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Resource Manual 2016:

Table of Contents

Tab 1: CMS Reporting

Tab 2: 2016 HAI Surveillance

Tab 3: Algorithms

Tab 4: Worksheet Generator (electronic) and Worksheets (manual)

Tab 5: Analysis Resources

Tab 6: Long-term Care Facility Resources

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CMS Reporting

Resources included:

1. Reporting Requirements and Deadlines in NHSN per CMS Current & Proposed Rules

2. NHSN Monthly Checklist for Reporting to CMS Hospital IQR

Reporting Requirements and Deadlines in NHSN per CMS Current & Proposed Rules

Healthcare Settings

Acute Care Facilities that participate in CMS Hospital IQR Program

*Medicare beneficiary number required for all NHSN events for applicable patients beginning July 2014*

NHSN Event

CLABSI

Start Ql 2015 - adult and pediatric medical, surgical, and medical/surgical wards

CMS Reporting Deadlines

Ql (Jan.-March): August 15

Q2 (April-June): November 15

Q3 (Jul.-Sept.): February 15

Start Ql 2012 - adult and pediatric ICUs Q2 (April-June): November 15


and medical/surgical wards Start Ql 2015 - adult and pediatric medical, surgical,

Q4 (Oct.-Dec.): May 15

551 (following COLO Procedures) (Start Ql 2012) . Q2 (April-June): November 15



(Start Ql 2012)

(Start Ql 2013)







C. difficile LablD Event (FacWidelN}

(Start Ql 2013)




I Q4 (Oct.-Dec.) - Ql (Jan.-March): May 15

Updated September 2015 Page 1 of 4

Healthcare Settings NHSN Event CMS Reporting Deadlines

Acute Care Facilities Healthcare Personnel Influenza Vaccination Q4 (Oct.-Dec.) - Ql (Jan.-March): May 15 that participate in the

(Start Q4 2014) CMS Hospital Outpatient Quality Reporting (OQR) Program

Outpatient Dialysis Q1-Q4 2012 (Jan.-Dec.: 3 month minimum): Dialysis Event (includes Positive blood

Facilities that April 30, 2013 culture, I.V. antimicrobial start, and Signs of

participate in CMS ESRD Q1-Q4 2013 (Jan.-Dec.: 6 month minimum):vascular access infection) QIPProgram April 15, 2014

Starting Ql 2014(Start 2012)

(Jan. - Dec.: 12 month minimum):

Ql (Jan.-March): June 30

Q2 (April-June): September 30

Q3 (Jul.-Sept.): December 31

Q4 (Oct.-Dec.): March 31

Healthcare Personnel Influenza Vaccination Q4 (Oct.-Dec.) - Ql (Jan.-March): May 15

(Start Q4 2015)

Long-term Acute Care Facilities (LTACs} that participate in CMS LTCHQR Program

*Starting with October 2015 data, reporting deadline will be 4.5 months after the end of the quarter.*

Data from Q3 2015 are due November 15, 2015.

Data from Q4 2015 are due on May 15, 2016.

Historical Reference

Q4 2012 - Q4 2013: Data due

4.5 months after the end of the quarter.

Ql 2014- Q3 2015: Data due 1.5 months after the end of the quarter.

Q4 2015 forward: Data due 4.5 months after the end of the quarter.

CLABSI (all bedded inpatient

care locations)

(Start Q4 2012)

CAUTI (all bedded inpatient care

locations)

(Start Q4 2012)

MRSA Bacteremia LablD Event

(FacWidelN)

(Start Ql 2015)

C. difficile LablD Event (FacWideIN)

(Start Ql 2015)

Ql 2014- Q3 2015

Ql (Jan.-March): May 15

Q2 (April-June): August 15

Q3 (Jul.-Sept.): November 15

Q4 (Oct.-Dec.): February 15

Ql 2014- Q3 2015





Ql 2014 - Q3 2015





Ql 2014 - Q3 2015





Starting Q4 2015





Starting Q4 2015





Starting Q4 2015





Starting Q4 2015





(LTAC requirements continued on next page)



Long-term Acute Care Q4 (Oct.-Dec.)- Ql (Jan.-March): May 15

Facilities (LTACs) that participate in CMS

LTCHQR Program VAE

(continued) (all bedded adult inpatient care locations) Q2 (April-June): November 15

(Start Ql 2016) Q3 (Jul.-Sept.): February 15


CAUTI (all bedded inpatient care locations) Inpatient Rehabilitation Facilities (IRFs) that (Start Q4 2012) Q2 (April-June): November 15

participate in CMS Q3 (Jul.-Sept.): February 15 IRFQR Program

*IRFs that are mapped as a MRSA Bacteremia LablD Event (FacWidelN)* Ql (Jan.-March): August 15 location within affiliated (Start Ql 2015) Q2 (April-June): November 15 acute care/critical access

Q3 (Jul.-Sept.): February 15 hospitals should pay special attention to the specific Q4 (Oct.-Dec.): May 15 MRSA and CDI LablD reporting details outlined in this document: C. difficile LablD Event (FacWidelN)* http://www.cdc.gov/nhsn/pd (Start Ql 2015) Q2 (April-June): November 15 fs/cms/irfs/settingup reporti

Q3 (Jul.-Sept.): February 15 ng labid event irf acutec.pd

f Q4 (Oct.-Dec.): May 15

Inpatient Psychiatric Healthcare Personnel Influenza Vaccination Q4 (Oct.-Dec.)- Ql (Jan.-March): May 15 Facilities {IPFs) that participate in CMS

(Start Q4 2015) IPFQR Program


http:acutec.pdhttp://www.cdc.gov/n

Healthcare Settings

PPS-Exempt Cancer Facilities that participate in CMS PCHQR Program

NHSN Event

CLABSI (all bedded inpatient care locations}

(Start Ql 2013)

CAUTI (all bedded inpatient care locations)

(Start Ql 2013)

SSI (following COLO Procedures)

(Start Ql 2014)

SSI (following HYST Procedures)

(Start Ql 2014)

MRSA Bacteremia labID Event (FacWidelN}

(Start Ql 2016)

C. difficile LablD Event (FacWidelN)

(Start Ql 2016)

Healthcare Personnel Influenza Vaccination

(Start Q4 2016)


























Q4 (Oct.-Dec.)- Ql (Jan.-March): May 15


June 2015

NHSN Monthly Checklist for Reporting to CMS Hospital IQR

DccN: Month/Vear: _____

DicusDicus Oco1 DcoLoMonthly Plan D Owards* Owards* DMRSA DHYST

Seasonal

Influenza

Vaccination D Summary

Data

DFACWIDEINMonthly DcoLo

DHYST

D,cus DicusDenominator OrnData

Dwards* Dwards* DObservation If Zero Events

or Zero

procedures

DcoLoDco1

DHYSTDMRSA

D,cus Dicus

Owards*

(SSls only}, Report no

Owards* Events or no Procedures

DemoDco,Dicus

DHYSTOwards* DMRSA

D,cus Enter Events

Owards*

Check for Oco1D,cusDicus DcoLo

Accuracy

Dwards* Owards*

D DHYSTDMRSA

Oco1 DDSave

quarterly D CMS Reports D

DMRSA

*For January 2015 and forward, includes those locations defined as, and mapped as, adult and pediatric medical,

surgical, and medical/surgical wards.

Note: This is a summary checklist that applies to acute care hospitals only; if you need additional information

please refer to the document below. This guide is not meant to cover requirements for other facility types,

including CMS-certified Inpatient Rehabilitation Facilities (IRFs) located as units within acute care hospitals.

11

June 2015

Table of Contents Monthly Checklist for Reporting to CMS Hospital IQR .................................................................................................1

Catheter-Associated Urinary Tract Infection (CAUTl) ...................................................................................................3

Central Line-Associated Bloodstream Infection (CLABSI) .............................................................................................4

Clostridium difficile Infection (COi} ...............................................................................................................................5

Methicillin-Resistant Staphylococcus aureus (MRSA Bacteremia) ...............................................................................6

Surgical Site Infection (SSI) ...........................................................................................................................................7

Healthcare Personnel (HCP) Influenza Vaccination ......................................................................................................8

Additional Resources:......................................................................................................................................... 9

Catheter-Associated Urinary Tract Infection (CAUTI) ...............................................................................................9

Central Line-Associated Bloodstream Infection (CLABSI) .........................................................................................9

Clostridium difficile Infection (COi) ...........................................................................................................................9

Methicillin-Resistant Staphylococcus aureus (MRSA Bacteremia) ...........................................................................9

Surgical Site Infection (SSI) .......................................................................................................................................9

Healthcare Personnel (HCP) Influenza Vaccination ..................................................................................................9

2 I

June 2015

Catheter-Associated Urinary Tract Infection {CAUTI) Monthly Checklist for CAUTI Reporting for the Centers for Medicare and Medicaid Services' Hospital Inpatient

Quality Reporting Program (CMS Reporting Program) via NHSN

Beginning in January, 2015, Acute Care Hospitals participating in the CMS Reporting Program must report CAUTI data from locations defined/mapped as adult and pediatric medical, surgical, and medical/surgical wards, in addition to all adult and pediatric /CUs.

