Antibiotic Stewardship Program Kick-off Survey Demographics Question Title * 1. Your Name Question Title * 2. Hospital Name Question Title * 3. City Question Title * 4. State Question Title * 5. Email address Question Title * 6. Phone Number Question Title * 7. Hospital type Community Hospital Critical Access Hospital Long-term Acute Care Hospital Rural Hospital Teaching Hospital Major teaching Hospital Other (please specify) Question Title * 8. Adoption of Antibiotic Stewardship Program (ASP) policy/procedures (check all that apply) a. Our hospital has developed or adopted an institution-specific ASP policy and/or procedure Our ASP policy/procedure received final hospital approvals The policy is being piloted The policy is in use but not adopted hospital-wide The policy is in use throughout the hospital Our hospital does NOT have a institute-specific ASP policy and/or procedure Comments (please specify) Question Title * 9. ASP committee or work group (check all that apply) Our hospital has convened a multidisciplinary ASP committee or work group Our ASP committee or work group is overseen or supervised by a physician Our hospital does NOT have a multidisciplinary ASP committee or work group Question Title * 10. Frequency of ASP committee/ work group meetings Monthly Quarterly Every six months Annually Not Applicable - we do not convene an ASP committee or work group on a regular basis Question Title * 11. Please indicate who are members of your ASP committee or work group (check all that apply) infectious disease physician critical care physician surgeon general medical and/or family practice physician pharmacy leadership clinical pharmacist nursing leadership nursing (frontline staff) laboratory representative infection preventionist staff patient or family member Other (please specify) Question Title * 12. Is your ASP supported by a physician who received formal antibiotic stewardship training? Yes No Do not know Question Title * 13. Is your ASP supported by a pharmacist who received formal antibiotic stewardship training? Yes No Do not know Question Title * 14. Are your ASP activities monitored to assess improvement over time? Yes No Question Title * 15. Are your ASP activities routinely reported to your hospital quality improvement committee(s)? Yes No Do not know Question Title * 16. Annual antibiogram (check all that apply) Our hospital produces an annual antibiogram Our antibiogram is developed following Clinical Laboratory Standards Institute (CLSI) guidelines Our hospital distributes the antibiogram to all medical staff Our hospital provides follow-up education about the new antibiogram to medical staff Our hospital does NONE of the above Question Title * 17. Our hospital has adopted institutional guidelines for the management of common infection syndromes (check all that have been adopted) Order sets Clinical pathways Empric antibiotic therapy guide Our hospital has NOT adopted institutional guidelines for management of common infection syndromes Other (please specify) Question Title * 18. Which of the following does your hospital use to monitor antibiotic use? (check all that apply) Our hospital monitors usage patterns of at least one antimicrobial The monitored antibiotics are selected based on a review of the hospital's antimicrobial resistance ecology Our hospital monitors antibiotic use by Defined Daily Dose (DDD) Our hospital monitors antibiotic use by Days of therapy (DOT) Our hospital uses the NHSN Antibiotic Use (AU) module to automatically collect and report monthly DOT data Our hospital is currently monitoring antimicrobial usage patterns Our hospital currently does NOT monitor antibiotic use Our hospital's ASP committee summaries and reviews antimicrobial usage data (please specify how frequently) Question Title * 19. Antimicrobial Stewardship education provided (please check all that apply) Our hospital staff are provided regular education about antimicrobial stewardship Antibiotic stewardship education is provided to patients and families Our hospital currently does NOT provided education about antimicrobial stewardship Antibiotic stewardship education is provided to hospital committees If yes, please indicate which staff/committees and frequency of ASP education Question Title * 20. Antimicrobial formulary (check all that apply) Our hospital has an antimicrobial formulary The antimicrobial formulary is reviewed annually changes to the formulary are based on our hospital's antibiogram Our antimicrobial formulary changed in the past 12 months Our hospital does NOT have an antimicrobial formulary Question Title * 21. Antimicrobial audits and feedback (check all that apply) Our hospital audits antimicrobial prescribing Audits are performed prospectively (i.e. real time) Feedback is provided as a result of antimicrobial prescribing audits Specific interventions are suggested as result of antimicrobial prescribing audits Our hospital does NOT preform antimicrobial audits Briefly describe your feedback process if you have one Question Title * 22. Formulary restriction requiring pre-authorization (check all that apply) Our hospital formulary restricts some antimicrobials Restricted antibiotics require pre-authorization in order to fill the prescriptions Our hospital formulary currently does NOT restrict antimicrobials Which antimicrobials require pre-authorization? (please specify) Question Title * 23. Which of the following interventions have been implemented or are you currently working on implementation? (check all that apply) Response Antibiotic time outs Have implemented Currently working on implementation have not implemented Antibiotic time outs Response menu Automatic changes from intravenous to oral antibiotic therapy Have implemented Currently working on implementation have not implemented Automatic changes from intravenous to oral antibiotic therapy Response menu Dose adjustments Have implemented Currently working on implementation have not implemented Dose adjustments Response menu Dose optimizations Have implemented Currently working on implementation have not implemented Dose optimizations Response menu Automatic alerts where therapy may be unnecessarily duplicated Have implemented Currently working on implementation have not implemented Automatic alerts where therapy may be unnecessarily duplicated Response menu Time-sensitive automatic stop orders for specified prescriptions Have implemented Currently working on implementation have not implemented Time-sensitive automatic stop orders for specified prescriptions Response menu Detection and prevention of antibiotic-related drug-drug interactions Have implemented Currently working on implementation have not implemented Detection and prevention of antibiotic-related drug-drug interactions Response menu Question Title * 24. Which of the following infection and syndrome specific interventions has your hospital implemented? (check all that apply) Response Community acquired pneumonia Have implemented Currently implementing Have NOT implemented Community acquired pneumonia Response menu Urinary tract infections (UTI) Have implemented Currently implementing Have NOT implemented Urinary tract infections (UTI) Response menu Skin and soft tissue Have implemented Currently implementing Have NOT implemented Skin and soft tissue Response menu Empiric coverage of MRSA infections Have implemented Currently implementing Have NOT implemented Empiric coverage of MRSA infections Response menu Clostridium difficile infections Have implemented Currently implementing Have NOT implemented Clostridium difficile infections Response menu Treatment of culture proven invasive infections Have implemented Currently implementing Have NOT implemented Treatment of culture proven invasive infections Response menu Done