0920-22BT Attachment D - Hospital Induction Questionnaire (2022)

National Hospital Ambulatory Medical Care Survey

Attachment D - Hospital Induction Questionnaire (2022)

Hospital Induction Interview 2022

OMB: 0920-0278

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2022 National Hospital and Medical Care Survey (NHAMCS)
Hospital Induction Questionnaire

Shape1

Notice – CDC estimates the average public reporting burden for this collection of information as 30 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333; ATTN: PRA (0920-0278).

 

Assurance of confidentiality – We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2018 (CIPSEA Pub. L. No. 115-435, 132 Stat. 5529 § 302). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you. In addition to the above cited laws, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 and 151 note) which protects Federal information systems from cybersecurity risks by screening their networks.




Form Approved: OMB No. 0920-0278; Expiration date: 09/30/2023

HOSPITAL SCREENER

INTRO_SCR

This is (Name of field representative) from the U.S. Census Bureau. I'm calling for the Centers for Disease Control and Prevention concerning their study of hospital emergency

departments.


You should have received a letter from Brian C. Moyer, the Director of the National Center for Health Statistics, describing the study. You've probably also received a letter from the U.S. Census Bureau, which is

collecting the data for this study.


Did you receive the letter(s)?

1=’Yes’

2=’No’

3=’Don’t Know’


LETTER

If the respondent does not recall receiving the letter, offer to read or mail another copy

NAMECHEK

Let me verify that I have the correct name and address for your hospital.

Is the correct name [Facility Name]?

1='Yes' (Skip to ADDCHEK)
2='No'


HSP_NAME

What is the name of your hospital?



ADDCHEK

Is your hospital located at (Facility Address)?

1='Yes' (Skip to MAILADD)
2='No'


HSP_ADDRESS

What is the correct address?

MAILADD

Is this also the mailing address?

1='Yes' (Skip to INTRO_AB)
2='No'


MHSP_STRET

What is the correct mailing address? Enter the number and street or press enter if same


INTRO_AB

(Although you have not received the letter,) I'd like to briefly explain the study to you at this time and answer any questions about it. The National Center for Health Statistics of the Centers for Disease Control and Prevention is conducting its annual study of hospital-based ambulatory care. (Intro for the survey) Before discussing the details, I would like to verify our basic information about (facility name) to be sure we have correctly included this hospital in the study. First, concerning licensing:


LICHOSP

Is facility a licensed hospital?

1='Yes' (Skip to OWN101)
2='No'



THANK_B1

Thank you, but it seems that our information is incorrect. Since (facility name) is not a licensed hospital, it should not have been chosen for our study. Thank you very much for your cooperation.

(Hospital is out of scope. Exit instrument)


OWN101

Is hospital non-profit, government or proprietary? Read answer categories out loud

1=Nonprofit (includes church-related, nonprofit corporation, other nonprofit ownership)

2=State or local government (includes state, county, city, city-county, hospital district or authority)

3=Proprietary (includes individually or privately owned, partnership or corporation)



OWNHCC

Is hospital owned, operated, or managed by a health care corporation that owns multiple health care facilities?

1='Yes'
2='No'
3='Unknown'



TEACHOSP

Is this a teaching hospital?

1='Yes'
2='No'



MERGER

Did this hospital either merge or separate from any OTHER hospital in the past 2 years?

1=’Merged or separated’

2=’No’ (Skip to conglomerate questions)

3=’Unknown’ (Skip to conglomerate questions)


MERSEP

Was this a merger or a separation?

1='Merger'
2='Separation'



MERGMEDR

Does your hospital share its electronic health records system with any other hospital?

1='Yes' (Skip to MEDRSEPT)

2='No' (Skip to MERGER)

3='Unknown' (Skip to MEDRSEPT)


MEDRSEPT

Can the medical records from the sample hospital be separated from all OTHER hospitals within the group or conglomerate?

