FAQs: Antimicrobial Use (AU) Option

General Submission

Q1: I’m interested in submitting data into the Antimicrobial Use (AU) Option. Where do I start?

If your facility is not enrolled in NHSN, follow the 5-step enrollment process here: 5-Step Enrollment for Acute Care Hospitals/Facilities.

If your facility is already enrolled in NHSN and now wants to submit AU data, ensure your facility meets the requirements for NHSN AU Option participation: 1) ability to obtain data from either an electronic medication administration record (eMAR) or barcoding medication administration (BCMA) system and 2) ability to package data into Clinical Data Architecture (CDA) standardized format for upload into NHSN.

The NHSN AU Option does not allow manual data entry due to the amount of data submitted each month. Many facilities use a vendor system to package and submit AU data to NHSN in CDA format. As of January 2021, all vendors that submit data to the NHSN AU Option are required to pass Synthetic Data Set (SDS) validation. The Vendors that have Passed the AU SDS Validation website lists vendors that have an NHSN-validated AU reporting solution. There are also a number of vendor systems listed on the Society for Infectious Disease Pharmacists (SIDP) websiteexternal icon that self-identify as providing services and software that allow NHSN AUR Module participation. The AU SDS FAQ explains the difference between these two listings. Please note that vendors identified on the SIDP website must also pass SDS validation to submit data to the NHSN AU Option.

Your facility may already use one of these vendors so start by asking if 1) your facility already has the capability to submit AU data to NHSN using your current vendor or 2) your current vendor offers this capability as an “add on” feature. Some facilities can leverage internal information technology and informatics resources to report these data via a “homegrown” system. However, NHSN does not recommend this submission method for most facilities because it requires specialized knowledge of coding and data aggregation. If your facility is considering taking up this work internally, you can find the AU and AR CDA toolkits, which contain sample CDA files, the link to the CDA Implementation Guide, and other helpful hints here: NHSN CDA Submission Support Portal (CSSP).

You can find details about the NHSN AU Option data requirements on the NHSN AUR Module webpage, within the training slides and AUR protocol.

 

Q2: Do I need Secure Access Management Services (SAMS) credentials to view or submit AU data to NHSN?

Yes, you need SAMS credentials to submit and/or view AU data. If you are new to NHSN, a user with administrative rights at your facility, such as the facility administrator, must first add you to the NHSN AU Option following the steps in question #7. After you receive the invitation to NHSN, review and accept the NHSN Rules of Behavior and complete the SAMS enrollment process pdf icon[PDF – 542 KB]. All NHSN users must follow these steps before using the application. While waiting for your SAMS credentials, you can complete the training in the AUR Educational Roadmap. After you receive your SAMS credentials, you’ll be able to log into your NHSN facility. You can find more information about SAMS on the About SAMS webpage.

 

Q3: I received my SAMS credentials and now have access to my NHSN facility. How do I submit AU data to NHSN?

Now that you have access to the NHSN AU Option, you must set up a monthly reporting plan before submitting your AU data. See question #16 for details on how to create a monthly reporting plan. CDC developed a 12-minute Quick Learn video discussing uploading CDA files into NHSN [Video – 12 min] to help facilities with this process.

 

Q4: Does the Centers for Medicare and Medicaid Services (CMS) require reporting to the NHSN AUR Module? If not, could you tell me when CMS will require hospitals to report data into the AUR Module?

CMS does not require NHSN AUR Module data submission for any quality reporting program. CMS determines when to include new measures in their quality reporting programs through their rulemaking process. Users should direct questions about inclusion of AU in quality reporting programs to CMS via the QualityNet Question and Answer Siteexternal icon.

However, NHSN AUR Module data submission via CDA is part of the CMS Promoting Interoperability Program (formerly Meaningful Use Stage 3 [MU3]) for Public Health Registry reporting for eligible hospitals. See questions #13-15 for more information about the Promoting Interoperability Program.

 

Q5: When is the deadline to submit AU data into NHSN each month?

There is no deadline for NHSN AU data submission. However, we recommend facilities upload data into NHSN within 30 days following the completion of the month to make the data most actionable. We also encourage facilities to upload retrospective data, if available, after initial AU Option implementation. See question #6 for retrospective data submission restrictions.

 

Q6: How far back can we submit retrospective AU Option data?

The business rules for monthly reporting plans determine how far back your facility can submit retrospective AU Option data. Your facility can submit AU Option data as far back as January 2012, if you have existing monthly reporting plans during that time, or January of the previous calendar year if no past monthly reporting plans exist.

Below are two examples to help explain this:

  • Facility A has existing monthly reporting plans for every month going back to January 2016. They can edit the monthly reporting plans to submit retrospective AU Option data back to January 2016.
  • Facility B just started submitting data to NHSN and does not have any existing monthly reporting plans (including monthly reporting plans for HAI data). They can add monthly reporting plans going back to January of the year they enrolled in NHSN or back to January of one calendar year in the past, whichever comes first.
    • If Facility B enrolled in January 2021 and it’s currently December 2021, they can add monthly reporting plans and submit AU Option data back to January 2021.
    • o If Facility B enrolled in January 2020 and it’s currently January 2022, they can add monthly reporting plans and submit AU Option data back to January 2021.

 

Q7: How do I allow someone at my facility to view or upload data into the AU Option?

A user with administrative rights, such as the facility administrator, must follow the steps below to grant users access to the AU Option.

