General Program Resources
OARs 409-023-0000 through 409-023-0035 provides information on required reporting for hospitals, ambulatory care, and long-term care facilities.
Oregon’s progress toward US HHS Action Plan Goals for HAIs (updated October 2011).
Comparison of State and Federal HAI Reporting Requirements (updated November 2011).
US HHS has released Partnering to Heal, a free, computer-based video-simulation training program on infection control practices for clinicians, health professional students, and patient advocates.
Association of Professionals in Infection Control and Hospital Epidemiology (APIC)
CDC Infection Control Guidelines
Get Smart for Healthcare -- CDC Resource for Improving Antibiotic Use in Healthcare Facilities
Infectious Diseases Society of America (IDSA)
Oregon and Southern Washington Association of Professionals in Infection Control and Epidemiology (OSWAPIC)
The Society for Healthcare Epidemiology in America (SHEA)
Note: To view the recorded presentations, go to OAHHS web site. If you cannot logon to the web site, contact Diane Waldo of OAHHS for more information.
National Healthcare Safety Network (NHSN) Resources
FAQ on NHSN, January 2012
We recommend all hospitals reporting procedures download a copy of the ICD-9 codes for each procedure that applies to their facility. NHSN procedures are determined by ICD-9 codes, and a common error is for hospitals to not report all codes associated with a given procedure category. We also recommend you provide a copy of these ICD-9 codes to your IT resource.
The CDC has extensive documentation on NHSN on its web site. The main NHSN training web page covers all components of the NHSN. To meet state reporting requirements, we recommend hospitals become familiar with the following resources:
- NHSN Patient Safety Manual. This provides a link to all chapters in the Patient Safety Manual. The following sections refer to specific chapters in the manual.
- NHSN CLABSI Protocol: Chapter 4 documents conventions to perform surveillance and report CLABSIs in NHSN. We recommend you consult this document frequently for CLABSI surveillance and reporting.
- NHSN SSI Protocol. Chapter 9 documents conventions to perform surveillance and report SSIs in NHSN. We recommend you consult this document frequently for SSI surveillance and reporting.
- CDC Clostridium difficile web page includes FAQ, 2010 SHEA/IDSA guidelines, and toolkits.
- CDC Location Labels and Descriptions Chapter 15 provides descriptions of location for devices, such as central lines, and will assist you mapping your locations to the correct CDC location description
- NHSN Key Terms. Chapter 16 includes definitions for concepts such as ASA score, wound classifications, data of event, type of SSI, etc.
- CDC/NHSN Surveillance Definition of Healthcare-Associated Infection and Criteria for Specific Types of Infections in the Acute Care Setting: Chapter 17 contains the CDC/NHSN surveillance definition of healthcare-associated infection (HAI) and criteria for all specific types of HAI.
- Additional resources related to NHSN can be found in the NHSN library.
Importing Patient Safety Procedure Data in NHSN
Many Oregon hospitals are using an Excel spreadsheet to import their surgical procedure data into NHSN. To do this, we offer the following tools: (1) the CDC protocol to prepare or record data in the spreadsheet, (2) a sample Excel spreadsheet (note: we have highlighted the header for the fields required for state reporting) and (3) directions to convert an Excel spreadsheet to a CSV file, which is required before importing in NHSN.
CDC has also prepared documentation to walk you through the procedure import process in NHSN.
Clinical Document Architecture for NHSN
Clinical Document Architecture (CDA) is a Health Level 7 (HL7) standard which provides framework for format of electronic documents. NHSN has been enabled to accept electronic infection reports, denominator data, and process of care data from commercial infection surveillance systems.
Important NHSN Contact Information
Email address for NHSN-related questions: email@example.com
Email address for SDN digital certificate/secure data network questions: firstname.lastname@example.org;
Internal Data Quality for NHSN
We recommend you create the following four custom reports to check your own data:
||Information in Report |
|CLABSI and SSI Infection Data
||BSI (includes location and dc date); SSI (includes ProcDate, DC date, and linked ProcID) |
||Monthly CLABSI count and CL days |
||All procedures by month with infection counts. |
||For all procedures, Pt ID, DOB, ProcID, AgeAtProc, ProcDur, swClass, trauma, ASA, outpatient status. |
CDC Quick Tips for NHSN Reports:
NHSN Annual Reports:
Surgical Care Improvement Project (SCIP) Measurements
All hospitals that do not have a waiver for SCIP reporting, must report SCIP measurements through the CMS data warehouse. To learn more about SCIP measurements, we refer you to Quality Net. As Quality Net continually issues new specifications manuals for SCIP measures, we recommend you type “SCIP” in the search box on the web page and look for the most updated specifications manual. For your SCIP questions, email Kathy Phipps of Acumentra or call her at (503) 382-3983.
Healthcare Worker Vaccination Survey for Hospitals, Long-Term Care Facilities, and Ambulatory Surgical Centers
The following surveys were released to hospitals and long-term care facilities for the 2010-2011 influenza season: survey form and sample declination form.
NHSN Enrollment and Training Information
Archived NHSN Trainings