The following steps should be completed prior to the quarterly CMS Reporting Program deadline:

D Verify Your Facility's CMS Certification Number (CCN) An accurate CCN is required for those facilities participating in the CMS Reporting Program, as this is the ID that will

be used to submit CAUTI data to CMS on your behalf. To update the CCN, use the Facility> Facility Info option

within NHSN. At the top of the Facility Information screen, verify and update, if necessary, the CCN in the

appropriate data entry field. If any changes have been made, remember to click the "Update" button at the bottom

of screen. Please be sure to double- and triple-check this number!

D Check the Monthly Reporting Plan each month When NHSN releases CAUTI data to CMS for those hospitals participating in the CMS Reporting Program, only those

months and applicable locations in which the facility included CAUTI in its NHSN monthly reporting plan (MRP) will

be included (i.e., in Plan CAUTI). It is the responsibility of each facility to check their MRPs for compliance with this

requirement.

D Enter denominator data for each required location and month under surveillance Denominator data (i.e., patient days and urinary catheter days) can be entered using the Summary Data > Add

option within NHSN and by selecting the appropriate Denominator Data type (e.g., ICU/Other).

D If no events have been identified, check "Report No Events" on denominator data form Facilities must appropriately Report No Events for those locations and months for which no events of

each type under surveillance were identified. If no events have been reported and this box is not checked, your data

will not be submitted to CMS. For instructions, please see: http://www.cdc.gov/nhsn/PDFs/CMS/how-to-report-No

Events-CLAB-CAU. pdf

D If CAUTI events have been identified, enter the appropriate events

CAUTI events can be entered by using the Event> Add option within NHSN.

D Use NHSN Analysis Tools to check for accuracy and completion The NHSN Analysis Output Option, "SIR - CAUTI Data for CMS IPPS" was created in order to allow facilities to review

those CAUTI data that would be submitted to CMS on their behalf. For more information about this output option,

please see Using the "SIR - CAUTI Data for CMS IPPS" Output Option on the NHSN website:

http://www.cdc.gov/nhsn/PDFs/CMS/CMS-IPPS-CAUTI-SIR.pdf

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June 2015

Central Line-Associated Bloodstream Infection {CLABSI) Monthly Checklist for CLABSI Reporting for the Centers for Medicare and Medicaid Services' Hospital Inpatient

Quality Reporting Program (CMS Reporting Program)

Beginning in January, 2015, Acute Care Hospitals participating in the CMS Reporting Program must report CLABSI data from locations defined/mapped as adult and pediatric medical, surgical, and medical/surgical wards, in addition to all adult, pediatric and neonatal ICUs.


D Verify Your Facility's CMS Certification Number (CCN) An accurate CCN is required for those facilities participating in the CMS Reporting Program, as this is the ID that will

be used to submit CLABSI data to CMS on your behalf. To update the CCN, use the Facility> Facility Info option

within NHSN. At the top of the Facility Information screen, verify and update, if necessary, the CCN in the



D Check the Monthly Reporting Plan each month When NHSN releases CLABSI data to CMS for those hospitals participating in the CMS Reporting Program, only those

months and applicable locations for which the facility included CLABSI in its NHSN monthly reporting plan (MRP) will

be included (i.e., in Plan CLABSI). It is the responsibility of each facility to check their MRPs for compliance with this

requirement.

D Enter denominator data for each required location and month under surveillance Denominator data (i.e., patient days and central line days) can be entered using the Summary Data> Add option

within NHSN and by selecting the appropriate Denominator Data type (e.g., ICU/Other, NICU).

D If no events have been identified, check "Report No Events" on denominator data form Facilities must appropriately Report No Events for those locations and months for which no events of

each type under surveillance were identified. If no events have been reported and this box is not checked, your data

will not be submitted to CMS. For instructions, please see: http://www.cdc.gov/nhsn/PDFs/CMS/how-to-report-No

Events-CLAB-CAU .pdf

D If CLABSI events have been identified, enter the appropriate events

CLABSI events can be entered by using the Event> Add option within NHSN.

D Use NHSN Analysis Tools to check for accuracy and completion The NHSN Analysis Output Option, "SIR - CLAB Data for CMS IPPS" was created in order to allow facilities to review

those CLABSI data that would be submitted to CMS on their behalf. For more information about this output option,

please see Using the "SIR - CLAB Data for CMS IPPS" Output Option on the NHSN website:

http://www.cdc.gov/nhsn/PDFs/CMS/CMS-IPPS-CLABSI-SIR.pdf

41

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June 2015

Clostridium difficile Infection (CDI) Monthly Checklist for FacWideln (facility-wide inpatient) CDI LablD Event Reporting for the Centers for

Medicare and Medicaid Services' Hospital Inpatient Quality Reporting (IQR) Program

The following steps should be completed prior to the quarterly CMS Hospital IQR Program deadline:

D Verify Your Facility's CMS Certification Number (CCN) An accurate CCN is required for those facilities participating in CMS's Hospital JQR Program, as this is the ID that will

be used to submit FacWideln CDI LablD data to CMS on your behalf. To update the CCN, use the Facility> Facility

Info option within NHSN. At the top of the Facility Information screen, verify and update, if necessary, the CCN in the



D Check the Monthly Reporting Plan each month When NHSN releases FacWideln CDI LablD data to CMS for those hospitals participating in CMS's Hospital IQR

Program, only those months in which the facility included FacWideln CDI LablD in its NHSN monthly reporting plan

(MRP) will be included. It is the responsibility of each facility to check their MRPs for compliance with this

requirement. NOTE: Beginning with January 2015 data, each ED and Observation location must be included on the

MRPs for CDI Lab ID.

D Enter FacWideln, ED, and Observation denominator data for each month under surveillance Overall, inpatient facility-wide denominator data (i.e., C. diff patient days and C. diff admissions) can be entered

using the Summary Data> Add option within NHSN and selecting "MORO and CDI Prevention Process and Outcomes

Monthly Monitoring Form". In addition, beginning with January 2015, denominator data for ED and Observation

locations {i.e., encounters) must be entered separately {i.e., one summary data record for each ED and Observation

unit that is located within your facility} for each month.

D If no events have been identified, check "Report No Events" on each denominator data form Facilities must appropriately Report No Events for those months for which no events of each type

under surveillance were identified. If no events have been reported and this box is not checked, your data will not be

submitted to CMS. For instructions, please see Step 5 of the following document:

http://www.cdc.gov/nhsn/PDFs/mrsa-cdi/How-T o-Set-U p-And-Report-M RSA-COi. pdf

D If CDI LablD events have been identified, enter these events into NHSN CDI Lab ID events can be entered by using the Event> Add option within NHSN. Note that you must specify the

location where the specimen was collected.

D Use NHSN Analysis Tools to check for accuracy and completion The NHSN Analysis Output Option, "SIR - FacWideln CDI LablD Data for CMS IPPS" was created in order to allow

facilities to review those CDI LablD data that would be submitted to CMS on their behalf. For more information

about this output option, please see the document Using the "SIR - FacWideln CDI LablD for CMS IPPS" Output

Option on the NHSN website: http:ljwww.cdc.gov/nhsn/PDFs/CMS/CMS-IPPS-CDI-SIR.pdf.

s I

http:ljwww.cdc.gov/nhsn/PDFs/CMS/CMS-IPPS-CDI-SIR.pdfhttp://www.cdc.gov/n

June 2015

Methicillin-Resistant Staphylococcus aureus (MRSA Bacteremia) Monthly Checklist for FacWideln (facility-wide inpatient) MRSA Bacteremia LablD Event Reporting for the

Centers for Medicare and Medicaid Services' Hospital Inpatient Quality Reporting (IQR) Program

The following steps should be completed prior to the quarterly CMS Hospital IQR Program deadline:

D Verify Your Facility's CMS Certification Number (CCN) An accurate CCN is required for those facilities participating in CMS's Hospital IQR Program, as this is the ID that will

be used to submit FacWideln MRSA Bacteremia LablD data to CMS on your behalf. To update the CCN, use the

Facility> Facility Info option within NHSN. At the top of the Facility Information screen, verify and update, if

necessary, the CCN in the appropriate data entry field. If any changes have been made, remember to click the

"Update" button at the bottom of screen. Please be sure to double- and triple-check this number!

Check the Monthly Reporting Plan each month

When NHSN releases FacWideln MRSA Bacteremia LablD data to CMS for those hospitals participating in CMS's

Hospital IQR Reporting Program, only those months in which the facility included FacWideln MRSA LablD (either "All

Specimens" or "Blood Specimens Only") in its NHSN monthly reporting plan (MRP) will be included. It is the

responsibility of each facility to check their MRPs for compliance with this requirement. NOTE: Beginning with

January 2015 data, each ED and Observation location must be included on a separate row in the MRPs for MRSA

LablD, to match the reporting for the FacWideln selection.

D Enter FacWideln, ED, and Observation location denominator data for each month under surveillance Overall, inpatient facility-wide denominator data (i.e., patient days and admissions) can be entered using the

Summary Data> Add option within NHSN and selecting "MORO and COi Prevention Process and Outcomes Monthly

Monitoring Form". Beginning with January 2015, denominator data for ED and Observation locations (i.e.,

encounters) must be entered separately (i.e., one summary record for each ED and Observation location) per month.

