Reporting of HealthcareAssociated Infection Rates by Hospitals,

Ambulatory Surgical Centers, and Abortion Facilities PURPOSE: This rule establishes requirements and procedures for reporting hospital, ambulatory surgical center, and abortion facility healthcare-associated infection incidence data to the Department of Health and Senior Services. (1) The following definitions shall be used in the interpretation of this rule: (A) Ambulatory Surgery Centers (ASCs) and Abortion Facilities (AFs) as defined in section 197.200, RSMo; (B) CDC means the federal Centers for Disease Control and Prevention; (C) Catheter-associated urinary tract infections (CAUTI) as defined by the National Healthcare Safety Network (NHSN), or its successor; (D) Central line-associated bloodstream infection (CLABSI) as defined by NHSN, or its successor, means central line-related bloodstream infection as referred to in section 192.667.12(3), RSMo; (E) Department means the Missouri Department of Health and Senior Services; (F) HAI means Healthcare Associated Infection; (G) Hospitals as defined in section 197.020, RSMo, but excluding Critical Access Hospitals, Psychiatric Hospitals, Rehabilitation Hospitals, and Long Term Acute Care Hospitals, as designated by the Centers for Medicare and Medicaid Services; (H) Intensive care unit (ICU) means coronary, medical, surgical, medical/surgical, pediatric intensive care unit (PICU), and neonatal intensive care units (NICU) as defined by NHSN; (I) NHSN means the National Healthcare Safety Network, CDC’s widely used healthcare-associated infection tracking system; (J) Risk index means grouping patients who have operations according to the American Society of Anesthesiologists (ASA) score, length of procedure, wound class, and other criteria as defined by the CDC for the purpose of risk adjustment as required in section 192.667.3, RSMo; (K) The Standardized Infection Ratio (SIR) is a summary measure used to track HAIs over time at a national, state, or facility level. It adjusts for various facility and/or patientlevel factors that contribute to HAI risk within each facility; (L) Surgical site infection (SSI) as defined by NHSN, or its successor; and (M) Ward means pediatric, medical, surgical, and medical/surgical hospital areas for the evaluation and treatment of patients, as defined by NHSN, or its successor. (2) All hospitals shall confer rights, via NHSN, to the department to access data necessary to compute HAI incidence metrics on the following: (A) CLABSIs detected in wards and ICUs; (B) SSIs from designated types of surgeries as set forth in section (4) of this rule; and (C) CAUTIs detected in wards and ICUs, excluding NICUs. (3) All ASCs and AFs shall submit to the department or NHSN, or its successor, data to compute HAI incidence metrics on SSIs from designated types of surgeries as set forth in section (5) of this rule. (4) Hospitals shall report SSIs and associated denominator data to NHSN, or its successor, related to a hip prosthesis, to an abdominal hysterectomy, to a colon surgery, and to a coronary artery bypass graft with both chest and donor site incisions performed. (5) ASCs and AFs shall report SSIs and associated denominator data by risk index related to breast surgery and herniorrhaphy. (6) All hospitals shall annually complete the NHSN Patient Safety Component- Annual Hospital Survey and confer rights to grant the department access to these survey results. (7) Any ASC or AF who voluntarily submits HAI data via NHSN shall annually complete the NHSN Patient Safety Component- Annual Facility Survey for ASC and confer rights to grant the department access to these survey results. (8) Any ASCs or AFs who do not voluntarily submit to NHSN shall complete an annual survey when prompted by the department, providing, at a minimum, the number of surgical procedures as required in section (5). (9) Based on the survey information reported in section (7), ASCs and AFs that reported performing fewer than twenty (20) surgeries per surgery type, as specified in section (5), shall be exempt from reporting the SSI information regarding the surgery. (10) Hospitals, ASCs, and AFs who submit HAI data to NHSN or its successor, shall meet the HAI reporting requirements if— (A) All NHSN mandatory data items are submitted; (B) All data are submitted to the NHSN within sixty (60) days of the end of the reporting month; and (C) All data are submitted to NHSN per NHSN guidelines. (11) If an ASC or AF chooses to not submit the required data to NHSN, the ASC or AF may meet the HAI reporting requirements by submitting to the department numerator and denominator data on electronic forms provided by the department, or in a format approved by the department, for each of the infections specified in section (5) and if— (A) All mandatory data items are submitted; (B) Policies and procedures are in place to ensure that all HAIs as required by this rule are detected and reported. Such policies and procedures shall be consistent with appropriate guidelines of CDC, or the SHEA, or the APIC; and (C) All data are submitted to the department within sixty (60) days of the end of the reporting month. AUTHORITY: section 192.667, RSMo Supp. 2017.* Original rule filed Feb. 1, 2005, effective July 30, 2005. Amended: Filed Oct. 24, 2017, effective April 30, 2018. *Original authority: 192.667, RSMo 1992, amended 1993, 1995, 2004, 2016, 2017.