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Ohio Laws and Rules
In accordance with rule 3701-14-03 of the Administrative Code, each hospital that is not a children's hospital shall report to the director all of the following measures, and each children's hospital shall report only the infection control measures and the pediatric measures listed in paragraphs (F) and (G) of this rule.
(A) The CMS and the joint commission's measures for acute myocardial infarction, heart failure, pneumonia, the surgical improvement project, and the hospital consumer assessment of healthcare providers and systems listed in appendix A to this rule.
(1) In calculating the appropriateness of care measure for acute myocardial infarction, each hospital shall report the per cent, including the numerator and denominator, of eligible patients for AMI-1, AMI-2, AMI-3, AMI-4, AMI-5, and AMI-8a interventions who received all indicated care they were eligible to receive.
(a) If an eligible patient did not receive all of the indicated acute myocardial infarction interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the AMI appropriateness of care measure, but not counted in the numerator of the AMI appropriateness of care measure.
(b) If an eligible patient receives all indicated acute myocardial infarction interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the AMI appropriateness of care measure and once in the numerator of the AMI appropriateness of care measure.
(2) In calculating the appropriateness of care measure for heart failure, each hospital shall report the per cent, including the numerator and denominator, of eligible patients for HF-1, HF-2, HF-3 and HF-4 interventions who received all indicated care they were eligible to receive.
(a) If an eligible patient did not receive all of the indicated heart failure interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the HF appropriateness of care measure, but not counted in the numerator of the HF appropriateness of care measure.
(b) If an eligible patient receives all indicated heart failure interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the HF appropriateness of care measure and once in the numerator of the HF appropriateness of care measure.
(3) In calculating the appropriateness of care measure for pneumonia, each hospital shall report the per cent, including the numerator and denominator, of eligible patients for PN-2, PN-3, PN-4, PN-5c, PN-6 and PN-7 who received all indicated care they were eligible to receive.
(a) If an eligible patient did not receive all of the indicated pneumonia interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the PN appropriateness of care measure, but not counted in the numerator of the PN appropriateness of care measure.
(b) If an eligible patient receives all indicated pneumonia interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the PN appropriateness of care measure and once in the numerator of the PN appropriateness of care measure.
(4) In calculating the appropriateness of care measure for the surgical care improvement project infection measures, each hospital shall report the per cent, including the numerator and denominator, of eligible patients for SCIP-Inf-1, SCIP-Inf-2, and SCIP-Inf-3 interventions who received all indicated care they were eligible to receive.
(a) If an eligible patient did not receive all of the indicated surgical care infection interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the SCIP appropriateness of care measure, but not counted in the numerator of the SCIP appropriateness of care measure.
(b) If an eligible patient receives all indicated surgical care infection interventions for which the patient was included in the denominator, then the patient is counted once in the denominator of the SCIP appropriateness of care measure and once in the numerator of the SCIP appropriateness of care measure.
(B) The joint commission's stroke measures listed in appendix A to this rule.
(C) The AHRQ's heart and patient safety measures listed in appendix A to this rule.
(D) The centers for disease control and prevention's surgical site infection event measures listed in appendix A to this rule for the following procedures:
(1) CABG with chest incision only;
(2) Cesarean section; and
(3) Knee prosthesis, initial surgery only.
(E) The centers for disease control and prevention's measures for hospital acquired Clostridium difficile and hospital-acquired methicillin resistant and methicillin susceptible staphylococcus aureus bacteremia listed in appendix A to this rule for patients eighteen years of age or older, using the following reporting options, definitions, and specifications of the CDC's national health care safety network:
(1) The laboratory-identified even option;
(2) The facility-wide reporting option with only one denominator for the entire facility; and
(3) The healthcare facility-onset incident definition to calculate the measure.
(F) The infection control information pertaining to influenza vaccination, using the specifications in appendix B to this rule and the information pertaining to the hospital's hand-washing program and infection control staffing specified in appendix C to this rule.