D If no events have been identified, check "Report No Events" on denominator data form Facilities must appropriately Report No Events for those months for which no events of each type

under surveillance were identified. If no events have been reported and this box is not checked, your data will not be

submitted to CMS. For instructions, please see Step 5 of the following document:

http://www.cdc.govInhsn/PDFs/m rsa-cdi/How-T o-Set-U p-And-Report-M RSA-CD I. pdf

D If MRSA Bacteremia LablD events have been identified, enter these events into NHSN MRSA Bacteremia lablD events can be entered by using the Event> Add option within NHSN. Note that you must

specify the location where the specimen was collected. You must also specify Specimen Body Site/Source= CARD

and Specimen Source= BLDSPC for NHSN to categorize the LablD event as MRSA bacteremia.

D Use NHSN Analysis Tools to check for accuracy and completion The NHSN Analysis Output Option, "SIR - MRSA Blood FacwidelN Lab ID Data for CMS IPPS" was created in order to

allow facilities to review those MRSA Bacteremia LablD data that would be submitted to CMS on their behalf. For

more information about this output option, please see the document Using the "SIR - MRSA Blood FacwidelN LablD

Data for CMS IPPS" Output Option on the NHSN website: http://www.cdc.gov/nhsn/PDFs/CMS/CMS-IPPS-MRSA

SIR.pdf

GI

http://www.cdc.gov/nhsn/PDFs/CMS/CMS-IPPS-MRSAhttp:http://www.cdc.gov

June 2015

Surgical Site Infection (SSI) Monthly Checklist for SSI Reporting for the Centers for Medicare and Medicaid Services' Hospital Inpatient

Quality Reporting Program (CMS Reporting Program) via NHSN


D Verify Your Facility's CMS Certification Number (CCN)

An accurate CCN is required for those facilities participating in the CMS Reporting Program, as this is the ID that will

be used to submit SSI data to CMS on your behalf. To update the CCN, use the Facility> Facility Info option within

NHSN. At the top of the Facility Information screen, verify and update, if necessary, the CCN in the appropriate data

entry field. If any changes have been made, remember to click the "Update" button at the bottom of screen. Please

be sure to double- and triple-check this number!

D Check the Monthly Reporting Plan each month

When NHSN releases SSI data to CMS for those hospitals participating in the CMS Reporting Program, only those

months in which the facility included SSI in its NHSN monthly reporting plan (MRP) will be included (i.e., in Plan SSI).

It is the responsibility of each facility to check their MRPs for compliance with this requirement.

D Enter procedure records for each procedure category and month under surveillance

Per the NHSN reporting requirements, facilities must enter a procedure record for each procedure performed that is

included in the SSI surveillance per the monthly reporting plan. If no inpatient procedures were performed for any

month and procedure type, make sure to check the "Report no Procedures" box.

D If no events have been identified, check "Report No Events"

Facilities must appropriately Report No Events for those procedures and months for which no events

of each type under surveillance were identified. If no events have been reported and this box is not checked, your

data will not be submitted to CMS. For instructions, please see: http:ljwww.cdc.gov/nhsn/PDFs/CMS/How-to

Report-No-Events-SSl.pdf

D If SSls have been identified, enter these events and link to the attributable procedure record

Per the NHSN reporting requirements, facilities must enter a record for each SSI identified following the procedure

categories under surveillance.

D Use NHSN Analysis Tools to check for accuracy and completion

The NHSN Analysis Output Option, "SIR - Complex 30-Day SSI Data for CMS IPPS" was created in order to allow

facilities to review those SSI data that would be submitted to CMS on their behalf. For more information about this

output option, please see Using the "SIR- Complex 30-Day SSI Data for CMS IPPS" Output Option on the NHSN

website: http:ljwww.cdc.gov/nhsn/PDFs/CMS/CMS-IPPS-SSI-SIR.pdf

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June 2015

Healthcare Personnel (HCP) Influenza Vaccination Checklist for Healthcare Personnel (HCP) Influenza Vaccination Reporting for the Centers for Medicare and Medicaid Services' Hospital Inpatient Quality Reporting (IQR) Program and Outpatient Quality Reporting (OQR) Program The following steps should be completed prior to the CMS Reporting Program deadline:

D Verify Your Facility's CMS Certification Number (CCN)

An accurate CCN is required for those facilities participating in the CMS Reporting Program, as this is the ID that will be used to submit HCP influenza vaccination data to CMS on your behalf. To update the CCN, use the Facility> Facility Info option within NHSN. At the top of the Facility Information screen, verify and update, if necessary, the CCN in the appropriate data entry field. If any changes have been made, remember to click the "Update" button at the bottom of screen. Please be sure to double- and triple-check this number!

D Activate the Healthcare Personnel Safety Component

HCP Influenza Vaccination reporting is done through NHSN's Healthcare Personnel Safety (HPS) Component. The HPS

Component must be activated by the NHSN Facility Administrator before the facility can report any data.

Instructions for activating the HPS Component can be found in the HCP Influenza Vaccination training slideset at:

http://www.cdc.gov/nhsn/PD F s/traini ng/H CP-fl u-Vaccination-Summarv-Reporti ng-General-Trai ni ng.pdf

D Create a Monthly Reporting Plan in the HPS Component

HCP influenza vaccination data from NHSN will only be sent to CMS for those hospitals participating in the CMS Reporting Program who have included the HCP influenza vaccination summary in their HPS Component monthly reporting plan. Unlike the other NHSN components and modules, when "Influenza Vaccination Summary" is selected on one reporting plan, the information is automatically updated on all reporting plans for the entire influenza season as defined by NHSN (which is July 1 to June 30).

D Enter HCP influenza vaccination summary data for the entire influenza season

The HCP influenza vaccination summary data form must be completed (Flu Summary->Add) for each influenza season. There is only a single form for each influenza season, and the form must be completed by each season's reporting deadline. Data for HCP in inpatient and outpatient departments should be reported together on the same form. Each time a user enters updated data for an influenza season, all previously entered data for that season are overwritten.

D Use NHSN Analysis Tools to check for accuracy and completion

The NHSN Analysis Output Option, "Line Listing - HCP Flu Vaccination Data for CMS IPPS and OPPS" was created to

allow facilities to review the HCP influenza vaccination data that will be submitted to CMS on their behalf. For more

information about this output option, please see Using the uline Listing - HCP Flu Vaccination Data for CMS !PPS

and OPPS" Output Option on the NHSN website at http://www.cdc.gov/nhsn/cms/index.html.

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June 2015

Additional Resources:

Catheter-Associated Urinary Tract Infection (CAUTI)

Operational Guidance for Acute Care Hospitals to Report Catheter-Associated Urinary Tract Infection {CAUTI) Data to

CDC's NHSN for the Purpose of Fulfilling CMS's Hospital Inpatient Quality Reporting (IQR) Requirements:

http://www.cdc.gov/nhsn/PDFs/CMS/Final-ACH-CAUTI-Guidance 2015.pdf

NHSN Surveillance for Urinary Tract Infections: http://www.cdc.gov/nhsn/acute-care-hospital/CAUTl/index.html

Central Line-Associated Bloodstream Infection (CLABSI}

Operational Guidance for Acute Care Hospitals to Report Central Line-Associated Bloodstream Infection (CLABSI) Data to CDC's NHSN for the Purpose of Fulfilling CMS's Hospital Inpatient Quality Reporting (IQR) Requirements: http://www.cdc.gov/nhsn/PDFs/CMS/Final-ACH-CLABSI-Guidance-2015.pdf

NHSN Surveillance for Central Line-Associated Bloodstream Infections (CLABSI): http://www.cdc.gov/nhsn/acutecare-hospital/clabsi/index.html

C/ostridium difficile Infection (CDI)

Operational Guidance: http://www.cdc.gov/nhsn/PDFs/mrsa-cdi/FINAL-ACH-CDI-Guidance.pdf

How to Set Up NHSN Reporting for Facility-Wide Inpatient MRSA Bacteremia and C. difficile LablD events for the CMS

Inpatient Quality Reporting Program: http://www.cdc.gov/nhsn/PDFs/mrsa-cdi/How-To-Set-Up-And-Report-MRSA

CDl.pdf

NHSN Surveillance for C. difficile, MRSA, and other Drug-resistant Infections: http://www.cdc.gov/nhsn/acute-care

hospital/cdiff-mrsa/index.html

Denominator guidance: http://www.cdc.gov/nhsn/PDFs/mrsa-cdi/AcuteCare-MRSA-CDI-LablDDenominator

Reporting.pdf

Methicillin-Resistant Staphylococcus aureus (MRSA Bacteremia)

Operational Guidance: http:ljwww.cdc.gov/nhsn/PDFs/mrsa-cdi/FINAL-ACH-MRSA-Bacteremia-Guidance.pdf

How to Set Up NHSN Reporting for Facility-Wide Inpatient MRSA Bacteremia and C. difficile Lab ID events for the CMS

Inpatient Quality Reporting Program: http://www.cdc.gov/nhsn/PDFs/mrsa-cdi/How-To-Set-Up-And-Report-MRSA

CDl.pdf

NHSN Surveillance for C. difficile, MRSA, and other Drug-resistant Infections: http://www.cdc.gov/nhsn/acute-care

hospital/cdiff-mrsa/index.html

Denominator guidance: http://www.cdc.gov/nhsn/PDFs/mrsa-cdi/AcuteCare-MRSA-CDI-LablDDenominator

Reporting.pdf.