If the person is not already registered as a user within your NHSN facility:

  1. From the NHSN Homepage, navigate to Users on the left-hand menu.
  2. Select Add User.
  3. Complete all fields marked with a red asterisk (*) and select Save.
    1. Consider whether you should designate this new user as an AU Option and/or AR Option contact. The NHSN AUR Team uses this information to target notifications for AUR-related content like AU and AR quarterly users calls, updates regarding AUR resources, and AUR data quality outreach.
  4. On the next screen, assign the user rights and select Save. Users need rights to the Patient Safety Component to view and submit AU data. If the user will submit AU data, NHSN recommends Administrator-level user rights. You can use the Custom Rights option to limit user rights to just AU data and no other patient safety modules. Be careful when assigning Custom Rights, as certain settings will prevent users from accessing AU data. When assigning Custom Rights, users also need rights to the Patient Safety Annual Facility Survey to view SAAR reports, as the SAARs use variables from the Patient Safety Annual Facility Survey for risk-adjustment.

If the person is already a user within your NHSN facility:

  1. From the NHSN Homepage, navigate to Users on the left-hand menu.
  2. Select Find User, locate the user, and click their name.
  3. Scroll down to the bottom of the page and click Edit, then Edit Rights.
  4. On the next screen, reassign user rights if needed and click Save. Users need rights to the Patient Safety Component to view and submit AU data. If the user will submit AU data, NHSN recommends Administrator-level user rights. You can use the Custom Rights option to limit user rights to just AU data and no other patient safety modules. Be careful when assigning Custom Rights, as certain settings will prevent users from accessing AU data. When assigning Custom Rights, users also need rights to the Patient Safety Annual Facility Survey to view SAAR reports, as the SAARs use variables from the Patient Safety Annual Facility Survey for risk-adjustment.

For complete details and instructions, please refer to the User Rights in NHSN – AUR Module document pdf icon[PDF – 491 KB].

Q8: Who can see my facility’s AU data in NHSN?

Once you upload data into NHSN, only users at your NHSN facility have access to view or edit your data unless one of the situations below applies.

There is a special option for Groups (such as a corporate healthcare system or quality improvement organization) to request rights to view your data, but you must accept the request before NHSN shares your data with them.

For the purposes of disease surveillance and prevention, state, local, and territorial health departments can have a special Data Use Agreement (DUA) with the CDC, which allows them to gain access to NHSN data from the facilities in their jurisdiction. Facilities in the state, local, or territorial health department’s jurisdiction are automatically added to a Group through the DUA process and health departments do not have to wait for facilities to accept the Confer Rights Template. You can find more information about the DUA process in the DUA Announcement.

In both cases, only users at the Group level can view your data. Facilities in the Group cannot view other facilities’ data. Additionally, Groups do not have the ability to add or edit your facility’s AUR data.

There are no CMS Quality Reporting Programs that include data submitted into the AUR Module. Therefore, NHSN does not share any AU Option data your facility submits to NHSN with CMS.

 

Q9: How do I delete AU data?

You can delete AU data by following the steps below:

  1. From the NHSN Homepage, select Summary Data then Delete AUR Data on the left-hand menu.
  2. Select Antimicrobial Use Data as the Summary Data Type, then select the Location, Month, and Year you want to delete and click the Delete button.

 

Q10: How do I edit AU data I already imported into NHSN?

The NHSN AU Option does not allow manual data editing. To update an existing record with new information, you can use succession management. Many vendors implemented this feature, which allows users to simply export a new version of files to NHSN, but you will need to work with your vendor to determine if they offer this option. You can find additional details on succession management on the NHSN CSSP.

If your vendor does not offer this feature, you can manually delete and re-upload the data by following the steps in question #9.

You must regenerate data sets within NHSN after uploading the corrected CDA file(s) to run analysis reports with the updated data.

 

Q11: I logged into my facility and can see that I have alerts for missing AU data. How do I get rid of them?

The missing summary data alerts mean that you included the AU Option in your monthly reporting plan but did not import these data into NHSN. You can clear the missing summary data alerts by:

  1. Submitting the AU data for those locations/months.
    OR
  2. Removing the AU Option for those locations from the monthly reporting plan(s).

The alerts are just a reminder and don’t affect your AU data in any way.

 

Q12: I’m from a health department. Could you tell me the names and NHSN orgIDs of the facilities submitting AU data in my jurisdiction?

Yes. NHSN’s updated Agreement to Participate and Consent allows NHSN to share specific information with state, local, and territorial health departments, Veterans Affairs (VA), and Department of Defense (DoD) for prevention purposes, such as the NHSN orgIDs and names of facilities submitting AU and/or AR data within your jurisdiction. Please send your request to NHSN@cdc.gov.

For the purposes of disease surveillance and prevention, state, local, and territorial health departments can have a special DUA with the CDC, which allows you to gain access to NHSN data from the facilities in your jurisdiction. Facilities in your jurisdiction are automatically added to a Group through the DUA process and you do not have to wait for the facilities to accept the Confer Rights Template. You can find more information about the DUA process in the DUA Announcement.


Promoting Interoperability (formerly Meaningful Use)

Q13: How do I enroll in the Promoting Interoperability Program?

NHSN AU and AR Option data submission via CDA are part of the Promoting Interoperability Program (formerly Meaningful Use 3 [MU3]) for eligible hospitals as outlined on the NHSN Promoting Interoperability Program webpage. Hospitals must submit both AU and AR Option data to qualify for the Promoting Interoperability Program. You can find additional details about the Promoting Interoperability Program here: CDC Public Health Data Interoperability.

 

Q14: On my MU3 report it shows “No” by AU and AR data, but my facility submitted data. Why is this?

Your vendor system must create CDA files using specific CDA Implementation Guide requirements to qualify for Promoting Interoperability Program (formerly Meaningful Use 3 [MU3]) reporting. To confirm that your AUR data uploaded successfully, generate data sets within NHSN and run a line list. If your data show up in the line list for the months listed as “No” in the MU3 report, we suggest you speak with your vendor to determine why your data are not showing up on the MU3 report. If your data do not show up in the line list, they did not successfully upload to NHSN. Re-upload the data, generate data sets, and try again.

