Emerging Infections Programs (EIP)
OMB Control Number 0920-0978
Expiration Date: 05/31/2021
Program Contact
Sonja Mali Nti-Berko
Emerging Infections Programs (EIP)
Division of Preparedness and Emerging Infections
National Center for Emerging and Zoonotic Infectious Diseases
Centers for Disease Control and Prevention
1600 Clifton Rd, MS-C18
Atlanta, GA 30329
Phone: (404) 488-4780
E-mail: [email protected]
Submission Date: August 23, 2018
Circumstances of Change Request for OMB 0920-0978
This is a nonmaterial/non-substantive change request for OMB No. 0920-0978, expiration date 02/28/2019, for the Emerging Infections Programs (EIP). All requested changes represent minor modifications to already-approved instruments including revised formatting, rewording, new answer options, and the addition/subtraction of a limited number of questions. Larger changes are being packaged together into a revision ICR that will be submitted in winter 2018/2019.
The Emerging Infections Programs (EIPs) are population-based centers of excellence established through a network of state health departments collaborating with academic institutions, local health departments, public health and clinical laboratories, infection control professionals, and healthcare providers. EIPs assist in local, state, and national efforts to prevent, control, and monitor the public health impact of infectious diseases.
Activities of the EIPs fall into the following general categories: (1) active surveillance; (2) applied public health epidemiologic and laboratory activities; (3) implementation and evaluation of pilot prevention/intervention projects; and (4) flexible response to public health emergencies. Activities of the EIPs are designed to: (1) address issues that the EIP network is particularly suited to investigate; (2) maintain sufficient flexibility for emergency response and new problems as they arise; (3) develop and evaluate public health interventions to inform public health policy and treatment guidelines; (4) incorporate training as a key function; and (5) prioritize projects that lead directly to the prevention of disease.
Activities in the EIP Network in which all applicants must participate are:
Active Bacterial Core surveillance (ABCs): active population-based laboratory surveillance for invasive bacterial diseases.
Foodborne Diseases Active Surveillance Network (FoodNet): active population-based laboratory surveillance to monitor the incidence of select enteric diseases.
Influenza Hospitalization Surveillance Network (FluSurv-NET): active population-based surveillance for laboratory confirmed influenza-related hospitalizations.
Healthcare-Associated Infections-Community Interface (HAIC) surveillance: active population-based surveillance for healthcare-associated pathogens and infections.
This non-substantive change request is for changes to the disease-specific data elements for ABCs, FluSurv-NET, and HAIC only. As a result of proposed changes, the estimated annualized burden is expected to decrease by 360 hours, from 40,347 to 39,987 and the estimated number of annual responses is shown to decrease by 8,850 from 115,600 to 106,750 responses. The data elements and justifications are described below.
The forms for which approval for changes are being sought include:
ABCs:
2019 ABCs Case Report Form (Att. 1)
2019 ABCs H. influenzae Neonatal Sepsis Expanded Surveillance Form (Att. 2)
2019 ABCs Neonatal Infection Expanded Tracking Form (Att. 3)
2019 ABCs Non-Invasive Pneumococcal Pneumonia (SNiPP) (discontinued)
FluSurv-NET:
Influenza Hospitalization Surveillance Network Case Report Form (Att. 4)
HAIC:
2019 Resistant Gram-Negative Bacilli (MuGSI) Case Report Form for Carbapenem-resistant Enterobacteriaceae and Acinetobacter baumannii (Att.5)
2019 Multi-site Gram-Negative Surveillance Initiative (MuGSI)- Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae (ESBL) (Att.6)
Multi-site Gram-Negative Surveillance Initiative (MuGSI)- Carbapenem-resistant Pseudomonas aeruginosa (CR-PA) (discontinued).
2019 Invasive Methicillin-resistant Staphylococcus aureus (MRSA) Infection Case Report Form (Att. 7)
2019 Invasive Methicillin-sensitive Staphylococcus aureus (MSSA) Infection Case Report Form (Att. 8)
2019 CDI Case Report and Treatment Form (Att. 9)
2019 HAIC Candidemia Case Report (Att. 10)
Description of Changes
ABCs:
2019 ABCs Case Report Form
There is no impact on burden due to the changes on this form. Changes include:
Question 3 – Added collection of Patient ID, which is a person ID, to be able to link persons with multiple recurrences of invasive bacterial disease.
Questions T1 – T8 – Reformatting method of collection for previous Questions 3a, 3b, 3c, 3d, 12a, 12b, 13, 13b, 14, 15, and 15b to standardize the method of collection with HL7 messaging format for these question as a repeating group.
Question 22a, added an option for ‘Left Against Medical Advice” (AMA) to aid in understanding impact on severity of illness.
Question 27, Underlying Conditions – adding checkbox for ‘HbA1C’ laboratory value and the date the value was collected. This will be collected for diabetic cases only to understand the level of management of the disease (diabetes) which can influence long-term sequelae.
Question 27c, Substance Use – change option ‘E-cigarette’ to ‘E-Nicotine Delivery System’
Question 27d, Substance Use – Added option for Marijuana/cannabinoid use (other than smoking), added checkbox for ‘Documented Use Disorder or Abuse’ for each Substance use category, added ‘Skin popping’ as option for mode of delivery for substance use. Changed ‘Illicit opioid’ to ‘Opioid, DEA schedule I (e.g. heroin)’, ‘Prescription opioid’ to ‘Opioid, DEA Schedule II – IV (e.g., methadone, oxycodone), and changed ‘Stimulant (cocaine, meth, etc.)’ to ‘Cocaine or methamphetamine’. All changes made to better capture information actually documented in the patient’s medical record and to understand the risk associated with substance use for ABCs cases.
Question 28c – adding ‘Medical Chart’ check box better capture the source of where vaccination history information is obtained.
2019 ABCs H. influenzae Neonatal Sepsis Expanded Surveillance Form
There is no impact on burden due to the changes on this form. Changes include:
Minor wording changes to instructions at the top of the form on the first page to clarify what information is being collected
Question 29 – added a ‘None listed’ option to better capture this information
2019 Neonatal Infection Expanded Tracking Form
There is no impact on burden due to the changes on this form. Changes include:
Question 35 will be recoded to harmonize with Question 5 on the ABCs CRF. Two wording changes:
Option 2: “Partial” changed to “Incomplete”.
Option 3 (now changing to option 4): “after 3 requests” added.
2018 Surveillance for Non-Invasive Pneumococcal Pneumonia (SNiPP)
This form is being removed from the package. Justification: Data collection is limited to only 9 respondents and there is no plan to increase the number of respondents in the foreseeable future. The removal of this form from the EIP ICR results in a decrease in burden of 208 hours per year.
FluSurv-Net:
Influenza Hospitalization Surveillance Network Case Report Form
On 5/22/2018, OMB approved a full revision including minor changes including test types, substance abuse, disease, treatment, and diagnosis. For this change request, proposed revisions include minor revised language and rewording to improve clarity of the data collection form and additional of several variables including minor additional choices for patient residence at time of hospitalization, pregnancy, acute signs/symptoms at admission, bacterial pathogens, and diagnosis. Select questions about date of onset of acute condition leading to hospitalization, treatment, and sign/symptoms were removed. Burden hours have remained unchanged for these changes.
HAIC:
2019 MuGSI Case Report Form for Carbapenem-resistant Enterobacteriaceae (CRE) and Acinetobacter baumannii (CRAB)
For the 2019 Carbapenem Resistant Enterobacteriaceae (CRE)/ Carbapenem Resistant A. baumannii (CRAB) Multi-site Gram-Negative Surveillance Initiative (MuGSI) Case Report Form (CRF), we are proposing the following changes: 1) we are requesting the addition of ten antimicrobial agents to the susceptibility table (three of these antimicrobials were added for harmonization purposes between this CRF and the ESBL CRF, we expect improved consistency will reduce burden among reviewers); 2) we reworded the questions related to carbapenemase testing to streamline data collection and to make data collection more intuitive and more efficient; 3) we added one new question related to CRAB cases; 4) we have changed the language of many of the existing questions so that it is the same for all the population based surveillance activities for HAIC, and we expect that this will add efficiency in completing these questions and reduce burden; 5) we have also reordered the questions based on feedback from the EIP sites, again in an effort to make the completion of the form more efficient and to reduce the time it will take to complete; 6) we have modified the way substance use is collected.
The language changes, listed above, were made in conjunction with all other HAIC pathogen groups to standardize the way questions are asked across all HAIC pathogens. In some instances, this resulted in minor modifications to the question wording and response options, including the order in which the responses are presented. Harmonization efforts have also resulted in moving questions from one section of the CRF to another. In several questions, we have added additional checkboxes; this includes 22 checkboxes in the underlying conditions section. The overall goal of these harmonization efforts is to simplify the form for respondents and to reduce the time it will take to complete the form.
We have modified the way substance use is collected. These data elements were collecting in a more general way, on previously approved HAIC data collection forms. The substance use questions are important to track the impact of the opioid epidemic on the disease burden for MuGSI pathogens. Information on substance use is already collected for other EIP pathogens, outside of the HAIC program.
The requested changes will have minimal impact on the burden of data collection and are anticipated to have a small impact on the time expected to complete the case report form. We are anticipating a 5 minute increase.
2019 Multi-site Gram-Negative Surveillance Initiative (MuGSI)- Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae (ESBL)
For the 2019 Extended-Spectrum Beta-Lactamase (ESBL)-Producing Enterobacteriaceae Multi-site Gram-Negative Surveillance Initiative (MuGSI) Case Report Form (CRF), we are requesting the following changes: 1) the addition of two new questions to better capture information on patients’ urine cultures and history of UTIs; 2) several questions were updated to align with the MuGSI CRE/CRAB CRF to harmonize between the two forms and to reduce the burden on chart abstractors (see detailed description of changes); 3) added questions to align with the MuGSI CRE/CRAB CRF (see detailed descriptions of changes); 4) removed the question 15b from the 2018 ESBL CRF; 6) we reworded the questions related to ESBL detection in clinical microbiology laboratories make the question more intuitive and thus reducing the burden it will take to complete this question, these changes were made as a result of analyzing the pilot ESBL data; 5) we have changed the language of many of the existing questions so that data collection of common questions is standardized across the population based surveillance activities for HAIC, and we expect that this will add efficiency in completing these questions and should reduce burden; 6) we have also reordered the questions based on feedback from the EIP sites, in an effort to make the completion of the form more efficient and to reduce the time it will take to complete the form; 7) we have modified the way substance use is collected.
Harmonization between this CRF and the CRE/CRAB CRF will save time and reduce burden on our chart reviewers that use these forms. The staff that complete this and the CRE/CRAB CRF in the EIP sites are the same.
Additionally, we have changed the language of many existing questions. These changes were made in conjunction with all other HAIC pathogen groups to standardize the way questions are asked across all HAIC pathogens. In some instances, this resulted in minor modifications to the question wording and response options, including the order in which the responses are presented. Harmonization efforts have also resulted in moving questions from one section of the CRF to another. In several questions, we have added additional checkboxes; this includes 22 checkboxes in the underlying conditions section. The overall goal of these harmonization efforts is to simplify the form for respondents and to reduce the time it will take to complete the form.
We have modified the way substance use is collected. These data elements were collected in a more general way, on previously approved HAIC data collection forms. The substance use questions are important to track the impact of the opioid epidemic on the disease burden for ESBL-producing pathogens. Information on substance use is already collected for other EIP pathogens, outside of the HAIC program.
The requested changes will have minimal impact on the burden of data collection and are anticipated to have a small impact on the time expected to complete the case report form. We are anticipating a 5 minute increase.
Multi-site Gram-Negative Surveillance Initiative (MuGSI)- Carbapenem-resistant Pseudomonas aeruginosa (CR-PA)
This form is being removed from the package. The removal of this form from the EIP ICR results in a decrease in burden of 2,580 hours per year. There is no longer a need for EIP to continue collecting data on Carbapenem-resistant Pseudomonas aeruginosa cases. Because of high case counts, sufficient medical record data has been collected.
Invasive MRSA Infection Case Report Form
Changes are being requested for the 2019 Methicillin-resistant Staphylococcus aureus (MRSA) Case Report Form: 1) the addition of susceptibility for two additional antimicrobial agents; 2) we have modified the way substance use is collected; 3) we have changed the language of many of the existing questions so that data collection of common questions is standardized across the population based surveillance activities for HAIC, and we expect that this will add efficiency in completing these questions and should reduce burden; 4) we have reordered the questions based on feedback from the EIP sites in an effort to make the completion of the form more efficient and to reduce the time it will take to complete the form.
We have changed the language of many existing questions. These changes were made in conjunction with all other HAIC pathogen groups to standardize the way questions are asked across all HAIC pathogens. In some instances, this resulted in minor modifications to the question wording and response options, including the order in which the responses are presented. Harmonization efforts have also resulted in moving questions from one section of the CRF to another. In several questions, we have added additional checkboxes; this includes 22 checkboxes in the underlying conditions section. The overall goal of these harmonization efforts is to simplify the form for respondents and to reduce the time it will take to complete the form.
We have modified the way substance use is collected. These data elements were collected in a more general way, on previously approved HAIC data collection forms. The substance use questions are important to track the impact of the opioid epidemic on the disease burden for MRSA. Information on substance use is already collected for other EIP pathogens, outside of the HAIC program.
The requested changes will have minimal impact on the burden of data collection and are anticipated to have a small impact on the time expected to complete the case report form. We are anticipating a 5 minute increase. Additionally, the estimated number of annual responses has been adjusted: from 609 to 474. The net change in burden is a 55 hour decrease.
2019 Invasive MSSA Infections Case Report Form
The following changes are requested for the 2019 Methicillin-sensitive Staphylococcus aureus (MSSA) Case Report Form: 1) addition of susceptibility for two additional antimicrobial agents; 2) we have modified the way substance use is collected; 3) we have changed the language of many of the existing questions so that data collection of common questions is standardized across the population based surveillance activities for HAIC, and we expect that this will add efficiency in completing these questions and should reduce burden; 4) we have reordered the questions based on feedback from the EIP sites in an effort to make the completion of the form more efficient and to reduce the time it will take to complete the form.
