FY 2020 CLABSI Validation Template

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Central line-associated bloodstream infection (CLABSI) Validation Template
In support of validation for the Hospital Inpatient Quality Reporting Program for the Fiscal Year (FY) 2021 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 2021 - CLABSI Validation Template
(Use this template beginning with 3Q18 positive blood cultures - all quarters must be submitted on separate templates)
FIELD (* indicates required field)
DESCRIPTION
SECTION
The National Healthcare Safety Network (NHSN)-assigned facility ID under which your hospital
NHSN Facility ID*
submits NHSN data.
Hospital's 6-digit CMS Certification Number (CCN).
Provider ID/CCN*
Hospital Name associated with CCN.
Hospital Name*
Enter the 2 character abbreviation for the state in which the hospital is located.
State*
Select from the drop-down list the calendar quarter to which the CLABSI Validation Template
Calendar Quarter*
pertains.
Hospital contact name for CMS to contact with questions.
Hospital Contact Name*
Phone number for hospital contact listed.
Contact Phone*
Email address for hospital contact listed.
Contact Email*
Total discharges in quarter with
The total number of patients discharged during the reporting quarter who had an ICU stay.
ICU stay
Patients with positive blood cultures are a subset of this group.
Select Yes or No from the drop-down list. Does the hospital have any final results for positive blood
Positive Blood Cultures (Y/N)*
cultures for ICU patients in the calendar quarter referenced?
The patient identifier assigned by the hospital. Use the same patient identifier that would be
Patient Identifier*
submitted to NHSN if the episode of care (EOC) would be reported as a CLABSI event.
The patient date of birth using MM/DD/YYYY format.
Birthdate*
Select Female, Male or unknown from the drop-down list to indicate the sex of the patient.
Sex*
Central line Y/N*
Admit Date*
Discharge Date*
First Name
Last Name

NHSN ICU Location*

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.
Enter date patient was admitted to hospital in MM/DD/YYYY format.
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 of patient.
Last name of patient.

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, accession number or specimen number corresponding to positive blood culture.
Provide the date the blood culture was collected in MM/DD/YYYY format.
Provide the time the blood was drawn if easily available.
Specify pathogen identified. Only pathogens from the drop-down will be accepted.
Specify pathogen identified. Only pathogens from the drop-down will be accepted.
Specify pathogen identified. Only pathogens from the drop-down will be accepted.

Lab ID*
Blood Culture Date*
Blood Culture Time
Pathogen Name (A)*
Pathogen Name (B)
Pathogen Name (C)
Blank cell
For additional information, view the appropriate CLABSI Abstraction Manual posted on the Inpatient Chart-Abstracted Data Validation page of QualityNet.

For the purposes of Hospital IQR Program Chart-Abstracted Data Validation, please note the differences between NHSN data submission
and validation template/medical record submission, as described below:
End of Spreadsheet

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information collection is 0938-XXXX (Expires XX/XX/XXXX). The time required to complete this information collection is estimated to average 10 hours 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, Maryland 21244-1850. ****CMS Disclosure**** 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 [email protected].

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
Admit Date* Discharge Date* First Name Last Name
Y/N*

NHSN ICU Location*

Lab ID*

Blood Culture Date*

Blood Culture Time

Pathogen Name (A)*

Pathogen Name (B)

Pathogen Name (C)

NHSN Locations Included in the Hospital IQR Program's CLABSI Reporting
CDC DESCRIPTION

DETAILS

CDC CODE

Inpatient Adult Critical Care Units
Burn Critical Care
Medical Cardiac Critical Care
Medical Critical Care
Medical/Surgical Critical Care
Neurologic Critical Care
Neurosurgical Critical Care
ONC Medical Critical Care
ONC Surgical Critical Care
ONC Medical-Surgical Critical Care
Prenatal Critical Care
Respiratory Critical Care
Surgical Cardiothoracic Critical Care
Surgical Critical Care
Trauma Critical Care

Pediatric Burn Critical Care
Pediatric Cardiothoracic Critical Care
Pediatric Medical Critical Care
Pediatric Medical Surgical Critical Care
Pediatric Neurosurgical Critical Care
Pediatric Respiratory Critical Care

Critical care area specializing in the care of patients with significant/major burns.

