NHSN Data and Reporting

This NHSN Data and Reporting page covers areas such as HAI Reporting Requirements, Dashboards, Reports, and User Group Calls. Understand Washington State's hospital reporting standards, access annual HAI reports, and explore interactive dashboards. Whether you're an ICAR facilitator, healthcare professional, or data enthusiast, find tools and information here. For inquiries, reach out to us using the provided email addresses in the Contact Us section.

Topics

HAI Reporting Requirements l HAI Reportable Events l Antimicrobial Use and Resistance Reporting l NHSN Reports and Dashboard l Washington NHSN User Group Calls l Contact Us

NHSN and HAI Reporting Requirements

The Healthcare-Associated Infections and Antimicrobial Resistance (HAI/AR) Program monitors and validates data on reportable HAIs from Washington hospitals. Hospitals licensed by the Washington State Department of Health are required to report information about certain HAIs using the National Healthcare Safety Network (NHSN) system. Reporting requirements differ based on Healthcare Type.

The HAI Epidemiology team monitors reported HAIs, provides technical support to facilities on the use of NHSN, and partners with healthcare facilities to reduce preventable infections associated with healthcare.

For detailed information regarding Washington State reporting requirements:

Some Multi-Drug Resistant Organisms (MDROs) and all suspected or confirmed healthcare outbreaks are reportable as notifiable conditions, separate from WAC 246-440-100. For more information on healthcare outbreaks, please see NEW LINK. For additional information on MDRO reporting, please see the List of Notifiable Conditions.

Reportable Events

Washington State updated WAC 246-440-100 Hospital reporting requirements for healthcare-associated infections effective January 2020 to align with the Centers for Medicare and Medicaid Services (CMS), which includes five reportable HAIs. For more information on these conditions, click on the linked HAIs below to view the CDC’s webpage for that infection.

The graphic below shows the five reportable HAIs by body location.

Catheter-associated Urinary Tract Infection (CAUTI) is represented by a urinary catheter, with an indicator to the location of the urinary tract.
Central Line-associated Bloodstream Infection (CLABSI) is represented by an IV stand with an indicator to the location of a vein where a central line would be placed.
Clostridioides difficile (C. difficile) infection with positive laboratory identification is represented by bacteria with an indicator to the location of the intestines.
Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia with positive laboratory identification is represented by bacteria, with an indicator to the location of major artery.
Surgical Site Infection (SSI) is reportable following an inpatient procedure for Abdominal Hysterectomy (SSI-HYST) or Colon Surgery (SSI-COLO). SSI-HYST is represented by a surgical incision with an indicator to the location of the uterus. SSI-COLO is represented by a surgical incision with an indictor to the location of the colon.

Silouette showing body locations for 5 reportable HAIs. — **Image of the human body, noting the five reportable HAIs by location**

Antimicrobial Use and Resistance (AUR) Reporting

The AUR module is designed to track, analyze, and compare antimicrobial use and resistance data to reduce antimicrobial resistant infections. Beginning in calendar year 2024, all facilities participating in the Medicare Interoperability Program must be in active engagement to submit data to the AUR module. The resources below provide further information how to complete on the AUR reporting requirements.

CDC Resources

CDC’S NHSN AUR Promoting Interoperability Guidance
Step-by-step directions to help facilities meet requirements
CDC’s FAQs: AUR Reporting for the CMS Promoting Interoperability Program
Contains answers to frequently asked questions about the AUR reporting requirements

CDC’S NHSN AUR Office Hours Presentation

FAQs about the new requirements and implementation, presented May 17, 2023 (PDF)

NHSN Reports and Dashboards

Annual HAI Reports

Under RCW 43.70.056, WA DOH is charged with using data submitted to the National Healthcare Safety Network (NHSN) to compile and publish reports. This report provides comprehensive and detailed information on Washington hospital performance.

The CDC also publishes annual reports using data reported to NHSN’s Patient Safety Component, which presents national and state-level HAI Standardized Infection Ratios (SIRs) and Standardized Utilization Ratios (SURs). To view the CDC’s Annual Reports, visit their webpage for HAI Progress Reports.

HAI Validation Report

Hospitals licensed by the WA DOH are required to report information about certain HAIs using NHSN. Washington State law (RCW 43.70.056) requires that WA DOH regularly evaluate the quality and accuracy of required HAI reporting. To do so, the HAI & AR Program follows validation guidance from the Centers for Disease Control and Prevention. This report provides detailed information on WA DOH’s annual validation efforts.

HAI Event Dashboards

HAI Event Dashboards are currently available for all five reportable HAIs. The dashboards show annual Washington State data on HAIs that hospitals have to report. The dashboards display the last 5 years of available data.

The Device-Associated HAI Dashboard includes data for CLABSI and CAUTI.
The LabID Dashboard contains data for CDI and MRSA bacteremia.
The SSI Dashboard includes data for SSI-COLO and SSI-HYST.

More information about the dashboards can be found on Washington Tracking Network’s HAI page.

NHSN Hospital User Group Call

NHSN Hospital User Group Call

The HAI Epi Team hosts a bimonthly informational meeting for hospital staff to discuss changes in NHSN reporting, review analysis of User Group data, and address any questions from NHSN users. This call takes place the second Tuesday of January, March, May, July, September, and November from 10:30am to 11:30am.

This call is open to all hospital staff who use NHSN. If you are interested in attending the NHSN User Group call, email the HAI Epi Team at NHSNEpi@doh.wa.gov and include “NHSN Hospital User Group” in the subject line.

NHSN Long Term Care Facilities User Group Call

The HAI Epi Team also hosts monthly information meeting to provide NHSN updates, foster collaboration, and increase user knowledge. This call takes place the second Thursday of every month from 11am to 12pm.

The LTC NHSN User Group Call is open to all LTCF staff who use NHSN. If you are interested in attending the Monthly NHSN LTC User Group, register at this Zoom webinar . Email NHSNEpi@doh.wa.gov with any questions.

For a more comprehensive list of all NHSN support options the HAI Epi Team can provide, see the NHSN Support and Technical Assistance for Skilled Nursing Facilities (PDF)

NHSN Antibiotic Use Reporting User Group

The MDRO team hosts quarterly information meetings to provide didactic presentations to help facilities get the most out of their NHSN AU data. This call takes place ____

This call is intended for ___. If you are interested in attending or would like more information, email the AMS team at ams@doh.wa.gov.

NHSN AUR Office Hour

The MDRO team also hosts office hours quarterly to assist facilities in Washington State who are just getting started with the AUR module. They consist of a 5-10 minute presentation on a feature of AUR, followed by time for questions. These calls take place __

These calls are intended for __. If you are interested in attending the office hours, register at this Zoom link. Email ams@doh.wa.gov with any questions.