N.Y. Public Health Law § 2819: Hospital acquired infection reporting

§ 2819. Hospital acquired infection reporting. 1. For the purposes of

this section, "hospital acquired infection" shall mean any localized or

systemic patient condition that:

(a) resulted from the presence of an infectious agent or agents, or

its toxin or toxins as determined by clinical examination or by

laboratory testing; and

(b) was not found to be present or incubating at the time of admission

unless the infection was related to a previous admission.

2. (a) Each general hospital shall maintain a program capable of

identifying and tracking hospital acquired infections for the purpose of

public reporting under this section and quality improvement.

(b) Such programs shall have the capacity to identify the following

elements: the specific infectious agents or toxins and site of each

infection; the clinical department or unit within the facility where the

patient first became infected; and the patient's diagnoses and any

relevant specific surgical, medical or diagnostic procedure performed

during the current admission.

(c) The department shall establish guidelines, definitions, criteria,

standards and coding for hospital identification, tracking and reporting

of hospital acquired infections which shall be consistent with the

recommendations of recognized centers of expertise in the identification

and prevention of hospital acquired infections including, but not

limited to the National Health Care Safety Network of the Centers for

Disease Control and Prevention or its successor. The department shall

solicit and consider public comment prior to such establishment.

(d) Hospitals shall be initially required to identify, track and

report hospital acquired infections that occur in critical care units to

include surgical wound infections and central line related bloodstream

infections.

(e) For hospital acquired infections for which the department requires

tracking and reporting as permitted in this section, hospitals shall be

required to report a suspected or confirmed hospital-acquired infection

associated with another hospital to the originating hospital.

Documentation of reporting should be maintained for a minimum of six

years.

(f) Subsequent to the initial requirements identified in paragraph (d)

of this subdivision the department may, from time to time, require the

tracking and reporting of other types of hospital acquired infections

(for example, ventilator - associated pneumonias) that occur in

hospitals in consultation with technical advisors who are regionally or

nationally-recognized experts in the prevention, identification and

control of hospital acquired infection and the public reporting of

performance data.

3. Each hospital shall regularly report to the department the hospital

infection data it has collected. The department shall establish data

collection and analytical methodologies that meet accepted standards for

validity and reliability. The frequency of reporting shall be monthly,

and reports shall be submitted not more than sixty days after the close

of the reporting period.

4. The commissioner shall establish a state-wide database of all

reported hospital acquired infection information for the purpose of

supporting quality improvement and infection control activities in

hospitals. The database shall be organized so that consumers, hospitals,

healthcare professionals, purchasers and payers may compare individual

hospital experience with that of other individual hospitals as well as

regional and state-wide averages and, where available, national data.

5. (a) Subject to paragraph (c) of this subdivision, on or before

September first of each year the commissioner shall submit a report to

the governor and the legislature, which shall simultaneously be

published in its entirety on the department's web site, that includes,

but is not limited to, hospital acquired infection rates adjusted for

the potential differences in risk factors for each reporting hospital,

an analysis of trends in the prevention and control of hospital acquired

infection rates in hospitals across the state, regional and, if

available, national comparisons for the purpose of comparing individual

hospital performance, and a narrative describing lessons for safety and

quality improvement that can be learned from leadership hospitals and

programs.

(b) The commissioner shall consult with technical advisors who have

regionally or nationally acknowledged expertise in the prevention and

control of hospital acquired infection and infectious disease in order

to develop the adjustment for potential differences in risk factors to

be used for public reporting.

(c)(i) No later than July first, two thousand six, the department

shall establish a hospital acquired infection reporting system capable

of receiving electronically transmitted reports from hospitals.

Hospitals shall begin to submit such reports as directed by the

commissioner but in no case later than January first, two thousand

seven.

(ii) The first year of data submission under this section shall be

considered the "pilot phase" of the statewide hospital acquired

infection reporting system. The purpose of the pilot phase is to ensure,

by various means, including any audit process referred to in subdivision

seven of this section, the completeness and accuracy of hospital

acquired infection reporting by hospitals. For data reported during the

pilot phase, hospital identifiers shall be encrypted by the department

in any and all public databases and reports. The department shall

provide each hospital with an encryption key for that hospital only to

permit access to its own performance data for internal quality

improvement purposes.

(iii) No later than one hundred eighty days after the conclusion of

the pilot phase, the department shall issue a report to hospitals

assessing the overall accuracy of the data submitted in the pilot phase

and provide guidance for improving the accuracy of hospital acquired

infection reporting. The department shall issue a report to the governor

and the legislature assessing the overall completeness and accuracy of

the data submitted by hospitals during the pilot phase and make

recommendations for the improvement or modification of hospital acquired

infection data reporting based on the pilot phase as well as share

lessons learned in prevention of hospital acquired infections. No

hospital identifiable data shall be included in the pilot phase report,

but aggregate or otherwise de-identified data may be included.

(iv) After the pilot phase is completed, all data submitted under this

section and compiled in the statewide hospital acquired infection

database established herein and all public reports derived therefrom

shall include hospital identifiers.

6. Subject to subdivision five of this section, a summary table, in a

format designed to be easily understood by lay consumers, that includes

individual facility hospital acquired infection rates adjusted for

potential differences in risk factors and comparisons with regional

and/or state averages shall be developed and posted on the department's

web site. The commissioner shall consult with consumer and patient

advocates and representatives of reporting facilities for the purpose of

ensuring that such summary table report format is easily understandable

by the public, and clearly and accurately portrays comparative hospital

performance in the prevention and control of hospital acquired

infections.

7. To assure the accuracy of the self-reported hospital acquired

infection data and to assure that public reporting fairly reflects what

actually is occurring in each hospital, the department shall develop and

implement an audit process.

8. For the purpose of ensuring that hospitals have the resources

needed for ongoing staff education and training in hospital acquired

infection prevention and control, the department may make such grants to

hospitals within amounts appropriated therefor.

9. Individual patient identifying information reported to the

department under this section shall be subject to paragraph (j) of

subdivision one of section two hundred six of this chapter. Regulations

under this section shall include standards to assure the protection of

patient privacy in data collected and released under this section and

standards for the publication and release of data reported under this

section.