Att G19_Sepsis

Adult Sepsis

Instructions for Completion of Adult Sepsis Form (CDC 57.129)
Data Field

Instructions for Data Collection

Facility ID

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

Event #

Event ID number will be auto-entered by the computer.

Patient ID

Required. Enter the alphanumeric patient ID number. This is the patient
identifier assigned by the hospital and may consist of any combination of
numbers and/or letters.

Social Security #

Optional. Enter the 9-digit numeric patient Social Security Number.

Secondary ID

Optional. Enter the alphanumeric ID number assigned by the facility.

Medicare #

Conditionally required. Enter the patient’s Medicare number for all
events reported as part of a CMS Quality Reporting Program.

Patient name

Optional. Enter the last, first, and middle name of the patient.

Gender

Required. Circle Female, Male, or Other to indicate the gender of the
patient.

Date of Birth

Required. Record the date of the patient birth using this format:
MM/DD/YYYY.

Ethnicity

Optional. Specify if the patient is either Hispanic or Latino, or Not
Hispanic or Not Latino.

Race

Optional. Specify one or more of the choices below to identify the
patient’s race:
American Indian/Alaska Native
Asian
Black or African American
Native Hawaiian/Other Pacific Islander White

Event type

Required. Adult Sepsis.

Date of event

Required. Enter the earlier date of either of the two criteria in “PART A:
Suspected Infection”: the culture or non-culture
laboratory diagnostic test collection date or the 1st Qualifying
Antimicrobial Day. For example, if a blood culture was collected on
hospital day 1 and the 1st Qualifying Antimicrobial Day was hospital day

January 2017

Adult Sepsis

Data Field

Instructions for Data Collection
1, enter hospital day 1 in this field. Conversely, if a blood culture was
collected on hospital day 5 and the 1st Qualifying Antimicrobial Day was
hospital day 4, enter hospital day 4 in this field. Enter the date of this
event using this format: MM/DD/YYYY.

Post-procedure

Optional. Check Y if this event occurred after an NHSN-defined
procedure but before discharge from the facility, otherwise check N.

NHSN procedure code

Conditionally required. If Post-procedure Adult Sepsis event = Y, enter
the appropriate NHSN procedure code.
NOTE: An Adult Sepsis event cannot be “linked” to an operative
procedure unless that procedure has already been added to NHSN. If the
procedure was previously added, and the “Link to Procedure” button is
clicked, the fields pertaining to the operation will be auto-entered by the
computer.

ICD-10-PCS and CPT
procedure code

Optional. The ICD-10-PCS or CPT code may be entered here instead of
(or in addition to) the NHSN Procedure Code. If the ICD-10-PCS or CPT
code is entered, the NHSN code will be auto-entered by the computer. If
the NHSN code is entered first, you will have the option to select the
appropriate ICD-10-PCS or CPT code. In either case, it is optional to
select the ICD-10-PCS or CPT code. The only allowed ICD-10-PCS or
CPT codes are those found in the excel documents in the SSI section of
the NHSN website in the “Supporting Materials’ section

Required. Enter “Yes”, if the pathogen is being followed for Infection
MDRO Infection Surveillance Surveillance in the MDRO/CDI Module in that location as part of your
Monthly Reporting Plan: MRSA, MSSA (MRSA/MSSA), VRE, CephRKlebsiella, CRE (E. coli, Klebsiella pneumoniae, Klebsiella oxytoca, or
Enterobacter), MDR-Acinetobacter, or C. difficile.
If the pathogen for this infection happens to be an MDRO but your facility
is not following the Infection Surveillance in the MDRO/CDI Module in
your Monthly Reporting Plan, answer “No” to this question.
Location

Required. Enter the inpatient location to which the patient was assigned
on the date of the Adult Sepsis event.
If the date of the Adult Sepsis event occurs on the day of transfer or
discharge from a location, or the next day, indicate the
transferring/discharging location, not the current location of the patient, in
accordance with the Transfer Rule (see Key Terms section).

January 2017

Adult Sepsis

Data Field
Date admitted to facility

Instructions for Data Collection
Required. Enter date patient is physically admitted to an inpatient
location using this format: MM/DD/YYYY. Do not use the date the
admission order is written. If a patient is sent to an inpatient location as an
“observation” patient, they are considered admitted for NHSN purposes.
Event Details

Part A: Suspected Infection

Required. Check each of the elements that were used to identify this Adult
Sepsis event.

Part B: Organ Dysfunction

Required. Check each of the elements that were used to identify this Adult
Sepsis event.

Died

Required. Check Y if patient died during the hospitalization, otherwise
check N.

Sepsis contributed to death

Conditionally required if patient died. Check “Yes” if such evidence is
available (e.g., death/discharge note, autopsy report, etc.) otherwise check
“No”

Discharge date

Conditionally required if patient discharged from facility. Date patient
discharged from facility using this format: MM/DD/YYYY.

Pathogen identified

Required. This field will be auto entered by the computer as Y. Specify
pathogens on subsequent pages of form.

If discharged from facility,
physical location of patient
after leaving facility (Check
one):

Conditionally required if discharged from facility. Select the location in
which the patient spent the night immediately after discharge or transfer
from your facility. Selections include: (1) Nursing Home/Skilled Nursing
Facility; (2) Personal Residence/Residential Care, which includes
personal homes or assisted living environments in which 24/7 care is not
provided in a group setting. Note: if the patient’s personal residence is a
nursing home or skilled nursing facility, then your selection should be
Nursing Home/Skilled Nursing Facility; (3) Other short term general
hospital for inpatient care; (4) Long term acute care hospital; (5) Hospice
inpatient medical facility; (6) Other facility not specified above; (7)
Unknown.

January 2017

Adult Sepsis

Data Field

Instructions for Data Collection

If discharged from the facility Conditionally Required if discharged to either nursing home/skilled
to either nursing home/skilled nursing facility or personal residence/residential care. Select “Yes” if the
nursing facility or personal
patient was discharged with hospice services arranged in the postresidence/residential care, were discharge period.
hospice services arranged for
the post-discharge period?
Pathogen # for specified Gram- Up to three pathogens may be reported. If multiple pathogens are
positive Organisms, Gramidentified, enter the pathogen judged to be the most important cause of
negative Organisms, Fungal
infection as #1, the next most as #2, and the least as #3 (usually this order
Organisms, or Other
will be indicated on the laboratory report). If the species is not given on
Organisms
the lab report or is not found on the NHSN drop down list, then select the
“spp” choice for the genus (e.g., Bacillus natto is not on the list so would
be reported as Bacillus spp.).
Antimicrobial agent and
susceptibility results

Conditionally required if Pathogen Identified = Y.


For those organisms shown on the back of an event form,
susceptibility results are required only for the agents listed.



For organisms that are not listed on the back of an event form, the
entry of susceptibility results is optional.

Circle the pathogen’s susceptibility result using the codes on the event
forms.
For each box listing several drugs of the same class, at least one drug
susceptibility must be recorded.

Custom Fields

Optional. Up to 50 fields may be customized for local or group use in any
combination of the following formats: date (MM/DD/YYYY), numeric,
or alphanumeric.
NOTE: Each custom field must be set up in the Facility/Custom Options
section of the application before the field can be selected for use.

Comments

January 2017

Optional. Enter any information on the event.