Network (NHSN) Manual. HEALTHCARE PERSONNEL SAFETY. COMPONENT PROTOCOL: Healthcare Personnel Exposure Module. Division of Healthcare ...
Network (NHSN) Manual. HEALTHCARE PERSONNEL SAFETY COMPONENT PROTOCOL: Healthcare Personnel Exposure Module . Division of Healthcare Quality Promotion . National Center for Emerging, Zoonotic and Infectious Diseases . Atlanta, GA, USA
The National Healthcare Safety Network (NHSN) Manual. Healthcare personnel safety component protocol. Healthcare Personnel Vaccination Module...
The National Healthcare Safety Network (NHSN) Manual
HEALTHCARE PERSONNEL SAFETY COMPONENT PROTOCOL:
Healthcare Personnel Exposure Module
Division of Healthcare Quality Promotion National Center for Emerging, Zoonotic and Infectious Diseases
Atlanta, GA, USA
Last reviewed March 2020
Table of Contents
Chapter
Title
1 Introduction to the Healthcare Personnel Safety Component
2 Healthcare Personnel Safety Reporting Plan
Blood/Body Fluid Exposure Options (With and Without 3 Exposure Management)
4 Influenza Exposure and Treatment Option
5 Tables of Instructions
6 Key Terms
7 CDC Codes (Occupations, Devices and PEP Drugs)
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Introduction to the HPS Component of NHSN
Introduction to Healthcare Personnel Safety Component of NHSN
In recent years, occupational hazards faced by healthcare personnel (HCP) in the United States have received increasing attention. Although recommendations, guidelines, and regulations to minimize HCP exposure to such hazards have been developed, additional information is needed to improve HCP safety. In particular, existing surveillance systems are often inadequate to describe the scope and magnitude of occupational exposures to infectious agents and noninfectious occupational hazards that HCP experience, the outcomes of these exposures and injuries, and the impact of preventive measures. The lack of ongoing surveillance of occupational exposures, injuries, and infections in a national network of healthcare facilities using standardized methodology also compromises the ability of the Centers for Disease Prevention and Control (CDC) and other public health agencies to identify emerging problems, to monitor trends, and to evaluate preventive measures.
The Healthcare Personnel Safety (HPS) Component of the National Healthcare Safety Network (NHSN) was launched in 2009. The component consists of two modules: 1) Healthcare Personnel Exposure; and (2) Healthcare Personnel Vaccination. The Healthcare Personnel Exposure module includes: Blood/Body Fluid Exposure Only; Blood/Body Fluid Exposure with Exposure Management; and Influenza Exposure Management. The Healthcare Personnel Vaccination module includes: Influenza Vaccination Summary.
Data collected in this component of NHSN will help healthcare facilities, HCP organizations, and public health agencies to monitor and report trends in blood/body fluid exposures, to assess the impact of preventive measures, to characterize antiviral medication use for exposures to influenza, and to monitor influenza vaccination rates among HCP. In addition, this surveillance component will allow CDC to monitor national trends, to identify newly emerging hazards for HCP, to assess the risk of occupational infection, and to evaluate measures, including engineering controls, work practices, protective equipment, and post-exposure prophylaxis designed to prevent occupationally-acquired infections. Hospitals and other healthcare facilities participating in this system will benefit by receiving technical support and standardized methodologies, including a web-based application, for conducting surveillance activities on occupational health. The NHSN reporting application will enable participating facilities to analyze their own data and compare these data with a national standard.
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Healthcare Personnel Safety Reporting Plan
Healthcare Personnel Safety Reporting Plan
The Healthcare Personnel Safety Monthly Reporting Plan Form (CDC 57.203) is used by an NHSN facility to inform CDC which healthcare personnel safety modules are used during a given month. This guides NHSN on what data to expect from the user in a given month and allows CDC to select the data that should be included into the aggregate data pool for analysis. Each participating facility is to enter a monthly plan to indicate the module to be used, if any, and the exposures and/or vaccinations that will be monitored.
A plan must be completed for every month that data are entered into NHSN, although a facility may choose "No NHSN Healthcare Personnel Safety Modules Followed this Month" as an option. The Instructions for Completion of Healthcare Personnel Safety Monthly Reporting Plan Form includes brief instructions for collection and entry of each data element on the form.
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Blood/Body Fluid Exposure Option
Blood/Body Fluid Exposure Option
Introduction: Transmission of bloodborne pathogens [e.g., Hepatitis B virus (HBV), Hepatitis C virus (HBC), Human Immunodeficiency Virus (HIV)] from patients to healthcare workers (HCW) is an important occupational hazard faced by healthcare personnel (HCP). The risk of bloodborne pathogen transmission following occupational exposure depends on a variety of factors that include source patient factors (e.g., titer of virus in the source patient's blood/body fluid), the type of injury and quantity of blood/body fluid transferred to the HCW during the exposure, and the HCW's immune status. The greatest risk of infection transmission is through percutaneous exposure to infected blood. Nevertheless, transmission of HBV, HCV, or HIV after mucous membrane or non-intact skin exposure to blood has also been reported. The risk of transmission of these pathogens through mucocutaneous exposure is considered lower than the risk associated with a percutaneous exposure.
An estimated 385,000 percutaneous injuries (i.e., needlesticks, cuts, punctures and other injuries with sharp objects) occur in U.S. hospitals each year. Prevention of occupational transmission of bloodborne pathogens requires a diversified approach to reduce blood contact and percutaneous injuries including improved engineering controls (e.g., safer medical devices), work practices (e.g., technique changes to reduce handling of sharps), and the use of personal protective equipment (e.g., impervious materials for barrier precautions). Since 1991, when the U.S. Occupational Safety and Health Administration (OSHA) first issued its Bloodborne Pathogens Standard, the focus of regulatory and legislative activity has been on implementing a hierarchy of control measures. The federal Needlestick Safety and Prevention Act signed into law in November 2000 authorized OSHA's revision of its Bloodborne Pathogens Standard to more explicitly require the use of safety-engineered sharp devices. (http://www.osha.gov/SLTC/bloodbornepathogens/). Other strategies to prevent infection include hepatitis B immunization and postexposure prophylaxis for HIV and HBV. Strategies for prevention of percutaneous injuries are addressed in CDC's Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Program at http://www.cdc.gov/sharpssafety/index.html.
Facilities are not required to collect data for exposures that involve intact skin or exposures to body fluids that do not carry a risk of bloodborne pathogen transmission (e.g., feces, nasal secretions, saliva, sputum, sweat, tears, urine and vomitus) unless these are visibly contaminated with blood. However, facilities that routinely collect data on such exposures may enter this information into the system.
(i) Methodology
Occupational exposures to blood and body fluids in healthcare settings have the potential to transmit HBV, HCV, or HIV. Use of the Blood/Body Fluid Exposure Option permits a
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Blood/Body Fluid Exposure Option
healthcare facility to record information about the exposure and its management. This option can be used in any healthcare setting where there is potential for occupational exposure to blood and body fluids among HCP. This option requires that data be entered into NHSN when exposures occur, as indicated in the Healthcare Personnel Safety Monthly Reporting Plan (CDC 57.203). In general, these data may be provided by the occupational health department in the facility or may be provided by the infection control/epidemiology department, as appropriate. NHSN forms should be used to collect all required data, using the definitions included for each data field.
Blood/Body Fluid Exposure with or without Exposure Management
A facility may choose to report exposure events alone or exposure events and subsequent management and follow-up of each event, including administration of postexposure prophylaxis (PEP) to the HCW and any laboratory test results collected as part of exposure management.
Settings: Any healthcare setting with the potential for occupational exposure to blood and body fluids.
Requirements: Blood and body fluid exposures are to be reported as they occur during the calendar year.
Definitions:
· Bite: A human bite sustained by a HCW from a patient, other HCW, or visitor.
· Bloodborne pathogens: Pathogenic microorganisms that may be present in human blood and can cause disease in humans. These pathogens include, but are not limited to hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV).
· HCW (Healthcare Worker): A person who works in the facility, whether paid or unpaid, who has the potential for exposure to infectious materials, including body substances, contaminated medical supplies and equipment, contaminated environmental surfaces, or contaminated air. Healthcare worker is the singular form of healthcare personnel.
· HCP (Healthcare Personnel): A population of healthcare workers working in a healthcare setting.
· Hollow-bore needle: Needle (e.g., hypodermic needle, phlebotomy needle) with a lumen through which material (e.g., medication, blood) can flow.
· Mucous membrane exposure: Contact of mucous membrane (e.g., eyes, nose, or mouth) with the fluids, tissues, or specimens listed below in "Occupational exposure."
· Non-intact skin: Areas of the skin that have been opened by cuts, abrasions, dermatitis, chapped skin, etc.
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Blood/Body Fluid Exposure Option
· Non-intact skin exposure: Contact of non-intact skin with the fluids, tissues, or specimens listed below in "Occupational exposure."
· Non-Responder to Hepatitis B vaccine: A HCW who has received two series of hepatitis B vaccine is serotested within 2 months after the last dose of vaccine and does not have antiHBs 10 mIU/mL.
· Occupational exposure: Contact with blood, visibly bloody fluids, and other body fluids (i.e., semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid, tissues, and laboratory specimens that contain concentrated virus) to which Standard Precautions apply and during the performance of an HCW's duties. Modes of exposure include percutaneous injuries, mucous membrane exposures, non-intact skin exposures, and bites.
· Percutaneous injury: An exposure event occurring when a needle or other sharp object penetrates the skin. This term is interchangeable with "sharps injury."
· Sharp: Any object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires.
· Sharps Injury: An exposure event occurring when any sharp object penetrates the skin. This term is interchangeable with "percutaneous injury."
· Solid Sharp: A sharp object (e.g., suture needle, scalpel) that does not have a lumen through which material can flow.
Reporting Instructions:
Forms Description and Purpose: (See also: Tables of Instructions for Completion of Healthcare Personnel Safety Component forms)
All NHSN facilities following the Blood/Body Fluids Exposure Option:
For either exposure reporting or exposure and exposure management reporting, a site should complete the following form:
Healthcare Personnel Safety Component Facility Survey (CDC Form 57.200) Used to collect facility administrative data including total patient beds set up and staffed, annual inpatient days, number of patient admissions per year, number of annual outpatient encounters, number of annual employee hours worked. The survey also collects annual data on the total number of HCP in selected occupational groups (fulltime equivalents and numbers of HCP, full or part-time).
Healthcare Personnel Safety Monthly Reporting Plan (CDC Form 57.203) Used to collect data on which modules and which months a facility intends to participate in
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Blood/Body Fluid Exposure Option
the NHSN HPS Component. This form should be completed for every month that the facility will participate in the HPS component.
Exposure-Only Reporting:
Those facilities participating in exposure-only reporting should complete the following forms:
Healthcare Worker Demographic Data (CDC Form 57.204) Used to collect data on HCW demographics such as gender and occupation for a healthcare worker who has reported a blood or body fluid exposure.
Exposure to Blood/Body Fluids (CDC Form 57.205) Used to collect information about individual blood and body fluid exposure events. Sections I IV should be completed for all reported exposures. For percutaneous injuries with a needle or sharp object that was not in contact with blood or other body fluids (as defined in "occupational exposure") prior to exposure, the completion of Sections V-IX is not required.
Exposure and Exposure Management Reporting:
Facilities participating in exposure reporting and exposure management should complete the forms:
Healthcare Worker Demographic Data (CDC Form 57.204) Used to collect data on HCW demographics such as gender and occupation for a healthcare worker who has reported a blood or body fluid exposure.
Exposure to Blood/Body Fluids (CDC Form 57.205) Used to collect information about individual blood and body fluid exposure events. Sections I IV should be completed for all reported exposures. If a facility chooses to follow the protocol for exposure management, Sections V IX are also required.
Healthcare Worker Prophylaxis/Treatment BBF Postexposure Prophylaxis (PEP) (CDC Form 57.206) Used to collect details of medications administered to a healthcare worker following blood or body fluid exposure to HIV or HBV.
Follow-Up Laboratory Testing (CDC Form 57.207) Used to collect additional laboratory testing results obtained on an HCW following a blood or body fluid exposure as part of exposure management. These serologic and other laboratory results are not required for exposure management but provide details for facilities opting for the long-term follow-up of exposures and evidence of seroconversion.
Data Analysis:
The use of the Blood/Body Fluid Exposure and Exposure Management Options will allow the participating NHSN site to estimate the nature, frequency, circumstances, and sequelae of occupational exposures to bloodborne pathogens (i.e., HBV, HCV, and/or HIV) through
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Blood/Body Fluid Exposure Option
percutaneous injuries, bites, mucous membrane exposures or non-intact skin exposures. In addition, facilities can assess for changes in percutaneous injuries with the implementation of safety devices and other prevention strategies, the timeliness of initiating HIV postexposure prophylaxis (PEP) when indicated, assess the duration of HIV prophylaxis, and the proportion of HCP experiencing adverse signs and symptoms after taking HIV PEP for occupational exposures.
Denominator data from the annual Facility Survey (CDC 57.200) can be used to estimate rates of exposures to blood/body fluids and to assess the effectiveness of engineering controls, work practices, and protective equipment in reducing exposure.
References:
The following CDC/PHS publications provide recommendations for management and follow-up of blood and body fluid exposures to HBV, HCV, and HIV:
· Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis (MMWR, June 29, 2001 / 50(RR11); 1-42)
· Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis (MMWR, September 30, 2005 / 54(RR09); 1-17). (PEP medications are updated in NHSN as required)
· A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States. (MMWR), December 8, 2006 / 55(RR16); 1-25)
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Influenza Exposure Management Option
Influenza Exposure Management Option
Introduction: The Advisory Committee on Immunization Practices (ACIP) recommends that all healthcare personnel (HCP) and persons in training for healthcare professions should be vaccinated annually against influenza.[1,2] Persons who are infected with influenza virus, including those with subclinical infection, can transmit influenza virus to persons at higher risk for complications from influenza. Vaccination of HCP has been associated with reduced work absenteeism [3] and with fewer deaths among nursing home patients [4,5] and elderly hospitalized patients.[5] Although annual vaccination is recommended for HCP and is a high priority for reducing morbidity associated with influenza in healthcare settings, national survey data have demonstrated vaccination coverage levels of <50% among HCP over several vaccination seasons.[1]
Although annual vaccination with the seasonal influenza vaccine is the best way to prevent infection, antiviral drugs can be effective for prevention and treatment of influenza. When HCP have not been vaccinated or are exposed to an influenza strain with no vaccine coverage (i.e., non-seasonal), a plan for anti-viral chemoprophylaxis and treatment could be implemented.
