his care, from critical care
through lower levels of care).
Hospital area for the evaluation and
treatment of a mixture of adult and

ONC Mixed Acuity Unit

MIX-ONC

pediatric patients whose conditions are
of varying levels of acuity (e.g., critical
care, ward-level care, step-down type
care, etc.). Such a care area may be
comprised of patients followed by
different hospital services (e.g.,
coronary, medical, surgical, etc.). This
care area may or may not include ''acuity
adaptable'' or ''universal'' beds (i.e., this
model of patient care allows a patient to
stay in same bed during all phases of his
care, from critical care through lower
levels of care)
Area for the evaluation and treatment of
a mixture of adult and pediatric oncology
patients whose conditions are of varying
levels of acuity (e.g., critical care, wardlevel care, step-down type care, etc.).
This care area may or may not include
''acuity adaptable'' or ''universal'' beds
(i.e., this model of patient care allows a
patient to stay in same bed during all
phases of care, from critical care through
lower levels of care).

Long-term Acute Care
LTAC ICU

CC-LTAC

Critical care area specializing in the
evaluation, treatment, and management
of patients that require high
observance/acuity and/or special care
that are suffering medically complex
conditions or who have suffered recent
catastrophic illness or injury and require
an extended stay in an acute care
environment.

LTAC Ward

W-LTAC

LTAC Pediatric ICU

CC-LTACPED

Hospital area for the evaluation and
treatment of patients suffering medically
complex conditions or who have suffered
recent catastrophic illness or injury, and
require an extended stay in an acute
care environment.
Critical care area specializing in the
evaluation, treatment, and management
of patients <= 18 years old that require
high observance/acuity and/or special
care that are suffering medically complex
conditions or who have suffered recent
catastrophic illness or injury and require
an extended stay in an acute care

PT Instructions_v1_20130620 Page 24 of 30

environment.
LTAC Pediatric Ward

1

W-LTACPED

Hospital area for the evaluation and
treatment of patients <=18 years old,
suffering medically complex conditions
or who have suffered recent catastrophic
illness or injury, and require an extended
stay in an acute care environment.

Definitions of Hospital-Based Newborn Services Used for Survey Performed by Section on
Perinatal Pediatrics American Academy of Pediatrics website:
http://aappolicy.aappublications.org/cgi/content/full/pediatrics;114/5/1341/T1 , accessed, July
8,2008.

PT Instructions_v1_20130620 Page 25 of 30

APPENDIX 2: ANTIMICROBIAL AGENT LIST
Note: Use this list when checking whether the patient is “on antimicrobials” on the Patient
Information Form.
This list is subject to change at any time.
Definition of an antimicrobial agent: A systemic (oral, enteral, or parenteral) or inhaled
antimicrobial agent found in the list presented in the Appendix below. Antimicrobial agents
administered via the following routes are EXCLUDED: topical (to the skin), to the ear, to the eye,
to the nasal mucosa, intravaginal, per rectum, intraperitoneal, intrathecal, intraventricular.
Antimicrobial agents administered via irrigation (such as in the operating room) are also
excluded. Medications used for the treatment of Human Immunodeficiency Virus (HIV), Hepatitis
C and Hepatitis B virus infections are excluded, with the exception of ribavirin. If ribavirin is
being administered to a surveyed patient for treatment of Hepatitis C, the data collector should
not document ribavirin on the Antimicrobial Use Form. However, other infection-related uses of
ribavirin should be documented in the Antimicrobial Use Form.
5-FC
Abelcet
acyclovir
amantadine
Ambisome
amikacin
Amikin
amoxicillin
amoxicillin/clavulanic acid
amoxicillin, clarithromycin, lansoprazole
Amoxil
amphotericin B cholesteryl sulfate complex
amphotericin B deoxycholate
amphotericin B lipid complex
amphotericin B liposome
Amphotec
ampicillin
ampicillin/sulbactam
Ancef
Ancobon
anidulafungin
Augmentin
Avelox
Azactam
azithromycin
aztreonam
Bactrim
Biaxin
Bio-Statin
PT Instructions_v1_20130620 Page 26 of 32

