00920-1290 COVID-19 Patient Impact Module Form 29MAY2020

National Healthcare Safety Network (NHSN) Patient Impact Module for Coronavirus (COVID-19) Surveillance in Healthcare Facilities

57.130_v4_COVID-19_PIMHC_BLANK_CLEAN

COVID-19 Patient Impact Module Form - Microbiologist

OMB: 0920-1290

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Form Approved

OMB No. 0920-1290

Exp. Date: 09/30/2020

www.cdc.gov/nhsn

COVID-19 Module

Patient Impact and Hospital Capacity Pathway

Facility ID #: _____________

Summary Census ID #: _________


*Date for which patient impact and hospital capacity counts are reported: ____/____/________


For the following questions, please collect data at the same time (for example, 7 AM)


Section 1: Patient Impact Data Elements

_________

PREVIOUS DAY’S ADMISSIONS WITH CONFIRMED COVID-19: New patients admitted to an inpatient bed who had confirmed COVID-19 at the time of admission


_________

PREVIOUS DAY’S ADMISSIONS WITH SUSPECTED COVID-19: New patients admitted to an inpatient bed who had suspected COVID-19 at the time of admission


_________


_________

PREVIOUS DAY’S NEW HOSPITAL ONSET: Current inpatients hospitalized for a condition other than COVID-19 with onset of suspected or confirmed COVID-19 on the previous day and the previous day is fourteen or more days since admission


Number of Previous Day’s New Hospital Onset with Confirmed COVID-19 (subset)


_________


_________

HOSPITALIZED: Patients currently hospitalized in an inpatient bed who have suspected or confirmed COVID-19


Number of Hospitalized with Confirmed COVID-19 (subset)


_________


_________

HOSPITALIZED and VENTILATED: Patients currently hospitalized in an inpatient bed who have suspected or confirmed COVID-19 and are on a mechanical ventilator


Number of Hospitalized and Ventilated with Confirmed COVID-19 (subset)


_________

_________

HOSPITALIZED and ICU: Patients currently hospitalized in an inpatient ICU bed who have suspected or confirmed COVID-19


Number of Hospitalized and ICU with Confirmed COVID-19 (subset)


_________


_________

HOSPITAL ONSET: Total current inpatients with onset of suspected or confirmed COVID-19 fourteen or more days after admission for a condition other than COVID-19


Number of Hospital Onset with Confirmed COVID-19 (subset)


_________


_________

ED/OVERFLOW: Patients with suspected or confirmed COVID-19 who currently are in the Emergency Department (ED) or any overflow location awaiting an inpatient bed


Number of ED/Overflow with Confirmed COVID-19 (subset)


_________


_________

ED/OVERFLOW and VENTILATED: Patients with suspected or confirmed COVID-19 who currently are in the ED or any overflow location awaiting an inpatient bed and on a mechanical ventilator


Number of ED/Overflow and Ventilated with Confirmed COVID-19 (subset)


_________

_________

PREVIOUS DAY’S DEATHS: Patients with suspected or confirmed COVID-19 who died in the hospital, ED, or any overflow location on the previous calendar day


Number of Previous Day’s Deaths with Confirmed COVID-19 (subset)






Section 2: Hospital Bed/ Intensive Care Unit (ICU)/ Ventilator Capacity Data Elements

_________

ALL HOSPITAL BEDS: Total number of all staffed inpatient and outpatient beds in your hospital, including all overflow and surge/expansion beds used for inpatients and for outpatients (includes all ICU beds)

_________

*HOSPITAL INPATIENT BEDS: Total number of staffed inpatient beds in your hospital including all overflow and surge/ expansion beds used for inpatients (includes all ICU beds)


_________

HOSPITAL INPATIENT BED OCCUPANCY: Total number of staffed inpatient beds that are occupied

_________


_________


ICU BEDS: Total number of staffed inpatient ICU beds


Number of ICU Beds that are Neonatal Beds (subset)


_________


_________


ICU BED OCCUPANCY: Total number of staffed inpatient ICU beds that are occupied

Number of Occupied ICU Beds that are Neonatal Beds (subset)


_________

MECHANICAL VENTILATORS: Total number of ventilators available

_________

MECHANICAL VENTILATORS IN USE: Total number of ventilators in use

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)).


CDC estimates the average public reporting burden for this collection of information as 40 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1290).

CDC 57.130 (Front)



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