COMPLETING THE QUESTIONNAIRES - Part 2

1. LECTURE 3 COMPLETING THE QUESTIONNAIRES - Part 2

2. LECTURE OBJECTIVES • To describe how to complete the remaining questionnaires/ sections of questionnaires.

3. QUESTIONNAIRES TO BE COMPLETED ON PPS DAY WARD LIST RESIDENT QUESTIONNAIRE INSTITUTIONAL QUESTIONNAIRE • Sections B and F

4. COMPLETING WARD LIST LTCF Identifier allocated by national coordinating centre Each ward should also be allocated a letter i.e. “A”, “B”, “C” etc. which is used for study numbers Ward lists should NOT be sent to coordinating centre but kept securely in LTCF

5. COMPLETING WARD LIST

6. COMPLETING WARD LIST List all the residents present on the day of the survey and their room/ bed number in columns 1 and 2 Complete column 3 to determine eligible residents Complete columns 4 to 14 for all eligible residents Write an ‘X’ if the risk factor or care load indicator is present on the day of the survey Allocate each resident a study number (see later)

7. COMPLETING WARD LIST Sum the ‘X’s in each column (3 to 14) and write the totals in the summary table at the end of the ward list Sum the totals of the summary tables in the different ward lists and report the totals in part B of the institutional questionnaire

8. COMPLETING WARD LIST- Example Enter room and bed number for each resident present on PPS day

9. COMPLETING WARD LIST- Example List all residents (eligible or not) in the ward present on PPS day Allocate each resident a study number using ward “letter” as prefix

10. COMPLETING WARD LIST- Example • Mark X for residents that meet all of the following: • Are living full time in facility • Have been admitted for at least 24hrs • Present at 8am on day of study or temporarily out of facility at 8am • = ELIGIBLE RESIDENTS i.e. Denominators INELIGIBLE RESIDENTS

11. COMPLETING WARD LIST- Example Complete columns 4 - 14 for eligible residents only. Write “X” if condition is true on day of survey

12. COMPLETING WARD LIST- Risk factors Systemic antimicrobial:residents on a course of one or more systemic antimicrobials at the time of the PPS. • Exclude: • Antivirals for systemic use • Antimicrobials for topical use • Antiseptics • Include: • All oral, rectal, intramuscular (IM) and intravenous (IV) treatment with: • - antibacterials and antimycotics for systemic use • - drugs for systemic treatment of tuberculosis • (antimycobacterials) • Antibiotic treatment by inhalation (aerosol therapy)

13. COMPLETING WARD LIST- Risk factors Signs/ symptoms of an infection:residents presenting signs or symptoms of a (suspected) infection (e.g. pyrexia, pain, inflammation, diarrhoea, vomiting etc.) on the day of the PPS or presenting signs/symptoms of an infection in the preceding days, while (s)he is still being treated with an antimicrobial on the PPS day.

14. COMPLETING WARD LIST- Risk factors Urinary catheter:Any tube system placed in the body to drain and collect urine from the bladder, e.g. an indwelling urinary catheter, suprapubic or abdominal wall catheter, a cystostomy Vascular catheter:Any tube system placed in the body to access the vascular (venous, arterial) system, (e.g. a peripheral intravenous catheter, an implanted vascular access system (port-à-cath) or any other intravascular access system (including arterio-venous fistula) Pressure sore:All grades of pressure sores should be considered, even the lowest grade characterised by discolouration of intact skin not affected by light finger pressure (non blanching erythema)

15. COMPLETING WARD LIST- Risk factors Other wound: All wounds other than a pressure sore, including leg ulcers, traumatic or surgical wounds and insertion sites for gastrostomy, tracheostomy, urostomy, colostomy or suprapubic and peritoneal catheters. Disoriented in time and/or space: Residents who suffer from periods of confusion especially as to time, place or identification of persons (e.g. he/she cannot find his/her room, has no idea of time and is not able to recognise persons he/she knows very well). Wheelchair bound or bedridden:non-ambulatory i.e. he/she cannot walk alone with or without canes, crutches, walkers but requires a wheelchair or is confined to bed

16. COMPLETING WARD LIST- Risk factors Surgery in the previous 30 days: Surgery is a procedure that takes place in an operation room (incl. operating room, c- section room, interventional radiology room, or cardiac catheterisation lab) where a surgeon makes at least one incision through the skin or mucous membrane, including laparoscopic approach, and closes the incision before the patient leaves the operating room. Urinary and/or faecal incontinence: lack of control of the sphincter from bladder or bowel resulting in an uncontrolled loose of urine or faeces) necessitating the use of diapers in the 24 hours prior to the PPS day (during the day and/or night). Because this indicator measures work load, a resident having a urinary catheter should be considered as continent.

