Form CDC 57.103 CDC 57.103 Patient Safety Component - Annual Hospital Survey

Form Approved

OMB No. 0920-0666

Exp. Date: 11/30/2019

www.cdc.gov/nhsn

Patient Safety Component—Annual Hospital Survey

Instructions for this form are available at: http://www.cdc.gov/nhsn/forms/instr/57_103-TOI.pdf

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*required for saving								Tracking #:
Facility ID:								*Survey Year:
Facility Characteristics (completed by Infection Preventionist)
*Ownership (check one):
□ For profit			□ Not for profit, including church			□ Government
□ Military			□ Veterans Affairs			□ Physician owned
If facility is a Hospital:
*Number of patient days: _________
*Number of admissions: __________
For any Hospital:
*Is your hospital a teaching hospital for physicians and/or physicians-in-training?									Yes	No
If Yes, what type:				____ Major	____ Graduate		____ Undergraduate
*Number of beds set up and staffed in the following location types (as defined by NHSN):
	a. ICU (including adult, pediatric, and neonatal levels II/III and III):						___________
	b. All other inpatient locations:						___________
Facility Microbiology Laboratory Practices (completed with input from Microbiology Laboratory Lead)
*1. Does your facility have its own laboratory that performs antimicrobial susceptibility testing? (check one)
□ Yes		□ No
If No, where is your facility’s antimicrobial susceptibility testing performed? (check one)
□ Affiliated medical center
□ Commercial referral laboratory
□ Other local/regional, non-affiliated reference laboratory
Continued >>
Assurance of Confidentiality: The information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.103 (Front) Rev. 10, v8.8

Patient Safety Component—Annual Hospital Survey

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Facility Microbiology Laboratory Practices (continued)
*2. For the following organisms please indicate which methods are used for:
(1) primary susceptibility testing and
(2) secondary, supplemental, or confirmatory testing (if performed).
If your laboratory does not perform susceptibility testing, please indicate the methods used at the outside laboratory.
Please use the testing codes listed below the table.
Pathogen			(1) Primary	(2) Secondary				Comments
Staphylococcus aureus			_______________	______________				______________
Enterobacteriaceae			_______________	______________				______________
1 = Kirby-Bauer disk diffusion	5.1 = MicroScan walkaway rapid				10 = E test
2 = Vitek (Legacy)	5.2 = MicroScan walkaway conventional				12 = Vancomycin agar screen (BHI + vancomycin)
2.1 = Vitek 2	5.3 = MicroScan auto or touchscan				13 = Other (describe in Comments section)
3.1 = BD Phoenix	6 = Other micro-broth dilution method
4 = Sensititre	7 = Agar dilution method
*3. Has the laboratory implemented the revised cephalosporin and monobactam breakpoints for Enterobacteriaceae recommended by CLSI as of 2010?							□ Yes			□ No
*4. Has the laboratory implemented the revised carbapenem breakpoints for Enterobacteriaceae recommended by CLSI as of 2010?							□ Yes			□ No
*5. Does the laboratory perform a special test for presence of carbapenemase?						□ Yes			□ No
If Yes, please indicate what is done if carbapenemase production is detected: (check one)
□ Change susceptible carbapenem results to resistant
□ Report carbapenem MIC results without an interpretation
□ No changes are made in the interpretation of carbapenems, the test is used for epidemiological or infection control purposes
If Yes, which test is routinely performed to detect carbapenemase: (check all that apply)
□ PCR		□ MBL screen
□ Modified Hodge Test		□ Carba NP
□ E test		□ Other (specify): _________________
Continued >>

