Form
Approved
OMB No. 0920-0666
Exp. Date: xx/xx/20xx
www.cdc.gov/nhsn
Long Term Care Facility Component—Annual Facility Survey
Long Term Care Facility Component—Annual Facility Survey
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Facility Microbiology Laboratory Practices |
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*1. Does your facility have its own laboratory that performs microbiology/antimicrobial susceptibility testing? |
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□ Yes |
□ No |
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If No, where is your facility’s antimicrobial susceptibility testing performed? (check one) |
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□ Affiliated medical center, within same health system |
□ Medical center, contracted locally |
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□ Commercial referral laboratory |
□ Other (specify): ____________________ |
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*2. Indicate whether your facility screens new admissions for any of the following multidrug-resistant organisms (MDROs): (check all that apply) |
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□ We do not screen new admissions for MDROs |
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□ Methicillin-resistant Staphylococcus aureus (MRSA) |
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If checked, indicate the specimen types sent for screening: (check all that apply) |
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□ Nasal swabs |
□ Wound swabs |
□ Sputum |
□ Other skin site |
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□ Vancomycin-resistant Enterococcus (VRE) |
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If checked, indicate the specimen types sent for screening: (check all that apply) |
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□ Rectal swabs |
□ Wound swabs |
□ Urine |
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□ Multidrug-resistant gram-negative rods (includes carbapenemase resistant Enterobacteriaceae; multidrug- resistant Acinetobacter, etc.) |
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If checked, indicate the specimen types sent for screening: (check all that apply) |
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□ Rectal swabs |
□ Wound swabs |
□ Sputum |
□ Urine |
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*3. 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) |
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□ Enzyme immunoassay (EIA) for toxin |
□ GDH plus NAAT (2-step algorithm) |
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□ Cell cytotoxicity neutralization assay |
□ GDH plus EIA for toxin, followed by NAAT for discrepant results |
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□ Nucleic acid amplification test (NAAT) (e.g., PCR, LAMP) |
□ Toxigenic culture (C. difficile culture followed by detection of toxins) |
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□ Glutamate dehydrogenase (GDH) antigen plus EIA for toxin (2-step algorithm) |
□ Other (specify): ______________________ |
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(“Other” should not be used to name specific laboratories, reference laboratories, or the brand names of C. difficile tests; most methods can be categorized accurately by selecting from the options provided. Please ask your laboratory, refer to the Tables of Instructions for this form, or conduct a search for further guidance on selecting the correct option to report.) |
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*4. Does your laboratory provide a report summarizing the percent of antibiotic resistance seen in common organisms identified in cultures sent from your facility (often called an antibiogram)? |
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□ Yes |
□ No |
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If Yes, how often is this summary report or antibiogram provided to your facility? (check one) |
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□ Once a year |
□ Every 2 years |
□ Other (specify): ____________________ |
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Continued >> |
Long Term Care Facility Component—Annual Facility Survey
Page 3 of 4 |
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Infection Control Practices |
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*5. Total staff hours per week dedicated to infection control activity in facility: |
________ |
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a. Total hours per week performing surveillance: |
________ |
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b. Total hours per week for infection control activities other than surveillance: |
________ |
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*6. Does the facility routinely require use of gowns/gloves for care of residents infected or colonized with MRSA? (check one) |
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□ Yes, all infected and colonized residents |
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□ Yes, only residents with active infection |
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□ Yes, only those with certain characteristics that make them high-risk for transmission (e.g., wounds, diarrhea, presence of an indwelling device) |
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□ No |
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*7. Does the facility routinely require use of gowns/gloves for care of residents infected or colonized with VRE? (check one) |
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□ Yes, all infected and colonized residents |
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□ Yes, only residents with active infection |
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□ Yes, only those with certain characteristics that make them high-risk for transmission (e.g., wounds, diarrhea, presence of an indwelling device) |
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□ No |
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*8. Does the facility routinely require use of gowns/gloves for care of residents infected or colonized with CRE? (check one) |
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□ Yes, all infected and colonized residents |
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□ Yes, only all residents with active infection |
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□ Yes, only those with certain characteristics that make them high-risk for transmission (e.g., wounds, diarrhea, presence of an indwelling device) |
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□ No |
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*9. Does the facility routinely require use of gowns/gloves for care of residents infected or colonized with ESBL-producing or extended spectrum cephalosporin resistant Enterobacteriaceae in contact precautions? (check one) |
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□ Yes, all infected and colonized residents |
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□ Yes, only residents with active infection |
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□ Yes, only those with certain characteristics that make them high-risk for transmission (e.g., wounds, diarrhea, presence of an indwelling device) |
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□ No |
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*10. When a resident colonized or infected with an MDRO is transferred to another facility, does your facility communicate the resident’s MDRO status to the receiving facility at the time of transfer? |
□ Yes |
□ No |
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Continued >> |
Long Term Care Facility Component—Annual Facility Survey
Page 4 of 4 |
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Infection Control Practices (continued) |
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*11. Among residents with an MDRO admitted to your facility from other healthcare facilities, what percentage of the time does your facility receive information from the transferring facility about the resident’s MDRO status? |
_____% |
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Antibiotic Stewardship Practices |
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*12. Is there a leader responsible for the impact of activities to improve use of antibiotics at your facility? |
□ Yes |
□ No |
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If Yes, what is the position of this leader? |
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□ Medical director |
□ Director of Nursing |
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□ Consultant Pharmacist |
□ Other (please specify): _______________________ |
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*13. Does your facility have a policy that requires prescribers to document in the medical record or during order entry, a dose, duration, and indication for all antibiotics? |
□ Yes |
□ No |
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If Yes, has adherence to a documentation policy (dose, duration, and indication) been monitored? |
□ Yes |
□ No |
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*14. Does your facility provide facility-specific treatment recommendations, based on national guidelines and local susceptibility, to assist with antibiotic decision making for common clinical conditions? |
□ Yes |
□ No |
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If Yes, has adherence to facility-specific treatment recommendations been monitored? |
□ Yes |
□ No |
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*15. Is there a formal procedure for performing a follow-up assessment 2-3 days after a new antibiotic start to determine whether the antibiotic is still indicated and appropriate (e.g. antibiotic time out)? |
□ Yes |
□ No |
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*16. Does a physician or pharmacist review courses of therapy for specified antibiotic agents and communicate results with prescribers (i.e., audit with feedback) at your facility? |
□ Yes |
□ No |
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*17. Does the pharmacy service provide a monthly report of antibiotic use (e.g., new orders, number of days of antibiotic treatment) for the facility? |
□ Yes |
□ No |
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*18. Has your facility provided education to clinicians and other relevant staff on improving antibiotic use in the past 12 months? |
□ Yes |
□ No |
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Electronic Health Record Utilization |
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*19. Indicate whether any of the following are available in an electronic health record (check all that apply): |
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□ Microbiology lab culture and antimicrobial susceptibility results |
□ Medication orders |
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□ Medication administration record |
□ Resident vital signs |
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□ Resident admission notes |
□ Resident progress notes |
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□ Resident transfer or discharge notes |
□ None of the above |
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Amy Schneider |
File Modified | 0000-00-00 |
File Created | 2021-01-27 |