Exhibit_A1_-_HBEDS_CDC-NHSN_Instruction_Book.docx

July/2025

NHSN Connectivity Initiative: Hospital Bed Capacity Project Instruction Book Instructions and technical specifications for reporting healthcare bed capacity data to CDC’s National Healthcare Safety Network (NHSN) Updated: July 2,, 2025 Version 4

CDPH HBEDS

Exhibit A1- CDC-NHSN Instruction Book

July 2025

Table of Contents

Introduction The COVID-19 pandemic demonstrated the need for the federal government to collect information about healthcare-system stress to increase patient safety during emergencies. Since March 2020, the U.S. government has consistently collected data from hospitals and states to better understand healthcare-system stress, capacity, capabilities, and hospitalizations. CDC is uniquely positioned to collect such surveillance information and to incorporate that data collection as part of the CDC Data Modernization Initiative (DMI). The NHSN Connectivity Initiative: Hospital Bed Capacity Project, which is part of the DMI, is an effort to strengthen the resiliency of healthcare systems and modernize data exchange. For this work, jurisdictions and hospitals collaborate to establish near real-time, automated collection and transmission of hospital bed capacity data.

The goals of the Hospital Bed Capacity Project are to establish and sustain ongoing automated collection of bed capacity data from hospitals and to ensure participants use standardized definitions of healthcare bed capacity.

Our collection of bed capacity data aligns with the Public Health Data Strategy (PHDS). The PHDS provides a way for public health partners, healthcare organizations, and the public to understand what we are doing and the progress we are making in key areas related to data, technology, policy, and administrative actions. One of the goals of the PHDS is to strengthen the core of public health data by better tracking information on topics like healthcare capacity.

NHSN is the nation’s tracking and response system to identify emerging and enduring threats across healthcare, including healthcare-associated infections (HAIs), antibiotic-resistant infections, and antibiotic use. NHSN provides medical facilities, states, regions, and the nation with data-collection and reporting capabilities to identify infection-prevention problems by facility, state, or specific quality-improvement project; benchmark progress of infection-prevention efforts; and comply with state and federal public-reporting mandates.

All acute-care and critical-access hospitals, including federal hospitals, are eligible to participate in the Hospital Bed Capacity Project. Such hospitals include the following types:

· Acute-care hospitals (general acute care, critical access, oncology, orthopedic, pediatric, women’s, women’s and children’s),

· Federal acute-care hospitals (Veterans Health Administration, Defense Health Administration, Indian Health Services)

· Long-term acute-care hospitals

· Inpatient Psychiatric Facilities (IPF): includes freestanding facilities and CMS-certified inpatient psychiatric facility units located within a hospital

· Inpatient Rehabilitation Facilities (IRF): includes freestanding facilities and CMS-certified inpatient rehabilitation facility units located within a hospital

This document provides instructions to end users for implementing the NHSN Connectivity Initiative: Hospital Bed Capacity Project and explains the following technical aspects:

· Connectivity pathways

· Process for file transmission

· Criteria for file validation and transmission

· Cadence of data transmission

· Data elements and definitions

Connectivity Options and Pathways The NHSN Bed Connectivity Initiative currently allows one of two options for establishing data transmission from individual hospitals to NHSN, which are described below.

Option 1: Utilizing a hospital-to-jurisdiction capacity system The first option available for facility-level bed capacity data transmission is to utilize a jurisdiction capacity system (“datastore”) as an intermediary between individual hospital electronic medical records (EMRs) and NHSN. This option involves two distinct points of connectivity, and can be established in one of two ways:

· By leveraging the existing data transmission mechanism and data model established through the centralized Oregon Health Authority (OHA) Resource Hub to create the jurisdiction capacity system and datastore.

· By creating and establishing an independent jurisdiction capacity system and datastore. A jurisdiction develops this directly or through a third-party vendor.

Regardless of the hospital-to-jurisdiction pathway chosen, the data should be transmitted from the individual hospital EMR every 15 minutes at minimum for collection in the jurisdiction capacity system and datastore, where reports and dashboards are updated in real-time. If an independent capacity system and datastore are pursued, all data elements, definitions, and requirements must match the existing data elements and requirements already defined by the NHSN Team and used by the OHA Resource Hub.

