Form 11 Attachment L: Clinical Outcomes Data for LTC

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Attachment L: Clinical Outcomes Data for LTC

AHRQ Safety Program for MRSA Prevention

Clinical Outcomes Data for Long Term Care Settings

(This will be an electronic form with dropdown menus for the List of Organisms. However, participating sites may choose to use the paper form and fax the information in.) 

Long-Term Care

Data monthly

1. Transfer of facility resident(s) to an acute care hospital, with reason (suspected or confirmed infection/not-infection) - monthly

Month, Year	Count of facility residents transferred to an acute care hospital by reason	Reason for transfer to acute care hospital – selected from dropdown menu (Suspected or confirmed infection vs. NO suspected or confirmed infection)

Public reporting burden for this collection of information is estimated to average 30 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports Clearance Officer, Attention: PRA, Paperwork Reduction Project (0935-0143), AHRQ, 5600 Fishers Lane, MS 0741A, Rockville, MD 20857

The confidentiality of your responses is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure.

2. All-cause bacteremia with causative organism – monthly (MRSA as well as other organisms)

Month, Year	Count of all-cause bacteremia cases by each causative organism	Organism – selected from dropdown menu (See List of Organisms, page 3)

1. Resident days – monthly

Month, Year	Total resident days

List of Organisms

Staphylococcus aureus

Methicillin-resistant (MRSA)

Methicillin-susceptible (MSSA)

Coagulase-Negative Staphylococcus

Candida

Candida albicans

Candida glabrata

Candida parapsilosis

Candida tropicalis

Candida krusei

Candida lusitaniae

Candida sp.(unspeciated)

Enterococcus

Enterococcus faecalis

Enterococcus faecium

Enterococcus sp.

Klebsiella

Klebsiella pneumoniae

Klebsiella oxytoca

Escherichia coli

Enterobacter

Enterobacter cloacae

Enterobacter aerogenes

Enterobacter agglomerans

Enterobacter sp.

Pseudomonas

Pseudomonas aeruginosa

Pseudomonas sp.

Streptococcus

Streptococcus viridans grp

Streptococcus, Group B

Streptococcus pneumoniae

Streptococcus, Group A

Streptococcus, Group C

Streptococcus anginosis grp

Streptococcus, Group F

Streptococcus, Group G

Acinetobacter

Acinetobacter baumannii

Acinetobacter lwoffii

Serratia

Serratia marcescens

Serratia sp.

Bacteroides

Bacteroides fragilis

Bacteroides, other sp.

Proteus mirabilis

Stenotrophomonas maltophilia

Clostridium

Citrobacter

Citrobacter freundii

Citrobacter koseri

Morganella morganii

Achromobacter sp.

Providencia stuartii

Alcaligenes xylosoxidans

Pantoea agglomerans

Other

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