Att G18_Surveys--Hospital, LTAC, IRF, and Dialysis

Att G18_Surveys - Hospital, LTAC, IRF, and Dialysis.pdf

The National Healthcare Safety Network (NHSN)

Att G18_Surveys--Hospital, LTAC, IRF, and Dialysis

OMB: 0920-0666

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0666 can be found here:

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Plan and Annual Surveys

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

Data Field
Facility ID #
Survey Year

Facility Characteristics
Ownership (check one)

Number of patient days

Number of admissions
Is your hospital a teaching
hospital for physicians and/or
physicians in training?
If Yes, what type?

January 2015

Required. The NHSN-assigned facility ID will be auto-entered by the computer.
Required. Select the calendar year for which this survey was completed.
The survey year should represent the last full calendar year. For example, in 2015,
a facility would complete a 2014 survey.
Required. Select the appropriate ownership of this facility:
 P - For profit
 NP - Not for profit, including church
 GOV - Government
 MIL - Military
 VA- Veterans Affairs
 PHY - Physician owned
Required. Enter the total number of patient days from inpatient locations in your
hospital during the last full calendar year. Newborns should be included in this
count.
Required. Enter the total number of inpatient admissions, including newborns, for
your hospital during the last full calendar year.
Required. If a teaching hospital, select ‘Yes'. Otherwise, select 'No'.

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

Plan and Annual Surveys

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

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

Enter the number of beds set up and staffed in all other inpatient locations used
for overnight stay patients in this hospital. This includes all inpatient beds in the
facility, and not just those that are subject to NHSN surveillance.
Facility Microbiology Laboratory Practices. Completion of this section requires the assistance from the
microbiology laboratory. Questions should be answered based on the testing methods that were used for the
majority of the last full calendar year.
1. Does your facility have its Required. Select 'Yes' if your laboratory performs antimicrobial susceptibility
own laboratory that
testing; otherwise, select 'No'.
performs antimicrobial
susceptibility testing? If No, Conditionally Required. If ‘No’, select the location where your facility's
where is the facility's
antimicrobial susceptibility testing is performed: Affiliated medical center,
antimicrobial susceptibility Commercial referral laboratory, or Other local/regional, non-affiliated reference
testing performed? (check laboratory. If multiple laboratories are used indicate the laboratory which
one)
performs the majority of the bacterial susceptibility testing. You must complete
the remainder of this survey with assistance from your outside laboratory.
b. All other inpatient
locations

January 2015

Plan and Annual Surveys

Facility Microbiology Laboratory Practices (continued)
2. Does the laboratory use
Required. Select 'Yes' if your laboratory uses CLSI antimicrobial susceptibility
CLSI (formerly NCCLS)
standards; otherwise, select 'No'.
antimicrobial susceptibility
standards?
If Yes, specify which
version of the M100
document the laboratory
used during the prior
calendar year (i.e., the
survey year)
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)

Conditionally Required. If ‘Yes’, specify the version used by your laboratory or
the referral laboratory during the prior calendar year.

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

4. Has your laboratory
implemented the revised
cephalosporin and
monobactam breakpoints for
Enterobacteriaceae
recommended by CLSI as of
2010?
5. Has your laboratory
Required. Select 'Yes' if your laboratory has implemented the revised carbapenem
implemented the revised
breakpoints for Enterobacteriaceae recommended by CLSI as of 2010; otherwise,
carbapenem breakpoints for select 'No'.
Enterobacteriaceae
recommended by CLSI as of
2010?
6. Does your laboratory
Required. Select 'Yes' if your laboratory performs a special test for carbapenemase
perform a special test for
production; otherwise, select 'No'.
carbapenemase production?
If Yes, please indicate what Conditionally Required. If ‘Yes’, specify what is done if carbapenemase
is done if carbapenemase
production is detected.
production is detected
(check one).
If Yes, which test is
Conditionally Required. If ‘Yes’, specify which test is performed to detect
routinely performed to
carbapenemase.

January 2015

Plan and Annual Surveys

detect carbapenemase (check
all that apply).

January 2015

Plan and Annual Surveys

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

January 2015

Plan and Annual Surveys

Facility Microbiology Laboratory Practices (continued)
12. Does your facility produce Required. Select ‘Yes’ if your facility produces an antibiogram; otherwise select
an antibiogram (i.e.,
‘No’.
cumulative antimicrobial
susceptibility report)?
If Yes, is the antibiogram
Conditionally Required. If ‘Yes’, indicate whether the antibiogram is produced at
produced at least annually? least annually.
If Yes, are data stratified by Conditionally Required. If ‘Yes’, indicate whether antibiogram data are stratified
hospital location?
by hospital location.
If No, please identify any
Conditionally Required. If ‘No’, indicate the obstacle(s) to producing an
obstacle(s) to producing an antibiogram at your facility. If ‘Other’ is selected, please specify.
antibiogram. (Check all that
apply)
Infection Control Practices. Completion of this section may require assistance from the Infection Preventionist,
Hospital Epidemiologist, other infection control personnel, and/or Quality Improvement Coordinator. Questions
should be answered based on the policies and practices that were in place for the majority of the last full calendar
year.
13. Number of infection
Required. Enter the number of individuals (full-time employees) who work in the
preventionists (IPs) in
infection prevention department of the hospital as infection prevention
facility
professionals. Certification in infection control, the CIC credential, is not required
to be considered an “IP” on this survey.
a. Total hours per week
Enter the number of hours per week engaged in activities designed to find and
performing surveillance report healthcare-associated infections (in the hospital) and the appropriate
denominators. Total should include time to analyze data and disseminate results.
b. Total hours per week for Enter the number of hours per week spent on infection prevention and control
infection control
activities other than surveillance. These activities include, but are not limited to,
activities other than
education, prevention, meetings, etc.
surveillance
For detailed description about the use of Contact Precautions, please refer to the CDC/HICPAC 2007 Guideline
for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
(http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf).
14. Does the facility routinely Required. Select ‘No’ if your facility does not routinely place any patient infected
place patients infected or
or colonized with MRSA in Contact Precautions; otherwise, select the single best
colonized with MRSA in
choice from the choices listed that most accurately describes the primary
contact precautions when
indication for placing admitted patients with MRSA on Contact Precautions at
these patients are admitted? your facility. If your facility never admits patients with MRSA, select ‘Not
(check one)
applicable’.
15. Does the facility routinely Required. Select ‘No’ if your facility does not routinely place any patient infected
place patients infected or
or colonized with VRE in Contact Precautions; otherwise, select the single best
colonized with VRE in
choice from the choices listed that most accurately describes the primary
contact precautions when
indication for placing admitted patients with VRE on Contact Precautions at your
these patients are admitted? facility. If your facility never admits patients with VRE, select ‘Not applicable’.
(check one)
16. Does the facility routinely Required. Select ‘No’ if your facility does not routinely place any patient infected
place patients infected or
or colonized with CRE in Contact Precautions; otherwise, select the single best
colonized with CRE in
choice from the choices listed that most accurately describes the primary
contact precautions when

January 2015

Plan and Annual Surveys

these patients are admitted? indication for placing admitted patients with CRE on Contact Precautions at your
(check one)
facility. If your facility never admits patients with CRE, select ‘Not applicable’.

January 2015

Plan and Annual Surveys

Infection Control Practices (continued)
17. Does the facility routinely
place patients infected or
colonized with ESBLproducing or extended
spectrum cephalosporin
resistant Enterobacteriaceae
in contact precautions when
these patients are admitted?
(check one)
18. Does the facility routinely
perform screening testing
(culture or non-culture) for
CRE?

Required. Select ‘No’ if your facility does not routinely place any patient infected
or colonized with ESBL-producing or extended spectrum cephalosporin-resistant
Enterobacteriaceae in Contact Precautions; otherwise, select the single best choice
from the choices listed that most accurately describes the primary indication for
placing admitted patients with ESBL-producing or extended spectrum
cephalosporin-resistant Enterobacteriaceae on Contact Precautions at your
facility. If your facility never admits patients with ESBL-producing or extended
spectrum cephalosporin-resistant Enterobacteriaceae, select ‘Not applicable’.
Required. Select ‘Yes’ if the facility routinely (i.e., it is standard practice to

perform the testing when the targeted patient group is present) does
screening using either culture or non-culture based methods for CRE;
select no if either testing is not routinely performed or not performed at all.

If Yes, in which situations
does the facility routinely Conditionally Required. If ‘Yes’, select all the situations for which screening
perform screening testing
testing is done routinely.
for CRE? (check all that
. If ‘Other’ is selected, please specify the situation(s) in which CRE screening is
apply)
performed.

19. Does the facility routinely
perform screening testing
(culture or non-culture) for
MRSA?
If yes, in which situation
does the facility routinely
perform screening testing
for MRSA? (check all that
apply)

20. Does the facility routinely

use chlorhexidine bathing
on any patient to prevent
transmission of MDROs in
your facility? (Note: this

perform the testing when the targeted patient group is present) does
screening using either culture or non-culture based methods for MRSA;
select no if either testing is not routinely performed or not performed at all.
Conditionally required. If ‘Yes’, select all the situations for which
screening testing is done routinely. If ‘Other’ is selected, please specify the
situation(s) in which MRSA screening is performed.

Required. Select ‘Yes’ if your facility routinely uses chlorhexidine bathing on
any patient in any ward or unit as an intervention to prevent the transmission of
any MDRO. Please do not include the use of this agent in patients

undergoing surgery if the purpose is to prevent surgical site infections.
Select ‘No’ if this agent is not used routinely or is not used at all or if it is
does not include the use of only used to prevent surgical site infections in pre-operative patients.
chlorhexidine in preoperative patients to prevent
surgical site infections)

January 2015

Plan and Annual Surveys

January 2015

Plan and Annual Surveys

Infection Control Practices (continued)
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)

Required. Select ‘Yes’ if the combination of topical chlorhexidine and
intranasal mupirocin is used routinely (i.e., it is standard practice to use
these agents when the targeted patient group is present) on patients in the
facility specifically to prevent transmission of MRSA. Please do not
include the use of these agents in patients undergoing surgery if the
purpose is to prevent surgical site infections. Select ‘No’ if these combined
agents are not used routinely or are not used at all or if they are only used
to prevent surgical site infections in pre-operative patients.