 

Q15: My facility no longer plans to use AUR reporting to qualify for the Promoting Interoperability Program. Can I remove my Promoting Interoperability Program intent to submit?

No. There is not currently a way to remove your Promoting Interoperability Program (formerly Meaningful Use 3 [MU3]) registration within NHSN. Since your facility registered its intent for the Promoting Interoperability Program within NHSN, you will still receive the automated monthly status report emails. You can disregard these emails if you no longer plan to participate AUR Module reporting for the Promoting Interoperability Program.


Monthly Reporting Plan

Q16: How do I include the AU Option in my monthly reporting plan?

To add a new monthly reporting plan, if one does not already exist, follow these steps:

  1. From the NHSN Homepage, select Reporting Plan from the left-hand menu.
  2. Click Add to add a new monthly reporting plan.
  3. Select the month and year for AU data submission.
  4. Scroll down to the Antimicrobial Use and Resistance Module section of the plan, enter all the locations for which you’ll submit AU data that month, and check the AU box (see screenshot below for reference). To include facility-wide inpatient (FacWideIN) in the monthly reporting plan for the AU Option, you MUST have at least one individual non-FacWideIN location (for example, medical ward, emergency department) added to the plan.
  5. Click the Save button at the bottom of the screen.

To edit an existing monthly reporting plan, if one already exists, follow these steps:

  1. From the NHSN Homepage, select Reporting Plan from the left-hand menu.
  2. Click Find to find an existing monthly reporting plan.
  3. Select the month and year for the AU data submission and click Find again.
  4. Scroll down to the bottom of the plan and click Edit.
  5. In edit mode, scroll to the Antimicrobial Use and Resistance Module section of the plan, enter all the locations for which you’ll submit AU data that month, and check the AU box (see screenshot below for reference). To include FacWideIN in the monthly reporting plan for the AU Option, you MUST have at least one individual non-FacWideIN location (for example, medical ward, emergency department) added to the plan.
  6. Click the Save button at the bottom of the screen.
Example selections for AU monthly reporting plan

NOTE: You do not have to check the AR boxes unless you also plan to submit AR Option data.

You need to add the AU Option to your monthly reporting plan for every month you plan to submit AU data.

 

Q17: Is a monthly reporting plan required for AU reporting?

Yes, the AU Option requires a monthly reporting plan with AU reporting indicated for every month you plan to submit AU data. You cannot enter AU data “off-plan”. See question #16 for how to set up a monthly reporting plan.

  • Non-FacWideIN locations can be the only location in the AU section of the monthly reporting plan.
  • To include FacWideIN, you MUST have at least one individual non-FacWideIN location (for example, medical ward, emergency department) in the plan to save the monthly reporting plan.

Note: CMS does not include AUR Module data in any quality reporting program so CDC will not share AUR data with CMS, even if included in the monthly reporting plan. View the complete list of data required for each CMS Quality Reporting Program pdf icon[PDF – 1 MB].


Locations

Q18: What locations can I report AU data for?

NHSN strongly encourages the submission of data from all NHSN-defined inpatient locations (including procedural areas like operating rooms), FacWideIN, and select outpatient acute care settings (specifically, outpatient emergency department, pediatric emergency department, and 24-hour observation area) from which AU Option numerator and denominator data can be accurately captured. Your facility should not submit data from locations that cannot accurately capture electronic data. Additionally, your facility should exclude these locations’ data from the FacWideIN record.

 

Q19: Can I submit only FacWideIN data to the AU Option or do I have to submit location-level data as well?

You can submit only FacWideIN data to the NHSN AU Option; however, NHSN does not recommend doing this. When FacWideIN data are uploaded into NHSN, they represent aggregate data for all the inpatient locations reported by each facility and NHSN doesn’t have the ability to tease apart the data to separate it into specific locations. Your facility will be limited in the AUR Module features and Analysis Reports you can use by submitting only FacWideIN data. The SAARs are risk-adjusted using location-level information, so you will be unable to generate SAARs when submitting only FacWideIN data.

Additionally, you will not be able to save your monthly reporting plan with only FacWideIN and no other locations selected for the AU Option (see question #17). Adding a location to the monthly reporting plan without submitting data from it each month will produce missing data alerts on the NHSN Alerts page. These alerts are just reminders and they do not affect your AU data in any way.

 

Q20: Should I include outpatient locations in the FacWideIN record for AU data submission?

No. For AU data submission, your facility should only include inpatient locations with electronically captured numerator (antimicrobial days) and denominator (days present and admissions) data in the FacWideIN record. Your facility should not include outpatient locations such as emergency department, pediatric emergency department, and 24-hour observation area in the FacWideIN record.

 

Q21: Should I count antimicrobials administered to observation patients in my AU data?

Your facility should include antimicrobials administered to all patients physically residing in an inpatient location at any time during a given month in the location-specific and FacWideIN CDA files, regardless of patient status (inpatient, outpatient, observation, etc.). While NHSN considers the 24-hour observation area location an outpatient location, not all facilities designate a separate physical location for observation patients. If your facility has a 24-hour observation area mapped in its NHSN Location Manager, you should not include antimicrobials administered to patients physically residing in the 24-hour observation area in the FacWideIN record. However, if your facility does not have a separate unit for observation patients, you may include their antimicrobial administrations in the location-specific and FacWideIN CDA files for the location in which they physically reside, regardless of patient status (inpatient, outpatient, observation, etc.).

 

Q22: Can I include AU data from the inpatient rehabilitation facility (IRF) and/or inpatient psychiatric facility (IPF) physically located in my hospital with the rest of my AU data?

