Site Assessment Tool Introduction - WHO

Site assessment tool for Global Rotavirus Surveillance Network & Global Pediatric Diarrhea Surveillance

Version 02 March 2020

Site Assessment Tool Introduction The World Health Organization-coordinated Global Rotavirus Surveillance Network (GRSN) and the Global

Pediatric Diarrhea Surveillance (GPDS)* Network is designed to provide valuable data on burden and etiology of pediatric acute watery diarrhea, dysentery, and persistent diarrhea among hospitalized children under the age of five. Using a standardized core variable table and basic surveillance protocol, participating sites have adapted surveillance tools to local standards and are currently implementing prospective surveillance. Local adaptation of the protocol and data collection tools may lead to avoidable and unavoidable site differences in admission procedures, case mixes, and laboratory capacity. Such differences may affect the interpretation of variable burden and etiology between sites and across regions Site assessments will be conducted to identify sources of heterogeneity in data collection procedures (if any) at each rotavirus or pediatric diarrhea surveillance site. The site assessment tool is designed to collect data at the site level (not country or regional level). Collecting information at this level will enable comparisons across sites within a country or region to verify that the same information is being collected. Some sites may use the same tools, in which case a single set of translations will be used, but all other information will be collected at the site level. Site assessments will be conducted by WHO and site supervisors. Site assessments will include information collected prior to the visit, direct observation by site assessment teams and site supervisor report (or interview). These activities (and objectives) are grouped as follows:

1) Case Report Form (CRF) Abstraction for Identification & Classification of Cases – To determine

differences in the way questions are worded across sites. For example, some sites may define dysentery by caregiver report alone, by observation in the hospital, or by both methods which could influence the frequency dysentery is reported.

2) Site Reporting/Interview and Observation of General Site Practices – Through reporting by site leaders and confirmed by observation, establish how and which children are selected into the

rotavirus or pediatric diarrhea surveillance site. 3) Direct Observation of Surveillance Enrollees – To observe, first-hand, how the process from

screening to stool sample storage occurs. Direct observation will also serve to validate, or identify discrepancies, between what is reported to be happening vs. what is actually happening at the site-level. Such information will provide an opportunity for identification of discrepancies and logistical realities that need to be accounted for in any recommended changes.

4) Malnutrition-specific Site Practices (Optional) – To determine how feasible it would be to include malnutrition screening in GPDS data collection.

*GRSN (Global Rotavirus Surveillance Network) is the surveillance of acute watery diarrhea, performed to

specifically identify rotavirus infection. GPDS (Global Pediatric Diarrhea Surveillance) is built off GRSN and

surveillance is expanded to include all types of diarrhea (acute watery diarrhea, dysentery, and persistent diarrhea)

performed to identify any pathogen causing diarrheal infection in children.



Surveillance Site Assessment Tool

Date

|___|___| - |___|___| - |___|___|___|___|

(dd-mm-yyyy)

City

___________________________________

Hospital Name

___________________________________

Type: Public Hospital Private Hospital

Other _____________

Is this a: General Hospital Pediatric Hospital

Other _____________

Country

WHO Region

WHO Site Code

___________________________________

___________________________________

___________________________________

Site Supervisor

___________________________________

WHO Country Office staff

___________________________________

WHO HQ staff

___________________________________

WHO Regional Office staff

___________________________________

Case Report Form (CRF) Abstraction for Identification and Classification of Case The goal of this section is to identify differences in how questions are worded across sites. This section should be completed if the CRF is not in English, or if the CRF

is in English but there is concern about the wording of questions.

If possible, to be completed by Site Supervisor prior to the Monitoring Visit. Please record how the following variables (from the core variable table) are worded in the

CRF. Please translate responses into English)

Section completed by ___________________________________ on |___|___| - |___|___| - |___|___|___|___|

(first name, last name) (dd-mm-yyyy)

Variable name (from core

variable table)

Variable Description

(from core variable

table)

Please record how

question is written in

CRF (translate into

English)

Are there instructions

available for how the

question should be

asked?