22. Among patients with an
Required. Please select the most appropriate response that indicates
MDRO admitted to your
approximately how often your facility receives information from a transferring
facility from another
facility about the MDRO status of a patient known to be colonized or infected
healthcare facility, please
with an MDRO. If your facility does not receive transferred patients, or does not
estimate how often your
receive transferred patients with an MDRO, select ‘Not applicable’.
facility receives information
from the transferring facility
about the patient’s MDRO
status?
Antibiotic Stewardship Practices. Completion of this by section may require assistance from the pharmacy and/or
physicians who focus on Antibiotic Stewardship or Infectious Diseases, where available, and/or members of the
Pharmacy and Therapeutic Committee. Antibiotic Stewardship refers to a coordinated, multidisciplinary approach
to optimize and measure antibiotic use. For further information, refer to Core Elements of Hospital Antibiotic
Stewardship Programs (http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html). Questions
should be answered based on the policies and practices that were in place for the majority of the last full calendar
year.
23. Does your facility have a
Required. Select 'Yes' if there is written evidence of senior-level management
written statement of support support focused on antibiotic use prescribing (e.g., formal letter of support for
from leadership that
efforts to improve antibiotic use, written communication to hospital staff that
supports efforts to improve encourages optimal antibiotic prescribing, communication of support that reaches
antibiotic use (antibiotic
staff beyond those who receive executive-level meeting notes); otherwise, select
stewardship)?
'No'.
24. Is there a leader responsible Required. Select 'Yes' if any individual has been identified as a lead to antibiotic
for outcomes of stewardship stewardship activities as evidenced by responsibility for improving antibiotic use
activities at your facility?
in the job description or performance review, authority to coordinate activities of
staff from multiple departments (e.g. laboratory, pharmacy, information
technology), and/or responsibility to report to senior level management on
program planning and outcomes.
If Yes, what is the position
of this leader? (check one)
25. Is there at least one
pharmacist responsible for
improving antibiotic use at
your facility?

January 2015

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

Plan and Annual Surveys

26. Does your facility provide
any salary support for
dedicated time for antibiotic
stewardship activities?

January 2015

Plan and Annual Surveys

Antibiotic Stewardship Practices (continued)
27. Does your facility have a
Required. Select 'Yes' if your facility has a policy requiring documentation of
policy that requires
dose, duration and indication for all antibiotics in the medical record or during
prescribers to document an order entry; otherwise, select 'No'.
indication for all antibiotics
in the medical record or
during order entry?
If Yes, has adherence to the Conditionally Required. If ‘Yes’ to question 27, select ‘Yes’ if charts have been
policy to document an
audited to confirm documentation of dose, duration, and indication in patient
indication been monitored? medical records; otherwise, select ‘No’.
28. Does your facility have
Required. Select 'Yes' if there are facility-specific recommendations for antibiotic
facility-specific treatment
treatment selection based on national guidelines and local susceptibility reports
recommendations, based on for ANY common clinical conditions (e.g., community required pneumonia,
national guidelines and local urinary tract infections, or skin and soft tissue infections); otherwise, select 'No'.
susceptibility, to assist with
antibiotic selection for
common clinical conditions?
If Yes, has adherence to
facility-specific treatment
recommendations been
monitored?
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)?
30. Do any specified antibiotic
agents need to be approved
by a physician or pharmacist
prior to dispensing at your
facility?
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?

January 2015

Conditionally Required. If ‘Yes’ to question 28, select ‘Yes’ charts have been
audited to confirm adherence to facility-specific treatment guidelines for ANY of
the common clinical conditions listed above; otherwise, select ‘No’.
Required. Select 'Yes' if your facility has developed a standardized way for
clinicians on the treating team (or attending physician? or physician of record?) to
reassess the continuing need and choice of antibiotics at or after 48 hours after the
initial orders (to confirm indication, review microbiology results, and review
antibiotic choice, dose, and duration); otherwise, select 'No'.
Required. Select 'Yes' if your facility has at least one antibiotic agent that requires
a physician or pharmacist to review and approve administration of the drug due to
its spectrum of activity, cost, or associated toxicities; otherwise, select 'No'.

Required. Select 'Yes' if your facility had physicians or pharmacists
knowledgeable in antibiotic use, and not part of the treating team, review courses
of therapy for specified antibiotic agents and communicate the results to
prescribers (such as audit with feedback); otherwise, select 'No'.

Plan and Annual Surveys

Antibiotic Stewardship Practices (continued)
32. Does your facility monitor Required. Select 'Yes' if your facility monitors antibiotic use or consumption at
antibiotic use (consumption) the unit, service, and/or facility wide level at least quarterly; otherwise, select
at the unit, service, and/or 'No'.
facility wide?
If Yes, by which metrics
(Check all that apply)

If Yes, are facility- and/or
unit-specific reports on
antibiotic use shared with
prescribers?
33. Do prescribers ever receive
feedback by the stewardship
program about how they can
improve their antibiotic
prescribing?
34. Has your stewardship
program provided education
to clinicians and other
relevant staff on improving
antibiotic use?

January 2015

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

Plan and Annual Surveys

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

Facility Characteristics
Ownership (check one)

Affiliation (check one)

Setting/Classification:
If classified as “Free-standing”,
does your LTAC hospital share
physical housing with one or
more of the following on-site
facilities or units? (check all that
apply)

January 2015

Instructions for Form Completion
Required. The NHSN-assigned facility ID will be auto-entered by the computer.
Required. Select the calendar year for which this survey was completed.
The survey year should represent the last full calendar year. For example, in
2015, a facility would complete a 2014 survey.
Required. Select the appropriate ownership of this facility:
 For profit
 Not for profit, including church
 Government
 Veterans Affairs
Required. Select the appropriate affiliation for this facility:
 Independent – The facility is a stand-alone facility that does not share a
building, staff, or policies (such as infection control) with any other
healthcare institution.
 Hospital system – The facility is affiliated with a local healthcare system.
Facility shares policies (such as infection control) with other institutions
within the hospital system. Facility may or may not share staff as well as a
building with other facilities that are part of that hospital system.
 Multi-facility organization (specialty network) – The facility is part of a
regional or national network of specialty facilities. Facilities share policies
(such as infection control), corporate leadership, and a common business
structure.
Required. Select the physical setting of the facility: free-standing or within a
hospital.
Conditionally Required. If facility is classified as free-standing, select one or
more of the following facility or unit types that share physical housing with
your LTAC:
 No (none)
 Skilled nursing facility (SNF)/nursing home
 Residential facility (assisted living)
 Inpatient rehabilitation facility
 Neuro-behavioral unit or facility
 Other: specify

Plan and Annual Surveys

Facility Characteristics (continued)
If classified as “Within a
Conditionally Required. If facility is classified as within a hospital, indicate
hospital”, is your LTAC hospital ‘Yes’ or ‘No’ if it is:
located:
 In a building that does not provide acute care services (e.g., psychiatric
hospital)
 Near (but not within) an acute care hospital
Note: These questions are to clarify the physical set-up of each HOSP-LTAC.
All separately licensed LTAC hospitals should be enrolled within NHSN as a
separate LTAC facility type regardless of the physical setting of the facility.
Number of Patient Days
Required. Enter the total number of patient days for your hospital during the last
full calendar year.
Number of Admissions
Required. Enter the total number of inpatient admissions for your hospital during
the last full calendar year.
Average daily census
Required. Enter the average number of patients housed each day during the last
full calendar year. Please round to the nearest whole number.
Numbers of LTAC beds in the Required. Enter the total number of LTAC beds in each on the following
following categories (categories categories during the last full calendar year:
should equal total number of
 Intensive care unit (ICU) or critical care beds
beds)
 High observation/special care/high acuity beds (not ICU)
 Other LTAC beds
Total number of LTAC beds
Required. The total number of LTAC beds in the facility during the last full
(licensed capacity)
calendar year will be automatically summed based on the above counts.
Number of single occupancy
Required. Enter the total number of single occupancy rooms during the last full
rooms
calendar year.
Total number of admissions with Required. Enter the total number of admissions with one of the following
one of the following conditions conditions identified on admission (present on admission, not developing during
identified on admission (present LTAC stay): (Note: These categories are not mutually exclusive.)
on admission, not developing
 Ventilator dependence
during LTAC stay):
 Hemodialysis
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

January 2015

Plan and Annual Surveys

Facility Microbiology Laboratory Practices. Completion of this section requires the assistance from the
microbiology laboratory. Questions should be answered based on the testing methods that were used for the
majority of the last full calendar year.
35. Does your facility have its Required. Select 'Yes' if your laboratory performs antimicrobial susceptibility
own on-site laboratory that testing; otherwise, select 'No'.
performs antimicrobial
susceptibility testing?
If No, where is your
facility's antimicrobial
susceptibility testing
performed? (check one)

Conditionally Required. If ‘No’, select the location where your facility's
antimicrobial susceptibility testing is performed: Affiliated medical center,
Commercial referral laboratory, or Other local/regional, non-affiliated reference
laboratory. If multiple laboratories are used indicate the laboratory which
performs the majority of the bacterial susceptibility testing. You must complete
the remainder of this survey with assistance from your outside laboratory.
Required. Select 'Yes' if your laboratory uses CLSI antimicrobial susceptibility
standards; otherwise, select 'No'.

36. Does the laboratory use
CLSI (formerly NCCLS)
antimicrobial susceptibility
standards?
If Yes, specify which
Conditionally Required. If ‘Yes’, specify the version used by your laboratory or
version of the M100
the referral laboratory during the prior calendar year.
document that the laboratory
used during the prior
calendar year.
37. For the following organisms Required. Select from the choices listed the appropriate (1) primary susceptibility
please indicate which
testing and (2) secondary, supplemental, or confirmatory testing method (if
methods are used for (1)
performed) for each organism.
primary susceptibility
testing and (2) secondary, Note: Repeat tests using the primary method should not be indicated as secondary
supplemental, or
methods; instead indicate in the ‘Comments’ column the number of times repeat
confirmatory testing (if
testing is done using the same primary method.
performed)
If your laboratory does not perform susceptibility testing, please indicate the
methods used at the referral laboratory. If ‘Other’ is selected as the method for any
pathogen, use the ‘Comments’ column to describe the method used.
38. Has the laboratory
Required. Select 'Yes' if your laboratory has implemented the revised
implemented the revised
cephalosporin and monobactam breakpoints for Enterobacteriaceae recommended
cephalosporin and
by CLSI as of 2010; otherwise, select 'No'.
monobactam breakpoints for
Enterobacteriaceae
recommended by CLSI as of
2010?
39. Has the laboratory
Required. Select 'Yes' if your laboratory has implemented the revised carbapenem
implemented the revised
breakpoints for Enterobacteriaceae recommended by CLSI as of 2010; otherwise,
carbapenem breakpoints for select 'No'.
Enterobacteriaceae
recommended by CLSI as of
2010?
January 2015

Plan and Annual Surveys

Facility Microbiology Laboratory Practices (continued)
40. Does the laboratory
perform a special test for
carbapenemase
production? If Yes, please
indicate what is done if
carbapenemase production
is detected (check one).
If Yes, which test is
routinely performed to
detect carbapenemase
(check all that apply)?
41. Does the laboratory
perform colistin or
polymyxin B susceptibility
testing for drug-resistant
gram negative bacilli?
If Yes, indicate methods
(check all that apply).

