Frequently Asked Questions

CLAB Manual - SSI Manual - VAP Prevention Manual

General

1. Where can information related to the National Healthcare Safety Network (NHSN) be found? 7/1/09
2. If a facility is using the NHSN system, can the facility do the actual reporting via MHIRS? 5/20/2005
3. If a facility is not required to report to DHSS can it still use the NHSN? 5/20/2005
4. Why aren't staffing and equipment requirements included in the rule?
5. Do any other states have standards regarding the number of infection control practitioners (ICPs) per facility or per patient load?
6. Are hospitals required to report all CLAB infections identified in the facility? 5/10/2005
7. If facilities choose not to use the CDC system, will they still have to provide patient identifiers?
8. Is "surgeon name" a required data item?
9. Are small hospitals purposely being exempted?
10. Will ambulatory surgery centers (ASCs) use the same risk factors that hospitals use for surgeries?
11. Has anyone from an ASC been contacted for feedback on the rules impacting ASCs? 5/10/2005
12. Do ASCs associated with a hospital report separately or are their data included with the hospital's data?
13. Is it a HIPAA violation for a hospital to report?
14. How are the data be presented for the public? 3/5/2008
15. When will DHSS publish reports and how many months of data will be included in the report? 3/5/2008
16. How should our hospital handle reporting for ICUs not mentioned in the rule, e.g., we have a cardiothoracic ICU, would this be considered a "coronary ICU"?
17. Our hospital has a medical/surgical ICU that is activated on an as-need basis only. Do we have to report?
18. Can facilities use separate systems to report the mandated information to the DHSS (e.g., Use AICE!® to report surgical procedures and MHIRS to report CLAB data)? 5/27/2005
19. Will the physician's name be part of the information reported to MHIRS? 6/1/2005
20. Our hospital has two medical ICUs. How do we report the data when we register for an exemption and when we report to MHIRS? (This would also apply if there were two surgical, coronary, pediatric, medical/surgical, or NICUs.)? 10/3/2005

1. Where can information related to the National Healthcare Safety Network (NHSN) be found? 7/1/2009
Information related to the NHSN may be found at http://www.cdc.gov/nhsn.

2. If a facility is using the NHSN system, can the facility do the actual reporting via MHIRS? 5/20/2005
Yes, if you would like to report it that way. You should register as using MHIRS, but please let the DHSS know that you are using the NHSN system to manage and analyze your data.

3. If a facility is not required to report to DHSS can it still use the NHSN? 5/20/2005
Yes, all healthcare delivery entities may participate.

4. Why aren't staffing and equipment requirements included in the rule?
The DHSS attorney indicated that we do not have statutory authority for a rule on staffing and equipment requirements. Staffing requirements will be covered in a hospital licensing rule.

5. Do any other states have standards regarding the number of infection control practitioners (ICPs) per facility or per patient load?
At this time, we are aware that New Jersey includes standards in their hospital licensing regulations and requires one full-time ICP to every 200 adjusted occupied beds, where the bed occupancy has been adjusted both for an outpatient factor and for the hospital's all-payer mix index (CMI) using a formula. It also states that for every hospital, there shall be at least one half-time ICP.

6. Are hospitals required to report all CLAB infections identified in the facility? 5/10/2005
No, only CLAB infections that occur in the specified intensive care units (ICUs) are required to be reported.

7. If facilities choose not to use the CDC system, will they still have to provide patient identifiers?
A patient identifier will not be needed for CLAB or VAP reporting. However, the patient's medical record number is required for the numerator and denominator for SSI reporting.

8. Is "surgeon name" a required data item?
No, this is not required by CDC and is not required in the DHSS system.

9. Are small hospitals purposely being exempted?
No, the exemptions in the rule were created to conform to the CDC reporting standards. When rates are based upon small numbers, the rates can fluctuate widely and are too unstable to confidently use them. The rule will exempt some hospitals reporting initially, however, it is intended to review this matter later so more hospitals may be required to report in the future.

