Healthcare Facility Assessment

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY
HEALTHCARE FACILITY ASSESSMENT

For EIP Team use only: CDC Hospital ID:

Form Approved
OMB No. 0920-0852
Exp. Date xx/xx/xxxx

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Sources of Information (NOT transmitted to CDC):
For each Section of the assessment below, list the names of person(s) and department(s) to contact for information.

Section

Description

I.

Information about person
responsible for ensuring
completion of assessment and
submission to EIP Team

II.

Hospital data

III.

Infection prevention and control

Person(s)

Department(s)

___________________

___________________

___________________

___________________

___________________

___________________

___________________

___________________

___________________

___________________

___________________ ___________________
___________________
IV.

Antimicrobial stewardship

___________________

___________________ ___________________
___________________

___________________

___________________ ___________________

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 30329; ATTN: PRA (0920-0852).

Phase5_HFA_20190221 Page 1 of 18

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Phase5_HFA_ 20190221 Page 2 of 18

For EIP Team use only: CDC Hospital ID:

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I: Information about person responsible for ensuring completion of assessment and
submission to EIP Team
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–

Phase5_HFA_ 20190221 Page 3 of 18

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Phase5_HFA_ 20190221 Page 4 of 18

For EIP Team use only: CDC Hospital ID:

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II. Hospital data

3) Complete the following table for your hospital, using the most current data available to you:
Hospital characteristic
No. of acute care licensed beds
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.

No. of full time equivalent (FTE) infection
preventionists
Enter the number of FTEs to the nearest hundreth of an FTE. For
example, if you have three staff members who each spend 35% of
their time on infection prevention, you would enter 1.05 FTE. If you
do not have any staff who serve part- or full-time as infection
preventionists, check “None.” If you do not know if your hospital has
any part- or full-time infection preventionists, check “Unknown.”

No. of FTE physician hospital epidemiologists
Enter the number of FTEs to the nearest hundreth of an FTE. For
example, if you have two physicians who spends 45% of their time
as hospital epidemiologists, you would enter 0.9 FTE. If you do not
have any physicians who serve part- or full-time as hospital
epidemiologists, check “None.” If you do not know if your hospital
has any part- or full-time hospital epidemiologists, check
“Unknown.”

No. of FTE interns/residents
Enter the number of FTE interns or residents that work in your
hospital to the nearest hundredth of an FTE (e.g., 50.25 FTE). If
your hospital does not have any interns or residents, check
“None” and skip to Question #4. If you do not know if your
hospital has interns or residents, check “Unknown.”

If your hospital has interns or residents:
Provide the official intern/resident to bed ratio (IRB)
If you do not know your hospital’s official IRB, check
"Unknown".
Phase5_HFA_ 20190221 Page 5 of 18

What year are
data from?

Number

☐☐☐☐

or

☐2018 ☐2019
☐Other: ______

☐☐☐☐

or

☐2018 ☐2019
☐Other: ______

☐ Unknown

☐ Unknown

☐☐.☐☐
or
☐ None
☐ Unknown

☐☐.☐☐
or
☐ None
☐ Unknown

☐☐☐.☐☐

or
☐ None
☐ Unknown
☐ <0.25
☐ ≥0.25
☐ Unknown

☐2018 ☐2019
☐Other: ______

☐2018 ☐2019
☐Other: ______

☐2018 ☐2019
☐Other: ______

☐2018 ☐2019
☐Other: ______

For EIP Team use only: CDC Hospital ID:

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4) For each type of unit in your hospital, check the one ratio that most accurately reflects the average
Registered Nurse (RN) to patient ratio during dayshift hours:
Note: “1:1” means one RN for one patient, “1:2” means one RN for every two patients, etc. Check
“NA” (not applicable) if your hospital does not have one of the listed unit types.
Adult

