Section 590-270-2 - Healthcare Associated Infection Quality Data Set Filing DescriptionA. For all patients identified as eligible cases in the specific denominator and numerator categories (minus exclusions) specified by NHSN, each hospital or their agent shall report data to the US CDC's NHSNf or the following healthcare associated infection (HAI) quality metricsin accordance with NHSN specifications: HAI-1 Central line catheter-associated blood stream infection rate for adult and pediatric patients in intensive care units, medical units, surgical units, medical/surgical units, and mixed acuity units (Measure steward - NHSN).
HAI-2 Central line catheter-associated blood stream infection rate for high-risk nursery patients (Measure steward - NHSN).
HAI-3 through HAI-5 have been purposefully deleted.
HAI-6 Catheter-associated urinary tract infection rates for adult and pediatric patients in intensive care units, medical units, surgical units, medical/surgical units, mixed acuity units and rehabilitation units beginning January 1, 2020. (Measure steward - NHSN).
B. For all patients identified as eligible cases in the specific denominator and numerator categories specified by NHSN, each hospital, or their agent, shall submit to the US CDC's National Healthcare Safety Network (NHSN), data for the following healthcare associated infection (HAI) quality metrics in accordance with NHSN specifications, beginning with all qualifying surgical procedures performed on or after January 1, 2020: HAI-7 Surgical Site Infection rate for patients undergoing inpatient knee prosthesis (arthroplasty of knee) surgical procedures (KPRO) (Measure steward - NHSN); and
HAI-8 Surgical Site Infection rate for patients undergoing inpatient hip prosthesis (arthroplasty of hip) surgical procedures (HPRO) (Measure steward - NHSN).
C. Each hospital shall submit to the US CDC's National Healthcare Safety Network (NHSN) MRSA blood specimen Lab ID Event data, for all facility-wide inpatients (FacWideIN) in accordance with NHSN specifications.(Measure steward - NHSN).D. Each hospital shall submit to the US CDC's NHSN data forClostridium difficileLab ID Events for all facility-wide inpatients(FacWideIN)in accordance with NHSNspecifications. (Measure steward - NHSN).E. Each nursing facility shall make a quarterly submission to the MHDO of data, separated by month, for Clostridium difficile Lab ID Events for all facility-wide residents (FacWideIN) in accordance with NHSN specifications beginning July 1, 2020. (Measure steward - NHSN).F. The Maine CDC shall have access to any healthcare associated infection measure data submitted under state mandate directlyto MHDO in lieu of NHSN, and the Maine CDC shall be authorized to use this data for data validation, public health surveillance and performance improvement purposes.G. In lieu of reporting data directly to MHDO, eachhealthcare facility shall authorize Maine CDC to have access to the NHSNfor facility-specific reports ofdatasubmitted for any healthcare associated infection measure under a state or federal mandate, and shall authorize the Maine CDC to use thisdatafor data validation, public health surveillance and performance improvement purposes.Such data accessed and used by Maine CDC is not considered MHDO data but is protected by 22 M.R.S.A. §42(5) to the extent it is individually identifiable.H. Each health care facility shall also authorize the MHDO to have access to the NHSN for facility-specific reports ofdata submitted for any healthcare associated infection measure under a state or federal mandate, for the purpose of public reporting.I. The MQF and Maine CDC shall develop and implement an external validation process to assure the accuracy of healthcare associated infection data submitted to the NHSN.Each hospital selected to participate in a State external validation study shall cooperate with the State's third-party external validation contractor and provide any hospital medical records or data required to complete the study.J. Any hospital selected for a federal validation study is exempt from state-level validation for that year and measure(s) with the understanding that the hospital must submit a copy of the federal validation report summary to the MQF within 14 days of their receipt of the final federal report.The MQF is authorized to use information from the federal validation report summary for the purpose of public reporting.90-590 C.M.R. ch. 270, § 2