Surgical Site Infection (SSI)

Operational Guidance for Reporting Surgical Site Infection Data to CDC's NHSN for the Purpose of Fulfilling CMS's

Hospital Inpatient Quality Reporting (IQR) Program Requirements: http://www.cdc.gov/nhsn/PDFs/CMS/Final-ACH

SSI-Guidance 2015.pdf

NHSN Surveillance for Surgical Site Infection (SSI) Events: http://www.cdc.gov/nhsn/acute-care-hospital/index.html

Healthcare Personnel (HCP) Influenza Vaccination

Operational Guidance for Acute Care Hospitals to Report Healthcare Personnel (HCP) Influenza Vaccination Data to CDC's National Healthcare Safety Network (NHSN) for the Purpose of Fulfilling CMS's Hospital Inpatient Quality Reporting (IQR) Program Requirements and CMS' Hospital Outpatient Quality Reporting (OQR) Program Requirements: http://www.cdc.gov/nhsn/PDFs/HCP/Operational-Guidance-ACH-HCP-Flu.pdf

NHSN HPS Component Manual: http://www.cdc.gov/nhsn/PDFs/HPS-manual/HPS Manual-exp-plus-flu-portfolio.pdf

91

http://www.cdc.gov/nhsn/PDFs/HPS-manual/HPShttp://www.cdc.gov/nhsn/PDFs/HCP/Operational-Guidance-ACH-HCP-Flu.pdfhttp://www.cdc.gov/nhsn/acute-care-hospital/index.htmlhttp://www.cdc.gov/nhsn/PDFs/CMS/Final-ACHhttp://www.cdc.gov/nhsn/PDFs/mrsa-cdi/AcuteCare-MRSA-CDI-LablDDenominatorhttp://www.cdc.gov/nhsn/acute-carehttp://www.cdc.gov/nhsn/PDFs/mrsa-cdi/How-To-Set-Up-And-Report-MRSAhttp:ljwww.cdc.gov/nhsn/PDFs/mrsa-cdi/FINAL-ACH-MRSA-Bacteremia-Guidance.pdfhttp://www.cdc.gov/nhsn/PDFs/mrsa-cdi/AcuteCare-MRSA-CDI-LablDDenominatorhttp://www.cdc.gov/nhsn/acute-carehttp://www.cdc.gov/nhsn/PDFs/mrsa-cdi/How-To-Set-Up-And-Report-MRSAhttp://www.cdc.gov/nhsn/PDFs/mrsa-cdi/FINAL-ACH-CDI-Guidance.pdfhttp://www.cdc.gov/nhsn/acutehttp://www.cdc.gov/nhsn/PDFs/CMS/Final-ACH-CLABSI-Guidance-2015.pdfhttp://www.cdc.gov/nhsn/acute-care-hospital/CAUTl/index.htmlhttp://www.cdc.gov/nhsn/PDFs/CMS/Final-ACH-CAUTI-Guidance

2016 HAI Surveillance

Resources included:

1. 2016 Patient Safety Component Manual Updates

2. Identifying Healthcare-associated Infections (HAI) for NHSN Surveillance

3. Secondary Bloodstream Infection (BSI) Guide

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2016 NHSN Patient Safety Component Manual Updates

This document highlights the January 2016 changes, revisions, and updates to the NHSN Patient Safety

Component Manual, which impact the way data are collected and reported to NHSN. Although other minor revisions, not highlighted here, have been made to the manual, they generally represent wording and/or format changes not deemed to significantly impact the collection or reporting ofNHSN data. Besides the changes listed

in this document, it is important to also review the Table of Instructions to ensure that data are collected and reported accurately. Users are expected to follow all updated guidance for definitions, rules, and criteria for events identified on or after January 1, 2016.

Changes Effecting Multiple Protocols

2-2 Fungal Pathogens which are most commonly community acquired and rarely associated with healthcare-associated infections, but which may meet NHSN surveillance criteria for healthcare-associated infections due to long incubation periods, will no longer be included in NHSN HAI reporting. These pathogens are limited to Blastomyces, Histoplasma, Coccidioides, Paracoccidioides, Cryptococcus, and Pneumocystis.

Included in infection criteria

Microbiologic non-culture diagnostic tests that provide organism identification on patient specimens ( e.g. PCR) will be accepted in addition to specimen cultures for infection criteria.

2-2 Specimens for microbiologic non-culture diagnostic testing or culture collected from patients documented brain dead AND maintained awaiting organ harvest will NOT be used for healthcare-associated infection surveillance.

Chapter 1:NHSN Overview

Chapter modified to reflect that the previous Long-Term Care Module is now a separate component in NHSN.

Chapter 2: Identifying Healthcare-associated Infections (HAI) in NHSN

2-2 Table 1 updated to add clarity

2-3 Added clarification and an example to address site-specific infection criteria that do not include a diagnostic test.

2-16 Added clarification and an example to address pathogen assignment related to Secondary BSis and subsequent positive blood cultures

See also General NHSN Surveillance Changes for additional applicable changes

Chapter 3: Patient Safety Monthly Reporting Piao and Annual Surveys

No substantive changes to this chapter.

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Chapter 4: CLABSI Event

4-2 Added "Impella Heart Device" to list of devices not considered central lines.

4-4, 4-11 Added guidance that allows a BSI that is accompanied by a healthcare worker's documentation in the patient's medical record specifying the patient is suspected of self-injecting into a vascular access device, or is observed to self-inject into a device, to be identified as a healthcare-associated BST, but not a central-line associated BST (CLABST). Documentation must occur during the BSI Infection Window Period.

4-10 Clarified that ANC/WBC levels should NOTnot be used to set the date of MBI-LCBI. The date the patient first meets the LCBI criteria is the date ofthe MBI-LCBI.

4-12 Added exclusion of Salmonella species as pathogens for primary BSI (Laboratory Confirmed Bloodstream Infection).

4-14 Added guidance that if a patient has clear evidence of infection associated with a non-central line site (or non-accessed central line site), the event will be identified as a healthcare-associated BSI, but not a central-line associated BSI (CLABSI). "Clear evidence" required is pus at the insertion site with a culture or microbiologic non-culture diagnostic test which identifies an organism also identified in the blood, during the BSI Infection Window Period.

4-20 Modified the Secondary BSI Guide to provide clarity, and updated examples.

4-25 Added guidance that when a BSI is suspected to be secondary to a lower respiratory tract infection and the BSI cannot be determined to be secondary to V AE, the PNEU definitions are available for secondary BSl assignment

See also General NHSN Surveillance Changes for additional applicable changes.

Chapter 5: CLIP

5-2 Updated requirements for skin prep compliance for Central Line Insertions Practices (CLIP) events for 2016. Only skin prep allowed to meet CLIP bundle adherence is chlorhexidine gluconate (CHG) for patients ::: 60 days old unless there is a documented contraindication to use of CHG recorded in NHSN upon CLIP event entry. CLIP Table oflnstructions provides guidance on recognized contraindications.

Chapter 6: Ventilator-Associated Pneumonia (VAP) Event

6-3 Added a note to emphasize pathogen exclusions apply to secondary BSI assignment for PNEU.

6-8 Table 4. Identification of matching Candida spp. from blood and respiratory specimen now includes BAL and protected specimen brushing in addition to sputum, and endotracheal aspirate.

See also General NHSN Surveillance Changes for additional applicable changes .

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Chapter 7: CAUTI Event

SUTI la Protocol has been updated to clarify that urinary urgency, frequency and dysuria cannot be Catheter- used as symptoms when catheter is in place. associated Protocol has been updated to clarify that Candida species or yeast not otherwise specified, Urinary Tract mold, dimorphic fungi or parasites are excluded as organisms in the UTI definition. (pages Infection 7-8). ( CA UTT) page 7-5 and SUTI lb Non-Catheterassociated Urinary Tract Infection (Non-CAUTI) page 7-6 and Flowchart 7-12

See also General NHSN Surveillance Changes for additional applicable changes

Chapter 9: SSI Event

Changes were made throughout the chapter to reflect the transition from ICD-9-CM codes to ICD-10-PCS/CM codes.

9-3 Table 1 deleted- the ICD-10-PCS codes and CPT codes are found in the SSI Section of the NHSN website under the "Supporting Materials" section. Link to the new documents is on page 3.

9-7 Superficial SSI criterion "c" was updated to reflect a symptomatic patient whose incision opened but no culture is obtained. Note that if a ( +) culture is obtained the patient meets criterion b.

9-22 Appendix 1 was added to the SSI protocol. This new appendix contains a list of all NHSN operative procedure groups and the site specific SSis that are available as events for each group.

SSI ICD-10-PCS Guidance was provided for spinal level and approach for FUSN procedures. Supporting Materials


Chapter 10: Ventilator-Associated Event (VAE)

10-16 Added the definition for matching organism.

10-22 Added guidance for Episode of Mechanical Ventilation (EMV) denominator data collection.

