- HAI in patients awaiting organ harvest
- POA & RIT
- Rationale for definition of Healthcare-associated infection (HAI)
- POA or HAI
- Surveillance vs. Clinical
- What are considered diagnostic tests
- Non-culture based microbiologic testing
- Active Surveillance Culture/Testing (ASC/AST)
- In-plan vs. off-plan NHSN reporting
- Facilities that share a CCN
- Positive surveillance screening and HAI
- Temperature (Fever)
- Temperature measurement
- Vital signs
- Patient identification
- Observation Patients & Denominator Counts
- Observation Patients in Inpatient beds, Swing beds, Hospice
- Mixed-acuity units
- Location codes
- Physician diagnosis
- Counting device days
- Device Counts
- Broth only cultures
- Yellow Triangle at bottom of page/Incompatible Browser
- Gross Anatomical
- Pathogen Reporting in NHSN
- Protocols for Patient Safety Component Modules
Q1: Do we need to report an HAI in a patient who is being supported for the purpose of organ harvest?
If the date of specimen collection is on or after the date of documentation of evidence of consent AND the patient is being supported for organ donation purposes, an event identified using the specimen culture result or microbiologic non-culture based diagnostic test result should not be reported as an HAI. The patient should, however, still be included in device and patient day denominator data collection.
Q2: Does the Repeat Infection Timeframe (RIT) apply to Present on Admission (POA) infections?
Yes. The repeat infection timeframe is set by the date of event (DOE). For surveillance purposes a POA infection may only have a DOE on the day of admission or the next day. If the first element within the infection window period occurred in the 2 days before admission, the DOE is considered the day of admission. The RIT is the 14-day time period where no new infections of the same type are reported, beginning with the date of event. Example: A UTI with E. Coli identified with DOE on the day of admission is considered POA. If, 10 days later a new urine culture shows K. pneumonia >100,000 CFU/ml, then the organism is added to the original UTI (no new event is cited but rather is considered a continuation of the original event). The UTI RIT remains Hospital Days 1-13.
NOTE: If a patient is admitted with a POA BSI, and subsequent blood specimens are collected, the POA BSI must be identified as either primary or secondary in nature. A primary POA BSI will set a BSI RIT. However, a POA BSI that is secondary to another site of infection will NOT set a BSI RIT. It will only set an RIT for the type of infection to which the BSI is secondary. Please see the article on page 3 of the September 2015 NHSN Newsletter pdf icon[PDF – 2 MB] for more details.
Q3: Can you please explain the rationale for the definition of healthcare-associated infection vs. an infection that was present on admission?
Several studies have demonstrated there was subjective application of the NHSN HAI surveillance definitions by different IPs and facilities, prior to 2013. During this time, the NHSN definitions allowed facilities to subjectively determine evidence that an infection was present or incubating on admission, which were not reportable to NHSN because it was not “healthcare-associated”. Subjectivity, providing an opportunity for inconsistent data collection, must be removed from surveillance definitions whenever possible. With this in mind, CDC and the HICPAC surveillance working group, a group made up of infectious disease professionals, healthcare epidemiologists, infection preventionists, and state public health representatives, developed a set of objective surveillance criteria to be implemented into NHSN and used by all reporting facilities reporting data to NHSN. Through the use of the same set of objective criteria it is expected that data reported to the system is useful for quality improvement activities.
POA or HAI
Q4: How do I determine if an infection is present on admission or healthcare- associated?
For infections of all types except VAE, SSI, LabID Event, to make a proper determination regarding a possible healthcare-associated infection, proceed in this order:
- First determine the date of the diagnostic test that is an element of the NHSN site-specific infection criterion that is met.
- Next determine the infection window period (3 days before the diagnostic test, the day of the test and 3 days after for a total of 7 days). NOTE: when the diagnostic test used to set the IWP is hospital day 3 or earlier, the days before the diagnostic test can only include those that occur in the POA timeframe specifically 2 days prior to admission.
- 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.
- If there is an event, next determine the date of event, specifically, the date that the first element used to meet the infection criterion occurs for the first time within the infection window period.
- Is the date of event in the POA time period (specifically during the 2 days before admission, the day of admission or the next day)? If yes, the infection is POA, if not, it is an HAI. Please note, when assigning a Repeat Infection Timeframe for a POA event, if the date of event is determined to be either of the two days prior to inpatient admission, then the date of event is considered hospital day 1.
Chapter 2 of the NHSN PSC Manual – Identifying HAI for NHSN Surveillance pdf icon[PDF – 1 MB] provides guidance and examples.
