This a follow-up letter to AFL 07-37 "Mandated use of the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) to Comply with Senate Bill (SB) 739 on the Reporting of Healthcare-Associated Infections (HAI) Process Measures," dated November 27, 2007. Please review and share this document with all persons in your facility responsible for infection prevention and control activities and quality management reporting.
Join the CDPH Group:
AFL 07-37 notified all general acute care hospitals of their obligation to register with NHSN so that process measures required by SB 739 could be reported into that database. Hospitals are instructed to join the California Department of Public Health (CDPH) group.
There are no alternative methods for complying with the requirements of this legislation.
Procedure: The facility NHSN administrator must log into the NHSN Secure Data Network, click on “join group” in the left navigation bar, then click on “Join”. Type in “12528” in the “Group ID” field, enter “joinCDPH” (no space, case sensitive) as the Group Joining Password”, then click “Join Group.”
How to Confer Rights for CDPH to Access Mandated Data:
This will be covered in a separate AFL after the implementation of the process modules by NHSN.
SB 739 Mandatory Reporting Requirements
The CDPH HAI Advisory Committee recommended that the following procedures be followed for compliance with SB 739 reporting requirements. These requirements are now mandatory and may be enforced by the CDPH Licensing and Certification Program.
Central Line Insertion Practices (CLIP)
CLIP reporting requirements as specified in Attachment 1 must be reported through NHSN effective July 1, 2008.
This information is being distributed now, in advance of the implementation of the reporting module by CDC, to ensure that hospitals have the processes in place to meet the start date. Note the requirement for daily assessment of central line necessity, which is in addition to the CLIP module. If no central lines are inserted by the facility during the course of a calendar year, the facility will be exempt from reporting of central line insertion practices.
• Attachment 2 is the reporting module.
• Attachment 3 contains instructions for filling out the module.
The official release date for the CLIP module by NHSN is anticipated to be May, 2008. Data cannot be entered into NHSN prior to official release. If for some reason the module is not released as scheduled, hospitals should still begin to collect data no later than July 1, 2008, and enter the data into NHSN as soon as the module is available for data entry.
Surgical Antimicrobial Prophylaxis Measures
Reporting of surgical antimicrobial prophylaxis measures, items 1-3 of the Centers for Medicare and Medicaid Services (CMS) Surgical Care Improvement Project (SCIP) 1-3, is now required. They are as follows: 1) prophylactic antibiotic received within one hour prior to surgical incision, 2) appropriate prophylactic antibiotic selection for surgical patients, and 3) prophylactic antibiotics discontinued within 24 hours after surgery end time (48 hours for cardiac patients).
- Hospitals who currently report SCIP measures 1-3 to CMS through vendors need take no further action. CDPH will download this data directly from the CMS Hospital Compare website.
- Hospitals who report through vendors to The Joint Commission but not to CMS must request that their vendor forward quarterly reports to CDPH, Attn: Sue Chen @ FAX (510) 620-3425 or via US Postal Service to:
HAI Reporting Program
850 Marina Bay Parkway, Bldg P, 2nd Floor
Richmond, CA 94804
- Hospitals who do not report SCIP measures 1-3 are directed to call (415) 677-2122 to receive assistance from Lumetra, California’s federally-designated Quality Improvement Organization (QIO) on how to utilize the CMS Abstraction and Reporting Tool (CART). The hospitals in this group who have a Medicare provider number will be instructed to report using the electronic interface, and their data will then be retrievable through the Hospital Compare website (as with Group #1 above.) For hospitals in this group who are unable to use the electronic interface, Lumetra will provide a quarterly reporting mechanism that coincides with the Hospital Compare timetable.
- Government hospitals and hospitals that do not perform surgeries on the applicable SCIP procedure tables are exempt from this reporting requirement. If unclear whether your facility performs SCIP procedures, contact Lumetra at (415) 677-2122.
Registration for Long Term Acute Care Facilities (LTACH) and Surgery Centers
Note: SB 739 requirements apply to all general acute care hospitals including LTACH facilities, since they are licensed as general acute care hospitals. LTACH facilities and Surgery Centers are instructed to register for NHSN now as an acute care hospital. This is to ensure that they can begin mandated reporting on July 1, 2008. NHSN will reclassify these facilities after the respective groups are formed,
but only if these facilities separately notify CDPH of their full mailing address and facility type (LTACH, etc.) at the time they register with NHSN. Failure to provide this notification may lead to future data misclassification. Please forward the information to Sue Chen; contact information is below.
Specification of Patient Identifier
CDPH strongly recommends that hospitals fill in the data point "Secondary ID" with the patient’s medical record number on all modules completed. This will enable future linkage of SCIP data with NHSN data. There is no need for facilities to make this Secondary ID data point visible to CDPH. AFL 08-10 Page 4 April 22, 2008
Please direct questions on these new requirements to Sue Chen, HAI Program Coordinator at
Sue.Chen@cdph.ca.gov, phone (510) 620-3434, or fax (510) 620-3425.
Original Signed by Pamela Dickfoss for
Kathleen Billingsley, R.N.
Central Line Insertion Practice (CLIP) Reporting Requirements
CLIP Report Form (PDF)
- Instructions for CLIP module
California Hospital Association
California Conference of Local Health Officers
HAI Advisory Committee