GAS_IL Medical Record Abstraction

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Investigation of GAS outbreak in LTCF, Illinois – 2015

Resident Record Extraction Form

Person Completing Form ______________________ Date Completed: ____/____/____

A. Resident Background

1. Sex:  Male  Female 2. Age: __________ 3. Date of Birth: ____/____/____

4. Room History since [DATE]:

Room Number	Unit	Dates	Type	Acuity
a.			 Private  Double	 Short Term  Long Term
b.			 Private  Double	 Short Term  Long Term
c.			 Private  Double	 Short Term  Long Term
d.			 Private  Double	 Short Term  Long Term
e.			 Private  Double	 Short Term  Long Term
f.			 Private  Double	 Short Term  Long Term
g.			 Private  Double	 Short Term  Long Term
g.			 Private  Double	 Short Term  Long Term

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)

5a. Does/did the patient have a roommate with GAS infection or colonization?  Yes  No  Unknown (If no or unknown,skip to 6)

(I)nfected or (C)olonized Roommate	Date of positive culture result	Site of Culture	Dates of Shared Rooms From To
b.	____/____/____		____/____/____	____/____/____
c.	____/____/____		____/____/____	____/____/____
d.	____/____/____		____/____/____	____/____/____
e.	____/____/____		____/____/____	____/____/____

6. Total length of stay at time of chart review (mark only one):  ≤ 1 week  1-3 weeks  4-8 weeks  ≥ 8 weeks

7a. Is resident currently living?  Yes  No If deceased, date of death ____/____/____

7b. If resident died, death was:  Related to GAS infection  Possibly related to GAS infection  Not related

 Not applicable

8a. Resident’s primary physician? __________________________________

8b. Was this patient admitted to this facility from home? .  Yes  No

8c. Was this patient discharged from this facility to home? .  Yes  No  Still in facility at time of chart review

9. List admission and discharge information since [5/1/2015].

Facility	Admission Date	Discharge Date	Diagnosis
a.	______ / _______ / _______	______ / _______ / _______
b.	______ / _______ / _______	______ / _______ / _______
c	______ / _______ / _______	______ / _______ / _______
d.	______ / _______ / _______	______ / _______ / _______
e.	______ / _______ / _______	______ / _______ / _______

B. Medical History

10a. Original date of admission to this facility: ______ / _______ / _______

10b. Facility patient admitted from? _____________________________________________________________

□ Patient admitted from home

10c. Primary diagnosis (reason for admission to facility): _______________________________________________________

11. Which medical condition(s) does the resident have? (mark ALL that apply):

 Diabetes  CHF/history of MI  Peripheral Vascular Disease  Stroke  Asthma/COPD

 Hypertension  Chronic Leg Edema  Recent Herpes Zoster  Dialysis

 Renal insufficiency  Dementia  Cancer (specify type) ­­­­­­­­­­­_________________________

 Vent dependence  None  Other: ____________ ­­­­­­­­­­­_________________________

12. Weight: ____________ lbs or kg (circle unit of measure) 12b. Height: __________

13a. Has the patient had a surgical procedure since [5/1/2015]?  Yes  No

Procedure	Date	Incision Site
	______ / _______ / _______
	______ / _______ / _______
	______ / _______ / _______
	______ / _______ / _______
	______ / _______ / _______

14b. Surgical skin wounds present since [5/1/2015] (mark ALL that apply):

 PICC line  Tracheostomy  PEG/PEJ site  Colostomy site

 AV fistula or graft  Suprapubic catheter  Hemodialysis catheter  None

 Surgical wound: ________________________________________________

 Other: ­­­­­­­­­­­­­­­­­­­­­­________________________________________________________

15. Type of IV access present at time of positive GAS culture  None  Not applicable

18a. Access Type	18b. Date of Insertion	18c. Person Inserting (e.g. RN)

16a. Since [5/1/2015], did the resident have non-surgical skin breakdown?  Yes  No (If no, skip to 17)

16b. Non-surgical skin breakdown since [5/1/2015] (mark ALL that apply):

 Sacrum  Ischium  Trochanter  Heel  Shoulder  Occipital  Lat. Malleolus

 Med. Malleolus  Elbow  Ear  Coccyx  Toe  Other: ________________________

17. Products used for wound care (surgical and nonsurgical):

 Versafoam  Granufoam  Prisma Wound  Matrix  Mepilex  Accuzyme

 Ethyzyme  DuoDerm  Biotane Foam  None  Other: _______________________________________

18a. Was a clinical diagnosis of cellulitis made since [5/1/2015]?  Yes  No (If no, skip to 19)

