57.100
|
NHSN Registration Form
|
No change
|
No changes
|
N/A
|
57.101
|
Facility Contact
Information
|
No change
|
Update form to
remove section for the Antimicrobial Use and Resistance
Component.
|
The
form was updated to remove applicable sections for the
Antimicrobial Use and Resistance Component as that functionality
will not be implemented within NHSN.
This change does not
affect the estimated burden of this form.
|
57.103
|
Patient Safety
Component-Annual Hospital Survey
|
No change
|
Removal
of the section specific to Ambulatory Surgery Centers (ASCs).
Wording
revisions on questions #2 and #20.
Clarified
the question wording and added an additional response option for
questions #14-17.
Clarified
the question wording and answer choices for question #18.
Added
new questions #19 and #21.
Re-categorized
the answer choices for question #22.
Removed
two questions within the Infection Control Practices section.
Added
an additional response option for question #24.
Lowering the
number of annual respondents from 6,000 to 5,000.
|
Due
to the number of questions and user confusion from those in
Ambulatory Surgery Centers (ASCs), ASCs will no longer complete
the hospital survey. Instead, they will be directed to complete
an ASC-specific survey.
Additional
wording added to questions #2 and #20 due to user confusion.
Additional
wording and a new answer choice added to questions #14-17 since
some hospitals rarely or never admit patients with Multi-drug
resistant organisms.
Additional
wording and answer choice for question #18 to make consistent
with Laboratory Practices section question #19.
New
questions were added in order to capture infection control
policies specifically around MRSA.
Re-categorized
the answer choices for question #22 due to user confusion with
previous order.
Two
questions were removed within the Infection Control Practices
section as the responses had become almost 100% unanimous and
therefore were no longer needed.
Additional
answer choice to #24 that states “co-led by both
pharmacist and physician” since this was a common answer
that users entered when selecting “Other” as a
response from last year’s survey.
Removal
of the ASC questions will remove roughly 1,000 respondents from
the total number of respondents completing this form annually.
These changes result in
a decrease of 833 burden hours for this form.
|
57.105
|
Group Contact Information
|
No change
|
No changes
|
N/A
|
57.106
|
Patient Safety Monthly
Reporting Plan
|
No change
|
No changes
|
N/A
|
57.108
|
Primary Bloodstream
Infection (BSI)
|
No change
|
No changes
|
N/A
|
57.111
|
Pneumonia (PNEU)
|
No change
|
Three response
options were revised.
|
Revisions
were made to response options to reflect updates to the
Ventilator Associated Pneumonia surveillance protocol: Lung
parenchyma was edited to read lung tissue to more clearly define
the specimen source and to be in concert with the language that
appears in the PNEU event protocol; Bordetella was added as an
eligible pathogen in the PNEU event protocol and consequently
added to the PNEU event reporting form; Tachycardia was replaced
with the correct term: tachypnea.
These
changes do not affect the estimated burden of this form.
|
57.112
|
Ventilator-Associated
Event
|
No change
|
No changes
|
N/A
|
57.114
|
Urinary Tract Infection
(UTI)
|
No change
|
Revision
of response options for urinary catheter status.
Response options
were removed and/or revised for the specific event criteria
section.
|
The
risk factors for urinary catheter status have been reworded to
avoid confusion on which to choose when a catheter has been in
place for greater than 2 days and is removed on the date of
event. In that case, the risk factor “In place”
should be chosen rather than “Removed” which is only
chosen if it is removed the day before the date of event.
The
CAUTI criteria have been revised to more accurately reflect
clinical interpretations through the removal of non-bacterial
organisms as a cause, and to remove symptomatic urinary tract
infection (SUTI) type 2 which had a lower colony count urine
culture in order to avoid differences in reporting due solely to
laboratory reporting practices. The form has had the excluded
criteria removed.
These
changes result in a decrease of 40,000 burden hours for this
form.
|
57.116
|
Denominators for Neonatal
Intensive Care Unit (NICU)
|
No change
|
Ventilator
days are no longer conditionally required.
