# Presentation: 527425

## Patient Safety Component –Annual Facility Survey 

| * required for saving |  Tracking #: |
| --- | --- |
|  Facility ID: | *Survey Year: |
| Facility Characteristics |  |
| *Ownership (check one):      
□ For profit         □ Not for profit, including church                 □ Government 
□ Military               □ Veteran’s Affairs                                     □ Physician owned             □ Managed Care Organization |  |
| If facility is a Hospital:
*Number of Patient Days: _________
*Number of Admissions:  _________ |  |
| For any Hospital except Long Term Acute Care Hospitals: |  |
| *Is your hospital affiliated with a medical school? :     Yes	No |  |
|              If Yes, what type of affiliation:        ____ MAJOR         ____ GRADUATE           ____ LIMITED |  |
| Number of beds set up and staffed:
          a. ICU beds (including adult, pediatric, and
              neonatal levels II/III and III):                                         ___________
          b. Specialty care beds (including hematology/oncology,
              bone marrow transplant, solid organ transplant, 
              inpatient dialysis, and long term acute care [LTAC]):         ___________
          c. All other beds:                                                                ___________ |  |
| For Hospitals that are Long Term Acute Care (LTAC):
Setting: ___ Within a hospital         ___ Free-standing
Number of beds set up and staffed:
          a. Ventilator beds:                                                              ___________
          b. High-observation beds:                                                   ___________
          c. All other beds:                                                                ___________ |  |
| If facility is an Ambulatory Surgery Center:
Setting: ___ Within a hospital        ___ Free-standing
Total number of procedures: ________       Percent of procedures that are surgical: ________ %
What percentage of your ambulatory surgery patients were discharged or transferred to the following places: 
Home/Customary residence:                                 _______%
Recovery care center (facility other than this one): _______ %
Acute care hospital (Emergency or inpatient):        _______ % |  |
| If facility is a Long Term Care (LTC) Facility: 
Number of resident days: ______                        Average length of stay: ___________ |  |
| Infection Control Practices
*Number of infection control professionals (ICPs) in facility:              __________
           a. Total hours per week performing surveillance:                   __________
           b. Total hours per week for infection control activities
               other than surveillance:                                                   __________                            Continued  >> |  |
| Assurance of Confidentiality:  The 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 30 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 57.103 (Front)  Rev.2, v1.3.5 |  |

**Patient Safety Component** –**Annual** **Facility Survey **

- Page 1 of 2

- OMB No. 0920-0666
- Exp. Date:  03-31-2011

## Patient Safety Component - Annual Facility Survey 

| Facility Microbiology Laboratory Practices |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- |
| *1.	Does your facility have its own laboratory that performs antimicrobial susceptibility testing?     
            □ Yes	      □ No
If No, where is your facility's antimicrobial susceptibility testing performed (check one)?
	 □ Affiliated medical center of hospital	 □ Commercial referral laboratory
*2.	Does the laboratory use CLSI (formerly NCCLS) antimicrobial susceptibility standards? 
            □ Yes     □ No
If Yes, specify what version of the M100 document the laboratory uses? ____________________
*3.	For the following organisms please indicate which methods are used for: (1) primary susceptibility testing and(2) secondary, supplemental, or confirmatory testing (if performed). If your laboratory does not perform susceptibility testing, please indicate the methods used at the referral laboratory. Please use the testing codes listed below the table. |  |  |  |  |  |
| Pathogen |  |  Primary | (2) Secondary |  | Comments |
| Coagulase-negative staphylococci
Staphylococcus aureus
Enterococcus spp.                                         
Escherichia coli                                    	
Klebsiella pneumoniae or K. oxytoca
Serratia marcescens
Enterobacter spp. 	
Pseudomonas aeruginosa
Acinetobacter spp. 
Stenotrophomonas maltophilia |  |  |  |  |  |
| 1 = Kirby-Bauer disk diffusion
2 = Vitek
2.1 = Vitek 2
3 = Sceptor
3.1 = BD Phoenix
4 = Sensititre | 5.1 = MicroScan walkaway rapid 
5.2= MicroScan walkaway conventional
5.3 = MicroScan auto or touchscan
6 = Other micro-broth dilution method
7 = Agar dilution method
8 = Pasco |  |  | 9 = Micromedia
10 = Etest
11 = Oxacillin screen (MHA + salt)
12 = Vancomycin agar screen(BHI + vancomycin)
13 = Other (describe in Comments column) |  |
| *4.	Are staphylococci that test as vancomycin resistant repeated using the same method? □ Yes     □ No
*5.       Does the laboratory confirm vancomycin resistant staphylococci using a second method? □ Yes     □ No
              If Yes, please check all methods performed either in your lab or at a referral laboratory:
              □ Disk diffusion      □ Etest      □ Vancomycin agar screen plate
            □ Other, please indicate using method codes in Question 3 above: ____________________
*6.	Does the laboratory do either screening or confirmatory testing for extended spectrum ß-lactamase (ESBL) production according to CLSI?	 □ Yes    □ No
*7.	If ESBL production is suspected how does the laboratory report the results to the clinician? □ Change susceptible and intermediate interpretations for third generation cephalosporins and aztreonam to resistant
              □ Suppress the results for third generation cephalosporins and aztreonam for the report
	 □ No changes are made in the interpretations reported to clinicians |  |  |  |  |  |

**Patient Safety Component - Annual Facility Survey **

- Page 2 of 2

- CDC 57.103 (Back) Rev. 2

- OMB No. 0920-0666
- Exp. Date:  03-31-2011