(G) The following pediatric measures:
(1) The joint commission and NQF endorsed children's asthma care measures for systemic corticosteroids for inpatient asthma and relievers for inpatient asthma (ages two to seventeen) overall rate listed in appendix A to this rule; and
(2) Using the specifications prescribed in appendix D to this rule, the following measures listed in appendix E to this rule for patients less than eighteen years of age:
(a) Prophylactic antibiotic received within one hour prior to surgical incision;
(b) Surgical site infection rates for cardiothoracic, neurosurgical and orthopedic procedures; and
(c) Catheter-associated bloodstream infection rate for ICU patients.
(H)
Except as otherwise indicated in
paragraph (E) of rule
3701-14-03 of the Administrative
Code, the perinatal measures listed in appendix E to this rule:
Appendix A Centers for Medicare and Medicaid Services (CMS)/The
Joint Commission *Denotes NQF Endorsed Acute Myocardial Infarction* All-or-none measure (AMI-1, AMI-2, AMI-3, AMI-4, AMI-5, AMI-8a)
AMI-1: Aspirin at Arrival AMI-2: Aspirin at Discharge AMI-3: ACEI or ARB for LVSD AMI-4: Smoking Cessation Counseling AMI-5: Beta Blocker at Discharge AMI-8a: Primary PCI received within 90 minutes of hospital
arrival Mort-30-AMI: AMI 30-Day Mortality Heart Failure* All-or-none measure (HF-1, HF-2, HF-3, HF-4) HF-1: Discharge Instructions HF-2: Evaluation of left ventricular systolic (LVS) Function
HF-3: ACEI or ARB for LVSD HF-4: Smoking Cessation Counseling Pneumonia* All-or-none measure ( PN-2, PN-3b, PN-4, PN-5c, PN-6, PN-7)
PN-2: Pneumococcal Vaccination PN-3b: Blood Culture Performed in Emergency Department Prior to
Initial Antibiotic Received in Hospital PN-4: Smoking Cessation Counseling PN5c: Initial Antibiotic received within 6 hours of hospital
arrival PN-6: Initial Antibiotic Selection for Community-Acquired
Pneumonia in Immunocompetent Patients PN-7: Influenza Vaccination Surgical Care Improvement Project
(SCIP)* Appropriateness of care measure (SCIP-Inf 1, 2, 3) SCIP-Inf 1a: Prophylactic Antibiotic Received Within One Hour
Prior to Surgical Incision - Overall Rate SCIP-Inf 1b: Prophylactic Antibiotic Received Within One Hour
Prior to Surgical Incision - CABG SCIP-Inf 1c: Prophylactic Antibiotic Received Within One Hour
Prior to Surgical Incision - Other Cardiac Surgery SCIP-Inf 1d: Prophylactic Antibiotic Received Within One Hour
Prior to Surgical Incision - Hip Arthroplasty SCIP-Inf 1e: Prophylactic Antibiotic Received Within One Hour
Prior to Surgical Incision - Knee Arthroplasty SCIP-Inf 1f: Prophylactic Antibiotic Received Within One Hour
Prior to Surgical Incision - Colon Surgery SCIP-Inf 1g: Prophylactic Antibiotic Received Within One Hour
Prior to Surgical Incision - Hysterectomy SCIP-Inf 1h: Prophylactic Antibiotic Received Within One Hour
Prior to Surgical Incision - Vascular Surgery SCIP-Inf-2a: Prophylactic Antibiotic Selection for Surgical
Patients - Overall Rate SCIP-Inf-2b: Prophylactic Antibiotic Selection for Surgical
Patients - CABG SCIP-Inf-2c: Prophylactic Antibiotic Selection for Surgical
Patients - Other Cardiac Surgery SCIP-Inf-2d: Prophylactic Antibiotic Selection for Surgical
Patients - Hip Arthroplasty SCIP-Inf-2e: Prophylactic Antibiotic Selection for Surgical
Patients - Knee Arthroplasty SCIP-Inf-2f: Prophylactic Antibiotic Selection for Surgical
Patients - Colon Surgery SCIP-Inf-2g: Prophylactic Antibiotic Selection for Surgical
Patients - Hysterectomy SCIP-Inf-2h: Prophylactic Antibiotic Selection for Surgical
Patients - Vascular Surgery SCIP-Inf-3a: Prophylactic Antibiotics Discontinued within 24
