Commonwealth of Kentucky Antibiotic Stewardship Practice Assessment For Long-Term Care Facilities Introduction As the problem of antibiotic resistance continues to worsen in all healthcare setting, we are assessing the current state of Antibiotic Stewardship throughout the Commonwealth. This information will only be used by the Kentucky Department of Public Health to develop strategies and tools to help Kentucky hospitals decrease rates of antibiotic resistance and improve patient safety. Please have this questionnaire completed by the person or persons who are most involved with Antibiotic Stewardship Practice at your facility. The questionnaire should only take 30 minutes to complete. Only aggregate data will be reported. Thank you for your participation. 1. Please select all those who assisted in completing this questionnaire. Please check all that apply: Data Analyst Healthcare Epidemiologist Infectious Disease(ID) Pharmacist Infectious Disease Physician Physician (Non-Infectious Disease-Subspecialty-Trained) Infection Preventionist Advanced Practice Registered Nurse (APRN) or Physician Assistant (PA) Pharmacy Director Other Pharmacist Quality Director Other (please specify) Yes No Don't 2. Does your facility currently have an Antibiotic Stewardship Practice program in place If YES, then how long has your program been in place? Less than 1 year 1-3 years 3-5 years Greater than 5 years Don't If NO, then please skip to QUESTION 52. Structure Indicators Leadership and Management Yes No Don't 3. Does your facility have a multidisciplinary committee focused on appropriate antibiotic use (e.g., Antibiotic Stewardship committee)? 4. Who sits on your Antibiotic Stewardship committee? (Check all that apply) Data analyst(s) Hospital epidemiologists(s) Hospitalist(s) Infectious Disease fellow(s) Infectious Disease pharmacist(s) Infectious Disease physician(s) Advanced Practice Registered Nurse (APRN) or Physician Assistant (PA) Infection Preventionist(s) Microbiologist(s) Other pharmacist(s) Pharmacy resident(s)
Quality Director(s) Other, please specify 5. Does your facility provide salary support for any of the following to perform Antibiotic Stewardship? If YES, is this a full-time or parttime position? a. Infectious Disease physician(s) b. Infectious Disease pharmacist(s) c. Physician (non-infectious Diseasetrained) d. Advanced Practice Registered Nurse (APRN) or Physician Assistant (PA) e. Pathology/Laboratory Medicine f. Pharmacist (non-infectious Diseasetrained)(s) g. Hospital epidemiologist(s) h. Data analyst(s) i. Infection Preventionist(s) j. Quality Director(s) Yes No Full Time Part- Time Don't k. Other (please specify): 6. Does this committee meet regularly (at least twice a year)? 7. Are minutes from the meetings of this committee sent to executive leadership? 8. Does your facility have a written strategy or plan to improve antibiotic use? 9. Does your facility produce an annual report focused on appropriate antibiotic use? 10. Does your facility have a formal mandate (directive?) from executive leadership to engage in efforts to promote appropriate antibiotic use? 11. Does your facility receive any budgeted financial support for Antibiotic Stewardship activities (e.g., support for salary, training, or informatics support)? 12. Has your facility supported any training on appropriate antibiotic use within the last year? Human Resources Yes No Don't 13. Is clinical infectious disease consultation available at your facility on the same day as requested? 14. Is a full-time pharmacist available on site at your facility every day of the week? 15. Who performs the functions related to assuring appropriate antibiotic use on a regular basis (at least weekly)? (Check all that apply) Infectious Disease Physician Physician (non-infectious Disease-trained) Pharmacist Advanced Practice Registered Nurse (APRN) or Physician Assistant (PA) Infection Preventionist or Hospital Epidemiologist Other 16. Is there a physician identified as a leader for stewardship activities at your facility? a. Does this physician receive any direct salary support from your facility for this role? b. Is this physician trained in infectious diseases (ID fellowship)?
