Healthcare Personnel (HCP) Influenza Vaccination Summary Reporting in NHSN

Denominator

What types of nurses are counted as licensed independent practitioners?
What types of HCP are included in the “other contract personnel” category?
For the 2013-2014 influenza season, should I continue to count only HCP who physically work in the facility for 30 days or more from October 1 through March 31?
Should I count HCP who are not working with patients, but because of staff meetings, etc. are physically in the facility?
Should employees who always work off-site or out-of-state be counted, such as employees practicing telemedicine?
My acute care hospital owns several outpatient provider practices that are physically separate from the main hospital campus. Employees of these clinics are on the hospital’s payroll, so should we include them in our HCP influenza vaccination reporting?
Our facility has an administrative building that is physically connected to the acute care facility by a skywalk. This building is only used for administrative duties and not inpatient care. Should I count HCP working in this building?
My healthcare system has two acute care facilities, A and B. If a HCW works at facility A for 1 day during the influenza season and works at facility B for 15 days during the influenza season, should I count the HCW in the influenza vaccination summary data for both facilities?
There are three hospitals within our hospital system. Can I collect and enter the HCP influenza vaccination summary data as a system since many of our staff members work at multiple hospitals?
My hospital system uses multiple payroll systems. Should I count corporate employees of the hospital who are paid through a corporate payroll in the employee category?
My hospital is part of a multi-hospital system that has one corporate payroll. Each hospital has its own NHSN number, so how should each hospital report its total number of HCP?
If an employee works half days, 5 times a month, must this be counted as 5 working days a month or 2.5 days a month?
Should I count an employee who starts at my facility after October 1, or leaves their position after October 1?
Should HCP who are employees of the healthcare system (e.g., university), but who are not hospital employees, be included?
In the protocol for the HCP Influenza Vaccination Summary, licensed independent practitioners are defined as physicians, advanced practice nurses, and physician assistants who are affiliated with the reporting facility, but are not directly employed by it, regardless of clinical responsibility or patient contact. What does it mean when HCP are “affiliated” with a facility?
How is a facility owner, particularly a physician owner, categorized?
Should physician fellows and residents be included?
When are licensed independent practitioners counted as “employees” and when are they counted as “licensed independent practitioners”?
Would you count a licensed independent practitioner who rarely comes into a facility during the influenza season?
Should you count licensed independent practitioners who work in the facility under a contract?
Are other licensed contract workers/non-employees such as nurses, technicians, therapists, etc. reported?
Are contractors such as housekeeping staff, environmental services staff, construction workers, etc. required to be included?
Should students who work for one day a week for 2 months during the reporting period be included?
Would you count instructors who accompany students to a healthcare facility if the instructors do not otherwise work at the facility?
High school students who are age 18 or older are allowed to volunteer at our facility. Should these students be counted, or do we only report vaccination among health professional students?
Should clergy members be included in the volunteer category of the non-employee group?
There are some HCP who work in the facility as part-time employees during the day and work as students by night. How should I classify these individuals?
How should my facility prepare to collect and report data for different denominator categories, especially licensed independent practitioners and students?
What does it mean when it is stated that “denominators are to be calculated separately for the three required categories”?

What types of nurses are counted as licensed independent practitioners?

All advanced practice nurses should be included in the licensed independent practitioner category. Advanced practice nurses include nurse practitioners, nurse midwives, clinical nurse specialists, and nurse anesthetists.

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What types of HCP are included in the “other contract personnel” category?

A suggested list of contract personnel who might work in a healthcare facility is located in Appendix[PDF – 45 KB](http://wwwdev.cdc.gov/migration/nhsn/pdfs/hps-manual/vaccination/12-appendix-a.pdf) of the Influenza Vaccination Summary Protocol, which can be found at: Healthcare Personnel Vaccination Module: Influenza Vaccination Summary Protocol August 2014[PDF – 328 KB] (http://wwwdev.cdc.gov/migration/nhsn/pdfs/hps-manual/vaccination/hps-flu-vaccine-protocol.pdf) .

For the 2013-2014 influenza season, should I continue to count only HCP who physically work in the facility for 30 days or more from October 1 through March 31?

No. The 30-day denominator requirement has been changed from the 2012-2013 influenza season. Therefore, beginning with the 2013-2014 influenza season, facilities should count HCP who are physically present in the facility for at least 1 working day from October 1 through March 31.

