Form CDC 57.150 CDC 57.150 Patient Safety Component -- Annual Faciity Survey for LT

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Patient Safety Component—Annual Facility Survey for LTAC

Instructions for this form are available at: http://www.cdc.gov/nhsn/forms/instr/TOI-57.150-LTAC.pdf

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*required for saving

Tracking #:

*Facility ID:

*Survey Year:

Facility Characteristics (completed by Infection Preventionist)

*Ownership (check one):

□ For profit

□ Not for profit, including church

□ Government

□ Veterans Affairs

*Affiliation (check one):

□ Independent

□ Multi-facility organization (specialty hospital network)

□ Hospital system

*Setting/classification:

____ Free-standing

____ Within a hospital

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)?

□ No

□ Skilled nursing facility (SNF)/nursing home

□ Residential facility (assisted living)

□ Inpatient rehabilitation facility

□ Neuro-behavioral unit or facility

□ Other (please specify: _______________________________________)

If classified as “Within a hospital,” is your LTAC hospital located: In a building that does not provide acute care services (e.g., psychiatric hospital)?

□ Yes

□ No

Near (but not within) an acute care hospital?

□ Yes

□ No

In the previous calendar year, indicate:

*Number of patient days: ___________

*Number of admissions: ___________

*Average daily census: ___________

*Numbers of LTAC beds in the following categories (categories should equal total):

a. Intensive care unit (ICU) or critical care beds:

_________

b. High observation/special care/high acuity beds (not ICU):

_________

c. General LTAC beds:

_________

*Total number of LTAC beds (licensed capacity):

_________

*Number of single occupancy rooms:

_________

* Total number of admissions with one of the following conditions identified on admission (present on admission, not developing during LTAC stay): (Note: These categories are not mutually exclusive.)

If helpful for your facility in identifying these conditions on admission, please review a list of ICD-9 and DRG codes commonly associated with these conditions found here: http://www.cdc.gov/nhsn/xls/DRGs-ICD-9s-NHSN-LTAC-Survey.xlsx

Ventilator dependence:

_________

Hemodialysis:

_________

Continued >>

Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 50 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.150 (Front) Rev. 3 , v8.5

Patient Safety Component—Annual Facility Survey for LTAC

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Facility Microbiology Laboratory Practices (completed with input from Microbiology Laboratory Lead)
*1. Does your facility have its own on-site laboratory that performs antimicrobial susceptibility testing?
□ Yes	□ No
If No, where is your facility’s antimicrobial susceptibility testing performed? (check one)
□ Affiliated medical center			□ Commercial referral laboratory				□ Other local/regional, non-affiliated reference laboratory
*2. Does the laboratory use CLSI (formerly NCCLS) antimicrobial susceptibility standards?
□ Yes	□ No
If Yes, specify the version of the M100 document that the laboratory used during the prior calendar year (i.e. the survey year): M100- S________
*3. For the following organisms please indicate which methods are used for:
(1) primary susceptibility testing and
(2) secondary, supplemental, or confirmatory testing (if performed).
If your laboratory does not perform susceptibility testing, please indicate the methods used at the outside laboratory.
Please use the testing codes listed below the table.
Pathogen				(1) Primary	(2) Secondary				Comments
Staphylococcus aureus				_______________	______________				______________
Enterococcus spp.				_______________	______________				______________
Enterobacteriaceae				_______________	______________				______________
Pseudomonas aeruginosa				_______________	______________				______________
Acinetobacter spp.				_______________	______________				______________
1 = Kirby-Bauer disk diffusion		5.1 = MicroScan walkaway rapid				10 = E test
2 = Vitek (Legacy)		5.2 = MicroScan walkaway conventional				12 = Vancomycin agar screen (BHI + vancomycin)
2.1 = Vitek 2		5.3 = MicroScan auto or touchscan				13 = Other (describe in Comments section)
3.1 = BD Phoenix		6 = Other micro-broth dilution method
4 = Sensititre		7 = Agar dilution method
*4. Has the laboratory implemented the revised cephalosporin and monobactam breakpoints for Enterobacteriaceae recommended by CLSI as of 2010?								□ Yes		□ No
*5. Has the laboratory implemented the revised carbapenem breakpoints for Enterobacteriaceae recommended by CLSI as of 2010?								□ Yes		□ No
Continued >>

Patient Safety Component—Annual Facility Survey for LTAC

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Facility Microbiology Laboratory Practices (continued)

*6. Does the laboratory perform a special test for presence of carbapenemase?

□ Yes

□ No

If Yes, please indicate what is done if carbapenemase production is detected: (check one)

□ Change susceptible carbapenem results to resistant

□ Report carbapenem MIC results without an interpretation

□ No changes are made in the interpretation of carbapenems, the test is used for epidemiological or infection control purposes

If Yes, which test is routinely performed to detect carbapenemase: (check all that apply)

□ PCR

□ MBL screen

□ Modified Hodge Test

□ Carba NP

□ E test

□ Other (specify): _________________

*7. Does the laboratory perform colistin or polymyxin B susceptibility testing for drug-resistant gram negative bacilli?

