Form Phase 4_HFA_201411 Phase 4_HFA_201411 HAI & Antimicrobial Use Prevalence Survey Healthcare Fac

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Form Approved
OMB No. 0920-0852
Exp. Date 12/31/2016

For EIP Team use only: Hospital ID: __________________________________________

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY
HEALTHCARE FACILITY ASSESSMENT
Instructions:
1) The hospital should designate one staff person to be responsible for ensuring completion of
this assessment and submitting the completed assessment to the EIP Team point of
contact. Indicate this information in the table below.
2) The person designated as the individual responsible for ensuring completion of the
assessment should consult as needed with other facility departments or colleagues to
answer the questions included in the assessment. Indicate this information in the table
below.
3) The assessment should be completed using the most up-to-date information available. For
example, if total annual discharge information is available from the year 2012 and 2013, the
2013 information should be used.
4) The assessment should be completed and returned to the EIP Team point of contact within
1-2 weeks.
For each section of the assessment, list person(s) and department(s) to contact for
information:
This information is for hospital and EIP Team use only; information is not transmitted to the CDC.

Section

Name

Department

1—Individual responsible for
ensuring completion of assessment
and submission to EIP Team
2—Hospital data (e.g., total
discharges, staffed beds, etc.)

3—Infection control resource and
practice information

4—Antimicrobial use resource and
practice information

Public reporting burden of this collection of information is estimated to average 45 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 Information Collection Request Office, 1600 Clifton Road NE, MS D-74,
Atlanta, Georgia 30333; ATTN: PRA (0920-0852).

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Phase 4_HFA_ 20141114 Page 2 of 18

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Section 1: If you are the individual responsible for ensuring completion of this
assessment, tell us about yourself:
03/12/2015
1) Enter the date you started to complete this assessment: _________

2) Which of the following best describes your role in the hospital?
☐ Infection preventionist
☐ Nurse
☐ Physician
☐ Microbiologist
☐ Pharmacist
☐ Administrator
☐ Other (specify): _________________________________________

–end of Section 1–

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Section 2: Tell us about your hospital
3) Complete the following table for your hospital, using the most current data available to you:
Number
No. of total annual discharges
(If discharges not available, enter total annual
admissions and check here: ☐)

What year are
data from?
☐2013
☐Other: ______

No. of total patient rooms

☐2014 ☐2013
☐Other: ______

No. of single patient rooms

☐2014 ☐2013
☐Other: ______

No. of acute care licensed beds

☐2014 ☐2013
☐Other: ______

(do not include nursing home or skilled nursing facility
beds)

No. of acute care staffed beds
(do not include nursing home or skilled nursing facility
beds)

Average daily acute care census
(do not include nursing home or skilled nursing facility
beds)

No. of intensive care unit beds

☐2014 ☐2013
☐Other: ______
☐2014 ☐2013
☐Other: ______
☐2014 ☐2013
☐Other: ______

No. of full time equivalent (FTE) infection
preventionists

☐2014 ☐2013
☐Other: ______

No. of FTE physician hospital
epidemiologists

☐2014 ☐2013
☐Other: ______

4) What is your hospital’s “intern/resident to bed ratio” (“IRB”) (check one)?
NOTE: This information may be available from one of your hospital’s administrative departments, such as the
finance department or other department that is responsible for Medicare-related issues. You are not expected
to calculate this ratio yourself.
“Resident” is defined according to the Code of Federal Regulations (CFR) § 413.75(b): “resident means an
intern, resident, or fellow who is formally accepted, enrolled, and participating in an approved medical
residency program, including programs in osteopathy, dentistry, and podiatry, as required in order to become
certified by the appropriate specialty board” (http://www.ecfr.gov/cgi-bin/textidx?c=ecfr&SID=0ba3fc79d200e9f2a259ecd570445aa1&rgn=div8&view=text&node=42:2.0.1.2.13.6.57.1&idn
o=42).