Should I count HCP who are not working with patients, but because of staff meetings, etc. are physically in the facility?

You should count HCP who physically work in the onsite acute care facility, who perform any work duty in the facility for at least 1 day from October 1 through March 31, and who meet protocol definitions, regardless of clinical responsibility or patient contact. For example, you should count a healthcare worker (HCW) who has official responsibilities in the facility for at least 1 day from October 1 through March 31, such as attending regularly scheduled meetings. However, you would not need to count HCP who are not officially in the facility for work duties (e.g., coming into the facility for lunch, etc.).

Should employees who always work off-site or out-of-state be counted, such as employees practicing telemedicine?

No. Only HCP physically working at the healthcare facility for at least 1 day from October 1 through March 31 are included.

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My acute care hospital owns several outpatient provider practices that are physically separate from the main hospital campus. Employees of these clinics are on the hospital’s payroll, so should we include them in our HCP influenza vaccination reporting?

These employees should not be counted in the vaccination reports for the acute care hospital, unless these employees also physically work at the acute care hospital for at least 1 day from October 1 through March 31.

Our facility has an administrative building that is physically connected to the acute care facility by a skywalk. This building is only used for administrative duties and not inpatient care. Should I count HCP working in this building?

You do not need to count HCP working in the administrative building unless they also physically work in the acute care facility that is located on the other side of the skywalk.

My healthcare system has two acute care facilities, A and B. If a HCW works at facility A for 1 day during the influenza season and works at facility B for 15 days during the influenza season, should I count the HCW in the influenza vaccination summary data for both facilities?

Yes, all employees, non-employee licensed independent practitioners, and non-employee adult students and volunteers who physically work at the facility for at least 1 day from October 1 through March 31 should be counted, for each facility where they work. Therefore, you would count the individual in your influenza vaccination summary data reporting for facility A and facility B. These reports describe influenza vaccination rates among HCP working at a specific facility. In order for this to be accurate, all eligible HCP must be counted by each facility where they work.

There are three hospitals within our hospital system. Can I collect and enter the HCP influenza vaccination summary data as a system since many of our staff members work at multiple hospitals?

No, the separate facilities need to be enrolled as separate acute care facilities in NHSN and need to report their influenza vaccination summary data separately. If a HCW physically works in multiple facilities in the hospital system for at least 1 day from October 1 through March 31, this individual should be counted in the total number of HCP for each facility where he/she works.

My hospital system uses multiple payroll systems. Should I count corporate employees of the hospital who are paid through a corporate payroll in the employee category?

Some hospital systems use multiple payroll systems; for example, certain individuals within a particular facility may be corporate employees paid directly through a corporate payroll, while others at the facility are hospital employees paid directly through a hospital payroll. For hospital systems using multiple payroll systems, a facility would only count employees of the hospital who are paid directly through a hospital payroll. Corporate employees who are not paid directly through the hospital payroll would not be counted in the employee category, although they could be counted in the licensed independent practitioner or other contract personnel categories, if they meet protocol definitions for either group. However, if a hospital is part of a system that has only one payroll for the entire system, then each facility would count all paid employees in the employee category, if they physically work in that facility for at least 1 day from October 1 through March 31.

My hospital is part of a multi-hospital system that has one corporate payroll. Each hospital has its own NHSN number, so how should each hospital report its total number of HCP?

Each facility should report the total number of HCP who physically work in that facility. If a HCW physically works in multiple facilities in the hospital system for at least 1 day from October 1 through March 31, this individual should be counted in the total number of HCP for each facility where he/she works.

If an employee works half days, 5 times a month, must this be counted as 5 working days a month or 2.5 days a month?

If a HCW is physically present in the facility for any part of a day, this is counted as working one day. Therefore, the employee would be counted as working five days a month. The measure reporting period lasts for six months (October 1 through March 31), so you would include this employee in the denominator since he/she will have worked at least 1 day from October 1 through March 31.

Should I count an employee who starts at my facility after October 1, or leaves their position after October 1?

Yes. All employees, non-employee licensed independent practitioners, and non-employee students and volunteers aged 18 and older who physically work at the facility for at least 1 day from October 1 through March 31, regardless of exact stop and start dates, should be counted.

Should HCP who are employees of the healthcare system (e.g., university), but who are not hospital employees, be included?

