HAI Updates: Dialysis Reporting

 

To: Dialysis Facility Administrators and Infection Preventionists From: CDPHE Healthcare-Associated Infections and Antimicrobial Resistance (HAI/AR) Program  Outpatient dialysis facility reporting and Centers for Medicare and Medicaid Services(CMS) exclusion criteria for facilities that see 10 or fewer patients  At the March 24th meeting, the HAI Advisory Committee voted to align Colorado reporting requirements for outpatient dialysis facilities to report access-related bloodstream infections with the Centers for Medicare and Medicaid Services (CMS) End Stage Renal Disease (ESRD) Quality Incentive Program (QIP) National Healthcare Safety Network (NHSN) Measures.  Facilities treating 10 or fewer patients in a calendar year are excluded from the Colorado access-related bloodstream infections reporting requirement. Please update your reporting plans accordingly. This change is reflected in the HAI Reportable Conditions listing on the CDPHE website. More information is available from CDC: About CMS ESRD QIP Rule | NHSN | CDC.

HAI Advisory Committee Meeting on March 24, 2026, 2-4p

 

To: Infection Preventionists and Facility Administrators From: CDPHE Healthcare-Associated Infections and Antimicrobial Resistance (HAI/AR) Program The next HAI Advisory Committee meeting is Tuesday, March 24, 2-4pm. During this meeting, we will discuss: 1. An overview of the Healthcare-Associated Infections and Antimicrobial Resistance (HAI/AR) Program, HAI reportable conditions, and findings from public health surveillance The National Healthcare Safety Network’s (NHSNs) new 202 standardized infection ratio (SIR) baseline and adoption for use in the HAI Annual Report Outpatient dialysis facility reporting in Colorado and Centers for Medicare and Medicaid Services (CMS) exclusion criteria for facilities that see 10 or fewer patients.  The agenda will be posted on the CDPHE website 24 hours prior to the meeting. We encourage interested stakeholders to join this discussion and contribute your thoughts. Contact cdphe_hai_ar@state.co.us to register for the HAI Advisory Committee meeting. For more information about the 2022 SIR rebaselining, review the Center for Disease Control and Prevention (CDC's) webpage on 2022 SIR Rebaseline. For more information about the Centers for Medicare and Medicaid Services reporting requirements for outpatient dialysis facilities, review the CDC frequently asked questions document. Note that CDPHE and CMS reporting requirements may differ.

CDPHE Recruiting 2 Members for HAI Advisory Committee

 

To: Facility Administrators, Physicians, Health Insurers, Infection Preventionists, Chief Medical Officers, Medical Staff From: CDPHE Healthcare-Associated Infections and Antimicrobial Resistance Program CDPHE is recruiting two new members of the Healthcare-Associated Infections Advisory (HAI) Committee. Currently, the committee is requesting applicants for the following two positions: Physician, and Representative from a health insurer The physician must be board-certified or board-eligible physician, licensed in the state of Colorado, affiliated with a Colorado hospital or medical school, an active member of a national organization specializing in health-care epidemiology or infection control, and have demonstrated an interest and expertise in health facility infection control.  Applicants must be a resident of Colorado and must be able to contribute objectively to committee meetings from the perspective of the position. All interested and qualified individuals should apply. This position will be appointed by the Executive Director of CDPHE for a term of three years. Please see the Recruitment Letter for details. For further information, contact Nicole Harty at cdphe_hai_ar@state.co.us.

Be part of a nursing home network to improve resident health and public safety!

 

To: Long term care facility directors of nursing and infection preventionists From: CDPHE Healthcare Associated Infection/Antimicrobial Resistance (HAI/AR) Program The CDPHE’s HAI/AR Program is starting recruitment for a CDC led project focusing on patient health and safety in nursing homes, and we would love for you to participate! CDPHE CDC Nursing Home Network details. For further information: Please contact Catherine Emanuel at catherine.emanuel@state.co.us or fill out the interest form.

NHSN Office Hours - Feb. 18, 2026 at 1:00 p.m.

To: Acute care hospitals, ambulatory surgery centers, critical access hospitals, outpatient hemodialysis centers, inpatient rehabilitation facilities, long-term acute care hospitals, pediatric hospitals From: The Healthcare-Associated Infections (HAI) and Antimicrobial Resistance (AR) Program at the Colorado Department of Public Health and Environment (CDPHE) The CDPHE HAI AR program provides quarterly National Healthcare Safety Network (NHSN) office hours. These are held in conjunction with the NHSN Antimicrobial Use and Resistance Module (AUR) office hours. These are a great way to connect with the HAI/AR program at CDPHE, and get your questions answered regarding antimicrobial stewardship, HAIs, or NHSN reporting.  The next NHSN office hours will be held on February 18, 2026, from 1:00 to 1:45 p.m Mountain Time via Zoom. You can register here. We will discuss updates to the HAI Annual Report and NHSN AUR module. There will also be a Q&A section, so bring any questions you might have. Office hours Zoom registration:  https://zoom.us/meeting/register/tJYqde6trzosHNIP_z82D2fBf9EAAdRmp4gE For further information, please contact the CDPHE HAI AR program, cdphe_hai_ar@state.co.us.

