Form 57.701 Glycemic Control module Hypo-Annual Hospital Survey

Form Approved

OMB No. 0920-0666

Exp. Date: 06/30/2026

www.cdc.gov/nhsn

Glycemic Control Module—Annual Hospital Survey
Instructions for this form are available at:
Page 0 of 2
*required for saving				Tracking #:
Facility ID:				*Survey Year:
Section 1. Facility Characteristics
Ownership (check one):
□ For profit	□ Not for profit, including church			□ Government
□ Military	□ Veterans Affairs			□ Physician owned
If facility is a Hospital:
*Number of patient days: _________
*Number of admissions: __________
For any Hospital:
2. Is your hospital a teaching hospital for physicians and/or physicians-in-training?							□ Yes	□ No
If Yes, what type:	□ Major		□ Graduate	□ Undergraduate
Number of beds set up and staffed in the following location types (as defined by NHSN):
a. ICU (including adult, pediatric, and neonatal levels II/III and III):				__________________________
b. All other inpatient locations:				__________________________
Section 2. Glycemic Control Program
Does your facility have an inpatient glycemic control quality improvement or safety program in place as demonstrated by: (Check all that apply.) Special team(s) dedicated to consulting on patients with diabetes that actively assist in the management of inpatients with diabetes Senior executive who serves as a point of contact or “champion” to help ensure the glycemic control program has resources and support to accomplish its mission Clinician (physician, nurse, or pharmacist) leader with dedicated time to manage the program and conduct daily interventions Allocation of dedicated resources to support glycemic control activities 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 120 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 (form number)  Rev (Add release and release date)                Staff from key support departments and groups who contribute to glycemic control activities At least annual presentation of information on glycemic control activities and outcomes to facility leadership and/or board At least annual opportunity to address glycemic control resource needs with facility leadership and/or board Facility communication mechanisms about glycemic control activities, via email, newsletters, events, or other avenues Provision of facility staff training and development on glycemic control activities Documented statement of facility support for glycemic control activities (e.g., a written policy or statement approved by the board) Our facility does not have a glycemic control quality improvement or safety program in place Our facility has other glycemic control programmatic components, please describe briefly: __________________
Section 3. Glycemic Control Practices*
Does your facility have inpatient glycemic control quality improvement or safety practices as demonstrated by: (Check all that apply.) Provider education Patient education Provider reminder systems Active surveillance for glucose control metrics, such as hypoglycemia/hyperglycemia events or other facilitated relay of clinical data to providers Audit and feedback on performance to providers Incentives, regulation, or policy that are provider- or health system-directed Insulin orders/protocols that are standardized across units or the facility Our facility does not have practices specific to glycemic control quality improvement or patient safety Our facility has other glycemic control practices, please describe briefly: ______________________________
Section 4. Insulin and Hypoglycemia/Hyperglycemia Management Practices**
Describe the current state of hypoglycemia management / prevention protocols at your facility: (Check one.) Nurse driven protocols for hypoglycemia management / prevention are not available at our facility Standardized nurse driven protocols for hypoglycemia management / prevention are available, but use of the protocols are not monitored Standardized nurse driven protocols for hypoglycemia management / prevention are available and use of the protocols are monitored Describe the level of coordination between point of care glucose testing, insulin delivery, and nutrition delivery on the non-critical care wards at your facility. (Check one.) There is not a systematic mechanism or protocol to coordinate glucose testing, insulin administration, and meal/nutrition scheduling There is a systematic mechanism or protocol to coordinate glucose testing, insulin administration, and meal/nutrition scheduling in some units but not all units There is a systematic mechanism or protocol to coordinate glucose testing, insulin administration, and meal/nutrition scheduling in all units of the facility Select the description that most accurately reflects the approach to glycemic control and insulin management in the non-critical care units at your facility: (Check one.) No protocol is available in the non-critical care units at our facility Our facility has a protocol for insulin and hyperglycemia management (including subcutaneous insulin orders) that outlines preferred insulin choices for different situations; however, the protocol guidance is not embedded in order sets Our facility has a protocol for insulin management and hyperglycemia (including, subcutaneous insulin orders) that is integrated into standardized order sets; however, providers must “opt in” Our facility has an institutionally-endorsed protocol for insulin and hyperglycemia management (including, subcutaneous insulin orders) that are integrated into standardized order sets and that require providers to “opt out” Our facility has an institutionally-endorsed protocol for insulin and hyperglycemia management (including, subcutaneous insulin orders) that are integrated into standardized order sets that require the provider to “opt out” and hyperglycemia/ hypoglycemia are monitored on a regular (daily) basis to allow correcting deficiencies in insulin / diabetes management Protocol-driven insulin management and hyperglycemia protocols are reinforced by other methods at our facility. Please briefly describe: __________________________________
Section 5. Glycemic Control Software Tools & Additional Information
Does your facility have an EHR-based glycemic control (“glucometrics”) software or tool to support a glycemic control quality program or activities? (Check one.) Yes If yes, what is the name of the software / tool: _____________________ No Unsure Approximately what percentage of your inpatient population with diabetes is utilizing continuous glucose monitoring (CGM): (Check one.) ______ % Unsure
*Adapted from Society for Hospital Medicine. The Glycemic Control Implementation Guide. 2nd ed. Ed. Maynard G, Berg K, Kulasa K, O’Malley C, Rogers KM. Available at: https://www.hospitalmedicine.org/globalassets/clinical-topics/clinical-pdf/gcmi-guide-m4.pdf. **Adapted from the University of California, San Diego Center for Innovation and Improvement Science, with permission from Greg Maynard, MD, MSc