Form 0920-0278 2019-2020 Hospital Induction Interview

Attachment B
2019 National Hospital and Medical Care Survey (NHAMCS)
Hospital and Ambulatory Unit Induction questionnaire

Form Approved OMB No. 0920-0278; Exp. Date: 06/30/2021
Notice – Public reporting burden for this collection of information is estimated to average 30 minutes per response,
including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed,
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burden to: CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN:
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identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS
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HOSPITAL INDUCTION
NAMECHEK

Correct name of hospital?
1='Yes'
2='No'

HSP_NAME

What is the name of your hospital?

ADDCHEK

MAILADD

MHSP_STRET

INTRO_AB

Is your hospital located at (Facility Address)
1='Yes'
2='No'
Is this also the mailing address?
1='Yes'
2='No'
What is the correct mailing address? Enter the number and street or
press enter if same
(Although you have not received the letter,) I'd like to briefly explain the
study to you at this time and answer any questions about it. The
National Center for Health Statistics of the Centers for Disease Control

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and Prevention is conducting its annual study of hospital-based
ambulatory care. (Intro for the survey) Before discussing the details, I
would like to verify our basic information about (facility name) to be
sure we have correctly included this hospital in the study. First,
concerning licensing:
LICHOSP

OWN101

OWNHCC

TEACHOSP

RECSHARE

Is facility a licensed hospital?
1='Yes'
2='No'
Is hospital non-profit, government or proprietary? Read answer
categories out loud
1=Nonprofit (includes church-related, nonprofit corporation, other nonprofit
ownership)
2=State or local government (includes state, county, city, city-county, hospital
district or authority)
3=Proprietary (includes individually or privately owned, partnership or
corporation)
Is hospital owned, operated, or managed by a health care corporation
that owns multiple health care facilities?
1='Yes'
2='No'
3='Unknown'
Is this a teaching hospital?
1='Yes'
2='No'
Does your hospital share its electronic health records system with any
other hospital?
1='Yes'
2='No'
3='Unknown'

NUMSHARE If yes, how many other hospitals? (Specify number)

MERGER

Did this hospital either merge or separate from any OTHER hospital in
the past 2 years?
1=’Merged or separated’
2=’No’
3=’Unknown’

MERSEP

Was this a merger or a separation?
1='Merger'
2='Separation'

OTHNAME

What is the name and address of this OTHER hospital?

OTHSTRET

What is the name and address of this OTHER hospital?
Enter number and street

OTHSTRET2

What is the name and address of this OTHER hospital?
Enter the second line of address or press enter if same/none

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OTHCITY

What is the name and address of the OTHER hospital?
Enter city

OTHSTATE

What is the name and address of this OTHER hospital?
Enter state

OTHZIP

What is the name and address of this OTHER hospital?
Enter zip code

PREVPAN
ESA24

ESANOT24

Was hospital in a previous panel?
Does this hospital provide emergency services that are staffed 24
HOURS each day either here at this hospital or elsewhere?
1='Yes'
2='No'
Does this hospital operate any emergency service areas that are not
staffed 24 HOURS each day?
1='Yes'
2='No'

TRAUMA

What is the trauma level rating of this hospital?
1='Level I'
2='Level II'
3='Level III'
4='Level IV'
5='Level V'
6='Other/unknown'
7='None'

ELIGREQ

Eligibility Requirements

STUDY_DESC

Thank you. Explain the following ONLY if this is a new hospital. Provide
the administrator or other hospital representative with a brief
description of the study. Cover the following points - Now I would like to
provide you with further information on the study.
(1) NHAMCS is the only source of national data on health care provided
in hospital emergency departments.
(2) NHAMCS is endorsed by the: American College of Emergency
Physicians, Emergency Nurses Association, Society for Academic
Emergency Medicine, American College of Osteopathic Emergency
Physicians, American Health Information Management Association.
(3) Nationwide sample of about 600 hospitals.
(4) Four-week data collection period
(5) Brief form completed for a sample of patient visits. As one of the
hospitals that has been selected for the study, your contribution will be
of great value in producing reliable, national data on ambulatory care.

