§ 2819 — Hospital acquired infection reporting

§ 2819. Hospital acquired infection reporting. 1. For the purposes of\nthis section, "hospital acquired infection" shall mean any localized or\nsystemic patient condition that:\n (a) resulted from the presence of an infectious agent or agents, or\nits toxin or toxins as determined by clinical examination or by\nlaboratory testing; and\n (b) was not found to be present or incubating at the time of admission\nunless the infection was related to a previous admission.\n 2. (a) Each general hospital shall maintain a program capable of\nidentifying and tracking hospital acquired infections for the purpose of\npublic reporting under this section and quality improvement.\n (b) Such programs shall have the capacity to identify the following\nelements: the specific infectious agents or toxins and site of each\ninfection; the clinical department or unit within the facility where the\npatient first became infected; and the patient's diagnoses and any\nrelevant specific surgical, medical or diagnostic procedure performed\nduring the current admission.\n (c) The department shall establish guidelines, definitions, criteria,\nstandards and coding for hospital identification, tracking and reporting\nof hospital acquired infections which shall be consistent with the\nrecommendations of recognized centers of expertise in the identification\nand prevention of hospital acquired infections including, but not\nlimited to the National Health Care Safety Network of the Centers for\nDisease Control and Prevention or its successor. The department shall\nsolicit and consider public comment prior to such establishment.\n (d) Hospitals shall be initially required to identify, track and\nreport hospital acquired infections that occur in critical care units to\ninclude surgical wound infections and central line related bloodstream\ninfections.\n (e) For hospital acquired infections for which the department requires\ntracking and reporting as permitted in this section, hospitals shall be\nrequired to report a suspected or confirmed hospital-acquired infection\nassociated with another hospital to the originating hospital.\nDocumentation of reporting should be maintained for a minimum of six\nyears.\n (f) Subsequent to the initial requirements identified in paragraph (d)\nof this subdivision the department may, from time to time, require the\ntracking and reporting of other types of hospital acquired infections\n(for example, ventilator - associated pneumonias) that occur in\nhospitals in consultation with technical advisors who are regionally or\nnationally-recognized experts in the prevention, identification and\ncontrol of hospital acquired infection and the public reporting of\nperformance data.\n 3. Each hospital shall regularly report to the department the hospital\ninfection data it has collected. The department shall establish data\ncollection and analytical methodologies that meet accepted standards for\nvalidity and reliability. The frequency of reporting shall be monthly,\nand reports shall be submitted not more than sixty days after the close\nof the reporting period.\n 4. The commissioner shall establish a state-wide database of all\nreported hospital acquired infection information for the purpose of\nsupporting quality improvement and infection control activities in\nhospitals. The database shall be organized so that consumers, hospitals,\nhealthcare professionals, purchasers and payers may compare individual\nhospital experience with that of other individual hospitals as well as\nregional and state-wide averages and, where available, national data.\n 5. (a) Subject to paragraph (c) of this subdivision, on or before\nSeptember first of each year the commissioner shall submit a report to\nthe governor and the legislature, which shall simultaneously be\npublished in its entirety on the department's web site, that includes,\nbut is not limited to, hospital acquired infection rates adjusted for\nthe potential differences in risk factors for each reporting hospital,\nan analysis of trends in the prevention and control of hospital acquired\ninfection rates in hospitals across the state, regional and, if\navailable, national comparisons for the purpose of comparing individual\nhospital performance, and a narrative describing lessons for safety and\nquality improvement that can be learned from leadership hospitals and\nprograms.\n (b) The commissioner shall consult with technical advisors who have\nregionally or nationally acknowledged expertise in the prevention and\ncontrol of hospital acquired infection and infectious disease in order\nto develop the adjustment for potential differences in risk factors to\nbe used for public reporting.\n (c)(i) No later than July first, two thousand six, the department\nshall establish a hospital acquired infection reporting system capable\nof receiving electronically transmitted reports from hospitals.\nHospitals shall begin to submit such reports as directed by the\ncommissioner but in no case later than January first, two thousand\nseven.\n (ii) The first year of data submission under this section shall be\nconsidered the "pilot phase" of the statewide hospital acquired\ninfection reporting system. The purpose of the pilot phase is to ensure,\nby various means, including any audit process referred to in subdivision\nseven of this section, the completeness and accuracy of hospital\nacquired infection reporting by hospitals. For data reported during the\npilot phase, hospital identifiers shall be encrypted by the department\nin any and all public databases and reports. The department shall\nprovide each hospital with an encryption key for that hospital only to\npermit access to its own performance data for internal quality\nimprovement purposes.\n (iii) No later than one hundred eighty days after the conclusion of\nthe pilot phase, the department shall issue a report to hospitals\nassessing the overall accuracy of the data submitted in the pilot phase\nand provide guidance for improving the accuracy of hospital acquired\ninfection reporting. The department shall issue a report to the governor\nand the legislature assessing the overall completeness and accuracy of\nthe data submitted by hospitals during the pilot phase and make\nrecommendations for the improvement or modification of hospital acquired\ninfection data reporting based on the pilot phase as well as share\nlessons learned in prevention of hospital acquired infections. No\nhospital identifiable data shall be included in the pilot phase report,\nbut aggregate or otherwise de-identified data may be included.\n (iv) After the pilot phase is completed, all data submitted under this\nsection and compiled in the statewide hospital acquired infection\ndatabase established herein and all public reports derived therefrom\nshall include hospital identifiers.\n 6. Subject to subdivision five of this section, a summary table, in a\nformat designed to be easily understood by lay consumers, that includes\nindividual facility hospital acquired infection rates adjusted for\npotential differences in risk factors and comparisons with regional\nand/or state averages shall be developed and posted on the department's\nweb site. The commissioner shall consult with consumer and patient\nadvocates and representatives of reporting facilities for the purpose of\nensuring that such summary table report format is easily understandable\nby the public, and clearly and accurately portrays comparative hospital\nperformance in the prevention and control of hospital acquired\ninfections.\n 7. To assure the accuracy of the self-reported hospital acquired\ninfection data and to assure that public reporting fairly reflects what\nactually is occurring in each hospital, the department shall develop and\nimplement an audit process.\n 8. For the purpose of ensuring that hospitals have the resources\nneeded for ongoing staff education and training in hospital acquired\ninfection prevention and control, the department may make such grants to\nhospitals within amounts appropriated therefor.\n 9. Individual patient identifying information reported to the\ndepartment under this section shall be subject to paragraph (j) of\nsubdivision one of section two hundred six of this chapter. Regulations\nunder this section shall include standards to assure the protection of\npatient privacy in data collected and released under this section and\nstandards for the publication and release of data reported under this\nsection.\n