Influenza Exposure Management Option
Use of the Influenza Exposure Management Option permits a healthcare facility to record information on antiviral medication use for chemoprophylaxis or treatment without reporting influenza vaccination. It can be used in any healthcare setting. This option includes reporting of individual-level antiviral medication use for chemoprophylaxis or treatment after exposure to influenza. The reason for antiviral medication use can be attributed to either seasonal or nonseasonal influenza. Use of this option will allow facilities and CDC to measure antiviral medication use related to the prevention and treatment of influenza.
Settings: Any healthcare settings
Requirements: Surveillance for influenza in the healthcare facility is to be conducted during the vaccination season.
Definitions:
· HCW (Healthcare Worker): A person who works in the facility, whether paid or unpaid, who has the potential for exposure to infectious materials, including body substances, contaminated medical supplies and equipment, contaminated environmental surfaces, or contaminated air. Healthcare worker is the singular form of healthcare personnel.
· HCP (Healthcare Personnel): The entire population of healthcare workers working in a healthcare setting.
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Influenza Exposure Management Option
· Non-seasonal influenza vaccine: A vaccine for additional/novel influenza virus strains (e.g., 2009 H1N1) not included in the seasonal influenza vaccine which may or may not be offered on an annual basis.
· Seasonal influenza vaccine: A vaccine for seasonal influenza virus strains that is offered on an annual basis.
· Severe adverse reaction to antiviral medication use for influenza chemoprophylaxis or treatment: Adverse reactions severe enough to affect daily activities and/or result in the discontinuation of the antiviral medication.
· Vaccination season: A 12-month period starting from July 1 of a year June 30 of the following year.
Reporting Instructions
Forms Description and Purpose: (See also: Tables of Instructions for Completion of Healthcare Personnel Safety Component forms)
All NHSN facilities following the Influenza Exposure Management Option: NHSN participants should complete the following forms:
Healthcare Personnel Safety Component Facility Survey (CDC 57.200) Used to collect facility administrative data including total patient beds set up and staffed, annual inpatient days, number of patient admissions per year, number of annual outpatient encounters, number of annual employee hours worked. The survey also collects annual data on the total number of HCP in selected occupational groups (full-time equivalents and numbers of HCP, full or part-time). Numbers of HCWs for at least one nurse occupation (e.g., registered nurse, nurse midwife) and one physician occupation (i.e., intern/resident, fellow, attending physician) are required. All other fields are optional for the Selected HCW Occupational Groups; you may enter 0 for these optional fields.
Healthcare Personnel Safety Monthly Reporting Plan (CDC 57.203) Used to collect data on which modules and which months a facility intends to participate in the NHSN HPS Component. This form should be completed for every month that the facility will participate in the HPS Component.
Healthcare Worker Demographic Data (CDC 57.204) Used to collect data on HCW demographics such as gender and occupation for each individual HCW. This form also is used optionally to collect information about immune status for certain vaccinepreventable diseases (e.g., measles, mumps, rubella).
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Influenza Exposure Management Option
Influenza Exposure Management Reporting: Facilities participating in influenza exposure management reporting for antiviral medication use should complete the following form:
Healthcare Worker Prophylaxis/Treatment Influenza (CDC 57.210) Used to collect data on which (if any) antiviral medications were administered to the HCW and any severe adverse reactions associated with their use.
Data Analyses: The use of the Influenza Exposure Management Option will allow facilities and CDC to measure antiviral medication use related to the prevention and treatment of influenza. Antiviral medication use for chemoprophylaxis or treatment after exposure to influenza can be evaluated and monitored. Frequencies and trends of antiviral medication use as a result of potential or confirmed exposures to influenza will be calculated and summarized. Also, frequency estimates of the personnel types and clinical areas more likely to require chemoprophylaxis or treatment may be analyzed as well as information on adverse effects associated with the receipt of antiviral medications (as part of chemoprophylaxis or treatment).
References:
[1] Centers for Disease Control and Prevention, Prevention and control of seasonal influenza with vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009, MMWR, 58 (2009) 1-52.
[2] Centers for Disease Control and Prevention, Influenza vaccination of health-care personnel, MMWR, 55 (2006) 1-16.
[3] R. T. Lester, A. McGeer, G. Tomlinson, and A. S. Detsky, Use of, effectiveness of, attitudes regarding influenza vaccine among house staff, Infection Control and Hospital Epidemiology, 24 (2003) 839-844.
[4] J. Potter, D. J. Stott, M. A. Roberts, A. G. Elder, B. ODonnell, P. V. Knight, and W. F. Carman, Influenza vaccination of health care workers in long-term-care hospitals reduces the mortality of elderly patients, Journal of Infectious Diseases, 175 (1997) 1-6.
[5] R. E. Thomas, T. O. Jefferson, V. Demicheli, and D. Rivetti, Influenza vaccination for health-care workers who work with elderly people in institutions: a systematic review, Lancet Infectious Diseases, 6 (2006) 273-279.
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NHSN Healthcare Personnel Safety Component Tables of Instructions
TABLE
CDC FORM
1 57.203
2 57.204
3 57.205
4 57.206
5 57.207 6 57.210 7 57.200
Tables of Instructions
TITLE
PAGE
Instructions for completion of the Healthcare Personnel
2
Safety Monthly Reporting Plan form
Instructions for completion of the Healthcare Worker
3
Demographic Data form
Instructions for completion of the Exposure to Blood/Body
5
Fluids form
Instructions for completion of the Healthcare Worker
14
Prophylaxis/Treatment BBF Postexposure Prophylaxis
(PEP) form
Instructions for completion of the Follow-up Laboratory
16
Testing form
Instructions for completion of the Healthcare Worker
17
Prophylaxis/Treatment Influenza form
Instructions for completion of the Healthcare Personnel
19
Safety Component Annual Facility Survey form
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NHSN Healthcare Personnel Safety Component Tables of Instructions
Table 1. Instructions for Completion of the Healthcare Personnel Safety Monthly Reporting Plan Form (CDC 57.203)
This form collects data on which options and which months a facility intends to participate in NHSN Healthcare Personnel Safety (HPS) Component. This form should be completed for every month that the facility will participate in the HPS Component.
Facility ID #
Data Field
Month/Year
No NHSN Healthcare Personnel Safety Modules Followed this Month
Instructions for Data Collection Required. The NHSN-assigned facility ID will be autoentered by the application. Required. Enter the month and year for the surveillance plan being recorded. Conditionally required. Check this box if you do not plan to follow any of the NHSN Healthcare Personnel Safety Modules during the month and year selected.
Healthcare Personnel Exposure Module
Blood/Body Fluid Exposure Only
Blood/Body Fluid Exposure with Exposure Management Influenza Exposure Management
Conditionally required. Check this box if you plan to follow blood/body fluid exposures only, without following exposure management during the month and year selected. Conditionally required. Check this box if you plan to follow blood/body fluid exposure with exposure management during the month and year selected.
Conditionally required. Check this box if you plan to follow influenza exposure management (i.e., antiviral chemoprophylaxis and/or treatment)
Healthcare Personnel Vaccination Module
Influenza Vaccination Summary
Conditionally required. Check this box if you plan to follow the influenza vaccination summary option. Once the influenza vaccination summary is selected on the reporting plan, it is automatically updated with this information for the entire NHSN-defined influenza season (July 1 to June 30).
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NHSN Healthcare Personnel Safety Component Tables of Instructions
Table 2. Instructions for Completion of the Healthcare Worker Demographic Data Form (CDC 57.204)
This form must be completed for all HCP who have information recorded in HPS component of NHSN (e.g., exposure to blood or body fluid or influenza vaccination.) Alternatively, data for all or selected personnel can be imported from the facility's personnel database at facility enrollment.
Data Field Facility ID # HCW ID #
Social Security # Secondary ID #
HCW Name: Last, First, Middle Street Address City State Zip Code Home Phone E-mail Address Gender Date of birth Born in the U.S.? Ethnicity Race Work Phone Start Date
Work Status Type of Employment
Work Location
Department
Instructions for Data Collection Required. The NHSN-assigned facility ID will be auto-entered by the application. Required. Enter the healthcare worker's (HCW) alphanumeric identification number. This identifier is unique to the healthcare facility. Optional. Enter the HCW's Social Security Number. Optional. Enter the HCW's secondary ID number. This could be the employee's medical record # or some other unique identifier. Optional. Enter demographic information for the HCW.
Required. Indicate the gender of the HCW by checking F (Female) or M (Male). Required. Enter the date of birth of the HCW using the format: mm/dd/yyyy. Optional. Select Yes, No, or Unknown. Optional. Select one ethnicity of the HCW. Optional. Select the race of the HCW. Check all that apply. Optional. Enter the work phone number of the HCW. Required. Enter the date the HCW began employment or affiliation with the facility (use format: mm/dd/yyyy). Required. Select Active, Inactive, or No longer affiliated. Required. Select from Full-time, Part-time, Contract, Volunteer, Other (please specify). Required. Select the code that best describes the HCW's current permanent work location. This refers to physical work location rather than to department assignment. For example, a radiology technician who spends most of his/her time performing portable x-rays throughout the facility works at multiple locations. In general, most interns/residents are not considered to work at a single location because they rotate every month or every few months. For HCP who do not work at least 75% of the time at a single location, the work location code for `float' should be entered. Location codes must be customized to the facility and set up prior to entering HCW records. The work location must be mapped to a CDC Location (http://www.cdc.gov/nhsn/PDFs/master-locations-descriptions.pdf). Optional. Enter the department in which the HCW works (facility defined).
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NHSN Healthcare Personnel Safety Component Tables of Instructions
Data Field Supervisor Occupation
Title
Clinical specialty Performs direct patient care
Custom Fields
Comments
Instructions for Data Collection Optional. Enter the name of the HCW's supervisor (facility defined). Required. Select the occupation code that most appropriately describes the HCW's job. These must be customized to the facility and set up prior to entering HCW records. The occupation must be mapped to a CDC Occupation Code. Conditionally required. Required only for HCP designated as Influenza Vaccinators if the facility intends on using NHSN to fulfill federal recordkeeping requirements for administration of vaccine covered by the Vaccine Injury Compensation Program. Enter the HCW's job title. Conditionally required. If Occupation is physician, fellow or intern/resident, select the appropriate clinical specialty. Conditionally required. Required only when the HCW has influenza vaccination and/or influenza chemoprophylaxis/treatment records. Select Y (Yes) if the HCW provides direct patient care (i.e., hands on, face-to-face contact with patients for the purpose of diagnosis, treatment and monitoring); otherwise select N (No). Optional. Up to two date fields, two numeric fields, and 10 alphanumeric fields that may be customized for local use. NOTE: Each Custom Field must be set up in the Facility/Custom Options section of the application before the field can be selected for use. Optional. Enter any information about the HCW. This information cannot be analyzed.
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NHSN Healthcare Personnel Safety Component Tables of Instructions
Table 3. Instructions for Completion of the Exposure to Blood/Body Fluids Form (CDC 57.205)
Information for all blood/body fluid exposures should be recorded using this form. The variables to be entered depend upon whether the facility selects the exposure event only reporting or exposure reporting and management.
Demographic data auto-entered by application if part of an existing HCW Demographic Data record (CDC 57.204).
Exposure Event
Exposure and Exposure
Data Field
Instructions for Data Collection
Event Only Management
Facility ID #
The NHSN-assigned facility ID will be auto- Required
Required
entered by the application.
Exposure Event # The exposure event number will be auto-
Required
Required
generated by the application.
HCW ID
Enter the HCW's alphanumeric identification Required
Required
number. This identifier is unique to the
healthcare facility.
HCW Name:
Enter the HCW's name.
Optional
Optional
Last, First, Middle
Gender
Indicate the gender of the HCW by checking F Required
Required
(Female) or M (Male).
Date of Birth
Enter the date of birth of the HCW using the
Required
Required
format: mm/dd/yyyy.
Work Location
Required. Select the code that best describes the Required
Required
HCW's current permanent work location. This
refers to physical work location rather than to
department assignment. Location codes are
customized to the facility and set up prior to
entering HCW records. See Table 2 for more
details.
Occupation
Required. Select the occupation code that most Required
Required
appropriately describes the HCW's job.
Occupation codes are customized to the facility
and set up prior to entering HCW records. See
Table 2 for more details.
Clinical Specialty If Occupation is physician, fellow or
Conditionally Conditionally
intern/resident, enter the appropriate clinical
required
required
specialty. The list of clinical specialties can be
found on Form CDC 57.204.
Exposure Type
The default setting is auto-entered by the
Required
Required
application as Blood/Body Fluids.
Section I General Exposure Information
1. Did the exposure Choose Y (Yes) or N (No).
Required
Required
occur at this facility
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NHSN Healthcare Personnel Safety Component Tables of Instructions
Data Field 1a. If No, specify the name of facility in which exposure occurred 2. Date of exposure 3. Time of exposure
4. Number of hours on duty 5. Is exposed person a temp/agency employee? 6. Location where exposure occurred
7. Type of Exposure
7a. Percutaneous:
Instructions for Data Collection If the exposure did not occur at the reporting facility, enter the name of the facility where the event occurred.
Enter date of exposure in mm/dd/yyyy format. Enter the time the exposure occurred and whether it was AM or PM. Enter the number of hours the HCW had been on duty when the exposure occurred. Choose Y (Yes) or N (No).
Choose the appropriate code for the physical location where the event took place. (This is customized to the facility). Check the appropriate exposure type. Check all that apply. If Type of Exposure was Percutaneous, then check this item.
Exposure Event Only Conditionally required
Exposure Event and Exposure Management Conditionally required
Required Required
Optional
Optional
Required Required
Optional
Optional
Required
Required
Required
Required
Conditionally Conditionally
required
required
Did the exposure involve a clean, unused needle or sharp object?
7b. Mucous membrane
7c. Skin:
If percutaneous is checked, then select Yes or No to indicate whether the exposure involved a clean, unused needle or sharp object. If the incident involved a clean, unused needle or sharp object you may not need to report this as an exposure (see your protocol for more information). If not, check No and complete Q8, Q9 and Section II. If following the protocol for exposure management also complete Sections V-XI. If Type of Exposure was Mucous Membrane, then check this item and complete Q8, Q9 and Section III. If following the protocol for exposure management also complete Sections V-XI. If Type of Exposure was Skin, then check this item.
Conditionally required
Conditionally required
Conditionally required
Conditionally required
Conditionally required
Conditionally required
Was skin intact?
If Skin is checked, then indicate Y (Yes), N (No) or (U) Unknown for whether the skin remained intact during the exposure. If the answer is No, complete Q8, Q9 and Section III. If following the protocol for exposure management also complete Sections V-XI.
Conditionally Conditionally
required
required
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NHSN Healthcare Personnel Safety Component Tables of Instructions
Data Field 7d. Bite
8. Type of fluid/tissue involved in exposure
Instructions for Data Collection If Type of Exposure was Bite, then check this item and complete Q9 and Section IV. If following the protocol for exposure management also complete Sections V-XI. Select the Type of fluid/tissue from the list.
