AQUA CAP Form

Attachment_I_c_AQUA CAP_Form.docx

Prevalence Survey of Healthcare Associated Infections (HAIs) and Antimicrobial Use in U.S. Acute Care Hospitals

AQUA CAP Form

OMB: 0920-0852

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HAI & ANTIMICROBIAL USE PREVALENCE SURVEY: ANTIMICROBIAL QUALITY ASSESSMENT (AQUA)

FORM 3c: CAP


CDC ID: - Date: // Data collector initials: _________



Clinical information

  1. Check any of the following ICD-10 codes that were present on admission for this patient: None

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):_____

2. CAP onset date (mm/dd/yy): ___ / ___ /___ or

Prior to survey hospitalization but specific date unknown Unable to determine

3. CAP signs and symptoms in first 2 hospital days; check all that apply: None

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

4. Did the patient require mechanical ventilation at any time during the hospitalization?

Yes

No

Unknown


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

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:



Date (mm/dd/yy)

Findings on chest imaging studies

1

___ / ___ / ___

Bronchopneumonia/pneumonia

New or worsening infiltrates

Infiltrate, single lobe

Air space density/opacity

No evidence of pneumonia

Infiltrate, multiple lobes

Consolidation Cavitation

Pleural effusion

Cannot rule out pneumonia

None of these

2

___ / ___ / ___

Bronchopneumonia/pneumonia

New or worsening infiltrates

Infiltrate, single lobe

Air space density/opacity

No evidence of pneumonia

Infiltrate, multiple lobes

Consolidation Cavitation

Pleural effusion

Cannot rule out pneumonia

None of these

3

___ / ___ / ___

Bronchopneumonia/pneumonia

New or worsening infiltrates

Infiltrate, single lobe

Air space density/opacity

No evidence of pneumonia

Infiltrate, multiple lobes

Consolidation Cavitation

Pleural effusion

Cannot rule out pneumonia

None of these

4

___ / ___ / ___

Bronchopneumonia/pneumonia

New or worsening infiltrates

Infiltrate, single lobe

Air space density/opacity

No evidence of pneumonia

Infiltrate, multiple lobes

Consolidation Cavitation

Pleural effusion

Cannot rule out pneumonia

None of these

5

___ / ___ / ___

Bronchopneumonia/pneumonia

New or worsening infiltrates

Infiltrate, single lobe

Air space density/opacity

No evidence of pneumonia

Infiltrate, multiple lobes

Consolidation Cavitation

Pleural effusion

Cannot rule out pneumonia

None of these



CDC ID: -

Antimicrobial drug treatment

6. Was the patient receiving antimicrobial treatment for this episode of CAP before the survey hospitalization?

Yes No Unknown

7. CAP treatment during the survey hospitalization:

First date (mm/dd/yy): ____ / ____ /____ or Unknown Last date (mm/dd/yy): ____ / ____ /____ or Unknown

8. Complete the table for all antimicrobial drugs given to treat CAP during the survey hospitalization:

No.

Drug name

First date (mm/dd/yy)

First route

Last date (mm/dd/yy)

Last route

1


____ / ____ / ____ Unk

IV IM

PO INH

____ / ____ / ____ Unk

IV IM

PO INH

2


____ / ____ / ____ Unk

IV IM

PO INH

____ / ____ / ____ Unk

IV IM

PO INH

3


____ / ____ / ____ Unk

IV IM

PO INH

____ / ____ / ____ Unk

IV IM

PO INH

4


____ / ____ / ____ Unk

IV IM

PO INH

____ / ____ / ____ Unk

IV IM

PO INH

5


____ / ____ / ____ Unk

IV IM

PO INH

____ / ____ / ____ Unk

IV IM

PO INH

More than 5 antimicrobial drugs were given to treat CAP:

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):

No.

Drug name*

First date (mm/dd/yy)

First Route

Last date (mm/dd/yy)

Last Route

1


____ / ____ / ____ Unk

IV IM

PO INH

____ / ____ / ____ Unk

IV IM

PO INH

2


____ / ____ / ____ Unk

IV IM

PO INH

____ / ____ / ____ Unk

IV IM

PO INH

3


____ / ____ / ____ Unk

IV IM

PO INH

____ / ____ / ____ Unk

IV IM

PO INH

4


____ / ____ / ____ Unk

IV IM

PO INH

____ / ____ / ____ Unk

IV IM

PO INH

5


____ / ____ / ____ Unk

IV IM

PO INH

____ / ____ / ____ Unk

IV IM

PO INH

*Enter separate records for vancomycin IV and vancomycin PO.

