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HOSPITAL ASSESSMENT OF

ANTIMICROBIAL STEWARDSHIP PROGRAM IMPLEMENTATION

National Hospital for Tropical Diseases Oxford University Clinical Research Unit Hospital ID 020 21 July 2023

Completed under the project 46HN: “Understanding variations in antimicrobial stewardship (AMS) programs in hospital networks in Asia through a newly developed context-specific tool” Funder: US Centers for Disease Control and Prevention

TABLE OF CONTENT INTRODUCTION

METHODS

RESULTS

1. Domain I. Item 1. Item 2. Item 3. Item 4. Item 5. Item 6. Item 7: Item 8. Item 9. Item 10. Item 11. Item 12. Item 13.

Self-Assessment for Antibiotic Stewardship Team in Healthcare Facilities 6 LEADERSHIP COMMITMENT & ACCOUNTABILITY Is antibiotic stewardship identified as a priority by the health-care facility management/leadership? Are antibiotic stewardship activities included in health-care facility annual plans with key performance indicators? Is there a mechanism to regularly monitor and measure the implementation of antibiotic stewardship activities? Does your healthcare facility have an antibiotic stewardship committee that reviews policies, procedures, treatment guidelines, and operational considerations related to antibiotic stewardship? Who are the members of the antibiotic stewardship committee at your healthcare facility (select all that apply)? Does the antibiotic stewardship committee meet on a regular basis (minimum monthly or quarterly)? Who are the members of the antibiotic stewardship team at your healthcare facility (select all that apply)? Does the antibiotic stewardship team meet on a regular basis? Does the antibiotic stewardship committee or team have authority to make decisions about policies or procedures related to antibiotic use at your healthcare facility? Which hospital department(s) or healthcare teams does your antibiotic stewardship committee or team collaborate with (select all that apply)? Does the healthcare facility participate in any external networks (e.g., multicenter studies, research, or quality improvement collaboratives, data sharing consortiums) related to antibiotic stewardship? Who is involved in antibiotic formulary/procurement decisions at your healthcare facility (select all that apply)? Is the evidence related to the safety, efficacy, and cost of new antibiotics evaluated before adding to the formulary at your healthcare facility? i

Hospital Assessment of Antimicrobial Stewardship Implementation

Domain II. Item 14. Item 15. Item 16. Item 17. Item 18. Item 19. Item 20. Item 21. Item 22. Item 23. Item 24. Item 25. Item 26.

RESOURCES 12 Has the healthcare facility allocated human and financial resources to initiate antibiotic stewardship activities? Which of the following are physically present at your healthcare facility (select all that apply)? Does the antibiotic stewardship team have an office or physical space to perform antibiotic stewardship activities? Does the antibiotic stewardship team have the basic equipment (e.g., telephone, computer) to perform antibiotic stewardship activities? Does your healthcare facility have information and decision support systems in place to support antibiotic stewardship activities (e.g., review and optimization of antibiotic prescriptions, pre-authorization)? Which of the following can the antibiotic stewardship team access (select all that apply)? Which data are available electronically at your healthcare facility (select all that apply)? Does the antibiotic stewardship team have access to updated evidence in the form of peer-reviewed scientific literature (e.g., published research)? Does the health-care facility have access to laboratory and imaging services (on-site or off-site) that can be used to support antibiotic stewardship interventions? Is the clinical microbiology laboratory used by your healthcare facility (on-site or off-site) open 24 hours per day to receive, process, and report microbiologic specimens? Is the clinical microbiology laboratory used by your healthcare facility (on-site or off-site) accredited? Does the clinical microbiology laboratory used by your healthcare facility (on-site or off-site) have a quality management system? Does the clinical microbiology laboratory used by your healthcare facility (on-site or off-site) have an electronic laboratory information system?

DOMAIN III: EDUCATION & TRAINING Item 27. Does the healthcare facility provide training on antibiotic stewardship (e.g., optimizing antibiotic use) in the staff induction training? Item 28. Does the healthcare facility offer continuous in-service training or continuous professional development on antibiotic stewardship and IPC to staff? Item 29. Does your healthcare facility provide training on antibiotic stewardship to students or trainees rotating at your healthcare facility? Item 30. Does the healthcare facility provide training for the antibiotic stewardship team on antibiotic stewardship/IPC? Item 31. Does your healthcare facility provide patients and/or families with education about antibiotics?