Your can include IRF and/or IPF AU data for IRFs/IPFs mapped as locations within your facility in NHSN. Your facility can also include the IRF/IPF location in your facility’s FacWideIN record. If your facility mapped the IRF/IPF as an NHSN location, you can add it to the AUR section of the monthly reporting plan regardless of whether it has a separate CMS Certification Number (CCN) from your hospital.

If your facility enrolled the IRF/IPF as a separate facility in NHSN (i.e., using a different orgID), you cannot report its AU data with the acute care hospital, but you can report it under the separate NHSN facility. The AU Option accepts data from an IRF or IPF enrolled in NHSN as its own facility using the rehabilitation hospital or psychiatric hospital designations, respectively. The submission process for these hospital designations is no different than a general acute care hospital.

Q23: How should I account for locations that changed function during the COVID-19 pandemic in my AU data submissions?

NHSN provides general guidance for location mapping during the COVID-19 pandemic in the COVID-19 Location Mapping document pdf icon[PDF – 173 KB]. However, because AU data are submitted electronically from vendor systems and it may not be possible to make certain changes within those systems, there are some additional considerations for reporting AU data. There are three options facilities can consider:

  1. Map temporary locations — Using the guidance linked above, you can work with your Infection Control/Infection Prevention department to determine if this is the right approach for your facility, as it will affect HAI reporting. Remapping in NHSN also requires mapping changes in your vendor system because the location information must be an exact match within both systems for AU files to successfully import into NHSN.
  2. Submit data to the locations as they are currently mapped — While this option doesn’t require remapping, facilities should use caution when interpreting SAAR values during the time the locations were affected by the COVID-19 pandemic because the SAARs are risk adjusted based on location designation. If the location designation doesn’t match the patient population of a given location, then any SAAR values involving that location will not be accurately risk adjusted. We recommend using AU rates instead of SAARs with this option.
  3. Submit data only for FacWideIN and outpatient locations — This option also doesn’t require remapping any locations but is not recommended. By not submitting location-specific data, you will not be able to generate SAARs or location-specific AU rates.

Antimicrobial Days

Q24: Should I include topical, ocular, and aural antimicrobial administrations in my AU data?

No. The AU Option only accepts four routes of administration: intravenous (IV), intramuscular (IM), digestive, and respiratory. Your facility should exclude any other routes of administration (for example, topical, antibiotic locks, intraperitoneal, intraventricular, ocular, aural, or irrigation) from AU Option reporting, including total antimicrobial days and sub-stratification of the routes of administration.

 

Q25: If a patient receives two different antimicrobials in one day, does that count as one or two antimicrobial days?

The AU Option considers each antimicrobial separately. If a patient receives two different antimicrobials (for example, meropenem and amikacin) in the same calendar day, that patient contributes one meropenem antimicrobial day and one amikacin antimicrobial day to the location where the provider administered the antimicrobials.

See Appendix C of the AUR Module Protocol pdf icon[PDF – 1 MB] for additional examples.

 

Q26: If a patient receives the same antimicrobial via two different routes in one day, does that count as one or two antimicrobial days?

If a patient is on a single antimicrobial (for example, ciprofloxacin) and the provider administers one dose in the morning via IV and another dose in the evening via PO, that patient contributes one IV ciprofloxacin antimicrobial day and one digestive ciprofloxacin antimicrobial day. Because a single patient cannot contribute more than one antimicrobial day to the total antimicrobial days for each antimicrobial in a single calendar day, the patient only contributes one total ciprofloxacin antimicrobial day for each location.

See Appendix C of the AUR Module Protocol pdf icon[PDF – 1 MB] for additional examples.

 

Q27: Providers administer vancomycin to patients in renal failure every other day but the drug stays in their system for two days. Does this count as one or two vancomycin antimicrobial days within the AU Option?

This counts as one vancomycin antimicrobial day because, even in the case of renal impairment, the AU Option only counts antimicrobials on the day of administration.

 

Q28: Why don’t the total antimicrobial days in my FacWideIN record equal the sum of antimicrobial days from all my location records?

The sum of location-specific antimicrobial days will always be greater than FacWideIN antimicrobial days because multiple administrations of the same antimicrobial in separate patient care locations within a single calendar day account for one antimicrobial day within each location but only one FacWideIN antimicrobial day. For example, if a patient received one dose of vancomycin in the medical ward and then transferred to the medical intensive care unit (ICU), where they received another dose of vancomycin on the same day, this patient contributes one vancomycin antimicrobial day to the medical ward and one vancomycin antimicrobial day to the medical ICU but only one vancomycin antimicrobial day to FacWideIN. Patients may only contribute one antimicrobial day to each location (including FacWideIN) per day.

 

Q29: The sum of the routes of administration in my AU line list does not equal total antimicrobial days for some antimicrobials. Why is this?

The sum of the four routes of administration for a given antimicrobial should always be greater than or equal to the antimicrobial’s total antimicrobial days. In cases where a provider administered the same antimicrobial more than once per day via multiple routes, the sum of the routes can be greater than the total antimicrobial days for that antimicrobial.

Keep in mind that the total antimicrobial days for a given antimicrobial should only include administrations via one of the four routes accepted into the AU Option (IV, IM, digestive, and respiratory). Your facility should exclude administrations via any other routes (for example, topical antimicrobials) from all AU Option data. Check with your vendor to make sure they only include the four routes listed above in your total antimicrobial days count.

 

Q30: Should incomplete antimicrobial administrations count towards antimicrobial days?

No, your facility should not include incomplete antimicrobial administrations (for example, partial infusions). Your facility should only include completed administrations in AU Option data.


Days Present & Admissions

Q31: Is the days present denominator used in the AU Option the same as the patient days denominator used in other parts of NHSN?

