Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 590 - MAINE HEALTH DATA ORGANIZATION › Chapter 270 - UNIFORM REPORTING SYSTEM FOR QUALITY DATA SETS › Section 590-270-2 - Healthcare Associated Infection Quality Data Set Filing Description

Current through 2024-29, July 17, 2024
A. For all patients identified as eligible
				cases in the specific denominator and numerator categories (minus exclusions)
				specified by NHSN, each hospital or their agent shall report data to the US
				CDC's NHSNf or the following healthcare associated infection (HAI) quality
				metricsin accordance with NHSN specifications:
HAI-1 Central line catheter-associated blood stream infection
				  rate for adult and pediatric patients in intensive care units, medical units,
				  surgical units, medical/surgical units, and mixed acuity units (Measure steward
				  - NHSN).
HAI-2 Central line catheter-associated blood stream infection
				  rate for high-risk nursery patients (Measure steward - NHSN).
HAI-3 through HAI-5 have been purposefully deleted.
HAI-6 Catheter-associated urinary tract infection rates for
				  adult and pediatric patients in intensive care units, medical units, surgical
				  units, medical/surgical units, mixed acuity units and rehabilitation units
				  beginning January 1, 2020. (Measure steward - NHSN).
B. For all patients identified as eligible
				cases in the specific denominator and numerator categories specified by NHSN,
				each hospital, or their agent, shall submit to the US CDC's National Healthcare
				Safety Network (NHSN), data for the following healthcare associated infection
				(HAI) quality metrics in accordance with NHSN specifications, beginning with
				all qualifying surgical procedures performed on or after January 1, 2020:
HAI-7 Surgical Site Infection rate for patients undergoing
				  inpatient knee prosthesis (arthroplasty of knee) surgical procedures (KPRO)
				  (Measure steward - NHSN); and
HAI-8 Surgical Site Infection rate for patients undergoing
				  inpatient hip prosthesis (arthroplasty of hip) surgical procedures (HPRO)
				  (Measure steward - NHSN).
C. Each hospital shall submit to the US CDC's
				National Healthcare Safety Network (NHSN) MRSA blood specimen Lab ID Event
				data, for all facility-wide inpatients (FacWideIN) in accordance with NHSN
				specifications.(Measure steward - NHSN).
D. Each hospital shall submit to the US CDC's
				NHSN data for
Clostridium difficile
Lab ID Events for all
				facility-wide inpatients(FacWideIN)in accordance with NHSNspecifications.
				(Measure steward - NHSN).
E. Each
				nursing facility shall make a quarterly submission to the MHDO of data,
				separated by month, for
Clostridium difficile
Lab ID Events
				for all facility-wide residents (FacWideIN) in accordance with NHSN
				specifications beginning July 1, 2020. (Measure steward - NHSN).
F. The Maine CDC shall have access to any
				healthcare associated infection measure data submitted under state mandate
				directlyto MHDO in lieu of NHSN, and the Maine CDC shall be authorized to use
				this data for data validation, public health surveillance and performance
				improvement purposes.
G. In lieu of
				reporting data directly to MHDO, eachhealthcare facility shall authorize Maine
				CDC to have access to the NHSNfor facility-specific reports ofdatasubmitted for
				any healthcare associated infection measure under a state or federal mandate,
				and shall authorize the Maine CDC to use thisdatafor data validation, public
				health surveillance and performance improvement purposes.Such data accessed and
				used by Maine CDC is not considered MHDO data but is protected by
				22 M.R.S.A.
				§42(5) to the extent it
				is individually identifiable.
H.
				Each health care facility shall also authorize the MHDO to have access to the
				NHSN for facility-specific reports ofdata submitted for any healthcare
				associated infection measure under a state or federal mandate, for the purpose
				of public reporting.
I. The MQF and
				Maine CDC shall develop and implement an external validation process to assure
				the accuracy of healthcare associated infection data submitted to the NHSN.Each
				hospital selected to participate in a State external validation study shall
				cooperate with the State's third-party external validation contractor and
				provide any hospital medical records or data required to complete the
				study.
J. Any hospital selected for
				a federal validation study is exempt from state-level validation for that year
				and measure(s) with the understanding that the hospital must submit a copy of
				the federal validation report summary to the MQF within 14 days of their
				receipt of the final federal report.The MQF is authorized to use information
				from the federal validation report summary for the purpose of public
				reporting.