Exposure Event Only Conditionally required
Exposure Event and Exposure Management Conditionally required
Required
Required
If Solutions or Body fluids are checked, indicate whether visibly bloody or not visibly bloody. For Body Fluids, indicate the primary body fluid type implicated in the exposure from the list.
Conditionally required
Conditionally required
9. Body site of exposure
If Other is selected for either the Type of Fluid/Tissue involved in the exposure or the Body Fluid Type, please specify the type. (Make sure it is not a body fluid that is already listed in the box on the right side of the form). Check body site of exposure from the list. Check all sites that were exposed.
Conditionally Conditionally
required
required
Required
Required
If the Body site of exposure was (Other), please
specify the site.
Section II Percutaneous Injury
1. Was the needle or Choose Y (Yes) or N (No).
sharp object visibly
contaminated with
blood prior to
exposure?
2. Depth of the
Indicate the depth of the injury from the needle
injury (check one) or sharp object using the list provided.
Exposures that are not obviously superficial
(e.g., scratch) or deep (e.g., "muscle contracted"
or "touched bone"), should be classified as
moderate.
Conditionally required Required
Conditionally required
Conditionally required Required
Conditionally required
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Data Field 3. What needle or sharp object caused the injury?
4. Manufacturer and model 5. Did the needle or other sharp object involved in the injury have a safety feature? 5a. If Yes, indicate the type of safety feature 5b. If the device had a safety feature, when did the injury occur?
Instructions for Data Collection Select one of the following categories: Device, Non-Device Sharp Object, or Unknown Sharp Object. If you select Device in the application you will be provided with a Device button that will take you to a screen to enter manufacturer, model, etc. Once a device has been entered you will be able to select it from the drop down list.
If a Non-Device Sharp is selected, please describe the item or object.
Within Devices, there are six categories: Hollow-bore needles, Suture needles, Other solid sharps, Glass, Plastic, Non-sharp safety devices, and Other devices.
If Other known device is selected, please specify. Enter the brand name and model of the device used. If the brand and model are unknown, generic device descriptors can be entered. Choose Y (Yes) or N (No). If Yes, answer 5a and 5b. If No, skip to Q6.
If above is Y (Yes), choose one item from the list of safety devices.
Choose the timing of the injury event with relation to the use of the safety device. Check one item from the list provided.
Exposure Event Only Conditionally required
Exposure Event and Exposure Management Conditionally required
Conditionally Conditionally
required
required
Conditionally required Conditionally required
Conditionally required Conditionally required
Conditionally Conditionally
required
required
Conditionally Conditionally
required
required
Conditionally Conditionally
required
required
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NHSN Healthcare Personnel Safety Component Tables of Instructions
Data Field 6. When did the injury occur? (check one) Before use of the item
Instructions for Data Collection Choose the timing of the injury event from the list provided.
Exposure Event Only Conditionally required
Exposure Event and Exposure Management Conditionally required
Injuries that occurred prior to intended use and usually involve clean needles or sharp objects. It may also include injuries that occurred with a clean device that passed through bloody gloves.
During use of the item
Injuries that occurred during the use of the needle or sharp object. It also includes surgical or other invasive procedures with many steps.
After use of item, before disposal
Injuries that occurred while in transit to disposal, cleaning instrument or recapping.
During or after disposal
Injuries that occurred during or after the process of disposal or because of improper disposal of a needle or other sharp object.
Unknown
Time of injury relative to the use of the device
or object is unknown.
7. For what purpose Choose from the lists provided. If Other specify
or activity was the the purpose in the space provided.
sharp device being used?
Select Unknown if injury was a result of contact with discarded or uncontrolled sharps, or in
circumstances where the intent of device or
object use is unknown or cannot be ascertained.
8. What was the
Choose the activity being performed at the time
activity at the time of injury involving the sharp object or needle. If
of injury?
the activity being performed at the time of the
injury was different than the purpose indicated
in Q7, select the activity at the time the actual
injury event took place.
9. Who was holding Select one answer.
the device at the
time the injury
occurred?
10. What happened Choose one item from the list.
when the injury
If Other, please record details in the space
occurred?
provided.
Section III Mucous Membrane and/or Skin Exposure
1. Estimate the
Select the estimated amount of blood or body
amount of
fluid involved in the mucous membrane or skin
blood/body fluid
exposure. Indicate Unknown if unable to
exposure
estimate the amount.
Conditionally required
Conditionally required
Conditionally required
Conditionally required
Conditionally required
Conditionally required
Conditionally required
Conditionally required
Conditionally required
Conditionally required
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NHSN Healthcare Personnel Safety Component Tables of Instructions
Exposure Event
Exposure and Exposure
Data Field
Instructions for Data Collection
Event Only Management
2. Activity/event
Select the activity or event at the time mucous Conditionally Conditionally
when exposure
membrane or skin exposure occurred.
required
required
occurred
If Other is selected record details of the activity Conditionally Conditionally
or event in the space provided.
required
required
3. Barriers used by Check all that apply.
Conditionally Conditionally
the worker at the
required
required
time of exposure
If Other is selected, list other barriers in the
Conditionally Conditionally
space provided.
required
required
Section IV Bite
1. Wound
Select the description of the bite wound from Conditionally Conditionally
description
the list provided.
required
required
2. Activity/event
Choose the activity or event when the bite
Conditionally Conditionally
when exposure
occurred.
required
required
occurred
If Other, specify the event in the space
Conditionally Conditionally
provided.
required
required
Sections V IX are required when following the protocols for Exposure Management
Section V Source Information
1. Was the source Choose Y (Yes) if the source of the exposure Optional
Required
patient known?
(patient) is known. Otherwise, select N (No).
2. Was HIV status Indicate Y (Yes) if the source patient's
Optional
Required
known at time of
serostatus was known at the time of exposure.
exposure?
3. Check the test
Use codes: P= positive, N= negative,
Optional
Required
results for the source I=Indeterminate, U=Unknown, R=Refused and
patient:
NT=Not tested.
Hepatitis B
Indicate the results of any tests performed prior
HbsAg HBeAg Total anti-HBc anti-HBs Hepatitis C anti-HCV EIA anti-HCV suppl
to the exposure (as found in the medical record) or performed immediately after the exposure. If the source is not known, check U. If the source refuses to be tested, check R. Not all tests listed on the form need to be offered after all exposures.
PCR-HCV RNA
HIV
HIV EIA, ELISA
Rapid HIV
Confirmatory HIV
Section VI For HIV Infected Source
1. Stage of Disease Indicate the stage of HIV disease of the source
patient. Use CDC surveillance definitions. For
end stage AIDS and acute HIV illness, use
definitions as defined in the protocol.
Optional
Conditionally required
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Data Field 2. Is the source patient taking antiretroviral drugs? 2a. If Yes, indicate drug(s)
3. Most recent CD4 count
Instructions for Data Collection Indicate if the source patient is was taking antiretroviral drugs at the time of the exposure, Y (Yes), N (No), or U (Unknown). If the source patient was taking anti-retroviral drugs at the time of the exposure, list them here. Drug codes are listed in Chapter 7 and will be in a drop down list in the application. If available, indicate the most recent CD4 count in mm3 for the source patient.
Exposure Event Only Optional
Optional
Optional
Exposure Event and Exposure Management Conditionally required
Conditionally required
Conditionally required
Date
Enter the month and year of the test for the
source patient.
4. Viral Load
If available, indicate the most recent HIV viral
load (# of copies per ml) or Undetectable for the
source patient.
Date
Enter the month and year of the test.
Section VII: Initial Care Given to Healthcare Worker
1. HIV postexposure
prophylaxis
Offered?
Choose Y (Yes), N (No), or U (Unknown) if antiretroviral drugs were offered to the HCW following this exposure.
Optional Optional
Taken? 2. HBIG given?
Choose Y (Yes), N (No), or U (Unknown) if antiretroviral drugs were taken by the HCW. If Yes is selected, complete Post-Exposure Prophylaxis/Treatment form (CDC form 57.206). Choose Y (Yes), N (No), or U Unknown) for whether Hepatitis B immunoglobulin was given.
Optional Optional
Conditionally required
Required Required
Required
Date administered
3. Hepatitis B vaccine given? Date first dose administered
Enter date HBIG prophylaxis pertaining to this exposure was administered. Use mm/dd/yyyy format. Choose Y (Yes), N (No), or U. (Unknown) for whether Hepatitis B vaccine was given after exposure.
Enter date of first dose of Hepatitis B vaccine (mm/dd/yyyy format). This and subsequent doses to complete the HBV series should be recorded in the HCW's file.
Optional Optional Optional
Conditionally Required
Required
Conditionally Required
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Data Field
Instructions for Data Collection
4. Is the HCW
Indicate the pregnancy status of HCW. Choose
pregnant?
Y (Yes), N (No), or U (Unknown).
4a. If yes, which
Check 1 (1st trimester), 2 (2nd trimester), or 3
trimester?
(3rd trimester) at the time of exposure. If stage of
pregnancy is unknown, check U.
Section VIII Baseline Lab Testing
Was baseline testing Choose Y (Yes) or N (No) or U (Unknown).
performed on the
Baseline lab tests should be performed within
HCW?
hours of the exposure .
HIV EIA
Enter the dates for each test performed and the
HIV confirmatory HepC anti-HCV EIA HepC anti-HCV-supp
result (Use codes: P= Positive, N= Negative, I=Indeterminate, U=Unknown, R=Refused).
HepC PCR HCV RNA
HepB HBsAg
HepB IgM anti-Hbc
HepB Total anti-Hbc
HepB Anti-HBs
Exposure Event Only Optional Optional
Optional
Optional
Exposure Event and Exposure Management Conditionally required Conditionally required
Required
Conditionally required
ALT
Additional baseline laboratory tests may be
Amylase Blood glucose Hematocrit Hemoglobin Platelets
completed to document potential physiologic changes associated with a blood/body fluid exposure. Enter the date (in mm/dd/yyyy format) and result, using the specified units.
Blood cells in urine
WBC
Creatinine
Other
Section IX Follow-up
1. Is it recommended Choose Y (Yes) or N (No).
that the HCW return
for follow-up of this
exposure?
1a. If Yes, will
Choose Y (Yes) or N (No).
follow-up be
performed at this
facility?
Section X Narrative
In the worker's
Enter the narrative of the HCW's description of
words, how did the how the injury occurred.
injury occur?
Section XI Prevention
Optional
Optional Optional Optional
Optional
Required Conditionally Required Optional
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Data Field In the worker's words, what could have prevented the injury? Custom Fields
Comments
Instructions for Data Collection Enter the narrative of the HCW's assessment of how the injury might have been prevented.
Exposure Event Only Optional
Exposure Event and Exposure Management Optional
Up to two date fields, two numeric fields, and 10 alphanumeric fields that may be customized for local use. NOTE: Each Custom Field must be set up in the Facility/Custom Options section of the application before the field can be selected for use. Enter any additional information about the HCW. CDC will not analyze this information.
Optional Optional
Optional Optional
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NHSN Healthcare Personnel Safety Component Tables of Instructions
Table 4. Instructions for Completion of the Healthcare Worker Prophylaxis/Treatment BBF Postexposure Prophylaxis (PEP) Form (CDC 57.206)
Use this form if HIV postexposure prophylaxis (PEP) was administered to a healthcare worker following a blood or body fluid exposure.
Demographic data auto-entered by application if part of an existing HCW Demographic Data record (CDC 57.204).
Data Field Facility ID # MedAdmin ID#
HCW ID #
HCW Name: Last, First, Middle Gender Date of Birth Infectious Agent Exposure Event #
Initial PEP Time between exposure and 1st dose Drug
Drug
Drug Drug Date Started
Date Stopped
Instructions for Data Collection Required. The NHSN-assigned facility ID will be auto-entered by the application. Required. Medical administration number. Data will be auto-entered by the application. Required. Enter the HCW's alphanumeric identification number. This identifier is unique to the healthcare facility. Optional. Enter the HCW's name.
Required. Indicate the gender of the HCW by checking F (Female) or M (Male). Required. Enter the date of birth of the HCW using the format: mm/dd/yyyy. Required. Enter HIV on form. Select HIV in the application. Required. The Exposure event number will be auto-entered by the system. Use the Link/Unlink button to find any exposures for the entered HCW, select, and link the exposure for which PEP is being administered. PEP records cannot be saved unless they are linked to an exposure. PEP records entered from the Blood and Body Fluid Exposure Form will automatically be linked to that exposure. Indication: Prophylaxis Required. Enter the number of hours between the exposure and when the 1st dose of PEP was administered. Required. Enter any drugs prescribed for prophylaxis. See Chapter 7 in the protocol for a list of individual drug codes. Conditionally required. Enter any additional drugs prescribed for initial prophylaxis. Conditionally required. Enter any additional drugs prescribed for prophylaxis. Conditionally required. Enter any additional drugs prescribed for prophylaxis. Required. Enter the date the initial PEP regimen commenced (mm/dd/yyyy format). The start date will apply to all drugs selected as the initial PEP regimen. The date started must be on or after the exposure date. Required. Enter the date the initial PEP regimen was stopped (mm/dd/yyyy format).
Note: If any drug(s) of a drug regimen are discontinued, the entire regimen is considered `stopped.' If select drugs in the regimen continue to be used as prophylaxis (and if other drugs are added) enter them as drugs under a PEP change with a new start date.
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Data Field Reason for Stopping
Instructions for Data Collection Required. Indicate the primary reason for stopping the initial PEP regimen by selecting the appropriate choice.
PEP Change 1 Drug Drug Drug Drug Date Started Date Stopped
Reason for Stopping PEP Change 2 Drug
Drug Drug Drug Date Started Date Stopped
Reason for Stopping Adverse Reactions Signs or symptoms of adverse reactions to post-exposure prophylaxis
Indication: Prophylaxis Required. Enter drugs prescribed for a second prophylaxis regimen. Note that the second PEP regimen may contain drugs that were included in the first regimen. Conditionally required. Enter any additional drugs prescribed for prophylaxis. Conditionally required. Enter any additional drugs prescribed for prophylaxis.
Conditionally required. Enter any additional drugs prescribed for prophylaxis. Conditionally required. Enter the date the second PEP regimen was started using mm/dd/yyyy format. Conditionally required. Enter the date the second PEP regimen was stopped using mm/dd/yyyy format.
Note: If any drug(s) of a drug regimen are discontinued, the regimen is considered `stopped.' Whatever drugs in the regimen are continued (and if other drugs are added) will constitute a new regimen and should be recorded as part of a new PEP regimen(s) with dates that resume from the last stop date. . Conditionally required. Indicate the primary reason for stopping this PEP regimen by selecting the appropriate choice. Indication: Prophylaxis Conditionally required. Enter drugs prescribed for a third prophylaxis regimen. Note that the third PEP regimen may contain drugs that were included in previous regimens. Conditionally required. Enter any additional drugs prescribed for prophylaxis. Conditionally required. Enter any additional drugs prescribed for prophylaxis. Conditionally required. Enter any additional drugs prescribed for prophylaxis. Conditionally required. Enter the date the new PEP regimen was started using mm/dd/yyyy format. Conditionally required. Enter the date the new PEP regimen was stopped using mm/dd/yyyy format.
