Form 57.701 Glycemic Control Module-HYPO Annual Survey

Form Approved

OMB No. 0920-0666

Exp. Date: 12/31/2026

www.cdc.gov/nhsn

Medication Safety Component — 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:
*Is your hospital a teaching hospital for physicians and/or physicians-in-training or nursing students?			□ 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:			__________________________
*Select the module(s) for which your facility currently reports or intends to report data:
□ Glycemic Control Module

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)). CDC (57.701)  Rev (13.0, December 2024)               

Public reporting burden of this collection of information is estimated to average 180 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 H21-8, Atlanta, GA 30333, ATTN:  PRA (0920-0666).

Section 2. Glycemic Control
Responses to questions in Section 2 are required if “Glycemic Control Module” is checked in Section 1. If unchecked, skip Section 2. Section 2a. Glycemic Control Program *Does your facility provide leadership support and clinical resources specifically for inpatient glycemic control quality improvement or safety program activities as demonstrated by: (Check all that apply.) Special team(s) dedicated to assisting 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 oversee development and implementation of glycemic control improvement interventions Allocation of dedicated resources to support glycemic control activities Our facility has other leadership support or clinical resources to address inpatient glycemic control practices, describe: _________________ Currently, our facility does not have leadership support or clinical resources specifically to address inpatient glycemic control as part of our patient safety and quality improvement activities Section 2b. Glycemic Control Practices† *Does your facility promote inpatient glycemic control practices as part of your patient safety and quality improvement activities as demonstrated by: (Check all that apply.) Offering provider education on glycemic control and best-practices for managing diabetic patients at least annually Offering prescriber (e.g., physician, nurse practitioner) education and/or training on glycemic control and best-practices for managing patients with diabetes at least annually Offering nurse education and/or training on glycemic control and best-practices for managing patients with diabetes at least annually Offering pharmacy education and/or training on glycemic control and best-practices for managing patients with diabetes at least annually Using facility communication to raise awareness about inpatient glycemic control activities via email, newsletters, events, or other avenues (e.g., grand rounds) Offering patient education Active surveillance for glucose control metrics, such as hypoglycemia/hyperglycemia events or other facilitated relay of clinical data to providers Insulin orders/protocols that are standardized across units or the facility Our facility uses other approaches to promote inpatient glycemic control practices, please describe : ______________________________ Currently, our facility does not have specific activities to promote inpatient glycemic control practices Section 2c. Insulin and Hypoglycemia/Hyperglycemia Management Practices‡ *Does your facility use the following strategies to implement inpatient glycemic control and insulin management practices? (Check all that apply.) Our facility has a standardized protocol for insulin use and hyperglycemia management (including subcutaneous insulin orders) that outlines preferred insulin choices for different situations 9a. If this response is selected, please indicate how this protocol is implemented. (Check one.) The insulin use protocol is available for use, but not embedded into any standardized (e.g., admission) order sets The insulin use protocol is integrated into standardized (e.g., admission) order sets; however, providers must “opt in” The insulin use protocol is integrated into standardized (e.g., admission) order sets that requires providers to “opt out” Our facility has standardized nurse-driven protocols for monitoring for and responding to hypoglycemia events 9b. If this response is selected, please indicate where these protocols are used. (Check one.) Nurse-driven glycemic control monitoring protocols are used only in critical care units Nurse-driven glycemic control monitoring protocols are used in select medical or surgical units Nurse-driven glycemic control monitoring protocols are used in all inpatient units Nurse-driven glycemic control monitoring protocols are used elsewhere; please indicate:___________ Our facility has standardized nurse-driven protocols for monitoring for and responding to hyperglycemia events 9c. If this response is selected, please indicate where these protocols are used. (Check one.) Nurse-driven glycemic control monitoring protocols are used only in critical care units Nurse-driven glycemic control monitoring protocols are used in select medical or surgical units Nurse-driven glycemic control monitoring protocols are used in all inpatient units Nurse-driven glycemic control monitoring protocols are used elsewhere; please indicate:___________ Our facility has a standardized process/protocol to coordinate glycemic control monitoring (i.e. glucose testing, insulin administration) with meal/nutrition scheduling 9d. If this response is selected. Please indicate where these protocols are used. (Check one.) Coordinating glycemic control with nutrition is done only in critical care units Coordinating glycemic control with nutrition is done in select medical or surgical units Coordinating glycemic control with nutrition is done in all inpatient units Coordinating glycemic control with nutrition is done elsewhere; please indicate:___________________ Our facility uses a different strategy to implement inpatient glycemic control practices, please describe: ________________ Currently, our facility does not have any standardized protocols to support implementation of inpatient glycemic control practices *Does your facility use the following approaches to monitor and report inpatient glycemic control and insulin management practices? (Check all that apply.) Our facility monitors the use of standardized protocols for insulin use and hyperglycemia management for inpatients with diabetes Our facility performs active surveillance for hypoglycemia events on a daily basis to allow real-time correction of insulin use / diabetes management Our facility performs active surveillance for hyperglycemia events on a daily basis to allow real-time correction of insulin use / diabetes management Our facility performs retrospective review of hypoglycemia / hyperglycemia events on a regular (monthly or quarterly) basis to identify opportunities to improve insulin use / diabetes management Our facility reports unit-level results of glycemic control event monitoring Our facility shares feedback to providers on the glycemic control of their inpatients with diabetes Our facility uses a different approach to monitor inpatient glycemic control and insulin management practices, please describe: ________________ Currently, our facility does not monitor inpatient glycemic control and insulin management practices Section 2d. 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 have a continuous glucose monitoring (CGM) device that is being used in the course of inpatient care: (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