Form 57.75LL Multi-drug Resistant Organism (MDRO) Prevention Process

* required for saving  **conditionally required based upon monitoring selection in Monthly Reporting Plan *Facility ID #: ____________    *Month:_______  *Year:________  *Location Code:_______
*Patient Days:_____               ** Admissions:_____
MDRO Infection Surveillance (Required)
(Specify)	MRSA	VRE	C. difficile	Klebsiella spp. ( ______ )	Acineto-bacter spp. ( ______ )	Candida spp. ( ______ )
MDRO Infections being monitored (check all that apply)						
Process Measures (Optional)
Hand Hygiene ** Performed:_____ ** Indicated:_____			Gown and Gloves ** Used:_____ ** Indicated:_____
Active Surveillance Culturing (ASC)
**Active surveillance cultures performed (check all that apply)						
**Timing of ASC † (circle one)	Adm Both	Adm Both		Adm   Both	Adm Both	Adm   Both
**Patients - ASC eligible ‡ (circle one)	All NHx	All NHx		All NHx	All NHx	All NHx
Admission ASC
** Performed
** Eligible
Discharge/Transfer ASC
** Performed
** Eligible

 

Outcome Measures (Optional)
Prevalent Cases
(Specify)	MRSA	VRE	C. difficile	Klebsiella spp. ( ______ )	Acineto-bacter spp. ( ______ )	Candida spp. ( ______ )
** ASC/clinical positive
** Known positive
Incident Cases:
** ASC/clinical positive
Numeric Fields Label: ___________________________     ___________ ___________________________     ___________ ___________________________     ___________ ___________________________     ___________ ___________________________     ___________ ___________________________     ___________ ___________________________     ___________ ___________________________     ___________ ___________________________     ___________ ___________________________     ___________ ___________________________     ___________ ___________________________     ___________ ___________________________     ___________ ___________________________     ___________ ___________________________     ___________			Alphanumeric Fields Label: ________________________      _____________ ________________________      _____________ ________________________      _____________ ________________________      _____________ ________________________      _____________

 

File Type	application/vnd.ms-powerpoint
File Title	Slide 1
Author	Jasie L. Jackson
Last Modified By	rfp9
File Modified	2007-07-26
File Created	2006-12-04