Investigation of GAS outbreak in LTCF 2016 - Resident Re

Study ID #: _R

Appendix 2. Investigation of GAS outbreak in an Long Term Care Facility, 2016

Resident Record Extraction Form

Form Approved; OMB No. OMB No. 0920-1011

Exp. Date 03/31/2017

Person completing form ______________________ Date Completed: ____/____/____

Resident (check one):  Case  Control

If CONTROL, date of matched case’s GAS culture: ____/____/____

1. GAS TESTING RESULTS

   1. Did resident have any cultures/tests positive for GAS?

 Yes  No

#	Date obtained	Site cultured
a.	____/_____/_______	 Blood  Pleural  Skin/Wound: _________  Rapid strep  Sputum  Joint  Other __________  Throat  Central line/TPN  Catheter
b.	____/_____/_______	 Blood  Pleural  Skin/Wound: _________  Rapid strep  Sputum  Joint  Other __________  Throat  Central line/TPN  Catheter
c.	____/_____/_______	 Blood  Pleural  Skin/Wound: _________  Rapid strep  Sputum  Joint  Other __________  Throat  Central line/TPN  Catheter
d.	____/_____/_______	 Blood  Pleural  Skin/Wound: _________  Rapid strep  Sputum  Joint  Other __________  Throat  Central line/TPN  Catheter
e.	____/_____/_______	 Blood  Pleural  Skin/Wound: _________  Rapid strep  Sputum  Joint  Other __________  Throat  Central line/TPN  Catheter
f.	____/_____/_______	 Blood  Pleural  Skin/Wound: _________  Rapid strep  Sputum  Joint  Other __________  Throat  Central line/TPN  Catheter

B. RESIDENT BACKGROUND

2. Sex:  Male  Female 3. Age: __________ 4. Date of birth: ____/____/____

5a. Room history for 1 month prior to GAS culture (for case) or time of time match (for control):

Room # (floor/wing)	Dates in room	Type of room	Roommate (dates)
a.	___/___/____ to ___/___/____	 Private  Double  Triple	___/___/____ to ___/___/____
b.	___/___/____ to ___/___/____	 Private  Double  Triple	___/___/____ to ___/___/____
c.	___/___/____ to ___/___/____	 Private  Double  Triple	___/___/____ to ___/___/____
d.	___/___/____ to ___/___/____	 Private  Double  Triple	___/___/____ to ___/___/____
e.	___/___/____ to ___/___/____	 Private  Double  Triple	___/___/____ to ___/___/____
f.	___/___/____ to ___/___/____	 Private  Double  Triple	___/___/____ to ___/___/____

5b. Did the resident have a roommate with GAS infection or colonization?

 Yes  No  Unknown If yes: initials of GAS+ roommate__ Dates room shared: ___________

5c. Did the resident have frequent visitors during his stay in the facility? (if no, skip to 6)

 Yes  No  Unknown

If yes: how many days per week?______ How many regular visitors/week?______________

6. Total length of stay at facility (most recent stay only) at time of GAS culture (mark only one):

 ≤ 1 week  1-3 weeks  4-8 weeks  ≥ 8 weeks

7a. Is the resident deceased?  Yes  No If yes, date of death: ____/____/____

b. If resident died, death was:  Related to GAS infection  Possibly related to GAS infection

 Not related  Not applicable

8. Resident’s physicians?

Physician’s name	Name of practice	Specialty (e.g., wound care, etc.)
a.
b.
c.
d.

9. List last admission prior to GAS infection or time of match for controls (including home, facility, hospitals, and any other LTCF).

Name & location	Admission date	Discharge date	Diagnosis (if applicable)	Admission from:
a.	______ / _______ / _______	______ / _______ / _______
b.	______ / _______ / _______	______ / _______ / _______

C. MEDICAL HISTORY

10. 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  Chronic skin condition

 Cancer, specify type: ­­­­­­­­­­­_________________  Immunosuppressed/immunosuppression  None

 Cirrhosis  Recent IV Drug Use  Prosthetic  Other: ____________­­­­­­­­­­­___________

(Note: immunosuppression includes: HIV/AIDS, chemo, radiation, immunosuppressive meds, including tacrolimus [Prograf], sirolimus [Rapamune], mycophenolate mofetil [Cellcept], high-dose or chronic steroids [prednisone, methylprednisone, hydrocortisone, dexamethasone] methotrexate.)

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

12. Did patient have any surgical wounds, pressure ulcers, or other wounds at the time of admission to the facility?

 Yes If yes, how many _____  No

13. Did patient have any surgical wounds, pressure ulcers, or other wounds at the time of first GAS isolation for case or at time-match for controls?

 No  Yes If yes, how many _____

Indicate location(s):

14. Did the patient receive wound care consultation services within 1 month prior to the GAS case or time-match for controls?

 Yes  No

Dates	Name(s) of doctors or nurses

15. Did the patient receive wound care WITHOUT wound care consultation within 1 month prior to GAS case or time-match for controls?

 Yes  No

16. Products used for wound care (surgical and nonsurgical) (check all):

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

 Ethyzyme  DuoDerm  Biotane Foam  Hydrogel  Wound vac

 Antimicrobial cleanser/cream  None  Other: _____________________________

17. Has the patient had a surgical procedure within 1 month of GAS infection or time match for control?

 Yes  No

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

18. Type of IV access present at time of positive GAS culture/referral from CC?  None  Not applicable

15a. Access Type	15b. Date of Insertion	15c. Person Inserting (e.g. RN)

19. At time of GAS culture (case) or time-match (for control), was the resident diagnosed with:

1. Cellulitis  Yes  No Date of onset ___/___/____

2. Wound infection  Yes  No Date of onset ___/___/____

3. Pharyngitis  Yes  No Date of onset ___/___/____

4. Bacteremia  Yes  No Date of onset ___/___/____

5. Pneumonia  Yes  No Date of onset ___/___/____

6. Joint Infection  Yes  No Date of onset ___/___/____

20. Within 1 month of GAS culture or time-match for control, did the resident have any of the following signs or symptoms? (mark ALL that apply)

		Date of onset (dd/mm/yy)
a.	 Fever (≥100.5oF or 38oC)	______ / _______ / _______	Max temp recorded:
b.	 Sore throat	______ / _______ / _______
d.	 Purulent discharge from wound	______ / _______ / _______	Site:
e.	 Wound – warm on touch	______ / _______ / _______	Site:
f.	 Wound – redness	______ / _______ / _______	Site:
g.	 Edema at the site	______ / _______ / _______	Site:
h.	 Increased pain at the site	______ / _______ / _______	Site:
i.	 Joint – warm on touch	______ / _______ / _______	Site:
j.	 Joint – redness	______ / _______ / _______	Site:
k.	 Joint – warm on touch	______ / _______ / _______	Site:

C. RESIDENT BASELINE STATUS (Can get further information from nursing)

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

 Tracheostomy  Nasal cannula  Oxygen mask  Chronic Foley

 G or J tube  Nasogastric tube  Colostomy/ileostomy  Temporary Foley

 Dialysis catheter  PICC line  Other, specify: ____________________________

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

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

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

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

24. Is the resident being tube fed?  Yes  No

25. Did the resident participate in the following activities in the 1 month prior to diagnosis or time-match for controls (mark ALL that apply):

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

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

c.  Podiatry Times per 2 month period: ______

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

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