Pilot Test - BSI

Appendix MM2

BLOOD STREAM INFECTION SURVEY

Please read through each survey question with the following elements in mind—

1. Consistency: Question made sense, logical possible responses.

2. Navigation: Easy to move through survey, any technical difficulties.

3. Text: Easy to read.

4. Other: Comments and/or suggestions for how to improve the question (e.g., there was not an answer that fit my laboratory, too few or too many responses).

• If you have no comments on the question, please write “no comment” in the “Other” box.

• If there are more questions fields on the form than you answered, disregard them.

• Keep track of how many minutes it takes you to complete the survey (not the collection form).

Name: ________________________________________________________________

Question	Elements		Specific Observations
21 Does your hospital have an antibiotic stewardship program? Yes/No/Not Sure
Does the clinical pharmacist have the authority to change a patient's antimicrobial therapy based on new laboratory data? Yes/no
Can any of the following people change therapy? (Check all that apply.) Attending physician House Staff Infectious disease physician Hospitalist
Do you currently use a rapid method to quickly identify blood culture isolates? Yes/no
6. Which of the following do you use? (Check all that apply.) Gram stain Phenotypic test (e.g., coagulase, latex assay) Other (please specify)
Consistency		Instead of leaving blank, it might be nice to have ‘N/A- not applicable’ option (McNult comment: Not sure this makes sense b.c if responder had answered “no” in Q5, he would not be asked Q6)
If you are using PNA FISH, what organism are you testing for?
If you are using Verigene, what organism are you testing for?

How many minutes did it take you to complete the Current Practice survey (not the collection form)? _10 mins, 2 min, 6 mins, 10 mins_

OVERALL SURVEY EVALUATION	Strongly Disagree	Disagree		Neutral		Agree	Strongly Agree
(Place an “X” to indicate your level of agreement for each statement below).	1		2	3		4	5
9. The survey questions are easy to understand.						1	4
10. I was always able to find an appropriate answer to choose.				1		2	2
11. The answer choices are clearly written.						1	4
12. There were not enough choices of answers.	1		2	1		1
13. I always found the answer that fit the circumstances in my laboratory.				1		3	1
14. Overall, the length of the survey was… (circle your answer)
too short	appropriate (5)				too long
15. What did you like best about the survey (strengths, weaknesses)? It was easy to understand and got right to the point.
16. Additional thoughts/comments: -You could also ask what organisms are tested for if you chose ‘other’ for question 5. -Easy to understand, navigate & read -short concise questions

Return your completed form to Peggy McNult by email, pmcnult@asmusa.org or fax (202) 942-9353 by December 22.

Thank you for your time and input!

1 The first survey question is the “name” field.

2