Please record instructions below:

1. symp_diarrhea_acute_YN Did case have acute diarrhea?

[ ] Yes [ ] No (skip next column)

2. symp_diarrhea_bloody_YN Did case have bloody diarrhea?


3. symp_dia_episodes Maximum number of diarrhea episodes in 24-




hour period, at peak of illness

4. symp_dia_duration Duration of diarrhea in days


5. symp_vomit_YN Did case vomit?




Site Reporting/Interview and Observation of General Site Practices

Site Reporting section to be completed by Site Supervisor prior to, or during the Monitoring Visit. During Monitoring Visit, WHO Coordinators will review

responses and make any notes to confirm practices and observations in the Coordinator Observations section.

Site Reporting

Section completed by ___________________________________ on |___|___| - |___|___| - |___|___|___|___|


Coordinator Observations/Notes

Section completed by ___________________________________

(first name, last name)

on |___|___| - |___|___| - |___|___|___|___|

(dd-mm-yyyy) 6. How is “acute” defined when identifying children

with acute diarrhea at this site?

[ ] Diarrhea lasting less than 7 days [ ] Diarrhea lasting less than 14 days [ ] Other ____________________________________________________ [ ] Undefined

7. How is “diarrhea” defined when identifying children with diarrhea at this site?

[ ] 3 or more loose or watery stools in the last 24 hours [ ] 3 or more abnormally loose or watery stools in the last 24 hours [ ] Other____________________________________________________ [ ] Undefined

8. How is “bloody diarrhea” defined when identifying a child with dysentery?

[ ] Caregiver observed blood in stool only [ ] Observation by surveillance team/hospital only [ ] Caregiver report OR by surveillance team/hospital only [ ] Other____________________________________________________ [ ] Undefined

9. How is an “episode” of diarrhea defined when determining the number of episodes that a child has had in last 24-hour period?

[ ] More than one hour between stool passing [ ] More than 24 hours between stool passing [ ] A single bowel movement [ ] Other____________________________________________________

10. Which type of wards are present at this site? Tick all that apply

[ ] General pediatric [ ] Gastroenterology/ diarrhea ward [ ] Emergency room/accident & emergency/acute care [ ] Short stay or rehydration [ ] Malnutrition [ ] Intensive care unit or high dependency unit (maybe with a ward) [ ] Newborn unit [ ] Other ____________________________________________________

11. On which wards are children with diarrhea managed? Tick all that apply

[ ] General pediatric [ ] Gastroenterology/ diarrhea ward [ ] Emergency room/accident & emergency/acute care [ ] Short stay or rehydration [ ] Malnutrition [ ] Intensive care unit or high dependency unit (maybe with a ward) [ ] Newborn unit [ ] Other ____________________________________________________



12. Are children ever given intravenous fluids in an outpatient clinic, such as a maternal child health clinic?

[ ] Yes [ ] No (skip to Q15)

13. If yes to Q13, are these children considered “hospitalized” and therefore eligible for surveillance enrollment?

[ ] Yes [ ] No

14. Are children managed on short stay wards or rehydration units considered admitted to the hospital?

[ ] Yes [ ] No [ ] The site does not have short stay wards/ rehydration units

15. On which wards are children screened for inclusion in acute watery diarrhea (rotavirus) surveillance? Tick all that apply

[ ] Note: If site not participating in GRSN, check here

and skip this question.

[ ] General pediatric [ ] Gastroenterology/ diarrhea ward [ ] Emergency room/Accident & emergency/Acute care [ ] Short stay or rehydration [ ] Malnutrition [ ] Intensive care unit or High dependency unit (maybe with a ward) [ ] Newborn unit [ ] Other ____________________________________________________

16. On which wards are children screened for inclusion in pediatric diarrhea surveillance? Tick all that apply

[ ] Note: If site not participating in GPDS, check here and skip this question.


