Attachment M: Completion Guide for ICU/Non-ICU Clinical Outcomes Data

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Attachment M: ICU/Non-ICU Clinical Outcomes Data

COMPLETION GUIDE FOR CLINICAL OUTCOMES DATA COLLECTION FORM – ICU/NON-ICU

1. Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia LabID (as defined by CDC/NHSN) with designation as either community-onset or hospital-onset

   1. As defined using existing Centers for Disease Control and Prevention (CDC), National Healthcare Safety Network (NHSN) definitions (updated January 2021). Available at: https://www.cdc.gov/nhsn/pdfs/pscmanual/12pscmdro_cdadcurrent.pdf

   2. These data are already collected by acute care hospitals as part of CMS public reporting requirements.

• Count how many MRSA bacteremia LabID events occurred as community-onset (on hospital day 1 or 2) and how many MRSA bacteremia LabID events occurred as hospital-onset (on hospital day 3 or later) in the participating unit in each month of the quarter for which you are reporting data.

• On each row of the table:

  • In the first column, select the appropriate month and year for which you are reporting data from the dropdown menu.

  • In the second column, enter the number (count) of MRSA bacteremia LabID events in the participating unit in the month for which you are reporting data.

  • In the third column, select either community-onset (on hospital day 1 or 2) or hospital-onset (on hospital day 3 or later) from the dropdown menu to indicate the timing of the events reported in column two.

• Repeat the data entry as above for community-onset and hospital onset MRSA bacteremia LabID events in each of the 3 months in the quarter for which you are reporting data.

2. Hospital-onset Bacteremia (HOB) (occurring on Day 3 or after of hospital admission) with causative organisms – monthly

   1. HOB is defined as a positive blood culture growing any organism from any cause (including contaminants and repeat positive blood cultures) sent from the participating unit and taken on day 3 or later after hospital admission.

   2. The HOB rate is defined as the number of HOB divided by the number of patient days in a participating unit in a specified time period.

• Count how many confirmed HOB events were caused by each type of organism on the list of organisms in the participating unit in each month of the quarter for which you are reporting data. (See List of Organisms, page 7, Attachment J: Clinical Outcomes Data for ICU/Non-ICU)

• On each row of the table:

  • In the first column, select the appropriate month and year for which you are reporting data from the dropdown menu.

  • In the second column, enter the number (count) of HOB cases by a given causative organism.

  • In the third column, select the specific causative organism that was identified to cause the reported HOB cases from the dropdown menu.

  • For HOB cases caused by multiple organisms (polymicrobial bacteremia), count the HOB only once as MRSA or MSSA if either of these grew in the blood culture. If the HOB was polymicrobial and both MRSA and MSSA grew in the blood culture, count the HOB only once and choose “MRSA” from the organism dropdown list. If the HOB was polymicrobial but neither MRSA nor MSSA grew in the blood culture, count the HOB only once and choose “polymicrobial” from the organism dropdown list.

• Repeat the data entry as above for each of the 3 months in the quarter for which you are reporting data.

3. Central line-associated bloodstream infection (CLABSI) cases with causative organisms – monthly

   1. As defined using existing CDC NHSN definitions, Chapter 4 of NHSN Patient Safety Component Manual (updated January 2021). Available at: https://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf

   2. These data are already collected by acute care hospitals as part of CMS public reporting requirements.

• Count how many confirmed CLABSI events were caused by each type of eligible BSI organism in the list of organisms in each month of the quarter for which you are reporting data. (See List of Organisms, page 7, Attachment J: Clinical Outcomes Data for ICU/Non-ICU)

• On each row of the table:

  • In the first column, select the appropriate month and year for which you are reporting data from the dropdown menu.

  • In the second column, enter the number (count) of CLABSI cases by a given causative organism.

  • In the third column, select the specific causative organism that was identified to cause the reported CLABSI cases from the dropdown menu.

  • For CLABSI cases caused by multiple organisms (polymicrobial bacteremia), count the CLABSI only once as MRSA or MSSA if either of these grew in the blood culture. If the CLABSI was polymicrobial and both MRSA and MSSA grew in the blood culture, count the CLABSI only once and choose “MRSA” or “MSSA” from the organism dropdown list. If the CLABSI was polymicrobial but neither MRSA nor MSSA grew in the blood culture, count the CLABSI only once and choose “polymicrobial” from the organism dropdown list.

• Repeat the data entry as above for each of the 3 months in the quarter for which you are reporting data.

