Custom Event Page 1 of 4 - PowerPoint Presentation

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Custom Event

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Facility ID:Event #:*Patient ID:Social Security #:Secondary ID:Patient Name, Last: First: Middle:*Gender: M F Other*Date of Birth:Ethnicity (specify):Race (specify):Event Details*Event Type:*Date of Event:Post Procedure Event: Yes NoDate of Procedure:NHSN Procedure Code:ICD-9-CM Procedure Code:*MDRO/CDI Infection Surveillance: NoDate Admitted to Facility:Location:Specific Event Type: Specify Criteria Used (check all that apply) Signs & Symptoms Abscess Apnea Vomiting Bradycardia Redness Cough Dysuria Fever Acute onset of diarrhea (liquid stools for > 12 hours) Purulent drainage or material Pain or tenderness New onset/change in sputum, increased secretions or increased suctioning Localized swelling Persistent microscopic or gross blood in stools Wheezing, rales or rhonchi Other evidence of infection found on direct exam, during surgery or by diagnostic testing+ Other signs and symptoms + Laboratory or Diagnostic Testing□ Positive culture□ Not cultured□ Positive blood culture□ Blood culture not done or no organisms detected in bloodPositive Gram stain when culture is negative or not done >15 colonies cultured from IV cannula tip using semiquantitative culture method Positive culture of pathogen Positive culture of skin contaminant Other positive laboratory tests Radiographic evidence of infectionClinical Diagnosis Physician diagnosis of this event type+ Physician institutes appropriate antimicrobial therapy++ Per specific event criteriaSecondary Bloodstream Infection: Yes NoDied: Yes No Event contributed to death? Yes NoDischarge Date: ____/____/________*Pathogens Identified: Yes No *If Yes, specify on pages 2-3.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)).

Heat

Hypotension

Hypothermia

Lethargy

Nausea

Suprapubic tendernessSlide2

Custom Event

OMB No. 0920-0666

Exp. Date: xx-xx-

xxxxPage 2 of 4Pathogen #Gram-positive Organisms _____Staphylococcuscoagulase-negativeVANCS I R N _____Enterococcusspp. (specify)__________AMPS I R NCIPRO/LEVO/MOXIS I R NDAPTOS NS NDOXY/MINOS I R NGENTHL§S R NLNZS I R N STREPHL§S R NTETRAS I R N TIGS NS NVANCS I R N _____EnterococcusfaeciumAMPS I R NCIPRO/LEVO/MOXIS I R N

DAPTO

S NS N

DOXY/MINO

S I R N

GENTHL

§S R NLNZS I R N QUIDALS I R NSTREPHL§S R NTETRAS I R NTIGS NS NVANCS I R N _____StaphylococcusaureusCHLORS I R NCIPRO/LEVO/MOXIS I R NCLINDS I R NDAPTOS NS NDOXY/MINOS I R NERYTHS I R NGENT S I R NLNZS R NOX/CEFOX/METHS I R NQUIDALS I R NRIFS I R NTETRAS I R NTIGS NS NTMZS I R NVANCS I R NPathogen #Gram-negative Organisms _____Acinetobacter spp. (specify)AMKS I R NAMPSUL S I R NAZTS I R NCEFEPS I R NCEFTAZS I R NCIPRO/LEVOS I R NCOL/PBS I R NGENTS I R N ___________IMIS I R NMERO/DORI S I R NPIP/PIPTAZS I R N TETRA/DOXY/MINOS I R NTMZS I R NTOBRA S I R N _____Escherichia coliAMKS I R NAMPS I R NAMPSUL/AMXCLVS I R NAZTS I R NCEFAZS I R NCEFEPS I R NCEFOT/CEFTRXS I R NCEFTAZS I R NCEFURS I R NCEFOX/CETETS I R NCHLORS I R NCIPRO/LEVO/MOXIS I R NCOL/PBS I R NERTAS I R NGENTS I R NIMIS I R NMERO/DORI S I R NPIPTAZS I R N TETRA/DOXY/MINOS I R NTIGS I R NTMZS I R NTOBRAS I R N _____Enterobacter spp. (specify)AMKS I R NAMPS I R NAMPSUL/AMXCLVS I R NAZTS I R NCEFAZS I R NCEFEPS I R NCEFOT/CEFTRXS I R N___________CEFTAZS I R NCEFURS I R NCEFOX/CETETS I R NCHLORS I R NCIPRO/LEVO/MOXIS I R NCOL/PBS I R NERTAS I R NGENTS I R NIMIS I R NMERO/DORI S I R NPIPTAZS I R N TETRA/DOXY/MINOS I R NTIGS I R NTMZS I R NTOBRAS I R N _____Klebsiella spp.(specify)AMKS I R NAMPS I R NAMPSUL/AMXCLVS I R NAZTS I R NCEFAZS I R NCEFEPS I R NCEFOT/CEFTRXS I R N___________CEFTAZS I R NCEFURS I R NCEFOX/CETETS I R NCHLORS I R NCIPRO/LEVO/MOXIS I R NCOL/PBS I R NERTAS I R NGENTS I R NIMIS I R NMERO/DORI S I R NPIPTAZS I R N TETRA/DOXY/MINOS I R NTIGS I R NTMZS I R NTOBRAS I R N