Non-hospital employees should only be included if they are physically in the facility for at least 1 day from October 1 through March 31 and meet the criteria for either the licensed independent practitioner category or the adult students/trainees and volunteers category. They would not be in the employee category if they are not on the hospital’s payroll.

In the protocol for the HCP Influenza Vaccination Summary, licensed independent practitioners are defined as physicians, advanced practice nurses, and physician assistants who are affiliated with the reporting facility, but are not directly employed by it, regardless of clinical responsibility or patient contact. What does it mean when HCP are “affiliated” with a facility?

HCP who are affiliated with the healthcare facility are those who perform a work duty in the facility, but are not directly employed by the facility (i.e., they do not receive a paycheck from the facility).

How is a facility owner, particularly a physician owner, categorized?

Any owner, even a physician owner, is categorized as an “employee” and included in this measure if he/she is present in the facility for at least 1 day from October 1 through March 31.

Should physician fellows and residents be included?

Yes. Physician fellows (post-residency) are categorized as licensed independent practitioners, unless they are paid directly by the facility, in which case they are employees. Residents and interns not on the facility’s payroll are categorized as students/trainees.

When are licensed independent practitioners counted as “employees” and when are they counted as “licensed independent practitioners”?

An “employee” is anyone on the payroll and receiving a paycheck from the facility. Regardless of their job duties, if they work at the facility for at least 1 day from October 1 through March 31, these HCP are reported as “employees.” The remaining licensed independent practitioners working at the facility for at least 1 day from October 1 through March 31 should be counted in the “non-employee, licensed independent practitioners” category which includes physicians, advanced practice nurses, and physician assistants. Post-residency fellows are also included in this category, unless they are paid directly by the facility, in which case they are employees.

Would you count a licensed independent practitioner who rarely comes into a facility during the influenza season?

He/she would be included in the measure if he/she works in the facility for at least 1 working day from October 1 through March 31.

Should you count licensed independent practitioners who work in the facility under a contract?

Yes. It is necessary to track contract physicians, advanced practice nurses, and physician assistants and report them as licensed independent practitioners. Other types of contract personnel who do not fall into the licensed independent practitioner category can be reported in the optional “other contract personnel” category, if desired.

Are other licensed contract workers/non-employees such as nurses, technicians, therapists, etc. reported?

Non-employee licensed or credentialed providers other than physicians, advanced practice nurses, and physician assistants are not required to be reported, but can be reported in the optional “other contract personnel” category, if desired.

Are contractors such as housekeeping staff, environmental services staff, construction workers, etc. required to be included?

No. The non-employee, non-LIP category is only for students/trainees and volunteers aged 18 and older. Non-licensed contract personnel can be reported in the optional “other contract personnel” category, if desired.

Should students who work for one day a week for 2 months during the reporting period be included?

Yes. You would count the students since they worked at least 1 day from October 1 through March 31.

Would you count instructors who accompany students to a healthcare facility if the instructors do not otherwise work at the facility?

No. These individuals would be categorized as other contract personnel since they are there to teach and/or supervise the students. If they are physically in the facility at least 1 day from October 1 through March 31, they could be reported in the optional “other contract personnel” category, if desired.

High school students who are age 18 or older are allowed to volunteer at our facility. Should these students be counted, or do we only report vaccination among health professional students?

All students/trainees and volunteers aged 18 and over should be counted if they are physically in the facility for at least 1 day from October 1 through March 31. Individuals aged 18 and over are counted, as that is when an individual can legally consent to influenza vaccination; it does not matter if an 18-year-old student is in high school, college, medical school, etc.

Should clergy members be included in the volunteer category of the non-employee group?

Yes. If they are physically in the facility for at least 1 day from October 1 through March 31, any unpaid personnel who are in the facility in a formal capacity (board member, auxiliary member, shadower, etc.) are considered volunteers.

There are some HCP who work in the facility as part-time employees during the day and work as students by night. How should I classify these individuals?

The following hierarchy should be used to classify HCP at your facility: if a HCW who works in the facility is on payroll, he/she should be counted as an employee (even if he/she works as a student or volunteer at other times). If a HCW is not on the facility payroll, you should determine whether he/she meets the definition of a licensed independent practitioner. If not, you should finally determine whether the HCW is a student/trainee or volunteer. If none of those are the case, then you do not need to count that particular HCW in your reports of HCP influenza vaccination.

