Form CDC 57.103 CDC 57.103 Annual Hospital Survey - Patient Safety Component

Form Approved

OMB No. 0920-0666

Exp. Date: 11/30/2021

www.cdc.gov/nhsn

Patient Safety Component—Annual Hospital Survey
Instructions for this form are available at: http://www.cdc.gov/nhsn/forms/instr/57_103-TOI.pdf
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*required for saving				Tracking #:
Facility ID:				*Survey Year:
Facility Characteristics (completed by Infection Preventionist)
*Ownership (check one):
□ For profit		□ Not for profit, including church			□ Government
□ Military		□ Veterans Affairs			□ Physician owned
If facility is a Hospital:
*Number of patient days: _________
*Number of admissions: __________
For any Hospital:
*Is your hospital a teaching hospital for physicians and/or physicians-in-training?						□ Yes	□ No
If Yes, what type:		□ Major		□ Graduate		□ Undergraduate
*Number of beds set up and staffed in the following location types (as defined by NHSN):
ICU (including adult, pediatric, and neonatal levels II/III and III):					__________________________
b. All other inpatient locations:					__________________________
Facility Microbiology Laboratory Practices (completed with input from Microbiology Laboratory Lead)
*1. Does your facility have its own on-site laboratory that performs bacterial antimicrobial susceptibility testing?						□ Yes	□ No
If No, where is your facility’s antimicrobial susceptibility testing performed? (check one)
□ Affiliated medical center
□ Commercial referral laboratory
□ Other local/regional, non-affiliated reference laboratory
						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 75 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. 11, v9.2



Patient Safety Component—Annual Hospital Survey
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Facility Microbiology Laboratory Practices (continued)
*2. 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 outside laboratory.
Please use the testing codes listed below the table.
Pathogen		(1) Primary		(2) Secondary		Comments
Staphylococcus aureus		_______________		______________		______________
Enterobacteriaceae		_______________		______________		______________
1 = Kirby-Bauer disk diffusion		5.1 = MicroScan WalkAway			10 = E test
2 = Vitek (Legacy)		5.2 = MicroScan autoSCAN			12 = Vancomycin agar screen (BHI + vancomycin)
2.1 = Vitek 2		6 = Other broth micro dilution method			13 = Other (describe in Comments section)
3.1 = BD Phoenix		7 = Agar dilution method
4 = Sensititre
*3. Has the laboratory implemented the revised cephalosporin and monobactam breakpoints for Enterobacteriaceae recommended by CLSI as of 2010?						□ Yes	□ No
*4. Has the laboratory implemented the revised carbapenem breakpoints for Enterobacteriaceae recommended by CLSI as of 2010?						□ Yes	□ No
*5. Does the laboratory perform a test for presence of carbapenemase? (this does not include automated testing instrument expert rules)						□ Yes	□ No
If Yes, please indicate what is done if carbapenemase production is detected: (check one)
□ Change susceptible carbapenem results to resistant
□ Report carbapenem MIC results without an interpretation
□ No changes are made in the interpretation of carbapenems, the test is used for epidemiological or infection control practices
If Yes, which test is routinely performed to detect carbapenemase: (check all that apply)
□ PCR			□MBL Screen
□ Modified Hodge Test			□ Carba NP
□ mCIM/CIM			□ Rapid CARB Blue
□ E test			□ Other (specify): _________________
□ Cepheid, BioFire array, Verigene®
If Yes, does the laboratory have a policy to routinely notify any of the following when CP-CRE are detected?
Physician	□ Yes	□ No
Infection Control	□ Yes	□ No





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Facility Microbiology Laboratory Practices (continued)
*6. Does the laboratory perform colistin or polymyxin B susceptibility testing for drug-resistant Gram-negative bacilli?						□ Yes	□ No
If Yes, please indicate methods: (check all that apply; answers listed are generic antimicrobial susceptibility testing methods and do not imply they are recommended for use in polymyxin susceptibility testing)
□ Vitek 2	□ MicroScan autoSCAN			□ Kirby-Bauer disk diffusion
□ BD Phoenix	□ Other broth microdilution method			□ Accelerate Pheno
□ Sensititre	□ Agar dilution method			□ Other (specify): _____________________
□ MicroScan WalkAway	□ E test
7*. Which of the following methods are used for yeast identification at your facility’s laboratory or at the outside laboratory serving your facility? (check all that apply)
□ MALDI-TOF MS System (Vitek MS)
□ MALDI-TOF MS System (Bruker Biotyper)
□ Vitek-2
□ BD Phoenix
□ MicroScan
□ Non-automated Manual Kit (e.g., API 20C, RapID, Germ Tube, PNA-FISH, etc.)
□ DNA sequencing
□ Other (specify) ______________________
8*. Candida isolated from which of the following body sites are usually fully identified to the species level? (check all that apply)
□ Blood
□ Other normally sterile body site (e.g.: CSF)
□ Urine
□ Respiratory
□ Other (specify) ______________________
□ None are fully identified to the species level
9*. What method is used for antifungal susceptibility testing (AFST) at your facility’s laboratory or the outside laboratory serving your facility? (check all that apply)
□ Broth microdilution	□ YeastOne colorimetric microdilution			□ E test		□ Vitek 2 card
□ Disk diffusion	□ Other (specify): ________________
Continued >>



