This letter serves to notify California general acute care hospitals (GACHs) of revised California Department of Public Health (CDPH) guidance for reporting surgical site infections (SSI) as mandated under HSC Section 1288.55, and per the terms of the settlement reached in the recent legal action by California Hospital Association and Association for Professional Infection Control and Epidemiology, Inc.

This letter revises the guidance provided in AFL 11-32.

As previously required, commencing with surgeries performed on or after June 1, 2011, GACHs must report to CDPH all SSI in accordance with HSC Section 1288.55 (a) (3):

"Each health facility shall report quarterly to the department 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."

Pursuant to the statute, CDPH will only require each GACH to report their SSI related patient safety data on a quarterly basis (not monthly). Quarterly reports will be due 30 days after the end of the quarter, specifically:

CDPH will access reported SSI data through the Centers for Disease Control Prevention National Healthcare Safety Network (NHSN). GACH's will not be required to report or update NHSN's fields of data that are indicated as optional in NHSN's reporting protocols for the purposes of fulfilling CDPH's requirements.

More information regarding the NHSN protocols for reporting SSI, including the importation of hospital procedure data from electronic data files, may be found online at the Centers for Disease Control and Prevention website: (https://www.cdc.gov/nhsn/enrolled-facilities/index.html).  

Additional guidance and assistance is available through the CDHP Healthcare –Associated Infection (HAI) Liaison Program, via phone at (510) 412-6060 or email at infectioncontrol@cdph.ca.gov.

Sincerely,

Original signed by Pamela Dickfoss

Pamela Dickfoss
Assistant Deputy Director
Center for Health Care Quality

Attachment:
NHSN Operative ProceduresIdentified by CDPH as Consistentwith Meetingthe Requirements of Health and Safety Code Section 1288.55 for Reporting of Surgical Site Infections