Q5: What is the difference between a surveillance definition of an infection and a clinical diagnosis? My physician states that a patient is not infected although the patient clearly meets the NHSN HAI criteria. How do I respond?
Surveillance definitions are designed to study and identify trends in a population. The application of these standardized criteria, and only these criteria, in a consistent manner allows confidence in aggregation and analysis of data. Alternatively, clinical diagnoses are patient specific. Unlike surveillance definitions, ALL available diagnostic data are considered in a clinical diagnosis, including additional clinical, epidemiological and laboratory data not used for NHSN surveillance. Therefore, a clinical diagnosis may be made even when a surveillance definition may not be met and vice versa is also true. Failure to meet a surveillance definition should never impede or override clinical judgment during diagnosis, management or treatment of patents. Nor should failure to meet clinical definitions result in non-reporting to NHSN infections meeting the NHSN surveillance criteria.
Q6: What are considered diagnostic tests for the purpose of defining the infection window period and date of event?
The following are considered diagnostic tests only when they are an element of the criteria that is met:
- laboratory specimen collection
- imaging test
- procedure or exam
Q7: In the NHSN HAI definitions, what is meant by the term “non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis and treatment (for example, not Active Surveillance Culture/Testing (ASC/AST)”
This term refers to the identification of microorganisms using a method of testing other than a culture. Culture based testing requires inoculation of a specimen to culture media, incubation and observation for actual growth of microorganisms. Depending on the organism identified, culturing can take several days to weeks for a final report. In contrast, non-culture based testing methods generally provide faster results, which can assist with early diagnosis and tailoring of antimicrobial therapy. Examples of non-culture based testing include, but are not limited to, PCR (polymerase chain reaction) and ELISA (Enzyme-linked immunosorbent assay) as well as DNA sequencing.
Q8: What is meant by the term Active Surveillance Culture/Testing?
For purposes of NHSN surveillance, Active Surveillance Culture/Testing (ASC/AST) refers to testing that is intended to identify the presence/carriage of microorganisms for the purpose of instituting or discontinuing isolation precautions (for example, nasal swab for MRSA, rectal swab for VRE), or monitoring for eradication of a carrier state. ASC/AST does NOT include identification of microorganisms with cultures or tests performed for diagnosis and treatment purposes (for example, specimens collected from sterile body sites including blood specimens). Also see Surveillance cultures
Q9: What is the meaning of “in-plan” and “off-plan” surveillance for NHSN surveillance?
“In plan” data is data which a facility has indicated in their NHSN Monthly Reporting Plan (MRP) will be performed. By including the data in the NHSN MRP, the facility is stating that the NHSN surveillance protocol(s) will be used, in its entirety, for that particular event. Only in-plan data are submitted to CMS in accordance with CMS’s Quality Reporting Programs. Only data that are entered into NHSN “in-plan” are included in NHSN annual reports or other NHSN publications.
Q10: Do separate facilities that share a single CCN (CMS certification number) need to enroll separately in NHSN?
If the facilities are physically separate buildings from each other, whether on the same property or over multiple campuses, then they should be enrolled separately in NHSN. Each facility should have its own, unique NHSN OrgID. When a CCN is shared across multiple facilities, the CDC will aggregate the data from all applicable NHSN OrgIDs and will send to CMS under the single CCN for CMS reporting purposes. Each distinct facility should monitor HAIs and prevention efforts separately, for the purposes of accurate tracking and targeted infection control.
Q11: A patient is admitted and is MRSA positive by admission screening then develops an infection with MRSA, Is that infection a healthcare-associated infection (HAI)?
Yes. A positive screening culture at admission does not mean that any subsequent infection with that organism is not a healthcare-associated infection (HAI). Many HAIs are caused by organisms from endogenous patient sources and prevention efforts may be employed to prevent these organisms from causing an HAI. A positive screening culture without evidence of infection usually represents colonization NOT incubation. Unless such a patient meets all other required criteria to fulfill the present on admission (POA) definition, no POA infection is identified. Also see definition of HAI.
Q12: If present, should a fever be applied to criteria of more than one type of HAI, or can it be determined that the fever is due to one type of infection but not another? For instance can a fever be deemed due to a pneumonia (PNEU) but not a coincidental urinary tract infection (UTI)?
Because fever is a non-specific sign of infection, it is possible that an individual may run a fever due to more than one infection at a time. It would be impossible to determine which infection (if not both) was the cause of the fever. Therefore, in this example, if all other criteria besides fever are met, the patient would have both an NHSN PNEU and an NHSN UTI. This process negates the use of clinical, subjective decision making to determine NHSN HAI events.