Guidance related
to central lines and umbilical catheters was removed.
|
The
double asterisk indicating “conditionally required
according to the events indicated in Plan” is removed from
vent data columns as NICUs can no longer perform in-plan
ventilator-associated event reporting in NHSN.
The
guidance to report a patient with both central line and
umbilical line as only a central line day is removed because,
umbilical lines are no longer differentiated from central lines.
These
changes do not affect the estimated burden of this form.
|
57.117
|
Denominators for Specialty
Care Area (SCA)/Oncology (ONC)
|
No change
|
No changes
|
N/A
|
57.118
|
Denominators for Intensive
Care Unit (ICU)/Other Locations (Not NICU or SCA)
|
No change
|
Increased the
annual number of responses per respondent to 60.
|
The
number of annual responses per respondent was increased to 60 to
account for the increased use of this form due to CMS required
reporting for additional location types.
These changes result in
a net increase of 180,000 burden hours for this form.
|
57.120
|
Surgical Site Infection
(SSI)
|
No change
|
Updated field
for ICD-10-PCS and CPT Procedure codes.
|
The
Change to ICD-10-PCS codes is needed due to the retirement of
ICD-9-CM codes as of October 1, 2015. The addition of the
ability to use CPT codes was based on the fact that some
facilities use these and will not be using ICD-10-codes. As well
as the fact that CPT codes are the usual codes used for ASCs.
These
changes do not affect the estimated burden of this form.
|
57.121
|
Denominator for Procedure
|
No change
|
Updated
field for ICD-10-PCS and CPT Procedure codes.
Removed
response option for RFUSN
Removed response
options for HPRO/KPRO section.
|
The
Change to ICD-10-PCS codes is needed due to the retirement of
ICD-9-CM codes as of October 1, 2015. The addition of the
ability to use CPT codes was based on the fact that some
facilities use these and will not be using ICD-10-codes. As well
as the fact that CPT codes are the usual codes used for ASCs.
RFUSN
was removed since it will no longer be its own NHSN operative
procedure group.
There
are four choices that were removed from the HPRO and KPRO
details since no ICD-9-CM codes currently map to these and the
decision was made to remove these from the form.
These
changes do not affect the estimated burden of this form.
|
57.123
|
Antimicrobial Use and
Resistance (AUR)-Microbiology Data Electronic Upload
Specification Tables
|
No change
|
No changes
|
N/A
|
57.124
|
Antimicrobial Use and
Resistance (AUR)-Pharmacy Data Electronic Upload Specification
Tables
|
No change
|
Seven new
antimicrobials were added to the form.
|
Seven
newly FDA-approved antimicrobials were added to the form to
allow facilities using this drugs to submit usage data as
appropriate.
These changes do not
affect the estimated burden of this form.
|
57.125
|
Central Line Insertion
Practices Adherence Monitoring
|
No change
|
New fields were
added for contraindication of chlorhexidine gluconate.
|
The
new fields reflect updates to chlorhexidine gluconate product
labeling which states “…use with care in premature
infants or infants under 2 months of age. These products may
cause irritation or chemical burns.”
This
change results in an increase in 33,333 burden hours for this
form.
|
57.126
|
MDRO or CDI Infection Form
|
No change
|
Revision
of criteria for five elements in signs and symptoms and
laboratory or diagnostic testing section.
|
“Acute
onset of diarrhea” was changed to “Diarrhea”
(per specific site criteria) to adhere to site specific criteria
and reporting rules. “Purulent drainage or material”
was changed to “Drainage or material” (per specific
site criteria); and three laboratory tests options were
consolidated to one “Other positive laboratory tests”
(per specific site criteria) to adhere to site specific criteria
and reporting rules.
These
changes do not affect the estimated burden of this form.
|
57.127
|
MDRO and CDI Prevention
Process and Outcome Measures Monthly Monitoring
|
No change
|
Two questions
revised with clarifying language.
|
Minor
wording changes made to the form to improve clarification and
adhere to reporting rules
These changes do not
affect the estimated burden of this form.
|
57.128
|
Laboratory-identified MDRO
or CDI Event
|
No change
|
‘Unknown’
was added as an applicable response option to one question.
