R386-705-3. Health Care Associated Infections Reporting

(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;

(c) Specialty 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;

(c) Surgical site infections from procedures on the colon and abdominal hysterectomy;

(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.