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This entry was published on 2014-09-22
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SECTION 2819
Hospital acquired infection reporting
Public Health (PBH) CHAPTER 45, ARTICLE 28
§ 2819. Hospital acquired infection reporting. 1. For the purposes of
this section, "hospital acquired infection" shall mean any localized or
systemic patient condition that:

(a) resulted from the presence of an infectious agent or agents, or
its toxin or toxins as determined by clinical examination or by
laboratory testing; and

(b) was not found to be present or incubating at the time of admission
unless the infection was related to a previous admission.

2. (a) Each general hospital shall maintain a program capable of
identifying and tracking hospital acquired infections for the purpose of
public reporting under this section and quality improvement.

(b) Such programs shall have the capacity to identify the following
elements: the specific infectious agents or toxins and site of each
infection; the clinical department or unit within the facility where the
patient first became infected; and the patient's diagnoses and any
relevant specific surgical, medical or diagnostic procedure performed
during the current admission.

(c) The department shall establish guidelines, definitions, criteria,
standards and coding for hospital identification, tracking and reporting
of hospital acquired infections which shall be consistent with the
recommendations of recognized centers of expertise in the identification
and prevention of hospital acquired infections including, but not
limited to the National Health Care Safety Network of the Centers for
Disease Control and Prevention or its successor. The department shall
solicit and consider public comment prior to such establishment.

(d) Hospitals shall be initially required to identify, track and
report hospital acquired infections that occur in critical care units to
include surgical wound infections and central line related bloodstream
infections.

(e) For hospital acquired infections for which the department requires
tracking and reporting as permitted in this section, hospitals shall be
required to report a suspected or confirmed hospital-acquired infection
associated with another hospital to the originating hospital.
Documentation of reporting should be maintained for a minimum of six
years.

(f) Subsequent to the initial requirements identified in paragraph (d)
of this subdivision the department may, from time to time, require the
tracking and reporting of other types of hospital acquired infections
(for example, ventilator - associated pneumonias) that occur in
hospitals in consultation with technical advisors who are regionally or
nationally-recognized experts in the prevention, identification and
control of hospital acquired infection and the public reporting of
performance data.

3. Each hospital shall regularly report to the department the hospital
infection data it has collected. The department shall establish data
collection and analytical methodologies that meet accepted standards for
validity and reliability. The frequency of reporting shall be monthly,
and reports shall be submitted not more than sixty days after the close
of the reporting period.

4. The commissioner shall establish a state-wide database of all
reported hospital acquired infection information for the purpose of
supporting quality improvement and infection control activities in
hospitals. The database shall be organized so that consumers, hospitals,
healthcare professionals, purchasers and payers may compare individual
hospital experience with that of other individual hospitals as well as
regional and state-wide averages and, where available, national data.

5. (a) Subject to paragraph (c) of this subdivision, on or before
September first of each year the commissioner shall submit a report to
the governor and the legislature, which shall simultaneously be
published in its entirety on the department's web site, that includes,
but is not limited to, hospital acquired infection rates adjusted for
the potential differences in risk factors for each reporting hospital,
an analysis of trends in the prevention and control of hospital acquired
infection rates in hospitals across the state, regional and, if
available, national comparisons for the purpose of comparing individual
hospital performance, and a narrative describing lessons for safety and
quality improvement that can be learned from leadership hospitals and
programs.

(b) The commissioner shall consult with technical advisors who have
regionally or nationally acknowledged expertise in the prevention and
control of hospital acquired infection and infectious disease in order
to develop the adjustment for potential differences in risk factors to
be used for public reporting.

(c)(i) No later than July first, two thousand six, the department
shall establish a hospital acquired infection reporting system capable
of receiving electronically transmitted reports from hospitals.
Hospitals shall begin to submit such reports as directed by the
commissioner but in no case later than January first, two thousand
seven.

(ii) The first year of data submission under this section shall be
considered the "pilot phase" of the statewide hospital acquired
infection reporting system. The purpose of the pilot phase is to ensure,
by various means, including any audit process referred to in subdivision
seven of this section, the completeness and accuracy of hospital
acquired infection reporting by hospitals. For data reported during the
pilot phase, hospital identifiers shall be encrypted by the department
in any and all public databases and reports. The department shall
provide each hospital with an encryption key for that hospital only to
permit access to its own performance data for internal quality
improvement purposes.

(iii) No later than one hundred eighty days after the conclusion of
the pilot phase, the department shall issue a report to hospitals
assessing the overall accuracy of the data submitted in the pilot phase
and provide guidance for improving the accuracy of hospital acquired
infection reporting. The department shall issue a report to the governor
and the legislature assessing the overall completeness and accuracy of
the data submitted by hospitals during the pilot phase and make
recommendations for the improvement or modification of hospital acquired
infection data reporting based on the pilot phase as well as share
lessons learned in prevention of hospital acquired infections. No
hospital identifiable data shall be included in the pilot phase report,
but aggregate or otherwise de-identified data may be included.

(iv) After the pilot phase is completed, all data submitted under this
section and compiled in the statewide hospital acquired infection
database established herein and all public reports derived therefrom
shall include hospital identifiers.

6. Subject to subdivision five of this section, a summary table, in a
format designed to be easily understood by lay consumers, that includes
individual facility hospital acquired infection rates adjusted for
potential differences in risk factors and comparisons with regional
and/or state averages shall be developed and posted on the department's
web site. The commissioner shall consult with consumer and patient
advocates and representatives of reporting facilities for the purpose of
ensuring that such summary table report format is easily understandable
by the public, and clearly and accurately portrays comparative hospital
performance in the prevention and control of hospital acquired
infections.

7. To assure the accuracy of the self-reported hospital acquired
infection data and to assure that public reporting fairly reflects what
actually is occurring in each hospital, the department shall develop and
implement an audit process.

8. For the purpose of ensuring that hospitals have the resources
needed for ongoing staff education and training in hospital acquired
infection prevention and control, the department may make such grants to
hospitals within amounts appropriated therefor.

9. Individual patient identifying information reported to the
department under this section shall be subject to paragraph (j) of
subdivision one of section two hundred six of this chapter. Regulations
under this section shall include standards to assure the protection of
patient privacy in data collected and released under this section and
standards for the publication and release of data reported under this
section.