Form 9 Attachment J: Clinical Outcomes Data for ICU/Non-ICU

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Attachment J: Clinical Outcomes Data for ICU/Non-ICU

AHRQ Safety Program for MRSA Prevention

Clinical Outcomes Data for ICU/Non-ICU

(This will be an electronic form with dropdown menus for the List of Organisms and the List of Specimen Types)

ICU & Non-ICU

Data reported quarterly and results broken down by month

1. Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia LabID (as defined by CDC/NHSN and outlined in the completion guide) – monthly

Month, Year	Count of MRSA bacteremia LabID events by month and community vs. hospital onset	Designation as either community onset (Day 1 or 2 of hospital admission) or hospital onset (Day 3 or after of hospital admission) – selected from dropdown menu

2. Hospital onset Bacteremia (HOB) (Day 3 or after of hospital admission) with causative organisms – monthly

This includes MRSA as well as well as other causative organisms.

Month, Year	Count of HOB cases by each causative organism	Organism – selected from dropdown menu (See List of Organisms, page 6)

Public reporting burden for this collection of information is estimated to average 30 minutes per response, the estimated time required to complete the survey. 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, AHRQ Reports Clearance Officer, Attention: PRA, Paperwork Reduction Project (0935-0143), AHRQ, 5600 Fishers Lane, MS 0741A, Rockville, MD 20857

The confidentiality of your responses is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure.

3. CLABSI cases with causative organisms – monthly

Month, Year	Count of CLABSI cases by each causative organism	Organism – selected from dropdown menu (See List of Organisms, page 6)

4. Central line days – monthly

Month, Year	Total central line days

5. Patient days – monthly

Month, Year	Total patient days

6. Clinical cultures growing MRSA on Day 3 or later of hospital admission – monthly

Month, Year	Count of clinical cultures growing MRSA on Day 3 or later of hospital admission by specimen type	Specimen type – selected from dropdown menu (See List of Specimen Types, page 7)

7. Point prevalence of MRSA nasal surveillance tests semi-annually (reporting is optional; will likely only be completed by participating sites that already perform MRSA nasal surveillance testing)

Number of patients with positive result on MRSA nasal surveillance testing during a designated 3-day time window	Number of total surveillance tests performed during a designated 3-day time window
_________________	_________________

List of Organisms

Staphylococcus aureus

Methicillin-resistant (MRSA)

Methicillin-susceptible (MSSA)

Coagulase-Negative Staphylococcus

Candida

Candida albicans

Candida glabrata

Candida parapsilosis

Candida tropicalis

Candida krusei

Candida lusitaniae

Candida sp.(unspeciated)

Enterococcus

Enterococcus faecalis

Enterococcus faecium

Enterococcus sp.

Klebsiella

Klebsiella pneumoniae

Klebsiella oxytoca

Escherichia coli

Enterobacter

Enterobacter cloacae

Enterobacter aerogenes

Enterobacter agglomerans

Enterobacter sp.

Pseudomonas

Pseudomonas aeruginosa

Pseudomonas sp.

Streptococcus

Streptococcus viridans grp

Streptococcus, Group B

Streptococcus pneumoniae

Streptococcus, Group A

Streptococcus, Group C

Streptococcus anginosis grp

Streptococcus, Group F

Streptococcus, Group G

Acinetobacter

Acinetobacter baumannii

Acinetobacter lwoffii

Serratia

Serratia marcescens

Serratia sp.

Bacteroides

Bacteroides fragilis

Bacteroides, other sp.

Proteus mirabilis

Stenotrophomonas maltophilia

Clostridium

Citrobacter

Citrobacter freundii

Citrobacter koseri

Morganella morganii

Achromobacter sp.

Providencia stuartii

Alcaligenes xylosoxidans

Pantoea agglomerans

Other

List of Specimen Types

Blood culture

Urine culture

Sputum culture

Wound culture

Abscess fluid

Peritoneal fluid

Pleural fluid

Cerebral spinal fluid

Joint aspiration fluid

Hardware or device (explanted)

Tissue culture

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