AQUA form 2

Attachment_H_AQUA General Patient Assessment Form.docx

Prevalence Survey of Healthcare Associated Infections (HAIs) and Antimicrobial Use in U.S. Acute Care Hospitals

AQUA form 2

OMB: 0920-0852

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HAI & ANTIMICROBIAL USE PREVALENCE SURVEY

ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM 2: GENERAL PATIENT ASSESSMENT

CDC ID: ___-_________ Date: ___/___/_______ Data collector initials: _____

Healthcare exposures

1. Indicate the location from which the patient was admitted to the survey hospital (check one):

Private residence Long term care/SNF LTACH Another acute care hospital Homeless Incarcerated

Other _________________________ Unknown

2. In the 30 days prior to admission to the survey hospital, did the patient receive (check all that apply):

IV antimicrobials Cancer chemotherapy Wound care Chronic hemodialysis Surgery

None Unknown

3. Was the patient hospitalized in an acute care hospital for ≥2 days in the 90 days prior to this admission?

Yes No Unknown

Antimicrobial allergies

4. Is an antimicrobial drug allergy recorded in the medical record? Yes No Unknown

4a. If yes, specify drug class or classes to which patient is allergic, and reaction(s):



Drug class

Nausea, vomiting and/or diarrhea

Hives or

urticaria

Other skin rash

Wheezing, throat tightness, trouble breathing

Angio-edema

or face swelling

Anaphylaxis

Not specified

Other (specify)

Penicillins

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Cephalosporins

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Sulfa drugs

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Macrolides

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Fluoroquinolones

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Vancomycin

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Other (specify):

________________

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________


Underlying conditions

5. Check all that apply: None: Unknown:


AIDS

Kidney stones/nephrolithiasis

Alcoholism in past year

Leukemia

Asplenia

Lymphoma or multiple myeloma

Asthma

MRSA colonization or infection history

Cerebrovascular disease/stroke (except hemiplegia)

Myocardial infarction

Chronic cognitive deficit

Neutropenia (absolute neutrophil count <500 cells / µL)

Chronic kidney disease

Peptic ulcer disease

Chronic liver disease

Peripheral vascular disease

Chronic obstructive pulmonary disease (COPD)/emphysema

Pregnancy

Chronic lung disease (other than COPD/emphysema, asthma)

Recurrent cystitis or urinary tract infection

Chronic steroid or other immunosuppressive therapy

Sickle cell disease

Congenital urinary tract abnormality (not VUR)

Smoking in home or living environment (other than patient)

Congenital heart disease

Smoking in past year (patient)

Congestive heart failure

Solid tumor malignancy, metastatic (not urologic/renal)

Connective tissue disease

Solid tumor malignancy, not metastatic (not urologic/renal)

Cystic fibrosis

Spinal cord injury or paraplegia or quadriplegia

Dementia

Transplant, hematopoietic stem cell or bone marrow

Diabetes mellitus with complications

Transplant, solid organ

Diabetes mellitus without complications

Ureteral stent

Hemiplegia

Urinary tract abnormality, not otherwise specified

HIV without AIDS

Urostomy or nephrostomy

IVDU in past year

Urologic or renal malignancy


Vesicoureteral reflux (VUR)



CDCID: ____-__________


Infections present during the hospitalization (Do not use NHSN definitions; use information documented in medical records)

6. Complete table: No infections:

No.

Infection (code)

Onset date

Signs and symptoms documented in medical record

(check all that apply)

Was infection treated with antimicrobials?

