Att G7_Demoninators 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. All patients with 1 or more central line(s) in place at the time of the
count are included in the denominator regardless of the number of days the
central line has been in place (i.e., central line day 1 and day 2 are included in the
denominator count). Use the manual data collection method, to collect this data or
capture the data electronically, as below:
Manual Method:
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. At the end of the month, total the daily counts and record the
sums by birthweight category for the month, in the NHSN system for Central
Line Days under the option to Add Summary Data.
Electronic Capture:
For any location, when denominator data are available from electronic sources
(e.g., central line days from electronic charting), these sources may be used as
long as the counts are not substantially different (+/- 5%) from manuallycollected, once a day counts, pre-validated for a minimum of three months.

January 2017

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Data Field

Instructions for Data Collection
The validation of electronic counts should be performed for each location
separately.
At the end of the month, record the sums of central line days by birthweight
category for the month, in the NHSN system for Central Line Days under the
option to Add Summary Data.

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.
Conditionally required. Complete if you have chosen Pediatric Ventilator
Associated Event (PedVAE) as an event to follow in your Plan for this month for
this unit.
This field can optionally be completed even though Ventilator Associated
Pneumonia (PedVAP) surveillance cannot be included in your plan in a NICU
location.
All patients on a ventilator at the time of the count are included in the
denominator regardless of eligibility for inclusion in PedVAP surveillance (i.e.,
ventilator day 1 and day 2 are included in the denominator count). Use the manual
data collection method, to collect this data or capture the data electronically, as
below:
Manual Method:
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.
At the end of the month, total the daily counts and record the sums by birthweight
category, in the NHSN system for Ventilator Days under the option to Add
Summary Data.
Electronic Capture:
For any location, when denominator data are available from electronic sources
(e.g., central line days from electronic charting), these sources may be used as
long as the counts are not substantially different (+/- 5%) from manuallycollected, once a day counts, pre-validated for a minimum of three months.
The validation of electronic counts should be performed for each location
separately.

January 2017

2

Data Field

Instructions for Data Collection
At the end of the month, record the sums of ventilator days by birthweight
category for the month, in the NHSN system for Ventilator Days under the option
to Add Summary Data.

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.
Number of
Optional. This field can be completed even though NICU CAUTI surveillance
patients with an
cannot be included in your plan. All patients with an indwelling urinary catheter
indwelling urinary in place at the time of the count are included in the denominator regardless of the
catheter (UrC)
number of days the catheter has been in place (i.e., catheter day 1 and day 2 are
included in the denominator count). Use the manual data collection method, to
collect this data or capture the data electronically, as below:
Manual Method:
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 an indwelling
urinary catheter. At the end of the month, total the daily counts and record the
sums by birthweight category, in the NHSN system for Urinary Catheter Days
under the option to Add Summary Data.
Electronic Capture:
For any location, when denominator data are available from electronic sources
(e.g., central line days from electronic charting), these sources may be used as
long as the counts are not substantially different (+/- 5%) from manuallycollected, once a day counts, pre-validated for a minimum of three months.
The validation of electronic counts should be performed for each location
separately.
At the end of the month, record the sums of urinary catheter days by birthweight
category for the month, in the NHSN system for Urinary Catheter Days under the
option to Add Summary Data.

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.
January 2017

3

Data Field
Total
Report No Events

Custom Fields

Instructions for Data Collection
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. .
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.

Instructions for Completion of PedVAE Optional Denominators for
Neonatal Intensive Care Unit (NICU)
Data Field
Facility ID #
Location code
Month
Year
Gestational Age
Categories
Number of
patients (Pts)
Number of
patients on a
ventilator (VNT)

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.
Optional. The gestational age categories are as follows: A = Extremely preterm
(<28 weeks), B =Very preterm (28 to <32 weeks), C = Moderate to late preterm
(32 to <37 weeks), D = Term (≥37 weeks)
Optional. For each day of the month selected, record the number of patients in
each gestational age category on the unit. Record this number at the same time
each day.
Optional. Complete if you have chosen Pediatric Ventilator Associated Event
(PedVAE) as an event to follow in your Plan for this month for this unit.
Manual Method:
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.
At the end of the month, total the daily counts and record the sums by birthweight
category, in the NHSN system for Ventilator Days under the option to Add
Summary Data.

January 2017

4

Data Field

Instructions for Data Collection
Electronic Capture:
For any location, when denominator data are available from electronic sources
(e.g., central line days from electronic charting), these sources may be used as
long as the counts are not substantially different (+/- 5%) from manuallycollected, once a day counts, pre-validated for a minimum of three months.
The validation of electronic counts should be performed for each location
separately.
At the end of the month, record the sums of ventilator days by birthweight
category for the month, in the NHSN system for Ventilator Days under the option
to Add Summary Data.