1='Yes' (Skip to MERGNUM)
2='No'
3='Unknown'



MERGNUM

If yes, how many other hospitals? (Specify number)


OTHNAME

What is the name and address of this OTHER hospital?

Enter name of hospital


OTHSTRET

What is the name and address of this OTHER hospital?

Enter number and street



OTHSTRET2

What is the name and address of this OTHER hospital?

Enter the second line of address or press enter if same/none



OTHCITY

What is the name and address of the OTHER hospital?

Enter city



OTHSTATE

What is the name and address of this OTHER hospital?

Enter state



OTHZIP

What is the name and address of this OTHER hospital?

Enter zip code


THANK_MERGSEP

Since your hospital has merged or separated within the last 2 years, I need to get further instructions from the Centers for Disease Control and Prevention (CDC) on how to proceed. I will call you back within a week and let you know which parts of your hospital will be in the survey. Thank you for your cooperation.


CALLRO_MERGSE

Call your RO and inform them of the situation. Await resolution from the RO before continuing with this case.

(Exit instrument and contact RO for further instructions)


If the sampled hospital does not have a conglomerate on the sample file:

CONG

Is this facility part of a conglomerate or group?

1='Yes' (Skip to CONGNM)
2='No' (Go to ESA24)



CONGNM

Enter conglomerate or group name

If the sampled hospital has a conglomerate on the sample file:

CONGID

We have identified you as part of the [FILL GROUPNAME] conglomerate or group. Is that true?

1='Yes' (Go to ESA24)
2='No' (Skip to CONGNM)


CONGNM

Enter conglomerate or group name

ESA24

Does this hospital provide emergency services that are staffed 24 HOURS each day either here at this hospital or elsewhere?

1='Yes' (Skip to TRAUMA)
2='No'



ESANOT24

Does this hospital operate any emergency service areas that are not staffed 24 HOURS each day?

1='Yes'
2='No'



THANK_B2

Thank you, but it seems that our information is incorrect. Since (facility name) does not have 24-hour emergency services, it should not have been chosen for our study. Thank you very much for your cooperation.

(ED is out of scope. Exit instrument)


TRAUMA

What is the trauma level rating of this hospital?

1='Level I'
2='Level II'
3='Level III'
4='Level IV'
5='Level V'
6='Other/unknown'
7='None'

ELIGREQ

Eligibility Requirements

1=’ED meets requirements’

2=’Hospital not licensed’

3=’Hospital does not have an ED’



STUDY_DESC

Thank you. Explain the following ONLY if this is a new hospital. Provide the administrator or other hospital representative with a brief description of the study. Cover the following points - Now I would like to provide you with further information on the study.


(1) NHAMCS is the only source of national data on health care provided in hospital emergency departments.

(2) NHAMCS is endorsed by the: American College of Emergency Physicians, Emergency Nurses Association, American Health Information Management Association.


(3) Nationwide sample of about 600 hospitals.


(4) Four-week data collection period


(5) Brief form completed for a sample of patient visits. As one of the hospitals that has been selected for the study, your contribution will be of great value in producing reliable, national data on ambulatory care.


SCREENER_THK

Thank you for your cooperation. I am looking forward to our meeting.

HOSPITAL INDUCTION
(The following questions pertain to entire ED)

INDUCTION_APPT

I would like to arrange a meeting with you so that I can better present the details of the study.

Is there a convenient time within the next week or so that I could contact you or your representative? Record day, date and time of appointment.

(Enter 999 if the respondent wants to continue with the induction now)


REVIEW

I would like to begin with a brief review of the background for this study. Provide the administrator or other hospital representative with a brief introduction to the study and a general overview of procedures.

(Press F1 for points to be covered)


SURGDAY

How many days in a week are inpatient elective surgeries scheduled?

(data range: 0-7)



BEDCZAR

Does your hospital have a bed coordinator, sometimes known as a bed czar?

1='Yes'
2='No'
3='Unknown'



BEDDATA

How often are hospital bed census data available?
1='Instantaneously'
2='Every 4 hours'
3='Every 8 hours'
4='Every 12 hours'
5='Every 24 hours'
6='Other'
7='Unknown'


HLIST

Does your hospital have hospitalists on staff?