(specify): _________________________

CDC 57.115 (back), Rev 2, v6.4Slide3

Custom Event

OMB No. 0920-0666

Exp. Date: xx-xx-

xxxxPage 3 of 4Pathogen #Gram-negative Organisms (continued) _____Serratia marcescensAMKS I R NAMPS I R NAMPSUL/AMXCLVS I R NAZTS I R NCEFAZS I R NCEFEPS I R NCEFOT/CEFTRXS I R NCEFTAZS I R NCEFURS I R NCEFOX/CETETS I R NCHLORS I R NCIPRO/LEVO/MOXIS I R NCOL/PBS I R NERTAS I R NGENTS I R NIMIS I R NMERO/DORI S I R NPIPTAZS I R N TETRA/DOXY/MINOS I R NTIGS I R NTMZS I R NTOBRAS I R N _____Pseudomonas aeruginosaAMKS I R NAZTS I R NCEFEPS I R NCEFTAZS I R NCIPRO/LEVOS I R NCOL/PB

S I R N

GENT

S I R N

IMI

S I R N

MERO/DORIS I R NPIP/PIPTAZS I R NTOBRAS I R N _____Stenotrophomonas maltophiliaLEVOS I R NTETRA/MINOS I R NTICLAVS I R NTMZS I R NPathogen#Fungal Organisms_____Candida spp.(specify)__________________ANIDS NS NCASPOS NS NFLUCOS S-DD R NFLUCYS I R NITRAS S-DD R NMICAS NS NVORIS S-DD R NPathogen #Other Organisms _____Organism 1(specify)______________________Drug 1S I R N____Drug 2S I R N____Drug 3S I R N____Drug 4S I R N____Drug 5S I R N____Drug 6S I R N____Drug 7S I R N____Drug 8S I R N____Drug 9S I R N _____Organism 2(specify)______________________Drug 1S I R N____Drug 2S I R N____Drug 3S I R N____Drug 4S I R N____Drug 5S I R N____Drug 6S I R N____Drug 7S I R N____Drug 8S I R N____Drug 9S I R N _____Organism 3(specify)______________________Drug 1S I R N____Drug 2S I R N____Drug 3S I R N____Drug 4S I R N____Drug 5S I R N____Drug 6S I R N____Drug 7S I R N____Drug 8S I R N____Drug 9S I R NResult CodesS = Susceptible I = Intermediate R = Resistant NS = Non-susceptible S-DD = Susceptible-dose dependent N = Not tested§ GENTHL and STREPHL results: S=Susceptible/Synergistic and R=Resistant/Not Synergistic Drug Codes:AMK = amikacinAMP = ampicillinAMPSUL = ampicillin/sulbactamAMXCLV = amoxicillin/clavulanic acidANID = anidulafunginAZT = aztreonamCASPO = caspofunginCEFAZ= cefazolinCEFEP = cefepimeCEFOT = cefotaximeCEFOX= cefoxitinCEFTAZ = ceftazidimeCEFTRX = ceftriaxone CEFUR= cefuroximeCETET= cefotetanCHLOR= chloramphenicolCIPRO = ciprofloxacinCLIND = clindamycinCOL = colistinDAPTO = daptomycinDORI = doripenemDOXY = doxycyclineERTA = ertapenemERYTH = erythromycinFLUCO = fluconazoleFLUCY = flucytosineGENT = gentamicinGENTHL = gentamicin – high level testIMI = imipenemITRA = itraconazoleLEVO = levofloxacinLNZ = linezolid MERO = meropenemMETH = methicillinMICA = micafunginMINO = minocyclineMOXI = moxifloxacinOX = oxacillinPB = polymyxin BPIP = piperacillinPIPTAZ = piperacillin/tazobactamQUIDAL = quinupristin/dalfopristinRIF = rifampinSTREPHL = streptomycin – high level testTETRA = tetracyclineTICLAV = ticarcillin/clavulanic acidTIG = tigecyclineTMZ = trimethoprim/sulfamethoxazoleTOBRA = tobramycinVANC = vancomycinVORI = voriconazoleCDC 57.115 (back), Rev 2, v6.4Slide4

Custom Event

OMB No. 0920-0666

Exp. Date: xx-xx-xxxx

Page 3 of 4Custom FieldsLabel ________________________ ___/___/___ ________________________ ___________ ________________________ ___________ ________________________ ___________ ________________________ ___________ ________________________ ___________ ________________________ ___________Label ________________________ ___/___/___ ________________________ ___________ ________________________ ___________ ________________________ ___________ ________________________ ___________ ________________________ ___________ ________________________ ___________CommentsCDC 57.115 (back), Rev 2, v6.4