A. Sample Reporting Form for SB 1058 Mandates
Senate Bill 1058, Chapter 296, Statutes of 2008 and Senate Bill 158, Chapter 294, Statutes of 2008 became effective January 1, 2009. The statutes require general acute care hospitals to implement specified procedures and processes designed to reduce the incidence of health care associated infections.
Specifically, beginning January 1, 2009, general acute care hospitals must begin testing each patient for Methicillin-resistant Staphylococcus aureus (MRSA) within 24 hours of admission to the hospital in the following cases:
- The patient is scheduled for inpatient surgery and has a documented medical condition making the patient susceptible to infection, based either upon federal Centers for Disease Control and Prevention findings or the recommendations of the Healthcare Associated Infection Advisory Committee or its successor.
- It has been documented that the patient has been previously discharged from a general acute care hospital within 30 days prior to the current hospital admission.
- The patient will be admitted to an intensive care unit or burn unit of the hospital.
- The patient receives inpatient dialysis treatment.
- The patient is being transferred from a skilled nursing facility.
If a patient tests positive for MRSA, the attending physician shall inform the patient or the patient’s representative immediately or as soon as practically possible, and prior to discharge, the hospital must provide oral or written instruction to the patient regarding aftercare and precautions to prevent the spread of the infection to others.
The law has retesting provisions for patients who show increased risk of invasive MRSA infections; however, those provisions are not effective until January 1, 2011.
Current Title 22 regulations require general acute care hospitals to have an infection control policy. Effective January 1, 2009, the law requires those policies to contain, in addition to what is already required in regulation, the following:
- Procedures to reduce health care associated infections.
- Regular disinfection of all restrooms, countertops, furniture, televisions, telephones, bedding, office equipment, and surfaces in patient rooms, nursing stations, and storage units.
- Regular removal of accumulations of bodily fluid and intravenous substances, and cleaning and disinfection of all movable medical equipment, including point-of-care testing devises such as glucometers, and transportable medical devices.
- Regular cleaning and disinfection of all surfaces in common areas in the facility such as elevators, meeting rooms, and lounges.
Note: In November 2008, the CDC issued the document "Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008" that supersedes the CDC Guideline for Handwashing and Environment Control, 1985. These guidelines apply to all types of health care facilities. CDPH recommends that all health care facilities review these new guidelines to ensure their policies and procedures for environmental cleaning, disinfection, and sterilization of patient care items are current. A copy may be downloaded from the CDC website at: Guideline for Disinfection and Sterilization in HealthcareFacilities, 2008 (PDF).
Effective January 1, 2009, in addition to the MRSA testing and policy requirements stated above, hospitals must comply with the following reporting requirements:
Using the federal Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN) definition of health-care-associated infection, hospitals must,
- quarterly report all cases of health care associated MRSA bloodstream infections, health care associated clostridium difficile infections, and health care associated Vancomycin-resistant enterococcal bloodstream infections, and the number of inpatient days;
- quarterly report central line associated bloodstream infections (CLABSIs) and the total central line days.
- quarterly report to the CDPH all health care associated surgical site infections of deep or organ space surgical sites, health care associated infections of orthopedic surgical sites, cardiac surgical sites, and gastrointestinal surgical sites designated as clean and clean-contaminated, and the number of surgeries involving deep or organ space, and orthopedic, cardiac, and gastrointestinal surgeries designated clean and clean-contaminated.
- These infections may be reported quarterly to the CDPH in a format similar to the attached sample. They may be reported through the NHSN Multidrug Resistant Organism module, but that module is not yet available. Hospitals enrolled in NHSN will be notified when that module is available.
Hospitals must designate an infection control officer who, in conjunction with the hospital infection control committee, shall ensure implementation of the testing and reporting provisions and other hospital infection control efforts. Reports shall be presented to the appropriate committee within the hospital for review. The name of the infection control officer shall be made publicly available, upon request.
No later than January 1, 2010, a physician designated as a hospital epidemiologist or infection surveillance, prevention, and control committee chairperson shall participate in a continuing medical education (CME) training program offered by the federal Centers for Disease Control and Prevention (CDC) and the Society for Healthcare Epidemiologists of America, or other recognized professional organization. The CME program shall be specific to infection surveillance, prevention, and control. Documentation of attendance shall be placed in the physician’s credentialing file.
Beginning January 2010, all staff and contract physicians and all other licensed independent contractors, including, but not limited to, nurse practitioners and physician assistants, shall be trained in methods to prevent transmission of HAI, including, but not limited to, MRSA and Clostridium difficile infection.
By January 2010, all permanent and temporary hospital employees and contractual staff, including students, shall be trained in hospital-specific infection prevention and control policies, including, but not limited to, hand hygiene, facility-specific isolation procedures, patient hygiene, and environmental sanitation procedures. The training shall be given annually and when new policies have been adopted by the infection surveillance, prevention, and control committee.
Environmental services staff shall be trained by the hospital and shall be observed for compliance with hospital sanitation measures. The training shall be given at the start of employment, when new prevention measures have been adopted, and annually thereafter. Cultures of the environment may be randomly obtained by the hospital to determine compliance with hospital sanitation procedures.
By January 1, 2011, the law requires the CDPH to post on its website the following:
Using a risk adjustment process that is consistent with the NHSN, or its successor, (unless the department adopts, by regulation, a fair and equitable risk adjustment process that is consistent with the recommendations of the Healthcare Associated Infection Advisory Committee):
- information regarding the incidence rate of health care acquired central line associated bloodstream infections acquired at each hospital in California, including information on the number of inpatient days, and
- information regarding the incidence rate of health care associated MRSA bloodstream infections, health care associated clostridium difficile infections, and health care associated Vancomycin-resistant enterococcal bloodstream infections, at each hospital in California, including information on the number of inpatient days.
The information in this AFL is a brief summary of SB 1058. Facilities are responsible for following all applicable laws. CDPH’s failure to expressly notify facilities of legislative changes does not relieve facilities of their responsibility for following all laws and for being aware of all legislative changes. Facilities should refer to the full text of SB 1058 to ensure compliance.
For questions, the point of contact at CDPH is Sue Chen, HAI Program Coordinator at Sue.Chen@cdph.ca.gov or phone (510) 620-3434.
Original Signed by Kathleen Billingsley, R.N.
Kathleen Billingsley, R.N.
Center for Health Care Quality
cc: California Hospital Association
California Conference of Local Health Officers
CDPH Emergency Preparedness Office
CDPH Licensing and Certification Program
CDPH Division of Communicable Disease Control
HAI Advisory Committee