NHSN Patient Safety Component Manual 2019

January 2021

National Healthcare Safety Network (NHSN)

Patient Safety Component Manual

Table of Contents Chapter 1: National Healthcare Safety Network (NHSN) Overview Chapter 2: Identifying Healthcare-associated Infections (HAI) for NHSN Surveillance Chapter 3: Patient Safety Monthly Reporting Plan and Annual Surveys Chapter 4: Bloodstream Infection Event (Central Line-Associated Bloodstream Infection and non- central line-associated Bloodstream Infection) Chapter 5: Central Line Insertion Practices (CLIP) Adherence Monitoring Chapter 6: Pneumonia (Ventilator-associated [VAP] and non-ventilator-associated Pneumonia [PNEU]) Event Chapter 7: Urinary Tract Infection (Catheter-Associated Urinary Tract Infection [CAUTI] and non- catheter-associated Urinary Tract Infection [UTI]) and Other Urinary System Infection (USI) Events Chapter 9: Surgical Site Infection (SSI) Event Chapter 10: Ventilator-Associated Event (VAE) Chapter 11: Pediatric Ventilator-Associated Event (pedVAE) Chapter 12: Multidrug-Resistant Organism & Clostridium difficile Infection (MDRO/CDI) Module Chapter 14: Antimicrobial Use and Resistance (AUR) Chapter 15: CDC Locations and Descriptions and Instructions for Mapping Patient Care Locations Chapter 16: General Key terms Chapter 17: CDC/NHSN Surveillance Definitions for Specific Types of Infections

Please Note: The NHSN Patient Safety Component Manual is updated annually based on subject matter expert review and user feedback. Over time, certain chapters have been retired or moved to other components. To avoid confusion, the chapters in the PSC manual do not shift to account for these changes; therefore, chapters 8 and 13 are not listed in the Table of Contents or included in this document.

January 2021

National Healthcare Safety Network (NHSN) Overview

The NHSN is a secure, Internet-based surveillance system that expands and integrates patient and healthcare personnel safety surveillance systems managed by the Division of Healthcare Quality Promotion (DHQP) at the Centers for Disease Control and Prevention. In addition, facilities that participate in certain reporting programs operated by the Centers for Medicare and Medicaid Services (CMS) can do so through use of NHSN. Furthermore, some U.S. states use NHSN as a means for healthcare facilities to submit data on healthcare-associated infections (HAIs) and transfusion-related adverse events mandated through their specific state legislation.

NHSN enables healthcare facilities to collect and use data about HAIs, adherence to clinical practices known to prevent HAIs, the incidence or prevalence of multidrug-resistant organisms within their organizations, trends and coverage of healthcare personnel safety and vaccination, and adverse events related to the transfusion of blood and blood products.

The NHSN includes six components: Patient Safety, Long-term Care Facility, Outpatient Dialysis, Healthcare Personnel Safety, Biovigilance, and Outpatient Procedure (Figure 1).

FIGURE 1: NHSN COMPONENTS

NHSN Components

Patient Safety

Long-term Care Facility

Outpatient Dialysis

Healthcare Personnel Safety

Biovigilance

Outpatient Procedure

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NHSN Overview

The Patient Safety Component includes five modules that focus on events associated with medical devices, surgical procedures, antimicrobial agents used during healthcare, multidrug resistant organisms, and Coronavirus Infectious Disease 2019 (COVID-19).

? Device-associated Module: o Bloodstream Infection (CLABSI ? Central line-associated bloodstream infection) o Central line insertion practices (CLIP) adherence o Urinary Tract Infection (CAUTI ? Catheter-associated urinary tract infection) o Pediatric Ventilator-associated events (PedVAE) (NICU and pediatric locations only) o Ventilator-associated events (VAE) (adult locations only) o Pneumonia (VAP ? Ventilator-associated pneumonia) - in pediatric locations (in-plan* or off-plan*), or NICU and adult locations (off-plan* only)

? Procedure-associated Module: o Surgical Site Infection (SSI)

? Antimicrobial Use and Resistance Module (AUR) ? Multidrug-Resistant Organism and Clostridium difficile Infection (MDRO/CDI) Module ? Coronavirus Infectious Disease 2019 (COVID-19) Module (off plan* only):

o Patient Impact and Hospital Capacity Pathway o Healthcare Worker Staffing Pathway o Healthcare Supply Pathway

