R386-705. Epidemiology, Health Care Associated Infection, R386. Health, Disease Control and Prevention, Epidemiology, Utah Administrative Code

Utah Administrative Code (Current through November 1, 2019)

R386. Health, Disease Control and Prevention, Epidemiology

R386-705. Epidemiology, Health Care Associated Infection

R386-705-1. Authority and Purpose

Latest version.

This rule establishes data sharing requirements for health care associated infections and for influenza vaccination of health care workers. It is authorized by Utah Code Sections 26-1-30(2), 26-6-3, 26-6-7, and 26-6-31.

R386-705-2. Definitions

Latest version.

For purposes of this rule:

(1) "Ambulatory surgical center" or "ASC" is as defined in Utah Code Section 26-21-2.

(2) "Department" means the Utah Department of Health.

(3) "End stage renal disease facility" is as defined in Utah Code Section 26-21-2.

(4) "General acute hospital" is s defined in Utah Code Section 26-21-2.

(5) "Health care facility" is as defined in Utah Code Section 26-21-2.

(6) "Health care workers" or "HCW"s include, but are not limited to, personnel such as physicians, nurses, nursing assistants, therapists, technicians, dental personnel, pharmacists, laboratory personnel, autopsy personnel, contractual staff not employed by the health care facility, and persons (e.g., clerical, dietary, housekeeping, maintenance, and volunteers) not directly involved in patient care, but potentially exposed to infectious agents that can be transmitted to and from employees of a healthcare facility.

(7) "Specialty hospital" is as defined in Utah Code Section 26-21-2.

R386-705-3. Health Care Associated Infections Reporting

Latest version.

(1) Pursuant to Utah Code Section 26-6-31, facilities required to report data on the incidence and rate of health care associated infections as mandated by the Center for Medicare and Medicaid Services (CMS) to the National Healthcare Safety Network (NHSN) in the Centers for Disease Control and Prevention (CDC) shall:

(a) Share data with the Department by joining the Department NHSN Group, UDOH HAI (ID# 17686), and confer rights to the Department in NHSN. All data shared with the Department under this rule shall exclude patient identifiers unless necessary for reporting requirements and data validation.

(b) Follow CMS rules and NHSN protocols for defining terms and criteria for reporting infection data.

(2) Facilities required to share data submitted to NHSN with the Department include:

(a) Ambulatory surgical facilities;

(b) General acute hospitals;

(d) End stage renal disease facilities; and

(e) Any other facilities as required by CMS.

(3) Facilities required to report data to NHSN shall confer rights to the Department for all reported data elements, except for patient identifiers unless necessary for reporting requirements, including for data validation, for the following conditions:

(a) Central line associated bloodstream infections (CLABSI);

(b) Catheter associated urinary tract infections;

(d) Methicillin-resistant Staphylococcus aureus bacteremia;

(e) Clostridium difficile infection of the colon; and

(f) Any other health care associated infections reported to NHSN as required by CMS.

R386-705-4. Influenza Vaccination Rate Reporting

Latest version.

(1) Each licensed hospital and licensed long term care facility shall report its influenza vaccination rates for the current influenza season by January 31.

(2) Reports of influenza vaccination rates shall include the total number of HCWs and the number of those workers who are documented to have received an influenza vaccine for the current influenza season.

(a) Licensed hospitals that report HCW influenza vaccination data to NHSN may confer rights to the Department to HCW influenza vaccination data (excluding any patient identifiers) to fulfill this reporting requirement.

(b) Licensed hospitals that do not confer rights to the Department for HCW influenza vaccination data through NHSN shall report HCW influenza vaccination data online to the Department through the Utah Facility Online Reporting System (UFORS). Facilities may contact the Bureau of Epidemiology at (801) 538-6191 with questions about UFORS, to report a problem, or to obtain instructions for using the system.

(c) Influenza vaccination rates reported to UFORS shall be measured using complete enumeration of all HCWs in the facility during the season and the number of them who were vaccinated during that season.

(d) Licensed long term care facilities shall report HCW influenza vaccination data according to requirements in Utah Administrative Code R432-40, the Long-Term Care Facility Immunizations Rule.

R386-705-5. Health Care Associated Infection Prevention

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Each facility required to share data with the Department as described in R386-705-3 shall implement processes to prevent the incidence of health care associated infections.

(1) The processes shall include at least one intervention that is proven by scientifically valid means to be effective in health care associated infection prevention. Interventions that have been recommended by an accepted health authority, including the CDC, or the federal Hospital Infection Control Practices Advisory Committee (HICPAC), meet this requirement.

(2) The facility shall have a system to monitor these processes and shall make information about them available upon request.

R386-705-6. Attestation Required

Latest version.

Each facility required to share data with the Department as described in R386-705-3 and R386-705-4 shall attest to the implementation and effectiveness of its health care infection prevention program, as described in R386-705-5, and its systems for reporting, as required by this rule, once every three years.

R386-705-7. Penalties

Latest version.

An entity that violates any provision of this rule may be assessed a penalty as provided in Utah Code Section 26-23-6.

R386-705-10. Health Care Associated Infection Prevention.

Latest version.

Each facility required to report under Subsection 3(1) shall implement processes to prevent central line associated blood stream infections.