HAI Advisory Committee Meeting - Jan. 27, 2026 - Possible of removal of reportable healthcare-associated infections from the HAI Annual Report

To: Health care facility administrators and infection preventionists in acute care hospitals and critical access hospitals. From: The Healthcare-Associated Infections and Antimicrobial Resistance (HAI/AR) Program, CDPHE We invite stakeholders to attend the HAI Advisory Committee Meeting from 2:00 - 4:00 p.m. on Monday, Jan. 27, 2026. During the meeting, the HAI Advisory Committee will discuss whether to remove the following conditions from the list of reportable conditions and from the HAI Annual Report: Surgical site infections (SSIs) following outpatient colon surgeries in acute care hospitals Central line-associated bloodstream infections in critical access hospitals SSIs following surgeries in critical access hospitals: inpatient hysterectomies, outpatient hysterectomies, inpatient breast surgeries, outpatient breast surgeries, outpatient colon surgeries, and  outpatient hip surgeries. The HAI Advisory Committee is considering removal of these reportable conditions, because small numbers of procedures and data suppression rules contribute to tables empty of data in the HAI Annual Report; however, the Committee must also consider whether the low numbers of procedures and infections may be due to underreporting, as well as alternative quality measures. Please join the remote HAI Advisory Committee Meeting on Jan. 27, as we value your input. To receive the Zoom link, contact cdphe_hai_ar@state.co.us. The meeting agenda will be posted on our webpage 24 hours in advance.

HAI Annual Report feedback survey

To: Acute care hospitals, ambulatory surgery centers, critical access hospitals, inpatient rehabilitation facilities, long-term acute care hospitals, pediatric hospitals, outpatient hemodialysis facilities  From: The Healthcare-Associated Infections and Antimicrobial Resistance Program at the Colorado Department of Public Health and Environment Please take a moment to complete this brief survey, which will help us gather feedback on how to improve the HAI Annual Report and HAI Dashboard.  https://docs.google.com/forms/d/e/1FAIpQLSd1lbrzZkPCuk1WE4TQ5ODbwAtRdmqZZ6YSk7o46YugEPxBog/viewform?usp=publish-editor Every year, the Colorado Department of Public Health and Environment (CDPHE) Healthcare-Associated Infections and Antimicrobial Resistance (HAI/AR) Program publishes the HAI Annual Report, which contains HAI data from facilities across the state. In 2025, we launched an HAI Dashboard alongside the annual report to give consumers an interactive data display. We are now evaluating how healthcare facilities utilize the HAI Annual Report and HAI Dashboard to identify opportunities for making them more widely available and effective. We ask that one or more administrators, infection preventionists, patient care providers, quality improvement professionals, or people in other relevant roles complete this brief 5-10 minute survey. The first part of the survey asks questions about the written HAI Annual Report. The second part of the survey asks questions about the HAI Dashboard.

