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pdfPlan and Annual Surveys
Instructions for Completion of the Patient Safety Component-Annual
Hospital Survey (CDC 57.103)
Instructions for Form Completion
Data Field
Facility ID #
Survey Year
Facility Characteristics
Ownership (check one)
Number of patient days
Number of admissions
Is your hospital a teaching
hospital for physicians and/or
physicians in training?
If Yes, what type?
January 2016
Required. The NHSN-assigned facility ID will be auto-entered by the computer.
Required. Select the calendar year for which this survey was completed.
The survey year should represent the last full calendar year. For example, in 2017,
a facility would complete a 2016 survey.
Required. Select the appropriate ownership of this facility:
P - For profit
NP - Not for profit, including church
GOV - Government
MIL - Military
VA- Veterans Affairs
PHY - Physician owned
Required. Enter the total number of patient days from inpatient locations in your
hospital during the last full calendar year. Newborns should be included in this
count.
Required. Enter the total number of inpatient admissions, including newborns, for
your hospital during the last full calendar year.
Required. If a teaching hospital, select ‘Yes'. Otherwise, select 'No'.
Conditionally Required. If a teaching hospital, select the type from the options
listed:
(Note: There is no minimum requirement for the number of students in training to
meet these definitions.)
Major: Facility has a program for medical students and post-graduate
medical training.
Graduate: Facility has a program for post-graduate medical training (i.e.,
residency and/or fellowships).
Undergraduate: Facility has a program for medical students only.
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Plan and Annual Surveys
Facility Characteristics (continued)
Number of beds set up and
Required. Record the maximum number of beds set up and staffed for the last full
staffed in the following location calendar year for the bed types listed below. If any bed type is new or has not
types (as defined by NHSN)
been available long enough to have a full calendar year’s worth of data from
which to obtain the maximum number, indicate the maximum number from the
number of months available. For definitions of CDC location types, see CDC
Locations and Descriptions chapter.
a. ICU
Enter the number of beds in locations designated as intensive care units (ICUs) in
the facility. This includes all adult, pediatric, and neonatal levels II/III and III.
Enter the number of beds set up and staffed in all other inpatient locations used
for overnight stay patients in this hospital. This includes all inpatient beds in the
facility, and not just those that are subject to NHSN surveillance.
Facility Microbiology Laboratory Practices. Completion of this section requires the assistance from the
microbiology laboratory. Questions should be answered based on the testing methods that were used for the
majority of the last full calendar year.
1. Does your facility have its Required. Select 'Yes' if your laboratory performs antimicrobial susceptibility
own laboratory that
testing; otherwise, select 'No'.
performs antimicrobial
susceptibility testing? If No, Conditionally Required. If ‘No’, select the location where your facility's
where is the facility's
antimicrobial susceptibility testing is performed: Affiliated medical center,
antimicrobial susceptibility Commercial referral laboratory, or Other local/regional, non-affiliated reference
testing performed? (check laboratory. If multiple laboratories are used indicate the laboratory which
one)
performs the majority of the bacterial susceptibility testing. You must complete
the remainder of this survey with assistance from your outside laboratory.
b. All other inpatient
locations
Facility Microbiology Laboratory Practices (continued)
2. For the following organisms
please indicate which
methods are used for (1)
primary susceptibility
testing and (2) secondary,
supplemental, or
confirmatory testing (if
performed)
3. Has your laboratory
implemented the revised
cephalosporin and
monobactam breakpoints for
Enterobacteriaceae
January 2016
Required. Select from the choices listed the appropriate (1) primary susceptibility
testing and (2) secondary, supplemental, or confirmatory testing method (if
performed) for each organism.
Note: Repeat tests using the primary method should not be indicated as secondary
methods; instead indicate in the ‘Comments’ column the number of times repeat
testing is done using the same primary method.
If your laboratory does not perform susceptibility testing, please indicate the
methods used at the referral laboratory. If ‘Other’ is selected as the method for any
pathogen, use the ‘Comments’ column to describe the method used.
Required. Select 'Yes' if your laboratory has implemented the revised
cephalosporin and monobactam breakpoints for Enterobacteriaceae recommended
by CLSI as of 2010; otherwise, select 'No'.
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Plan and Annual Surveys
recommended by CLSI as of
2010?
4. Has your laboratory
Required. Select 'Yes' if your laboratory has implemented the revised carbapenem
implemented the revised
breakpoints for Enterobacteriaceae recommended by CLSI as of 2010; otherwise,
carbapenem breakpoints for select 'No'.
Enterobacteriaceae
recommended by CLSI as of
2010?
5. Does your laboratory
Required. Select 'Yes' if your laboratory performs a special test for carbapenemase
perform a special test for
production; otherwise, select 'No'.
carbapenemase production?
If Yes, please indicate what Conditionally Required. If ‘Yes’, specify what is done if carbapenemase
is done if carbapenemase
production is detected.
production is detected
(check one).
If Yes, which test is
Conditionally Required. If ‘Yes’, specify which test is performed to detect
routinely performed to
carbapenemase.
detect carbapenemase (check
all that apply).
Facility Microbiology Laboratory Practices (continued)
6. Does your laboratory
perform colistin or
polymyxin B susceptibility
testing for drug-resistant
gram negative bacilli?
If Yes, indicate methods
(check all that apply).
7. Does your facility have its
own laboratory that
performs antifungal
susceptibility testing for
Candida species?
If No, where your facility's
antifungal susceptibility
testing is performed? (check
one).
8. If antifungal susceptibility
testing is performed at your
facility or an outside
laboratory, what methods
are used? (check all that
apply)
January 2016
Required. Select 'Yes' if your laboratory performs colistin or polymyxin B
susceptibility testing for drug-resistant gram negative bacilli; otherwise, select
'No'.
Conditionally Required. If ‘Yes’, select the method(s) used from the choices
provided. If ‘Other’ is selected, please specify.
Required. Select 'Yes' if your laboratory performs antifungal susceptibility testing
for Candida species; otherwise, select 'No'.
Conditionally Required. If ‘No”, select one of the choices provided.
Required. Select from the choices listed the method(s) of antifungal susceptibility
testing performed at your facility or an outside laboratory. If ‘Other’ is selected,
please specify.
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Plan and Annual Surveys
9. Is antifungal susceptibility Required. Select the appropriate Candida species and drugs for which your
testing performed
laboratory or outside laboratory automatically/reflexively performs antifungal
automatically/reflexively for susceptibility testing from normally sterile body sites (such as blood), without
any of the following
needing a specific order or request for susceptibility testing from the clinician. If
Candida species cultured
antifungal susceptibility testing is not performed automatically on Candida
from normally sterile body species, select “Automatic testing is not performed for any Candida species”.
sites (such as blood),
without needing a specific
order or request for
susceptibility testing from
the clinician?
Check all species and
corresponding drugs for
which automatic testing is
done.
10. What is the primary testing Required. Select from the choices listed the testing methods used to perform C.
method for C. difficile used difficile testing by your facility’s laboratory or the outside laboratory where your
most often by your facility’s facility’s testing is done. If ‘Other’ is selected, please specify.
laboratory or the outside
laboratory where your
Note: “Other” should not be used to name specific laboratories, reference
facility’s testing is
laboratories, or the brand names of C. difficile tests; most methods can be
performed? (check one)
categorized accurately by selecting from the options provided. Please ask your
laboratory or conduct a search for further guidance on selecting the correct option
to report.
January 2016
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Plan and Annual Surveys
Facility Microbiology Laboratory Practices (continued)
11. Does your facility produce Required. Select ‘Yes’ if your facility produces an antibiogram; otherwise select
an antibiogram (i.e.,
‘No’.
cumulative antimicrobial
susceptibility report)?
If Yes, is the antibiogram
Conditionally Required. If ‘Yes’, indicate whether the antibiogram is produced at
produced at least annually? least annually.
If Yes, are data stratified by Conditionally Required. If ‘Yes’, indicate whether antibiogram data are stratified
hospital location?
by hospital location.
If No, please identify any
Conditionally Required. If ‘No’, indicate the obstacle(s) to producing an
obstacle(s) to producing an antibiogram at your facility. If ‘Other’ is selected, please specify.
antibiogram. (Check all that
apply)
Infection Control Practices. Completion of this section may require assistance from the Infection Preventionist,
Hospital Epidemiologist, other infection control personnel, and/or Quality Improvement Coordinator. Questions
should be answered based on the policies and practices that were in place for the majority of the last full calendar
year.
