Case Capture User Guide
Contents
1. Created Date Once the case has been entered and saved this field is auto completed with the date on which the case was saved showing users the date the case was created Data Collections The four Data Collections covered in this guide are C difficile E coli MRSA MSSA The main Data Collection Tab is the Episode Details page which is the same across all Data Collections there are also Data Collection specific tabs Table 2 HCAIDCS Case Capture UserGuide v1 0 Table 2 List of Data Collection Tabs expected for each Data Collection Data Collection Data Collection Tabs C difficile Episode Details Risk Factors Healthcare Interactions Inpatient Details E coli Episode Details Risk Factors MRSA Episode Details Source of Bacteraemia amp Associated Infections Risk Factors amp Treatment Healthcare Interactions MSSA Episode Details Source of Bacteraemia amp Associated Infections Risk Factors amp Treatment Healthcare Interactions HCAIDCS Case Capture UserGuide v1 0 3 Episode Details Tab Once a Data Collection has been selected the Episode Details screen will be presented Figure 2 Figure 2 The Episode Details tab Case Capture Episode Details Risk Factors Healthcare Interactions satient Details Data Upload Wizard User Administration 0 Mandatory fields are masked with red asterisk p3 Mandatory for2. Select ki sve Table 11 Overview of the Risk Factors and Treatment Tab fields Field name Comment Pre disposing factors Were there any pre disposing risk factors for Only if Yes is selected is it possible to select the bacteraemia a pre disposing factor List of pre disposing factors As many pre disposing factors as applicable can be selected Prior S aureus History Prior S aureus history If any option except None Unknown and Other is selected When Select the timescale Treatment of bacteraemia 25 HCAIDCS Case Capture UserGuide v1 0 Treatment of bacteraemia Select as many options as appropriate from the drop down list Healthcare Interactions Tab Table 12 Overview of the Healthcare Interactions Tab fields Field name Comment Healthcare interactions tab Do you want to add a healthcare interaction Only if Yes is answered will further questions be enabled When Select the timescale within which the interaction occurred Type of interaction Select the type of interaction Where Select where the interaction occurred NHS acute Trust organisation If NHS acute Trust is selected from Where the name of the organisation must be selected from the drop down list which is enabled Independent Sector Provider Organisation If Independent Sector Provider is
3. Sign Off fields are marked with red hash Reports Help amp Support Organisation Details Reporting Organisation BARTS HEALTH NHS TRUST This page provides the facility to create a new infection episode 3 Specimen Details If NHS number is unknown Specimen Date 2303 2015 please enter 999 999 9999 See FAQs and Content for more info Type of Specimen Date Date Specimen Taken Date Received in Lab Specimen No Key to Screen Symbols Laboratory where specimen processed Select Patient Details B Close Ser x eee O di NHS Number EZZ A Attention 0 Information Forename O mme Surname Date of Birth 7 ry Sex J Male Female O Unknown Hospital Number Episode Category Select Admission Details Patient Location s Select Provenance Select Treatment Details Admitted any time during this episode Select On Dialysis Select 3 Additional Comments Messages displayed under the Tabs will either be information messages or error messages Figure 3 The initial message displayed when a Data Collection is selected is an Information message indicating which fields need to be completed to allow a case to be saved and signed off Table 3 Each of the Episode Details Tab contains fields with super scripts or amp beside them HCAIDCS Case Capture UserGuide v1 0 Figure 3 The information and error messages bar Episode Details Risk Factors Heal
4. hospital site within which the patient was 15 HCAIDCS Case Capture UserGuide v1 0 located Treatment Details section This section captures further information on the patient s treatment Table 6 Overview of the Treatment Details section Field Name Comment Treatment Details Admitted any time during this episode This field captures whether the patient was admitted at any point during the episode This differs from the Date Admitted field in Admission Details section which captures admission information about the patient at the time of specimen collection On Dialysis This captures whether the patient is receiving dialysis If Yes Established RF is selected the record should be shared with the renal unit providing the renal care Please refer to the Sharing User Manual for more information Main Speciality triggered field This field is enabled when NHS acute Trust Non acute NHS provider Independent Sector Provider or Mental Health Provider is selected as the Patient Location This refers to the specialty of the consultant the patient was under at the time the specimen was collected Treatment Speciality triggered field This field is enabled when NHS acute D 66 Trust Non acute NHS provider 16 HCAIDCS Case Capture UserGuide_v1 0 Independent Sector Provider or Men