4. Central line (CL) days – monthly

   1. As defined using existing CDC NHSN definitions, Chapter 4 of NHSN Patient Safety Component Manual (updated January 2021). Available at: https://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf

   2. Denominator data (patient days and device days) should be collected at the same time, every day, for each location performing surveillance to ensure that differing collection methods don’t inadvertently result in device days being greater than patient days.

   3. Data may be collected by any of the 3 methods outlined by NHSN in Chapter 4 of the Patient Safety Component Manual, Table 7, page 4-25 through 4-27; manual, daily; manual, sampled once per week; or electronic with periodic data validation.

• Count how many central line (CL) days occurred in the participating unit in each month of the quarter for which you are reporting data.

• On each row of the table:

  • In the first column, select the appropriate month and year for which you are reporting data from the dropdown menu.

  • In the second column, enter the number (count) of CL days for the participating unit in the specified time period.

• Repeat the data entry as above for each of the 3 months in the quarter for which you are reporting data.

5. Patient days - monthly

   1. As defined using existing CDC NHSN definitions, as detailed in the NHSN Multidrug-resistant Organism and Clostridioides difficile Infection (MDRO/CDI) Module (updated January 2021). Available at: https://www.cdc.gov/nhsn/pdfs/pscmanual/12pscmdro_cdadcurrent.pdf

   2. Patient days: The cumulative number of days that each patient spent in the participating unit during a month for which you are reporting data. Each of these days contributes to the exposure risk for MRSA and other multidrug-resistant organisms.

   3. For NHSN reporting purposes, the date the patient is admitted to and physically locates to the participating unit is counted as day 1. All days spent in an inpatient unit, regardless of local admission status and/or billing status are included in the counts of inpatient days for the participating location.

   4. For further information on counting patient days, see the Instructions for Completion of the MDRO/CDI Monthly Denominator Form. Available at: https://www.cdc.gov/nhsn/forms/instr/57_127.pdf

• Count how many patient days occurred in the participating unit in each month of the quarter for which you are reporting data.

• On each row of the table:

  • In the first column, select the appropriate month and year for which you are reporting data from the dropdown menu.

  • In the second column, enter the number (count) of patient days for the participating unit for the specified time period.

• Repeat the data entry as above for each of the 3 months in the quarter for which you are reporting data.

6. Clinical cultures growing MRSA on Day 3 or later of hospital admission – monthly

   1. Include all clinical cultures from patient samples in the participating unit that grow MRSA on day 3 or later of hospital admission (hospital onset).

   2. Include clinical cultures from the list of specimen types. (See List of Specimen Types, page 7, Attachment J: Clinical Outcomes Data for ICU/Non-ICU)

   3. Do not include MRSA surveillance culture results in this reporting.

   4. For each patient, during a single hospital admission, include only the first (index) clinical culture growing MRSA in each specimen type in the participating unit unless more than 14 days have passed for that patient without any clinical cultures growing MRSA from that specimen type. If more than 14 days have passed for that patient without any clinical cultures growing MRSA from a given specimen type, then count another index culture for that patient/specimen type if a clinical culture taken in the participating unit grows MRSA. For more information, please see the NHSN Patient Safety Module regarding the role of the “repeat infection timeframe” in surveillance for healthcare-associated infections.

   5. If a patient is discharged from the hospital and then readmitted, start over and count and report the first clinical culture of a given specimen type as a new index culture.

• Count how many clinical cultures grew MRSA on Day 3 or later of hospital admission in the participating unit in each month of the quarter for which you are reporting data.

• On each row of the table:

  • In the first column, select the appropriate month and year for which you are reporting data from the dropdown menu.

  • In the second column, enter the number (count) of clinical cultures that grew MRSA on Day 3 or later of hospital admission for the participating unit for the specified time period.

• Repeat the data entry as above for each of the 3 months in the quarter for which you are reporting data.

7. Point prevalence survey of positive MRSA nasal surveillance tests in the participating unit – OPTIONAL REPORTING semi-annually

   1. If the participating unit performs routine nasal surveillance tests to detect MRSA colonization, the unit may elect to report data on the point prevalence of positive MRSA nasal surveillance tests in a specified 3-day period, semi-annually.

   2. Numerator: the count of the MRSA nasal surveillance tests that were positive for MRSA in the participating unit during the specified 3-day semi-annual period. The surveillance tests can be cultures, polymerase chain reaction, or other methodology to detect MRSA.

   3. Denominator: the count of the MRSA nasal surveillance tests that were performed in the participating unit during the specified 3-day semi-annual period. The surveillance tests can be cultures, polymerase chain reaction, or other methodology to detect MRSA.