10. Will ambulatory surgery centers (ASCs) use the same risk factors that hospitals use for surgeries?
Yes.

11. Has anyone from an ASC been contacted for feedback on the rules impacting ASCs? 5/10/2005
Officers of the newly formed Missouri Ambulatory Surgery Center Association (MASCA) were sent a draft of the rule requesting comments. A MASCA representative has attended Advisory Panel meetings.

12. Do ASCs associated with a hospital report separately or are their data included with the hospital's data?
ASCs that are individually licensed must report separately from the hospital.

13. Is it a HIPAA violation for a hospital to report?
Since reporting is required by state law, it is allowable under HIPAA.

14. How are the data be presented for the public? 3/5/08
The Advisory Panel assisted in defining the report for public release. Users can access the data interactively on the DHSS web site. The annual Report to the Governor and the General Assembly may also be accessed at this site.

15. When will DHSS publish reports and how many months of data will be included in the report? 3/5/08
The web site containing the data will be updated quarterly and contain the most current 12 months of data.

16. How should our hospital handle reporting for ICUs not mentioned in the rule, e.g., we have a cardiothoracic ICU, would this be considered a "coronary ICU"?
Your hospital would not have to report for the cardiothoracic ICU. There are many types of ICUs within hospital systems. However, for the purpose of the initial implementation of MHIRS, the DHSS will only require hospitals to report on the ICUs that are listed in the rule: coronary, medical, surgical, medical/surgical, pediatric, and NICU. Reporting information on these ICUs will permit the greatest number of hospitals to report, thus, ultimately making the public reporting of healthcare-associated infections more reliable and accurate for the general public.

17. Our hospital has a medical/surgical ICU that is activated on an as-need basis only. Do we have to report?
Your hospital should complete the on-line MHIRS registration form, check the type of ICU that you have (in this case "medical/surgical") and indicate the number of central line-days for calendar year requested. If you do not know the number of central line-days you may leave that box blank - do not estimate. If the box is left blank, your hospital will be required to report for that ICU. Each year hospitals will report the number of central line-days, by type of ICU, for the preceding year. If an ICU has less than 50 central line-days in the previous calendar year, the hospital will not be required to report on that ICU for the current reporting year.

18. Can facilities use separate systems to report the mandated information to the DHSS (e.g., Use AICE!® to report surgical procedures and MHIRS to report CLAB data)? 5/27/2005
No, all of the required data must be reported using a single reporting system.

19. Will the physician's name be part of the information reported to MHIRS? 6/1/2005
No, physician name or a physician code is not reportable to MHIRS.

20. Our hospital has two medical ICUs. How do we report the data when we register for an exemption and when we report to MHIRS? (This would also apply if there were two surgical, coronary, pediatric, medical/surgical, or NICUs.)? 10/3/2005
When registering for an exemption, your facility should combine the number of central line-days (or ventilator-days, if that is the case) for the two medical ICUs and report that combined number for the central line-days (or ventilator-days) for your medical ICUs. When reporting the number of CLABs or VAPs and corresponding central line-days or ventilator-days for the reporting month, combine the numerator data and the denominator data for the two medical ICUs. (This would also apply if there were two surgical, coronary, pediatric, medical/surgical, or NICUs.)

 

CLAB Manual

1. If a patient in an ICU has a temporary (Quinton) or tunneled (ASHE) hemodialysis catheter, is that device counted as a central line in the central line-days? 5/20/2005
2. Do central lines include the following: implantable-ports, non-tunneled TLC, Swan Ganz catheter, tunneled-Broviac, Groshong, Quinton, Hickman, ASHE catheter, PICC, and umbilical lines? If yes, would they be counted in central line days for that unit? 5/20/2005
3. Is a dialysis catheter considered a central line since it isn’t used for infusion? 5/20/2005
4. Are permanent shunts and balloon pumps considered central lines? 5/20/2005
5. If a patient is admitted to the ICU with a central line in place, is it counted in the central line-days? 5/20/2005
6. What if: a patient had a central line inserted in the ICU; 6 days later the patient has a positive blood culture; and the patient meets the definition for laboratory confirmed bloodstream infection (LCBI). Would this patient be counted as a CLAB infection? 5/20/2005
7. Will maternally-acquired infections in the NICU be counted as CLAB infections? 5/20/2005
8. How do you determine which unit to “credit” with a bloodstream infection (BSI)? E.g., on May 2 patient is in the medical ICU; on May 3 patient is transferred to the coronary ICU; symptoms develop on May 4. Which unit is “credited”? 5/20/2005
9. What should be done if a device-day is not counted? 5/20/2005
10. What should be done if the device-day count sheet is lost or if the person who is designated to count does not complete it for a month? 5/20/2005
11. What should you do if you discover an infection or determine an error occurred after the data was submitted to the DHSS? 5/20/2005
12. The following two questions/situations relate to an ICU patient undergoing dialysis: 6/8/2005

