Att G8_Denominators for Patient Safety Component

Instructions for Completion of Denominators for Neonatal Intensive Care
Unit (NICU) (CDC 57.116)
Data Field
Facility ID #
Location code
Month
Year
Birthweight
Categories
Number of
patients (Pts)
Number of
patients with a
central line (CL):

Instructions for Data Collection
The NHSN-assigned facility ID will be auto-entered by the computer.
Required. Enter the location code of the unit where you collect the data.
Required. Record the 2-digit month during which the data were collected for this
location.
Required. Record the 4-digit year during which the data were collected for this
location.
Required. The birthweight categories are as follows: A = ≤750 g; B = 751-1000 g;
C = 1001-1500 g; D = 1501-2500 g; E = >2500 g. Data on this form are stratified
by this category.
Required. For each day of the month selected, record the number of patients in
each birthweight category on the unit. Record this number at the same time each
day.
Conditionally required. Complete if you have chosen central line-associated
bloodstream infection (CLABSI) as an event to follow in your Plan for this month
for this unit.
For each day of the month, at the same time each day, record the number of
patients in each birthweight category on the selected unit who have 1 or more
central line(s). Central line days are counted beginning with the date of insertion
or, if the infant is admitted with a permanent line in place, the first day of access
and continuing until the line is physically removed or the patient is discharged
from the facility. “Access” is defined as line placement, infusion or withdrawal
through the line.

Number of
patients on a
ventilator (VNT)

NOTES:
 Umbilical catheters are considered central lines.
 If a device has been pulled on the first day of the month in a location
where there are no other device days in that month, and a deviceassociated infection develops after the device is pulled, attribute the
infection to the previous month.
Optional. This field can be completed even though NICU-VAP surveillance
cannot be included in your plan.
For each day of the month, at the same time each day, record the number of
patients in each birthweight category on the selected unit who are on a ventilator.
NOTE: If a device has been pulled on the first day of the month in a location
where there are no other device days in that month, and a device-associated
infection develops after the device is pulled, it is recommended to attribute the
infection to the previous month.

January 2015

1

Data Field
Instructions for Data Collection
Number of
Optional. This field can be completed even though NICU CAUTI surveillance
patients with an
cannot be included in your plan.
indwelling urinary
catheter (UrC)
NOTE: If a device has been pulled on the first day of the month in a location
where there are no other device days in that month, and a device-associated
infection develops after the device is pulled, attribute the infection to the previous
month.
Total
Required. Totals for each column should be calculated. This is the number that
will be entered into the NHSN application.
Report No Events While not on the paper data collection form, when completing summary data
entry on-line, if no events included on your monthly reporting plan are reported,
you will be required to check the appropriate Report No Events box(es), i.e.,
CLABSI. .
Custom Fields
Optional. Up to 50 fields may be customized for local or group use in any
combination of the following formats: date (MMDDYYYY), numeric, or
alphanumeric.
NOTE: Each Custom Field must be set up in the Facility/Custom Options section
of NHSN before the field can be selected for use.

January 2015

2

Instructions for Completion of Denominators for Specialty Care Area
(SCA)/Oncology (ONC) (CDC 57.117)
Data Field
Facility ID #
Location code
Month
Year
Number of
patients
Number of
patients with 1
or more central
lines

Instructions for Data Collection
The NHSN-assigned facility ID will be auto-entered by the computer.
Required. Enter the location code of the unit where you collect the data.
Required. Record the 2-digit month during which the data were collected for this
location.
Required. Record the 4-digit year during which the data were collected for this
location.
Required. For each day of the month selected, record the number of patients on
the unit. Record this number at the same time each day.
Conditionally required. Complete if you have chosen central line-associated
bloodstream infection (CLABSI) as an event to follow in your Plan for this
month.

