CMS-10210 CLABSI Validation Template

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Overview

Definitions
Template
NHSN ICU Location

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Sheet 1: Definitions

Central line-associated bloodstream infection (CLABSI) Validation Template In support of validation for the Hospital Inpatient Quality Reporting Program for the Fiscal Year (FY) 2017 Payment determination. • Each hospital selected for CLABSI validation is to produce a list of positive blood cultures for intensive care unit (ICU) patients, which is annotated to identify patients with central lines placed during the stay. • The line list should include all final results for positive blood cultures collected during an ICU stay. • For each patient confirm: 1) The patient had an ICU admission during this hospital stay; and 2) The patient had a positive blood culture drawn during the ICU stay. (The list should include all positive blood cultures for patients in the ICU at the time the culture was drawn.) 3) Whether a central line was in place at any time during the hospital stay.
FY 2017 - CLABSI Validation Template (postive blood cultures for discharges beginning 3Q14)
FIELD (* indicates required field)	DESCRIPTION	SECTION
NHSN Facility ID*	The National Healthcare Safety Network (NHSN)-assigned facility ID under which your hospital submits NHSN data.	Hospital Information Section Complete the first row in the spreadsheet. The information provided in the first row will be applied to all positive blood cultures listed on the template.
Provider ID/CCN*	Hospitals CMS Certification Number.
Hospital Name*	Hospital Name associated with CCN.
State*	Enter the 2 character abbreviation for the state in which the hospital is located.
Calendar Quarter*	Select from the dropdown list the calendar quarter to which the CLABSI Validation Template pertains.
Hospital Contact Name*	Hospital contact name for CMS to contact with questions.
Contact Phone*	Phone number for hospital contact listed.
Contact Email*	Email address for hospital contact listed.
Total discharges in quarter with ICU stay	The total number of patients discharged during the reporting quarter who had an ICU stay. Patients with positive blood cultures are a subset of this group.
Positive Blood Cultures (Y/N)*	Select Yes or No from the dropdown list. Does the hospital have any final results for positive blood cultures for ICU patients in the calendar quarter referenced?
Patient HIC*	The patient's Medicare Beneficiary Number, also known as the health insurance claim (HIC) number. No dashes, spaces or special characters should be included. Must be between 7 and 12 characters. This field is required for Medicare patients when the HIC number is known. Leave blank if not applicable.	Blood Culture Section Complete for every final positive blood culture.
Patient Identifier*	The patient identifier assigned by the hospital. Use the same patient identifier that would be submitted to NHSN if the episode of care (EOC) would be reported as a CLABSI event.
Birthdate*	The patient date of birth using MM/DD/YYYY format.
Sex*	Select Female, Male or unknown from the dropdown list to indicate the sex of the patient.	Patient Information Section Complete once per patient episode of care.
Central line Y/N*	Select Yes or No from the dropdown list. Did the patient have a central line in place at any time during their hospital stay? Please include central lines already in place when the patient was admitted.
Admit Date*	Enter date patient was admitted to hospital in MM/DD/YYYY format.
Discharge Date*	Enter date patient was discharged from the hospital in MM/DD/YYYY format. If a patient has not been discharged from the hospital enter ‘Not Discharged’ for the Discharge Date field.
First Name	First name of patient.
Last Name	Last name of patient.
NHSN ICU Location*	Select from the drop down list, the NHSN ICU location to which the patient was assigned when the positive blood culture was collected. Include only cultures collected during an ICU stay.	Blood Culture Section Complete for every final positive blood culture.
Lab ID*	Lab ID, accession number or specimen number corresponding to positive blood culture.
Blood Culture Date*	Provide the date the blood culture was collected in MM/DD/YYYY format.
Blood Culture Time	Provide the time the blood was drawn if easily available.
Pathogen Name (A)*	Specify pathogen identified. The drop down menu includes the most common pathogens. Only final lab results should be included.
Pathogen Name (B)	Specify pathogen identified. The drop down menu includes the most common pathogens. Only final lab results should be included.
Pathogen Name (C)	Specify pathogen identified. The drop down menu includes the most common pathogens. Only final lab results should be included.
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Sheet 2: Template

NHSN Facility ID*

Provider ID/CCN*

Hospital Name*

State*

Calendar Quarter*

Hospital Contact Name*

Contact Phone*

Contact Email*

Total discharges in quarter with ICU stay

Positive Blood Cultures (Y/N)*

Patient HIC*

Patient Identifier*

Birthdate*

Sex*

Central line Y/N*

Admit Date*

Discharge Date*

First Name

Last Name

NHSN ICU Location*

Lab ID*

Blood Culture Date*

Blood Culture Time

Pathogen Name (A)*

Pathogen Name (B)

