​What are the California HAI reporting deadlines?

In 2012, a judicial ruling defined the quarterly reporting deadline for as 30 days after the end of each quarter (Settlement and Release Agreement for Action No. CGC-11-511271, AFL 12-15). All required data must be entered into the NHSN system for CDPH access by the quarterly deadlines:  Quarter 1–April 30, Quarter 2–July 30, Quarter 3–Oct 30, Quarter 4–January 30.   The only exception is for SSI following procedures with a 90-day surveillance period, which are due no later than 90 days after the procedure date.  All HAI should be reported as soon they are identified to allow local response as needed.

​What is the HAI Advisory Committee?

California law established a HAI Advisory Committee to make recommendations to the CDPH on issues related to HAI surveillance, reporting, and prevention (Health & Safety Code Section 1288.5).  The HAI Advisory Committee is comprised of voting members with HAI expertise or interest and non-voting liaison members who represent California HAI stakeholder organizations. Visit the HAI Advisory Committee webpage to for more information.

​Why are California hospitals required to track and report surgical site infections for 28 surgical procedures types? 

California law requires hospitals to report surgical site infections (SSI) resulting from “deep and organ/space surgical sites,” including (but not limited to) orthopedic, cardiac and gastrointestinal surgical procedures (Health and Safety Code Section 1288.55).   In 2011, CDPH published the list of required reportable procedures as aligned to 29 NHSN procedure categories (AFL 11-32). Although the original ICD-9 codes are outdated, the required NHSN procedure types (PDF) remain the same.  Up-to-date ICD-10 and CPT codes that align with California-reportable procedures are available on the CDC NHSN website via links in the SSI surveillance protocol (PDF). Since 2016, when NHSN combined FUSN and REFUSN into a single procedure category, the number of required surgical procedure types has been reduced to 28. 

​Which practice (process) measures are required to be reported? 

In addition to HAI, hospitals are also required to report central line insertion practices (CLIP) and influenza vaccination of healthcare personnel (Health and Safety Code Section 1288.8). 

For all central lines inserted in all intensive care unit (ICU) locations (adult, pediatric, and neonatal units), hospitals must document and report observed CLIP.  Rules and requirements for CLIP reporting can be found at Surveillance for CLIP Adherence (CDC, NHSN).

Healthcare personnel (HCP) influenza vaccinations reporting is required for all personnel who worked in the facility for at least 1 day between October 1 and March 31. Hospitals are required to track and report vaccination status for four HCP categories:  1) employees (staff on payroll), 2) non-employee licensed independent practitioners (physicians, advanced practice nurses and physician assistants), 3) other contract personnel, and 4) adult students, trainees and volunteers.  Rules and requirements for influenza reporting are located at Influenza Vaccination Summary Reporting (CDC, NHSN).

​Central line associated bloodstream infections
(CLABSI)

​Surveillance for CLABSI 
(CDC NHSN)

​Vancomycin resistant enterococcus bloodstream infection
(VRE BSI)

Surveillance for C. difficile, MRSA, and other Drug-Resistant Infections 
(CDC NHSN)

​Surgical Site infections
(SSI)

Superficial incisional,* deep incisional, and organ/space infections that meet NHSN definitions and are associated with any of the 28 NHSN procedure codes mandated for CA hospital reporting;  specifically,
AAA, APPY, BILI, CARD, CBGB, CBGC, CHOL, COLO, CSEC, FUSN, FX, GAST, HPRO, HTP, HYST, KPRO, KTP, LAM, LTP, NEPH, OVRY, PACE, REC, SB, SPLE, THOR, VHYS, XLAP**

Descriptions and associated ICD-10 codes for each procedure category can be found on the NHSN website at  NHSN Procedure Codes and Associated ICD-10 Codes (EXCEL)

*Superficial SSI are not included in the CDPH annual public HAI report, but are required to be reported per NHSN protocols for appropriate SSI risk adjustment

​Central line insertion
practices
(CLIP)

• ​Adherence to central line insertion bundle elements for each line inserted