For each day of the month, at the same time each day, record the number of
Temporary patients on the selected unit who have 1 or more non-tunneled and nonimplanted central lines.
For each day of the month, at the same time each day, record the number of
Permanent patients on the selected unit who have 1 or more tunneled or implanted central
lines beginning on the first day the permanent line was inserted or was accessed
(if the patient was admitted with the central line in place) and continuing until
the line is physically removed or the patient is discharged. “Access” is defined as
line placement, infusion or withdrawal through the line.

Number of
patients with a
urinary
catheter

January 2015

NOTES:
 If a patient has both a temporary and a permanent line in place, count
only the temporary line.
 If a device has been pulled on the first day of the month in a location
where there are no other device days in that month, and a deviceassociated infection develops after the device is pulled, attribute the
infection to the previous month.
Conditionally required. Complete if you have chosen catheter-associated urinary
tract infection (CAUTI) as an event to follow in your Plan for this month. For
each day of the month, at the same time each day, record the number of patients
on the selected unit who have an indwelling urinary catheter. NOTE: If a device
has been pulled on the first day of the month in a location where there are no
other device days in that month, and a device-associated infection develops after
the device is pulled, attribute the infection to the previous month.
3

Data Field
Number of
patients on a
ventilator

Instructions for Data Collection
Conditionally required. Complete if you have chosen ventilator-associated event
(VAE—for adults) or pediatric ventilator-associated pneumonia (PedVAP) as an
event to follow in your Plan for this month.
NOTE: There are two sub-columns within this data field: one for “Total
Patients” and one for “Number on APRV.”
“Total Patients”: For each day of the month, at the same time each day, record
the total number of patients on the selected unit who are on a ventilator.
“Number on APRV”: This field should only be completed if you have chosen
VAE as an event to follow in your Plan for this month. For each day of the
month, at the same time each day (and at the same time that “Total Patients” is
assessed), record the number of patients on the selected unit, among the total
number of patients on that unit who are on a ventilator, who are on Airway
Pressure Release Ventilation (APRV) or a related mode of mechanical
ventilation (e.g., BiLevel, Bi Vent, BiPhasic, PCV+, DuoPAP).

Number of
Episodes of
Mechanical
Ventilation

Total
Report No
Events

January 2015

NOTE: If a device has been pulled on the first day of the month in a location
where there are no other device days in that month, and a device-associated
infection develops after the device is pulled, attribute the infection to the
previous month.
Optional. “Number of Episodes of Mechanical Ventilation (EMV)”: This field is
an optional field if you have chosen VAE as an event to follow in your Plan.
Count all patients that were on mechanical ventilation the first day of the month.
On each subsequent day, count each additional new patient that was started on
mechanical ventilation to include new episodes in previously ventilated patients.
At the end of the month total all counts. Day 1 Episodes plus all subsequent day
Episodes equals the total EMV for the month.
NOTE: An episode of mechanical ventilation is defined by the number of
consecutive days during which the patient was mechanically ventilated. A period
of at least 1 calendar day off the ventilator, followed by reintubation or reinitiation of mechanical ventilation, defines a new episode of mechanical
ventilation. A patient may have more than one episode of mechanical ventilation
per month.
Required. Totals for each column should be calculated. This is the number that
will be entered into the NHSN application.
While not on the paper data collection form, when completing summary data
entry on-line, if no events included on your monthly reporting plan are reported,
you will be required to check the appropriate Report No Events box(es), i.e.,
CLABSI, CAUTI, VAE, PedVAP.
4

Data Field
Custom Fields

Instructions for Data Collection
Optional. Up to 50 fields may be customized for local or group use in any
combination of the following formats: date (MMDDYYYY), numeric, or
alphanumeric.
NOTE: Each Custom Field must be set up in the Facility/Custom Options
section of NHSN before the field can be selected for use.

