Form CDC 57.150 CDC 57.150 Patient Safety Component - Annual Facility Survey for LT

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/xxxx

www.cdc.gov/nhsn

Patient Safety Component—Annual Facility Survey for LTAC
Instructions for this form are available at: http://www.cdc.gov/nhsn/forms/instr/TOI-57.150-LTAC.pdf
Page 1 of 12
*required for saving								Tracking #:
*Facility ID:								*Survey Year:
Facility Characteristics (completed by Infection Preventionist)
*Ownership (check one):
□ For profit	□ Not for profit, including church			□ Government							□ Veterans Affairs
*Affiliation (check one):	□ Independent					□ Multi-facility organization (specialty hospital network)
	□ Hospital system
*Setting/classification:	____ Free-standing			____ Within a hospital
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)?
□ No
□ Skilled nursing facility (SNF)/nursing home
□ Residential facility (assisted living)
□ Inpatient rehabilitation facility
□ Neuro-behavioral unit or facility
□ Other (please specify: _______________________________________)
If classified as “Within a hospital,” is your LTAC hospital located:
In a building that does not provide acute care services (e.g., psychiatric hospital)?										□ Yes		□ No
Near (but not within) an acute care hospital?										□ Yes		□ No
In the previous calendar year, indicate:
*Number of patient days:		_________
*Number of admissions:		_________
*Average daily census:		_________
*Numbers of LTAC beds in the following categories (categories should equal total):
a. Intensive care unit (ICU) or critical care beds:							_________
b. High observation/special care/high acuity beds (not ICU):							_________
c. General LTAC beds:
*Total number of LTAC beds (licensed capacity):							_________
*Number of single occupancy rooms:							_________
*Total number of admissions with one of the following conditions identified on admission (present on admission, not developing during LTAC stay): (Note: These categories are not mutually exclusive.)
If helpful for your facility in identifying these conditions on admission, please review a list of ICD-10 and DRG codes commonly associated with these conditions found here: http://www.cdc.gov/nhsn/xls/DRGs-ICD-9s-NHSN-LTAC-Survey.xlsx
Ventilator dependence:			_________
Hemodialysis:			_________
Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 70 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.150 (Front) Rev. 6 , v9.4

Patient Safety Component—Annual Facility Survey for LTAC Page 2 of 12

Facility Microbiology Laboratory Practices (completed with input from Microbiology Laboratory Lead)

*1. Does your facility have its own on-site laboratory that performs antimicrobial bacterial susceptibility testing?

□ Yes

□ No

If No, where is your facility’s antimicrobial susceptibility testing performed? (check one)

□ Affiliated medical center

□ Commercial referral laboratory

□ Other local/regional, non-affiliated reference laboratory

*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).

If your laboratory does not perform susceptibility testing, please indicate the methods used at the outside laboratory.

Please use the testing codes listed below the table.

Pathogen

(1) Primary

(2) Secondary

Comments

Staphylococcus aureus

_______________

______________

______________

Enterobacteriaceae

_______________

______________

______________

1 = Kirby-Bauer disk diffusion

5.1 = MicroScan WalkAway

10 = E test

2 = Vitek (Legacy)

5.2 = MicroScan autoSCAN

12 = Vancomycin agar screen (BHI + vancomycin)

2.1 = Vitek 2

6 = Other broth micro dilution method

13 = Other (describe in Comments section)

3.1 = BD Phoenix

7 = Agar dilution method

4 = Sensititre

*3. Has the laboratory implemented the revised cephalosporin and monobactam breakpoints for Enterobacteriaceae recommended by CLSI as of 2010?

□ Yes

□ No

*4. Has the laboratory implemented the revised carbapenem breakpoints for Enterobacteriaceae recommended by CLSI as of 2010?

□ Yes

□ No

*5. Does the laboratory perform a test for presence of carbapenemase? (this does not include automated testing instrument expert rules)

□ Yes

□ No

If Yes, please indicate what is done if carbapenemase production is detected: (check one)

□ Change susceptible carbapenem results to resistant

□ Report carbapenem MIC results without an interpretation

□ No changes are made in the interpretation of carbapenems, the test is used for epidemiological or infection control practices

If Yes, which test is routinely performed to detect carbapenemase: (check all that apply)

□ PCR

□MBL Screen

□ Modified Hodge Test

□ Carba NP

□ mCIM/CIM

□ Rapid CARB Blue

□ E test

□ Other (specify): _________________

□ Cepheid, BioFire array, Verigene®

If Yes, does the laboratory have a policy to routinely notify any of the following when CP-CRE are detected?

