The Commonwealth of Massachusetts

Executive Office of Health and Human Services
Department of Public Health
Center for Quality Assurance and Control
99 Chauncy Street, 2nd floor
Boston, MA 02111
(617)753-8000

DEVAL L. PATRICK
GOVERNOR
TIMOTHY P. MURRAY
LIEUTENANT GOVERNOR
JUDYANN BIGBY, MD
SECRETARY
PAUL J. COTE, JR.
COMMISSIONER	

Circular Letter:  DHCQ 07-02-474
						
TO:   		Hospital Chief Executive Officers
          		Risk Managers 
Infection Control Officers

FROM:	Paul Dreyer, Ph.D.
		Associate Commissioner

DATE:	February 15, 2007

SUBJECT:	Hospital Reporting Requirements

This letter is one of an ongoing series of communications with hospitals regarding their obligations to report serious incidents to the Department as set out in hospital licensure regulations 105 CMR 130.331.  Previous letters #5-95-352, #12-98-385, and
#04-03-439 outline reporting requirements.  Circular letters #12-98-385 and #04-03-439 are available on the Division of Health Care Quality’s website at http://www.mass.gov/dph/dhcq . (The information in circular letter #5-95-352 was repeated in #12-98-385 and therefore the 1995 letter is not included separately on the website.)

This letter addresses two ongoing issues:

1.	Requirements to report emergency conditions, and 
2.	Requirements to report ‘reportable infectious disease outbreaks’

Emergency Conditions. In recent months several hospitals have experienced emergency conditions that have necessitated the closure of units or the transfer of patients. These conditions have resulted from such events as flooding, smoke damage, and fires.  Such incidents must be reported to the Division of Health Care Quality immediately by telephone as described in Circular Letter 12-98-385, however please note that although the telephone number for reporting incidents during normal business hours is still (617) 753-8150, the telephone number for reporting incidents after normal business hours is now (617) 363-0755.
  
Please contact Lillian Jette at the Division of Health Care Quality at (617) 753-8000 if you have any questions on this reporting requirement.  Please note that if written reports are mailed rather than faxed, they should be sent to the Division’s current address at: 

Division of Health Care Quality
99 Chauncy Street, 2nd floor
Boston, MA   02111

Reportable Infectious Disease Outbreaks. Hospitals are obligated to report certain ‘infectious disease outbreaks’ to the Division of Health Care Quality, certain outbreaks to the Bureau of Communicable Disease Control (or the Local Board of Health), and certain outbreaks to both. We have attached a letter addressed to Hospital Infection Control Departments that explains the circumstances that lead to the different reporting requirements.  Please share these materials with the staff responsible for infection control at your facility.

Questions on reportable outbreaks may be directed to the Division of Epidemiology and Immunization at (617) 983-6800.

The Commonwealth of Massachusetts

Executive Office of Health and Human Services
Department of Public Health
250 Washington Street, Boston, MA 02108-4619

DEVAL L. PATRICK
GOVERNOR
TIMOTHY P. MURRAY
LIEUTENANT GOVERNOR
JUDYANN BIGBY, MD
SECRETARY
PAUL J. COTE, JR.
COMMISSIONER	

TO:  	    Infection Control Departments, Licensed Hospitals 

FROM:   Paul Dreyer, Ph.D., Associate Commissioner 
                Alfred DeMaria, Jr., Associate Commissioner

DATE:    February 15, 2007

RE:	    Reporting Requirements for Nosocomial Infections

This letter clarifies reporting requirements for clusters or outbreaks of nosocomial (hospital-acquired) infection. 

The Reportable Diseases, Surveillance, and Isolation and Quarantine Regulations (105 CMR 300.134) require the reporting of illness believed to be part of an outbreak or cluster.  This portion of the regulations was adopted primarily to authorize practitioners to report community outbreaks of undiagnosed or ill-defined illness so that public health interventions could be initiated.  

An outbreak or cluster is defined as cases of illness clearly in excess of the number of cases normally expected.  The number of cases considered to be a cluster will vary with the circumstances and in all cases is identified by a significant increase in the usual frequency (cases over time).  Health care facilities differ in size and patient acuity, so consideration of the facility circumstances, background rates of the infection in question and similar infections, and the clinical situation underlying potential clusters must be factored in the identification of clusters or outbreaks.  Individual facilities should maintain surveillance records that establish baselines against which clusters in time and space might be recognized.   

The hospital licensure regulations governing the reporting of serious incidents and accidents (105 CMR 130.331) require hospitals to report incidents that seriously affect the health and safety of patients, including “reportable infectious disease outbreaks” (see Circular Letter: DHCQ 12-98-385 at http://www.mass.gov/dph/dhcq ).

The attached chart describes circumstances under which clusters should be reported to the Division of Health Care Quality and those circumstances under which clusters/outbreaks should be reported to local boards of health or the Department of Public Health’s Bureau of Communicable Disease Control.  Questions may be directed to the Division of Epidemiology and Immunization at (617) 983-6800.

MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH (MDPH)
DIVISION OF HEALTH CARE QUALITY and
BUREAU OF COMMUNICABLE DISEASE CONTROL
HOSPITAL INFECTIOUS DISEASE REPORTING REQUIREMENTS 

Report to MDPH Division of Health Care Quality:
During normal business hours: (617) 753-8150 
After normal business hours: (617) 363-0755
For information: (617) 753-8000	

Clusters of two or more infections, of an unusual or unexpected nature, occurring greater than 48 hours after admission, that directly result in morbidity or mortality above that expected,
OR
lead to closure of a clinical unit or curtailment of services.

Report to the Local Board of Health 
or the MDPH Bureau of Communicable Disease Control:
For information: (617) 983-6800 	

Single or multiple cases
of any disease or condition on the list of reportable diseases
(105 Code of Massachusetts Regulations 300);  see http://www.mass.gov/dph/cdc/surveillance/rdiq_reg_summary.pdf
Consult with the Bureau of Communicable Disease Control
about any clusters/outbreaks of community-acquired disease.