INDUCTION_APPT

I would like to arrange to meet with you so that I can better present the
details of the study. Is there a convenient time within the next week or
so that I could meet with you or your representative? Record day, date
and time of appointment. Enter 999 if the respondent wants to continue
with the induction now.

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SCREENER_THK

Thank you for your cooperation. I am looking forward to our meeting.

THANK_MERGSEP

Since your hospital has merged or separated within the last 2 years, I
need to get further instructions from the Centers for Disease Control
and Prevention (CDC) on how to proceed. I will call you back within a
week and let you know which parts of your hospital will be in the
survey. Thank you for your cooperation.

CALLRO_MERGSE

Call your RO and inform them of the situation. Await resolution from the
RO before continuing with this case.

THANK_B1

Thank you, but it seems that our information is incorrect. Since (facility
name) is not a licensed hospital, it should not have been chosen for our
study. Thank you very much for your cooperation.

THANK_B2

Thank you, but it seems that our information is incorrect. Since (facility
name) does not have 24-hour emergency services, it should not have
been chosen for our study. Thank you very much for your cooperation.

REVIEW

I would like to begin with a brief review of the background for this study.
Provide the administrator or other hospital representative with a brief
introduction to the study and a general overview of procedures. Press
F1 for points to be covered

SURGDAY

How many days in a week are inpatient elective surgeries scheduled?

BEDCZAR

Does your hospital have a bed coordinator, sometimes known as a bed
czar?
1='Yes'
2='No'
3='Unknown'

BEDDATA

How often are hospital bed census data available?
1='Instantaneously'
2='Every 4 hours'
3='Every 8 hours'
4='Every 12 hours'
5='Every 24 hours'
6='Other'
7='Unknown'

HLIST

HLISTED

Does your hospital have hospitalists on staff?
A hospitalist is a physician whose primary professional focus is the general
care of hospitalized patients. He/she may oversee ED patients being admitted
to the hospital.
1='Yes'
2='No'
3='Unknown'
Do the hospitalists on staff at your hospital admit patients from your
ED?
1='Yes'
2='No'
3='Unknown'

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EMEDRES

PERMPART

PERMPARTSPEC

PERM_THANK
RO_PERMISSION

VSREPPER

CINFO

THANK_RESP

Does hospital have Emergency Medicine residency program?
1='Yes'
2='No'
3='Unknown'
As I mentioned earlier, I would like to discuss the plan for conducting
the study. This hospital has been assigned to a 4- week data collection
period beginning on Monday, (Reporting period begin date). First, I
would like to discuss the steps needed to obtain approval for the study.
Are there any additional steps needed to obtain permission for the
hospital to participate in the study?
1=Yes
2=No
Specify the necessary steps needed to obtain permission for the
hospital to participate in the study Include the name, address, phone
and title of the person(s) who can grant approval
Thank you for your help.
Call the Regional Office to inform them of the additional steps needed to
obtain permission
Now I would like to make arrangements to obtain the information
needed for sampling. I will need to (know/verify) how your (emergency
department) (is/are) organized and obtain an estimate of the number of
patient visits expected during the 4-week reporting period. Would you
prefer I (get/verify) this information from you or someone else?
1=Respondent
2=Someone else
What is the name of the person with whom I should speak? Enter 1 to
enter/update hospital contact information Enter 2 to enter/update
department contact information
1=Hospital level contact
2=Department contact
3=Continue interview
Thank current respondent for his/her time and cooperation

AMBULATORY UNIT (AU) INDUCTION: EMERGENCY DEPARTMENT (ED)
INTRO_ESA

If necessary, introduce yourself and explain the survey Explain that in
order to develop a sampling plan, you would like to collect more
specific information about this hospital's emergency department

ESA_NUM

ESA number

DEL_ESA

Does (ESA name) still exist and is it still operational? (Enter 97 to delete
this ESA / If No, Enter 97 to delete If Yes, Press END to move to number of
visits)

ESA_NAME

What is the name of this ESA?

