Prescriber Assessment

Form Approved

OMB Control No. 0920-1154

Exp. date: 1/31/2020

Sponsored by The Centers for Disease Control and Prevention (CDC)

PROJECT TITLE: Core Elements of Antimicrobial Stewardship in Nursing Homes

LEAD BY: Stefan Gravenstein, MD, MPH, Principal Investigator (PI), Professor of Medicine and Health Services Policy and Practice-Warren Alpert Medical School, Brown School of Public Health, and Providence Veterans Hospital; Adjunct Professor of Medicine- University Hospitals Cleveland Medical Center, Case Western Reserve University

David Manning, ScM, Project Coordinator

Prescriber Assessment

You received this needs assessment based on your affiliation with [nursing home corporation] and your credentials to prescribe. For this assessment, please consider residents to include all individuals for whom you are credentialed to prescribe and:

1) Which receive care in a Skilled Nursing Center or Long-term Care Center, and

2) Whose health information is reportable to the Centers for Medicare & Medicaid Services (CMS).

Please take a few minutes to provide some information about yourself and your experiences with prescribing. Thank you for your participation.

Deciding to Start: Antibiotics

This section is about you, the prescriber, and your perceptions about antibiotic prescribing.

1. In the past month, how many antibiotic prescriptions did you write for residents at this [center]: (number of prescriptions)

0 prescriptions	1-2 prescriptions	3-4 prescriptions	5+ prescriptions
			

2. How frequently do you encounter each of the following conditions at this [center]:

	Never	Rarely	Sometimes	Often	Always
Suspected Urinary Tract Infection					
Suspected Upper Respiratory Infection					
Suspected Lower Respiratory Infection					
Suspected Skin or Soft Tissue Infection					

When considering the following two questions:

• Medical necessity refers to the use of antibiotics only in the case of bacterial infection.

• The determination of bacterial infection can be based on physical assessment or examination of the resident, documented signs and symptoms, culture results or diagnostic test results.

3. How confident are you in your ability to distinguish between the two conditions presented:

	Not at all confident	Not very confident	Somewhat confidant	Very Confident	Extremely confident
Asymptomatic bacteriuria Vs. Symptomatic Urinary Tract Infection					
Viral sinusitis Vs. Bacterial sinusitis					
Viral Lower Respiratory Infection Vs. Bacterial Pneumonia					
Colonized wound Vs. infected wound					

4. How frequently do you perform each of the following: (select one)

	Never	Rarely	Sometimes	Often	Always
Prescribe antibiotics as prophylaxis for urinary tract infection (UTI)					
Wait for results of a urine culture before prescribing antibiotics for UTI					
Prescribe an antibiotic just in case there is an infection					
Delay antibiotic therapy and Monitor symptoms					
Delay antibiotic therapy and Provide supportive therapy (e.g., hydration)					
Review site-specific definitions of infection (revised McGeer criteria) or minimum prescribing criteria (Loeb’s criteria)					
Use order sets for prescribing antibiotics					
Use order sets that include non-pharmacologic orders					

5. When you are not the one to personally identify a change in condition for a resident, how often do the follow situations occur regarding a change in condition?

	Never	Rarely	Sometimes	Often	Always
I am notified by the resident or a family member of the resident.					
I am present at the center and am notified of a change in condition by nursing staff.					
I am not present at the center and am notified of a change in condition by nursing staff.					

6. For each item below, indicate how frequently:

	Never	Rarely	Sometimes	Often	Always
You are physically present at the skilled nursing center when a change in condition is identified.					
You are familiar with the resident for whom you are prescribing an antibiotic.					
Nursing staff performs a physical assessment prior to starting an antibiotic.					
You perform an exam prior to your prescribing an antibiotic.					
You have sufficient clinical information to confidently start an antibiotic.					
Lab results or other relevant objective data are available prior making an antibiotic prescribing decision.					

Selecting an appropriate antibiotic: diagnosed bacterial infection

For the following questions, please think about your experiences selecting and prescribing an antibiotic regimen for your residents.

