The CONNECT Study Questionnaire Mount Sinai Hospital and Samuel Lunenfeld Research Institute November 2006
Demographics 1. Sex M F Please fill out the following questions 2. Year of Birth: 3. Primary ward or location within which you work: or Rotating/Multiple 4. We would like to ask: Does your pay cheque come from: MSH SLRI U of T Volunteer Other (e.g. physician, UHN) 5. Occupation: (Please check one answer, the list continues on pg 2/11) Staff physician, specialty: Nurse Receptionist Volunteer Patient Attendant/Sitter Medical Imaging Technologist Pharmacist Medical Student Postgraduate Medical Trainee Other student discipline: Ward Clerk Physiotherapist/Occupational Therapist Respiratory Therapist Housekeeping Social Worker 1 of 11
Service Assistant Central Supply Technician Other, specify: 6. Do you also work in any other health care settings such as another hospital, clinic, nursing home, etc.? No If yes: Employed Volunteer Cross-coverage 7. Are you employed in any other non-health care settings? No Yes If yes, please specify: 8. Number in household (including self): 9. Ages of others in household (if any): 10. Type of dwelling: Detached House Townhouse Condominium/Apartment, please specify number of units: <50 50-99 100-199 200+ units Other, specify: 11. On average, how many hours do you work at this hospital per week? Occupational History The following questions ask you about your activity in a typical week. In order to understand how infections spread through a hospital setting, we need to know your physical movement in a typical week. Think of it as tracking your every move. That is the best way for us to see how infections spread. As you complete the following questions, think of all the locations you have worked or visited during the week. We are asking that you list the locations and how long you were at the location. Remember to include things like going to Xray with a patient, dropping off samples to the lab, going down the elevator to the cafeteria or standing in line at the Second Cup. 2 of 11 *Please note the information you provide is for a typical week.
As you complete these questions, imagine that you are watching a video of your movement and you are writing down all that you see. The more you can tell us, the better we may understand how infections can be spread. If you cannot remember a typical week then try to remember the last full week you worked. 12. Please check all the areas you worked in or visited during a typical week and enter the hours and/or minutes in spaces provided. 600 UNIVERSITY AVENUE 1st Floor 1 st Floor-Samuel Lunenfeld Research Institute Biomedical Engineering Central Dispatch Stores Communications (Switchboard & Locating) Graphics and New Media House Staff Locker Room Housekeeping Image Centre Informatics Mailroom Mechanical Stores 2nd Floor Audiology Auxiliary Cafeteria Emergency Department Administration Infection Control Nutrition & Food Services Otologic Function Unit Medical Student Lounge Peter Sullivan Centre for Int l. Health Print Shop Receiving Dock Respiratory Therapy Sterile Processing Storage Area Student Locker Room Uniform Distribution Union Office Patient Simulation Receiving Staff Locker Room -Female Staff Locker Room -Male Surgical Skills Lab Volunteer Services Other 3rd Floor/Main Level Admitting Bioethics Chinese Community Outreach Programs Indigo Spirit Lobby Café Medical Education Murray St. Info Desk 3 of 11 *Please note the information you provide is for a typical week.
3rd Floor/Main Level con t. Communications / Marketing Dentistry Admin Office Doctor s Lounge Elective Outpatient Surgery Emergency Department Executive Offices Finance/Accounting Fire Control Room G. Turner Dept of Nursing Human Resources Outpatient Pharmacy Patient Relations/ Risk Management Payroll Second Cup Security Desk Surgical Waiting Rm Synagogue Other 4th Floor Ambulatory Internal Medicine Clinic Dentistry Gastroenterology Offices General Surgery Intern/Med. Student Lockeroom Medical Record Services Medicine Offices Ophthalmology Orthopaedic Surgery Offices Otolaryngology (ENT) Outpatient Lab Pre-Admission Unit Pulmonary Function Lab Social Work (Medical Social Services) Other 5th Floor Bone and Tissue Bank Cystoscopy Day Surgery Fracture Clinic Interventional Radiology IVF Lab Medical Imaging CT Scan MRI Ultrasound Xray Operating Room Patient Reception Post Anaesthesia Unit (Recovery Room) Other 4 of 11 *Please note the information you provide is for a typical week.
