2012 Delaware Code
Title 16 - Health and Safety
CHAPTER 10A. HOSPITAL INFECTIONS DISCLOSURE ACT
§ 1003A. Hospital reports.

(a) Individual hospitals shall collect data on hospital acquired infection rates related to specific clinical procedures as determined by the Advisory Committee and set forth in regulations promulgated by the Department. Examples may include the following categories:

(1) Surgical site infections such as total hip and knee arthoplasty;

(2) Central line-related bloodstream infections in an intensive care unit (ICU);

(3) Direct healthcare provider's influenza vaccination rates; and

(4) Other categories as provided under subsection (d) of this section.

(b)(1) Infection control professionals, or a designee, of hospitals shall submit quarterly reports on their hospital-acquired infection rates to the Department using the accepted Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) definitions. Prevention and control data related to quality measures will be based on nationally recognized and recommended standards that may include those developed by the CDC, Centers for Medicare and Medicaid, and/or the Agency for Healthcare, Research and Quality, to name a few. Data in quarterly reports must cover a period ending not earlier than 45 days prior to submission of the report. Quarterly reports shall be made available to each hospital 45 days after submittal to the Department for review by the hospitals. The hospitals shall have 7 days to review the quarterly reports and report any changes or provide additional summary information as provided in paragraph (b)(3) of this section below to the Department. Following the 7-day review period, such quarterly reports shall be made available to the public at each hospital and through the Department (the "Public Report"). The first Public Report issued by the Department shall cover an entire calendar year and shall be due no later than June 30, 2009. After this initial annual Public Report, the Department will issue quarterly Public Reports in accordance with this section.

(2) Each quarterly report shall provide background information about each hospital as determined by regulations of the Department. Such background criteria shall include the adult and pediatric populations of each hospital, whether the hospital provides tertiary care, bed size, specialty divisions of each hospital and whether a hospital is a teaching or a nonteaching institution. This background information shall be included in the Public Report.

(3) Each quarterly report shall include a brief summary report to allow hospitals to comment on performance improvement and changes in patient population and risk factors. The information contained in this report shall be considered proprietary information and shall be utilized by the Department had shall not be made available in the Public Report and shall not be subject to disclosure under the State's Freedom of Information Act [Chapter 100 of Title 29].

(4) Each physician who performs a clinical procedure to be reported in accordance with this chapter shall report to the hospital at which the clinical procedures was performed, a hospital-acquired infection the physician diagnoses at a follow-up appointment with the patient; the Advisory Committee created in subsection (c) of this section shall establish standardized criteria and methods for these reports. The infection control department of each hospital shall only be required to report those physician-reported infections that meet the accepted NHSN definitions. This information shall be included in the hospital reports to the Department.

(5) If the hospital is a division or subsidiary of another entity that owns or operates other hospitals or related organizations, the quarterly report shall be for the specific division of subsidiary and not for the other entity.

(c)(1) The Secretary of the Department shall appoint an Advisory Committee, which shall include 1 infection control professional who has responsibility for infection control programs from each hospital or health care system in Delaware, 4 infection disease physicians with expertise in infection control, 1 representative of the Delaware Health Care Facilities Association, and 1 representative from the State Division of Public Health and the Public Health Hospital Infections Specialist responsible for collating and reporting data. The Secretary shall also appoint 8 other members of the Committee including representatives from direct care nursing staff, academic researchers, consumer organizations, health insurers, health maintenance organizations, organized labor and purchasers of health insurance, such as employers. The Advisory Committee shall have the authority to engage personnel with appropriate training and/or certification in infection prevention and control for the purposes of collecting data.

(2) The Advisory Committee shall assist the Department in the development of all aspects of the Department's methodology for collection, analyzing and disclosing the information collected under this chapter, including collection methods, formatting and methods and means for release and dissemination.

(3) In developing the methodology for collecting and analyzing the infection rate data, the Department and the Advisory Committee shall adopt the methodologies and system for data collection from the Centers for Disease Control's National Healthcare Safety Network, or its successor. The data collection and analysis methodology shall be disclosed to the public prior to any public disclosure of hospital-acquired infection rates.

(4) The Department and the Advisory Committee shall meet on a regular basis to review the definitions and assess the methodologies of data collection. The Advisory Committee will periodically evaluate the impact on the individual hospitals and be able to recommend and support modifications to the public reporting system, if necessary.

(d) After June 30, 2010, and upon consultation with the Advisory Committee and other experts in infection, prevention, identification and control, the Department may revise categories of infections set forth in subsection (a) of this section.

76 Del. Laws, c. 122, § 1; 77 Del. Laws, c. 233, §§ 1, 2.;