17. Are children referred from other hospitals eligible for rotavirus or pediatric diarrhea surveillance?

[ ] Yes [ ] No

18. Who screens children for participation in rotavirus or pediatric diarrhea surveillance? Tick all that apply

[ ] All hospital clinicians [ ] All hospital nurses or other ward staff [ ] Specific clinician(s) whose primary role is pediatric diarrhea surveillance [ ] Specific nurse(s) whose primary role is pediatric diarrhea surveillance [ ] Specific clinician(s) who’ve received pediatric diarrhea surveillance training [ ] Specific nurse(s) who’ve received pediatric diarrhea surveillance training [ ] Other, please elaborate: ______________________________________________________________________



19. If children are screened at more than one ward, (as indicated by more than one ward being ticked in Q16 and/or Q17), are the same screeners used across all wards or does each ward have its own screener?

[ ] Same screening personnel across wards [ ] Different screening personnel per ward [ ] Other, please elaborate: ______________________________________________________________________ ______________________________________________________________________

20. Which of the following clinical presentations in a child would result in the child being further investigated as a possible case of diarrhea? Tick all that apply

[ ] Diarrhea [ ] Vomiting [ ] Dehydration [ ] Gastroenteritis [ ] Shock [ ] Chronic gastroenteritis [ ] Malnutrition and diarrhea [ ] Other ______________________________

21. Which children are screened for inclusion in rotavirus or pediatric diarrhea surveillance? Tick all that apply

[ ] Children with a diagnosis of “gastroenteritis” or “diarrhea” written in medical record [ ] Children with “diarrhea” or “gastroenteritis” recorded in their medical history or as a presenting complaint at admission but not necessarily listed as a diagnosis. [ ] Children admitted to the ward, irrespective of diagnosis and history, to establish whether the child has had 3 or more loose stools in 24 hours [ ] Other, please elaborate: ______________________________________________________________________ ______________________________________________________________________

22. Children with diarrhea or dysentery may be very

severely unwell at admission. If the child is very severely unwell (requiring very urgent

management or “peri-arrest”), which of the

following approaches are most commonly

practiced by this site in relation to rotavirus or pediatric diarrhea surveillance?

[ ] The child is not considered for enrollment in rotavirus or pediatric diarrhea surveillance

[ ] The child is considered for enrollment in rotavirus or pediatric diarrhea surveillance only after the child has been

stabilized

[ ] The child is considered for enrollment in rotavirus or pediatric diarrhea surveillance as soon as s/he is screened

irrespective of need for stabilization



23. Which of following cases would you consider

eligible for pediatric diarrhea surveillance?

Assume all cases are aged 0-59 months, and that the scenarios/diseases are possible in your setting

(e.g. malaria maybe rare/not present in your setting, but please still consider the question). Tick all cases you would consider eligible for inclusion.

[ ] A child with >3 loose stools in 24 hours, but the diarrhea is thought be caused by severe sepsis secondary to pneumonia.

[ ] A child with >3 loose stools in 24 hours, but the admitting clinician believes these symptoms are secondary to recent

antibiotic use in the community.

[ ] A child with >3 loose stools in 24 hours, but the diarrhea is thought to be secondary to malaria, and the child has a

positive malaria parasite smear. [ ] A child with “gastroenteritis” listed as a diagnosis on the

patient file but had <3 loose/watery stools in last 24 hours [ ] A child with “diarrhea” listed in presenting complaints but

no diagnosis of “diarrhea” listed

[ ] A child admitted for severe acute malnutrition management who has had 4 loose stools in the last 24 hours

[ ] All of the above cases are eligible

24. What challenges does your site have in collecting

stool from pediatric diarrhea surveillance

enrollees?

[ ] Too much time passes between children being enrolled and

collection of stool [ ] Caregivers/children are uncomfortable with providing

stool [ ] Too messy

[ ] Other____________________________________________________

25. Is data for the surveillance system collected

prospectively (while child is being seen in the hospital) or retrospectively (from notes/chart

review after child has been released from the hospital)?