6 th Floor Autopsy Suite Andrology Clinic Bio-Chemistry Lab Blood Transfusion Srvcs Bone Density Bone and Mineral Cell Biology Lab Chromatography Cytology Education Centre (6 th floor classroom) Electron Microscopy Endoscopy Unit Histology Lab Morgue Nuclear Medicine Pathology and Lab Medicine Offices Rapid Response Lab Research Respiratory Medicine (Therapy) Urology-Surgery Other 7th Floor Breast Feeding Centre Breast Feeding Shop Breast Pump Rooms Care by Parent Rooms Endocrinology Offices 7 th Level-Labour & Delivery Level II Nursery NICU (Level III Nursery) Obstetrics - Antepartum/ Combined Care Obstetrics Day Unit Parent Lounge Patient Family Areas (Waiting Rooms etc) Perinatology Offices Other 8th Floor 8 th Fl. Samuel Lunenfeld Research Institute Mechanical Other 9th Floor 9 th Floor Samuel Lunenfeld Research Institute 9S- Day Treatment & Community 9S- Psychiatry/ Outreach Program Psychiatry Admin Psychotherapy Research Offices Other 5 of 11 *Please note the information you provide is for a typical week.
10th Floor 10 th Fl Samuel Lunenfeld Research Institute 10 th Level- Obstetrics - Post Partum Nursing Unit Infant Hearing Program Offices Level I Nursery Obstetrics & Gynecology Offices Research Ethics Board Offices Other 11th Floor 11N- Inpatient Unit (Ortho, Gynecology, Dental/ENT /Eye) 11S- Inpatient Unit (Ortho/ Sarcoma) Liver Study Unit Occupational Therapy Physiotherapy Gymnasium Sports Clinic Therapeutic Pool Wasser Pain Mgmt Centre Other 12th Floor 12N- Ambulatory Marvelle Koffler Breast Centre Oncology Unit 12S- Medical Unit Engineering Biopsy Chemotherapy Mammography Fetal Medicine Centre Reception/ Doctors Offices North Waiting Room Ruth Burnett Centre for Pharmacy Satellite Outpatient Oncology Other 14th Floor 14 th Floor Classroom 14N- Surgical Oncology Unit 14S- Inflammatory Bowel Unit Microbiology Lab Step Down Unit 14N Other 15th Floor Anna Prosserman Heart Human Rights and Function Clinic Diversity Offices Chaplaincy Medical Education Computer Training Classrooms Pharmacy Other 6 of 11*Please note the information you provide is for a typical week.
16 th Floor 16N- Cardiology/Medicine Cardiac Research Lab Coronary Care Unit (CCU) Electrocardiogram Pacemaker Clinic Other 17 th Floor 17N- Medicine/Geriatric 17S- Medicine/Geriatric Step Down Unit Resident s Room & Staff Lounge Other 18 th Floor Intensive Care Unit (ICU) 18 th Floor Foyer Auditorium Chaplaincy Computer Training Room ICU Waiting Room ICU Offices Student s Lounge Sidney Liswood Library Other 60 MURRAY STREET Ground Floor Occupational Health & Safety Ophthalmology Toronto Centre Phenogenomics Bio-informatics Other Main Level- 2 nd Floor Rebecca MacDonald Centre Patient Registration Security Office Ambulatory Lab Rheumatology Other 7 of 11 *Please note the information you provide is for a typical week.