5. selected will further questions become available Only one option can be selected Certainty Select the certainty Inpatient details For inpatients what specialty was the infection thought to have been acquired in Augmented Care If Not applicable is selected the field Treatment Specialty becomes available This is different from the information entered on the Episode Details tab as it relates to the specialty where the infection was thought to have been acquired Treatment specialty triggered question This is different from the information entered on the Episode Details tab as it relates to the specialty where the infection was thought to have been acquired Not applicable can be selected Date From Date To The dates from and to that the patient was in the treatment specialty 24 HCAIDCS Case Capture UserGuide v1 0 Risk Factors amp Treatment Tab Figure 9 The Risk Factors and Treatment Tab Episode Details Source of Bacteraemia amp Associated Infections Risk Factors amp Treatment Healthcare Interactions Renai Mandatory fields are marked with red asterisk Mandatory for Sign Off fields are marked with red hash 3 Pre disposing Factors Were there any pre disposing risk factors for the bacteraemia X Prior S aureus History Prior S aureus history Select a Treatment of Bacteraemia Treatment of bacteraemia
6. aos Public Health England Protecting and improving the nation s health HCAI Data Capture System Case Capture Main Data Collections User Manual Version 1 0 HCAIDCS Case Capture UserGuide v1 0 About Public Health England Public Health England exists to protect and improve the nation s health and wellbeing and reduce health inequalities It does this through world class science knowledge and intelligence advocacy partnerships and the delivery of specialist public health services PHE is an operationally autonomous executive agency of the Department of Health Public Health England Wellington House 133 155 Waterloo Road London SE1 8UG Tel 020 7654 8000 www gov uk phe Twitter PHE_uk Facebook www facebook com PublicHealthEngland Crown copyright 2015 You may re use this information excluding logos free of charge in any format or medium under the terms of the Open Government Licence v2 0 To view this licence visit OGL or email psi nationalarchives gsi gov uk Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned Corporate member of Plain English Campaign Committed to clearer communication HCAIDCS Case Capture UserGuide v1 0 Document History Revision date Author Version 01 09 2015 Public Health England HCAIDCS Case Capture UserGuide v1 0 Contents Case Capture le D OR le Introduction Ente
7. der or Mental Health Provider This field categorises the patient at the time the specimen was taken into one of the groups shown in the dropdown menu Any subsequent location of the patient after the sample was taken is not relevant here for example if the patient was admitted after having a sample taken in A amp E the patient category is still A amp E only Do you know the admission date triggered field This field is triggered when Patient Category In patient Day patient Emergency Assessment Other or Unknown is selected Date Admitted triggered field Selecting Yes for the above field triggers the Admission Date field Admission Method triggered field This field is triggered when Patient Category In patient Day patient Emergency Assessment Other or Unknown is selected This field is used to determine the admission method of the patient Provenance The location of the patient prior to arriving at the healthcare facility Trust Provider Admitted From triggered field This field is enabled when Hospital UK or abroad Non acute NHS Provider Independent Sector Provider or Mental Health Provider are selected as the Provenance Hospital Site Admitted From triggered field This field is enabled when a Trust Provider Admitted From is selected It is the specific