Option 2: Direct facility reporting to NHSN Facilities can participate directly in the NHSN Connectivity Initiative, independently of the OHA Resource Hub or jurisdictional capacity system. For facilities pursuing this option, it is still critical that all data elements, definitions, and requirements match the existing data elements and requirements already defined by the NHSN Team and used by the OHA Resource Hub.

IMPORTANT! Accessing CDC Secure Access Management System (SAMS) and establishing an API connection with NHSN is required for transmitting data in JSON file format to NHSN, regardless of the reporting option and pathway chosen. All details and instructions for setting up SAMS access and establishing the API connection can be found on the NHSN Bed Capacity Website: https://www.cdc.gov/nhsn/bed-capacity/index.html.

Future data transmission options Alignment with HL7 and FHIR We are aligning aspects of the NHSN Connectivity Initiative: Bed Capacity Project data file structure and transmission procedures to Health Level Seven International (HL7) standards, to provide the option of reporting the data to NHSN via HL7 Fast Healthcare Interoperability Resource (FHIR). We anticipate this option being available for implementation in 2025, following a successful HL7 testing and balloting cycle. We will release more information on FHIR reporting capabilities and timeline for availability and implementation when available.

File validation and transmission criteria File type and validation File type NHSN requires data to be submitted in JSON file format (“.JSON” extension). The file name must include some representation of the jurisdiction or vendor submitting (such as state abbreviation) and a date/time reference.

The following is an example of an acceptable file name:

· state[abbreviation]-day-time.JSON

· XX-yyyymmdd-hh:mm:ss.JSON Appendix C contains a sample JSON with formats for reference.

Files can contain records for multiple collection dates, and in the case of data coming from a jurisdictional capacity store via third-party vendor, states or jurisdictions (in that instance, it is recommended to include the vendor’s name in the file name). Files do not need to include previously submitted records unless updates to previously submitted records are needed. Otherwise, files can include new records not previously submitted for each transmission to NHSN.

Please note that if updates or corrections are needed for any previously submitted records, an entire record of data needs to be included. In other words, all values, including updated/corrected values, need to be included upon resubmission rather than records that contain only the updated/corrected values, with other fields empty.

File validation Each file submitted undergoes the following validation checks to ensure file structure and schema meet minimum requirements for submission and use:

· Column names and format match as expected

· Correctly formatted data for each of the following columns must also be included in the submission for the file to be accepted for processing:

a. NHSN OrgID (Organization Identification Number, a unique facility identifier) is included and correct for each record

b. Context is included and correct for each record

c. Reporting status (indicator of whether or not the record represents validated, production data, can be used for fulfilling other reporting requirements, or is test data)

d. Collection date: bed capacity values as of the date/time captured for collection date

e. Extraction date: date/time the bed capacity values were pulled from the source system The NHSN OrgID is required for successful record transmission and processing. The NHSN OrgID included on the records is validated against the NHSN OrgID assigned and maintained by NHSN upon the facility’s enrollment in the application.

Context is required for successful record transmission and processing. It is a critical component of determining unique facility-level data since facilities can report under one NHSN OrgID with multiple contexts to allow for subunit or “facility-within-facility” bed capacity reporting. Therefore, additional validation ensures completeness and accuracy of the context data element reported with each record.

Facility Identifier Validation The NHSN team works with participating jurisdictions and facilities to ensure all NHSN OrgIDs and contexts are reviewed and accurate prior to initiating file transmission. We conduct a testing period to ensure file type and validation specifications are met successfully.

We recommend the following steps to validate the NHSN OrgID and associated context. Option 1 is preferred because a facility should know their NHSN OrgID. An NHSN OrgID may change if a facility or health system has expanded or merged since its last interaction with the health department. We recommend Option 2 only once a contract has been executed with a vendor or other third party. As it is the vendor’s responsibility to send data to NHSN, and since the NHSN OrgID is a required data field, the health department must provide the contracted vendor with a list of NHSN OrgIDs in order for the vendor to successfully report data.

