Texas Department of State Health Services, Infectious Disease Control Unit

UPDATED: The Association for Prevention of Infection and Control (APIC) is providing free NHSN reporting training. The following contains the content of the training sessions.

NHSN Training Slides Part 1 (PDF, 9,399 KB)

NHSN Training Slides Part 2 (PDF, 9,911 KB)

NOTE: The CDC Division of Healthcare Quality Promotion has endorsed the DSHS/APIC NHSN training as meeting the requirements for a face-to-face NHSN training. The CDC NHSN Program recommends you also review their training sessions (www.cdc.gov/nhsn/training/), especially for those protocols and topics which may not have been covered during CDC-endorsed trainings. When registering as a user of NHSN, you may enter the date of the CDC-endorsed training you attended as the training completion date.

Incomplete/Missing Alerts Instructional Guide (PDF, 130 MB)

How to Report Zero CLABSI (PDF)

How to Report Zero Surgical or SSI Events (PDF)

ICU Type Definitions

Texas National Healthcare Safety Network Course: Using Excel to Import Knee Surgical Denominators (PDF)
NHSN spreadsheet example (XML 61KB)

Healthcare Facility HAI Reporting Requirements to CMS via NHSN-Current and Proposed Requirements (PDF)

Frequently Asked Questions (PDF, 783.5 KB)

Compliant Health Care Facilities, May 2013

Thanks to these health care facilities (PDF) that have conferred data rights to Texas!

Facilities must join the HAITexas group and accept the Confer Rights Template in order to be compliant with mandatory reporting for Texas. For instructions on how to join the group and confer rights, please see the Guide to Conferring Rights (PDF) and associated Appendices.

*This list is updated monthly. If your facility's name does not appear on this list, you have not successfully joined the group and conferred rights. Please review Guide to Conferring Rights and associated Appendices on the HAI Reporting page, or contact CDC's NHSN help desk for assistance to resolve this issue.

HAI Related Acronyms
HAI - health care-associated infection
CLABSI - central line-associated bloodstream infection
NHSN - National Healthcare Safety Network
ASC - ambulatory surgical center
DSHS - Department of State Health Services
LTAC - long-term acute care (facility)
ICU - intensive care unit
CCU - critical care unit
IP - infection preventionist
SSI - surgical site infection
RSV - respiratory syncytial virus
PAE - preventable adverse event
CMS - Centers for Medicare and Medicaid Services
CABGs - coronary artery bypass grafts
IPPS - Inpatient Prospective Payment System
NICU - neonatal intensive care unit
ICD-9-CM - International Classification of Diseases, 9th Revision Clinical Modification
SIR - standardized infection ratio
DHQP- Division of Healthcare Quality Promotion
APIC - Association for Prevention of Infection and Control
MRSA - methicillin resistant staphylococcus aureus
MDRO - multi drug resistant organisms
CDI - clostridium difficile infection
SHEA - The Society for Healthcare Epidemiology of America
VAE - ventilator-associated event
VAP- ventilator-associated pneumonia

HAI Related Resources

American Health Quality Association

HICPAC Healthcare Infection Control Practices Advisory Committee

Institute for Healthcare Improvement

The Joint Commission

The National Coalition on Health Care

National Health Care Safety Network (NHSN)

National Quality Forum

Texas Administrative Code Title 25, Chapter 200 (Health Care-Associated Infections)

Texas Health and Safety Code Chapter 98 (PDF, 75 KB)

Texas Hospital Association

Third Phase of HAI Reporting for Texas Begins

January 1, 2013

For ASCs and General Hospitals:

REMINDER: The third phase (and last phase for this set of HAIs) of Mandatory Health Care-Associated Infection (HAI) reporting for Texas begins January 1, 2013. Data on the following procedures need to be entered into NHSN and rights conferred to Texas: Abdominal (HYST) and Vaginal (VHYS) Hysterectomies, Colon (COLO), Peripheral Vascular Bypass (PVBY), Carotid Endarterectomy (CEA), and Abdominal Aortic Aneurysm (AAA) surgeries and their related Surgical Site Infections (SSI). You should currently be reporting Central Line-Associated Blood Stream Infections (CLABSI) for ICU, CCU, and NICU and Knee Prosthesis (KPRO), Hip Prosthesis (HPRO), Coronary Artery Bypass Graft with chest incision only (CBGC), and Coronary Artery Bypass Graft with both chest and donor site incisions (CBGD) surgeries and their related Surgical Site Infections (SSI) for Texas reporting. Make sure you have conferred rights to HAITexas in NHSN. See the Guide to Conferring Rights and Guide to Conferring Rights Appendices. If you have already conferred rights to HAITexas, just be sure to add VHYS, HYST, COLO, PVBY, CEA, and AAA to your Monthly Reporting Plan in NHSN and begin reporting your data. If you do not perform any of these procedures, then you do not have to alter your Monthly Reporting Plan.

For questions or concerns, please email HAITexas@dshs.state.tx.us or call 512-776-6878

For Pediatric Hospitals:

REMINDER: The third phase (and last phase for this set of HAIs) of Mandatory Health Care-Associated Infection (HAI) reporting for Texas begins January 1, 2013. Data on the following procedures need to be entered into NHSN and rights conferred to Texas: Spinal Fusion (FUSN), Refusion of Spine (RFUSN), and Laminectomy (LAM) surgeries and their related Surgical Site Infections (SSI). You should currently be reporting Central Line-Associated Blood Stream Infections (CLABSI) for ICU, CCU, and NICU and Ventricular Shunt (VSHN) and Cardiac (CARD) surgery including Heart Transplant (HTP) and their related Surgical Site Infections (SSI) for Texas reporting. Make sure you have conferred rights to HAITexas in NHSN. See the Guide to Conferring Rights and Guide to Conferring Rights Appendices. If you have already conferred rights to HAITexas, just be sure to add FUSN, RFUSN, CARD, and HTP to your Monthly Reporting Plan in NHSN and begin reporting your data. If you do not perform any of these procedures, then you do not have to alter your Monthly Reporting Plan.

For questions or concerns, please email HAITexas@dshs.state.tx.us or call 512.776.6878

ATTENTION:
Some Long Term Acute Care (LTAC) Facilities are not required to report health care-associated infections to Texas.

The Texas mandatory HAI reporting law applies to General Hospitals licensed under Chapter 241 of the Texas Health and Safety Code. Some LTACs are licensed as Special Hospitals and therefore are NOT required to report.

If your CEO received the September 15, 2011 reporting notification letter from Dr. Lakey, Commissioner of the Department of State Health Services (DSHS), you are licensed as a general hospital according to the DSHS and are required to report if you have an ICU and/or perform any reportable procedures. If you are unsure, check with your hospital regulatory department to determine if your facility is licensed as a general hospital.

If you are licensed as a SPECIAL HOSPITAL and you have joined the HAITexas Group in NHSN in error, please click and follow the directions to leave the HAITexas Group (PDF).

For questions or concerns, please email HAITexas@dshs.state.tx.us.

CEOs Sent Reporting Notification

A letter detailing HAI reporting requirements was sent to Chief Executive Officers or Senior Administrators of every hospital and ambulatory surgery center on record with the Department of State Health Services on September 15, 2011. Mandatory HAI reporting began October 1, 2011. Read the letter (PDF).