8. e Interactions Y Inpatient Details Mandatory fields are marked with red asterisk Mandatory for Sign Off fields are marked with red hash Onset of Diarrhoea this episode Best estimate of date of onset of diarrhoea 2402 2015 E Antimicrobial Usage Was patient on antimicrobials when specimen was taken Yes Select antimicrobials when specimen was taken Enfuvirtide T 20 Was patient on any other antimicrobials in the preceding 7 days Yes Select antimicrobials in the preceding 7 days Fluconazole Reference Laboratory Result Was the specimen sent for typing Yes Date sent osm22015 Specimen Category Outbreak Cluster 18 HCAIDCS Case Capture UserGuide v1 0 Table 7 Overview of the Risk Factors Tab fields Field Name Comment Onset of Diarrhoea this episode Best estimate of the date of onset of diarrhoea Enter the Best estimate of the date of onset of diarrhoea associated with the current Clostridium difficile infection episode The date can be chosen using the Date Selector Antimicrobial usage Was patient on antimicrobial use at the time when the specimen was taken If Yes is selected the following question is enabled Select antimicrobials when specimen was taken triggered field Select all the relevant antimicrobials from the drop down list Was patient on another antimicrobials in the preceding 7 days If Yes is selected the fol
9. ed Please note the system will not prevent a duplicate case being entered Please double check the NHS number and date of ae 0 a birth match and that the second episode period Please note if an infection episode exists with Patient Detail Admission Details section This collects information about the patient s admission and location prior to attendance at the healthcare facility It is important that any data in this section relates to the time at which the specimen was collected It should not be amended to reflect any subsequent changes Table 5 Overview of the Admissions Details section Field Name Comment Admission Details Patient Location The actual location of the patient when the specimen was taken Trust Provider triggered field This field is only made available if NHS acute Trust Non acute NHS provider Independent Sector Provider or Mental Health Provider is selected Hospital Site triggered field This field is only made available if NHS acute Trust Non acute NHS provider Independent Sector Provider or Mental Health Provider is selected in the Patient Location field It is the specific hospital site within which the patient was located 14 HCAIDCS Case Capture UserGuide v1 0 Patient Category triggered field This field is only made available if a provider organisation is selected i e NHS acute Trust Non acute NHS provider Independent Sector Provi
10. estion Factors directly predisposing to this episode Select an option from the drop down List of predisposing factors The list is only enabled if Yes is selected to the previous question Generally one factor should be selected but it may be applicable to select more than one 27 HCAIDCS Case Capture UserGuide v1 0 Is this episode likely to be an HCAI Select an option from the drop down This is enabled if Likely or Possible is selected in answer to the question Is this episode likely to be an HCAI Where was the infection likely to have been acquired 28
11. lowing question is enabled Select antimicrobials in the preceding 7 days triggered field Select all the relevant antimicrobials from the drop down Reference Laboratory Result Was the specimen sent for typing Only if Yes is selected are the following questions enabled Date sent The date the specimen was sent Specimen category The specimen category 19 HCAIDCS Case Capture UserGuide v1 0 Healthcare Interactions Tab This section deals with any contact the patient may have had with the present Trust or another Trust in the 12 weeks prior to the specimen date Figure 6 The Healthcare Interaction Tab Episode Details Risk Factors Healthcare Interactions Inpatient Details Mandatory fields are marked with red asterisk Mandatory for Sign Off fields are marked with red hash Healthcare Interactions in 12 Weeks Prior to Specimen In the 12 weeks prior to specimen date did the patient attend your TrustASH In the 12 weeks prior to specimen date did the patient attend a different acute TrustSH Other acute TrustAndependent Sector Healthcare provider WALSALL HEALTHCARE NHS TRUST Other ES EUX ES Table 8 Overview of the Healthcare Interactions in the 12 Weeks Prior to Specimen Tab fields Field Name Comment Healthcare Interactions in the 12 Weeks Prior to Specimen In the 12 weeks prior to specimen date did the Select an option from the drop down lis