10-26 Added the following 6 new antimicrobial agents to the Appendix "List of Antimicrobials Agents Eligible for IVAC, PVAP":

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Chapter 11: AUR

The AU Option portion of the protocol was updated to provide information on the new analysis output option that allows facilities that have submitted AU Option data to generate Standardized Antimicrobial Administration Ratios (SAARs) for specific groups of antimicrobials and specific location types. The AR Option of the protocol was updated to clarify the requirements for data submission.

Chapter 12: Multidrug-Resistant Organism and Clostridium difficile Infection (MDRO/CDI) Module

TO Is 2 questions currently conditionally required will move to required status. The questions are "Last physical overnight location of patient immediately prior to arrival into facility" and "Has the patient been discharged from another facility in the past 4 weeks?"

When developed, the LablD Event surveillance module was intended to reduce the manual data collection burden otherwise required to identify MDRO/CDI infection, by providing a proxy measure that focused on data that is more amendable to electronic capture. Requiring these two variables as "required" is not intended to be a departure from this original intent. Substantial benefits could be gained from consistent collection of the data; however, NHSN has reassessed the associated collection burden and determined that, at present, the data may not be retrievable or may be excessively burdensome to collect in some facilities. Therefore, for 2016 LabID Event Reporting, we ask facilities to provide the most accurate information that is available for these fields, making use of the response option "Unknown" if identifying the required information presents undue burden.

2 questions added to CRE reporting. The results for 'production of carbapenemase' will be required for CRE-Klebsiella, CRE-E.coli and CRE-Enterobacter. The questions are "Was the bacterial isolate tested for carbapenemase; Ifyes, then which test was done" and "Did the isolate test positive for carbapenemase; lf yes, identify which carbapenemase were identified."


Chapter 15: CDC Locations and Descriptions

15-7 Added guidance to "Inaccurate CDC Location Descriptions" under scenario 2 in order to provide instruction on how users can connect data from an older location to a newly mapped location.

15-37/38 Added four (4) new outpatient locations for Ambulatory Surgery Centers.

Chapter 16: Key Terms

16-1 Added definition of "Clinical Correlation".

Chapter 17: CDC/NHSN Surveillance Definition of HAI and Criteria for Specific Types of Infections

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17-19 IAB-Intraabdominal infection definition has been updated: Criterion #2 has been updated to add blood as an element. There are certain organisms that may be used for a ( +) blood culture. Criterion #3b has been updated: There are certain organisms that may be used for a(+) blood culture.


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Identifying Healthcare-associated Infections

Identifying Healthcare-associated Infections (HAI) for NHSN Surveillance

To standardize the classification of an infection as present on admission (POA) or a healthcare-associated

infection (HAI), the following objective surveillance definitions and guidance will be used for NHSN surveillance:

7-day Infection Window Period

Date of Event

POA

HAI

14-day Repeat Infection Timeframe (RIT)

Secondary Bloodstream Infection Attribution Period

To make a proper infection definition determination, proceed in this order: (This doesn't apply to SSls, VAEs, and MDRO/CDI LablD Events)

1. Determine the date of the diagnostic test that is an element of the site-specific criterion.

2. Then from that determine the infection window period (IWP) (3 days before the diagnostic test, the day

of the test and 3 days after for a total of 7 days).

3. Then determine if all of the elements of the criterion are met during the infection window period. If

they are, there is an infection event. If they are not, there is no event.

4. Next determine the date of event (DOE), i.e., the date that the first element used to meet the infection

criterion occurs for the first time within the infection window period.

5. Is the date of event in the POA time period? If yes, the infection is POA, if not, it is an HAI. (POA time

period is defined as the day of admission to an inpatient location, the 2 days before admission, and the

calendar day after admission)

6. Next (if appropriate) determine if the HAI is device-associated, i.e. CAUTI. If the date of event occurred

on or after day 3 of device use, and the device was in place on that day or the day before, the HAI is

device-associated.

7. Using the Transfer Rule if applicable, determine the location to which the HAI should be attributed. If

the date of event is on the date of transfer or discharge, or the next day, the infection is attributed to

the transferring/discharging location. In instances where a patient has been transferred to more than

one location on the date of an infection, or the day before, attribute the infection to the first location in

which the patient was housed the day before the infection's date of event.

8. Set Repeat Infection Timeframe (RIT): The date of event is Day 1 of the 14-day RIT.

9. For infection definition determinations other than BSls, define the Secondary BSI Attribution Period. This

period includes the Infection Window Period combined with the Repeat Infection Timeframe (RIT). It is

14-17 days in length depending upon where, within the infection window period, the date of event

occurs.

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Case Example: (

11/18 Patient admitted to medical unit 11/19 Patient transferred to ICU, intubated, indwelling urinary catheter inserted ( 11/20 Patient remains catheterized ( 11/21 Patient extubated, remains catheterized (11/22 Urinary catheter remains, temp 101.8F 11/23 Urine culture grows >100,000 colonies/ml Coag Neg Staph. Highest temp 100 degrees F. ( 11/24 Foley catheter removed (

('Case Determination: (Th is case determination is noted in RED)

Identifying Healthcare-associated Infections

Case Example as illustrated in Worksheet Generator:

AC1m1t aate: 1111812015

. 11/ 21/ 201 5

5. -11/ 22/ 201 5 Fever

6. 11/ 23/ 2015 Positive urine culture

7. 11/ 24/ 201 5

8 . 11/ 25/ 201 5

. 11/ 26/ 2015

10. 11/ 27/ 2015

11. 11/28/ 2015

12. 11/29/ 2015

13 . 11/ 30/ 2015

14. 12/ 1/ 2015

15. 12/2/ 2015

16. 12/3/ 2015

17. 12/ 4/ 201 5

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Appendixl: Secondary Bloodstream Infection (BSI) Guide (not applicable to Ventilator-associated Events [VAEJ)

The purpose of using the CDC/NHSN infection criteria is to identify and consistently categorize infections that are healthcare-associated into major and specific infection sites or types. LCBI criteria include the caveat that the organism(s) identified from the blood cannot be related to infection at another site (i.e., must be a primary BSI). One must be sure that there is no other CDC/NHSN defined primary site-specific infection that may have seeded the bloodstream secondarily; otherwise the bloodstream infection may be misclassified as a primary BSI and erroneously associated with the use of a central line, i.e., called a CLABSI. For locations performing in-plan VAE surveillance, refer to Fi2:ure 1 in this appendix, as well as the V AE chapter for specific guidance on assigning a secondary BSI to a V AE.

Secondary BSI Scenarios

For purposes ofNHSN, in order for a bloodstream infection to be determined secondary to another site of infection the following requirements must be met: t

The patient must meet one of the NHSN site-specific definitions (CDC/NHSN Surveillance Definitions for Specific Types of Infections, UTI, PNEU or SSI),

AND Either "l" or "2" below must also be true:

1. An organism identified from the site specific infection is used as an element to meet the site-specific infection criterion, AND the blood specimen contains at least one matching organism to that site specific specimen, and is collected during the secondary BSI attribution period.

OR

2. The positive blood specimen is an element used to meet the site-specific infection criterion, and is collected during the site specific infection's infection window period

!Exception:

Necrotizing enterocolitis (NEC) criteria include neither a site-specific specimen nor organism identified from blood specimen, however an exception for assigning a BSI secondary to NEC is provided. A BSI is considered secondary to NEC if the patient meets one of the two NEC criteria AND an organism identified from blood specimen collected during the secondary BSI attribution period is an LCBI pathogen, or the same common commensal is identified from two or more blood specimens drawn on separate occasions on the same or consecutive days.

Below are examples with guidance on how to distinguish between the primary or secondary nature ofa BSI. The definition of "matching organisms" and important notes and reporting instructions are also provided.

January 2016

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See Figure 3: Secondary BSr Guide for algorithmic display of the following instructions.

Scenario 1: An organism identified from the site-specific infection is used as an element to meet the site-specific infection criterion, AND the blood specimen contains at least one matching organism to that site specific specimen. The positive blood specimen must be collected during the site-specific infection's secondary BSI attribution period.

a. Example: Patient meets NHSN criteria for a symptomatic urinary tract infection (suprapubic tenderness and>105 CFU/ml of E. coli) and blood specimen collected during the SUTT secondary BSI attribution period is positive for E. coli. This is a SUTT with a secondary BSl and the reported organism is E. coli.

b. Example: Patient meets NHSN criteria for a symptomatic urinary tract infection (suprapubic tenderness and>105 CFU/ml of E.coli) and blood specimen collected during the SUTI secondary BSI attribution period grows E. coli and P. aeruginosa. This is a SUTI with a secondary BSI and the reported organisms are E. coli and P. aeruginosa, since both site and blood specimens are positive for at least one matching pathogen.

c. Example: Patient meets NHSN criteria for a symptomatic urinary tract infection (suprapubic tenderness and>105 CFU/ml of E.coli) and a single blood specimen collected during the SUTI secondary BSI attribution period E. coli and S. epidermidis. This is a SUTI with a secondary BSI and the reported organism is only E. coli, since the single common commensal S. epidermidis positive blood specimen by itself does not meet BSI criteria.

