Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Investigation of GAS outbreak in LTCF, Illinois – 2015
Resident Record Extraction Form
Person Completing Form ______________________ Date Completed: ____/____/____
A. Resident Background
1. Sex: Male Female 2. Age: __________ 3. Date of Birth: ____/____/____
4. Room History since [DATE]:
Room Number |
Unit |
Dates |
Type |
Acuity |
a. |
|
|
Private
|
Short
Term |
b. |
|
|
Private
|
Short
Term |
c. |
|
|
Private
|
Short
Term |
d. |
|
|
Private
|
Short
Term |
e. |
|
|
Private
|
Short
Term |
f. |
|
|
Private
|
Short
Term |
g. |
|
|
Private
|
Short
Term |
g. |
|
|
Private
|
Short
Term |
Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)
5a. Does/did the patient have a roommate with GAS infection or colonization? Yes No Unknown (If no or unknown,skip to 6)
(I)nfected or (C)olonized Roommate |
Date of positive culture result |
Site of Culture |
Dates of Shared Rooms
From To |
|
b. |
____/____/____ |
|
____/____/____ |
____/____/____ |
c. |
____/____/____ |
|
____/____/____ |
____/____/____ |
d. |
____/____/____ |
|
____/____/____ |
____/____/____ |
e. |
____/____/____ |
|
____/____/____ |
____/____/____ |
6. Total length of stay at time of chart review (mark only one): ≤ 1 week 1-3 weeks 4-8 weeks ≥ 8 weeks
7a. Is resident currently living? Yes No If deceased, date of death ____/____/____
7b. If resident died, death was: Related to GAS infection Possibly related to GAS infection Not related
Not applicable
8a. Resident’s primary physician? __________________________________
8b. Was this patient admitted to this facility from home? . Yes No
8c. Was this patient discharged from this facility to home? . Yes No Still in facility at time of chart review
9. List admission and discharge information since [5/1/2015].
Facility |
Admission Date |
Discharge Date |
Diagnosis |
a. |
______ / _______ / _______ |
______ / _______ / _______ |
|
b. |
______ / _______ / _______ |
______ / _______ / _______ |
|
c |
______ / _______ / _______ |
______ / _______ / _______ |
|
d. |
______ / _______ / _______ |
______ / _______ / _______ |
|
e. |
______ / _______ / _______ |
______ / _______ / _______ |
|
B. Medical History
10a. Original date of admission to this facility: ______ / _______ / _______
10b. Facility patient admitted from? _____________________________________________________________
□ Patient admitted from home
10c. Primary diagnosis (reason for admission to facility): _______________________________________________________
11. Which medical condition(s) does the resident have? (mark ALL that apply):
Diabetes CHF/history of MI Peripheral Vascular Disease Stroke Asthma/COPD
Hypertension Chronic Leg Edema Recent Herpes Zoster Dialysis
Renal insufficiency Dementia Cancer (specify type) _________________________
Vent dependence None Other: ____________ _________________________
12. Weight: ____________ lbs or kg (circle unit of measure) 12b. Height: __________
13a. Has the patient had a surgical procedure since [5/1/2015]? Yes No
Procedure |
Date |
Incision Site |
|
______ / _______ / _______ |
|
|
______ / _______ / _______ |
|
|
______ / _______ / _______ |
|
|
______ / _______ / _______ |
|
|
______ / _______ / _______ |
|
14b. Surgical skin wounds present since [5/1/2015] (mark ALL that apply):
PICC line Tracheostomy PEG/PEJ site Colostomy site
AV fistula or graft Suprapubic catheter Hemodialysis catheter None
Surgical wound: ________________________________________________
Other: ________________________________________________________
15. Type of IV access present at time of positive GAS culture None Not applicable
18a. Access Type |
18b. Date of Insertion |
18c. Person Inserting (e.g. RN) |
|
|
|
16a. Since [5/1/2015], did the resident have non-surgical skin breakdown? Yes No (If no, skip to 17)
16b. Non-surgical skin breakdown since [5/1/2015] (mark ALL that apply):
Sacrum Ischium Trochanter Heel Shoulder Occipital Lat. Malleolus
Med. Malleolus Elbow Ear Coccyx Toe Other: ________________________
17. Products used for wound care (surgical and nonsurgical):
Versafoam Granufoam Prisma Wound Matrix Mepilex Accuzyme
Ethyzyme DuoDerm Biotane Foam None Other: _______________________________________