Medical critical care unit

☐ 1:1

☐ 1:2

☐ 1:3

☐ 1:4

☐ 1:5

☐ 1:6

Surgical critical care unit

☐ 1:1

☐ 1:2

☐ 1:3

☐ 1:4

☐ 1:5

☐ 1:6

Medical-surgical critical care
unit

☐ 1:1

☐ 1:2

☐ 1:3

☐ 1:4

☐ 1:5

☐ 1:6

Medical ward

☐ 1:1

☐ 1:2

☐ 1:3

☐ 1:4

☐ 1:5

☐ 1:6

☐ 1:1

☐ 1:2

☐ 1:3

☐ 1:4

☐ 1:5

☐ 1:6

☐ 1:1

☐ 1:2

☐ 1:3

☐ 1:4

☐ 1:5

☐ 1:6

Medical critical care unit

☐ 1:1

☐ 1:2

☐ 1:3

☐ 1:4

☐ 1:5

☐ 1:6

Surgical critical care unit

☐ 1:1

☐ 1:2

☐ 1:3

☐ 1:4

☐ 1:5

☐ 1:6

☐ 1:1

☐ 1:2

☐ 1:3

☐ 1:4

☐ 1:5

☐ 1:6

☐ 1:1

☐ 1:2

☐ 1:3

☐ 1:4

☐ 1:5

☐ 1:6

☐ 1:1

☐ 1:2

☐ 1:3

☐ 1:4

☐ 1:5

☐ 1:6

☐ 1:1

☐ 1:2

☐ 1:3

☐ 1:4

☐ 1:5

☐ 1:6

Surgical ward
Medical-surgical ward

Medical-surgical critical care
unit
Medical ward
Surgical ward
Medical-surgical ward

☐ Other, specify:_________
☐ Other, specify:_________
☐ Other, specify:_________
☐ Other, specify:_________
☐ Other, specify:_________
☐ Other, specify:_________
Pediatric
☐ Other, specify:_________
☐ Other, specify:_________
☐ Other, specify:_________
☐ Other, specify:_________
☐ Other, specify:_________
☐ Other, specify:_________
–End of Section 2–

Phase5_HFA_ 20190221 Page 6 of 18

☐ Unknown
☐ Unknown

☐ Unknown
☐ Unknown
☐ Unknown
☐ Unknown
☐ Unknown
☐ Unknown
☐ Unknown
☐ Unknown
☐ Unknown
☐ Unknown

☐ NA
☐ NA
☐ NA
☐ NA
☐ NA
☐ NA
☐ NA
☐ NA
☐ NA
☐ NA
☐ NA
☐ NA

For EIP Team use only: CDC Hospital ID:

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III. Infection prevention and control

5) Does your facility have an infection control team or program with at least one staff member
responsible for developing and implementing infection control policies and practices and
related activities?
☐ Yes
☐ No (if “No,” skip to question #9)
6) 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): _____________________________
7) If your hospital has an infection control team/program, how long has the infection control team/
program been in place (check one)?
☐ < 1 year
☐ 1 – 3 years
☐ 4 – 6 years
☐ 7 – 9 years
☐ ≥ 10 years
8) 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

Phase5_HFA_ 20190221 Page 7 of 18

For EIP Team use only: CDC Hospital ID:

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9) Is there a committee in your hospital that reviews infection control-related activities (such as
reports, policies and procedures, etc)?
☐ Yes
☐ No (if “No,” skip to question #12)
10) 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
☐ Nursing unit managers or supervisors
☐ Physician staff
☐ Nursing staff
☐ Other (specify): __________________________
11) 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
12) For each HAI surveillance statement below, check YES, NO, or UNKNOWN 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.

Phase5_HFA_ 20190221 Page 8 of 18

YES

NO

UNKNOWN

☐

☐

☐

☐

☐

☐

For EIP Team use only: CDC Hospital ID:

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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 (e.g., nurses, physicians, etc.).

YES

NO

UNKNOWN

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

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

NO

UNKNOWN

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.

☐

☐

☐

☐

☐

☐

14) For each statement about monitoring adherence to infection control policy, check YES, NO, or
UNKNOWN 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.