Required. Select 'Yes' if your laboratory performs a special test for
carbapenemase production; otherwise, select 'No'.
Conditionally Required. If ‘Yes’, specify what is done if carbapenemase
production is detected.

Conditionally Required. If ‘Yes’, specify which test is performed to detect
carbapenemase.
Required. Select 'Yes' if your laboratory performs colistin or polymyxin B
susceptibility testing for drug-resistant gram negative bacilli; otherwise, select
'No'.

Conditionally Required. If ‘Yes’, select the method(s) used from the choices
provided. If ‘Other’ is selected, please specify.
42. Does your facility have its Required. Select 'Yes' if your laboratory performs antifungal susceptibility
own laboratory that
testing for Candida species; otherwise, select 'No'.
performs antifungal
susceptibility testing for
Candida species?
If No, where your facility's Conditionally Required. If ‘No”, select one of the choices provided.
antifungal susceptibility
testing is performed?
(check one).
43. If antifungal susceptibility Conditionally Required. Select from the choices listed the method(s) of
testing is performed at your antifungal susceptibility testing performed at your facility or an outside
facility or an outside
laboratory. If ‘Other’ is selected, please specify.
laboratory, what methods
are used? (check all that
apply)
44. Is antifungal susceptibility Required. Select 'Yes' if your laboratory or outside laboratory
testing performed
automatically/reflexively performs antifungal susceptibility testing for
automatically/reflexively Candida species which are from normally sterile body sites (such as blood),
for Candida spp. cultured without needing a specific order or request for susceptibility testing from the
from normally sterile body clinician; otherwise, select 'No'.
sites (such as blood),
without needing a specific
order or request for
susceptibility testing from
the clinician?
Conditionally Required. If ‘Yes’, select from the choices listed the antifungal
If Yes, what antifungal
drugs which are tested automatically/reflexively. If ‘Other’ is selected, please
drugs are tested
specify.
automatically/reflexively?
(check all that apply)
January 2015

Plan and Annual Surveys

Facility Microbiology Laboratory Practices (continued)
45. What is the primary testing Required. Select from the choices listed the testing methods used to perform C.
method for C. difficile used difficile testing by your facility’s laboratory or the outside laboratory where your
most often by your
facility’s testing is done. If ‘Other’ is selected, please specify.
facility’s laboratory or the
outside laboratory where Note: “Other” should not be used to name specific laboratories, reference
your facility’s testing is
laboratories, or the brand names of C. difficile tests; most methods can be
performed? (check one)
categorized accurately by selecting from the options provided. Please ask your
laboratory or conduct a search for further guidance on selecting the correct option
to report.
46. Does your facility produce Required. Select ‘Yes’ if your facility produces an antibiogram; otherwise select
an antibiogram (i.e.,
‘No’.
cumulative antimicrobial
susceptibility report)?
If Yes, is the antibiogram Conditionally Required. If ‘Yes’, indicate whether the antibiogram is produced at
produced at least annually? least annually.
If Yes, are data stratified Conditionally Required. If ‘Yes’, indicate whether antibiogram data are stratified
by hospital location?
by hospital location.
If No, please identify any Conditionally Required. If ‘No’, indicate the obstacle(s) to producing an
obstacle(s) to producing an antibiogram at your facility. If ‘Other’ is selected, please specify.
antibiogram. (Check all
that apply)
Infection Control Practices. Completion of this section may require assistance from the Infection Preventionist,
Hospital Epidemiologist, other infection control personnel, and/or Quality Improvement Coordinator. Questions
should be answered based on the policies and practices that were in place for the majority of the last full calendar
year.
47. Number of trained or
Required. Enter the number of individuals (full-time employees) who work in the
certified infection
infection prevention department of the hospital as infection prevention
preventionists (IPs) in
professionals. Certification in infection control, the CIC credential, is not required
facility
to be considered an “IP” on this survey.
c. Total hours per week Enter the number of hours per week engaged in activities designed to find and
performing
report healthcare-associated infections (in the hospital) and the appropriate
surveillance
denominators. Total should include time to analyze data and disseminate results.
d. Total hours per week Enter the number of hours per week spent on infection prevention and control
for infection control
activities other than surveillance. These activities include, but are not limited to,
activities other than
education, prevention, meetings, etc.
surveillance
Infection Control Practices (continued)
For detailed description about the use of Contact Precautions, please refer to the CDC/HICPAC 2007 Guideline
for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
(http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf).

January 2015

Plan and Annual Surveys

48. Does the facility routinely
place patients infected or
colonized with MRSA in
contact precautions when
these patients are admitted?
(check one)
49. Does the facility routinely
place patients infected or
colonized with VRE in
contact precautions when
these patients are admitted?
(check one)
50. Does the facility routinely
place patients infected or
colonized with CRE in
contact precautions when
these patients are admitted?
(check one)
51. Does the facility routinely
place patients infected or
colonized with ESBLproducing or extended
spectrum cephalosporin
resistant Enterobacteriaceae
in contact precautions when
these patients are admitted?
(check one)
52. Does the facility routinely
perform screening testing
(culture or non-culture) for
CRE?
If Yes, in which situations
does the facility routinely
perform screening testing
for CRE? (check all that
apply)

Required. Select ‘No’ if your facility does not routinely place any patient infected
or colonized with MRSA in Contact Precautions; otherwise, select the single best
choice from the choices listed that most accurately describes the primary
indication for placing admitted patients with MRSA on Contact Precautions at
your facility. If your facility never admits patients with MRSA, select ‘Not
applicable’.
Required. Select ‘No’ if your facility does not routinely place any patient infected
or colonized with VRE in Contact Precautions; otherwise, select the single best
choice from the choices listed that most accurately describes the primary
indication for placing admitted patients with VRE on Contact Precautions at your
facility. If your facility never admits patients with VRE, select ‘Not applicable’.
Required. Select ‘No’ if your facility does not routinely place any patient infected
or colonized with CRE in Contact Precautions; otherwise, select the single best
choice from the choices listed that most accurately describes the primary
indication for placing admitted patients with CRE on Contact Precautions at your
facility. If your facility never admits patients with CRE, select ‘Not applicable’.
Required. Select ‘No’ if your facility does not routinely place any patient infected
or colonized with ESBL-producing or extended spectrum cephalosporin-resistant
Enterobacteriaceae in Contact Precautions; otherwise, select the single best choice
from the choices listed that most accurately describes the primary indication for
placing admitted patients with ESBL-producing or extended spectrum
cephalosporin-resistant Enterobacteriaceae on Contact Precautions at your facility.
If your facility never admits patients with ESBL-producing or extended spectrum
cephalosporin-resistant Enterobacteriacae, select ‘Not applicable’.
Required. Select ‘Yes’ if the facility routinely (i.e., it is standard practice to
perform the testing when the targeted patient group is present) does screening
using either culture or non-culture based methods for CRE; select no if either
testing is not routinely performed or not performed at all.
Conditionally Required. If ‘Yes’, select all the situations for which screening
testing is done routinely. If ‘Other’ is selected, please specify the situation(s) in
which CRE screening is performed.

Note: ‘Epidemiologically-linked’ patients refer to contacts of the patient with
newly identified CRE. This might include current or prior roommates or patients
who shared the same healthcare personnel or patients who are located on the same
unit or ward.
53. Does the facility routinely Required. Select ‘Yes’ if the facility routinely (i.e., it is standard practice to
perform screening testing
perform the testing when the targeted patient group is present) does screening
(culture or non-culture) for using either culture or non-culture based methods for MRSA; select no if either
MRSA?
testing is not routinely performed or not performed at all.

If yes, in which situation Conditionally Required. If ‘Yes’, select all the situations for which screening
does the facility routinely testing is done routinely. If ‘Other’ is selected, please specify the situation(s) in
perform screening testing which MRSA screening is performed.
January 2015

Plan and Annual Surveys

for MRSA? (check all that
apply)
54. Does the facility routinely Required. Select ‘Yes’ if your facility routinely uses chlorhexidine bathing on
use chlorhexidine bathing on any patient in any ward or unit as an intervention to prevent the transmission of
any patient to prevent
any MDRO. Please do not include the use of this agent in patients undergoing
transmission of MDROs in surgery if the purpose is to prevent surgical site infections. Select ‘No’ if this
your facility? (Note: this
agent is not used routinely or is not used at all or if it is only used to prevent
does not include the use of surgical site infections in pre-operative patients.
chlorhexidine in preoperative patients to prevent
surgical site infections)

Infection Control Practices (continued)
55. Does the facility routinely Required. Select ‘Yes’ if the combination of topical chlorhexidine and intranasal
use topical chlorhexidine
mupirocin is used routinely (i.e., it is standard practice to use these agents when
and intranasal mupirocin on the targeted patient group is present) on patients in the facility specifically to
any patients to prevent
prevent the transmission of MRSA. Please do not include the use of these agents
transmission of MRSA in in patients undergoing surgery if the purpose is to prevent surgical site infections.
the facility? (Note: this does Select ‘No’ if these combined agents are not used routinely or are not used at all
not include the use of these or if they are only used to prevent surgical site infections in pre-operative patients.
agents in pre-operative
patients to prevent surgical
site infections)
56. Among patients with an
Required. Please select the most appropriate response that indicates approximately
MDRO admitted to your
how often your facility receives information from a transferring facility about the
facility from another
MDRO status of a patient known to be colonized or infected with an MDRO. If
healthcare facility, please
your facility does not receive transferred patients, or does not receive transferred
estimate how often your
patients with an MDRO, select ‘Not applicable’.
facility receives information
from the transferring facility
about the patient’s MDRO
status?
Antibiotic Stewardship Practices. Completion of this by section may require assistance from the pharmacy and/or
physicians who focus on Antibiotic Stewardship or Infectious Diseases, where available, and/or members of the
Pharmacy and Therapeutic Committee. Antibiotic Stewardship refers to a coordinated, multidisciplinary approach
to optimize and measure antibiotic use. For further information, refer to Core Elements of Hospital Antibiotic
Stewardship Programs (http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html). Questions
should be answered based on the policies and practices that were in place for the majority of the last full calendar
year.
57. Does your facility have a
Required. Select 'Yes' if there is written evidence of senior-level management
written statement of support support focused on antibiotic use prescribing (e.g., formal letter of support for
from leadership that
efforts to improve antibiotic use, written communication to hospital staff that
supports efforts to improve encourages optimal antibiotic prescribing, communication of support that reaches
January 2015

Plan and Annual Surveys

antibiotic use (antibiotic
stewardship)?