12. Number or fraction of
Required. Enter the number or fraction of individuals (full-time employees) who
infection preventionists (IPs) work in the infection prevention department of the hospital as infection
in facility
prevention professionals. Certification in infection control, the CIC credential, is
not required to be considered an “IP” on this survey.
a. Total hours per week
Enter the number of hours per week engaged in activities designed to find and
performing surveillance report healthcare-associated infections (in the hospital) and the appropriate
denominators. Total should include time to analyze data and disseminate results.
b. Total hours per week for Enter the number of hours per week spent on infection prevention and control
infection control
activities other than surveillance. These activities include, but are not limited to,
activities other than
education, prevention, meetings, etc.
surveillance
13. Number or fraction of full- Required. Enter the number or fraction of individuals (full-time employees) who
time employees (FTEs) for a perform the functions of a hospital epidemiologist in the facility. An official title
designated hospital
of “hospital epidemiologist” is not required. Hospital epidemiologists traditionally
epidemiologist (or
have a doctorate level degree with training in infection control, however such
equivalent role) affiliated
training is not required to be counted on this survey.
with your facility
For detailed description about the use of Contact Precautions, please refer to the CDC/HICPAC 2007 Guideline
for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
(http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf).
14. Is it a policy in your facility Required. Select ‘No’ if your facility does not routinely place any patient infected
that patients infected or
or colonized with MRSA in Contact Precautions; otherwise, select the single best
colonized with MRSA are choice from the choices listed that most accurately describes the primary
routinely placed in contact indication for placing admitted patients with MRSA on Contact Precautions at
precautions while these
your facility. If your facility never admits patients with MRSA, select ‘Not
patients are in your facility? applicable’.
(check one)
15. Is it a policy in your facility Required. Select ‘No’ if your facility does not routinely place any patient infected
that patients infected or
or colonized with VRE in Contact Precautions; otherwise, select the single best
colonized with VRE are
choice from the choices listed that most accurately describes the primary
January 2016
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Plan and Annual Surveys
routinely placed in contact indication for placing admitted patients with VRE on Contact Precautions at your
precautions while these
facility. If your facility never admits patients with VRE, select ‘Not applicable’.
patients are in your facility?
(check one)
16. Is it a policy in your facility Required. Select ‘No’ if your facility does not routinely place any patient infected
that patients infected or
or colonized with CRE in Contact Precautions; otherwise, select the single best
colonized with CRE
choice from the choices listed that most accurately describes the primary
(regardless of confirmatory indication for placing admitted patients with CRE on Contact Precautions at your
testing for carbapenemase facility. If your facility never admits patients with CRE, select ‘Not applicable’.
production) are routinely
placed in contact precautions
while these patients are in
your facility? (check one)
Infection Control Practices (continued)
17. Is it a policy in your facility
that patients infected or
colonized with suspected or
confirmed ESBL-producing
or extended spectrum
cephalosporin resistant
Enterobacteriaceae are
routinely placed in contact
precautions while these
patients are in your facility?
(check one)
18. Does the facility routinely
perform screening testing
(culture or non-culture) for
CRE?
Required. Select ‘No’ if your facility does not routinely place any patient infected
or colonized with ESBL-producing or extended spectrum cephalosporin-resistant
Enterobacteriaceae in Contact Precautions; otherwise, select the single best choice
from the choices listed that most accurately describes the primary indication for
placing admitted patients with ESBL-producing or extended spectrum
cephalosporin-resistant Enterobacteriaceae on Contact Precautions at your
facility. If your facility never admits patients with ESBL-producing or extended
spectrum cephalosporin-resistant Enterobacteriaceae, select ‘Not applicable’.
Required. Select ‘Yes’ if the facility routinely (i.e., it is standard practice to
perform the testing when the targeted patient group is present) does screening
using either culture or non-culture based methods for CRE; select no if either
testing is not routinely performed or not performed at all.
If Yes, in which situations
does the facility routinely Conditionally Required. If ‘Yes’, select all the situations for which screening
perform screening testing testing is done routinely. If ‘Other’ is selected, please specify the situation(s) in
for CRE? (check all that
which CRE screening is performed.
apply)
Note: ‘Epidemiologically-linked’ patients refer to contacts of the patient with
newly identified CRE. This might include current or prior roommates or patients
who shared the same healthcare personnel or patients who are located on the same
unit or ward.
January 2016
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Plan and Annual Surveys
19. Does the facility routinely
perform screening testing
(culture or non-culture) for
MRSA?
Required. Select ‘Yes’ if the facility routinely (i.e., it is standard practice to
perform the testing when the targeted patient group is present) does screening
using either culture or non-culture based methods for MRSA; select no if either
testing is not routinely performed or not performed at all.
If yes, in which situation
Conditionally required. If ‘Yes’, select all the situations for which screening
does the facility routinely testing is done routinely. If ‘Other’ is selected, please specify the situation(s) in
perform screening testing which MRSA screening is performed.
for MRSA? (check all that
apply)
20. Does the facility routinely Required. Select ‘Yes’ if your facility routinely uses chlorhexidine bathing on
use chlorhexidine bathing on any patient in any ward or unit as an intervention to prevent the infection or
any patients to prevent
transmission of any MDRO. Please do not include the use of this agent in patients
infection or transmission of undergoing surgery if the purpose is to prevent SSIs.
MDROs at your facility?
Note: this does not include Select ‘No’ if this agent is not used routinely or is not used at all or if it is only
the use of such bathing in
used to prevent surgical site infections in pre-operative patients.
pre-operative patients to
prevent surgical site
infections (SSIs)
Infection Control Practices (continued)
21. Does the facility routinely
use a combination of topical
chlorhexidine and intranasal
mupirocin (or equivalent
agent) on any patients to
prevent infection or
transmission of MRSA at
your facility? (Note: this
does not include the use of
these agents in pre-operative
surgical patients or dialysis
patients)
22. Among patients with an
MDRO admitted to your
facility from another
healthcare facility, please
estimate how often your
facility receives information
from the transferring facility
about the patient’s MDRO
status?
January 2016
Required. Select ‘Yes’ if the combination of topical chlorhexidine and intranasal
mupirocin is used routinely (i.e., it is standard practice to use these agents when
the targeted patient group is present) on patients in the facility specifically to
prevent transmission of MRSA. Please do not include the use of these agents in
dialysis patients or patients undergoing surgery if the purpose is to prevent
surgical site infections. Select ‘No’ if these combined agents are not used
routinely or are not used at all or if they are only used to prevent surgical site
infections in pre-operative patients or to prevent infection in dialysis patients.
Required. Please select the most appropriate response that indicates
approximately how often your facility receives information from a transferring
facility about the MDRO status of a patient known to be colonized or infected
with an MDRO. If your facility does not receive transferred patients, or does not
receive transferred patients with a known MDRO, select ‘Not applicable’.
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Plan and Annual Surveys
Antibiotic Stewardship Practices. Completion of this by section may require assistance from the pharmacy and/or
physicians who focus on Antibiotic Stewardship or Infectious Diseases, where available, and/or members of the
Pharmacy and Therapeutic Committee. Antibiotic Stewardship refers to a coordinated, multidisciplinary approach
to optimize and measure antibiotic use. For further information, refer to Core Elements of Hospital Antibiotic
Stewardship Programs (http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html). Questions
should be answered based on the policies and practices that were in place for the majority of the last full calendar
year.
23. Does your facility have a
Required. Select 'Yes' if there is written evidence of senior-level management
written statement of support support focused on antibiotic use prescribing (e.g., formal letter of support for
from leadership that
efforts to improve antibiotic use, written communication to hospital staff that
supports efforts to improve encourages optimal antibiotic prescribing, communication of support that reaches
antibiotic use (antibiotic
staff beyond those who receive executive-level meeting notes); otherwise, select
stewardship)?
'No'.
24. Is there a leader responsible Required. Select 'Yes' if any individual has been identified as a lead to antibiotic
for stewardship activities at stewardship activities as evidenced by responsibility for improving antibiotic use
your facility?
in the job description or performance review, authority to coordinate activities of
staff from multiple departments (e.g. laboratory, pharmacy, information
technology), and/or responsibility to report to senior level management on
program planning and outcomes.
If Yes, what is the position
of this leader? (check one)
25. Is there at least one
pharmacist responsible for
improving antibiotic use at
your facility?