Total
Report No Events

Custom Fields

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.
Optional. 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.,
PedVAE .
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 2017

5

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.
All patients with 1 or more central line(s) in place at the time of the count are
included in the denominator regardless of the number of days the central line has
been in place (i.e., central line day 1 and day 2 are included in the denominator
count). Use the manual data collection method, to collect this data or capture the
data electronically, as below:
Manual Method:

Temporary

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 non-tunneled and nonimplanted central lines. At the end of the month, total the daily counts and record
the sum for the month in the NHSN system for Temporary Central Line Days
under the option to Add Summary Data.

Permanent

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 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. At the end of the
month, total the daily counts and record the sum for the month in the NHSN
system for Permanent Central Line Days under the option to Add Summary
Data.

Electronic Capture:

January 2017

6

Data Field

Instructions for Data Collection
For any location, when denominator data are available from electronic sources
(e.g., central line days from electronic charting), these sources may be used as
long as the counts are not substantially different (+/- 5%) from manuallycollected, once a day counts, pre-validated for a minimum of three months.
The validation of electronic counts should be performed for each location
separately.
At the end of the month, record the sums for the month in the NHSN system
separately for Permanent Central Line Days and for Temporary Central Line
Days (see Manual Method above) under the option to Add Summary Data.

Number of
patients with a
urinary
catheter

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. All
patients with an indwelling urinary catheter in place at the time of the count are
included in the denominator regardless of the number of days the catheter has
been in place (i.e., catheter day 1 and day 2 are included in the denominator
count).). Use the manual data collection method, to collect this data or capture
the data electronically, as below:
Manual Method:
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. At the end
of the month, total the daily counts and record the sum for the month in the
NHSN system for Urinary Catheter Days under the option to Add Summary
Data
Electronic Capture:
For any location, when denominator data are available from electronic sources
(e.g., urinary catheter days from electronic charting), these sources may be used
as long as the counts are not substantially different (+/- 5%) from manuallycollected, once a day counts, pre-validated for a minimum of three months.

January 2017

7

Data Field

Instructions for Data Collection
The validation of electronic counts should be performed for each location
separately.
At the end of the month, record the sum of urinary catheter days in the NHSN
system for Urinary Catheter Days under the option to Add Summary Data.

Number of
total patients
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, attribute the infection to the
previous month.
Conditionally required. Complete if you have chosen ventilator-associated event
(VAE—for adults), pediatric ventilator-associated event (PedVAE) or pediatric
ventilator-associated pneumonia (PedVAP) as an event to follow in your Plan for
this month.
All patients on a ventilator at the time of the count are included in the
denominator regardless of eligibility for inclusion in VAE, PedVAE or PedVAP
surveillance (i.e., ventilator day 1 and day 2 are included in the denominator
count). Similarly patients excluded from VAE surveillance due to mode of
ventilator support (i.e., high frequency ventilation, extracorporeal life support)
are included in the denominator.

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 (to include those on an
APRV mode and excluded mode and those who have been ventilated < 3 days)

Number of
patients on
APRV

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 and 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

Optional. This field is an optional field if you have chosen VAE or PedVAE as
an event to follow in your Plan for this month. Count all patients, regardless of
eligibility for inclusion in VAE or PedVAE surveillance, that were on
mechanical ventilation in the location on the first day of the month. On each

January 2017

8

Data Field

Total
Report No
Events

Custom Fields

Instructions for Data Collection
subsequent day, count each additional patient that was started on mechanical
ventilation. This would include those that are admitted to the location already on
mechanical ventilation, those that are newly ventilated and any previously
ventilated patients who have new episodes of mechanical ventilation occurring
during the same month. 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.
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 2017

9

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.
NOTE: If participating in weekly denominator sampling, in addition to
daily recording of the number of patients on the unit, the number of
patients present on the unit must be identified and recorded for the day
that weekly device day sampling is collected, i.e. central line days,
urinary catheter days. This data must be identified and entered into
NHSN in the Sample Values for Estimating Denominator Data section
under the option to Add Summary Data.
Conditionally required. Complete if you have chosen central lineassociated bloodstream infection (CLABSI) as an event to follow in your
Plan for this month. All patients with 1 or more central line(s) in place at
the time of the count are included in the denominator regardless of the
number of days the central line has been in place (i.e., central line day 1
and day 2 are included in the denominator count). Use one of the two
manual data collection methods, to collect this data or capture the data
electronically, as below:
Manual Methods:
Daily collection: 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. At the end of the month, total the daily counts
and record the sum for the month in the NHSN system for Central Line
Days under the option to Add Summary Data.
Sampling (weekly): On a designated day each week (e.g., every
Tuesday), at the same time during the month, 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. At the end of the month, total the sampled counts and record the

January 2017

10

Data Field

Instructions for Data Collection
sum for the month in the NHSN system for Central Line Days under the
option to Add Summary Data.