Hours after Surgery End Time - Overall Rate SCIP-Inf-3a: Prophylactic Antibiotics Discontinued Within 48
Hours After Surgery End Time - CABG SCIP-Inf-3a: Prophylactic Antibiotics Discontinued Within 48
Hours After Surgery End Time - Other Cardiac SCIP-Inf-3a: Prophylactic Antibiotics Discontinued Within 24
Hours After Surgery End Time - Hip Arthroplasty SCIP-Inf-3a: Prophylactic Antibiotics Discontinued Within 24
Hours After Surgery End Time - Knee Arthroplasty SCIP-Inf-3a: Prophylactic Antibiotics Discontinued Within 24
Hours After Surgery End Time - Colon Surgery SCIP-Inf-3a: Prophylactic Antibiotics Discontinued Within 24
Hours After Surgery End Time - Hysterectomy SCIP-Inf-3a: Prophylactic Antibiotics Discontinued Within 24
Hours After Surgery End Time - Vascular Surgery SCIP-Card-2: Surgery Patients on Beta Blocker Therapy Prior to
Admission who Received a Beta Blocker during SCIP-VTE-1: Surgery Patients with Recommended Venous
Thromboembolism Prophylaxis Ordered SCIP-VTE-2: Surgery Patients who Received Appropriate Venous
Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours after
Surgery Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS) Communication with Nurses Communication with Doctors Responsiveness of Hospital Staff Pain Management Communication about Medicines Cleanliness of Hospital Environment Quietness of Hospital Environment Discharge Information Overall Rating of this Hospital Willingness to Recommend This Hospital Joint Commission Stroke Measures DSC/Stroke-01: Deep Vein Thrombosis (DVT) Prophylaxis DSC/Stroke-02: Discharged on Antithrombotic Therapy DSC/Stroke-03: Patients with Atrial Fibrillation Receiving
Anticoagulation Therapy DSC/Stroke-04: Thrombolytic Therapy Administered DSC/Stroke-05: Antithrombotic Therapy by End of Hospital Day
Two DSC/Stroke-06: Discharged on Cholesterol Reducing Medication
DSC/Stroke-07: Dysphagia Screening DSC/Stroke-08: Stroke Education DSC/Stroke-09: Smoking Cessation /Advice/Counseling DSC/Stroke-10: Assessed for Rehabilitation Agency for Healthcare Research and Quality (AHRQ) Other Heart Measures IQI-6: Percutaneous Coronary Intervention (Angioplasty) (PCTA)
volume IQI-30: Percutaneous Coronary Intervention (Angioplasty) (PCTA)
mortality rate IQI-5: Coronary Artery Bypass Graft (CABG) volume IQI-12: Coronary Artery Bypass Graft (CABG) mortality rate
Patient Safety Measures PSI-1: Complications of Anesthesia PSI-3: Decubitus Ulcer PSI-5: Foreign Body Left During Procedure Infection Measures *Denotes NQF Endorsed Centers for Disease Control and Prevention-
National Healthcare Safety Network (NHSN) Surgical Site Infection Event - Coronary artery bypass graft
with chest incision only * Surgical Site Infection Event - Cesarean Section* Surgical Site Infection Event - Knee Prosthesis, initial
surgery only* Hospital-Acquired Clostridium difficile (C. Diff.) Hospital-Acquired Methicillin Resistant and Methicillin
Susceptible Staphylococcus aureus Bacteremia (MRSA/MSSA Bacteremia) (SAB)
Infection Control Information Hand-washing Program Infection Control Staffing Perinatal Measures *Denotes NQF Endorsed California Maternal Quality Care
Collaborative Cesarean Rate for Low-Risk First Birth Women (NTSV CS Rate)*
Infants Under 1500g Not Delivered at Appropriate Level of Care*
Providence St. Vincent's
Hospital/CWISH Appropriate use of Antenatal Steroids* Pediatric Measures *Denotes NQF Endorsed The Joint Commission - Children's Asthma
Care CAC-1a: Systemic Corticosteroids for Inpatient Asthma (age
2-17) overall rate* CAC-2a: Relievers for Inpatient Asthma (age 2-17) overall rate*