Physician

□ Yes

□ No

Infection Control

□ Yes

□ No

Continued >>

Patient Safety Component—Annual Facility Survey for LTAC

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Facility Microbiology Laboratory Practices (continued)

*6. Does the laboratory perform colistin or polymyxin B susceptibility testing for drug-resistant Gram-negative bacilli?

□ Yes

□ No

If Yes, please indicate methods: (check all that apply; answers listed are generic antimicrobial susceptibility testing methods and do not imply they are recommended for use in polymyxin susceptibility testing)

□ Vitek 2

□ MicroScan autoSCAN

□ Kirby-Bauer disk diffusion

□ BD Phoenix

□ Other broth microdilution method

□ Accelerate Pheno

□ Sensititre

□ Agar dilution method

□ Other (specify): _____________________

□ MicroScan WalkAway

□ E test

*7. Which of the following methods are used for yeast identification at your facility’s laboratory or at the outside laboratory serving your facility? (check all that apply)

□ MALDI-TOF MS System (Vitek MS)

□ MALDI-TOF MS System (Bruker Biotyper)

□ Vitek-2

□ BD Phoenix

□ MicroScan

□ Non-automated Manual Kit (e.g., API 20C, RapID, Germ Tube, PNA-FISH, etc.)

□ DNA sequencing

□ Other (specify) ______________________

*8. Candida isolated from which of the following body sites are usually fully identified to the species level? (check all that apply)

□ Blood

□ Other normally sterile body site (e.g.: CSF)

□ Urine

□ Respiratory

□ Other (specify) ______________________

□ None are fully identified to the species level

*9. What method is used for antifungal susceptibility testing (AFST) at your facility’s laboratory or the outside laboratory serving your facility? (check all that apply)

□ Broth microdilution

□ YeastOne colorimetric microdilution

□ E test

□ Vitek 2 card

□ Disk diffusion

□ Other (specify): ________________

Continued >>





Patient Safety Component—Annual Facility Survey for LTAC

Page 4 of 12

Facility Microbiology Laboratory Practices (continued)

*10. Antifungal susceptibility testing is performed on fungal isolates in which of the following situations:

Candida albicans:

□ Always □ Only when isolated from sterile sites (eg: blood, CSF, etc) □ Only when ordered by a clinician; □ Other (specify):___________________

Candida glabrata:

□ Always □ Only when isolated from sterile sites (eg: blood, CSF, etc) □ Only when ordered by a clinician; □ Other (specify):____________________

All other Candida species:

□ Always □ Only when isolated from sterile sites (eg: blood, CSF, etc) □ Only when ordered by a clinician; □ Other (specify) ):_____________________

*11. What is the primary testing method for C. difficile used most often by your facility’s laboratory or the outside laboratory where your facility’s testing is performed? (check one)

□ Enzyme immunoassay (EIA) for toxin

□ Cell cytotoxicity neutralization assay

□ Nucleic acid amplification test (NAAT) (e.g., PCR, LAMP)

□ NAAT plus EIA, if NAAT positive (2-step algorithm)

□ Glutamate dehydrogenase (GDH) antigen plus EIA for toxin (2-step algorithm)

□ GDH plus NAAT (2-step algorithm)

□ GDH plus EIA for toxin, followed by NAAT for discrepant results

□ Toxigenic culture (C. difficile culture followed by detection of toxins)

Infection Control Practices

(completed with input from Hospital Epidemiologist and/or Quality Improvement Coordinator)

*12. Number or fraction of infection preventionists (IPs) in facility:

a. Total hours per week performing surveillance:

________________________

b. Total hours per week for infection control activities other than surveillance:

________________________

*13. Number or fraction of full-time employees (FTEs) for a designated hospital epidemiologist (or equivalent role) affiliated with your facility:

________________________

*14. Is it a policy in your facility that patients infected or colonized with MRSA are routinely placed in contact precautions while these patients are in your facility? (check one)

□ Yes, all infected or colonized patients

□ No

□ Not applicable: my facility never admits these patients

Continued >>

Patient Safety Component—Annual Facility Survey for LTAC Page 5 of 12

Infection Control Practices (continued)

If Yes, please check the type of patients that are routinely placed in contact precautions while I your facility (check one):

□ All infected or colonized patients

□ Only all infected patients

□ Only infected or colonized patients with certain characteristics (check all that apply)

□ Patients admitted to high risk settings

□ Patients at high risk for transmission

*15. Is it a policy in your facility that patients infected or colonized with VRE are routinely placed in contact precautions while these patients are in your facility? (check one)

