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EDMUND G. BROWN JR.
Governor

State of California—Health and Human Services Agency
California Department of Public Health


AFL 21-18
June 8, 2021


TO:
General Acute Care Hospitals (GACH)

SUBJECT:
GACH Reporting Requirements of Specified Health-Associated Infections (HAI)  
(This AFL supersedes AFLs 07-37, 08-10, and 13-03)

AUTHORITY:     Health and Safety Code sections 1288.5 and 1288.8


All Facilities Letter (AFL) Summary

  • This AFL informs GACHs of the discontinuation of the following process measure reporting requirements pursuant HSC section 1288.8:
    • Central Line Insertion Practices (CLIP) reporting requirements to the California Department of Public Health (CDPH) via the National Healthcare Safety Network (NHSN)
    • Surgical Antimicrobial Prophylaxis Measures reporting
  • GACHs must continue to report the following to CDPH through the NHSN:
    • Central line associated bloodstream infection (CLABSI)
    • Clostridium difficile infection (CDI)
    • Influenza vaccination of healthcare personnel (HCP)
    • Methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection (BSI)
    • Surgical site infection (SSI)
    • Vancomycin-resistant enterococci (VRE) BSI

Background

Health and Safety Code 1288.8 requires that each GACH report to CDPH on infection prevention process measures that have been recommended by the Centers for Disease Control and Prevention (CDC) Healthcare Infection Control Practices Advisory Committee (HICPAC). Initially, these process measures included the CDC guidelines for CLIP and surgical antimicrobial prophylaxis. Health and Safety Code 1288.5 provides that the Healthcare Associated Infection Advisory Committee (HAI-AC) makes "recommendations on the use of national guidelines and the public reporting of process measures for preventing the spread of HAI that are reported to the department pursuant to subdivision (b) of Section 1288.8. Based on the HAI-AC recommendations CDPH has determined these process measures can be discontinued. This AFL provides updated guidance for mandated HAI reporting to CDPH via the NHSN.

HAI Reporting Requirements

Per Health and Safety Code section 1288.55, hospitals must report the following to CDPH via the NHSN:

  • Central line associated bloodstream infection (CLABSI)
  • Clostridium difficile infection (CDI)
  • Influenza vaccination of healthcare personnel (HCP)
  • Methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection (BSI)
  • Surgical site infection (SSI)
  • Vancomycin-resistant enterococci (VRE) BSI

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. HSC section 1288.55 requires hospitals to report HAI quarterly; however, NHSN's reporting templates are only provided in a month by month format. 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.

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.

Discontinuation of CLIP Reporting

The CLIP reporting process was designed to ensure GACHs were following the best patient safety practices and protocols to prevent central line-associated bloodstream infections (CLABSI). Between 2012-2019, statewide CLIP adherence rates have been 97-98 percent annually. On December 3, 2020, the HAI Advisory Committee recommended to discontinue GACH CLIP reporting requirements to CDPH via the NHSN. The HAI Advisory Committee determined that the elements included in CLIP have become the standard of care, and the time and resources required to report CLIP data into NHSN can be redirected to other activities, such as monitoring adherence to central line care and maintenance practices that support CLABSI prevention.

GACHs should continue to adhere to CLIP for each central line insertion, and review adherence to CLIP checklist elements when CLABSI occur. CDPH continues to require GACHs to perform surveillance and report CLABSI via NHSN. CDPH also publishes data annually to enable monitoring the CLABSI prevention progress of each GACH over time (pursuant to HSC 1288.55). 

Discontinuation of Surgical Antimicrobial Prophylaxis Measures

Due to high adherence rates of more than 95 percent over consecutive years, CMS and the Joint Commission retired the Surgical Care Improvement Project in 2014, including the surgical antimicrobial prophylaxis measures. CDPH discontinued publicly posting GACH surgical prophylaxis data when no longer available. CDPH continues to require surveillance and reporting of SSI for 28 procedure types and publishes annual SSI data pursuant to HSC 1288.55.  

CDPH and the HAI Advisory Committee understand the importance of ensuring the health and safety of all Californians in the hospital environment. CDPH will continue to promote quality healthcare and support compliance with HAI reporting requirements as recommended for public reporting by CDC and HICPAC.

If you have questions regarding this AFL, please contact CDPH Healthcare-Associated Infections Program via email at HAIProgram@cdph.ca.gov.

 

Sincerely,

Original signed by Cassie Dunham

Cassie Dunham

Acting Deputy Director


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