We have changed the language of many existing questions. These changes were made in conjunction with all other HAIC pathogen groups to standardize the way questions are asked across all HAIC pathogens. In some instances, this resulted in minor modifications to the question wording and response options, including the order in which the responses are presented. Harmonization efforts have also resulted in moving questions from one section of the CRF to another. In several questions, we have added additional checkboxes; this includes 22 checkboxes in the underlying conditions section. The overall goal of these harmonization efforts is to simplify the form for respondents and to reduce the time it will take to complete the form.
We have modified the way substance use is collected. These data elements were collected in a more general way, on previously approved HAIC data collection forms. The substance use questions are important to track the impact of the opioid epidemic on the disease burden for MSSA. Information on substance use is already collected for other EIP pathogens, outside of the HAIC program.
The requested changes will have minimal impact on the burden of data collection and are anticipated to have a small impact on the time expected to complete the case report form. We are anticipating a 5 minute increase. Additionally, the estimated number of annual responses has been adjusted: from 1,035 to 754. The net change in burden is a 308 hour decrease.
2019 CDI Case Report Form and Treatment Form
Changes are requested for the 2019 CDI Case Report Form and Treatment Form: 1) we removed the audit question; 2) we have added a question to track substance use; 3) we have changed the language of many of the existing questions so that data collection of common questions is standardized across the population based surveillance activities for HAIC, and we expect that this will add efficiency in completing these questions and should reduce burden; 4) we have also reordered the questions based on feedback from the EIP sites, again in an effort to make the completion of the form more efficient and to reduce the time it will take to complete the form.
The language changes, listed above, were made in conjunction with all other HAIC pathogen groups to standardize the way questions are asked across all HAIC pathogens. In some instances, this resulted in minor modifications to the question wording and response options, including the order in which the responses are presented. Harmonization efforts have also resulted in moving questions from one section of the CRF to another. The overall goal of these harmonization efforts is to simplify the form for respondents and to reduce the time it will take to complete the form.
We have added a new question to track substance use. The substance use questions are important to track the impact of the opioid epidemic on the disease burden for CDI. Information on substance use is already collected, but in a more general way on previously approved HAIC data collection forms.
The requested changes will have minimal impact on the burden of data collection and are anticipated to have a small impact on the time expected to complete the case report form. We are anticipating a 5 minute increase.
12. 2019 HAIC Candidemia Case Report
For the 2019 Candidemia case report form (CRF), we have added three new questions and deleted two. The changes were made based on feedback from sites about the usefulness of certain questions and the need to capture different data based on the changing epidemiology of candidemia in the United States. we have changed the language of many of the existing questions so that data collection of common questions is standardized across the population based surveillance activities for HAIC, and we expect that this will add efficiency in completing these questions and should reduce burden; 3) we have also reordered the questions based on feedback from the EIP sites, again in an effort to make the completion of the form more efficient and to reduce the time it will take to complete the form; 4) we have modified the way substance use is collected.
The language changes, listed above, were made in conjunction with all other HAIC pathogen groups to standardize the way questions are asked across all HAIC pathogens. In some instances, this resulted in minor modifications to the question wording and response options, including the order in which the responses are presented. Harmonization efforts have also resulted in moving questions from one section of the CRF to another. In several questions, we have added additional. The overall goal of these harmonization efforts is to simplify the form for respondents and to reduce the time it will take to complete the form.
We have modified the way substance use is collected. The substance use questions are important to track the impact of the opioid epidemic on the disease burden for candida. Information on substance use was already collected, this modified question is now harmonized with the other HAIC data collections.
The requested changes will have no impact on the burden of data collection.
Justification for changes: The changes made to the HAIC forms under this non-substantive request will aid in improving surveillance efficiency and data quality to clarify the burden of disease and possible risk factors for disease. This information can be used to inform strategies for preventing disease and negative outcomes. Specifically, changes were made for clarification purposes, to assist data collectors in capturing data in a standardized fashion to improve accuracy.
Cross walk - 2019 form changes
ABCs:
2019 ABCs Case Report Form
Current Form |
Proposed changes |
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Added 3. Patient I.D. |
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T1 – Test Type Options: 1=PCR, 2=Culture, 3=Antigen, 4=Immunohistochemistry, 5=Latex Agglutination, 7=Other, 9=Unknown |
3b. Date first positive culture collected |
T2 – Date of first positive specimen collection |
3c. Date first positive Culture Independent Diagnostic Test (CIDT, e.g. PCR) COLLECTED |
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3d. Type of CIDT: Biofire Meningitis Panel Filmarray BCID Verigene BCT Other ________________ Unknown |
T3 – Test method (non-culture) Options: 1=Biofire FilmArray M/E Panel, 2=other, 3=Biofire Filmarray Blood Culture ID (BCID) Panel, 4=Verigene Gram + Blood Culture Test (BCT), 5=Bruker MALDI Biotyper CA System, 6=BD Directigen Meningitis Combo Test Kit, 7=ThermoFisher Wellcogen Bacterial Antigen Rapid, 8=Alere BinaxNOW Antigen Card, 9=Unknown |
13. Sterile Sites from which organism isolated: CSF Blood Peritoneal fluid Bone Pericardial Fluid Pleural fluid Joint Muscle/Fascia/Tendon Internal Body Site (specify)______________ Other normally sterile site (specify) ________________ |
T4 – Site from which organism isolated Options: 1=Amniotic fluid, 2=Blood, 3=Bone, 4=Brain, 5=CSF, 6=Heart, 7=Other Sterile Site, 8=Joint, 9=unknown, 10=Kidney, 11=Liver, 12=Lung, 13=Lymph node, 14=Middle ear, 15=Muscle/Fascia/Tendon, 16=Ovary, 17=Pancreas, 18=Pericardial Fluid, 19=Peritoneal Fluid, 20=Placenta, 21=Pleural fluid, 22=Respiratory secretion, 23=Sinus, 24=Spleen 25=Sputum, 26=Vitreous, 27=Wound, 28=Unknown |
13b. CIDT STERILE SITE FROM WHICH ORGANISM WAS DETECTED: CSF Blood Other, _____________ |
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14. Other sites from which organism isolated: Wound Amniotic Fluid Placenta Middle ear Sinus |
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Q12a. Bacterial Species isolated from any normally sterile site: Neisseria meningitidis Haemophilus influenzae Group B Streptococcus Group A Streptococcus Streptococcus pneumoniae |
T5- Bacterial species isolated*: Options: 1=Neisseria meningitidis, 2=Haemophilus influenzae, 3=Group B Streptococcus, 5=Group A Streptococcus 6=Streptococcus pneumoniae
* For other bacterial pathogens (i.e. non-ABCs) write-in pathogen name |
Q12b. Other bacterial species isolated from any normally sterile site: ______________________________ |
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3a. Was a culture performed? 1 □ Yes, Positive 2 □ Yes, Negative 3 □ No |
T6 – Test Result Options: 1=Positive, 0=Negative, 9=Indeterminant |
15. Is Isolate available: Yes No |
T7- Isolate/Specimen Available? Options: 1=Yes, 2=No |
15b. If Isolate Not available, why not? N/A at hospital lab N/A at state lab Hospital refuses Isolate discrepancy (2x) No DNA (non-viable) |
T8- If isolate/specimen not available, why not? Options: 1=N/A at Hospital Lab 2=N/A at State Lab, 3=Hospital refuses, 4=Isolate Discrepancy (2x), 5=No DNA (non-viable) |
22a. If survived, patient discharged to: Home LTC/SNF LTACH Unknown Other, Specify __________ If discharged to LTC/SNF or LTACH, list Facility ID____________ |
Added checkbox, ‘Left AMA’ 22a. If survived, patient discharged to: Home LTC/SNF LTACH Left AMA Unknown Other, Specify __________ If discharged to LTC/SNF or LTACH, list Facility ID____________ |
27. Underlying causes or prior illnesses |
27. Added Checkbox for lab test, HbA1C ___________ % and Date collected ___/___/______ For diabetic patients only |
27c. Smoking: None Unknown Tobacco E-Cigarrettes Marijuana |
Changed ‘E-cigarrete’ option to ‘E-nicotine delivery system’ 27c. Smoking: None Unknown Tobacco E-Nicotine Delivery System Marijuana |
27d. Other substance abuse, current None Unknown If yes, check all that apply: mode of delivery Illicit opioid IDU non-IDU Unk Prescription Opioid IDU non-IDU Unk Stimulant IDU non-IDU Unk Other ___________ IDU non-IDU Unk Unknown Substance IDU non-IDU Unk
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Added Documented use disorder option for all substance categories and added skin-popping option for mode of delivery. Also, changed substance categories for ‘illicit opioid’, ‘prescription opioid’, and ‘stimulant’. Added ‘Marijuana/cannabinoid’ substance category. 27d. Other substances None Unknown Documented Use disorder mode of delivery Marijuana/Cannabinoid (other than smoking) DUD or Abuse IDU Skin Popping non-IDU Unk Opioid, DEA Schedule I DUD or Abuse IDU Skin Popping non-IDU Unk Opioid, DEA Schedule II- IV DUD or Abuse IDU Skin Popping non-IDU Unk Cocain or methamphetamine DUD or Abuse IDU Skin Popping non-IDU Unk Other ___________ DUD or Abuse IDU Skin Popping non-IDU Unk Unknown Substance DUD or Abuse IDU Skin Popping non-IDU Unk |
28c. Were records obtained to verify vaccination history? Yes No If yes, what is the source of the information? Vaccine Registry Healthcare Provider Other (specify)_____________________ |
Added ‘Medical chart’ option below 28c. Were records obtained to verify vaccination history? Yes No If yes, what is the source of the information? Medical Chart Vaccine Registry Healthcare Provider Other (specify)_____________________ |
2019 ABCs H. influenzae Neonatal Sepsis Expanded Surveillance Form
Current Form |
Proposed Changes |
Indicate type of HiNSES case: □ Neonatal: infant (sterile isolates only) – complete #1-10, 11-31
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Updated instructions at top of form to clarify information to be collected. Indicate type of HiNSES case: □ Neonatal: infant (sterile isolates only) – complete #1-31
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Indicate type of HiNSES case: □ Other maternal cases (specify) □ Fetal death Hi isolated from placenta/amniotic fluid □ Stillbirth – complete #1-3, 12-31 □ Spontaneous abortion – complete #1-2b, 12-18, 28-31
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Updated instructions at top of form to clarify information to be collected. Indicate type of HiNSES case: □ Fetal cases (any gestational age –specify isolate/outcome): □ Hi from sterile site in stillbirth – complete #1-3, 12-31 □ Fetal death Hi isolated from placenta/amniotic fluid □ Stillbirth – complete #1-3, 12-31 □ Spontaneous abortion – complete #1-2b, 12-18, 28-31
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29. During the intrapartum period or in the week prior to spontaneous abortion did the mother have any of the following symptoms or diagnoses? (check all that apply)
Unknown Uterine Tenderness Foul smelling amniotic fluid Urinary tract infection Maternal tachycardia (>100 beats/min) Fetal tachycardia (>160 beats/min) Intrapartum fever (>,=100.4 F/38 C) Maternal WBC >20 or 20,000
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Added ‘none listed’ option 29. During the intrapartum period or in the week prior to spontaneous abortion did the mother have any of the following symptoms or diagnoses? (check all that apply)
Unknown None Listed Uterine Tenderness Foul smelling amniotic fluid Urinary tract infection Maternal tachycardia (>100 beats/min) Fetal tachycardia (>160 beats/min) Intrapartum fever (>,=100.4 F/38 C) Maternal WBC >20 or 20,000
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2019 Neonatal Infection Expanded Tracking Form
Current Form |
Proposed Changes |
35. Neonatal infection Expanded Form Tracking Status: 1 □ Complete, 2 □ Partial, 2 □ Chart Unavailable, 2 □ Edited & Corrected |
Two wording changes: Option 2: “Partial” changed to “Incomplete”, Option 4: “after 3 requests” added 35. Neonatal infection Expanded Form Tracking Status: 1 □ Complete, 2 □ Incomplete, 3 □ Edited & Corrected, 4 □ Chart Unavailable after 3 requests |
Non-Invasive Pneumococcal Pneumonia (SNiPP)– Form Discontinued
FluSurv-NET
Influenza Hospitalization Surveillance Network Case Report Form
Question on 2017-18 Form |
Question on 2018-19 Form |
C14. Where did patient reside at the time of hospitalization?
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C14. Where did patient reside at the time of hospitalization?
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E1. Date of onset of acute condition resulting in current hospitalization
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N/A (Question removed) |
E11m. Did patient have any of the following pre-existing medical conditions? If pregnant, specify gestational age in weeks
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E10m. Did patient have any of the following pre-existing medical conditions?
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E2. Acute signs/symptoms present at admission (began or worsened within 2 weeks prior to admission)
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E1. Acute signs/symptoms present at admission (began or worsened within 2 weeks prior to admission)
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F1a. Number of ICU Admissions: ______
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N/A (Question removed) |
G3a. If yes, specify pathogen |
G3a. If yes, specify pathogen Aspergillus (fungus) |
H1. Was patient tested for any of the following viral respiratory pathogens within 3 days of admission? |
H1. Was patient tested for any viral respiratory pathogens within 14 days prior to or within 3 days after admission? |
I2b-I4b. Method of Administration: Oral Intravenous (IV) Inhaled Unknown
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N/A (question removed)
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I2c. End Date: ________
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I2c. End Date: ________ OR Total Duration (days) |
I2e-14e. Dose ________ Dose Unknown |
N/A (question removed)
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I2f-14f: Frequency ______________ Frequency Unknown |
N/A (question removed)
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K1. Did the patient have any of the following new diagnoses at discharge? (check all that apply)
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K1. Did the patient have any of the following new diagnoses at discharge? (check all that apply)
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K3a. If patient was pregnant on admission but not longer pregnant at discharge, indicate pregnancy outcome at discharge.
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K3a. If patient was pregnant on admission but not longer pregnant at discharge, indicate pregnancy outcome at discharge.