*Note: "In-plan" surveillance means that the facility has committed to following the NHSN surveillance protocol, in its entirety, for that particular event, as shown in the facility's NHSN monthly reporting plan. "Off-plan" surveillance is surveillance that is done because a facility has decided to track a particular event for internal use. Data that are entered into NHSN "off-plan" are not included in NSHN annual reports or other NHSN publications. A facility makes no commitment to follow the NHSN protocol for "off-plan" events. Further, "off-plan" data cannot be uploaded into NHSN via Clinical Document Architecture (CDA) and must be manually entered. Instructions and standardized surveillance methods and definitions for each module of the Patient Safety Component are provided in this manual and on the NHSN website (nhsn). Modules may be used singly or simultaneously.

The NHSN Long-term Care Facility Component provides long-term care facilities (LTCFs) with standardized surveillance methods and definitions for four modules: (1) Multidrug resistant organism (MDRO) and Clostridioides difficile Infection (CDI) laboratory-identified (LabID) Events; (2) Urinary Tract Infections (UTI); (3) Prevention Process Measures 4) Coronavirus Infectious Disease (COVID-19). The component is ideal for use by nursing homes, skilled nursing facilities, chronic care facilities, and assisted living and residential care facilities. LTCF surveillance protocols, training materials, data collection forms, instructions, and other supporting materials are provided on the Long-term Care Facility Component website: .

Outpatient hemodialysis centers have several surveillance options tailored to their patients and setting in the Dialysis Component. The component consists of 3 modules: 1) Dialysis Event; (2) Prevention Process Measures; and (3) Dialysis Patient Influenza Vaccination. Facilities that treat hemodialysis outpatients should refer to the Dialysis Component instructions and standardized surveillance methods and definitions at nhsn/dialysis/index.html.

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NHSN Overview

There are two modules in the Healthcare Personnel Safety (HPS) Component of NHSN: The Healthcare Personnel Exposure Module and the Healthcare Personnel Vaccination Module. The Healthcare Personnel Exposure Module includes: Blood/Body Fluid Exposure Only; Blood/Body Fluid Exposure with Exposure Management; and Influenza Exposure Management. This module is no longer available for enrollment and should only be used by facilities that have already been reporting Blood/Body Fluid Exposure and Exposure Management data to the system. The Healthcare Personnel Vaccination Module includes: Influenza Vaccination Summary. Data collected in this surveillance system can assist healthcare facilities, health systems, and public health agencies to monitor and report trends in blood/body fluid exposures, to characterize antiviral medication use for exposures to influenza, and to monitor influenza vaccination coverage among healthcare personnel. These modules may be used separately or simultaneously. Instructions and standardized surveillance methods and definitions for the Healthcare Personnel Vaccination Module is provided in the NHSN Manual: HPS Component Protocol

The NHSN Biovigilance Component, Hemovigilance Module facilitates national surveillance of transfusion-related recipient adverse events. The Hemovigilance Module is designed for transfusion service staff to collect data on annual facility and transfusion service characteristics, individual reports on adverse transfusion reactions, errors or accidents associated with adverse reactions, and monthly counts of transfused or discarded components. The Hemovigilance Module surveillance protocol, training materials, data collection forms, instructions, and other supporting materials are provided on the Hemovigilance Module website: nhsn/acute-care-hospital/bio-hemo/index.html.

The Outpatient Procedure Component (OPC) includes two modules that focus on adverse events associated with surgical procedures performed in Ambulatory Surgery Centers (ASCs). The two modules include Same Day Outcome Measures and Surgical Site Infections.

? Same Day Outcome Measures (OPC-SDOM) are a grouping of outpatient care quality indicators that represent a broad range of risks encountered by patients accessing care in various outpatient settings. The four individual outcome measures are: o Patient Burn o Patient Fall o Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant o All-Cause Hospital Transfer/Admission

? Surgical Site Infection (OPC-SSI) - SSI surveillance for outpatient operative procedures using the Outpatient Procedure Component (OPC) replaces the use of the Patient Safety Component SSI event chapter for ASCs.

The OPC surveillance protocols, training materials, data collection forms, instructions, and other supporting materials are provided on the Outpatient Procedure Component website: .