January 2015

staff beyond those who receive executive-level meeting notes); otherwise, select
'No'.

Plan and Annual Surveys

Antibiotic Stewardship Practices (continued)
58. Is there a leader responsible Required. Select 'Yes' if any individual has been identified as a lead to antibiotic
for outcomes of stewardship stewardship activities as evidenced by responsibility for improving antibiotic use
activities at your facility?
in the job description or performance review, authority to coordinate activities of
staff from multiple departments (e.g. laboratory, pharmacy, information
technology), and/or responsibility to report to senior level management on
program planning and outcomes.
If Yes, what is the position
of this leader? (check one)
59. Is there at least one
pharmacist responsible for
improving antibiotic use at
your facility?
60. Does your facility provide
any salary support for
dedicated time for antibiotic
stewardship activities?
61. Does your facility have a
policy that requires
prescribers to document an
indication for all antibiotics
in the medical record or
during order entry?

Conditionally Required. If ‘Yes’, specify the qualification or job title of the
leader(s). If ‘Other’ is selected, please specify the position.
Required. Select 'Yes' if your facility has at least one pharmacist who dedicates
time distinct from general pharmacy duties to educate staff, and track or monitor
antibiotic use to ensure optimal prescribing practices; otherwise, select 'No'.
Required. Select 'Yes' if any individual was given salary support at least 4 hours
per week (0.1 full-time employees) to engage in duties to improve or monitor
antibiotic use that are not part of their general clinical duties; otherwise, select
'No'.
Required. Select 'Yes' if your facility has a policy requiring documentation of
dose, duration and indication for all antibiotics in the medical record or during
order entry; otherwise, select 'No'.

January 2015

Conditionally Required. If ‘Yes’ to question 29, select ‘Yes’ charts have been
audited to confirm adherence to facility-specific treatment guidelines for ANY of
the common clinical conditions listed above; otherwise, select ‘No’.
Required. Select 'Yes' if your facility has developed a standardized way for
clinicians on the treating team (or attending physician? or physician of record?) to
reassess the continuing need and choice of antibiotics at or after 48 hours after the
initial orders (to confirm indication, review microbiology results, and review
antibiotic choice, dose, and duration); otherwise, select 'No'.

Plan and Annual Surveys

Antibiotic Stewardship Practices (continued)
64. Do any specified antibiotic Required. Select 'Yes' if your facility has at least one antibiotic agent that requires
agents need to be approved a physician or pharmacist to review and approve administration of the drug due to
by a physician or pharmacist its spectrum of activity, cost, or associated toxicities; otherwise, select 'No'.
prior to dispensing at your
facility?
65. Does a physician or
Required. Select 'Yes' if your facility had physicians or pharmacists
pharmacist review courses knowledgeable in antibiotic use, and not part of the treating team, review courses
of therapy for specified
of therapy for specified antibiotic agents and communicate the results to
antibiotic agents and
prescribers (such as audit with feedback); otherwise, select 'No'.
communicate results with
prescribers (i.e., audit with
feedback) at your facility?
66. Does your facility monitor Required. Select 'Yes' if your facility monitors antibiotic use or consumption at
antibiotic use (consumption) the unit, service, and/or facility wide level at least quarterly; otherwise, select 'No'.
at the unit, service, and/or
facility wide?
If Yes, by which metrics?
(Check all that apply)

If Yes, are facility- and/or
unit-specific reports on
antibiotic use shared with
prescribers?
67. Do prescribers ever receive
feedback by the stewardship
program about how they can
improve their antibiotic
prescribing?
68. Has your stewardship
program provided education
to clinicians and other
relevant staff on improving
antibiotic use?

January 2015

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

Plan and Annual Surveys

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

Facility Characteristics
Ownership (check one)

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

January 2015

Plan and Annual Surveys

Number of patient days

Required. Enter the total number of patient days for your facility during the last
full calendar year.

Facility Characteristics (continued)
Average length of stay

Required. Enter the average length of stay of patients in your inpatient
rehabilitation facility during the last full calendar year. Please round to the nearest
whole number.
Indicate the number of
Required. For your inpatient rehabilitation facility during the last full calendar
admissions with the primary
year, enter the number of admissions with the primary diagnosis for each of the
diagnosis for each of the
categories listed.
following rehabilitation
 Traumatic spinal cord dysfunction
categories (must sum to the total  Non-traumatic spinal cord dysfunction
number of admissions listed
 Stroke
below)
 Brain dysfunction (non-traumatic or traumatic)
 Other neurologic conditions (e.g. multiple sclerosis, Parkinson’s disease, etc)
 Orthopedic conditions (incl. fracture, joint replacement, other)
 All other admissions
Total number of admissions
Required. The total number of admissions will be automatically summed from the
categories above.
Additionally, enter the total number of admissions that were patients on a
ventilator as well as the number that were pediatric admissions.
Facility Microbiology Laboratory Practices. Completion of this section requires the assistance from the
microbiology laboratory. Questions should be answered based on the testing methods that were used for the
majority of the last full calendar year.
69. Does your facility have its Required. Select 'Yes' if your laboratory performs antimicrobial susceptibility
own on-site laboratory that testing; otherwise, select 'No'.
performs antimicrobial
susceptibility testing?
If No, where is your
facility's antimicrobial
susceptibility testing
performed? (check one)

70. Does the laboratory use
CLSI (formerly NCCLS)
antimicrobial susceptibility
standards?
If Yes, specify which
Conditionally Required. If ‘Yes’, specify the version used by your laboratory or
version of the M100
the referral laboratory during the prior calendar year.
document that the laboratory
used during the prior
calendar year (i.e. the survey
year).

January 2015

Plan and Annual Surveys

Facility Microbiology Laboratory Practices (continued)
71. For the following organisms
please indicate which
methods are used for (1)
primary susceptibility
testing and (2) secondary,
supplemental, or
confirmatory testing (if
performed)

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

January 2015

Plan and Annual Surveys

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

January 2015

Plan and Annual Surveys

Facility Microbiology Laboratory Practices (continued)
80. Does your facility produce Required. Select ‘Yes’ if your facility produces an antibiogram; otherwise select
an antibiogram (i.e.,
‘No’.
cumulative antimicrobial
susceptibility report)?
If Yes, is the antibiogram
Conditionally Required. If ‘Yes’, indicate whether the antibiogram is produced at
produced at least annually? least annually.
If Yes, are data stratified by Conditionally Required. If ‘Yes’, indicate whether antibiogram data are stratified
hospital location?
by hospital location.
If No, please identify any
Conditionally Required. If ‘No’, indicate the obstacle(s) to producing an
obstacle(s) to producing an antibiogram at your facility. If ‘Other’ is selected, please specify.
antibiogram. (Check all that
apply)
Infection Control Practices. Completion of this section may require assistance from the Infection Preventionist,
Hospital Epidemiologist, other infection control personnel, and/or Quality Improvement Coordinator. Questions
should be answered based on the policies and practices that were in place for the majority of the last full calendar
year.
81. Number of trained or
Required. Enter the number of individuals (full-time employees) who work in the
certified infection
infection prevention department of the hospital as infection prevention
preventionists (IPs) in
professionals. Certification in infection control, the CIC credential, is not required
facility
to be considered an “IP” on this survey.
e. Total hours per week
Enter the number of hours per week engaged in activities designed to find and
performing surveillance report healthcare-associated infections (in the hospital) and the appropriate
denominators. Total should include time to analyze data and disseminate results.
f. Total hours per week for Enter the number of hours per week spent on infection prevention and control
infection control
activities other than surveillance. These activities include, but are not limited to,
activities other than
education, prevention, meetings, etc.
surveillance
For detailed description about the use of Contact Precautions, please refer to the CDC/HICPAC 2007 Guideline
for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
(http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf).
82. Does the facility routinely Required. Select ‘No’ if your facility does not routinely place any patient infected
place patients infected or
or colonized with MRSA in Contact Precautions; otherwise, select the single best
colonized with MRSA in
choice from the choices listed that most accurately describes the primary
contact precautions when
indication for placing admitted patients with MRSA on Contact Precautions at
these patients are admitted? your facility. If your facility never admits patients with MRSA, select ‘Not
(check one)
applicable’.
Infection Control Practices (continued)
83. Does the facility routinely
place patients infected or
colonized with VRE in
contact precautions when
these patients are admitted?
(check one)

January 2015

Required. Select ‘No’ if your facility does not routinely place any patient infected
or colonized with VRE in Contact Precautions; otherwise, select the single best
choice from the choices listed that most accurately describes the primary
indication for placing admitted patients with VRE on Contact Precautions at your
facility. If your facility never admits patients with VRE, select ‘Not applicable’.

Plan and Annual Surveys

84. Does the facility routinely
place patients infected or
colonized with CRE in
contact precautions when
these patients are admitted?
(check one)
85. Does the facility routinely
place patients infected or
colonized with ESBLproducing or extended
spectrum cephalosporin
resistant Enterobacteriaceae
in contact precautions when
these patients are admitted?
(check one)
86. Does the facility routinely
perform screening testing
(culture or non-culture) for
CRE?