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K3b. N/A |
K3b. If no longer pregnant, indicate date of delivery or end of pregnancy: ______ |
HAIC
2019 MuGSI Case Report Form for Carbapenem-resistant Enterobacteriaceae (CRE) and Acinetobacter baumannii (CRAB)
Question on 2018 form |
Question on 2019 form |
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24. Date reported to EIP site: □□/□□/□□□□ |
DATE REPORTED TO EIP SITE: ___ ___ - ___ ___ - ___ ___ ___ ___
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Title: 2018 Multi-site Gram-Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report |
Title: 2019 Carbapenem Resistant Enterobacteriaceae (CRE)/ Carbapenem Resistant A. baumannii (CRAB) Multi-site Gram-Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report |
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4a. LABORATORY ID WHERE CULTURE IDENTIFIED: ____________________________ |
4a. LABORATORY ID WHERE INCIDENT SPECIMEN IDENTIFIED: __________________________
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6. DATE OF BIRTH: □□/□□/□□□□ |
5. DATE OF BIRTH: ___ ___ - ___ ___ - ___ ___ ___ ___ |
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7a. AGE: □□□
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6. AGE ____ ____ ____
Days Mos. Years
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7b. Is age in day/mo/yr? Days Mos. Years
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8a. Sex: Male Female |
7. SEX AT BIRTH: Male Female Unknown Check if transgender
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8b. ETHNIC ORIGIN: Hispanic or Latino Not Hispanic or Latino Unknown |
8a. ETHNIC ORIGIN: Hispanic or Latino Not Hispanic or Latino Unknown |
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8c. RACE: (Check all that apply) White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Unknown
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8b. RACE: (Check all that apply)
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10a. DATE OF INITIAL CULTURE □□/□□/□□□□ |
9. DATE OF INCIDENT SPECIMEN COLLECTION (DISC): ___ ___ - ___ ___ - ___ ___ ___ ___
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13a. ORGANISM ISOLATED FROM INITIAL NORMALLY STERILE SITE OR URINE:
Carbapenem-resistant: □ Enterobacteriaceae (CRE) □ Escherichia coli □ Enterobacter cloacae □ Enterobacter aerogenes □ Klebsiella pneumoniae □ Klebsiella oxytoca □ A. baumannii (CRAB)
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10. ORGANISM:
Carbapenem-resistant: □ Enterobacteriaceae (CRE) □ Escherichia coli □ Enterobacter cloacae □ Klebsiella aerogenes □ Klebsiella pneumoniae □ Klebsiella oxytoca □ A. baumannii (CRAB) |
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14. INITIAL CULTURE SITE: Blood CSF Pleural fluid Peritoneal fluid Pericardial fluid Joint/Synovial fluid Bone Urine Other normally sterile site _____________ |
11. Incident specimen collection site (check all that apply) Blood Bone CSF Internal body site (specify): ________ Joint/Synovial fluid Muscle Pericardial fluid Peritoneal fluid Pleural fluid Urine Other normally sterile site (specify): ________
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10b. LOCATION OF CULTURE COLLECTION: Hospital Inpatient ICU Surgery/OR Radiology Other Unit
Emergency Room
Outpatient Clinic/Doctors Office Surgery Other outpatient Dialysis center
Observational/clinical decision unit LTCF Facility ID: ____________ LTACH Facility ID: ____________ Autopsy Unknown
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12. LOCATION OF SPECIMEN COLLECTION: Outpatient Facility ID:_______ Emergency room Clinic/Doctor’s office Dialysis center Surgery Observational/clinical decision unit Other outpatient Inpatient Facility ID: ______ ICU OR Radiology Other inpatient LTCF Facility ID: ______ LTACH Facility ID: ______ Autopsy Other (specify):_______ Unknown |
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5. Where was the patient located on the 4th calendar day prior to the date of initial culture? Private residence LTCF Facility ID:__________ LTACH Facility ID:__________ Homeless Incarcerated Hospital inpatient Was patient transferred from this hospital? Yes No Unknown Facility ID: ___________ Other (specify): __________ Unknown
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13. WHERE WAS THE PATIENT LOCATED ON THE 3RD CALENDAR DAY BEFORE THE DISC?
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9. WAS PATIENT HOSPITALIZED AT THE TIME OF, OR WITHIN 30 CALENDAR DAYS AFTER, INITIAL CULTURE? Yes No Unknown
If yes: Date of admission □□/□□/□□□□
Date of discharge □□/□□/□□□□ |
14. WAS THE PATIENT HOSPITALIZED AT THE TIME OF OR IN THE 29 CALENDAR DAYS AFTER THE DISC? Yes No Unknown
IF YES, DATE OF ADMISSION:
___ ___ - ___ ___ - ___ ___ ___ ___
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11a. Was the patient in the ICU in the 7 days prior to their initial culture? Yes No Unknown
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15a. WAS THE PATIENT IN AN ICU IN THE 7 DAYS BEFORE THE DISC? Yes No Unknown IF YES, DATE OF ICU ADMISSION: ___ ___ - ___ ___ - ___ ___ ___ ___ OR □ Date unknown
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11b. Was the patient in the ICU on the date of or in the 7 days after the initial culture? Yes No Unknown
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15b. WAS THE PATIENT IN AN ICU ON THE DAY OF INCIDENT SPECIMEN COLLECTION OR IN THE 6 DAYS AFTER THE DISC? Yes No Unknown IF YES, DATE OF ICU ADMISSION: ___ ___ - ___ ___ - ___ ___ ___ ___ OR □ Date unknown
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12. PATIENT OUTCOME: Survived Died Unknown
If survived, transferred to:
If died, date of death: □□/□□/□□□□ Was the organism cultured from a normally sterile site or urine, ≤ calendar day 7 before death?
Yes No Unknown
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16. PATIENT OUTCOME:
Survived Date of discharge: ___ ___ - ___ ___ - ___ ___ ___ ___ OR Date unknown Left against medical advice (AMA)
If survived, discharged to:
Died Date of death: ___ ___ - ___ ___ - ___ ___ ___ ___ ON THE DAY OF OR IN THE 6 CALENDAR DAYS BEFORE DEATH, WAS THE PATHOGEN OF INTEREST ISOLATED FROM A SITE THAT MEETS THE CASE DEFINITION? Yes No Unknown
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19. TYPES OF INFECTION ASSOCIATED WITH CULTURE(S) (check all that apply):
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17. TYPES OF INFECTION ASSOCIATED WITH CULTURE(S): (Check all that apply) None Unknown □ Abscess, not skin □ AV fistula/graft infection □ Bacteremia □ Bursitis □ Catheter site infection (CVC) □ Cellulitis □ Chronic ulcer/wound (not decubitus) □ Decubitus/pressure ulcer □ Empyema □ Endocarditis □ Epidural Abscess □ Meningitis □ Osteomyelitis □ Peritonitis □ Pneumonia □ Pyelonephritis □ Septic arthritis □ Septic emboli □ Septic shock □ Skin abscess □ Surgical incision infection □ Surgical site infection (internal) □ Traumatic wound □ Urinary tract infection □ Other (specify): ____________
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20. UNDERLYING CONDITIONS (check all that apply): None Unknown
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18. UNDERLYING CONDITIONS: (Check all that apply) None Unknown
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20. UNDERLYING CONDITIONS (check all that apply): None Unknown
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19. SUBSTANCE USE, CURRENT
SMOKING (Check all that apply): None Unknown Tobacco E-nicotine delivery system Marijuana
ALCOHOL ABUSE: Yes No Unknown
OTHER SUBSTANCES: (Check all that apply)
None
Unknown DOCUMENTED USE DISORDER (DUD)/ABUSE: MODE OF DELIVERY: (Check all that apply)
□ Marijuana/cannabinoid (other than smoking) □ DUD or abuse □ IDU □ Skin popping □ Non-IDU □ Unknown
□ Opioid, DEA schedule I (e.g., heroin) □ DUD or abuse □ IDU □ Skin popping □ Non-IDU □ Unknown
□ Opioid, DEA schedule II-IV (e.g., methadone, oxycodone) □ DUD or abuse □ IDU □ Skin popping □ Non-IDU □ Unknown
□ Cocaine or methamphetamine □ DUD or abuse □ IDU □ Skin popping □ Non-IDU □ Unknown
□ Other (specify): ___________ □ DUD or abuse □ IDU □ Skin popping □ Non-IDU □ Unknown
□ Unknown substance □ DUD or abuse □ IDU □ Skin popping □ Non-IDU □ Unknown
Some of the data in this section was formerly collected in the underlying conditions section (IVDU [changed to injection drug user], Current smoker [changed to smoking], Alcohol Abuse (see highlighted conditions in the prior column). The collection of more information for other drug use is new. There are six new check boxes that allow other drug use to be captured in more detail. These questions focus on type of drug and mode of delivery.
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21. RISK FACTORS OF INTEREST (check all that apply):
None Unknown
Culture collected ≥ calendar day 3 after hospital admission
Hospitalized within year before date of initial culture: If yes, enter mo/yr □□/□□□□ OR Unknown If known, prior hospital ID:_________________
Surgery within year before date of initial culture
Current chronic dialysis: □ Hemodialysis □ Peritoneal □ Unknown Hemodialysis Access: □ AV fistula/graft □ CVC □ Unknown
Residence in LTCF within year before date of initial culture If known, facility ID: ______________________
Admitted to a LTACH within year before initial culture date If known, facility ID: ______________________
Central venous catheter in place on the day of culture (up to time of culture) or at any time in the 2 calendar days prior to the date of culture
Urinary catheter in place on the day of culture (up to time of culture) or at any time in the 2 calendar days prior to the date of culture If checked, indicate all that apply: Indwelling Urethral Catheter Suprapubic Catheter Condom Catheter Other: _____________
Any OTHER indwelling device in place on the day of culture (up to time of culture) or at any time in the 2 calendar days prior to the date of culture If checked, indicate all that apply: ET/NT Tube Gastrostomy Tube NG Tube Tracheostomy Nephrostomy Tube Other: _____________
Patient traveled internationally in the two months prior to the date of initial culture.
Country:__________________, ___________________, __________________
Patient was hospitalized while visiting country(ies) listed above
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20. RISK FACTORS: (Check all that apply)
Unknown
WAS INCIDENT SPECIMEN COLLECTED 3 OR MORE CALENDAR DAYS AFTER HOSPITAL ADMISSION? Yes No (please note, this field is auto calculated in the data management system (DMS), therefore, the user does not ever complete this filed and there is not burden associated with its collection. It is on the paper form because our users want to continue to view this in the DMS)
Previous hospitalization in the year before DISC Yes No Unknown If yes, date of discharge closed to DISC: ___ ___ - ___ ___ - ___ ___ ___ ___ Facility ID: ___________ OR, Date Unknown
Overnight stay in LTCF in the year before DISC Yes No Unknown Facility ID: ___________
Overnight stay in LTACH in the year before DISC Yes No Unknown Facility ID: ___________
Surgery in the year before DISC Yes No Unknown
CURRENT CHRONIC DIALYSIS: IF YES, TYPE: □ Hemodialysis □ Peritoneal □ Unknown IF HEMODIALYSIS, TYPE OF VASCULAR ACCESS: □ AV fistula/graft □ Hemodialysis central line □ Unknown
CENTRAL LINE IN PLACE ON THE DISC (UP TO THE TIME OF COLLECTION), OR AT ANY TIME IN THE 2 CALENDAR DAYS BEFORE DISC: Yes No Unknown Check here if central line in place for > 2 calendar days: □
URINARY CATHETER IN PLACE ON THE DISC (UP TO THE TIME OF COLLECTION), OR AT ANY TIME IN THE 2 CALENDAR DAYS BEFORE DISC: Yes No Unknown IF YES, CHECK ALL THAT APPLY: □ Indwelling Urethral Catheter □ Suprapubic Catheter □ Condom Catheter □ Other (specify):__________
ANY OTHER INDWELLING DEVICE IN PLACE ON THE DISC (UP TO THE TIME OF COLLECTION), OR AT ANY TIME IN THE 2 CALENDAR DAYS BEFORE DISC: Yes No Unknown IF YES, CHECK ALL THAT APPLY: □ ET/NT Tube □ Gastrostomy Tube □ NG Tube □ Tracheostomy □ Nephrostomy Tube □ Other (specify):_____
PATIENT TRAVELED INTERNATIONALLY IN THE YEAR BEFORE DISC: Yes No Unknown COUNTRY: ______, ______, ______
PATIENT HOSPITALIZED WHILE VISITING COUNTRY(IES) ABOVE: Yes No Unknown
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8d. WEIGHT: ______lbs ______oz OR ______kg □ Unknown |
21a. WEIGHT: _________lbs. ______ oz. OR _____kg □ Unknown |
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8e. HEIGHT: ______ft ______in OR ______cm □ Unknown |
21b. HEIGHT: _________ft. _______ in. OR _____cm □ Unknown |
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8f. BMI (Record only if ht and/or wt is not available): ___________________________ □ Unknown |
21c. BMI: _________ □ Unknown |
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URINE Cultures ONLY: 14a. Was the urine collected through an indwelling urethral catheter? Yes No Unknown |
URINE CULTURES ONLY: 22a. WAS THE URINE COLLECTED THROUGH AN INDWELLING URETHRAL CATHETER? Yes No Unknown |
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URINE Cultures ONLY: 14b. Record the colony count _________________________
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URINE CULTURES ONLY: 22b. RECORD THE COLONY COUNT: ________________ |
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URINE Cultures ONLY: 14c. Signs and Symptoms associated with urine culture. Please indicate if any of the following symptoms where reported during the 5 day time period including the 2 calendar days before through the 2 calendar days after the date of initial culture. Then go to question 14d. □ None □ Costovertebral angle pain or tenderness □ Dysuria □ Fever [temperature ≥ 100.4 °F (38 °C)] □ Unknown □ Frequency □ Suprapubic tenderness □ Urgency
Symptoms for patients ≤ 1 year of age only: □ Apnea □ Bradycardia □ Lethargy □ Vomiting
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URINE CULTURES ONLY: 22c. SIGNS AND SYMPTOMS ASSOCIATED WITH URINE CULTURE Please indicate if any of the following symptoms where reported during the 5 day time period including the 2 calendar days before through the 2 calendar days after the DISC. □ None □ Costovertebral angle pain or tenderness □ Dysuria □ Fever [temperature ≥ 100.4 °F (38 °C)] □ Unknown □ Frequency □ Suprapubic tenderness □ Urgency
Symptoms for patients ≤ 1 year of age only: □ Apnea □ Bradycardia □ Lethargy □ Vomiting |
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URINE Cultures ONLY: 14d. Was a blood culture positive in the 3 calendar days before through the 3 calendar days after the initial urine culture for the same MuGSI organism? Yes No Unknown |
URINE CULTURES ONLY: 22d. WAS A BLOOD CULTURE POSITIVE IN THE 3 CALENDAR DAYS BEFORE THROUGH THE 3 CALENDAR DAYS AFTER THE DISC FOR THE SAME MuGSI ORGANISM? Yes No Unknown |
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13b. Was the initial culture polymicrobial?