12. o have been acquired in Augmented care Select from the drop down list This is different from the information entered on the Episode Details tab as it relates to the specialty where the infection was thought to have been acquired What specialty was the infection thought to have been acquired in Treatment Specialty triggered question If Not applicable is selected for field Treatment Specialty becomes available This is different from the information entered on the Episode Details tab as it relates to the specialty where the infection was thought to have been acquired HCAIDCS Case Capture UserGuide v1 0 Date From Date To The dates that the patient was in the specialty for If applicable did the care within this particular treatment specialty end in discharge or death Select either Discharge or Death Date of Discharge Death Enter the date or use the Data selector Ward Type The ward type the patient was in Total number of beds triggered field This is enabled if Nightingale or Other is selected as the ward type 22 HCAIDCS Case Capture UserGuide v1 0 5 MRSA and MSSA additional tabs Source of Bacteraemia amp Associated Infections This section is used to record what was considered to be the cause of bacteraemia following a root cause analysis RCA The information entered here may differ from that on the E
13. pisode Details tab For example the Treatment Specialty and Augmented Care information entered here should reflect the outcome of the RCA Figure 8 The Source of Bacteraemia and Associated Infections tab Y Episode Details Source of Bacteraemia amp Associated Infections Risk Factors amp Treatment Healthcare Interactions Mandatory fields are marked with red asterisk Mandatory for Sign Off fields are marked with red hash Source of bacteraemia Do you know of source of the bacteraemia Source of bacteraemia Certainty Associated Clinical Infections Yes Dialysis line Highly likely Associated Clinical Infection Certainty Inpatient Details For inpatients what specialty was the infection thought to have been acquired in Augmented Care Meningitis Highly likely Renal Unit Table 10 Overview of the Source of Bacteraemia and Associated Infections Tab fields Field name Comment Source of bacteraemia Do you know the source of bacteraemia Only if Yes is selected will further questions be available Source of bacteraemia Select from the drop down list Only one option can be selected Certainty Select the certainty with which the selected 23 HCAIDCS Case Capture UserGuide v1 0 source explains the cause of the bacteraemia Associated clinical infections Associated clinical infection Only if an option is
14. ring a case Episode Details Tab Clostridium difficile infection Additional tabs MRSA and MSSA additional tabs E coli additional tabs oo O1 18 27 HCAIDCS Case Capture UserGuide v1 0 Case Capture 1 Introduction This User Manual describes the process of entering a case infection episode of MRSA MSSA of Escherichia coli bacteraemia or Clostridium difficile infection Please refer to the specific Quarterly Mandatory Laboratory Return QMLR User Guide for information on how to enter QMLRs Additional detail on each of the data items collected and their rationale for collection is provided in the Data Dictionary User Manual A case may be entered onto the HCAI data capture system via two routes 1 Case Capture By selecting Enter a case ne ee from Case Capture option in the New Infection Episode Menu Toolbar on the left hand My Dashboard Data Collection m e n u Search Case Capture E Manage Shared Cases Enter a case Sign Off Cases Data Upload Wizard System Administration Case Administration User Administration System Reports Reports Help amp Support voue TONEY Loonay Hep AA KES 2 Search By selecting Search from the left hand menu and New Infection Episode from the bottom right of the Search screen HCAIDCS Case Capture UserGuide v1 0 2 Entering a case The process of entering a new case is the same whether yo
15. s For C difficile infection a duplicate is any specimen collected from the same patient within 28 days Any positive specimens collected after 14 days MRSA MSSA and E coli bacteraemia or 28 days C difficile infection are considered to be a new episode and must be entered onto the HCAI DCS Whilst entering patient details the HCAI DCS will identify whether a patient s details have previously been entered onto the system based on the Data Collection patients surname date of birth and specimen date which includes a window based on the organism specific episode length Existing records that fulfil the criteria for being a duplicate will be show in a popup along with the case currently being entered Figure 4 You will have the option to either abandon creating the infection episode or continue entering the infection episode Please Note It is necessary for organisations entering data to ensure that duplicates as defined above are not entered or retained on the HCAI DCS HCAIDCS Case Capture UserGuide v1 0 Figure 4 The Potential Duplicate Infection Episode popup window HCAI DCS Potential Duplicate Infection Episode A Date Help amp Support Data ip Est Sraa cof Collectic Name Birth Specime Specime Date Number sae NHS ei Neue Gend Organisation PUBLIC This page displays a list of c 17 09 20 RUE El duplicates andi die 40826 Test Test popop 9999999 U HEALTH 170920 o BW triggered when one is creat