□ Yes, all infected or colonized patients

□ No

□ Not applicable: my facility never admits these patients

If Yes, please check the type of patients that are routinely placed in contact precautions while I your facility (check one):

□ All infected or colonized patients

□ Only all infected patients

□ Only infected or colonized patients with certain characteristics (check all that apply)

□ Patients admitted to high risk settings

□ Patients at high risk for transmission

*16. Is it a policy in your facility that patients infected or colonized with CRE (regardless of confirmatory testing for carbapenemase production) are routinely placed in contact precautions while these patients are in your facility? (check one)

□ Yes, all infected or colonized patients

□ No

□ Not applicable: my facility never admits these patients

If Yes, please check the type of patients that are routinely placed in contact precautions while I your facility (check one):

□ All infected or colonized patients

□ Only all infected patients

□ Only infected or colonized patients with certain characteristics (check all that apply)

□ Patients admitted to high risk settings

□ Patients at high risk for transmission

Continued >>

Patient Safety Component—Annual Facility Survey for LTAC Page 6 of 12

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)

□ Yes, all infected or colonized patients

□ No

□ Not applicable: my facility never admits these patients

If Yes, please check the type of patients that are routinely placed in contact precautions while I your facility (check one):

□ All infected or colonized patients

□ Only all infected patients

□ Only infected or colonized patients with certain characteristics (check all that apply)

□ Patients admitted to high risk settings

□ Patients at high risk for transmission

*18. Does the facility routinely perform screening testing (culture or non-culture) for CRE?

□ Yes

□ No

If Yes, in which situations does the facility routinely perform screening testing for CRE? (check all that apply)

□ Surveillance testing at admission for all patients

□ Surveillance testing of epidemiologically-linked patients of newly identified CRE patients (e.g., roommates)

□ Surveillance testing at admission of high-risk patients (e.g., admitted from LTAC or LTCF)

□ Surveillance testing at admission of patients admitted to high-risk settings (e.g. ICU)

*19. Does the facility routinely perform screening testing (culture or non-culture) for MRSA for any patients admitted to non-NICU settings?

□ Yes

□ No

If yes, in which situations does the facility routinely perform screening testing for MRSA for non-NICU settings? (check all that apply)

□ Surveillance testing at admission for all patients

□ Surveillance testing at admission of high-risk patients (e.g., admitted from LTAC or LTCF)

□ Surveillance testing at admission of patients admitted to high-risk settings (e.g. ICU)

□ Surveillance testing of pre-operative patients to prevent surgical site infections

□ Other (please specify): _________________

Continued >>

Patient Safety Component—Annual Facility Survey for LTAC

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Infection Control Practices (continued)

*20. Does the facility routinely use chlorhexidine bathing on any patient to prevent infection or transmission of MDROs at your facility? (Note: this does not include the use of such bathing in pre-operative patients to prevent SSIs)

□ Yes

□ No

*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)

□ Yes

□ No

Antibiotic Stewardship Practices

(completed with input from Physician and Pharmacist Stewardship Champions )

*22. Our facility has a formal statement of support for antibiotic stewardship (e.g., a written policy or statement approved by the board).

□ Yes

□ No

*23. Facility leadership has demonstrated a commitment to antibiotic stewardship efforts by: (Check all that apply.)

  Communicating to staff about stewardship activities, via email, newsletters, events, or other avenues.

  Providing opportunities for staff training and development on antibiotic stewardship.

  Allocating information technology resources to support antibiotic stewardship efforts.

  None of the above

*24. Our facility has a committee responsible for antibiotic stewardship.

□ Yes

□ No

If Yes, membership in our facility’s antibiotic stewardship committee includes: (Check all that apply.)

  Non-infectious diseases trained prescriber(s)

  Infectious disease physician(s)

  Pharmacist(s)

  Nurse(s)

  Infection preventionist(s)

  Microbiologist(s)

  Information technologist(s)

  A patient representative

  None of the Above

*25. Our facility has a leader (or co-leaders) responsible for antibiotic stewardship outcomes.

□ Yes

□ No

If Yes, what is the position of this leader? (Check one.)