Phase5_HFA_ 20190221 Page 9 of 18

YES

NO

UNKNOWN

☐

☐

☐

☐

☐

☐

☐

☐

☐

For EIP Team use only: CDC Hospital ID:

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My hospital shares adherence rates to specific policies
(e.g., hand hygiene) with relevant staff.
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

UNKNOWN

☐

☐

☐

☐

☐

☐

15) 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): ___________________________
16) For each multidrug-resistant organism (MDRO) management statement below, check YES, NO,
or UNKNOWN to indicate what is being done in your hospital at the time of this assessment:
My hospital has a mechanism to identify, on admission,
patients previously infected or colonized with the
following MDROs:
Methicillin-resistant Staphylococcus aureus (MRSA):

YES

NO

UNKNOWN

☐

☐

☐

Vancomycin-resistant Enterococcus (VRE):

☐

☐

☐

Carbapenem-resistant Enterobacteriaceae (CRE):

☐

☐

☐

Clostridioides difficile (C. diff):

☐

☐

☐

Phase5_HFA_ 20190221 Page 10 of 18

For EIP Team use only: CDC Hospital ID:

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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):

YES

NO

UNKNOWN

☐

☐

☐

☐

☐

☐

Carbapenem-resistant Enterobacteriaceae (CRE):

☐

☐

☐

Clostridioides difficile (C. diff):

☐

☐

☐

YES

NO

UNKNOWN

☐

☐

☐

☐

☐

☐

Carbapenem-resistant Enterobacteriaceae (CRE):

☐

☐

☐

Clostridioides difficile (C. diff):

☐

☐

☐

YES

NO

UNKNOWN

☐

☐

☐

☐

☐

☐

Carbapenem-resistant Enterobacteriaceae (CRE):

☐

☐

☐

Clostridioides difficile (C. diff):

☐

☐

☐

YES

NO

UNKNOWN

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

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):

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):

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):
Clostridioides difficile (C. diff):

Phase5_HFA_ 20190221 Page 11 of 18

For EIP Team use only: CDC Hospital ID:

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17)What is the primary testing method for Clostridioides difficile (C. difficile) used most often by your
hospital’s laboratory or the outside laboratory where your hospital’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): ______________________________

18)Which of the following Clostridioides difficile (C. 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 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.
☐ Other (specify):______________________________
☐ 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 Clostridioides difficile (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):______________________________
☐ NA (all rooms in my hospital are private rooms, or there is always a sufficient number of
private rooms available)

Phase5_HFA_ 20190221 Page 12 of 18

For EIP Team use only: CDC Hospital ID:

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20)For patients with active Clostridioides difficile (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 Methicillin-resistant
Staphylococcus aureus (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)?
☐ 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)IIn 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
Phase5_HFA_ 20190221 Page 13 of 18

–End of Section 3–

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Phase5_HFA_ 20190221 Page 14 of 18

For EIP Team use only: CDC Hospital ID:

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IV. Antimicrobial stewardship
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)?
☐ < 1 year
☐ 1 – 3 years
☐ 4 – 6 years
☐ 7 – 9 years
☐ ≥ 10 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

Phase5_HFA_ 20190221 Page 15 of 18

For EIP Team use only: CDC Hospital ID:

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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
☐ Formal recognition as a hospital committee
☐ Other (specify): _______________________________________
☐ No formal support from administration
29) For each statement listed below, regardless of whether you have an antimicrobial
stewardship team, check YES, NO, or UNKNOWN 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 a system that automatically alerts
prescribers and/or member(s) of antimicrobial
stewardship team in situations where therapy might be
unnecessarily duplicative.
My hospital has guidelines for surgical prophylaxis.

Phase5_HFA_ 20190221 Page 16 of 18

YES

NO

UNKNOWN

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

For EIP Team use only: CDC Hospital ID:

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My hospital has guidelines for first-line antimicrobial therapy
for common infections (e.g., community-acquired
pneumonia, urinary tract infections, etc.).
My hospital monitors prescribers’ adherence to
guidelines (drug, dose, duration, and indication) in
specific patient care units or hospital-wide.
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.
My hospital provides training/educational session on
appropriate antimicrobial use to prescribers at least
annually
My hospital requires prescribers to participate in a training/
educational 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

UNKNOWN

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

☐

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☐

☐

☐

☐

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30)Is antimicrobial consumption monitored in your hospital?
☐ Yes
☐ No (If “No,” STOP as Healthcare Facility Assessment is complete)

Phase5_HFA_ 20190221 Page 17 of 18

For EIP Team use only: CDC Hospital ID:

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31)IIf 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
☐ Other (specify): __________________________
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
☐ Standardized Antimicrobial Administration Ratio (SAAR)
☐ Other (specify): __________________________
34)IIf 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–

Phase5_HFA_ 20190221 Page 18 of 18

FORM IS COMPLETE