HAI form

Attachment_E_HAI Form.docx

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

HAI form

OMB: 0920-0852

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HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: HAI FORM


CDC ID: -

Data collector initials: ___________

Survey date: //

Date form completed: //

Enter the TOTAL no. of HAIs for this patient __________. If no HAIs, check here: None and the form is complete.


HAI

Specific site and infection data

Event date

Secondary BSI

Rx start date

Pathogens

Location of attribution

BJ

Check one: BONE DISC JNT PJI

____/____/____

or BH Unk

Yes No

Unk

____/____/___

Unk None

1: _______ 2: _______

3: _______ or None

_________

Unk

BSI

Check one: LCBI MBI-LCBI Central line-associated? Yes No

Check all that apply: ECMO VAD EB Self-injection in central line

Munchausen syndrome (factitious disorder)

Matching organism is identified in blood and from a site-specific specimen, both collected within the IWP and pus is present at 1 of the following vascular sites from which the specimen was collected:

Arterial catheter Arteriovenous fistula

Arteriovenous graft Atrial lines (Right and Left)

Hemodialysis reliable outflow (HERO) catheter Peripheral IV or Midline catheter

Intra-aortic balloon pump (IABP) device Non-accessed central line (not accessed nor

inserted during the admission)

None

____/____/____

or BH Unk

NA

____/____/___

Unk None

1: _______ 2: _______

3: _______ or None

_________

Unk

CNS

Check one: IC MEN SA

____/____/____

or BH Unk

Yes No

Unk

____/____/___

Unk None

1: _______ 2: _______

3: _______ or None

_________

Unk

CVS

Check one: CARD ENDO MED VASC

____/____/____

or BH Unk

Yes No

Unk

____/____/___

Unk None

1: _______ 2: _______

3: _______ or None

_________

Unk

EENT

Check one: CONJ EAR EYE ORAL SINU UR

____/____/____

or BH Unk

Yes No

Unk

____/____/___

Unk None

1: _______ 2: _______

3: _______ or None

_________

Unk

GI

Check one: CDI GE GIT IAB NEC

If CDI, which C. diff tests were performed (check all that apply)? Unknown

GDH EIA Positive Negative Unknown

Toxin EIA Positive Negative Unknown

Combined GDH EIA and Toxin EIA Positive Intermediate Negative Unknown

NAAT Positive Negative Unknown

Cell cytotoxicity neutralization assay (CCNA) Positive Negative Unknown

Toxigenic culture Positive Negative Unknown

If CDI, which test was the LAST test result placed in the medical record?

GDH EIA Toxin EIA NAAT CCNA Toxigenic culture Unknown

____/____/____

or BH Unk

Yes No

Unk

____/____/___

Unk None

1: _______ 2: _______

3: _______ or None

_________

Unk

LRI

Check one: LUNG

____/____/____

or BH Unk

Yes No

Unk

____/____/___

Unk None

1: _______ 2: _______

3: _______ or None

_________

Unk

PNEU

Check one: PNU1 PNU2 PNU3 Ventilator-associated? Yes No

If PNU 2/3, check specimen types that apply: BAL ETA PSB Sputum Blood

Pleural fluid Lung tissue Other, specify: ____________

If PNU3: check conditions that apply: SOT, date: ___/___/___ or Date unk

HSCT, date: ___/___/___ or Date unk Low-dose steroids High-dose steroids

Splenectomy HIV positive with CD4 count <200 ANC or WBC <500/mm3

Cytotoxic chemotherapy

____/____/____

or BH Unk

Yes No

Unk

____/____/___

Unk None

1: _______ 2: _______

3: _______ or None

_________

Unk

REPR

Check one: EMET EPIS OREP VCUF

____/____/____

or BH Unk

Yes No

Unk

____/____/___

Unk None

1: _______ 2: _______

3: _______ or None

_________

Unk


SSI


Proc: ______ Proc date: ____/____/____

Check one: SI DI O/S, site: ________

If SI or DI check one: Primary incision Secondary incision

PATOS: Yes No

____/____/____

or BH Unk

Yes No

Unk

____/____/___

Unk None

1: _______ 2: _______

3: _______ or None

NA

SST

Check one: BRST BURN CIRC DECU SKIN ST UMB

____/____/____

or BH Unk

Yes No

Unk

____/____/___

Unk None

1: _______ 2: _______

3: _______ or None

_________

Unk

UTI

Check one: SUTI ABUTI USI Catheter-associated? Yes No

Was fever the only sign/symptom? Yes No Unknown Not applicable

____/____/____

or BH Unk

Yes No

Unk

____/____/___

Unk None

1: _______ 2: _______

3: _______ or None

_________

Unk


If the patient had >1 HAI of the same type at the time of the survey, enter below or check Not applicable. Note: This is not common.

