TITLE XI
HOSPITALS AND SANITARIA

CHAPTER 151
RESIDENTIAL CARE AND HEALTH FACILITY LICENSING

Reporting of Hospital Infections

Section 151:33

    151:33 Hospitals Required to Report. –
    I. Any hospital licensed pursuant to this chapter shall maintain a program capable of identifying and tracking infections for the purpose of reporting under this section. Such program shall have the capacity to identify the following elements:
       (a) The specific infectious agents or toxins and site of each infection;
       (b) The clinical department or unit within the facility where the patient first became infected or was first diagnosed; and
       (c) The patient's diagnoses at time of admission and any relevant specific surgical, medical, or diagnostic procedure performed during the current admission.
    II. (a) Hospitals shall initially identify, track, and report infections to include:
          (1) Central line related bloodstream infections;
          (2) Ventilator associated pneumonia; and
          (3) Surgical wound infections.
       (b) Hospitals shall also initially identify, track, and report process measures including:
          (1) Adherence rates of central line insertion practices;
          (2) Surgical antimicrobial prophylaxis; and
          (3) Coverage rates of influenza vaccination for health care personnel and patients/residents.
    III. Subsequent to the initial requirements identified in paragraph II, the department shall, from time to time, require the tracking and reporting of other types of infections, including urinary tract infections when reporting protocols are identified by the department, that occur in hospitals in consultation with technical advisors who are regionally or nationally-recognized experts in the prevention, identification, and control of hospital infections and the reporting of performance data. The department shall make progress reports every 6 months to the oversight committee on health and human services, established in RSA 126-A:13, concerning the development of reporting protocols for tracking of urinary tract infections and shall notify the oversight committee on health and human services when the tracking of urinary tract infections has commenced, which shall be on or before July 1, 2007.

[Paragraph IV effective until January 1, 2010; see also paragraph IV set out below.]


    IV. The department shall establish guidelines, definitions, criteria, standards, and coding for hospital identification, tracking, and reporting of infections which shall be consistent with the recommendations of recognized centers of expertise in the identification and prevention of infections including, but not limited to the National Health Care Safety Network and the Healthcare Infection Control Practices Advisory Committee of the Centers for Disease Control and Prevention or its successor, the Joint Commission on the Accreditation of Healthcare Organizations, the Centers for Medicare and Medicaid Services, the Hospital Quality Alliance, the National Quality Forum, and the New Hampshire health care quality assurance commission under RSA 151-G.

[Paragraph IV effective January 1, 2010; see also paragraph IV set out above.]


    IV. The commissioner of the department shall adopt rules, pursuant to RSA 541-A, for hospital identification, tracking, and reporting of infections which shall be consistent with the recommendations of recognized centers of expertise in the identification and prevention of infections including, but not limited to the National Health Care Safety Network and the Healthcare Infection Control Practices Advisory Committee of the Centers for Disease Control and Prevention or its successor, the Joint Commission on the Accreditation of Healthcare Organizations, the Centers for Medicare and Medicaid Services, the Hospital Quality Alliance, the National Quality Forum, and the New Hampshire health care quality assurance commission under RSA 151-G.

[Paragraph V effective until January 1, 2010; see also paragraph V set out below.]


    V. Each hospital shall regularly report to the department the hospital infection data it has collected. The commissioner shall establish data collection and analytical methodologies that meet accepted standards for validity and reliability. In no case shall the frequency of reporting be required to be more frequently than once every 3 months, and reports shall be submitted not more than 60 days after the close of the reporting period.

[Paragraph V effective January 1, 2010; see also paragraph V set out above.]


    V. Each hospital shall regularly report to the department hospital acquired infections and the infection data it has collected. Such reporting shall be done in the manner directed by the department in accordance with rules adopted pursuant to RSA 541-A. The commissioner shall establish data collection and analytical methodologies that meet accepted standards for validity and reliability. In no case shall the frequency of reporting be required to be more frequently than once every 3 months, and reports shall be submitted not more than 60 days after the close of the reporting period.

Source. 2006, 292:1, eff. July 1, 2007. 2009, 225:1, eff. Jan. 1, 2010.