2063 Health care associated infection benchmarking areas for hospitals under the Medical Care Availability and Reduction of Error (MCARE) Act
Health Care Associated Infection Benchmarking Areas for Hospitals under the Medical Care Availability and Reduction of Error (MCARE) Act [41 Pa.B. 6454]
[Saturday, December 3, 2011]Section 408(8) of the Medical Care Availability and Reduction of Error (MCARE) Act (40 P. S. § 1303.408(8)) requires that the Department of Health (Department) develop, in consultation with the Patient Safety Authority (PSA) and the Pennsylvania Health Care Cost Containment Council (Council), ''reasonable benchmarks to measure the progress [hospitals] make toward reducing health care-associated infections.'' On December 5, 2007, in a letter to hospital chief executive officers, hospitals were informed that the Department would be developing and utilizing benchmarks to measure the progress hospitals make toward reducing health care-associated infections in the following areas:
• Central Line Associated Blood Stream Infections (CLABSI)—Housewide
• Catheter Associated Urinary Tract Infections (CAUTI)—Housewide
• Surgical Site Infections (SSI) for:
o Hip prosthetics
o Knee prosthetics
o Abdominal hysterectomies
o Coronary artery bypass grafts with both chest and donor site incisions
o Coronary artery bypass grafts with chest incision only
o Cardiac surgery
As explained in the December 5, 2007, letter, these benchmarking areas were selected because they align with National efforts, are of either high impact or high volume, or both.
Beginning January 1, 2012, hospitals will be required to report surgical site infection data for colon surgeries to the United States Centers for Disease Control and Prevention, National Healthcare Safety Network (NHSN) to comply with the United States Centers for Medicare and Medicaid Services 2012 Medicare Hospital Inpatient Prospective Payment System. See 76 F.R. 51476 (August 18, 2011). For consistency with National data collection efforts and following consultation with the PSA and the Council, the Department is adding infections following colon surgery to the benchmarking areas previously listed. As of January 1, 2012, the revised complete list of benchmarking areas is as follows:
• Central Line Associated Blood Stream Infections—Housewide
• Catheter Associated Urinary Tract Infections—Housewide
• Surgical Site Infections for:
o Hip prosthetics
o Knee prosthetics
o Abdominal hysterectomies
o Coronary artery bypass grafts with both chest and donor site incisions
o Coronary artery bypass grafts with chest incision only
o Cardiac surgery
o Colon surgery.
As provided in section 404(b) of the MCARE Act (40 P. S. § 1303.404(b)), hospitals shall report health care associated infection (HAI) data for these benchmarking areas in accordance with the NHSN Manual, Patient Safety Component Protocol. In addition to the reporting of the actual HAI events (numerator data), the MCARE Act and NHSN Manual require collection and monthly reporting of denominator data that assists in the calculation of infection rates. This denominator data consists of:
• For CLABSI and CAUTI data—Total patient days and total line or device days for each.
• For SSI data—Total procedures and patient-level data elements for each procedure type.
The Department will review hospital HAI data reports to ensure that numerator and denominator data for HAIs in the benchmarking areas is reported in accordance with the NHSN Manual. In the near future, as required by section 408(9) of the MCARE Act, the Department will also publish and seek public comment on the benchmark methodology that will be utilized to measure the progress hospitals make toward reducing HAIs in the areas identified previously.
The Department appreciates the continued efforts of hospitals in complying with the MCARE Act and in improving infection surveillance and control to reduce HAIs in this Commonwealth. Questions regarding this notice or the HAI reporting requirements under the MCARE Act may be directed to Kimberly Buffington, Director, Health Care-Associated Infection Prevention Section, Department of Health, 8th Floor, Forum Place, 555 Walnut Street, Harrisburg, PA 17101, (717) 425-5422.
Persons with a disability who wish to obtain a copy of the proposed report and order and require an auxiliary aid, service or other accommodation to do so should contact Kimberly Buffington at the address and phone number listed previously, or for speech and/or hearing impaired persons V/TT (717) 783-6154, or the Pennsylvania AT&T Relay Service at (800) 654-5984.
ELI N. AVILA, MD, JD, MPH, FCLM,
Secretary[Pa.B. Doc. No. 11-2063. Filed for public inspection December 2, 2011, 9:00 a.m.]
