CMS Operational Guidance for Acute Care Hospitals to Report FACWIDEIN MRSA LabId Event Data

Operational Guidance for Acute Care Hospitals to Report Facility-Wide Inpatient (FacWideIN)

Methicillin-Resistant Staphylococcus aureus (MRSA) Blood Specimen (Bacteremia)

Laboratory-Identified (LabID) Event Data to CDC’s NHSN for the Purpose of Fulfilling CMS’s

Hospital Inpatient Quality Reporting (IQR) Requirements

Updated November 2019

The Centers for Medicare and Medicaid Services (CMS) published final rules in the Federal

Staphylococcus aureus (MRSA) blood specimen (bacteremia) laboratory-identified (LabID) event

reporting from acute care hospitals via the Centers for Disease Control and Prevention’s (CDC’s)

National Healthcare Safety Network (NHSN) in the CMS Hospital Inpatient Quality Reporting

(IQR) Program requirements for 2013. This operational guidance provides additional

information about reporting FacWideIN MRSA bacteremia LabID event data to NHSN as part of

the Hospital IQR Program for acute care hospitals beginning on January 1, 2013. The

requirements for FacWideIN MRSA bacteremia LabID event reporting to NHSN for this CMS

program do not preempt or supersede any state mandates for reporting of healthcare-

associated infections or events to NHSN (specifically, hospitals in states with a reporting

mandate must abide by their state’s requirements, even if they are more extensive than the

requirements for this CMS program).

NHSN users reporting FacWideIN MRSA bacteremia LabID event data to the system must

adhere to the definitions and reporting requirements for FacWideIN MRSA bacteremia LabID

events as specified in the NHSN Multidrug-Resistant Organism (MDRO) and Clostridioides

difficile Infection (CDI) Module protocol

http://www.cdc.gov/nhsn/PDFs/pscManual/12pscMDRO_CDADcurrent.pdf. This includes

individually mapping all inpatient locations (location mapping guidance can be found at

http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf) from the

entire acute care facility in NHSN. As of January 1, 2015 facilities must also map and report from

outpatient emergency departments (ED) (specifically, adult and pediatric) and 24-hour

observation locations. Facilities will report a single monthly FacWideIN denominator summed

for all inpatient locations (total facility patient days and total facility admissions), as well as

separate denominators to capture ED and 24-hour observation location(s) encounters for each

mapped location. Additionally, as of January 1, 2015 facilities are required to exclude and

indicate that inpatient rehabilitation facilities (IRFs) and inpatient psychiatric facilities (IPFs)

locations that have CMS Certification Numbers (CCNs) that are different from the acute care

facility (even if only different by a single letter in the 3

position) have been removed from

monthly FacWideIN denominator counts (patient days and admissions).

Facilities will continue to report all MRSA blood specimen LabID events, which are defined as

Staphylococcus aureus cultured from a blood specimen obtained for clinical decision making

purposes (specifically, no surveillance cultures) that tests oxacillin-, cefoxitin-, or methicillin-

resistant by standard susceptibility test methods, or by a lab test that is FDA-approved for

MRSA detection from isolated colonies, or by methods that provide a positive result by any

FDA-approved test for MRSA detection from the specimen source, from a patient in a specific

inpatient, ED, or 24-hour observation location having no previous like specimen identified from

a laboratory result from that patient in that location in the previous 14 days. Please see the

MDRO/CDI Module protocol for more detailed guidance on MRSA blood specimen LabID event

reporting.

Acute care hospitals must report MRSA bacteremia LabID events from inpatient, ED, and 24-

hour observation locations with a specimen collection date on or after January 1, 2015 and

associated facility-wide inpatient (excluding units with separate CCNs), outpatient ED, and 24-

hour observation denominator data starting on January 1, 2015.

Monthly reporting plans must be created or updated in NHSN to include FacWideIN, ED, and

24-hour observation location MRSA blood specimen LabID events, specifically, FacWideIN

MRSA blood specimen LabID event surveillance must be in the monthly reporting plans (“in-

plan”) in order for data to be shared with CMS. Mapped active ED and 24-hour observation

locations will be automatically populated on the monthly reporting plan if FacWideIN MRSA

LabID reporting has been added by the facility. If a facility is reporting all MRSA specimens, and

not just blood specimens, CDC will only share the blood specimen data with CMS. All data fields

required for both numerator and denominator data collection must be submitted to NHSN,

including the “no events” field for any month during which no MRSA blood specimen LabID

events were identified. Data must be reported to NHSN by means of manual data entry into the

NHSN web-based application or via file imports using the Clinical Document Architecture (CDA)

file format for numerator and denominator data (resources available at

http://www.cdc.gov/nhsn/CDA/index.html).

CDC/NHSN requires that data be submitted on a monthly basis and strongly encourages

healthcare facilities to enter each month’s data within 30 days of the end of the month for

which it is collected (for example, all March data should be entered by April 30) so it has the

greatest impact on infection prevention activities. However, for purposes of fulfilling CMS

quality measurement reporting requirements, each facility’s data must be entered into NHSN

no later than 4 ½ months after the end of the reporting quarter. In other words, Q1

(January/February/March) data must be entered into NHSN by August 15, Q2 data must be

entered by November 15, Q3 data must be entered by February 15, and Q4 data must be

entered by May 15 to be shared with CMS.

FacWideIN MRSA bacteremia LabID event data submitted to NHSN by hospitals that have

completed their Annual Payment Update (APU) pledges will be reported by CDC to CMS for

each CCN. CDC will share all in-plan FacWideIN healthcare facility-onset (HO) MRSA bacteremia

LabID event data from participating acute care hospital CCNs. CDC will provide a FacWideIN HO

MRSA bacteremia standardized infection ratio (SIR) for each reporting CCN. Although the metric

reported to CMS will be a HO SIR, the community-onset (CO) events and the admission

prevalence of a hospital will play an important role in risk adjustment, and so both HO and CO

LabID events must be reported to NHSN. NHSN will assign these onset categories to the LabID

events as they are entered into the system.