  Physician

  Pharmacist

  Co-led by both Pharmacist and Physician

  Other (please specify):________________

Continued >>

Patient Safety Component—Annual Facility Survey for LTAC Page 8 of 12
Antibiotic Stewardship Practices (continued)
If Physician or Co-led is selected, which of the following describes your antibiotic stewardship physician leader? (Check all that apply.)
  Has antibiotic stewardship responsibilities in their contract or job description
  Is physically on-site in your facility (either part-time or full-time)
  Completed an ID fellowship
  Completed a certificate program or other coursework
  None of the above
If Pharmacist or Co-led is selected, which of the following describes your antibiotic stewardship pharmacist leader? (Check all that apply.)
  Has antibiotic stewardship responsibilities in their contract or job description
  Is physically on-site in your facility (either part-time or full-time)
  Completed a PGY2 ID residency and/or ID fellowship
  Completed a certificate program or other coursework
  None of the above
If Physician or Other, is there at least one pharmacist responsible for improving antibiotic use at your facility?					□ Yes		□ No
*26. Our facility has a policy or formal procedure for: (Check all that apply.)
  Required documentation of indication for antibiotic orders.
If selected: Our stewardship team audits antibiotic orders to review appropriateness indications.				□ Yes		□ No
  Required documentation of duration for antibiotic orders.
  The treating team to review antibiotics 48-72 hours after initial order (i.e., antibiotic time-out).
  The stewardship team to review courses of therapy for specific antibiotic agents and provide real-time feedback and recommendations to the treating team (i.e., prospective audit and feedback).
If selected: For which categories of antimicrobials? (Check all that apply.)
  Cefepime, ceftazidime, or piperacillin/tazobactam
  Ertapenem, imipenem/cilastatin, or meropenem
  Ceftazidime/avibactam, ceftolozane/tazobactam, meropenem/vaborbactam, or other recently FDA-approved beta-lactam/beta-lactamase inhibitors
  Colistin or polymyxin B
  Quinolones
  Vancomycin
  Daptomycin, linezolid, or other anti-MRSA agents
  Anidulafungin, caspofungin, or micafungin
  Isavuconazole, posaconazole, or voriconazole
  Amphotericin B and/or lipid-based amphotericin B
  None of the above	Continued >>

Patient Safety Component—Annual Facility Survey for LTAC Page 9 of 12
Antibiotic Stewardship Practices (continued)
  Required authorization by the stewardship team before restricted antibiotics on the formulary can be dispensed (i.e., prior authorization).
If selected: For which categories of antimicrobials? (Check all that apply.)
  Cefepime, ceftazidime, or piperacillin/tazobactam
  Ertapenem, imipenem/cilastatin, or meropenem
  Ceftazidime/avibactam, ceftolozane/tazobactam, meropenem/vaborbactam, or other recently FDA-approved beta-lactam/beta-lactamase inhibitors
  Colistin or polymyxin B
  Quinolones
  Vancomycin
  Daptomycin, linezolid, or other anti-MRSA agents
  Anidulafungin, caspofungin, or micafungin
  Isavuconazole, posaconazole, or voriconazole
  Amphotericin B and/or lipid-based amphotericin B
  None of the above
  None of the above
*27. Providers have access to facility- or region-specific treatment guidelines or recommendations for commonly encountered infections.				□ Yes		□ No
If Yes: Our stewardship team monitors adherence to facility- or region-specific treatment guidelines or recommendations for commonly encountered infections.				□ Yes		□ No
*28. Our facility targets select diagnoses for active interventions to optimize antibiotic use (e.g., intervening on duration of therapy for patients with community-acquired pneumonia according to clinical response).				□ Yes		□ No
*29. Our stewardship team monitors: (Check all that apply.)
  Antibiotic resistance patterns (either facility- or region-specific)
  Clostridioides difficile
  Antibiotic use in days of therapy (DOT) per 1000 patient days or days present, at least quarterly
  Antibiotic use in defined daily doses (DDD) per 1000 patient days, at least quarterly
  Antibiotic expenditures (i.e., purchasing costs), at least quarterly
  Antibiotic use in some other way (please specify): ________
 None of the above
If antibiotic use in DOT, DDD, or some other way is selected: Our stewardship team provides individual-, unit-, or service-specific reports on antibiotic use to prescribers, at least annually.			□ Yes		□ No
If Yes is selected: Our stewardship team uses individual-, unit-, or service-specific antibiotic use reports to target feedback to prescribers about how they can improve their antibiotic prescribing, at least annually.			□ Yes		□ No
Continued >>

Patient Safety Component—Annual Facility Survey for LTAC Page 10 of 12

Antibiotic Stewardship Practices (continued)

*30. Our stewardship team provides the following updates or reports, at least annually: (Check all that apply.)

  Updates to facility leadership on antibiotic use and stewardship efforts.

  Outcomes for antibiotic stewardship interventions to staff.

 None of the above

*31. Which of the following groups receive education on appropriate antibiotic use at least annually? (Check all that apply.)

  Prescribers

  Nursing staff

  Pharmacists

 None of the above

Optional Antibiotic Stewardship Practices Questions

Responses to the following questions are not required to complete the annual survey.