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*10. Antifungal susceptibility testing is performed on fungal isolates in which of the following situations:
Candida albicans:
□ Always □ Only when isolated from sterile sites (eg: blood, CSF, etc) □ Only when ordered by a clinician; □ Other (specify):_________
Candida glabrata:
□ Always □ Only when isolated from sterile sites (eg: blood, CSF, etc) □ Only when ordered by a clinician; □ Other (specify):_________
All other Candida species:
□ Always □ Only when isolated from sterile sites (eg: blood, CSF, etc) □ Only when ordered by a clinician; □ Other (specify):_________
Facility Microbiology Laboratory Practices (continued)
*11. 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
□ Cell cytotoxicity neutralization assay
□ Nucleic acid amplification test (NAAT) (e.g., PCR, LAMP)
□ NAAT plus EIA, if NAAT positive (2-step algorithm)
□ Glutamate dehydrogenase (GDH) antigen plus EIA for toxin (2-step algorithm)
□ GDH plus NAAT (2-step algorithm)
□ GDH plus EIA for toxin, followed by NAAT for discrepant results
□ Toxigenic culture (C. difficile culture followed by detection of toxins)
*12. Please indicate the primary and definitive method used to identify microbes from blood cultures collected in your facility.  (SELECT ONE ANSWER)
□ MALDI-TOF MS System (Vitek MS)
□ MALDI-TOF MS System (Bruker Biotyper)
□ Automated Instrument (e.g., Vitek, MicroScan, Phoenix, OmniLog, Sherlock, etc.)
□ Non-automated Manual Kit (e.g., API, Crystal, RapID, etc.)
□ Rapid Identification (e.g., Verigene, BioFire FilmArray, PNA-FISH, Gene Xpert, etc.)
□16S rRNA Sequencing
*13. Please indicate any additional secondary methods used for microbe identification from blood cultures collected in your facility (e.g., a rapid method that is confirmed with the primary method, a secondary method if the primary method fails to give an identification, or a method that is used in conjunction with the primary method).  (SELECT ALL THAT APPLY)
□ MALDI-TOF MS System (Vitek MS)
□ MALDI-TOF MS System (Bruker Biotyper)
□ Automated Instrument (e.g., Vitek, MicroScan, Phoenix, OmniLog, Sherlock, etc.)
□ Non-automated Manual Kit (e.g., API, Crystal, RapID, etc.)
□ Rapid Identification (e.g., Verigene, BioFire FilmArray, PNA-FISH, Gene Xpert, etc.)
□16S rRNA Sequencing

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Infection Control Practices
(completed with input from Hospital Epidemiologist and/or Quality Improvement Coordinator)
*14. Number or fraction of infection preventionists (IPs) in facility:
a. Total hours per week performing surveillance:					________________________
b. Total hours per week for infection control activities other than surveillance:					________________________
*15. Number or fraction of full-time employees (FTEs) for a designated hospital epidemiologist (or equivalent role) affiliated with your facility:					________________________
Infection Control Practices
(completed with input from Hospital Epidemiologist and/or Quality Improvement Coordinator)
*16. Is it a policy in your facility that patients infected or colonized with MRSA are routinely placed in contact precautions while these patients are in your facility? (check one)
□ Yes, all infected or colonized patients
□ No
□ Not applicable: my facility never admits these patients
If Yes, please check the type of patients that are routinely placed in contact precautions while I your facility (check one):
□ All infected or colonized patients
□ Only all infected patients
□ Only infected or colonized patients with certain characteristics (check all that apply)
□Patients admitted to high risk settings
□Patients at high risk for transmission
*17. Is it a policy in your facility that patients infected or colonized with VRE are routinely placed in contact precautions while these patients are in your facility? (check one)
□ Yes, all infected or colonized patients
□ No
□ Not applicable: my facility never admits these patients
If Yes, please check the type of patients that are routinely placed in contact precautions while I your facility (check one):
□ All infected or colonized patients
□ Only all infected patients
□ Only infected or colonized patients with certain characteristics (check all that apply)
□Patients admitted to high risk settings
□Patients at high risk for transmission