How should my facility prepare to collect and report data for different denominator categories, especially licensed independent practitioners and students?

Facilities may involve various departments, medical schools, and credentialing offices when developing strategies to collect data, including securing access to payroll and occupational health records. Please see: Methods and strategies used to collect healthcare personnel influenza vaccination data Adobe PDF file [PDF – 0187 KB]. Each facility should also ensure that staff who will be entering data can access NHSN.

What does it mean when it is stated that “denominators are to be calculated separately for the three required categories”?

The instruction to calculate the denominator data separately means that a facility is required to count and report the number of employees, licensed independent practitioners, and adult students/trainees and volunteers separately instead of reporting a total number of HCP working at the facility. That way, vaccination status can be determined for each of the three groups. For example, to determine the declination rate for employees, you would divide the number of employees who reported a declination by the total number of employees who worked in your facility for at least 1 day from October 1 through March 31. You would then multiply this by 100 to obtain a percentage.

Numerator

If a HCW was vaccinated at his/her doctor’s office in August, should he/she be included?

Yes. This HCW should be counted in the numerator, since influenza vaccine for a given influenza season may be available as early as July or August. The strict reporting period for the measure (October 1 through March 31) applies to the denominator category. This HCW would be required to provide documentation of influenza vaccination and would be counted in the “vaccinated outside of the healthcare facility” category. If the HCW did not provide acceptable documentation as described below, his/her vaccination status would be counted as “unknown.”

What is acceptable documentation for a HCW vaccinated outside of the healthcare facility?

Acceptable forms of documentation include a signed statement or form, or an electronic form or e-mail from the HCW indicating when and where he/she has received the influenza vaccine, or a note, receipt, vaccination card, etc. from the outside vaccinating entity stating that the HCW received the influenza vaccine at that location. Verbal statements are not acceptable for the purposes of this measure.

If a HCW can only be reached by phone, and he/she states they were vaccinated elsewhere, how is this reported?

Their vaccination status is reported as “unknown” unless documentation is provided. Verbal statements are not acceptable for the purposes of this reporting measure. However, this HCW could send an e-mail or mail a written statement attesting that he/she was vaccinated outside the facility.

What conditions allow categorizing HCP as having a medical contraindication?

Only HCP who have a severe allergic reaction to eggs or other components of the influenza vaccine or a history of Guillain-Barré Syndrome (a severe paralytic illness, also called GBS) within 6 weeks after a previous influenza vaccination can be reported as having a medical contraindication to vaccination with inactivated influenza vaccines.

Is documentation required for medical contraindications or vaccine declinations?

No. Documentation is not required for reporting a medical contraindication or a declination; therefore, verbal statements are acceptable for reporting these. Documentation is only required for those vaccinated outside the facility.

How should I categorize a volunteer who was offered influenza vaccination, but verbally refused vaccination and stated that he/she had an egg allergy with history of an anaphylactic reaction?

The volunteer should be categorized as having a medical contraindication. Written documentation is not required for contraindications.

How do I categorize HCP who report that they have a medical contraindication but do not confirm that it is one of the two defined by the measure?

They are reported as “declined to receive the influenza vaccine.”

Our facility has a HCW with a medical condition that prevents him/her from receiving any type of vaccine. How should I categorize this individual, since it is a medical contraindication that is not one of the two medical contraindications defined by the measure?

This individual should be categorized as “declined to receive the influenza vaccine.” For the purposes of this measure, a medical contraindication to vaccination with inactivated influenza vaccine (IIV) is defined as having a severe allergic reaction to eggs or other components of the influenza vaccine or a history of Guillain-Barré Syndrome within 6 weeks after a previous influenza vaccination. Your healthcare facility may grant medical exemptions to HCP with other conditions besides those defined by the 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 for 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. If your facility would like to track this subset of individuals within NHSN, the Custom Field can be used to keep a separate count for your own purposes.

My facility offers the live attenuated influenza vaccine (LAIV) to HCP who do not want to receive an injection. Are the acceptable medical contraindications the same for LAIV as for the inactivated influenza vaccine (IIV)?