Please provide additional information about your facility’s antibiotic stewardship activities and leadership.

32. Antibiotic stewardship activities are integrated into quality improvement and/or patient safety initiatives.

□ Yes

□ No

33. Our facility accesses targeted remote stewardship expertise (e.g., tele-stewardship) to obtain facility-specific support for our antibiotic stewardship efforts.

□ Yes

□ No

34. Our stewardship team works with the microbiology laboratory to inform cascade and/or selective reporting protocols for isolate susceptibilities.

□ Yes

□ No

 Not applicable, our facility does not use cascade and/or selective reporting

35. Our stewardship team monitors compliance with appropriate surgical prophylaxis.

□ Yes

□ No

36. If you selected ‘Yes’ to question 25 (your facility has a leader (or co-leaders) responsible for antibiotic stewardship outcomes): Which committees or leadership entities provide oversight of your facility’s antibiotic stewardship efforts? (Check all that apply.)

  Pharmacy director

  Pharmacy & therapeutics

  Patient safety

  Quality improvement

  Executive leadership (e.g., CEO, CMO)

  Board of directors

  Other (please specify): _____________

  None

Continued >>

Patient Safety Component—Annual Facility Survey for LTAC Page 11 of 12

Optional Antibiotic Stewardship Practices (continued)

37. If you selected ‘Physician’ or ‘Co-led…’ (your facility’s leader (or co-leader) responsible for antibiotic stewardship outcomes is a Physician): On average, what percent time does the physician (co) leader dedicate to antibiotic stewardship activities in your facility? (Check one.)

  1-25%

  26-50%

  51-75%

  76-100%

38. If you selected ‘Pharmacist’ or ‘Co-led…’ (your facility’s leader (or co-leader) responsible for antibiotic stewardship outcomes is a Pharmacist): On average, what percent time does the pharmacist (co) leader dedicate to antibiotic stewardship activities in your facility? (Check one.)

  1-25%

  26-50%

  51-75%

  76-100%

39. If you selected that the physician (co) leader has antibiotic stewardship responsibilities in their contract or job description: What percent time for antibiotic stewardship activities is specified in the physician (co) leader’s contract or job description? (Check one.)

  1-25%

  26-50%

  51-75%

  76-100%

  Not specified

40. If you selected that the pharmacist (co) leader has antibiotic stewardship responsibilities in their contract or job description: What percent time for antibiotic stewardship activities is specified in the pharmacist (co) leader’s contract or job description? (Check one.)

  26-50%

  51-75%

  76-100%

  Not specified

Facility Water Management Program (WMP)

(Optional section. Responses to the following questions are not required to complete the annual survey. Completed with input from WMP team members.)

41. Have you ever conducted a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system (e.g., piping infrastructure)?

□ Yes

□ No

If Yes, If Yes, when was the most recent assessment conducted? (Check one)

□ ≤ 1 year ago □ 1-3 years ago

□ ≥ 3 years ago

Continued >>

Patient Safety Component—Annual Facility Survey for LTAC Page 12 of 12

Water Management Program (continued)

42. Does your facility have a water management program to prevent the growth and transmission of Legionella and other opportunistic waterborne pathogens?

□ Yes

□ No

If Yes, who is represented on your facility WMP team? (Check all that apply)

□ Hospital Epidemiologist/ Infection Preventionist

□ Compliance/Safety Officer

□ Hospital Administrator/Leadership

□ Risk/Quality Management Staff

□ Facilities Manager/ Engineer □ Maintenance Staff □ Environmental Services □ Equipment/Chemical Acquisition/Supplier

□ Infectious Disease Clinician □ Consultant □ Laboratory Staff □ Other (please specify): _____________

43. Do you regularly monitor the following parameters in your building’s water system? (Check all that apply)

Disinfectant (such as residual chlorine):

□ Yes

□ No

If Yes, do you have a plan for corrective actions when disinfectant (s) are not within acceptable limits as determined by your water management program?

□ Yes

□ No

Temperature:

□ Yes

□ No

If Yes, do you have a plan for corrective actions when temperatures are not within acceptable limits as determined by your water management program? Heterotrophic plate counts:

□ Yes □ Yes

□ No □ No

If Yes, do you have a plan for corrective actions when heterotrophic plate counts are not within acceptable limits as determined by your water management program?

□ Yes

□ No

Specific tests for Legionella:

□ Yes

□ No

If Yes, do you have a plan for corrective actions when Specific tests for Legionella are not within acceptable limits as determined by your water management program?

□ Yes

□ No