CDC - Advancing Hemovigilance to Identify Transfusion-Transmitted Infections

To: Facility Administrators and Infection Preventionists From: The Healthcare-Associated Infections and Antimicrobial Resistance Program, Communicable Disease Branch, Colorado Department of Public Health and Environment The CDPHE Healthcare-Associated Infections and Antimicrobial Resistance (HAI/AR) Program encourages healthcare facilities to enroll in the National Healthcare Safety Network (NHSN) hemovigilance module in 2026. The module is designed to track infrequent (a handful of events in the U.S. every 1-2 years) but serious transfusion-transmitted infections (TTI) nationwide and facilitate a rapid public health response. All U.S. healthcare facilities where blood components and manufactured blood products are transfused are eligible to report.  CDC is updating the hemovigilance module of the Biovigilance Component of NHSN in early 2026 to quickly and systematically identify emerging pathogens that can be transmitted through blood transfusions. The new module (version 3.0) is substantially streamlined relative to the current version. Participating healthcare facilities will have their laboratory system flag pathogens of interest.* The flag will trigger the hospital epidemiologist or infection preventionist to review the patient’s transfusion history in the prior 30 days and send an alert to CDC via NHSN if positive. CDC will work with the CDPHE HAI/AR Program to investigate TTIs in Colorado.  Eligible healthcare facilities can enroll in the new hemovigilance module and complete the Annual Facility Survey in January 2026. Reporting can begin at the end of March 2026 (estimated March 19). In the meantime, CDC will announce and host dedicated office hours for enrolled facilities.  TTIs can be severe and geographically widespread, but they are under-identified. Enrolling in the NHSN hemovigilance module 3.0 will help keep patients and the public safe. Enrollment is voluntary. To enroll your healthcare facility, go to www.cdc.gov/nhsn. We anticipate updated guidance to be posted in January. For questions about the use of NHSN or the public health response to TTIs in Colorado, email the HAI/AR Program at cdphe_hai_ar@state.co.us. *Pathogens of interest include:  Viruses: Cache Valley virus, Colorado tick fever virus, Dengue virus, Eastern Equine Encephalitis virus, Hepatitis A virus, Hepatitis E virus, Japanese Encephalitis Virus, Oropouche virus, Powassan virus, St. Louis encephalitis virus, Tick-borne encephalitis virus, Chikungunya, Yellow Fever virus, Zika virus.  Bacteria: Acinetobacter baumannii, Anaplasma phagocytophilum, Brucella spp., Coxiella burnetii (Q Fever), Ehrlichia spp., Leclercia adecarboxylata, Rickettsia rickettsii.  Parasites: Babesia spp., Leishmania spp., Plasmodium spp. (Malaria).

The 2025 HAI Annual Report and HAI Dashboard have been reposted

To: Administrators and infection preventionists at acute care hospitals, critical access hospitals, ambulatory surgery centers, inpatient rehabilitation facilities, long-term acute care hospitals, outpatient dialysis centers, pediatric hospitals   From: The Healthcare-Associated Infections and Antimicrobial Resistance Program at the Colorado Department of Public Health and Environment The 2025 Healthcare-Associated Infections (HAI) Annual Report and HAI Dashboard have been re-posted to the CDPHE website. In the original September publication of the 2025 HAI Annual Report, there were errors in the data reported for surgical site infections in ambulatory surgery centers. The errors included the representation of multiple years of data reported to the National Healthcare Safety Network, rather than one year of data, for the year 2024. The corrected tables and text are included in this revised report, completed Oct. 21, 2025. For any questions, email cdphe_hai_ar@state.co.us.

Infection control breach related to reprocessing of a transrectal ultrasound probe

 

To: Hospitals, Ambulatory Surgical Centers, and Free Standing Emergency Departments From: The Colorado Department of Public Health and Environment Healthcare-Associated Infections and Antimicrobial Resistance Program The Colorado Department of Public Health and Environment Healthcare-Associated Infections and Antimicrobial Resistance Program recently identified that a transrectal ultrasound probe was reprocessed using low-level disinfection (LLD) instead of high-level disinfection (HLD), which was contrary to the manufacturer’s instructions for use (MIFU). This is a semi-critical device for which HLD is necessary. Failure to reprocess this device by HLD according to the MIFU may create a low risk of bacterial, viral, and bloodborne pathogens. In this scenario, the transrectal ultrasound probe was being reprocessed and supplied by a hospital vendor. We are not aware of any infections related to this event. Infection preventionists and sterile processing departments (SPDs) should review the MIFU for endocavitary probes, including transrectal ultrasound probes and similar devices such as endovaginal probes that come into contact with mucous membranes, and ensure that they are reprocessed according to the MIFU. CDC guidelines recommend the use of a new probe cover and HLD between patients, CDC. Disinfection and Sterilization Guideline. Ensure proper reprocessing by internal SPD staff and by external vendors that supply the instrument. If patients are exposed to improperly reprocessed endocavitary probes, conduct a risk assessment for infection or other harm, and consider patient notification as appropriate. Contact the Healthcare-Associated Infections and Antimicrobial Resistance (HAI/AR) Program at the Colorado Department of Public Health and Environment for assistance: email cdphe_hai_ar@state.co.us or call 303-692-2700.

Apply to become a member of the Healthcare-Associated Infections Advisory Committee

 