Pathogen Name (C)

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Sheet 3: NHSN ICU Location

NHSN Locations Included in the Hospital IQR Program's CLABSI Reporting
	CDC DESCRIPTION	DETAILS	CDC CODE
Inpatient Adult Critical Care Units	Burn Critical Care	Critical care area specializing in the care of patients with significant/major burns.	IN:ACUTE:CC:B
	Medical Cardiac Critical Care	Critical care area specializing in the care of patients with serious heart problems that do not require heart surgery.	IN:ACUTE:CC:C
	Medical Critical Care	Critical care area for patients who are being treated for nonsurgical conditions.	IN:ACUTE:CC:M
	Medical/Surgical Critical Care	An area where critically ill patients with medical and/or surgical conditions are managed.	IN:ACUTE:CC:MS
	Neurologic Critical Care	Critical care area for the care of patients with life-threatening neurologic diseases.	IN:ACUTE:CC:N
	Neurosurgical Critical Care	Critical care area for the surgical management of patients with severe neurologic diseases or those at risk for neurologic injury as a result of surgery.	IN:ACUTE:CC:NS
	ONC Medical Critical Care	Critical care area for the care of oncology patients who are being treated for nonsurgical conditions related to their malignancy.	IN:ACUTE:CC:ONC_M
	ONC Surgical Critical Care	Critical care area for the evaluation and management of oncology patients with serious illness before and/or after cancer-related surgery.	IN:ACUTE:CC:ONC_S
	ONC Medical-Surgical Critical Care	Critical care area for the care of oncology patients with medical and/or surgical conditions related to their malignancy.	IN:ACUTE:CC:ONC_MS
	Prenatal Critical Care	Critical care area for the care of pregnant patients with complex medical or obstetric problems requiring a high level of care to prevent the loss of the fetus and to protect the life of the mother.	IN:ACUTE:CC:PNATL
	Respiratory Critical Care	Critical care area for the evaluation and treatment of patients with severe respiratory conditions.	IN:ACUTE:CC:R
	Surgical Cardiothoracic Critical Care	Critical care area specializing in the care of patients following cardiac and thoracic surgery.	IN:ACUTE:CC:CT
	Surgical Critical Care	Critical care area for the evaluation and management of patients with serious illness before and/or after surgery.	IN:ACUTE:CC:S
	Trauma Critical Care	Critical care area specializing in the care of patients who require a high level of monitoring and/or intervention following trauma or during critical illness related to trauma.	IN:ACUTE:CC:T
Inpatient Pediatric Critical Care Units	Pediatric Burn Critical Care	Critical care area specializing in the care of patients ≤ 18 years old with significant/major burns.	IN:ACUTE:CC:B_PED
	Pediatric Cardiothoracic Critical Care	Critical care area specializing in the care of patients ≤ 18 years old following cardiac and thoracic surgery.	IN:ACUTE:CC:CT_PED
	Pediatric Medical Critical Care	Critical care area for patients ≤ 18 years old who are being treated for nonsurgical conditions. In the NNIS system, this was called Pediatric ICU (PICU).	IN:ACUTE:CC:M_PED
	Pediatric Medical Surgical Critical Care	An area where critically ill patients ≤ 18 years old with medical and/or surgical conditions are managed.	IN:ACUTE:CC:MS_PED
	Pediatric Neurosurgical Critical Care	Critical care area specializing in the surgical management of patients ≤ 18 years old with severe neurological diseases or those at risk for neurological injury as a result of surgery.	IN:ACUTE:CC:NS_PED
	Pediatric Respiratory Critical Care	Critical care area for the evaluation and treatment of the patients ≤ 18 years old with severe respiratory conditions.	IN:ACUTE:CC:R_PED
	Pediatric Surgical Critical Care	Critical care area for the evaluation and management of patients ≤ 18 years old with serious illness before and/or after surgery.	IN:ACUTE:CC:S_PED
	Pediatric Trauma Critical Care	Critical care area specializing in the care of patients ≤ 18 years old who require a high level of monitoring and/or intervention following trauma or during critical illness related to trauma.	IN:ACUTE:CC:T_PED
Inpatient Neonatal Units	Neonatal Critical Care Level II/III	Combined nursery housing both Level II and III newborns and infants.	IN:ACUTE:CC_STEP:NURS
	Neonatal Critical Care Level III	A hospital neonatal intensive care unit (NICU) organized with personnel and equipment to provide continuous life support and comprehensive care for extremely high-risk newborn infants and those with complex and critical illness. Level III is subdivided into 4 levels differentiated by the capability to provide advanced medical and surgical care.	IN:ACUTE:CC:NURS
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