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healthcare-associated infections (HAI) program

CDPH HAI Antimicrobial Stewardship Program (ASP) Honor Roll Outcomes

Part III - Demonstration of Outcomes (Required for Silver and Gold Designations)

ASP Honor Roll Silver designation logo​

Demonstration of Outcomes Overview 

  • Part III requires reporting a clinically meaningful outcome related to a stewardship intervention (see details of outcomes and interventions below). The stewardship intervention should have been performed within two years of the application deadline, and the most recent outcome data should have been obtained within one-year of the deadline. 
  • The goal of Part III is to determine if your program has progressed beyond meeting standard CDC core elements. 
  • Reviewers of Part III will be external and blinded antimicrobial stewardship program (ASP) experts. They will evaluate your intervention and outcome as if it were a scientific abstract using the rubrics below as applicable. Please ensure that all facility-identifying information is redacted (Part III only). 
  • Optional: In addition to answering the questions on the application, you may upload additional documentation such as graphs, publications, abstracts, posters, or reports supporting the intervention and outcomes reported in the application. 
  • Please provide complete answers in the online application. ​

Renewal Applicants 

  • If you are renewing, you will be prompted to clarify if you are submitting a new project not previously submitted to the CDPH HAI ASP Honor Roll or submitting an updated version of a previously submitted project. 
  • If the project has been previously submitted, please describe the need for the ongoing project, adjustments made since the last application, and updated results from the past year. 
  • Note: We cannot accept a previously submitted project without justification of ongoing need, discussion of modifications, and demonstration of new clinically meaningful outcomes. 

Clinically Meaningful Outcomes  

  • Clinically meaningful outcomes refer to outcomes directly linked to the facility’s intervention and should go beyond general antimicrobial use (AU) metrics like days of therapy (DOT). 
    • Appropriate outcomes may include evaluating the appropriateness of antimicrobial use, prescribing behavior, adherence to guidelines, and use of diagnostic testing. 
    • Other potential clinically meaningful outcome examples include, but are not limited to, clinical outcomes, mortality, morbidity, adverse drug reactions, and 30-day readmission rates. 
  • Appropriate outcomes depend on the project submitted and may vary by facility. 
  • Tracking NHSN required hospital-wide antimicrobial use (e.g., days of therapy), hospital-wide resistance, or hospital-wide C. diff rates alone is no longer sufficient, though indication specific data may still qualify. Please refer to Rubric below. 
  • Note: Clinically meaningful outcomes refer to the outcome being measured and not the result. Facilities can still qualify even if outcomes do not show improvement. ​

Examples of New Interventions

  • Reducing fluoroquinolone use in response to prescribers overprescribing fluoroquinolones, prescribing fluoroquinolones outside of guideline recommendations, or increased fluoroquinolone resistance. 
    • Clinically meaningful outcomes may include guideline adherence and clinical cure rates. 
    • Interventions could include an antimicrobial timeout when fluoroquinolones are prescribed. Other considerations include creating or publicizing new indication specific guidance documents, requiring prior authorization for fluoroquinolones, or having the AS team review all quinolone use. 
  • Targeting Staphylococcus aureus blood stream infection (SAB) in response to high mortality rates or delays in appropriate empiric or definitive therapy 
    • Clinically meaningful outcomes could include SAB rates, treatment outcomes including mortality rates, time to initiation of appropriate antimicrobials in hours, and duration of therapy. 
    • Interventions could include implementation of a SAB bundle using clinical decision support software. Other considerations include improved communication between the laboratory and provi​ders in response to positive blood cultures, requiring an infectious disease (ID) consult for SAB, or requiring stewardship team review of positive blood cultures. ​

Examples of Resubmitted Interventions

​Not acceptable resubmission due to lack of adjustment to project: 
 ​Acceptable resubmissions with substantial adjustment to project:​
​Original Intervention: Fluoroquinolones were removed as suggested empiric therapy from several guidelines to reduce fluoroquinolone use. Outcomes included tracking quinolone resistance   

Update/Rationale to continue: Project was successful in reducing fluoroquinolone use 

Reasons why this would not be accepted: 
Lacks better rationale for why the previous project was resubmitted and description of ongoing improvements. There is no change in clinically meaningful outcomes (which are limited to antimicrobial use and resistance) or adjustments to the intervention. The only update is submission of recent data. 

