LTC Respiratory Surveillance Line List and Surveillance ...



ColumnDescriptionFor StaffFor ResidentCASE DEMOGRAPHICSFill in each line with name, age and gender of each person (Resident and/or Staff) affectedUse (S) to indicate case is a Staff memberUse (RP) to indicate case Permanent Resident, (RR) for Respite ResidentCASE LOCATIONRecord where case was identified or where staff member* was working*staff = any person on site that provides a service, i.e.: nurses, PCW, allied health, life style, food services, cleaner. Whether employed, contracted, consulting or volunteer.Record the primary care location allocated for the staff member at the time of illness onset.Or record unit/floor where the resident is located, room number and bed number (i.e.: if sharing a room)For BOTH Staff & ResidentsSIGNS AND SYMPTOMS Record the date (day/month/year) each person developed/ reported/ demonstrated signs/symptomsTick (?) all relevant symptomsFever (> 37.5C), Sore throat, Cough, Shortness of Breath, FatigueDIAGNOSTICSRecord the type of specimens taken, tests ordered/performed and resultsIf more than one specimen taken, test ordered or test result, ensure all are recorded Record the Date of collection: (day/month/year)Record which Laboratory the specimen(s) were sent to for testingX-Ray: Tick (?) if performedSpecimens: Use following symbols to record the specimen(s) collected NP:Nasopharyngeal swabOP:Oropharyngeal swab S:Sputum B:Blood O:Other (Specify): if specimen is not listed, record it in this column Type of Test Ordered: Use following numbers to record the type of test(s) 0:Test unable to be performed 1:Culture 2:Polymerase Chain Reaction (PCR), also called nucleic acid testing 3:Other (Specify): if test is not listed, record it in this columnTest Result: Use the following codes to record organism(s) identified 1:Negative 2:Bacterial 2a: 2b: 2c: 2d: Streptococcus pneumoniae Mycoplasma Haemophilus Legionella 3:Viral 3a: 3b: 3c: 3d: Influenza (flu) COVID-19 Respiratory Syncytial Virus (RSV) Rhinovirus (common cold) 4. Other (specify): if organism is not listed, record it in this column OUTCOMERecord Symptom resolution date: date illness resolved (symptom free for 24hrs)Note: Details regarding staff maybe recorded/held by Human Resources Hospitalized: Tick (?) if Resident or Staff Member required hospitalization in relation to the illness.Died: Use (Y) or (N) if Resident or Staff Member passed away due to illness.Case: Use (C) if illness meets Case definition. Leave blank if does not meet definition.Date:// This worksheet was adapted from the Centers for Disease Control and Prevention resources (Source: ). It aims to help residential aged care homes detect, characterize and investigate a possible outbreak of respiratory illness.CASE DEMOGRAPHICSCASE LOCATIONSIGNS AND SYMPTONS (S/S)DIAGNOSTICSOUTCOME DURING OUTBREAKNameAgeGender (M/F)Resident Permanent (RP), Resident Respite (RR) or Staff (S)Unit/Floor resides (Resident) or Primary Care allocation (Staff)RESIDENTS ONLY: Room/Bed No.Symptom onset date Fever (≥37.5)Sore throatCoughShortness of breathFatigueO – 0ther: Specify: ____________________Date of collection Laboratory specimen sent toSpecimen collected (can be multiple codes)Type of test ordered (can be multiple codes)Test Result (code required)Symptom resolution dateHospitalised Died Case (C) or Not a case (Leave blank)12345678910If sending to your local Public Health Department, please complete the following information:Facility NameRACS/Service IDStateContact PersonPhoneEmailA Note: Outbreak defined as date of first case to resolution of last case. ................
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