For this measure, in addition to a severe allergic reaction after a previous vaccine dose or to a vaccine component, including egg protein, and history of Guillain-Barré Syndrome within 6 weeks after a previous influenza vaccination, the following conditions are medical contraindications to LAIV: pregnancy; known severe immunodeficiency (e.g., hematologic and solid tumors; receiving chemotherapy; congenital immunodeficiency; long-term immunosuppressive therapy; patients with HIV infection who are severely immunocompromised); certain chronic medical conditions include asthma and chronic pulmonary, cardiovascular (except isolated hypertension), renal, hepatic, neurologic/neuromuscular, hematologic, or metabolic disorders. Individuals older than 49 years of age are also not eligible to receive LAIV. HCP who have a medical contraindication to LAIV other than a severe allergic reaction to a vaccine component and history of Guillain-Barré Syndrome within 6 weeks after a previous influenza vaccination, should be offered IIV by their facility, if available. If IIV is then offered, but declined because of aversion to an injection, a HCW would be categorized as “declined to receive the influenza vaccine.” Contraindications to LAIV other than a severe allergic reaction after a previous vaccine dose or to a vaccine component, including egg protein, and history of Guillain-Barré Syndrome within 6 weeks after a previous influenza vaccination, are not acceptable medical contraindications for this measure.

How should I categorize a pregnant HCW who states that her provider recommended against influenza vaccination?

A HCW who does not receive the influenza vaccine because of pregnancy, or any other medical reason other than the two specified contraindications, should be categorized as “declined to receive the influenza vaccine.” For this measure, in addition to a severe allergic reaction after a previous vaccine dose or to a vaccine component, including egg protein, and history of Guillain-Barré Syndrome within 6 weeks after a previous influenza vaccination, the following conditions are medical contraindications to live attenuated influenza vaccine (LAIV): pregnancy; known severe immunodeficiency (e.g., hematologic and solid tumors; receiving chemotherapy; congenital immunodeficiency; long-term immunosuppressive therapy; patients with HIV infection who are severely immunocompromised); certain chronic medical conditions include asthma and chronic pulmonary, cardiovascular (except isolated hypertension), renal, hepatic, neurologic/neuromuscular, hematologic, or metabolic disorders. Individuals older than 49 years of age are also not eligible to receive LAIV. HCP who have a medical contraindication to LAIV other than a severe allergic reaction to a vaccine component and history of Guillain-Barré Syndrome within 6 weeks after a previous influenza vaccination, should be offered for the inactivated influenza vaccine (IIV) by their facility, if available. Contraindications to LAIV other than a severe allergic reaction after a previous vaccine dose or to a vaccine component, including egg protein, and history of Guillain-Barré Syndrome within 6 weeks after a previous influenza vaccination, are not acceptable medical contraindications for this measure.

What is the distinction between the “declined, deferred all reporting period” and “unknown” categories?

HCP who deferred vaccination throughout the entire measure reporting period should be categorized as “declined,” because it is known they were offered the opportunity to be vaccinated. HCP should be categorized as “unknown” if their vaccination status was unable to be confirmed or they did not otherwise meet the criteria for the other numerator categories.

How should I categorize HCP who decline vaccination because they are ill at the time the influenza vaccine is initially offered and then never have another opportunity to receive it?

They are reported as “declined to receive the influenza vaccine.”

How should I categorize a HCW who was granted a religious or personal belief exemption to influenza vaccination according to his/her hospital’s policy?

A HCW who declines to receive vaccination for any reason other than the two specified medical contraindications for the HCP Vaccination Module should be categorized as “declined to receive the influenza vaccine.” This is true even if your hospital permits religious or philosophical exemptions for influenza vaccination.

How should I categorize a HCW who received a medical exemption for influenza vaccination under his/her hospital’s policy, which permits exemptions for conditions other than those specified in the NHSN protocol?

A HCW who declines to receive vaccination for any reason other than the two specified medical contraindications for HCP influenza vaccination summary reporting should be categorized as “declined to receive the influenza vaccine.” This is true even if your hospital permits medical exemptions for reasons other than those defined in the NHSN protocol. In some cases, HCP who are considered medically exempt from vaccination by the facility where they work will be counted as declining vaccination for the purposes of NHSN reporting. Counting only HCP with one of the two specified conditions as having a medical contraindication to influenza vaccination ensures that the data reported to NHSN can be compared across different facilities.

How should I categorize HCP who never came to a clinic or returned a declination form?

If you were unable to confirm a HCW's influenza vaccination status for any reason, he/she should be counted in the "unknown" category.

