Draft AQUA form 2

HAI & ANTIMICROBIAL USE PREVALENCE SURVEY
ANTIMICROBIAL QUALITY ASSESSMENT (AQUA) FORM 2: GENERAL PATIENT ASSESSMENT
CDC ID:

-

/

Date:

/

Data collector initials: _____

Healthcare exposures
1. Indicate the location from which the patient was admitted to the survey hospital (check one):
Private residence
Long term care/SNF
LTACH
Another acute care hospital
Homeless
Other _________________________
Unknown

Incarcerated

2. In the 30 days prior to admission to the survey hospital, did the patient receive (check all that apply):
IV antimicrobials
Cancer chemotherapy
Wound care
Chronic hemodialysis
Surgery
None
Unknown
3. Was the patient hospitalized in an acute care hospital for ≥2 days in the 90 days prior to this admission?
Yes
No
Unknown
Antimicrobial allergies
4. Is an antimicrobial drug allergy recorded in the medical record?
Yes
No
4a. If yes, specify drug class or classes to which patient is allergic, and reaction(s):
Drug class

Nausea,
vomiting
and/or
diarrhea

Hives or
urticaria

Other
skin
rash

Wheezing,
throat
tightness,
trouble
breathing

Angioedema
or face
swelling

Anaphylaxis

Unknown

Not
specified

Other (specify)

Penicillins

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Cephalosporins

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Sulfa drugs

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Macrolides

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Fluoroquinolones

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Vancomycin

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes____________

Other (specify):
________________

Underlying conditions
5. Check all that apply:

None:

Unknown:

AIDS
Alcoholism in past year
Asplenia
Asthma
Cerebrovascular disease/stroke (except hemiplegia)
Chronic cognitive deficit
Chronic kidney disease
Chronic liver disease
Chronic obstructive pulmonary disease (COPD)/emphysema
Chronic lung disease (other than COPD/emphysema, asthma)
Chronic steroid or other immunosuppressive therapy
Congenital urinary tract abnormality (not VUR)
Congenital heart disease
Congestive heart failure
Connective tissue disease
Cystic fibrosis
Dementia
Diabetes mellitus with complications
Diabetes mellitus without complications
Hemiplegia
HIV without AIDS
IVDU in past year

AQUA General Patient Assessment_20150331

Kidney stones/nephrolithiasis
Leukemia
Lymphoma or multiple myeloma
MRSA colonization or infection history
Myocardial infarction
Neutropenia (absolute neutrophil count <500 cells / µL)
Peptic ulcer disease
Peripheral vascular disease
Pregnancy
Recurrent cystitis or urinary tract infection
Sickle cell disease
Smoking in home or living environment (other than patient)
Smoking in past year (patient)
Solid tumor malignancy, metastatic (not urologic/renal)
Solid tumor malignancy, not metastatic (not urologic/renal)
Spinal cord injury or paraplegia or quadriplegia
Transplant, hematopoietic stem cell or bone marrow
Transplant, solid organ
Ureteral stent
Urinary tract abnormality, not otherwise specified
Urostomy or nephrostomy
Urologic or renal malignancy
Vesicoureteral reflux (VUR)

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CDCID:

Infections present during the hospitalization
6. Complete table:
No.

Infection
(code)

Before hospitalization
Hospital days 1-2
On/after hosp day 3
In hospital, day unk
Unknown
Before hospitalization
Hospital days 1-2
On/after hosp day 3
In hospital, day unk
Unknown
Before hospitalization
Hospital days 1-2
On/after hosp day 3
In hospital, day unk
Unknown
Before hospitalization
Hospital days 1-2
On/after hosp day 3
In hospital, day unk
Unknown

1
Y

________
2
SSI?

Y

________
3
SSI?

Y

________
4
SSI?

Y

Was infection
treated with
antimicrobials?