Note: If any drug(s) of a drug regimen are discontinued, the regimen is considered `stopped.' Whatever drugs in the regimen are continued (and if other drugs are added) will constitute a new regimen and should be entered as such. Conditionally required. Indicate the primary reason for stopping this PEP regimen by selecting the appropriate choice.
Optional. Indicate any adverse signs/symptoms the HCW experienced while receiving postexposure prophylaxis. You may select up to six.
If Other is selected, briefly specify details of adverse reaction.
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Data Field Custom Fields
Comments
Instructions for Data Collection Optional. Up to two date fields, two numeric fields, and 10 alphanumeric fields that may be customized for local use. NOTE: Each Custom Field must be set up in the Facility/Custom Options section of the application before the field can be selected for use. Optional. Enter any additional information about the HCW. CDC will not analyze this information.
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Table 5: Instructions for Completion of Follow-Up Laboratory Testing Form (CDC 57.207)
This form should be completed for HCP who have additional laboratory testing done as a result of blood or body fluid exposures. These tests would occur after baseline laboratory testing had been completed.
Demographic data auto-entered by application if part of an existing HCW Demographic Data record (CDC 57.204).
Data Field Facility ID # Lab # HCW ID # HCW Name: Last, First, Middle Gender Date of birth Exposure Event #
Lab Results Lab Test
Date Result Custom Fields
Comments
Instructions for Data Collection Required. The NHSN-assigned facility ID will be auto-entered by the application. Required. The lab testing ID number will be auto-generated by the application. Required. Enter the HCW's alphanumeric identification number. This identifier is unique to the healthcare facility. Optional. Enter the HCW's name.
Required. Indicate the gender of the HCW by checking F (Female) or M (Male). Required. Enter the date of birth of the HCW using the format: mm/dd/yyyy. Required. The user is required to link the laboratory follow-up record to a blood and body fluid exposure record using the Link feature within the application. Once the exposure is selected and submitted, the form will display the message "Lab is Linked." Laboratory records must be linked to an exposure.
Required (At least one laboratory test and date are required). Multiple test results may be recorded on this form. Select lab test from dropdown menu:
HIV EIA
ALT
HIV confirmatory
Amylase
HepC anti-HCV EIA
Blood glucose
HepC anti-HCV-supp
Hematocrit
HepC PCR HCV RNA
Hemoglobin
HepB HBsAg
Platelets
HepB IgM anti-Hbc
Blood cells in urine
HepB Total anti-Hbc
WBC
HepB Anti-HBs
Creatinine
Other
Required. Indicate date of test using mm/dd/yyyy format.
Conditionally required. Select one of the result codes:
Use codes: P= positive, N= negative, I=Indeterminate, U=Unknown, R=Refused)
Optional. Up to two date fields, two numeric fields, and 10 alphanumeric fields that
may be customized for local use. NOTE: Each Custom Field must be set up in the
Facility/Custom Options section of the application before the field can be selected
for use.
Optional. Enter any additional information about the HCW. CDC will not analyze
this information.
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NHSN Healthcare Personnel Safety Component Tables of Instructions
Table 6. Instructions for Completion of the Healthcare Worker Prophylaxis/Treatment Influenza Form (CDC 57.210)
This form should be completed when an HCW receives antiviral medications as influenza treatment or as chemoprophylaxis against influenza infection. It is used to collect information on which antiviral medications were administered, when, and what (if any) adverse reactions were experienced by the HCW.
Demographic data auto-entered by application if part of an existing HCW Demographic Data record (CDC 57.204).
Data Field Facility ID # Med Admin ID #
HCW ID #
HCW Name: Last, First, Middle Gender Date of Birth Work Location
Occupation
Clinical Specialty
Performs direct patient care
Infectious agent For season
#
Indication Influenza subtype
Antiviral medication Start date Stop date
Instructions for Data Collection Required. The NHSN-assigned facility ID will be auto-entered by the application. Required. The medication administration ID number will be auto-generated by the application. Required. Enter the HCW's alphanumeric identification number. This identifier is unique to the healthcare facility. Optional. Enter the HCW's name.
Required. Indicate the gender of the HCW by checking F (Female) or M (Male). Required. Enter the date of birth of the HCW using the format: mm/dd/yyyy. Required. Select the code that best describes the HCW's current permanent work location. This refers to physical work location rather than to department assignment. Location codes are customized to the facility and set up prior to entering HCW records. See Table 2 for more details. Required. Select the occupation code that most appropriately describes the HCW's job. Occupation codes are customized to the facility and set up prior to entering HCW records. See Table 2 for more details. Conditionally required. If Occupation is physician, fellow or intern/resident, enter the appropriate clinical specialty. The list of clinical specialties can be found on Form CDC 57.204. Required. Select Yes if the HCW provides direct patient care (i.e., hands on, face-toface contact with patients for the purpose of diagnosis, treatment and monitoring); otherwise select No. Required. Auto-filled on hard copy form. Select Influenza in application. Required. Select the vaccination season. Specify the year(s) during which this chemoprophylaxis or treatment date falls. For NHSN purposes, the vaccination "season" is 7/1 of the first year to 6/30 of the next calendar year. Required. Indicate up to 10 antiviral medications given using sequential numbers starting with 1. Required. Select Prophylaxis or Treatment as appropriate. Required. Select the influenza subtype for which the HCW is receiving antiviral medications (for post-exposure chemoprophylaxis or for treatment). Select Unknown, if you do not know the specific subtype necessitating antiviral medication use. Required. Enter the code of the antiviral medication that was administered to the HCW using the codes listed at the bottom of the form. Required. Enter the start date of the antiviral using mm/dd/yyyy format. Conditionally required. Enter the stop date of the antiviral using mm/dd/yyyy format.
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Data Field Adverse reactions?
Adverse reactions to antiviral medication #1...#10
Custom Fields
Comments
Instructions for Data Collection Required. Check Yes if the HCW had a severe adverse reaction attributable to the influenza antiviral medication; otherwise check No. If it is unknown whether or not the HCW experienced any adverse reactions, check Don't Know. Conditionally required. If the HCW had a severe adverse reaction, check all reactions that apply for each medication administered. Please correlate the antiviral medication # with the antiviral medication on page 1. If an adverse reaction is not listed, check Other and specify the adverse reaction in the space provided. All Other adverse reactions should be included if the reactions were severe enough to affect daily activities and/or resulted in the discontinuation of the antiviral medication. Optional. Up to two date fields, two numeric fields, and 10 alphanumeric fields that may be customized for local use. NOTE: Each Custom Field must be set up in the Facility/Custom Options section of the application before the field can be selected for use. Optional. Enter any additional information about the HCW. CDC will not analyze this information.
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Table 7. Instructions for Completion of Healthcare Personnel Safety Component Annual Facility Survey (CDC 57.200)
This form must be completed once a year by any facility using the Healthcare Personnel Safety Component.
Data Field Tracking # Facility ID # Survey year Total beds set up and staffed Patient admissions Inpatient days Outpatient encounters Number of hours worked by all employees
Number of HCWs
Number of FTEs
Instructions for Data Collection/Entry Required. The NHSN-assigned Tracking # will be auto-entered by the application. Required. The NHSN-assigned facility ID will be auto-entered by the application. Required. Enter the year of the survey using the format: yyyy. Required. Enter the number of all active beds across specialties and intensive care units. Required. Enter the number of patients, excluding newborns, admitted for inpatient service. Required. Enter the number of adult and pediatric days of care, excluding newborn days of care, rendered during a specified reporting period. Required. Enter the number of visits by patients who are not admitted as inpatients to the hospital while receiving medical, dental, or other services. Optional. Number of hours worked is available from OSHA300 reporting logs. The value can also be calculated by identifying the number of full time employees working in your facility within a year, multiply by the number of work hours for one full time employee in a year (typically ranges from 2000-2100 hours per year). Add in overtime hours and total hours worked by part-time, temporary, and contracted staff. Required. HCWs are all persons who work in the hospital. Calculate the number of attending physicians by including only those who are active or associate staff (e.g. similar methodology to the American Hospital Association annual survey, if applicable). Do not include courtesy, consulting, honorary, provisional, or other attending physicians in this number. If you cannot determine the exact number for a particular category, please estimate it. If the facility does not have any HCP in a specific occupation, the user may enter 0. This is the denominator when used to calculate rates of particular exposure events per HCW. Required. A subset of total number of HCP. FTEs are all HCP whose regularly scheduled workweek is 35 hours or more. To calculate the number of FTE's add the number of FTEs to ½ the number of part-time HCP (e.g., 2 part-time HCP = 1 FTE). If you cannot determine the exact number for a particular category, please estimate it. If the facility does not have any FTEs in a specific occupation, the user may enter 0. This is the denominator used to calculate rates of particular exposure events per FTE.
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NHSN Healthcare Personnel Safety Component Tables of Instructions
REFERENCES
The following CDC/PHS publications provide recommendations for management and follow-up of blood and body fluid exposures to HBV, HCV, and HIV:
· Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. (MMWR, June 29, 2001 / 50(RR11); 142)
· Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis (PEP regimens have been changed). (MMWR, September 30, 2005 / 54(RR09); 1-17)
The following CDC/PHS publication provides recommendations for the immunization of HCP: · A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States. (MMWR, December 8, 2006 / 55(RR16); 1-25) · Influenza Vaccination of Health-care Personnel. (MMWR, February 24, 2006 / 55(RR02); 1-16) · Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP). (MMWR, July 29, 2009 / 58(Early Release); 1-52)
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NHSN Healthcare Personnel Safety Component Key Terms
Key Terms
Key term
Definition
Antiviral medications for influenza
Drugs used to treat or to prevent influenza infections, not necessarily to treat the symptoms of influenza (e.g., analgesics)
Adverse reaction to influenza vaccine
A reaction experienced by the HCW that is attributable to the influenza vaccine. The Vaccine Information Statement defines a reaction as "Any unusual condition, such as high fever or behavior changes." Typically, adverse reactions to vaccines are only known when the HCW notifies you (i.e., passive surveillance) rather than you following up after the vaccination (i.e., active surveillance).
Bite
A human bite sustained by a HCW from a patient, other HCW, or visitor.
Bloodborne pathogens
Pathogenic microorganisms that may be present in human blood and can cause disease in humans. These pathogens include, but are not limited to hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV).
CDC Location
A CDC-defined designation given to a patient care area housing patients who have similar disease conditions or who are receiving care for similar medical or surgical specialties. Each facility location that is monitored is "mapped" to one CDC Location. The specific CDC Location code is determined by the type of patients cared for in that area according to the 80% Rule. That is, if 80% of patients are of a certain type (e.g., pediatric patients with orthopedic problems) then that area is designated as that type of location (in this case, an Inpatient Pediatric Orthopedic Ward). Work locations must be mapped to a CDC location. For CDC locations, see http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf
CDC (occupation) A CDC-defined designation for each occupation type in a facility. A facility
Code
occupation is "mapped" to one CDC Code. See Chapter 7 of protocol for list of
occupations.
Contractor
Individual facilities may have differing classifications of work status. According to the Bureau of Labor Statistics, workers with no explicit or implicit contract for a long-term employment arrangement, such as temporary or term positions, are considered contingent or contract workers. Facilities should use their own definition of a contractor.
Device
Any of the following devices (hollow-bore needle, suture needle, glass, plastic, other solid sharps, and non-sharp safety devices) used at the healthcare facility.
Direct patient care Hands on, face-to-face contact with patients for the purpose of diagnosis, treatment and monitoring.
Float
A work location for HCP who do not work at least 75% of the time in a single location. For example, a radiology technician who spends most of his/her time performing portable x-rays throughout the facility.
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NHSN Healthcare Personnel Safety Component Key Terms
Key term
Definition
Full Time
HCP whose regularly scheduled workweek is 35 hours or more. To calculate the
Equivalent (FTE) number of FTE's add the number of FTEs to ½ the number of part-time HCP (e.g.,
2 part-time HCWs = 1 FTE).
Healthcare personnel (HCP)
A population of healthcare workers working in a healthcare setting. HCP might include (but are not limited to) physicians, nurses, nursing assistants, therapists, technicians, emergency medical service personnel, dental personnel, pharmacists, laboratory personnel, autopsy personnel, students and trainees, contractual staff not employed by the healthcare facility, and persons (e.g., clerical, dietary, housekeeping, maintenance, and volunteers) not directly involved in patient care but potentially exposed to infectious agents that can be transmitted to and from HCP. It includes students, trainees, and volunteers.
Healthcare worker (HCW)
A person who works in the facility, whether paid or unpaid, who has the potential for exposure to infectious materials, including body substances, contaminated medical supplies and equipment, contaminated environmental surfaces, or contaminated air. Healthcare worker is the singular form of healthcare personnel.
Hollow-bore needle Needle (e.g., hypodermic needle, phlebotomy needle) with a lumen through which material (e.g., medication, blood) can flow.
Location
The patient care area to which an HCW is assigned while working in the healthcare facility. See also CDC Location for how locations are defined. CDC location codes may be accessed: at http://www.cdc.gov/nhsn/PDFs/masterlocations-descriptions.pdf
Mucous membrane Contact of mucous membrane (e.g.., eyes, nose, or mouth) with the fluids, tissues,
exposure
or specimens listed on the blood and body fluids exposure form.
Non-intact skin
Areas of the skin that have been opened by cuts, abrasions, dermatitis, chapped skin, etc.
Non-intact skinexposure
Contact of non-intact skin with the fluids, tissues, or specimens listed under Occupational Exposure
Non-Responder to An HCW, who has received two series of hepatitis B vaccine, is serotested within Hepatitis B vaccine 2 months after the last dose of vaccine and does not have anti-HBs 10 mIU/mL.
Non-seasonal influenza vaccine
A vaccine for additional/novel influenza virus strains (e.g., 2009 H1N1) not included in the seasonal influenza vaccine which may or may not be available on an annual basis.
Occupational exposure
Contact with blood, visibly bloody fluids, and other body fluids (i.e., semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid, tissues, and laboratory specimens that contain concentrated virus) to which Standard Precautions apply and during the performance of a healthcare worker's duties. Modes of exposure include percutaneous injuries, mucous membrane exposures, non-intact skin exposures, and bites.
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NHSN Healthcare Personnel Safety Component Key Terms
Key term
Definition
Part Time
HCP whose regularly scheduled workweek is less than 35 hours. Two PTEs equal
Equivalent (PTE) 1 FTE.
Percutaneous injury An exposure event occurring when a needle or other sharp object penetrates the skin.