HAI

Specific site and infection data

Event date

Secondary

BSI

Rx start date

Pathogens

Location of attribution

BSI-2

Check one: LCBI MBI-LCBI Central line-associated? Yes No

Check all that apply: ECMO VAD EB Self-injection in central line

Munchausen syndrome (factitious disorder)

Matching organism is identified in blood and from a site-specific specimen, both collected within the IWP and pus is present at one of the following vascular sites from which the specimen was collected:

Arterial catheter Arteriovenous fistula

Arteriovenous graft Atrial lines (Right and Left)

Hemodialysis reliable outflow (HERO) catheter Peripheral IV or Midline catheter

Intra-aortic balloon pump (IABP) device Non-accessed central line (not accessed nor

inserted during the admission)

None

____/____/____

or BH Unk

NA

____/____/___

Unk None

1: _______ 2: _______

3: _______ or None

_________

Unk

SSI-2

Check one: SI DI O/S, site: ________

If SI or DI check one: Primary incision Secondary incision

PATOS: Yes No

Proc: ______ Proc date: ____/____/____

____/____/____

or BH Unk

Yes No

Unk

____/____/___

Unk None

1: _______ 2: _______

3: _______ or None

NA

___-2

_______

____/____/____

or BH Unk

Yes No

Unk

____/____/___

Unk None

1: _______ 2: _______

3: _______ or None

_________

Unk

___-2

_______

____/____/____

or BH Unk

Yes No

Unk

____/____/___

Unk None

1: _______ 2: _______

3: _______ or None

_________

Unk


Refer to Operational Manual for HAI type and specific site descriptions and definitions. ECMO=extracorporeal membrane oxygenation. EB=epidermolysis bullosa. VAD=ventricular assist device. Proc=NHSN operative procedure category code. Proc date=operative procedure date. Rx start date=antimicrobial treatment start date. NA=not applicable. PATOS=infection present at time of surgery. BH=before hospital admission. Unk=unknown. SOT=solid organ transplantation. HSCT=hematopoietic stem cell transplantation. IWP=infection window period. HIV=human immunodeficiency virus. ANC=absolute neutrophil count. WBC=white blood cells count.


CDC ID: -



CDCID: -


  1. Complete the Antimicrobial Susceptibility Table below if one or more of the specified organisms is reported as a pathogen for one or more of the HAIs entered on page 1 and 2 of this form.

  2. Enter each of the patient’s HAI codes (e.g., BSI, PNEU, GI-2, etc.) in the top row of the table in the space(s) indicated.

  3. Check the box next to any of the organisms below reported as a pathogen for one or more of the patient’s HAIs. Antimicrobial susceptibility test results can be entered for each organism for up to 4 different HAIs.

  4. Circle the appropriate test result for each pathogen/drug combination in the column for the HAI for which the organism was a reported pathogen (S=sensitive/susceptible, S-DD=susceptible dose-dependent, I=intermediate, R=resistant, NS=non-susceptible, N=not tested).


Antimicrobial Susceptibility Table: If NONE of the organisms below are pathogens for any of the patient’s HAIs, check here:


Organism

HAI #1: _______, or NA

HAI #2: _______, or NA

HAI #3: _______, or NA

HAI #4: _______, or NA

Acinetobacter (any species)