Appendix B Health Care Provider Influenza Vaccination Measure Measure Name -- Health Care Provider Influenza Vaccination
Data Source -- Hospital Employee Health Records Numerator -- Number of paid employees receiving either nasal
spray or shot of Influenza vaccine from September 1 to March 31 Denominator -- Total number of paid hospital employees that
were employed as of March 31 Exclusions -- None Note: -- Count all employees who received a vaccination regardless of
where they received the vaccination (i.e. physician's office or clinic) -- Count paid employees as of March 31st each year -- Count only employees who work in an inpatient facility
APPENDIX C Hand-washing Program and Infection Control
Staffing Hand Washing:
1.
Does
your hospital have a program to improve hand hygiene practices?
Yes No Under development
2.
Does your hospital teach principles of
hand hygiene and proper use of gloves to all clinical staff upon hire?
Yes No
3.
Does
your hospital monitor and provide feedback to clinical staff regarding their
hand hygiene practices?
Yes, both Partial, monitor only No
4.
In
your hospital's clinical settings, are alcohol-based hand rubs available for
use at the point of care?
Yes No
5.
In
your hospital's clinical settings, are gloves available for use at the point of
care?
Yes No
6.
Does
your hospital prohibit the wearing of artificial nails by direct-care
providers?
Yes No Staffing:
1.
Does
your hospital employ a qualified Infection Control Professional (ICP)?
Yes No
2.
Does
your hospital employ an Infection Control Professional (ICP)/Infection
Preventiionist who is board certified in infection control (CIC)? (To qualify
for the certification examination, one must have a baccalaureate degree OR
current license as medical technologist, clinical laboratory scientist,
physician or registered nurse AND a minimum of two years experience in
infection control practice within the most current five year period and with a
minimum of 800 hours worked prior to the date of the examination.)
Yes No
3.
Does
your hospital have a board-certified Infectious Disease Physician either on
staff or available for consult?
Yes No APPENDIX D PEDIATRIC MEASURE SPECIFICATIONS Measure: Percentage of Patient Trips to the Operating
Room with Prophylactic Antibiotics Initiated 0-60 Minutes Prior to Incision;
0-120 minutes for those antimicrobials that require a longer infusion
time. The National Healthcare Safety Network (NHSN) Manual: Patient
Safety Component Protocol list of designated surgical procedures governing the
reporting period for which information is being submitted will serve as the
official reference guide for eligible surgical procedures.
I.
Population Definition (Note: All
designated surgical procedures require prophylactic antibiotics.)
Inclusion Criteria: Patients < 18 years of age, as of the date the designated
surgical procedures are performed. Exclusion Criteria: Patients > 18 years of age, as of
the date the designated surgical procedures are performed. Patients with physician, advanced practice nurse, or physician
assistant documentation of any type of active infection at the time of the
designated surgical procedures.
II.
Calculation
Numerator: Number of patient trips to the operating room for
designated surgical procedures where required prophylactic antibiotics were
initiated 0-60 minutes prior to incision (0-120 minutes for those
antimicrobials that require a longer infusion time). Denominator: Number of patient trips to the operating room for
designated surgical procedures performed during the applicable reporting period
in patients < 18 years of age, as of the date the procedures are performed.
