COVID-19 Patient Impact Module Form - Business/Financial Operations

National Healthcare Safety Network (NHSN) Patient Impact Module for Coronavirus (COVID-19) Surveillance in Healthcare Facilities

Att4b_Instructions for COVID-19 Patient Impact Module Form_clean

COVID-19 Patient Impact Module Form - Business/Financial Operations

OMB: 0920-1290

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Attachment 4b. Instructions for COVID-19 Patient Impact Module Form

Instructions for Completion of the COVID-19 Patient Impact Module Form

Data Field

Instruction for Data Collection

Facility ID #

The NHSN-assigned facility ID will be auto-entered by the computer.

Summary Census ID #

Auto-generated by the computer.

Date for which patient counts are reported

Required. Select the date of which the data for the following questions was collected.

CENSUS: Inpatient census, specifically, current number of patients in all NHSN inpatient care locations

Required. Enter the total number of patients currently hospitalized in all inpatient care locations in your acute-care facility.


A NHSN Inpatient Location is one in which at least 80% of the patients are admitted as inpatients to the hospital and whose admission and discharge days fall on two different calendar days.

BEDS: Inpatient beds in your hospital

Enter the total number of beds set up and staffed in all inpatient care locations. This includes all inpatient beds in the facility and any additional inpatient beds added specific to response efforts.

The number of beds from your facility’s most recent NHSN annual survey will auto-populate this field, please change according to the current status of your facility.

HOSPITALIZED: Patients currently hospitalized in an NHSN inpatient care location who have suspected or confirmed COVID-19

Enter the number of patients currently hospitalized in an NHSN inpatient location who have suspected or confirmed COVID-19. This includes the patients with laboratory-confirmed or clinically diagnosed COVID-19.

Confirmed: A patient with a laboratory-confirmed COVID-19 diagnosis

Suspected: A patient without a laboratory confirmed COVID-19 diagnosis who has signs and symptoms compatible with COVID-19 (most patients with confirmed COVID-19 have developed fever and/or symptoms of acute respiratory illness, such as cough, difficulty breathing).  

HOSPITALIZED and VENTILATED: Patients currently hospitalized in an NHSN inpatient care location who have suspected or confirmed COVID-19 and are on a mechanical ventilator

Enter the number of patients currently hospitalized in an NHSN inpatient care location who have suspected or confirmed COVID-19 and are currently on a mechanical ventilator*. This includes the patients with laboratory-confirmed or clinically diagnosed COVID-19.

*Ventilator: Any device used to support, assist or control respiration (inclusive of the weaning period) through the application of positive pressure to the airway when delivered via an artificial airway, specifically an oral/nasal endotracheal or tracheostomy tube.

Note: Ventilation and lung expansion devices that deliver positive pressure to the airway (for example: CPAP, BiPAP, bi-level, IPPB and PEEP) via non-invasive means (for example: nasal prongs, nasal mask, full face mask, total mask, etc.) are not considered ventilators unless positive pressure is delivered via an artificial airway (oral/nasal endotracheal or tracheostomy tube).

HOSPITAL ONSET: Patients currently hospitalized in an NHSN inpatient care location with onset of suspected or confirmed COVID-19 fourteen or more days after hospitalization

Enter the number of patients currently hospitalized in an NHSN inpatient care location with onset of suspected or confirmed COVID-19 fourteen or more days after hospitalization. This includes laboratory-confirmed or clinically diagnosed COVID-19 cases.

ED/OVERFLOW: Patients with suspected or confirmed COVID-19 who are currently in the ED or any overflow location awaiting an inpatient bed


Enter the number of patients with suspected or confirmed COVID-19 who are currently in the ED or any overflow location awaiting placement in an inpatient bed. This includes patients with laboratory-confirmed or clinically diagnosed COVID-19. Overflow locations include any physical locations created to accommodate patients, include but not limited to 24-hour observation units, hallways, parking lots, or tents.

ED/OVERFLOW and VENTILATED: Patients with suspected or confirmed COVID-19 who are currently in the ED or any overflow location awaiting an inpatient bed and on a mechanical ventilator

Enter the number of patients with suspected or confirmed COVID-19 who are currently in the ED or any overflow location on a mechanical ventilator*. This includes patients with laboratory-confirmed or clinically diagnosed COVID-19.

*Ventilator: Any device used to support, assist or control respiration (inclusive of the weaning period) through the application of positive pressure to the airway when delivered via an artificial airway, specifically an oral/nasal endotracheal or tracheostomy tube.

Note: Ventilation and lung expansion devices that deliver positive pressure to the airway (for example: CPAP, Bipap, bi-level, IPPB and PEEP) via non-invasive means (for example: nasal prongs, nasal mask, full face mask, total mask, etc.) are not considered ventilators unless positive pressure is delivered via an artificial airway (oral/nasal endotracheal or tracheostomy tube).

DEATHS: Patients with suspected or confirmed COVID-19 who died in the hospital, ED, or any overflow location

Enter the number of patients with suspected or confirmed COVID-19 who died in the hospital, ED, or any overflow location. This includes patients with laboratory-confirmed or clinically diagnosed COVID-19. Please enter the count of death newly occurred, instead of cumulated number.



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorWu, Hsiu (CDC/DDID/NCEZID/DHQP)
File Modified0000-00-00
File Created2021-01-13

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