We encourage facilities to continue successful projects. However, for renewals, we expect to see new interventions or modifications to the original project with the aim of demonstrating ongoing improvement in stewardship in your facility. Submitting a new project is often best. 
 ​Original Intervention:  Reducing fluoroquinolone use due to increasing resistance and concern for adverse events. Clinically meaningful outcomes in addition to antimicrobial use were fluoroquinolone resistance rates and Clostridioides difficile infection rates. (Note: for these metrics to now be acceptable they would have to go beyond hospital-wide data. Indication specific data could qualify.) 

Update/Rational to continue: Project was continued as, although inpatient fluoroquinolone use improved, prescribers were often inappropriately discharging patients with a fluoroquinolone. Thus, the intervention was adjusted to add oral cephalosporins as a discharge option. Duration of therapy was added as an outcome. 

Original Intervention: Implementing rapid diagnostic testing (RDT) of blood cultures to reduce time to effective antimicrobials. Various clinically meaningful outcomes were evaluated including length of stay, antimicrobial use, and mortality. 

Update/Rational to continue: Project was continued because, although RDT made results available sooner, time to directed therapy was still delayed as prescribers were unaware of the results. Thus, time to directed therapy could be further improved through addition of pharmacy driven intervention in response to RDT results.

Rubric for Outcomes (Part III)

Below are rubrics for new and resubmitted projects for use by reviewers.

New Interventions

​Questions (Time frame should include most recent one year prior to deadline):
​Was an outcome clearly reported?  
     0 – Unclear 
     1 – Not explicitly stated, but discernable 
     2 – Not explicitly stated, but implied in the results 
     3 – Explicitly stated (measurable) 

Was the outcome(s) clinically meaningful?  Results must include actual data. (The below rubric presents an incomplete list of examples. Reviewer will select the highest score): 
     0 – No outcome provided     
     1 – Antimicrobial use only (AU data alone is not sufficient for Part III) 
     2 – Antimicrobial associated events (e.g., C. diff or resistance rates in study population, adverse drug events)  
     3 – Prescribing appropriateness (e.g.​, guideline adherent therapy) and/or prescribing behavioral changes (e.g., requests for a restricted antimicrobial) 
     4 – Clinical outcomes (e.g., mortality, readmissions, length of stay, clinical success/cure)
​Originality 
     0 – Partially or completely missing results or plan 
     1 – Old idea without clinically significant results  
     2 – Replicates important intervention done by others with clinically significant results 
     3 – Original or innovative intervention with clinically significant results (e.g. new population not previously described)
​Overall impression  
     0 – Does not appear to be an effective/successful intervention 
     1 – Intervention is partially effective/successful 
     2 – Intervention is effective/successful 
     3 – Intervention serves as a model for others (sustainable changes/intervention)​​
​Additional comments (general)
​Specific comments on Outcome Reporting
​Specific comments on Clinically Meaningful Outcome ​
​Specific comments on Originality 
​​Specific comments on Overall Impression (accuracy of data, e.g. check denominators)

Previously Submitted Interventions​

​Questions (Time frame should include most recent one year prior to deadline): 
​Need for continuing the intervention  
     0 - Unclear 
     1 - Not explicitly stated, but discernable 
     2 - Some description 
     3 - Explicitly stated; demonstrated clear need for continuation
​Was the outcome(s) clinically meaningful?  Results must include actual data. (The below rubric presents an incomplete list of examples. Reviewer will select the highest score): 
     0 – No outcome provided     
     1 – Antimicrobial use only (AU data alone is not sufficient for Part III) 
     2 – Antimicrobial associated events (e.g., C. diff or resistance rates in study population, adverse drug events)  
     3 – Prescribing appropriateness (e.g., guideline adherent therapy) and/or prescribing behavioral changes (e.g., requests for a restricted antimicrobial) 
     4 – Clinical outcomes (e.g., mortality, readmissions, length of stay, clinical success/cure) 
​Adjustment in methods or outcomes. Use scale below. 
     0 – No adjustment in methods or additional clinically meaningful outcomes. No updated results    
     1 – Minor adjustment in methods or additional clinically meaningful outcomes with updated results  
     2 - Moderate adjustment in methods or additional outcomes with updated results 
     3 – Significant adjustment in methods or outcomes with updated results 
​Overall impression. Use scale below. 
     0 - Does not appear to be an effective/successful intervention 
     1 - Intervention is partially effective/successful 
     2 - Intervention is effective/successful 
     3 - Intervention serves as a model for others (sustainable changes/intervention)
​Additional comments (general)
​Specific comments on Need for Continuation
​Specific comments on Clinically Meaningful Outcome
​Specific comments on Adjustments
​Specific comments on Overall Impression (accuracy of data, e.g. check denominators)​

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