26. Does your facility provide
any salary support for
dedicated time for antibiotic
stewardship leadership
activities?
Conditionally Required. If ‘Yes’, specify the qualification or job title of the
leader(s). If ‘Other’ is selected, please specify the position.
Required. Select 'Yes' if your facility has at least one pharmacist who dedicates
time distinct from general pharmacy duties to educate staff, and track or monitor
antibiotic use to ensure optimal prescribing practices; otherwise, select 'No'.
Required. Select 'Yes' if any individual was given salary support (any amount) to
serve as a leader of the stewardship program; otherwise, select 'No'.
Antibiotic Stewardship Practices (continued)
27. Does your facility have a
Required. Select 'Yes' if your facility has a policy requiring documentation of
policy that requires
dose, duration and indication for all antibiotics in the medical record or during
prescribers to document an order entry; otherwise, select 'No'.
indication for all antibiotics
in the medical record or
during order entry?
If Yes, has adherence to the
policy to document an
indication been monitored?
28. Does your facility have
facility-specific treatment
recommendations, based on
national guidelines and local
January 2016
Conditionally Required. If ‘Yes’ to question 27, select ‘Yes’ if charts have been
audited to confirm documentation of dose, duration, and indication in patient
medical records; otherwise, select ‘No’.
Required. Select 'Yes' if there are facility-specific recommendations for antibiotic
treatment selection based on national guidelines and local susceptibility reports
for ANY common clinical conditions (e.g., community required pneumonia,
urinary tract infections, or skin and soft tissue infections); otherwise, select 'No'.
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Plan and Annual Surveys
susceptibility, to assist with
antibiotic selection for
common clinical conditions?
If Yes, has adherence to
facility-specific treatment
recommendations been
monitored?
29. Is there a formal procedure
for all clinicians to review
the appropriateness of all
antibiotics at or after 48
hours from the initial orders
(e.g. antibiotic time out)?
30. Do any specified antibiotic
agents need to be approved
by a physician or pharmacist
prior to dispensing at your
facility?
31. Does a physician or
pharmacist review courses
of therapy for specified
antibiotic agents and
communicate results with
prescribers at your facility?
Conditionally Required. If ‘Yes’ to question 28, select ‘Yes’ charts have been
audited to confirm adherence to facility-specific treatment guidelines for ANY of
the common clinical conditions listed above; otherwise, select ‘No’.
Required. Select 'Yes' if your facility has developed a standardized way for
clinicians on the treating team (or attending physician? or physician of record?) to
reassess the continuing need and choice of antibiotics at or after 48 hours after the
initial orders (to confirm indication, review microbiology results, and review
antibiotic choice, dose, and duration); otherwise, select 'No'.
Required. Select 'Yes' if your facility has at least one antibiotic agent that requires
a physician or pharmacist to review and approve administration of the drug due to
its spectrum of activity, cost, or associated toxicities; otherwise, select 'No'.
Required. Select 'Yes' if your facility had physicians or pharmacists
knowledgeable in antibiotic use, and not part of the treating team, review courses
of therapy for specified antibiotic agents and communicate the results to
prescribers (such as audit with feedback); otherwise, select 'No'.
If yes, what type of feedback Conditionally required. Select the type of feedback that is provided to prescribers.
is provided to prescribers?
January 2016
9
Plan and Annual Surveys
Antibiotic Stewardship Practices (continued)
32. Does your facility monitor Required. Select 'Yes' if your facility monitors antibiotic use or consumption at
antibiotic use (consumption) the unit, service, and/or facility wide level at least quarterly; otherwise, select
at the unit, service, and/or 'No'.
facility wide?
If Yes, by which metrics
(Check all that apply)
If Yes, are facility- and/or
unit-specific reports on
antibiotic use shared with
prescribers?
33. Has your facility provided
education to clinicians and
other relevant staff on
improving antibiotic use?
January 2016
Conditionally Required. If ‘Yes’, select from the choices of listed antibiotic use
metrics. Days of Therapy (also known as Antimicrobial Days) is defined by any
amount of a specific antimicrobial agent administered in a calendar day to a
particular patient (i.e., each antimicrobial agent administered to a patient counted
as one day of therapy). The Defined Daily Dose is the assumed average
maintenance dose per day for a drug used for its main indication in adults and is
derived from the total number of grams of each antibiotic purchased, dispensed,
or administered. If ‘Other’ is selected, please specify the method(s) or metric(s)
used.
Conditionally Required. Select 'Yes' if facility and/or unit-specific reports on
antibiotic use are shared with prescribers (individually, by service line, by
medical group, etc.); otherwise, select 'No'.
Required. Select 'Yes' if your facility has provided education on how to improve
antibiotic use to clinicians and other relevant staff (e.g. Grand Rounds, in-service
training, or direct instruction); otherwise, select 'No'.
10
Plan and Annual Surveys
Instructions for Completion of the Patient Safety Annual Facility Survey
for LTAC (CDC 57.150)
Data Field
Facility ID #
Survey Year
Facility Characteristics
Ownership (check one)
Affiliation (check one)
Setting/Classification:
If classified as “Free-standing”,
does your LTAC hospital share
physical housing with one or
more of the following on-site
facilities or units? (check all that
apply)
December 2015
Instructions for Form Completion
Required. The NHSN-assigned facility ID will be auto-entered by the computer.
Required. Select the calendar year for which this survey was completed.
The survey year should represent the last full calendar year. For example, in
2017, a facility would complete a 2016 survey.
Required. Select the appropriate ownership of this facility:
For profit
Not for profit, including church
Government
Veterans Affairs
Required. Select the appropriate affiliation for this facility:
Independent – The facility is a stand-alone facility that does not share a
building, staff, or policies (such as infection control) with any other
healthcare institution.
Hospital system – The facility is affiliated with a local healthcare system.
Facility shares policies (such as infection control) with other institutions
within the hospital system. Facility may or may not share staff as well as a
building with other facilities that are part of that hospital system.
Multi-facility organization (specialty network) – The facility is part of a
regional or national network of specialty facilities. Facilities share policies
(such as infection control), corporate leadership, and a common business
structure.
Required. Select the physical setting of the facility: free-standing or within a
hospital.
Conditionally Required. If facility is classified as free-standing, select one or
more of the following facility or unit types that share physical housing with
your LTAC:
No (none)
Skilled nursing facility (SNF)/nursing home
Residential facility (assisted living)
Inpatient rehabilitation facility
Neuro-behavioral unit or facility
Other: specify
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Plan and Annual Surveys
Facility Characteristics (continued)
If classified as “Within a
Conditionally Required. If facility is classified as within a hospital, indicate
hospital”, is your LTAC hospital ‘Yes’ or ‘No’ if it is:
located:
In a building that does not provide acute care services (e.g., psychiatric
hospital)
Near (but not within) an acute care hospital
Note: These questions are to clarify the physical set-up of each HOSP-LTAC.
All separately licensed LTAC hospitals should be enrolled within NHSN as a
separate LTAC facility type regardless of the physical setting of the facility.
Number of Patient Days
Required. Enter the total number of patient days for your hospital during the last
full calendar year.
Number of Admissions
Required. Enter the total number of inpatient admissions for your hospital during
the last full calendar year.
Average daily census
Required. Enter the average number of patients housed each day during the last
full calendar year. Please round to the nearest whole number.
Numbers of LTAC beds in the Required. Enter the total number of LTAC beds in each on the following
following categories (categories categories during the last full calendar year:
should equal total number of
Intensive care unit (ICU) or critical care beds
beds)
High observation/special care/high acuity beds (not ICU)
Other LTAC beds
Total number of LTAC beds
Required. The total number of LTAC beds in the facility during the last full
(licensed capacity)
calendar year will be automatically summed based on the above counts.
Number of single occupancy
Required. Enter the total number of single occupancy rooms during the last full
rooms
calendar year.
Total number of admissions with Required. Enter the total count of patients identified on admission or upon initial
one of the following conditions assessment and review of patient during admission with the following conditions
identified on admission
(Note: these categories are not mutually exclusive).
Ventilator dependence
Hemodialysis
For a list of ICD-9, ICD-10, and DRG codes associated with these conditions
please review this spreadsheet: http://www.cdc.gov/nhsn/xls/DRGs-ICD9s-NHSN-LTAC-Survey.xlsx
December 2015
2
Plan and Annual Surveys
Facility Microbiology Laboratory Practices. Completion of this section requires the assistance from the
microbiology laboratory. Questions should be answered based on the testing methods that were used for the
majority of the last full calendar year.
