Draft AQUA form 1

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY
ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM 1: CASE ELIGIBILITY
CDCID:

-

Date:

/

/

Data collector initials: _____

Instructions: Refer to question 5 on the Antimicrobial Use Form (AUF); complete each section below, or check
“Not applicable based on AUF” if the patient is not eligible based on question 5 of the AUF.
A. Patient age eligibility
1. Was the patient ≥1 year old on the survey date or day prior?
No  NOT eligible for ANY AQUA Form. Go to HAI Form.
Yes  MAY be eligible for one or more AQUA Forms.
B. VANCOMYCIN eligibility

Not applicable based on AUF

2. Patient ≥1 year old and received vancomycin IV for infection treatment on the survey date or day prior?
No  NOT eligible for AQUA Vancomycin Form.
Yes  Eligible for AQUA Vancomycin Form.
C. FLUOROQUINOLONE eligibility

Not applicable based on AUF

3. Patient ≥18 years old and received a fluoroquinolone for infection treatment on the survey date or day prior?
No  NOT eligible for AQUA Fluoroquinolone Form.
Yes Eligible for AQUA Fluoroquinolone Form.
D. COMMUNITY-ACQUIRED PNEUMONIA (CAP) eligibility

Not applicable based on AUF

4. In patients ≥1 year old given an antimicrobial drug(s) for site code “PNE” with onset “C” on the survey date
or day prior, is there documentation in the medical record of any of the following conditions?
Nursing home or long term care facility or long term acute care hospital residence prior to survey hospital admission
Hospitalized ≥2 days in the 90 days prior to admission
Received IV antimicrobials in the 30 days prior to admission
Received cancer chemotherapy in the 30 days prior to admission
Received wound care in the 30 days prior to admission
Chronic hemodialysis
Home mechanical ventilation
AIDS
Solid organ, bone marrow, or stem cell transplant
Long-term (>30 days) high-dose corticosteroid or other immunosuppressive treatment
Other congenital or acquired immunodeficiency
Cystic fibrosis
None
5. Based on question 4, confirm patient eligibility for the AQUA CAP Form:
≥1 condition checked in question 4  NOT eligible for AQUA CAP Form.
“None” checked in question 4  Eligible for AQUA CAP Form.
E. URINARY TRACT INFECTION (UTI) eligibility

Not applicable based on AUF

6. Patient ≥1 year old and site code “UTI” with onset “C,” “L” or “O” for any antimicrobial drug on the survey
date or day prior?
No  NOT eligible for AQUA UTI Form.
Yes  Eligible for AQUA UTI Form.
F. AQUA eligibility summary
7. Check all AQUA Forms that need to be completed for this patient:
AQUA Vancomycin
AQUA Fluoroquinolone
AQUA CAP
AQUA UTI
None
8. Confirm next steps in data collection:
If “None” is checked in question 7  Antimicrobial use data collection is complete. Go to HAI Form.
If any of the AQUA Form boxes are checked in question 7  Complete AQUA Form 2: General Patient
Assessment, then complete the appropriate AQUA Forms 3a-3d. HAI Form also required.

***FORM IS COMPLETE***
AQUA Case Eligibility_20150421

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