No. The days present denominator is different from the patient days denominator. Days present are the number of patients present at any time on a given day in each patient care location. Patient days are the number of patients present in each patient care location during the once daily census count.

For example, a patient admitted to the medical ward on Monday and discharged two days later, on Wednesday, will contribute three days present to the medical ward because the patient was there at some point during each of the three calendar days (Monday, Tuesday, and Wednesday). If this medical ward used midnight as the time of their daily census count, this same patient would only attribute two patient days because they were present for the midnight census count on Monday and Tuesday only.

Please note, the NHSN AU Option only counts a patient once for each location each day. For a given location or FacWideIN, the days present count should almost always be higher than the patient days count because days present take patient transfers and discharges into account while patient days do not.

 

Q32: If a patient transfers between locations in one calendar day, how many days present does that patient contribute to the FacWideIN record?

The patient contributes one day present to the FacWideIN record. The NHSN AU Option only counts a patient once per calendar day for the FacWideIN record.

 

Q33: Should my days present be equal to my patient days for a given location?

No. For a given location or FacWideIN, the days present count will almost always be higher than the patient days count because days present take patient transfers and discharges into account while patient days do not. On average, for all NHSN AU Option reporting hospitals, days present are 24% higher than patient days for the same month/location. There is some variation based on the location type. The percent difference is generally smaller in locations with longer lengths of stay and larger in locations with shorter lengths of stay. The table below provides the median percent difference between days present and patient days for select location types and the interpretation based on the average for all AU Option reporting facilities. NHSN calculated the percent difference with the following formula:

Percent difference between days present and patient days equals days present minus patient days, divided by days present, and multiplied by 100.

 

Table: Median percent difference between days present and patient days for select location types and the interpretation based on the average for all AU Option reporting facilities
Location Type Median Percent Difference Interpretation
FacWideIN 24% Days present are 24% higher than patient days for the same month/location at the FacWideIN level.
Adult ICUs 25% Days present are 25% higher than patient days for the same month/location in adult ICUs.
Adult Wards 25% Days present are 25% higher than patient days for the same month/location in adult ward locations.
Pediatric ICUs 24% Days present are 24% higher than patient days for the same month/location in pediatric ICUs.
Pediatric Wards 35% Days present are 35% higher than patient days for the same month/location in pediatric ward locations.
Neonatal ICUs 8% Days present are 8% higher than patient days for the same month/location in neonatal ICU locations.
Neonatal Step-Down Unit 16% Days present are 16% higher than patient days for the same month/location in neonatal step-down units.
Well Baby Nursery (Level I) 34% Days present are 34% higher than patient days for the same month/location in well baby nursery locations.
Labor, Delivery, Postpartum Units 43% Days present are 43% higher than patient days for the same month/location in labor and delivery locations.
Outpatient Locations
(ED, Pediatric ED, 24 Hour Observation Locations)
14% Days present are 14% higher than encounters for the same month/location in outpatient locations.

Take a closer look at your AU days present denominators to ensure your vendor system aggregates them correctly, as they can influence your SAAR calculations. Additionally, NHSN recommends validating your AU days present denominators using the methodology starting on page 10 in the AU Option Implementation Data Validation protocol pdf icon[PDF – 1 MB].

 

Q34: Which patients are counted in the FacWideIN admissions?

Admissions are defined as the aggregate number of patients admitted to an inpatient location within the facility (FacWideIN) starting on first day of each calendar month through the last day of the calendar month. A patient is counted as an admission when they arrive in an NHSN designated inpatient location regardless of patient status (for example, inpatient, observation). Further, a patient admitted to an inpatient location is counted as an admission even if they are discharged that same calendar day.

Please note, the admissions definition used in the AUR Module is different than the definition used for the NHSN Multidrug-Resistant Organism (MDRO)/Clostridioides difficile Infection (CDI) Module.

 

Q35: How do I count patient admissions when a patient’s stay extends from one month to another?

The day a patient enters the door to a facility or location is the date of their admission to that facility/location regardless of patient status (for example, inpatient, observation). If the facility does not discharge the patient, then that stay is all part of that same admission, no matter how long. A stay that continues across multiple calendar months is still only one admission.

If the patient is discharged and then returns on a separate calendar day, then count the patient as a new admission with a new admission date. If the patient is discharged and then returns on the same calendar day, do not count the patient as another admission since a single patient can only attribute 1 admission per calendar day to the monthly total.


Data Import

Q36: Can I enter AU data manually?

No. Though some NHSN Modules allow for both CDA import and manual data entry, the AU Option only accepts data via CDA import due to the amount of data submitted each month. Please review the Uploading CDA Files into NHSN Quick Learn video [Video – 12 min] for additional details.

 

Q37: My vendor asked me to provide my facility’s OID. What is an OID and where do I get one?

An Object Identifier (OID) is a unique identifier for your NHSN facility. The AU Option uses the OID in CDA files to identify which facility submitted the files. If your facility submits data to other NHSN Modules via CDA import, you may already have an OID. To verify if your facility has or needs an OID, users with administrative rights can navigate through the NHSN application following the steps below:

  • Navigate to Facility then Facility Info on the left-hand menu.
  • On the Edit Facility Information page, you’ll find the OID section on the top right of the screen (see screenshot below).
Screenshot showing where to find the OID section on the Facility Information screen

If you’ve verified that your facility does not have an OID, follow the steps outlined here to obtain one: Object Identifier (OID) Entry Procedure pdf icon[PDF – 30 KB].

 

Q38: Can I submit AU and AR CDA files together in the same zip file?

Yes, you can submit AU and AR CDA files together in the same zip file. For manual upload, all the CDA files in a zip file must be from one facility. For DIRECT submission, the zip file can contain CDA files for multiple facilities. For both manual and DIRECT submission, the zip file can contain up to 1,000 CDA files or a maximum of 2 MB, whichever comes first.