Note: A patient trip to the operating room is counted only
once, regardless of the number of procedures performed. (Numerator/Denominator) x 100 (Note: reported as a percentage)
III.
Data
Collection/Reporting
Instances where required prophylactic antibiotics were not
administered are counted the same as not initiated 0-60 minutes prior to
incision (0-120 minutes for those antimicrobials that require a longer infusion
time).
IV.
Notes
Appropriate timing of antibiotic re-dosing during surgical
procedures is not addressed. Appropriate antibiotic selection is not addressed. Adjusting data for differences in case mix, volumes, or patient
severity across reporting hospitals is not required for this measure.
V.
Eligible Surgical Procedures
The neurosurgical, orthopedic, and cardiothoracic procedures
and corresponding CPT and ICD-9-CM procedure codes, based on the following
Centers for Disease Control/National Healthcare Safety Network reporting
categories: VSHN, FUSN, and CARD. Measure: Surgical Site Infections (SSI) per 100 Patient
Trips to the Operating Room The National Healthcare Safety Network (NHSN) Manual: Patient
Safety Component Protocol and list of eligible surgical procedures governing
the reporting period for which information is being submitted will serve as the
official reference guide for defining/reporting surgical site infections of the
pediatric population. However, hospitals are not required to use the NHSN forms
or prepare monthly surveillance plans for purposes of reporting this measure.
I.
Population Definition
Inclusion Criteria: Patients < 18 years of age, as of the date the designated
surgical procedures are performed. Exclusion Criteria: Patients > 18 years of age, as of
the date the designated surgical procedures are performed.
II.
Calculation
Numerator: Number of SSIs related to designated surgical
procedures. Denominator: Number of patient trips to the operating room for
designated surgical procedures during the applicable reporting period in
patients < 18 years of age, as of the date the procedures are performed.
Note: A patient trip to the operating room is counted only
once, regardless of the number of procedures performed. (Numerator/Denominator) x 100 (Note: reported as SSIs per 100
patient trips to the operating room.)
III.
Data Collection/Reporting
CDC-defined surveillance periods for identifying SSIs: -- 30 days for non-implanted devices. -- 365 days for implanted devices. Minimum required scope of surveillance to identify SSIs
includes hospital-based encounters (e.g. inpatient, ED/urgent care,
hospital-based outpatient clinics). SSI rate is reported separately for each of the following
surgical procedure categories: neurosurgical, orthopedic, and cardiothoracic.
SSIs are assigned to the month when the attributable surgical
procedures were performed. Due to challenges communicating information across hospitals,
should the attributable procedure be performed at a hospital other than the
hospital where the SSI was identified, the following guidelines apply: -- Hospital performing attributable procedure: add patient trip
to the operating room to the denominator, even if unable to add the related SSI
to the numerator (due to lack of awareness that the SSI has occurred); add SSI
to the numerator if aware that the SSI has been identified by another hospital.
-- Hospital identifying the SSI: exclude SSI from the numerator
since the patient trip to the operating room where the attributable procedure
was performed is within the denominator of a different hospital. (Note:
hospital identifying the SSI should contact the infection control department of
the hospital that performed the attributable procedure; cross-hospital
communication of patient information should comply with legal, legislative, and
regulatory requirements.)
IV.
Notes
NHSN SSI risk-adjustment methodologies will not be utilized.
NHSN algorithm based on operation duration, wound class, and ASA classification
has not been validated for pediatric populations. As pediatric-specific SSI
prevalence rates for the designated surgical procedures are not available from
evidence-based literature, the alternative NHSN methodology based on "observed
vs. expected" cannot be applied.
V.
