On this page: Background | Educational Resources | Data & Reporting | Regulatory Resources | Collaborations
Background
Hospitals offer a place to get diagnosed, treated, or rehabilitated. Hospital settings include:
- Acute Care Hospitals
- Children's Hospitals
- Critical Access Hospitals
- Long-Term Acute Care Hospitals
- Psychiatric Hospitals
- Inpatient Rehabilitation Facilities
Special considerations for infection prevention in these settings:
- CDC Interfacility Transfer Form - The patient transfer form helps make it easier to share information when patients are moved between different places for care. Hospitals and groups focused on making patient safety better can change and use this form to fit their needs.
VDH Infection Prevention and Control Assessments
Our team is available to conduct no cost, consultative, non-regulatory, and non-punitive onsite assessments for infection prevention and control (IPC) programs in Virginia.
Benefits of Collaborating with VDH for IPC Assessments:
- The VDH Team can help strengthen your facility’s IPC program and activities
- IPC Program improvements make your facility safer for patients and staff
- VDH experts can answer your questions and provide education and training at no cost
What to Expect at your IPC Assessment:
- Before the in-person assessment, VDH will ask you some demographic questions to understand your facility better.
- During the visit, VDH staff will tour your facility to learn and observe IPC practices.
- After the visit, VDH staff will:
- Provide a written summary of facility strengths and recommendations for IPC improvement
- Offer follow-up discussion
- Supply resources and education tailored to your needs
Educational Resources
General resources for hospital settings
- HQIN - Hospital Resources: select “Hospitals” under “Settings” to filter resources
- Statewide Program in Infection Control and Epidemiology (SPICE) – acute care courses and resources
Return to the Resources Hub to view all healthcare settings.
Infections and organism webpages with resources specific to hospital settings:
- Bloodborne Pathogens
- Candida auris
- Carbapenem-Resistant Organisms (CRO)
- Catheter-Associated Urinary Tract Infections (CAUTI) / UTI
- Central Line-Associated Bloodstream Infections (CLABSI)
- Clostridioides difficile
- COVID-19
- Staphylococcus Aureus
- Scabies & Bed Bugs
- Surgical Site Infections (SSI)
Return to the Resources Hub to view all infections and organisms.
Healthcare-associated infections and antimicrobial resistance (HAI/AR) topic webpages with resources specific to hospital settings:
Return to the Resources Hub to view all HAI/AR topics.
Data & Reporting
National Healthcare Safety Network (NHSN)
On March 21, 2005, the Virginia General Assembly approved House Bill 1570 that amended the Code of Virginia (by adding §32.1-35.1) to make information on selected nosocomial (i.e., healthcare-associated) infections reportable to VDH through NHSN. The Code further directed the Board of Health to develop regulations that specify the infections to be reported and the patient populations to be included. After significant consultation with stakeholders to determine the kind of data that would be both reliable and useful, the Regulations for Disease Reporting and Control were amended to add a section (12VAC5-90-370) related to HAIs. In Virginia, central line-associated bloodstream infection data from hospital adult intensive (critical) care units have been shared with VDH since July 2008.
On September 25, 2015, the HAI reporting regulations were amended to expand the amount of HAI data that are shared with VDH. The regulations aligned reporting to the state health department with what hospitals are already reporting to NHSN for the purposes of complying with CMS reporting requirements. See Table 1 for measures that are part of the state reporting requirements for acute care hospitals. Note that the table lists the current reporting requirements. VDH reporting requirements will expand as CMS reporting requirements expand.
Table 1. HAI Reporting Requirements for Acute Care Hospitals in Virginia
CMS Reporting Program | HAI Event | Applicable Units | Reporting Start Date |
---|---|---|---|
Hospital Inpatient Quality Reporting (IQR) Program | Central line-associated bloodstream infections (CLABSI) | Adult, pediatric, and neonatal intensive care units | July 2008 (VDH); January 2011 (CMS) |
IQR Program | CLABSI | Adult and pediatric medical, surgical, and medical/surgical inpatient wards | January 2015 |
IQR Program | Catheter-associated urinary tract infections (CAUTI) | Adult and pediatric intensive care units | January 2012 |
IQR Program | CAUTI | Adult and pediatric medical, surgical, and medical/surgical inpatient wards | January 2015 |
IQR Program | Surgical site infections (SSIs) following colon procedures | Inpatient procedures | January 2012 |
IQR Program | SSIs following abdominal hysterectomy procedures | Inpatient procedures | January 2012 |
IQR Program | Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia laboratory-identified events | Facility wide inpatients (FacWideIN) including ED, 24-hour observation | January 2013 |
IQR Program | Clostridioides difficile (C. difficile) laboratory-identified events | Facility wide inpatients (FacWideIN) including ED, 24-hour observation | January 2013 |
IQR Program | Healthcare personnel influenza vaccination | All inpatient healthcare personnel | January 2013 |
Long-term acute care hospitals are acute care hospitals that provide services and treatment for patients who are generally very sick and stay, on average, more than 25 days. There are five long-term acute care hospitals in Virginia.