1. Does your facility have its Required. Select 'Yes' if your laboratory performs antimicrobial susceptibility
own on-site laboratory that testing; otherwise, select 'No'.
performs antimicrobial
susceptibility testing?
Conditionally Required. If ‘No’, select the location where your facility's
antimicrobial susceptibility testing is performed: Affiliated medical center,
Commercial referral laboratory, or Other local/regional, non-affiliated reference
laboratory. If multiple laboratories are used indicate the laboratory which
performs the majority of the bacterial susceptibility testing. You must complete
the remainder of this survey with assistance from your outside laboratory.
2. For the following organisms Required. Select from the choices listed the appropriate (1) primary susceptibility
please indicate which
testing and (2) secondary, supplemental, or confirmatory testing method (if
methods are used for (1)
performed) for each organism.
primary susceptibility
testing and (2) secondary, Note: Repeat tests using the primary method should not be indicated as secondary
supplemental, or
methods; instead indicate in the ‘Comments’ column the number of times repeat
confirmatory testing (if
testing is done using the same primary method.
performed)
If your laboratory does not perform susceptibility testing, please indicate the
methods used at the referral laboratory. If ‘Other’ is selected as the method for any
pathogen, use the ‘Comments’ column to describe the method used.
3. Has the laboratory
Required. Select 'Yes' if your laboratory has implemented the revised
implemented the revised
cephalosporin and monobactam breakpoints for Enterobacteriaceae recommended
cephalosporin and
by CLSI as of 2010; otherwise, select 'No'.
monobactam breakpoints for
Enterobacteriaceae
recommended by CLSI as of
2010?
4. Has the laboratory
Required. Select 'Yes' if your laboratory has implemented the revised carbapenem
implemented the revised
breakpoints for Enterobacteriaceae recommended by CLSI as of 2010; otherwise,
carbapenem breakpoints for select 'No'.
Enterobacteriaceae
recommended by CLSI as of
2010?
If No, where is your
facility's antimicrobial
susceptibility testing
performed? (check one)
December 2015
3
Plan and Annual Surveys
Facility Microbiology Laboratory Practices (continued)
5. Does the laboratory
perform a special test for
carbapenemase
production? If Yes, please
indicate what is done if
carbapenemase production
is detected (check one).
If Yes, which test is
routinely performed to
detect carbapenemase
(check all that apply)?
6. Does the laboratory
perform colistin or
polymyxin B susceptibility
testing for drug-resistant
gram negative bacilli?
If Yes, indicate methods
(check all that apply).
Required. Select 'Yes' if your laboratory performs a special test for
carbapenemase production; otherwise, select 'No'.
Conditionally Required. If ‘Yes’, specify what is done if carbapenemase
production is detected.
Conditionally Required. If ‘Yes’, specify which test is performed to detect
carbapenemase.
Required. Select 'Yes' if your laboratory performs colistin or polymyxin B
susceptibility testing for drug-resistant gram negative bacilli; otherwise, select
'No'.
Conditionally Required. If ‘Yes’, select the method(s) used from the choices
provided. If ‘Other’ is selected, please specify.
7. Does your facility have its Required. Select 'Yes' if your laboratory performs antifungal susceptibility
own laboratory that
testing for Candida species; otherwise, select 'No'.
performs antifungal
susceptibility testing for
Candida species?
If No, where your facility's Conditionally Required. If ‘No”, select one of the choices provided.
antifungal susceptibility
testing is performed?
(check one).
8. If antifungal susceptibility Conditionally Required. Select from the choices listed the method(s) of
testing is performed at your antifungal susceptibility testing performed at your facility or an outside
facility or an outside
laboratory. If ‘Other’ is selected, please specify.
laboratory, what methods
are used? (check all that
apply)
9. Is antifungal susceptibility Required. Select the appropriate Candida species and drugs for which your
testing performed
laboratory or outside laboratory automatically/reflexively performs antifungal
automatically/reflexively susceptibility testing from normally sterile body sites (such as blood), without
for any of the following
needing a specific order or request for susceptibility testing from the clinician.
Candida species cultured If antifungal susceptibility testing is not performed automatically on Candida
from normally sterile body species, select “Automatic testing is not performed for any Candida species”.
sites (such as blood),
without needing a specific
order or request for
susceptibility testing from
the clinician?
Check all species and
corresponding drugs for
December 2015
4
Plan and Annual Surveys
which automatic testing is
done.
Facility Microbiology Laboratory Practices (continued)
10. What is the primary testing Required. Select from the choices listed the testing methods used to perform C.
method for C. difficile used
difficile testing by your facility’s laboratory or the outside laboratory where your
most often by your facility’s
facility’s testing is done. If ‘Other’ is selected, please specify.
laboratory or the outside
laboratory where your facility’s Note: “Other” should not be used to name specific laboratories, reference
testing is performed? (check
laboratories, or the brand names of C. difficile tests; most methods can be
one)
categorized accurately by selecting from the options provided. Please ask your
laboratory or conduct a search for further guidance on selecting the correct option
to report.
11. Does your facility produce Required. Select ‘Yes’ if your facility produces an antibiogram; otherwise select
an antibiogram (i.e.,
‘No’.
cumulative antimicrobial
susceptibility report)?
If Yes, is the antibiogram Conditionally Required. If ‘Yes’, indicate whether the antibiogram is produced at
produced at least annually? least annually.
If Yes, are data stratified Conditionally Required. If ‘Yes’, indicate whether antibiogram data are stratified
by hospital location?
by hospital location.
If No, please identify any Conditionally Required. If ‘No’, indicate the obstacle(s) to producing an
obstacle(s) to producing an antibiogram at your facility. If ‘Other’ is selected, please specify.
antibiogram. (Check all
that apply)
Infection Control Practices. Completion of this section may require assistance from the Infection Preventionist,
Hospital Epidemiologist, other infection control personnel, and/or Quality Improvement Coordinator. Questions
should be answered based on the policies and practices that were in place for the majority of the last full calendar
year.
12. Number or fraction of
Required. Enter the number or fraction of individuals (full-time employees) who
infection preventionists (IPs) in work in the infection prevention department of the hospital as infection prevention
facility
professionals. Certification in infection control, the CIC credential, is not required
to be considered an “IP” on this survey.
c. Total hours per week Enter the number of hours per week engaged in activities designed to find and
performing
report healthcare-associated infections (in the hospital) and the appropriate
surveillance
denominators. Total should include time to analyze data and disseminate results.
d. Total hours per week Enter the number of hours per week spent on infection prevention and control
for infection control
activities other than surveillance. These activities include, but are not limited to,
activities other than
education, prevention, meetings, etc.
surveillance
13. Number or fraction of full- Required. Enter the number or fraction of individuals (full-time employees) who
time employees (FTEs) for a perform the functions of a hospital epidemiologist in the facility. An official title of
designated hospital
“hospital epidemiologist” is not required. Hospital epidemiologists traditionally
epidemiologist (or equivalent have a doctorate level degree with training in infection control, however such
role) affiliated with your
training is not required to be counted on this survey.
facility
December 2015
5
Plan and Annual Surveys
Infection Control Practices (continued)
For detailed description about the use of Contact Precautions, please refer to the CDC/HICPAC 2007 Guideline
for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
(http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf).
14. Is it a policy in your facility Required. Select ‘No’ if your facility does not routinely place any patient infected
that patients infected or
or colonized with MRSA in Contact Precautions; otherwise, select the single best
colonized with MRSA are
choice from the choices listed that most accurately describes the primary
routinely placed in contact
indication for placing admitted patients with MRSA on Contact Precautions at
precautions while these patients your facility. If your facility never admits patients with MRSA, select ‘Not
are in your facility? (check one) applicable’.
