Form CDC 57.600 CDC 57.600 State Health Department Validation Record

Form Approved

OMB No. 0920-xxxx

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

State Health Department Validation Record

Page 1 of 6

*required **conditionally required

Facility Validation Overview

*Facility ID:

*Facility Type:

□ Acute care hospital

□ Long term acute care hospital (LTAC/LTCH)

□ Oncology hospital

□ Inpatient rehabilitation facility (IRF)

*Sampling version:

□ CDC Version 1 (Targeted Sampling)

*Data for year:

□ 2013

*HAI validated at this facility, and reason:

□ CLABSI (ICU, includes NICUs if applicable)

□ CAUTI (ICU, excludes NICUs)

□ COLO (DI/OS SSI)

□ HYST (DI/OS SSI)

□ MRSA bacteremia LabID event

□ CDI LabID event

Reason:

□ All facilities are validated

□ Targeted facility

□ 5% random sample facility

Numerator Validation

*Sampling information for numerator audit at this facility

Event

Sampling frame elements

Sampling Frame (# elements eligible for review for year)

Total # events from facility reported to NHSN for year (before validation)

**ICU (including NICU) CLABSI

Medical records with positive ICU blood culture(s)

______

______

**ICU (excluding NICU) CAUTI

Medical records with positive ICU urine culture(s)

______

______

**DI/OSa COLO SSI

COLO procedures

______

______

**DI/OSa HYST SSI

HYST procedures

______

______

**MRSA bacteremia labID event

Inpatientb blood cultures positive for MRSA

______

______

**CDI labID event

Inpatientb stools toxin-positive for C. difficile, excluding those from “baby locations”

______

______

aDI/OS - deep incisional or organ/space SSI

bInpatient includes specimens collected on day of admission from ED or other outpatient location

Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.600 (Front) v8.1

State Health Department Validation Record

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Numerator Validation (continued)
*Facility audit results, numerators
**CLABSI in ICU (including NICU):
	Facility determination	Audit-CLABSI Yes	Audit-CLABSI No
	Date-matched CLABSI reported	a. ____	b. ____
	Date-matched CLABSI NOT reported	c. ____	d. ____
**CAUTI in ICU (excluding NICU):
	Facility determination	Audit-CAUTI Yes	Audit-CAUTI No
	Date-matched CAUTI reported	a. ____	b. ____
	Date-matched CAUTI NOT reported	c. ____	d. ____
**DI/OS COLO SSI:
	Facility determination	Audit-DI/OS SSI Yes	Audit-DI/OS SSI No
	Date-matched DI/OS SSI reported	a. ____	b. ____
	Date-matched DI/OS SSI NOT reported	c. ____	d. ____
**DI/OS HYST SSI:
	Facility determination	Audit-DI/OS SSI Yes	Audit-DI/OS SSI No
	Date-matched DI/OS SSI reported	a. ____	b. ____
	Date-matched DI/OS SSI NOT reported	c. ____	d. ____
**MRSA bacteremia LabID event:
	Facility determination	Audit-MRSA bacteremia culture reportable LabID event	Audit-MRSA bacteremia culture NOT reportable LabID event
	Date-matched MRSA blood culture reported as LabID event	a. ____	b. ____
	Date-matched MRSA blood culture NOT reported as LabID event	c. ____	d. ____
**CDI LabID event:
	Facility determination	Audit-CDI test reportable LabID event	Audit-CDI test NOT reportable LabID event
	Date-matched CDI test reported as LabID event	a. ____	b. ____
	Date-matched CDI test NOT reported as LabID event	c. ____	d. ____

State Health Department Validation Record

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Denominator Validation: CLABSI
**Which method was used by this facility for ICU CLABSI denominator (patient days and central line days) counting for this year?
□ Manual counting		□ Electronic counting		□ Both manual and electronic counting
**Has this facility completed an internal validation of ICU CLABSI denominator data for this year?							□ Yes		□ No
Note: Validation of manual denominator data counting requires either: Method A – Concurrent dual counting (with more experienced counter as reference) for ≥ three months OR Method B – Concurrent patient level data (reference) and standard counting for ≥ three months Validation of electronic denominator data counting requires: Method C – Concurrent manual denominator counting (reference) vs. electronic data for ≥ three months
**If yes, provide the following information for all locations and months validated:
	Location of validation		Month of validation		Validation method	Count 1		Count 2
					A, B, or C
					A, B, or C
					A, B, or C
					A, B, or C
					A, B, or C
Note: If Method A is chosen, Count 1 should be “Usual Count” and Count 2 should be “Expert (Referent) Count”; If Method B is chosen, Count 1 should be “Usual Count” and Count 2 should be ”Patient-level (Referent) Count”; If Method C is chosen, Count 1 should be “Manual Count” and Count 2 should be “Electronic Count.”
Denominator Validation: CAUTI
**Which method was used by this facility for ICU CAUTI denominator (patient days and catheter days) counting for this year?
□ Manual counting		□ Electronic counting		□ Both manual and electronic counting
**Has this facility completed an internal validation of ICU CAUTI denominator data for this year?							□ Yes		□ No
Note: Validation of manual denominator data counting requires either: Method A – Concurrent dual counting (with more experienced counter as reference) for ≥ three months OR Method B – Concurrent patient level data (reference) and standard counting for ≥ three months Validation of electronic denominator data counting requires: Method C – Concurrent manual denominator counting (reference) vs. electronic data for ≥ three months
**If yes, provide the following information for all locations and months validated:
	Location of validation		Month of validation		Validation method	Count 1		Count 2
					A, B, or C
					A, B, or C
					A, B, or C
					A, B, or C
					A, B, or C
	Note: If Method A is chosen, Count 1 should be “Usual Count” and Count 2 should be “Expert (Referent) Count”; If Method B is chosen, Count 1 should be “Usual Count” and Count 2 should be ”Patient-level (Referent) Count”; If Method C is chosen, Count 1 should be “Manual Count” and Count 2 should be “Electronic Count.”