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ESATYPE

ESA_EVISITS

I_ESA

I_ESA_EVISITS

ESA_EVISITS_TOTAL

What type of ESA is (ESA name)?
1='General'
2='Adult'
3='Pediatric'
4='Urgent care/Fast track'
5='Psychiatric'
6='Other'
What is the expected number of visits from (Reporting period begin
date) to (Reporting period end date) for (ESA name)?
ESA name from previous year in panel

Estimated visits form previous year in panel

Total number of ED visits for all good ESAs

TOTVSED

Estimated visits range (compared with estimated visits from previous
year)

TWICELY

Is the number of expected visits to any of the ESAs more than twice the
number shown on the previous sampling plan?
1='Yes'
2='No'

TWICELY_SPEC

Specify why visits have increased this year or were too low the last time
the ED participated

HALFLY

Is the number of expected visits to any of the ESAs less than half the
number shown on the previous sampling plan?
1='Yes'
2='No'

HALFLYSPEC

Specify why visits have decreased this year or were too high the last
time the ED participated

EDPRIM

When patients with identified primary care physicians arrive at the
Emergency Department, how often do you electronically send
notifications to the patients' primary care physicians?
1='Always'
2='Sometimes'
3='Rarely'
4='Never'
5='Unknown'

EDINFO

When patients arrive at the Emergency Department, are you able to
query for patients' healthcare information electronically (e.g.,
medications, allergies) from outside sources?
1='Yes'
2='No'
3='Don’t Know'

OBSUNITS

Does your ED have an observation or clinical decision unit?

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OBSSEP

Is this observation or clinical decision unit physically separate from the
ED?

OBSDECMD

What type of physicians make decisions for patients in this observation
or clinical decision unit? Enter all that apply, separate with commas
1=ED physicians
2=Hospitalists
3=Other physicians
4=Unknown

BOARD

BOARDHOS

AMBDIV

TOTHRDIV

Are admitted ED patients ever "boarded" for more than 2 hours in the
ED or the observation unit while waiting for an inpatient bed?
1='Yes'
2='No'
3='Unknown'
Does your ED allow some admitted patients to move from the ED to
inpatient corridors while awaiting a bed ('boarding') - sometimes called
'full capacity protocol'?
1='Yes'
2='No'
3='Unknown'
Did your ED go on ambulance diversion in 2017?
1='Yes'
2='No'
3='Unknown'
What is the total number of hours that your hospital's ED was on
ambulance diversion in 2017?

REGDIV

Is ambulance diversion actively managed on a regional level versus
each hospital adopting diversion if and when it chooses?
1='Yes'
2='No'
3='Unknown'

ADMDIV

Does your hospital continue to admit elective or schedule surgery cases
when ED is on ambulance diversion?
1='Yes'
2='No'
3='Unknown'

NUMSTATX

As of last week, how many standard treatment spaces did your ED
have? Standard treatment spaces are beds or treatment spaces specifically
designed for ED patients to receive care, including asthma chairs.
Enter CTRL-D if data not available

NUMOTHTX

As of last week, how many other treatment spaces did your ED have?
Other treatment spaces are other locations where patients might receive care
in the ED, including chairs, stretchers in hallways that may be used during
busy times.
Enter CTRL-D if data not available

EDSPACES

In the last two years, did your ED increase the number of standard
treatment spaces?

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1='Yes'
2='No'
3='Unknown'
PHYSSPACE

In the last two years, did your ED's physical space expand?
1='Yes'
2='No'
3='Unknown'

EXPAND

Do you have plans to expand your ED's physical space within the next
two years?
1='Yes'
2='No'
3='Unknown'

BEDREG

Does your ED use bedside registration?
1='Yes'
2='No'
3='Unknown'

KIOSELCHK

CATRIAGE

Does ED use kiosk self-check-in
1='Yes'
2='No'
3='Unknown'
Does your ED use computer-assisted triage?
1='Yes'
2='No'
3='Unknown'

IMBED

Does your ED use immediate bedding (no triage when ED is not at
capacity)?
1='Yes'
2='No'
3='Unknown'

ADVTRIAG

Does your ED use advanced triage (triage-based care) protocols?
1='Yes'
2='No'
3='Unknown'