[ ] Prospectively

[ ] Retrospectively [ ] Other/ mix of both

____________________________________________________-____________________________________________________

26. Please describe the process from when a child

seeks care for diarrhea or gastroenteritis to where

the case is registered and entered into the

pediatric diarrhea surveillance system with a case

report form completed.

____________________________________________________

____________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

____________________________________________________

Case Detection 27. When is specimen collection for rotavirus or

pediatric diarrhea surveillance at this hospital

conducted? (Tick all that apply.)

[ ] During daytime hours only

[ ] Conducted 24h (i.e. also after hours) [ ] During weekdays only

[ ] Conducted daily, including weekends/holidays

28. Are there any standard operating procedures (SOPs), manuals and/or guidelines available for

rotavirus or pediatric diarrhea surveillance?

[ ] Yes, observed [ ] Yes, but not observed (skip to Q31)

[ ] No (skip to Q31)



29. If observed, does the SOP specify when specimen

should be obtained relative to when the child first arrives at the hospital?

[ ] Yes [ ] No

[ ] Unknown

30. If rotavirus surveillance only, does the SOP specify the

maximum duration of diarrhea at time of arrival to

hospital for which a child can still be enrolled into surveillance system?

[ ] Yes [ ] No

[ ] Unknown

Case Registration and Reporting

31. Are there any SOPs, manuals and/or guidelines

describing case registration or completion of case report forms?

[ ] Yes, observed [ ] Yes, not observed

[ ] No

[ ] Unknown

32. Using an actual case report form, please indicate which of the following data are collected routinely

(tick all that apply):

[ ] Unique patient ID [ ] Age in months

[ ] Birthdate

[ ] Admission date [ ] Sex

[ ] Diarrhea (episodes and duration) [ ] Vomiting (episodes and duration)

[ ] Any symptom onset date [ ] Dehydration level

[ ] Type of rehydration given

[ ] Stool specimen collection date [ ] Outcome at discharge

[ ] Rotavirus vaccination history

33. Where and how are epidemiological and laboratory

information for the same patient combined or

linked?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

34. Are surveillance data from this level reported to the national level (Ministry of Health (MoH) and

WHO country office)?

[ ] Yes [ ] No (skip to Q38)

[ ] Unknown (skip to Q38)

35. If yes to Q34, how often is surveillance information

reported to the next level?

[ ] Weekly

[ ] Monthly

[ ] Annually [ ] Other ____________

36. If yes to Q34, how is surveillance information

reported to the next level?

As: By: [ ] Aggregate data [ ] Email or electronic submission

[ ] Case-based data [ ] Paper forms

[ ] Unknown [ ] Mobile phone/handheld computer

[ ] Fax [ ] Other _____________



37. If yes to Q34, were data reports observed? [ ] Yes, observed

[ ] No, not observed

Specimen Collection 38. Are there any SOPs, manuals, and/or guidelines

available for taking stool samples?

[ ] Yes, observed [ ] Yes, not observed (skip to Q40)

[ ] No (skip to Q40)


39. If yes to Q38, are the stool collection instructions in

the SOPs/guidelines clearly described?

Note: These should include clear, written instructions on the following items:

• how/where/when to collect samples;

• eligibility;

• who collects samples; and

• how they should be transported to the nearest laboratory

[ ] Yes, clearly described with written instructions including

the items indicated

[ ] No, not clearly described without written instructions including the items indicated

40. Are SOPs available for transport of specimens from ward to the hospital or national laboratory where

they will be tested? Please record the times your hospital considers normal working hours (i.e. 9am to 5pm):

Monday: _______________________________

Tuesday: _______________________________ Wednesday: ____________________________

Thursday: ______________________________ Friday: ________________________________

Saturday: ______________________________ Sunday: _______________________________

[ ] Yes, both during and after normal working hours

[ ] Yes, only during working hours [ ] Yes, only after working hours [ ] No (skip to Q43 )

[ ] Unknown

41. If yes to Q40, do the SOPs include criteria/standards

for the maximum time interval between specimen collection and arrival in the laboratory?