Eligible Surgical Procedures
The neurosurgical, orthopedic, and cardiothoracic procedures
and corresponding CPT and ICD-9-CM procedure codes, based on the following
Centers for Disease Control/National Healthcare Safety Network reporting
categories: VSHN, FUSN, and CARD. Measure: Laboratory-Confirmed Catheter-Associated
Bloodstream Infections (CABSI) per 1,000 Catheter Days for ICU Patients
I.
Population Definition
Inclusion criteria: All patients < 18 years of age on date of admission or
re-admission to ICU setting who have a central venous catheter. Includes patients in applicable ICU settings with central
venous catheters regardless of place of insertion (e.g., tunneled/implanted
central lines inserted in OR, PICC lines inserted in interventional radiology).
Includes all ICU settings, except NICUs. Includes immunocompromised patients. Includes the following catheter types: -- Tunneled/implanted central line (e.g., Hickman, Broviac,
Mediport). -- Percutaneous central line (e.g., central venous catheter,
subclavianinserted central catheter). -- Peripherally-inserted central catheter (PICC): must be
threaded in or near heart or great vessel to qualify as "central line." -- Umbilical venous catheter. NHSN definition of central line: intravascular catheter that
terminates at, or close to, the heart, or in one of the great vessels, which is
used for infusion, withdrawal of blood, or hemodynamic monitoring. Patients with an existing central venous catheter where a
CA-BSI develops within 48 hours after inter- or intra-hospital transfer from an
ICU within the hospital reporting this measure to another clinical setting
(e.g., inpatient unit, ICU). (Note: the hospital reporting this measure should
capture catheter days for these patients in their denominator, and the CA-BSIs
for these patients in their numerator.) Exclusion Criteria: Patients > 18 years of age on date
of admission or re-admission to ICU setting. Patients in the NICU. (Note: NICUs within children's hospitals
are part of this exclusion criteria; decisions regarding NICU-related quality
measures for public reporting were deferred to the ODH Perinatal Workgroup.)
Catheter days for patients while in the NICU and infections
attributed to the NICU are excluded. Intermediate care unit patients. Patients with an existing central venous catheter where a
CA-BSI develops within 48 hours after inter- or intra-hospital transfer to an
ICU within the hospital reporting this measure.
II.
Calculation
Numerator: Number of laboratory-confirmed CA-BSIs. Clarifications: Positive blood cultures drawn from multiple sites are counted
as one infection if due to the same organism. A laboratory-confirmed bloodstream infection (LCBI) must meet
one of the following three criteria: (Note: LCBI criteria 1 and 2 may be used
for patients of any age, including patients < 1
year of age.) (Source: "CDC/NHSN Surveillance Definition of Health-Care
Associated Infection and Criteria for Specific Types of Infections in the Acute
Care Setting," American Journal of Infection Control, 2008; 36: 309-332;
National Association of Children's Hospitals and Related Institutions CA-BSI
collaborative.) Criterion 1: Patient has a recognized pathogen cultured from one or more
blood cultures And Organism cultured from blood is not related to infection at
another site. (See Notes 1 and 2 in addendum.) Criterion 2: Patient has at least one of the following signs/symptoms: fever
(>38°C), chills, or hypotension And Signs/symptoms and positive laboratory results are not related
to an infection at another site And Common skin contaminant (i.e., diphtheroids [Corynebacterium
spp.], Bacillus [not B. anthracis] spp., Propionibacterium spp.,
coagulase-negative staphylococci [including S. epidermidis], viridans group
streptococci, Aerococcus spp., Micrococcus spp.) is cultured from two or more
blood cultures drawn on separate occasions. (See Notes 3 and 4 in addendum.)