Signs and symptoms documented in medical record
(check all that apply)

Onset date

________
SSI?

No infections:

Cough or dyspnea
Diarrhea
Fever
Hypotension
Unknown
Cough or dyspnea
Diarrhea
Fever
Hypotension
Unknown
Cough or dyspnea
Diarrhea
Fever
Hypotension
Unknown
Cough or dyspnea
Diarrhea
Fever
Hypotension
Unknown

Mental status change
Nausea or vomiting
Pain at infection site
Positive imaging
None
Mental status change
Nausea or vomiting
Pain at infection site
Positive imaging
None
Mental status change
Nausea or vomiting
Pain at infection site
Positive imaging
None
Mental status change
Nausea or vomiting
Pain at infection site
Positive imaging
None

Pus, drainage, abscess
Redness or swelling
Urinary frequency
Urinary urgency
Other____________
Pus, drainage, abscess
Redness or swelling
Urinary frequency
Urinary urgency
Other____________
Pus, drainage, abscess
Redness or swelling
Urinary frequency
Urinary urgency
Other____________
Pus, drainage, abscess
Redness or swelling
Urinary frequency
Urinary urgency
Other____________

Yes
No
Unknown

Yes
No
Unknown

Yes
No
Unknown

Yes
No
Unknown

More infections than fit in the table:
Infection codes: BJI, BSI, CDI, CNS, CVI, DIS, ENT, GTI, HEB, IAB, LRI, PNE, REP, SST, UND, UNK, UTI

Severity of illness
7. Was the patient in an ICU at any time during the hospitalization? Yes
No
Unknown
7a. If yes, enter the dates of the first ICU admission during the hospitalization:
ICU admission date: ____ / ____ /____ or Unknown
ICU discharge date: ____ / ____ /____ or

Unknown

8. Complete the table using data from the first 24-hour period of treatment during the hospitalization:
First day, CAP treatment:

First day, IV vancomycin:

First day, fluoroquinolone:

____ / ____ / ____ or

____ / ____ / ____ or

First day, UTI treatment

Parameter
____ / ____ / ____ or

NA

NA

NA

____ / ____ / ____ or

NA

Temperature:
Highest:

____

°C

°F or

Unk

____

°C

°F or

Unk

____

°C

°F or

Unk

____

°C

°F or

Unk

Lowest:

____

°C

°F or

Unk

____

°C

°F or

Unk

____

°C

°F or

Unk

____

°C

°F or

Unk

Heart rate:
Highest:

____ bpm or

Unk

____ bpm or

Unk

____ bpm or

Unk

____ bpm or

Unk

Lowest:

____ bpm or

Unk

____ bpm or

Unk

____ bpm or

Unk

____ bpm or

Unk

____ bpm or

Unk

____ bpm or

Unk

____ bpm or

Unk

____ bpm or

Unk

Respiratory:
Highest resp rate:
Lowest PaCO2:
Mechanical vent:

____ mmHg or
Yes

No

Unk
Unk

____ mmHg or
Yes

No

Unk
Unk

____ mmHg or
Yes

No

Unk
Unk

____ mmHg or
Yes

No

Unk
Unk

WBC count:
Highest:
Lowest:
Highest %bands:
Blood pressure:
Lowest systolic
BP:
Lowest mean
arterial pressure:
On vasopressors:
Lactate

________ cells/mm3
or Unk
________ cells/mm3
or Unk
____ % or
Unk

________ cells/mm3
or Unk
________ cells/mm3
or Unk
____ % or
Unk

________ cells/mm3
or Unk
________ cells/mm3
or Unk
____ % or
Unk

________ cells/mm3
or Unk
________ cells/mm3
or Unk
____ % or
Unk

____ mmHg or

Unk

____ mmHg or

Unk

____ mmHg or

Unk

____ mmHg or

Unk

____ mmHg or

Unk

____ mmHg or

Unk

____ mmHg or

Unk

____ mmHg or

Unk

Yes
______

No
mg/dL
or Unk

Unk
mmol/L

Yes
______

No
mg/dL
or Unk

Unk
mmol/L

Yes
______

No
mg/dL
or Unk

Unk
mmol/L

Yes
______

No
mg/dL
or Unk

Unk
mmol/L

***FORM IS COMPLETE***  Go to AQUA Forms 3a-3d
AQUA General Patient Assessment_20150331

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