17. COMPLETING WARD LIST- Example Identifying Numerators i.e. residents with signs and symptoms of infection and/or on antimicrobial therapy (columns 6 and/or 7)

18. COMPLETING WARD LIST- Example 10 Resident questionnaires must be completed for these numerators No resident questionnaires for ineligible residents or those without condition(s) of interest S. Shylock will be discussed in case studies

19. A resident questionnaire must be completed for each resident with a systemic antimicrobial and/or signs/symptoms of an infection on the day of the survey (i.e. “X” in columns 6 and/or 7*)

20. COMPLETING WARD LIST- Example Identify which residents/ study numbers require a resident questionnaire (study number must also be entered in corresponding resident questionnaire)

21. COMPLETING WARD LIST- Example Once ward list data is completed add up all the “X”s in each column

22. Enter the number of residents absent from the ward on PPS day due to acute hospital admittance The sum of the “X”s from each column is entered into the summary table of ward list. Add up the totals of the summary tables from the different ward lists (if more than one ward list is completed) and enter the totals into Part B of Institutional Questionnaire.

23. RESIDENT QUESTIONNAIRE • Demographic data & any additional risks for infection • Antimicrobial treatment • Signs & symptoms of infection

24. RESIDENT QUESTIONNAIRE Study number allocated to the eligible resident with condition(s) of interest (from ward list) should be entered on each page of the resident questionnaire It is very important that the study numbers on the ward lists and on the resident questionnaires match the same resident

25. RESIDENT QUESTIONNAIRE Ward List Resident form for O. Ophelia from sample ward List A 0 1

26. RESIDENT QUESTIONNAIRE Demographic data Resident Data How long has the resident been living in the LTCF?

27. RESIDENT QUESTIONNAIRE Demographic data Resident Data Was the resident admitted to an acute care hospital during the 3 months preceding the PPS study date? (only admissions to acute care hospitals -with at least a medical or surgical ward- for at least 24h of stay) Definitions as per ward list

28. RESIDENT QUESTIONNAIRE Demographic data Resident Data Tick which one applies to the resident

29. RESIDENT QUESTIONNAIRE Antimicrobial treatment • Include: • all oral, rectal, intramuscular (IM) and intravenous (IV) treatment with: • - antibacterials and antimycotics for systemic use • - drugs for systemic treatment of tuberculosis (antimycobacterials) • antibiotic treatment by inhalation (aerosol therapy) • Exclude: • Antivirals for systemic use • Antimicrobials for topical use • Antiseptics

30. RESIDENT QUESTIONNAIRE Antimicrobial treatment Enter the name of antimicrobial here.

31. RESIDENT QUESTIONNAIRE Antimicrobial treatment How are the antimicrobials administered to the resident on the PPS day? X

32. RESIDENT QUESTIONNAIRE Antimicrobial treatment Check resident’s medical notes for end/review date of antimicrobial treatment X Is the treatment prophylactic (to prevent occurrence of an infection) or therapeutic (antimicrobials prescribed to actually treat the infection)? ***

33. RESIDENT QUESTIONNAIRE Antimicrobial treatment What site is the antimicrobial therapy (treatment or prophylaxis) prescribed for? X X Where was the antimicrobial prescribed? Who prescribed the antimicrobial?

34. RESIDENT QUESTIONNAIRE Antimicrobial treatment Was a dipstick test carried out on a urine sample (in the case of a suspected UTI) prior to antimicrobial prescribing (treatment or prophylaxis) Was a sample taken from infection site and sent for culture before antimicrobial was prescribed? This culture sample question applies to all infection sites not just the urinary tract. Urine dipstick test: impregnation of a paper or cardboard stick in urine to test it for the presence of white blood cells (leukocyte esterase) and/or nitrites. NOT dip slide test (test for presence of microorganisms in liquids by incubating dip slides).