More drugs than fit in the table:

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):

No.

Drug name

Route (check all that apply)

Indication (check all that apply)

1


IV IM PO INH Unk

CAP Other Unknown

2


IV IM PO INH Unk

CAP Other Unknown

3


IV IM PO INH Unk

CAP Other Unknown

4


IV IM PO INH Unk

CAP Other Unknown

5


IV IM PO INH Unk

CAP Other Unknown

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

Laboratory testing

10. Complete table below for POSITIVE cultures collected in the first 5 hospital days:

No positive cultures: Culture data unknown:

No.

Specimen

Collect date (mm/dd/yy)

Culture result final date (mm/dd/yy)

Pathogens identified (insert codes)

Culture growth quantity* for lower respiratory cultures only

Antimicrobial drugs given on the DAY AFTER the test result was final

Were pathogens susceptible (S) to ≥1 antimicrobial the patient was getting the DAY AFTER the test result was final?

1

Sputum Blood

ETA Urine

BAL Stool

Upper resp

Other _____

____ / ___ / ___

____ / ___ / ___

Path1 ________

Path2 ________

Path3 ________

Path1: 104 CFU/ml or similar <104 or similar Unk

Path2: 104 CFU/ml or similar <104 or similar Unk

Path3: 104 CFU/ml or similar <104 or similar Unk

Drug1 ________

Drug2 ________

Drug3 ________

Drug4 ________

Path1: Y N U

Path2: Y N U

Path3: Y N U

2

Sputum Blood

ETA Urine

BAL Stool

Upper resp

Other _____

____ / ___ / ___

____ / ___ / ___

Path1 ________

Path2 ________

Path3 ________

Path1: 104 CFU/ml or similar <104 or similar Unk

Path2: 104 CFU/ml or similar <104 or similar Unk

Path3: 104 CFU/ml or similar <104 or similar Unk

Drug1 ________

Drug2 ________

Drug3 ________

Drug4 ________

Path1: Y N U

Path2: Y N U

Path3: Y N U

3

Sputum Blood

ETA Urine

BAL Stool

Upper resp

Other _____

____ / ___ / ___

____ / ___ / ___

Path1 ________

Path2 ________

Path3 ________

Path1: 104 CFU/ml or similar <104 or similar Unk

Path2: 104 CFU/ml or similar <104 or similar Unk

Path3: 104 CFU/ml or similar <104 or similar Unk

Drug1 ________

Drug2 ________

Drug3 ________

Drug4 ________

Path1: Y N U

Path2: Y N U

Path3: Y N U

4

Sputum Blood

ETA Urine

BAL Stool

Upper resp

Other _____

____ / ___ / ___

____ / ___ / ___

Path1 ________

Path2 ________

Path3 ________

Path1: 104 CFU/ml or similar <104 or similar Unk

Path2: 104 CFU/ml or similar <104 or similar Unk

Path3: 104 CFU/ml or similar <104 or similar Unk

Drug1 ________

Drug2 ________

Drug3 ________

Drug4 ________

Path1: Y N U

Path2: Y N U

Path3: Y N U

5

Sputum Blood

ETA Urine

BAL Stool

Upper resp

Other _____

____ / ___ / ___

____ / ___ / ___

Path1 ________

Path2 ________

Path3 ________

Path1: 104 CFU/ml or similar <104 or similar Unk

Path2: 104 CFU/ml or similar <104 or similar Unk

Path3: 104 CFU/ml or similar <104 or similar Unk

Drug1 ________

Drug2 ________

Drug3 ________

Drug4 ________

Path1: Y N U

Path2: Y N U

Path3: Y N U

6

Sputum Blood

ETA Urine

BAL Stool

Upper resp

Other _____

____ / ___ / ___

____ / ___ / ___

Path1 ________

Path2 ________

Path3 ________

Path1: 104 CFU/ml or similar <104 or similar Unk

Path2: 104 CFU/ml or similar <104 or similar Unk

Path3: 104 CFU/ml or similar <104 or similar Unk

Drug1 ________

Drug2 ________

Drug3 ________

Drug4 ________

Path1: Y N U

Path2: Y N U

Path3: Y N U

7

Sputum Blood

ETA Urine

BAL Stool

Upper resp

Other _____

____ / ___ / ___

____ / ___ / ___

Path1 ________

Path2 ________

Path3 ________

Path1: 104 CFU/ml or similar <104 or similar Unk