  1. A patient with a dialysis catheter is in one of the ICUs under surveillance for CLABs. If this patient's dialysis catheter is only accessed in the dialysis center, are the central line-days for this patient counted in the ICU's central line-day count?

  2. A patient with a dialysis catheter is in one of the ICUs under surveillance for CLABs. Someone from the dialysis center comes to the ICU to perform the dialysis. Will the central line-days for this patient be counted in the ICU's central line-day count?

13. Can a patient have more than one CLAB infection during his/her stay in the ICU? 7/1/2005
14. Does the birthweight of the infant ever change? E.g., an infant is admitted to a NICU from another hospital. Do you use the weight on admission or do you use the birthweight? 9/16/2005
15. If the patient is discharged with a central line in place and returns two to four weeks after discharge with a central line infection, should this infection be counted as a healthcare-associated infection? 9/28/2005

1. If a patient in an ICU has a temporary (Quinton) or tunneled (ASHE) hemodialysis catheter, is that device counted as a central line in the central line-days? 5/20/2005
If a line meets the definition, then it is a central line and should be counted. The only exception to this would be an implanted device that is not used. In this situation, the line would only be counted beginning on the first day it is accessed (e.g., physician orders that the port-a-cath be flushed). Then it would be counted every day thereafter.

2. Do central lines include the following: implantable-ports, non-tunneled TLC, Swan Ganz catheter, tunneled-Broviac, Groshong, Quinton, Hickman, ASHE catheter, PICC, and umbilical lines? If yes, would they be counted in central line-days for that unit? 5/20/2005
Yes to all of the above if they meet the definition. Central lines are not defined by type of device.

3. Is a dialysis catheter considered a central line since it isn’t used for infusion? 5/20/2005
A dialysis catheter is considered a central line if it meets the definition of a central line. It is used for infusion of the patient’s own blood.

4. Are permanent shunts and balloon pumps considered central lines? 5/20/2005
Yes, if they meet the definition of a central line. Central lines are not defined by type of device.

5. If a patient is admitted to the ICU with a central line in place, is it counted in the central line-days? 5/20/2005
It must first be determined if it meets the definition of a central line. If it meets the definition and it is accessed, then it is counted (e.g., a patient is admitted with a central line that is not being used; the physician comes in on day three and flushes the line; the day of the flush is considered the first central line day).

6. What if: a patient had a central line inserted in the ICU; 6 days later the patient has a positive blood culture; and the patient meets the definition for laboratory confirmed bloodstream infection (LCBI). Would this patient be counted as a CLAB infection? 5/20/2005
If the line was not discontinued, it would be counted as a CLAB. If the line were to be discontinued on day 4 or earlier, it would not be counted as a CLAB.

7. Will maternally-acquired infections in the NICU be counted as CLAB infections? 5/20/2005
No. If an infection in a neonate occurs within 48 hours of delivery, then it is considered nosocomial and maternally acquired. Note: if an infection is maternally acquired it cannot also be device-associated. Maternal acquisition takes precedence over the device.

8. How do you determine which unit to “credit” with a bloodstream infection (BSI)? E.g., on May 2 patient is in the medical ICU; on May 3 patient is transferred to the coronary ICU; symptoms develop on May 4. Which unit is “credited”? 5/20/2005
The patient is followed for 48 hours after transfer to another unit. If a BSI develops within that 48 hour period, the original unit is “credited” with the infection. See the definition for "Transfer Rule".

