INFECTION SCREENING/SURVEILLANCE FORM FOR HOME ACQUIRED INFECTIONS

Ideal HomeHealth Care, LLC

INFECTION SCREENING/SURVEILLANCE FORM FOR HOME ACQUIRED INFECTIONS

URINARY TRACT INFECTION

Yes

No

Must meet One of the following criteria and/or had an indwelling catheter within the last 7 days :

Two of the following signs/symptoms :

Fever or chills

Flank pain or suprapubic pain or tenderness or frequency or urgency

Worsening mental status or functional status

Changes in urine character AND urinalysis or culture not done

One of the following two signs or symptoms :

Fever or chills

Flank pain or suprapubic pain or tenderness or frequency or urgency

AND

Bacteria (positive culture or nitrite) and pyuria (>10 wbc/hpf or leukocytes) on urinalysis

CENTRAL LINE ASSOCIATED BLOOD STREAM INFECTIONS

Yes

No

Must meet One of the following criteria and had a central line within the last 48 hours :

Recognized pathogen cultured from one or more blood cultures AND organism is not related to an infection at another site

Patient has a least One of the following signs or symptoms:

Fever

Chills

Hypotension

AND

Common skin contaminant is cultured from two or more blood cultures.

GASTROINTESTINAL INFECTIONS

Yes

No

Gastroenteritis must meet One of the following three criteria :

Two or > loose watery stools in 24 hours

Two or > vomiting episodes in 24 hours

Stool culture for gastrointestinal pathogen AND any of the following S/S:

Nausea

Vomiting

Abdominal pain or tenderness

Diarrhea

CLOSTRIDIUM DIFFICILE BACTERIUM (C.Diff.)

Yes

No

Must meet Both of the following :

Two or more loose watery stools

Positive assay for C.Diff. toxin

INFLUENZA LIKE ILLNESS

Yes

No

Must meet Both of the following criteria :

Fever

Three of the following signs and symptoms :

New headache or eye pain

Myalgia

Malaise or loss of appetite

Sore throat

Chills

New or increased cough

SKIN & SOFT TISSUE INFECTIONS

Yes

No

Must meet One of the following:

Purulent drainage from wound, skin or soft tissue site, ostomy and drains

Four of the following signs or symptoms :

Fever or worsening mental/functional status

Pain or tenderness at the affected site

Localized swelling at the affected site

Redness at the affected site

Heat at the affected site

Serious discharge at the affected site

RESPIRATORY INFECTION

Yes

No

Bronchitis: No chest x-ray or chest x-ray is negative AND three of the following eight signs and symptoms:

New or increased cough

New or increased sputum production

New or increased purulence of sputum

Fever

Pleuritic chest pain

New or increased physical findings on exam (Rales, Rhonchi, Bronchial Breathing)

Change in status or breathing difficulty (new or increase SOB, resp rate > 25 bpm)

Worsening mental functional/mental status

Pneumonia : Above criteria and positive chest x-ray

EYE, EAR, NOSE AND MOUTH INFECTIONS

Yes

No

Conjunctivitis : Must meet one of the following two criteria

Pus from one or both eyes

Redness with or without itching or pain

Ear Infection : Must meet one of the following two criteria

Physician diagnosis

New purulent fluid in the middle ear accompanied by ear pain or tympanic redness

Sinusitis : Must meet at least one of the following three criteria

Physician diagnosis

Organism is cultured from purulent material from the sinus cavity

One of the following four signs or symptoms with One other recognized cause:

Fever

Pain or tenderness over the involved sinus

Headache

Purulent exudates or nasal obstruction

Must be physician diagnosed with the presence of white patches in the oral cavity.

Patient referred to:

Physician Office

Yes

No

Emergency Department

Yes

No

Acute Care

Yes

No

Treatment prescribed:

Oral Antibiotic

IV Antibiotic

Emergency Room Visit

Office Visit

Rehospitalization

No Treatment

Other :

Did the infection resolve?

Yes

No

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