Required. Select ‘No’ if your facility does not routinely place any patient infected
or colonized with CRE in Contact Precautions; otherwise, select the single best
choice from the choices listed that most accurately describes the primary
indication for placing admitted patients with CRE on Contact Precautions at your
facility. If your facility never admits patients with CRE, select ‘Not applicable’.
Required. Select ‘No’ if your facility does not routinely place any patient infected
or colonized with ESBL-producing or extended spectrum cephalosporin-resistant
Enterobacteriaceae in Contact Precautions; otherwise, select the single best choice
from the choices listed that most accurately describes the primary indication for
placing admitted patients with ESBL-producing or extended spectrum
cephalosporin-resistant Enterobacteriaceae on Contact Precautions at your facility.
If your facility never admits patients with ESBL-producing or extended spectrum
cephalosporin-resistant Enterobacteriacae, select ‘Not applicable’.
Required. Select ‘Yes’ if your facility routinely (i.e., it is standard practice to
perform the testing when the targeted patient group is present) does screening
using either culture or non-culture based methods for CRE; select no if either
testing is not routinely performed or not performed at all.

If Yes, in which situations
does the facility routinely Conditionally required. If ‘Yes’, select all the situations for which screening
perform screening testing testing is done routinely. If ‘Other’ is selected, please specify the situation(s) in
for CRE? (check all that
which CRE screening is performed.
apply)
Note: ‘Epidemiologically-linked’ patients refer to contacts of the patient with
newly identified CRE. This might include current or prior roommates or patients
who shared the same healthcare personnel or patients who are located on the same
unit or ward.
87. Does the facility routinely Required. Select ‘Yes’ if your facility routinely (i.e., it is standard practice to
perform screening testing
perform the testing when the targeted patient group is present) does screening
(culture or non-culture) for using either culture or non-culture based methods for MRSA; select no if either
MRSA?
testing is not routinely performed or not performed at all.

If yes, in which situation
does the facility routinely Conditionally required. If ‘Yes’, select all the situations for which screening
perform screening testing testing is done routinely. If ‘Other’ is selected, please specify the situation(s) in
for MRSA? (check all that which MRSA screening is performed.
apply)
88. Does the facility routinely Required. Select ‘Yes’ if your facility routinely uses chlorhexidine bathing on
use chlorhexidine bathing on any patient in any ward or unit as an intervention to prevent the transmission of
any patient to prevent
any MDRO; otherwise, select ‘No’. Please do not include the use of this agent in
transmission of MDROs in patients undergoing surgery if the purpose is to prevent surgical site infections.
your hospital? (Note: this
Select ‘No’ if this agent is not used routinely or is not used at all or if it is only
does not include the use of used to prevent surgical site infections in pre-operative patients.
chlorhexidine in pre-

January 2015

Plan and Annual Surveys

operative patients to prevent
surgical site infections)
Infection Control Practices (continued)
89. Does the facility routinely Required. Select ‘Yes’ if the combination of topical chlorhexidine and intranasal
use topical chlorhexidine
mupirocin is used routinely (i.e., it is standard practice to use these agents when
and intranasal mupirocin on the targeted patient group is present) on patients in the facility specifically to
any patients to prevent
prevent transmission of MRSA. Please do not include the use of these agents in
transmission of MRSA in patients undergoing surgery if the purpose is to prevent surgical site infections.
the facility? (Note: this does Select ‘No’ if these combined agents are not used routinely or are not used at all
not include the use of these or if they are only used to prevent surgical site infections in pre-operative patients.
agents in pre-operative
patients to prevent surgical
site infections)
90. Among patients with an
Required. Please select the most appropriate response that indicates approximately
MDRO admitted to your
how often your facility receives information from a transferring facility about the
facility from another
MDRO status of a patient known to be colonized or infected with an MDRO. If
healthcare facility, please
your facility does not receive transferred patients, or does not receive transferred
estimate how often your
patients with an MDRO, select ‘Not applicable’.
facility receives information
from the transferring facility
about the patient’s MDRO
status?
Antibiotic Stewardship Practices. Completion of this by section may require assistance from the pharmacy and/or
physicians who focus on Antibiotic Stewardship or Infectious Diseases, where available, and/or members of the
Pharmacy and Therapeutic Committee. Antibiotic Stewardship refers to a coordinated, multidisciplinary approach
to optimize and measure antibiotic use. For further information, refer to Core Elements of Hospital Antibiotic
Stewardship Programs (http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html). Questions
should be answered based on the policies and practices that were in place for the majority of the last full calendar
year.
91. Does your facility have a
Required. Select 'Yes' if there is written evidence of senior-level management
written statement of support support focused on antibiotic use prescribing (e.g., formal letter of support for
from leadership that
efforts to improve antibiotic use, written communication to hospital staff that
supports efforts to improve encourages optimal antibiotic prescribing, communication of support that reaches
antibiotic use (antibiotic
staff beyond those who receive executive-level meeting notes); otherwise, select
stewardship)?
'No'.
92. Is there a leader responsible Required. Select 'Yes' if any individual has been identified as a lead to antibiotic
for outcomes of stewardship stewardship activities as evidenced by responsibility for improving antibiotic use
activities at your facility?
in the job description or performance review, authority to coordinate activities of
staff from multiple departments (e.g. laboratory, pharmacy, information
technology), and/or responsibility to report to senior level management on
program planning and outcomes.
If Yes, what is the position
of this leader? (check one)

January 2015

Conditionally Required. If ‘Yes’, specify the qualification or job title of the
leader(s). If ‘Other’ is selected, please specify the position.

Plan and Annual Surveys

93. Is there at least one
pharmacist responsible for
improving antibiotic use at
your facility?

January 2015

Required. Select 'Yes' if your facility has at least one pharmacist who dedicates
time distinct from general pharmacy duties to educate staff, and track or monitor
antibiotic use to ensure optimal prescribing practices; otherwise, select 'No'.

Plan and Annual Surveys

Antibiotic Stewardship Practices (continued)
94. Does your facility provide
any salary support for
dedicated time for antibiotic
stewardship activities?
95. Does your facility have a
policy that requires
prescribers to document an
indication for all antibiotics
in the medical record or
during order entry?

Required. Select 'Yes' if any individual was given salary support at least 4 hours
per week (0.1 full-time employees) to engage in duties to improve or monitor
antibiotic use that are not part of their general clinical duties; otherwise, select
'No'.
Required. Select 'Yes' if your facility has a policy requiring documentation of
dose, duration and indication for all antibiotics in the medical record or during
order entry; otherwise, select 'No'.

If Yes, has adherence to the Conditionally Required. If ‘Yes’ to question 28, select ‘Yes’ if charts have been
policy to document an
audited to confirm documentation of dose, duration, and indication in patient
indication been monitored? medical records; otherwise, select ‘No’.
96. Does your facility have
Required. Select 'Yes' if there are facility-specific recommendations for antibiotic
facility-specific treatment treatment selection based on national guidelines and local susceptibility reports
recommendations, based on for ANY common clinical conditions (e.g., community required pneumonia,
national guidelines and local urinary tract infections, or skin and soft tissue infections); otherwise, select 'No'.
susceptibility, to assist with
antibiotic selection for
common clinical conditions?
If Yes, has adherence to
Conditionally Required. If ‘Yes’ to question 29, select ‘Yes’ charts have been
facility-specific treatment audited to confirm adherence to facility-specific treatment guidelines for ANY of
recommendations been
the common clinical conditions listed above; otherwise, select ‘No’.
monitored?
97. Is there a formal procedure Required. Select 'Yes' if your facility has developed a standardized way for
for all clinicians to review clinicians on the treating team (or attending physician? or physician of record?) to
the appropriateness of all
reassess the continuing need and choice of antibiotics at or after 48 hours after the
antibiotics at or after 48
initial orders (to confirm indication, review microbiology results, and review
hours from the initial orders antibiotic choice, dose, and duration); otherwise, select 'No'.
(e.g. antibiotic time out)?
98. Do any specified antibiotic Required. Select 'Yes' if your facility has at least one antibiotic agent that requires
agents need to be approved a physician or pharmacist to review and approve administration of the drug due to
by a physician or pharmacist its spectrum of activity, cost, or associated toxicities; otherwise, select 'No'.
prior to dispensing at your
facility?
99. Does a physician or
Required. Select 'Yes' if your facility had physicians or pharmacists
pharmacist review courses knowledgeable in antibiotic use, and not part of the treating team, review courses
of therapy for specified
of therapy for specified antibiotic agents and communicate the results to
antibiotic agents and
prescribers (such as audit with feedback); otherwise, select 'No'.
communicate results with
prescribers (i.e., audit with
feedback) at your facility?

January 2015

Plan and Annual Surveys

Antibiotic Stewardship Practices (continued)
100. Does your facility
Required. Select 'Yes' if your facility monitors antibiotic use or consumption at
monitor antibiotic use
the unit, service, and/or facility wide level at least quarterly; otherwise, select 'No'.
(consumption) at the unit,
service, and/or facility wide?
If Yes, by which metrics?
(Check all that apply)

If Yes, are facility- and/or
unit-specific reports on
antibiotic use shared with
prescribers?
101. Do prescribers ever
receive feedback by the
stewardship program about
how they can improve their
antibiotic prescribing?
102. Has your stewardship
program provided education
to clinicians and other
relevant staff on improving
antibiotic use?

January 2015

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

Plan and Annual Surveys

Instructions for the Outpatient Dialysis Center Practices Survey
(CDC 57.500)
A complete survey is an annual reporting requirement specified in the NHSN Dialysis Event
Protocol. Users cannot create Monthly Reporting Plans or submit monthly data for May through
December until a survey for that year is completed.
Print a blank survey from:
http://www.cdc.gov/nhsn/forms/57.104_PSOutpatientDialysisSurv_BLANK.pdf
A worksheet is available to calculate answers for patient- and staff-specific questions. Click here to
access the worksheet: http://www.....
Complete one survey per center. Surveys are completed for the current year. It is strongly
recommended that the survey is completed in February of each year by someone who works in
the center and is familiar with current practices within the center. Complete the survey based on
the actual practices at the center, not necessarily the center policy, if there are differences.
Survey Question
Facility ID #
Survey Year

Instructions for Data Collection
The NHSN-assigned facility ID will auto-populate in this field.
Required. Enter the 4-digit year that the data were collected for this
facility. (format: YYYY)
ESRD Network #
Required. Enter the 2-digit ESRD Network number that your facility is
part of.
A.
Dialysis Center Information
A.1. General
1.
Ownership
Required. Select the ownership of your dialysis center (Choose one
option only):




Location/Hospital
affiliation

Required. Select the location/hospital affiliation of your dialysis center (Choose
one option only):

o
o
o

January 2015

Government
Not for profit
For profit

Freestanding: the dialysis center is not hospital affiliated.
Hospital based: the dialysis center is affiliated with a hospital and the
building is attached to, or part of, the hospital.
Freestanding, but owned by a hospital: the dialysis center is affiliated
with a hospital, but the building is not attached to the hospital.