1

­­­________



SSI? Y


COVID-19? Y

Before hospitalization

Hospital days 1-2

On/after hosp day 3

In hospital, day unk

Unknown

Cough or dyspnea

Diarrhea

Fever

Hypotension

Unknown

Mental status change

Nausea or vomiting

Pain at infection site

Positive imaging

None

Pus, drainage, abscess

Redness or swelling

Urinary frequency

Urinary urgency

Other____________

Yes

No

Unknown

2

­­­________



SSI? Y


COVID-19? Y

Before hospitalization

Hospital days 1-2

On/after hosp day 3

In hospital, day unk

Unknown

Cough or dyspnea

Diarrhea

Fever

Hypotension

Unknown

Mental status change

Nausea or vomiting

Pain at infection site

Positive imaging

None

Pus, drainage, abscess

Redness or swelling

Urinary frequency

Urinary urgency

Other____________

Yes

No

Unknown

3

­­­________



SSI? Y


COVID-19? Y

Before hospitalization

Hospital days 1-2

On/after hosp day 3

In hospital, day unk

Unknown

Cough or dyspnea

Diarrhea

Fever

Hypotension

Unknown

Mental status change

Nausea or vomiting

Pain at infection site

Positive imaging

None

Pus, drainage, abscess

Redness or swelling

Urinary frequency

Urinary urgency

Other____________

Yes

No

Unknown

4

­­­________



SSI? Y


COVID-19? Y

Before hospitalization

Hospital days 1-2

On/after hosp day 3

In hospital, day unk

Unknown

Cough or dyspnea

Diarrhea

Fever

Hypotension

Unknown

Mental status change

Nausea or vomiting

Pain at infection site

Positive imaging

None

Pus, drainage, abscess

Redness or swelling

Urinary frequency

Urinary urgency

Other____________

Yes

No

Unknown

More infections than fit in the table:

Infection codes: BJI, BSI, CDI, CNS, CVI, DIS, ENT, GTI, HEB, IAB, LRI, PNE, REP, SST, UND, UNK, UTI

Severity of illness

7. Was the patient in an ICU at any time during the hospitalization? Yes No Unknown

7a. If yes, enter the dates of the first ICU admission during the hospitalization:

ICU admission date: ____ / ____ /____ or Unknown ICU discharge date: ____ / ____ /____ or Unknown

8. Complete the table using data from the first 24-hour period of treatment during the hospitalization:

Parameter

First day, CAP treatment:

____ / ____ / ____ or NA

First day, IV vancomycin:

____ / ____ / ____ or NA

First day, fluoroquinolone:

____ / ____ / ____ or NA

First day, UTI treatment

____ / ____ / ____ or NA

Temperature:





Highest:

______ °C °F or Unk

______ °C °F or Unk

______ °C °F or Unk

_____ °C °F or Unk

Lowest:

______ °C °F or Unk

______ °C °F or Unk

______ °C °F or Unk

_____ °C °F or Unk

Heart rate:





Highest:

______ bpm or Unk

______ bpm or Unk

______ bpm or Unk

______ bpm or Unk

Lowest:

______ bpm or Unk

______ bpm or Unk

______ bpm or Unk

______ bpm or Unk

Respiratory:





Highest resp rate:

______ bpm or Unk

________ bpm or Unk

______ bpm or Unk

______ bpm or Unk

Lowest PaCO2:

______ mmHg or Unk

________ mmHg or Unk

______ mmHg or Unk

______ mmHg or Unk

Mechanical vent:

Yes No Unk

Yes No Unk

Yes No Unk

Yes No Unk

WBC count:





Highest:

______ cells/mm3 or Unk

______ cells/mm3 or Unk

______ cells/mm3 or Unk

______ cells/mm3 or Unk

Lowest:

______ cells/mm3 or Unk

______ cells/mm3 or Unk

______ cells/mm3 or Unk

______ cells/mm3 or Unk

Highest %bands:

______ % or Unk

______ % or Unk

______ % or Unk

______ % or Unk

Blood pressure:





Lowest systolic BP:

______ mmHg or Unk

______ mmHg or Unk

______ mmHg or Unk

______ mmHg or Unk

Lowest mean

arterial pressure:

______ mmHg or Unk

______ mmHg or Unk

______ mmHg or Unk

______ mmHg or Unk

On vasopressors:

Yes No Unk

Yes No Unk

Yes No Unk

Yes No Unk

Lactate


______ mg/dL mmol/L

or Unk

______ mg/dL mmol/L

or Unk

______ mg/dL mmol/L

or Unk

______ mg/dL mmol/L

or Unk


***FORM IS COMPLETE*** Go to AQUA Forms 3a-3d

Phase 5_AQUA General Patient Assessment Form_20210513 Page 1 of 2

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