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*18. Is it a policy in your facility that patients infected or colonized with CRE (regardless of confirmatory testing for carbapenemase production) are routinely placed in contact precautions while these patients are in your facility? (check one)
□ Yes, all infected or colonized patients
□ No
□ Not applicable: my facility never admits these patients
If Yes, please check the type of patients that are routinely placed in contact precautions while I your facility (check one):
□ All infected or colonized patients
□ Only all infected patients
□ Only infected or colonized patients with certain characteristics (check all that apply)
□Patients admitted to high risk settings
□Patients at high risk for transmission
*19. Is it a policy in your facility that patients infected or colonized with suspected or confirmed ESBL-producing or extended spectrum cephalosporin resistant Enterobacteriaceae are routinely placed in contact precautions while these patients are in your facility? (check one)
□ Yes, all infected or colonized patients
□ No
□ Not applicable: my facility never admits these patients
If Yes, please check the type of patients that are routinely placed in contact precautions while I your facility (check one):
□ All infected or colonized patients
□ Only all infected patients
□ Only infected or colonized patients with certain characteristics (check all that apply)
□ Patients admitted to high risk settings
□ Patients at high risk for transmission
Infection Control Practices
(completed with input from Hospital Epidemiologist and/or Quality Improvement Coordinator)
*20. Does the facility routinely perform screening testing (culture or non-culture) for CRE?
						□ Yes	□ No
If Yes, in which situations does the facility routinely perform screening testing for CRE? (check all that apply)
□ Surveillance testing at admission for all patients
□ Surveillance testing of epidemiologically-linked patients of newly identified CRE patients (e.g., roommates)
□ Surveillance testing at admission of high-risk patients (e.g., admitted from LTAC or LTCF)
□ Surveillance testing at admission of patients admitted to high-risk settings (e.g. ICU)
□ Other (please specify): _________________



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*21. Does the facility routinely perform screening testing (culture or non-culture) for MRSA for any patients admitted to non-NICU settings?

□ Yes

□ No

If yes, in which situations does the facility routinely perform screening testing for MRSA for non-NICU settings? (check all that apply)

□ Surveillance testing at admission for all patients

□ Surveillance testing at admission of high-risk patients (e.g., admitted from LTAC or LTCF)

□ Surveillance testing at admission of patients admitted to high-risk settings (e.g. ICU)

□ Surveillance testing of pre-operative patients to prevent surgical site infections

□ Other (please specify): _________________

 

 

*22.Does the facility routinely perform screening testing (culture or non-culture) for MRSA for any patients admitted to NICU settings?

□ Yes

□ No

If yes, in which situations does the facility routinely perform screening testing for MRSA for NICU settings? (check all that apply)

□ Surveillance testing at admission for all transferred patients

□ Surveillance testing of patients from known MRSA positive mothers

□ Surveillance testing of high-risk patients (e.g. infants born premature)

□ Routine active surveillance testing (i.e., point prevalence surveys)

□ Other (please specify): _________________

 

 

*23. Does the facility routinely use chlorhexidine bathing on any patient to prevent infection or transmission of MDROs at your facility? (Note: this does not include the use of such bathing in pre-operative patients to prevent SSIs)

□ Yes

□ No

*24. Does the facility routinely use a combination of topical chlorhexidine AND intranasal mupirocin (or equivalent agent) on any patients to prevent infection or transmission of MRSA at your facility? (Note: this does not include the use of these agents in pre-operative surgical patients or dialysis patients)

□ Yes

□ No

 

 

Facility Neonatal or Newborn Patient Care Practices and Admissions Information

*25. Was this section completed in collaboration with your facility’s neonatal or newborn patient care team For example,was input sought from a neonatal or newborn patient care team member, such as a NICU Medical Director, Lead Neonatal Physician, Neonatal Nurse Manager, Lead Neonatal Nurse Practitioner?

