2015 CAMC UR & SINU Upper Respiratory Tract Infection & Sinusitis Worksheet

2015 CAMC UR & SINU – Upper Respiratory Tract Infection & Sinusitis Worksheet Name DOB Age Birthweight Test Period Unit Event Date M F (gms) (Neonates only) MR # Account # Medicare ID # Pt expire Admit date D/C date Yes No Admitting Attending / ID ICU Admit date ICU D/C date Diagnosis Consultant

Culture date Pathogen(s) Culture Site Culture date Pathogen(s) Culture Site

SINU-Sinusitis Sinusitis must meet at least one of the following criteria: Date

1. Patient has organisms cultured from fluid or tissue from the sinus cavity obtained during an invasive procedure. 2. Patient has at least one of the following signs or symptoms: fever (>38.0°C±), pain or tenderness over the involved sinus*, headache*, purulent exudate*, or nasal obstruction* AND Imaging test evidence of sinusitis (e.g., x-ray, CT scan) * With no other recognized cause ± As documented in the medical record

UR-Upper respiratory tract infection, pharyngitis, laryngitis, epiglottitis Upper respiratory tract infections must meet at least one of the following criteria: Date 1. Patient has at least two of the following signs or symptoms: fever (>38.0°C±), erythema of pharynx*, sore throat*, cough*, hoarseness*, or purulent exudate in throat* AND at least one of the following: a. Organisms cultured from upper respiratory site [i.e. larynx, pharynx, and epiglottis] (Note: excludes sputum because sputum is not an upper respiratory specimen) b. Positive non-culture diagnostic laboratory test from upper respiratory site [i.e. larynx, pharynx, and epiglottis] (Note: excludes sputum because sputum is not an upper respiratory specimen) c. Diagnostic single antibody titer (IgM) or 4-fold increase in paired sera (IgG) for organism d. Physician diagnosis of an upper respiratory infection 2. Patient has an abscess on gross anatomical or histopathologic exam or imaging test. 3. Patient ≤1 year of age has at least two of the following signs or symptoms: fever (>38.0°C±), hypothermia (<37.0°C± ), apnea*, bradycardia*, nasal discharge*, or purulent exudate in throat* AND at least one of the following: a. Organisms cultured from upper respiratory site [i.e. larynx, pharynx, and epiglottis] (Note: excludes sputum because sputum is not an upper respiratory specimen) b. Positive non-culture diagnostic laboratory test from upper respiratory site [i.e. larynx, pharynx, and epiglottis] (Note: excludes sputum because sputum is not an upper respiratory specimen) c. Diagnostic single antibody titer (IgM) or 4-fold increase in paired sera (IgG) for organism d. Physician diagnosis of an upper respiratory infection * With no other recognized cause ± As documented in the medical record Notes/Comments: 2015 CAMC UR & SINU – Upper Respiratory Tract Infection & Sinusitis Worksheet Table of Events Inf ecti Ho Dat on spi Dat e of Wi Uni tal RIT e Eve nd t Da nt ow y Per iod

Infection Window Period (first + diagnostic test, 3 days before & 3 days after) Repeat Infection Timeframe-RIT (14 day timeframe where date of event = day 1) Date of Event (date the first element occurs for the first time within the infection window period) Secondary BSI Attribution Period (Infection Window Period + RIT)