Path2: 104 CFU/ml or similar <104 or similar Unk

Path3: 104 CFU/ml or similar <104 or similar Unk

Drug1 ________

Drug2 ________

Drug3 ________

Drug4 ________

Path1: Y N U

Path2: Y N U

Path3: Y N U

8

Sputum Blood

ETA Urine

BAL Stool

Upper resp

Other _____

____ / ___ / ___

____ / ___ / ___

Path1 ________

Path2 ________

Path3 ________

Path1: 104 CFU/ml or similar <104 or similar Unk

Path2: 104 CFU/ml or similar <104 or similar Unk

Path3: 104 CFU/ml or similar <104 or similar Unk

Drug1 ________

Drug2 ________

Drug3 ________

Drug4 ________

Path1: Y N U

Path2: Y N U

Path3: Y N U

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

12. Complete the table for NEGATIVE cultures collected during the first 5 hospital days:

No negative cultures: Culture data unknown:

No.

Collect date

(mm/dd/yy)

Specimen

Culture result final date (mm/dd/yy)


No.

Collect date

(mm/dd/yy)

Specimen

Culture result final date (mm/dd/yy)

1

___ / ___ / ___

Blood Lower resp

Urine Stool

Other ___________



____ / ___ / ___


6

___ / ___ / ___

Blood Lower resp

Urine Stool

Other ___________


____ / ___ / ___

2

___ / ___ / ___

Blood Lower resp

Urine Stool

Other ___________



____ / ___ / ___


7

___ / ___ / ___

Blood Lower resp

Urine Stool

Other ___________



____ / ___ / ___

3

___ / ___ / ___

Blood Lower resp

Urine Stool

Other ___________



____ / ___ / ___


8

___ / ___ / ___

Blood Lower resp

Urine Stool

Other ___________


____ / ___ / ___

4

___ / ___ / ___

Blood Lower resp

Urine Stool

Other ___________



____ / ___ / ___


9

___ / ___ / ___

Blood Lower resp

Urine Stool

Other ___________



____ / ___ / ___

5

___ / ___ / ___

Blood Lower resp

Urine Stool

Other ___________



____ / ___ / ___


10

___ / ___ / ___

Blood Lower resp

Urine Stool

Other ___________



____ / ___ / ___

More negative cultures than fit in the table:

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:

No.

Collect Date (mm/dd/yy)

Specimen

Test

What pathogen(s) were tested for?

Result

1

____ / ___ / ___

Blood Lower resp

Upper resp

Urine Stool

Other ______

PCR

DFA

Antigen test

Other_____

Legionella Cdiff RSV

Pneumococcus Adeno

Influenza hMPV Paraflu

Other ________

Negative Unknown

Positive (insert code):

Path1_______Path2_______

Path3_______

2

____ / ___ / ___

Blood Lower resp

Upper resp

Urine Stool

Other ______

PCR

DFA

Antigen test

Other_____

Legionella Cdiff RSV

Pneumococcus Adeno

Influenza hMPV Paraflu

Other ________

Negative Unknown

Positive (insert code):

Path1_______Path2_______

Path3_______

3

____ / ___ / ___

Blood Lower resp

Upper resp

Urine Stool

Other ______

PCR

DFA

Antigen test

Other_____

Legionella Cdiff RSV

Pneumococcus Adeno

Influenza hMPV Paraflu

Other ________

Negative Unknown

Positive (insert code):

Path1_______Path2_______

Path3_______

4

____ / ___ / ___

Blood Lower resp

Upper resp

Urine Stool

Other ______

PCR

DFA

Antigen test

Other_____

Legionella Cdiff RSV

Pneumococcus Adeno

Influenza hMPV Paraflu

Other ________

Negative Unknown

Positive (insert code):

Path1_______Path2_______

Path3_______

5

____ / ___ / ___

Blood Lower resp

Upper resp

Urine Stool

Other ______

PCR

DFA

Antigen test

Other_____

Legionella Cdiff RSV

Pneumococcus Adeno

Influenza hMPV Paraflu

Other ________

Negative Unknown

Positive (insert code):

Path1_______Path2_______

Path3_______

More tests than fit in the table:

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 1 of 4


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