A hospitalist is a provider whose primary professional focus is the general care of hospitalized patients. He/she may oversee ED patients being admitted to the hospital.

1='Yes'
2='No' (Skip to EMEDRES)
3='Unknown' (Skip to EMEDRES)



HLISTED

Do the hospitalists on staff at your hospital admit patients from your ED?

1='Yes'
2='No'

3='Unknown'


EMEDRES

Does hospital have Emergency Medicine residency program?

1='Yes'
2='No'
3='Unknown'



COVID_INTRO

Now I would like to ask you a few questions about characteristics of your emergency department, including the utilization of telemedicine. After these questions, I will then ask a few questions about the coronavirus disease (COVID-19) and the impact it had on operations in your emergency department and on your staff.

TELEMED_USE

During the past four weeks, did your emergency department use telemedicine technology (e.g., audio, audio with video, web videoconference) for patient visits?

1= ‘Yes’

2= ‘No (Skip to COVID_TURNAWAY)’

3= ‘Don’t know’ (Skip to COVID_TURNAWAY)’


TELEMED_TYPE

During the past four weeks, what type(s) of telemedicine tool(s) did you use for patient visits? (Select all that apply)

  1. = ‘Telephone audio’

  2. = ‘Videoconference software with audio (e.g., Zoom, Webex, Facetime)’


  1. = ‘Telemedicine platform NOT integrated with Electronic Health Record (EHR) (e.g., Doxy.me)’


  1. = ‘Telemedicine platform integrated with EHR (e.g., update clinical documentation during telemedicine visit)’


  1. = ‘Other tool(s):’_____


  1. = ‘Don’t know’


TELEMED_PERCENT

During the past four weeks, what percentage of this hospital’s emergency department patient visits were through telemedicine technology?


1= ‘Less than 25%’

2= ‘25% to 49%’

3= ‘50%to 74%’

4= ‘75% or more’

5= ‘Don’t know’


TELEMED_STOP

Does your emergency department plan to discontinue using telemedicine visits in the next year?

1= ‘Yes’

2= ‘No’

3= ‘Don’t know’




COVID_TURNAWAY

During the past four weeks, did your emergency department need to turn away or refer elsewhere any patients with confirmed or suspected COVID-19 infection?


1 = ‘No COVID-19 patients were turned away or referred elsewhere’

2 = ‘Some COVID-19 patients were turned away or referred elsewhere’

3 = ‘Most COVID-19 patients were turned away or referred elsewhere’

4 = ‘All COVID-19 patients were turned away or referred elsewhere’

5 = ‘Not applicable – the emergency department did not have any COVID-19 patients.’

6 = ‘Don’t know’


COVID_REQUIRED

Has your hospital ever required or mandated COVID-19 vaccination for healthcare personnel/staff?

  1. = ‘Yes’

  2. = ‘No’

  3. = ‘Don’t know’


COVID_OFFER

Did your hospital ever offer COVID-19 vaccinations to healthcare personnel/staff?

  1. = ‘Yes’

  2. = ‘No’ (Skip to PERMPART)

  3. = ‘Don’t know’


COVID_VACCINE

Which COVID-19 vaccine were ever offered to healthcare personnel/staff at your hospital? (Select all that apply)

1 = ‘Moderna’

2 = ‘Johnson & Johnson/Janssen’

3 = ‘Pfizer’

4 = ‘AstraZeneca’

5 = ‘Other (Specify):’

6 = ‘Don’t know’

PERMPART

As I mentioned earlier, I would like to discuss the plan for conducting the study. This hospital has been assigned to a 4- week data collection period beginning on Monday, (Reporting period begin date). First, I would like to discuss the steps needed to obtain approval for the study. Are there any additional steps needed to obtain permission for the hospital to participate in the study?