For percutaneous injuries with a needle or sharp object that was not in contact with blood or other body fluids prior to exposure, collection of data is optional. Facilities are not required to collect data that involve intact skin or exposures to body fluids to which contact precautions do not apply unless they are visibly bloody. However, facilities that routinely collect data on such exposures may enter this information into the system.
Safety device
Includes any safety device (e.g., needless IV systems, blunted surgical needles, self-sheathing needles) used at the healthcare facility.
Seasonal influenza A vaccine for seasonal influenza virus strains that is offered on an annual basis. vaccine
Severe adverse reaction to antiviral medication use for influenza chemoprophylaxis or treatment
Adverse reactions severe enough to affect daily activities and/or result in the discontinuation of the antiviral medication.
Sharp
Any object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires.
Sharps Injury Solid Sharp
Vaccination season Work location
An exposure event occurring when any sharp object penetrates the skin
A sharp object (e.g., suture needle, scalpel) that does not have a lumen through which material can flow.
A 12-month period starting from July 1 of a year to June 30 of the following year.
A HCW's current permanent work location. This refers to physical work location rather than to department assignment.
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NHSN Healthcare Personnel Safety Component CDC Codes
CDC occupation Codes used to code ("map") facility locations
CDC (occupation) Code
ATT-Attendant/orderly CLA-Clerical/administrative CNA-Nurse Anesthetist CNM-Nurse Midwife CSS-Central Supply CSW-Counselor/Social Worker DIT-Dietician DNA-Dental Assistant/Tech DNH-Dental Hygienist DNO-Other Dental Worker DNT-Dentist DST-Dental Student EMT-EMT/Paramedic FEL-Fellow FOS-Food Service HEM-Hemodialysis Technician HSK-Housekeeper
BLS SOC (2000)* 31-1012
33-7012 21-1020 29-1030 31-9091 29-2021
29-1020
29-2041
35-0000
37-2010
CDC (occupation) Code
ICP-Infection Control Professional IVT-IVT Team Staff LAU-Laundry Staff LPN-Licensed Practical Nurse MLT -Medical Laboratory Technician MNT-Maintenance/Engineering MOR-Morgue Technician MST-Medical Student MTE-Medical Technologist NUA-Nursing Assistant NUP-Nurse Practitioner OAS-Other Ancillary Staff OFR-Other First Responder OH-Occupational Health Professional OMS-Other Medical Staff ORS-OR/Surgery Technician
BLS SOC (2000)*
29-2061 29-2012
29-2090
29-9010 29-2055
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NHSN Healthcare Personnel Safety Component CDC Codes
CDC (occupation) Code
OTH-Other OTT-Other Technician/Therapist PAS-Physician Assistant PCT-Patient Care Technician PHA-Pharmacist PHL-Phlebotomist/IV Team PHW-Public Health Worker PHY-Physician PLT-Physical Therapist PSY-Psychiatric Technician RCH-Researcher RDT-Radiologic Technologist RES-Intern/Resident RNU-Registered Nurse RTT-Respiratory Therapist/Tech STU-Other Student TRA-Transport/Messenger/Porter VOL-Volunteer
BLS SOC (2000)*
29-2099 29-1071
29-1051
29-1060 29-1123 29-2053 19-1040 29-2034
29-1111 29-1126
* Bureau of Labor Statistics (BLS) Standard Occupational Codes (SOC), available online at the United States Department of Labor, Bureau of Labor Statistics at http://www.bls.gov/soc/
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NHSN Healthcare Personnel Safety Component CDC Codes
CDC Device description used to code ("map") medical devices used in the facility
CDC Device Description
CDC Device Description
IVPER - IV catheter - peripheral
BCUT - Bone cutter
IVCATH - IV catheter central line
BOVIE - Electrocautery device
HYPO - Hypodermic needle, attached syringe
BUR - Bur
UNATT - Unattached hypodermic needle
ELEV - Elevator
PREFILL - Prefilled cartridge syringe
EXPL - Explorer
STYLET - I.V. Stylet
FILE - File
VHOLD - Vacuum tube holder/needle
FORCEPS - Extraction Forceps
SPINAL - Spinal or epidural needle
LANCET - Lancet
BMARROW - Bone marrow needle
MICRO - Microtome blade
BIOPSY - Biopsy needle
PIN - Pin
OTH-HOL - Other hollow-bore needle
RAZOR - Razor
UNK-HOL - Hollow-bore needle, type unknown
RETRACT - Retractor
HUBER - Huber needle
ROD - Rod (orthopaedic)
WINGED - Winged-steel (ButterflyTM-type) needle
SCALE - Scaler/curette
HEMODIAL - Hemodialysis needle
SCALPEL - Scalpel blade
HYPO-TUB - Hypodermic, attached to IV tubing
SCIS - Scissors
DENTASP -Dental aspirating syringe with needle
TENAC - Tenaculum
ABCD - Arterial Blood Collection Device
TROCAR - Trocar
SUTR - Suture needle
WIRE - Wire
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CDC Device Description COLLTUBE - Blood collection tubes CAPILL - Capillary tube MED - Medication ampule/vial/IV bottle PIPE - Pipette (glass) SLIDE - Slide TUBE - Specimen/test/vacuum tube BCADAP - Blood culture adapter IVDEL - IV Delivery System CATHSECD - Catheter Securement Device PCOLLTUBE - Blood collection tubes - plastic PCAPILL - Capillary tube - plastic PTUBE - Specimen/test/vacuum tube - plastic UNK - Unknown type of sharp object OTHER - Other sharp
NHSN Healthcare Personnel Safety Component CDC Codes
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NHSN Healthcare Personnel Safety Component CDC Codes
Antiretroviral and Associated Drug Codes for Use on Healthcare Worker BBF Postexposure Prophylaxis form (CDC 57.206)
CDC Drug Code 3TC - lamivudine ABC - abacavir ATV - atazanavir CD4 - CD4 therapies D4T - stavudine ddI - didanosine DLV - delavirdine DRV - darunavir EFV - efavirenz ENF - enfuvirtide (T-20) ETR - etravirine fAPV - fosamprenavir FTC - emtricitabine HU - hydroxyurea IDV - indinavir IL2 - interleukin2 INT - interferon LPV - lopinavir
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NFV - nelfinavir NVP - nevirapine OTH - other RLT - raltegravir RIL - Rilpivirine RTV - ritonavir SQV - saquinavir TDF - tenofovir TIP - tipranavir (PNU-140690) ZDV - zidovudine (AZT)
NHSN Healthcare Personnel Safety Component CDC Codes
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The National Healthcare Safety Network (NHSN) Manual
HEALTHCARE PERSONNEL SAFETY COMPONENT PROTOCOL
Healthcare Personnel Vaccination Module: Influenza Vaccination Summary
Division of Healthcare Quality Promotion National Center for Emerging and Zoonotic Infectious Diseases
Atlanta, GA, USA
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Table of Contents
Chapter
Title
1 Introduction to the Healthcare Personnel Safety Component
2 Healthcare Personnel Safety Monthly Reporting Plan
Healthcare Personnel Vaccination Module: Influenza 3 Vaccination Summary
4 Forms and Tables of Instructions
5 Key Terms
Influenza Vaccination Summary: List of Contracted Appendix Healthcare Personnel Examples
A
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1. Introduction to Healthcare Personnel Safety Component
In recent years, occupational hazards faced by healthcare personnel (HCP) in the United States have received increasing attention. Although recommendations, guidelines, and regulations to minimize HCP exposure to such hazards have been developed, additional information is needed to improve HCP safety. In particular, existing surveillance systems are often inadequate to describe the scope and magnitude of occupational exposures to infectious agents and noninfectious occupational hazards that HCP experience, the outcomes of these exposures and injuries, and the impact of preventive measures. The lack of ongoing surveillance of occupational exposures, injuries, and infections in a national network of healthcare facilities using standardized methodology also compromises the ability of the Centers for Disease Control and Prevention (CDC) and other public health agencies to identify emerging problems, to monitor trends, and to evaluate preventive measures.
The Healthcare Personnel Safety (HPS) Component of the National Healthcare Safety Network (NHSN) was launched in 2009. The component consists of two modules: 1) Healthcare Personnel Exposure; and (2) Healthcare Personnel Vaccination. The exposure module includes: Blood/Body Fluid Exposure Only; Blood/Body Fluid Exposure with Exposure Management; and Influenza Exposure Management. The Healthcare Personnel Vaccination Module, , includes: Influenza Vaccination Summary.
Data collected in this surveillance system will assist healthcare facilities, HCP organizations, and public health agencies to monitor and report trends in blood/body fluid exposures, to assess the impact of preventive measures, to characterize antiviral medication use for exposures to influenza, and to monitor influenza vaccination coverage among HCP. In addition, this surveillance component will allow CDC to monitor national trends, to identify newly emerging hazards for HCP, to assess the risk of occupational infection, and to evaluate measures, including engineering controls, work practices, protective equipment, and post-exposure prophylaxis designed to prevent occupationally-acquired infections. Hospitals and other healthcare facilities will benefit by receiving technical support and standardized methodologies, including a Webbased application, for conducting surveillance activities on occupational health. The NHSN reporting application will enable facilities to analyze their own data and compare these data with a national database.
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2. Healthcare Personnel Safety Monthly Reporting Plan
The Healthcare Personnel Safety Monthly Reporting Plan (CDC 57.203) is used by NHSN facilities to inform CDC which Healthcare Personnel Safety component modules are used during a given month. This allows CDC to select data that should be included in the aggregate data pool for analysis. Each facility must enter a monthly reporting plan to indicate the modules to be used, if any, and the exposures and/or vaccinations that will be monitored.
For the Exposure Module, a plan must be completed for every month that data are entered into NHSN, although a facility may choose "No NHSN Healthcare Personnel Safety Modules Followed this Month" as an option. When creating a plan for influenza vaccination summary data reporting in the Healthcare Personnel Vaccination Module, all months will be included in the plan regardless of whether data are entered each month. Once the influenza vaccination summary is selected on the reporting plan for any given month, all reporting plans are automatically updated with this information for the entire NHSN-defined influenza season (July 1 through June 30 of the following year). The Instructions for Completion of the Healthcare Personnel Safety Monthly Reporting Plan Form includes brief instructions for collection and entry of each data element on the form.
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3. Healthcare Personnel Vaccination Module: Influenza Vaccination Summary
Introduction The Advisory Committee on Immunization Practices (ACIP) recommends that all persons six months of age and older, including HCP and persons in training for healthcare professions, should be vaccinated annually against influenza. [1,2] Persons infected with influenza virus, including those who are pre-symptomatic, can transmit the virus to coworkers and patients, some of who may be at higher risk for complications from influenza. Vaccination of working age adults, including HCP, has been associated with reduced risk of influenza illness, and reduced work absenteeism, antibiotic use, and medical visits. [3,4] In addition, HCP influenza vaccination has reduced deaths among nursing home patients [5,6] and elderly hospitalized patients.[6] Annual vaccination is recommended for all HCP and is a high priority for reducing morbidity associated with influenza in healthcare settings. National survey data have demonstrated that HCP influenza vaccination coverage levels are approximately 80% [7], falling short of the Healthy People 2020 target of 90% for HCP influenza vaccination [8]. HCP influenza vaccination varies substantially by provider type and healthcare setting. [7]
Healthcare facilities should provide influenza vaccine to HCP using approaches that have demonstrated effectiveness in increasing vaccination coverage. [1, 2] Healthcare administrators should consider the level of vaccination coverage among HCP to be one measure of a patient safety quality program and consider obtaining signed declinations from personnel who decline influenza vaccination for reasons other than medical contraindications. [2; 9-12] Influenza vaccination rates (including ward-, unit-, and specialty-specific coverage rates) among HCP within facilities should be regularly measured and reported to facility administrators and staff. [2,12]
Healthcare facilities should offer influenza vaccinations to all eligible HCP, [2] including part-time and temporary staff. Efforts should be made to educate HCP on the benefits of vaccination and the potential health consequences of influenza illness for their patients, themselves, and their family members [2]. Studies have demonstrated that organized campaigns can attain higher rates of vaccination among HCP with moderate effort and by using strategies that increase vaccine acceptance.[9,13,14] All HCP should be provided convenient access to influenza vaccine at the work site, free of charge. [9,14]
HCP Influenza Vaccination Measure The HCP influenza vaccination measure is designed to ensure that reported HCP influenza vaccination percentages are consistent over time within a single healthcare facility and comparable across facilities. Using this measure to monitor influenza vaccination among HCP may also result in increased influenza vaccination uptake among HCP, because improvements in tracking and reporting HCP influenza vaccination status will allow healthcare institutions to better identify and target unvaccinated HCP. Increased influenza vaccination coverage among HCP is expected to result in reduced morbidity and mortality related to influenza virus infection among patients. The HCP Vaccination Module of the HPS Component will allow NHSN users to report HCP influenza vaccination percentages using this HCP influenza vaccination measure.
Settings All types of healthcare facilities including acute care hospitals, long-term acute care hospitals, inpatient psychiatric facilities, inpatient rehabilitation facilities, outpatient dialysis centers, ambulatory surgery centers, and long-term care facilities are invited to join NHSN and use the measure.
Requirements Participating facilities are required to report data according to this protocol, using the NHSN definitions described herein, to ensure data are uniformly reported across facilities. Within the HPS Component, monthly reporting plans must
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be created or updated to include HCP influenza vaccination summary reporting. Once the "Influenza Vaccination Summary" box is checked on one monthly reporting plan, then the system will auto-check that same box on every monthly reporting plan throughout the entire NHSN-defined influenza season (defined as the 12 months from July 1 June 30).
CDC/NHSN encourages that HCP influenza vaccination summary data be updated on a monthly basis and suggests that healthcare facilities update data within 30 days of the end of each month (for example, all October data should be added by November 30) so they have the greatest impact on influenza vaccination activities. However, entering a single influenza vaccination summary report at the conclusion of the measure reporting period will meet the minimum data requirements for NHSN participation.
Reporting Instructions
Forms, Description, and Purpose (See also: Tables of Instructions for Completion of Healthcare Personnel Influenza Vaccination Summary Form in Chapter 4)
All facilities using the HCP Vaccination Module for HCP influenza vaccination summary data reporting must complete the following forms: the Healthcare Personnel Safety Monthly Reporting Plan form and the Healthcare Personnel Influenza Vaccination Summary form. In addition, dialysis centers that do not provide in-center hemodialysis are also required to complete the Home Dialysis Center Practices survey.
· Healthcare Personnel Safety Monthly Reporting Plan Form (CDC 57.203) This is used to collect data on which modules and which months (if any) the facility intends to participate in the NHSN HPS Component. Once the influenza vaccination summary is selected on the reporting plan, it is automatically updated with this information for the entire NHSN-defined influenza season (July 1 to June 30).
