Oregon Bulletin
Rule Caption: Amendments to the Health Care Acquired Infection Reporting and Public
Disclosure Rules.
Adm. Order No.: OHP 4-2011(Temp)
Filed with Sec. of State: 7-28-2011
Certified to be Effective: 8-1-11 thru 1-25-12
Notice Publication Date:
Rules Amended: 409-023-0000, 409-023-0010, 409-023-0012, 409-023-0015
Subject: The Oregon Health Authority, Office for Oregon
Health Policy and Research in implementing amendments to the health care
acquired infection (HAI) reporting. The rules implement health care acquired
infection (HAI) reporting, public disclosure, and other applicable mandates of
ORS 442.420 and Ch. 838 section 1-6 and 12, which was enacted by the 74th
Legislative Assembly. The proposed rules are intended to fulfill the mandates
by prescribing the HAIs that are reported , how they are reported, the health
care facilities that report them, and how they are publicly disclosed.
These
temporary rules are available on the OHPR website: http://www.oregon.gov/OHA/OHPR/rulemaking/index.shtml.
Rules Coordinator: Zarie Haverkate—(503) 373-1574
409-023-0000
Definitions
The
following definitions apply to OAR 409-023-0000 to 409-023-0035:
(1) “Administrator”
means the administrator of the Office for Oregon Health Policy and Research as
defined in ORS 442.011, or the administrator’s designee.
(2) “ASC”
means ambulatory surgical center as defined in ORS 442.015(3) and that is
licensed pursuant to ORS 441.015.
(3) “CBGB”
means coronary bypass graft surgery with both chest and graft incisions, as
defined in the NHSN Manual.
(4) “CDC”
mean the federal Centers for Disease Control and Prevention.
(5) “CDI”
means Clostridium difficile infection as defined in the NHSN Manual.
(6) “CLABSI”
means central line associated bloodstream infection as defined in the NHSN
Manual.
(7) “CMS”
mean the federal Centers for Medicare and Medicaid Services.
(8) “COLO”
means colon procedures as defined in the NHSN Manual.
(9) “Committee”
means the Health Care Acquired Infections Advisory Committee as defined in
notes following ORS 442.851 relating to Health Care Acquired Infections.
(10) “Dialysis
facility” means outpatient renal dialysis facility as defined in ORS
442.015(20).
(11) “Follow-up”
means post-discharge surveillance intended to detect CBGB, COLO, HPRO, HYST,
KRPO, and LAM surgical site infection (SSI) cases occurring after a procedure.
(12) “HAI”
means health care acquired infection as defined in notes following ORS 442.851
relating to Health Care Acquired Infections.
(13) “Health
care facility” means a facility as defined in ORS 442.015(10).
(14) “Hospital”
means a facility as defined in ORS 442.015(13) and that is licensed pursuant to
ORS 441.015.
(15) “Hospital
Inpatient Quality Reporting Program” means the initiative administered by CMS
and formerly referred to as RHQDAPU.
(16) “HPRO”
means hip prosthesis procedure as defined in the NHSN Manual.
(17) “HYST”
means abdominal hysterectomy procedure as defined in the NHSN Manual.
(18) “ICU”
means an intensive care unit as defined in the NHSN Manual.
(19) “KPRO”
means knee prosthesis procedure as defined in the NHSN Manual.
(20) “Lab
ID” means laboratory-identified event as defined in the NHSN Manual.
(21) “LAM”
means laminectomy procedure as defined in the NHSN Manual.
(22) “LTC
facility” means long term care facility as defined in ORS 442.015(16).
(23) “MDS”
mean the Centers for Medicare and Medicaid Services’ minimum data set nursing
home resident assessment and screening tool, version 2.0 or its successor,
including but not limited to manuals, forms, software, and databases.
(24) “Medical
ICU” means a non-specialty intensive care unit that serves 80% or more adult
medical patients.
(25) “Medical/Surgical
ICU” means a non-specialty intensive care unit that serves less than 80% of
either adult medical, adult surgical, or specialty patients.