□ Yes

□ No

□ N/A, my facility does not provide neonatal or newborn patient care services at any level (i.e., my facility does not provide delivery services. Level 1 well newborn care, Level II special care, or neonatal intensive care)

 

 

If N/A was selected in question 25 above, questions 26-30 below do not apply to your facility and should be skipped. If your facility does care for neonates or newborns (at any level), please complete questions below.

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Questions should be answered based on the policies and practices that were in place for the majority of the last full calendar year.

*26. Excluding Level I units (well newborn nurseries), record the number of neonatal admissions to Special Care Nurseries (Level II) and Intensive Care Units (Level II/III, Level III, Level IV):

a.     Inborn Admissions: _____________________

b. Outborn Admissions: _____________________

 

 

*27. Excluding Level I units (well newborn nurseries), record the number of neonatal admissions (both inborn and outborn) to Special Care (Level II) and Intensive Care (Level II/III, Level III, Level IV) in each of following birth weight categories:

a.     Less than or equal to 750 grams: ____________________

b.     751-1000 grams: ____________________

c.     1001-1500 grams: ____________________

d.     1501-2500 grams: ____________________

e.     More than 2500 grams: ____________________

 

 

*28. Does your facility provide Level III (or higher) neonatal intensive care as defined by the American Academy of Pediatrics (e.g. capable of providing sustained life support, comprehensive care for infants born <32 weeks gestation and weighing <1500 grams, a full range of respiratory support that may include conventional and/or high-frequency ventilation)?

□ Yes □ No

*29. Does your facility accept neonates as transfers for any of the following procedures: Omphalocele repair; ventriculoperitoneal shunt; tracheoesophageal fistula (TEF)/esophageal atresia repair; bowel resection/reanastomosis; meningomyelocele repair; cardiac catheterization.

□ Yes

□ No

To help us better understand your facility’s practices and protocols for administering antimicrobials to newborns, please answer the following questions:

*30. If babies are roomed with their mother in a labor and delivery or postpartum ward and are administered oral or parenteral antimicrobials, such as ampicillin, what location is the medication administration attributed to in the electronic medication administration record (eMAR) system and/or bar code medication administration (BCMA) system?

Please ask your clinical pharmacist to review the eMAR system and/or BCMA system to determine this and select all that apply:

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□ a. Level I Well Newborn Nursery

□ b. Labor and Delivery Ward, Postpartum Ward, or Labor, Delivery, Recovery, Postpartum Suite

□ c. N/A my facility does not provide delivery services

□ d. N/A my facility requires that babies receiving antimicrobials intravenously (IV) are transferred out of their mother’s room in order for IV antimicrobials to be administered (babies receiving oral or intramuscular antimicrobials may remain in their mother’s room for antimicrobial administration)

□ e. N/A my facility requires that babies receiving oral and/or parenteral (including IV) antimicrobials are transferred out of their mother’s room in order for antimicrobials to be administered

If answer choice d. or e. was selected above, to which neonatal unit would a baby be transferred in order to receive oral or parenteral antimicrobials (select all that apply):

□ Level I Well Newborn Nursery separate from the mother’s room

□ Level II Special Care Nursery

□ Level II/III or higher Neonatal Intensive Care Unit

Antibiotic Stewardship Practices

(completed with input from Physician and Pharmacist Stewardship Champions )

31*. Our facility has a formal statement of support for antibiotic stewardship (e.g., a written policy or statement approved by the board).

 

□ Yes

□ No

32*. Facility leadership has demonstrated a commitment to antibiotic stewardship efforts by: (Check all that apply.)

  Communicating to staff about stewardship activities, via email, newsletters, events, or other avenues.

  Providing opportunities for staff training and development on antibiotic stewardship.

  Allocating information technology resources to support antibiotic stewardship efforts.

  None of the above

33*. Our facility has a committee responsible for antibiotic stewardship.

□ Yes

□ No

If Yes, membership in our facility’s antibiotic stewardship committee includes: (Check all that apply.)

  Non-infectious diseases trained prescriber(s)

  Infectious disease physician(s)

  Pharmacist(s)

  Nurse(s)

  Infection preventionist(s)

  Microbiologist(s)

  Information technologist(s)

  A patient representative

  None of the Above

34*. Our facility has a leader (or co-leaders) responsible for antibiotic stewardship outcomes.

□ Yes

□ No

If Yes, what is the position of this leader? (Check one.)

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  Physician  

  Pharmacist  

  Co-led by both Pharmacist and Physician

  Other (please specify):________________

If Physician or Co-led is selected, which of the following describes your antibiotic stewardship physician leader? (Check all that apply.)

