Study ID #: _R
Appendix 3. Invasive GAS in Long Term Care Facility 2016
Wound Care Survey
Form Approved; OMB No. 0920-1011
Exp. Date 03/31/2017
A. Employee Background |
1. Name: 2. Age: |
||
3. Sex: Male Female |
4. Employed at Facility since: ______/______/______ |
||
5. What is your level of professional training on the wound care team? RN MD LPN LVN Other___________ 6. a. Have you received training in infection control practices? Yes No Unknown b. If yes, when was your most recent training? < 1month 2-6 months 6-12months >1year |
|
||
B. Wound care |
7. How many new wound consults do you see per day? 0-4 5-9 10 or more |
||
11. How often do you reassess wounds and document wound healing? Daily 3-7 days 8-14 days Monthly Quarterly Other: _________ 12. What types of care do you perform on the wound care team? Incision and Drainage Undressing/Redressing Cleaning wound Wound vac care Other: ______________________ 13. Have you ever discovered pieces of foam/cotton gauze present in the wound from previous dressing changes? Yes No Unknown |
|||
C. Negative-pressure wound therapy |
14. Have you been specifically trained in the use of negative-pressure wound therapy? Yes No |
||
15. If so, when was your most recent training? < 1month 2-6 months 6-12months >1year 16. How many residents require negative-pressure wound therapy/wound vac? _________ 17. What type of wound vac is used at your facility?______________________________ 18. Who is responsible for the original placement and replacement of the wound vac? Patient RN CNA MD Only wound care team Other 19. Who is allowed to change the wound vac cartridges and settings? (select more than 1 if applicable)? Patient RN CNA MD Only wound care team Other 20. How often is a patient with a wound vac reassessed? Daily 2-3xweek Weekly Monthly Other 21. Are their patients per week are found to have full drainage cartridges or fluid backing up into the drainage tubing? 22. If yes, how would this issue be reported? Medical Chart Report to Nurse Report to Doctor Other 23. When replacing the wound vac on the same patient, are any of the following re-used? (select more than 1 if applies) foam/gauze adhesive dressing drainage tubing other 24. If worsening wound is observed, is the wound vac replaced before a physician consult? Yes No Symptoms specific 25. If symptoms specific please specify what symptoms would prompt you to replace the wound vac before a physician consult? 26. What symptoms for a “worsening wound” prompts a physician consult? change in character of drained fluid increase in fluid drainage increasing erythema pain increase in size |
Public reporting burden of this collection of information is estimated to average 15 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)
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Ahmed, Sana Shreen (CDC/OPHSS/CSELS) (CTR) |
File Modified | 0000-00-00 |
File Created | 2021-01-23 |