15. Is it a policy in your facility Required. Select ‘No’ if your facility does not routinely place any patient infected
that patients infected or
or colonized with VRE in Contact Precautions; otherwise, select the single best
colonized with VRE are
choice from the choices listed that most accurately describes the primary
routinely placed in contact
indication for placing admitted patients with VRE on Contact Precautions at your
precautions while these patients facility. If your facility never admits patients with VRE, select ‘Not applicable’.
are in your facility? (check one
16. Is it policy in your facility Required. Select ‘No’ if your facility does not routinely place any patient infected
that patients infected or
or colonized with CRE in Contact Precautions; otherwise, select the single best
colonized with CRE (regardless choice from the choices listed that most accurately describes the primary
of confirmatory testing for
indication for placing admitted patients with CRE on Contact Precautions at your
carbapenemase production) are facility. If your facility never admits patients with CRE, select ‘Not applicable’.
routinely placed in contact
precautions while these patients
are in your facility? (check one)
17. Is it a policy in your facility Required. Select ‘No’ if your facility does not routinely place any patient infected
that patients infected or
or colonized with ESBL-producing or extended spectrum cephalosporin-resistant
colonized with suspected or
Enterobacteriaceae in Contact Precautions; otherwise, select the single best choice
confirmed ESBL-producing or from the choices listed that most accurately describes the primary indication for
extended spectrum
placing admitted patients with ESBL-producing or extended spectrum
cephalosporin resistant
cephalosporin-resistant Enterobacteriaceae on Contact Precautions at your facility.
Enterobacteriaceae are routinely If your facility never admits patients with ESBL-producing or extended spectrum
placed in contact precautions
cephalosporin-resistant Enterobacteriacae, select ‘Not applicable’.
while these patients are in your
facility? (check one)
18. Does the facility routinely Required. Select ‘Yes’ if the facility routinely (i.e., it is standard practice to
perform screening testing
perform the testing when the targeted patient group is present) does screening
(culture or non-culture) for
using either culture or non-culture based methods for CRE; select no if either
CRE?
testing is not routinely performed or not performed at all.
If Yes, in which situations
does the facility routinely
perform screening testing
for CRE? (check all that
apply)
December 2015
Conditionally Required. If ‘Yes’, select all the situations for which screening
testing is done routinely. If ‘Other’ is selected, please specify the situation(s) in
which CRE screening is performed.
Note: ‘Epidemiologically-linked’ patients refer to contacts of the patient with
newly identified CRE. This might include current or prior roommates or patients
who shared the same healthcare personnel or patients who are located on the same
unit or ward.
6
Plan and Annual Surveys
19. Does the facility routinely
perform screening testing
(culture or non-culture) for
MRSA?
Required. Select ‘Yes’ if the facility routinely (i.e., it is standard practice to
perform the testing when the targeted patient group is present) does screening
using either culture or non-culture based methods for MRSA; select no if either
testing is not routinely performed or not performed at all.
If yes, in which situation does Conditionally Required. If ‘Yes’, select all the situations for which screening
the facility routinely perform
testing is done routinely. If ‘Other’ is selected, please specify the situation(s) in
screening testing for MRSA?
which MRSA screening is performed.
(check all that apply)
20. Does the facility routinely Required. Select ‘Yes’ if your facility routinely uses chlorhexidine bathing on
use chlorhexidine bathing on any any patient in any ward or unit as an intervention to prevent the infection or
patients to prevent infection or transmission of any MDRO. Please do not include the use of this agent in patients
transmission of MDROs at your undergoing surgery if the purpose is to prevent surgical site infections. Select
facility? Note: this does not
‘No’ if this agent is not used routinely or is not used at all or if it is only used to
include the use of such bathing prevent surgical site infections in pre-operative patients.
in pre-operative patients to
prevent surgical site infections
(SSIs)
Infection Control Practices (continued)
21. Does the facility routinely
use a combination of topical
chlorhexidine and intranasal
mupirocin (or equivalent agent)
on any patients to prevent
infection or transmission of
MRSA at your facility? (Note:
this does not include the use of
these agents in pre-operative
surgical patients or dialysis
patients)
Required. Select ‘Yes’ if the combination of topical chlorhexidine and intranasal
mupirocin is used routinely (i.e., it is standard practice to use these agents when
the targeted patient group is present) on patients in the facility specifically to
prevent the transmission of MRSA. Please do not include the use of these agents
in dialysis patients or patients undergoing surgery if the purpose is to prevent
surgical site infections. Select ‘No’ if these combined agents are not used
routinely or are not used at all or if they are only used to prevent surgical site
infections in pre-operative patients or to prevent infection in dialysis patients.
22. Among patients with an
Required. Please select the most appropriate response that indicates approximately
MDRO admitted to your
how often your facility receives information from a transferring facility about the
facility from another
MDRO status of a patient known to be colonized or infected with an MDRO. If
healthcare facility, please
your facility does not receive transferred patients, or does not receive transferred
estimate how often your
patients with a known MDRO, select ‘Not applicable’.
facility receives information
from the transferring facility
about the patient’s MDRO
status?
Antibiotic Stewardship Practices. Completion of this by section may require assistance from the pharmacy and/or
physicians who focus on Antibiotic Stewardship or Infectious Diseases, where available, and/or members of the
Pharmacy and Therapeutic Committee. Antibiotic Stewardship refers to a coordinated, multidisciplinary approach
December 2015
7
Plan and Annual Surveys
to optimize and measure antibiotic use. For further information, refer to Core Elements of Hospital Antibiotic
Stewardship Programs (http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html). Questions
should be answered based on the policies and practices that were in place for the majority of the last full calendar
year.
Required. Select 'Yes' if there is written evidence of senior-level management
23. Does your facility have a
support focused on antibiotic use prescribing (e.g., formal letter of support for
written statement of support
efforts to improve antibiotic use, written communication to hospital staff that
from leadership that supports
efforts to improve antibiotic use encourages optimal antibiotic prescribing, communication of support that reaches
staff beyond those who receive executive-level meeting notes); otherwise, select
(antibiotic stewardship)?
'No'.
Antibiotic Stewardship Practices (continued)
24. Is there a leader
responsible for stewardship
activities at your facility?
If Yes, what is the position
of this leader? (check one)
25. Is there at least one
pharmacist responsible for
improving antibiotic use at
your facility?
26. Does your facility provide
any salary support for
dedicated time for antibiotic
stewardship leadership
activities?
27. Does your facility have a
policy that requires
prescribers to document an
indication for all antibiotics
in the medical record or
during order entry?
Required. Select 'Yes' if any individual has been identified as a lead to antibiotic
stewardship activities as evidenced by responsibility for improving antibiotic use
in the job description or performance review, authority to coordinate activities of
staff from multiple departments (e.g. laboratory, pharmacy, information
technology), and/or responsibility to report to senior level management on
program planning and outcomes.
Conditionally Required. If ‘Yes’, specify the qualification or job title of the
leader(s). If ‘Other’ is selected, please specify the position.
Required. Select 'Yes' if your facility has at least one pharmacist who dedicates
time distinct from general pharmacy duties to educate staff, and track or monitor
antibiotic use to ensure optimal prescribing practices; otherwise, select 'No'.
Required. Select 'Yes' if any individual was given salary support (any amount) to
serve as a leader of the stewardship program; otherwise, select 'No'.
Required. Select 'Yes' if your facility has a policy requiring documentation of
dose, duration and indication for all antibiotics in the medical record or during
order entry; otherwise, select 'No'.
If Yes, has adherence to the Conditionally Required. If ‘Yes’ to question 28, select ‘Yes’ if charts have been
policy to document an
audited to confirm documentation of dose, duration, and indication in patient
indication been monitored? medical records; otherwise, select ‘No’.
28. Does your facility have
Required. Select 'Yes' if there are facility-specific recommendations for antibiotic
facility-specific treatment
treatment selection based on national guidelines and local susceptibility reports
recommendations, based on for ANY common clinical conditions (e.g., community required pneumonia,
national guidelines and local urinary tract infections, or skin and soft tissue infections); otherwise, select 'No'.
susceptibility, to assist with
antibiotic selection for
common clinical conditions?
December 2015
8
Plan and Annual Surveys
If Yes, has adherence to
facility-specific treatment
recommendations been
monitored?
29. Is there a formal procedure
for all clinicians to review
the appropriateness of all
antibiotics at or after 48
hours from the initial orders
(e.g. antibiotic time out)?
Conditionally Required. If ‘Yes’ to question 29, select ‘Yes’ charts have been
audited to confirm adherence to facility-specific treatment guidelines for ANY of
the common clinical conditions listed above; otherwise, select ‘No’.
Required. Select 'Yes' if your facility has developed a standardized way for
clinicians on the treating team (or attending physician? or physician of record?) to
reassess the continuing need and choice of antibiotics at or after 48 hours after the
initial orders (to confirm indication, review microbiology results, and review
antibiotic choice, dose, and duration); otherwise, select 'No'.