Patient Safety Component—Annual Hospital Survey

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Facility Microbiology Laboratory Practices (continued)
*6. Does the laboratory perform colistin or polymyxin B susceptibility testing for drug-resistant gram negative bacilli?														□ Yes	□ No
If Yes, please indicate methods: (check all that apply)
□ Vitek (Legacy)				□ MicroScan walkaway rapid								□ Agar dilution method
□ Vitek 2				□ MicroScan walkaway conventional								□ E test
□ BD Phoenix				□ MicroScan auto or touchscan								□ Other (specify): _____________________
□ Sensititre				□ Other micro-broth dilution method
*7. Does your facility have its own laboratory that performs antifungal susceptibility testing for Candida species?
□ Yes	□ No
If No, where is your facility’s antifungal susceptibility testing performed? (check one)
□ Affiliated medical center											□ Commercial referral laboratory
□ Other local/regional, non-affiliated reference laboratory											□ Not offered by my facility
8. If antifungal susceptibility testing is performed at your facility or an outside laboratory, what methods are used? (check all that apply)
□ Broth macrodilution						□ Broth microdilution				□ YeastOne colorimetric microdilution			□ E test
□ Vitek 2 card						□ Disk diffusion				□ Other (specify): ________________
*9. Is antifungal susceptibility testing performed automatically/reflexively without needing a specific order or request for susceptibility testing from the clinician for the below Candida species when cultured from normally sterile body sites (such as blood)?
Candida albicans:		□ Yes					□ No
If Yes, what antifungal drugs are tested automatically/reflexively? (check all that apply)
□ Fluconazole				□ Voriconazole					□ Anidulafungin/Caspofungin/Micafungin
Candida glabrata:		□ Yes					□ No
If Yes, what antifungal drugs are tested automatically/reflexively? (check all that apply)
□ Fluconazole				□ Voriconazole					□ Anidulafungin/Caspofungin/Micafungin
Candida parapsilosis:			□ Yes					□ No
If Yes, what antifungal drugs are tested automatically/reflexively? (check all that apply)
□ Fluconazole				□ Voriconazole					□ Anidulafungin/Caspofungin/Micafungin
Other Candida species:					□ Yes			□ No
If Yes, what antifungal drugs are tested automatically/reflexively? (check all that apply)
□ Fluconazole				□ Voriconazole					□ Anidulafungin/Caspofungin/Micafungin
□ Automatic testing is not performed for any Candida species
Continued >>

Patient Safety Component—Annual Hospital Survey

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Facility Microbiology Laboratory Practices (continued)

*10. What is the primary testing method for C. difficile used most often by your facility’s laboratory or the outside laboratory where your facility’s testing is performed? (check one)

□ Enzyme immunoassay (EIA) for toxin

□ Cell cytotoxicity neutralization assay

□ Nucleic acid amplification test (NAAT) (e.g., PCR, LAMP)

□ NAAT plus EIA, if NAAT positive (2-step algorithm)

□ Glutamate dehydrogenase (GDH) antigen plus EIA for toxin (2-step algorithm)

□ GDH plus NAAT (2-step algorithm)

□ GDH plus EIA for toxin, followed by NAAT for discrepant results

□ Toxigenic culture (C. difficile culture followed by detection of toxins)

□ Other (specify): ______________________ (“Other” should not be used to name specific laboratories, reference laboratories, or the brand names of C. difficile tests; most methods can be categorized accurately by selecting from the options provided. Please ask your laboratory or conduct a search for further guidance on selecting the correct option to report.)

*11. Does your facility produce an antibiogram (i.e., cumulative antimicrobial susceptibility report)?

□ Yes

□ No

If Yes, is the antibiogram produced at least annually?

□ Yes

□ No

If Yes, are data stratified by hospital location?

□ Yes

□ No

If No, please identify any obstacle(s) to producing an antibiogram. (Check all that apply)

□ The laboratory data are difficult to access

□ Limited or no information technology tool for data analysis

□ Limited personnel time for data analysis

□ Limited personnel skills for data analysis

□ Limited interest in an antibiogram from staff who prescribe antibiotics

□ Our institution does not have enough isolates of any or most species (i.e., < 30 isolates per species) to produce an antibiogram

□ Other (please specify): ___________________________________________

12. Please indicate the primary and definitive method used to identify microbes from blood specimens collected in your facility.  (SELECT ONE ANSWER)

□ MALDI-TOF MS System (Vitek MS)

□ MALDI-TOF MS System (Bruker Biotyper)

□ Automated Instrument (e.g., Vitek, MicroScan, Phoenix, OmniLog, Sherlock, etc.)

□ Non-automated Manual Kit (e.g., API, Crystal, RapID, etc.)

□Rapid Identification (e.g., Verigene, BioFire FilmArray, PNA-FISH, Gene Xpert, etc.)

□16S rRNA Sequencing

Patient Safety Component—Annual Hospital Survey Page 5 of 9

13. Please indicate any additional secondary methods used for microbe identification from blood specimens collected in your facility (e.g., a rapid method that is confirmed with the primary method, a secondary method if the primary method fails to give an identification, or a method that is used in conjunction with the primary method).  (SELECT ALL THAT APPLY)

□ MALDI-TOF MS System (Vitek MS)

□ MALDI-TOF MS System (Bruker Biotyper)

□ Automated Instrument (e.g., Vitek, MicroScan, Phoenix, OmniLog, Sherlock, etc.)