7. How confident are you in your ability to appropriately select an antibiotic for the following conditions: (select)

	Not at all confident	Not very confident	Somewhat confidant	Very Confident	Extremely confident
Symptomatic Urinary Tract Infection					
Diagnosed bacterial sinusitis					
Diagnosed bacterial pneumonia					
Cellulitis or infected wound					

8. For each of the following tasks, how confident are you in your ability to perform each task relating to prescribing an antibiotic:

	Not at all confident	Not very confident	Somewhat confidant	Very Confident	Extremely confident
Choosing an appropriate antibiotic for a given site of infection					
Choosing an appropriate antibiotic dose					
Choosing the correct dosing interval (e.g., daily or twice daily)					
Choosing an appropriate length of therapy					
Choosing the correct antibiotic based on resident factors (e.g., age, weight, renal function, allergies, drug interactions, contraindications)					
Using culture results to inform your prescribing decision					
Reading Nursing Center specific antibiograms, when they are available, to inform your prescribing decision.					

Influence of nurses

The following questions ask about your perceptions of the influence the nurse staff have on antibiotic prescriptions.

9. For the following question, consider the situation where:

“You receive a phone call from a nurse at a nursing center. Your resident is experiencing isolated behavioral change, and is without fever or localizing symptoms.”

Thinking of your experiences at [center] how frequently do the following occur:

	Never	Rarely	Sometimes	Often	Always
Nurse provides thorough assessment					
Nurse communicates details without prompting					
Nurse provides sufficient information to determine if an antibiotic is needed					
Nurse requests diagnostic testing of resident for presumed infection					
Nurse requests an antibiotic for a resident					
You trust the nurse’s assessment					
You comply with the nurse’s requests for diagnostic testing					
You comply with the nurse’s request for an antibiotic and prescribe the antibiotic					

10. For each item below, please indicate how important you feel it is to a productive collaboration with nursing staff (choose one answer):

	Not at all important	Not very important	Somewhat important	Very important	Extremely important
Acknowledging the role of nurses in Skilled Nursing Centers					
Seeking contributions from nurses regarding antibiotic prescribing					
Addressing misconceptions about the roles when I observe them.					
Respecting the expertise and unique contributions of nursing staff					
Identifying overlapping professional skills that I share with nursing staff					
Valuing the benefits of a collaborative experience with nursing staff					

Influence of family and caregivers

11. For the following question, please think about the following situation:

“Your resident has experienced a change in condition. You have been notified by nursing staff, and you are still considering whether or not to start an antibiotic.”

In reference to the decision to prescribe an antibiotic, how frequently do the following occur at [center]?

	Never	Rarely	Sometimes	Often	Always
A family member or caregiver contacts you to discuss the change in condition					
Nursing staff informs you a family member or caregiver would like to discuss the change in condition with you.					
A family member or caregiver asks you to prescribe an antibiotic in response to a non-specific change in condition.					
A family member or caregiver asks you to avoid using antibiotics in response to a non-specific change in condition.					
A family member or caregiver asks you to assess the resident in person.					

12. For the following question, please think about the following situation:

“Your resident has experienced a change in condition. A family member or caregiver has contacted you to discuss starting an antibiotic in response to a change in condition.”

In reference to the discussion with the family member or caregiver, how frequently do the following occur at [center]?

	Never	Rarely	Sometimes	Often	Always
Educate him/her on the importance of using an antibiotic only when an infection is bacterial, not viral.					
Educate him/her on the possibility that other health conditions may resemble a bacterial infection.					
Educate him/her of the risks of using antibiotics (for example, C. difficile infection or antimicrobial resistance).					
Prescribe an antibiotic because a family member or caregiver has requested it, though you are not certain the antibiotic is needed.					

13. In your opinion, how important are each of the following when deciding to prescribe an antibiotic or not? (select one)

	Not at all important	Not very important	Somewhat important	Very important	Extremely important
Consider the requests of family members or caregivers.					
Counsel the family about appropriate antibiotic prescribing.					
Involve family members and caregivers in antibiotic decision making, even if they do not initiate contact.					

14. For each of the following tasks, how confident are you in your ability to discuss antibiotic use with a resident’s family member or caregiver?

	Not at all confident	Not very confident	Somewhat confidant	Very Confident	Extremely confident
Educating a family member or caregiver on the risks of unnecessary antibiotic use.					
Discussing the process of diagnosing a bacterial infection with a family member or caregiver.					
Discussing the process of monitoring a resident whose change in condition does not clearly indicate a bacterial infection.					
Discussing the process of choosing an appropriate antibiotic for a diagnosed bacterial infection.					

