N.H. Admin. Code § He-P 309.11

Current through Register No. 50, December 12, 2024

Section He-P 309.11 - Surgical Antimicrobial Prophylaxis and Intravenous Antimicrobial Administration

(a) Hospitals shall report surgical antimicrobial prophylaxis annually on or before April 30th for the prior year via the "Hospital Annual Surgical Antimicrobial Prophylaxis Survey" as described in (d) below.

(b) The department shall contact all hospitals via email no later than March 15th of each year and provide a link to the survey, as well as a pdf.

(c) Hospitals shall either:

(1) Complete the survey via the survey link; or

(2) Complete the.pdf version of the survey and return to the department via:

a. Email, as an email attachment, to haiprogram@dhhs.nh.gov;

b. Fax, at (603) 271-0545; or

c. Mail, to:

Healthcare Associated Infections Surveillance Program

Bureau of Disease Control

Division of Public Health Services

29 Hazen Drive

Concord, NH 03301

(d) Hospitals shall report the following measures on the "Hospital Annual Surgical Antimicrobial Prophylaxis Survey" form:

(1) Hospital contact information including the following:

a. Facility name;

b. Name of person completing the survey;

c. Professional title of the person completing the survey;

d. Email address of the person completing the survey; and

e. Telephone number of the person completing the survey;

(2) Total number of patients with order for prophylactic antibiotic during the reporting period;

(3) Total number of patients that received prophylactic antibiotic within one hour prior to surgery during the reporting period;

(4) Total number of patients that received the prophylactic antibiotic during the reporting period;

(5) Total number of patients whose prophylactic antibiotic was discontinued within 24 hours after surgery; and

(6) Any other desired comments the hospital wishes to share.

(e) End stage renal dialysis centers shall, when submitting ESRD data, report intravenous antimicrobial administration by complying with the United States Centers for Disease Control and Prevention, National Healthcare Safety Network, "End Stage Renal Dialysis (ESRD) Event" protocol (February 2018 edition), available as noted in Appendix A at http://www.cdc.gov/nhsn/pdfs/pscmanual/8pscdialysiseventcurrent.pdf.

(f) In addition to the reporting requirements identified in (e) above, end stage renal dialysis centers shall submit ESRD data within 60 days of the close of each quarter, as follows:

(1) Quarter 1 data, from January 1st to March 31st, shall be reported on or before May 30th;

(2) Quarter 2 data, from April 1st to June 30th, shall be reported on or before August 29th;

(3) Quarter 3 data, from July 1st to September 30th, shall be reported on or before November 29th; and

(4) Quarter 4 data, from October 1st to December 31st, shall be reported on or before March 1st of the following calendar year.

(g) Ambulatory surgical centers shall report the list of procedures during which the patient received intravenous prophylactic antibiotic to the department on the "Intravenous Antibiotic Reporting Form" within 60 days of the close of each quarter, as follows:

(1) Quarter 1 data, from January 1st to March 31st, shall be reported on or before May 30th;

(2) Quarter 2 data, from April 1st to June 30th, shall be reported on or before August 29th;

(3) Quarter 3 data, from July 1st to September 30th, shall be reported on or before November 29th; and

(4) Quarter 4 data, from October 1st to December 31st, shall be reported on or before March 1st of the following calendar year.

(h) The department shall contact all ambulatory surgery centers via email no later than March 15 of each year, and provide the survey, as well as a pdf copy.

(i) Ambulatory surgery centers shall either:

(1) Complete the survey; or

(2) Complete the pdf version of the survey and return to the department via:

a. Email, as an email attachment, to haiprogram@dhhs.nh.gov;

b. Fax, at (603) 271-0545; or

c. Mail, to:

Healthcare Associated Infections Surveillance Program

Bureau of Disease Control

Division of Public Health Services

Department of Health and Human Services

29 Hazen Drive

Concord, NH 03301

(j) Ambulatory surgery centers shall report the following measures on the "Intravenous Antibiotic Reporting Form":

(1) Facility name;

(2) Unique patient identification number;

(3) Date of the surgery or procedure;

(4) Type of procedure using codes as defined by the World Health Organization's "International Classification of Diseases (ICD) " (11th Revision), available as noted in Appendix B;

(5) Type of prophylactic antibiotic;

(6) Time of the start of the intravenous antibiotic was included; and

(7) Time of the start of the incision.

(k) Specialty hospitals shall not be required to report surgical antimicrobial prophylaxis data and intravenous antimicrobial administration.

(l) Residential care facilities, assisted living residences, nursing homes, and the veterans' home shall not be required to report surgical antimicrobial prophylaxis data and intravenous antimicrobial administration.

N.H. Admin. Code § He-P 309.11

Derived from Volume XL Number 2, Filed January 9, 2020, Proposed by #12943, Effective 12/11/2019, Expires 12/11/2029.