c. If the physician leader for your stewardship committee is not trained in infectious disease, then what is their specialty? (Check one below) General Internal Medicine Internal Medicine Subspecialty (Non-Infectious Disease) General Surgery Surgical Subspecialty Family Medicine OBGYN Anesthesiology Other 17. Is there a clinical pharmacist identified as a leader for stewardship activities at your facility? a. Are stewardship duties included in his or her job description and/or annual review? b. Has this pharmacist had specialized training in ID or Antibiotic Stewardship? Microbiology and resistance patterns Yes No Don't 18. Does your facility perform its routine microbiology tests on site (urine, blood, sputum cultures)? 19. Does the facility produce an antibiogram (microbiological sensitivity and/or antibiotic susceptibility report) at least annually? 20. Is the current antibiogram distributed to prescribers? 21. How is the antibiogram distributed to prescribers? (Check all that apply) Printed and actively distributed to physicians Printed and made available for physicians to utilize Electronic version posted 22. Are antibiotics usage guidelines provided to care providers based on the current antibiogram? IT System Inventory Yes No Don't 23. Does your facility use any of the following healthcare information technology (IT)? a. Electronic medical or health record (EMR or EHR) b. IT system for prescribing (i.e., Computerized Order Entry) : c. IT system for medication administration (i.e., emar, Bar coded): d. IT system for laboratory results (i.e., electronic laboratory reporting system)? e. IT capability to electronically link pharmacy, laboratory, and medical records? 24. Does your facility use the IT resources to facilitate information gathering for the Antibiotic Stewardship Practice? Process Indicators Policies, guidelines and protocols Yes No Don't 25. Does your facility have a defined formulary of antibiotic agents? 26. Does your facility have a written procedure for approving new antibiotic agents onto the formulary? 27. Does your facility have a written policy that requires prescribers to document in the medical record or during order entry the following information for antibiotic prescriptions? a. An indication for antibiotic prescription(s)?
b. The duration or date for review for the length of treatment? 28. Does your facility have facility-specific guidelines, based on national guidelines and local antibiotic susceptibility patterns, to assist with antibiotic selection for the following? a. Community acquired pneumonia b. Urinary tract infection 29. If your facility has facility-specific guidelines to assist with antibiotic selection, are these guidelines reviewed at least annually? 30. Are these facility specific guidelines easily accessible on all wards and to prescribers (e.g., printed pocket guide or electronic summaries on appropriate networked computers)? 31. Does your facility have protocols for the following actions? a. Switching from parenteral (IV) to oral (PO) antibiotics? b. De-escalation of therapy based on microbiology results? c. Review of antibiotic prescriptions by a certain time period (e.g. choice, duration, route)? d. Dose optimization for antibiotics? e. Dose adjustment for renal or hepatic insufficiency? f. Automatic substitutions by pharmacy (e.g., Moxifloxacin to Levofloxacin)? Activities and Interventions 32. Do specified antibiotic agents need to be approved by a physician or pharmacist prior to dispensing (i.e., pre-authorization) at your facility? 33. Does a physician or pharmacist review incoming prescriptions for specified antibiotic agents (i.e., prospective audit) at your facility? 34. What criteria are used to target cases for Antibiotic Stewardship review? (Please check all that apply) Yes No Don't Antibiotics with high potential misuse Antibiotics with high risk of adverse effects Broad spectrum antibiotics Combination antibiotics for coverage of organisms High cost antibiotics High use antibiotics Potential for IV to PO conversion Bacterial resistance profiles (E.g. Multi-Drug-Resistant Organisms, MRSA, VRE, etc) Site of infection: e.g. Catheter-Line-Associated Bloodstream Infection (CLABSI), Catheter-Associated Urinary Tract Infection (CAUTI), etc. Clostridium difficile diarrhea/colitis cases. Syndromic approach: e.g. positive urine cultures without symptoms of UTI (asymptomatic bacturia), or positive wound culture without signs of infection (i.e. wound colonization) Other (Please specify) 35. Does your facility use printed antibiotic ordering forms or electronic order entry with embedded clinical decision making support for specific diagnoses or drugs? 