Scenario 2: The positive blood culture is an element used to meet the site-specific infection criterion, and is collected during the site specific infection's infection

window period. (For your convenience, a list of infection criteria that include positive blood culture as an element are included in Table 5 below).

a. Example: Patient becomes febrile and complains of nausea and abdominal pain. CT scan done that day shows fluid collection suggestive of infection.

Blood specimen collected that day results in identification ofBacteroides .fragilis. Because the patient meets lAB criterion 3b, using the identification of an organisms from the blood specimen as an element (fever, nausea or

abdominal pain, positive blood specimen and CT scan showing infection in abdominal cavity), the BSI is considered secondary to IAB.

b. Example: Patient is febrile, has a new onset of cough and has positive chest imaging test indicating the presence of an infiltrate. Blood specimens collected identify Pseudomonas aeruginosa. Because the patient can meet PNU2 definition by using identification of organisms from blood specimen as one of the elements of the infection criterion (i.e., infiltrate on chest imaging test, fever, new onset of cough and organism identified from blood specimen ), the BSI is considered secondary to PNEU.

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NOTE: In scenarios where an NHSN infection definition can be met using more than one criterion of the infection definition, it is possible that identification of organism from blood and site-specific specimens may not match and a BSI may still be considered as a secondary BSI. Consider the following:

d. Example: During the SSI surveillance period, a postoperative patient becomes febrile and complains of nausea and abdominal pain. CT scan done that day shows fluid collection suggestive of infection. Culture results show Escherichia coli from the T-tube drainage specimen and the blood specimen grows Bacteroides fragilis. Although the organisms in the blood culture and site-specific culture do not match for at least one organism, the blood culture is considered secondary to IAB. This is because the patient meets organ/space SSI IAB criterion 3b, using the identification of organism in blood specimen as an element (fever, nausea or abdominal pain, organisms identified from blood specimen and CT scan showing infection in abdominal cavity). This patient also meets JAB criterion 3a using the positive site culture plus fever, and nausea or abdominal pain even though the organism involved is different from that used for IAB criterion 3b. In this case, the BSI is considered secondary to the organ/space SSI [AB and both organisms would be listed as IAB infection pathogens.

e. Example: Patient is febrile, has a new onset of cough and has positive chest imaging test indicating the presence of an infiltrate. Blood and bronchoalveolar lavage (BAL) specimens are collected. Results identify Klebsiella pneumoniae > 104 CFU/ml from the BAL and Pseudomonas aeruginosa from the blood. Although the organisms in the blood specimen and site-specific specimen do not match for at least one organism, because the patient can meet PNU2 definition using either the identification of organism from blood specimen or BAL specimen as one of the elements of the infection criterion (i.e. infiltrate on chest imaging test, fever, new onset of cough and organism identified from blood specimen or identified from BAL specimen), the blood is considered a secondary BSI to PNEU and both organisms would be listed as PNEU pathogens.

If there is no matching organism identified from blood and site-specific specimen which is used to meet the site-specific infection definition, nor is an organism identified from blood specimen used to meet the site-specific infection criterion, secondary BSI attribution cannot be assigned.

a. Example: Patient has pustules on their abdomen with tenderness and swelling. Purulent material is obtained from the pustules and is positive for Streptococccus Group B. A blood specimen collected the same day

January 2016

identifies methicillin resistant Staphylococcus aureus. Because the organisms from the site and blood specimens do not match, and there is no site-specific criterion for SKIN that includes organisms identified from blood specimen, both a site-specific infection, SKIN (criteria I and 2a) and a primary BSI would be reported.

b. Example: A patient has an abscess in the soft tissue around a percutaneous endoscopic gastrostomy (PEG) tube, identified by CT scan, and there is also purulent drainage from that site. No site-specific specimen was collected, but a blood specimen is positive for Staphylococcus aureus. No other sites of infection are identified. Because no culture of the site was collected, and the patient therefore cannot meet ST criterion 1, and because there is no ST criterion which uses identification of organism from blood specimen as an element, this patient has a ST infection with unknown pathogen (criterion 2), and a primary BSI with the pathogen Staphylococcus aureus for NHSN purposes.

January 2016

Table 5: Site-specific criteria that require positive blood specimens

Organisms identified from blood as an Organisms identified from blood with element imaging test evidence of infection

Site Element Page Site Element Page

BURN 1 17-23 BONE 3a 17-5

IAB 2b 17-19 DISC 3a 17-5

JNT 3c 17-6 GIT 2c 17-18

MEN 2c& 3c 17-8 IAB 3b 17-19

OREP 3a 17-22 SA 3a 17-9

PNU2 Lab finding 6-6 USI 3b&4b 17-26

4a, 4b, 5a & PNU3 Lab finding 6-8 5b (specific

UMB lb 17-25 ENDO organisms) 17-10

6e & 7e plus other criteria

as listed

A matching organism is defined as one of the following:

1. Ifgenus and species are identified in both specimens, they must be the same. a. Example: A blood specimen reported as Enterobacter cloacae and an

intraabdominal specimen ofEnterobacter cloacae are matching organisms. b. Example: A blood specimen reported as Enterobacter cloacae and an

intraabdominal specimen ofEnterobacter aerogenes are NOT matching organisms as the species are different.

2. If the organism is less definitively identified in one specimen than the other, the identifications must be complementary.

a. Example: A surgical wound growing Pseudomonas spp. and a blood specimen growing Pseudomonas aeruginosa are considered a match at the genus level and therefore the BSI is reported as secondary to the SSL

b. Example: A blood specimen reported as Candida albicans and a culture from a decubitus reported as yeast not otherwise specified are considered to have matching organisms because the organisms are complementary, i.e. Candida is a type of yeast.

Notes:

January 2016

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1. Antibiograms of the blood and potential primary site isolates do not have to match. 2. If the blood specimen by itself does not meet BSI criteria ( e.g., only one positive

blood specimen positive for a common commensal), then that specimen may not be used to indicate the presence of a secondary BSI (see scenario le).

Reporting Instructions: For reporting secondary BSI for possible V AP (PV AP), see figure 4 and Chapter

10. Do not report secondary bloodstream infection for vascular (V ASC) infections,

Ventilator-Associated Conditions (VAC), or Infection-related VentilatorAssociated Complications (TVAC), pneumonia 1 (PNEU 1 ).

When a BSI is suspected to be secondary to a lower respiratory tract infection and the BSI cannot be determined to be secondary to V AE, the PNEU definitions are

available for secondary BSI assignment (see Figure 4).

Site-specific organism exclusions apply to secondary BSI attribution as well.

Pathogen Assignment

Pathogens identified from secondary BSls, should be added to those pathogens reported for the primary infection type. The Secondary BSI data collection field should be checked yes.

A secondary BSI pathogen may be assigned to two different primary site infections (e.g., UTI and an IAB infection). In example 1 below, two primary site infections have been identified and a blood culture is collected within both the SUTI and the IAB secondary

BSI attribution period. The blood culture pathogen matches both primary site infection pathogens (SUTI and IAB). Therefore the pathogen is reported for both primary sites of infection as a secondary bloodstream infection.

January 2016

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Example 1 : Pathogen Assignment

Hospital Day

BSI RIT Infection Window Period

Infection Window Period

BSI

I 2 3

4 I Urine culture: > 100,000 cfu/ml K. pneumoniae

5 2 Fever > 38.0 C 6 3 7 4 8 5 Fever >38.0 C,

Abdominal oain 9 6 CT Scan :

Abdominal abscess

10 7 Blood cu lture: K. pneumoniae

Blood culture: K. pneumoniae

11 8 12 9 13 10 14 11 15 12 16 13

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SUTI & Secondary BSI Date of Event =4 Pathogen: K. p11eumo11iae

JAB & Secondary BSI Date of Event =8 Pathogen: K. p11 eumo11iae

Infection Window Period (First positive diagnostic test, 3 days

before and 3 days after)

Repeat Infection Timeframe (RIT)

(date ofevent - day I)

Date of Event (DOE)

(Date tbe first clement occurs for the

first time within tbe infection window

period)

Pathogens excluded from specific infection definitions (e.g., yeast in UTI, or Enterococcus spp. for PNEU) are also excluded as pathogens for BS Is secondary to that type of infection (i.e., they cannot be added on to one of these infections as a pathogen). ln example 2 below, the excluded organism must be accounted for as either 1) a primary bloodstream infection (BST/CLABS1) or, 2) a secondary bloodstream infection attributed to another primary infection (e.g., IAB, SINU). A blood culture with yeast and E. faecalis is collected during the SUTI RIT. A BSI secondary to SUTI is identified. E. jaecalis is already documented as a pathogen, but the yeast will not be reported as a secondary BSI pathogen, because yeasts are excluded as organisms in the UTI definition. Because no other primary source of infection for which the yeast BSI can be assigned as secondary is found, a primary BSI with yeast is identified.

Note: The Enterococcus faecal is is not reported as a pathogen for the primary BSI because if an excluded organism had not been identified, a primary BSI would not have been reported.