9. What should be done if a device-day is not counted? 5/20/2005
Days should not be skipped. If days are not recorded (say on the weekend), then the staff should be interviewed and charts reviewed to determine what the counts were at the appropriate time.

10. What should be done if the device-day count sheet is lost or if the person who is designated to count does not complete it for a month? 5/20/2005
Missouri has determined device-day counts for specified ICUs to be a requirement. Facilities may wish to establish criteria for staff to follow to insure that this scenario doesn’t occur.

11. What should you do if you discover an infection or determine an error occurred after the data was submitted to the DHSS? 5/20/2005
You may make the necessary changes and resubmit the data.

12. The following two questions/situations relate to an ICU patient undergoing dialysis: 6/8/2005

  1. A patient with a dialysis catheter is in one of the ICUs under surveillance for CLABs. If this patient's dialysis catheter is only accessed in the dialysis center, are the central line-days for this patient counted in the ICU's central line-day count?
    No, in this instance, the central line-days would not be counted in the ICU central line-day count.
  2. A patient with a dialysis catheter is in one of the ICUs under surveillance for CLABs. Someone from the dialysis center comes to the ICU to perform the dialysis. Will the central line-days for this patient be counted in the ICU's central line-day count?
    Yes, in this instance, the central line-days would be counted in the ICU central line-day count.

Note: As it is with all surveillance protocols, you set a definition and apply it consistently. If the line is accessed (by any of the staff) on the unit where surveillance is being conducted, then the line is counted. We do, of course, realize that patients are occasionally dialized on the unit, but this is the exception rather than the rule -- the line days should be counted.

13. Can a patient have more than one CLAB infection during his/her stay in the ICU? 7/1/2005
Yes, however, the first infection must be completely resolved before the second infection begins.

14. Does the birthweight of the infant ever change? E.g., an infant is admitted to a NICU from another hospital. Do you use the weight on admission or do you use the birthweight? 9/16/2005
Birthweight is always the weight at birth. See definition for "Birthweight".

15. If the patient is discharged with a central line in place and returns two to four weeks after discharge with a central line infection, should this infection be counted as a healthcare-associated infection? 9/28/2005
If the central line is accessed outside the facility, it no longer becomes a healthcare-associated infection.

Surgical Site Infections (SSI) Manual

1. If another surgery is performed during an abdominal hysterectomy (e.g., BSO, appendectomy, adhesion removal, etc.), how is the duration of the hysterectomy calculated? 11/2/2005
2. If two separate procedures are done through two incisions (e.g., a breast augmentation and an abdominal liposuction), how is the duration of the breast surgery calculated? 3/5/2008
3. What if a CABG patient returns to the operating room for bleeding greater than 24 hours after the initial surgery and subsequently develops an infection. Is the infection related to the CABG or is it related to the re-exploration for bleeding? 3/5/2008
4. If a patient's chest is left open after a CABG, should they be captured in the denominator even though they would not be counted in the numerator if they developed an infection? 1/19/2006
5. Are there additional "markers" for the superficial infection definition? For example, if the physician describes the wound as red and starts antibiotics, or antibiotics are started but the physician really does not think it is an infection. 1/19/2006
6. Should a patient that has an infection in the hip joint at the time of their replacement or revision be included in the denominator and would they be counted as an SSI ff they developed a post-op infection? 1/19/2006
7. A patient has chronic hip infections, has a hip replacement and develops an infection. After treatment, the patient returns to the OR for revision and develops an infection with the same organism. Is this person counted twice in the denominator and twice for an infection? The patient appeared to have been completely treated, so wound class was designated as "clean". 1/19/2006
8. Are laparoscopic hysterectomies reportable? 1/19/2006
9. If a patient has an infection at the donor site for a CBGB procedure, is it reported in MHIRS? 6/9/2006

1. If another surgery is performed during an abdominal hysterectomy (e.g., BSO, appendectomy, adhesion removal, etc.), how is the duration of the hysterectomy calculated? 11/2/2005
The duration is for all procedures (together) that are done through the same incision. If the hysterectomy takes 90 minutes and the appendectomy takes 20 minutes, then the duration for the hysterectomy is 1 hour 50 minutes and the duration for the appendectomy is 1 hour 50 minutes.