Yes No Unknown |
23. WAS THE INCIDENT SPECIMEN POLYMICROBIAL? Yes No Unknown |
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13c. Was the initial isolate tested for carbapenemase?
Yes No Laboratory not testing Unknown
If yes, what testing method was used (check all that apply): Automated Molecular Assay (specify): _________________ CarbaNP PCR E Test Modified Hodge Test (MHT) Other (specify):____________ Unknown
If tested, what was the testing result? □ Positive □ Negative □ Indeterminate □ Unknown
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24a. WAS THE INCIDENT SPECIMEN TESTED FOR CARBAPENEMASE? Yes No Laboratory not testing Unknown |
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24b. IF YES, WHAT TESTING METHOD WAS USED? (Check all that apply): Non-Molecular Tests □ CarbaNP □ Carbapenemase Incactivation Method (CIM) □ Disk Diffusion/ROSCO Disk □ E-test □ Modified Carbapenemase Incactivation Method (mCIM) □ Modified Hodge Test (MHT) □ RAPIDEC □ Other (specify):_____________ □ Unknown
Molecular Tests □ Automated Molecular Assay □ Carba-R □ Check Points □ MALDI-TOF MS □ Next Generation Nucleic Acid Sequencing □ PCR □ Other (specify):_____________ □ Unknown |
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24c. IF TESTED, WHAT WAS THE TESTING RESULT? Non-Molecular Test Results: □ Positive □ Negative □ Indeterminate □ Unknown Molecular Test Results:
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15. Was the same organism (Q13a) cultured from a different sterile site or urine in the 30 days after the date of initial culture (of this current episode)? Yes No Unknown IF YES, SOURCE: (check all that apply) Blood CSF Pleural fluid Pericardial fluid Peritoneal fluid Joint/Synovial fluid Bone Urine Other normally sterile site__________
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25. WAS THE SAME ORGANISM (Q10) CULTURED FROM A DIFFERENT STERILE SITE OR URINE IN THE 30 DAYS AFTER THE DISC? Yes No Unknown IF YES, SOURCE: (check all that apply) Blood Bone CSF Internal body site (specify): ________ Joint/Synovial fluid Muscle Pericardial fluid Peritoneal fluid Pleural fluid Urine Other normally sterile site (specify): ________
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16. Enterobacteriaceae ONLY: Were cultures of sterile site(s) or urine positive in the 30 days prior to the date of initial culture, for a DIFFERENT organism (Q13a)? Yes No Unknown N/A IF YES, SOURCE: (check all that apply) Blood CSF Pleural fluid Pericardial fluid Peritoneal fluid Joint/Synovial fluid Bone Urine Other normally sterile site__________
If yes, indicate organism type and associated State ID for the incident closest to the date of initial culture:
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26. ENTEROBACTERIACEAE ONLY: WERE CULTURES OF STERILE SITE(S) OR URINE POSITIVE IN THE 30 DAYS BEFORE THE DISC, FOR A DIFFERENT ORGANISM (Q10)? Yes No Unknown N/A IF YES, SOURCE: (check all that apply) Blood Bone CSF Internal body site (specify): ________ Joint/Synovial fluid Muscle Pericardial fluid Peritoneal fluid Pleural fluid Urine Other normally sterile site (specify): ________
IF YES, INDICATE ORGANISM TYPE AND ASSOCIATED STATE ID FOR THE INCIDENT CLOSEST TO THE DISC:
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16a. A. baumannii Cultures ONLY: Were cultures of OTHER sterile site(s) or urine positive in the 30 days prior to the date of initial culture, for another A. baumannii?
Yes No Unknown N/A
Yes No Unknown N/A IF YES, SOURCE: (check all that apply) Blood CSF Pleural fluid Pericardial fluid Peritoneal fluid Joint/Synovial fluid Bone Urine Other normally sterile site__________
If yes, State ID for the organism closest to the date of initial culture: ______________
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27a. A. BAUMANNII CULTURES ONLY: WERE CULTURES OF OTHER STERILE SITE(S) OR URINE POSITIVE IN THE 30 DAYS BEFORE THE DISC, FOR ANOTHER A. BAUMANNII?
Yes No Unknown N/A IF YES, SOURCE: (check all that apply) Blood Bone CSF Internal body site (specify): ________ Joint/Synovial fluid Muscle Pericardial fluid Peritoneal fluid Pleural fluid Urine Other normally sterile site (specify): ________
IF YES, STATE ID FOR THE INCIDENT CLOSEST TO THE DISC: ________________ |
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16b. A. baumannii Cultures ONLY: Did the patient have a sputum culture positive for CRAB in the 30 days prior to the date of culture (Day 1)?
Yes No Unknown N/A
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27b. A. BAUMANNII CULTURES ONLY: DID THE PATIENT HAVE A SPUTUM CULTURE POSITIVE FOR CRAB IN THE 30 DAYS BEFORE THE DISC? Yes No Unknown N/A
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27c. A. BAUMANNII CULTURES ONLY: RISK FACTORS IN THE 7 DAYS BEFORE THE DISC: □ Non-invasive positive pressure ventilation (CPAP or BiPAP) at any time in the 7 calendar days before the DISC □ Nebulizer treatment at any time in the 7 calendar days before the DISC □ Mechanical ventilation at any time in the 7 calendar days before the DISC
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17a. Was this patient positive for the SAME organism in the year prior to the date of the initial culture (Q10a):
Yes No (GO TO Q17c) Unknown (GO TO Q17c)
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28a. WAS THE PATIENT POSITIVE FOR THE SAME ORGANISM IN THE YEAR BEFORE THE DISC?
Yes No Unknown
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17b. If yes, specify date of culture and State ID for the first positive culture in the year prior:
□□/□□/□□□□ State ID:________________________
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28b. IF YES, SPECIFY DATE OF CULTURE AND STATE ID FOR THE FIRST POSITIVE CULTURE IN THE YEAR BEFORE:
DATE OF CULTURE: ___ ___ - ___ ___ - ___ ___ ___ ___ STATE ID:_____________________
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17c. Enterobacteriaceae ONLY: Was this patient positive for a MuGSI Enterobacteriaceae in the year prior to the date of initial culture (Q10a)? Yes No (GO TO Q18) Unknown (GO TO Q18) NA (GO TO Q18)
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29a. ENTEROBACTERIACEAE ONLY: WAS THE PATIENT POSITIVE FOR A MuGSI ENTEROBACTERIACEAE IN THE YEAR BEFORE THE DISC?
Yes No Unknown N/A
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17d. If yes, specify organism, date of culture and State ID for the first positive Enterobacteriaceae culture in the year prior to the date of initial culture (Q10a): Carbapenem-resistant Enterobacteriaceae (CRE): □ Escherichia coli □ Enterobacter cloacae □ Enterobacter aerogenes □ Klebsiella pneumoniae □ Klebsiella oxytoca
Date of Culture: □□/□□/□□□□ State ID:________________________
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29b. IF YES, SPECIFY ORGANISM, DATE OF CULTURE, AND STATE ID FOR THE FIRST POSITIVE ENTEROBACTERIACEAE CULTURE IN THE YEAR BEFORE THE DISC: Carbapenem-resistant Enterobacteriaceae (CRE): □ Escherichia coli □ Enterobacter cloacae □ Klebsiella aerogenes □ Klebsiella pneumoniae □ Klebsiella oxytoca
DATE OF CULTURE: ___ ___ - ___ ___ - ___ ___ ___ ______ __ ___ ___ ___ STATE ID:_____________________
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18. Susceptibility Results: (please complete the table below based on the information found in the indicated data source). Shaded antibiotics are required to have the MIC entered into the MuGSI-CM system, if available. |
30. SUSCEPTIBILITY RESULTS: Please complete the table below based on the information found in the indicated data source. Shaded antibiotics are required to have the MIC entered into the MuGSI-CM system, if available.
Add option to collect ten additional drug susceptibilities: □ Meropenem-vaborbactam □ Minocycline □ Doxycycline □ Plazomicin □ Tetracycline □ Rifampin\ □ Ceftazidime/Avibactam □ Ceftolozane/Tazobactam □ Fosfomycin □ Imipenem-relebactam
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22. Was case first identified through audit? □ Yes □ No □ Unknown |
31a. WAS CASE FIRST IDENTIFIED THROUGH AUDIT? □ Yes □ No |
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23. CRF status: □ Complete □ Pending □ Chart unavailable |
31b. CRF STATUS:
□ Complete □ Pending □ Chart unavailable after 3 requests |
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25. SO initials:______________ |
31c. SO INITIALS: __________
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26. Comments:__________________________ _______________________________________
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31d. COMMENTS: __________________________________ _________________________________________________
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2019 Multi-site Gram-Negative Surveillance Initiative (MuGSI)- Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae (ESBL)
Question on 2018 form |
Question on 2019 form |
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21. Date reported to EIP site: ___ ___ - ___ ___ - ___ ___ ___ ___
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DATE REPORTED TO EIP SITE: ___ ___ - ___ ___ - ___ ___ ___ ___
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Title: Pilot Assessment: Feasibility of Conducting Surveillance for Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae Multi-site Gram-Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report |
Title: 2019 Extended-Spectrum Beta-Lactamase (ESBL)-Producing Enterobacteriaceae Multi-site Gram-Negative Surveillance Initiative (MuGSI) Healthcare Associated Infection Community Interface (HAIC) Case Report |
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4a. LABORATORY ID WHERE CULTURE IDENTIFIED: ____________________________ |
4a. LABORATORY ID WHERE INCIDENT SPECIMEN IDENTIFIED: __________________________
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6. DATE OF BIRTH: ___ ___ - ___ ___ - ___ ___ ___ ___ |
5. DATE OF BIRTH: ___ ___ - ___ ___ - ___ ___ ___ ___ |
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7a. AGE: ____ ____ ____
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6. AGE ____ ____ ____
Days Mos. Years
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7b. Is age in day/mo/yr? Days Mos. Years
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8a. Sex: Male Female Unknown |
7. SEX AT BIRTH: Male Female Unknown Check if transgender
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8b. ETHNIC ORIGIN: Hispanic or Latino Not Hispanic or Latino Unknown |
8a. ETHNIC ORIGIN: Hispanic or Latino Not Hispanic or Latino Unknown |
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8c. RACE: (Check all that apply) White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Unknown |
8b. RACE: (Check all that apply)
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10a. DATE OF INITIAL CULTURE ___ ___ - ___ ___ - ___ ___ ___ ___ |
9. DATE OF INCIDENT SPECIMEN COLLECTION (DISC): ___ ___ - ___ ___ - ___ ___ ___ ___
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13a. ORGANISM ISOLATED FROM INITIAL NORMALLY STERILE SITE OR URINE:
Extended-Spectrum Cephalosporin-resistant: □ Escherichia coli □ Klebsiella pneumoniae □ Klebsiella oxytoca
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10. ORGANISM:
Extended-Spectrum Cephalosporin-resistant: □ Escherichia coli □ Klebsiella pneumoniae □ Klebsiella oxytoca |
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14. INITIAL CULTURE SITE:
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11. Incident specimen collection site (check all that apply) Blood Bone CSF Internal body site (specify): ________ Joint/Synovial fluid Muscle Pericardial fluid Peritoneal fluid Pleural fluid Urine Other normally sterile site (specify): ________
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10b. LOCATION OF CULTURE COLLECTION:
Outpatient:
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12. LOCATION OF SPECIMEN COLLECTION: Outpatient Facility ID:_______ Emergency room Clinic/Doctor’s office Dialysis center Surgery Observational/clinical decision unit Other outpatient Inpatient Facility ID: ______ ICU OR Radiology Other inpatient LTCF Facility ID: ______ LTACH Facility ID: ______ Autopsy Other (specify):_______ Unknown |
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5. Where was the patient located on the 4th calendar day prior to the date of initial culture? Private residence LTCF Facility ID:__________ LTACH Facility ID:__________ Homeless Incarcerated Hospital inpatient Was patient transferred from this hospital? Yes No Unknown Facility ID: ___________ Other (specify): __________ Unknown
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13. WHERE WAS THE PATIENT LOCATED ON THE 3RD CALENDAR DAY BEFORE THE DISC?
