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Introduction to the Hospital Infections Disclosure Act HIDA DHEC Reporting and Training Requirements

Objectives. Describe Hospital Infections Disclosure Act (HIDA) requirementsDescribe the steps hospitals must take to implement HIDADescribe DHEC and CDC resources for hospital acquired infections (HAI) information and communicationDescribe HIDA training requirements. SC Statute 44-7-2410 to 2460.

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Introduction to the Hospital Infections Disclosure Act HIDA DHEC Reporting and Training Requirements

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    1. Introduction to the Hospital Infections Disclosure Act (HIDA) DHEC Reporting and Training Requirements Dixie Roberts, MPH, APRN DHEC Division of Acute Disease Epidemiology July 11, 2007

    2. Objectives Describe Hospital Infections Disclosure Act (HIDA) requirements Describe the steps hospitals must take to implement HIDA Describe DHEC and CDC resources for hospital acquired infections (HAI) information and communication Describe HIDA training requirements

    3. SC Statute 44-7-2410 to 2460 “Hospitals” shall collect data on HAI rates for specific procedures recommended by Advisory Committee and determined by DHEC Must include SSI, VAPs, CLABSI, “other” Must report completeness of certain infection control processes “Hospitals” defined as requiring overnight stay for nursing/medical care and licensed by DHEC

    4. Hospital Infections Disclosure Act (continued) 5. Hospitals report every 6 months (by 2/1/08) to DHEC and made available to the public. 6. Create HIDA Advisory Committee 7. Consider data methods -including NHSN 8. Reports by DHEC must be risk-adjusted for comparisons (requires patient risk data) 9. Must Validate: evaluate quality and accuracy of data regularly

    5. Hospital Infections Disclosure Act (continued) 10. Submit an annual report to legislature & public by Feb.1,2009 11. Must be publicized widely to interested parties – easily understandable language 12. Assure strict patient confidentiality 13. DHEC shall ensure and enforce compliance as a condition of licensure

    6. HIDA - DHEC and Advisory Committee’s Mission Provide fair and comparable hospital-level reports on certain hospital-acquired infection rates and control processes to the public and the legislature Assure that data are clearly understandable and risk-adjusted Validate that all hospitals provide complete and accurate data We hope that these efforts will eventually promote reductions in HAI rates

    7. DHEC and HIDA Advisory Committee Consensus Adopt the CDC National Healthcare Safety Network (NHSN) data collection system for South Carolina HAI reporting. Develop data models and methods to link Office of Research and Statistics (ORS) hospital discharge data and NHSN data for use when validating data, estimating cost of infections, and to identify other information that will contribute to accurately informing the public about HAI.

    8. Phase I Reporting Requirements Surgical Site Infections for the following procedures, in all acute care hospitals where these procedures are performed: Coronary Artery Bypass Graph (CABG) Hysterectomies (vaginal and abdominal) Central Line Associated Bloodstream Infections (CLABSI) in Medical-Surgical Intensive Care Units (all combinations of Medical and Surgical Intensive Care units as defined by the CDC NHSN system).

    9. NHSN Reporting The Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) system has been selected for reporting risk adjusted hospital acquired infections. http://www.cdc.gov/ncidod/dhqp/nhsn_members.html NHSN is a web based reporting system requires a secure digital certificate from CDC requires ICPs to have routine access to a computer with internet connection. requires the computer to meet NHSN system specifications

    10. Reporting (cont.) Hospitals must assign rights to DHEC to view their reportable data in the NHSN system Instructions for assigning rights to DHEC will be sent to the Hospital NHSN Facility Administrator

    11. HIDA Hospital Contacts Hospitals should designate two employees as HIDA Contacts to facilitate communications with DHEC. NHSN Facility Administrator (required by the CDC to enroll into NHSN and maintain hospital user system) The other contact should be a hospital manager with Infection Control responsibility. Contacts will receive updates from DHEC and share HIDA information within their hospitals.

    12. Communications between Hospitals and DHEC DHEC is establishing an e-mail listserv for the two hospital HIDA Contacts and a DHEC HIDA website for hospitals to include information about assigning DHEC rights to view the NHSN data CDC operates the NHSN system and all enrollment and user questions should be sent to the CDC NHSN e-mail or phone #

    13. New Hospitals Established after initial reporting July 1, 2007: submit to DHEC the HIDA Registration / Enrollment/ Training Form (DHEC will reply with current instructions for the HIDA Training and Enrollment Process) designate two HIDA Hospital Contacts assure training of Infection Control staff responsible for HIDA reporting enroll in the CDC NHSN and assign viewing rights to DHEC begin reporting into the NHSN no later than 3 months after the first patient admission.

    14. Staff Turnover Hospitals should have a contingency plan to continue reporting when staff resign or are transferred to another position.

    15. HIDA Training Tool Kit CDC http://www.cdc.gov/ncidod/dhqp/nhsn_members.html NHSN Manuals and Protocols NHSN Training Webinars DHEC / APIC / SCNA Introduction to the Hospital Infections Disclosure Act -DVD (Connie Steed- APIC; Dixie Roberts – DHEC) The CDC NHSN: Perspecitves from an Experienced User (Linda Green, Rochester General Hospital –DVD)

    16. HIDA Training Tool Kit Contents will enable the NHSN user to use independent study resources for basic training needs: Introduction to HIDA DVD and handouts Perspectives of An Experienced User DVD DHEC Guidance Information on web sites, resources, and how to sign up for the HIDA listserv (limited to 2 hospital contacts)

    17. Case Studies Results of training evaluations stress the value of case studies in helping the ICP to apply the standardized surveillance definitions DHEC plans to coordinate future periodic statewide or regional case study groups to facilitate standardized reporting

    18. DHEC & Advisory Committee Future Tasks Develop, Monitor, and Evaluate NHSN/ORS data models for use Develop Data Reports and Web site Develop Executive Summary with public friendly language to explain data Identify infection control processes for reporting Develop HIDA Validation Plan Review infections /procedures/ processes for next phase of reporting Identify Policy Recommendations

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