Hospital Antibiotic Stewardship Core Element Assessment

Attachment A. Hospital Antibiotic Stewardship Core Element Assessment

Form Approved

OMB No. 0920-1154

Expiration Date 01/31/2020

Hospital Antibiotic Stewardship Core Element Assessment

Instructions: The purpose of this assessment tool is to understand the ways in which your facility has implemented CDC’s Core Elements of Hospital Antibiotic Stewardship Programs (available at http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html). Please coordinate with your stewardship team, as needed, to respond to the items below.

1. Please complete basic information about your hospital and your title.

2. For each of the 7 core elements, please read through each statement below and indicate whether the statement applies to your facility by selecting Yes or No for each item.

Respondent Information
In what hospital setting do you work? ☐Academic acute-care hospital ☐Non-academic acute care hospital ☐Critical access hospital
What is your job title? ☐Physician ☐Clinical pharmacist ☐Other (specify):
Leadership Support	Yes	No
Facility leadership has provided a formal statement of support for antibiotic stewardship (e.g., a policy or statement approved by the board).	☐	☐
Facility leadership has communicated their support of stewardship to staff via email, newsletters, events, or other avenues.	☐	☐
Salary support has been provided for a physician to (co)lead stewardship efforts.	☐	☐
Salary support has been provided for a pharmacist to (co)lead stewardship efforts.	☐	☐
Formal commitments of staff time to antibiotic stewardship activities have been made.	☐	☐
Support has been provided for staff to receive training on antibiotic stewardship.	☒	☐
Funding has been provided for information technology and/or laboratory resources to support antibiotic stewardship efforts.	☐	☐
A formalized antibiotic stewardship committee has been convened.	☐	☐
Membership in our facility’s formalized antibiotic stewardship committee includes clinician(s).	☐	☐
Membership in our facility’s formalized antibiotic stewardship committee includes pharmacy representation.	☐	☐
Membership in our facility’s formalized antibiotic stewardship committee includes nursing.	☐	☐
Membership in our facility’s formalized antibiotic stewardship committee includes infection prevention.	☐	☐
Membership in our facility’s formalized antibiotic stewardship committee includes microbiology.	☐	☐
Membership in our facility’s formalized antibiotic stewardship committee includes information technology (IT).	☐	☐
Facility leadership regularly monitors / is updated on antibiotic use and stewardship efforts in the facility.	☐	☐
Antibiotic stewardship activities are integrated into quality improvement and/or patient safety initiatives.	☐	☐
Accountability and Drug Expertise	Yes	No
Our facility has a physician leader (or co-leader) responsible for antibiotic stewardship outcomes.	☐	☐
[If ‘yes’ to Q10] Our facility’s physician (co) leader…
has completed formal training in antibiotic stewardship.	☐	☐
has antibiotic stewardship program efforts in their contract or job description.	☐	☐
has designated time for stewardship work.	☐	☐
is physically located in our hospital (vs. working remotely).	☐	☐
Our facility has a pharmacist leader (or co-leader) responsible for antibiotic stewardship outcomes.	☐	☐
[If ‘yes’ to Q11] Our facility’s pharmacist (co) leader…
has completed formal training in antibiotic stewardship.	☐	☐
has antibiotic stewardship program efforts in their job description.	☐	☐
has designated time for stewardship work.	☐	☐
is physically located in our hospital (vs. working remotely).	☐	☐
Actions to Support Optimal Antibiotic Use	Yes	No
Our facility has local treatment guidelines or recommendations for commonly encountered infections such as empiric therapy for community-acquired pneumonia.	☐	☐
Our facility targets select diagnoses for active interventions to optimize antibiotic use, such as intervening on duration of therapy for patients with community-acquired pneumonia according to clinical response, etc.	☐	☐
Our facility requires documentation of diagnosis/indication for all antibiotic orders.	☐	☐
Our facility has a policy or formal procedure for a physician or pharmacist to review antibiotic orders for specified drugs before they can be dispensed (i.e., prior approval).	☐	☐
Our facility has a policy or formal procedure for the stewardship team to review antibiotics after prescription and give input to the treating team (post-prescription review or audit with feedback).	☐	☐
Our facility has a policy for the treating team to review antibiotics prescribed after 48-72 hours (i.e., antibiotic time-out).	☐	☐
Tracking and Monitoring Antibiotic Prescribing, Use, and Resistance	Yes	No
Our antibiotic stewardship program…
tracks antibiotic resistance patterns.	☐	☐
tracks Clostridium difficile infection rates.	☐	☐
monitors antibiotic use in days of therapy per 1000 patient days.	☐	☐
monitors antibiotic use in defined daily doses per 1000 patient days.	☐	☐
monitors antibiotic expenditures (i.e., purchasing costs).	☐	☐
monitors antibiotic use in some other way (e.g. number of antibiotics starts).	☐	☐
monitors antibiotic use at the provider level	☐	☐
monitors appropriate prescribing in some way (e.g. monitoring adherence to treatment guidelines.	☐	☐
Reporting Information on Improving Antibiotic Use and Resistance	Yes	No
Our antibiotic stewardship program…
regularly updates facility leadership on antibiotic use and stewardship efforts.	☐	☐
provides regular reports to clinical staff on antibiotic use and resistance	☐	☐
regularly reports outcomes for interventions to staff.	☐	☐
Education	Yes	No
Prescribers, including licensed independent practitioners, get regular education on appropriate antibiotic use and targeted prescriber stewardship activities such as the role of diagnostics.	☐	☐
Nursing staff get regular education on appropriate antibiotic use and targeted nurse stewardship activities such as proper urine culture technique.	☐	☐
Pharmacists get regular education on appropriate antibiotic use and targeted pharmacist stewardship activities such as de-escalation.	☐	☐
Patients get information on antibiotic use and resistance.	☐	☐

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