Assessment of Appropriateness of Antibiotics (Hospital Level Sheet) PQC, Revised 02/16/2017 For this assessment, antibiotic use is defined as receiving when it is not necessary, not making timely adjustments in the and prescribing but choosing the wrong due to unsuitable spectrum of activity for targeted infection, wrong duration, wrong dose, wrong route and wrong interval. This assessment by the frontline provider with support of their Antibiotic Stewardship Program (ASP) is based on national guidelines and/or your facility s guidelines, formulary and local microbiology. This form is to aggregate information about your s and the antibiotic use for all the patients that your team reviewed antibiotic prescribing on. Do not submit any patient level data. NOTE: Please submit one form for each participating hospital with a unique NHSN number. 1. Hospital Name 2. Health System Affiliation 3. Hospital Contact 4. Phone 5. Email address 6. Total number of licensed hospital beds Total number of licensed beds 7. participating s 8. participating types (please indicate number next to each type) Medical Surgical Medical/ Surgical (MS) Cardiac/ surgical Tele/ cardiac Neuro Neonatal Pediatric Other (specify): 9. General Information about s in this hospital: A. Describe the setting (check all that apply): Community hospital Teaching hospital Rural/ Suburban Urban Resource limited population B. Does this hospital have an Antibiotic Stewardship Program? Y N unsure (check one)
C. Does this hospital have an antibiogram of local susceptibility information? D. Do these s have their own antibiogram? E. What additional molecular diagnostics were used to guide management (check all that apply)? Procalcitonin Viral respiratory panel MALDI-ToF MS microbial identification PNA-FISH Other The following questions will pertain only to the s in your hospital that participated in the appropriateness assessment on. 10. Do the participating s have a dedicated pharmacist who implements ASP interventions? 11. Please complete the following table. If patients are on more than one category of (i.e., empiric AND prophylactic), they may be counted more than once. Medical Surgical Medical/Surgical Cardiac/Surgical Tele/Cardiac Neuro Neonatal Pediatric Other (specify) patients on on that your team reviewed on empiric directed patients on prophylactic
12. Please complete the following table for an on. If patients are on more than one category of (i.e., empiric AND prophylactic), they may be counted more than once Total number of patients for which an was identified an empiric an directed an prophylactic Medical Surgical Medical/Surgical Cardiac/Surgical Tele/cardiac Neuro Neonatal Pediatric Other (specify) 13. For s, indicate the number of the in question for 72 hours. Medical Medical/ Surgical (MS) Tele/ cardiac Neonatal Surgical Cardiac/ surgical Neuro Pediatric
No indicated Non-infectious syndrome Non-bacterial syndrome Treatment of colonization Adjustment in not made in a timely manner Antibiotics indicated but, wrong Regimen does not cover all pathogens required (under coverage) Spectrum of activity too broad (over coverage) Redundant antimicrobial coverage (over coverage) Duration longer than necessary for treatment Duration longer than necessary for empiric Dosing longer than necessary for prophylactic Dosing, route or interval Dosing not correct for infection or renal function Route not correct (such as IV rather than PO conversion) Interval not correct for infection or renal function 14. Please complete the following table. Each patient should have only one reason for use. If there were more than one reason the was, reviewers should select the most important reason. Medical Surgical Medical/Surgical Cardiac/Surgical Tele/cardiac Neuro Neonatal Pediatric Other (specify) 15. Based on this review of the and assessment of appropriateness by your team in the what are the top three that are ly used in your facility? 16. Based on this review of the and assessment of appropriateness by your team in the, what opportunities have you identified to improve prescribing (check all that apply)? Improved empiric s Education on antibiogram and local microbiology Assistance with dose, route or interval Review of s for de- escalation or discontinuation of Promotion of shorter duration for infectious syndromes Avoidance of for non-infectious syndromes or colonization Improve choice or duration of prophylaxis s
17. Please indicate the number of people involved in this assessment from your hospital: 18. Please indicate the average amount of time each patient assessment took for all the people working on it: 1-15 minutes 16-30 minutes 31-45 minutes 46-60 minutes > 60 minutes