If I use a survey to collect the numerator information, how should persons who did not respond to the survey be counted?

If your facility decides to use a survey to collect vaccination status, HCP who do not respond to the survey should be counted in the “unknown” category. The measure was not pilot-tested for use with a survey, and facilities are strongly encouraged to track influenza vaccination data from written records instead of using a survey. Surveys should never be used to collect denominator data.

What does it mean when it is stated that the “numerator data for this measure should be calculated separately for each group”?

The instruction to calculate the numerator data separately means that when calculating the vaccination coverage for your facility, you should not add up the number of HCP vaccinated with the other numerator groups (those HCP who declined vaccination, reported contraindications, or whose vaccination status could not be assessed).

CMS Reporting Requirements

Where can I find information on the CMS final rules on reporting requirements for HCP influenza vaccination?

The final rules can be found at the following links:
Final rule for Hospital Inpatient Prospective Payment:Federal Register Vol.76 No.160 (pp. 51631-51633) .

Final rule for Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment: Federal Register Vol.76 No. 230 (pp. 74470-74472 and 74510).

Where can I find the operational guidance for acute care hospitals to report HCP influenza vaccination summary data for fulfilling CMS’s hospital IQR requirements?

The operational guidance for the hospital IQR program requirements can be found under “CMS Supporting Materials” at Surveillance for Healthcare Personnel Vaccination

Which groups are required to be reported to CMS?

CMS requires reporting on three categories of HCP: employees (regardless of patient contact), licensed independent practitioners (non-employee physicians, advanced practice nurses, and physician assistants), and adult students/trainees and volunteers (aged 18 and over). In other words, there is one category pertaining to all employees, and two separate categories of non-employees. NHSN also includes a space to enter data on influenza vaccination coverage among contract workers, but currently these data are NOT required by CMS and are optional according to the NHSN protocol. Facilities wishing to track influenza vaccination rates among their contract personnel, can choose to use this optional reporting capacity.

I work at a cancer hospital. Is this facility required to report influenza vaccination summary data to NHSN?

CDC encourages individual institutions to contact CMS directly to ascertain whether they are subject to CMS requirements, as CDC cannot make those determinations on behalf of CMS. However, cancer hospitals that are not one of the “11-exempt cancer hospitals” are included in the IPPS reporting requirements for acute care hospitals. Specifically, the final IPPS rule from August 18, 2011 states that: “Under section 1886(d)(1)(B) of the Act, as amended, certain hospitals and hospital units are excluded from the IPPS. These hospitals and units are: Rehabilitation hospitals and units; long term care hospitals (LTCHs); psychiatric hospitals and units; children’s hospitals; and cancer hospitals.” Please note that facilities that are not required to report influenza vaccination data to CMS are still welcome to track their data using NHSN. However, NHSN data from facilities that are not required to report will not be transmitted to CMS.

My facility has various units (e.g., rehabilitation units) that are physically located within the acute care hospital. Should I count these units when reporting HCP influenza vaccination summary data?

To report HCP influenza vaccination summary data, facilities should include all HCP who are physically working in the acute care facilityfor at least 1 day from October 1 through March 31 and who meet the criteria for one of the three required denominator categories: employees, licensed independent practitioners, or adult students/trainees and volunteers. Acute care facilities should count HCP working in all units that are physically considered a part of the inpatient acute care facility site, regardless of the size or type of unit. A helpful rule of thumb to use: If the location is staffed by acute care facility workers, follows the acute care infection control policies, and answers to the acute care administration, then the workers in that location should be included for the acute care influenza vaccination coverage. The decision to include or exclude HCP from the acute care facility’s HCP influenza vaccination counts should be based on whether individuals meet the specified NHSN criteria and are physically working in a location/unit that is considered any part of the on-site acute care facility that is being monitored.

For example:
HCP working in an IRF unit that is mapped as an Inpatient Rehabilitation Ward within an acute care facility (has a “T” or “R” in the 3rd position of the CCN) would be included in the acute care facility’s HCP influenza vaccination counts, because the IRF unit is a location of that acute care facility.
HCP working in a long-term acute care facility (LTAC) or a free-standing IRF that has enrolled as a separate facility within NHSN would not be included in the acute care facility’s influenza vaccination counts, because they are enrolled as a facility that is separate from the acute care facility.
HCP working in locations that are off-site, such as separate satellite clinics, should not be included in the on-site acute care facility’s influenza vaccination counts.
Long-term care facilities (LTCFs) (e.g., skilled nursing facilities) that are considered separate entities from the acute care facility should be enrolled in NHSN as a separate LTC facility and therefore should not be included in the acute care facility’s influenza vaccination counts.

