COVID-19 Patient Impact Module Form - State and Local Health Departments

Instructions for Completion of the COVID-19 Patient Impact and Hospital Capacity Pathway (CDC 57.130)

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 impact and hospital capacity counts are reported	Required. Select the date for which the recorded data was collected for the following questions.

Section-1: Patient Impact

The following definitions for Confirmed COVID-19 patient and Suspected COVID-19 patient apply to the data collection for Section 1: Patient Impact.

Confirmed: A patient with a positive COVID-19 (SARS CoV-2) laboratory viral test indicating current infection (Note this does not include serology testing for antibody.)

Suspected: A patient without COVID-19 (SARS CoV-2) laboratory viral test indicating current infection (note, this does not include serology testing for antibody) who in accordance with CDC’s Evaluating and Testing Persons for Coronavirus Disease 2019 (COVID-19), has signs and symptoms compatible with COVID-19. Most patients with confirmed COVID-19 have fever and/or symptoms of acute respiratory illness (cough, shortness of breath, difficulty breathing) but some people may present with other symptoms such as chills, repeated shaking with chills, muscle pain, new loss of taste or smell, headache or sore throat.

Data Field	Instruction for Data Collection
PREVIOUS DAY’S ADMISSIONS WITH CONFIRMED COVID-19: New patients admitted to an inpatient bed who had confirmed COVID-19 at the time of admission	Enter the number of patients who were admitted on the previous calendar day with confirmed COVID-19 at the time of admission to an inpatient bed.
PREVIOUS DAY’S ADMISSIONS WITH SUSPECTED COVID-19: New patients admitted to an inpatient bed who had suspected COVID-19 at the time of admission	Enter the number of patients who were admitted on the previous calendar day with suspected COVID-19 at the time of admission to an inpatient bed.
PREVIOUS DAY’S NEW HOSPITAL ONSET: Current inpatients hospitalized for a condition other than COVID-19 with onset of suspected or confirmed COVID-19 on the previous day and previous day is fourteen or more days since admission.	Enter the current number of inpatients hospitalized for a condition other than COVID-19 with onset of suspected or confirmed COVID-19 on the previous day and the previous day is fourteen or more days since admission. Admission date is equal to hospital day 1. This includes laboratory-confirmed or suspected COVID-19 cases. Note, include only those patients identified on the previous calendar day. Do not include hospital onset COVID-19 patients (suspected or confirmed) identified prior to the previous calendar day. Do not report the cumulative number of hospital onset COVID-19 patients. This field is intended to represent incidence.
HOSPITALIZED: Patients currently hospitalized in an inpatient bed who have suspected or confirmed COVID-19	Enter the number of patients hospitalized in an inpatient bed at the time the data is collected who have suspected or confirmed COVID-19.
HOSPITALIZED and VENTILATED: Patients currently hospitalized in an inpatient bed who have suspected or confirmed COVID-19 and are on a mechanical ventilator	Enter the number of patients hospitalized in an inpatient bed who have suspected or confirmed COVID-19 and are currently on a mechanical ventilator* at the time the data is collected. *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: Total current inpatients with onset of suspected or confirmed COVID-19 fourteen or more days after admission for a condition other than COVID-19	Enter the total number of current inpatients at the time of data collection who had onset of suspected or confirmed COVID-19 fourteen or more days after admission for a condition other than COVID-19 Admission date = hospital day 1.1). Do include hospital onset COVID-19 inpatients (suspected or confirmed) identified prior to the current calendar day and still inpatients at the time of data collection. This field is intended to represent prevalence.
ED/OVERFLOW: Patients with suspected or confirmed COVID-19 who are currently in the Emergency Department (ED) or any overflow location awaiting an inpatient bed	Enter the number of patients with suspected or confirmed COVID-19 who are in the Emergency Department (ED) or any overflow/expansion location awaiting placement in an inpatient bed at the time the data is collected. Overflow locations include any physical locations created to accommodate patients including 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 currently are 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 in the ED or any overflow/expansion location on a mechanical ventilator* at the time the data is collected. *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).
PREVIOUS DAY’S DEATHS: Patients with suspected or confirmed COVID-19 who died in the hospital, ED or any overflow location on the previous calendar day	Enter the number of patients with suspected or confirmed COVID-19 who died in the hospital, ED, or any overflow location on the previous calendar day.. Note, Do not report the cumulative number of deaths.

Section-2: Hospital Bed/ICU/Ventilator Capacity

Data Field	Instruction for Data Collection
ALL HOSPITAL BEDS: Total number of all staffed inpatient and outpatient beds in your hospital, including all overflow and surge/ expansion beds used for inpatients or for outpatients (includes all Intensive Care Unit (ICU) beds)	Enter the total number of all staffed hospital beds, including all inpatient and outpatient beds, overflow and surge/expansion beds used for inpatients or outpatients. This includes all ICU beds.
HOSPITAL INPATIENT BEDS: Total number of all staffed inpatient beds in your hospital, including overflow and surge/expansion beds used for inpatients (includes all ICU beds)	Required. Enter the total number of all staffed inpatient beds including overflow and surge/expansion beds used for inpatient care. This includes all ICU beds.
HOSPITAL INPATIENT BED OCCUPANCY: Total number of staffed inpatient beds that are occupied	Enter the total number of staffed inpatient beds occupied by patients at the time the data is collected, including all overflow and surge/expansion beds used for inpatient care. This includes all ICU beds.
ICU BEDS: Total number of staffed inpatient ICU beds	Enter the total number of all staffed ICU beds including overflow, surge/expansion beds used for critically ill inpatients. This includes adult, pediatric and neonatal ICU beds.
ICU BED OCCUPANCY:  Total number of staffed inpatient ICU beds that are occupied	Enter the total number of all staffed ICU beds occupied by patients at the time the data is collected. This includes occupied adult, pediatric and neonatal ICU beds.
MECHANICAL VENTILATORS: Total number of ventilators available	Enter the total number (in use and not in use) of all mechanical ventilators, including adult, pediatric, neonatal ventilators, anesthesia machines and portable/transport ventilators available in the facility. Include BiPAP machines if the hospital uses BiPAP to deliver positive pressure ventilation via artificial airways.
MECHANICAL VENTILATORS IN USE: Total number of ventilators in use	Enter the total number of mechanical ventilators in use at the time the data is collected, including adult, pediatric, neonatal ventilators, anesthesia machines and portable/transport ventilators. Include BiPAP machines if the hospital uses BiPAP to deliver positive pressure ventilation via artificial airways.

March 2020 v.3 2