TABLE OF CONTENT (cont.) Domain IV. ANTIBIOTIC STEWARDSHIP ACTIONS 17 Item 32. Which of the following treatment guidelines exist at your healthcare facility (select all that apply)? Item 33. Which of the following is/are included in treatment guidelines at your healthcare facility (select all that apply)? Item 34. Are the guidelines reviewed and updated periodically based on availability of new evidence, with changes communicated to prescribers? Item 35. Does the antibiotic stewardship team review the healthcare facility antibiogram on a regular basis to modify treatment guidelines? Item 36. Antibiotic Stewardship Activities? Item 37. Is antibiotic stewardship activity performed facility-wide? Item 38. Are there standardized operating procedures for specific antibiotic stewardship activities (e.g., audit and feedback, guideline development, testing protocols) at your healthcare facility? Item 39. Does the activity report produced by the antibiotic stewardship committee or team include the following (select all that apply)? Item 40. Who is the antibiotic stewardship activity report disseminated to (select all that apply)? Item 41. Does the health-care facility have a formulary/ list of approved antibiotics for use based on the national formulary? Item 42. Does the health-care facility formulary specify lists of restricted antibiotics that require approval by a designated team or person (pre-authorization)? Item 43. Does the approval of restricted antibiotics take place throughout the workday? Item 44. Does the healthcare facility communicate modifications to the antibiotic formulary to prescribers? Item 45. Do nurses at your healthcare facility do any of the following antibiotic stewardship activities (select all that apply)? Item 46. Does your healthcare facility have a policy that requires prescribers to document antibiotic dose, duration, and indication in the medical record? Item 47. Does the clinical microbiology laboratory used by your healthcare facility (on-site or off-site) utilize rapid diagnostic testing to facilitate early antibiotic adjustments? Item 48. Does the clinical microbiology laboratory used by your healthcare facility (on-site or off-site) have technology to identify the most relevant resistance mechanisms (e.g., extended spectrum beta-lactamases, carbapenemases)? Item 49. Does the clinical microbiology laboratory used by your healthcare facility (on-site or off-site) provide culture and susceptibility results to prescribers in a timely manner (e.g., within 72 hours)? Oxford University Clinical Research Unit

iii

Hospital Assessment of Antimicrobial Stewardship Implementation

Item 50. Item 51. Item 52. Item 53.

Does the clinical microbiology laboratory used by your healthcare facility (on-site or off-site) utilize selective or cascading antibiotic susceptibility testing reporting (e.g., not reporting an antibiotic that would not be appropriate for the source, not reporting a broad-spectrum antibiotic when a narrower spectrum is available)? Does the clinical microbiology laboratory used by your healthcare facility (on-site or off-site) put comments in culture results to improve antibiotic prescribing? Does the antibiotic stewardship team communicate the emergence of new resistance mechanisms to prescribers? Has the antibiotic stewardship team conducted an analysis of the barriers, challenges and opportunities for antibiotic stewardship implementation at your healthcare facility?

Domain V: Item 54. Item 55. Item 56. Item 57. Item 58. Item 59. Item 60. Item 61. Item 62. Item 63.

ANTIBIOTIC USE TRACKING, MONITORING & REPORTING 23 Are regular prescription audits, point prevalence surveys to assess the appropriateness of antibiotic prescribing undertaken at the facility by the antibiotic stewardship committee or relevant team? Does the health-care facility regularly monitor and report the quantity and types of antibiotic use (purchased, prescribed, or dispensed)? What metric does the antibiotic stewardship team use to measure antibiotic use or consumption at your healthcare facility (select all that apply)? Does the antibiotic stewardship team develop action plans in response to problems identified related to optimization of antibiotic use (e.g., increase in the consumption of broad-spectrum antibiotics)? Does the antibiotic stewardship team monitor compliance with at least one specific antibiotic stewardship activity (e.g. compliance with treatment guidelines) at the health-care facility? Does the antibiotic stewardship committee or team implement strategies (e.g., presentation to healthcare workers on implementation of new infectious diseases treatment guideline) to increase compliance with prioritized antibiotic stewardship activities? Which of the following metrics are monitored by the antibiotic stewardship team to assess the impact of antibiotic stewardship activities (select all that apply)? Which data can be stratified by hospital unit/ward at your healthcare facility (select all that apply)? Does the healthcare facility regularly monitor shortages/stockouts of essential antimicrobials? Does your healthcare facility monitor shortages/stockouts of laboratory supplies (e.g., reagents, plates)?

TABLE OF CONTENT (cont.) Item 64. Item 65. Item 66. Item 67. Item 68.

