Accrediting and Licensing DISTRIBUTION LIST –
This is the only copy being sent to your facility. Please distribute copies to:
Chief Executive Officer
Quality Management Department
Infection Control Committee Chair
Statutes: Health and Safety Code sections 1288.55 and 1288.8
Attachment: Table of Reporting Requirements
The purpose of this letter is to notify California general acute care hospitals of new California Department of Public Health (CDPH) instructions for reporting mandated by Senate Bill (SB) 1058 and SB 739 (enacted by Health and Safety Code sections 1288.55 and 1288.8, respectively). Commencing April 1, 2010, the department will accept data for:
- central line associated bloodstream infections (CLABSIs),
- clostridium difficile infections, and
- Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcal (VRE) bloodstream infections
only if reported through the Centers for Disease Control and Prevention National Healthcare Safety Network (NHSN). The department will continue to accept data for central line insertion practices only if reported through NHSN.
These statutes require that the department use a risk adjustment process consistent with the methodology of NHSN prior to public posting of healthcare-associated infection data, which is to commence January 1, 2011. They further require that an infection shall be reported using NHSN definitions. These requirements can be met only if data is reported through NHSN.
CDPH strongly encourages hospital administrators to recognize the increased surveillance and data entry burden placed on those departments responsible for fulfilling these requirements. It is the hospital’s responsibility to assess and address staffing to accommodate these requirements while still maintaining infection prevention programs able to meet State and federal requirements for patient and personnel safety.
As detailed in All Facilities Letter (AFL) 08-10, dated April 15, 2008, in order to meet the reporting requirements of Health and Safety Code section 1288.8, each hospital must join the CDPH NHSN Group and additionally grant permission to CDPH to see required data elements. If the proper permissions are not granted, the necessary data will not be reported to the department as required, and your facility will not be in compliance with licensing requirements.
While using NHSN is labor-intensive, its use offers distinct advantages over aggregate reporting. Of most importance, the NHSN system includes data on individual patient demographics, location, and location unit type which contribute to appropriate risk adjustment. The system also ensures a higher level of data quality assurance through built-in logic and edit checks for data entry. NHSN has developed capacity to electronically upload data from commercial electronic infection surveillance systems. And, for those facilities that do not currently have an electronic data system, NHSN provides access to electronic facility-specific data on both the global and location-specific levels.
Per Health and Safety Code section 1288.55, commencing January 1, 2009 and using NHSN definitions, 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: and
- 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.
By January 1, 2011, the law requires the CDPH to post on its website the following:
- 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.
Commencing January 1, 2012, the law requires CDPH to post on its website information regarding the incidence rate of deep or organ space surgical site infections, orthopedic, cardiac, and gastrointestinal surgical procedures designated as clean and clean-contaminated, acquired at each health facility in California, including information on the number of inpatient days.
For any information reported publicly, the department must follow a risk adjustment process that is consistent with the NHSN, and use its definitions.
Central Line Associated Bloodstream Infections (CLABSI)
Facility-wide CLABSI data must now be reported through NHSN by location. NHSN recently added a risk adjustment method for CLABSI called the Standardized Infection Ratio (SIR). The department cannot apply the SIR unless that data is entered into NHSN by hospitals. The department will not provide an alternative method for reporting CLABSI after April 1, 2010 (start of the second quarter of 2010). Hospitals may enter data entered into NHSN for the preceding quarter, which would allow for a longer period for comparison of rates. Advantages to hospitals using NHSN to report CLABSI data are that patient-specific infections can be electronically linked to Central Line Insertion Practices (CLIP) process measures, rates benchmarked against national averages, and the standardized infection ratio applied.
Clostridium Difficile Infections (CDI)
Clostridium difficile surveillance is now required to be reported using the NHSN Multidrug Resistant Organism (MDRO) LabID (laboratory-identified) reporting module, Method C (facility-wide option). The definition used by NHSN in this module is intended to provide proxy measures of C. difficile infection and hospital acquisition, based on laboratory data and admission date. CDPH can only be assured that hospitals are using a uniform definition if all hospitals use the same process, the LabID Events module. This also represents the most reasonable workload for reporting hospitals. Electronic reporting of CDI data from commercial infection surveillance systems is expected to be available by the end of 2010. The department will not provide an alternative method for reporting CDI after April 1, 2010 (start of the second quarter of 2010); data entered into NHSN for the preceding quarter would allow for a longer period for comparison of rates. The link to the NHSN page with all instructions, education, and forms for use of the MDRO module including the training webcast is:
CDC - NHSN: Surveillance for C. difficile, MRSA, and other Drug-resistant Infections
MRSA and VRE Bloodstream Infections (BSI)
MRSA and VRE BSI events must now be reported through the MDRO LabID module facility wide (Method D; blood specimens only). Only bloodstream infections are required to be reported with the appropriate permissions. Hospitals using the MDRO module for reporting infections in addition to those required by California law may grant permission for all in order to simplify the permission process. CDPH will only access information required by law to be reported to the department. The department will not provide an alternative method for reporting MRSA and VRE BSI after April 1, 2010 (start of the second quarter of 2010).
Surgical Site Infections (SSI)
Only SSI data reported through NHSN can be used by CDPH to comply with the public reporting requirement commencing 2012. To risk adjust SSIs requires American Society of Anesthesiologists (ASA) score, duration of surgery, and wound classification. This is only feasible through the use of NHSN. The use of NHSN can additionally provide hospitals risk-adjusted data by surgeon. CDPH is aware of the reporting burden involved with this requirement. Electronic reporting of denominator data from hospital systems is currently available and can help alleviate the reporting burden. Instructions are on the NHSN website. Since public posting of SSI data by CDPH is not required until 2012, at this time it is requested that hospitals currently using NHSN for SSI surveillance voluntarily confer rights to CDPH to see this data.
Central Line Insertion Practices (CLIP)
CLIP surveillance data must be submitted through NHSN as required by statute. Submit the complete CLIP data set (all asterisked data fields) to NHSN as set forth by the CDC for all ICUs including adult, pediatric, and NICUs within your facility. Soon to be implemented changes to NHSN will reduce some CLIP data entry requirements. Collaboration with NHSN is underway to develop clinical documentation architecture to facilitate electronic capture of CLIP data and upload capability into NHSN.
For questions, the point of contact at CDPH is the Healthcare-Associated Infections Program at firstname.lastname@example.org or phone (510) 412-6060.
Original Signed by Kathleen Billingsley, R.N.
Kathleen Billingsley, R.N.
Attachment: Table of Reporting Requirements
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