(a) Each facility regulated under this chapter with an annual average daily census of at least twenty-five (25) inpatients based on the most recent JAR public data, where applicable, or an outpatient facility that performs an annual average of twenty-five (25) procedures per day shall join the centers for disease control’s national nosocomial infection surveillance/national healthcare safety network (NNIS/NHSN) surveillance system within one hundred twenty (120) days of when it becomes open to the facility’s type of license in order to unify reporting systems and to benchmark against a national standard. Facilities shall meet data reporting timeframes as required by NHSN and shall utilize standard methods, including healthcare acquired case-finding techniques, CDC infection definitions and other relevant terms, and NHSN software for data collection and reporting. Data submitted by the reporting facility shall be reported without any patient identifiers.
Facility: means any institution, place or building providing health care services that is required to be licensed under this chapter. See Tennessee Code 68-11-201
Hospital: means any institution, place, building or agency represented and held out to the general public as ready, willing and able to furnish care, accommodations, facilities and equipment for the use, in connection with the services of a physician or dentist, of one (1) or more nonrelated persons who may be suffering from deformity, injury or disease or from any other condition for which nursing, medical or surgical services would be appropriate for care, diagnosis or treatment. See Tennessee Code 68-11-201
Patient: includes , but is not limited to, any person who is suffering from an acute or chronic illness or injury or who is crippled, convalescent or infirm, or who is in need of obstetrical, surgical, medical, nursing or supervisory care. See Tennessee Code 68-11-201
Record: means information that is inscribed on a tangible medium or that is stored in an electronic or other medium and is retrievable in a perceivable form. See Tennessee Code 1-3-105
(b)(1) Facilities shall grant the department of health access to the NHSN database on:
(A) Central line associated bloodstream infections (CLABSI) in intensive care units for hospital specific reporting on the department of health’s website. CLABSIs for burn units and Level 1 trauma units are excluded. The department shall disseminate the public reports based on data compiled for a period of twelve (12) months, no sooner than six (6) months but not later than eight (8) months following the month the facility reports the data. The reports shall be updated every six (6) months with the most recent four (4) quarters of data. The department shall only display facility specific rates for facilities with greater than thirty (30) central line insertions per year; and(B) Surgical site infections for coronary artery bypass grafts (CABG). On surgical site infections for CABG data, all facility identifiers shall be confidential and may not be released by the department. The department shall report only aggregate statewide performance on CABG surgical infection rates.(2) The department shall maintain the confidentiality of all medical record information abstracted by or reported to the agency. The department shall be granted initial access one (1) year after NHSN becomes open to facilities. Every six (6) months the department shall update information posted on the department’s website received from the NHSN database authorized for public review.