IN:ACUTE:CC:B

Critical care area specializing in the care of patients with serious heart problems
IN:ACUTE:CC:C
that do not require heart surgery.
Critical care area for patients who are being treated for nonsurgical conditions.
IN:ACUTE:CC:M
An area where critically ill patients with medical and/or surgical conditions are
IN:ACUTE:CC:MS
managed.
Critical care area for the care of patients with life-threatening neurologic diseases. IN:ACUTE:CC:N
Critical care area for the surgical management of patients with severe neurologic
IN:ACUTE:CC:NS
diseases or those at risk for neurologic injury as a result of surgery.
Critical care area for the care of oncology patients who are being treated for
IN:ACUTE:CC:ONC_M
nonsurgical conditions related to their malignancy.
Critical care area for the evaluation and management of oncology patients with
IN:ACUTE:CC:ONC_S
serious illness before and/or after cancer-related surgery.
Critical care area for the care of oncology patients with medical and/or surgical
IN:ACUTE:CC:ONC_MS
conditions related to their malignancy.
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 IN:ACUTE:CC:PNATL
to protect the life of the mother.
Critical care area for the evaluation and treatment of patients with severe
IN:ACUTE:CC:R
respiratory conditions.
Critical care area specializing in the care of patients following cardiac and thoracic
IN:ACUTE:CC:CT
surgery.
Critical care area for the evaluation and management of patients with serious
IN:ACUTE:CC:S
illness before and/or after surgery.
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 IN:ACUTE:CC:T
trauma.
Inpatient Pediatric Critical Care Units
Critical care area specializing in the care of patients ≤ 18 years old with
IN:ACUTE:CC:B_PED
significant/major burns.
Critical care area specializing in the care of patients ≤ 18 years old following
IN:ACUTE:CC:CT_PED
cardiac and thoracic surgery.
Critical care area for patients ≤ 18 years old who are being treated for nonsurgical
IN:ACUTE:CC:M_PED
conditions. In the NNIS system, this was called Pediatric ICU (PICU).
An area where critically ill patients ≤ 18 years old with medical and/or surgical
IN:ACUTE:CC:MS_PED
conditions are managed.
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
IN:ACUTE:CC:NS_PED
result of surgery.
Critical care area for the evaluation and treatment of the patients ≤ 18 years old
IN:ACUTE:CC:R_PED
with severe respiratory conditions.

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.

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 IN:ACUTE:CC:T_PED
related to trauma.

Neonatal Critical Care Level II/III

Combined nursery housing both Level II and III newborns and infants.

IN:ACUTE:CC:S_PED

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
IN:ACUTE:CC:NURS
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.

USER GUIDE AND SUBMISSION INSTRUCTIONS

---> The FY 2021 Validation Template User Guide and Submission Instructions , along with supporting documentation, can be found on QualityNet by hovering
over the Hospitals - Inpatient drop-down and selecting the [Data Validation (Chart-Abstracted & eCQM)] link, followed by selecting the
[Chart-Abstracted Data Validation] program. From the navigation bar on the left side of the Chart-Abstracted Data Validation Overview page, select [Resources]:

https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier4&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 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.
Do not add, delete, or rename column headings.
Do not leave the first row blank or skip rows between patient data.
Make sure the State field contains the 2 character abbreviation for your state, not the full state name.
Verify the Calendar Quarter listed on each Validation Template is correct.
Review all dates for accuracy and correct format as specified on the [Definitions] tab.
Make sure pathogens entered on each row of the template are found within the drop-down provided.
If a patient has not been discharged from the hospital, enter ‘Not Discharged’ for the Discharge Date field.
Perform quality check of data entered into this template against what was entered into NHSN; stay mindful of differing CMS and NHSN deadlines.
Check to ensure any cases with a separate Inpatient Rehabilitation Facility (IRF) or Inpatient Psychiatric Facility (IPF) CCN are not included on the template.
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_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].