[ ] Yes, both during and after normal working hours [ ] Yes, only during working hours

[ ] Yes, only after working hours

[ ] No [ ] Unknown

42. If yes to Q40, do the SOPs include criteria/standards

for the minimum volume of stool to be obtained? [ ] Yes—what is the recommended minimum? ____________

[ ] No

[ ] Unknown



43. Whose responsibility is it to ensure specimens are collected and transported to the hospital or national

laboratory properly?

(i) Specimen collection: During normal working hours?

[ ] Clinical staff [ ] Lab staff

[ ] Other, specify:____________

After normal working hours?

[ ] Clinical staff [ ] Lab staff

[ ] Other, specify:____________

(ii) Specimen transport:

During normal working hours? [ ] Clinical staff

[ ] Lab staff [ ] Other, specify:____________

After normal working hours?

[ ] Clinical staff

[ ] Lab staff [ ] Other, specify:____________

44. Is someone available to transport specimens from

the ward to the laboratory?

(i) During normal working hours?

[ ] Yes

[ ] No [ ] Unknown

(ii) After normal working hours?

[ ] Yes

[ ] No [ ] Unknown

45. Is there a mechanism for controlling the temperature of specimens during transport from

ward to laboratory?

(i) During normal working hours? [ ] Yes, explain: _________________________________

[ ] No

[ ] Unknown

(ii) After normal working hours? [ ] Yes, explain: _________________________________

[ ] No [ ] Unknown

46. How is the laboratory notified when a patient

specimen has been collected?

(i) During normal working hours? _______________________

____________________________________________________

(ii) After normal working hours? _______________________ ____________________________________________________

47. What is the procedure if the stool specimen cannot be delivered to the laboratory as soon as possible (or

within the recommended time)?

[ ] Stored until normal working hours [ ] Discarded

[ ] Other, specify: _____________________________________



48. What information is included on the specimen label? (Tick all that apply.)

[ ] Patient ID number [ ] Patient initials/name

[ ] Date specimen collected

[ ] Other _____________________________

49. What information is included on the laboratory

request form? (Tick all that apply.) [ ] Patient ID number [ ] Patient initials/name

[ ] Date specimen collected

[ ] Time specimen collected [ ] Other _____________________________

50. If patient ID number is used on the laboratory

request form, is this the same as the unique patient ID number on the case reporting form?

[ ] Yes

[ ] No [ ] Unknown

51. Do you ever receive any results for samples which

do not match case reports by patient ID or name? [ ] Yes [ ] No (skip to Q53)


52. If yes to Q51, what is the process for reconciling the

unmatched results?

____________________________________________________

________________________________________________________________________________________________________

Data Management: Data entry, cleaning, validation, and clean-up 53. How are surveillance data stored at your hospital? [ ] Electronically (on a database or spreadsheet)

[ ] On paper (skip to Q59)


54. Which of the following procedures are performed in your hospital? If not done at a hospital, which of

the following procedures are performed at the Ministry of Health or at another institution where

data is managed? (Tick all that apply. If ticked, circle approximate number of time/year.)

*Note: Data cleaning or validation is the process by which data are checked for accuracy, missing values, duplicates, etc.

Frequency of completion

[ ] Data entry W BW M BM Q

[ ] Double data entry >52 27-52 13-26 5-12 0-4

[ ] Data management >52 27-52 13-26 5-12 0-4 (cleaning/validation)

[ ] Database or computer >52 27-52 13-26 5-12 0-4 backpack

[ ] Data analysis >52 27-52 13-26 5-12 0-4

Frequency abbreviations: W= weekly, BW= bi-weekly, M= monthly, BM= bi-monthly, Q= quarterly

55. If the procedures indicated on Q54 are not

performed at your hospital, where are they performed?

