Current through Register Vol. 42, No. 11, August 30, 2024
(1) Healthcare facilities shall begin
collecting HAI data using NHSN to report to ADPH no later than January 1, 2011.
Healthcare facilities may begin collecting HAI data to report to ADPH using
NHSN prior to January 1, 2011. Data reported prior to January 1, 2011 will be
considered test data and will not be publicly reported.
(2) HAI data shall be reported to ADPH from
the following categories:
(a) Central
Line-Associated Bloodstream Infections (CLABSI) from the following critical
care units within a healthcare facility:
1.
Adult Critical Care Units
2.
Pediatric Critical Care Units
3.
Neonatal Critical Care Units
(b) Surgical Site Infections (SSI) from the
following procedures:
1. Colon
2. Hysterectomy - abdominal
(c) Catheter-Associated Urinary
Tract Infections (CAUTI) from the following patient care locations within a
healthcare facility:
1. General Medical
Wards
2. General Surgical
Wards
3. General Medical/Surgical
Wards
4. Adult Critical Care
Units
5. Pediatric Critical Care
Units
6. Healthcare facilities that
cannot comply with reporting CAUTIs from General Medical, General Surgical, and
General Medical/Surgical Wards shall report CAUTIs from Mixed Acuity and Mixed
Age, Mixed Acuity Wards.
(3) The Advisory Council and ADPH shall
review and make recommendations for regulatory modifications of HAI reporting
categories annually.
(4) Healthcare
facilities shall perform the following NHSN administrative responsibilities no
later than January 1, 2011.
(a) Assign an
NHSN Facility Administrator and primary HAI contacts.
(b) Submit contact information to ADPH
including the healthcare facility name, and names, email addresses, and phone
numbers of the NHSN Facility Administrator and primary HAI contacts.
(c) Notify ADPH in writing of changes in
healthcare facility staff assigned as NHSN Facility Administrator and primary
HAI contacts no later than 30 days after the change occurs.
(d) Ensure appropriate personnel, including
healthcare facility individuals with HAI surveillance program oversight
responsibilities and other facility personnel responsible for entering data
into NHSN, complete the initial CDC NHSN training modules and any subsequent
updates.
(e) Maintain a list of
NHSN users and their initial and subsequent CDC NHSN training dates, and submit
this information to ADPH by January 31 of each calendar year.
(f) Distribute the appropriate NHSN
instruction manuals, training materials, data collection forms, and methods for
data entry submission to appropriate staff.
(g) Join the ADPH NHSN group and report
mandatory HAI data to ADPH.
(h)
Follow the CDC NHSN definitions and guidelines for reporting HAI data as
referenced in The National Healthcare Safety Network (NHSN) Manual:
"Patient Safety Component Protocol", CDC, Atlanta, GA, March 2009,
which is hereto adopted by reference, including but not limited to definitions,
key terms, location codes, and selected module protocols.
(i) Follow the collection methods as
described in Rule
420-4-5-.04.
(j) Ensure a method of quality control in
reporting HAI data is established and maintained.