If there is a concern about substandard quality of antibiotics (e.g., falsified antibiotics) and diagnostics, is there a mechanism to report this at the healthcare facility? Does the antibiotic stewardship committee or team regularly monitor and report antibiotic susceptibility and resistance rates for a range of key indicator bacteria? Does the antibiotic stewardship team communicate findings from audits/reviews of the quality/appropriateness of antibiotic use to prescribers along with specific action points? Does the antibiotic stewardship team report metrics used to assess the impact of antibiotic stewardship activities to leadership at your healthcare facility? Does the healthcare facility develop and aggregate antibiogram and regularly update it?

Knowledge, attitudes, and perceptions (KAP) survey results

Summary of qualitative data from in-depth interviews and focus group discussions

3.1. 3.2. 3.3.

Strengths of and opportunities for AMS implementation 30 Weaknesses of and barriers for AMS implementation 30 Factors influencing antibiotic prescribing practices 30

Summary of quantitative antibiotic use indicators

Recommendations for the next AMS action plan

APPENDIX

Appendix 1: Antibiotic Stewardship Survey for Healthcare Workers Appendix 2: Self-Assessment for Antibiotic Stewardship Team in Inpatient Healthcare Facilities

REFERENCES

Oxford University Clinical Research Unit

Hospital Assessment of Antimicrobial Stewardship Implementation

Acronyms AMR

Antimicrobial Resistance

AMS

Antimicrobial Stewardship

AMU

Antimicrobial Use

AWaRE

Access - Watch - Reserve

CPD

Continuous Professional Development

EML

Essential Medicines List

FIT

Facility Improvement Too

HAI

Healthcare-Associated Infection

HCF

Healthcare Facility

Health Worker

IPC

Infection Prevention and Control

M&E

Monitoring & Evaluatation

MoH

Ministry of Health

NCM

National Coordination Machanism

PHC

Primary Health Care

SOP

Standard Operating Procedure

Tuberculosis

TOR

Terms of Reference

UHC

Universal Health Coverage

WAAW

World Antimicrobial Awareness Week

WASH

Water, Sanitation and Hygiene

WHO

World Health Organization

INTRODUCTION Vietnam is facing an alarming increase in antimicrobial resistance (AMR) rates for many important bacteria causing diseases in human, is one of the countries with the highest resistance rates in Asia and the world [1-3]. Antimicrobial stewardship (AMS) is one of the key strategies in the global and national AMR Action Plan, and has been shown to be effective in reducing the inappropriate use of antimicrobials [47] and therefore helping to reduce AMR. The Vietnam Ministry of Health (MoH) has issued Guidelines for the Implementation of AMS Programs in Healthcare Facilities under Decision 5631/QD-BYT in 2020 (replacing the guidance in Decision 772/QDBYT in 2016) and the Antibiotic Treatment Guidelines in 2015 to support hospitals in AMS implementation. Recently, MoH has also released a new Guidelines for AMS implementation in district-level hospitals to support the activities in these lessresourced settings (Decision 2115/QD-BYT, dated 11 May 2023). The research team from Oxford University Clinical Research Unit (OUCRU) in collaboration with the National Hospital for Tropical Diseases is assessing the AMS implementation status at Hospital ID 020 to understand the successes, challenges, and gaps, and identify areas for improvement. This is part of a multi-country research project entitled, “Understanding variations in Antimicrobial Stewardship Programs in hospital networks in Asia through a newly developed context-specific tool” to provide evidence for hospitals across different countries in Asia to improve their institutional AMS programs. The assessment used a contextualized assessment tool that could support hospitals in identifying implementation targets and utilizing resources and opportunities effectively within the national and local contexts. The research project and the development of the assessment tool through a multi-stage process has been led by our team of investigators at University of Oxford and Duke Antimicrobial Stewardship Outreach Network, in collaboration with the US Centers for Disease Control and Prevention (CDC). The project was funded by US CDC under the Contract No 200-2021-11957; FY 21 BAA Topic 4.6 – University of Oxford. There are altogether 19 hospitals in five countries (Indonesia, Nepal, Thailand, Viet Nam, and US) participating in this project. This report describes the assessment results at Hospital ID 020. Here the terms “antibiotic” and “antimicrobial” were used interchangeably to indicate the antimicrobial agents that are within the scope of the hospital’s AMS program/ activities.