[ ] Ministry of Health

[ ] Other: _________________________________________

56. Which software is used for the database and analysis?

Database: _______________________________

Analysis: ________________________________

57. How do you backup your data to prevent loss of

data from hardware or software failure or theft? [ ] Backup to portable external data storage e.g. floppy disks,

CDs, DVDs, or USB drive [ ] Backup to another computer

[ ] Backup to an external hard drive or server

[ ] Other _______________________________________



58. How are your data backups kept? (Tick all that apply)

[ ] In a locked room/storage [ ] On a different site from the original database

[ ] Other: ______________________________________

59. Who is responsible for backing up the data? [ ] Surveillance coordinator or equivalent [ ] IT manager or equivalent

[ ] Other________________________________________

60. Do you perform any analyses of the data at your hospital?

[ ] Yes [ ] No

[ ] Unknown [ ] N/A

61. If N/A was entered on Q59, are any analyses of the

data performed at the location indicated on Q55? [ ] Yes

[ ] No [ ] Unknown

62. Are there any manuals/guidelines/SOPs outlining

the above procedures and their frequency? [ ] Yes [ ] No

[ ] Unknown

Data Confidentiality

63. Are there procedures in place to define those who can access or modify patient data (e.g. password

protection)?

[ ] Yes [ ] No

[ ] Unknown

Data Feedback

64. Are supervisory visits (or site assessments) of the

hospital rotavirus surveillance teams conducted?

(i) For clinical staff:

[ ] Yes—how often: ____________

[ ] No

(ii) For laboratory staff: [ ] Yes—how often: ____________

[ ] No

65. Do you receive feedback from the national level on

data you have reported, e.g. about data quality, information on duplicated records, etc.?

[ ] Yes [ ] No



Direct Observation of GPDS/GRSN Enrollees

To be completed by WHO or site coordinator. Directly observe the entire process of screening and enrollment from 5 (or as many as is feasibly possible)

consecutively screened children during the monitoring visit time and record the following information from observation and available hospital files. This section can

still be completed for children who are determined to be ineligible for rotavirus or pediatric diarrhea surveillance. Do not abstract this information from CRFs as

this data will be used to verify information being recorded in CRFs. If children are screened from multiple wards, an attempt should be made to observe these

processes at each of the wards where recruitment is taking place. Information being collected in this section is being used solely for the purpose of external

monitoring/ quality assurance and not to be used for research purposes.

Section completed by ___________________________________ on |___|___| - |___|___| - |___|___|___|___| Type of Surveillance: [ ] GRSN [ ] GPDS


Child 1

Child 2

Child 3

Child 4

[ ] Unable to observe

Child 5 [ ] Unable to observe

66. Date and time of arrival at the

hospital

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy) [ ]unknown

|___|___| : |___|___|

(hh:min–24hr) [ ]

unknown

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___|

(hh:min–24hr) [ ]

unknown

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___|

(hh:min–24hr) [ ] unknown

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___|

(hh:min–24hr) [ ]

unknown

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___|

(hh:min–24hr) [ ]

unknown

67. Date and time of admission

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___|

(hh:min–24hr)

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___|

(hh:min–24hr)

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___|

(hh:min–24hr)

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___|

(hh:min–24hr)

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___|

(hh:min–24hr)

68. Ward that the child was

admitted

[ ] General pediatric [ ] Gastroenterology/ diarrhea ward [ ] Emergency room/Accident & emergency/Acute care [ ] Short stay or rehydration [ ] Malnutrition [ ] Intensive care unit or High dependency unit (maybe with a ward) [ ] Newborn unit [ ] Other

_______________________________


_______________________________


_______________________________


_______________________________


_______________________________

69. Date and time of screening for participation in rotavirus and

pediatric diarrhea surveillance

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___|

(hh:min–24hr)

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___|

(hh:min–24hr)

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___|

(hh:min–24hr)

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___|

(hh:min–24hr)

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___|

(hh:min–24hr)



70. Ward that the child was screened for rotavirus and

pediatric diarrhea surveillance


_______________________________


_______________________________


_______________________________


_______________________________


_______________________________

71. Was the child diagnosed with

conditions other than diarrhea/gastroenteritis?