Phase 4_HFA_20141114 Page 5 of 18

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For EIP Team use only: Hospital ID: __________________________________________

☐ The IRB is 0.25 or greater (i.e., there is at least one intern or resident for every 4
hospital beds). (Skip to question #6)
☐ The IRB is less than 0.25, but greater than zero. (Skip to question #6)
☐ My hospital does not have any interns or residents. (Skip to question #6)
☐ I do not know if my hospital has interns or residents. (Skip to question #6)
☐ My hospital has interns/residents, but I do not know my hospital’s IRB. (If you do not
know the IRB, go to question #5)
5) If your hospital has interns/residents but you do not know your hospital’s IRB, do you know
the number of full-time equivalent interns and residents in your hospital (where “interns and
residents” are defined as noted above in question #4)?
☐ Yes (enter number here: ___________________, for year __________ )
☐ No

–end of Section 2–

Phase 4_HFA_20141114 Page 6 of 18

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Section 3: Tell us about infection control resources and practices in your hospital
6) Does your facility have an infection control team or program with one or more staff
members responsible for developing and implementing infection control policies and
practices and related activities?
☐ Yes
☐ No (if “No,” skip to question #10)
7) If your hospital has an infection control team/program, who participates in the infection
control team/program (check all that apply)?
☐ Infectious diseases physician
☐ Other physician (not infectious diseases)
☐ Nurse infection preventionist, Certified in Infection Control (CIC®)
☐ Other infection preventionist (not a nurse), Certified in Infection Control (CIC®)
☐ Nurse, not Certified in Infection Control (CIC®)
☐ Other infection preventionist (not a nurse), not Certified in Infection Control (CIC®)
☐ Data analyst
☐ Informatics support staff
☐ Quality or patient safety department staff
☐ Other (specify): _____________________________
8) If your hospital has an infection control team/program, how long has the infection control
team/program been in place (check one)?
☐ Less than 1 year
☐ Between 1 and 3 years
☐ Between 4 and 6 years
☐ Between 7 and 9 years
☐ 10 or more years
9) If your hospital has an infection control team/program, how often does the team/program
meet (check one)?
☐ More frequently than monthly
☐ Monthly
☐ Every other month or quarterly
☐ Less than quarterly

Phase 4_HFA_20141114 Page 7 of 18

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10) Is there a committee in your hospital that reviews infection control-related activities (such
as reports, policies and procedures, etc., developed by the infection control
team/program)?
☐ Yes
☐ No (if “No,” skip to question #13)
11) If there is a committee in your hospital that reviews infection control-related activities,
indicate the members represented on the committee (check all that apply):
☐ Facility executive leaders (e.g., CEO, COO) or board members
☐ Nursing leaders or administrators
☐ Medical/physician leaders or administrators
☐ Quality department
☐ Pharmacy department
☐ Environmental services
☐ Unit managers or supervisors
☐ Physician staff
☐ Nursing staff
☐ Other (specify): __________________________
12) If there is a committee in your hospital that reviews infection control-related activities, how
frequently does this committee meet (check one)?
☐ More frequently than monthly
☐ Monthly
☐ Every other month or quarterly
☐ Less than quarterly
13) For each HAI surveillance statement below, check YES or NO to indicate what is currently
being done in your hospital (at the time of this assessment, or during the 6 months prior to
this assessment):
My hospital performs surveillance for one or more types of HAIs, in
one or more inpatient locations, in compliance with local, state and/or
federal reporting requirements.
In addition to required HAI reporting, my hospital performs
surveillance for one or more types of HAIs not currently included in
any local, state or federal reporting requirements.

YES

NO

☐

☐

☐

☐

Phase 4_HFA_20141114 Page 8 of 18

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My hospital tracks rates or standardized infection ratios (SIR) of HAIs
over time to identify trends (e.g., monthly, quarterly, annually, etc.).
My hospital creates HAI summary reports (e.g., trends).
My hospital shares HAI surveillance data with hospital leaders (e.g.,
CEO, COO, Chief Medical Officer, Chief Nursing Officer, department
heads).
My hospital shares HAI surveillance data with individual patient unit
managers.
My hospital shares HAI surveillance data with frontline providers.