Antibiotic Stewardship Practices (continued)
30. Do any specified antibiotic Required. Select 'Yes' if your facility has at least one antibiotic agent that requires
agents need to be approved a physician or pharmacist to review and approve administration of the drug due to
by a physician or pharmacist its spectrum of activity, cost, or associated toxicities; otherwise, select 'No'.
prior to dispensing at your
facility?
31. Does a physician or
Required. Select 'Yes' if your facility had physicians or pharmacists
pharmacist review courses of knowledgeable in antibiotic use, and not part of the treating team, review courses
therapy for specified
of therapy for specified antibiotic agents and communicate the results to
antibiotic agents and
prescribers (such as audit with feedback); otherwise, select 'No'.
communicate results with
prescribers at your facility?
If yes, what type of feedback Conditionally required. Select the type of feedback that is provided to prescribers.
is provided to prescribers?
32. Does your facility monitor Required. Select 'Yes' if your facility monitors antibiotic use or consumption at
antibiotic use (consumption) the unit, service, and/or facility wide level at least quarterly; otherwise, select 'No'.
at the unit, service, and/or
facility wide?
If Yes, by which metrics?
(Check all that apply)
Conditionally Required. If ‘Yes’, select from the choices of listed antibiotic use
metrics. Days of Therapy (also known as Antimicrobial Days) is defined by any
amount of a specific antimicrobial agent administered in a calendar day to a
particular patient (i.e., each antimicrobial agent administered to a patient counted
as one day of therapy). The Defined Daily Dose is the assumed average
maintenance dose per day for a drug used for its main indication in adults and is
derived from the total number of grams of each antibiotic purchased, dispensed, or
administered. If ‘Other’ is selected, please specify the method(s) or metric(s)
used.
If Yes, are facility- and/or
unit-specific reports on
antibiotic use shared with
prescribers?
33. Has your facility provided
education to clinicians and
Conditionally Required. Select 'Yes' if facility and/or unit-specific reports on
antibiotic use are shared with prescribers (individually, by service line, by medical
group, etc.); otherwise, select 'No'.
December 2015
Required. Select 'Yes' if your facility has provided education on how to improve
antibiotic use to clinicians and other relevant staff (e.g. Grand Rounds, in-service
training, or direct instruction); otherwise, select 'No'.
9
Plan and Annual Surveys
other relevant staff on
improving antibiotic use?
December 2015
2
Plan and Annual Surveys
Instructions for Completion of the Patient Safety Annual Facility
Survey for IRF (CDC 57.151)
Data Field
Facility ID #
Survey Year
Instructions for Form Completion
Required. The NHSN-assigned facility ID will be auto-entered by the computer.
Required. Select the calendar year for which this survey was completed.
The survey year should represent the last full calendar year. For example, in 2017,
a facility would complete a 2016 survey.
Facility Characteristics
Ownership (check one)
Required. Select the appropriate ownership of this facility:
For profit
Not for profit, including church
Government
Veterans Affairs
Affiliation (check one)
Required. Select the appropriate affiliation for this facility:
Independent – The facility is a stand-alone facility that does not share a
building, staff, or policies (such as infection control) with any other
healthcare institution.
Hospital system – The facility is affiliated with a local healthcare system.
Facility shares policies (such as infection control) with other institutions
within the hospital system. Facility may or may not share staff as well as a
building with other facilities that are part of that hospital system.
Multi-facility organization (specialty network) – The facility is part of a
regional or national network of specialty facilities. Facilities share policies
(such as infection control), corporate leadership, and a common business
structure.
How would you describe your Required. Select the appropriate classification of your inpatient rehabilitation
licensed inpatient rehabilitation facility:
facility? (check one)
Free-standing - The rehabilitation facility functions as a stand-alone facility.
Patients receive all required care within the constructs of this facility. The
facility may share a building with another healthcare facility, but does not
share staff, patients, or policies (such as infection control) with the other
healthcare facility.
Healthcare facility based - The rehabilitation facility functions as part of a
larger healthcare facility. Patients can be transported from the rehabilitation
area to the healthcare facility area on a regular/daily basis for procedures or
therapy. The facility may share staff and policies (such as infection control)
with the affiliated healthcare facility.
Total number of beds
Required. Enter the total number of beds in your inpatient rehabilitation facility
during the last full calendar year.
Average daily census
Required. Enter the average number of patients housed each day in your inpatient
rehabilitation facility during the last full calendar year. Please round to the nearest
whole number.
December 2015
1
Plan and Annual Surveys
Number of patient days
Required. Enter the total number of patient days for your inpatient rehabilitation
facility during the last full calendar year.
Facility Characteristics (continued)
Average length of stay
Required. Enter the average number of days that patients stay in your inpatient
rehabilitation facility during the last full calendar year. Please round to the nearest
whole number.
Indicate the number of
Required. For your inpatient rehabilitation facility during the last full calendar
admissions with the primary
year, enter the number of admissions with the primary diagnosis for each of the
diagnosis for each of the
categories listed.
following rehabilitation
Traumatic spinal cord dysfunction
categories (must sum to the total Non-traumatic spinal cord dysfunction
number of admissions listed
Stroke
below)
Brain dysfunction (non-traumatic or traumatic)
Other neurologic conditions (e.g. multiple sclerosis, Parkinson’s disease, etc)
Orthopedic conditions (incl. fracture, joint replacement, other)
All other admissions
Total number of admissions
Required. The total number of admissions will be automatically summed from the
categories above.
Additionally, enter the total number of admissions that were patients on a
ventilator as well as the number that were pediatric admissions.
Facility Microbiology Laboratory Practices. Completion of this section requires the assistance from the
microbiology laboratory. Questions should be answered based on the testing methods that were used for the
majority of the last full calendar year.
1. Does your facility have its Required. Select 'Yes' if your laboratory performs antimicrobial susceptibility
own on-site laboratory that testing; otherwise, select 'No'.
performs antimicrobial
susceptibility testing?
If No, where is your
facility's antimicrobial
susceptibility testing
performed? (check one)
December 2015
Conditionally Required. If ‘No’, select the location where your facility's
antimicrobial susceptibility testing is performed: Affiliated medical center,
Commercial referral laboratory, or Other local/regional, non-affiliated reference
laboratory. If multiple laboratories are used indicate the laboratory which
performs the majority of the bacterial susceptibility testing. You must complete
the remainder of this survey with assistance from your outside laboratory.
2
Plan and Annual Surveys
Facility Microbiology Laboratory Practices (continued)
2. For the following organisms
please indicate which
methods are used for (1)
primary susceptibility
testing and (2) secondary,
supplemental, or
confirmatory testing (if
performed)
Required. Select from the choices listed the appropriate (1) primary susceptibility
testing and (2) secondary, supplemental, or confirmatory testing method (if
performed) for each organism.
Note: Repeat tests using the primary method should not be indicated as secondary
methods; instead indicate in the ‘Comments’ column the number of times repeat
testing is done using the same primary method.
If your laboratory does not perform susceptibility testing, please indicate the
methods used at the referral laboratory. If ‘Other’ is selected as the method for any
pathogen, use the ‘Comments’ column to describe the method used.
Required. Select 'Yes' if your laboratory has implemented the revised
cephalosporin and monobactam breakpoints for Enterobacteriaceae recommended
by CLSI as of 2010; otherwise, select 'No'.
3. Has the laboratory
implemented the revised
cephalosporin and
monobactam breakpoints for
Enterobacteriaceae
recommended by CLSI as of
2010?
4. Has the laboratory
Required. Select 'Yes' if your laboratory has implemented the revised carbapenem
implemented the revised
breakpoints for Enterobacteriaceae recommended by CLSI as of 2010; otherwise,
carbapenem breakpoints for select 'No'.
Enterobacteriaceae
recommended by CLSI as of
2010?
5. Does the laboratory perform Required. Select 'Yes' if your laboratory performs a special test for carbapenemase
a special test for
production; otherwise, select 'No'.
carbapenemase production?
If Yes, please indicate what Conditionally Required. If ‘Yes’, specify what is done if carbapenemase
is done if carbapenemase
production is detected.
production is detected
(check one).
If Yes, which test is
Conditionally Required. If ‘Yes’, specify which test is performed to detect
routinely performed to
carbapenemase.
detect carbapenemase (check
all that apply)?