OPTION 1 (preferred)

1. The vendor, with support from the health department, recruits hospitals into the project. The hospital provides the facility’s NHSN OrgID to the vendor.

2. The vendor compiles the list of participating NHSN OrgIDs and sends the list to the NHSN team for verification.

3. The NHSN team sends back comments to the vendor and health department.

4. The vendor reconciles any mismatches with the hospital (e.g., the NHSN team provides an alternate NHSN OrgID for a mismatch if one is found in the NHSN system, which is updated in the vendor system).

5. The vendor shares the verified, up-to-date list of NHSN OrgIDs with the health department.

OPTION 2

1. The health department or other contracted third-party entity recruits hospitals into the project. The health department verifies the NHSN OrgID with the facility.

2. The health department compiles the list of participating NHSN OrgIDs and sends the list to the NHSN team for verification.

3. The NHSN team sends comments back to the health department.

4. The health department reconciles any mismatches with the hospital (e.g., the NHSN team provides an alternate NHSN OrgID for a mismatch if one is found in the NHSN system. The health department updates their list of participating NHSN OrgIDs).

5. The health department shares the verified, up-to-date list of NHSN OrgIDs with the vendor.

File transmission frequency and record granularity Reporting requirements have a specified minimum file transmission frequency (“how often”) and granularity (“how much”).

For frequency, data are required to be sent to NHSN every three hours at the minimum. For example, minimum transition times might be 1 am, 4 am, 7 am, 10 am, 1 pm, 4 pm, 7 pm, and 10 pm.

For granularity, s at least one record of bed capacity data for each hour (at the minimum) must be provided to NHSN since the previous transmission. Reporters may transmit more frequently if they wish. All times are local and are reported using UTC format.

Example schedules

1. Minimum frequency and granularity

a. Transmission: every 3 hours

b. Granularity: one record of bed capacity data for each hour since previous transmission

AM

PM

Transmission time:

Bed capacity as of:

Transmission time:

1 am

4 am

7 am

4 pm

7 pm

10 pm

Bed capacity as of:

10 pm 11 pm 12 am

1 am 2 am 3 am

4 am 5 am 6 am

7 am 8 am 9 am

10 am 11 am 12 pm

1 pm 2 pm 3 pm

4 pm 5 pm 6 pm

7 pm 8 pm 9 pm

Note: Any bed capacity snapshot during the designed hour increment can be included (e.g., for 10 pm bed capacity, any timepoint during 10:00-10:59 pm local time can be captured).

2. Hourly frequency and granularity

a. Transmission: every hour

b. Granularity: one record of bed capacity data for each hour since previous transmission

Note: Any bed capacity snapshot during the designed hour increment can be included (e.g., for 1 am bed capacity, any timepoint during 12:00-12:59 am local time can be captured). Any data prior to 12:00-12:59 am can also be resubmitted if needed.

Data elements The NHSN Connectivity Initiative collects and transmits to NHSN 78 total data elements, the majority of which capture information on bed censuses (occupied beds) and availability (unoccupied beds) across a variety of bed types. That total breaks down into the following types:

· Bed censuses (occupied beds) and availability (unoccupied beds) captured separately by adult and pediatric beds: 28 total

· Bed censuses (occupied beds) and availability (unoccupied beds) not captured separately for adult and pediatric beds: 39 total

· Data elements specific to the emergency department including emergency department (ED) census and number of patients admitted, also captured separately for adult and pediatric beds: 6 total

· Data elements specific to facility information and date/time stamps: 5 total All bed censuses (occupied beds) and availability (unoccupied beds) captured represent facility-level aggregate values for the specified date and time.

The NHSN Connectivity Initiative does not include pathogen-specific data elements (such as number of beds occupied by patients with COVID-19) or any data specific to operational status, supplies, staffing shortages, or similar data.

