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Oregon Bulletin

September 1, 2011

 

Oregon Health Authority,
Office for Oregon Health Policy and Research
Chapter 409

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.

2.) Copyright 2011 Oregon Secretary of State: Terms and Conditions of Use

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