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NHSN Overview

Surveillance Techniques

Some of the options in the following modules require active, patient-based, prospective surveillance of events and their corresponding denominator data by a trained Infection Preventionist (IP). This means that the IP shall seek out infections during a patient's stay by screening a variety of data sources, such as laboratory, pharmacy, admission/discharge/transfer, radiology/imaging, and pathology databases, as well as patient charts, including history and physical exam notes, nurses'/physicians' notes, temperature charts, etc. Others may be trained to screen data sources for these infections, but the IP must make the final determination. Laboratory-based surveillance should not be used alone, unless all possible criteria for identifying an infection are solely determined by laboratory evidence (for example, LabID event detection in the MDRO/CDI Module). Retrospective chart reviews should be used only when patients are discharged before all information can be gathered. NHSN forms should be used to collect all required data, using the NHSN definitions of each data field. To minimize the IP's data collection burden, others may be trained to collect the denominator data and process of care data (for example, central line insertion practices).

Procedure-Associated Module

Surgical site infection (SSI) monitoring is offered through this module. SSI surveillance requires active, patient-based, prospective surveillance techniques (see Surveillance Techniques above). To minimize IPs' workload of collecting denominator data, operating room data may be downloaded (see file specifications at: )

Both pre-discharge and post-discharge surveillance methods should be used to detect SSIs. Surveillance may include both inpatient and outpatient operative procedures. These methods include 1) direct examination of patients' wounds during hospitalization, or follow-up visits to either surgery clinics or physicians' offices, 2) review of medical records or surgery clinic patient records, 3) surgeon surveys by mail or telephone, and 4) patient surveys by mail or telephone (though patients may have a difficult time assessing their infections). Any combination of these methods is acceptable for use; however, CDC criteria for SSI must be applied.

Device-Associated Module

Medical instrumentation increases the risk of development of an HAI and most patients admitted for health care are exposed to some kind of medical device in the course of their treatment. Such devices include, but are not limited to, vascular and urinary catheters, and ventilators. NHSN enables facilities to monitor infectious complications associated with the use of these devices and to monitor processes related to their use which might increase infection risk. Specifically, surveillance of central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), ventilator-associated events (VAE), and/or ventilator-associated pneumonia (VAP) is possible using the NHSN. In addition, central line insertion practices (CLIP) can be monitored to inform facilities of the appropriateness of their processes and how they may relate to HAI development. See Dialysis Component for detailed instructions for Dialysis Event (DE) surveillance of hemodialysis outpatients (nhsn/dialysis/index.html).

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NHSN Overview

Device-associated denominator data should be collected at the same time each day, or by weekly sampling methods, in certain locations, for CLABSI and CAUTI surveillance (see the CLABSI and CAUTI protocols for guidance). When denominator data are available from electronic databases (for example, ventilator days from respiratory therapy), these sources may be used as long as the counts are not substantially different (+/- 5%) from manually-collected counts that have been validated for a minimum of three months. See the respective device-associated event protocols for detailed surveillance instructions.

Antimicrobial Use and Resistance (AUR) Module

The use of antimicrobial agents has a direct effect on antimicrobial resistance patterns of pathogens. The observed increase in multidrug resistance is in part due to inappropriate prescription of, as well as only partial completion of courses of antibiotics.

The AUR Module allows facilities to collect information on the amount of antimicrobials that are used for patient care within their systems, as well as to collect data on the prevalence of drug-resistant organisms in their inpatient and outpatient areas. Electronic capture and reporting of microbiology and pharmacy data are the only available options for reporting data into this module.

See the Antimicrobial Use and Resistance protocol for detailed surveillance instructions.

Multidrug-resistant Organism and Clostridium difficile Infection (MDRO/CDI) Module

The NHSN MDRO/CDI Module offers a means for facilities to meet criteria and metrics that are outlined in several organizational guidelines to control and measure the spread of MDROs and CDI within their healthcare system. The module has two separate and independent reporting options, Laboratoryidentified (LabID) Event and Infection Surveillance that may be tailored to meet the needs of participating NHSN facilities.

In addition, the following process measures are available: (1) adherence to hand hygiene; (2) adherence to contact precautions when caring for patients infected or colonized with an MDRO or C. difficile; and (3) adherence to active surveillance testing (AST) of MRSA and/or VRE. Active surveillance testing outcome measures is also available in locations where AST adherence is being performed and enables facilities to use the results of AST to monitor the incidence and prevalence of positive MRSA and/or VRE cultures. See the MDRO/CDI protocol for detailed surveillance instructions.