) January 2016

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Example 2: Pathogen Assignment (continued)

Hospital BSI RIT Infection Infection RIT Dav Window Period Window Period Infection Window Period

(First positive diagnostic test, 3 days before

2 and 3 days after)

" Dysuria.:,

4 Urine culture: > 100,000 cfu/ml E. faecalis

5 6 7 8 9 10 Date of Event (DOE) 11 Blood culture: Blood culture: (Date the first element occurs for the first

E. aecalis I Yeast E. faecalis I Yeast time within the infection window period)

12 13 14 15 16

17 18 19 20 21 22 23 24 25

UTI & Secondary Primary BSI BSI Date of Event= Date of Event =3 11 Pathogen: E. Pathogen: Yeast aeca/is

January 2016

Figure 3: Secondary BSI Guide for eligible organisms*t (Not applicable to Ventilator-associated Events /VAEJ, See Figure 4)

Positive blood specimen. Sitespecific infection suspected as

source.

Is the positive site-specific specimen used as an element to

Yes meet the infection site criteria?* No

Pooiti'."e blood specimen and sitespecific specimen, which is

collected during the secondary BSI attribution period, match for at

least 1 organism"

Yes

STOP:

Secondary

BSI

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v,hich is collected during the infection window period, be used to meet the site-specific infection

criteria?

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STOP: STOP: Secondary Primary

BSI BSI

tException: Necrotizing enterocolitis (NEC) criteria include neither a site-specific specimen nor organism identified from blood specimen, however an exception for assigning a BSI secondary to NEC is provided. A BSI is considered secondary to NEC if the patient meets one of the 2 NEC criteria AND an organism identified from blood specimen collected during the secondary BSI attribution period is an LCBI pathogen or the same common commensal is identified from 2 or more blood specimens drawn on separate occasions on the same or consecutive days.

January 2016

Figure 4: VAE Guidance for Secondary BSI Determination

Positive blood specimen.

Lower respiratory tract infection suspected as source.

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BSI secondary to PVAPperVAE

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Refer to Figure 1

*Secondary BSis may be reported for possible VAP (PY AP) events, provided that at least one

organism identified from the blood specimen matches an organism identified from an appropriate respiratory tract specimen (including respiratory secretions, pleural fluid and lung tissue). The respiratory tract specimen must have been collected on or after the 3rd day ofmechanical ventilation and within 2 calendar days before or after the day of onset of worsening oxygenation to be considered as a criterion for meeting the PV AP definitions. In addition, the blood specimen must have been collected during the 14-day event period, where day 1 is the day of onset of worsening oxygenation.

In cases where PV AP is met with only the histopathology criterion and no culture or non culture based test is performed on an eligible respiratory specimen, and there is also a positive blood specimen, a secondary BSI to V AE is not reported.

In cases where a culture or non-culture based test of respiratory secretions, pleural fluid or lung tissue is performed and does not identify an organism that matches an organism identified from blood, a secondary BSI to V AE is not reported.

January 2016

Note: Candida species or yeast not otherwise specified, coagulase-negative Staphylococcus species, and Enterococcus species identified from blood cannot be deemed secondary to a PVAP, unless the organism was also identified from pleural fluid or lung tissue.

January 2016

)> iE 0.., ;::;::r 3 t/1

Algorithms

Resources included:

1. 2016 UTI Flowchart

2. 2016 Secondary BSI Algorithms

3. 2016 PNEU Algorithms

4. 2016 VAE Algorithms

5. 2016 LabID Algorithms

Organism identified* from blood specimen with at least one matching

bacterium to bacterium in the urine at ~100,000 du/ml?

* identified from by a culture or non-culture based microbiologic testing method which is

performed for purposes of clinical diagnosis or treatment (e.g., not Active Surveillance

Culture/Testing (ASC/AST).

Ye..

Does not meet UTI criteria

Identifying Symptomatic Urinary Tract Infections (SUTI) &

Asymptomatic Bacteremic Urinary Tract Infections (ABUTI)

Positive urine culture with no more than 2 species of organisms, at least one of which is a bacterium of :::105 CFU/ml.

All elements of the UTI criterion must occur during the Infection Window Period (Note: if none of the organisms

present at :::105 cfu/ml are bacteria, answer= No)

YesNo

Had an indwelling urinary catheter that had been in place for > 2 days, AND was either:

1. Still present for any portion of the calendar day on date of event OR

2. Removed day before date of event?

Does not

meet UTI

criteria

No Yes

At least one of the following signs or symptoms? suprapubic tenderness* costovertebral angle pain* urgency" frequency" dysuria" fever (> 38.0 C) -In a patient that is :S. 65 years

of age * With no other recognized cause I\ These symptoms cannot be used when catheter is in place.

Yes No

At least one of the following signs or symptoms?

a. Any age patient: fever(> 38.0 C), suprapubic tenderness*, costovertebral angle pain*, urgency", dysuria ", frequency"

b. Patients~ 1 year of age: fever(> 38.0 C), hypothermia (

Figure 3: Secondary BSI Guide for eligible organisms*t (Not applicable to Ventilator-associated Events [VAEJ, See Figure 4)

Positi..-e blood specimen. Sitespecific infection suspected as

source.

Is the positive site-specific specimen used as an element to meet the infection site criteria?*

Pobfr,;e blood specimen and site- Can the positive blood specimen, specific specimen, which is which is collected during the 'N I .I t o Icollected during the secondary BSI infection window period, be used

attribution period, match for at to meet the site-specific infection least l organism0 criteria?

STOP: \ STOP: STOP: Secondary Primary

BSI\,~~:~"'I BSI

+Exception: Necrotizing enterocolitis (NEC) criteria include neither a site-specific specimen nor organism identified from blood specimen, however an exception for assigning a BSI secondary to NEC is provided. A BSI is considered secondary to NEC if the patient meets one of the 2 NEC criteria AND an organism identified from blood specimen collected during the secondary BSI attribution period is an LCBI pathogen or the same common commensal is identified from 2 or more blood specimens drawn on separate occasions on the same or consecutive days.

January 2016

Figure 4: VAE Guidance for Secondary BSI Determination

BSI secondary to PV AP per V:.,IB

surveillance protocol*

Positive blood specimen.

Lower respiratory tract infection suspected as source.

PVA.P

BSINOT secondary to PVAP

Detem1ine ifBSI is secondary to another site-specific infection

Refer to Figure 1

VAC,IVAC or

No VA.E

Detem1ine ifBSI is secondary to another site-specific infection

Refer to Figure 1

*Secondary BS Is may be reported for possible VAP (PVAP) events, provided that at least one

organism identified from the blood specimen matches an organism identified from an appropriate respiratory tract specimen (including respiratory secretions, pleural fluid and lung tissue). The respiratory tract specimen must have been collected on or after the 3rd day of mechanical ventilation and within 2 calendar days before or after the day of onset of worsening oxygenation to be considered as a criterion for meeting the PV AP definitions. In addition, the blood specimen must have been collected during the 14-day event period, where day 1 is the day ofonset of worsening oxygenation.

In cases where PVAP is met with only the histopathology criterion and no culture or nonculture based test is perfom1ed on an eligible respiratory specimen, and there is also a positive blood specimen, a secondary BSI to V AE is not reported.

In cases where a culture or non-culture based test of respiratory secretions, pleural fluid or lung tissue is performed and does not identify an organism that matches an organism identified from blood, a secondary BSI to VAE is not reported.

January 2016

Note: Candida species or yeast not otherwise specified, coagulase-negative Staphylococcus species, and Enterococcus species identified from blood cannot be deemed secondary to a PVAP, unless the organism was also identified from pleural fluid or lung tissue.

January 2016

Device-associated Module PNEU

Table 1: Specific Site Algorithms for Clinically Defined Pneumonia (PNU 1)

Imaging Test Evidence

Signs/Symptoms/Laboratory

Two or more serial chest imaging test results with at least one of the followingl-J:

New or progressive and persistent infiltrate

Consolidation

Cavitation

Pneumatoceles, in infants :SI year old

Note: In patients wit/tout underlying pulmonary or cardiac disease (e.g., respiratory distress syndrome, bronchopulmonary dysplasia, pulmonary edema, or chronic obstructive pulmonary disease), one definitive imaging test result is

For ANY PATIENT, at least Q!1f of the following:

Fever (>38.0C or>100.4F) Leukopenia (:S4000 WBC/mm3) or leukocytosis (:::12,000 WBC/1111113) For adults :::70 years old, altered mental status ,vith no other recognized cause

And_at least two of the following:

New onset ofpurulent sputum2 or change in character of sputum, or increased respiratory secretions, or increased suctioning requirements

New onset or worsening cough, or dyspnea, or tachypnea2

Rales" or bronchial breath sounds Worsening gas exchange (e.g., 02 desaturations (e.g., PaOJFi02 :::240)2, increased

oxygen requirements, or increased ventilator demand)

ALTERNATE CRITERIA, for infants :SI year old:

Worsening gas exchange (e.g., 02 desaturations [e.g., pulse oximetry 170 beats/min)

ALTERNATE CRITERIA, for child >1 year old or :Sl2 years old, at least three of the follmving:

Fever (>38. 0C or >100. 4F) or hypothermia (


Table 2: Specific Site Algorithms for Pneumonia with Common Bacterial or Filamentous Fungal Pathogens and Specific Laboratory Findings (PNU2)