YES

NO

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

14) For each infection control policy statement below, check YES or NO to indicate whether a
policy is in place in your hospital at the time of this assessment:
YES

NO

My hospital has a hand hygiene policy.

☐

☐

My hospital has an Isolation Precautions policy.

☐

☐

My hospital has a policy on cleaning and disinfection of shared
medical equipment.
My hospital has an environmental cleaning policy.

☐

☐

☐

☐

15) For each statement about monitoring adherence to infection control policy, check YES or
NO to indicate what is currently being done in your hospital (at the time of this assessment,
or during the 6 months prior to this assessment):
My hospital measures adherence to hand hygiene policies in at least
one patient care area.
My hospital measures adherence to Isolation Precautions among
staff (e.g., the percentage of those who comply with wearing of
gloves or donning of gowns).
My hospital monitors/observes environmental cleaning practices to
ensure consistent cleaning and disinfection practices are followed.
My hospital shares adherence rates to specific policies (e.g., hand
hygiene) with relevant staff.

YES

NO

☐

☐

☐

☐

☐

☐

☐

☐

Phase 4_HFA_20141114 Page 9 of 18

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All hospital units, services and/or staff members are held
accountable for complying with infection control policies (e.g., there
are positive consequences for good compliance, and/or negative
consequences for poor compliance).

YES

NO

☐

☐

16) When does your hospital require staff members to participate in training on infection
control topics (check all that apply)?
☐ Staff members are required to participate in training at the time of new employee
orientation.
☐ Staff members are required to participate in training on an as-needed basis, when
specific infection control issues arise.
☐ Staff members participate in required training on a regular basis, as follows (check one):
☐ More frequently than once per month
☐ Once per month
☐ Every other month or quarterly
☐ Twice per year
☐ Once per year
☐ My hospital does not require staff members to participate in infection control training.
☐ Other (specify): ___________________________
17) For each multidrug-resistant organism (MDRO) management statement below, check YES
or NO to indicate what is being done in your hospital at the time of this assessment:
YES

NO

My hospital has a mechanism to identify, on admission, patients
previously infected or colonized with the following MDROs:
Methicillin-resistant Staphylococcus aureus (MRSA):

☐

☐

Vancomycin-resistant Enterococcus (VRE):

☐

☐

Carbapenem-resistant Enterobacteriaceae (CRE):

☐

☐

Clostridium difficile:

☐

☐

Phase 4_HFA_20141114 Page 10 of 18

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YES

NO

My hospital has policies that specifically address the implementation
of Isolation Precautions that are used in addition to Standard
Precautions for patients infected or colonized with the following
MDROs:
Methicillin-resistant Staphylococcus aureus (MRSA):

☐

☐

Vancomycin-resistant Enterococcus (VRE):

☐

☐

Carbapenem-resistant Enterobacteriaceae (CRE):

☐

☐

Clostridium difficile:

☐

☐

My hospital has policies that specifically address the discontinuation
of Isolation Precautions that are used in addition to Standard
Precautions for patients infected or colonized with the following
MDROs:
Methicillin-resistant Staphylococcus aureus (MRSA):

☐

☐

Vancomycin-resistant Enterococcus (VRE):

☐

☐

Carbapenem-resistant Enterobacteriaceae (CRE):

☐

☐

Clostridium difficile:

☐

☐

My hospital has a process for communicating with other facilities
about patients colonized or infected with the following MDROs at the
time of transfer:
Methicillin-resistant Staphylococcus aureus (MRSA):

☐

☐

Vancomycin-resistant Enterococcus (VRE):

☐

☐

Carbapenem-resistant Enterobacteriaceae (CRE):

☐

☐

Clostridium difficile:

☐

☐

My hospital has a strategy for identifying appropriate roommate
selection for patients admitted with the following MDROs who cannot
be placed in a private room:
Methicillin-resistant Staphylococcus aureus (MRSA):

