§ 2819. Hospital acquired infection reporting. 1. For the purposes of\nthis section, "hospital acquired infection" shall mean any localized or\nsystemic patient condition that:\n (a) resulted from the presence of an infectious agent or agents, or\nits toxin or toxins as determined by clinical examination or by\nlaboratory testing; and\n (b) was not found to be present or incubating at the time of admission\nunless the infection was related to a previous admission.\n 2. (a) Each general hospital shall maintain a program capable of\nidentifying and tracking hospital acquired infections for the purpose of\npublic reporting under this section and quality improvement.\n (b) Such programs shall have the capacity to identify the following\nelements: the specific infectious agents or toxins and site of each\ninfection; the clinical department or unit within the facility where the\npatient first became infected; and the patient's diagnoses and any\nrelevant specific surgical, medical or diagnostic procedure performed\nduring the current admission.\n (c) The department shall establish guidelines, definitions, criteria,\nstandards and coding for hospital identification, tracking and reporting\nof hospital acquired infections which shall be consistent with the\nrecommendations of recognized centers of expertise in the identification\nand prevention of hospital acquired infections including, but not\nlimited to the National Health Care Safety Network of the Centers for\nDisease Control and Prevention or its successor. The department shall\nsolicit and consider public comment prior to such establishment.\n (d) Hospitals shall be initially required to identify, track and\nreport hospital acquired infections that occur in critical care units to\ninclude surgical wound infections and central line related bloodstream\ninfections.\n (e) For hospital acquired infections for which the department requires\ntracking and reporting as permitted in this section, hospitals shall be\nrequired to report a suspected or confirmed hospital-acquired infection\nassociated with another hospital to the originating hospital.\nDocumentation of reporting should be maintained for a minimum of six\nyears.\n (f) Subsequent to the initial requirements identified in paragraph (d)\nof this subdivision the department may, from time to time, require the\ntracking and reporting of other types of hospital acquired infections\n(for example, ventilator - associated pneumonias) that occur in\nhospitals in consultation with technical advisors who are regionally or\nnationally-recognized experts in the prevention, identification and\ncontrol of hospital acquired infection and the public reporting of\nperformance data.\n 3. Each hospital shall regularly report to the department the hospital\ninfection data it has collected. The department shall establish data\ncollection and analytical methodologies that meet accepted standards for\nvalidity and reliability. The frequency of reporting shall be monthly,\nand reports shall be submitted not more than sixty days after the close\nof the reporting period.\n 4. The commissioner shall establish a state-wide database of all\nreported hospital acquired infection information for the purpose of\nsupporting quality improvement and infection control activities in\nhospitals. The database shall be organized so that consumers, hospitals,\nhealthcare professionals, purchasers and payers may compare individual\nhospital experience with that of other individual hospitals as well as\nregional and state-wide averages and, where available, national data.\n 5. (a) Subject to paragraph (c) of this subdivision, on or before\nSeptember first of each year the commissioner shall submit a report to\nthe governor and the legislature, which shall simultaneously be\npublished in its entirety on the department's web site, that includes,\nbut is not limited to, hospital acquired infection rates adjusted for\nthe potential differences in risk factors for
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