□ Non-automated Manual Kit (e.g., API, Crystal, RapID, etc.)

□Rapid Identification (e.g., Verigene, BioFire FilmArray, PNA-FISH, Gene Xpert, etc.)

□16S rRNA Sequencing

Infection Control Practices (completed with input from Hospital Epidemiologist and/or Quality Improvement Coordinator)

*14. Number or fraction of infection preventionists (IPs) in facility:

_______

a. Total hours per week performing surveillance:

_______

b. Total hours per week for infection control activities other than surveillance:

_______

*15. Number or fraction of full-time employees (FTEs) for a designated hospital epidemiologist (or equivalent role) affiliated with your facility:

_______

Infection Control Practices (completed with input from Hospital Epidemiologist and/or Quality Improvement Coordinator)

*16. Is it a policy in your facility that patients infected or colonized with MRSA are routinely placed in contact precautions while these patients are in your facility? (check one)

□ Yes, all infected or colonized patients

□ Yes, only all infected patients

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

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

□ No

□ Not applicable: my facility never admits these patients

*17. Is it a policy in your facility that patients infected or colonized with VRE are routinely placed in contact precautions while these patients are in your facility? (check one)

□ Yes, all infected or colonized patients

□ Yes, only all infected patients

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

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

□ No

□ Not applicable: my facility never admits these patients

Continued>>

Patient Safety Component—Annual Hospital Survey Page 6 of 99

*18. Is it a policy in your facility that patients infected or colonized with CRE (regardless of confirmatory testing for carbapenemase production) are routinely placed in contact precautions while these patients are in your facility? (check one)

□ Yes, all infected or colonized patients

□ Yes, only all infected patients

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

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

□ No

□ Not applicable: my facility never admits these patients

*19. Is it a policy in your facility that patients infected or colonized with suspected or confirmed ESBL-producing or extended spectrum cephalosporin resistant Enterobacteriaceae are routinely placed in contact precautions while these patients are in your facility? (check one)

□ Yes, all infected or colonized patients

□ Yes, only all infected patients

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

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

□ No

□ Not applicable: my facility never admits these patients

Infection Control Practices (completed with input from Hospital Epidemiologist and/or Quality Improvement Coordinator)

*20. Does the facility routinely perform screening testing (culture or non-culture) for CRE?

□ Yes

□ No

If Yes, in which situations does the facility routinely perform screening testing for CRE? (check all that apply)

□ Surveillance testing at admission for all patients

□ Surveillance testing of epidemiologically-linked patients of newly identified CRE patients (e.g., roommates)

□ Surveillance testing at admission of high-risk patients (e.g., admitted from LTAC or LTCF)

□ Surveillance testing at admission of patients admitted to high-risk settings (e.g. ICU)

□ Other (please specify): _________________

*21. Does the facility routinely perform screening testing (culture or non-culture) for MRSA?

□ Yes

□ No

If yes, in which situations does the facility routinely perform screening testing for MRSA? (check all that apply)

□ Surveillance testing at admission for all patients

□ Surveillance testing at admission of high-risk patients (e.g., admitted from LTAC or LTCF)

□ Surveillance testing at admission of patients admitted to high-risk settings (e.g. ICU)

□ Surveillance testing of pre-operative patients to prevent surgical site infections

□ Other (please specify): _________________

Continue >>

Patient Safety Component—Annual Hospital Survey Page 7 of 9

*22. Does the facility routinely use chlorhexidine bathing on any patient to prevent infection or transmission of MDROs at your facility? (Note: this does not include the use of such bathing in pre-operative patients to prevent SSIs)

□ Yes

□ No

*23. Does the facility routinely use a combination of topical chlorhexidine AND intranasal mupirocin (or equivalent agent) on any patients to prevent infection or transmission of MRSA at your facility? (Note: this does not include the use of these agents in pre-operative surgical patients or dialysis patients)

□ Yes

□ No

*24. Among patients with an MDRO admitted to your facility from another healthcare facility, please estimate how often your facility receives information from the transferring facility about the patient’s MDRO status?