State Health Department Validation Record

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Denominator Validation: COLO

**Document number of COLO procedures from two systems by month:

Month

Number of COLO procedures entered into NHSN by facility before validation

Number of ICD-9 procedure codes for COLO identified from hospital discharge billing

Denominator Validation: HYST

**Document number of HYST procedures from two systems by month:

Month

Number of HYST procedures entered into NHSN by facility before validation

Number of ICD-9 procedure codes for HYST identified from hospital discharge billing

Denominator Validation: MRSA bacteremia LabID event & CDI LabID event

NHSN inpatient location validation

**Do any inpatient locations require mapping or re-mapping within NHSN?

□ Yes

□ No

**If yes, indicate which locations need to be mapped/re-mapped and recommendations:

Location

Current CDC location code designation

Current bed count

Recommended CDC location code designation

Recommended bed count

**How does this facility obtain inpatient admissions data?

□ Electronic from billing

□ Electronic from vendor system

□ Electronic from ADT

□ Other (specify): ____________________________________________

**How does this facility obtain inpatient patient days data?

□ Electronic from billing

□ Electronic from vendor system

□ Electronic from ADT

□ Other (specify): ____________________________________________

State Health Department Validation Record

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Denominator Validation: MRSA bacteremia LabID event & CDI LabID event (continued)

**Has this facility completed any internal validation of LabID event denominator data counting?

□ Yes

□ No

Note: Validation of denominator data counting requires concurrent patient level denominator counting (reference) vs. standard electronic data for three specified location types [one ICU, one LDRP if available, and one or more wards where observation patients are frequently housed] for ≥1 month; validated data should fall within 5% of the reference standard (see validation Guidance and Toolkit Appendix 1).

**If yes, provide the following information for all months validated:

MRSA bacteremia LabID event

Location of validation

Month of validation

Admissions

Patient Days

Usual count

Manual count

Usual count

Manual count

CDI LabID eventc

Location of validation

Month of validation

Admissions

Patient Days

Usual count

Manual count

Usual count

Manual count

cExcludes ‘baby locations’

Risk Adjustment Variable Validation

**ICU mapping (ICU CLABSI [includes NICUs], ICU CAUTI [excludes NICUs])

Number of ICU locations correctly mapped as ICUs in NHSN (includes NICUs):

_________

Number of locations incorrectly mapped as ICUs (includes NICUs):

_________

Number of ICUs (includes NICUs) omitted from ICU mapping:

_________

Number of ICU mapping errors (ICUs vs. non-ICUs):

_________

**Teaching hospital affiliation (ICU CLABSI, ICU CAUTI, MRSA bacteremia LabID event, CDI LabID event)

Facility teaching hospital affiliation reported on 2013 NHSN annual facility survey:

□ Non-teaching

□ Major

□ Graduate

□ Undergraduate

□ N/A (IRF & LTAC)

Is facility teaching hospital affiliation correct?

□ Yes

□ No

**ASA score (COLO, HYST)

Number (% of audited) correct for COLO:

_________

Number (% of audited) correct for HYST:

_________

State Health Department Validation Record

Page 6 of 6
Risk Adjustment Variable Validation (continued)
**Patient age (COLO, HYST)
Number (% of audited) correct for COLO:		_________
Number (% of audited) correct for HYST:		_________
**Facility bed size (all inpatient locations, including ‘baby locations’) (MRSA bacteremia LabID event, CDI LabID event)
Facility bed size reported on 2013 NHSN annual facility survey:				_________
Validated bed size:				_________
Custom Fields
Label			Label
_________________________	____/____/_____		_______________________		____/____/_____
_________________________	______________		_______________________		______________
_________________________	______________		_______________________		______________
_________________________	______________		_______________________		______________
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