[ ] Yes [ ] No skip to Q71





72. If yes to Q69, what were those

other conditions, as diagnosed by the admitting clinician? Tick all that apply

[ ] Dehydration

[ ] Pneumonia/ LRTI

[ ] Malaria

[ ] Malnutrition

[ ] Severe bacterial

infection/ sepsis

[ ] Other:

_______________________

_______________________

[ ] Dehydration

[ ] Pneumonia/ LRTI

[ ] Malaria

[ ] Malnutrition


infection/ sepsis

[ ] Other:

_______________________

_______________________

[ ] Dehydration

[ ] Pneumonia/ LRTI

[ ] Malaria

[ ] Malnutrition


infection/ sepsis

[ ] Other:

_______________________

_______________________

[ ] Dehydration

[ ] Pneumonia/ LRTI

[ ] Malaria

[ ] Malnutrition


infection/ sepsis

[ ] Other:

_______________________

_______________________

[ ] Dehydration

[ ] Pneumonia/ LRTI

[ ] Malaria

[ ] Malnutrition


infection/ sepsis

[ ] Other:

_______________________

_______________________

73. Did the child previously seek medical care for this illness?






74. If yes to Q71, was the child

hospitalized for this illness?

[ ] Yes

[ ] No

[ ] Yes

[ ] No

[ ] Yes

[ ] No

[ ] Yes

[ ] No

[ ] Yes

[ ] No

75. Optional: Was mid upper arm

circumference (MUAC), length,

and/or weight recorded in the medical record? Tick all that apply

[ ] MUAC [ ] Length/height

[ ] Weight [ ] None of the above









76. Date and time of stool collection

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___| (hh:min – 24hr)

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___| (hh:min – 24hr)

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___| (hh:min – 24hr)

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___| (hh:min – 24hr)

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___| (hh:min – 24hr)

77. Who collected the stool? [ ] Caregiver

[ ] Hospital/GPDS staff

[ ] Caregiver


[ ] Caregiver


[ ] Caregiver


[ ] Caregiver




[ ] Other _______________________

[ ] Other

_______________________

[ ] Other

_______________________

[ ] Other

_______________________

[ ] Other

_______________________

78. Was this considered a case of

bloody diarrhea? Note: if rotavirus (acute watery diarrhea) surveillance only, skip this question.






79. If yes to Q76, how was “bloody”

determined? Tick all that apply

[ ] Caregiver report

[ ] Hospital chart

[ ] Stool observation by

hospital/surveillance staff

[ ] Other: ______________


[ ] Hospital chart


hospital/ surveillance staff

[ ] Other: ______________


[ ] Hospital chart



[ ] Other: ______________


[ ] Hospital chart



[ ] Other: ______________


[ ] Hospital chart



[ ] Other: ______________

80. Did the child receive an antibiotic?


[ ] Unknown


[ ] Unknown


[ ] Unknown


[ ] Unknown


[ ] Unknown

81. If yes to Q78, where was

information about the antibiotic recorded? Tick all that apply

[ ] Patient record [ ] Prescription booklet

[ ] Other: ______________


[ ] Other: ______________


[ ] Other: ______________


[ ] Other: ______________


[ ] Other: ______________

82. If yes to Q78, when was the

antibiotic given relative to stool collection?

[ ] Before stool collection

[ ] After stool collection

[ ] Unknown timing



[ ] Unknown timing



[ ] Unknown timing



[ ] Unknown timing



[ ] Unknown timing

83. Was a memory aid or calendar

used to ask questions around

duration of diarrhea/ vomiting?