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9. WAS PATIENT HOSPITALIZED AT THE TIME OF, OR WITHIN 30 CALENDAR DAYS AFTER, INITIAL CULTURE? Yes No Unknown
If yes: Date of admission ___ ___ - ___ ___ - ___ ___ ___ ___
Date of discharge ___ ___ - ___ ___ - ___ ___ ___ ___
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14. WAS THE PATIENT HOSPITALIZED AT THE TIME OF OR IN THE 29 CALENDAR DAYS AFTER THE DISC? Yes No Unknown
IF YES, DATE OF ADMISSION:
___ ___ - ___ ___ - ___ ___ ___ ___
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11a. Was the patient in the ICU in the 7 days prior to their initial culture? Yes No Unknown
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15a. WAS THE PATIENT IN AN ICU IN THE 7 DAYS BEFORE THE DISC? Yes No Unknown IF YES, DATE OF ICU ADMISSION: ___ ___ - ___ ___ - ___ ___ ___ ___ OR □ Date unknown
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11b. Was the patient in the ICU on the date of or in the 7 days after the initial culture? Yes No Unknown
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15b. WAS THE PATIENT IN AN ICU ON THE DAY OF INCIDENT SPECIMEN COLLECTION OR IN THE 6 DAYS AFTER THE DISC? Yes No Unknown IF YES, DATE OF ICU ADMISSION: ___ ___ - ___ ___ - ___ ___ ___ ___ OR □ Date unknown
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12. PATIENT OUTCOME: Survived Died Unknown
If survived, transferred to:
If died, date of death: ___ ___ - ___ ___ - ___ ___ ___ ___
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16. PATIENT OUTCOME:
Survived Date of discharge: ___ ___ - ___ ___ - ___ ___ ___ ___ OR Date unknown Left against medical advice (AMA)
If survived, discharged to:
Died Date of death: ___ ___ - ___ ___ - ___ ___ ___ ___
ON THE DAY OF OR IN THE 6 CALENDAR DAYS BEFORE DEATH, WAS THE PATHOGEN OF INTEREST ISOLATED FROM A SITE THAT MEETS THE CASE DEFINITION? Yes No Unknown
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16. TYPES OF INFECTION ASSOCIATED WITH CULTURE(S) (check all that apply): None Unknown □ Abscess, not skin □ Appendicitis □ AV fistula/graft infection □ Bacteremia □ Catheter site infection (CVC) □ Cholangitis □ Chronic ulcer/wound (not decubitus) □ Decubitus/pressure ulcer □ Diverticulitis □ Empyema □ Endocarditis □ Epididymitis □ Epidural Abscess □ Meningitis □ Osteomyelitis □ Peritonitis □ Pneumonia □ Prostatitis □ Pyelonephritis □ Septic arthritis □ Surgical incision infection □ Surgical site infection (internal) □ Traumatic wound □ Urinary tract infection □ Other (specify): ____________
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17. TYPES OF INFECTION ASSOCIATED WITH CULTURE(S): (Check all that apply) None Unknown □ Abscess, not skin □ AV fistula/graft infection □ Bacteremia □ Bursitis □ Catheter site infection (CVC) □ Cellulitis □ Chronic ulcer/wound (not decubitus) □ Decubitus/pressure ulcer □ Empyema □ Endocarditis □ Epidural Abscess □ Meningitis □ Osteomyelitis □ Peritonitis □ Pneumonia □ Pyelonephritis □ Septic arthritis □ Septic emboli □ Septic shock □ Skin abscess □ Surgical incision infection □ Surgical site infection (internal) □ Traumatic wound □ Urinary tract infection □ Other (specify): ____________
Five types of infections were removed from this question. |
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NEW QUESTION |
18. RECURRENT UTI □ Yes □ No □ Unknown |
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27. UNDERLYING CONDITIONS (check all that apply): None Unknown
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19. UNDERLYING CONDITIONS: (Check all that apply) None Unknown
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27. UNDERLYING CONDITIONS (check all that apply): None Unknown
Urinary Tract Problems/Abnormalities |
20. SUBSTANCE USE, CURRENT
SMOKING (Check all that apply): None Unknown Tobacco E-nicotine delivery system Marijuana
ALCOHOL ABUSE: Yes No Unknown
OTHER SUBSTANCES: (Check all that apply)
None
Unknown DOCUMENTED USE DISORDER (DUD)/ABUSE: MODE OF DELIVERY: (Check all that apply)
□ Marijuana/cannabinoid (other than smoking) □ DUD or abuse □ IDU □ Skin popping □ Non-IDU □ Unknown
□ Opioid, DEA schedule I (e.g., heroin) □ DUD or abuse □ IDU □ Skin popping □ Non-IDU □ Unknown
□ Opioid, DEA schedule II-IV (e.g., methadone, oxycodone) □ DUD or abuse □ IDU □ Skin popping □ Non-IDU □ Unknown
□ Cocaine or methamphetamine □ DUD or abuse □ IDU □ Skin popping □ Non-IDU □ Unknown
□ Other (specify): ___________ □ DUD or abuse □ IDU □ Skin popping □ Non-IDU □ Unknown
□ Unknown substance □ DUD or abuse □ IDU □ Skin popping □ Non-IDU □ Unknown
Some of the data in this section was formerly collected in the underlying conditions section (IVDU [changed to injection drug user], Current smoker [changed to smoking], Alcohol Abuse (see highlighted conditions in the prior column). The collection of more information for other drug use is new. There are six new check boxes that allow other drug use to be captured in more detail. These questions focus on type of drug and mode of delivery.
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21. RISK FACTORS OF INTEREST (check all that apply):
None Unknown
Hospitalized within year before date of initial culture: If yes, enter mo/yr □□/□□□□ OR Unknown If known, prior hospital ID:_________________
Surgery within year before date of initial culture
Current chronic dialysis: □ Hemodialysis □ Peritoneal □ Unknown Hemodialysis Access: □ AV fistula/graft □ CVC □ Unknown
Residence in LTCF within year before date of initial culture If known, facility ID: ______________________
Admitted to a LTACH within year before initial culture date If known, facility ID: ______________________
Central venous catheter in place on the day of culture (up to time of culture) or at any time in the 2 calendar days prior to the date of culture
Urinary catheter in place on the day of culture (up to time of culture) or at any time in the 2 calendar days prior to the date of culture If checked, indicate all that apply: Indwelling Urethral Catheter Suprapubic Catheter Condom Catheter Other: _____________
Any OTHER indwelling device in place on the day of culture (up to time of culture) or at any time in the 2 calendar days prior to the date of culture If checked, indicate all that apply: ET/NT Tube Gastrostomy Tube NG Tube Tracheostomy Nephrostomy Tube Other: _____________
Patient traveled internationally in the two months prior to the date of initial culture.
Country:__________________, ___________________, __________________
Patient was hospitalized while visiting country(ies) listed above
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21. RISK FACTORS: (Check all that apply)
Unknown
WAS INCIDENT SPECIMEN COLLECTED 3 OR MORE CALENDAR DAYS AFTER HOSPITAL ADMISSION? Yes No (please note, this field is auto calculated in the data management system (DMS), therefore, the user does not ever complete this filed and there is not burden associated with its collection. It is on the paper form because our users want to continue to view this in the DMS)
Previous hospitalization in the year before DISC Yes No Unknown If yes, date of discharge closed to DISC: ___ ___ - ___ ___ - ___ ___ ___ ___ Facility ID: ___________ OR, Date Unknown
Overnight stay in LTCF in the year before DISC Yes No Unknown Facility ID: ___________
Overnight stay in LTACH in the year before DISC Yes No Unknown Facility ID: ___________
Surgery in the year before DISC Yes No Unknown
CURRENT CHRONIC DIALYSIS: IF YES, TYPE: □ Hemodialysis □ Peritoneal □ Unknown IF HEMODIALYSIS, TYPE OF VASCULAR ACCESS: □ AV fistula/graft □ Hemodialysis central line □ Unknown
CENTRAL LINE IN PLACE ON THE DISC (UP TO THE TIME OF COLLECTION), OR AT ANY TIME IN THE 2 CALENDAR DAYS BEFORE DISC: Yes No Unknown Check here if central line in place for > 2 calendar days: □
URINARY CATHETER IN PLACE ON THE DISC (UP TO THE TIME OF COLLECTION), OR AT ANY TIME IN THE 2 CALENDAR DAYS BEFORE DISC: Yes No Unknown IF YES, CHECK ALL THAT APPLY: □ Indwelling Urethral Catheter □ Suprapubic Catheter □ Condom Catheter □ Other (specify):__________
ANY OTHER INDWELLING DEVICE IN PLACE ON THE DISC (UP TO THE TIME OF COLLECTION), OR AT ANY TIME IN THE 2 CALENDAR DAYS BEFORE DISC: Yes No Unknown IF YES, CHECK ALL THAT APPLY: □ ET/NT Tube □ Gastrostomy Tube □ NG Tube □ Tracheostomy □ Nephrostomy Tube □ Other (specify):_____
PATIENT TRAVELED INTERNATIONALLY IN THE YEAR BEFORE DISC: Yes No Unknown COUNTRY: ______, ______, ______
PATIENT HOSPITALIZED WHILE VISITING COUNTRY(IES) ABOVE: Yes No Unknown
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NEW QUESTION |
22a. WEIGHT: _________lbs. ______ oz. OR _____kg □ Unknown |
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NEW QUESTION |
22b. HEIGHT: _________ft. _______ in. OR _____cm □ Unknown |
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NEW QUESTION |
23c. BMI: _________ □ Unknown |
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NEW QUESTION |
URINE CULTURES ONLY: 23a. RECORD THE COLONY COUNT: ________________
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URINE Cultures ONLY: 14b. Signs and Symptoms associated with urine culture. Please indicate if any of the following symptoms where reported during the 5 day time period including the 2 calendar days before through the 2 calendar days after the date of initial culture. Then go to question 14d. □ None □ Costovertebral angle pain or tenderness □ Dysuria □ Fever [temperature ≥ 100.4 °F (38 °C)] □ Unknown □ Frequency □ Suprapubic tenderness □ Urgency
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URINE CULTURES ONLY: 23b. SIGNS AND SYMPTOMS ASSOCIATED WITH URINE CULTURE Please indicate if any of the following symptoms where reported during the 5 day time period including the 2 calendar days before through the 2 calendar days after the DISC. □ None □ Costovertebral angle pain or tenderness □ Dysuria □ Fever [temperature ≥ 100.4 °F (38 °C)] □ Unknown □ Frequency □ Suprapubic tenderness □ Urgency Symptoms for patients ≤1 year of age only: □ Apnea □ Bradycardia □ Lethargy □ Vomiting
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15b. Did clinical laboratory identify isolate as ESBL producer? Yes No Unknown
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This question was removed. |
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NEW QUESTION |
24a. WAS THE INCIDENT SPECIMEN POLYMICROBIAL? □ Yes □ No □ Unknown
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15c. What confirmatory testing method(s) was used? (Check all that apply): □ Broth Microdilution (ATI) □ Disk Diffusion □ Other (Specify):____________ □ None □ Unknown
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24b. WHAT SCREENING/ CONFIRMATORY METHOD WAS USED FOR ESBL DETECTION? (Check all that apply): □ Broth Microdilution (ATI detection) □ ESBL well □ Expert rule (ATI flag) □ Broth Microdilution (Manual) □ Disk Diffusion □ E-test □ Molecular test (specify):____________ □ Other non-molecular test (specify):________ □ None □ Unknown
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15d. IF TESTED, what was the test result?
□ Positive □ Negative □ Indeterminate □ Unknown
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24c. IF SCREENING/ CONFIRMATORY METHOD WAS USED, WHAT WAS THE RESULT?
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19a. Is antimicrobial use (IV or oral) in the 30 days before the date of initial culture collection documented in the H&P or medical administration record?
□ Yes (complete 19b) □ No □ Unknown
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25a. IS ANTIMICROBIAL USE (IV OR ORAL) IN THE 30 DAYS BEFORE THE DISC DOCUMENTED?
□ Yes □ No □ Unknown |
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19b . If yes, indicate all antibiotics given in the 30 days before the date of initial culture collection:
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25b. IF YES, CHECK ALL ANTIMICROBIALS USED IN THE 30 DAYS BEFORE THE DISC: (Check all that apply)
□ Unknown □ Amikacin □ Amoxicillin □ Amoxicillin/clavulanic acid □ Ampicillin □ Ampicillin/sulbactam □ Azithromycin □ Aztreonam □ Cefazolin □ Cefdinir □ Cefepime □ Cefixime □ Cefotaxime □ Cefoxitin □ Cefpodoxime □ Ceftaroline □ Ceftazidime □ Ceftazidime/avibactam □ Ceftizoxime □ Ceftolozane/tazobactam □ Ceftriaxone □ Cefuroxime □ Cephalexin □ Ciprofloxacin □ Clarithromycin □ Clindamycin □ Dalbavancin □ Daptomycin □ Delafloxacin □ Doripenem □ Doxycycline □ Ertapenem □ Fidaxomicin □ Fosfomycin □ Gentamicin □ Imipenem/cilastatin □ Levofloxacin □ Linezolid □ Meropenem □ Meropenem/vaborbactam □ Metronidazole □ Moxifloxacin □ Nitrofurantoin □ Oritavancin □ Penicillin □ Piperacillin/tazobactam □ Polymyxin B □ Polymyxin E (colistin) □ Rifaximin □ Tedizolid □ Telavancin □ Tigecycline □ Tobramycin □ Trimethoprim □ Trimethoprim/sulfamethoxazole □ Vancomycin □ IV □ PO □ Other (specify): _____________________ □ Other (specify): _____________________ □ Other (specify): _____________________
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15a. Susceptibility Results: Please complete the table below based on the primary antibiotic testing report. Shaded antibiotics are required to have the MIC entered into the ESBL Case Management system, if available. |
26. SUSCEPTIBILITY RESULTS: Please complete the table below based on the information found in the indicated data source. Shaded antibiotics are required to have the MIC entered into the MuGSI-CM system, if available.