Identifiers The NHSN OrgID (also called NHSN Facility ID), is a facility’s unique numeric identifier in the NHSN application and is assigned to the brick-and-mortar level of the facility based on its physical location and address. The NHSN OrgID serves as the unique identifier for hospital-specific bed capacity records and allows bed capacity data to be linked with other hospital-specific data in NHSN, including the Respiratory Hospital Data reporting (informally referred to as the “COVID-19 Hospital Data Reporting”).

Reporting Status All records submitted to NHSN must include an indicator of the reporting status for a given hospital on a given day. The reporting status indicator serves two primary purposes:

1. Reporting status is used as the main link between the data reported into the Bed Capacity project and the NHSN Respiratory Hospital Data (HRD) reported per Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoP)1. For example, hospitals can indicate a reporting status as ‘ActiveCMS’ in their records to ensure NHSN

1 Beginning on November 1, 2024, the Centers for Medicare & Medicaid Services (CMS) will require acute care hospitals and critical access hospitals to electronically report information via NHSN about COVID-19, Influenza, and RSV, including confirmed infections of respiratory illnesses among hospitalized patients, hospital bed census and capacity (both overall and by hospital setting and population group [adult or pediatric]), and limited patient demographic information, including age.

This reporting will have a new standardized format and frequency in order to provide situational awareness of the impact of these respiratory diseases. (FY 2025 Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) Final Rule, pgs. 2462-2490.) More information on NHSN HRD reporting can be found here: https://www.cdc.gov/nhsn/psc/hospital-respiratory-reporting.html is able to use these data to automatically fulfil certain requirements of the HRD CoP, where possible.

2. Reporting status can also be used to indicate which records are reflective of test data, which are submitted to NHSN as part of the onboarding and validation process. A reporting status of ‘Test’ ensures data are excluded from CMS requirements as well as from analytic products and reports.

Bed inclusion criteria For all bed censuses and availability counts, all inpatient staffed and unblocked beds are included.

Bed exclusion criteria For all bed censuses and availability counts, the following bed types are excluded:

· Virtual beds or locations in the EMR that are not physical spaces (i.e., beds used for interoperative phase of care or in certain operative settings or virtual staging areas for admissions)

· Beds no longer in use, even in case of surge

· Blocked beds (e.g., beds blocked due to logistical or maintenance challenges, staffing restrictions, isolation, etc.)

Differentiating zero, null, and not applicable bed counts The following scenarios ensure bed counts of zero can be differentiated from “not applicable” bed counts.

TABLE 1: DIFFERENTIATING ZERO, NULL, AND NOT APPLICABLE BED AND CENSUS COUNTS

Service/bed type available or offered at hospital, no beds occupied or unoccupied (zero really means zero)

Zero

available.

Service/bed type not available or offered at hospital (not applicable)

Jurisdictions must work with vendors to implement the above guidance to ensure that valid data are captured and reported to NHSN and can be accurately included in analytics and reports.

Clarifications for criteria and bed types Unit vs. bed-level data collection and descriptions Bed censuses and counts are not limited to specific units or locations within the hospital when applying criteria and definitions listed below. Some unit or location-specific information is included for many of the bed fields listed in the data elements table to provide more detailed definitions and context for these fields (and where such beds may be found in a given hospital). Therefore, censuses and counts represent totals across any/all units where a given bed type may be present at the point of data collection.

Special Case/Exception While working with jurisdictions to validate the NHSN OrgID for Hospital Respiratory Data reporting, NHSN identified a scenario referred to as “facility-within-facility,” which refers to units/floors/wings of a hospital or facility that are currently reporting data independently of the facility in which these units/floors/wings are housed. These units/floors/wings have the same NHSN OrgID as the facility in which they are housed. The Reporting Context field exists to differentiate these facility-within-facility scenarios and addresses the additional specificity needed and allow for this reporting option in both the Hospital Respiratory Data and bed capacity data collections.

Please note that use of any other context but HOSP (applicable to brick-and-mortar level data) should be rare. The NHSN team reviews all NHSN OrgIDs and contexts with the recipient before data transmission begins and identifies any scenarios that might benefit from or require a facility-within-facility context.

