Form #3 Form #3 ASP Questionnaire - intervention sites

OMB-Attachment D

Form Approved

OBM No. 0935-XXX

Exp. Date XX/XX/20XX

ERASE- C. diff. Antimicrobial Stewardship Survey

Intervention Sites

Enclosed is a brief survey about your hospital’s recent efforts to combat C-difficile infection by introduction of an antimicrobial stewardship program. This project, ERASE C-diff, is funded by U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality (AHRQ) through AHRQ’s ACTION Program. Its goal is to learn about the optimal ways to decrease C-difficile infection through antimicrobial stewardship programs. We are interested in understanding your perceptions of C-difficile in your facility, the effect of your earlier environmental practices and your experiences with antimicrobial stewardship program implementation. On behalf of CDC and AHRQ, the research team from Greater New York Hospital Association (GNYHA) and Boston University School of Public Health (BUSPH) would appreciate your participation in this survey. All responses will be anonymous - neither your name nor identifying information is requested on the survey form and answers will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c); data will only be reported in the aggregate. Thus, there is no way that your supervisor (or anyone else here) will ever know how you answered the survey questions. Please place your completed survey in the enclosed envelope and return it to the person outside the meeting room who gave you the survey. Thank you in advance; your opinions and views are important, and we look forward to receiving your responses. If you have any questions about this project or about the survey, please contact Maria Woods of GNYHA at 212-259-0767 or Mari-Lynn Drainoni of BUSPH at 617-414-1417.

Public reporting burden for this collection of information is estimated to average 7 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

ERASE- C. diff. Antimicrobial Stewardship Survey¹

Please indicate your agreement or disagreement with the following statements about your institution.

(This survey is designed to be administered pre- and post-intervention and to both intervention and control institutions)

Antimicrobial Resistance: Scope of the Problem and Key Contributors

	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree
Antibiotic resistance is a problem in this institution.
Patient rooms are cleaned according to hospital cleaning protocol once a C. difficile patient has been discharged.
Adherence to hand hygiene protocols is excellent at this institution.
Adherence to isolation and contact precautions is excellent at this institution.
This institution does NOT do enough to control the development of C. difficile.
This institution provides adequate staff education regarding C. difficile.
A patient is likely to develop a C. difficile infection during their stay at this institution.

Antibiotic Prescribing Practices

	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree
Microbiology lab results are efficiently communicated to the treating physician.
I regularly refer to the susceptibility/sensitivity patterns at this institution (e.g., an antibiogram) when prescribing antibiotics.
If medically appropriate, intravenous antibiotics should be stepped down to an oral alternative after 3 days.
Restrictions on antibiotics impair my ability to provide good patient care.
Antibiotics are overused at this institution.
A majority of patients admitted to this institution will be prescribed at least one antibiotic during their hospital stay.
Many of my patients receive 5 or more days of antibiotics during their stay at this institution.
Few of my patients are discharged from this institution on antibiotics.
When discharged to a nursing home or long term care facility, most of my patients are on IV antibiotics.

Antimicrobial Stewardship Programs

(A formal program that monitors and manages the appropriate use of antibiotics).

	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree
Antimicrobial stewardship programs can improve patient care.
Antimicrobial stewardship programs reduce the problem of antimicrobial resistance.
Antimicrobial stewardship programs can impact this institution’s C. difficile rates.
This institution has an effective antimicrobial stewardship program.
This institution does NOT provide adequate training on antimicrobial prescribing and use.
Additional staff education on antimicrobial prescribing is needed.
Prescribing physicians are the only disciplines who need to understand antimicrobial stewardship.

Background Information

1. What is your primary work area or unit in this health care facility? (Please check ONE answer)

Many different units/No specific unit
Medicine (non-surgical)	Intensive care unit (any type)	Radiology
Surgery	Psychiatry/mental health	Anesthesiology
Obstetrics	Rehabilitation	Other (please specify:
Pediatrics	Pharmacy	                    )
Emergency department	Laboratory

2. How long have you worked in this health care facility?

Less than 1 year	11 to 15 years
1 to 5 years	16 to 20 years
6 to 10 years	21 years or more

3. What is your staff position in this health care facility?

Attending/Staff physician	Physician assistant
Resident physician/Interns	Nurse practitioner
Fellows	Infection control practitioner
Pharmacist	Other (please specify:                    )

4. How long have you worked in your current specialty or profession?

Less than 1 year	6 to 10 years	16 to 20 years
1 to 5 years	11 to 15 years	21 years or more

¹Antimicrobial Stewardship Survey based on the AHRQ Hospital Survey on Patient Safety Culture. <http://www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm>

4

Site _________