2. If two separate procedures are done through two incisions (e.g., a breast augmentation and an abdominal liposuction), how is the duration of the breast surgery calculated? 3/5/2008
See the Protocol section of the SSI Reporting Manual.  Under denominator data it states, “If more than one MHIRS procedure is performed during the same trip to the OR, a record is generated for each operative procedure.”  In the instance cited above, the ASC would note the incision time to closure time for the breast augmentation.

3. What if a CABG patient returns to the operating room for bleeding greater than 24 hours after the initial surgery and subsequently develops an infection. Is the infection related to the CABG or is it related to the re-exploration for bleeding? 3/5/2008
See the Protocol section of the SSI Reporting Manual.  Under numerator data it states, "If a patient has several operative procedures prior to a surgical site infection, assign the infection to the operation that was performed most closely in time prior to the surgical site infection date, unless there is evidence that the infection is associated with a different operation."

4. If a patient's chest is left open after a CABG, should they be captured in the denominator even though they would not be counted in the numerator if they developed an infection? 1/19/2006
A wound that is left open does not meet the definition of an "Operative Procedure" and is not counted in either the denominator or the numerator.

5. Are there additional "markers" for the superficial infection definition? For example, if the physician describes the wound as red and starts antibiotics, or antibiotics are started but the physician really does not think it is an infection. 1/19/2006
You will need to apply the definition for SSI superficial by going down the list of criteria and seeing if all are met. If the criteria are met, it is considered an infection - even if the physician doesn't say it is. However, if the physician says it's an infection - it's an infection, even if it doesn't meet the criteria. There are no "markers" for the surgeon diagnosis (e.g., treatment). Either the infection meets the criteria or it doesn't.

6. Should a patient that has an infection in the hip joint at the time of their replacement or revision be included in the denominator and would they be counted as an SSI ff they developed a post-op infection? 1/19/2006
Every patient that undergoes a HPRO procedure is included in the denominator. If the old infection reappears it would not be counted in the numerator because it was "present or incubating at the time of admission". If a new infection develops it will be counted. For example, the HPRO is a revision and there is pus in the organ space when the incision is opened. First of all, the wound class would be "Dirty". Let's assume that the culture grows MRSA. If, two weeks later the patient develops a superficial SSI that grows e. coli, it's probably a new infection and would be counted. The ICP may have to make a decision if it's questionable.

7. A patient has chronic hip infections, has a hip replacement and develops an infection. After treatment, the patient returns to the OR for revision and develops an infection with the same organism. Is this person counted twice in the denominator and twice for an infection? The patient appeared to have been completely treated, so wound class was designated as "clean". 1/19/2006
Every patient that undergoes a HPRO procedure is included in the denominator - the replacement and revision are two separate procedures and should be counted as such. Either the patient has an infection at the time of surgery or he/she does not. The concept of "chronic infection" does not figure into the equation. The wound class is not assigned prior to the procedure, but at the conclusion of the procedure. If there does not appear to be an infection when the surgeon opens the patient, then it would be classified accordingly - if the patient then develops an infection it would be counted in the numerator.

8. Are laparoscopic hysterectomies reportable? 1/19/2006
Yes. The definition for "Operative Procedure", includes the laparoscopic approach.

9. If a patient has an infection at the donor site for a CBGB procedure, is it reported in MHIRS? 6/9/2006
Yes, it should be reported in MHIRS. The NHSN defines this type of infection as a superficial incisional secondary infection. However, MHIRS does not require that you report the infection site.

