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{"sheet":"Instructions","index":0,"n_rows":46,"n_cols":1,"rows_kept":46,"cut":false,"hidden":false,"merged":[[3,0,3,4],[5,0,5,4]]}
["Note: This template contains sample data and information to demonstrate how the template may be used. Please remove pre-populated data prior to utilizing at your facility. "]
["Infection Surveillance Log for Long-Term Care Facilities"]
["Purpose:"]
["Surveillance data can be used to track infections, detect clusters and outbreaks, identify emerging diseases, and initiate containment strategies. Surveillance data is also used to ensure compliance with federal and state regulations or mandatory reporting requirements. Data analysis and reports should be shared with key members of the organization, such as the infection control committee and the quality assurance and performance improvement (QAPI) committee. This tool is intended to help long-term care facility (LTCF) infection preventionists establish infection surveillance logs for the facility. The infection surveillance log should be based upon the facility's surveillance policies and protocols, with a goal of reducing or eliminating the spread of infections within the facility. The tool should be modified as needed to fit the facility's specific needs."]
["Background:"]
["Comprehensive infection surveillance involves surveillance for both residents as well as employees. Employees may include paid and unpaid staff, providers, trainees, students, and volunteers. Facilities may utilize standardized criteria* (such as McGeer, Loeb, or National Healthcare Safety Network {NHSN}) to compare infection rates over time. Infection preventionists may receive information about potentially infectious residents and employees in a variety of ways, such as verbally, electronic notification, or by built-in surveillance programs. It is important that the infection preventionist has a defined method for receiving this information, and that all staff who may be involved in the notification process understand their role. "]
["Instructions for using this log:"]
["1. Using the \"Resident Surveillance Log\" tab:"]
["a. \"Unit\": List the unit name or number where the resident resides, if applicable."]
["b. \"Room\": List the room number where the resident resides. If the room is not single occupancy, also note the bed in which the resident resides."]
["c. \"Resident\": List the resident's name."]
["d. \"Admit date\": List the date the resident was admitted to the facility."]
["e. \"Room admission date\": List date of resident admission to current room, if different from facility admission date and if the date of the room change is relevant to the infection."]
["f. \"Signs and symptoms\": List all relevant infectious signs and symptoms that are present in the resident. "]
["g. \"Date of onset\": List the date of onset of the first infectious symptom."]
["h. \"Infection type\": List the type of infection the resident is experiencing (such as upper respiratory, urinary tract infection, gastrointestinal infection)."]
["i. \"Isolation precautions type initiated\": List the type of transmission-based precautions (such as contact, droplet, or airborne) that were initiated based upon the symptoms the resident displayed. Isolation should be implemented imperically based upon resident symptoms. Utilize the Wisconsin Healthcare-Associated Infections Prevention Program's Transmission-Based Precautions In Health Care Settings Reference Guide (https://www.dhs.wisconsin.gov/publications/p03366.pdf) and CDC (Centers for Disease Control and Prevention) Appendix A: Type and Duration of Precautions (https://www.cdc.gov/infection-control/hcp/isolation-precautions/appendix-a-type-duration.html) to guide decision making."]
["j. \"Date of isolation precautions initiated\": List the date isolation precautions were initiated."]
["k. \"Surveillance criteria met?\": Indicate \"yes\" or \"no\" as to whether the resident has met the specific surveillance criteria that the facility follows (such as McGeer, Loeb, or NHSN). "]
["l. \"Healthcare-associated infection?\" Indicate \"yes\" or \"no\" as to whether the infection was health-care associated."]
["m. \"Lab or x-ray date\": Note the date performed for any lab tests or xrays that have been performed to evaluate evidence of infection."]
["n. \"Lab or x-ray result\": Note any relevant lab or x-ray results."]
["o. \"Pathogen\": For any cultures or molecular tests that were ordered, if positive, list the pathogens that were found. If none, leave blank or enter \"n/a.\""]
["p. \"Linked to facility outbreak (Yes/No)\": Indicate \"yes\" or \"no\" as to whether this infection may be linked to a current outbreak in the facility. For additional information regarding respiratory illness outbreaks, please visit the Wisconsin Department of Health Services Preventing and Controlling Respiratory Illness Outbreaks in Long-Term Care Facilities and Other Health Care Settings webpage (https://www.dhs.wisconsin.gov/disease/respiratory-outbreak.htm). "]
["q. \"Exposed inviduals (residents and staff)\": Document results of contact tracing."]
["r. \"Reportable to public health (Yes/No)\": Indicate \"yes\" or \"no\" as to whether this infection or condition is reportable to public health authorities. Utilize guidance from the Wisconsin Division of Public Health to determine whether an infection or condition is reportable (https://www.dhs.wisconsin.gov/publications/p03305.pdf). "]
["s. \"Date reported to public health (if applicable)\": Indicate the date that the reportable communicable infection or condition was reported to public health authorities."]
["t. \"Antibiotic\": List antibtioics that were prescribed."]
["u. \"Date isolation removed\": List the date the isolation was discontinued. Utilize the Wisconsin Healthcare-Associated Infections Prevention Program's Transmission-Based Precautions In Health Care Settings Reference Guide (https://www.dhs.wisconsin.gov/publications/p03366.pdf)and CDC (Centers for Disease Control and Prevention) Appendix A: Type and Duration of Precautions (https://www.cdc.gov/infection-control/hcp/isolation-precautions/appendix-a-type-duration.html) to guide decision making."]
[]
["2. Utilizing the \"Employee Surveillance Log\" tab:"]
["a. \"Employee\": List the employee's name."]
["b. \"Signs and symptoms\": List all relevant infectious signs and symptoms that are present in the employee."]
["c. \"Date of onset\": List the date of onset of the first infectious symptom."]
["d. \"Lab or x-ray date\": Note the date performed for any lab tests or xrays that have been performed to evaluate evidence of infection."]
["e. \"Lab or x-ray result\": Note any relevant lab or xray results."]
["f. \"Pathogen\": For any cultures or molecular tests that were ordered, if positive, list the pathogens that were found. If none, leave blank or enter \"n/a.\""]
["g. \"Reportable to public health (Yes/No)\": Indicate \"yes\" or \"no\" as to whether this infection or condition is reportable to public health authorities. Utilize guidance from the Wisconsin Division of Public Health to determine whether an infection or condition is reportable (https://www.dhs.wisconsin.gov/publications/p03305.pdf). "]
["h. \"Date Reported to public health\": Indicate the date that the reportable communicable infection or condition was reported to public health authorities, if applicable. Otherwise, enter \"n/a.\""]
["i. \"Worked during infectious period\": Indicate whether the employee worked in the facility during their infectious period (for example, 48 hours prior to symptom onset)"]
["j. \"Unit worked\": Indicate the unit where the employee worked during the infectious period. Otherwise, enter \"n/a.\""]
["k. \"Exposed inviduals (residents and staff)\": Document results of contact tracing."]
["l. \"Linked to facility outbreak (Yes/No)\": Indicate \"yes\" or \"no\" as to whether this infection may be linked to a current outbreak in the facility. For additional information regarding respiratory illness outbreaks, please visit the Wisconsin Department of Health Services Preventing and Controlling Respiratory Illness Outbreaks in Long-Term Care Facilities and Other Health Care Settings webpage (https://www.dhs.wisconsin.gov/disease/respiratory-outbreak.htm). For additional information regarding gastrointestinal illness outbreaks, please see the Wisconsin Department of Health Services Recommendations for Prevention and Control of Acute Gastroenteritis Outbreaks in Wisconsin Long-Term Care Facilities (https://www.dhs.wisconsin.gov/publications/p0/p00653.pdf). "]
["m.  \"Follow-up actions\": Document what actions the facility put in place (such as outbreak testing, staff education) or additional relevant information."]
[]
["*The Healthcare-Associated Infections Prevention (HAI) Program does not endorse any particular surveillance criteria."]