Staffed vs. licensed beds Staffed bed counts represent the available inpatient beds for current staffing at a single point in time;

licensed beds are not used in place of staffed beds, as licensed beds likely do not represent the facility’s actual capacity at any point in time. Staffed beds represent the number of physically available beds with hospital staff on hand to attend to patients that could occupy the bed.

Specialty Beds Several fields specific to specialty beds are collected or referenced as inclusion/exclusion criteria for many other fields listed below. The following list of bed types describes what is referred to as “specialty beds” throughout:

· Non-crib specialty beds

· Obstetrics

· Rehabilitation

· Psychiatric

· Crib specialty beds

· NICU (levels 1, 2, 3, 3 Plus, and 4)

· Nursery

Rehabilitation and psychiatric beds Beds included in rehabilitation or psychiatric bed censuses and counts include those beds that meet criteria for CMS certification of these bed types.

Surge beds Surge bed fields include beds designated as “surge” in addition to any non-virtual beds or beds without headwalls, overflow, or hallway beds.

ICU-LOC bed census The criteria for adult and pediatric ICU-LOC (level of care) are based on what care a patient requires and where they receive it, as specified by the Society of Critical Care Medicine (SCCM) guidelines. The ICU-LOC census represents the number of patients in an adult or pediatric ICU bed meeting criteria for critical care, which is a subset of the overall ICU bed census.

Obstetric beds Obstetric beds include beds designated for antepartum, labor and delivery, or postpartum care that are part of a hospital’s maternal and newborn service. All are included in the obstetric bed count and census fields.

The full data dictionary can be downloaded from the NHSN Bed Connectivity Project website.

Data quality considerations The NHSN team routinely reviews all data submitted for potential data-quality issues. While no data are rejected from submission based on potential quality issues, they may be excluded from analytic reports and dashboards. We provide data-quality summaries to reporters, indicating potential issues that need further investigation and possible mitigation.

We implement data-quality checks in the NHSN pipeline. Records meeting the criteria are flagged, summarized, and provided back to jurisdictions on a routine basis following successful implementation of data transmission to NHSN. These checks include flagging null values and values that are logically invalid when comparing two or more columns to each other (for example, if the value reported for total occupied adult beds exceeds the total of all occupied beds). NHSN provides a list of data-quality checks to jurisdictions and vendors as part of the onboarding process to provide an opportunity to review and implement any corrections to the jurisdiction capacity system before transmitting data to NHSN.

The NHSN team continues to develop and refine data-quality checks over time and provide updates on this process as it is finalized and available.

Accessing the NHSN Application Jurisdiction and facility users need to have an active NHSN user profile to access the Patient Safety (PS) Component (and jurisdiction group, if applicable). New users are invited to create a profile by contacting their NHSN facility administrator or jurisdiction’s group administrator. If the facility or group administrator is not known, please reach out to the NHSN team through the NHSN ServiceNow Customer Portal (https://www.cdc.gov/nhsn/about-nhsn/helpdesk.html) or by email (NHSN@cdc.gov).

The facility or group administrator adds new users by logging into the facility/group and navigating to the Users menu, then to Add. Existing NHSN users are immediately added to the facility/group, while new users receive a separate email from CDC Secure Access Management Service (SAMS) to begin the registration process.