Two
questions have been changed from optional to be required for
completion.
One
question was revised from ‘3 months’ to ‘4
weeks.’
Two new questions
were added to request information on carbapenemase testing.
|
‘Unknown’
was added as an applicable response option to one question to
adhere to reporting rules which allow event completion when
previous facility discharge information is not available.
Two
questions were changed to be required for completion to adhere
to reporting rules, which support the continuity of surveillance
across facilities.
One
question was revised from ‘3 months’ to ‘4
weeks’ to be consistent with the current CDI
categorizations.
Two
new questions were added to request information on carbapenemase
testing to adhere to new CRE reporting rules by collecting
additional information in relation to CRE laboratory tests
methods.
These
changes result in an increase in 120,000 burden hours for this
form.
|
57.137
|
Long-Term Care Facility
Component – Annual Facility Survey
|
No change
|
One
question was removed from the form.
Two questions were
reworded.
|
The
National Provider ID was removed from the form as that data is
no longer used by NHSN.
Two
questions were reworded to align with updated terminology used
in infection prevention.
These changes do not
affect the estimated burden of this form.
|
57.138
|
Laboratory-identified MDRO
or CDI Event for LTCF
|
No change
|
One
question was revised from ‘3 months’ to ‘4
weeks.’
|
One
question was revised from ‘3 months’ to ‘4
weeks’ to be consistent with the current CDI
categorizations.
This change does not
affect the estimated burden of this form.
|
57.139
|
MDRO and CDI Prevention
Process Measures Monthly Monitoring for LTCF
|
No change
|
No changes
|
N/A
|
57.140
|
Urinary Tract Infection
(UTI) for LTCF
|
No change
|
No changes
|
N/A
|
57.141
|
Monthly Reporting Plan for
LTCF
|
No change
|
No changes
|
N/A
|
57.142
|
Denominators for LTCF
Locations
|
No change
|
No changes
|
N/A
|
57.143
|
Prevention Process
Measures Monthly Monitoring for LTCF
|
No change
|
No changes
|
N/A
|
57.150
|
Patient Safety Component-
Annual Facility Survey for LTAC
|
No change
|
Clarified
the wording regarding facility admissions and removed two
response categories.
Wording
revisions on questions #2 and #20.
Clarified
the question wording and added an additional response option for
questions #14-17.
Clarified
the question wording and answer choices for question #18.
Added
new questions #19 and #21.
Re-categorized
the answer choices for question #22.
Removed
three questions within the Infection Control Practices section.
Added an
additional response option for question #24.
|
The
original question was deemed too confusing and after discussions
with LTAC facility stakeholders, it was decided to re-word the
question and remove two response categories as those categories
were too subjective to measure appropriately.
Additional
wording added to questions #2 and #20 due to user confusion.
Additional
wording and a new answer choice added to questions #14-17 since
some hospitals rarely or never admit patients with Multi-drug
resistant organisms.
Additional
wording and answer choice for question #18 to make consistent
with Laboratory Practices section question #19.
New
questions were added in order to capture infection control
policies specifically around MRSA.
Re-categorized
the answer choices for question #22 due to user confusion with
previous order.
Three
questions were removed within the Infection Control Practices
section as the responses had become almost 100% unanimous and
therefore were no longer needed.
Additional
answer choice to #24 that states “co-led by both
pharmacist and physician” since this was a common answer
that users entered when selecting “Other” as a
response from last year’s survey.
These changes do not
affect the estimated burden of this form.
|
57.151
|
Patient Safety
Component-Annual Facility Survey for IRF
|
No change
|
Clarified
the wording in the form instructions.
Wording
revisions on questions #2 and #20.
Clarified
the question wording and added an additional response option for
questions #14-17.
Clarified
the question wording and answer choices for question #18.
Added
new questions #19 and #21.
Re-categorized
the answer choices for question #22.
Removed
three questions within the Infection Control Practices section.
Added an
additional response option for question #24.
|
Added
additional language around the instructions for bed size/patient
days, etc. to clarify that these counts should be representative
of the IRF only.
Additional
wording added to questions #2 and #20 due to user confusion.