PHYSPRACTRIA

FASTTRAK

EDPTOR

Does your ED use physician/practitioner at triage?
1='Yes'
2='No'
3='Unknown'
Does your ED use separate fast track unit for non-urgent care?
1='Yes'
2='No'
3='Unknown'
Does your ED use separate operating room dedicated to ED patients?
1='Yes'
2='No'
3='Unknown'

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DASHBORD

RFID

WIRELESS

Does your ED use electronic dashboard?
1='Yes'
2='No'
3='Unknown'
Does your ED use radio frequency identification (RFID) tracking?
1='Yes'
2='No'
3='Unknown'
Does ED use wireless communication devices by providers?
1='Yes'
2='No'
3='Unknown'

ZONENURS

Does your ED use zone nursing?
1='Yes'
2='No'
3='Unknown'

POOLNURS

Does your ED use pool nurses?
1='Yes'
2='No'
3='Unknown'

AU_ONSITE

Is this ESA on-site?
1=Yes
2=No

EDDK_CHECK

Are there any Don't Know items that you need to callback for? Press
Ctrl-M to review DKs and RFs Press Shift-F5 to review all DK Follow-up
remarks If you MUST close this case now, due to pending close-out, and
you will not be collecting your remaining DKs and RFs, please select 2
"No", and make any required explanation in the case notes.
1=Yes
2=No

DONE_ED

Enter 1 to continue to the next department WARNING: once you pass
this screen, the ED portion of the induction interview will be closed, and
you will not be allowed to re-enter to change any answers or add
additional AUs. If you need to go back, use your up arrow to go back
now, or press F10 to come back in later. DO NOT press 1 if you need to
come back to this department section later.

I_EDMIN
I_EDMAX
TOT_GOODESA
AMBULATORY UNIT (AU) INDUCTION: GENERAL QUESTIONS
NUMPRFS

Total number of PRFs filled out for this AU.

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NUMTRLEV

How many levels are in this ESA's triage system?
1=Three
2=Four
3=Five
4=Other – Specify
5=None Do not conduct triage

NUMTRLEV_SP
NUMADM
ADMIT_ZERO

ADMIT_ZERO_SP
LOG105

LOG105_SP

PARTICIP

CLOSED

NONINT_TYPE

Specify other triage levels
Number of PRFs with visit disposition of 'Admit to Hospital'
Are you not receiving any hospital admissions because the charts were
not available at the time of abstractions?
Explanation of why zero admissions
There were PRFs with a disposition of *Admit to Hospital* but are
missing hospital discharge information. Will you be able to get this
information?
1 = 'Yes'
2='No'
Specify the reason

Participated
1 = 'Patients seen'
2 = 'No patients seen'
Closed
1 = 'Temporary'
2 = 'Permanent'
Type of Non-interview
1='Unable to locate - Call RO'
2='Abstraction delayed by facility'
3='AU ineligible - not under auspices or hospital'
4='AU ineligible - only ancillary services provided'
5='AU ineligible - care not provided by or under the direct supervision of a
physician'
6='AU ineligible - AU classified out of scope'
7='AU ineligible - Other'
8='Closed - Temporary'
9='Closed - Permanent'
10='Hospital refused'
11='Whole department refused'
12='Potential refusal - follow-up required'
13='Refused (TRANSMIT)'

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NONINT_SP

Specify other ineligible

ELECTRONIC HEALTH RECORDS (EHR): ED (E)
EHRINSYRE

HHSMUE

EHRNAME

EHRNAMOTHE

EHRINSE

In which year did your ED install the EMR/EHR system?

Does your current system meet meaningful use criteria as defined by
the Department of Health and Human Services?
1='Yes'
2='No'
3='Unknown'
What is the name of your current EMR/EHR system?
1='Allscripts'
2='Amazing Charts'
3='athenahealth'
4='Cerner'
5='eClinicalWorks'
6='e-MDs'
7='Epic'
8='GE/Centricity'
9=’Modernizing Medicine’
10='NextGen'
11='Practice Fusion'
12='Sage/Vita/Greenway Medical'
13='Other - Specify'
Other - specify name of EHR/EMR system

Does your ED have plans for installing a new EHR/EMR system within
the next 18 months?
1='Yes'
2='No'
3='Maybe'
4='Unknown'

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