6. Does the laboratory perform Required. Select 'Yes' if your laboratory performs colistin or polymyxin B
colistin or polymyxin B
susceptibility testing for drug-resistant gram negative bacilli; otherwise, select
susceptibility testing for
'No'.
drug-resistant gram negative
bacilli?
If Yes, indicate methods
Conditionally Required. If ‘Yes’, select the method(s) used from the choices
(check all that apply).
provided. If ‘Other’ is selected, please specify.
December 2015
3
Plan and Annual Surveys
Facility Microbiology Laboratory Practices (continued)
7. Does your facility have its Required. Select 'Yes' if your laboratory performs antifungal susceptibility testing
own laboratory that
for Candida species; otherwise, select 'No'.
performs antifungal
susceptibility testing for
Candida species?
If No, where is your
Conditionally Required. If ‘No”, select one of the choices provided.
facility's antifungal
susceptibility testing
performed? (check one).
8. If antifungal susceptibility Conditionally Required. Select from the choices listed the method(s) of antifungal
testing is performed at your susceptibility testing performed at your facility or an outside laboratory. If ‘Other’
facility or an outside
is selected, please specify.
laboratory, what methods
are used? (check all that
apply)
9. Is antifungal susceptibility Required. Select the appropriate Candida species and drugs for which your
laboratory or outside laboratory automatically/reflexively performs antifungal
testing performed
automatically/reflexively for susceptibility testing from normally sterile body sites (such as blood), without
needing a specific order or request for susceptibility testing from the clinician. If
any of the following
antifungal susceptibility testing is not performed automatically on Candida
Candida species cultured
from normally sterile body species, select “Automatic testing is not performed for any Candida species”.
sites (such as blood),
without needing a specific
order or request for
susceptibility testing from
the clinician?
Check all species and
corresponding drugs for
which automatic testing is
done.
10. What is the primary testing Required. Select from the choices listed the testing methods used to perform C.
method for C. difficile used difficile testing by your facility’s laboratory or the outside laboratory where your
most often by your facility’s facility’s testing is done. If ‘Other’ is selected, please specify.
laboratory or the outside
laboratory where your
Note: “Other” should not be used to name specific laboratories, reference
facility’s testing is
laboratories, or the brand names of C. difficile tests; most methods can be
performed? (check one)
categorized accurately by selecting from the options provided. Please ask your
laboratory or conduct a search for further guidance on selecting the correct option
to report.
December 2015
4
Plan and Annual Surveys
Facility Microbiology Laboratory Practices (continued)
11. Does your facility produce Required. Select ‘Yes’ if your facility produces an antibiogram; otherwise select
an antibiogram (i.e.,
‘No’.
cumulative antimicrobial
susceptibility report)?
If Yes, is the antibiogram
Conditionally Required. If ‘Yes’, indicate whether the antibiogram is produced at
produced at least annually? least annually.
If Yes, are data stratified by Conditionally Required. If ‘Yes’, indicate whether antibiogram data are stratified
hospital location?
by hospital location.
If No, please identify any
Conditionally Required. If ‘No’, indicate the obstacle(s) to producing an
obstacle(s) to producing an antibiogram at your facility. If ‘Other’ is selected, please specify.
antibiogram. (Check all that
apply)
Infection Control Practices. Completion of this section may require assistance from the Infection Preventionist,
Hospital Epidemiologist, other infection control personnel, and/or Quality Improvement Coordinator. Questions
should be answered based on the policies and practices that were in place for the majority of the last full calendar
year.
12. Number or fraction of
Required. Enter the number or fraction of individuals (full-time employees) who
infection preventionists (IPs) work in the infection prevention department of the hospital as infection prevention
in facility
professionals. Certification in infection control, the CIC credential, is not required
to be considered an “IP” on this survey.
e. Total hours per week
Enter the number of hours per week engaged in activities designed to find and
performing surveillance report healthcare-associated infections (in the hospital) and the appropriate
denominators. Total should include time to analyze data and disseminate results.
f. Total hours per week for Enter the number of hours per week spent on infection prevention and control
infection control
activities other than surveillance. These activities include, but are not limited to,
activities other than
education, prevention, meetings, etc.
surveillance
13. Number or fraction of full- Required. Enter the number or fraction of individuals (full-time employees) who
time employees (FTEs) for a perform the functions of a hospital epidemiologist in the facility. An official title
of “hospital epidemiologist” is not required. Hospital epidemiologists traditionally
designated hospital
have a doctorate level degree with training in infection control, however such
epidemiologist (or
training is not required to be counted on this survey.
equivalent role) affiliated
with your facility
For detailed description about the use of Contact Precautions, please refer to the CDC/HICPAC 2007 Guideline
for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
(http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf).
14. Is it a policy in your facility Required. Select ‘No’ if your facility does not routinely place any patient infected
that patients infected or
or colonized with MRSA in Contact Precautions; otherwise, select the single best
colonized with MRSA are choice from the choices listed that most accurately describes the primary
routinely placed in contact indication for placing admitted patients with MRSA on Contact Precautions at
precautions while these
your facility. If your facility never admits patients with MRSA, select ‘Not
patients are in your facility? applicable’.
(check one)
Infection Control Practices (continued)
December 2015
5
Plan and Annual Surveys
15. Is it a policy in your facility Required. Select ‘No’ if your facility does not routinely place any patient infected
that patients infected or
or colonized with VRE in Contact Precautions; otherwise, select the single best
colonized with VRE are
choice from the choices listed that most accurately describes the primary
routinely placed in contact indication for placing admitted patients with VRE on Contact Precautions at your
precautions while these
facility. If your facility never admits patients with VRE, select ‘Not applicable’.
patients are in your facility?
(check one)
16. Is it a policy in your facility Required. Select ‘No’ if your facility does not routinely place any patient infected
that patients infected or
or colonized with CRE in Contact Precautions; otherwise, select the single best
colonized with CRE
choice from the choices listed that most accurately describes the primary
(regardless of confirmatory indication for placing admitted patients with CRE on Contact Precautions at your
testing for carbapenemase facility. If your facility never admits patients with CRE, select ‘Not applicable’.
production) are routinely
placed in contact precautions
while these patients are in
your facility? (check one)
17. Is it a policy in your facility Required. Select ‘No’ if your facility does not routinely place any patient infected
that patients infected or
or colonized with ESBL-producing or extended spectrum cephalosporin-resistant
colonized with suspected or Enterobacteriaceae in Contact Precautions; otherwise, select the single best choice
confirmed ESBL-producing from the choices listed that most accurately describes the primary indication for
or extended spectrum
placing admitted patients with ESBL-producing or extended spectrum
cephalosporin resistant
cephalosporin-resistant Enterobacteriaceae on Contact Precautions at your facility.
Enterobacteriaceae are
If your facility never admits patients with ESBL-producing or extended spectrum
routinely placed in contact cephalosporin-resistant Enterobacteriaceae, select ‘Not applicable’.
precautions while these
patients are in your facility?
(check one)
18. Does the facility routinely Required. Select ‘Yes’ if your facility routinely (i.e., it is standard practice to
perform screening testing
perform the testing when the targeted patient group is present) does screening
(culture or non-culture) for using either culture or non-culture based methods for CRE; select no if either
CRE?
testing is not routinely performed or not performed at all.
If Yes, in which situations
does the facility routinely Conditionally required. If ‘Yes’, select all the situations for which screening
perform screening testing testing is done routinely. If ‘Other’ is selected, please specify the situation(s) in
for CRE? (check all that
which CRE screening is performed.
apply)
Note: ‘Epidemiologically-linked’ patients refer to contacts of the patient with
newly identified CRE. This might include current or prior roommates or patients
who shared the same healthcare personnel or patients who are located on the same
unit or ward.
19. Does the facility routinely Required. Select ‘Yes’ if your facility routinely (i.e., it is standard practice to
perform screening testing
perform the testing when the targeted patient group is present) does screening
(culture or non-culture) for using either culture or non-culture based methods for MRSA; select no if either
MRSA?
testing is not routinely performed or not performed at all.