Additional
wording and a new answer choice added to questions #14-17 since
some hospitals rarely or never admit patients with Multi-drug
resistant organisms.
Additional
wording and answer choice for question #18 to make consistent
with Laboratory Practices section question #19.
New
questions were added in order to capture infection control
policies specifically around MRSA.
Re-categorized
the answer choices for question #22 due to user confusion with
previous order.
Three
questions were removed within the Infection Control Practices
section as the responses had become almost 100% unanimous and
therefore were no longer needed.
Additional
answer choice to #24 that states “co-led by both
pharmacist and physician” since this was a common answer
that users entered when selecting “Other” as a
response from last year’s survey.
These
changes do not affect the estimated burden of this form.
|
57.154
|
Antimicrobial
Use & Resistance Component - Monthly Reporting Plan
|
No change
|
This form will
be removed from the package as NHSN AUR Component was not
implemented.
|
After
evaluation of the proposed NHSN AUR Component, it was determined
that this form was no longer required as the NHSN AUR Component
was not implemented in NHSN.
Removing this form
decreases the package burden by 100 burden hours.
|
57.200
|
Healthcare Personnel
Safety Component Annual Facility Survey
|
No change
|
No changes
|
N/A
|
57.203
|
Healthcare Personnel
Safety Monthly Reporting Plan
|
No change
|
A
new response option was added to this form: ‘influenza
vaccination summary for the inpatient psychiatric facility
unit(s).’
Number of
respondents increased from 11,000 to 17,000.
|
This
response option was added to allow facilities to separate the
reporting of influenza vaccination summary data from the
inpatient psychiatric facility units for CMS reporting purposes.
Due
to an increase in CMS required reporting of influenza
vaccination summary data, this form must be completed by all
inpatient psychiatric facilities and outpatient dialysis centers
in CMS reporting programs. Therefore, the number of respondents
using this form has been increased to 17,000.
These
changes result in a net increase of 500 burden hours for this
form.
|
57.204
|
Healthcare Worker
Demographic Data
|
No change
|
No changes
|
N/A
|
57.205
|
Exposure to Blood/Body
Fluids
|
No change
|
No changes
|
N/A
|
57.206
|
Healthcare Worker
Prophylaxis/Treatment
|
No change
|
No changes
|
N/A
|
57.207
|
Follow-Up Laboratory
Testing
|
No change
|
No changes
|
N/A
|
57.210
|
Healthcare Worker
Prophylaxis/Treatment-Influenza
|
No change
|
No changes
|
N/A
|
57.300
|
Hemovigilance Module
Annual Survey
|
No change
|
The
order of the check box answer choices for type of teaching
hospital was changed.
‘Other
Accrediting Org’ was changed to ‘Other Accrediting
Organization.’
Trauma
and ED’ was changed to ‘Trauma/Emergency’ and
‘Obstetrics and gynecology’ was changed to
‘Obstetrics/gynecology.’
‘Dedicated
physicians’, ‘MLTs’, and ‘MTs’ was
changed to ‘physicians’, ‘medical laboratory
technicians’, and ‘medical technologists’,
respectively.
The
word ‘cellular’ was added to ‘leuko-poor
components.’
One question was
added to ask facilities to indicate their average pool size.
|
The
order of the check box answer choices for type of teaching
hospital was changed. This was done to align with other annual
surveys in NHSN.
‘Other
Accrediting Org’ was changed to ‘Other Accrediting
Organization.’ The abbreviation was expanded for
clarification.
Trauma
and ED’ was changed to ‘Trauma/Emergency’ and
‘Obstetrics and gynecology’ was changed to
‘Obstetrics/gynecology’ for clarification.
‘Dedicated
physicians’, ‘MLTs’, and ‘MTs’ was
changed to ‘physicians’, ‘medical laboratory
technicians’, and ‘medical technologists’,
respectively. These chances were made to expand the
abbreviations for clarity and an instructional sentence was
added.
The
word ‘cellular’ was added to ‘leuko-poor
components’ for clarification.
Facilities
report two types of pooled products. Currently, data collection
for these two types of pooled products are different. The
addition of this question will add consistency the way pooled
product data are collected.