Location	Surgical Site	Date of Onset	Treated with Antibiotics
b.	 Yes  No	______ / _______ / _______	 Yes  No
c.	 Yes  No	______ / _______ / _______	 Yes  No
d.	 Yes  No	______ / _______ / _______	 Yes  No

19. Since [5/1/2015] new, nonsurgical breakdown (mark ALL that apply):  None  Not applicable

 Sacrum  Ischium  Trochanter  Heel  Shoulder  Occipital

 Lat. Malleolus  Med. Malleolus  Elbow  Ear  Coccyx

 Toe  Other: ________________________

20. Surgical procedures since [5/1/2015] (mark ALL that apply):  None  Not applicable

 PICC line insertion  Tracheostomy site  PEG/PEJ site

 Colostomy site  Suprapubic catheter  Hemodialysis catheter

 AV fistula or graft  Surgical incision: ________________________

 Debridement  Other: ­­­­­­­­­­­­­­­­­­­­­­_________________________________

21a. Was a new clinical diagnosis of cellulitis made since [5/1/2015]?  Yes  No  Not applicable (If no or not applicable, skip to 22)

Location	Surgical Site	Date of Onset	Treated with Antibiotics
21b.	 Yes  No	______ / _______ / _______	 Yes  No
21c.	 Yes  No	______ / _______ / _______	 Yes  No
21d.	 Yes  No	______ / _______ / _______	 Yes  No

22a. Does/Did the resident receive negative pressure wound therapy via a vacuum-assisted closure device?

 Yes  No

23b. If yes, date of initiation: _____ / _____ / _____

24b. Stop date: _____ / _____ / _____ or

 still in place at time of discharge from facility or at time of chart review

23. Since [5/1/2015], did the resident have any of the following signs or symptoms? (mark ALL that apply)

		Date of onset (dd/mm/yy)
24a.	 Fever (≥100.5oF)	______ / _______ / _______	Max temp recorded:
24b.	 Sore throat	______ / _______ / _______
24c.	 Cough	______ / _______ / _______	Productive?  Yes  No
24d.	 Purulent discharge from wound	______ / _______ / _______	Site:

C. Resident Baseline Status (Can get further information from nursing)

24. Which appliances does the resident use (mark ALL that apply):

 Tracheostomy  Nasal Cannula  Oxygen Mask  Nebulizer treatment

 G or J tube  Nasogastric tube  Colostomy  Suprapubic catheter

 Chronic Foley  Temporary Foley  Texas/Condom catheter

 Dialysis Catheter  PICC Line  Other ____________________________

25. Describe the resident’s ambulatory status: (mark ALL that apply)

 Walks independently  Walks with support  Wheelchair  Geri chair  Bed bound

26. Indicate if resident incontinent of: (mark ALL that apply)

 Stool  Urine  Not Incontinent  Urinary catheter  Colostomy  Unknown

27. Does the resident require tube feeds or TPN?  Yes  No

28. Does the patient have an alcohol-based hand-gel dispenser in his/her room?  Yes  No

29. How often did the resident participate in the following activities (mark ALL that apply):

30a.  PT/OT Times per 2 month period: ______

30b.  Speech pathology Times per 2 month period: ______

30c.  Podiatry Times per 2 month period: ______

30d.  Other: ____________________ Times per 2 month period: ______

D. Medications

30. Which of the following medications did the resident receive since [5/1/2015]? (mark ALL that apply):

30a.  Steroids

30b.  Chemotherapy

30c.  Radiation therapy

30d.  Immunosuppressive agents to treat autoimmune disorders (e.g. methotrexate, infliximab)

(name)______________________________

E. Laboratory Results

31a. Did resident have a rapid Strep test since [5/1/2015]?  Yes  No

31b. Date ______ / _______ / _______

31c. Result?  Positive  Negative

32a. Did resident have an OP Strep culture since [5/1/2015]?

 Yes  No

32b. Date ______ / _______ / _______

32c. Result?  GAS Positive  GAS Negative

32d.  Positive for other Strep species 32e. List type ________________________

33a. Did resident have other cultures positive for GAS since [5/1/2015]  Yes  No (if No skip to 35)

33b. Culture #1 33c. Date obtained ______ / _______ / _______

33d. Site:  Skin/Wound: _____________________  Blood  Lung  Sputum

 Other _________________

33e. Culture #2 33f. Date obtained ______ / _______ / _______

33g. Site:  Skin/Wound: _____________________  Blood  Lung  Sputum

 Other _________________

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Version 2, 1/24/2021