Bismuth subcitrate, metronidazole,
tetracycline
Bismuth subsalicylate, metronidazole,
tetracyline
Cancidas
caspofungin
Cayston
Ceclor
Cedax
cefaclor
cefadroxil
cefazolin
cefdinir
cefditoren
cefepime
cefixime
Cefizox
Cefotan
cefotetan
cefotaxime
cefoxitin
cefpodoxime
cefprozil
ceftibuten
Ceftin
ceftaroline
ceftazidime
ceftizoxime
ceftriaxone

cefuroxime
Cefzil
cephalexin
chloramphenicol
cidofovir
Cipro
ciprofloxacin
Claforan
clarithromycin
Cleocin
clindamycin
clotrimazole
colistin
colistimethate sodium
colistin/polymyxin B
Cotrimaxozole
Cubicin
Cytovene
dapsone
daptomycin
dicloxacillin
Dificid
Diflucan
Doribax
doripenem
doxycycline
Duricef
Dynapen
Eraxis
ertapenem
EryPed
Ery-Tab
Erythrocin
erythromycin
erythromycin ethylsuccinate and sulfisoxazole
acetyl
ethambutol
Factive
famciclovir
Famvir
Fasigyn
fidaxomicin
Flagyl
Floxin
fluconazole
PT Instructions_v1_20130620 Page 27 of 30

flucytosine
Flumadine
Fortaz
foscarnet
Foscavir
fosfomycin
Fungizone
ganciclovir
Garamycin
gemifloxacin
gentamicin
griseofulvin
Helidac
Hiprex
imipenem
Invanz
isoniazid
isoniazid and rifampin
isoniazid, pyrazinamide, and rifampin
itraconazole
kanamycin
Kantrex
Keflex
Ketek
ketoconazole
Lamisil
Levaquin
levofloxacin
linezolid
Macrobid
Macrodantin
Maxipime
Mefoxin
meropenem
Merrem
methenamine
metronidazole
micafungin
miconazole
Minocin
minocycline
Monurol
Moxatag
moxifloxacin
Mycamine

Mycelex
Mycobutin
Mycostatin
nafcillin
Nallpen
neomycin
Nilstat
nitrofurantoin
Nizoral
norfloxacin
Noroxin
Noxafil
nystatin
ofloxacin
Omnipen
Omnicef
Oravig
oseltamivir
oxacillin
penicillin G
penicillin G benzathine
penicillin G benzathine and penicillin G
procaine
penicillin G procaine
penicillin V
pentamidine isethionate
peramivir
piperacillin
piperacillin/tazobactam
polymyxin B
posaconazole
pyrazinamide
Prevpac
Priftin
Primaxin
Primsol
Principen
Proquin XR
Pylera
quinupristin/dalfopristin
Raniclor
Relenza
ribavirin
rifabutin
Rifadin
PT Instructions_v1_20130620 Page 28 of 30

Rifamate
rifampin
rifapentine
Rifater
rifaximin
Rimactane
rimantadine
Rocephin
Septra
spectinomycin
Spectracef
Sporanox
streptomycin
sulfisoxazole
sulfamethoxazole/trimethoprim
Suprax
Symmetrel
Synercid
Tamiflu
Tazicef
Teflaro
telavancin
telithromycin
terbinafine
tetracycline
ticarcillin/clavulanate
tigecycline
Timentin
Tindamax
tinidazole
Tobi
tobramycin
trimethoprim
trimethoprim/sulfamethoxazole
Trimox
Trobicin
Tygacil
Unasyn
Unipen
Urex
valacyclovir
Valcyte
valganciclovir
Valtrex
vancomycin

Vancocin
Vantin
Vfend
Vibativ
Vistide
voriconazole
Xifaxan
zanamivir
Zinacef
Zithromax
Zmax
Zosyn
Zovirax
Zyvox

PT Instructions_v1_20130620 Page 29 of 30