3 rd Floor Conference Rooms Digestive Disease Clinical Research Centre Housekeeping Other 5 th Floor Epidemiology and Biostatistics Offices Prosserman Centre for Health Research Leadership Sinai Centre for Diabetes Other OPG 3 rd Floor Main Registration Area Out Patient Lab Family Planning High Risk Pregnancy Clinic In-Vitro Fertilization Low Risk Obstetric Clinic Maternal Infant Program Menopause Clinic Premature Ovarian Failure Clinic Prenatal Diagnosis & Medical Genetics Prenatal Education Program Special Pregnancy Program 8 th Floor Cytogenetics Cytopathology Human Resources Informatics Technovision Unit 6 th Floor Murray Koffler Urologic Wellness Centre Cancer Genetics Lab Advanced Centre for Detection of Cancer Other 4 th Floor Family Medicine Temmy Latner Centre for Palliative Care Other Sperm Bank Women s Unit Urodynamics Lab Ultrasound Prenatal Reception/Waiting Area Doctor s Offices North Doctor s Offices South Social Work Office Reproductive Biology Unit Other LIS Operators Organization Development Other 8 of 11
13. I answered the above questions based on: a typical week or last week or the last full week worked The following questions ask you about your activity on a typical day. If you cannot remember a typical day then try to remember the last full day you worked. 14. On a typical day, with how many patients are you in direct contact (within 1 meter/3 feet)? <5 5-9 10 19 20-29 30-39 40-49 50+ patients 15. On average, how many minutes do you spend in direct contact with any one patient per day (within 1 meter/3 feet) < 5 5-10 11-20 20+ minutes 16. On average, with how many patients do you have indirect contact (same room but not closer than 1 meter/3 feet) per day? 1 5 6-10 11 15 16-20 21-25 26-30 30+ patients 17. On average, with how many health care co-workers (HCW) do you have direct contact per day (within 1 meter for at least two minutes)? 1 5 6-10 11 15 16-20 21-25 26-30 30+ HCWs 18. I answered the above questions based on: a typical day or yesterday or the last full day worked 19. In your experience, how regularly do your colleagues comply with disease infection control guidelines? Please circle your response, rated from 0 (full non-compliance) and 10 (full compliance). Non-compliance Compliance 0 1 2 3 4 5 6 7 8 9 10 9 of 11
20. Sometimes, direct contact with a patient (within 1 metre) is a patient care activity that should be documented in the health record and sometimes not. On average, how regularly are your contacts with a patient recorded in the patient s chart? Please circle your response, rated from 0 (never record) and 10 (always record). Never Always 0 1 2 3 4 5 6 7 8 9 10 21. Usually, you have more than one contact with a patient on a shift. If you have more than one direct contact with the same patient on any given day, how regularly would you record your name in the patient s chart? Please circle your response, rated from 0 (never record) and 10 (always record). Never Always 0 1 2 3 4 5 6 7 8 9 10 22. Imagine a patient that is diagnosed with a respiratory tract infection (e.g. influenza, RSV, adenovirus) that is spread by droplets. Please check all precautions you would take when you are within three feet (1 metre) of this patient: surgical/procedure mask face or eye shield single pair of gloves N95 mask (not fit tested) two pairs of gloves gown N95 mask (fit-tested) goggles hand washing 23. How regularly do you comply with recommended infection prevention measures for patients with respiratory tract infections noted above? Please circle your response, rated from 0 (never) to 10 (always). Never Always 0 1 2 3 4 5 6 7 8 9 10 24. How regularly are you able to comply with MRSA precautions? Please circle your response, rated from 0 (never) to 10 (always). Never Always 0 1 2 3 4 5 6 7 8 9 10 10 of 11
25. Imagine a patient that is diagnosed with active pulmonary tuberculosis and who is coughing up mucus. Please check all precautions you would take when you are in the same room with this patient: surgical/procedure mask face or eye shield single pair of gloves N95 mask (not fit tested) two pairs of gloves gown N95 mask (fit-tested) goggles hand washing 26. How regularly are you able to comply with recommended infection prevention measures for patients with active pulmonary tuberculosis who are coughing up mucus? Please circle your response, rated from 0 (never) to 10 (always). Never Always 0 1 2 3 4 5 6 7 8 9 10 27. Imagine a patient that is diagnosed with chickenpox and you have had the infection in childhood. Please check all precautions you would take when you are in the same room with this patient: surgical/procedure mask face or eye shield single pair of gloves N95 mask (not fit tested) two pairs of gloves gown N95 mask (fit-tested) goggles hand washing 28. How regularly are you able to comply with recommended infection prevention measures for patients with chickenpox? Please circle your response, rated from 0 (never) to 10 (always). Never Always 0 1 2 3 4 5 6 7 8 9 10 29. Do you get a yearly influenza vaccine? No (never) Yes, every year Yes, but not every year 30. On average, how many times per year do you come down with a cough or cold illness? Thank you for completing this questionnaire. Please return the questionnaire to the study center using the self-addressed envelope. 11 of 11
If you are interested in the draw for a $50 gift certificate to Second Cup or Indigo, remove the draw number at the bottom of this page. Do not remove the matching number above it. The matching number will be removed once the questionnaire is received at the study office and it will be placed in a ballot box. Fifty random draws will take place during the study period and the winning numbers will be posted on the hospital intranet. Do not remove this number: Tear at the dotted line and keep this number to claim your prize. Draw for a $50 gift certificate. Keep this number to claim your prize, if your number is drawn.