Ala. Admin. Code r. 420-4-5-.02

Current through Register Vol. 43, No. 1, October 31, 2024

Section 420-4-5-.02 - Healthcare Facility Responsibilities

(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.

Ala. Admin. Code r. 420-4-5-.02

New Rule: Filed June 23, 2010; effective July 28, 2010. Amended: Filed January 20, 2012; effective February 24, 2012. Amended: Filed October 21, 2013; effective November 25, 2013.

Author: Kelly M. Stevens, M.S.

Statutory Authority:Code of Ala. 1975, § 22-11A-113; 22-11A-119; 22-2-2(6).