□ All the time

□ More than half of the time

□ About half of the time

□ Less than half of the time

□ None of the time

□ Not applicable: my facility does not receive transferred patients with a known MDRO

Antibiotic Stewardship Practices (completed with input from Physician and Pharmacist Stewardship Champions)

*25. Does your facility have a written statement of support from leadership that supports efforts to improve antibiotic use (antibiotic stewardship)?

□ Yes

□ No

*26. Is there a leader responsible for stewardship activities at your facility?

□ Yes

□ No

If Yes, what is the position of this leader: (check one)

□ Physician

□ Co-led by both Pharmacist and Physician

□ Pharmacist

□ Other (please specify): _______________________

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

□ Yes

□ No

*28. Does your facility provide any salary support for dedicated time for antibiotic stewardship leadership activities?

□ Yes

□ No

*29. Does your facility have a policy that requires prescribers to document an indication for all antibiotics in the medical record or during order entry?

□ Yes

□ No

If Yes, has adherence to the policy to document an indication been monitored?

□ Yes

□ No

Continued>>

Patient Safety Component—Annual Hospital Survey Page 8 of 9

*30. Does your facility have facility-specific treatment recommendations, based on national guidelines and local susceptibility, to assist with antibiotic selection for common clinical conditions?

□ Yes

□ No

If Yes, has adherence to facility-specific treatment recommendations been monitored?

□ Yes

□ No

*31. Is there a formal procedure for all clinicians to review the appropriateness of all antibiotics at or after 48 hours from the initial orders (e.g. antibiotic time out)?

□ Yes

□ No

*32. Do any specified antibiotic agents need to be approved by a physician or pharmacist prior to dispensing at your facility?

□ Yes

□ No

*33. Does a physician or pharmacist review courses of therapy for specified antibiotic agents and communicate results with prescribers at your facility?

□ Yes

□ No

If Yes, what type of feedback is provided to prescribers? (check all that apply)

□ Feedback on antimicrobial route and/or dosage

□ Feedback on the selection of antimicrobial therapy and/or duration of therapy

□ Other (please specify) : ___________________________________________

*34. Does your facility monitor antibiotic use (consumption) at the unit, service, and/or facility wide?

□ Yes

□ No

If Yes, by which metrics? (Check all that apply)

□ Days of Therapy (DOT)

□ Purchasing Data

□ Defined Daily Dose (DDD)

□ Other (please specify): ________________________

If Yes, are facility- and/or unit- or service-specific reports on antibiotic use shared with prescribers?

□ Yes

□ No

*35. Has your facility provided education to clinicians and other relevant staff on improving antibiotic use?

□ Yes

□ No

Facility Water Management and Monitoring Program

36. Have you ever conducted a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system (e.g., piping infrastructure)?

□ Yes

□ No

If Yes, when was the most recent assessment conducted? (Check one)

□ ≤ 1 year ago

□ ≥ 1-3 years ago

□ ≥ 3 years ago

37. Does your facility have a water management program to prevent the growth and transmission of Legionella and other opportunistic waterborne pathogens?

□ Yes

□ No

If Yes, who is represented on the team? (Check all that apply)

Continued>>>

Patient Safety Component—Annual Hospital Survey Page 9 of 9

□ Hospital Administrator

□ Hospital Epidemiologist/ Infection Preventionist

□ Consultant

□ Facilities Manager/ Engineer

□ Maintenance Staff

□ Infectious Disease Clinician

□ Risk/Quality Management Staff

□ Compliance Officer

□ Equipment/ Chemical Supplier

□ Other (specify): ______________________________

38. Do you regularly monitor the following parameters in your building’s water system? (Check all that apply)

Disinfectant (such as residual chlorine)

□ Yes

□ No

If Yes, do you have a plan for corrective actions when disinfectant (s) are not within acceptable limits as determined by your water management program?

□ Yes

□ No

Temperature

□ Yes

□ No

If Yes, do you have a plan for corrective actions when temperatures are not within acceptable limits as determined by your water management program?

□ Yes

□ No

Heterotrophic plate counts

□ Yes

□ No

If Yes, do you have a plan for corrective actions when heterotrophic plate counts are not within acceptable limits as determined by your water management program?

□ Yes

□ No

Specific tests for Legionella

□ Yes

□ No

If Yes, do you have a plan for corrective actions when Specific tests for Legionella are not within acceptable limits as determined by your water management program?

□ Yes

□ No