Please note: NHSN only accepts alphanumeric characters, hyphens, and underscores in CDA and zip file names. NHSN does not accept other special characters.

 

Q39: Do I need to include all antimicrobials that are required by the NHSN AU Option in my AU CDA file?

Yes, all required antimicrobials for the reporting calendar year must be included in the AU Option CDA files, regardless of whether your facility used all of them that month. Appendix B of the AUR Protocol pdf icon[PDF – 1 MB] lists the required antimicrobials for the reporting calendar year. See question #40 below for how to report required antimicrobials that were not administered during a calendar month.

In response to the COVID-19 pandemic, users are required to report the following drugs related to COVID-19 treatment to the AU Option:

  • Remdesivir must be reported for summary months on or after July 2020. AU files for summary months on or after July 2020 will fail to upload into NHSN if they do not include remdesivir. Users can optionally include remdesivir in AU files for summary months January – June 2020.
  • Molnupiravir and nirmatrelvir must be reported for summary months on or after March 2022. AU files for summary months on or after March 2022 will fail to upload into NHSN if they do not include molnupiravir and nirmatrelvir. Users can optionally include molnupiravir and nirmatrelvir in AU files for summary months January – February 2022.

 

Q40: What do I do if I did not have at least one administration of all required antimicrobials each month?

You must report a value – a specific number, 0, or NA – for every antimicrobial listed in Appendix B of the AUR Protocol pdf icon[PDF – 1 MB], regardless of actual administration in your facility/location in a given month.

  • Zero (0) — Use when your facility can electronically capture administrations of the antimicrobial in the eMAR/BCMA but did not administer it to any patients during the given month.
    • Example: If your system can electronically capture amoxicillin via eMAR/BCMA but no providers administered it to patients during the month, the amoxicillin total antimicrobial days count should be 0.
    • The CDA file expresses this as value=”0”.
  • Not applicable (NA) — Use when your facility cannot electronically capture administrations of the antimicrobial.
    • Example: If a provider gives amikacin via respiratory route to patients throughout the month, but the eMAR/BCMA cannot accurately capture the administrations, the amikacin antimicrobial day respiratory count should be ”NA”.
    • Facilities should only use “NA” for non-formulary agents when those agents, if administered, cannot be accurately electronically captured. If use of non-formulary agents can be accurately electronically captured, no use of those agents in each location/month should be reported as “0” (zero).
    • Facilities should use “NA” consistently across all locations and FacWideIN, and across months.
    • The CDA file expresses this as nullFlavor=”NA” but the NHSN AU Option reports display NA as “.”.

 

Q41: I don’t see an option for uploading AU data. Please help!

In NHSN, after selecting Import/Export on the navigation bar, you should see “AUR Summary Data” or “Events, Summary Data, Procedures Denominators” as an option to upload CDA files [Video – 12 min]. Both options allow you to upload AU data into NHSN. If you do not see either of these options, a user with administrative rights must change your user rights. See the NHSN AUR User Rights pdf icon[PDF – 350 KB] document for more information.

 

Q42: How do I know if all the CDA files I submitted together in the same zip file uploaded into NHSN successfully?

Sometimes, when uploading multiple AU files together, some files successfully upload and others do not. Here is a screenshot of what it looks like when you submit files together and some records pass but others fail. Note that both the Error Report and Submit buttons are enabled:

Screenshot of import events, procedures and/or summary data and what it looks like when both the error report and submit buttons are enabled

 

If you click on the Summary Data tab in the Validation Results table, you can see the files that passed and failed validation by looking in the Status column. In this instance, the user submitted two records – one passed validation and one failed. When they click the Submit button, only the file that successfully passed validation uploads to NHSN. Clicking the submit button generates a PDF report, which shows the file(s) that successfully imported and the file(s) that did not pass validation and did not import.

Please view and save the PDF report for your records each time you import data into the AU Option. The NHSN Help Desk requires information from the PDF report to assist you with inquiries related to data import errors.

 

Q43: When I try to upload my AU data, I get an error message that says “Please upload files with .zip extensions only. Try again.” What does that mean?

The NHSN AU Option requires users to upload CDA files in a zip file. Try zipping the file(s) and resubmitting. Note that each zip file can contain up to 1,000 CDA files or a maximum of 2 MB, whichever comes first.

 

Q44: When I try to upload my AU data, I get an error message that says, “Antimicrobial Use and Resistance Module not followed for this month, year, and location.” What does that mean?

This error message means that you did not add the month, year, and location in the CDA file you’re trying to upload in the Antimicrobial Use and Resistance portion of your Monthly Reporting Plan. You must add the location(s) to the Antimicrobial Use and Resistance portion of your Monthly Reporting Plan for every month you plan to submit AU data. NHSN will not accept out-of-plan data. To edit your monthly reporting plan to include AU, follow the steps in question #16. After you edit your monthly reporting plan to include AU for the desired month, year, and location, NHSN should accept the CDA file.

If you verified this location is on your monthly reporting plan and NHSN still does not accept the file, incorrect location information in your CDA file may be causing the error. See question #45 below for details on location errors.

 

Q45: When I try to upload my AU data, I get an error message that says my location does not exist and I need to add it to my NHSN facility. I know my location is already mapped in NHSN. What does this error mean?

The location information used in the AU CDA file must be an exact match to the location information in your NHSN facility. This includes the location name (the “Your Code” value in NHSN) and the CDC Location Designation (for example, medical ward). This error message is telling you that the location name used in your CDA file does not match a location currently mapped in your NHSN facility.