If you require further guidance to make this decision, please e-mail the NHSN Helpdesk at nhsn@cdc.gov and include “HPS Flu Summary” in the subject line.

Our acute care hospital includes a long-term acute care unit that has its own CMS Certification Number (CCN). Should HCP working in this unit be counted?

Because the long-term acute care unit has its own CCN and should have already enrolled in NHSN as a separate HOSP-LTAC facility, HCP who work in this unit/facility would not be included in the IPPS reported measure, unless they also work in the short-stay acute care facility. CMS reporting requirements for long-term acute care hospitals are separate from requirements for short-stay acute care hospitals.

Which data collection forms are facilities required to complete for reporting HCP influenza vaccination summary data?

In order to report HCP influenza vaccination summary data, staff members at each facility must complete two required forms: 1) the HCP Safety Monthly Reporting Plan form; and 2) the HCP Influenza Vaccination Summary form. The Seasonal Survey on Influenza Vaccination Programs for HCP is not required at this time. However, facilities are encouraged to complete this short survey, as the information will be very helpful for CDC.

Are the data reporting timeframes the same for the denominator and numerator?

The timeframes for the denominator and numerator are different. The denominator includes HCP who are physically present in the healthcare facility for at least 1 working day from October 1 through March 31, because October 1 through March 31 is the reporting period. The numerator timeframe begins “as soon as vaccine is available.” Therefore, vaccinations given any time during the influenza season from the time that vaccine is available at a facility through March 31 should be reported. For example, if a HCW was vaccinated in September but then ceased to work at the facility before October 1, he/she would not be counted. However, a vaccination given in September would be counted for a HCW who physically works at the facility for at least 1 day from October 1 through March 31. The reason the numerator and denominator cover different timeframes is to account for potential delays in vaccine availability.

When should facilities begin collecting vaccination data?

Beginning with the 2013-2014 influenza season, acute care facilities are required to submit data for the entire influenza vaccination season (October 1 through March 31), as specified in the NHSN protocol. Please note that this is a change from the 2012-2013 influenza season, when acute care facilities were only required to submit vaccination data from January 1, 2013 through March 31, 2013. Therefore, facilities can begin collecting vaccination data as soon as influenza vaccine becomes available at the facility.

What is the monthly reporting plan in NHSN?

The monthly reporting plan indicates to the NHSN system which modules and protocols a user intends to follow for surveillance purposes in a specific month. The plan must be completed before data are entered for that month. Monthly reporting plans must be created or updated to include HCP influenza vaccination summary reporting, i.e., HCP influenza vaccination must be “in-plan” in order for data to be shared with CMS for the hospital IQR program. Once the “Influenza Vaccination Summary” box is checked on a 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).

Do I need to report data each month?

HCP influenza vaccination summary reporting in NHSN consists of a single data entry screen per influenza season, and this can be entered at any time during the influenza season, which is defined by NHSN as July 1 to June 30. Therefore, monthly reporting in NHSN is not required, and entering a single influenza vaccination summary report at the end of the reporting period for the influenza season will meet the minimum data requirements for NHSN participation. However, CDC/NHSN encourages that HCP influenza vaccination summary counts be updated on a monthly basis so they can be used at the facility level to impact influenza vaccination activities. For the purposes of fulfilling CMS quality measurement reporting requirements, the summary report will only be submitted once to CMS.

How long will facilities be able to edit the vaccination data?

For the purposes of fulfilling CMS quality measurement reporting requirements, the HCP influenza vaccination summary report for each influenza season must be entered no later than May 15. In other words, each acute care facility’s HCP influenza vaccination summary data must be entered into NHSN by May 15 for data to be shared with CMS. However, the influenza season is defined by NHSN as July 1 to June 30. Facilities can edit data any time after May 15, but these changes will not be sent to CMS. In addition, changes after June 30 of an influenza season may not be used for national reporting by CDC for that season.

When is the deadline for submitting data to CMS?

To meet CMS requirements, the HCP influenza vaccination summary data report must be entered into NHSN no later than May 15 for each influenza season. Reporting acute care facilities will be able to edit their data after May 15, but revised data will not be sent to CMS.

