2007 California Health and Safety Code Article 3.5. Hospital Infectious Disease Control Program .. 1288.5-1288.9

CA Codes (hsc:1288.5-1288.9)

1288.5.  By July 1, 2007, the department shall appoint a Healthcare
Associated Infection (HAI) Advisory Committee that shall make
recommendations related to methods of reporting cases of hospital
acquired infections occurring in general acute care hospitals, and
shall make recommendations on the use of national guidelines and the
public reporting of process measures for preventing the spread of HAI
that are reported to the department pursuant to subdivision (b) of
Section 1288.8. The advisory committee shall include persons with
expertise in the surveillance, prevention, and control of
hospital-acquired infections, including department staff, local
health department officials, health care infection control
professionals, hospital administration professionals, health care
providers, health care consumers, physicians with expertise in
infectious disease and hospital epidemiology, and integrated health
care systems experts or representatives.


1288.6.  (a) (1) Each general acute care hospital, in collaboration
with infection prevention and control professionals, and with the
participation of senior health care facility leadership shall, as a
component of its strategic plan, at least once every three years,
prepare a written report that examines the hospital's existing
resources and evaluates the quality and effectiveness of the hospital'
s infection surveillance and prevention program.
   (2) The report shall evaluate and include information on all of
the following:
   (A) The risk and cost of the number of invasive patient procedures
performed at the hospital.
   (B) The number of intensive care beds.
   (C) The number of emergency department visits to the hospital.
   (D) The number of outpatient visits by departments.
   (E) The number of licensed beds.
   (F) Employee health and occupational health measures implemented
at the hospital.
   (G) Changing demographics of the community being served by the
hospital.
   (H) An estimate of the need and recommendations for additional
resources for infection prevention and control programs necessary to
address the findings of the plan.
   (3) The report shall be updated annually, and shall be revised at
regular intervals, if necessary, to accommodate technological
advances and new information and findings contained in the triennial
strategic plan with respect to improving disease surveillance and the
prevention of HAI.
   (b) Each general acute care hospital that uses central venous
catheters (CVCs) shall implement policies and procedures to prevent
occurrences of health care associated infection, as recommended by
the Centers for Disease Control and Prevention intravascular
bloodstream infection guidelines or other evidence-based national
guidelines, as recommended by the advisory committee. A general acute
care hospital that uses CVCs shall internally report CVC associated
blood stream infection rates in intensive care units, utilizing
device days to calculate the rate for each type of intensive care
unit, to the appropriate medical staff committee of the hospital on a
regular basis.


1288.7.  By July 1, 2007, the department shall require that each
general acute care hospital, in accordance with the Centers for
Disease Control guidelines, take all of the following actions:
   (a)  Annually offer onsite influenza vaccinations, if available,
to all hospital employees at no cost to the employee. Each general
acute care hospital shall require its employees to be vaccinated, or
if the employee elects not to be vaccinated, to declare in writing
that he or she has declined the vaccination.
   (b) Institute respiratory hygiene and cough etiquette protocols,
develop and implement procedures for the isolation of patients with
influenza, and adopt a seasonal influenza plan.
   (c) Revise an existing or develop a new disaster plan that
includes a pandemic influenza component. The plan shall also document
any actual or recommended collaboration with local, regional, and
state public health agencies or officials in the event of an
influenza pandemic.



1288.8.  (a) By January 1, 2008, the department shall take all of
the following actions to protect against health care associated
infection (HAI) in general acute care hospitals statewide:
   (1) Implement an HAI surveillance and prevention program designed
to assess the department's resource needs, educate health facility
evaluator nurses in HAI, and educate department staff on methods of
implementing recommendations for disease prevention.
   (2) Investigate the development of electronic reporting databases
and report its findings to the HAI advisory committee established
pursuant to Section 1288.5.
   (3) Revise existing and adopt new administrative regulations, as
necessary, to incorporate current Centers for Disease Control and
Prevention guidelines and standards for HAI prevention.
   (4) Require that general acute care hospitals develop a process
for evaluating the judicious use of antibiotics, the results of which
shall be monitored jointly by appropriate representatives and
committees involved in quality improvement activities.
   (b) On and after January 1, 2008, each general acute care hospital
shall implement and annually report to the department on its
implementation of infection surveillance and infection prevention
process measures that have been recommended by the Centers for
Disease Control and Prevention (CDC) Healthcare Infection Control
Practices Advisory Committee, as suitable for a mandatory public
reporting program. Initially, these process measures shall include
the CDC guidelines for central line insertion practices, surgical
antimicrobial prophylaxis, and influenza vaccination of patients and
healthcare personnel. In consultation with the advisory committee
established pursuant to Section 1288.5, the department shall make
this information public no later than six months after receiving the
data.
   (c) The Healthcare Associated Infection Advisory Committee shall
make recommendations for phasing in the implementation and public
reporting of additional process measures and outcome measures by
January 1, 2008, and, in doing so, shall consider the measures
recommended by the CDC.
   (d)  Each general acute care hospital shall also submit data on
implemented process measures to the National Healthcare Safety
Network of the CDC, or to any other scientifically valid national HAI
reporting system based upon the recommendation of the Centers for
Disease Control (CDC) Healthcare Infection Control Practices Advisory
Committee.  Hospitals shall utilize the Centers for Disease Control
and Prevention definitions and methodology for surveillance of HAI.
Hospitals participating in the California Hospital Assessment and
Reporting Task Force (CHART) shall publicly report those HAI measures
as agreed to by all CHART hospitals.


1288.9.  By January 1, 2009, the department shall do all of the
following:
   (a) Require each general acute care hospital to develop,
implement, and periodically evaluate compliance with policies and
procedures to prevent secondary surgical site infections (SSI). The
results of this evaluation shall be monitored by the infection
prevention committee and reported to the surgical committee of the
hospital.
   (b) Require each general acute care hospital to develop policies
and procedures to implement the current Centers for Disease Control
and Prevention guidelines and Institute for Healthcare Improvement
(IHI) process measures designed to prevent ventilator associated
pneumonia.
   (c) During surveys, evaluate the facility's compliance with
existing policies and procedures to prevent HAI, including any
externally or internally reported HAI process and outcome measures.