  Has antibiotic stewardship responsibilities in their contract or job description

  Is physically on-site in your facility (either part-time or full-time)

  Completed an ID fellowship

  Completed a certificate program or other coursework

  None of the above

If Pharmacist or Co-led is selected, which of the following describes your antibiotic stewardship pharmacist leader? (Check all that apply.)

  Has antibiotic stewardship responsibilities in their contract or job description

  Is physically on-site in your facility (either part-time or full-time)

  Completed a PGY2 ID residency and/or ID fellowship

  Completed a certificate program or other coursework

  None of the above

If Physician or Other, is there at least one pharmacist responsible for improving antibiotic use at your facility?

□ Yes

□ No

35*. Our facility has a policy or formal procedure for: (Check all that apply.)

  Required documentation of indication for antibiotic orders.

If selected: Our stewardship team audits antibiotic orders to review appropriateness indications.

□ Yes

□ No

  Required documentation of duration for antibiotic orders.

  The treating team to review antibiotics 48-72 hours after initial order (i.e., antibiotic time-out).

  The stewardship team to review courses of therapy for specific antibiotic agents and provide real-time feedback and recommendations to the treating team (i.e., prospective audit and feedback).

If selected: For which categories of antimicrobials? (Check all that apply.)

  Cefepime, ceftazidime, or piperacillin/tazobactam

  Ertapenem, imipenem/cilastatin, or meropenem

  Ceftazidime/avibactam, ceftolozane/tazobactam, meropenem/vaborbactam, or other recently FDA-approved beta-lactam/beta-lactamase inhibitors

  Colistin or polymyxin B

  Quinolones

  Vancomycin

  Daptomycin, linezolid, or other anti-MRSA agents

  Anidulafungin, caspofungin, or micafungin

  Isavuconazole, posaconazole, or voriconazole

  Amphotericin B and/or lipid-based amphotericin B

  None of the above

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  Required authorization by the stewardship team before restricted antibiotics on the formulary can be dispensed (i.e., prior authorization).

If selected: For which categories of antimicrobials? (Check all that apply.)

  Cefepime, ceftazidime , or piperacillin/tazobactam

  Ertapenem, imipenem/cilastatin, or meropenem

  Ceftazidime/avibactam, ceftolozane/tazobactam, meropenem/vaborbactam, or other recently FDA-approved beta-lactam/beta-lactamase inhibitors

  Colistin or polymyxin B

  Quinolones

  Vancomycin

  Daptomycin, linezolid, or other anti-MRSA agents

  Anidulafungin, caspofungin, or micafungin

  Isavuconazole, posaconazole, or voriconazole

  Amphotericin B and/or lipid-based amphotericin B

  None of the above

36*. Providers have access to facility- or region-specific treatment guidelines or recommendations for commonly encountered infections.

□ Yes

□ No

If Yes: Our stewardship team monitors adherence to facility- or region-specific treatment guidelines or recommendations for commonly encountered infections.

□ Yes

□ No

37*. Our facility targets select diagnoses for active interventions to optimize antibiotic use (e.g., intervening on duration of therapy for patients with community-acquired pneumonia according to clinical response).

 

□ Yes

□ No

38*. Our stewardship team monitors: (Check all that apply.)

  Antibiotic resistance patterns (either facility- or region-specific)

  Clostridioides difficile

  Antibiotic use in days of therapy (DOT) per 1000 patient days or days present, at least quarterly

  Antibiotic use in defined daily doses (DDD) per 1000 patient days, at least quarterly

  Antibiotic expenditures (i.e., purchasing costs), at least quarterly

  Antibiotic use in some other way (please specify): ________

 None of the above

If antibiotic use in DOT, DDD, or some other way is selected: Our stewardship team provides individual-, unit-, or service-specific reports on antibiotic use to prescribers, at least annually.

□ Yes

□ No

If Yes is selected: Our stewardship team uses individual-, unit-, or service-specific antibiotic use reports to target feedback to prescribers about how they can improve their antibiotic prescribing, at least annually.

□ Yes

□ No

39*. Our stewardship team provides the following updates or reports, at least annually: (Check all that apply.)

  Updates to facility leadership on antibiotic use and stewardship efforts.

  Outcomes for antibiotic stewardship interventions to staff.

 None of the above

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40*. Which of the following groups receive education on appropriate antibiotic use at least annually? (Check all that apply.)