If yes, in which situation
does the facility routinely
December 2015
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Plan and Annual Surveys
perform screening testing Conditionally required. If ‘Yes’, select all the situations for which screening
for MRSA? (check all that testing is done routinely. If ‘Other’ is selected, please specify the situation(s) in
which MRSA screening is performed.
apply)
20. Does the facility routinely Required. Select ‘Yes’ if your facility routinely uses chlorhexidine bathing on
use chlorhexidine bathing on any patient in any ward or unit as an intervention to prevent the infection or
any patients to prevent
transmission of any MDRO; otherwise, select ‘No’. Please do not include the use
infection or transmission of of this agent in patients undergoing surgery if the purpose is to prevent SSIs.
MDROs at your facility?
Select ‘No’ if this agent is not used routinely or is not used at all or if it is only
Note: this does not include used to prevent surgical site infections in pre-operative patients.
the use of such bathing in
pre-operative patients to
prevent surgical site
infections (SSIs)
Infection Control Practices (continued)
21. Does the facility routinely Required. Select ‘Yes’ if the combination of topical chlorhexidine and intranasal
use a combination of topical mupirocin is used routinely (i.e., it is standard practice to use these agents when
chlorhexidine and intranasal the targeted patient group is present) on patients in the facility specifically to
mupirocin (or equivalent
prevent transmission of MRSA. Please do not include the use of these agents in
agent) on any patients to
dialysis patients or patients undergoing surgery if the purpose is to prevent
prevent infection or
surgical site infections. Select ‘No’ if these combined agents are not used
transmission of MRSA at
routinely or are not used at all or if they are only used to prevent surgical site
your facility? (Note: this
infections in pre-operative patients or to prevent infection in dialysis patients.
does not include the use of
these agents in pre-operative
surgical patients or dialysis
patients)
22. Among patients with an
Required. Please select the most appropriate response that indicates approximately
MDRO admitted to your
how often your facility receives information from a transferring facility about the
facility from another
MDRO status of a patient known to be colonized or infected with an MDRO. If
healthcare facility, please
your facility does not receive transferred patients, or does not receive transferred
estimate how often your
patients with a known MDRO, select ‘Not applicable’.
facility receives information
from the transferring facility
about the patient’s MDRO
status?
Antibiotic Stewardship Practices. Completion of this by section may require assistance from the pharmacy and/or
physicians who focus on Antibiotic Stewardship or Infectious Diseases, where available, and/or members of the
Pharmacy and Therapeutic Committee. Antibiotic Stewardship refers to a coordinated, multidisciplinary approach
to optimize and measure antibiotic use. For further information, refer to Core Elements of Hospital Antibiotic
Stewardship Programs (http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html). Questions
should be answered based on the policies and practices that were in place for the majority of the last full calendar
year.
23. Does your facility have a
Required. Select 'Yes' if there is written evidence of senior-level management
written statement of support support focused on antibiotic use prescribing (e.g., formal letter of support for
from leadership that
efforts to improve antibiotic use, written communication to hospital staff that
December 2015
7
Plan and Annual Surveys
supports efforts to improve
antibiotic use (antibiotic
stewardship)?
24. Is there a leader responsible
for stewardship activities at
your facility?
If Yes, what is the position
of this leader? (check one)
25. Is there at least one
pharmacist responsible for
improving antibiotic use at
your facility?
encourages optimal antibiotic prescribing, communication of support that reaches
staff beyond those who receive executive-level meeting notes); otherwise, select
'No'.
Required. Select 'Yes' if any individual has been identified as a lead to antibiotic
stewardship activities as evidenced by responsibility for improving antibiotic use
in the job description or performance review, authority to coordinate activities of
staff from multiple departments (e.g. laboratory, pharmacy, information
technology), and/or responsibility to report to senior level management on
program planning and outcomes.
Conditionally Required. If ‘Yes’, specify the qualification or job title of the
leader(s). If ‘Other’ is selected, please specify the position.
Required. Select 'Yes' if your facility has at least one pharmacist who dedicates
time distinct from general pharmacy duties to educate staff, and track or monitor
antibiotic use to ensure optimal prescribing practices; otherwise, select 'No'.
Antibiotic Stewardship Practices (continued)
26. Does your facility provide
any salary support for
dedicated time for antibiotic
stewardship leadership
activities?
27. Does your facility have a
policy that requires
prescribers to document an
indication for all antibiotics
in the medical record or
during order entry?
Required. Select 'Yes' if any individual was given salary support (any amount) to
serve as a leader of the stewardship program; otherwise, select 'No'.
Required. Select 'Yes' if your facility has a policy requiring documentation of
dose, duration and indication for all antibiotics in the medical record or during
order entry; otherwise, select 'No'.
If Yes, has adherence to the Conditionally Required. If ‘Yes’ to question 28, select ‘Yes’ if charts have been
policy to document an
audited to confirm documentation of dose, duration, and indication in patient
indication been monitored? medical records; otherwise, select ‘No’.
28. Does your facility have
Required. Select 'Yes' if there are facility-specific recommendations for antibiotic
facility-specific treatment treatment selection based on national guidelines and local susceptibility reports
recommendations, based on for ANY common clinical conditions (e.g., community required pneumonia,
national guidelines and local urinary tract infections, or skin and soft tissue infections); otherwise, select 'No'.
susceptibility, to assist with
antibiotic selection for
common clinical conditions?
If Yes, has adherence to
facility-specific treatment
December 2015
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Plan and Annual Surveys
recommendations been
monitored?
Conditionally Required. If ‘Yes’ to question 29, select ‘Yes’ charts have been
audited to confirm adherence to facility-specific treatment guidelines for ANY of
the common clinical conditions listed above; otherwise, select ‘No’.
29. Is there a formal procedure Required. Select 'Yes' if your facility has developed a standardized way for
for all clinicians to review clinicians on the treating team (or attending physician? or physician of record?) to
the appropriateness of all
reassess the continuing need and choice of antibiotics at or after 48 hours after the
antibiotics at or after 48
initial orders (to confirm indication, review microbiology results, and review
hours from the initial orders antibiotic choice, dose, and duration); otherwise, select 'No'.
(e.g. antibiotic time out)?
30. Do any specified antibiotic Required. Select 'Yes' if your facility has at least one antibiotic agent that requires
agents need to be approved a physician or pharmacist to review and approve administration of the drug due to
by a physician or pharmacist its spectrum of activity, cost, or associated toxicities; otherwise, select 'No'.
prior to dispensing at your
facility?
31. Does a physician or
Required. Select 'Yes' if your facility had physicians or pharmacists
pharmacist review courses knowledgeable in antibiotic use, and not part of the treating team, review courses
of therapy for specified
of therapy for specified antibiotic agents and communicate the results to
antibiotic agents and
prescribers (such as audit with feedback); otherwise, select 'No'.
communicate results with
prescribers at your facility?
If yes, what type of feedback Conditionally required. Select the type of feedback that is provided to prescribers.
is provided to prescribers?
Antibiotic Stewardship Practices (continued)
32. Does your facility monitor Required. Select 'Yes' if your facility monitors antibiotic use or consumption at
antibiotic use (consumption) the unit, service, and/or facility wide level at least quarterly; otherwise, select 'No'.
at the unit, service, and/or
facility wide?
If Yes, by which metrics?
(Check all that apply)
Conditionally Required. If ‘Yes’, select from the choices of listed antibiotic use
metrics. Days of Therapy (also known as Antimicrobial Days) is defined by any
amount of a specific antimicrobial agent administered in a calendar day to a
particular patient (i.e., each antimicrobial agent administered to a patient counted
as one day of therapy). The Defined Daily Dose is the assumed average
maintenance dose per day for a drug used for its main indication in adults and is
derived from the total number of grams of each antibiotic purchased, dispensed, or
administered. If ‘Other’ is selected, please specify the method(s) or metric(s)
used.
If Yes, are facility- and/or
unit-specific reports on
antibiotic use shared with
prescribers?
33. Has your facility provided
education to clinicians and
Conditionally Required. Select 'Yes' if facility and/or unit-specific reports on
antibiotic use are shared with prescribers (individually, by service line, by medical
group, etc.); otherwise, select 'No'.
December 2015
Required. Select 'Yes' if your facility has provided education on how to improve
antibiotic use to clinicians and other relevant staff (e.g. Grand Rounds, in-service
training, or direct instruction); otherwise, select 'No'.
9
Plan and Annual Surveys
other relevant staff on
improving antibiotic use?
December 2015
10
| File Type | application/pdf |
| File Title | Table of Contents |
| Author | Mary Andrus |
| File Modified | 2016-05-05 |
| File Created | 2016-05-05 |