(26) “NHSN”
means the CDC’s National Healthcare Safety Network.
(27) “NHSN
Inpatient” means a patient whose date of admission to the healthcare facility
and the date of discharge are different days as defined in the NHSN Manual.
(28) “NHSN
Manual” means the Patient Safety Component Protocol of the NHSN manual, version
March 2009 or its successor, as amended, revised, and updated from time to
time.
(29) “NICU”
means a specialty intensive care unit that cares for neonatal patients.
(30) “Office”
means the Office for Oregon Health Policy and Research.
(31) “Oregon
HAI group” means the NHSN group administered by the Office.
(32) “Overall-facility
wide” means data is collected for the entire facility as defined in the NHSN
Manual.
(33) “Patient
information” means individually identifiable health information as defined in
ORS 179.505(c).
(34) “Person”
has the meaning as defined in ORS 442.015(21).
(35) “Procedure”
means an NHSN operative procedure as defined in the NHSN Manual.
(36) “Provider”
means health care services provider as defined in ORS 179.505(b).
(37) “QIO”
means the quality improvement organization designated by CMS for Oregon.
(38) “RHQDAPU”
means the Reporting Hospital Quality Data for Annual Payment Update initiative
administered by CMS.
(39) “SCIP”
means the Surgical Care Improvement Project.
(40) “SCIP-Inf-1”
means the HAI process measure published by SCIP defined as prophylactic
antibiotic received within one hour prior to surgical incision.
(41) “SCIP-Inf-2”
means the HAI process measure published by SCIP defined as prophylactic
antibiotic selection for surgical patients.
(42) “SCIP-Inf-3”
means the HAI process measure published by SCIP defined as prophylactic
antibiotics discontinued within 24 hours after surgery end time (48 hours for
cardiac patients).
(43) “SCIP-Inf-4”
means the HAI process measure published by SCIP defined as cardiac surgery
patients with controlled 6 a.m. postoperative serum glucose.
(44) “SCIP-Inf-6”
means the HAI process measure published by SCIP defined as surgery patients
with appropriate hair removal.
(45) “SCIP-Inf-9”
means urinary catheter removed on postoperative day 1 or postoperative day 2
with day of surgery being day zero.
(46) “SCIP-Inf-10”
means the HAI process measure published by SCIP defined as surgery patients
with perioperative temperature management.
(47) “Specialty
ICU” mean an intensive care unit with at least 80% of adults are specialty
patients including but not limited to oncology, trauma, and neurology.
(48) “SSI”
means a surgical site infection event as defined in the Patient Safety
Component Protocol of the NHSN manual, version January 2008.
(49) “Staff”
means any employee of a health care facility or any person contracted to work
within a health care facility.
(50) “State
agency” shall have the meaning as defined in ORS 192.410(5).
(51) “Surgical
ICU” means a non-specialty intensive care unit that serves 80% or more adult
surgical patients.
Stat.
Auth.: ORS 442.420 &OL 2007, Ch. 838 § 1-6 & 12
Stats.
Implemented: ORS 179.505, 192.410, 192.496, 192.502, 441.015, 442.011, 442.400,
442.405, & OL 2007, Ch. 838 § 1-6 & 12
Hist.: OHP
1-2008, f. & cert. ef. 7-1-08; OHP 1-2009, f. & cert. ef. 7-1-09; OHP
4-2010, f. 6-30-10, cert. ef. 7-1-10; OHP 4-2011(Temp), f. 7-28-11, cert. ef.
8-1-11 thru 1-25-12
409-023-0010
HAI
Reporting for Hospitals
(1)
Hospitals shall begin collecting data for HAI outcome and process measures for
the HAI reporting program for services provided on and after January 1, 2009,
except:
(a) NICU
shall begin collecting data for HAI outcome and process measures for the HAI
reporting program for services provided on and after January 1, 2010.
(b)
Hospitals shall report the SCIP-Inf-6 process measure for the HAI reporting
program for services provided on and after January 1, 2010.
