MRSA Healthcare Facility In-patient Survey
This survey is designed to exemplify the potential of Keypoint in carrying out a large scale survey. Depending on the medium chosen, this can be carried out online in one data entry session or it can be saved and completed in more than one session. Collecting data for multiple facilities can be carried out at different times.
Part 1 - Facility-wide data
The questions in the first section relate to facility-wide information. If you are reporting for multiple facilities, then each facility should be entered separately. You can however adapt this so that if this survey was being used as a single survey across a multi-facility that the responses could be identified to a unit, ward or facility.
Q1.
Response Number
Q2.
How many infection prevention and control professionals are present at your facility?
Healthcare demographics
Q3.
Location of your healthcare facility
Q4.
Is your healthcare facility classed as
Urban
Rural
Q5.
Type of healthcare facility (check all that apply):
Public
Pediatric only
Acute care
Private
Woman only
Rehabilitation
Adult only
Cancer hospital
GP
Adult and Pediatric
Cardiac facility
Long-term care
Q6.
Number of beds
Q7.
Number of inpatient's on day of survey:
Q8.
Which of the following are present in the healthcare facility (tick all that apply):
Medical ICU
Burn unit
Long term care
Surgical ICU
Hematology-oncology unit
Rehabilitation unit
Combined Medical-Surgical ICU
Prisoner facilities
Cardiac surgery
Chronic hemodialysis unit
Transplant unit
Trauma surgery
Q9.
What is the percentage of ICU beds of the total beds available?
Q10.
What type of Health care Associated Infections (HAI) routine surveillance do you perform?
Facility-wide
Targeted
Q11.
If targeted, please specify:
All ICU patients
All surgical patients
High risk patients
Some ICU patients
Some surgical patients
Q12.
Which site(s) of infection do you routinely survey:
Q13.
Do you perform active surveillance cultures for MRSA
Yes
No
Q14.
If yes, which of the following populations do you perform surveillance cultures? (Tick all that apply).
All healthcare facility admissions
All ICU admissions
Selected surgical populations
Transfers from other healthcare facilities
All dialysis patients
Transfers from long-term care facilities
All hematology-oncology patients
All admissions to ICU's
Patients with repeated/recurrent facility admissions
Selected unit patients
Other
Q15.
Are your surveillance cultures:
Routinely performed i.e. as per protocol
Both
Physician directed order
Q16.
Which methods do you use for your surveillance cultures?
Q17.
Approximately on what percent of your total occupied beds do you perform active surveillance cultures for MRSA?
Q18.
On the day of your point prevalence survey, how many health care facility inpatients had cultures positive for MRSA?
Q19.
What type of isolation do you currently require for known MRSA culture positive patients?
Standard precautions only
Contact isolation
No isolation
MRSA - Infected Patients - ICU
MRSA Infected Patients - Non ICU
MRSA colonized patients - ICU
MRSA colonised patients - Non ICU
Part 2 - Individual care data
Provide the following information for each MRSA-positive patient from your point prevalence survey.
Q20.
Gender
Male
Female
Q21.
Age
Q22.
Service
Medical
Surgical
ICU
Other unit or service
Q23.
Duration: Admit to +MRSA
Less than 48 hours
More than 48 hours
Q24.
Culture type
Clinical culture
Surveillance culture
Q25.
Infections sites
Blood
Skin- soft tissue
Urine
Pneumonia
Surgical site
Q26.
Underlying conditions
Diabetes
Transfer from long term care facility
Chronic renal failure
Transfer from other health care facility
Cardiac disease
Repeated healthcare facility admissions in past 12 months
Prematurity
Multiple courses of antibiotics
Homelessness
Surgery in past 12 months
Prisoner
Hematology-oncology patient
Q27.
Antibiotics
Resistant
Susceptible
Not tested
Trimethoprim-sulfamethoxazole
Clindamycin
Erythromycin
Gentamicin
Tetracycline
Levofloxicin