Plan and Annual Surveys

Survey Question
3.a. Dialysis services

Instructions for Data Collection
Required. Indicate all dialysis service types that are offered by your
facility (Select all that apply):
o
o
o
o

In-center daytime hemodialysis
In-center nocturnal hemodialysis
Peritoneal dialysis
Home hemodialysis (includes home, home-assisted, and NxStage®1
patients)

3.b. Patient population Required. Indicate what patient population your center serves.




Hemodialysis
Stations

Group/chain

a. Group/chain
name
6.

Data collector

Adult only
Pediatric only
Mixed: adult and pediatric

Conditionally required if for question 3, “in-center hemodialysis” was
selected. Enter the number of useable in-center hemodialysis stations
in your facility.
Required. Select “Yes” if your facility is part of a group or chain of
dialysis centers.
Select “No” if your facility is not owned by a group or chain of dialysis
centers.
Conditionally required. Enter the name of the dialysis facility group or
chain. If owned and managed by two different groups, then indicate the
managing company.
Required. Select “Yes” if the person who is primarily responsible for
collecting the NHSN survey data performs patient care in the facility.
Select “No” if the person who is primarily responsible for collecting
these survey data does not perform patient care in the facility.
Required. Select “Yes” if there is at least one person at your dialysis
center who is designated in charge of infection control. Select “No” if no
one at your dialysis center is designated in charge of infection control.
Conditionally required. Select all the description(s) that best describe
the person(s) in charge of infection control in your dialysis facility.

Person in charge
of infection
control
a. Person in
charge of infection
control
description
8.
Vascular access
Required. Select “Yes” if there is a dedicated vascular access nurse or
nurse/coordinator coordinator, either full or part-time, at your facility. Select “No” if there
is no dedicated vascular access nurse or coordinator.
A.2. Isolation and Screening

Use of trade names and commercial sources is for identification only and does not imply endorsement.

January 2015

Plan and Annual Surveys

Survey Question
9.
Capacity to isolate
hepatitis B
patients

10. Conditions
isolated/cohorted

11. TB screening

A.3. Patient Records
12. Station
assignment
13. Machine
assignment
14. BSI
hospitalizations

15. Hospital lab
records

January 2015

Instructions for Data Collection
Required. Select “Yes, use hepatitis B isolation room” if a separate
room exists where patients positive for hepatitis B virus infection
receive hemodialysis. Select “Yes, use hepatitis B isolation area” if a
specific section of the hemodialysis clinic is designated as an area for
patients positive for hepatitis B virus infection to receive hemodialysis.
Select “No hepatitis B isolation” if your facility does not have the
capacity to isolate patients who are positive for hepatitis B virus
infection.
Required. Select all of the conditions for which patients are routinely
isolated or cohorted for treatment within your facility.
 Select only those conditions that are admitted and isolated by
your facility. If your facility would refer the patient with the
condition (e.g., Active tuberculosis [TB disease]) elsewhere for
dialysis, do not select that condition on the survey.
 Select only those conditions for which all patients that are
positive for the condition are isolated. If additional criteria are
used to isolate some positive patients (e.g., active diarrhea,
draining wound), but not all, do not select this condition for the
survey.
If none of the conditions listed are routinely isolated or cohorted for
treatment within your facility, select “No - None.”
Required. Select “Yes” if your center routinely screens patients for
latent tuberculosis infection (LTBI) upon admission. Select “No” if
patients are not routinely screened for TB upon admission.
Required. Select “Yes” if your facility maintains records of patients’
hemodialysis station assignment. Select “No” if these records are not
maintained.
Required. Select “Yes” if your facility maintains records of patients’
hemodialysis machine assignment. Select “No” if these records are not
maintained.
Required. Following a hospitalization, indicate the frequency with
which your facility is able to determine whether a bloodstream
infection contributed to the patient’s hospital admission. Select “N/A –
not pursued” only if your facility does not routinely try to determine
the cause of hospitalizations.
Required. Following a hospitalization, indicate the frequency with
which your facility is able to obtain the patient’s hospital microbiology
lab records. Select “N/A – not pursued” only if your facility does not
routinely request microbiology lab records after a patient is
hospitalized.
13

Plan and Annual Surveys

Survey Question
Instructions for Data Collection
B. Patient and staff census
16. Operational
Required. Select “Yes” if your facility was open for hemodialysis
during first week
treatment during the first week of February (the first seven calendar
of February
days of the month) of the survey year.
Select “No” if your facility was closed for hemodialysis treatment
during the first week of February of the survey year.


17. Number of
dialysis patients in
1st week of
February

a. In-center
hemodialysis

b. Home
hemodialysis

c. Peritoneal
dialysis.

If you select “No,” proceed to answer subsequent questions about the
first week of February and enter zeros for quantitative questions.

Required. Indicate the total number of all the maintenance, nontransient, dialysis patients assigned to your facility during the first
week of February (the first seven calendar days of the month) of the
survey year (include in-center hemodialysis, home hemodialysis, and
peritoneal dialysis patients). The sum of 17.a., 17.b., and 17.c., must be
less than or equal to the answer to question 17.
Conditionally required. If “in-center hemodialysis” was selected for
question 3, then of the patients specified in question 17, indicate how
many underwent in-center hemodialysis during the first week of
February.
Conditionally required. If “home hemodialysis” was selected for
question 3, then of the patients specified in question 17, indicate how
many underwent home hemodialysis during the first week of February.
Include home, home-assisted, and NxStage®2 patients.
Conditionally required. If “peritoneal dialysis” was selected for
question 3, then of the patients specified in question 17, indicate how
many underwent peritoneal dialysis during the first week of February.

Use of trade names and commercial sources is for identification only and does not imply endorsement.

January 2015

Plan and Annual Surveys

Survey Question
18. Number of staff in
1st week of
February

a.-h. Occupational
categories

C. Vaccines
19. a. Patients
received hepatitis
B vaccine

January 2015

Instructions for Data Collection
Required. Indicate the total number of patient care staff (including
full time, part time, and affiliated with) who worked in your center
during the first week of February (the first seven calendar days of the
month) of the survey year. Include only those staff persons whose role
involves direct contact with dialysis patients or equipment.
 Count each person as 1, even if they work part-time.
 If a person works at more than one facility, they are counted as 1
at each facility.
 Include physicians who see patients in the facility.
 Include patient care staff who are normally present during the
year, but were absent this week due to vacation or other leave.
 Include per diem staff only if they are consistently part of facility
staffing.
 If your facility was not operational during the 1st week of
February, enter 0.
Conditionally required if answer to question 18 is equal to 1 or more.
Of the total number of patient care staff specified in question 18,
indicate the number per occupational category. The sum of the
occupational categories 18.a. – 18.h. must equal the number of patient
care staff indicated in question 18.
Conditionally required if answer to question 17 is equal to 1 or more.
Of all maintenance, non-transient patients indicated in question 17 (a.c.), indicate how many have ever received at least 3 doses of hepatitis B
vaccine.
 Do not count patients who are in the process of completing the
hepatitis B vaccine series.
 Include all patients who have received 3 or more doses, even if
the brand of hepatitis B vaccine being used requires four doses to
complete the series.
 Include patients with documentation of having received 3 or
more doses, even if they were not vaccinated at your facility.
 If no patients received 3 or more doses of the hepatitis B vaccine,
enter 0.

Plan and Annual Surveys

Survey Question
b. All hemodialysis
patients who
received influenza
vaccine

c. Patients
received
pneumococcal
vaccine

Instructions for Data Collection
Conditionally required if answer to question 17 is equal to 1 or more.
Of all maintenance, non-transient patients indicated in question 17 (a.c.), indicate how many received the influenza (flu) vaccine for this flu
season (September or later).
 This question refers to the flu season that began in the year
preceding the survey year. For example, if the survey year is
2015, count flu vaccinations for the 2014-2015 flu season.
 Include patients who report having received a flu vaccination for
this season (or for whom there is documentation) even if they
were not vaccinated at your facility.
 If no patients received the influenza vaccine for the current/most
recent flu season, enter 0.
Conditionally required if answer to question 17 is equal to 1 or more.
Of the total number of maintenance, non-transient patients indicated in
question 17, indicate how many have ever received at least one dose of
the pneumococcal vaccine, even if they were not vaccinated at your
facility.


20a. Number of incenter
hemodialysis
patients
vaccinated against
hepatitis B

January 2015

If no patients received the pneumococcal vaccine ever, enter 0.

Conditionally required. Of the total number of maintenance, nontransient hemodialysis patients indicated in question 17a, indicate how
many ever received at least 3 doses of hepatitis B vaccine.
 Do not count patients who are in the process of completing the
series.
 Include all hemodialysis patients who received 3 or more doses,
even if the brand of hepatitis B vaccine being used requires four
doses.
 Include patients who have documentation of having a complete
hepatitis B vaccine series, even if not received at your facility.
 If no in-center hemodialysis patients received at least 3 doses of
the hepatitis B vaccine, enter 0.

Plan and Annual Surveys

Survey Question
b. In-center
hemodialysis
patients received
influenza vaccine

Instructions for Data Collection
Conditionally required if answer to question 17a is 1 or greater. Of all
these maintenance, non-transient, in-center patients indicated in
question 17a, indicate how many received the influenza (flu) vaccine
for this flu season (September 2014 or later).
 This question refers to the flu season that began in the year
preceding the survey year. For example, if the survey year is
2015, count flu vaccinations for the 2014-2015 flu season.
 Include patients who report having received a flu vaccination for
this season (or for whom there is documentation) even if they
were not vaccinated at your facility.
 If no maintenance, non-transient patients receiving in-center
hemodialysis reported receiving the influenza vaccine for the
current/most recent flu season, enter 0.
c. In-center
Conditionally required if answer to question 17a is equal to 1 or more.
hemodialysis
Of the total number of maintenance, non-transient patients indicated in
patients received
question 17a, indicate how many have ever received at least one dose
at least one dose
of the pneumococcal vaccine, even if they were not vaccinated at your
of pneumococcal
facility.
vaccine ever
If no patients received the pneumococcal vaccine ever, enter 0.
21. a. Patient care
Conditionally required. Of the patient care staff members counted in
staff who received question 18, indicate how many have ever received at least 3 doses of
hepatitis B vaccine hepatitis B vaccine.






