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    Denominators For Intensive Care Unit (ICU) /other Locations (Not NICU or SCA)

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    ardhena ekasari
    This document is a form for reporting monthly denominator data for an intensive care unit (ICU) or other non-NICU/SCA locations. It collects numbers of patients for the month by various categories including total patients, patients with central lines, patients with urinary catheters, patients on ventilators, and episodes of mechanical ventilation. Totals for patient days and device days in each category are also reported. The form includes disclaimers about voluntary reporting and guarantee of confidentiality according to federal regulations.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Denominators For Intensive Care Unit (ICU) /other Locations (Not NICU or SCA)

    Uploaded by

    ardhena ekasari
    37 views1 page
    This document is a form for reporting monthly denominator data for an intensive care unit (ICU) or other non-NICU/SCA locations. It collects numbers of patients for the month by various categories including total patients, patients with central lines, patients with urinary catheters, patients on ventilators, and episodes of mechanical ventilation. Totals for patient days and device days in each category are also reported. The form includes disclaimers about voluntary reporting and guarantee of confidentiality according to federal regulations.

    Original Title

    57.118_DenominatorICU_BLANK

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    This document is a form for reporting monthly denominator data for an intensive care unit (ICU) or other non-NICU/SCA locations. It collects numbers of patients for the month by various categories including total patients, patients with central lines, patients with urinary catheters, patients on ventilators, and episodes of mechanical ventilation. Totals for patient days and device days in each category are also reported. The form includes disclaimers about voluntary reporting and guarantee of confidentiality according to federal regulations.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    37 views1 page

    Denominators For Intensive Care Unit (ICU) /other Locations (Not NICU or SCA)

    Uploaded by

    ardhena ekasari
    This document is a form for reporting monthly denominator data for an intensive care unit (ICU) or other non-NICU/SCA locations. It collects numbers of patients for the month by various categories including total patients, patients with central lines, patients with urinary catheters, patients on ventilators, and episodes of mechanical ventilation. Totals for patient days and device days in each category are also reported. The form includes disclaimers about voluntary reporting and guarantee of confidentiality according to federal regulations.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 1

    Form Approved

    OMB No. 0920-0666


    Exp. Date: 01/31/24
    www.cdc.gov/nhsn
    Denominators for Intensive Care Unit (ICU)/Other Locations
    (not NICU or SCA)
    Page 1 of 1
    *required for saving
    Facility ID: *Location Code: *Month: *Year:
    **Number Number of
    **Number of patients **Number of patients Number of
    *Number of total Episodes of
    Date with 1 or more central with a urinary patients on
    Mechanical
    of Patients patients on APRV
    lines catheter Ventilation
    a ventilator
    1
    2
    3
    4
    5
    6
    7
    8
    9
    10
    11
    12
    13
    14
    15
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    17
    18
    19
    20
    21
    22
    23
    24
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    26
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    30
    31
    *Totals
    Episodes of
    Patient-days Central-line days Urinary catheter-days Ventilator-days Mechanical
    Ventilation
    **Conditionally required according to the events indicated in Plan.
    Label _____________ _____________ _____________ _____________ _____________
    Data _____________ _____________ _____________ _____________ _____________
    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)).

    Public reporting burden of this collection of information is estimated to average 5.02 hours per response, including the time for reviewing instructions, searching existing
    data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a
    person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate
    or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74,
    Atlanta, GA 30333, ATTN: PRA (0920-0666).
    CDC 57.118, Rev.3, v8.8

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