Form CDC 57.127 CDC 57.127 MDRO and CDI Prevention Process and Outcome Measures Mon

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

MDRO and CDI Prevention Process and Outcome

Measures Monthly Reporting

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*required for saving

**conditionally required based upon monitoring selection in Monthly Reporting Plan

Facility ID #: _________

*Month: __________

*Year: _________

*Location Code: ______________________

Setting: Inpatient **Total Facility Patient Days: _____________

**Total Facility Admissions: ________________

Setting: Outpatient Total Facility Encounters: ___________________

If monitoring MDRO FACWIDE, then subtract all counts from patient care units with separate CCNs (IRF and IPF) from Totals:

**MDRO Patient Days: ________

**MDRO Admissions: _________

**MDRO Encounters: _________

If monitoring C. difficile FACWIDE, then subtract all counts from patient care units with separate CCNs (IRF and IPF) as well as NICU & Well Baby counts from Totals:

**CDI Patient Days: ________

**CDI Admissions: _________

**CDI Encounters: _________

**For this quarter, 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)

□ Enzyme immunoassay (EIA) for toxin

□ GDH plus NAAT (2-step algorithm)

□ Cell cytotoxicity neutralization assay

□ GDH plus EIA for toxin, followed by NAAT for discrepant results

□ Nucleic acid amplification test (NAAT) (e.g., PCR, LAMP)

□ Toxigenic culture (C. difficile culture followed by detection of toxins)

□ Glutamate dehydrogenase (GDH) antigen plus EIA for toxin (2-step algorithm)

□ Other (specify): ______________________

(“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 or conduct a search for further guidance on selecting the correct option to report.)

MDRO & CDI Infection Surveillance or LabID Event Reporting

Specific Organism Type

MRSA

VRE

CephR-Klebsiella

CRE- E. coli

CRE-Enterobacter

CRE-Klebsiella

MDR-Acinetobacter

C. difficile

Infection Surveillance

LabID Event (All specimens)

LabID Event (Blood specimens only)

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 15 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 57. 127 (Front) Rev. 6, v8.3

MDRO and CDI Prevention Process and Outcome

Measures Monthly Reporting

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Process Measures (Optional)

Hand Hygiene

Gown and Gloves

**Performed: ________

**Indicated: __________

**Used: __________

**Indicated: __________

Active Surveillance Testing (AST)

**Active Surveillance Testing performed

**Timing of AST † (circle one)

Adm Both

Adm Both

**AST Eligible Patients ‡ (circle one)

All NHx

All NHx

Admission AST

**Performed

**Eligible

Discharge/Transfer AST

**Performed

**Eligible

Outcome Measures (Optional)

Prevalent Cases

(Specific Organism Type)

MRSA

VRE

**AST/Clinical Positive

**Known Positive

Incident Cases

**AST/Clinical Positive

Custom Fields

Label

_______________

_______________

_______________

_______________

_______________

Data

_______________

_______________

_______________

_______________

_______________

† Adm – Admission testing Both – Admission and Discharge/Transfer testing ‡ All – All patients tested NHx – Only patients tested are those who have no documentation at the admitting facility in the previous 12 months of MDRO-colonization or infection at the time of admission.