Criterion 3: Patient < 1 yr of age has at least
one of the following signs or symptoms: fever (>38°C, rectal),
hypothermia (<37°C, rectal), apnea, or bradycardia. Note: for patients < 1 year of age,
the following temperature equivalents for fever and hypothermia may be used:
-- Fever: 38°C rectal/tympanic/temporal artery=37°C
oral=36°C axillary. -- Hypothermia: 37°C rectal/tympanic/temporal
artery=36°C oral=35°C axillary. And Signs/symptoms and positive laboratory results are not related
to an infection at another site And Common skin contaminant (i.e., diphtheroids [Corynebacterium
spp.], Bacillus [not B. anthracis] spp., Propionibacterium spp.,
coagulase-negative staphylococci [including S. epidermidis], viridans group
streptococci, Aerococcus spp., Micrococcus spp.) is cultured from two or more
blood cultures drawn on separate occasions. (See Notes 3 and 4 in addendum.)
Denominator: Number of catheter days during applicable
reporting period in patients < 18 years of age on date of admission or
re-admission to ICU setting. Clarifications: Definition of "catheter days" sum of patients with 1 or more
central lines (excluding arterial lines), measured at the same time each day.
Patients with multiple central lines, and central lines with
multiple lumens/ports per line, are counted as 1 catheter day. Only count line days that occurred within applicable ICU
settings. For patients transferred between ICUs within the same hospital,
line days are combined across applicable ICU settings for the reporting period.
-- E.g. During the reporting period, a patient is admitted to
the NICU, is later transferred to an applicable ICU setting, and then is
transferred back to the NICU. As the NICU is not an applicable ICU setting,
catheter days associated with that setting are not counted in the denominator.
(Numerator/Denominator) x 1,000 (Note: reported as CA-BSIs per
1,000 catheter days.)
III.
Data Collection/Reporting
Data is reported to the ODH on a quarterly basis. Due to challenges communicating information across hospitals,
should corresponding catheter days be recorded by a hospital other than the
hospital where the CA-BSI was identified, the following guidelines apply:
-- Hospital reporting this measure: add catheter days to
denominator, even if unable to add related CA-BSI to numerator (due to lack of
awareness/knowledge that the CA-BSI has occurred); add the CA-BSI to numerator
if aware that the CA-BSI was identified by another hospital. -- Hospital identifying the CA-BSI: exclude the CA-BSI from
numerator since corresponding catheter days are within the denominator of a
different hospital. (Note: hospital identifying the CA-BSI should contact the
infection control department of hospital where patient previously received
care; cross-hospital communication of patient information should comply with
legal, legislative and regulatory requirements.)
IV.
Notes
Data is not adjusted for differences in case mix, volumes, or
patient severity across reporting hospitals Measure does not distinguish between infections due to central
venous catheter insertion vs. maintenance practices. Specimen collection considerations (Source: "CDC/NHSN
Surveillance Definition of Health-Care Associated Infection and Criteria for
Specific Types of Infections in the Acute Care Setting," American Journal of
Infection Control, 2008; 36: 309-332): ideally, blood culture specimens should
be obtained from two to four blood draws from separate venipuncture sites
(e.g., right and left antecubital veins), not through a vascular catheter.
These blood draws should be performed simultaneously or over a short period of
time (i.e., within a few hours). If the hospital does not currently obtain
specimens using this technique, BSIs can still be reported based on the
aforementioned criteria and notes listed in the addendum, but the hospital
should work with appropriate personnel to facilitate better specimen collection
practices for blood cultures.
VI.
Addendum
Notes from CDC/NHSN Surveillance Definition of Health-Care
Associated Infection and Criteria for Specific Types of Infections in the Acute
Care Setting, American Journal of Infection Control, 2008; 36: 309-332:
1. In criterion 1, the phrase "gone or more blood cultures" means that at least one bottle from a blood draw is reported by the laboratory as having grown organisms (i.e., "positive" blood culture).
2. In criterion 1, the term "recognized pathogen" does not include organisms considered common skin contaminants (see criteria 2 and 3 for list of common skin contaminants). Examples of "recognized pathogens" include: S. aureus, Enterococcus spp., E. coli, Pseudomonas spp., Klebsiella spp., and Candida spp.