Remove: □ Other (Specify):_________________
Add: Medical record column Meropenem-vaborbactam Minocycline Doxycycline Plazomicin Tetracycline Rifampin Imipenem-relebactam
7 new antibiotic were added to this form for consistency with the CRE/CRAB CRF. |
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27a. WAS CASE FIRST IDENTIFIED THROUGH AUDIT? □ Yes □ No |
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20. CRF status: □ Complete □ Pending □ Chart unavailable |
27b. CRF STATUS:
□ Complete □ Pending □ Chart unavailable after 3 requests |
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22. SO initials:______________ |
27c. SO INITIALS: __________
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23. Comments:__________________________ _______________________________________
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27d. COMMENTS: __________________________________ _________________________________________________
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Multi-site Gram-Negative Surveillance Initiative (MuGSI)- Carbapenem-resistant Pseudomonas aeruginosa (CR-PA) - Form Discontinued
2019 Invasive MRSA Infection Case Report Form
2018 Paper CRF Question |
Changes to the 2019 Paper CRF Question |
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1. State (Residence of patient) ___ ___ |
1. State ___ ___ (Updated question wording) |
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2. County (Residence of patient) __________ |
2. County __________ (Updated question wording) |
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3. State I.D.: __________ |
3. State I.D.: __________ (No change) |
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Patient ID: ______________ |
4. Patient ID: _____________ (Updated question number; this was previously at the top of the CRF and not numbered). |
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4a. Hospital/Lab I.D. where culture identified __________ |
5. Laboratory ID where incident specimen identified __________ (Updated question number and wording) |
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4b. Hospital I.D. where patient treated _________ |
6. Facility ID where patient treated __________ (Updated question number and wording) |
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5. Sex: Male Female |
7. Sex at birth: Male Female Unknown Check if transgender (Updated question number and wording, added two new options—one for unknown sex at birth and a checkbox if the patient is transgender) |
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6. Date of Birth __/__/______ |
8. Date of birth __/__/______ (Updated question number) |
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7. Age ____ ____ ____ |
9. Age ____ ____ ____ Days Mos. Years (Updated question number and combined with question below [7b on old form]) |
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7b. Is age in day/mo/yr Days Mos. Years
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This text (Is age in day/mo/yr) has been removed and the option day/mo/year is now included as a part of question 9 |
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12b. Race White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Unknown |
10. Race (Check all that apply)
(Updated question number and order of responses; all response options remain the same) |
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12a. Ethnic Origin Hispanic or Latino Not Hispanic or Latino Unknown |
11. Ethnic origin Hispanic or Latino Not Hispanic or Latino Unknown (Updated question number) |
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12c. Weight Unknown _____ lbs _____oz OR _____kg
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12. Weight _____ lbs _____oz OR _____kg Unknown (Updated question number and order of responses; all response options remain the same) |
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12d. Height Unknown _____ft. _____ in. OR _____cm
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13. Height _____ft. _____ in. OR _____cm Unknown (Updated question number and order of responses; all response options remain the same) |
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12e. BMI (do not calculate, only if available in the MR) Unknown _____ |
14. BMI (record only if ht. and/or wt. is not available) _____ Unknown (Updated question number, wording, and order of responses; all response options remain the same) |
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9. Date of Initial Culture ___/___/______ |
15. Date of Incident Specimen Collection (DISC) ___/___/______ (Updated question number and wording) |
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10a. Was the patient hospitalized at the time of, or within 30 calendar days after, initial culture? Yes No Unknown If yes, date of admission ___/___/______ |
16. Was the patient hospitalized at the time of, or in the 29 calendar days after, the DISC? Yes No Unknown If yes, date of admission ___/___/______ (Updated question number and wording) |
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11. Was culture collected >3 calendar days after hospital admission? Yes (HO-MRSA case) No (Complete CRF, CA-MRSA or HACO-MRSA case)
If yes, was case selected for full CRF based on sampling frame 1:10? Yes (Complete CRF) No (STOP data abstraction) |
17. Was incident specimen collected 3 or more calendar days after hospital admission? Yes (HO-MRSA case) No (CA-MRSA or HACO-MRSA case)
(Updated question number and wording, dropped second part of question, “If yes, was case selected for full CRF based on sampling frame 1:10?”) |
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8. Sterile site(s) from which MRSA was initially isolated (check all that apply) Blood CSF Pleural fluid Peritoneal fluid Pericardial fluid Joint/Synovial fluid Bone Muscle Internal body site (specify________) Other sterile site (specify________) |
18. Incident specimen collection site (check all that apply) Blood Bone CSF Internal body site (specify________) Joint/Synovial fluid Muscle Pericardial fluid Peritoneal fluid Pleural fluid Other normally sterile site (specify________) (Updated question number, wording, order of responses, and wording of one response options [other sterile site is now other normally sterile site], though all response options remain the same) |
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16. Location of culture collection (check one) Hospital inpatient ICU Surgery/OR Radiology Other unit Outpatient Clinic/Doctor’s office Surgery Dialysis/Renal Clinic Other outpatient
Emergency Room Observational Unit/clinical decision unit LTCF Facility ID:_______ LTACH Facility ID: _______ Autopsy Unknown Other |
19. Location of specimen collection Outpatient Facility ID:_______ Emergency room Clinic/Doctor’s office Dialysis center Surgery Observational/clinical decision unit Other outpatient Inpatient Facility ID: ______ ICU OR Radiology Other inpatient LTCF Facility ID: ______ LTACH Facility ID: ______ Autopsy Other (specify):_______ Unknown
(Updated question number. Added checkboxes for headings “Outpatient” and “Inpatient”. Added a facility ID for “Outpatient” and “Inpatient”. Updated the order of responses. Changed the wording of the response “Dialysis/Renal clinic to “Dialysis” and “Other unit” to “Other inpatient”) |
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17. Were cultures of the SAME or OTHER sterile sites positive within 30 days after initial culture date? Yes No Unknown If yes, indicate site and date of last positive culture. Blood, Date:_______ CSF, Date: _______ Pleural fluid, Date:_______ Peritoneal fluid, Date: _______ Pericardial fluid, Date: _______ Joint/Synovial fluid, Date: _______ Bone, Date: _______ Muscle, Date: _______ Internal body site (specify________) Date: _______ Other sterile site (specify________) Date: _______ |
20. Were cultures of the SAME or OTHER sterile site(s) positive within 29 days after DISC? Yes No Unknown If yes, indicate site and date of last positive culture. Blood, Date:______ Bone, Date:______ CSF, Date:______ Internal body site (specify________), Date:______ Joint/Synovial fluid, Date:______ Muscle, Date:______ Pericardial fluid, Date:______ Peritoneal fluid, Date:______ Pleural fluid, Date:______ Other normally sterile site (specify____) Date:______ (Updated question number and wording, order of responses, and wording of one of the response options [other sterile site is now other normally sterile site]) |
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17b. Date of first SA blood culture after which SA not isolated for 14 days ___/___/______ |
21. Date of first SA blood culture after which SA not isolated for 14 days ___/___/______ (Updated question number) |
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22. Susceptibility Results Cefoxitin S R U Oxacillin S R U Vancomycin S I R U Clindamycin S I R U Trimethoprim-sulfamethoxazole S I R U |
22. Susceptibility Results Cefazolin S I R U Nafcillin S I R U Cefoxitin S R U Oxacillin S R U Vancomycin S I R U Clindamycin S I R U Trimethoprim-sulfamethoxazole S I R U (Added two antimicrobial agents-Cefazolin and Nafcillin) |
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15. Where was the patient located on the 4th calendar day prior to the date of initial culture? Private residence Long term care facility Facility ID: Long term acute care hospital Facility ID: Homeless Incarcerated Hospital inpatient Facility ID: Other____________ Unknown |
23. Where was the patient located on the 3rd calendar day before the DISC?
(Updated question number and wording, Updated order of the responses, added the response: Was patient transferred from this hospital? Yes No Unknown for patients that were indicated to be a hospital inpatient.)
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14. If case is ≤12 months of age, type of birth hospitalization NICU/SCN Well baby nursery Unknown |
24. If case is ≤12 months of age, type of birth hospitalization NICU/SCN Well baby nursery Unknown (Updated question number) |
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20. Underlying conditions: Premature birth Birth weight _____ lb _____oz OR ______ g Estimated gestational age ______ weeks |
25. If patient <2 years of age were they born premature (<37 weeks gestation)? Yes No Unknown ---If YES, birth weight: _____ lb _____oz OR ______ g OR Unknown birth weight ---If YES, estimated gestational age: ______ weeks OR Unknown gestational age
(Updated question number and wording. Added “Unknown” checkboxes for birth weight and gestational age) |
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10b. If patient was hospitalized, was this patient admitted to the ICU during hospitalization? Yes No Unknown |
26. Was the patient in an ICU in the 2 days before the DISC? Yes No Unknown ---if YES, date of ICU admission: _ _-_ _-_ _ _ _ OR Date Unknown (Updated question number and wording, broke into two questions, added date of admission) |
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10b. If patient was hospitalized, was this patient admitted to the ICU during hospitalization? Yes No Unknown |
27. Was the patient in an ICU on the DISC or in the 2 days after the DISC? Yes No Unknown ---if YES, date of ICU admission: _ _-_ _-_ _ _ _ OR Date Unknown (Updated question number and wording, broke into two questions, added date of admission) |
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19. Types of MRSA infection associated with culture(s)
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28. Types of MRSA infection associated with culture(s)
(Updated question number, no change to the responses) |
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20. Underlying Conditions
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29. Underlying Conditions
(Updated question number, re-ordered options based on system and alphabet, moved 6 conditions to another location on the CRF [IVDU, Other drug use, Current smoker, Premature birth, birth weight, estimated gestational age], removed 2 conditions [abscess/boil (recurrent), influenza (within 10 days of initial culture)], and added 22 conditions [an option under diabetes for “with chronic complications”; congenital heart disease; diverticular disease; inflammatory bowel disease; cerebral palsy; epilepsy/seizure/seizure disorder; multiple sclerosis; neuropathy; Parkinson’s disease; other neurologic condition; quadriplegia; lowest serum creatinine for those with chronic kidney disease; surgical wound; other chronic ulcer or wound; primary immunodeficiency; transplant, hematopoietic stem cell; transplant, solid organ; ascites; hepatitis C; 2 options under hepatitis C: treated, in SVR and current, chronic, cirrhosis; hepatic encephalopathy; variceal bleeding]. There were minor wording changes for eight conditions [CVA/stroke to CVA/Stroke/TIA; Diabetes to Diabetes mellitus; Hematologic malignancy to Malignancy, hematologic; metastatic solid tumor to Malignancy, solid organ (metastatic); myocardial infarct to myocardial infarction; obesity to obesity or morbid obesity; peripheral vascular disease to peripheral vascular disease (PVD); solid tumor (non metastatic) to Malignancy, solid organ (non-metastatic)], one question was broken into two [Hemiplegia and paraplegia are now their own checkboxes rather than hemiplegia/paraplegia). One condition (pregnancy) was added to this question, but had previously stood as a stand-alone question (Q13). |
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20. Underlying Conditions
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30. Substance Use, current Smoking: (Check all that apply)
Alcohol Abuse:
Other Substances (Check all that apply):
The data in this section was formerly collected in the underlying conditions section (IVDU [changed to injection drug user], Current smoker [changed to smoking], and other drug use). See the highlighted conditions in the prior column.
There are six new check boxes that allow “other drug” use to be captured in more detail. These questions focus on type of drug and mode of delivery. |
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13.At the time of first positive culture, patient was: Pregnant Post-partum Neither Unknown |
This question has been deleted. A pregnancy checkbox is now included in Q20, underlying conditions |
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21. Prior healthcare exposure None Unknown Previous document MRSA infection or colonization If yes, Month____ Year ______ or previous state id: _________
Hospitalized within year before initial culture date If yes, Month ____ Day ____ Year ________ Unknown If known, Facility ID: ___________
Admitted to a LTACH within year before initial culture date If known, Facility ID: _____________
Residence in a long-term care facility within year before initial culture date If known, Facility ID: _____________
Surgery within year before initial culture date
If yes, list the surgeries and dates of surgery that occurred within 90 days prior to the initial culture:
Central vascular catheter in place at or any time in the 2 calendar days prior to initial culture
Dialysis within year before initial culture date (hemodialysis or peritoneal dialysis)
Current chronic dialysis Type Peritoneal Unknown Hemodialysis Type of vascular access AV fistula/graft Hemodialysis CVC Unknown |
31. Prior healthcare exposure(s)
Previous documented MRSA infection or colonization Yes No Unknown If yes, Month____ Year ______ or previous state id: _________
Previous hospitalization in the year before DISC Yes No Unknown If yes, date of discharge closed to DISC: ___/___/___ Facility ID: ___________
Overnight stay in LTACH in the year before DISC Yes No Unknown Facility ID: ___________
Overnight stay in LTCF in the year before DISC Yes No Unknown Facility ID: ___________
Surgery in the year before DISC Yes No Unknown
If yes, list the surgeries and dates of surgery that occurred within 90 days prior to the DISC:
Central line in place on the DISC (up to the time of collection), or at any time in the 2 calendar days before DISC Yes No Unknown
Dialysis in the year before DISC (hemodialysis or peritoneal dialysis) Yes No Unknown
Current chronic dialysis Yes No Unknown Type: Hemodialysis Peritoneal Unknown If hemodialysis, type of vascular access: AV fistula/graft Hemodialysis central line Unknown
(Updated question number and wording. Checkboxes were updated to yes/no/unknown responses, removing the need for None/Unknown checkboxes on prior CRF. Order of sub-questions has changed [not shown].)