18a. Was a clinical diagnosis of cellulitis made since [5/1/2015]? Yes No (If no, skip to 19)
Location |
Surgical Site |
Date of Onset |
Treated with Antibiotics |
b. |
Yes No |
______ / _______ / _______ |
Yes No |
c. |
Yes No |
______ / _______ / _______ |
Yes No |
d. |
Yes No |
______ / _______ / _______ |
Yes No |
19. Since [5/1/2015] new, nonsurgical breakdown (mark ALL that apply): None Not applicable
Sacrum Ischium Trochanter Heel Shoulder Occipital
Lat. Malleolus Med. Malleolus Elbow Ear Coccyx
Toe Other: ________________________
20. Surgical procedures since [5/1/2015] (mark ALL that apply): None Not applicable
PICC line insertion Tracheostomy site PEG/PEJ site
Colostomy site Suprapubic catheter Hemodialysis catheter
AV fistula or graft Surgical incision: ________________________
Debridement Other: _________________________________
21a. Was a new clinical diagnosis of cellulitis made since [5/1/2015]? Yes No Not applicable (If no or not applicable, skip to 22)
Location |
Surgical Site |
Date of Onset |
Treated with Antibiotics |
21b. |
Yes No |
______ / _______ / _______ |
Yes No |
21c. |
Yes No |
______ / _______ / _______ |
Yes No |
21d. |
Yes No |
______ / _______ / _______ |
Yes No |
22a. Does/Did the resident receive negative pressure wound therapy via a vacuum-assisted closure device?
Yes No
23b. If yes, date of initiation: _____ / _____ / _____
24b. Stop date: _____ / _____ / _____ or
still in place at time of discharge from facility or at time of chart review
23. Since [5/1/2015], did the resident have any of the following signs or symptoms? (mark ALL that apply)
|
|
Date of onset (dd/mm/yy) |
|
24a. |
Fever (≥100.5oF) |
______ / _______ / _______ |
Max temp recorded: |
24b. |
Sore throat |
______ / _______ / _______ |
|
24c. |
Cough |
______ / _______ / _______ |
Productive? Yes No |
24d. |
Purulent discharge from wound |
______ / _______ / _______ |
Site: |
C. Resident Baseline Status (Can get further information from nursing)
24. Which appliances does the resident use (mark ALL that apply):
Tracheostomy Nasal Cannula Oxygen Mask Nebulizer treatment
G or J tube Nasogastric tube Colostomy Suprapubic catheter
Chronic Foley Temporary Foley Texas/Condom catheter
Dialysis Catheter PICC Line Other ____________________________
25. Describe the resident’s ambulatory status: (mark ALL that apply)
Walks independently Walks with support Wheelchair Geri chair Bed bound
26. Indicate if resident incontinent of: (mark ALL that apply)
Stool Urine Not Incontinent Urinary catheter Colostomy Unknown
27. Does the resident require tube feeds or TPN? Yes No
28. Does the patient have an alcohol-based hand-gel dispenser in his/her room? Yes No
29. How often did the resident participate in the following activities (mark ALL that apply):
30a. PT/OT Times per 2 month period: ______
30b. Speech pathology Times per 2 month period: ______
30c. Podiatry Times per 2 month period: ______
30d. Other: ____________________ Times per 2 month period: ______
D. Medications
30. Which of the following medications did the resident receive since [5/1/2015]? (mark ALL that apply):
30a. Steroids
30b. Chemotherapy
30c. Radiation therapy
30d. Immunosuppressive agents to treat autoimmune disorders (e.g. methotrexate, infliximab)
(name)______________________________
E. Laboratory Results
31a. Did resident have a rapid Strep test since [5/1/2015]? Yes No
31b. Date ______ / _______ / _______
31c. Result? Positive Negative
32a. Did resident have an OP Strep culture since [5/1/2015]?
Yes No
32b. Date ______ / _______ / _______
32c. Result? GAS Positive GAS Negative
32d. Positive for other Strep species 32e. List type ________________________
33a. Did resident have other cultures positive for GAS since [5/1/2015] Yes No (if No skip to 35)
33b. Culture #1 33c. Date obtained ______ / _______ / _______
33d. Site: Skin/Wound: _____________________ Blood Lung Sputum
Other _________________
33e. Culture #2 33f. Date obtained ______ / _______ / _______
33g. Site: Skin/Wound: _____________________ Blood Lung Sputum
Other _________________
Version
2,
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Group A Strep Investigation - 2003 |
Author | EPO |
File Modified | 0000-00-00 |
File Created | 2021-01-24 |