These
changes do not affect the estimated burden of this form.
|
57.301
|
Hemovigilance Module
Monthly Reporting Plan
|
No change
|
No changes
|
N/A
|
57.303
|
Hemovigilance Module
Monthly Reporting Denominators
|
No change
|
One
required question will be added to the form to assess whether
facilities transfuse pathogen-reduced products.
A conditional
question table will be added to summarize the total number of
pathogen-reduced units transfused by product type.
|
One
required question will be added to the form to assess whether
facilities transfuse pathogen-reduced products. Pathogen
reduction technology is a method used to reduce the risk of
transfusion transmitted infections. Psoralen + UV light is a
pathogen reduction technology recently approved by the FDA. The
mandatory question will allow for understanding of industry
uptake of psoralen-treated product.
The
conditional question with table will allow for calculation of
transfusion reaction rates for psoralen-treated products.
These changes do not
affect the estimated burden of this form.
|
57.304
|
Hemovigilance Adverse
Reaction
|
No change
|
A check box
will be added to the Adverse Reaction form to allow users to
mark reports to be shared with FDA.
|
NHSN
HV Module will be one mechanism for facilities to report
transfusion reaction that meet the Safety Reporting Rule
requirement to FDA. Facilities will check the box if the report
is to be shared with FDA. This reporting mechanism will reduce
reporting burden for facilities that report transfusion
reactions to both NHSN HV Module and FDA.
This
change does not affect the estimated burden of this form.
|
57.305
|
Hemovigilance Incident
|
No change
|
The question
‘If Yes, result(s) of analysis: (check all that apply)’
and all options will be removed from the Investigation Results
section.
|
The
conditional question conflicts with Patient Safety Organization
rules. The Agency for Healthcare Research and Quality (AHRQ)
requested the question be removed. The question is not used for
NHSN BV analysis.
This change does not
affect the estimated burden of this form.
|
57.400
|
Patient Safety
Component—Annual Facility Survey for Ambulatory Surgery
Center (ASC)
|
Outpatient Procedure
Component—Annual Facility Survey
|
The
name of the form was changed.
One
question was removed.
Two questions were
reworded.
|
The
name of the form was changed to align with the movement of this
form from the Outpatient Procedure Component to the Patient
Safety Component.
One
question was removed since all respondents would have been
answering the question in the same way therefore providing no
additional information to NHSN.
Two
questions were reworded for clarification.
These changes do not
affect the estimated burden of this form.
|
57.401
|
Outpatient Procedure
Component - Monthly Reporting Plan
|
No change
|
No changes
|
N/A
|
57.402
|
Outpatient Procedure
Component Event
|
No change
|
No changes
|
N/A
|
57.403
|
Outpatient Procedure
Component - Monthly Denominators and Summary
|
No change
|
No changes
|
N/A
|
57.500
|
Outpatient Dialysis Center
Practices Survey
|
No change
|
Added
question for patient population served by respondent facility.
Removed
question assessing how many patients received at least 3 doses
of hepatitis B vaccine.
Added
question to assess number of patients receiving pneumococcal
vaccine.
Added
question to assess number of patients who reverse seroconverted.
Added
question to assess how many patients reuse dialyzers.
Added
question to assess facility’s water quality.
Added
question to assess type of reused dialyzer.
Added
question to assess how dialyzer is reprocessed.
Added
question to assess how antibiotics are administered to patients
within the facility.
Added
question to assess skin preparation prior to buttonhole
cannulation.
Revisions of
question and response wording.
|
Added
“What patient population does your center serve?” to
capture whether facility patients are adult, pediatric, or mixed
adult and pediatric, each of which may have different risk
factors and practices.
“Of
your center’s maintenance, non-transient home hemodialysis
patients from question 17.b., how many received at least 3 doses
of hepatitis B vaccine (ever)?” was removed because it did
not fit in with the new categories established in question 20.
Added
“Of the in-center hemodialysis patients counted in
question 17a, how many received at least one dose of
pneumococcal vaccine (ever)?” to determine the number of
in-center hemodialysis patients (subset of patients in Q19) who
have received the pneumococcal vaccine. Also parallels the
structure of question 19.
