Form CDC 57.118 CDC 57.118 Denominators for Intensive Care Unit (ICU)/Other locatio

[NCEZID] The National Healthcare Safety Network (NHSN)

57.118_DenominatorICU_BLANK.DOCX

57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA)

OMB: 0920-0666

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Form Approved

OMB No. 0920-0666

Exp. Date: 11/30/2019

www.cdc.gov/nhsn

Denominators for Intensive Care Unit (ICU)/Other Locations

(not NICU or SCA)

Page 1 of 1

*required for saving

Facility ID:

*Location Code:

*Month:

*Year:

Date

*Number of Patients

**Number of patients with 1 or more central lines

**Number of patients with a urinary catheter

**Number of total patients on a ventilator

Number of patients on APRV

Number of Episodes of Mechanical Ventilation

1







2







3







4







5







6







7







8







9







10







11







12







13







14







15







16







17







18







19







20







21







22







23







24







25







26







27







28







29







30







31







*Totals








Patient-days

Central-line days

Urinary catheter-days

Ventilator-days

Episodes of Mechanical Ventilation

**Conditionally required according to the events indicated in Plan.

Label

_____________

_____________

_____________

_____________

_____________

Data

_____________

_____________

_____________

_____________

_____________


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 5.02 hours 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 57.118, Rev.3, v8.8




File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title57.118 ICU/Other Denominator
SubjectNHSN OMB FORM 2018
AuthorCDC/NCZEID/DHQP
File Modified0000-00-00
File Created2024-09-16

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