Appendix A: List of Acronyms

Appendix B: Sample JSON "collectionDate":"2022-09-05T19:00:58.907", "ExtractionDate":"2023-01-27T12:25:04.123", "orgID": 0, "Context": "CH", "ReportingStatus": "ActiveCMS", "AllBedsOccupied": 161, "AllBedsUnoccupied": 20, "AdultTotalOccupied": 118, "AdultTotalUnoccupied": 9, "AdultICUOccupied": 8, "AdultICUUnoccupied": 1, "AdultICULOCOccupied": 110, "AdultNonICUOccupied": 8, "AdultNonICUUnoccupied": 0, "AdultPCUOccupied": 0, "AdultPCUUnoccupied": 110, "AdultMTMSOccupied": 8, "AdultMTMSUnoccupied": 0, "AdultObsOccupied": 0, "AdultObsUnoccupied": 0, "PedsTotalOccupied": 0, "PedsTotalUnoccupied": 0, "PedsICUOccupied": 0, "PedsICUUnoccupied": 0, "PedsICULOCOccupied": 0, "PedsNonICUOccupied": 0, "PedsNonICUUnoccupied": 0, "PedsPCUOccupied": 110, "PedsPCUUnoccupied": 0, "PedsMTMSOccupied": 0, "PedsMTMSUnoccupied": 0, "PedsObsOccupied": 43, "PedsObsUnoccupied": 11, "SpecialtyTotalOccupied": 25, "SpecialtyTotalUnoccupied": 9, "SpecialtyNonCribOccupied": 25, "SpecialtyNonCribUnoccupied": 9, "OBOccupied": 18, "OBUnoccupied": 0, "NICUOccupied": 0, "NICUUnoccupied": 0, "NICU4Occupied": 0, "NICU4Unoccupied": 0, "NICU3PlusOccupied": 18, "NICU3PlusUnoccupied": 2, "NICU3Occupied": 0, "NICU3Unoccupied": 0, "NICU2Occupied": 0, "NICU2Unoccupied": 0, "NICU1Occupied": 0, "NICU1Unoccupied": 0, "NurseryOccupied": 0, "NurseryUnoccupied": 0, "AdultPsychOccupied": 0, "AdultPsychUnoccupied": 0, "PedsPsychOccupied": 0, "PedsPsychUnoccupied": 0, "RehabOccupied": 0, "RehabUnoccupied": 0, "SurgeActiveTotalOccupied": 0, "SurgeActiveTotalUnoccupied": 0, "SurgeInactiveTotalUnoccupied": 0, "SurgeActiveICUOccupied": 0, "SurgeActiveICUUnoccupied": 0, "SurgeInactiveICUUnoccupied": 0, "SurgeActiveNonICUOccupied": 0, "SurgeActiveNonICUUnoccupied": 0, "SurgeInactiveNonICUUnoccupied": 0, "BurnOccupied": 18, "BurnUnoccupied": 0, "NegativePressureOccupied": 18, "NegativePressureUnoccupied": 1, "AdultEDCensus": 2, "AdultEDAdmittedCensus": 0, "PedsEDCensus": 18, "PedsEDAdmittedCensus": 1, "TotalEDCensus":412, "TotalEDAdmittedCensus":1921

Appendix C. Instruction Book Change Log The change log details changes in the instructions for reporting hospital bed capacity data to NHSN to aid partners in tracking updates.

Changes from previous version (Version 3, dated October 8, 2024)

· Content updates

· Updated connectivity and SAMS sections and other relevant text to reflect new direct-to-NHSN API capabilities and removed references and diagrams for obsolete connectivity options

· Removed redundant table and appendices and replaced with references and hyperlinks to new, separate resources

· Edited Appendix C: Sample JSON to include a closing square bracket.

Changes from previous version (Version 2, dated August 16, 2024)

· Data elements

· New data elements

· None

· Updates to existing data elements

· Additional clarification was added to the description of collectionDate

· IDs and subIDs were added to all data elements for easier tracking and grouping; these are also reflected in the full data dictionary.

· Content updates

· A status indicator (i.e., required or optional) was added to the data element table

· As of version 3, five data elements are required for successful transmission of data to NHSN

Changes from the previous version (Version 1, dated August 1, 2024)

· Data elements:

· New data elements:

· ReportingStatus was added to the full list of data elements and in the sample JSON.

· Updates to existing data elements:

· Additional clarification was added to the descriptions for Context and the emergency department data elements (Adult ED Total Census, Adult ED Admitted Census, Peds ED Census, Peds ED Admitted Census, Total ED Census, Total ED Admitted Census)

· Content updates:

· File naming convention: updated instructions on acceptable file naming convention was added.

· Updates to required fields for file submission: the following fields have been updated as required for successful file/record submission and validation to NHSN:

July/2025

· NHSN Org ID

· Context

· Reporting status

· Collection date

· Extraction date

· Clarification and justification on incorporation of reporting status added to data elements narrative image1.jpeg image2.jpeg