Meeting Request

Visit Request

NOTE: We are currently at capacity for this lecture series. Please complete this form, and we will retain your information and contact you if we have additional openings.

To schedule a visit from an expert OPC team, please use one of the following methods.

Online: Complete the form below
Phone: 1-877-499-CDAD (2323)

Requester Information
Organization:	*
First Name:	*	Last Name:	*
Degree:
Address:	*
City:	*	State:	*
Zip Code:	*	Phone:	*
Fax:		Cell:
Email:	*

Date and Time Selection (Please note: This is a 2-hour program)
1st Date:	- : *
2nd Date:	- :


Meeting Location
Location/Room No.:
Address:
City:
State:		Zip Code:

Do you have the following audiovisual equipment available?:
LCD projector Computer Screen

How did you hear about this program?	*
	*Required field
Meeting Participants

1) How many healthcare providers will be in attendance during your onsite visit?*

2) Which type(s) of healthcare provider(s) will be in attendance during your onsite visit? Please check all that apply.*
Physicians Medical students/residents Pharmacists Nurses Infection control practitioners Infectious diseases specialists Hospital policymakers Other

Meeting Format

3) In addition to the topics covered in the CME lecture presentation (epidemiology, infection control, and antibiotic stewardship), please indicate which of the following you would like the OPC expert and accompanying healthcare professional to address during the Customized Discussion portion of the program. Please select 1 to 3 areas of interest.*

I would like the OPC expert to:
Present slides and/or discuss interesting patient cases or the history and management of outbreaks at their own institution Meet with nursing leadership or staff nurses to provide advice on infection control procedures Meet with environmental services to provide instruction on environmental cleaning techniques Meet with hospital pharmacists to help them develop and implement an antimicrobial stewardship program Meet with hospital administration to inform them about the impact of C. difficile in the hospital setting Visit intensive care units to provide advice on ways to prevent the spread of C. difficile in the acute care setting Remain at my institution to answer additional questions from the CME lecture participants. Other


Pre-Visit Survey

1) Are you currently experiencing a C. difficile-associated disease (CDAD) outbreak (increase in the number of cases)?* Yes No

2) Have you experienced a CDAD outbreak in the past?* Yes No
If so, when?

3) Are you currently experiencing an increase in CDAD severity?* Yes No

4) How many cases of CDAD do you see per year?* <10 10-50 51-100 >100 Don't know; we do not track CDAD

5) If you track CDAD, do you calculate rates? Yes No

6) If yes, what denominator do you use? 1,000 admissions 1,000 discharges 1,000 patient-days 10,000 patient-days

7) What is your average CDAD rate over the last 12 months? <1 1-5 5-10 10-15 15-20 20-30 >30

8) How many beds does your hospital have? * <50 51-100 101-300 301-500 >500

9) What is your hospital type? * Community Academic (e.g., affiliated with a university) Government/VA

10) What is your hospital location?* Urban Suburban Rural

11) How many ICU beds does your hospital have?* <10 10-20 21-30 >30

12) Do you treat bone marrow and/or solid organ transplant patients?* Yes No

13) Which of the following do you track in your hospital? Check all that apply. Clostridium difficile infection Hand hygiene Contact precautions Room cleaning

14) What methods do you currently employ to prevent CDAD in your hospital? Check all that apply. Contact precautions Isolation room Bleach Hand hygiene Antibiotic restriction/stewardship Case identification/tracking/CDAD rates




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