{"sheet":"Resident Surveillance Log","index":1,"n_rows":7,"n_cols":21,"rows_kept":7,"cut":false,"hidden":false,"merged":[[1,0,1,8],[0,0,0,8]]}
["Resident Surveillance Log"]
["Organization name: "]
[]
["Unit","Room","Resident","Admit date","Room admission date","Signs and symptoms","Date of symptom onset","Infection type","Type of isolation precautions initiated","Date isolation precautions were initiated","Surveillance criteria met? (Yes/No)","Healthcare-associated infection? (Yes/No)","Lab or x-ray date","Lab or x-ray result","Pathogen","Linked to facility outbreak? (Yes/No)","Exposed individuals","Reportable to public health? (Yes/No)","Date reported to public health (if applicable)","Antibiotic prescribed","Date isolation precautions removed"]
[100,111,"Jane Doe","2024-04-24","2024-04-24","Productive cough, Fever","2024-06-01","Pneumonia",null,null,null,null,null,"RLL pneumonia\n­ WBC, Positive Sputum Culture","Klebsiella pneumoniae",null,null,null,null,"Keflex 300mg BID "]
[200,222,"Jake Fawn","2024-04-24","2024-05-02","nausea, Loose stools, Emesis","2024-06-10","GI","Contact","2024-06-10",null,"Yes","2024-06-11","Norovirus +","Norovius","Yes","Ben Smith (S)","Yes","2024-06-11","NA"]
[200,224,"Gertrude Martin","2022-03-12","2022-03-12","Loose stools, Fever","2024-06-11","GI","Contact","2024-06-11",null,"Yes","NA","NA","Presumptive Norovirus","Yes",null,"Yes","2024-06-11","NA"]

{"sheet":"Employee Surveillance Log","index":2,"n_rows":6,"n_cols":13,"rows_kept":6,"cut":false,"hidden":false,"merged":[[0,0,0,8],[1,0,1,8]]}
["Employee Surveillance Log"]
["Organization name: "]
[]
["Employee name","Signs and symptoms","Date of symptom onset","Lab or x-ray testing date","Lab or x-ray results","Pathogen","Reportable to public health? (Yes/No)","Date reported to public health","Worked during infectious period? (Yes/No)","Unit worked","Exposed individuals (residents and staff)","Linked to facility outbreak? (Yes/No)","Follow-up actions"]
["Mindy Jones","nausea, Loose stools","2024-06-09",null,null,null,"Y","2024-06-11","Yes",200,"Jake Fawn (R), Mark Ferrell (S), Gertrude Martin (R), Ben Smith (S)","Yes","Can return to work after 48 hours symptom free.  Soonest return date of 6/12/2024"]
["Ben Smith","Loose stools, Emesis","2024-06-11",null,null,null,"Y","2024-06-11","Yes",200,"All 200 unit residents","Yes","Can return to work after 48 hours symptom free.  Soonest return date of 6/14/2024"]

{"sheet":"Drop-Down Table Selections","index":3,"n_rows":5,"n_cols":3,"rows_kept":5,"cut":false,"hidden":false,"merged":[]}
["Signs and symptoms",null,"Isolation precaution types"]
["Productive cough",null,"Contact"]
["Fever",null,"Droplet"]
["Loose stools",null,"Airborne"]
["Emesis",null,"Enhanced-barrier"]