☐

☐

Vancomycin-resistant Enterococcus (VRE):

☐

☐

Carbapenem-resistant Enterobacteriaceae (CRE):

☐

☐

Clostridium difficile:

☐

☐

18) Which of the following Clostridium difficile infection control practices are performed in your
hospital (check all that apply)?
☐ Patients with suspected C. difficile infection (i.e., patients who are having symptoms
typical of C. difficile infection and who have risk factors for C. difficile infection but who

Phase 4_HFA_20141114 Page 11 of 18

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do not yet have a positive diagnostic test confirming C. difficile infection) are placed on
Contact Precautions.
☐ Patients with active C. difficile infection (i.e., patients who have tested positive for C.
difficile and are having symptoms) are placed on Contact Precautions.
☐ All patients with active C. difficile infection (i.e., patients who have tested positive for C.
difficile and are having symptoms) are placed in private rooms.
☐ None of the above
19) If your hospital does not have a sufficient number of private rooms available, what does
your hospital do with patients who are identified with active C. difficile infection (check all
that apply)?
☐ Place with other C. difficile infection patients (cohort)
☐ Place with other patients but use separate commodes/bathrooms
☐ Place with other patients sharing bathrooms
☐ Other (specify):______________________________
☐ Not applicable (all rooms in my hospital are private rooms, or there is always a sufficient
number of private rooms available)
20) For patients with active C. difficile infection, what is the preferred method of hand hygiene
used in your hospital (check one)?
☐ Soap and water
☐ Alcohol hand gel
☐ Not specified (i.e., both available but neither preferred)
☐ Other (specify): ______________________________
21) In what settings and/or patients does your hospital routinely perform MRSA surveillance
testing (culture or PCR) on admission for the purpose of detecting MRSA colonization
(active surveillance) (check all that apply)?
☐ Hospital-wide
☐ In one or more intensive care units
☐ In one or more non-intensive care units
☐ In one or more specific patient populations (e.g., patients undergoing cardiac surgery,
dialysis, recent hospital discharge, etc…)
☐ Other (specify): ________________________________
☐ None of the above
22) In what settings and/or patients does your hospital routinely use chlorhexidine bathing
(check all that apply)?

Phase 4_HFA_20141114 Page 12 of 18

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☐
☐
☐
☐
☐
☐
☐
☐

In one or more intensive care units
In one or more non-intensive care units
In one or more specific patient populations (e.g., patients undergoing cardiac surgery)
In patients who are current MRSA carriers
In patients who are past MRSA carriers
In patients who are not known to be current or past MRSA carriers
Other (specify): ________________________________
None of the above

23) In what settings and/or patients does your hospital routinely use mupirocin (check all that
apply)?
☐ In one or more intensive care units
☐ In one or more non-intensive care units
☐ In one or more specific patient populations (e.g., patients undergoing cardiac surgery)
☐ In patients who are current MRSA carriers
☐ In patients who are past MRSA carriers
☐ In patients who are not known to be current or past MRSA carriers
☐ Other (specify): ________________________________
☐ None of the above

–end of Section 3–

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Section 4: Tell us about antimicrobial use resources and practices in your hospital
24) Does your hospital have a multidisciplinary team focused on promoting appropriate
antimicrobial use (antimicrobial stewardship)?
☐Yes
☐No (If “No,” skip to question #29)
25) If your hospital has an antimicrobial stewardship team, who participates in the stewardship
team (check all that apply)?
☐ Infectious diseases physician
☐ Other physician (not infectious diseases)
☐ Infectious diseases pharmacist
☐ Pharmacist (without specialized infectious diseases training)
☐ Microbiologist
☐ Infection preventionist
☐ Data analyst
☐ Informatics support staff
☐ Other (specify): ________________________
26) If your hospital has an antimicrobial stewardship team, how long has the team been in
place (check one)?
☐ Less than 1 year
☐ Between 1 and 3 years
☐ Between 4 and 6 years
☐ Between 7 and 9 years
☐ 10 or more years
27) If your hospital has an antimicrobial stewardship team, how often does the team meet
(check one)?
☐ More frequently than monthly
☐ Monthly
☐ Every other month or quarterly
☐ Less than quarterly
28) If your hospital has an antimicrobial stewardship team, what support does the team receive
from hospital administration (check all that apply)?
☐ Full salary support for one or more team members
☐ Partial salary support for one or more team members