16. s first name Only the initial is displayed when a user who is not authorised to view the Patient Identifiable Information PII views the case Surname The patient s surname This is used to create a Soundex code which is displayed when a user who is not authorised to view the PII views the case Date of Birth Patient s date of birth DoB An error message will occur if the DoB is invalid e g in the future or if it is after the Specimen or Admission Date An accurate DoB is essential for increasing the chances of an accurate attribution to CCG Please note Potential duplicate cases will be identified by the system if certain key fields being entered match an existing record please refer to the Duplicates on Case Capture section below and Figure 4 Sex Patient s gender Hospital Number The patient s local hospital identifier This 12 HCAIDCS Case Capture UserGuide_v1 0 may be determined by checking the patient s hospital documentation Useful for identifying duplicate entries for the same person This allows users to indicate whether this record applies to a new infectious Episode Category episode a continuing infection or whether the patient has suffered a repeat infection or a relapse Duplicates on case capture The definition of a duplicate for MRSA MSSA and E coli bacteraemia is any specimen collection from the same patient within 14 day
17. se you will need to select the relevant site from the drop down Specimen Details Date when specimen was taken If this is not known the date the specimen was received in the laboratory should be used instead E g fora GP sample the date Specimen Date the specimen was taken may not be available An error message will occur if this date is earlier than the Date of Birth or Admission Date Depending on where the specimen was obtained users are able to identify whether the Specimen Date is when the Type of Specimen Date specimen was actually taken or when the specimen was received e g GP sample the date the specimen was taken may not be available Specimen No The specimen number of the sample Laboratory where the specimen was Laboratory where specimen processed processed can be from the options in the drop down list Patient Details 11 HCAIDCS Case Capture UserGuide v1 0 NHS number A unique number assigned to individuals registered with the NHS If the NHS number is not known all 9 s can be entered however the NHS number should be completed as soon as it is known Please Note The only instance where this can be kept as 9 s is where the patient is a non UK national and does not have an NHS number e g a patient from overseas A correct NHS number is vital for increasing the chances of an accurate attribution to CCG Forename The patient
18. selected from Where the name of the organisation must be selected from the drop down list which is enabled Date from Date to The dates from and to that the interaction occurred Reason for interaction Select the reason for interaction Admission method Select the admission method Do you want to add another interaction 26 If yes is selected another Healthcare Interactions tab is triggered with the same questions asked for the additional healthcare interaction Up to 45 individual healthcare interactions can be added HCAIDCS Case Capture UserGuide_v1 0 6 E coli additional tabs Risk Factors This section collects important additional information related to how the E colimay have been acquired Figure 10 The Risk Factors Tab Episode Details Risk Factors Mandatory fields are marked with red asterisk Mandatory for Sign Off fields are marked with red hash Risk Factors Do you know of a primary focus of the bacteraemia Factors directly predisposing to this episode Is this episode likely to to be an HCAI Table 13 Overview of the Risk Factors Tab fields Select Select Select Field name Comment Risk factors tab Do you know of a primary focus of the bacteraemia Select an option from the drop down Most likely primary focus A focus only needs to be entered if Yes is selected to the above qu
19. t patient attend your Trust ISH available In the 12 weeks prior to specimen date did the Select an option from the drop down list patient attend a different acute Trust ISH available Other acute Trust Independent Sector Healthcare This field is triggered if Yes is selected in Provider triggered question response to the previous question Select an option from the drop down list 20 HCAIDCS Case Capture UserGuide v1 0 The Inpatient details Tab This tab should only be completed for Inpatients only Figure 7 The Inpatient Details tab Episode Details Risk Factors Healthcare Interactions Inpatient Details Mandatory fields are marked with red asterisk Mandatory for Sign Off fields are marked with red hash Inpatient Details For inpatients only do you have further information about where the patient acquired their infection Yes What Specialty was the infection thought to have been acquired in Augmented Care Cardiothoracic Intensive ICU Date From 05 05 2015 Date To 14052015 Date Of Discharge Date 03062015 Ward Type 6 bedded bay Table 9 Overview of Inpatient Details Tab fields Field name Comment Inpatient details tab For inpatients only do you have further information about where the patient acquired their infection Only if Yes is selected will further questions be available What specialty was the infection thought t