In February 2019, the Virginia General Assembly passed House Bill 2425, which amended the Code of Virginia (§32.1-35.1) to expand statewide surveillance for HAIs to additional healthcare settings. Under this bill, long-term acute care hospitals (LTACHs) are required to share data with VDH as of July 1, 2019. Data required to be reported to NHSN to meet CMS requirements should be shared with VDH through the NHSN system. See Table 1 for measures that are part of the state reporting requirements for LTACHs. Note that the table lists the current reporting requirements. VDH reporting requirements will expand as CMS reporting requirements expand.
Table 1. HAI Reporting Requirements for Long-Term Acute Care Hospitals in Virginia
CMS Reporting Program | HAI Event | Applicable Units | Reporting Start Date |
---|---|---|---|
Long-Term Care Hospital Quality Reporting (LTCHQ) Program | Central line-associated bloodstream infections (CLABSI) | Adult and pediatric long-term acute care intensive care units and wards | October 2012 |
LTCHQ Program | Catheter-associated urinary tract infections (CAUTI) | Adult and pediatric long-term acute care intensive care units and wards | October 2012 |
LTCHQ Program | Clostridioides difficile (C. difficile) laboratory-identified events | Facility-wide inpatients (FacWideIN) | January 2015 |
LTCHQ Program | Healthcare personnel influenza vaccination | All inpatient healthcare personnel | October 2014 |
Inpatient rehabilitation facilities (IRFs) are hospitals, or part of a hospital, that provide intensive rehabilitation services using an interdisciplinary team approach. Admission to an IRF is appropriate for patients with complex nursing, medical management, and rehabilitative needs. There are ten freestanding IRFs and 18 rehabilitation locations within other hospitals in Virginia.
In February 2019, the Virginia General Assembly passed House Bill 2425, which amended the Code of Virginia (§32.1-35.1) to expand statewide surveillance for HAIs to additional healthcare settings. Under this bill, inpatient rehabilitation facilities (IRFs) are required to share data with VDH as of July 1, 2019. Data required to be reported to NHSN to meet CMS requirements should be shared with VDH through the NHSN system. See Table 1 for measures that are part of the state reporting requirements for IRFs. Note that the table lists the current reporting requirements. VDH reporting requirements will expand as CMS reporting requirements expand.
Table 1. HAI Reporting Requirements for Inpatient Rehabilitation Facilities in Virginia
CMS Reporting Program | HAI Event | Applicable Units | Reporting Start Date |
---|---|---|---|
Inpatient Rehabilitation Facility Quality Reporting (IRFQR) Program | Catheter-associated urinary tract infections (CAUTI) | Adult and pediatric inpatient rehabilitation facility wards | October 2012 |
IRFQR Program | Clostridioides difficile (C. difficile) laboratory-identified events | Facility-wide inpatients (FacWideIN) | January 2015 |
IRFQR Program | Healthcare personnel influenza vaccination | All inpatient healthcare personnel | October 2014 |
Reporting
- Surveillance Tools for Enrolled Acute Care Hospitals (CDC) – NHSN protocols and resources specific to acute care hospitals
- CMS Reporting Resources for Acute Care Hospitals (CDC) – Operational guidance and monthly checklists for reporting for acute care hospitals
- CMS Care Compare – Public information about the quality of care at CMS-certified facilities; use to find hospitals, inpatient rehabilitation facilities, or long-term care hospitals (LTACHs) and compare facilities
- Surveillance Tools for Enrolled Long-term Acute Care Hospitals (CDC) – NHSN protocols and resources specific to long-term acute care hospitals
- CMS Reporting Resources for Long-term Acute Care Hospitals (CDC) – Operational guidance and monthly checklists for reporting for long-term acute care hospitals
- CMS Reporting Resources for Inpatient Rehabilitation Facilities (CDC) – Operational guidance and monthly checklists for reporting for inpatient rehabilitation facilities
- Surveillance Tools for Enrolled Inpatient Rehabilitation Facilities (CDC) – NHSN protocols and resources specific to inpatient rehabilitation facilities
Virginia Communicable Disease & Outbreak Reporting Requirements
- Virginia Reportable Disease List
- Outlines diseases and conditions (including outbreaks) that are reportable to the local health department by physicians, directors of medical care facilities, and directors of laboratories.
- Part of the Regulations for Disease Reporting and Control
- Confidential Morbidity Report Form (Paper version)
- Suspected Outbreak Reporting Portal
Regulatory Resources
- Virginia Healthcare and Congregate Care Facility Licensing and Regulatory Crosswalk
- Virginia Regulatory Town Hall – source of information about proposed changes to Virginia’s regulations; includes online forums where the public can make comments on proposed regulations
- VDH Disease Reporting and Control Regulations page
- VDH Office of Licensure and Certification (OLC) page