NHSN Reporting
The National Health Safety Network (NHSN) is the primary tool used for collecting healthcare-associated infection (HAI) data from healthcare facilities in most U.S. states and territories. The HAI Program uses NHSN data to estimate the burden of HAIs in Oregon and provides data to measure the impact of Oregon surveillance and prevention programs. The following are required reporting under
OAR 333-018, to the NHSN.
HAI Tableau Dashboard
Mandatory healthcare-associated infections reporting includes:
- Central line-associated bloodstream infections (CLABSIs)
- Catheter-associated urinary tract infections (CAUTIs)
- Laboratory-identified methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSIs)
- Laboratory-identified Clostridioides difficile infections (CDI) (previously Clostridium difficile)
- Surgical site infections (SSIs) resulting from the following procedures:
- Coronary artery bypass graft (CBGB)
- Knee prosthesis (KPRO)
- Colon surgery (COLO)
- Hip prosthesis (HPRO)
- Abdominal hysterectomy (HYST)
View the HAI Data Dashboard
Mandatory healthcare-associated infections reporting includes:
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Dialysis events
- IV antimicrobial start
- Positive blood culture
- Pus, redness, or increased swelling at vascular access site
Healthcare Worker Influenza Vaccination Reporting
Healthcare workers as a group are at greater risk of exposure to some communicable diseases than the general population because of their contact with patients or infective material in their working environment. There is also a risk that infected healthcare workers could contribute to transmission of disease to vulnerable patients at higher risk for severe illness, complications and death.
Protection of healthcare workers through vaccination is therefore an important part of patient safety and infection prevention and control in healthcare settings, as well as a cornerstone of occupational health and safety.
Questions
Contact Monika Samper at at
monika.e.samper@oha.oregon.gov or 971-673-1111
Healthcare Worker Vaccine Tableau Dashboard
Who this applies to
- Hospitals
- Nursing facilities
- Dialysis facilities
- Free-standing ambulatory surgical centers
- Inpatient psychiatric facilities
What data are required?
- Staff influenza vaccinations
- Documented contraindications
- Informed declination rates for staff
Why is it required?
In accordance with ORS 442.851 and OAR 333-018-0000 through 333-018-0145
Deadline
May 31, 2024 (for the 2023-2024 influenza season)
Failure to meet this deadline may result in fines up to $500 per day.
Acute Care Facilities
Definition for counting healthcare personnel in an Acute Care Facility:
- Acute care hospital inpatient and outpatient counts are to be combined and submitted on a single influenza vaccination summary data form.
- Inpatient and outpatient units/departments must share the same CMS Certification Number (CCN) as the hospital AND be physically attached to the acute care facility OR be co-located on the same medical campus and function as units of the acute care facility.
Report through NHSN
Skilled Nursing Facilities
Starting with the 2022 – 2023 flu season, SNFs should be reporting Healthcare Worker Influenza Vaccination data via the National Healthcare Safety Network (NHSN) to align with new Centers for Medicare and Medicaid Services (CMS) requirements. In order for OHA to access SNF data in NHSN, each nursing facility needs to join the OHA group and confer rights. This needs to be done by each facility NHSN facility administrator.
Other Facility Types
Inpatient Rehabilitation facilities (IRFs)
Ambulatory Surgery Centers (ASCs), Inpatient Psychiatric Facilites, and Outpatient Dialysis Facilities
While the CMS no longer requires these facilities to report HCP influenza vaccination data through NHSN, the state of Oregon does require these facilities to report the data.
How to Collect Data
There are two documents to assist in collecting data:
HAI and Outbreak Reporting
Every day, patients get infections in healthcare facilities while they are being treated for something else. These infections can have devastating emotional, financial, and medical effects. Worst of all, they can be deadly.
When an emerging bug is found in a health care setting, providers play an important role in reporting it to public health. We respond to identify other infected people so that infection prevention and control measures can be targeted to prevent the spread to others.
Monthly Communicable Disease Tableau Dashboard
- Acute care hospitals
- Long-term acute care hospitals (LTACHs)
- Long-term care facilities, nursing homes, residential care facilities, assisted living facilities, adult foster homes
- Ambulatory surgical centers (ASCs)
- Freestanding birth centers
- Outpatient renal dialysis centers
- Other defined healthcare facilities (ORS 442.015)
Report to the local health authority:
- Any known or suspected common-source outbreaks, including outbreaks associated with health care, regardless of whether the disease, infection, microorganism, or condition is specified in the reportable disease rule; or
- Any uncommon illness of potential public health significance, including:
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Carbapenem resistant Enterobacterales (CRE)
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Any carbapenemase-producing organism (CPO)*
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Candida auris*
- Organisms that are pan-nonsusceptible (intermediate or resistant using current CLSI breakpoints) to all antibiotics tested by the clinical laboratory*
Reportable HAIs are summarized in the HAI Disease Reporting Poster (pdf) and MDRO Disease Reporting Poster (pdf).