(c)
Hospitals shall report the SCIP-4-Inf and SCIP-10-Inf process measures for
services provided on and after January 1, 2011.
(d)
Hospitals shall report the NHSN Inpatient COLO, HPRO, HYST, and LAM outcome
measures for services provided on and after January 1, 2011.
(e)
Hospitals shall report facility-wide NHSN Inpatient CDI data using the Lab-ID
method for CDI in NHSN for services provided on or after January 1, 2012.
(f)
Hospitals shall report SCIP-Inf-9 performance measures for services provided on
or after January 1, 2012.
(2)
Reportable HAI outcome measures are:
(a) SSIs
for NHSN Inpatient CBGB, COLO, HPRO, HYST, KPRO, and LAM procedures.
(b) CLABSI
in medical ICUs, surgical ICUs, and combined medical/surgical ICUs.
(c) NHSN
Inpatient CDI facility-wide.
(3) The
infection control professional (ICP), as defined by the facility, shall
actively seek out infections defined in sections (2)(a) and (b) of this rule
during a patient’s stay by screening a variety of data that may include but is
not limited to:
(a)
Laboratory;
(b)
Pharmacy;
(c)
Admission;
(d)
Discharge;
(e)
Transfer;
(f)
Radiology;
(g)
Imaging;
(h)
Pathology; and
(i) Patient
charts, including history and physical notes, nurses and physicians notes, and
temperature charts.
(4) The ICP
shall use follow-up surveillance methods to detect SSIs for procedures defined
in section (2)(a) of this rule using at least one of the following:
(a) Direct
examination of patients’ wounds during follow-up visits to either surgery
clinics or physicians’ offices;
(b) Review
of medical records, subsequent hospitalization records, or surgery clinic
records;
(c) Surgeon
surveys by mail or telephone;
(d) Patient
surveys by mail or telephone; or
(e) Other
facility surveys by mail or telephone.
(5) Others
employed by the facility may be trained to screen data sources for these
infections, but the ICP must determine that the infection meets the criteria
established by these rules.
(6) The HAI
reporting system for HAI outcome measures shall be NHSN. Each Oregon hospital
shall comply with processes and methods prescribed by CDC for NHSN data
submission. This includes but is not limited to definitions, data collection,
data reporting, and administrative and training requirements. Each Oregon
hospital shall:
(a) Join
the Oregon HAI group in NHSN.
(b)
Authorize disclosure of NHSN data to the Office as necessary for compliance of
these rules including but not limited to summary data and denominator data for
all SSIs, the annual hospital survey and data analysis components for all SSIs,
and summary data and denominator data for all medical ICUs, surgical ICUs, and
combined medical/surgical ICUs.
(c) Report
its data for outcome measures to NHSN no later than 30 days after the end of
the collection month. The NHSN field “Discharge Date” is mandatory for all
outcome measures.
(7) Each
hospital shall report on a quarterly basis according to 409-023-0010(1) the
following HAI process measures:
(a)
SCIP-Inf-1;
(b)
SCIP-Inf-2;
(c)
SCIP-Inf-3;
(d)
SCIP-Inf-4;
(e)
SCIP-Inf-6;
(f)
SCIP-Inf-9; and
(g)
SCIP-Inf-10.
(8) The
reporting system for HAI process measures shall be the Hospital Inpatient
Quality Reporting Program, formerly referred to as the RHQDAPU program as
configured on July 1, 2008. Each Oregon hospital shall:
(a) Comply
with reporting processes and methods prescribed by CMS for the RHQDAPU program.
This includes but is not limited to definitions, data collection, data
reporting, and administrative and training requirements; and
(b) Report
data quarterly for HAI process measures. Data must be submitted to and
successfully accepted into the QIO clinical warehouse no later than 11:59 p.m.
central time, on the 15th calendar day, four months after the end of the
quarter.
(9) For
NICUs, the HAI reporting system for outcome measures shall be NHSN. Each Oregon
hospital with a NICU shall comply with processes and methods prescribed by NHSN
for the CLABSI reporting including but not limited to definitions, data
collection, data submission, and administrative and training requirements. Each
Oregon hospital shall:
(a)
Authorize disclosure of NHSN data to the Office as necessary for compliance
with these rules, including but not limited to facility identifiers.
