IDENTIFIERS AND ABSTRACTED DATA:

1. IDENTIFIERS AND ABSTRACTED DATA:

Use Tables on page 1 to document information as needed to answer questions beginning on page 2.

State Facility (NHSN) orgID

Date of Audit ___/___/____ Patient ID

(circle): ACH / LTACH / CancerH / Other

Patient DOB ___/___/____

Reviewer Initials

Review Start Time:

End Time:

Time spent reviewing this record (minutes):

FACILITY Admission Date: ___/___/____

FACILITY Discharge Date: ___/___/____

Positive Blood specimens /Repeat Infection Timeframe: Pre-screening Question: Were any positive blood specimens drawn on or after facility day 3 or was the DOE the day of transfer or discharge, or the next

day?  If Yes, continue  If No, (all positive blood specimens were drawn before facility day 3) there was no HAI/CLABSI Event. STOP, record outcome (a) No candidate VL

CLABSI

a. Document ALL positive blood specimens sequentially below in Table 1a..Then using information from “Table 1b. Locations” below, indicate which were “Validation Location (VL) blood specimens”, defined as those collected during VL stays, or on day of or day after VL discharge. Note: These VL blood specimens are eligible for possible VL CLABSI. (Non VL blood specimens may also be important to establish BSI repeat infection timeframe and other location of attribution.). Complete Table 1c. which documents presence placed/accessed. b. For each organism, indicate whether it is a pathogen (P) or common commensal (cc); the list of common commensals is available in LCBI Criteria. Note:

Common commensals should only be evaluated as matched pairs/multiples if they were drawn on same/consecutive days; otherwise they are considered contaminants.

The matching common commensals represent a single element; therefore, the collection date of the first common commensal is the date of the element used occur within the 3 days prior to date of element, the first sign/symptom is used as the date of event to determine the RIT dates.

c. Using clinical information (which can include signs/symptoms, and test results), divide listed blood specimens into distinct “RITs” and assign a RIT Number. Positive blood specimens during previous BSIRIT (regardless of possible change in organism) are considered a single Infection Event.

Note: Infection Window Period (IWP): The NHSN Infection Window Period is defined as the 7-days during which all site-specific infection criteria must be met. It includes the day the first positive diagnostic test that is used as an element of the site-specific infection criterion, was obtained, the 3 calendar days before and the 3 calendar days after.

___/___/___ *BC=blood specimen, P=pathogen, CC=common commensal, RIT= Repeat Infection Timeframe, DOE=Date of Event. Add rows if needed.

Table 1b. Locations:

Table 1c. Central Lines*:

Document all facility locations and dates sequentially for this Document time periods below with ANY central line in place for at least part episode of care below, and indicate locations being validated for

of a day, following placement or access (do not document individual lines CLABSI by circling Yes or No (VL=validation location).

removed and replaced on same/ consecutive days) (CL=central line) Facility

*Central line: IV catheter ending at/near heart or in great vessel (aorta, PA, Location

SVC, IVC, brachiocephalic, internal jugular, subclavian, external iliac, common Order

Transfer IN

OUT

(include ED)

VL?

iliac, or femoral vein; umbilical artery/vein), placed or accessed and used for infusion, blood draw, or hemodynamic monitoring (NHSN Manual 4-2)

CL placed or

CL removed

without replacement

Locations housed with CL 3 ___/___/___

Add rows if needed

Add rows if needed