Healthcare-Associated Infections Reporting

Whether you are new to Healthcare-Associated Infections (HAIs) reporting for Texas or need help with your current reporting, this is the place for you! Here you can find information on the Texas Reporting Requirements and get help navigating the National Healthcare Safety Network (NHSN) and the Texas Healthcare Safety Network (TxHSN).
 

HAI Reporting Requirements

Chapter 98 of the Texas Health and Safety Code, (Reporting of HAIs and Preventable Adverse Events (PAEs)), and 25 Texas Administrative Code, Chapter 200 (HAIs) requires the Texas Department of State Health Services to establish the Texas HAI reporting system. These were created to provide the public with HAI data and to support quality improvement and infection control activities in health care facilities. Below is a list of HAIs that are required to be reported by Texas general hospitals.

Texas Reportable HAIs (as of January 1, 2020)

Reporting Timeline/Schedule

Below is a table showing the reporting schedule. It indicates major deadlines associated with reporting HAI data to Texas.

Getting Started with NHSN

All facilities are required to report their data through the NHSN. Below is a list of steps to help guide facilities through this process.

1. NHSN Enrollment 
   The first step in HAI reporting is to enroll your facility in NHSN. To do this, follow the instructions linked below for your facility type.
   
   NOTE: Facilities with more than one campus at different physical locations must enroll each campus location separately, unless connected by a skybridge or other physical connector.  This is regardless of whether the campuses all share a CMS or other license number.
   
   NOTE: If you cannot register your facility with your CMS Certification Number or your AHA number, you can request a temporary CDC Registration ID by emailing NHSN@cdc.gov.
   
   Instructions for General Hospitals
   
   Instructions for Ambulatory Surgery Centers
    
2. Setting up your facility
   Once your facility is enrolled in NHSN, you must perform some set-up steps to add additional users, locations within your facility (if you are a general hospital), and surgeons (optional) (surgeon information will not be sent to DSHS).
    
3. Conferring Rights
   In order for Texas to have access to your data in NHSN, you must join the appropriate HAI reporting group in NHSN and accept the confer rights template. To do this, follow the instructions for your facility type. Please note that the only user that can complete this process is the NHSN Facility Administrator (usually the person who enrolled your facility in NHSN). For questions, please email haitexas@dshs.texas.gov.
   
   Instructions for General Hospitals: Texas Hospital Confer Rights (PDF)
    

   NHSN Facility Users
   Once you have enrolled and accepted the confer rights template, you can add additional users for your NHSN facility. To do this, your NHSN Facility Administrator (usually the person who enrolled your facility in NHSN) will need to add you as a Facility User. The Facility Administrator can do this in NHSN, under the User page.

   After enrollment, the new user must follow the steps provided on the CDC NHSN Group Users webpage.

   NOTE: If you are the current NHSN Facility Administrator and are leaving your facility, you must re-assign the Facility Administrator role to another user.

   NOTE: If the NHSN Facility Administrator leaves without reassigning the administrator role to another user, the facility will need to contact NHSN at NHSN@cdc.gov indicating that they need to manually change the administrator.

4. Set up your Texas Health Care Safety Network (TxHSN) users: TxHSN was developed to help coordinate and simplify the communication process between Texas and reporting healthcare facilities. It is a web-based application that facility contacts will be able to log into to view reports and make comments about their HAI data.

The diagram above shows how the general reporting process will work. Each healthcare facility will login to NHSN  and enter all applicable HAI data. DSHS will have rights to pull your data from NHSN. The data that DSHS gets from NHSN will then be stored in TxHSN and facility-specific reports will be generated there. TxHSN will email facility contacts to notify them that their reports are ready to view in TxHSN. The facility contacts will then log into TxHSN and run reports as instructed and comment on data as they see fit.
 

TxHSN Designated Contacts

Each facility is allowed up to two designated HAI contacts. These contacts are the individuals responsible for communicating with DSHS, reviewing reports and making comments on the Facility HAI reports that will be available to the public.

