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healthcare-associated infections (hai) program

 CDPH HAI Antimicrobial Stewardship Program (ASP) Honor Roll 

  • Please refer to the online application​  for instructions for answering each question in the application. 
  • Also, refer to “Tips on uploading documentation​” to help simplify the process.
  • Only documentation examples (not a complete list) for each element are described below. 
  • Unless noted, at least one item for each core element is required to be uploaded for all designations.
  • Documentation must be inclusive of the three-year period prior to the deadline date. ​

​See details in each corresponding core element item below.

Additional Documentation  

Documentation in addition to the minimum described above can be submitted. Below are examples that can be submitted. The more documentation you submit can provide us with a more comprehensive understanding and appreciation of your program. 

Action 

  1. Requirements for prescribers to document indication on medical record or during order entry for all antibiotic prescriptions screenshot or policy/guideline (may use policy/protocol or screenshot if only available online). 
  2. Requirements for documenting or a procedure for defining duration for all antibiotics once a diagnosis has been established (may use policy/protocol or screenshot if only available online). 
  3. Formal procedure for all prescribers to conduct daily reviews of antibiotic selection until a definitive diagnosis and treatment duration are established (i.e. time out). 

Tracking 

  1. Preauthorization interventions by tracking which agents are being requested for which conditions 
    • ​Facility-wide, Individual-, unit-, or service-specific report 

  2. MUE data that assesses course of therapy for select antibiotic and/or infections 
  3. Facility-wide, individual-, unit-, or service-specific data of antibiotic timeouts proportion/percentage of how often they are done and if being acted upon, etc. 
  4. Facility-wide, individual-, unit-, or service-specific data based on a specific antibiotic and/or infection of how often patients are discharged on the correct antibiotics for the recommended duration. Acceptable to have monitoring that is periodic review for assessing how often patients are discharged on the correct antibiotics for the recommended duration. 
  5. Antibiotic resistance data (this may be different than your antibiogram). 
    • May include data that is tracked in addition to or more frequently monitored than your antibiogram. This may be individual-, unit-, or service-specific data. 
    • You may also upload your recent report from the NHSN AR module. 
  6. Clostridioides difficile infection (CDI) rates in context of antibiotic use. These may be table/graphs of CDI rates in relation to antibiotic use 

Reporting 

  1. Report of various ASP activities, antibiogram, antibiotic use, and so on that is shared with stakeholders (such as staff, prescribers, leadership, etc.) 
  2. Report of adherence to treatment recommendations. Examples include institution specific reports disseminated to prescribers/stakeholders, such as results from medication use evaluation.  

Education 

  1. Copy of other types of education not listed under minimum documentation above: examples newsletters, in-services, memos, etc. 
NOTES  
  1. Do not send line lists of protected health information (identifiable information as medical record numbers, date of birth, etc.) 
  2. Please send aggregated data as applicable and not line lists of individual cases/interventions. These line lists are great for your facility to know which patients to follow-up on; however, it is not useful for us to evaluate your program overall. Also include time period data was collected, such as by month or quarter. Most facilities have submitted data for the most recent 1 to 2 years, while a few have submitted longitudinal data over the life of their AS program.  
  3. Make sure to include definitions for acronyms or non-standard terminology.  
  4. Please define your metrics if they are not stated in graphs, tables or reports, etc. 
  5. If submitting analysis of adherence or compliance to guidelines or clinical pathways, please also submit the actual guideline/clinical pathway.​
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