· Healthcare Personnel Influenza Vaccination Summary Form (CDC 57.214) This is used to collect data on summary influenza vaccination counts among HCP working in a facility. HCP influenza vaccination summary reporting in NHSN consists of a single data entry screen per influenza season. Each time a user enters updated data for a particular influenza season, all previously entered data for that season will be overwritten and a new modified date will be auto-filled by the system. When entering data, all required fields indicated with an asterisk must be completed. Otherwise, the data cannot be saved. Users should enter "0" in a field if no HCP at the facility fall into that category.
· Home Dialysis Center Practices Survey (CDC 57.507) Dialysis centers that do not provide in-center hemodialysis are required to complete the Home Dialysis Center Practices Survey before they can enter the HCP influenza vaccination summary data into NHSN. This survey captures information about various topics such as surveillance practices, vaccination, and vascular access.
The Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel (CDC 57.215) is not required at this time. The survey collects data on types of personnel groups that are included in a facility's annual influenza vaccination campaign, methods a facility is using to deliver influenza vaccine to its HCP, strategies a facility uses to promote/enhance HCP influenza vaccination, etc. Facilities are encouraged to complete one survey at the end of the influenza season.
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Measure Specifications
Denominator The denominator for this measure consists of HCP who are physically present in the healthcare facility for at least 1 working day between October 1 through March 31 of the following year. Denominators are to be calculated separately for three required categories of HCP and can also be calculated for a fourth optional category:
a. Employees (required): This includes all persons receiving a direct paycheck from the reporting facility (i.e., on the facility's payroll), regardless of clinical responsibility or patient contact.
b. Licensed independent practitioners (LIPs) (required): This includes physicians (MD, DO), advanced practice nurses, and physician assistants who are affiliated with the reporting facility, but are not directly employed by it (i.e., they do not receive a paycheck from the facility), regardless of clinical responsibility or patient contact. Post-residency fellows are also included in this category if they are not on the facility's payroll.
c. Adult students/trainees and volunteers (required): This includes medical, nursing, or other health professional students, interns, medical residents, or volunteers aged 18 or older who are affiliated with the healthcare facility, but are not directly employed by it (i.e., they do not receive a paycheck from the facility), regardless of clinical responsibility or patient contact.
d. Other contract personnel (optional): Contract personnel are defined as persons providing care, treatment, or services at the facility through a contract who do not fall into any of the other - denominator categories. (See Appendix A for a list of contract personnel examples.) Reporting for this category is optional at this time.
Denominator Notes 1. The denominator includes HCP who worked at the facility for at least 1 working day from October 1 through March 31 during the reporting period, regardless of clinical responsibility or patient contact. This includes HCP who joined after October 1 or left before March 31, or who were on extended leave during part of the reporting period. Working for any number of hours a day counts as one working day.
2. Both full-time and part-time personnel should be included. HCP should be counted as individuals rather than full-time equivalents. If a healthcare worker (HCW) works in two or more facilities, each facility should include the HCW in their denominator data.
3. Licensed practitioners who receive a direct paycheck from the reporting facility, or who are owners of the reporting facility, should be counted as employees.
4. The denominator categories are mutually exclusive. The numerator data are to be reported separately for each of the denominator categories.
Numerator The numerator for this measure consists of HCP in the denominator population, who fall into one of the categories below. HCP should be counted as vaccinated if they receive influenza vaccine any time from when it first became available, such as August or September, through March 31 of the following year:
a. received an influenza vaccination administered at the healthcare facility; or
b. reported in writing (paper or electronic) or provided documentation that influenza vaccination was received elsewhere; or
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c. were determined to have a medical contraindication/condition of severe allergic reaction to eggs or other component(s) of the vaccine, or history of Guillain-Barré Syndrome (GBS) within 6 weeks after a previous influenza vaccination; or
d. were offered but declined influenza vaccination; or
e. had an unknown vaccination status or did not otherwise meet any of the definitions of the other numerator categories.
Numerator Notes 1. Persons who declined vaccination because of conditions other than those specified in category (c) above should be categorized as declined vaccination.*
2. Persons who declined vaccination and did not provide any other information should be categorized as declined vaccination.
3. Persons who did not receive vaccination because of religious or philosophical exemptions should be categorized as declined vaccination.
4. Persons who deferred vaccination all season should be categorized as declined vaccination.
5. The numerator data are mutually exclusive. The sum of the numerator categories should be equal to the denominator for each HCP group.
*Note: For the purposes of this measure, a medical contraindication to vaccination with is defined as having a severe allergic reaction to eggs or other components of the influenza vaccine or a history of GBS within 6 weeks after a previous influenza vaccination. A healthcare facility may grant medical exemptions to HCP with other conditions besides those defined for this measure and may include these conditions in its list of acceptable medical contraindications to influenza vaccination. However, to ensure that data are comparable across different facilities reporting data using this measure, only those HCP with one of the two conditions stated above should be reported to NHSN as having a medical contraindication to influenza vaccination.
Data Sources Data sources for the required data elements include management/personnel data, medical or occupational health records, and vaccination records. HCP can self-report in writing (paper or electronic) that the vaccination was received elsewhere or provide documentation of receipt of the influenza vaccine elsewhere. Documentation should include the date and location of vaccine receipt. For this reporting measure, verbal statements are not acceptable proof of vaccination outside the facility. However, HCP can provide verbal statements for medical contraindications to and declination of the influenza vaccine, as written documentation is not required for NHSN reporting.
Methodology The influenza vaccination summary data reporting enables a healthcare facility to record influenza vaccination data for HCP working in the healthcare facility for at least 1 day from October 1 through March 31. Data must be entered for the three denominator categories of HCP groups and the five numerator fields describing vaccination status. A fourth denominator category for other contract personnel is optional at this time.
This module requires that data be collected as per CDC reporting requirements. Data covering the entire denominator reporting period (October 1 through March 31) must be entered once into NHSN for each reporting year. The data can
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be entered on a monthly and/or quarterly basis, but only cumulative data should be entered. Any new data that are entered into NHSN will overwrite previously entered data. Thus, if a facility would like to keep track of its monthly numbers, it should maintain its own record of monthly summary reports as it will not be able to review previously entered data in NHSN.
Data Analyses Influenza vaccination status is calculated separately among each of the three required denominator categories: employees, LIPs, and adult students/trainees and volunteers. Influenza vaccination status can also be calculated for the fourth optional category of other contract personnel using the modify option within the analysis function. Separate measures are calculated by dividing the number of HCP in one numerator field (for example, number of HCP who received an influenza vaccination at this healthcare facility since influenza vaccine became available this season) by the number of HCP in that denominator group, and multiplying by 100 to produce a vaccination percentage for that specific group. Percentages of vaccination received elsewhere, medical contraindications, declinations, and unknown vaccination status can also be calculated using the second, third, fourth, and fifth numerator fields, respectively. Calculations for employee vaccination percentages are shown below. Vaccination percentages for LIPs, adult students/trainees and volunteers, and other contract personnel are calculated in the same manner.
Employee Vaccination Percentages
Employee Vaccination Percentage (at this healthcare facility)
# Employees vaccinated onsite ×100 = Pct. of Employees Vaccinated Onsite
# Employees working in the required time period
Employee Vaccination Percentage (outside this healthcare facility)
# Employees vaccinated elsewhere ×100 = Pct. of Employees Vaccinated Elsewhere
# Employees working in the required time period
Employee Medical Contraindication Percentage
# Employees reporting contraindication ×100 = Pct. of Employees Reporting Contraindication
# Employees working in the required time period
Employee Declination Percentage
# Employees declined vaccine ×100 = Pct. of Employees Reporting Declination
# Employees working in the required time period
Employee Unknown Vaccination Percentage
# Employees with unknown vaccination # Employees working in the required time period ×100 = Pct. Employees with Unknown Status
HCP Vaccination Percentages In addition to calculating vaccination percentages for individual denominator groups, percentages can be calculated for all HCP (both employees and non-employees). Percentages can also be calculated including the optional category of
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contract personnel using the modify option within the analysis function. To determine vaccination for all HCP, the system will add the total number of HCP (employees, LIPs, and adult students/trainees and volunteers) in one numerator field (for example, total number of HCP who received an influenza vaccination at this healthcare facility since influenza vaccine became available this season). The number is divided by the total number of HCP who worked at this healthcare facility for at least 1 working day from October 1 through March 31, and multiplied by 100 to produce a vaccination percentage for that HCP group. Percentages of vaccination received elsewhere, medical contraindications, declinations, and unknown vaccination status can also be calculated using the second, third, fourth, and fifth numerator fields, respectively. Calculations for total HCP vaccination percentages are shown below. The second calculation in this section shows how an onsite vaccination percentage is computed for all facility HCP including other contract personnel (OCP). Other vaccination percentages for all HCP including other contract personnel are computed in the same manner as the other calculations in this section.
HCP Vaccination Percentage (at this healthcare facility) [excluding OCP]
# Employees + # LIPs + # ASTV vaccinated onsite ×100 = Pct. of HCP Vacc. Onsite (exc. OCP)
# Employees + # LIPs + # ASTV working in the required time period
HCP Vaccination Percentage (at this healthcare facility) [including OCP]
# Employees + # LIPs + # ASTV + # OCP vaccinated onsite ×100 = Pct. of HCP Vacc. Onsite (inc. OCP)
# Employees + # LIPs + # ASTV + # OCP working in the required time period
HCP Vaccination Percentage (outside this healthcare facility) [excluding OCP]
# Employees + # LIPs + # ASTV vaccinated elsewhere ×100 = Pct. of HCP Vacc. Elsewhere (exc. OCP)
# Employees + # LIPs + # ASTV working in the required time period
HCP Medical Contraindication Percentage [excluding OCP]
# Employees + # LIPs + # ASTV reporting contraindication ×100 = Pct. of HCP Reporting Contra. (exc. OCP)
# Employees + # LIPs + # ASTV working in the required time period
HCP Declination Percentage [excluding OCP]
# Employees + # LIPs + # ASTV declined vaccine ×100 = Pct. of HCP Reporting Declination (exc. OCP)
# Employees + # LIPs + # ASTV working in the required time period
HCP Unknown Vaccination Percentage [excluding OCP]
# Employees + # LIPs + # ASTV with unknown status ×100 = Pct. of HCP with Unknown Status (exc. OCP)
# Employees + # LIPs + # ASTV working in the required time period
Non-Employee Vaccination Percentages Vaccination percentages can be calculated for all non-employees (LIPs and adult students/trainees and volunteers). Percentages can also be calculated including the optional category of other contract personnel using the modify option within the analysis function. To determine vaccination for all non-employees, the system will add the total number of non-employee HCP (LIPs and adult students/trainees and volunteers) in one numerator field (for example, number of HCP who received an influenza vaccination at this healthcare facility since influenza vaccine became available this season). The number is divided by the total number of HCP who worked at this healthcare facility for at least 1 working day from October 1 through March 31, and multiplied by 100 to produce a vaccination percentage for that group of non-
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employees. Percentages of vaccination received elsewhere, medical contraindications, declinations, and unknown vaccination status can also be calculated using the second, third, fourth, and fifth numerator fields, respectively. Calculations for non-employee vaccination percentages are shown below. The second calculation in this section shows how a percentage is computed for other contract personnel.
Non-Employee Vaccination Percentage (at this healthcare facility) [excluding OCP]
# LIPs + # ASTV vaccinated onsite ×100 =Pct. of Non-Employees Vacc. Onsite (exc. OCP)
LIPs + # ASTV working in the required time period
Non-Employee Vaccination Percentage (at this healthcare facility) [including OCP]
# LIPs + # ASTV + # OCP vaccinated onsite ×100 = Pct. of Non-Employees Vacc. Onsite (inc. OCP)
# LIPs + # ASTV + # OCP working in the required time period
Non-Employee Vaccination Percentage (outside this healthcare facility) [excluding OCP]
# LIPs + # ASTV vaccinated elsewhere ×100 = Pct. of Non-Employees Vacc. Elsewhere (exc. OCP)
# LIPs + # ASTV working in the required time period
Non-Employee Medical Contraindication Percentage [excluding OCP]
# LIPs + # ASTV reporting contraindication ×100 = Pct. of Non-Employees Reporting Contra. (exc. OCP)
# LIPs + # ASTV working in the required time period
Non-Employee Declination Percentage [excluding OCP]
# LIPs + # ASTV declined vaccine ×100 = Pct. of Non-Employees Reporting Declination (exc. OCP)
# LIPs + # ASTV working in the required time period
Non-Employee Unknown Vaccination Percentage [excluding OCP]
# LIPs + # ASTV with unknown vaccination ×100 = Pct. of Non-Employees with Unknown Status (exc. OCP)
# LIPs + # ASTV working in the required time period
Vaccination Compliance To determine vaccination compliance, the system will add the total number of HCP who received an influenza vaccination at this healthcare facility to the total number of HCP who provided a written report or documentation of influenza vaccination outside this healthcare facility since influenza vaccine became available this season. The number is divided by the total number of HCP who worked at this healthcare facility for at least 1 working day from October 1 through March 31. This number is then multiplied by 100 to obtain a percentage. Percentages can also be calculated including the optional category of other contract personnel using the modify option within the analysis function. Calculations for employee vaccination compliance, HCP vaccination compliance, and non-employee vaccination compliance percentages are shown below. Vaccination compliance percentages for LIPs, adult students/trainees and volunteers, and other contract personnel are calculated in the same manner.
Employee Vaccination Compliance Percentage
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# Employees vaccinated onsite + # Employees vaccinated elsewhere ×100 = Pct. of Employee Vacc. Compliance
# Employees working in the required time period
HCP Vaccination Compliance Percentage [excluding OCP]
(# Emp. + # LIPs + # ASTV vacc. onsite) + (# Emp. + # LIPs + # ASTV vacc. elsewhere) ×100 = Pct. of HCP Vacc. Comp. (exc. OCP)
# Emp. + # LIPs + # ASTV working in the required time period
HCP Vaccination Compliance Percentage [including OCP]
(# Emp. + # LIPs + # ASTV + # OCP vacc. onsite) + (# Emp. + # LIPs + # ASTV + # OCP vacc. elsewhere) ×100 = Pct. of HCP Vacc. Comp. (inc. OCP)
# Emp. + # LIPs + # ASTV + # OCP working in the required time period
Non-Employee Vaccination Compliance Percentage [excluding OCP]
(# LIPs + # ASTV vacc. onsite) + (# LIPs + # ASTV vacc. elsewhere) ×100 = Pct. of Non-Employee Vacc. Comp. (exc. OCP)
# LIPs + # ASTV working in the required time period
Non-Employee Vaccination Compliance Percentage [including OCP]
(# LIPs + # ASTV + # OCP vacc. onsite) + (# LIPs + # ASTV + # OCP vacc. elsewhere) ×100 = Pct. of Non-Employee Vacc. Comp. (inc. OCP)
# LIPs + # ASTV + # OCP working in the required time period
Vaccination Non-Compliance To determine vaccination non-compliance, the system will add the total number of HCP who declined to receive the influenza vaccination to the total number of HCP with unknown vaccination status. The number is divided by the total number of HCP who worked at this healthcare facility for at least 1 working day between October 1 through March 31. This number is then multiplied by 100 to obtain a percentage. Percentages can also be calculated including the optional category of other contract personnel using the modify option within the analysis function. Calculation for employee vaccination non-compliance, HCP vaccination non-compliance, and non-employee vaccination non-compliance percentages are shown below. Vaccination non-compliance percentages for LIPs, adult students/trainees and volunteers, and other contract personnel are calculated in the same manner.