Ventilator-Associated Pneumonia (VAP) Prevention Manual

1. Who can document a contraindication?  Does it have to be a physician or can a nurse document the contraindication in the nursing notes? (9/14/07)
2. As of July 1, 2009, is participation still voluntary? (7/1/09)
3. Who makes the observations? (9/14/07)
4. Do you have to make the actual observation or can it be done by chart review? (9/14/07)
5. For small facilities with limited ventilator usage, do we do 100% review? (9/14/07)
6. Are we required to use the permutation table, or can we choose another method to randomly select our observation day? (9/14/07)
7. Are patients on tracheostomy tubes counted? (9/14/07)
8. What do you do if the patient’s bed is “down” for a valid reason during the observation (e.g., turning patient, patient is having an abdominal x-ray or a procedure that requires a supine position)? (9/14/07)
9. Data collection will be difficult on weekends, due to the shortage of staff.  Can we adjust the permutation schedule to exclude data collection on weekends? (9/14/07)
10. Some of the small hospitals have very few ventilated patients.  When using the permutation table, there may be several weeks when there isn’t a patient on the ventilator in the ICU on the specified day for HOB observations.  Should the hospital still adhere to the day listed in the table, or, should they record their observations when they have a ventilated patient in the ICU regardless of the day of the week? (9/14/07)
11. We have a burn unit that has two ICU beds.  Are there a certain number of ventilator days an ICU should have before they are included in the HOB elevation reporting? (9/14/07)
12. What are contraindications to HOB elevation to 30º or greater? (9/14/07)

1. Who can document a contraindication?  Does it have to be a physician or can a nurse document the contraindication in the nursing notes?
It will be up to the hospital to determine who will determine contraindications and how they will be documented.

2. As of July 1, 2009, is participation still voluntary?
Yes, participation is voluntary at this time. We anticipate the law will be amended. We are hoping that broad participation by hospitals will help support efforts to amend the law.  If the law is not amended, it is likely that VAP incidence reporting will become a reality.

3. Who makes the observations?
Anyone who is trained in the proper methods may do the observations.

4. Do you have to make the actual observation or can it be done by chart review?
Chart review or a computer monitoring system is not an acceptable method of observation.  The patient must actually be observed.

5. For small facilities with limited ventilator usage, do we do 100% review?
No.  Observations should be performed using the permutation table schedule.  Facilities with less than 100 ventilator days in 2006 are exempt from reporting.

6. Are we required to use the permutation table, or can we choose another method to randomly select our observation day?
All hospitals must use the same process to do the random selection.  This will eliminate any bias that might occur if the selection process is not randomized.  The permutation table is already in random order and all hospitals should use it.  It indicates on which days HOB should be monitored for each month and does not require modification or skipping of any rows.

7. Are patients on tracheostomy tubes counted?
Yes, all patients on a ventilator are counted.

8. What do you do if the patient’s bed is “down” for a valid reason during the observation (e.g., turning patient, patient is having an abdominal x-ray or a procedure that requires a supine position)?
Ideally, you would return when the procedure was completed to make the observation.  If this is not possible, you would record N/A because a valid observation was unable to be made.

9. Data collection will be difficult on weekends, due to the shortage of staff.  Can we adjust the permutation schedule to exclude data collection on weekends?
No.  Random selection means just that.  If weekends are excluded, the observations will no longer be random and will not be comparable to data from hospitals that do monitor on weekends.  Also, it is just as important for a patient’s HOB to be elevated on the weekends as it is during the week.

10. Some of the small hospitals have very few ventilated patients.  When using the permutation table, there may be several weeks when there isn’t a patient on the ventilator in the ICU on the specified day for HOB observations.  Should the hospital still adhere to the day listed in the table, or, should they record their observations when they have a ventilated patient in the ICU regardless of the day of the week?
The hospital should adhere to the permutation table.  If there are no ventilated patients on the designated observation day, there will be nothing to count.  Remember, hospitals that had less than 100 ventilator days in 2006 are exempt from reporting, so this may eliminate small hospitals.

11. We have a burn unit that has two ICU beds.  Are there a certain number of ventilator days an ICU should have before they are included in the HOB elevation reporting?
Hospitals that had 100 or more ventilator days for 2006 are asked to report HOB elevation information.  If your hospital meets those criteria, you would report the HOB elevation information for the burn unit as one of the components of “Other ICUs”.

12. What are contraindications to HOB elevation to 30º or greater?
Contraindications should be determined by the medical staff of the hospital and documented in some manner (e.g., standards or in the patient’s chart).  Following is a non-inclusive list of possible contraindications: