Mandatory Reporting of Healthcare Associated Infections in Texas . Jennifer Steinhausen, MPH, CIC Healthcare Associated Infections Clinical Specialist 512.458.7111 ext. 3773 [email protected]. Presentation Overview. Identify the HAI Problem HAI Legislation - PowerPoint PPT Presentation
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Mandatory Reporting of Mandatory Reporting of Healthcare Associated Healthcare Associated
Infections in Texas Infections in Texas
Jennifer Steinhausen, MPH, CICHealthcare Associated Infections
Chapter 98 Requirements Establish 18 member Advisory Panel Establish Healthcare Associated Infections (HAI) reporting system Compile and make available to the public a data summary, by
health care facility, at least annually Allow health care facilities to submit concise written comments Provide education and training Ensure confidentiality & legal protections Verify the accuracy and completeness of the data reported Receiving reports from the public Enforcement
• Central line-associated bloodstream infections in the following special care settings: adult, pediatric and/or adolescent ICUs & CCUs, NICUs (Level II/III & Level III Nurseries)
• Surgical site infectionso PEDS/ADOLESCENT HOSPITALS: Cardiac procedures, spinal
surgery with instrumentation, and ventriculoperitoneal shunt procedures
o ALL OTHER HOSPITALS: Colon surgeries, hip & knee arthroplasties, abdominal & vaginal hysterectomies, vascular procedures, and coronary artery bypass grafts
Facilities shall report HAI data on patients who are admitted to the facility for inpatient treatment of a surgical site infections associated with a reportable procedure within 30 calendar days of the procedure or within 1 year of the procedure if the procedure involved an implant.
Facilities will be required to report surgical site infections back to the originating facility, if identified.
Originating facility will be required to report the SSI, using NHSN.
Alternative for surgical site infections• A facility that does not perform a least a monthly
average of 50 of any combination of the listed reportable procedures, shall report the surgical site infections relating to the three (3) most frequently performed NHSN procedures.
National Healthcare Safety Network (NHSN) developed and sustained by the Centers for Disease Control & Prevention is the anticipated designated reporting system.
Advantages of NHSN Training is very thorough and explains, in detail, the
“rules” for complying with NHSN surveillance protocols.
National comparative data is available when reporting infection rates
Surgical denominator data can be uploaded all at once rather than individually entered (IF the user has an electronic surgical record & all required data elements are present)
Vendors have developed compatible software for uploading facility data
Enroll your facility in NHSN, using CMS #• May need to request Registration ID from NHSN
Establish facility contact for TEXAS: Primary and secondary contacts who coordinate communications related to data submissions, verifications and approval of data summary to NHSN and DSHS. • Encourage use several contacts and a general facility