36. Is there a formal procedure for a physician or pharmacist review the appropriateness of an antibiotic 2 to 3 days after its initial order (e.g. antibiotic time out)? 37. Are results of antibiotic audits or reviews provided directly to prescribers through in-person, telephone, or electronic communication? 38. Are any antibiotic prescriptions subject to time-sensitive automatic stop orders? 39. Is there dedicated time during which a clinical team at your facility reviews and discusses antibiotic orders for their assigned patients (antibiotic ward rounds)? Monitoring Appropriate Use Yes No Don't 40. Are adverse drug events associated with antibiotics reported to an antibiotic committee, team, or other group? 41. What outcomes data is your facility measuring to assess your Antibiotic Stewardship Practice? (Please check all that apply) None Adverse drug events associated with antibiotics
Antibiotic costs Antibiotic resistance patterns Antibiotic use Clostridium difficile rates MDRO (multi-drug-resistant organism) rates Frequency of primary physician s acceptance of Antibiotic Stewardship committee? recommendations Other Consumption Yes No Don't 42. Does your facility monitor antibiotic use (consumption) on a regular basis? If YES, what data metrics are used to monitor antibiotic use? a. Pharmacy purchasing data (gram or dollars per patient per day)? b. Antibiotic agent(s) administered to patients per day (Days of Therapy) 43. Are reports on antibiotic use (consumption) provided to prescribers at your facility? 44. Is analysis performed of trends in appropriate use of antibiotics and/or emergence of resistance patterns? Compliance Yes No Don't 45. If facility-specific guidelines to assist with antibiotic selection exist (e.g., UTI, pneumonia, etc.), is adherence monitored at least once a year? 46. If any type of antibiotic recommendations are routinely provided (e.g., choice, de-escalation, conversion to oral), is acceptance by the primary prescriber tracked? 47. If specified antibiotic agents need to be approved by a physician or pharmacist prior to dispensing (i.e., pre-authorization), is unauthorized antibiotic prescribing monitored? 48. Is compliance with any antibiotic policy, guideline or protocol reviewed at least annually with the following groups? a. A multidisciplinary committee focused on appropriate antibiotic use b. Prescribers (Individually or by specialty groups) 49. In your opinion, how often do physicians at your facility utilize recommendations given by the Antibiotic Stewardship committee? Always Often Sometimes Rarely Never Education Yes No Don't 50. Do all newly hired prescribers receive information on appropriate, safe use of antibiotic along with the antibiotic formulary, policies and guidelines during their orientation? 51. Are patients or their legal guardian routinely information about antibiotics they have received (indication, course length, possible risks, what to do if side effects develop at home, etc.)? For Facilities Without Current Antibiotic Stewardship Practice The following questions are for the facilities that indicated they do not have an active Antibiotic Stewardship Practice. If your facility does has an active Antibiotic Stewardship Practice, then please skip to QUESTION 54. 52. If NO, then what is your future plans regarding establishment of an Antibiotic Stewardship program? No plans to implement In the process of initiating a program Currently under consideration
53. What are the major barriers to implementation of Antibiotic Stewardship Practice at your facility? (Please check all that apply) Lack of expertise/training in Antibiotic Stewardship Lack of funding Staffing constraints Lack of buy in from administration Lack of buy in from Clinical staff (Physicians/pharmacy/infection control/lab/nursing) Not high priority Organized program has not been proposed Other (please specify) Conclusion (For All Facilities) 54. On what areas of Antibiotic Stewardship Practice would you like further training or guidance (check all that apply): How to get buy in from administration How to get buy in from staff Establishing Clinical Pathways and guidelines using IDSA and CDC examples Initiating target consultations (review of cases, changing prescription habits, advocate timely start and discontinuation of antibiotics) De-escalation of antibiotics (e.g. Get Smart Treatment Guidelines) Antibiotic dose optimization Formulary restriction Other (Please specify)