The purpose of this letter is to notify California general acute care hospitals (GACHs) of new California Department of Public Health (CDPH) instructions for reporting of surgical site infections as mandated by Senate Bill (SB) 1058 [enacted by Health and Safety Code (HSC) Section 1288.55]. Commencing with surgeries performed on or after April 1, 2011, the Department will accept data for surgical site infections (SSI) only if reported to the Department through the Centers for Disease Control and Prevention National Healthcare Safety Network (NHSN).

Per Health and Safety Code Section 1288.55, commencing January 1, 2009:

"Each health facility shall report quarterly to the department all health-care-associated surgical site infections of deep or organ space surgical sites, health-care-associated infections of orthopedic surgical sites, cardiac surgical sites, and gastrointestinal surgical sites designated as clean and clean-contaminated, and the number of surgeries involving deep or organ space, and orthopedic, cardiac, and gastrointestinal surgeries designated clean and clean-contaminated."

By January 1, 2012, the law requires CDPH to post on its website:

"Information regarding the incidence rate of deep or organ space surgical site infections, orthopedic, cardiac, and gastrointestinal surgical procedures designated as clean and clean-contaminated, acquired at each health facility in California, including information on the number of inpatient days."
For infection information reported publicly, per HSC Section 1288.5 (c)(1), the Department must follow a risk adjustment process that is consistent with NHSN methodology.

On January 21, 2009, CDPH issued All Facility Letter (AFL) 09-07 to inform GACHs of these reporting requirements. Hospitals were directed to report infection information by email or fax to the Department. In October 2010, NHSN introduced a new SSI risk adjustment process and the calculation of the Standardized Infection Ratio (SIR). This method requires reporting via NHSN to accomplish SSI risk adjustment. More information on the SIR can be found at

NHSN e-News: SIRs Special Edition

Therefore, for surgeries performed on or after April 1, 2011, CDPH will accept data for SSIs only if reported through NHSN. CDPH will continue to accept SSI data submitted by email or fax for surgeries performed prior to April 1, 2011, as evidence of compliance with the statutory reporting requirements.
The list of NHSN operative procedure categories inclusive of orthopedic, cardiac, and gastrointestinal procedures is extensive (see Attachment A). CDPH recognizes that reporting through NHSN requires information to be reported on every patient undergoing the procedures included in a hospital’s reporting plan. Based upon the recommendation of the Healthcare Associated Infections Advisory Committee (December 9, 2010), CDPH requires that hospitals report SSIs through NHSN following the table below:

NHSN protocols for identifying and reporting these infections must be followed, including the use of each of the listed ICD-9 codes to identify patients. Although statutes mandate only the reporting of deep or organ space SSI, compliance with NHSN protocols requires the reporting of all SSI, including superficial incisional SSI and must be followed. CDPH will publically report only those SSI rates required by statute, which at this time are deep and organ space SSIs. Data must be submitted for each patient undergoing the specified surgical procedures. Information on these NHSN protocols is available at CDC - NHSN, including the importation of procedure data from electronic data files. NHSN will allow importation of procedure data by generating import files from hospital information systems that follow clinical document architecture (CDA) standards as published by NHSN at http://www.cdc.gov/nhsn/CDA_eSurveillance.html, in an ASCII (American Standard Code for Information Interchange) comma delimited text, or are in a CSV (comma separated value) file format. Guidance on the necessary steps to develop CSV importation capabilities is available through the CDPH HAI Liaison Program. Contact information for Liaison Program staff is available at CDPH - HAI.  

The Healthcare Associated Infections Advisory Committee further recommended (February 17, 2011) that all hospitals performing surgery report SSI to the Department through NHSN for two procedures. Based on the recommendation of the Committee, hospitals that do not perform coronary artery bypass graft procedures (the two NHSN procedure categories count as one procedure) and/or hip prosthesis must choose one or two additional procedures from the attached list. The choice of procedures must be based upon a risk assessment performed by each hospital. This assessment should take into account the number of procedures performed each year and the rate of infections for each. The number of procedures performed each year should be at least 25, unless no procedure is performed that frequently. Procedures with a combination of highest volume and rate of infection in each hospital should be selected. Guidance on selecting procedures is available through the CDPH HAI Liaison Program.

Hospitals that do not expect to perform any of the procedures listed during 2011 should notify the Department by sending an email to infectioncontrol@cdph.ca.gov.

For questions, the point of contact at CDPH is the Healthcare-Associated Infections Program at infectioncontrol@cdph.ca.gov or phone (510) 412-6060.

Sincerely,

Original Signed by Pamela Dickfoss

Pamela Dickfoss
Acting Deputy Director

Attachment: NHSN Operative Procedures