Signs/Symptoms Laboratory

Two or more serial chest imaging test results with at least !!EE. ofthe followingL~:


Consolidation

Cavitation

Pneumatoceles, in infants :Sl year old

Note: In patients without underlying pulmonary or cardiac disease (e.g., respiratory distress syndrome, bronchopulmonary dysplasia, pulmonary edema, or chronic obstructive pulmonary disease), one definitive chest imaging test result is aceeptable.l

At least !!EE. of the following:

Fever (>38.0C or>100.4F)

Leukopenia (:::;4000 WBC/mm3) or leukoeytosis (:::12,000 WBC/mm3)

For adults :::70 years old, altered mental status with no other recognized cause

And at least !!EE. of the following:

New onset of purulent sputum:i or change in character of sputum:!, or increased respiratory secretions, or increased suctioning requirements

New onset or worsening cough, or dyspnea or tachypnea;,

Ralesli or bronchial breath sounds

Worsening gas exchange (e.g., 02 desaturations [ e.g., Pa02/Fi02 ::::240]2, increased oxygen

At least !!EE. of the following:

Organism identified from blood ill

Organism identified from pleural fluid9 13

Positive quantitative culture2 from minimally-contaminated LIU specimen ( e.g., BAL or protected specimen brushing)

2:5% BAL-obtained cells contain intracellular bacteria on direct microscopic exam ( e.g., Gram's stain)

Positive quantitative culture'!. oflung tissue

Histopathologic exam shows at least !!!1!I. of the following evidences of pneumonia:

0 Abscess formation or foci of consolidation with intense PMN accumulation in bronchioles and alveoli

requirements, or increased ventilator demand) Evidence of lung parenchyma 0

invasion by fungal hyphae or pseudohyphae

January 2016


Table 3: Specific Site Algorithms for Viral, Legionella, and other Bacterial Pneumonias with Definitive Laboratory Findings (PNU2)



Two or more serial chest imaging test results with at least one of the followingl-1:


Consolidation

Cavitation

Pneumatoceles, in infants :Sl year old

Note: In patients without underlying pulmonary or cardiac disease ( e.g., respiratory distress syndrome, bronchopulmonary dysplasia, pulmonary edema, or chronic obstructive pulmonary disease), one definitive chest imaging test result is aeceptable.l

J\t least !111. of the following:

Fever (>38.0C or >I00.4F)

Leukopenia (s;.4000 W13C/mm3) or leukoeytosis (:::12,000 WBC/mrn3)

For adults :::70 years old, altered mental status with no other recognized cause

And at least !111. of the following:

New onset of purulent sputuml or change in character of sputum'!, or increased respiratory secretions, or increased suctioning requirements

New onset or worsening cough or dyspnea, or tachypnea;.

Rales2 or bronchial breath sounds

Worsening gas exchange (e.g., 02 desaturations [ e.g., PaOiFi02 ::;240F, increased oxygen requirements, or increased ventilator demand)

J\t least !111. of the following:

Virus, Bordetella.. Legionella, Chlamydia or Mycoplasma identified from respiratory secretions or tissue by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment ( e.g., not Active Surveillance Culture/Testing (ASC/AST).

Fourfold rise in paired sera (lgG) for pathogen (e.g., influenza viruses, Chlamydia)

Fourfold rise in Legionella pneumophila serogroup 1 antibody titer to ;::: 1: 128 in paired acute and convalescent sera by indirect IF A.

Detection of L. pneumophila serogroup 1 antigens in urine by RIA or EIA

January 2016


Table 4: Specific Site Algorithm for Pneumonia in Immunocompromised Patients (PNU3)



Two or more serial chest imaging test results with at least one of the followingl-J:


Consolidation

Cavitation

Pneumatoceles, in infants :::Sl year old

Note: In patients without underlying pulmonary or cardiac disease (e.g., respiratory distress syndrome, bronchopulmonary dysplasia, pulmonary edema, or chronic obstructive pulmonary disease), one definitive chest imaging test result is acceptable.1

Patient who is immunocompromised (see definition in footnote l!2 ) has at least{!!!. of the following:

Fever (>38.0C or>100.4F)

For adults ::::70 years old, altered mental status with no other recognized cause

New onset ofpurulent sputum\ or change in character ofsputum, or increased respiratory secretions, or increased suctioning requirements

New onset or worsening cough, or dyspnea,ortachypneai

Rales!i or bronchial breath sounds

Worsening gas exchange ( e.g., 02 desaturations [e.g., Pa02/Fi02 ~240]1, increased oxygen requirements, or increased ventilator demand)

Hemoptysis

At least{!!!. of the following:

Identification of matching Candida spp. from blood and sputum, endotracheal aspirate, BAL or protected specimen brushing.11.12.1 J

Evidence of fungi from minimally-contaminated LRT specimen (e.g., BAL or protected specimen brushing) from one of the following:

- Direct microscopic exam - Positive culture of fungi - Non-culture diagnostic laboratory test

Any of the following from:

LABORATORY CRITERIA DEFINED UNDER PNU2

Pleuritic chest pain

January 2016

(!)

I-Patientwith mdel1ringdQemesU has 2a m:im imagimtmtmaJlls with!!!!! of the tollowing:

:l New or progressive and persistoot infiltrate

:i Consolidation :i Cavitation :l Pnocmatoceles, in :s:1 y.o

At leastJ;Jlll of the following: :l Fever (>38.0'C/100.4'F) :l Leukopenia (S 4,000 WBClrnmi) fl!: leukoc}'tosis (l'.12,000

WBO'rnmi) :l Altered mental status with no otller cause, in i!:70 y.o.

Atleast two of the following: :l

:l

:l

:l

.~

i 0

i s

New onSGtofpuruloot sputum,, or change in character ofsputum, or respiratory SGcretlons, or

suctioning requirGments New onsetorworSGning cough, or d'Jspnea, or tachypnea' Rales or bronchial breath sounds Worsooing gas GXchange (e.g., Oz desats [e.g., PaOz/FiOz::S..240]7, O, req, or~ ventilation demand)

At leastQ'.lPof the following:

a Organism identified from blood l.tl

:i Organism identified from pleural fluid


Figure 2: Pneumonia Flow Diagram, Alternative Criteria for Infants and Children

Facility ID# ______Event # _________ Event Date

1

Infants :S1 y.o.

O Worsening gas exchange (e.g., 02 desats [e.g., pulse oximetry


Footnotes to Algorithms and Flow Diagrams:

1. Occasionally, in non-ventilated patients, the diagnosis of healthcare-associated pneumonia may be quite clear on the basis of symptoms, signs, and a single definitive chest imaging test result. However, in patients with pulmonary or cardiac disease (e.g., interstitial lung disease or congestive heart failure), the diagnosis of pneumonia may be particularly difficult. Other non-infectious conditions (e.g., pulmonary edema from decompensated congestive heart failure) may simulate the presentation of pneumonia. In these more difficult cases, serial chest imaging test results must be examined to help separate infectious from non-infectious pulmonary processes. To help confirm difficult cases, it may be useful to review multiple imaging test results spanning over several calendar days. Pneumonia may have rapid onset and progression, but does not resolve quickly. Imaging test evidence of pneumonia will persist. Rapid imaging resolution suggests that the patient does not have pneumonia, but rather a non-infectious process such as atelectasis or congestive heart failure.

2. Note that there are many ways of describing the imaging appearance of pneumonia. Examples include, but are not limited to, "air-space disease", "focal opacification", "patchy areas of increased density". Although perhaps not specifically delineated as pneumonia by the radiologist, in the appropriate clinical setting these alternative descriptive wordings should be seriously considered as potentially positive findings.

3. Purulent sputum is defined as secretions from the lungs, bronchi, or trachea that contain 2:25 neutrophils and :::IO squamous epithelial cells per low power field (x 100). Refer to the table below if your laboratory reports these data semi-quantitatively or uses a different format for reporting Gram stain or direct examination results ( e.g., "many WBCs" or "few squamous epithelial cells"). This laboratory confirmation is required since written clinical descriptions ofpurulence are highly variable.

How do I use the purulent respiratory secretions criterion if ...

Instruction

My laboratory reports counts of "white blood cells" or "polymorphonuclear leukocytes" or "leukocytes" rather than counts of "neutrophils"?

Assume that counts of cells identified by these other descriptors (e.g., "white blood cells") are equivalent to counts of neutrophils, unless the laboratory tells you this is not the case.

My laboratory reports semi-quantitative results (not quantitative results) for numbers ofneutrophils and squamous epithelial cells?

Check with the laboratory to get information about what quantitative ranges the semi-quantitative reports correspond to.

My laboratory cannot provide additional information on how its semi-quantitative reporting corresponds to quantitative reporting ranges for neutrophils and squamous epithelial cells?

Use the following direct examination results to meet the purulent respiratory secretions criterion: heavy, 4+, or 2:25 neutrophils per low power field (lpf) [xl 00], AND rare, occasional, few, 1 + or 2+, or :SI O squamous epithelial cells per Jpff x 1001 [191.

My laboratory reports only the numbers of neutrophils present, without reporting the number of squamous epithelial cells?

In this situation, the purulent secretions criterion may be met using the specified quantitative and semiquantitative thresholds for neutrophils alone (i.e.

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