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18. Patient outcome Survived Date of discharge: __/__/____ If survived, was the patient transferred to a LTCF? Yes No Unknown If yes, facility ID: _________________ If survived, was the patient transferred to a LTACH? Yes No Unknown If yes, facility ID: _________________
Died Date of death: __/__/____ Was MRSA cultured from a normally sterile site < calendar day 7 before death? Yes No Unknown
Unknown |
32. Patient outcome Survived Date of discharge: __/__/____ Left against medical advice (AMA) If survived, discharged to:
Died Date of death: __/__/____ On the day of or in the 6 calendar days before death, was the pathogen of interest isolate from a site that meets the case definition? Yes No Unknown
Unknown
(Updated question number and wording. Collapsed two questions (If patient survived, was the patient transferred to a LTCF and If patient survived was the patient transferred to a LTACH) into a single question (If survived, discharged to) and added a checkbox for “left against medical advice” and for “date unknown” (for both date of discharge [if survived] and date of death [if died]) |
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23. Was case first identified through audit? Yes No Unknown |
33. Was case first identified through audit? Yes No Unknown (Updated question number) |
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24. CRF status Complete Incomplete Edited & Correct Chart unavailable after 3 requests |
34. CRF Status Complete Incomplete Edited & Correct Chart unavailable after 3 requests (Updated question number) |
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25. Does this case have recurrent MRSA disease? Yes No Unknown If yes, previous (1st) state ID _______________ |
35. Does this case have recurrent MRSA disease? Yes No Unknown If yes, previous (1st) state ID ___________________ (Updated question number) |
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26. Date reported to EIP site ___/___/______ |
36. Date reported to EIP site ___/___/______ (Updated question number) |
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27. Initials of S.O. __________ |
37. S.O. Initials ____________ (Updated question number and wording) |
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2019 Invasive MSSA Infections Case Report Form
2018 Paper CRF Question |
Changes to the 2019 Paper CRF Question |
||||||||||||||||||||||||||||||||||||||||||||||||
1. State (Residence of patient) ___ ___ |
1. State ___ ___ (Updated question wording) |
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2. County (Residence of patient) __________ |
2. County __________ (Updated question wording) |
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3. State I.D.: __________ |
3. State I.D.: __________ (No change) |
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Patient ID: ______________ |
4. Patient ID: _____________ (Updated question number; this was previously at the top of the CRF and not numbered). |
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4a. Hospital/Lab I.D. where culture identified __________ |
5. Laboratory ID where incident specimen identified __________ (Updated question number and wording) |
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4b. Hospital I.D. where patient treated _________ |
6. Facility ID where patient treated __________ (Updated question number and wording) |
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5. Sex: Male Female |
7. Sex at birth: Male Female Unknown Check if transgender (Updated question number and wording, added two new options—one for unknown sex at birth and a checkbox if the patient is transgender) |
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6. Date of Birth __/__/______ |
8. Date of birth __/__/______ (Updated question number) |
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7. Age ____ ____ ____ |
9. Age ____ ____ ____ Days Mos. Years (Updated question number and combined with question below [7b on old form]) |
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7b. Is age in day/mo/yr Days Mos. Years
|
This text (Is age in day/mo/yr) has been removed and the option day/mo/year is now included as a part of question 9 |
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12b. Race White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Unknown |
10. Race (Check all that apply)
(Updated question number and order of responses; all response options remain the same) |
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12a. Ethnic Origin Hispanic or Latino Not Hispanic or Latino Unknown |
11. Ethnic origin Hispanic or Latino Not Hispanic or Latino Unknown (Updated question number) |
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12c. Weight Unknown _____ lbs _____oz OR _____kg
|
12. Weight _____ lbs _____oz OR _____kg Unknown (Updated question number and order of responses; all response options remain the same) |
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12d. Height Unknown _____ft. _____ in. OR _____cm
|
13. Height _____ft. _____ in. OR _____cm Unknown (Updated question number and order of responses; all response options remain the same) |
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12e. BMI (do not calculate, only if available in the MR) Unknown _____ |
14. BMI (record only if ht. and/or wt. is not available) _____ Unknown (Updated question number, wording, and order of responses; all response options remain the same) |
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9. Date of Initial Culture ___/___/______ |
15. Date of Incident Specimen Collection (DISC) ___/___/______ (Updated question number and wording) |
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10a. Was the patient hospitalized at the time of, or within 30 calendar days after, initial culture? Yes No Unknown If yes, date of admission ___/___/______ |
16. Was the patient hospitalized at the time of, or in the 29 calendar days after, the DISC? Yes No Unknown If yes, date of admission ___/___/______ (Updated question number and wording) |
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11. Was culture collected >3 calendar days after hospital admission? Yes (HO case) No |
17. Was incident specimen collected 3 or more calendar days after hospital admission? Yes (HO-MSSA case) No (CA-MSSA or HACO-MSSA case) |
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8. Sterile site(s) from which MSSA was initially isolated (check all that apply) Blood CSF Pleural fluid Peritoneal fluid Pericardial fluid Joint/Synovial fluid Bone Muscle Internal body site (specify________) Other sterile site (specify________) |
18. Incident specimen collection site (check all that apply) Blood Bone CSF Internal body site (specify________) Joint/Synovial fluid Muscle Pericardial fluid Peritoneal fluid Pleural fluid Other normally sterile site (specify________) (Updated question number, wording, order of responses, and wording of one response options [other sterile site is now other normally sterile site], though all response options remain the same) |
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16. Location of culture collection (check one) Hospital inpatient ICU Surgery/OR Radiology Other unit Outpatient Clinic/Doctor’s office Surgery Dialysis/Renal Clinic Other outpatient
Emergency Room Observational Unit/clinical decision unit LTCF Facility ID:_______ LTACH Facility ID: _______ Autopsy Unknown Other |
19. Location of specimen collection Outpatient Facility ID:_______ Emergency room Clinic/Doctor’s office Dialysis center Surgery Observational/clinical decision unit Other outpatient Inpatient Facility ID: ______ ICU OR Radiology Other inpatient LTCF Facility ID: ______ LTACH Facility ID: ______ Autopsy Other (specify):_______ Unknown
(Updated question number. Added checkboxes for headings “Outpatient” and “Inpatient”. Added a facility ID for “Outpatient” and “Inpatient”. Updated the order of responses. Changed the wording of the response “Dialysis/Renal clinic to “Dialysis” and “Other unit” to “Other inpatient”) |
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17. Were cultures of the SAME or OTHER sterile sites positive within 30 days after initial culture date? Yes No Unknown If yes, indicate site and date of last positive culture. Blood, Date:_______ CSF, Date: _______ Pleural fluid, Date:_______ Peritoneal fluid, Date: _______ Pericardial fluid, Date: _______ Joint/Synovial fluid, Date: _______ Bone, Date: _______ Muscle, Date: _______ Internal body site (specify________) Date: _______ Other sterile site (specify________) Date: _______ |
20. Were cultures of the SAME or OTHER sterile site(s) positive within 29 days after DISC? Yes No Unknown If yes, indicate site and date of last positive culture. Blood, Date:______ Bone, Date:______ CSF, Date:______ Internal body site (specify________), Date:______ Joint/Synovial fluid, Date:______ Muscle, Date:______ Pericardial fluid, Date:______ Peritoneal fluid, Date:______ Pleural fluid, Date:______ Other normally sterile site (specify____) Date:______ (Updated question number and wording, order of responses, and wording of one of the response options [other sterile site is now other normally sterile site]) |
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17b. Date of first SA blood culture after which SA not isolated for 14 days ___/___/______ |
21. Date of first SA blood culture after which SA not isolated for 14 days ___/___/______ (Updated question number) |
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22. Susceptibility Results Cefoxitin S R U Oxacillin S R U Vancomycin S I R U Clindamycin S I R U Trimethoprim-sulfamethoxazole S I R U |
22. Susceptibility Results Cefazolin S I R U Nafcillin S I R U Cefoxitin S R U Oxacillin S R U Vancomycin S I R U Clindamycin S I R U Trimethoprim-sulfamethoxazole S I R U (Added two antimicrobial agents-Cefazolin and Nafcillin) |
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15. Where was the patient located on the 4th calendar day prior to the date of initial culture? Private residence Long term care facility Facility ID: Long term acute care hospital Facility ID: Homeless Incarcerated Hospital inpatient Facility ID: Other____________ Unknown |
23. Where was the patient located on the 3rd calendar day before the DISC?
(Updated question number and wording, Updated order of the responses, added the response: Was patient transferred from this hospital? Yes No Unknown for patients that were indicated to be a hospital inpatient.)
|
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14. If case is ≤12 months of age, type of birth hospitalization NICU/SCN Well baby nursery Unknown |
24. If case is ≤12 months of age, type of birth hospitalization NICU/SCN Well baby nursery Unknown (Updated question number) |
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20. Underlying conditions: Premature birth Birth weight _____ lb _____oz OR ______ g Estimated gestational age ______ weeks |
25. If patient <2 years of age were they born premature (<37 weeks gestation)? Yes No Unknown ---If YES, birth weight: _____ lb _____oz OR ______ g OR Unknown birth weight ---If YES, estimated gestational age: ______ weeks OR Unknown gestational age
(Updated question number and wording. Added “Unknown” checkboxes for birth weight and gestational age) |
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10b. If patient was hospitalized, was this patient admitted to the ICU during hospitalization? Yes No Unknown |
26. Was the patient in an ICU in the 2 days before the DISC? Yes No Unknown ---if YES, date of ICU admission: _ _-_ _-_ _ _ _ OR Date Unknown (Updated question number and wording, broke into two questions, added date of admission) |
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10b. If patient was hospitalized, was this patient admitted to the ICU during hospitalization? Yes No Unknown |
27. Was the patient in an ICU on the DISC or in the 2 days after the DISC? Yes No Unknown ---if YES, date of ICU admission: _ _-_ _-_ _ _ _ OR Date Unknown (Updated question number and wording, broke into two questions, added date of admission) |
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19. Types of MSSA infection associated with culture(s)
|
28. Types of MSSA infection associated with culture(s)
(Updated question number, no change to the responses) |
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20. Underlying Conditions
|
29. Underlying Conditions
(Updated question number, re-ordered options based on system and alphabet, moved 6 conditions to another location on the CRF [IVDU, Other drug use, Current smoker, Premature birth, birth weight, estimated gestational age], removed 2 conditions [abscess/boil (recurrent), influenza (within 10 days of initial culture)], and added 22 conditions [an option under diabetes for “with chronic complications”; congenital heart disease; diverticular disease; inflammatory bowel disease; cerebral palsy; epilepsy/seizure/seizure disorder; multiple sclerosis; neuropathy; Parkinson’s disease; other neurologic condition; quadriplegia; lowest serum creatinine for those with chronic kidney disease; surgical wound; other chronic ulcer or wound; primary immunodeficiency; transplant, hematopoietic stem cell; transplant, solid organ; ascites; hepatitis C; 2 options under hepatitis C: treated, in SVR and current, chronic, cirrhosis; hepatic encephalopathy; variceal bleeding]. There were minor wording changes for eight conditions [CVA/stroke to CVA/Stroke/TIA; Diabetes to Diabetes mellitus; Hematologic malignancy to Malignancy, hematologic; metastatic solid tumor to Malignancy, solid organ (metastatic); myocardial infarct to myocardial infarction; obesity to obesity or morbid obesity; peripheral vascular disease to peripheral vascular disease (PVD); solid tumor (non metastatic) to Malignancy, solid organ (non-metastatic)], one question was broken into two [Hemiplegia and paraplegia are now their own checkboxes rather than hemiplegia/paraplegia). One condition (pregnancy) was added to this question, but had previously stood as a stand-alone question (Q13). |
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20. Underlying Conditions
|
30. Substance Use Smoking:
Alcohol Abuse:
Other Substances (Check all that apply):
The data in this section was formerly collected in the underlying conditions section (IVDU [changed to injection drug user], Current smoker [changed to smoking], and other drug use). See the highlighted conditions in the prior column.
There are six new check boxes that allow “other drug” use to be captured in more detail. These questions focus on type of drug and mode of delivery.
|
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13.At the time of first positive culture, patient was: Pregnant Post-partum Neither Unknown |
This question has been deleted. A pregnancy checkbox is now included in Q20, underlying conditions |
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21. Prior healthcare exposure None Unknown Previous document MSSA infection or colonization If yes, Month____ Year ______ or previous state id: _________
Hospitalized within year before initial culture date If yes, Month ____ Day ____ Year ________ Unknown If known, Facility ID: ___________
Admitted to a LTACH within year before initial culture date If known, Facility ID: _____________
Residence in a long-term care facility within year before initial culture date If known, Facility ID: _____________
Surgery within year before initial culture date
If yes, list the surgeries and dates of surgery that occurred within 90 days prior to the initial culture:
Central vascular catheter in place at or any time in the 2 calendar days prior to initial culture
Dialysis within year before initial culture date (hemodialysis or peritoneal dialysis)
Current chronic dialysis Type Peritoneal Unknown Hemodialysis Type of vascular access AV fistula/graft Hemodialysis CVC Unknown |
31. Prior healthcare exposure(s)
Previous documented MSSA infection or colonization Yes No Unknown If yes, Month____ Year ______ or previous state id: _________
Previous hospitalization in the year before DISC Yes No Unknown If yes, date of discharge closed to DISC: ___/___/___ Facility ID: ___________
Overnight stay in LTACH in the year before DISC Yes No Unknown Facility ID: ___________
Overnight stay in LTCF in the year before DISC Yes No Unknown Facility ID: ___________
Surgery in the year before DISC Yes No Unknown
If yes, list the surgeries and dates of surgery that occurred within 90 days prior to the DISC:
Central line in place on the DISC (up to the time of collection), or at any time in the 2 calendar days before DISC Yes No Unknown
Dialysis in the year before DISC (hemodialysis or peritoneal dialysis) Yes No Unknown
Current chronic dialysis Yes No Unknown Type: Hemodialysis Peritoneal Unknown If hemodialysis, type of vascular access: AV fistula/graft Hemodialysis central line Unknown
(Updated question number and wording. Checkboxes were updated to yes/no/unknown responses, removing the need for None/Unknown checkboxes on prior CRF. Order of sub-questions has changed [not shown].)
|
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18. Patient outcome Survived Date of discharge: __/__/____ If survived, was the patient transferred to a LTCF? Yes No Unknown If yes, facility ID: _________________ If survived, was the patient transferred to a LTACH? Yes No Unknown If yes, facility ID: _________________
Died Date of death: __/__/____ Was MSSA cultured from a normally sterile site < calendar day 7 before death? Yes No Unknown
Unknown |
32. Patient outcome Survived Date of discharge: __/__/____ Left against medical advice (AMA) If survived, discharged to:
Died Date of death: __/__/____ On the day of or in the 6 calendar days before death, was the pathogen of interest isolate from a site that meets the case definition? Yes No Unknown
Unknown
(Updated question number and wording. Collapsed two questions (If patient survived, was the patient transferred to a LTCF and If patient survived was the patient transferred to a LTACH) into a single question (If survived, discharged to) and added a checkbox for “left against medical advice” and for “date unknown” (for both date of discharge [if survived] and date of death [if died]) |
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23. Was case first identified through audit? Yes No Unknown |
33. Was case first identified through audit? Yes No Unknown (Updated question number) |
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24. CRF status Complete Incomplete Edited & Correct Chart unavailable after 3 requests |
34. CRF Status Complete Incomplete Edited & Correct Chart unavailable after 3 requests (Updated question number) |
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25. Does this case have recurrent MSSA disease? Yes No Unknown If yes, previous (1st) state ID _______________ |
35. Does this case have recurrent MSSA disease? Yes No Unknown If yes, previous (1st) state ID ___________________ (Updated question number) |
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26. Date reported to EIP site ___/___/______ |
36. Date reported to EIP site ___/___/______ (Updated question number) |
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27. Initials of S.O. __________ |
37. S.O. Initials ____________ (Updated question number and wording) |
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2018 CDI Case Report and Treatment Form
Question on 2018 Form |
Question on 2019 Form |
28. Identified
through audit
|
Removed |
5. DATE
OF BIRTH
|
10. DATE
OF BIRTH
|
6. Age |
12. Age (years)
|
7a. SEX:
|
12. Sex
at birth
|
9.