We recommend meeting with your NHSN Facility Administrator to have them export the location list out of NHSN (Facility > Locations > Export Location List), so you can compare what’s in NHSN to what’s in your vendor system. Decide the best way to rectify the differences (update NHSN or update the vendor software) with your Infection Control/Infection Prevention department. Once you’ve matched the locations across both systems, re-export your AU CDA files and import them into NHSN.

 

Q46: I just uploaded data to the AU Option, but I don’t see it in the analysis reports. What happened to my data?

Newly uploaded data do not appear in the NHSN analysis outputs until you generate new data sets. Your data set is a snapshot of the data currently in your NHSN facility during the time period specified when you click the “Generate Reporting Data Sets” button. Always generate new data sets after uploading data into NHSN. See the Generating Datasets Guide pdf icon[PDF – 400 KB] for more information.

Note: Each NHSN user has their own data sets. You may not see the same data as your coworkers if you generated data sets at different times or with different parameters.


AU Option Analysis and Standardized Antimicrobial Administration Ratios (SAARs)

Q47: How do I view my AU data once I upload it into NHSN?

You can only view AU Option data using the NHSN Analysis function. You can find details on AU Option analysis in the NHSN AUR Module Protocol pdf icon[PDF – 1 MB] or in the Analysis Resources section of the NHSN AUR Module web page.

NHSN provides two-to-four-page analysis quick reference guides to assist with viewing, modifying, and interpreting AU Option data:

You must generate datAntimicrobial Use – SAAR Bar Chart by Location pdf icon[PDF – 1 MB]a sets within NHSN after uploading new data to run analysis reports with the most current data. See question #46 for more information about generating data sets.

 

Q48: What is the Standardized Antimicrobial Administration Ratio (SAAR) and how is it calculated?

The SAAR is a metric developed by CDC to analyze and report summary antimicrobial use data. NHSN calculates the SAAR by dividing observed antimicrobial days by predicted antimicrobial days. More information on how NHSN calculates the SAAR can be found in the NHSN AUR Module Protocol pdf icon[PDF – 1 MB] and the Guide to the SAApdf iconKeys to Success with the SAARR pdf icon[PDF – 2 MB]. Additionally, the Keys to Success with the SAAR webpage provides a short overview of the SAAR and its components, and SAAR training videos can be found under Training here: NHSN AUR Training.

Keys to Success with the SAAR

Q49: My facility has a SAAR over 1. Is that bad? 

A high SAAR that achieves statistical significance indicates that location or group of locations used more antimicrobials than predicted. A SAAR that is not statistically different from 1.0 indicates antimicrobial use is equivalent to the referent population’s antimicrobial use. A low SAAR that achieves statistical significance indicates that location or group of locations used fewer antimicrobials than predicted. However, the SAAR alone is not a definitive measure of the appropriateness or judiciousness of antibacterial use. Any SAAR may warrant further investigation. For example, a SAAR above 1.0 that does not achieve statistical significance may be associated with meaningful antimicrobial overuse and require further investigation. Keep in mind, a SAAR statistically different from 1.0 may still not lead to productive investigation.

 

Q50: What locations do the 2017 baseline adult and pediatric SAARs include?

NHSN only generates 2017 baseline adult and pediatric SAARs for locations mapped using one of the following thirteen CDC location types:

  1. Adult Medical Critical Care
  2. Adult Medical-Surgical Critical Care
  3. Adult Surgical Critical Care
  4. Adult Medical Ward
  5. Adult Medical-Surgical Ward
  6. Adult Surgical Ward
  7. Adult Oncology General Hematology-Oncology Ward
  8. Adult Stepdown Unit
  9. Pediatric Medical Critical Care
  10. Pediatric Medical-Surgical Critical Care
  11. Pediatric Medical Ward
  12. Pediatric Medical-Surgical Ward
  13. Pediatric Surgical Ward

While NHSN encourages facilities to submit AU data from all NHSN-defined inpatient locations, FacWideIN, and select outpatient acute-care settings (specifically, emergency department, pediatric emergency department, and 24-hour observation area), the only locations that can generate SAARs are those mapped to the thirteen CDC locations listed above. In the future, as more facilities submit AU data, NHSN hopes to develop SAARs for additional location types.

You can still examine antimicrobial use in other locations using line lists, rate tables, or charts. See question #47 for more information on NHSN AU Option Analysis.

You can find more information about NHSN location mapping for the SAAR in Table 5 of the AUR Protocol pdf icon[PDF – 1 MB].

 

Q51: What locations do the 2018 baseline neonatal SAARs include?

NHSN only generates 2018 baseline neonatal SAARs for locations mapped using one of the following four CDC location types:

  1. Step down Neonatal Nursery
  2. Neonatal Critical Care (Level II/III)
  3. Neonatal Critical Care (Level III)
  4. Neonatal Critical Care (Level IV)

See question #50 for more information about SAAR locations.

 

Q52: I uploaded FacWideIN AU data to NHSN but cannot generate a SAAR report. Why not?

FacWideIN is currently not a SAAR-eligible location. It is the aggregate of ALL individual inpatient locations. The FacWideIN record captures facility-wide data; specifically, data from all inpatient locations from which the AU numerator and denominator are captured. When FacWideIN data are uploaded into NHSN, they represent aggregate use for all inpatient locations reported by your facility. NHSN is not able to tease apart the FacWideIN counts to know how many antimicrobial days and days present came from each individual inpatient location.

The SAAR models were developed for specific patient care locations. FacWideIN was not included in the SAAR modeling because it includes different patient and location types mapped within NHSN for each facility. Please refer the list of locations in questions #50 and #51 to see which adult, pediatric, and neonatal location types can generate SAAR reports. To generate a SAAR report, you must report data from at least one of the individual inpatient location types listed in questions #50 & #51.

Please refer to question #19 for additional information on limitations of reporting only FacWideIN AU data.

