CMS-10210 CLABSI Validation Template 1Q18-2Q18

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Overview

Definitions
Template
NHSN ICU Location
FY20 Submission Instructions

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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) 2020 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. If the patient was not in the ICU when the culture was drawn, do not include these on the Validation Template.)
3) Whether a central line was in place at any time during the hospital stay.
	FY 2020 - CLABSI Validation Template
	(Use this template for 1Q18 & 2Q18 positive blood cultures - all quarters must be submitted on separate templates)
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.
Provider ID/CCN*	Hospital's 6-digit CMS Certification Number (CCN).
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 drop-down 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 drop-down list. Does the hospital have any final results for positive blood cultures for ICU patients in the calendar quarter referenced?
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 drop-down list to indicate the sex of the patient.
Central line Y/N*	Select Yes or No from the drop-down 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. Only locations from the drop-down will be accepted; do not use a hospital-assigned location.
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. Only pathogens from the drop-down will be accepted.
Pathogen Name (B)	Specify pathogen identified. Only pathogens from the drop-down will be accepted.
Pathogen Name (C)	Specify pathogen identified. Only pathogens from the drop-down will be accepted.
PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1022.The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, MD 21244-1650. Please do not send applications, claims, payments, medical records, or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Validation Support Contractor at [email protected]. Expiration Date: xx-xx-xxxx

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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 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
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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Sheet 4: FY20 Submission Instructions

USER GUIDE AND SUBMISSION INSTRUCTIONS

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The FY 2020 Validation Template User Guide and Submission Instructions, along with supporting documentation, can be downloaded from QualityNet

under the [Hospitals-Inpatient] tab drop-down and selecting “Resources” (direct link below):

https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier3&cid=1140537256076

The only acceptable method of sending Validation Templates is through the QualityNet Secure Portal Secure File Transfer Mailbox.

Validation Templates contain Protected Health Information (PHI) and cannot be sent via personal email -- even if a template were sent encrypted from a secure

workplace email, it would still be considered a security violation.

It is recommended to submit Validation Templates at least a week prior to the submission deadline in case there are difficulties with

transmitting files and to allow time for revisions/corrections when necessary.

If you are unable to log in to the Secure Portal, the first person to contact is your hospital's QualityNet Security Administrator.

If your Security Administrator is unable to reestablish your access, you will need to contact the QualityNet HelpDesk at (866) 288-8912.

It is recommended hospitals have two QualityNet Security Administrators at all times to ensure the ability to upload Validation

Templates to My QualityNet by the established submission deadlines.

TEMPLATE COMPLETION & SUBMISSION TIPS

Prior to submitting Validation Templates to CMS, it is recommended that quality assurance is performed on the data within the template.

Review the [Definitions] tab to ensure correct information is entered in each field.

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Do not add, delete, rename, or change the order of the tabs.

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Do not add, delete, or rename column headings.

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Do not leave the first row blank or skip rows between patient data.

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Make sure the State field contains the 2 character abbreviation for your state, not the full state name.

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Verify the Calendar Quarter listed on each Validation Template is correct.

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Review all dates for accuracy and correct format as specified on the [Definitions] tab.

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Make sure pathogens entered on each row of the template are found within the drop-down provided.

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If a patient has not been discharged from the hospital, enter ‘Not Discharged’ for the Discharge Date field.

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Append the file name with the 6-digit CMS Certification Number (CCN)/Provider ID, followed by an underscore and the quarter.

For example: 012345_3QYY_FY20_CLABSI_ValidationTemplate.xlsx

• When submitting templates via the [Compose Mail] button under the Mailbox section on the Secure File Transfer screen, input the subject of the message

with the 6-digit CCN/Provider ID, Submission Quarter, and Template type(s) attached.

For example: CCN 012345 3QYY CLABSI and CAUTI Validation Templates

• When choosing recipients, do NOT select any individual person(s) from the recipient list; only select the "VALIDATION CONTRACTOR" recipient.

Individual accounts are not regularly monitored—sending to any one individual risks delay in processing.

• As soon as the Validation Support Contractor has downloaded the template(s), Secure File Transfer will deliver an automatic email letting the submitter

know the file has been downloaded. After a file has been downloaded, it will be in the queue for processing.

• It is suggested that users verify a message has been sent by clicking on the [Sent] link under the Mailbox section of the Secure File Transfer screen.

The message should be in your Sent folder with a status of "Received".

NOTE: It typically takes a couple minutes for messages to appear in the Sent folder with a "Received" status. Please, do NOT re-send messages

multiple times, as this significantly delays processing and requires version confirmation.

• You will receive email confirmation (usually within 2 business days of being downloaded) from the Validation Support Contractor letting you know the Validation

Templates were processed. If you do not receive a processing confirmation, please include your hospital's 6-digit CCN/Provider ID in an

email to

[email protected].