January 2015

5

Instructions for Completion of Denominators for Intensive Care Unit
(ICU)/Other Locations (Not NICU or SCA) (CDC 57.118)
Data Field
Facility ID #
Location code
Month
Year
Number of patients
Number of patients with 1
or more central lines

Instructions for Data Collection
The NHSN-assigned facility ID will be auto-entered by the computer.
Required. Enter the location code of the unit where you collect the data.
Required. Record the 2-digit month during which the data were
collected for this location.
Required. Record the 4-digit year during which the data were collected
for this location.
Required. For each day of the month selected, record the number of
patients on the unit. Record this number at the same time each day.
Conditionally required. Complete if you have chosen central lineassociated bloodstream infection (CLABSI) as an event to follow in your
Plan for this month.
For each day of the month, at the same time each day, record the number
of patients on the selected unit who have 1 or more central lines. Only
record 1 central line day for a patient that has more than 1 central line in
place.

Number of patients with a
urinary catheter

January 2015

NOTES:
 If the patient has only a tunneled or implanted central line, begin
recording days on the date the central line was inserted or the first
day the line was accessed if the patient was admitted to the
facility with the line in place and continue until the line is
physically removed or the patient is discharged. “Access” is
defined as line placement, infusion or withdrawal through the
line.
 If a device has been pulled on the first day of the month in a
location where there are no other device days in that month, and a
device-associated infection develops after the device is pulled,
attribute the infection to the previous month.
Conditionally required. Complete if you have chosen catheter-associated
urinary tract infection (CAUTI) as an event to follow in your Plan for
this month. For each day of the month, at the same time each day, record
the number of patients on the selected unit who have an indwelling
urinary catheter. NOTE: If a device has been pulled on the first day of
the month in a location where there are no other device days in that
month, and a device-associated infection develops after the device is
pulled, attribute the infection to the previous month.
6

Data Field
Number of patients on a
ventilator

Instructions for Data Collection
Conditionally required. Complete if you have chosen ventilatorassociated event (VAE—for adults) or pediatric ventilator-associated
pneumonia (PedVAP) as an event to follow in your Plan for this month.
Note that there are two sub-columns within this data field: one for “Total
Patients” and one for “Number on APRV.”
“Total Patients”: For each day of the month, at the same time each day,
record the total number of patients on the selected unit who are on a
ventilator.
“Number on APRV”: This field should only be completed if you have
chosen VAE as an event to follow in your Plan for this month. For each
day of the month, at the same time each day (and at the same time that
“Total Patients” is assessed), record the number of patients on the
selected unit, among the total number of patients on that unit who are on
a ventilator, who are on Airway Pressure Release Ventilation (APRV) or
a related mode of mechanical ventilation (e.g., BiLevel, Bi Vent,
BiPhasic, PCV+, DuoPAP).

Number of Episodes of
Mechanical Ventilation

Total
Report No Events
January 2015

NOTE: If a device has been pulled on the first day of the month in a
location where there are no other device days in that month, and a
device-associated infection develops after the device is pulled, attribute
the infection to the previous month.
Optional. This field is an optional field if you have chosen VAE as an
event to follow in your Plan. Count all patients that were on mechanical
ventilation the first day of the month. On each subsequent day, count
each additional new patient that was started on mechanical ventilation to
include new episodes in previously ventilated patients. At the end of the
month total all counts. Day 1 Episodes plus all subsequent day Episodes
equals the total EMV for the month.
NOTE: An episode of mechanical ventilation is defined by the number
of consecutive days during which the patient was mechanically
ventilated. A period of at least 1 calendar day off the ventilator, followed
by reintubation or re-initiation of mechanical ventilation, defines a new
episode of mechanical ventilation. A patient may have more than one
episode of mechanical ventilation per month.
Required. Totals for each column should be calculated. This is the
number that will be entered into the NHSN application.
While not on the paper data collection form, when completing summary
data entry on-line, if no events included on your monthly reporting plan
7

Data Field

Custom Fields

Instructions for Data Collection
are reported, you will be required to check the appropriate Report No
Events box(es), i.e., CLABSI, CAUTI, VAE, PedVAP.
Optional. Up to 50 fields may be customized for local or group use in
any combination of the following formats: date (MMDDYYYY),
numeric, or alphanumeric.
NOTE: Each Custom Field must be set up in the Facility/Custom
Options section of NHSN before the field can be selected for use.

January 2015

8