1. (a) ICD-CM codes as designated by the federal Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) or its successor shall constitute the definition of events listed in this rule. Facilities shall adapt to changes in ICD-CM specifications as directed by NHSN and the department.
2. (b) All general hospitals shall report the number of device days and laboratory-confirmed central line-associated primary bloodstream infections in special care settings including the causative pathogen.
3. (c) All general hospitals, including pediatric and adolescents hospitals shall report the number of urinary catheter device days and laboratory-confirmed catheter-associated urinary tract infections in special care settings.

4. (d) General hospitals, other than pediatric and adolescent hospitals, and ambulatory surgical centers shall report the HAI data related to the following surgical procedures. The surgical procedure is defined by the NHSN operative procedure and the associated ICD-CM codes linked to that operative procedure in NHSN.

   1. (1) Colon surgeries (Colon surgery).
   2. (2) Hip arthroplasties (Hip prosthesis).
   3. (3) Knee arthroplasties (Knee prosthesis).
   4. (4) Abdominal hysterectomies (Abdominal hysterectomy).
   5. (5) Vaginal hysterectomies (Vaginal hysterectomy).
   6. (6) Coronary artery bypass grafts (Coronary artery bypass graft with both chest and donor site incisions and Coronary artery bypass graft with chest incision only).
   7. (7) Vascular procedures (Abdominal aortic aneurysm repair, Carotid endarterectomy, and Peripheral vascular bypass surgery).

5. (e) Pediatric and adolescent hospitals shall report the HAI data relating to the following surgical procedures. The surgical procedure is defined by the NHSN operative procedure and the associated ICD-CM codes linked to that operative procedure in NHSN.

   1. (1) Spinal surgery with instrumentation (Spinal fusion, Laminectomy, and Refusion of spine).
   2. (2) Cardiac procedures, excluding thoracic cardiac procedures (Cardiac surgery and Heart transplant).
   3. (3) Ventriculoperitoneal shunt procedures (Ventricular shunt operations), including revision and removal of shunt.
6. (f) Facilities shall report whether the HAI or the NHSN-reported PAE contributed to a patient's death either directly or by exacerbating an existing disease condition which then led to death.

7. (g) General hospitals and ambulatory surgical centers shall report any of the following preventable adverse events involving the facility's patient.

   1. (1) A health care-associated adverse condition or event for which the Medicare program will not provide additional payment to the facility under a policy adopted by the federal Centers for Medicare and Medicaid Services.
   2. (2) An event included in the list of adverse events identified by the National Quality Forum.
   3. (3) The executive commissioner may exclude an adverse event from the reporting requirement if the executive commissioner, in consultation with the advisory panel, determines that the adverse event is not an appropriate indicator of a preventable adverse event.

8. (h) Facilities shall also report denominator data as indicated in TxHSN protocols for TxHSN-reported PAEs. For the HAI events identified in this section for calculation of risk adjusted infection rates as required in Texas Health and Safety Code, §98.106(b), NHSN protocols shall be used for the determination of denominator data for HAI and NHSN-reported PAEs. The following facility information shall be entered by the facility for each reporting period.

   1. (1) Number of beds.
   2. (2) Number of surgeries or invasive procedures performed during the reporting period.
   3. (3) Number of patient days.
9. (i) If a facility has no HAI and/or PAE during the reporting period, facilities shall report this information through NHSN for HAI and NHSN-reported PAEs. Facilities shall report the absence of TxHSN-reported PAEs through the TxHSN portal or its successor.

Source Note:The provisions of this §200.4 adopted to be effective May 4, 2011, 36 TexReg 2729; amended to be effective August 7, 2012, 37 TexReg 5793; amended to be effective April 21, 2013, 38 TexReg 2363; amended to be effective September 17, 2014, 39 TexReg 7340; amended to be effective January 18, 2015, 40 TexReg 245.