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☐ Formal recognition as a hospital committee
☐ Other support (specify): _______________________________________
☐ No formal support from administration
29) For each statement listed below, whether you have an antimicrobial stewardship team or
not, check YES or NO based on practices or policies in place in your hospital at the time of
this assessment:
My hospital has a defined formulary of antimicrobial agents, and
prescribing is generally restricted to those agents on the formulary.
My hospital requires pre-authorization or approval of selected
antimicrobials by an infectious diseases physician, pharmacist or
other hospital staff member.
Use of selected antimicrobials is reviewed or audited on a daily or
weekly basis by an infectious diseases physician, pharmacist, or
other hospital staff member.
Results of audits/reviews of antimicrobial use are provided directly
to prescribers, through in-person, telephone, or electronic
communications
Automatic stop orders (e.g., after 2-3 days, subject to
documentation of the need for ongoing therapy) are in place for
selected antimicrobials.
My hospital has guidelines for switching from parenteral to oral
antimicrobials.
My hospital has guidelines for surgical prophylaxis.
My hospital has guidelines for first-line antimicrobial therapy for
common infections (e.g., community-acquired pneumonia, urinary
tract infections, etc.).
Providers have access to hospital information technology support
for prescribing antimicrobials.
Providers are required to document (in the medical record or in the
computerized provider order entry system) the indication for
antimicrobial prescriptions.
Providers are required to document (in the medical record or in the
computerized provider order entry system) the anticipated duration
of antimicrobial therapy.

YES

NO

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

Phase 4_HFA_20141114 Page 16 of 18

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Prescribers are required to participate in a training/educational
program or session on appropriate antimicrobial use at least
annually.
My hospital produces a hospital-wide antibiogram (i.e., antimicrobial
susceptibility data aggregated across the entire facility, rather than
broken down by patient units) at least annually, and makes the
antibiogram available to prescribers.
My hospital produces a patient unit-specific antibiogram at least
annually, and makes the antibiogram available to prescribers.

YES

NO

☐

☐

☐

☐

☐

☐

30) Is antimicrobial consumption monitored in your hospital?
☐ Yes
☐ No (If “No,” hospital assessment is complete)
31) If antimicrobial consumption is monitored in your hospital, in what settings are antimicrobial
consumption patterns monitored (check all that apply)?
☐ Hospital-wide
☐ On specific patient care units
☐ Other (specify): __________________________
32) If antimicrobial consumption is monitored in your hospital, what are the data sources for
monitoring antimicrobial consumption (check all that apply)?
☐ Purchasing data (e.g., grams or dollars per patient per day)
☐ Ordering data from the pharmacy or computerized provider order entry system
☐ Dispensed data from the pharmacy information system
☐ Administered data from paper or electronic medication administration records
☐ Unknown
33) If antimicrobial consumption is monitored in your hospital, what are the measures used to
monitor antimicrobial consumption (check all that apply)?
☐ Defined Daily Dose (DDD)
☐ Days of Therapy (DOT)
☐ Length of Therapy (LOT)
☐ Grams or dollars
☐ Other (specify): ____________________________
☐ Unknown

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34) If antimicrobial consumption is monitored in your hospital, who in the hospital is
antimicrobial consumption data reported to (check all that apply)?
☐ Antimicrobial stewardship team
☐ Administrators
☐ Front line providers or clinical leaders
☐ Other (specify): ______________________________

–end of Section 4–

The Healthcare Facility Assessment is now complete. Thank you!
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