Reporting Time Period: Answer questions #1-12 based your hospital’s most current NHSN Annual Hospital Survey (must be 2015 or 2016 survey) or based on your hospital’s current structure. Does your facility have a written statement of support from leadership that Yes supports efforts to improve antibiotic use (antibiotic stewardship)? No Is there a leader responsible for outcomes of stewardship activities at your facility? Yes No If skip 2a and move on to question #3. “no,” Physician 2a) If yes, what is the position of this leader? (check one) Pharmacist (please specify): Yes Is there at least one pharmacist responsible for improving antibiotic use at No your facility? Does your facility provide any salary support for dedicated time for antibiotic Yes stewardship activities? No Does your facility have a policy that requires prescribers to document an indication for all antibiotics in the medical record or during order entry? Yes No If skip 5a and move on to question #6. “no,” 5a) If Yes, has adherence to the policy to document an indication been Yes monitored? No Does your facility have facility-specific treatment recommendations, based on national guidelines and local susceptibility, to assist with antibiotic Yes selection for common clinical conditions? No If skip 6a and move on to question #7. “no,” 6a) If Yes, has adherence to facility-specific treatment recommendations been Yes monitored? No Is there a formal procedure for all clinicians to review the appropriateness of Yes all antibiotics at or after 48 hours from the initial orders (e.g. antibiotic time No out)? Do any specified antibiotic agents need to be approved by a physician or Yes pharmacist prior to dispensing at your facility? No Does a physician or pharmacist review courses of therapy for specified Yes antibiotic agents and communicate results with prescribers (i.e., audit with No feedback) at your facility? Does your facility monitor antibiotic use (consumption) at the unit, service, and/or facility wide? Yes No If skip 10a and 10b and move on to question #11. “no,” Days of Therapy Defined Daily Dose
Reporting Time Period: Answer questions #1-12 based your hospital’s most current NHSN Annual Hospital Survey (must be 2015 or 2016 survey) or based on your hospital’s current structure. Does your facility have a written statement of support from leadership that supports efforts to improve antibiotic use (antibiotic stewardship)? Yes No Is there a leader responsible for outcomes of stewardship activities at your facility? If “no,” skip 2a and move on to question #3. Yes No 2a) If yes, what is the position of this leader? (check one) Physician Pharmacist (please specify): Is there at least one pharmacist responsible for improving antibiotic use at your facility? Yes No Does your facility provide any salary support for dedicated time for antibiotic stewardship activities? Yes No Does your facility have a policy that requires prescribers to document an indication for all antibiotics in the medical record or during order entry? If “no,” skip 5a and move on to question #6. Yes No 5a) If Yes, has adherence to the policy to document an indication been monitored? Yes No Does your facility have facility-specific treatment recommendations, based on national guidelines and local susceptibility, to assist with antibiotic selection for common clinical conditions? If “no,” skip 6a and move on to question #7. Yes No 6a) If Yes, has adherence to facility-specific treatment recommendations been monitored? Yes No Is there a formal procedure for all clinicians to review the appropriateness of all antibiotics at or after 48 hours from the initial orders (e.g. antibiotic time out)? Yes No Do any specified antibiotic agents need to be approved by a physician or pharmacist prior to dispensing at your facility? Yes No Does a physician or pharmacist review courses of therapy for specified antibiotic agents and communicate results with prescribers (i.e., audit with feedback) at your facility? Yes No Does your facility monitor antibiotic use (consumption) at the unit, service, and/or facility wide? If “no,” skip 10a and 10b and move on to question #11. Yes No Days of Therapy Defined Daily Dose