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REGULATORY REVIEW


Data Collection Data collection for ASC-8 takes place for the influenza season between October 1, 2014, and March 31, 2015. It is important to note, however, that vaccinations given at any point after the current influenza season’s vaccine becomes available at a facility through March 31, 2015, should be reported. For example, a vaccination given in August would be counted for a health care worker who physically works at the facility for at least one day from October 1 through March 31. If a vaccination is given at the facility in August to an employee who quits in September, that HCP should not be included in the facility’s report. Facilities must report vaccina- tion data for three categories of HCP: employees on payroll


(regardless of


patient contact); licensed indepen- dent practitioners (who are physicians, advanced practice nurses and physician assistants affiliated with the facility but not on payroll); and students, trainees and volunteers aged 18 or older. Any owner, even a physician owner, is catego- rized as an “employee” and included in this measure if present in the facility for at least one day from October 1 through March 31. Data on vaccinations received at the facility, vaccinations received out- side of the facility, medical contra-indi- cations and declinations are reported for all three categories of HCP. If an HCP receives a vaccination


outside of the health care facility, there must be written documentation indi- cating that a vaccination was adminis- tered. Acceptable forms of documen- tation include a signed statement or form, an electronic form or e-mail indi- cating when and where the health care worker received the influenza vaccine, or a note, receipt, vaccination card, etc., from the outside vaccinating entity. Ver- bal statements are not acceptable. Only HCP who have a severe aller- gic reaction to eggs or other components of the influenza vaccine or a history of


ASC-8 Reporting Resources


For more information on ASC-8 reporting, visit www.ascassociation.org/ ASC8FAQs.


The operational guidance containing the ASCQR program requirements related to ASC-8 reporting can be found under “CMS Supporting Materials” at www.cdc. gov/nhsn/ambulatory-surgery/hcp-vaccination/index.html.


Direct questions regarding NHSN training, enrollment and submission should be sent to NHSN@cdc.gov with “HPS Flu Summary-ASC” in the subject line.


The NHSN enrollment process can take several weeks, so ASCs that are not already enrolled in NHSN are advised to register immediately.”


—Kara Newbury


Guillain-Barré Syndrome (a severe para- lytic illness, also called GBS) within six weeks after a previous influenza vacci- nation can be reported as having a medi- cal contraindication to vaccination with inactivated influenza vaccines. All oth- ers who decline are simply counted as “declined to receive.” Documentation is not required for reporting a medical contraindication or a declination; there- fore, verbal statements are acceptable for reporting these numerator categories. There is a catch-all option for those HCP with unknown vaccination status. This is the box where HCP should go if there is no documentation of vaccination, there is no medical contraindication to vaccination or it is not known whether the HCP declined vaccination. ASCs are supposed to make an effort to determine all eligible HCPs vaccination status.


Reporting To report HCP influenza vaccination sum- mary data, each facility must complete two required forms and submit them through NHSN between January 1 and May 15, 2015: 1) the HCP Safety Monthly Report- ing Plan form; and 2) the HCP Influenza Vaccination Summary form.


For ASCs, the HCP Safety Monthly


Reporting Plan form must be filled out and submitted only once during the reporting period. The form must include the Facility ID and month and year of sub- mission, and the box should be checked next to “Influenza Vaccination Summary.” On the Influenza Vaccination Sum-


mary form, the ASC must account for the vaccination status of the three categories of individuals (employees, licensed inde- pendent practitioners and students, train- ees or volunteers) who were physically present in the ASC between October 1, 2014, and March 31, 2015. NHSN also includes a space to enter data on influ- enza vaccination coverage among con- tract workers, but currently these data are not required by CMS and are optional according to the NHSN protocol. HCP influenza vaccination sum-


mary reporting in NHSN consists of a single data entry screen per influenza season. It is designed to ensure that reported HCP influenza vaccination coverage is consistent over time within a single health care facility and compa- rable across facilities.


Kara Newbury is the assistant director of health policy at ASCA. Write her at knewbury@ascassociation.org.


ASC FOCUS JANUARY 2015 21


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