Can I review my facility’s HCP influenza vaccination summary data in NHSN before they are sent to CMS?

Yes, acute care facilities may review the HCP influenza vaccination summary data report that will be sent to CMS. Instructions on generating the report in NHSN can be found at: CMS Reporting: Healthcare Personnel Influenza Vaccination (Acute Care Hospitals) .

How will the data collected through the measure be used?

The tracking and reporting of HCP influenza vaccination status will assist healthcare facilities to identify and target unvaccinated HCP. This may result in reduced morbidity and mortality related to influenza virus infection among patients. HCP influenza vaccination summary data submitted to NHSN by May 15, will be reported by CDC to CMS for each acute care hospital. CDC will provide a hospital-specific HCP influenza vaccination percentage for each reporting hospital that has entered in-plan HCP influenza vaccination summary data into NHSN. Public reporting of the data from acute care hospitals on Hospital Compare will begin with the 2013-2014 influenza season.

General

What do I have to do to report to NHSN for the HCP Influenza Vaccination Summary Measure?

Facilities reporting to NHSN for the HCP Influenza Vaccination Summary Measure must follow the Healthcare Personnel Vaccination Module: Influenza Vaccination Summary Protocol October 2016 [PDF – 468K] .

Does NHSN require data to be reported on each individual employee?

No. Facilities are required to report summary-level data and not individual-level data. Therefore, information such as demographic data on employees is not required.

The HCP Influenza Vaccination Summary Form in NHSN defines the influenza season as July 1 to June 30. Does this mean that my facility is required to report on twelve months of data when we do not vaccinate for all twelve months?

No. Although influenza may occur any time of the year, you should report data for the period specified in the NHSN protocol, which is from October 1 to March 31 for the denominator, including all vaccinations given during the influenza season in the numerator. The July 1 to June 30 time period is used by NHSN to clearly define the end of one influenza season and the beginning of the next influenza season.

Which month and year should I select on the monthly reporting plan for the HCP Vaccination Module?

You can select any month within the current influenza season. Therefore, it is fine if you enter a single summary data report for one month (e.g., March 2013). Unlike the other NHSN components and modules, when “Influenza Vaccination Summary” is selected on one reporting plan, the information is automatically updated on all reporting plans for the entire influenza season as defined by NHSN (which is July 1 to June 30). Adding other reporting plans after the initial plan has been added is not necessary.

Can facilities review the data that are entered into NHSN by each month?

No. 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. For example, the aggregate data that are entered at the end of November would include summed data from both October and November. Facilities wishing to maintain monthly records should save their own copies of each data entry.

How can I modify the HCP influenza vaccination summary data that have been entered in NHSN?

To edit the data, first click “Edit” at the bottom of the HCP influenza vaccination summary data entry screen. Next, you will proceed to enter the updated data. Once this is complete, you must save the updated data by clicking the “Save” button at the bottom of the screen. You should then see a message at the top of your screen confirming that your data have been saved.

Is each facility required to calculate vaccination percentages when using the NHSN module?

No. Facilities will not need to calculate vaccination percentages. You will only need to enter the number of HCP that fall into the numerator and denominator categories. The system will calculate the percentage for vaccination coverage for you.

Can I create reports with the HCP influenza vaccination summary data I entered in NHSN?

Yes. Facilities can view data and run reports on their HCP influenza vaccination summary data within NHSN. To view data, you should go into the Healthcare Personnel Safety Component. After generating a new data set, go to “Output Options” under “Analysis” on the navigation bar. You will see several folders on the screen; click on “HCW Vaccination Module,” “Influenza,” and “CDC Defined Output.” To view the default output, click “Run” to view line listings, bar charts, and pie charts.

Where can I find training on collecting HCP influenza vaccination summary data?

A “refresher training” was developed for the 2013-2014 influenza season. PowerPoint slides and a recording of this training are available at: CDC’s Vaccines & Immunizations webpage. Comprehensive training slides on collecting and entering HCP influenza vaccination summary data are available at: Surveillance for Healthcare Personnel Vaccination for acute-care facilities.

Who do I contact for questions related to NHSN reporting?

Questions should be sent via e-mail to NHSN@cdc.gov. Please include “HPS Flu Summary” in the subject line of the e-mail.

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