Employee Vaccination Non-Compliance Percentage
# Employees declined vacc. + # Employees with unknown status
×100 = Pct. of Employee Vacc. Non-Compliance
# Employees working in the required time period
HCP Vaccination Non-Compliance Percentage [excluding OCP]
(# Emp. + # LIPs + # ASTV declined vacc.) + (# Emp. + # LIPs + # ASTV with unknown status)
# Emp. + # LIPs + # ASTV working in the required time period
×100 =Pct. of HCP Vacc. Non-Comp. (exc. OCP)
HCP Vaccination Non-Compliance Percentage [including OCP]
(# Emp. + # LIPs + # ASTV + # OCP dec. vacc.) + (# Emp. + # LIPs + # ASTV + # OCP with unknown status) # Emp. + # LIPs + # ASTV + # OCP working in the required time period
×100 =Pct. of HCP Vacc. Non-Comp. (inc. OCP)
Non-Employee Vaccination Non-Compliance Percentage [excluding OCP]
(# LIPs + # ASTV declined vacc.) + (# LIPs + # ASTV with unknown status) ×100 = Pct. of Non-Employee Vacc. Non-Comp. (exc. OCP)
# LIPs + # ASTV working in the required time period
Last reviewed March 2020
Non-Employee Vaccination Non-Compliance Percentage [including OCP]
(# LIPs + # ASTV + # OCP declined vacc.) + (# LIPs + # ASTV + # OCP with unknown status)
# LIPs + # ASTV + # OCP working in the required time period
×100 = Pct. of Non-Emp. Vacc. Non-Comp. (inc. OCP)
References [1] L.A Grohskopf, E. Alyanak, K.R. Broder, E.B. Walter, A.M. Fry, D.B. Jernigan. Prevention and Control of
Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices -- United States, 201920 Influenza Season. MMWR Recomm Rep 2019;68(No. RR-3):121. DOI: http://dx.doi.org/10.15585/mmwr.rr6803a1external icon
[2] Centers for Disease Control and Prevention, Influenza vaccination of health-care personnel, MMWR, 55 (2006) 116.
[3] R. T. Lester, A. McGeer, G. Tomlinson, and A. S. Detsky, Use of, effectiveness of, attitudes regarding influenza vaccine among house staff, Infection Control and Hospital Epidemiology, 24 (2003) 839-844.
[4] C.B. Bridges, W.W. Thompson, M.I. Meltzer, G.R. Reeve, W.J. Talamonti, N.J. Cox, H.A. Lilac, H. Hall, A. Klimov, and K. Fukuda, Effectiveness and Cost-Benefit of Influenza Vaccination of Healthy Working Adults, Journal of the American Medical Association, 284 (2000) 1655-1663.
[5] J. Potter, D. J. Stott, M. A. Roberts, A. G. Elder, B. ODonnell, P. V. Knight, and W. F. Carman, Influenza vaccination of health care workers in long-term-care hospitals reduces the mortality of elderly patients, Journal of Infectious Diseases, 175 (1997) 1-6.
[6] R. E. Thomas, T. O. Jefferson, V. Demicheli, and D. Rivetti, Influenza vaccination for health-care workers who work with elderly people in institutions: a systematic review, Lancet Infectious Diseases, 6 (2006) 273-279.
[7] B. Bardenheier, M.C. Lindley, MPH, X. Yue, I. Oyegun, S.W. Ball, R. Devlin, M. A. de Perio, A.S. Laney, P. Lu, R.V. Fink, Influenza Vaccination Coverage Among Health Care Personnel -- United States, 201819 Influenza Season. (https://www.cdc.gov/flu/fluvaxview/hcp-coverage_1819estimates.htm) (Accessed April 22, 2020)
[8] Healthy People 2020. Immunization and Infectious Diseases. (http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=23) (Accessed April 20, 2020)
[9] F. J. Walker, J. A. Singleton, P. Lu, K. G. Wooten, and R. A. Strikas, Influenza vaccination of healthcare workers in the United States, 1989-2002, Infection Control and Hospital Epidemiology, 27 (2006) 257-265.
[10] P. M. Polgreen, Y. Chen, S. Beekmann, A. Srinivasan, M. A. Neill, T. Gay, J. E. Cavanaugh, and Infect Dis Soc Amer Emer Infect, Elements of influenza vaccination programs that predict higher vaccination rates: Results of an emerging infections network survey, Clinical Infectious Diseases, 46 (2008) 14-19.
[11] Centers for Disease Control and Prevention, Interventions to increase influenza vaccination of health-care workersCalifornia and Minnesota, MMWR, 54(08) (2005) 196-199.
[12] National Quality Forum. National Voluntary Consensus Standards for Influenza and Pneumococcal Immunizations. http://www.qualityforum.org/Publications/2008/12/National_Voluntary_Consensus_Standards_for_Influenza_and_ Pneumococcal_Immunizations.aspx , 1-68. 2008. Washington DC, National Quality Forum. 8-12-2009.
Last reviewed March 2020
[13] G. A. Poland, P. Tosh, and R. M. Jacobson, Requiring influenza vaccination for health care workers: seven truths we must accept, Vaccine, 23 (2005) 2251-2255.
[14] Joint Commission on Accreditation of Healthcare Organizations, New infection control requirement for offering influenza vaccination to staff and licensed independent practitioners, Joint Commission Perspectives, 26 (2006) 1011.
Healthcare Personnel Safety
Form Approved OMB No. 0920-0666 Exp. Date: 12/31/22
www.cdc.gov/nhsn
Page 1 of 1 *required for saving
Monthly Reporting Plan
Facility ID#: ____________________________
*Month/Year: __________ /________
No NHSN Healthcare Personnel Safety Modules followed this month
Healthcare Personnel Exposure Modules
Blood/Body Fluid Exposure Only Blood/Body Fluid Exposure with Exposure Management Influenza Exposure Management
Healthcare Personnel Vaccination Module
Influenza Vaccination Summary Influenza Vaccination Summary for the Hospital Influenza Vaccination Summary for the Inpatient Rehabilitation Facility Unit(s) Influenza Vaccination Summary for the Inpatient Psychiatric Facility Unit(s)
Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).
Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333 ATTN: PRA (0920-0666).
CDC 57.203, v3, r8.4
Last reviewed March 2020
4. Table 1. Instructions for Completion of the Healthcare Personnel Safety Monthly Reporting Plan Form (CDC 57.203)
This form collects data on which options and which months a facility intends to participate in NHSN Healthcare Personnel Safety (HPS) Component. This form should be completed for every month that the facility will participate in the HPS Component.
Data Field Facility ID #
Month/Year
No NHSN Healthcare Personnel Safety Modules Followed this Month
Instructions for Data Collection Required. The NHSN-assigned facility ID will be auto-entered by the application. Required. Enter the month and year for the surveillance plan being recorded. Conditionally required. Check this box if you do not plan to follow any of the NHSN Healthcare Personnel Safety Modules during the month and year selected.
Healthcare Personnel Exposure Module
Blood/Body Fluid Exposure Only
Blood/Body Fluid Exposure with Exposure Management Influenza Exposure Management
Conditionally required. Check this box if you plan to follow blood/body fluid exposures only, without following exposure management during the month and year selected. Conditionally required. Check this box if you plan to follow blood/body fluid exposure with exposure management during the month and year selected.
Conditionally required. Check this box if you plan to follow influenza exposure management (for example, antiviral chemoprophylaxis and/or treatment)
Healthcare Personnel Vaccination Module
Influenza Vaccination Summary
Conditionally required. Check this box if you plan to follow the influenza vaccination summary option. Once the box is checked on one monthly reporting plan, the system will auto-check that same box on every monthly reporting plan throughout the entire NHSN-defined influenza season (July 1 through June 30 of the following year).
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Healthcare Personnel Influenza Vaccination Summary
Page 1 of 2 *required for saving, ^conditionally required for saving
Record the number of healthcare personnel (HCP) for each category below for the influenza season being tracked.
*Facility ID#:
^Location:
*Vaccination type: *Influenza subtypea:
Influenza
Seasonal
1. Number of HCP who worked at this healthcare facility for at least 1 day between October 1 and March 31
2. Number of HCP who received an influenza vaccination at this healthcare facility since influenza vaccine became available this season
3. Number of HCP who provided a written report or documentation of influenza vaccination outside this healthcare facility since influenza vaccine became available this season
4. Number of HCP who have a medical contraindication to the influenza vaccine
*Influenza Seasonb:
Date Last Modified:
__/__/____
Employee HCP
Non-Employee HCP
*Employees (staff on facility payroll)
*Licensed independent practitioners:
Physicians, advanced practice nurses, & physician assistants
*Adult students/ trainees & volunteers
Other Contract Personnel
5. Number of HCP who declined to receive the influenza vaccine
6. Number of HCP with unknown vaccination status (or criteria not met for questions 2-5 above)
Custom Fields
Label _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ Comments
____/____/_____ ______________ ______________ ______________ ______________ ______________
Label _________________________ _________________________ _________________________ _________________________ _________________________ _________________________
____/____/_____ ______________ ______________ ______________ ______________ ______________
a For the purposes of NHSN, influenza subtype refers to whether seasonal or non-seasonal vaccine is used. Seasonal is the default and only current choice. b For the purposes of NHSN, a flu season is defined as July 1 to June 30.
Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). CDC 57.214 v2, R8.2
Last reviewed March 2020
Healthcare Personnel Influenza Vaccination Summary
Page 2 of 2
Question 1 (Denominator) Notes: · Include all HCP who have worked at the facility for at least 1 working day during the reporting period, regardless
of clinical responsibility or patient contact. This includes HCP who joined after October 1 or left before March 31, or who were on extended leave during part of the reporting period. Working for any number of hours a day counts as one working day. · Include both full-time and part-time persons. If a HCW works in two or more facilities, each facility should include the HCW in their denominator. Count HCP as individuals rather than full-time equivalents. · Licensed practitioners who receive a direct paycheck from the reporting facility, or who are owners of the reporting facility, should be counted as employees. · The HCP categories are mutually exclusive. Each HCP should be counted only once in the denominator (question 1). Questions 2-6 (Numerator) Notes: · Questions 2-6 are mutually exclusive. The sum of the HCP in questions 2-6 should equal the number of HCP in question 1 for each HCP category. Questions 2-6 are to be reported separately for each of the three HCP categories. · Only the following HCP should be counted in question 4: HCP with (1) a severe allergic reaction to eggs or other vaccine component(s) or (2) a history of Guillain-Barré Syndrome within 6 weeks after a previous influenza vaccination. · The following should be counted in question 5 (declined to receive influenza vaccine): o HCP who declined vaccination because of conditions other than those included in question 4. o HCP who declined vaccination and did not provide any other information. o HCP who did not receive vaccination because of religious or philosophical exemptions. o HCP who deferred vaccination for the entire influenza season (for example, from October 1 through March
31).
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4. Table 2. Instructions for Completion of Healthcare Personnel Influenza Vaccination Summary Form (CDC 57.214)
This form is used to collect information on summary influenza vaccination counts among healthcare personnel (HCP). Data can be entered monthly but should represent cumulative counts for an entire influenza season. A monthly reporting plan for the influenza season for which data were collected (CDC 57.203) must be completed before data can be entered in NHSN. Facilities are encouraged to complete the Seasonal Survey on Influenza Vaccination Programs for HCP (CDC 57.215) but this is optional.
Data Fields Facility ID # Location
Vaccination Type Influenza Subtype Influenza Season Date Last Modified Employee HCP (staff on facility payroll) Non-Employee HCP: Licensed independent practitioners: Physicians, advanced practice nurses & physician assistants
Non-Employee HCP: Adult students/trainees and volunteers
Non-Employee HCP: Other contract personnel
Question 1 (Denominator)
Instructions for Completion Required. The NHSN-assigned facility ID will be auto-entered.
Conditionally Required. Hospitals with CMS inpatient rehabilitation facility (IRF) units and/or inpatient psychiatric facility (IPF) units must specify if they are reporting data for their hospital or their CMS IRF unit(s) and/or CMS IPF unit(s). Required. Influenza is the default and only current choice.
Required. Seasonal is the default and only current choice.
Required. Select the influenza season years for which data were collected (for example, 2019/2020). The Date Last Modified will be auto-entered and indicate the date that these data were last changed by a user. Required. Defined as all persons receiving a direct paycheck from the healthcare facility (i.e., on the facility's payroll), regardless of clinical responsibility or patient contact. Required. Defined as physicians (MD, DO); advanced practice nurses; and physician assistants only who are affiliated with the healthcare facility, but are not directly employed by it (i.e., they do not receive a paycheck from the facility), regardless of clinical responsibility or patient contact. Post-residency fellows are also included in this category. Required. Defined as adult students/trainees and volunteers: medical, nursing, or other health professional students, interns, medical residents, or volunteers aged 18 or older that are affiliated with the healthcare facility, but are not directly employed by it (i.e., they do not receive a paycheck from the facility), regardless of clinical responsibility or patient contact. Optional. Defined as persons providing care, treatment, or services at the facility through a contract who do not fall into any other denominator categories. The denominator categories are mutually exclusive. The numerator data are to be reported separately for each of the denominator categories.
Last reviewed March 2020
Data Fields 1. Number of HCP who worked at
this healthcare facility for at least 1 day between October 1 and March 31
Instructions for Completion Required. Indicate the number of HCP working at this healthcare facility for at least 1 working day between October 1 through March 31 of the influenza season. This includes HCP who joined after October 1 or left before March 31, or who were on extended leave during part of the reporting period. Working for any number of hours a day counts as one working day.
Both full-time and part-time persons should be included. HCP should be counted as individuals rather than full-time equivalents. If a healthcare worker (HCW) works in two or more facilities, each facility should include the HCW in their denominator.
Questions 2-6 (Numerator)
2. Number of HCP who received an influenza vaccination at this healthcare facility since influenza vaccine became available this season
3. Number of HCP who provided a written report or documentation of influenza vaccination outside this healthcare facility since influenza vaccine became available this season
4. Number of HCP having a medical contraindication to the influenza vaccine
Licensed practitioners receiving a direct paycheck from the reporting facility, or who are owners of the reporting facility, should be counted as employees. The numerator data are mutually exclusive. The sum of the numerator categories should be equal to the denominator for each HCP group. Required. Enter the total number of HCP that received an influenza vaccination at this healthcare facility since the influenza vaccine became available this season.