(b) Submit
NICU data to be NHSN according to the NHSN Manual.
(10) Each
hospital shall complete an annual survey, as defined by the Office, of
influenza vaccination of staff and submit the completed survey to the Office.
The survey shall include but not be limited to questions regarding influenza
vaccine coverage of facility staff:
(a) Number
of staff with a documented influenza vaccination during the previous influenza
season.
(b) Number
of staff with a documented medical contraindication to influenza vaccination
during the previous influenza season.
(c) Number
of staff with a documented refusal of influenza vaccination during the previous
influenza season.
(d)
Facility assessment of influenza vaccine coverage of facility staff during the
previous influenza season and plans to improve vaccine coverage of facility
staff during the upcoming influenza season.
Stat.
Auth.: ORS 442.420 &OL 2007, Ch. 838 § 1-6 & 12
Stats.
Implemented: ORS 179.505, 192.410, 192.496, 192.502, 441.015, 442.011, 442.400,
442.405, & OL 2007, Ch. 838 § 1-6 & 12
Hist.: OHP
1-2008, f. & cert. ef. 7-1-08; OHP 1-2009, f. & cert. ef. 7-1-09; OHP
4-2010, f. 6-30-10, cert. ef. 7-1-10; OHP 4-2011(Temp), f. 7-28-11, cert. ef.
8-1-11 thru 1-25-12
409-023-0012
HAI
Reporting for Ambulatory Surgery Centers
(1) Each
ASC shall complete a survey of evidenced-based elements of patient safety
performance as defined by the Office.
(2) The
survey shall be submitted annually by each ASC to the Office no later than 30
days after receipt of survey.
(3)
Starting with the 2011-2012 influenza season, each ASC shall complete an annual
survey, as defined by the Office, of influenza vaccination of staff and submit
the completed survey to the Office. The survey shall include but not be limited
to questions regarding influenza vaccine coverage of facility staff:
(a) Number
of staff with a documented influenza vaccination during the previous influenza
season.
(b) Number
of staff with a documented medical contraindication to influenza vaccination
during the previous influenza season.
(c) Number
of staff with a documented refusal of influenza vaccination during the previous
influenza season.
(d)
Facility assessment of influenza vaccine coverage of facility staff during the
previous influenza season and plans to improve vaccine coverage of facility
staff during the upcoming influenza season.
Stat.
Auth.: ORS 442.420(3)(d) & OL 2007, Ch. 838 § 1-6 and 12
Stats.
Implemented: ORS 442.405 & OL 2007, Ch. 838 § 1-6 and 12
Hist.: OHP
1-2009, f. & cert. ef. 7-1-09; OHP 4-2011(Temp), f. 7-28-11, cert. ef.
8-1-11 thru 1-25-12
409-023-0015
HAI
Reporting for Other Health Care Facilities
Dialysis
facilities shall begin collecting data for the HAI reporting program for
services provided on and after January 1, 2013 pursuant to rules amended no
later than July 1, 2012.
Stat.
Auth.: ORS 442.420(3)(d) & OL 2007, Ch. 838 § 1-6 and 12
Stats.
Implemented: ORS 442.405 & OL 2007, Ch. 838 § 1-6 and 12
Hist.: OHP
1-2008, f. & cert. ef. 7-1-08; OHP 1-2009, f. & cert. ef. 7-1-09; OHP
4-2011(Temp), f. 7-28-11, cert. ef. 8-1-11 thru 1-25-12
Notes
1.) This online version of the OREGON BULLETIN is provided for convenience of reference and enhanced access. The official, record copy of this publication is contained in the original Administrative Orders and Rulemaking Notices filed with the Secretary of State, Archives Division. Discrepancies, if any, are satisfied in favor of the original versions. Use the OAR Revision Cumulative Index found in the Oregon Bulletin to access a numerical list of rulemaking actions after November 15, 2010.
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