(1) The processes shall include at least one intervention proven by scientifically valid means to be effective in preventing CLA-BSI. Interventions that have been recommended by an accepted health authority, including the Centers for Disease Control and Prevention, or the federal Hospital Infection Control Practices Advisory Committee, meet this requirement.

(2) The facility shall have a system to monitor that program and shall make information about the program available upon request.

R386-705-20. Central Line Days.

Latest version.

(1) Each facility required to report under this rule shall report central line patient days.

(a) The facility shall count the number of patients who were at least one year of age and with a central line in place and resident in the ICU at the time of the count.

(b) The count shall be performed at the same time each day, within 1 hour before or after the target time, during the reporting period.

(c) A patient with two or more central lines in place at the time of the count is counted as one patient with a central line on that day.

(d) The facility shall calculate the sum of the individual daily counts for each day in the reporting period to arrive at the total for the reporting period.

(2) The number of central line days may be estimated based on a valid sampling method.

R386-705-21. Blood Stream Infection Reports.

Latest version.

(1) Each facility required to report under this rule shall report each case of CLA-BSI that occurs in each patient who is at least one year of age and who was either:

(a) in an ICU at the time the CLA-BSI was identified and had been in the ICU for at least 2 days prior to that time; or

(b) had been in an ICU within 2 days prior to the time the CLA-BSI was identified;

(2) The time the CLA-BSI is identified is the time that the first positive blood culture result used to identify the CLA-BSI was collected from the patient.

(3) A case of CLA-BSI is reportable if meets the criteria in Subsections 22(1), (4), and (5) and does not meet the criteria in Subsection 22(3).

(4) For each case of CLA-BSI, the hospital shall report:

(a) the date the CLA-BSI was identified;

(b) the type of ICU in which the case occurred, i.e., the ICU in which the patient resided at identification of the CLA-BSI if in ICU at the time, or the ICU from which patient was most recently discharged if not in ICU at the time;

(d) whether the CLA-BSI was considered a mixed BSI episode based on meeting the criteria in Subsections 22(2).

(5) The Utah Department of Health shall evaluate the case definitions and reporting algorithm at least annually with input from the users group and make any needed clarifications or changes.

R386-705-22. Classification Criteria for Central Line Associated Bloodstream Infections.

Latest version.

Definitions of bloodstream infections established in this rule are not to be construed as technical medical definitions of bloodstream infections, but only as definitions necessary to establish a reporting requirement. In reporting CLA-BSI under this rule, facilities shall apply the following criteria as required by Section R386-705-21:

(1) Criteria 1-BSI:

(a) at least one blood culture result includes a pathogenic organism;

(b) at least two blood culture results from specimens obtained at different times or from specimens drawn at different phlebotomy sites, e.g., left arm and right arm, within a 2 day period include the same type of common skin commensal organism; or

(c) at least one blood culture result includes a common skin commensal organism and antibiotic treatment effective against that organism was started on the day that the culture was collected and was continued for greater than three days.

(2) Criteria 2-Mixed BSI:

A BSI is a mixed BSI episode if more than one type of organism is identified in blood culture results obtained within a 5 day period.

(3) Criteria 3-Secondary BSI:

(a) A BSI is a secondary BSI if the organism is a pathogenic organism and is detected in a culture from a source other than blood that:

(i) was obtained from the patient within the 3 days before or 7 days after the positive blood culture;

(ii) is not a surveillance culture, i.e., a culture obtained routinely to detect carriage of an organism and not to diagnose an infection that is suspected based on clinical findings;

(iii) is not a culture of a catheter tip; and

(iv) is not a yeast obtained in a culture from respiratory source.

(b) A mixed BSI episode is secondary if any one of the organisms detected in blood cultures during the current episode meets the criteria for a secondary BSI.

(4) Criteria 4-New Episode:

A primary BSI is a new episode of BSI if:

(a) it is the first BSI in the patient during the patient's current hospitalization;

(b) it is the first time this organism is detected in the patient and no other BSI was detected in the patient in the previous 5 days; or

(c) the organism was detected in a previous blood culture from this patient and that blood culture was collected more than 30 days before the blood culture indicating the current BSI episode.

(5) Criteria 5-Central Line:

A BSI is a CLA-BSI if a central line was in place for at least two days before the first blood culture identifying the BSI was collected.

R386-705-25. Influenza Vaccination Rate Reporting.

Latest version.

(1) Reports of influenza vaccination rates shall include the number of health care workers and the number of those workers who are documented to have received an influenza vaccine for the current influenza season. Influenza vaccination rates may be measured by complete enumeration of all health care workers in the facility during the season and the number of them who were vaccinated during that season or may be estimated by a cross-sectional assessment.

(2) Each hospital and licensed long term care facility shall report its influenza vaccination rates for the current influenza season by January 31.

R386-705-100. Attestation Required.

Latest version.

Each facility required to report under Subsection 3(1), shall attest to the implementation and effectiveness of its health care infection prevention program and its systems for reporting, as required by this rule, once every three years.

R386-705-101. Penalties.

Latest version.

As required by Section 63-46a-3(5): An entity that violates any provision of this rule may be assessed a civil money penalty as provided in Section 26-23-6.