Required. Enter the total number of HCP that reported in writing (paper or electronic) or provided documentation of influenza vaccination outside this healthcare facility since the influenza vaccine became available this season. For the purposes of this reporting measure, verbal statements of vaccine receipt outside the facility are not acceptable. Required. Enter the total number of HCP determined to have a medical contraindication to influenza vaccination. Documentation is not required for reporting a medical contraindication.
5. Number of HCP who declined to receive the influenza vaccine
For this measure, accepted contraindications include: (1) severe allergic reaction (for example, anaphylaxis) after a previous vaccine dose or to a vaccine component, including egg protein, and (2) history of Guillain-Barré Syndrome within 6 weeks after a previous influenza vaccination. Required. Enter the total number of HCP that were offered an influenza vaccination but declined to receive one. Documentation is not required for reporting a declination.
Last reviewed March 2020
Data Fields
Instructions for Completion
6. Number of HCP with unknown vaccination status (or criteria not met for questions 2-5 above)
The following individuals should be counted in this category: · HCP that declined vaccination because of health conditions other than those included in Question 4. · HCP that declined vaccination and did not provide any other information. · HCP that did not receive vaccination because of religious or philosophical exemptions. · HCP that deferred vaccination for the entire measure reporting period (for example, from October 1 through March 31).
Required. Enter the total number of HCP with unknown vaccination status (or who did not meet the criteria for Questions 2-5 above).
Custom Fields & Comments Custom fields
Comments
Instructions for Completion Optional. Can be used to fulfill other reporting requirements not supported by the categories above; for example, reporting vaccination rates by occupational group or by unit/department. Optional. Enter any additional information on the HCP influenza vaccination summary data. This information will not be analyzed by CDC.
Last reviewed March 2020
Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel
Page 1 of 2 Facility ID #: ______________________________ *Date Entered: _________________________
(Month/Year)
*For Season: ________ - _________ (Specify years)
*required for saving
*1. Which personnel groups are included in your facility's annual influenza vaccination campaign? (check all that apply)
Full-time employees
Part-time employees
Licensed independent practitioners:
Non-employee physicians
Non-employee advanced practice nurses
Non-employee physician assistants Students and trainees (for example, interns, residents)
Adult volunteers Other contract personnel Other, specify: ____________________________________
*2. Are healthcare personnel at your facility required to pay out-of-pocket costs for influenza vaccination received at your facility?
Yes No
If yes, how much do each of the following groups need to pay for influenza vaccination?
Full-time employees:
$ ______
Part-time employees:
$ ______
Non-employee physicians:
$ ______
Non-employee advanced practice nurses:
$ ______
Non-employee physician assistants:
$ ______
Students and trainees:
$ ______
Adult volunteers:
$ ______
Other contract personnel
$ ______
Other, specify:_____________________________________
*3. Which of the following methods is your facility using this influenza season to deliver vaccine to your healthcare personnel? (check all that apply)
Have mobile vaccination carts Provide vaccination in Occupational/Employee Health Provide vaccination in wards, clinics, cafeterias, or common areas Provide vaccination during nights and weekends Provide vaccination at any meetings or grand rounds Provide visible vaccination of any key personnel/leadership Other, specify: _____________________________________ None of the above
Assurance of Confidentiality: The information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). CDC 57.215 Rev. 1, NHSN v7.1
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Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel
Page 2 of 2 *4. Which of the following strategies does your facility use to promote/enhance healthcare personnel influenza vaccination at your
facility? (check all that apply)
Send vaccination reminders by mail, e-mail, and/or pager Coordinate vaccination with other annual programs (for example, tuberculin skin testing) Require receipt of vaccination for credentialing (if no contraindications) Require receipt of vaccination as a condition of employment Advertise vaccination with a campaign including posters, flyers, buttons, and/or fact sheets Provide education on the benefits and risks of vaccination Track unit-based vaccination rates for some or all units/departments Plan to provide feedback on vaccination rates to facility administration Provide incentives for vaccination Track vaccination on a regular basis for targeting purposes Other, specify: ____________________________________ No formal promotional activities are planned
*5. What is your facility's influenza vaccination policy for healthcare personnel? (check one)
Influenza vaccination is required; unvaccinated personnel are terminated from employment Influenza vaccination is required with consequences other than termination for unvaccinated personnel Influenza vaccination is recommended but not required My facility does not have a specific influenza vaccination policy for personnel Other, specify: __________________
*6. Which personnel groups are covered by your facility's influenza vaccination policy? (check all that apply)
Full-time employees Part-time employees
Licensed independent practitioners: Non-employee physicians Non-employee advanced practice nurses Non-employee physician assistants
Students and trainees (for example, interns, residents) Adult volunteers Other contract personnel Other, specify: __________________
*7. Does your facility require healthcare personnel who receive off-site influenza vaccination to provide documentation of their vaccination status?
Yes No
If yes, what type of documentation is acceptable? (check all that apply) Receipt or other proof of purchase from pharmacy or other vaccinator Insurance claim for receipt of influenza vaccination Note from person or organization that administered the vaccination Handwritten statement or e-mail from healthcare worker Signature of healthcare worker on standard facility form attesting to vaccination Other, specify: ____________________________________
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Last reviewed March 2020 *8. What does your facility require from healthcare personnel who refuse influenza vaccination? (check one)
Standardized paper or electronic declination form completed by healthcare worker Reading a statement about the risks of non-vaccination (no signature required) Verbal declination of vaccination by healthcare worker Facility does not track vaccine declinations Other, specify: ____________________________________ *9. Does your facility require healthcare personnel who refuse influenza vaccination to wear a mask or other personal protective equipment (PPE)? Yes No
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4. Table 3. Instructions for Completion of Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel (CDC 57.215)
This survey is used to collect information on the influenza vaccination programs at each healthcare facility. Facilities are encouraged to complete this survey, but it is not required at this time. Only one survey should be completed per facility per year, at the end of each influenza season.
Data Fields Facility ID # Date Entered
For Season
1. Which personnel groups are included in your facility's annual influenza vaccination campaign?
Instructions for Completion Required. The NHSN-assigned facility ID will be auto-entered. Required. The month and year of the seasonal survey will be autoentered. Required. Enter the years of the influenza season for which the survey was completed. This is entered in the format: yyyy yyyy. Influenza season is July 1 of the current year through June 30 of the following year. Required. Select the personnel group(s) you included in your campaign or program.
Employee healthcare personnel (staff on facility payroll): Defined as all persons receiving a direct paycheck from the healthcare facility (i.e., on the facility's payroll), regardless of clinical responsibility or patient contact. (This is a required denominator category for reporting healthcare personnel [HCP] influenza vaccination summary data.)
Non-employee HCP : Licensed independent practitioners: Defined as physicians (MD, DO); advanced practice nurses; and physician assistants only who are affiliated with the healthcare facility, but are not directly employed by it (i.e., they do not receive a paycheck from the facility), regardless of clinical responsibility or patient contact. Post-residency fellows are also included in this category. (This is a required denominator category for reporting HCP influenza vaccination summary data.)
Non-employee HCP : Adult students/trainees and volunteers: Defined as medical, nursing, or other health professional students, interns, medical residents, or volunteers aged 18 or older that are affiliated with the healthcare facility, but are not directly employed by it (i.e., they do not receive a paycheck from the facility), regardless of clinical responsibility or patient contact. (This is a required denominator category for reporting HCP influenza vaccination summary data.)
Non-employee healthcare personnel: Other contract personnel: Defined as persons providing care, treatment, or services at the facility through a contract who do not meet the definition of any other required denominator
Last reviewed March 2020
Data Fields
Instructions for Completion category. (This is an optional denominator category for reporting HCP influenza vaccination summary data.)
2. Are healthcare personnel at your facility required to pay out-of-pocket costs for influenza vaccination received at your facility? 3. Which of the following methods is your facility using this influenza season to deliver vaccine to your healthcare personnel? 4. Which of the following strategies does your facility use to promote/enhance healthcare personnel influenza vaccination at your facility? 5. What is your facility's influenza vaccination policy for healthcare personnel? 6. Which personnel groups are covered by your facility's influenza vaccination policy?
Required. Select Yes or No. If yes, indicate the exact amount of out-ofpocket costs that the personnel groups were required to pay for influenza vaccination at your facility.
Required. Select all methods that your facility used this influenza season to deliver influenza vaccine to your HCP.
Required. Select all strategies that your facility used to promote/enhance HCP influenza vaccination at your facility.
Required. Select the one option that best describes the influenza vaccination policy for HCP at your facility.
Required. Select all personnel groups covered by your facility's influenza vaccination policy. Full-time employees: Defined as all persons receiving a direct paycheck from the healthcare facility (i.e., on the facility's payroll), regardless of clinical responsibility or patient contact. These individuals work at the facility on a full-time basis.
Part-time employees: Defined as all persons receiving a direct paycheck from the healthcare facility (i.e., on the facility's payroll), regardless of clinical responsibility or patient contact. These individuals work at the facility on a part-time basis.
Licensed independent practitioners: Non-employee physicians: Defined as physicians (MD, DO) who are affiliated with the healthcare facility, but are not directly employed by it (i.e., they do not receive a paycheck from the facility), regardless of clinical responsibility or patient contact. Postresidency fellows are also included in this category.
Last reviewed March 2020
Data Fields
Instructions for Completion Licensed independent practitioners: Non-employee advanced practice nurses: Defined as advanced practice nurses who are affiliated with the healthcare facility but are not directly employed by it (i.e., they do not receive a paycheck from the facility), regardless of clinical responsibility or patient contact. Advanced practice nurses include nurse practitioners, nurse midwives, clinical nurse specialists, and nurse anesthetists.
Licensed independent practitioners: Non-employee physician assistants: Defined as physician assistants who are affiliated with the healthcare facility but are not directly employed by it (i.e., they do not receive a paycheck from the facility), regardless of clinical responsibility or patient contact.
Students and trainees: Defined as medical, nursing, or other health professional students, interns, medical residents, aged 18 or older that are affiliated with the healthcare facility, but are not directly employed by it (i.e., they do not receive a paycheck from the facility), regardless of clinical responsibility or patient contact.
Adult volunteers: Defined as volunteers aged 18 or older that are affiliated with the healthcare facility but are not directly employed by it (i.e., they do not receive a paycheck from the facility), regardless of clinical responsibility or patient contact.
Other contract personnel: Defined as persons providing care, treatment, or services at the facility through a contract who do not meet the definition of any other required denominator category.
7. Does your facility require healthcare personnel who receive offsite influenza vaccination to provide documentation of their vaccination status? 8. What does your facility require from healthcare personnel who refuse influenza vaccination? 9. Does your facility require healthcare personnel who refuse influenza vaccination to
Required. Select Yes or No. If yes, select all types of documentation for off-site influenza vaccination that your facility accepted.
Required. Select one option that best describes what your facility requires from HCP who refused influenza vaccination.
Required. Select Yes or No. Select yes if your facility requires HCP to wear a mask or other PPE if they refuse influenza vaccination. Select no if your healthcare facility does not have this requirement.
Last reviewed March 2020
Data Fields wear a mask or other personal protective equipment (PPE)?
Instructions for Completion
Last reviewed March 2020
5. Key Terms
Key term
Adult students/trainees and volunteers
Definition for purposes of the HCP Influenza Vaccination Summary Module
Medical, nursing, or other health professional students, interns, medical residents, or volunteers aged 18 or older that are affiliated with the healthcare facility, but are not directly employed by it (i.e. they do not receive a paycheck from the facility), regardless of clinical responsibility or patient contact.
Contract personnel
Persons providing care, treatment, or services at the facility through a contract, regardless of clinical responsibility or patient contact, who do not meet the definition of employees, licensed independent practitioners, or adult students/trainees and volunteers.
Employees
Persons receiving a direct paycheck from the healthcare facility (i.e. on the facility's payroll), regardless of clinical responsibility or patient contact.
Healthcare personnel (HCP)
The entire population of healthcare workers working in healthcare settings. HCP might include (but are not limited to) physicians, nurses, nursing assistants, therapists, technicians, emergency medical service personnel, dental personnel, pharmacists, laboratory personnel, autopsy personnel, students/ trainees, and volunteers, contractual staff not employed by the healthcare facility (for example, clerical, dietary, housekeeping, maintenance, and volunteers), regardless of clinical responsibility or patient contact.
HCP influenza vaccination measure reporting period
The reporting period for the HCP influenza vaccination measure is October 1 through March 31. This reporting period refers to the denominator only.
Healthcare worker (HCW)
A person who works in a healthcare facility, whether paid or unpaid, regardless of clinical responsibility or patient contact. Healthcare worker is the singular form of HCP.
Influenza season For the purposes of NHSN reporting, an influenza season is defined as July 1 through June 30 of the following year.
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Key term Licensed independent practitioners (LIPs)
Seasonal influenza vaccine
Definition for purposes of the HCP Influenza Vaccination Summary Module
Physicians (MD, DO), advance practice nurses, and physician assistants who are affiliated with the healthcare facility, but are not directly employed by it (i.e. they do not receive a paycheck from the facility), regardless of clinical responsibility or patient contact. Post-residency fellows are also included in this category if they are not on a facility's payroll.
A vaccine to protect against infection with seasonal influenza virus strains that is offered on an annual basis.
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Appendix A
Influenza Vaccination Summary: List of Contracted Healthcare Personnel
Examples The list below includes examples of contracted healthcare personnel (HCP) who provide direct patient care and who perform non-direct or non-patient care duties. HCP listed below can acquire influenza from or transmit influenza to patients, families, and other staff members. This list is not exhaustive.
Contracted HCP can include the following non-employee direct care providers: · Agency nurses · Chaplains · Dieticians · Dialysis technicians · EKG technicians · EMG technicians · Home health aides · Laboratory: Phlebotomists · Nursing aides · Occupational therapists · Patient care technicians · Pharmacists · Pharmacy/medication technicians · Physical therapists · Psychologists · Psychology technicians/Mental health workers · Radiology: X-ray technicians · Recreational therapists/Music therapists · Respiratory therapists · Speech therapists · Social workers/Case managers · Surgical technicians · Traveling nurses · Ultrasound technicians
Contracted HCP can include the following non-employee non-direct providers: · Admitting staff/clerical support/registrars · Biomedical engineers · Central supply staff
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Last reviewed March 2020
· Construction workers · Dietary/food service staff · Housekeeping staff · Information Technology staff · Laboratory: technicians · Landscapers · Laundry staff · Maintenance staff/engineers · Pharmacists · Pharmacy/medication technicians · Patient transporters · Security staff · Utilization review nurses
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