Evaluations of this method have repeatedly shown that use of Saturday or
Sunday generate the least accurate estimates of denominator data,
therefore, these days should not be selected as the designated day.6-8 If
the day designated for the collection of sampled data is missed, collect
the data on the next available day instead.
When these data are entered, the NHSN application will calculate an
estimate of central line-days.
Electronic Capture:
For any location, when denominator data are available from electronic
sources (e.g., central line days from electronic charting), these sources
may be used as long as the counts are not substantially different (+/- 5%)
from manually-collected, once a day counts, pre-validated for a
minimum of three months.
The validation of electronic counts should be performed for each location
separately.
At the end of the month, record the sum of central line day counts in the
NHSN system for Central Line Days under the option to Add Summary
Data.

Number of patients with a
urinary catheter
January 2017

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. All patients with an indwelling urinary catheter in place at
11

Data Field

Instructions for Data Collection
the time of the count are included in the denominator regardless of the
number of days the catheter has been in place (i.e., catheter day 1 and
day 2 are included in the denominator count).Use one of the two manual
data collection methods to collect this data or capture the data
electronically, as below:
Manual Methods:
Daily collection: 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. At the end of the month, total the daily
counts and record the sum for the month in the NHSN system for Urinary
Catheter Days under the option to Add Summary Data.

Sampling (weekly): On a designated day each week (e.g., every
Tuesday), at the same time during the month, record the number of
patients on the selected unit who have an indwelling urinary catheter.
This data must be identified and entered into NHSN in the Sample
Values for Estimating Denominator Data section under the option to Add
Summary Data. At the end of the month, total the sampled counts and
record the sum for the month in the NHSN system for Urinary Catheter
Days under the option to Add Summary Data.
Evaluations of this method have repeatedly shown that use of Saturday or
Sunday generate the least accurate estimates of denominator data,
therefore, these days should not be selected as the designated day.6-8 If
the day designated for the collection of sampled data is missed, collect
the data on the next available day instead.
When these data are entered, the NHSN application will calculate an
estimate of urinary catheter days.
Electronic Capture:
For any location, when denominator data are available from electronic
sources (e.g., urinary catheter days from electronic charting), these
sources may be used as long as the counts are not substantially different
(+/- 5%) from manually-collected, once a day counts, pre-validated for a
minimum of three months.
The validation of electronic counts should be performed for each location
separately.
January 2017

12

Data Field

Instructions for Data Collection
At the end of the month, record the sum of urinary catheter day counts in
the NHSN system for Urinary Catheter Days under the option to Add
Summary Data.

Number of total patients
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, attribute
the infection to the previous month.
Conditionally required. Complete if you have chosen ventilatorassociated event (VAE—for adults), pediatric ventilator-associated event
(PedVAE) or pediatric ventilator-associated pneumonia (PedVAP) as an
event to follow in your Plan for this month.
All patients on a ventilator at the time of the count are included in the
denominator regardless of eligibility for inclusion in VAE, PedVAE or
PedVAP surveillance (i.e., ventilator day 1 and day 2 are included in the
denominator count). Similarly patients excluded from VAE surveillance
due to mode of ventilator support (i.e., high frequency ventilation,
extracorporeal life support) are to be include in the denominator.
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 (to
include those on an APRV mode and excluded mode and those who have
been ventilated < 3 days).

Number of patients on
APRV

Number of Episodes of
Mechanical Ventilation

January 2017

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 for this month. For each day of the month, at
the same time each day (and at the same time that number of total
patients on a ventilator 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).
Optional. This field is an optional field if you have chosen VAE or
PedVAE as an event to follow in your Plan for this month. Count all
patients, regardless of eligibility for inclusion in VAE surveillance, that
were on mechanical ventilation in the location on the first day of the
13

Data Field

Total
Report No Events

Custom Fields

Instructions for Data Collection
month. On each subsequent day, count each additional patient that was
started on mechanical ventilation. This would include those that are
admitted to the location already on mechanical ventilation, those that are
newly ventilated and any previously ventilated patients who have new
episodes of mechanical ventilation occurring during the same month.
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
are reported, you will be required to check the appropriate Report No
Events box(es), i.e., CLABSI, CAUTI, VAE, PedVAE, 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 2017

14