Form CDC 57.127 CDC 57.127 MDRO and CDI Prevention Process and Outcome Measures Mon

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/xxxx

www.cdc.gov/nhsn

MDRO and CDI Monthly Denominator Form

Page 1 of 2

*required for saving

**conditionally required based upon monitoring selection in Monthly Reporting Plan

Facility ID #: ________

*Month: __________

*Year: _________

*Location Code: ______________________

Line 1: Setting: Inpatient **Total Facility Patient Days: ____________

**Total Facility Admissions: ____________

Line 2: If your facility has a CMS-certified rehab unit (IRF) or CMS-certified psych unit (IPF), please subtract these counts from “Total Facility Patient Days” and “Total Admissions” (Line 1). If you do not have these units, enter the same values you entered on Line 1. Counts= [Total Facility – (IRF + IPF)]

Patient Days: ________

Admissions: _________

Line 3: If your facility has a CMS-certified IRF, CMS-certified IPF, NICU, or Well Baby Unit, please subtract those counts from “Total Facility Patient Days” and “Total Admissions” (Line 1). If you do not have these units, enter the same values you entered on Line 1. Counts= [Total Facility – (IRF + IPF + NICU + Well Baby Unit)]

Patient Days: ________

Admissions: _________

**For this quarter, 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

□ GDH plus NAAT (2-step algorithm)

□ Cell cytotoxicity neutralization assay

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

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

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

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

□ Other: ______________________

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

Note: “Other” should not be used to name specific laboratories, reference laboratories, generic testing methods (such as “PCR”) or the brand names of C. difficile tests; most methods can be categorized accurately by selecting from the options provided. Please ask your laboratory or contact the NHSN helpdesk for further guidance.

Organism Selection/Confirmation of No Events

Specific Organism Type

MRSA

C. difficile

MSSA

CephR-Klebsiella

CRE- E. coli

CRE-Enterobacter

CRE-Klebsiella

MDR-Acinetobacter

VRE

Infection Surveillance

LabID Event (All specimens)

LabID Event (Blood specimens only)

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 15 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. 127 (Front) Rev. 9, v9.4

MDRO and CDI Monthly Denominator Form

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Process Measures: Hand Hygiene, Gown and Glove Use, and AST

Hand Hygiene

Gown and Gloves

**Performed: ________

**Indicated: __________

**Used: __________

**Indicated: __________

Active Surveillance Testing (AST)

**Active Surveillance Testing performed

**Timing of AST † (circle one)

Adm Both

Adm Both

**AST Eligible Patients ‡ (circle one)

All NHx

All NHx

Admission AST

**Performed

**Eligible

Discharge/Transfer AST

**Performed

**Eligible

Outcome Measures: AST

Prevalent Cases

(Specific Organism Type)

MRSA

VRE

**AST/Clinical Positive

**Known Positive

Incident Cases

**AST/Clinical Positive

Custom Fields

Label

_______________

_______________

_______________

_______________

_______________

Data

_______________

_______________

_______________

_______________

_______________

† Adm – Admission testing Both – Admission and Discharge/Transfer testing ‡ All – All patients tested NHx – Only patients tested are those who have no documentation at the admitting facility in the previous 12 months of MDRO-colonization or infection at the time of admission.