January 2015

Do not count staff members who are in the process of completing the
series.

Include all staff members who received 3 or more doses, even if
the brand of hepatitis B vaccine being used requires four doses.
Include patient care staff members who report having received at
least 3 doses of hepatitis B vaccine (or for whom there is
documentation) even if not received at your facility.
If none of the patient care staff members indicated in question 18
have received at least 3 doses of the hepatitis B vaccine ever,
enter 0.

Plan and Annual Surveys

Survey Question
b. Patient care
staff who received
influenza vaccine

22. Vaccine standing
orders

Instructions for Data Collection
Conditionally required. Of the patient care staff members counted in
question 18, indicate how many received the flu vaccine for the
current/most recent flu season.
 This refers to the flu season that began in the year preceding the
survey year. For example, if the survey year is 2014, count flu
vaccinations for the 2014-2015 flu season.
 Include patient care staff members who report having received a
flu vaccination for this season (or for whom there is
documentation) even if they were not vaccinated at your facility.
 If none of the patient care staff members indicated in question 18
have received the influenza vaccine for the current/most recent
flu season, enter 0.
Required. Select “Yes” if your facility uses standing orders to allow
nurses to administer some or all of the vaccines mentioned in
questions 19, 20, and 21 to patients without a specific physician order.
These vaccines include:




23. Type of
pneumococcal
vaccine(s)

Hepatitis B vaccine
Influenza vaccine for the current/most recent flu season
Pneumococcal vaccine

Select “No” if there are no standing orders for any of the mentioned
vaccines.
Required. Choose only one type of pneumococcal vaccine offered to
your facility’s patients:
o
o

Polysaccharide: pneumococcal polysaccharide vaccine, called PPSV23 or
Pneumovax®.3
Conjugate: pneumococcal conjugate vaccine, called PCV13 or Prevnar®
13.3

If type of vaccine offered is unknown, select “Offered, but type
unknown.” If pneumococcal vaccine is not offered, select “Not offered.”

D.
Hepatitis B and C
D.1. Hepatitis B - Complete this section even if your facility does not treat hepatitis B surface
antigen (HBsAg) positive patients.

Use of trade names and commercial sources is for identification only and does not imply endorsement.

January 2015

Plan and Annual Surveys

24.

a. In-center HD
patients with HBV
infection during
1st week of
February

Required. Of the maintenance, non-transient, in-center hemodialysis
patients specified in question 17a, indicate how many were hepatitis B
virus surface antigen (i.e., HBsAg) positive in the first week of February
(i.e., the first seven calendar days of the month). This is a measure of
prevalence of hepatitis B virus infection among patients in your facility
during this period.
a.i. In-center HD
Required. Of the maintenance, non-transient, in-center hemodialysis
patients with HBV patients specified in question 24a, indicate how many were hepatitis B
infection upon
virus surface antigen (i.e., HBsAg) positive when they were first
admission
admitted to your facility (i.e., they had hepatitis B virus infection upon
admission). This is a measure of prevalence of hepatitis B virus
infection among your incoming patients.
b. In-center HD
Required. Of the maintenance, non-transient, in-center hemodialysis
patients acquired patients specified in question 17a, indicate how many converted from
HBV infection in
hepatitis B virus surface antigen (i.e., HBsAg), negative to positive,
12 months prior
during the 12 months prior to February (i.e., they acquired HBV
to February
infection in the past year). Do not include patients who were antigen
positive before they were first dialyzed in your center (i.e., patients
specified in question 24a.i). This is a measure of annual incidence of
hepatitis B virus infection among patients in your facility.
25. Hepatitis B
Required. Indicate whether one or more hemodialysis patients had
reverse
evidence of reverse seroconversion of hepatitis B virus.
seroconverted
D.2. Hepatitis C
26. Hepatitis C
Required. Select “Yes” if your facility screens hemodialysis patients for
antibody
hepatitis C antibody (anti-HCV) upon admission. Select “No” if your
admission
facility does not screen hemodialysis patients for hepatitis C antibody
screening
(anti-HCV) upon admission.
27. Hepatitis C
Required. Select “Yes” if your facility screens hemodialysis patients for
antibody
hepatitis C antibody (anti-HCV) at any time other than upon admission.
screening at times Select “No” if your facility does not screen hemodialysis patients for
other than
hepatitis C antibody (anti-HCV) at any other times than upon
admission
admission. Select “No” if hepatitis C testing is diagnostic only.
a. Hepatitis C
Conditionally required. If answered yes to question 26, indicate the
antibody
frequency of non-admission hepatitis C antibody (anti-HCV) screening.
o Twice annually: screening is two times per year, after admission.
screening
o Annually: if screening is once per year, any time after admission.
frequency
Otherwise, select “Other” and specify the frequency of post-admission
HCV screening.

January 2015

Plan and Annual Surveys

28.

a. In-center HD
patients with HCV
infection during
1st week of
February

Required. Of the maintenance, non-transient, in-center hemodialysis
patients specified in question 17a, indicate how many were hepatitis C
virus antibody (i.e., anti-HCV) positive in the first week of February
(the first seven calendar days of the month). If your facility does not
screen for hepatitis C antibody, respond by counting patients with
records of known history of HCV infection. This is a measure of
prevalence of hepatitis C virus infection among your patients.
a.i. In-center HD
Required. Of the maintenance, non-transient, in-center hemodialysis
patients with HCV patients specified in question 27a, indicate how many were hepatitis C
infection upon
antibody (anti-HCV) positive when they were first admitted to your
admission
facility (i.e., they had hepatitis C virus infection upon admission). If
your facility does not screen for hepatitis C antibody, respond to the
question counting patients with records of known history of HCV
infection. (Note: if your facility does not screen for hepatitis C upon
admission, respond by counting patients with records of known
history of HCV infection.) This is a measure of prevalence of hepatitis C
virus infection among your patients.
b. In-center HD
Required. Of the maintenance, non-transient, in-center hemodialysis
patients acquired patients specified in question 17a, indicate how many converted from
HCV infection in
hepatitis C antibody (i.e., anti-HCV) negative to positive during the 12
12 months prior
months prior to February (i.e., they acquired HCV infection in the past
to February
year). Do not include patients who were antibody positive before they
were first dialyzed in your center (i.e., patients specified in question
27a.i). If your facility does not screen for hepatitis C antibody, respond
by counting patients with records of known history of HCV infection.
This is a measure of annual incidence of hepatitis C virus infection
among your patients.
E. Dialysis Policies and Practices
E.1. Dialyzer Reuse
29. Dialyzer reuse
Required. Select “Yes” if dialyzers are reused for any patients. Select
“No” if dialyzers are never reused.
o Facilities that use non-disposable dialyzers for more than one
patient treatment should answer “Yes” to this question.
o All facilities with a dialyzer reuse program would answer “Yes” to
this question.
a. In-center
Conditionally required if the response to 17 is greater than or equal to
hemodialysis
1. Indicate the number of in-center hemodialysis patients who
patients
participate in dialyzer reuse.
participate in
dialyzer reuse

January 2015

Plan and Annual Surveys

b. R.O. water
testing

c. Dialyzer
refrigeration
d. Dialyzer reuse
limit

e. Sealed (nonremovable)
header caps
f.

Dialyzer
reprocessing
location
i. Dialyzer
header cleaning
ii. Automated or
manual
reprocessing

E.2.
30.

Dialysate
Type of dialysate

Conditionally required if the center reuses dialyzers for any patients.
Indicate whether the reverse osmosis (R.O.) water is tested for both
culture and endotoxin whenever a reuse patient has a pyrogenic
reaction.
Conditionally required if the center reuses dialyzers for any patients.
Indicate approximately how many reuse dialyzers are refrigerated
prior to reprocessing.
Conditionally required. If there is a limit on the number of times a
dialyzer can be reused at your facility, select “Yes” and indicate the
maximum number of times dialyzers may be reused. Otherwise select
“No limit as long as dialyzer meets certain criteria.”
Conditionally required if the center reuses dialyzers for any patients.
Indicate approximately how many reuse dialyzers have sealed (nonremovable) header caps.
Conditionally required. Indicate whether dialyzers are reprocessed at
your facility, if they are transported to an off-site facility for
reprocessing, or if they are reprocessed both at your facility and offsite.
Conditionally required if dialyzers are reprocessed at the facility. Select
all dialyzer header cleaning methods in use. If there is no header
cleaning step, select “No separate header cleaning step performed.”
Conditionally required if dialyzers are reprocessed at the facility.
Indicate whether reprocessing occurs using an automated process or is
completed manually by hand.
Required. Choose only one type of dialysate that is used for in-center
hemodialysis patients at your center.

o
o

31.

Culture and
endotoxin tests
after pyrogenic
reactions

E.3.
32.

Priming Practices
Waste Handling
Option (WHO)
ports

January 2015

Ultrapure: dialysate with a viable microbial count less than 0.1 CFU/ml
and an endotoxin level less than 0.03 EU/ml.
Conventional: dialysate that does not meet the ultrapure definition above.

Required. Select “Yes” only if your facility routinely tests a patient’s
dialysate for both culture and endotoxin whenever a patient has a
pyrogenic reaction. Select “No” if testing dialysate for both culture and
toxin is not routine practice. If there has never been a pyrogenic
reaction among your patients, respond based on facility policy.
Required. A waste handling option (WHO) port is a feature of some
hemodialysis machines that is designed to dispose of any saline that is
flushed through the dialyzer before the machine is used for a patient.
Select “Yes” if your facility uses WHO ports. Select “No” if the
hemodialysis machines at your facility do not have WHO ports or if
WHO ports are present, but not used.
21

Plan and Annual Surveys

33.

Bled onto
machine

E.4.
34.

Injection Practices
Form of
Required. Select one form of erythropoiesis stimulating agent (ESA)
erythropoiesis
that is most often used in your facility. “Single-dose” (also known as
stimulating agent “single-use”) and “multi-dose” refer to specific manufacturer
designations that are printed on the product packaging/label, not the
dosing practice in use. Please refer to the ESA’s label to determine if
the product most frequently used in your facility is labeled “singledose” or “multi-dose.” If ESA is not used, select “N/A.”
a. ESA single-dose Conditionally required. Select “Yes” if ESA from a single-dose vial or
vial or syringe
syringe is ever administered to more than one patient. Select “No” if
ESA from a single-dose vial or syringe is never administered to more
than one patient.
Medication
Required. Select one location where medications are most commonly
preparation
drawn into syringes to prepare for patient administration.
location
Technician IV
Required. Select “Yes” if technicians ever administer any IV
med
medications or infusates, such as heparin or saline, to patients. Select
administration
“No” if technicians never administer IV medications to patients.
Antibiotic Use
a.-d. Appropriate Required. Select “Yes” only for those practices that have been
antibiotic use
implemented for the purpose of “appropriate antibiotic use.” If
antibiotics are restricted, but for another purpose (e.g., cost
management), select “No.” Select “No” if there are no antimicrobial
restrictions in your center.

