This letter serves to notify general acute care hospitals (GACHs) of revised procedures for fulfilling the mandated healthcare associated infections (HAI) reporting required by HSC Sections 1288.55 and 1288.8. HAI data must be reported to the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN). For 2012 HAI reporting, hospitals must include all data intended for reporting to the California Department of Public Health (CDPH) in their NHSN Patient Safety Monthly Reporting Plan.
CDPH obtains HAI data for the mandated annual public reports by accessing data that hospitals report to NHSN related to the following:
- Clostridium difficile infection (CDI),
- central line associated bloodstream infection (CLABSI),
- central line insertion practices (CLIP),
- influenza vaccination,
- methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection (BSI),
- surgical site infection (SSI), and
- vancomycin-resistant enterococci (VRE) BSI.
Starting in 2012, CDPH will consider only the data in NHSN that hospitals have designated as "in-plan" data in each month’s Patient Safety Monthly Reporting Plan as fulfilling the mandate. The use of in-plan data is important for two reasons:
- NHSN’s automated data quality checks, which assure a basic level of data quality and completeness, are only performed on in-plan data.
- Only in-plan data are included in the national NHSN database and published HAI reports. Further, only in-plan data are shared by NHSN with the Centers for Medicare and Medicaid Services (CMS) to fulfill Hospital Inpatient Quality Reporting Program requirements.
HSC Section 1288.55 requires hospitals to report HAI quarterly, however NHSN’s reporting templates are only provided in a month by month format. In effect this means that while a Monthly Reporting Plan must be completed for each individual month, hospitals that complete the individual reports for multiple months on a quarterly basis are compliant with state law.
By default, the Monthly Reporting Plans are blank and require hospitals to designate which areas of HAI surveillance and reporting are being performed. Areas of surveillance that a hospital does not identify in any given month’s plan are considered "out-of-plan." Up until the 2011 HAI reports CDPH did not distinguish between "in-plan" and "out-of-plan" data reported to NHSN.
Hospitals are encouraged to avoid accidental miscategorization of data as out-of-plan for each area of surveillance mandated for public reporting to CDPH. Specifically,
- For CLABSI, hospitals are required to perform surveillance in and report on all hospital locations. Each inpatient location (e.g. critical care units, wards, and special care areas) must be included in each Monthly Reporting Plan. For months in which there were no central line days in an inpatient location, 0 line days must be entered in the monthly Summary data for the affected unit.
- For SSI reporting, hospitals that perform any of the 29 mandated procedure categories must indicate each procedure category performed in each Monthly Reporting Plan. Indicate SSI surveillance will be performed for surgical procedure categories performed on hospitalized inpatients (SSI "IN"). Patients undergoing each procedure must be monitored for SSI both when they are in the hospital (or re-admitted) and when they leave the hospital for a specified time period per NHSN SSI surveillance protocol. For months in which no surgeries are performed in a procedure category that has been included in the Monthly Reporting Plan, an NHSN Alert will be generated. On the NHSN Alerts tab labeled Missing Procedures, use the "No Procedures Performed" checkbox for that procedure category for the affected month(s).
- For CDI and MRSA- and VRE-BSI, surveillance and reporting are required facility-wide for all hospitalized inpatients; the surveillance location "FACWideIN" must be indicated in each Monthly Reporting Plan.
CDPH provides quarterly QA/QC Reports to hospitals that identify data out-of-plan. Hospitals are encouraged to review these reports carefully to determine if any data recorded as out-of-plan are unintentional, and correct any errors in the affected Monthly Reporting Plan.
We appreciate your efforts to ensure hospital infection reports are as accurate and complete as possible. We hope this change in procedure will also increase the utility of these reports to you.
Guidance specific to California hospitals for completing the Monthly Reporting Plan in NHSN is available on the CDPH HAI Program web page under Monthly Plan Set-up at:
Health Care-associated Infections (HAI) Program
Additional guidance and assistance is available through the CDPH HAI Program, via our website (http://www.cdph.ca.gov/hai), phone at (510) 412-6060, or email at firstname.lastname@example.org
Original signed by Debby Rogers
Debby Rogers, RN, MS, FAEN