Was patient
hospitalized on the date of or in the 6 calendar days after
incident C. diff+ stool collection?
|
15. Was
patient hospitalized on the date of or in the 6 calendar days
after incident C. diff+ stool collection?
|
10. Where
was the patient located on the 3rd calendar day before the date
of incident C. diff+ stool collection?
|
16. Where
was the patient located on the 3rd calendar day before the date
of incident C. diff+ stool collection?
|
8c.
Location of incident C.
diff+ stool collection:
|
17. Location
of incident C. diff+ stool collection:
|
11a. Was incident C. diff+ stool collected at least 3 calendar days after the date of hospital admission? □ Yes (HCFO – go to 11d) □ No |
18a. Was incident C. diff+ stool collected at least 3 calendar days after the date of hospital admission? □ Yes (HCFO – go to 18d) □ No |
11b. Was incident C. diff+ stool collected at an outpatient setting for a LTCF resident, or in a LTCF or LTACH? □ Yes (HCFO – go to 11d) □ No |
18b. Was incident C. diff+ stool collected at an outpatient setting for a LTCF resident, or in a LTCF or LTACH? □ Yes (HCFO – go to 18d) □ No |
11c. Was the patient admitted from a LTCF or a LTACH? □ Yes (HCFO – go to 11d) □ No (CO - stop data abstraction here) Facility ID: ____________________ |
18c. Was the patient admitted from a LTCF or a LTACH? □ Yes (HCFO – go to 18d) □ No (CO - stop data abstraction here) Facility ID: ____________________ |
14.
Exclusion criteria for
CA-CDI:
□ Hospitalized
(overnight) in the 12 weeks before the date of incident C. diff+
stool collection
□ Overnight stay in
LTACH in the 12 weeks before the date of incident C.diff + stool
collection □ Residence in LTCF in the 12 weeks before the date of incident C.diff + stool collection Facility ID _______________
|
20a-20c. Exposures to healthcare in the 12 weeks before the date of incident C. diff+ stool collection Previous
hospitalization Overnight
stay in LTACH Overnight
stay in LTCF
|
15a. Chronic
Hemodialysis
|
20d. Chronic
dialysis
|
15b. Surgical
procedure
|
20e. Surgery
|
21.
UNDERLYING CONDITIONS:
(Check all that apply)
|
21. UNDERLYING
CONDITIONS:
(Check all that apply)
|
17b. ICU
Admission (in
the 2 calendar days before, the day of, or the 6 calendar days
after the date of incident C. diff+ stool collection)
|
26, 27 Was
the patient in an ICU on the day of or in the 6 days after the
date of incident C. diff+ stool collection?
|
18, 20.2e RADIOGRAPHIC
FINDINGS (in
the 6 calendar days before, the day of, or the 6 calendar days
after the date of incident C. diff+ stool collection)
|
28. Toxic
megacolon and ileus (in the 6 calendar days before, the day of,
or the 6 calendar days after the date of incident C. diff+ stool
collection)
|
17a.
Colectomy
(related to CDI):
|
30. Colectomy
(related to CDI):
|
23d.
Antimicrobial therapy
( Check all that apply) □ Imipenem □ Rifampin □Tetracycline
|
33d. Antimicrobial
therapy ( Check
all that apply) □
Cefixime □
Ceftazidime/avibactam □
Dalbavancin □
Fosfomycin □
Oritavancin □
Tedizolid
|
17c. Any
additional positive stool test for C. diff ≥2 and ≤8 weeks
after the date of incident C. diff+ stool collection?
|
36. Any
recurrent C. diff episodes following this incident C. diff
episode?
|
24. Treatment
|
34. Treatment
|
2019 HAIC Candidemia Case Report
2018 CRF Question |
2019 CRF Question |
|||||||||||||||||||||||||||||||
15. Sex: Female Male Check if transgender |
15. Sex at birth: Male Female Unknown Check if transgender (Updated order of responses) |
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19. Race White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Unknown |
19. Race (Check all that apply)
(Updated question number and order of responses; all response options remain the same) |
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22. Location of specimen collection (check one) Hospital inpatient Hospital Inpatient Facility ID: _________ ICU Surgery/OR Radiology Other Unit
Outpatient Clinic/Doctor’s office Surgery Dialysis center Other outpatient Emergency Room Observational/clinical decision unit LTCF Facility ID: _________ LTACH Facility ID: _________ Autopsy Unknown Other (specify): ________________________
|
22. Location of specimen collection Outpatient Facility ID:_______ Emergency room Clinic/Doctor’s office Dialysis center Surgery Observational/clinical decision unit Other outpatient Inpatient Facility ID: ______ ICU OR Radiology Other inpatient LTCF Facility ID: ______ LTACH Facility ID: ______ Autopsy Other (specify):_______ Unknown
(Added checkboxes for headings “Outpatient” and “Inpatient”. Added a facility ID for “Outpatient” and “Inpatient”. Updated the order of responses). |
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25. Antifungal susceptibility testing (check here if no testing done/no test reports available):
Amphotericin B
S
SDD I
R NS
|
25. Antifungal susceptibility testing (check here if no testing done/no test reports available):
(added options “NI” and “ND” for each drug –see above for example)
Amphotericin B
S
SDD I
R NS
NI ND |
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26. Additional non-Candida organisms isolated from blood cultures on the same day as DISC: 1 Yes 0 No 9 Unknown 26a. If yes, additional organisms (Enter up to 3 pathogens): ____________________, ____________________, ____________________ |
26. Additional non-Candida organisms isolated from blood cultures on the day of or in the 7 days before DISC: 1 Yes 0 No 9 Unknown 26a. If yes, additional organisms (Enter up to 3 pathogens): ____________________, ____________________, ____________________ |
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|
27. At the time of DISC, was the patient known to be colonized with or being managed as if they were colonized with multi-drug resistant organism (MDRO) infection control (e.g.: on contact precautions)? MDROs include CRE, CRPA, CRAB, MRSA, and VRE. 1 Yes 0 No 9 Unknown 27a. If yes, specify organisms (Enter up to 3 pathogens): ____________________, ____________________, ____________________ (added new question) |
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29. Other known sites of Candida/yeast infection or colonization in the 7 days before or 3 days after the DISC? (check all that apply): None Unknown Peritoneal fluid or abdominal cavity Urine Respiratory specimen Pleural fluid CSF Bone Skin Catheter tip Other site (specify): _____________________
|
30. Did the patient have any of the following types of infection/colonization related to their Candida infection? (check all that apply): None Unknown Abscess Splenic Liver Pulmonary Candiduria CNS involvement (meningitis, brain abscess) Eyes (endophthalmitis or chorioretinitis) Endocarditis Peritonitis Respiratory specimen with Candida Septic emboli Lungs Brain Osteomyelitis Skin lesions Other (specify): _____________________
(changed question number, wording slightly and changed more options) |
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32. Patient outcome: 1 Survived 9 Unknown Date of discharge: ___ ___ - ___ ___ - ___ ___ ___ ___ Unknown
|
33. Patient outcome Date of discharge: 1 Survived 9 Unknown ___ ___ - ___ ___ - ___ ___ ___ ___ Unknown Left against medical advice (AMA) (updated number and added option for left AMA) |
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|
34. Did the patient have any of the following classes or specific ICD-10 codes, including any sub-codes for this hospitalization? (Check all that apply): None Unknown B37 (candidiasis) Specify sub-code: ___________________ Specify sub-code: ___________________ P37.5 (neonatal candidiasis) B48 (other mycoses, not classified elsewhere) B49 (unspecified mycoses) T80.211 (BSI due to central venous catheter) A41.9 (sepsis, unspecified organism) R65.2 (severe sepsis) (new question) |
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|
38. Underlying Conditions
(Updated question number, changed wording of Hepatitis C question and added 2 options under hepatitis C: treated, in SVR and current, chronic, cirrhosis; removed “skin conditions” after “other”) |
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37. Social History (check all that apply): None Unknown
Smoker E-Cigarette Use Alcohol Abuse Injection Drug Use Skin Popping Other drug use |
39. Substance Use Smoking:
Alcohol Abuse:
Other Substances (Check all that apply):
|
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44a. If yes, date of neutropenia (mm-dd-yyyy): -- *Neutropenia: ANC ≤ 500 OR calculated as: WBC count * (% polys + % bands) ≤500 Laboratory-calculated ANC:_______ __________ * (% _____ + % ______) = _________ |
Removed in the new version |
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47. Did the patient have a CVC on the day of incident specimen collection or at any time in the 2 calendar days before DISC?
1 Yes 2 No 3 Had CVC but can’t find dates 9 Unknown
|
51. Did the patient have a CVC in the 2 calendar days before DISC?
1 Yes 2 No 3 Had CVC but can’t find dates 9 Unknown (update number and changed wording of question slightly) |
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48. Did the patient have a midline catheter on the day of incident specimen collection or at any time in the 2 calendar days before DISC? 1 Yes 0 No 9 Unknown |
52. Did the patient have a midline catheter in the 2 calendar days before DISC? 1 Yes 0 No 9 Unknown
(updated number and changed working of question slightly)
|
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NEW QUESTION |
53. Did the patient have any of the following indwelling devices present in the 3 calendar days before DISC? Urinary Catheter Indwelling urethral Suprapubic Respiratory ET/NT Tracheostomy Gastrointestinal Gastrostomy
(Added new question)
|
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Estimated Annualized Burden Hours
As a result of proposed changes to forms highlighted in yellow, the estimated annualized burden is expected to decrease by 360 hours, from 40,349 to 39,989 and the estimated number of annual responses is shown to decrease by 8,850 from 115,600 to 106,750 responses. The changes to the amended forms have minimal to no impact on burden estimates.
The following table is updated for the entire 0920-0978 burden table. The forms included in this change request are highlighted:
Type of Respondent |
Form Name |
No. of respondents |
No. of responses per respondent |
Avg. burden per response (in hours) |
Current Total Burden |
After Proposed Changes |
State Health Department
|
ABCs Case Report Form (Att. 1) |
10 |
809 |
20/60 |
2697 |
2697 |
ABCs Invasive Pneumococcal Disease in Children Case Report Form |
10 |
22 |
10/60 |
37 |
37 |
|
ABCs H. influenzae Neonatal Sepsis Expanded Surveillance Form (Att. 2) |
10 |
6 |
10/60 |
10 |
10 |
|
ABCs Severe GAS Infection Supplemental Form |
10 |
136 |
20/60 |
453 |
453 |
|
ABCs Neonatal Infection Expanded Tracking Form (Att. 3) |
10 |
37 |
20/60 |
123 |
123 |
|
|
|
|
|
|
0 |
|
FoodNet Campylobacter |
10 |
850 |
21/60 |
2975 |
2975 |
|
FoodNet Cryptosporidium |
10 |
130 |
10/60 |
217 |
217 |
|
FoodNet Cyclospora |
10 |
3 |
10/60 |
5 |
5 |
|
FoodNet Listeria monocytogenes |
10 |
13 |
20/60 |
43 |
43 |
|
FoodNet Salmonella |
10 |
827 |
21/60 |
2895 |
2895 |
|
FoodNet Shiga toxin producing E. coli |
10 |
190 |
20/60 |
633 |
633 |
|
FoodNet Shigella |
10 |
290 |
10/60 |
483 |
483 |
|
FoodNet Vibrio |
10 |
25 |
10/60 |
42 |
42 |
|
FoodNet Yersinia |
10 |
30 |
10/60 |
50 |
50 |
|
FoodNet Hemolytic Uremic Syndrome |
10 |
10 |
1 |
100 |
100 |
|
Influenza Hospitalization Surveillance Network Case Report Form (Att 4) |
10 |
1000 |
25/60 |
4167 |
4167 |
|
Influenza Hospitalization Surveillance Project Vaccination Phone Script Consent Form (English) |
10 |
333 |
5/60 |
278 |
278 |
|
Influenza Hospitalization Surveillance Project Vaccination Phone Script Consent Form (Spanish) |
10 |
333 |
5/60 |
278 |
278 |
|
Influenza Hospitalization Surveillance Project Provider Vaccination History Fax Form (Children/Adults) |
10 |
333 |
5/60 |
278 |
278 |
|
MuGSI Case Report Form for Carbapenem-resistant Enterobacteriaceae (CRE) and Acinetobacter baumannii (CRAB) (Att 5) |
10 |
500 |
25/60 |
1667 |
2083 |
|
MuGSI Extended-Spectrum Beta-Lactamase-Producing Enterobacteriaceae (ESBL) (Att 6) |
10 |
1200 |
25/60 |
4000 |
5000 |
|
FORM DISCONTINUED |
|
|
|
|
0 |
|
Invasive Methicillin-resistant Staphylococcus aureus (MRSA) Infection Case Report Form (Att 7) |
10 |
474
|
25/60
|
2030 |
1975 |
|
Invasive Methicillin-sensitive Staphylococcus aureus (MSSA) Infection Case Report Form (Att 8) |
10 |
754
|
25/60
|
3450 |
3142 |
|
CDI Case Report and Treatment Form (Att 9) |
10 |
1650 |
35/60 |
8250 |
9625 |
|
HAIC Candidemia Case Report (Att 10) |
9 |
800 |
20/60 |
2400 |
2400 |
|
TOTAL |
|
40,349 |
39,989 |
|||
| File Type | application/msword |
| File Title | OMB CY 08 |
| Author | wsb2 |
| Last Modified By | SYSTEM |
| File Modified | 2018-09-13 |
| File Created | 2018-09-13 |