HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL QUALITY ASSESSMENT (AQUA)
FORM 3c: CAP
CDC ID: - Date: // Data collector initials: _________
Clinical information |
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J09.X1 J09.X2 J09.X3 J10.00 J10.01 J10.08 J10.1 J10.2 J10.81 J10.82 J10.83 J10.89 J11.00 J11.08 J11.1 J11.2 J11.81 J11.82 J11.83 J11.89 J12.0 J12.1 J12.2 J12.3 J12.81 J12.89 J12.9 J13 J14 J15.0 J15.1 J15.3 J15.4 J15.20 J15.211 J15.212 J15.29 J15.5 J15.6 J15.7 J15.8 J15.9 J16.0 J16.8 J18.0 J18.1 J18.9 A48.1 Other (specify):_____ |
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2. CAP onset date (mm/dd/yy): ___ / ___ /___ or Prior to survey hospitalization but specific date unknown Unable to determine |
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3. CAP signs and symptoms in first 2 hospital days; check all that apply: None |
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Fever Chills or rigors Cough Dyspnea O2 saturation < 90% Sore throat |
Increased secretions/sputum production Hemoptysis Chest pain Mental status changes or functional decline Apnea Rhinorrhea |
Grunting Nasal flaring Head bobbing Chest wall retractions Wheezing Muscle aches |
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4. Did the patient require mechanical ventilation at any time during the hospitalization? Yes No Unknown
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4a. If yes, was the patient removed from mechanical ventilation before hospital discharge? Yes, clinical status improved Yes, removed from mechanical ventilation for end-of-life care (or for reasons other than improvement) No Unknown |
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5. Complete the chest imaging table, recording studies done in the first 5 hospital days (____/____/____ through ____/____/____): No imaging studies done: Unknown whether imaging studies were done:
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CDC ID: -
Antimicrobial drug treatment |
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6. Was the patient receiving antimicrobial treatment for this episode of CAP before the survey hospitalization? Yes No Unknown |
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7. CAP treatment during the survey hospitalization: First date (mm/dd/yy): ____ / ____ /____ or Unknown Last date (mm/dd/yy): ____ / ____ /____ or Unknown |
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8. Complete the table for all antimicrobial drugs given to treat CAP during the survey hospitalization:
More than 5 antimicrobial drugs were given to treat CAP: |
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8a. Did the patient receive other antimicrobial drugs in the hospital during the CAP treatment period? Yes—complete table below in 8b. No Unknown 8b. Other antimicrobial drugs given in the hospital (during the CAP treatment period defined by the dates in #7):
9. Were antimicrobial drugs prescribed at hospital discharge (i.e., prescribed to be administered to the patient for additional days after hospital discharge) to treat CAP or for other reasons? Yes No Unknown 9a. Antimicrobial drugs prescribed at discharge for CAP or other reasons (enter CAP drugs first):
More drugs than fit in the table:
9b. If antimicrobials were prescribed at discharge for CAP, what was the total duration of the post-discharge CAP treatment? _____ days, OR the prescription end date is ____ / ____ / _____, OR Duration is unknown
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Laboratory testing |
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10. Complete table below for POSITIVE cultures collected in the first 5 hospital days: No positive cultures: Culture data unknown: |
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More positive cultures than fit in the table: ETA=endotracheal aspirate (or tracheal aspirate). BAL=bronchoalveolar lavage (includes bronchial lavage, mini-BAL). *Check “≥104 CFU/ml or similar” if quantity of growth in the culture is reported to be as follows: moderate, many, heavy, abundant, etc. Check “<104 or similar” if quantity of growth in the culture is reported to be <104 CFU/ml or as follows: few, scarce, scant, rare, etc. Check “unknown” if no organism quantity is noted in the culture report. |
CDC ID: -
CDC ID: -
11. During the first 5 hospital days, did the patient have a Gram stain of lower respiratory secretions (sputum, BAL, ETA, etc.)? Yes No Unknown 11a. If yes, did the Gram stain report indicate the following: Heavy, 4+, or ≥25 neutrophils (or white blood cells) per low power field [x100] Rare, occasional, few, 1+ or 2+, or ≤10 squamous epithelial cells per low power field [x100] Neither of the above Unknown |
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12. Complete the table for NEGATIVE cultures collected during the first 5 hospital days: No negative cultures: Culture data unknown:
More negative cultures than fit in the table: |
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13. Complete the table for non-culture microbiology tests (positive and negative) collected during the first 5 hospital days: No non-culture tests done: Non-culture test data unknown:
More tests than fit in the table: |
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14. Did the patient have any of the following blood test results during the first 2 hospital days? Check all that apply, or None. Arterial pH < 7.35 BUN > 30 mg/dL (11 mmol/L) Glucose > 250 mg/dL PaO2 < 60 mmHg Sodium < 130 mmol/L Hematocrit < 30% |
***FORM IS COMPLETE***
Phase
5_AQUA CAP Form_20200113 Page
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Shelley Magill |
File Modified | 0000-00-00 |
File Created | 2022-08-04 |