Cross-covering prescribers

The following questions focus on the role of cross-covering prescribers in prescribing antibiotics

15. In the past month, how many antibiotic prescriptions were started one of your residents by a cross-covering prescriber at [center]? (select one)

0 prescriptions	1-2 prescriptions	3-4 prescriptions	5+ prescriptions
			

16. Thinking about your experiences at [center], where are your residents when they are started on an antibiotic? (select all that apply)

 Skilled nursing center where they reside

 Outpatient clinic

 Urgent care

 Emergency department (not admitted to inpatient)

 Hospital stay (inpatient or observation stay)

17. For the following question, please think about the following situation:

“Your resident is started on antibiotics by a covering prescriber. This prescriber can be a cross-covering prescriber or an Emergency Department prescriber.”

In reference to the antibiotic prescribed by the covering prescriber, how frequently do the following occur at [center]?

	Never	Rarely	Sometimes	Often	Always
You are unsure why your resident was started on the antibiotic.					
You change the antibiotic that was prescribed.					
You change the antibiotic dose that was prescribed.					
You change the duration the antibiotic was prescribed.					
You discontinue the antibiotic prescribed.					

Nursing Center Influence

The following questions focus on your experiences and perceptions at [center]

18. How often does [center] provide feedback to you on your use of antibiotics? (Select one)

Never	Once a year	Twice a year	Quarterly	Monthly
				

19. Appropriate antibiotic prescribing refers to a comprehensive approach to antibiotic prescribing. This approach includes:

1) Using antibiotics only for bacterial infections,

2) Selecting an antibiotic that matches the infection site or bacterial pathogen,

3) Selecting the an appropriate antibiotic dose and duration, and

4) Re-evaluating the resident after an antibiotic has been started.

Below is a list of policies or activities that could be implemented to improve appropriate antibiotic use at Skilled Nursing Centers. Each item may affect one or more components of appropriate antibiotic use.

How impactful would each of the following be at improving appropriate antibiotic use at [center]?

	Not at all impactful	Not very impactful	Somewhat impactful	Very impactful	Extremely Impactful
Nursing center specific antibiotic diagnosing guidelines					
Minimum antibiotic prescribing guidelines					
Computer-assisted order entry					
Nursing center specific antibiogram					
Pharmacist review of antibiotic choice					
Pharmacist review of antibiotic dose and duration					
	Not at all impactful	Not very impactful	Somewhat impactful	Very impactful	Extremely Impactful
Pharmacist review of culture and sensitivity results					
Access to resident culture data at time of antibiotic prescribing					
Thorough nurse assessment of resident					
Clear communication of resident change in condition from nurse					
Condition-specific, protocol-driven antibiotic prescribing recommendation from nurse					
Timely notification of updates or changes in resident condition					
Annual staff influenza immunization					
Policies restricting or eliminating antibiotic starts overnight					
Limiting choice of antibiotics on units to antibiogram susceptible antibiotics					
Developing a formulary based on the Nursing Center antibiogram					

Post-prescribing Optimization

For the following questions please think about what happens after a resident is prescribed an antibiotic.

20. In the past month, at [center], how many antibiotic prescriptions did you review for appropriateness after it was started? Please include reviews you performed on antibiotics prescribed by a cross-covering prescriber. (select one)

0 prescriptions	1-2 prescriptions	3-4 prescriptions	5+ prescriptions
			

21. How frequently do the following occur either by you or another staff member (for example, nursing staff, pharmacy staff, or other prescribers) when caring for residents at [center]:

	Never	Rarely	Sometimes	Often	Always
Residents are re-examined for resolution of infection-related symptoms.					
Antibiotic prescriptions are reviewed when culture and sensitivity data becomes available.					
Antibiotic prescriptions are reviewed when other diagnostic test results become available					

22. How important it is for you to perform the following:

	Not at all important	Not very important	Somewhat important	Very Important	Extremely important
Review an antibiotic prescription when culture and sensitivity data become available					
Switch to a narrower-spectrum antibiotic when culture and sensitivity data support this.					
Review other diagnostic test results (labs, imaging, etc.)					
Re-assess a resident after starting an antibiotic for resolution of symptoms					
Stopping an antibiotic upon resolution of symptoms					
Evaluate a resident after starting an antibiotic for side effects					
Shortening a long course of antibiotic therapy					

Antibiotic Stewardship

Antibiotic Stewardship interventions often focus on one or more component of antibiotic prescribing. These three components are: 1) diagnosing an infection, 2) choosing an effective antibiotic, and 3) ensuring an antibiotic is optimally prescribed as the resident’s condition progresses.

