CJW Medical Center, like most acute care hospitals, identifies healthcare-associated infections through "targeted surveillance" based on an annual risk assessment. This risk assessment is used to prioritize the identified risks for acquiring and transmitting infections within the patient population and community we serve. Infection Preventionists dedicate much of their time and resources to conducting surveillance for reporting measures that impact patient care based on their annual risk assessment. The proposed regulations, as they are written, would not initiate strategies to improve quality or clinical outcomes related to patient care. In addition, “VDH does not plan to conduct data validation on the accuracy of the data reported. In the absence of data validation, it is unclear how the proposed reporting requirements could be effectively enforced.” We respectfully request that any proposed regulations provide a method of validation to ensure that HAIs are being accurately and completely reported and that rates are comparable among all hospitals reporting.

In regard to the proposed regulation for central line associated blood stream infections the statement could be revised to include NICUs to coincide with the Centers for Medicare and Medicaid Services (CMS) requirement. Remove the statement: "wards selected should be those with the longest length of stay during the previous calendar year, excluding cardiology, obstetrics, psychiatry, hospice, and step-down units" in an effort to align with our current reporting requirements. As written, this regulation will be difficult to compare among all hospitals reporting.

Eliminate the proposed regulation for C-difficile lab data, since it does not correlate with our current method of data collection or reporting. The state could provide assistance with the promotion of antibiotic management through a statewide campaign to facilitate antibiotic stewardship in the healthcare setting.

The proposed regulation for reporting SCIP data could be eliminated, since SCIP data is currently available to the public and a link could be added to the VDH website for public access and review.