 

Q53: Can I generate a SAAR report for just one location and one month?

Yes. You can generate a SAAR by month, quarter, half year, year, or cumulative time periods. You can generate a SAAR report for a specific location or location type. To generate a SAAR by location and month, follow the steps in the SAAR Table — by location Quick Reference Guide. pdf icon[PDF – 500 KB]. NHSN provides quick reference guides for each SAAR report on the Analysis Quick Reference Guides webpage.

 

Q54: What years can I generate SAARs for?

NHSN currently offers three SAAR baselines, each applicable to a select set of patient care locations and time periods. You can generate historical 2014 baseline adult and pediatric SAARs for data between January 1, 2014 and December 31, 2018. You can generate 2017 baseline adult and pediatric SAARs for data from January 1, 2017 going forward. You can generate 2018 baseline neonatal SAARs for data from January 1, 2018 going forward. Please note: You cannot directly compare SAARs calculated under the 2014 baseline with 2017 baseline SAAR values.

2018 baseline neonatal SAARs are available from 2018 forward. 2017 baseline adult and pediatric SAARs are available from 2017 forward. The historical 2014 baseline adult and pediatric SAARs are available for 2014-2018.

 

To generate a SAAR by location and month, follow the steps in the SAAR Table—by location Quick Reference Guide. pdf icon[PDF – 500 KB].

 

Q55: I uploaded AU data to NHSN, generated data sets, and ensured my location is one of the SAAR locations, but I still cannot generate a SAAR report. What is going on?

You may not have the correct user rights to view the SAAR reports. NHSN uses the Patient Safety Annual Facility Survey for risk adjustment in the SAARs. Without access to the survey data, you cannot view the SAAR data. Review your user rights with your NHSN Facility Administrator and, once the Facility Administrator corrects your rights, generate new data sets. Refer to the guidance document pdf icon[PDF – 350 KB] that outlines minimum AU rights.

There are a few circumstances under which you cannot either generate SAAR reports or obtain a SAAR value for certain locations.

You will not be able to obtain a SAAR value in the following situations.

All SAARs:

  • Locations reporting zero days present for the selected time period.
  • Locations reporting more antimicrobial days than days present for any SAAR agent category (except the adult and pediatric All Antibacterial Agents SAARs).
  • Locations with less than one predicted antimicrobial day.

You will not be able to generate SAAR reports in the following situations:

Adult SAARs:

Adult SAAR locations in a long-term acute care (LTAC) hospital, orthopedic hospital, psychiatric hospital, or rehabilitation hospital are not able to generate SAAR reports. The 2017 SAAR baseline adult referent population does not include these facility types.

Pediatric SAARs:

Pediatric SAAR locations in a critical access hospital, LTAC hospital, oncology hospital, orthopedic hospital, pediatric LTAC hospital, psychiatric hospital, rehabilitation hospital, surgical hospital, women’s hospital, or VA hospital are not able to generate SAAR reports. The 2017 SAAR baseline pediatric referent population does not include these facility types.

Neonatal SAARs:

  • Neonatal SAAR locations in a critical access hospital, LTAC hospital, oncology hospital, orthopedic hospital, pediatric LTAC hospital, psychiatric hospital, rehabilitation hospital, surgical hospital, or VA hospital are not able to generate SAAR reports. The 2018 SAAR baseline neonatal referent population does not include these facility types.
  • Facilities missing relevant Patient Safety Annual Survey data or facilities that indicate that their facility does not care for neonates
  • Facilities reporting zero inborn and zero outborn admissions.

If you tried everything in the FAQs above and still can’t generate a SAAR, please email the NHSN Helpdesk at nhsn@cdc.gov.

 

Q56: How can I compare my SAAR values to other facilities?

The NHSN AU Data Reports provide summaries of SAAR distributions and percentages of use within SAAR antimicrobial agent categories in adult, pediatric, and neonatal locations. The SAAR distributions can help inform stewardship efforts by enabling hospitals to see how their SAARs compare to the national distribution. Facilities can use distributions to help set facility-specific SAAR goals. The percentage of AU by class and drug within a SAAR antimicrobial agent category provides insight into prescribing practices across differing patient locations, such as medical critical care units compared to medical wards. Facilities may evaluate these usage patterns in context of their local treatment guidelines, antimicrobial resistance rates, and formulary.

 

Q57: I’m not submitting data into the AU Option, but I’d like to compare my antimicrobial use against other facilities using the SAAR. Is this possible?

Currently, NHSN only makes the SAAR available for facilities reporting into the AU Option. NHSN published papers on the 2017 SAAR methodology and baseline model details (NHSN SAARs: A Progress Report and Risk Modeling Update Using 2017 Dataexternal icon). and 2018 neonatal SAAR methodology (National Healthcare Safety Network 2018 Baseline Neonatal Standardized Antimicrobial Administration Ratiosexternal icon) for reference.

Keep in mind, facilities not participating in the NHSN AU Option must still capture the NHSN AU Option-defined antimicrobial days and days present accurately to calculate their own SAARs.

Q58: Does the SAAR account for changes in antimicrobial use during the COVID-19 pandemic?

No. The AU Option does not collect patient-level information, including information on indication for use, co-morbidities, or severity of illness, nor does NHSN collect data on hospitals’ burden of COVID-19. Because of this, the SAARs are not adjusted for COVID-19 rates.

It is also possible that NHSN patient care locations changed function during the COVID-19 pandemic. These location changes may not be reflected in the SAARs because hospitals may not have remapped their patient care locations within NHSN due to the ongoing public health emergency. See question #23 for additional information on location changes during the COVID-19 pandemic.

The 2020 NHSN AU Data Report pdf icon[PDF – 633 KB] provides some additional insight on AU rates during the COVID-19 pandemic starting on page 3.