Q13: Is there a standard or recommendation regarding the use of, or the conversion of, axillary temperature readings to an oral or core equivalent?
The issue of the route of temperature measurement was considered here at NHSN and a decision was made to forego requiring a certain route of measurement, since our aim is not to direct care, but rather to measure the effect of care on outcomes. A detailed literature search was performed and subject matter experts consulted regarding the many routes of measurement and what they may mean when compared to others. The final determination was that there are no research-based guidelines concerning converting temperatures based on route of measurement. When using fever as an element of an NHSN infection criterion, use the temperature documented in the patient’s medical record (no conversion of temperature based on route of collection).
Q14: How do we determine if a patient has an abnormal vital sign when it is not concretely defined in NHSN, for example, “bradycardia” in the LCBI 3 criterion?
If a specific value for a vital sign is not stated in a CDC/NHSN HAI definition criterion (for example bradycardia, hypotension), the facility should use the vital sign parameters as stated in its own policies and procedures for clinical practices. Additionally, documentation of these conditions in the medical chart may also be used, for example, “…patient is hypotensive” would satisfy the element of “hypotension”.
Q15: Which Patient ID should be used when reporting data to NHSN: the visit/account number or the medical record number?
The patient ID is the key identifier in NHSN for each facility. Therefore, the patient ID should be an identifier that remains constant for the patient on any subsequent visits; oftentimes, this is the medical record number. The use of an identifier that changes with each visit to the facility, for example, would result in the inability to link an SSI to a procedure, as well as inappropriate assignment and calculation of LabID events and subsequent measures.
Q16: Are observation patients, housed in an inpatient location, included in the location’s surveillance?
For determining accurate device and/or patient day counts in inpatient locations, any patient present in an inpatient location at the time of the count(s) should be included, regardless of whether they spend the night. The facility’s designation of a patient as “inpatient” is not necessary to meet the NHSN inpatient definition.
Q17: Should observation patients, swing bed patients, or hospice patients housed in an inpatient unit be included in our HAI and inpatient LabID event surveillance efforts?
Yes. All patients residing in an inpatient unit should be included in the surveillance efforts for that unit regardless of the facility’s categorization as “observation” or “hospice” patient, that they are being provided only palliative or support care, or that they are in a swing bed within an inpatient location.
Q18: Our critical care unit is actually both a medical critical care and step-down unit because we don’t have a step-down unit in our hospital. So would the location designation for this type of unit be “Mixed Acuity” ward and if “yes”, would CLABSIs in this location need to be reported for participation in the Centers for Medicare and Medicaid Services’ (CMS) Hospital Inpatient Quality Reporting Program?
The designation of Mixed Acuity Unit should be used only when both of the following are true: 1.) Less than 80% of the patients are of the same acuity level, for example, critical care, step down or ward level; AND 2.) “Virtual” locations cannot be set up within NHSN to identify groups of patients of the same acuity levels. Use of virtual locations requires the ability to identify separate patient days and device days for these groups of patients. Correct mapping of facility locations is vital for appropriate comparison and calculation of device-associated SIRs. Detailed guidance can be found at: http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdfFor CMS IPPS reporting, CLABSI reporting is mandatory for adult & pediatric ICUs, medical wards, surgical wards & combined medical/surgical wards as well as neonatal ICUs for acute care facilities. Long-Term Acute Care facilities are required to report CLABSIs for all inpatient locations. The data that NHSN shares with CMS will not include data for locations mapped as Mixed Acuity Units. For more details regarding the reporting requirements for CMS Quality Reporting Programs, as they pertain to NHSN surveillance, please visit: CMS Requirements.
Q19: How do I know if I have my location codes set-up correctly?
Please refer to the guidance that is provided in the CDC Locations and Descriptions Chapter (Chapter 15) pdf icon[PDF – 1 MB]. The beginning of this chapter offers a guide which will help you set up your locations properly.
Q20: Can physician diagnosis be used to identify an infection that is present on admission to the facility?
Only if physician diagnosis is a part of an NHSN site- specific infection criteria may it be used in the determination that an infection was present on admission (POA). For example, since the BSI criteria do not include physician diagnosis as part of the criteria, a physician documentation of BSI cannot be used to meet CDC/NHSN criteria for a BSI. As a reminder, the date of event of a CDC/NHSN site-specific infection criterion must occur within the POA time period (specifically the 2 days before admission, the day of admission or the next day) for the infection to be considered present on admission. This is regardless of admitting diagnosis or treatments the patient may be receiving upon admission (for example, antibiotics).