1=’Yes’

2=’No’ (Skip to VSREPPER)


PERMPARTSPEC

Specify the necessary steps needed to obtain permission for the hospital to participate in the study. Include the name, address, phone and title of the person(s) who can grant approval


PERM_THANK

Thank you for your help.


RO_PERMISSION

Call the Regional Office to inform them of the additional steps needed to obtain permission


VSREPPER

Now I would like to make arrangements to obtain the information needed for sampling. I will need to (know/verify) how your (emergency department) (is/are) organized and obtain an estimate of the number of patient visits expected during the 4-week reporting period. Would you prefer I (get/verify) this information from you or someone else?
1=’Respondent’ (Skip to TWICELY)

2=’Someone else’


CINFO

What is the name of the person with whom I should speak? Enter 1 to enter/update hospital contact information Enter 2 to enter/update department contact information

1=’Hospital level contact’

2=’Department contact’

3=’Continue interview’


THANK_RESP

Thank current respondent for his/her time and cooperation



INTRO_ED

(At this stage in the induction interview, the field representative collects the name, type (Adult, Pediatric etc.), and visit characteristics of each of the 24-hour Emergency Service Areas in the ED.)

If necessary, introduce yourself and explain the survey. Provide the administrator with the introductory letter and ensure you obtained verbal consent before proceeding with the interview.


Explain that in order to develop a sampling plan, you would like to collect more specific information about this hospital's emergency department.


ESA_MANY

How many emergency service areas at this hospital are open 24 hours a day? Remind the respondent to include satellite (off-site) locations that are also open 24 hours a day. Ensure those locations meet the ROOFS criteria.

(enter number)


TWICELY

(only asked if the instrument detects a significant difference between the current and previous visit volumes)

Is the number of visits to any of the ESAs more than twice the number shown on the previous sampling plan?

1='Yes'
2='No'



TWICELY_SPEC

(only asked if the instrument detects a significant difference between the current and previous visit volumes)

Specify why visits have increased this year or were too low the last time the ED participated


HALFLY

(only asked if the instrument detects a significant difference between the current and previous visit volumes)

Is the number of expected visits to any of the ESAs less than half the number shown on the previous sampling plan?

1='Yes'
2='No'



HALFLYSPEC

(only asked if the instrument detects a significant difference between the current and previous visit volumes)

Specify why visits have decreased this year or were too high the last time the ED participated


EDPRIM

(after EHRINSE)

When patients with identified primary care providers arrive at the Emergency Department, how often do you electronically send notifications to the patients' primary care providers?

1='Always'
2='Sometimes'
3='Rarely'
4='Never'
5='Unknown'



EDINFO

When patients arrive at the Emergency Department, are you able to query for patients' healthcare information electronically (e.g., medications, allergies) from outside sources?

1='Yes'
2='No'
3='Don’t Know'



OBSCLIN

Does your ED have an observation or clinical decision unit?

1='Yes'
2='No' (Skip to BOARD)
3='Unknown' (Skip to BOARD)



OBSSEP

Is this observation or clinical decision unit physically separate from the ED?

1='Yes'
2='No'
3='Unknown'



OBSDECMD

What type of providers make decisions for patients in this observation or clinical decision unit? Enter all that apply, separate with commas

1=ED physicians, APRN, PA

2=Hospitalists

3=Other physicians, APRN, PA

4=Unknown



BOARD

Are admitted ED patients ever "boarded" for more than 2 hours in the ED or the observation unit while waiting for an inpatient bed?

1='Yes'
2='No'
3='Unknown'



BOARDHOS

Does your ED allow some admitted patients to move from the ED to inpatient corridors while awaiting a bed ('boarding') - sometimes called 'full capacity protocol'?

1='Yes'
2='No'
3='Unknown'


AMBDIV

Did your ED go on ambulance diversion in [last year]?

1='Yes'
2='No' (Skip to NUMSTATX)
3='Unknown' (Skip to NUMSTATX)



TOTHRDIV

What is the total number of hours that your hospital's ED was on ambulance diversion in [last year]?