In the next three questions, please provide your opinions as they relate to components of an Antibiotic Stewardship intervention.

23. In your opinion, how important is each of the following items to appropriate antibiotic use in Skilled Nursing Facilities:

	Not at all important	Not very important	Somewhat important	Very important	Extremely important
Differentiating between asymptomatic bacteriuria and symptomatic Urinary Tract Infection (UTI)					
Differentiating between viral Upper Respiratory Tract Infection (URTI) and bacterial sinusitis					
Differentiating between viral Lower Respiratory Tract Infection (LRTI) and bacterial pneumonia					
Differentiating wound colonization and wound infection					
Choosing the appropriate antibiotic for diagnosed infection					
Follow up of residents started on antibiotics for diagnosed infection					

24. In your opinion, how important are your individual prescribing practices to the overall development of antimicrobial resistance at [center]? (select one)

	Not at all important	Not very important	Somewhat important	Very important	Extremely important
Overall use of antibiotics					
Using as narrow spectrum an antibiotic as possible					
Avoiding long courses of antibiotic therapy					

25. In your opinion, how important are each of the Nursing Center attributes in antibiotic stewardship interventions?

	Not at all important	Not very important	Somewhat important	Very important	Extremely important
Leadership of Nursing center administration					
Quality of care provided by Nursing center staff					
Communication between nursing staff and me, the prescriber					
Effectiveness of the Infection Control Professional (ICP)					
On-going Pharmacist review of medications					

General Provider Information

Programming note: [facility] – indicates a program instruction to insert selected facility name in this place holder.

26. Do you have prescribing privileges? (if no, terminate survey administration)

 Yes

 No

The following questions pertain to your role as a prescriber.

27. How many skilled nursing centers do you currently work in? (number of centers)

1	2	3	4+
			

28. How long have you been in practice? (years)

< 1 year	1 – 5 years	6 – 10 years	11 – 15 years	16+ years
				

For the next questions, please think about the skilled nursing center affiliated with [corporation] where you work most frequently. What is the name of this center?

[Drop down menu listing all centers]

29. Thinking of your affiliation with [facility], how long have you been working at this center: (years)

	< 1 year	1 – 5 years	6 – 10 years	11 – 15 years	16+ years
In your current position?					
In total at this location?					

30. Thinking about the corporation that [facility] is a part of, how would you best describe your employment status?

I am:

 Employed full-time by this corporation.

 Employed part-time by this corporation.

 Not at all employed by this corporation.

31. What percentage of your professional time do you spend at this center? (percent of total professional time)

< 20%	21 - 40%	41 – 60%	61 – 80%	81 – 100%
				

32. How frequently are you on-site at this center? (times on-site)

Less than once per month	Once per month	Multiple times per month	Once per week	Multiple times per week	Daily
					

33. In your opinion, how important is quality improvement to leaders at this nursing center? (select one)

Not at all important	Not very important	Somewhat important	Very important	Extremely important
				

34. Does this center have a champion for antibiotic prescription/surveillance? (select one)

 No

 Yes

 Unsure

35. Who is the champion for antibiotic prescription/surveillance at this center? (If more than one, select all that apply)

 We do not have an antibiotic prescription/surveillance champion

or

 Administrator

 Director of Nursing

 Medical Director

 Infection Control Staff

 Nursing Staff

 Pharmacist

 Infectious Disease Consultant

 Other

 Unsure

36. In your opinion, if [facility] was rated today what quality star rating would they receive? (select one)

 1 Star

 2 Stars

 3 Stars

 4 Stars

 5 Stars

Demographics

37. What prescribing degrees have you attained? (Select all that apply)

 D.O.

 M.D.

 M.P.A

 N.D.

 N.P.

 P.A.

 Pharm.D.

 Other – Please specify: ________________________________

38. What is your primary specialty? (Select one)

 Family Practice

 Geriatrics

 Hospice and/or Palliative medicine

 Infectious disease

 Internal medicine

 Pulmonary and/or Critical care

 Other - Please specify____________________

 N/A

39. Number of years since graduation from medical school? (years)

0 – 10	11 – 20	21 – 30	31+
			

40. What is your gender?

 Male

 Female

41. Which best describes your ethnicity?

 Hispanic

 Non-Hispanic

42. Which of the following best describes your race?

 American Indian or Alaska Native

 Asian

 Black/African American

 Hawaiian/Pacific Islander

 Latino

 White

 Multiracial

 Other – Please specify ______________________

Thank you for your time.

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