Why is it required?
In accordance with OAR 333-018-0000, specifically,
OAR 333-018-0015;
ORS 433.004.
Deadline
Within 1 working day of identification.
Submit a report to the local health authority in the county of residence of the patient, either electronically or
call/fax the local public health authority (OAR 333-018-0015).
Local health authorities need to report HAI outbreaks, including MDRO outbreaks, to the Acute and Communicable Disease Prevention Program at 971-673-1111 within 24 hours of receiving an outbreak report. Local health authorities are empowered to
investigate such outbreaks under OAR 333-019-0000, ORS 433.006.
-
General definitions: an “unusual" number of patients or residents with the same healthcare-associated infection, including MDROs, clustered by time and place.
-
Working definition: two or more patients or residents with a healthcare-associated infection in the same healthcare facility who have matching organism (genus, species), including MDROs, similar exposures, and onset dates within 12 months of each other.
Lab-Multidrug Resistant Organism (MDRO) Reporting
Who this applies to:
All labs in Oregon
What is required?
All labs in Oregon are required to submit these organisms to the Oregon State Public Health Lab (OSPHL):
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All pan-non-susceptible Gram-negative bacilli isolates— i.e., those found to be intermediate or resistant to the entire antibiotic susceptibility panel used in the clinical lab.
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Confirmed or suspectedCandida auris from any sterile or non-sterile site. Several yeast identification methods can misidentify C. auris as other rare Candida species. See CDC's algorithm for when to suspect Candida auris.
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All carbapenem-resistant (MIC ≥ 8) Acinetobacter species isolates from any sterile or non-sterile site.
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All carbapenem-resistant Enterobacterales species isolates from any sterile or non-sterile site.
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All confirmed carbapenemase-producing organism (CPO) identified by labs performing their own carbapenemase testing (e.g., Carba-R assay, Carba NP).
In addition, Portland Tri-county area labs submit:
Why is it required?
In accordance with OAR 333-018-0018
Who can participate?
Any laboratory in Oregon.
What needed?
Labs send the following isolates to OSPHL or the Antibiotic Resistance Laboratory Network (ARLN) laboratory in Washington state:
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Carbapenem-resistant (MIC >8) Pseudomonas aeruginosa (CRPA) isolates (Ertapenem has weak activity and should not be used to determine carbapenem resistance.)
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Candida spp. isolates excluding Candida albicans: from all sites
-
Unspeciated Candida isolates: from all sites
Why is this important?
The OSPHL tests all CRPA isolates for carbapenamese production, a concerning feature of some CRPAs. This allows us to monitor rates of carbapenemase producing organisms (CPOs) among CRPA in Oregon. If we notice increases in CPOs, we can adjust our prevention plans and prevent further spread.
Similarly, the Candida sentinel surveillance program will help detect Candida (Candidozyma) auris and new emerging strains of highly resistant Candida species in Oregon.
How to join
Email us at hai@odhsoha.oregon.gov.
For more information about reporting requirements:
Interfacility Transfer MDRO Notification
- Hospitals
- Long-term acute care hospitals
- Ambulatory surgery centers
- Outpatient renal dialysis
- Nursing homes
- Residential care facilities
- Assisted living facilities
- Adult foster homes
What is required?
When a healthcare facility transfers or discharges a patient who is infected or colonized with a multidrug-resistant organism (MDRO) or pathogen which warrants Transmission-based Precautions, it must include written notification of the infection or colonization to the receiving facility in transfer documents. The referring facility must ensure that the documentation is readily accessible to all parties involved in patient transfer (for example, referring facility, medical transport, emergency department, receiving facility).
Why is it required?
Precautions taken when a patient with an MDRO or transmissible pathogen enters a healthcare facility is the best measure
to prevent spread in a new facility. Depending on the bug, precautions to prevent transmission (e.g., Transmission-based Precautions) include hand washing and wearing gowns and gloves.
Staff responsible for facility infection control should work with clinical and administrative staff who oversee the admission and discharge process to identify how this information will be added to current transfer procedures. Some facilities use a pre-made form (see examples below), or add a field in the electronic medical record to populate their transfer worksheets.
Resources