□ Yes

□ No

If Yes, please indicate methods: (check all that apply)

□ Vitek (Legacy)

□ MicroScan walkaway rapid

□ Agar dilution method

□ Vitek 2

□ MicroScan walkaway conventional

□ E test

□ BD Phoenix

□ MicroScan auto or touchscan

□ Other (specify): _____________________

□ Sensititre

□ Other micro-broth dilution method

*8. Does your facility have its own laboratory that performs antifungal susceptibility testing for Candida species?

□ Yes

□ No

If No, where is your facility’s antifungal susceptibility testing performed? (check one)

□ Affiliated medical center

□ Commercial referral laboratory

□ Other local/regional, non-affiliated reference laboratory

□ Not offered by my facility

9. If antifungal susceptibility testing is performed at your facility or an outside laboratory, what methods are used? (check all that apply)

□ Broth macrodilution

□ Broth microdilution

□ YeastOne colorimetric microdilution

□ E test

□ Vitek 2 card

□ Disk diffusion

□ Other (specify): ________________

*10. Is antifungal susceptibility testing performed automatically/reflexively for Candida spp. cultured from normally sterile body sites (such as blood), without needing a specific order or request for susceptibility testing from the clinician?

□ Yes

□ No

If Yes, what antifungal drugs are tested automatically/reflexively? (check all that apply)

□ Fluconazole

□ Itraconazole

□ Voriconazole

□ Caspofungin

□ Micafungin

□ Anidulafungin

□ Flucytosine

□ Other

Continued >>

Patient Safety Component—Annual Facility Survey for LTAC

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Facility Microbiology Laboratory Practices (continued)
*11. What is the primary testing method for C. difficile used most often by your facility’s laboratory or the outside laboratory where your facility’s testing is performed? (check one)
□ Enzyme immunoassay (EIA) for toxin
□ Cell cytotoxicity neutralization assay
□ Nucleic acid amplification test (NAAT) (e.g., PCR, LAMP)
□ Glutamate dehydrogenase (GDH) antigen plus EIA for toxin (2-step algorithm)
□ GDH plus NAAT (2-step algorithm)
□ GDH plus EIA for toxin, followed by NAAT for discrepant results
□ Toxigenic culture (C. difficile culture followed by detection of toxins)
□ Other (specify): ______________________ (“Other” should not be used to name specific laboratories, reference laboratories, or the brand names of C. difficile tests; most methods can be categorized accurately by selecting from the options provided. Please ask your laboratory or conduct a search for further guidance on selecting the correct option to report.)
*12. Does your facility produce an antibiogram (i.e., cumulative antimicrobial susceptibility report)?
□ Yes	□ No
If Yes, is the antibiogram produced at least annually?
□ Yes		□ No
If Yes, are data stratified by hospital location?
□ Yes		□ No
If No, please identify any obstacle(s) to producing an antibiogram. (Check all that apply)
□ The laboratory data are difficult to access
□ Limited or no information technology tool for data analysis
□ Limited personnel time for data analysis
□ Limited personnel skills for data analysis
□ Limited interest in an antibiogram from staff who prescribe antibiotics
□ Our institution does not have enough isolates of any or most species (i.e., < 30 isolates per species) to produce an antibiogram
□ Other (please specify): ___________________________________________
Infection Control Practices (completed with input from Hospital Epidemiologist and/or Quality Improvement Coordinator)
*13. Number of trained or certified infection preventionists (IPs) in facility:			_________
a. Total hours per week performing surveillance:			_________
b. Total hours per week for infection control activities other than surveillance:			_________
Continued >>

Patient Safety Component—Annual Facility Survey for LTAC

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Infection Control Practices (continued)

*14. Does the facility routinely place patients infected or colonized with MRSA in contact precautions when these patients are admitted? (check one)

□ Yes, all infected or colonized patients

□ Yes, only all infected patients

□ Yes, only those with certain characteristics that make them high-risk for transmission (e.g., wounds, diarrhea, presence of an indwelling device)

□ Yes, only those admitted to high-risk settings (e.g., ICU)

□ No

□ Not applicable: my facility never admits these patients

*15. Does the facility routinely place patients infected or colonized with VRE in contact precautions when these patients are admitted? (check one)

□ Yes, all infected or colonized patients

□ Yes, only all infected patients

□ Yes, only those with certain characteristics that make them high-risk for transmission (e.g., wounds, diarrhea, presence of an indwelling device)

□ Yes, only those admitted to high-risk settings (e.g., ICU)

□ No

□ Not applicable: my facility never admits these patients

*16. Does the facility routinely place patients infected or colonized with CRE in contact precautions when these patients are admitted? (check one)

□ Yes, all infected or colonized patients

□ Yes, only all infected patients

□ Yes, only those with certain characteristics that make them high-risk for transmission (e.g., wounds, diarrhea, presence of an indwelling device)

□ Yes, only those admitted to high-risk settings (e.g., ICU)