  Prescribers

  Nursing staff

  Pharmacists

 None of the above

Optional Antibiotic Stewardship Practices Questions

Responses to the following questions are not required to complete the annual survey.

Please provide additional information about your facility’s antibiotic stewardship activities and leadership.

42. Our facility accesses targeted remote stewardship expertise (e.g., tele-stewardship) to obtain facility-specific support for our antibiotic stewardship efforts.

□ Yes

□ No

43. Our stewardship team works with the microbiology laboratory to inform cascade and/or selective reporting protocols for isolate susceptibilities.

□ Yes

□ No

 Not applicable, our facility does not use cascade and/or selective reporting

44. Our stewardship team monitors compliance with appropriate surgical prophylaxis.

 

□ Yes

□ No

45. If you selected ‘Yes’ to question 34 (your facility has a leader (or co-leaders) responsible for antibiotic stewardship outcomes): Which committees or leadership entities provide oversight of your facility’s antibiotic stewardship efforts? (Check all that apply.)

  Pharmacy director

  Pharmacy & therapeutics

  Patient safety

  Quality improvement

  Executive leadership (e.g., CEO, CMO)

  Board of directors

  Other (please specify): _____________

  None

46. If you selected ‘Physician’ or ‘Co-led…’ (your facility’s leader (or co-leader) responsible for antibiotic stewardship outcomes is a Physician): On average, what percent time does the physician (co) leader dedicate to antibiotic stewardship activities in your facility? (Check one.)

  1-25%

  26-50%

  51-75%

  76-100%

47. If you selected ‘Pharmacist’ or ‘Co-led…’ (your facility’s leader (or co-leader) responsible for antibiotic stewardship outcomes is a Pharmacist): On average, what percent time does the pharmacist (co) leader dedicate to antibiotic stewardship activities in your facility? (Check one.)

  1-25%

  26-50%

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  51-75%

  76-100%

48. If you selected that the physician (co) leader has antibiotic stewardship responsibilities in their contract or job description: What percent time for antibiotic stewardship activities is specified in the physician (co) leader’s contract or job description? (Check one.)

  1-25%

  26-50%

  51-75%

  76-100%

  Not specified

49. If you selected that the pharmacist (co) leader has antibiotic stewardship responsibilities in their contract or job description: What percent time for antibiotic stewardship activities is specified in the pharmacist (co) leader’s contract or job description? (Check one.)

  26-50%

  51-75%

  76-100%

  Not specified

Facility Water Management Program (WMP)

(*Optional section. Responses to the following questions are not required to complete the annual survey. Completed with input from WMP team members.)

 

 

50. Have you ever conducted a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system (e.g., piping infrastructure)?

□ Yes

□ No

If Yes, If Yes, when was the most recent assessment conducted? (Check one)

□ ≤ 1 year ago □ ≥ 1-3 years ago

□ ≥ 3 years ago

 

 

51. Does your facility have a water management program to prevent the growth and transmission of Legionella and other opportunistic waterborne pathogens?

□ Yes

□ No

If Yes, who is represented on your facility WMP team? (Check all that apply)

□ Hospital Epidemiologist/ Infection Preventionist

□ Compliance/ Safety Officer

□ Hospital Administrator/Leadership

□ Risk/Quality Management Staff

□ Facilities Manager/ Engineer

□ Maintenance Staff

□ Equipment/Chemical Acquisition/Supplier

□ Environmental Services

□ Infectious Disease Clinician

□ Consultant

□ Laboratory Staff

□ Other (please specify): _____________

 

 

Patient Safety Component—Annual Hospital Survey

Page 14 of 14

52. Do you regularly monitor the following parameters in your building’s water system? (Check all that apply)

 

 

Disinfectant (such as residual chlorine):

If Yes, do you have a plan for corrective actions when disinfectant (s) are not within acceptable limits as determined by your water management program?

□ Yes

□ Yes

□ No

□ No

Temperature:

□ Yes

□ No

If Yes, do you have a plan for corrective actions when temperatures are not within acceptable limits as determined by your water management program?

Heterotropic plate counts

If Yes, do you have a plan for corrective actions when heterotrophic plate counts are not within acceptable limits as determined by your water management program?

□ Yes

□ Yes

□ Yes

□ No

□ No

□ No

Specific tests for Legionella:

□ Yes

□ No

If Yes, do you have a plan for corrective actions when Specific tests for Legionella are not within acceptable limits as determined by your water management program?

 

□ Yes

□ No

CDC 57.103(Back), Rev11, v9.2