3. In criteria 2 and 3, the phrase "two or more blood cultures drawn on separate occasions" means: 1) that blood from at least two blood draws were collected within two days of each other (e.g., blood draws on Monday and Tuesday or Monday and Wednesday would be acceptable for blood cultures drawn on separate occasions, but blood draws on Monday and Thursday would be too far apart to meet this criterion), and 2) that at least one bottle from each blood draw is reported by the laboratory as having grown the same common skin contaminant organism (i.e., "positive" blood culture). (See Note 4 for determining sameness of organisms.)
a. Example: an adult patient has blood drawn at 8 a.m. and again at 8:15 a.m. of the same day. Blood from each blood draw is inoculated into two bottles and incubated (four bottles total). If one bottle from each blood draw set is positive for coagulase-negative staphylococci, this part of the criterion is met.
b. Example: A neonate has a blood culture drawn on Tuesday and again on Saturday, and both grow the same common skin contaminant. Because time between blood cultures exceeds the two-day period for blood draws stipulated in criteria 2 and 3, this part of the criteria is not met.
c. A blood culture may consist of a single bottle for a pediatric blood draw because of volume constraints. Therefore, to meet this part of the criterion, each bottle from two or more draws would have to be culturepositive for the same skin contaminant.
4. There are several issues to consider when determining sameness of organisms.
a.
If the
common skin contaminant is identified to the species level from one culture,
and a companion culture is identified with only a descriptive name (i.e., to
the genus level), then it is assumed that the organisms are the same. The
speciated organism should be reported as the infecting pathogen (see table
below).
Culture -- Companion Culture -- Report as ... S. epidermidis -- Coagulase-negative staphylococci -- S.
epidermidis Bacillus spp. (not anthracis) -- B. cereus -- B. cereus S. salivarius -- Strep viridans -- S. salivarius
b. If common skin contaminant organisms from the cultures are speciated but no antibiograms are done, or they are done for only one of the isolates, it is assumed that the organisms are the same.
c. If the common skin contaminants from the cultures have antibiograms that are different for 2 or more antimicrobial agents, it is assumed that the organisms are not the same (see table below).
d.
For the purpose
of NHSN antibiogram reporting, the category interpretation of intermediate (I)
should not be used to distinguish whether two organisms are the same.
Organism Name -- Isolate A -- Isolate B -- Interpret as... S
epidermidis -- All drugs S -- All drugs S -- Same S. epidermidis -- OX R CEFAZ R -- OX S CEFAZ S --
Different Corynebacterium spp. -- PENG R CIPRO S -- PENG S CIPRO R --
Different Strep viridans -- All drugs S -- All drugs S except ERYTH R --
Same Appendix E Perinatal Measures *Denotes NQF Endorsed Christiana Care Health Services/NPIC Incidence of Episiotomy* HCA-St Marks Perinatal Center Elective Delivery Prior to 39 Completed Weeks Gestation*
Pediatric Measures Prophylactic Antibiotic Received within One Hour Prior to
Surgical Incision Catheter-Associated Bloodstream Infection Rate for ICU Patients
Surgical Site Infection Rate for cardiothoracic, neurosurgical
and orthopedic procedures Replaces: 3701-14-02
Cite as Ohio Admin. Code 3701-14-04
Five Year
Review (FYR) Dates: 09/17/2014 and
09/15/2019
Promulgated
Under: 119.03
Statutory
Authority: 3727.41
Rule
Amplifies: 3727.33,
3727.41
Prior
Effective Dates: 1/27/2007, 6/28/09
Prior History: (Effective:
06/28/2009
R.C.
119.032 review dates: 06/01/2014
Promulgated Under:
119.03
Statutory
Authority: 3727.41
Rule
Amplifies: 3727.33,
3727.41
Prior
Effective Dates: 1/27/2007 )