□ No

□ Not applicable: my facility never admits these patients

*17. Does the facility routinely place patients infected or colonized with ESBL-producing or extended spectrum cephalosporin resistant Enterobacteriaceae in contact precautions when these patients are admitted? (check one)

□ Yes, all infected or colonized patients

□ Yes, only all infected patients

□ Yes, only those with certain characteristics that make them high-risk for transmission (e.g., wounds, diarrhea, presence of an indwelling device)

□ Yes, only those admitted to high-risk settings (e.g., ICU)

□ No

□ Not applicable: my facility never admits these patients

Continued >>

Patient Safety Component—Annual Facility Survey for LTAC

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Infection Control Practices (continued)
*18. Does the facility routinely perform screening testing (culture or non-culture) for CRE?
□ Yes	□ No
If Yes, in which situations does the facility routinely perform screening testing for CRE? (check all that apply)
□ Surveillance cultures at admission of all patients
□ Surveillance cultures of epidemiologically-linked patients of newly identified CRE patients (e.g., roommates)
□ Surveillance cultures at admission of high-risk patients (e.g., admitted from LTAC or LTCF)
□ Surveillance cultures at admission of patients admitted to high-risk settings (e.g. ICU)
□ Other (please specify): _________________
*19. Does the facility routinely perform screening testing (culture or non-culture) for MRSA?
□ Yes	□ No
If yes, in which situations does the facility routinely perform screening testing for MRSA? (check all that apply)
□ Surveillance cultures at admission of all patients
□ Surveillance cultures at admission of high-risk patients (e.g., admitted from LTAC or LTCF)
□ Surveillance cultures at admission of patients admitted to high-risk settings (e.g. ICU)
□ Surveillance cultures of pre-operative patients to prevent surgical site infections
□ Other (please specify): _________________
*20. Does the facility routinely use chlorhexidine bathing on any patient to prevent transmission of MDROs in your facility? (Note: this does not include the use of chlorhexidine in pre-operative patients to prevent surgical site infections)
□ Yes	□ No
*21. Does the facility routinely use topical chlorhexidine and intranasal mupirocin on any patients to prevent transmission of MRSA in the facility? (Note: this does not include the use of these agents in pre-operative patients to prevent surgical site infections)
□ Yes	□ No
*22. Among patients with an MDRO admitted to your facility from another healthcare facility, please estimate how often your facility receives information from the transferring facility about the patient’s MDRO status?
□ All the time
□ More than half of the time
□ About half of the time
□ Less than half of the time
□ None of the time
□ Not applicable: my facility does not receive transferred patients with an MDRO
Continued >>

Patient Safety Component—Annual Facility Survey for LTAC

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Antibiotic Stewardship Practices (completed with input from Physician and Pharmacist Stewardship Champions)
*23. Does your facility have a written statement of support from leadership that supports efforts to improve antibiotic use (antibiotic stewardship)?
□ Yes	□ No
*24. Is there a leader responsible for outcomes of stewardship activities at your facility?
□ Yes	□ No
If Yes, what is the position of this leader: (check one)
□ Physician			□ Co-led by both Pharmacist and Physician
□ Pharmacist			□ Other (please specify): _______________________
*25. Is there at least one pharmacist responsible for improving antibiotic use at your facility?
□ Yes	□ No
*26. Does your facility provide any salary support for dedicated time for antibiotic stewardship activities?
□ Yes	□ No
*27. Does your facility have a policy that requires prescribers to document an indication for all antibiotics in the medical record or during order entry?
□ Yes	□ No
If Yes, has adherence to the policy to document an indication been monitored?
□ Yes		□ No
*28. Does your facility have facility-specific treatment recommendations, based on national guidelines and local susceptibility, to assist with antibiotic selection for common clinical conditions?
□ Yes	□ No
If Yes, has adherence to facility-specific treatment recommendations been monitored?
□ Yes		□ No
*29. Is there a formal procedure for all clinicians to review the appropriateness of all antibiotics at or after 48 hours from the initial orders (e.g. antibiotic time out)?
□ Yes	□ No
*30. Do any specified antibiotic agents need to be approved by a physician or pharmacist prior to dispensing at your facility?
□ Yes	□ No
*31. Does a physician or pharmacist review courses of therapy for specified antibiotic agents and communicate results with prescribers (i.e., audit with feedback) at your facility?
□ Yes	□ No
Continued >>

Patient Safety Component—Annual Facility Survey for LTAC

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Antibiotic Stewardship Practices (continued)
*32. Does your facility monitor antibiotic use (consumption) at the unit, service, and/or facility wide?
□ Yes	□ No
If Yes, by which metrics? (Check all that apply)
□ Days of Therapy (DOT)			□ Purchasing Data
□ Defined Daily Dose (DDD)			□ Other (please specify): ________________________
If Yes, are facility- and/or unit- or service-specific reports on antibiotic use shared with prescribers?
□ Yes		□ No
*33. Do prescribers ever receive feedback by the stewardship program about how they can improve their antibiotic prescribing?
□ Yes	□ No
*34. Has your stewardship program provided education to clinicians and other relevant staff on improving antibiotic use?
□ Yes	□ No