Infection
Type | Hospital
Locations
Included in
Surveillance | Infection
(Event)
Data Required
Monthly | Denominator
(Summary)
Data Required
Monthly | Link to NSHN Surveillance and Reporting Protocols |
Central line associated bloodstream infections
(CLABSI) | All inpatient locations | Positive blood specimen from inpatients with central lines that meets NSHN criteria for CLABSI | - Central line days for each inpatient location
- Inpatient days for each location
| Surveillance for CLABSI
(CDC NHSN) |
Methicillin
resistant staphylococcus aureus
bloodstream infection
(MRSA BSI) | - Facility wide inpatient locations
- Emergency Department
- 24-hour observation units
- Acute independent rehabilitation facilities (IRF) (defined as having a separate CCN)
| All positive MRSA blood specimens | - Inpatient days
- Admissions
- Inpatient days minus IRF and independent psychiatric facility (IPF) (separate CCN)
- Admissions minus IRF and IPF
- Emergency Department encounters
- 24-hour observation unit encounters
| Surveillance for C. difficile, MRSA, and other Drug-Resistant Infections
(CDC NHSN) |
Vancomycin resistant enterococcus bloodstream infection
(VRE BSI) | - Facility wide inpatient locations
- Emergency Department
- 24-hour observation units
- IRF
| All positive VRE blood specimens | - Inpatient days
- Admissions
- Inpatient days minus IRF and IPF days
Admissions minus IRF and IPF admissions - Emergency Department encounters
- 24-hour observation unit encounters
| Surveillance for C. difficile, MRSA, and other Drug-Resistant Infections
(CDC NHSN) |
Clostridioides difficile
infections
(CDI) | - Facility wide inpatient locations, excluding NICU and well-baby
- Emergency Department
- 24-hour observation units
- IRF
| All positive CDI stool specimens | - Inpatient days
- Admissions
- Inpatient days minus NICU/Well-baby days
- Inpatient admissions minus NICU/Well-baby admissions
- Inpatient days minus IRF/IPF days
- Admissions minus IRF/IPF admissions
- Emergency Department encounters
- 24-hour observation unit encounters
| Surveillance for C. difficile, MRSA, and other Drug-Resistant Infections
(CDC NHSN) |
Surgical
Site infections
(SSI) | Operative procedures on patients whose admission (surgery) and discharge dates are different calendar days | Superficial incisional,* deep incisional, and organ/space infections that meet NHSN definitions and are associated with any of the 28 NHSN procedure codes mandated for CA hospital reporting; specifically,
AAA, APPY, BILI, CARD, CBGB, CBGC, CHOL, COLO, CSEC, FUSN, FX, GAST, HPRO, HTP, HYST, KPRO, KTP, LAM, LTP, NEPH, OVRY, PACE, REC, SB, SPLE, THOR, VHYS, XLAP** Descriptions and associated ICD-10 codes for each procedure category can be found on the NHSN website at NHSN Procedure Codes and Associated ICD-10 Codes (EXCEL) *Superficial SSI are not included in the CDPH annual public HAI report, but are required to be reported per NHSN protocols for appropriate SSI risk adjustment | Enter every qualifying inpatient operative procedure performed from the list of the 28 NHSN procedure codes that have CA mandated surveillance. | NHSN Surveillance for SSI Events
(CDC NHSN) |
Measure
Type | Included
in
Surveillance | Numerator
Data | Denominator
Data | Link to NHSN Requirements and Protocols |
Central line insertion
practices
(CLIP) | Central lines inserted in all intensive care unit locations (including adult, pediatric, and neonatal ICUs) | - Adherence to central line insertion bundle elements for each line inserted
| Not applicable; denominator is the number of line insertions reported | Surveillance for CLIP Adherence (CDC NHSN) |
Healthcare Personnel
Influenza Vaccination | Hospital healthcare personnel (HCP) in categories: - Employees (staff on payroll)
- Non-employee licensed independent practitioners (physicians, advanced practice nurses and physician assistants)
- Other contract personnel
- Adult students, trainees and volunteers
| From October 1-March 31, the numbers of HCP (by category) who: - Received influenza vaccination administered at the hospital
- Provided documentation of influenza vaccine elsewhere
- Had medical contraindication to the vaccine
- Declined influenza vaccination
- Had an unknown vaccination status or did not otherwise meet any of the definitions of the above-mentioned criteria
| Total number of HCP (by category) working in the hospital for at least 1 day between October 1 and March 31 | Surveillance for Healthcare Personnel Vaccination (CDC NHSN) |