Coronavirus Infectious Disease 2019 (COVID-19) Module

The NHSN Coronavirus Infectious Disease 2019 Module was created during the COVID-19 outbreak as a means to monitor associated impacts on the human and material resources of acute care facilities. The module allows a facility to report information on the hospital's capacity to respond to COVID-19 by reporting bed and mechanical ventilator availability as well as current and impending staffing and personal protective equipment shortages.

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January 2021

Identifying Healthcare-associated Infections (HAI) for NHSN Surveillance

To standardize the classification of an infection as present on admission (POA) or a healthcare-associated infection (HAI), the following objective surveillance definitions and guidance are used for NHSN surveillance:

Table of Contents

General Instructions ................................................................................................................................................. 1 Infection Window Period.............................................................................................................................. 3 Date of Event (Event Date) ........................................................................................................................... 7

Present on Admission (POA) ......................................................................................................................8 Hospital Acquired Infection (HAI) ..............................................................................................................8 Location of Attribution (LOA)....................................................................................................................... ............9 Transfer Rule ............................................................................................................................................................10 Repeat Infection Timeframe....................................................................................................................... 11 Secondary BSI Attribution Period ............................................................................................................. 16 Secondary BSI Attribution Tables............................................................................................................17 Pathogen Assignment Guidance................................................................................................................. 18 Appendix....................................................................................................................................................................27

The intention of this approach is to align criteria and definitions and decrease subjectivity while maintaining epidemiologic standardization and clinical relevance. A variety of scenarios to include repeat infections of the same type, concurrent infections of differing types, and pathogen assignment in multipathogen infections are addressed. See Appendix Flow Diagram for NHSN Event Determination.

General Instructions

1. The guidance found in this Chapter is not applicable when performing SSI, VAE, PedVAE or LabID surveillance. Infection window period, Date of Event, POA, HAI, and RIT, SBAP definitions as defined in this chapter do not apply to SSI, VAE, PedVAE, or LabID Events (Table 1). Please refer to Chapters 9, 10, 11 and 12 respectively for guidance specific to these event determinations

2. Organisms belonging to the following genera are typically causes of community-associated infections and are rarely or are not known to be causes of healthcare-associated infections. They are excluded and cannot be used to meet any NHSN definition: Blastomyces, Histoplasma, Coccidioides, Paracoccidioides, Cryptococcus and Pneumocystis. Additionally, refer to the

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Identifying Healthcare-associated Infections

individual event protocols for pathogen exclusions specific to the event being reported for example, BSI, UTI, PNEU, ENDO, GIT, IAB.

3. If the date of specimen collection is on or after the date of documentation of evidence of consent AND the patient is being supported for organ donation purposes, an event identified using the specimen culture result or microbiologic non-culture based diagnostic test result should not be reported as an HAI. The patient should, however, still be included in device and patient day denominator data collection.

4. Hospice, palliative or comfort care patients are not excluded from NHSN surveillance.

5. Identification of organisms from specimens collected during post-mortem examination (autopsy) are only eligible for use in meeting the CNS/IC (Intracranial) infection definition and the PNEU infection definition using lung tissue specimen obtained by transthoracic or transbronchial biopsy immediately post-mortem. For all other NHSN definitions autopsy specimens/reports are not eligible for use.

6. Infections occurring in newborns with date of event on hospital day 1 or day 2 are considered POA. Those with date of event on day 3 or later are HAI. This includes infections acquired transplacentally (for example but not limited to herpes simplex, toxoplasmosis, rubella, cytomegalovirus, or syphilis) or as a result from passage through the birth canal. Exception: See guidance about non-reporting of CLABSIs with Group B Streptococcus during a neonate's first 6 days of life found in the Comments and Reporting Instructions section of the Bloodstream Infection Event (Central Line-Associated Bloodstream Infection and Non-central line-associated Bloodstream Infection) protocol.

7. Reactivation of a latent infection (for example but not limited to herpes, shingles, syphilis, or tuberculosis) is not considered to be an HAI.

8. For purposes of NHSN surveillance, if an observation patient is admitted to an inpatient location, the patient must be included in all surveillance events designated in the monthly reporting plan and included in patient and device day counts. The patient is being housed, monitored, and cared for in an inpatient location and therefore is at risk for acquisition of an HAI.

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