Q21: How are partial device days, or single day vacations from medical devices handled when determining if a device has been in place for the minimum > 2 calendar days on the date of event and the infection therefore device-associated?
If a device is present for any part of a calendar day, then that day contributes to the minimum day requirement for the device-associated infection. Examples include when a device is removed and then reinserted on that calendar day or the next. If instead, a full calendar day passes without device presence, then the day count begins anew for device days, if the device is reinserted. An example is the removal of a device on Monday, without reinsertion until Wednesday or later.
Q22: Do I need to do daily device counts to collect device days?
Denominator data are collected at the same time, every day, per location. Alternatively, a denominator sampling method can be used where the number of patients in the location (patient days) and the number of patients with an indwelling device (urinary catheter/central line/ventilator) is collected on a designated day each week at the same time. For accuracy, do not use Saturday or Sunday for sampling purposes and only non-oncology ICUs and wards with an average of 75 or more device days per month in the previous year are eligible to use this method. When using this method, the patient days must also be counted each day of the week. See the Denominator Data section in the involved surveillance protocol for details.
Q23: How do I interpret ‘broth only’ for the final culture report when reporting infection events in NHSN?
Positive cultures from broth only are considered a positive culture result and treated as such for surveillance purposes. Such media can be enriched to identify organisms that might otherwise be missed.
Q24: I can’t get the NHSN application to work correctly. The rows on my monthly reporting plan are not populating.
I have a yellow exclamation mark in a triangle at the bottom of my screen. What does this mean?
If you have a yellow triangle error message at the bottom of the screen, it may be an indication of a JAVA program issue/incompatible browser.
- Open Internet Explorer, make sure that compatibility mode is on.
- Click on Tools, >compatibility view>toggle to turn on compatibility view if it’s not on the Internet Options.
- Choose Security Tab.
- Click on Custom Level.
- Check the radio button against Enable, under ActiveX controls and Plug-ins.
- Click OK.
- In warning window asking “Are you sure you want to change the security settings at this zone”? Click Yes.
- Click Apply and then Click OK.If the Active X controls are already enabled then you need to add *.cdc.gov to your trusted sites. To do this do the following:
- Open Internet Explorer.
- Click on Tools then Internet Options.
- Choose Security Tab.
- Click sites next to Trusted Sites.
- Add *.cdc.gov to the trusted sites.
Q25: What is acceptable evidence of infection found on gross anatomical exam?
Evidence of infection elicited or visualized on physical examination or observed during an invasive procedure. This includes findings elicited on physical examination of a patient during admission or subsequent assessments of the patient and may include findings noted during a medical/invasive procedure dependent upon the location of the infection as well as the NHSN infection criterion.
An intraabdominal abscess will require an invasive procedure to visualize the abscess.
Visualization of pus or purulent drainage (includes from a drain).
SSI only: Abdominal pain or tenderness post Cesarean section (CSEC) or hysterectomy (HYST or VHYS) is sufficient evidence of infection detected without an invasive procedure to meet general Organ Space SSI criterion “c”. Allowing the documentation of abdominal pain or tenderness as gross anatomic evidence of infection to meet general Organ Space SSI criterion “c” allows the SSI determination to move on to meet a site-specific organ/space infection criteria.
Note: Imaging test evidence of infection cannot be applied to meet gross anatomic evidence of infection. Imaging test evidence has distinct findings in the HAI definitions. (for example, IAB “3b”).
Q26: How should I assign different organisms for a site-specific infection? What is the proper order for reporting pathogens?
Up to three pathogens may be reported. If multiple pathogens are identified, enter the pathogen judged to be the most important cause of infection as #1, the next most as #2, and the least as #3 (usually this order is indicated on the laboratory report). If the species is not given on the lab report or is not found on the NHSN drop down list, then select the genus only. (Report all site-specific pathogens before secondary BSI pathogens).
Additional pathogens recovered during the Repeat Infection Timeframe from the same type of infection are added to the event.
Example: Pt. admitted 1-1-15 meeting criteria of Symptomatic Urinary Tract Infection (SUTI), urine cult = E. coli. On 1-12 another urine cult shows K. pneumoniae >100,000 CFU/ml. The assignment is SUTI – E. coli and K. pneumonia. The exception to this is that excluded organisms for a specific type of infection cannot be added to that type of infection. For example, Candida albicans cannot be added to a previously reported UTI, as Candida is an excluded pathogen for UTI.
Q27: Is there a shortcut to finding the major category NHSN protocols?