35. RESIDENT QUESTIONNAIRE Antimicrobial treatment X Indicate what micro-organism(s) (up to three) were isolated in this culture sample using the code list OR select one of the following options: _NOEXA: EXAMINATION NOT (YET) DONE _NA: RESULTS NOT AVAILABLE _NONID: MICROORGANISM NOT IDENTIFIED _STERI: STERILE EXAMINATION

36. RESIDENT QUESTIONNAIRE

37. RESIDENT QUESTIONNAIRE Antimicrobial treatment EXAMPLE Staphylococcus epidermidis X Staphylococcus aureus S T A E P I S T A A UR For some microorganisms (highlighted in red in code list) the antimicrobial susceptibility should be reported

38. RESIDENT QUESTIONNAIRE Antimicrobial treatment S: Sensitive/ susceptible R: Resistant/ non-susceptible Intermediatesusceptibilityshouldbeclassified as resistant (R) ?: unknownsusceptibilityresult

39. RESIDENT QUESTIONNAIRE Antimicrobial treatment EXAMPLE X S T A E P I S T A A U R MRSA

40. RESIDENT QUESTIONNAIRE Signs and symptoms of infection

41. RESIDENT QUESTIONNAIRE Signs and symptoms of infection • ALL signs/symptoms of infection (fever, nausea, swelling etc.) present on the study day should be noted in resident questionnaire. • When the resident no longer has signs/symptoms of infection but is still being treated with an antimicrobial on day of the study, all signs/symptoms that were previously present, and resulted in the prescribing of the antimicrobial, should be noted in the resident questionnaire.

42. RESIDENT QUESTIONNAIRE Signs and symptoms of infection

43. RESIDENT QUESTIONNAIRE Signs and symptoms of infection How is the presence of an infection recorded in the resident questionnaire? • Infection algorithms are completed for those residents presenting with signs and symptoms of an infection on PPS study day. • Depending on the infection site, surveyors will decide, with the aid of the algorithm criteria, whether or not enough signs/symptoms are present to consider the infection as probable or confirmed.

44. RESIDENT QUESTIONNAIRE Signs and symptoms of infection • Constitutional signs and symptoms must be considered e.g. presence of fever, leuocytosis acute changes in mental status, acute functional decline. • Acute functional decline is based upon an increase in total ADL (Activities of Daily Living) score from baseline or increased dependency by scales other than ADL.

45. RESIDENT QUESTIONNAIRE Signs and symptoms of infection • Exclude infections already present or in incubation at the time of admission or re-admission to the LTCF. Recently admitted/readmitted residents - Is infection acquired before or after admission? ⇒ Decision based on the type of infection and the expected incubation period. • All symptoms must be new or acutely worse. Many residents have chronic symptoms, such as cough or urinary urgency, that are not associated with infection. However, a change in the resident’s status is an important indication for infection in development.

46. RESIDENT QUESTIONNAIRE Signs and symptoms of infection • Non-infectious causes of signs and symptoms should always be considered before a diagnosis of infection is made. • Identification of infection should not be based on a single piece of evidence. Microbiological and radiological findings should be used only to confirm clinical evidence of infection.

47. CELLULITIS/ SOFT TISSUE/ WOUND INFECTIONS ALGORITHM- Cellulitis example All signs/symptoms present are recorded in resident form algorithms which in turn lead to a decision as to whether or not the resident meets the criteria necessary to confirm an infection Only the information in the grey boxes (i.e. infection confirmation (confirmed/probable); local antibiotic use; urine dipstick result and other infections) are reported in the software

48. ALGORITHMS FOR SIGNS/ SYMPTOMS • Exhaustive searching of signs/symptoms present in residents is crucial in order to be able to confirm infections. • Record in the resident questionnaire algorithms, all signs & symptoms of each possible infection e.g. if a resident has a possible UTI and signs/ symptoms of other infections complete the UTI algorithm and repeat for other infections the resident may have (skin, respiratory infection etc).

49. ALGORITHMS FOR SIGNS/ SYMPTOMS • Only the information in the grey boxes (i.e. infection confirmation (confirmed/probable); local antibiotic use; urine dipstick result and other infections) are ultimately reported in the software BUT signs and symptoms MUST BE ticked off in resident questionnaire algorithms. • Refer to the PPS protocol for definitions of signs/symptoms and infection criteria.

50. INSTITUTIONAL QUESTIONNAIRE - SECTION B Information from the summary table from ward lists is used to complete this section If no residents are receiving AB treatment on study day, zero must be entered here. Necessiating the use of diapers in the 24 hours prior to PPS, during the day and/or night