Form CDC 57.300 CDC 57.300 Hemovigilance Module - Annual Survey

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Hemovigilance Module - Annual Facility Survey

Acute Care Facility

*Required for saving

*Facility ID#: ____________________

*Survey Year: ____________

For all questions, use information from previous full calendar year.

Facility Characteristics

*1. Ownership: (check one)

Government

Military

Not for profit, including church

For profit

Veteran’s Affairs

Physician-owned

*2. Is your hospital a teaching hospital for physicians and/or physicians-in-training?

Yes

No

If Yes, check type:

Major

Graduate

Undergraduate

*3. Community setting of facility:

Urban

Suburban

Rural

*4. How is your hospital accredited? (check one)

The Joint Commission

American Osteopathic Association (AOA)

National Integrated Accreditation for Healthcare Organizations (DNV)

Other Accrediting Organization

*5. Total beds served by the transfusion service.

___________

*6. Number of surgeries performed per year:

Inpatient:

_______

Outpatient:

_______

*7. At what trauma level is your facility certified?

I

II

III

IV

N/A

Transfusion Service Characteristics

*8. Primary classification of facility areas served by the transfusion service: (check all that apply)

Cancer center

Orthopedic

General medical and surgical

Children’s cancer center

Children’s orthopedic

Children’s general medical and surgical

Chronic disease

Burn center

Obstetrics/Gynecology

Children’s chronic disease

Trauma/Emergency

Other (specify) ________________________

*9. Does your healthcare facility provide all of its own transfusion services, including all laboratory functions?

Yes

No, we contract with a blood center for some transfusion service functions.

No, we contract with another healthcare facility for some transfusion service functions.

*10. Is the transfusion service part of the facility’s core laboratory?

Yes

No

*11. How many dedicated transfusion service staff members are there? (Count full-time equivalents; include supervisors.)

Physicians:

____

Medical Technologists:

_____

Medical Laboratory Technicians:

_____

Assurance of Confidentiality: The voluntarily provided 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 2 hours 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).

*12. Does your hospital have a dedicated position or FTE in a quality or patient safety function (e.g., TSO) for investigation of transfusion-related adverse reactions?

Yes

No

*13. Does your hospital have a dedicated position or FTE in a quality or patient safety function (e.g., TSO) for investigation of transfusion errors (i.e., incidents)?

Yes

No

*14. Is the transfusion service laboratory accredited?

Yes

No

If Yes, select all that apply:

College of American Pathologists (CAP)

AABB

TJC

*15. Does your facility have a committee that reviews blood utilization?

Yes

No

*16. Total number of patient samples collected for type and screen or crossmatch:

________

*17. Total number of units/aliquots transfused annually:

Units:

Aliquots:

Whole blood derived red blood cells

__________

__________

Apheresis red blood cells

__________

__________

Whole blood derived platelet concentrates

__________

What is your average pool size?

__________

Apheresis platelets

__________

__________

Whole blood derived plasma (Incl. FFP, thawed, etc.)

__________

__________

Apheresis plasma

__________

__________

Cryoprecipitate

__________

What is your average pool size?

__________

Granulocytes

__________

__________

Lymphocytes

__________

__________

*18. Are any of the following issued through the transfusion service? (check all that apply)

Albumin

Factors (VIIa, VIII, IX, ATIII, etc.)

Immunoglobulin (IV)

Immunoglobulin (IM or subcutaneous)

RhIg

None

*19. Does your facility attempt to transfuse only leukocyte-reduced or leuko-poor cellular components?

Yes

No

*20. Are all units stored in the transfusion service?

Yes

No

If No, indicate the location(s) of satellite storage: (check all that apply)

Ambulatory Care

Cancer Center

Cardiac ICU

Emergency Department

Labor and Delivery

Medical Flight Facility

Operating Room

Other: (specify) __________________________________________

*21. To what extent does the transfusion service modify products? (check all that apply)

Aliquot

Deglycerolizing

Irradiation

Leukoreduction

Plasma reduction

Pooling

Washing

None of these

*22. Do you collect blood for transfusion at your facility?

Yes

No

If Yes, check all that apply:

Allogeneic

Autologous

Directed

*23. Does your facility perform viral testing on blood for transfusion?

Yes

No

*24. Does your facility perform point-of-issue bacterial testing on platelets prior to transfusion?

Yes

No

Transfusion Service Computerization

*25. Is the transfusion service computerized?

Yes

No (If No, skip to next section)

If Yes, select system(s) used: (check all that apply)

BBCS®

BloodTrack Tx® (Haemonetics)

Cerner Classic®

Cerner Millennium®

HCLL®

Horizon BB®

Hemocare®

Lifeline®

Meditech®

Misys®

Safetrace Tx® (Haemonetics)

Softbank®

Western Star®

Other (specify) __________________________________________

*26. Is the system ISBT-128 compliant?

Yes

No

*27. Does the transfusion service system interface with the patient registration system?

Yes

No

*28. Are the transfusion service adverse events entered into a hospital-wide electronic reporting system?

Yes

No

If Yes, specify system used: ________________________________

*29. Does your facility use positive patient ID technology for the transfusion service?

Yes, hospital wide

Yes, certain areas

Not used

If Yes, select purpose(s): (check all that apply)

Specimen collection

Product administration

If Yes, select system(s) used: (check all that apply)

Mechanical barrier system (e.g., Bloodloc®)

Separate transfusion ID wristband system (e.g., Typenex®)

Radio frequency identification (RFID)

Bedside ID band barcode scanning

Other (specify) ____________________________________________________________

*30. Does your facility have physician online order entry for test requesting?

Yes

No

*31. Does your facility have physician online order entry for product requesting?

Yes

No

Transfusion Service Specimen Handling and Testing

*32. Are transfusion service specimens drawn by a dedicated phlebotomy team?

Always

Sometimes, approximately _______% of the time

Never

*33. What specimen labels are used at your facility? (check all that apply)

Handwritten

Addressograph

Computer generated from laboratory test request

Computer generated by bedside device

Other (specify) _______________________

*34. Are phlebotomy staff members allowed to correct patient identification errors on pre-transfusion specimen labels?

Yes

No

*35. What items can be used to verify patient identification during specimen collection and prior to product administration at your facility? (check all that apply)

Medical record (or other unique patient ID) number

Date of birth

Gender

Patient first name

Patient last name

Transfusion specimen ID system (e.g., Typenex®)

Patient verbal confirmation of name or date of birth

Other (specify) ____________________

*36. How is routine type and screen done? (check all that apply and estimate frequency of each)

Manual technique

_______%

Automated technique

_______%

Both automated and manual technique

_______%

Total should equal 100%

*37. Is the ABO group of a pre-transfusion specimen routinely confirmed?

Yes

No

If Yes, check one:

All samples

If there is no laboratory record of previous determination of patient’s ABO group

If there is no laboratory record of previous determination of patient’s ABO group AND the patient is a candidate for electronic crossmatching

If Yes, is the confirmation required on a separately-collected specimen before a unit of Group A, B or AB red blood cells is issued for transfusion?

Yes

No

*38. How many RBC type and screen and crossmatch procedures were performed at your facility by any method?

RBC type and screen:

________

RBC crossmatch

________

Estimate the % of crossmatch procedures done by each method: (check all that apply)

Electronically

_____%

Serologically

_____%

Don’t know

Total may be >100%

CDC 57.300 Rev. 6, v8.6

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