The Colorado Department of Public Health and Environment (CDPHE) is recruiting four new members of the Healthcare-Associated Infections Advisory (HAI) Committee. Currently, the committee is requesting applicants for the following positions Medical statistician OR clinical microbiologist with an advanced degree, Representative from a health insurer, Infection control practitioner from a long-term care setting, Representative from a rural hospital. Applicants must be a resident of Colorado and must be able to contribute objectively to committee meetings from the perspective of the position. All interested and qualified individuals should apply. This position will be appointed by the Executive Director of CDPHE for a term of three years. The HAI Advisory Committee was established under Colorado Revised Statute (C.R.S.) 25-3-602 to provide oversight to CDPHE for the collection and public reporting of data on HAI infection rates from health facilities. The committee typically meets every other month on the fourth Tuesday of the month from 2 - 4 p.m. CDPHE facilitates committee meetings using video conferencing. There are 11 members who represent a variety of stakeholders. Membership is voluntary. Participation on the HAI Advisory Committee is a great way to learn about HAIs and play an important role in state public health! We appreciate a diversity of input. Membership is not labor intensive, apart from participating in committee meetings. CDPHE invites qualified persons to complete and submit the fillable application with a resume or curriculum vitae by email to cdphe_hai_ar@state.co.us. You may submit additional pages with the application if needed to answer the “additional questions.” The deadline for submission is October 31, 2025. The CDPHE Healthcare-Associated Infections and Antimicrobial Resistance Program will review applicants internally before making a recommendation to the Executive Director for appointment. For more information, please see the HAI Advisory Committee Website or contact Chris Czaja MD, DrPH at christopher.czaja@state.co.us or 303-692-2700.

Healthcare-associated infections (HAI) reporting requirements and the HAI Annual Report – June 2025

 

Healthcare-associated infections (HAI) reporting requirements and the HAI Annual Report – June 2025 All separately licensed healthcare facilities in Colorado must report healthcare-associated infections (HAIs) to the Colorado Department of Public Health and Environment (CDPHE) through the National Healthcare Safety Network (NHSN) as required in Colorado Revised Statutes (C.R.S) 25-3-601-607. Reporting requirements are determined by the HAI Advisory Committee and CDPHE and differ by facility type and reporting location. Facility types include: Acute care hospitals,  Ambulatory surgery centers,  Critical access hospitals,  Inpatient rehabilitation facilities,  Long-term acute care hospitals,  Outpatient hemodialysis centers, and  Pediatric hospitals. Colorado HAI reporting requirements and deadlines can be found on the HAI/AR Program website. In order to meet the reporting requirements, healthcare facilities must include the reportable conditions in their NHSN reporting plan AND confer rights to CDPHE by joining the appropriate CDPHE reporting group in NHSN.  Separately licensed healthcare facilities in separate locations should report separately, even if they share a CMS certification number (CCN). This is consistent with NHSN guidance for facilities that share a CCN. The Centers for Disease Control and Prevention (CDC) will aggregate the data from all applicable NHSN Org IDs and will send data to Centers for Medicare and Medicaid Services (CMS) under the single CCN for CMS reporting purposes. Additionally, healthcare facilities that do not have a CCN are able to use NHSN to fulfill Colorado reporting requirements. The HAI/AR Program in the CDPHE Communicable Disease Branch distributes a survey to healthcare facilities annually in order to determine HAI reporting eligibility and status of reporting. HAI reporting requirements are verified at the time of license renewal as well.  In April 2025, C.R.S. 25-3-603 was amended such that the publication date for HAI Annual Report was changed from July 15th to September 15th beginning in 2025. The timeline for reporting HAI reportable conditions to CDPHE has not changed. Healthcare facilities are responsible for the quality and accuracy of their data reported to CDPHE through NHSN for representation in the HAI Annual Report. NHSN offers training for HAI reporting on the NHSN website. NHSN has announced the Patient Safety Component Annual Training Summer Series to start in June 2025.  For questions about Colorado HAI reporting requirements and timeline, how to confer rights for data access to CDPHE in NHSN, the annual HAI reporting survey, or the HAI Annual Report, email the HAI/AR Program at cdphe_hai_ar@state.co.us. The HAI/AR Program offers NHSN office hours quarterly and provides technical assistance for NHSN reporting upon request. The HAI/AR Program website has information about the HAI Advisory Committee and HAI reporting.

Agency for Healthcare Research and Quality (AHRQ) is offering a free CLABSI Program for Acute Care Hospitals.

 

To: Acute Care Hospitals, Critical Access Hospitals, and Long term-Acute Care Hospitals From: CDPHE HAI/AR Program on behalf of the Agency for Healthcare Research and Quality (AHRQ). AHRQ is currently recruiting acute care hospital units for a free 9-month program to implement and improve evidence-based practices for prevention of central line-associated bloodstream infections (CLABSI). Units will receive training and one-on-one expert coaching to implement sustainable improvements to their infection prevention practices. To learn if your hospital is eligible, attend one of our informational webinars and view our flyer! The Webinars will be held on the following dates and times: Webinars are in Eastern Time (ET) Click on the links below each date and time to register. Thurs, June 5, 2025 10:30-11 a.m. Wed, June 11, 2025 1:30-2 p.m. To learn more about the program, sign up for an informational webinar, or apply for the program please visit: safetyprogram4hai-prevention.ahrq.gov