AMPSUL

CEFTAZ

COL/PB

IMI

MERO/DORI

TIG

S I R N

S I R N

S I R N

S I R N

S I R N

S I R N

AMPSUL

CEFTAZ

COL/PB

IMI

MERO/DORI

TIG

S I R N

S I R N

S I R N

S I R N

S I R N

S I R N

AMPSUL

CEFTAZ

COL/PB

IMI

MERO/DORI

TIG

S I R N

S I R N

S I R N

S I R N

S I R N

S I R N

AMPSUL

CEFTAZ

COL/PB

IMI

MERO/DORI

TIG

S I R N

S I R N

S I R N

S I R N

S I R N

S I R N

Candida albicans

ANID

CASPO

FLUCO

MICA

S I R N

S I R N

S S-DD R N

S I R N

ANID

CASPO

FLUCO

MICA

S I R N

S I R N

S S-DD R N

S I R N

ANID

CASPO

FLUCO

MICA

S I R N

S I R N

S S-DD R N

S I R N

ANID

CASPO

FLUCO

MICA

S I R N

S I R N

S S-DD R N

S I R N

Candida glabrata

ANID

CASPO

FLUCO

MICA

S I R N

S I R N

S S-DD R N

S I R N

ANID

CASPO

FLUCO

MICA

S I R N

S I R N

S S-DD R N

S I R N

ANID

CASPO

FLUCO

MICA

S I R N

S I R N

S S-DD R N

S I R N

ANID

CASPO

FLUCO

MICA

S I R N

S I R N

S S-DD R N

S I R N

Candida parapsilosis

ANID

CASPO

FLUCO

MICA

S I R N

S I R N

S S-DD R N

S I R N

ANID

CASPO

FLUCO

MICA

S I R N

S I R N

S S-DD R N

S I R N

ANID

CASPO

FLUCO

MICA

S I R N

S I R N

S S-DD R N

S I R N

ANID

CASPO

FLUCO

MICA

S I R N

S I R N

S S-DD R N

S I R N

E. coli

ERTA

IMI

MERO/DORI

S I R N

S I R N

S I R N

ERTA

IMI

MERO/DORI

S I R N

S I R N

S I R N

ERTA

IMI

MERO/DORI

S I R N

S I R N

S I R N

ERTA

IMI

MERO/DORI

S I R N

S I R N

S I R N

Enterobacter cloacae

ERTA

IMI

MERO/DORI

S I R N

S I R N

S I R N

ERTA

IMI

MERO/DORI

S I R N

S I R N

S I R N

ERTA

IMI

MERO/DORI

S I R N

S I R N

S I R N

ERTA

IMI

MERO/DORI

S I R N

S I R N

S I R N

Enterococcus faecalis

DAPTO

LNZ

VANC

S NS N

S I R N

S I R N

DAPTO

LNZ

VANC

S NS N

S I R N

S I R N

DAPTO

LNZ

VANC

S NS N

S I R N

S I R N

DAPTO

LNZ

VANC

S NS N

S I R N

S I R N

Enterococcus faecium

DAPTO

LNZ

VANC

S NS N

S I R N

S I R N

DAPTO

LNZ

VANC

S NS N

S I R N

S I R N

DAPTO

LNZ

VANC

S NS N

S I R N

S I R N

DAPTO

LNZ

VANC

S NS N

S I R N

S I R N

Klebsiella (Enterobacter) aerogenes

ERTA

IMI

MERO/DORI

S I R N

S I R N

S I R N

ERTA

IMI

MERO/DORI

S I R N

S I R N

S I R N

ERTA

IMI

MERO/DORI

S I R N

S I R N

S I R N

ERTA

IMI

MERO/DORI

S I R N

S I R N

S I R N

Klebsiella oxytoca

ERTA

IMI

MERO/DORI

S I R N

S I R N

S I R N

ERTA

IMI

MERO/DORI

S I R N

S I R N

S I R N

ERTA

IMI

MERO/DORI

S I R N

S I R N

S I R N

ERTA

IMI

MERO/DORI

S I R N

S I R N

S I R N

Klebsiella pneumoniae

ERTA

IMI

MERO/DORI

S I R N

S I R N

S I R N

ERTA

IMI

MERO/DORI

S I R N

S I R N

S I R N

ERTA

IMI

MERO/DORI

S I R N

S I R N

S I R N

ERTA

IMI

MERO/DORI

S I R N

S I R N

S I R N

Pseudomonas aeruginosa

CEFTAZ

COL/PB

GENT

IMI

MERO/DORI

PIP/PIPTAZ

TOBRA

S I R N

S I R N

S I R N

S I R N

S I R N

S I R N

S I R N

CEFTAZ

COL/PB

GENT

IMI

MERO/DORI

PIP/PIPTAZ

TOBRA

S I R N

S I R N

S I R N

S I R N

S I R N

S I R N

S I R N

CEFTAZ

COL/PB

GENT

IMI

MERO/DORI

PIP/PIPTAZ

TOBRA

S I R N

S I R N

S I R N

S I R N

S I R N

S I R N

S I R N

CEFTAZ

COL/PB

GENT

IMI

MERO/DORI

PIP/PIPTAZ

TOBRA

S I R N

S I R N

S I R N

S I R N

S I R N

S I R N

S I R N

Staphylococcus aureus

CEFOX/

METH/OX

DAPTO

LNZ

VANC

S I R N


S NS N

S R N

S I R N

CEFOX/

METH/OX

DAPTO

LNZ

VANC

S I R N


S NS N

S R N

S I R N

CEFOX/

METH/OX

DAPTO

LNZ

VANC

S I R N


S NS N

S R N

S I R N

CEFOX/

METH/OX

DAPTO

LNZ

VANC

S I R N


S NS N

S R N

S I R N

Drug codes: AMPSUL=ampicillin/sulbactam, ANID=anidulafungin, CASPO=caspofungin, CEFOX/OX/METH=cefoxitin, oxacillin or methicillin, CEFTAZ=ceftazidime, COL/PB=colistin or polymyxin B, DAPTO=daptomycin, ERTA=ertapenem, FLUCO=fluconazole, GENT=gentamicin, IMI=imipenem, LNZ=linezolid, MERO/DORI=meropenem or doripenem, MICA=micafungin, PIP/PIPTAZ=piperacillin or piperacillin/tazobactam, TIG=tigecycline, TOBRA=tobramycin, VANC=vancomycin


***FORM IS COMPLETE***


Phase5_HAI Form_20200113 Page 2 of 4


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