20. tal Health Provider is selected as the Patient Location This refers to the specialty of the consultant the patient was under at the time the specimen was collected Augmented Care triggered field This field is enabled when NHS acute Trust Non acute NHS provider Independent Sector Provider or Mental Health Provider is selected as the Patient Location This refers to the specialty of the consultant the patient was under at the time the specimen was collected Additional Comments This is a free text field for any general comments users wish to record Please ensure any comments are entered using standard characters on the keyboard Save and Cancel Options When a new case has been entered or an existing case altered the save button at the bottom of the page will be enabled Once either Cancel or Save buttons are pressed a dialogue box will pop up Any missing fields or validation errors will be highlighted upon save in the information and error messages bar Figure 3 17 HCAIDCS Case Capture UserGuide v1 0 4 Clostridium difficile infection additional tabs Risk Factors Tab The Risk Factor tab is only enabled once the main data entry section has been successfully saved This screen collects important additional information related to how the infection may have been acquired Figure 5 The Risk Factors tab Episode Details Risk Factors Healthcar
21. thcare Interactions Inpatient Details Mandatory fields are marked with red asterisk Mandatory for Sign Off fields are marked with red hash Table 3 Super Scripts for mandatory fields Superscript Comment Mandatory fields need to be completed in order for a case to be saved Mandatory fields that need to be completed in order for the case to be signed off A case may be saved without this information being entered but it cannot be signed off with this information missing Throughout the Episode Details tab and the Data Collection specific tabs many fields are triggered become visible on screen based on responses to previous questions Thus depending on the information entered you may see different fields on the Data Collection tabs Where Other is selected from a drop down list a free text box allowing the other information to be entered will be triggered Each field in the Episode Details Tab and Data Collection specific tabs are detailed below Triggered questions except other are indicated 10 HCAIDCS Case Capture UserGuide v1 0 Table 4 Overview of Episode Detail Tab Fields Field Name Comment Organisational Details The name of the acute Trust or IS Provider entering the case details This will be autocompleted by the system Reporting Organisation unless you have permissions to enter data for more than one site in which ca
22. u have navigated to it via the Case Capture or Search Menu Items The process is described below in more detail Click on Enter a Case or New infection episode to initiate the following screen The Data Collection field needs to be selected before any of the data collection fields are displayed Figure 1 The top banner of the Case Capture screen Public Health England New Infection Episode Menu Toolbar a Collection SEA My Dashboard HCAI DCS System HCAIWEBPORO4 Search Case Capture Welcome TOONEY Looney Help aAA created Date Table 1 Overview of fields in the top banner of the Case Capture screen Field Description Data Collection Select the appropriate organism from the drop down This field informs users which organism the case is being entered for this may be amended during initial data entry up until the case is saved and assigned an ID number however any entered data will be lost It is not possible to change the Data Collection selection of a case that has already been entered and assigned an ID number The case would need to be deleted and re entered selecting the HCAIDCS Case Capture UserGuide v1 0 correct data collection This is a unique 6 digit ID number which is automatically assigned by the DCS to a case once the case is saved This ID can be used in communication with PHE about any case entered on the system
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