TOI Instructions

PNEU

Instructions for Completion of Pneumonia (PNEU) (CDC 57.111)
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 #	Optional. Enter the patient’s Medicare number.
Patient name	Optional. Enter the last, first, and middle name of the patient.
Gender	Required. Check 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. PNEU.
Date of event	Required. The date of event is the date when the first element used to meet the PNEU infection criterion occurred for the first time, during the Infection Window Period. Enter date of this event using this format: MM/DD/YYYY. 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.
Post-procedure PNEU	Optional. Check Y if this event occurred after an NHSN- defined procedure but before discharge from the facility, otherwise check N.
Date of procedure	Conditionally required. If Post-procedure PNEU = Y, then enter the date the procedure was done.
NHSN procedure code	Conditionally required. If Post-procedure PNEU = Y. Answer this question only if this patient developed the PNEU during the same admission as an operative procedure. Enter the appropriate NHSN procedure code. Note: A PNEU 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.
ICD-10-PCS or 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.
MDRO Infection Surveillance	Required. Enter “Yes”, if the pathogen is being followed for Infection Surveillance in the MDRO/CDI Module in that location as part of your Monthly Reporting Plan: MRSA, MSSA (MRSA/MSSA), VRE, CephR-Klebsiella, CRE (E. coli, Klebsiella pneumoniae, Klebsiella oxytoca, Klebsiella aerogenes 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 PNEU event. If the PNEU occurs on the day of transfer/discharge 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).
Date admitted to facility	Required. Enter date patient admitted to an inpatient location using this format: MM/DD/YYYY. When determining a patient’s admission dates to both the facility and specific inpatient location, the NHSN user must take into account all such days, including any days spent in an inpatient location as an “observation” patient before being officially admitted as an inpatient to the facility, as these days contribute to exposure risk. Therefore, all such days are included in the counts of admissions and patient days for the facility and specific location, and facility and admission dates must be moved back to the first day spent in the inpatient location. When reporting a PNEU which occurs on the day of or day after discharge use the previous date of admission as admission date.
Risk Factors Ventilator Birth weight	Required. Check Y if the patient with PNEU had a device to assist or control respiration through a tracheostomy or by endotracheal intubation that had been in place for more than two calendar days on the date of the event inclusive of the weaning period, otherwise check N. Date of device insertion = Day 1. If ventilator was in place prior to inpatient admission, the ventilator day count begins with the admission date to the first inpatient location. Optional. For off-plan reporting in a NICU patient, enter the patient’s birth weight in grams, not the weight on the date of event.
Location of device insertion	Optional. Enter the patient location where the intubation and ventilation procedure was performed
Date of device insertion	Optional. Enter the date the intubation and ventilation procedure was performed.
Event Details: PNEU Specific event	Required. Check one: Clinically Defined Pneumonia (PNU1), Pneumonia with specific laboratory findings (PNU2), or Pneumonia in immunocompromised patients (PNU3), whichever criteria are met for this event.
Event Details: Specify criteria used	Required. Check each of the elements that were used to identify the specific type of PNEU being reported.
Event Details: Secondary bloodstream infection	Required. Check Y if there is a bloodstream infection (BSI) identified related to PNEU, otherwise check N. For detailed instructions on identifying whether a blood specimen identification represents a secondary BSI, refer to the Secondary BSI Guide (Appendix B) of the BSI Event protocol. Note: Secondary BSI is N if the specific event is PNU1
COVID – 19	Optional. Check Y if the patient met the definition of suspected or confirmed COVID-19 on the date of event, otherwise check N. If Y select Suspected or Confirmed. 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.
Event Details: Died	Required. Check Y if patient died during the hospitalization, otherwise check N.
Event Details: PNEU contributed to death	Conditionally required. If the patient died, check Y if such evidence is available (for example: death/discharge note, autopsy report, etc.) otherwise check N.
Event Details: Discharge date	Optional. Date patient discharged from facility.
Event Details: Pathogens identified	Required. Enter Y if Pathogen Identified, N otherwise; if Yes, specify organism. Note: Pathogens identified defaults to N if the specific event is PNU1
Pathogen # for specified Gram-positive Organisms, Gram-negative Organisms, Fungal Organisms, or Other Organisms	Up to three pathogens may be reported. If multiple pathogens are identified, enter the pathogen judged to be the most important cause of infection as #1, the next most as #2, and the least as #3 (usually this order will be indicated on the laboratory report). If secondary BSI pathogens are entered, they should be entered only after site-specific pathogens are entered. If the species is not given on the lab report or is not found on the NHSN organism list, then select the genus (for example: Bacillus natto is not on the list so would be reported as Bacillus).
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	Optional. Enter any information on the event.

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