Skip Navigation LinksCA_SpecificReportingGuidelines

healthcare-associated infections (HAI) program

HAI Reporting Guidance for California Hospitals

GettyImages-681407458_GearsRulesRegsPoliciesStandardsCompliance

​Which healthcare-associated infections (HAI) are required to be reported by California hospitals to be in compliance with state laws?

California hospitals are required to report HAI data to CDPH via the National Healthcare Safety Network (NHSN), specifically, all cases of methicillin resistant Staphylococcus aureus (MRSA) bloodstream infections (BSI), vancomycin resistant Enterococcus (VRE) BSI, Clostridioides difficile infections (CDI), central line associated BSI (CLABSI) and surgical site infections (SSI). (Health and Safety (HSC) Sections 1288.55;  All Facilities Letter (AFL) 10-07, 11-32 and 13-03.

​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.

​Why are California hospitals required to report using the NHSN system and protocols?

California law requires that CDPH follow a risk adjustment process consistent with the federal Centers for Disease Control and Prevention's NHSN (or its successor) and use NHSN definitions and protocols, unless CDPH “adopts, by regulation, a fair and equitable risk adjustment process that is consistent with the recommendations of the HAI Advisory Committee” (Health and Safety Code Section 1288.55).  

​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.

​What does CDPH do with the HAI data reported by hospitals?

CDPH is required by law to publish on its website annual reports of HAI data and information (Health and Safety Code 1288.55 and 1288.8). The CDPH HAI Program monitors trends and offers consultation and assistance to hospitals with high infection rates. See the annual report page to view hospital-specific data trends.

​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. 

​Are any hospitals exempt from HAI reporting? 

All CDPH-licensed General Acute Care Hospitals (GACH), including long term acute care (LTAC), critical access, and acute rehabilitation hospitals, regardless of size, must report HAI and practice measures.   Acute inpatient rehabilitation facilities or units (IRF), defined as those with a CCN number distinct from the hospital CCN, are required to report data separately.  Psychiatric (behavioral health) hospitals are not licensed as GACHs and therefore don’t fall under the law.  Acute inpatient psychiatric facilities or units (IPF), those with distinct CCN numbers, are excluded from California HAI reporting requirements.

​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).

California HAI Reporting Requirements

The requirements for HAI reporting are summarized in the table below and in the document, California General Acute Care Hospital Reporting Requirements for Healthcare-Associated Infections (HAI) and Related Measures (PDF).  Hospitals are required to adhere to NHSN protocols and definitions to ensure standardization and comparability.

​Infection
Type

Hospital
Locations
Included in
Surveillance

​Infection
(Event)
Data Required
Monthly

​Denominator
(Summary)
Data Required
Monthly

​Link to NSHN Surveillance and Reporting Protocols

Central line associated bloodstream infections
(CLABSI)

​All inpatient locations

​Positive blood specimen from inpatients with central lines that meets NSHN criteria for CLABSI
  • ​Central line days for each inpatient location
  • Inpatient days for each location

​Surveillance for CLABSI 
(CDC NHSN)

​Methicillin
resistant staphylococcus aureus 
bloodstream infection
(MRSA BSI)

  • ​Facility wide inpatient locations
  •  Emergency Department
  • 24-hour observation units
  • Acute independent rehabilitation facilities (IRF) (defined as having a separate CCN)
​All positive MRSA blood specimens
  • ​Inpatient days
  • Admissions
  • Inpatient days minus IRF and independent psychiatric facility (IPF) (separate CCN)
  • Admissions minus IRF and IPF
  • Emergency Department encounters
  • 24-hour observation unit encounters

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

​Vancomycin resistant enterococcus bloodstream infection
(VRE BSI)

  • ​Facility wide inpatient locations
  • Emergency Department
  •  24-hour observation units
  • IRF
​All positive VRE blood specimens
  • ​Inpatient days
  • Admissions
  • Inpatient days minus IRF and IPF days
    Admissions minus IRF and IPF admissions
  • Emergency Department encounters
  • 24-hour observation unit encounters

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

Clostridioides  difficile
infections
(CDI)

  • ​Facility wide inpatient locations, excluding NICU and well-baby
  • Emergency Department
  • 24-hour observation units
  • IRF
​All positive CDI stool specimens
  • ​Inpatient days
  • Admissions
  • Inpatient days minus NICU/Well-baby days
  • Inpatient admissions minus NICU/Well-baby admissions
  • Inpatient days minus IRF/IPF days
  • Admissions minus IRF/IPF admissions
  • Emergency Department encounters
  • 24-hour observation unit encounters

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

Surgical Site infections
(SSI)

​Operative procedures on  patients whose admission (surgery) and discharge dates are different calendar days

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

​Enter every qualifying inpatient operative procedure performed from the list of the 28 NHSN procedure codes that have CA mandated surveillance.

NHSN Surveillance for SSI Events
(CDC NHSN)

Measure
Type

Included
in
Surveillance

​Numerator
Data

Denominator
Data

Link to NHSN Requirements and Protocols

Central line insertion
practices
(CLIP)

​Central lines inserted in all intensive care unit locations (including adult, pediatric, and neonatal ICUs)
  • ​Adherence to central line insertion bundle elements for each line inserted
​Not applicable; denominator is the number of line insertions reported Surveillance for CLIP Adherence (CDC NHSN)

Healthcare Personnel
Influenza Vaccination

​Hospital healthcare personnel (HCP) in categories:

  • Employees (staff on payroll)
  • Non-employee licensed independent practitioners (physicians, advanced practice nurses and physician assistants)
  • Other contract personnel
  • Adult students, trainees and volunteers

​From October 1-March 31,  the numbers of HCP (by category) who:

  • Received influenza vaccination administered at the hospital
  • Provided documentation of influenza vaccine elsewhere
  • Had medical contraindication to the vaccine
  • Declined influenza vaccination
  • Had an unknown vaccination status or did not otherwise meet any of the definitions of the above-mentioned criteria
​Total number of HCP (by category) working in the hospital for at least 1 day between October 1 and March 31Surveillance for Healthcare Personnel Vaccination (CDC NHSN)

NHSN Monthly Checklist for Reporting to CDPH

CDPH developed the NHSN Monthly Checklist for Reporting to CDPH (PDF) to assist California hospital infection preventionists and surveillance personnel with NHSN monthly reporting in compliance state laws.  The CDPH NHSN Checklist, which was adapted from the CMS NHSN monthly reporting checklist, provides guidance specific to California hospitals. 

To compare similarities and differences with California hospital NHSN reporting requirements with CMS hospital NHSN reporting requirements, please refer to the NHSN Monthly Checklist for Reporting to CMS Hospital IQR Program, March 2019 (PDF).

Additional CDPH Resources

Throughout the year, the CDPH HAI Program posts QA/QC reports to the CalHEART website to allow hospitals to review their NHSN-reported HAI data for accuracy, errors, and omissions. Hospitals are expected to make needed corrections in NHSN to ensure data quality and completeness necessary to ensure the integrity of the CDPH annual public report and hospital comparisons.

For technical assistance with California NHSN reporting, CalHEART, or QA/QC reports, please contact HAI_Data@cdph.ca.gov

Additional CDC NHSN Resources

Page Last Updated :