35.

36.

E.5.
37.

Required. Select “Yes” if any patients in your facility are “bled onto the
hemodialysis machine,” a process where blood is allowed to reach or
almost reach the prime waste receptacle or WHO port. Select “No” if
patients are not bled onto their machines.

o
o
o
o

38.

Antibiotics before
cultures

January 2015

Have a written policy on antibiotic use: any written plan to guide and
determine the present and future decisions about appropriate antibiotic
use.
Formulary restrictions: the existence of rules that limit the use of certain
types of antimicrobials.
Antibiotic use approval process: a mechanism exists to ensure specific
criteria are met before antibiotics are administered.
Automatic stop orders for antibiotics: in the absence of a physician’s
review and order for continuation, antibiotics are automatically
discontinued after a specified period.

Required. Indicate the frequency with which antibiotics are
administered to a patient for a suspected bloodstream infection before
blood cultures are drawn.

Plan and Annual Surveys

39.

Infection
prevention
initiatives
a. Initiative types

40.

CDCrecommended
core
interventions for
BSI prevention in
dialysis settings

41.

Hand hygiene
audits

42.

Vascular access
care and catheter
access practice
observation

43.

Vascular access
care and catheter
access practice
competency

E.7.
44.

Peritoneal Dialysis
Peritoneal
dialysis catheter
antimicrobial
ointment

F.
F.1.

Required. Select “Yes” if your facility participates in any national or
regional infection prevention initiatives. This includes infection
prevention initiatives directed by your ESRD Network.
Conditionally required. If responded “Yes” to question 37, indicate the
primary focus of the initiative. If involved in more than one initiative,
indicate the primary focus of each initiative.
Required. Select “Yes, all” if your facility follows all nine CDCrecommended Core Interventions for BSI prevention in dialysis
settings for all of your in-center hemodialysis patients. Select “Yes,
some” if your facility follows more than 1 but not all nine CDCrecommended core interventions. Select “No, none” if none of the nine
core interventions are implemented among all of your hemodialysis
patients. Select “Don’t know” if you are uncertain about whether all
nine CDC-recommended core interventions are followed for all of your
facility’s hemodialysis patients.
Required. Select “Yes” if your facility performs hand hygiene audits
monthly, or more frequently. Select “No” if your facility does not
perform hand hygiene audits, or if the audits are performed less often
than monthly.
Required. Select “Yes” if your facility performs vascular access care
observations and catheter access observations quarterly, or more
frequently. Select “No” if your facility does not perform vascular access
care observations and catheter access observations, or if the
observations are performed less often than quarterly.
Required. Select “Yes” if your facility performs staff competency
assessments for vascular access care and catheter accessing annually,
or more frequently. Select “No” if your facility does not perform staff
competency assessments for vascular access care and catheter
accessing, or if the assessments are performed less often than yearly.
Required. Select “Yes” if antimicrobial ointment is routinely applied to
peritoneal dialysis catheter exit sites during dressing changes.
Select “No” if antimicrobial ointment is not routinely applied to the
peritoneal dialysis catheter exit site during dressing changes. Select
“N/A” if your facility does not have a procedure in place to routinely
apply antimicrobial ointment to peritoneal dialysis catheter exit sites.
Conditionally required. Select one antimicrobial ointment that is most
commonly applied to the peritoneal dialysis catheter exit site during
dressing changes.

a. Peritoneal
dialysis catheter
antimicrobial
ointment type
Vascular Access
General Vascular Access Information

January 2015

Plan and Annual Surveys

45.

a.-e. Hemodialysis
access types

Required. Of the total number of maintenance, non-transient in-center
and home hemodialysis patients indicated in questions 17a and 17b,
indicate how many patients received hemodialysis through each access
type during the first week of February (the first seven calendar days of
the month).
 Note: this question requires a different counting process than the
Denominators for Outpatient Dialysis form: count all accesses
that were used for hemodialysis during the week.
F.2. Arteriovenous (AV) Fistulas or Grafts
46. Graft/fistula
Required. Indicate whether the graft/fistula site is most often
cleanser used
cleansed with soap and water, or alcohol-based handrub, prior to
before prep
prepping the area for puncture. Select “Other” and specify if a different
cleanser is used. Select “Nothing” if a cleanser is not used to cleanse the
fistula or graft site for cannulation.
47. Graft/fistula
Required. To prep the graft or fistula for puncture, select one
puncture prep
antiseptic/disinfectant that is most often used to prep the area.
a. Graft/fistula
Conditionally required. If you responded to question 45 with an
puncture prep
answer other than “Nothing,” indicate the form of the
form
antiseptic/disinfectant used to prep grafts or fistulas for puncture.
Select “N/A” if you answered “Nothing” to question 45.
48. Buttonhole
Required. Buttonhole cannulation is a technique where a patient’s
cannulation
fistula is regularly accessed by inserting a blunt needle (cannula) into
the fistula at the same location each time using an established track.
Indicate if “All,” “Most,” “Some,” or “None” of your fistula patients
undergo buttonhole cannulation.
a. Buttonhole
Conditionally required. If you responded “All,” “Most,” or “Some” to
patients
question 46, of these patients whose fistulae are accessed via the
buttonhole cannulation technique, indicate whether they are in-center
hemodialysis patients only, home hemodialysis patients only, or both.
b. Buttonhole
Conditionally required. Among the in-center hemodialysis patients,
cannulation
indicate whether buttonhole cannulation is most often performed by a
performed by
nurse, the patient, or a technician. Otherwise, select “Other” and
specify who most often performs buttonhole cannulation.
d. Buttonhole site Conditionally required. Indicate what buttonhole sites are most
prep
commonly prepped with prior to cannulation.
b. Buttonhole
Conditionally required. Select “Yes” if antimicrobial ointment is applied
antimicrobial
at the buttonhole cannulation site to prevent infections. Select “No” if
ointment
antimicrobial ointment is not used at the buttonhole cannulation site
to prevent infections.

January 2015

Plan and Annual Surveys

F.3.
49.

50.

51.

52.

53.

54.

Hemodialysis Catheters
If there are no patients with hemodialysis catheters, refer to facility policy to answer the
following questions.
Catheter hub prep Required. Prior to accessing hemodialysis catheters, select one
product that is most commonly used to prep the catheter hubs. Select
“Other” and specify what product is most commonly used to prep the
catheter hubs if it is not listed. Otherwise, if no product is used to prep
the catheter hubs, select “Nothing.”
a. Catheter hub
Conditionally required. If a product is used to prep the catheter hubs,
prep form
indicate the form of the antiseptic/disinfectant used to prep catheter
hubs prior to accessing hemodialysis catheters.
Catheter hub
Required. Select “Yes” if catheter hubs are routinely scrubbed after
scrub
the cap is removed, but before the catheter is accessed. Select “No” if
scrubbing catheter hubs is not routine practice or if the process is not
appropriately implemented.
Catheter exit site
Required. When a catheter exit site dressing is changed, select one
prep
antiseptic/disinfectant that is most often used to prep the area.
a. Catheter exit
Conditionally required. Indicate the form of the antiseptic/disinfectant
site prep form
used to prep catheter exit sites when the dressing is changed.
Catheter exit site
Required. Select “Yes” if antimicrobial ointment is routinely applied to
antimicrobial
the hemodialysis catheter exit site during dressing changes. Select “No”
ointment
if antimicrobial ointment is not routinely applied to the hemodialysis
catheter exit site during dressing changes.
a. Catheter exit
Conditionally required. If responded “Yes” to question 50, select one
site antimicrobial antimicrobial ointment that is most commonly applied to the
ointment type
hemodialysis catheter exit site during dressing changes, indicate the
type of ointment that is most commonly used.
Hemodialysis
Required. Select one job classification that describes the staff
catheter care staff members who most often perform hemodialysis catheter care (i.e.,
accesses catheters or changes dressings) in your center. Select “Other”
and specify the job classification if the staff members who most often
who perform hemodialysis catheter care in your facility are not nurses
or technicians.
Antimicrobial
Required. Indicate whether antimicrobial lock solutions are used to
lock solutions to
prevent hemodialysis catheter infections for all catheter patients in
prevent infection your facility, for some catheter patients in your facility, or for none of
the catheter patients in your facility.
a. Antimicrobial
Conditionally required. If you indicated that antimicrobial lock
lock solutions
solutions are used for all or some catheter patients in your facility,
select one type of antimicrobial lock solution that is most commonly
used in your facility.

January 2015

Plan and Annual Surveys

55.

56.

Closed connector
luer access
devices
a. Closed
connector luer
access device type
b. Closed
connector luer
access device
patients
Other
antimicrobial/
antiseptic
products

Required. Select “Yes” if closed connector devices are used on
hemodialysis catheters in your facility. Select “No” if closed connector
devices are not used on hemodialysis catheters in your facility.
Conditionally required. If you answered “Yes” to question 53, indicate
the type of closed connector device used on hemodialysis catheters in
your center.
Conditionally required. If you answered “Yes” to question 53, indicate
for which patients they are used (e.g. home hemodialysis patients, incenter hemodialysis patients, or both).
Required. Select all of the applicable antimicrobial/antiseptic
products that are used for hemodialysis catheters in your facility.

Comments

Optional. Use this field to add any additional information about the
dialysis survey necessary to interpret your responses. If the character
limit is inadequate, please email your comments to the NHSN Helpdesk
at [email protected].

Save as …

A complete survey is an annual reporting requirement specified in the
NHSN Dialysis Event Surveillance Protocol. Users are prevented from
creating Monthly Reporting Plans and submitting monthly data for
April through December until a survey for that year has been “Saved as
Complete.” Surveys can be saved as complete as early as February 8
each year.

For additional assistance, email the NHSN Helpdesk ([email protected]) and include “Dialysis” in
the subject line.

January 2015

File Type	application/pdf
File Title	Table of Contents
Author	Mary Andrus
File Modified	2015-06-03
File Created	2015-06-03