Healthcare-Associated Infections Reporting Requirements
Reporting Requirements for 2018
To fulfill DPH HAI reporting requirements, facilities must use the National Healthcare Safety Network (NHSN), a free of charge, web-based surveillance system established and maintained by the Centers for Disease Control and Prevention (CDC). Information about NHSN and enrollment instructions for facilities new to this reporting are available here: http://www.cdc.gov/nhsn/.
Connecticut HAI reporting requirements mirror those established by the federal Centers for Medicaid and Medicare Services (CMS) for facilities participating in CMS quality improvement and reporting programs. The following measures are mandated to be reported through the end of calendar year 2018.
Acute care hospitals:
- Central line-associated bloodstream infections (CLABSI) in all adult, pediatric, and neonatal intensive care units (ICU) as well as in all adult and pediatric medical, surgical, and medical/surgical wards;
- Catheter-associated urinary tract infections (CAUTI) in all adult and pediatric ICU as well as in all adult and pediatric medical, surgical, and medical/surgical wards;
- Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia identified using laboratory testing methods (LabID Events) in all inpatient locations;
- Clostridium difficile infection (CDI) LabID Events in all inpatient locations;
- Surgical site infections (SSI) following colon surgical procedures; and
- SSI following abdominal hysterectomies.
Long-term acute care hospitals:
- CLABSI in all bedded inpatient care locations;
- CAUTI in all bedded inpatient care locations;
- MRSA bacteremia LabID Events in all inpatient locations;
- CDI LabID Events in all inpatient locations; and
- Ventilator-associated events (VAE) in all adult inpatient care locations (intensive care, ward).
Inpatient rehabilitation facilities:
- CAUTI in all bedded inpatient care locations;
- MRSA bacteremia LabID Events in all inpatient locations; and
- CDI LabID Events in all inpatient locations.
Outpatient hemodialysis facilities:
- Dialysis events, including positive blood cultures, intravenous antimicrobial starts, and signs of vascular access infection.
Although the reporting of these measures may align with those of CMS or other organizations, reporting to federal agencies or accreditation boards does not fulfill the separate DPH reporting requirements. DPH reporting requirements are pursuant to Connecticut state law and must be carried out in addition to any other reporting via NHSN. In order to report HAI data to DPH, facilities must confer rights to the appropriate DPH group(s) within the NHSN application. Three NHSN groups have been established for facilities currently required to report HAI measures to DPH:
- CT-DPH (NHSN group ID 12666): Acute care hospitals
- CT-DPH LTACH/IRF (NHSN group ID 31849): Long-term acute care hospitals and inpatient rehabilitation facilities
- CT-DPH Dialysis (NHSN group ID 34853): Outpatient hemodialysis facilities
Facilities are required to collect and report these data into the surveillance system in accordance with specific definitions, and protocols established by NHSN, which include the requirement that data be entered within 30 days following the month reported on. Failure to follow these instructions is a violation of the NHSN Rules of Behavior, which all users agree to comply with upon enrollment. Resources for facilities enrolled in NHSN, including training, surveillance protocols, forms, support materials, analysis resources, and frequently asked questions are available online at http://www.cdc.gov/nhsn/enrolled-facilities/index.html. Training is required for those new to the NHSN reporting system; at a minimum, new users should read all protocols, complete all self-guided trainings, and be familiar with all forms that are relevant to the measures their facility is responsible for reporting to DPH. Because protocols may be updated annually, continuing users are expected to stay abreast of these changes by re-reading protocols and re-training where necessary.
Facilities may choose to use NHSN for additional activities beyond the scope of DPH’s HAI reporting requirements, including quality assurance, quality improvement, and prevention activities; this is encouraged but not required.
Note: Reporting of the healthcare personnel (HCP) influenza vaccination measure is not required by DPH at this time. Healthcare facilities currently using NHSN to report this measure are asked to voluntarily confer rights to DPH.
These instructions are effective through the end of calendar year 2018. It is expected that DPH reporting requirements for HAI will continue to expand, mirroring CMS requirements, in future years; DPH may establish additional NHSN groups or reorganize its existing groups commensurate with these expansions, if necessary. Mandatory HAI reporting deadlines in Connecticut also align with the CMS quality reporting deadlines. NHSN reports are due to both CMS and DPH according to the following schedule: http://www.cdc.gov/nhsn/pdfs/cms/cms-reporting-requirements-deadlines.pdf.
To contact the Connecticut DPH HAI Program with questions regarding this guidance, see: http://www.portal.ct.gov/DPH/Infectious-Diseases/HAI/Healthcare-Associated-Infections---Contact-Us.
To contact the Healthcare Associated Infections Program, please call 860-509-7995.