Mandatory Reporting of HAIs

On this page:

• Reporting Forms and Information
• Reporting Requirements
• Hospital HAI Internal Validation Guidance
• Exemptions to Reporting Requirements
• About HAI Reporting and the HAIAC
• About the National Healthcare Safety Network

Reporting Forms and Information

• Healthcare worker influenza vaccination
• HAI Disease Repoting Poster (pdf)
  
• MDRO Disease Reporting Poster (pdf)
  

Reporting Requirements

View Oregon Administrative Rules related to disease reporting: OAR 333-018.

For hospitals, mandatory healthcare-associated infections reporting to State of Oregon includes:

• Central line-associated bloodstream infections (CLABSIs)
• Catheter-associated urinary tract infections (CAUTIs)
• Laboratory-identified methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSIs)
• Laboratory-identified Clostridioides difficile  infections (CDI) (previously Clostridium difficile)
• Surgical site infections (SSIs) resulting from the following procedures: 
• Coronary artery bypass graft (CBGB)
• Knee prosthesis (KPRO)
• Colon surgery (COLO)
• Hip prosthesis (HPRO)
• Abdominal hysterectomy (HYST)

For additional information about reporting requirements, see our HAI Disease Reporting Poster.

Hospital HAI Internal Validation

OHA staff review all data submitted and provide each facility with their annual data for each reported measure before publication. Facilities have two weeks to respond and correct any errors. Final data are then provided, with a second opportunity for facilities to review and make any needed edits.

The HAI Program offers technical assistance to help resolve any data discrepancies. This process is known as internal validation.

Please see our Internal Validation Guidance (pdf)  for more information about this process.

Exemptions to Reporting Requirements

• The HAI Program has historically offered exemptions eliminating the need to report SSI and CLABSI to facilities with low numbers of certain surgical procedures and central line days, respectively.
• On March 28, 2018, the Healthcare-Associated Infections Advisory Committee (HAIAC) voted to eliminate these exemptions starting with data for January 2019. This change will allow the HAI Program to more effectively allocate resources to protect patient safety and will improve the quality and generalizability of our state's HAI data.
• Starting with January 2019 data, Oregon hospitals will be required to perform surveillance for and report CLABSIs and SSIs to OHA for applicable locations/procedures, regardless of the number of procedures or central line days observed annually. Facilities will not be required to report if they do not have the applicable location types for CLABSI or do not perform the relevant surgical procedures. To assist facilities with this transition, we have developed training resources for CLABSI and SSI reporting. Please visit our Lunch and Learn page and review training information from August 29th, 2018 and September 25th, 2018.

About the HAI Reporting Program and the HAIAC

In 2007, the Oregon State Legislature passed House Bill 2524 with the intent of creating a mandatory healthcare-associated infection (HAI) reporting program. This program's activities are directed by Oregon Administrative Rule 333-018-0100: Health Care Acquired Infection Reporting and Public Disclosure, and Oregon Revised Statute 442.853-856.

OHA established the Oregon Healthcare-Associated Infections Advisory Committee (HAIAC), a diverse group of stakeholders, to inform policy for reporting HAIs. On July 1, 2008, based on determinations by the Oregon HAIAC, the OHA published rules for HAI reportability and chose NHSN as the reporting system to be used for inpatient HAI outcome measures.

About the National Healthcare Safety Network

NHSN, which is a secure, internet-based surveillance system, is the primary tool used for collecting hospital HAI data in most U.S. states and territories. The Oregon Public Health Division uses NHSN data to estimate the burden of HAIs in Oregon and provides data to measure the impact of Oregon surveillance and prevention programs. Additionally, to ensure the accuracy of occurrences and data reported, the validation of NHSN data is independently audited by state employees.