(Enter number of diversions)



REGDIV

Is ambulance diversion actively managed on a regional level versus each hospital adopting diversion if and when it chooses?

1='Yes'
2='No'
3='Unknown'


ADMDIV

Does your hospital continue to admit elective or schedule surgery cases when ED is on ambulance diversion?

1='Yes'
2='No'
3='Unknown'



NUMSTATX

As of last week, how many standard treatment spaces did your ED have? Standard treatment spaces are beds or treatment spaces specifically designed for ED patients to receive care, including asthma chairs.

Enter CTRL-D if data not available



NUMOTHTX

As of last week, how many other treatment spaces did your ED have? Other treatment spaces are other locations where patients might receive care in the ED, including chairs, stretchers in hallways that may be used during busy times.

Enter CTRL-D if data not available



EDSPACES

In the last two years, did your ED increase the number of standard treatment spaces?

1='Yes'
2='No'
3='Unknown'



PHYSSPACE

In the last two years, did your ED's physical space expand?

1='Yes'
2='No'
3='Unknown'



EXPAND

Do you have plans to expand your ED's physical space within the next two years?

1='Yes'
2='No'
3='Unknown'



BEDREG

Does your ED use bedside registration?

1='Yes'
2='No'
3='Unknown'



KIOSELCHK

Does ED use kiosk self-check-in

1='Yes'
2='No'
3='Unknown'



CATRIAGE

Does your ED use computer-assisted triage?

1='Yes'
2='No'
3='Unknown'



IMBED

Does your ED use immediate bedding (no triage when ED is not at capacity)?

1='Yes'
2='No'
3='Unknown'



ADVTRIAG

Does your ED use advanced triage (triage-based care) protocols?

1='Yes'
2='No'
3='Unknown'



PHYSPRACTRIA

Does your ED use physician, APRN, PA at triage?

1='Yes'
2='No'
3='Unknown'



FASTTRAK

Does your ED use separate fast track unit for non-urgent care?

1='Yes'
2='No'
3='Unknown'


EDPTOR

Does your ED use separate operating room dedicated to ED patients?

1='Yes'
2='No'
3='Unknown'



DASHBORD

Does your ED use electronic dashboard?

1='Yes'
2='No'
3='Unknown'



RFID

Does your ED use radio frequency identification (RFID) tracking?

1='Yes'
2='No'
3='Unknown'



WIRELESS

Does ED use wireless communication devices by providers?

1='Yes'
2='No'
3='Unknown'



ZONENURS

Does your ED use zone nursing?

1='Yes'
2='No'
3='Unknown'



POOLNURS

Does your ED use pool nurses?

1='Yes'
2='No'
3='Unknown'



ELECTRONIC HEALTH RECORDS (EHR): ED (E)
(Questions pertain to Emergency Service Area (ESA) with most visits)

EMEDRECE
(after HALFLYSPEC)

Does your ED use an electronic health record (EHR) system? Do not include billing record systems?

1=‘Yes, all electronic’
2=‘Yes, part paper and part electronic’
3=‘No’
4=‘Unknown’

EHRINSYRE

In which year did your ED install the EMR/EHR system?

HHSMUE

Does your current system meet meaningful use criteria as defined by the Department of Health and Human Services?
1='Yes'
2='No'
3='Unknown'

EHRNAME

What is the name of your current EMR/EHR system?
1='Allscripts'

2='athenahealth'
3='Cerner'
4='eClinicalWorks'
5='e-MDs'
6='Epic'

7=’Modernizing Medicine’
8='NextGen'
9='Practice Fusion'
10=Greenway Medical'
11='Other - Specify' (Go to EHRNAMOTHE)

EHRNAMOTHE

Other - specify name of EHR/EMR system
(Enter name of EHR system)

EHRINSE

Does your ED have plans for installing a new EHR/EMR system within the next 18 months?
1='Yes'
2='No'
3='Maybe'
4='Unknown'



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