Added
the question “In the past year, has your center ≥1
hemodialysis patients who reverse seroconverted (i.e., had
evidence of resolved hepatitis B infection followed by
reappearance of hepatitis B surface antigen)?” to estimate
the national prevalence with which reverse hepatitis B virus
seroconversion occurs.
Added
“Of the maintenance, non-transient in-center hemodialysis
patients counted in 17a, how many of them participate in
dialyzer reuse?” to determine the national prevalence of
dialyzer reuse, a potential risk factor for bloodstream
infections and outbreaks.
Added
“Does your center routinely test reverse osmosis (R.O.)
water from the reuse room for culture and endotoxin whenever a
reuse patient has a pyrogenic reaction?” to assess the
national extent of this practice, which can help inform if the
facility’s water is compromised and placing patients at
risk.
Added
“Of all reused dialyzers in your center, how many of them
have sealed (non-removable) header caps?” to determine how
common these device types are, which when reused, may be a risk
factor for inadequate cleaning and subsequently cause
bloodstream infections.
Added
“How are dialyzers reprocessed? Automated/Manually”
to determine the prevalence of each practice, which may be a
risk factor for bloodstream infections among reuse patients.
Added
“In your center, how often are antibiotics administered
for a suspected bloodstream infection before blood cultures are
drawn (or without performing blood cultures)?” to assess
the extent of this recommended practice, both for patient care
and antimicrobial stewardship.
Added
“Before cannulation, what is the buttonhole site most
often prepped with?” to determine if prep practices vary
for buttonhole cannulation patients.
After
internal and external review, many of the questions and response
options have been edited for clarification purposes.
These
changes result in a net increase of 1,625 burden hours for this
form.
|
57.501
|
Dialysis Monthly Reporting
Plan
|
No change
|
No changes
|
N/A
|
57.502
|
Dialysis Event
|
No change
|
Added
a new question to assess whether the patient’s dialyzer
was reused.
Added a new
question to assess whether the antibiotic start was new or a
continuation.
|
Added
“Patient’s dialyzer is reused? Yes/No” because
dialyzer reuse has been identified as important risk factor for
infection. By including this field on both numerator and
denominator forms, it will be possible to calculate a dialyzer
reuse rate.
Added
“Was this a new outpatient start or a continuation of an
inpatient course?” to determine the proportion of
antimicrobial starts dialysis facilities report that occur as a
result of inpatient care and are outside of the dialysis
facility’s control.
These changes result in
a net increase of 32,500 burden hours for this form.
|
57.503
|
Denominators for Dialysis
Event Surveillance
|
No change
|
Added a
question to assess the number of patients for whom dialyzers are
reused.
|
Added
“Number of these patients for whom dialyzers are reused”
because dialyzer reuse has been identified as important risk
factor for infections. By including this field on both numerator
and denominator forms, it will be possible to calculate a
dialyzer reuse rate.
These changes result in
a net increase of 5,200 burden hours for this form.
|
57.504
|
Prevention Process
Measures Monthly Monitoring for Dialysis
|
No change
|
Modified
existed question.
|
Feedback
from users indicates that auditing injection safety is best done
in two parts: assessment of medication preparation process
(which is typically completed for multiple patients at one time
at a specific med prep area) and medication administration
(which is completed one patient at a time at the patient’s
chair). So the current summary data collection field has been
separate into two to track audit results for each part of
injection safety separately.
These changes result in
a net increase of 13,500 total burden hours for this form.
|
57.505
|
Dialysis Patient Influenza
Vaccination
|
No change
|
No changes
|
N/A
|
57.506
|
Dialysis Patient Influenza
Vaccination Denominator
|
No change
|
No changes
|
N/A
|
57.600
|
State Health Department
Validation Record
|
No change
|
This form will
be removed from the package as this form was not implemented in
NHSN.
|
After
evaluation of the proposed State Health Department Validation
Record, it was determined that this form was no longer required
as the functionality was not implemented in NHSN.
Removing this form
decreases the package burden by 1,900 burden hours.
|