[ ] Yes [ ] No

[ ] Yes [ ] No

[ ] Yes [ ] No

[ ] Yes [ ] No

[ ] Yes [ ] No

84. Was stool sample weighed? [ ] Yes [ ] No skip to Q84





85. If yes to Q82, what was the

weight of the stool sample

(without the container)

______μL or mg? circle unit





86. Date and time of stool placed in

refrigerator for enzyme immunoassay (EIA) rotavirus

testing

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___| (hh:min – 24hr format)

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___| (hh:min – 24hr format)

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___| (hh:min – 24hr format)

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___| (hh:min – 24hr format)

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___| (hh:min – 24hr format)

87. Refrigerator temperature at the time of stool refrigeration

|___|___|°C

[ ] Unknown

|___|___|°C

[ ] Unknown

|___|___|°C

[ ] Unknown

|___|___|°C

[ ] Unknown

|___|___|°C

[ ] Unknown

88. Date and time of stool placed in

freezer for storage

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___|

(hh:min – 24hr format)

|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___|


|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___|


|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___|


|___|___| - |___|___| -

|___|___|___|___|

(dd-mm-yyyy)

|___|___| : |___|___|


89. Freezer temperature at the time

of freezing

|___|___|°C

[ ] Unknown

|___|___|°C

[ ] Unknown

|___|___|°C

[ ] Unknown

|___|___|°C

[ ] Unknown

|___|___|°C

[ ] Unknown



90. Was this child enrolled in

rotavirus or pediatric diarrhea surveillance?

[ ] Rotavirus surveillance

[ ] Pediatric diarrhea

surveillance

[ ] Neither



surveillance

[ ] Neither



surveillance

[ ] Neither



surveillance

[ ] Neither



surveillance

[ ] Neither

Feasibility of Assessing Malnutrition Through Rotavirus or Pediatric Diarrhea Surveillance (Optional—to be completed if interested in assessing the

feasibility of incorporating nutritional screening into the surveillance network.) 91. Which of the following measurements are used to

identify acute malnutrition (wasting) among admitted children at this hospital? Tick all that apply

[ ] Mid upper arm circumference (MUAC)

[ ] Weight alone [ ] Weight-for-age Z-score/Gomez classification

[ ] Weight-for-height Z-score

[ ] Bilateral pitting edema

92. Which children are screened for acute malnutrition? Tick all that apply

[ ] All children who present to the hospital (even if they don’t appear wasted)

[ ] All children who present to the hospital who appear wasted.

[ ] All children who are admitted to the hospital (even if they don’t appear wasted)

[ ] All children who are admitted to the hospital who appear wasted.

93. Which wards are children screened for acute malnutrition? Tick all that apply


94. Do you believe it would be appropriate/feasible to collect MUAC on children enrolled in

surveillance?

[ ] Yes [ ] No

[ ] Unknown

95. What are some of the challenges you anticipate in measuring MUAC at your site? Tick all that apply

[ ] There are no MUAC tapes

[ ] The staff have not been trained on MUAC use

[ ] MUAC is not appropriate for this setting [ ] More children might be identified for malnutrition treatment which

would burden the hospital [ ] It would add too much burden on surveillance staff

[ ] Other ______________________________ [ ] There are no challenges

96. Is length/height measured in admitted children at

this hospital? [ ] Yes [ ] No skip to Q96

[ ] Unknown skip to Q96

97. If yes to Q94, how is length measured? Tick all that apply

[ ] Length/height board

[ ] Tape measure [ ] Other ______________________________

98. Do you believe it would be appropriate/feasible

to collect length/height on children enrolled in surveillance?

[ ] Yes

[ ] No [ ] Unknown



99. What are some of the challenges with length/height measurement you anticipate at your site? Tick all that apply

[ ] Length boards unavailable [ ] Not a useful clinical indicator

[ ] It would add too much burden on GPDS staff [ ] Other ______________________________

[ ] There are no challenges

Site Assessment Tool Introduction - WHO

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