In order to keep our records up to date with the most current contact information, letters to each facility’s CEO will be sent out annually. This letter will request information regarding whether the facility is required to report and who should be designated as the TxHSN contacts.

It is very important that the contact information we have for your facility is correct. If either of these contacts change, complete this Contact Change Form and email to haitexas@dshs.texas.gov. Please let us know as soon as possible so we can update your facility’s user accounts appropriately.
 

What is the TxHSN Internal Data Review Report?

The TxHSN Internal Data Review Report (IDRR) shows the number of records that were submitted to NHSN for each record type for a given reporting time period. The report shows the total number of Event (infection) records for central line-associated blood stream infections (CLABSIs), catheter-associated urinary tract infections, (CAUTIs), and surgical site infections (SSIs) and Procedure records that we have pulled from NHSN for your facility. Total numbers of Event and Procedure records are shown in the first table of the IDRR. Subsequent tables on the IDRR show the number of records reported by unit type or procedure type and year/month. Please verify these record counts to make sure all HAIs have been reported to Texas.

NOTE: This report will only display record counts for which your facility has conferred rights to Texas to view.

To review the IDRR:

1. Log in to TxHSN 2.0
    
2. On the Welcome page, Click on the HAI icon on the left panel to open the HAI menu options. Then click Reports.
    
3. The HAI Reports page displays menu selections for category and type of HAI reports. Click the first drop down menu arrow to open options for report Category. Select Healthcare Safety Report. Click the second drop down menu arrow to open options for Report type. Select Internal Data Review Report. Click the Next button.
    
4. On the facility directory page, click to highlight the desired healthcare facility. Click Generate Report button.
    
5. The report will open in a separate window for download files.
    

How do I preview the Facility HAI Reports?

Facility specific HAI reports are also included in the Healthcare Safety Report – Consumer Version and the Healthcare Safety Report – Technical Version. To review these Facility reports:

1. Log in to TxHSN 2.0
    
2. On the Welcome page, Click on the HAI icon on the left panel to open the HAI menu options. Then click Reports.
    
3. The HAI Reports page displays menu selections for category and type of HAI reports. Click the first drop down menu arrow to open options for report Category. Select Healthcare Safety Report. Click the second drop down menu arrow to open options for Report type. Select either Consumer Healthcare Safety Report or Technical Healthcare Safety Report. Click the Next button.
    
4. On the facility directory page, click to highlight the desired healthcare facility. Click Generate Report button.
    
5. The report will open in a separate window for download files.
    

How do I submit a comment regarding my Facility HAI Report?

If you wish, you may submit a comment to add to your facility's HAI Reports. This comment will appear at the bottom of both versions of the report for the public to view. Please note that DSHS does not have expectations for the content of these comments. Please review the general guidelines below.

To submit a comment:

1. Log in to TxHSN 2.0
    
2. On the Welcome page, Click on the HAI icon on the left panel to open the HAI menu options. Then click HAI Comments.
    
3. The HAI Comments page displays a list of facilities for which you have log in access as a HAI contact.
    
4. Click View in the Actions column for the facility you wish to add a comment.
    
5. The HAI Comment History displays a list of half year reporting periods (January-June; July-December).  Click Add in the Actions column to enter a new HAI comment.
    
6. Type comment in the free text field on the HAI Add Comment page. Click Save Comment to return later to edit the comments before deadline. Click Submit Comment to send final comments to DSHS for review and approval.
    

Additional Instructions and Information: 

You are not required to submit a comment. Please do NOT enter and submit a comment that says, "No comment." Comments will not be approved if they contain any of the following:

• Inappropriate language.
• References to another health care facility.
• Do not reflect the current reporting time period.
• Were submitted after the Facility Comments Deadline.
   

DSHS will review your facility comment for approval. Your comments will appear on the Facility Healthcare Safety Report – Consumer Version and Healthcare Safety Report – Technical Version for the public to view.