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Mandatory Reporting of HAIs

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Reporting Forms and Information

Reporting Requirements

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

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 Clostridium difficile infections (CDI)

And 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)
  • Laminectomy (LAM)

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

Exemptions to Reporting Requirements

A hospital may request an exemption to mandatory reporting in some circumstances. Examples of these are:

  • Facilities which perform less than 20 specific surgical procedures (i.e. laminectomy) may request an exemption from reporting that surgical site infection (SSI).
  • Facilities which have less than 50 central line (CL) days per year may request an exemption from reporting CL-associated blood stream infections (CLABSI).

Exemptions are determined prospectively based on data reported to the HAI program via web-based survey.

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 OARS: Hospital Reporting: Health Care Acquired Infection Reporting and Public Disclosure and Oregon Revised Statute 442.851. (Scroll to 442.990) (Temporary provisions relating to healthcare-acquired infections are compiled as Notes following ORS 442.851.)

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 accuracy of occurrences and data reported, validation of NHSN data is independently audited by state employees.

Learn more about NHSN.

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