Oxford University Clinical Research Unit

Hospital Assessment of Antimicrobial Stewardship Implementation

Photo: National workshop on AMS implementation in Hanoi - Vietnam

METHODS The assessment used a global tool and instruction (see Appendix 1 and Appendix 2), which includes two components: Component 1: Component 2:

The “Antibiotic Stewardship Survey for Healthcare Workers” assesses the knowledge, attitudes, and perceptions (KAP) of various healthcare workers (e.g., physicians, pharmacists, nurses) regarding antibiotic use, antibiotic stewardship, and antibiotic resistance. The “Self-Assessment for Antibiotic Stewardship Team in Healthcare Facilities” assesses core elements, structure, education and training, facility processes, and the presence or absence of activities related to antibiotic stewardship practices. Component 2 also includes assessment items developed by the World Health Organization (WHO).

The United States Centers for Disease Control and Prevention (CDC) in collaboration with Johns Hopkins University, University of Oxford/Duke University, and the University of Pennsylvania has developed this global tool to assess antibiotic stewardship (AMS) practices in healthcare facilities. This two-component comprehensive diagnostic tool will help facilities to build capacity for implementing AMS activities, identify opportunities to improve AMS programs, and monitor progress of AMS actions over time. At Hospital ID 020, we conducted following activities to collect information for the completion of the assessment tool and to gain in-depth understanding of the contextual factors that can influence the implementation of AMS program in hospitals and identify the next steps for improvement: 1. In-depth Interviews (IDIs) with staff (n=6) who are members of the AMS committee on the process of design, implementation, and evaluation of AMS programs, including the perceived successes and failures, barriers, and facilitating factors underpinning these successes and failures; this follows the assessment items in Component 2 of the assessment tool. 2. Focus Group Discussions (FGDs) with senior doctors (n=5), junior doctors (n=5), and nurses (n=5) to understand their experience and perceptions about antibiotic prescribing practices in relation to AMS implementation. 3. Quantitative Knowledge, Attitudes, and Perceptions (KAP) survey of all study participants (n=20) on AMS implementation and antibiotic prescription; this follows Component 1 of the assessment tool.

Oxford University Clinical Research Unit

Hospital Assessment of Antimicrobial Stewardship Implementation

4. Collection of quantitative data on antimicrobial use including a point prevalence survey in selected wards and extraction of routine datasets from hospital information systems. 5. Collection of existing documents that can be used to verify and provide additional contextual information for the review of each assessment aspect. For details of the assessment activities, please refer to the project study protocol, forms and SOPs (study code: 46HN). This report first provides the results completed by the AMS team on the self-assessment for each item in the Component 2. This is followed by the results of KAP survey in the Component 1. After this, a summary of the qualitative findings from the IDIs and FGDs is presented, followed by summary data for key antibiotic use indicators. The report concludes with a list of recommendations for an action plan in the next period of implementation at the hospital.

RESULTS

Hospital Assessment of Antimicrobial Stewardship Implementation

Self-Assessment for Antibiotic Stewardship Team in Healthcare Facilities

Members of the AMS committee provided one response per question based on the following options: • • •

Yes = the activity/core element is in place and is fully implemented; Partially implemented = the activity/core element is in place but is only partially implemented requiring further action or strengthening; No = the activity/core element is not in place or has not been implemented OR

•

“Select all that apply” based on the provided answer choices for relevant questions.

The overall score for each domain of AMS implementation at this hospital is shown in Table 1.1.

Earned points/ Total points possible

Percentage

I. Leadership Commitment & Accountability

62.5 / 65

96.2%

II. Resources

50 / 65

76.9%

III. Education & Training

22.5 / 25

90%

IV. Antibiotics Stewardship Actions

85 / 105

81%

V. Antibiotic Use Tracking, Monitoring & Reporting

62.5 / 75

83.3%

OVERALL

282.5 / 335

84.3%

Domain

Table 1.1: Scoring rubric for each domain of AMS implementation

List of respondents who are the members of the AMS committees or assigned by the hospital leader to be responsible for providing responses to the specific AMS domains are in Table 1.2. Responses were given on the corresponding assessment items which was sent to the respondents prior to the interviews. During the interviews, further clarifications were provided to justify the responses.

No.

Participant ID

Professional role

46HN-IDI-001-020-01

Department of General Medicine, Coordinator of AMS committee

46HN-IDI-001-020-02

Department of Microbiology - Molecular biology, Member of AMS committee

46HN-IDI-001-020-03

Department of Virology and Parasitology, Member of AMS committee

46HN-IDI-001-020-04

Department of Pharmacy, Member of AMS committee

46HN-IDI-001-020-05

Intensive Care Unit, Member of AMS committee

46HN-IDI-001-020-06

Emergency Department, Member of AMS committee Table 1.2: List of respondents

Summary of scores achieved at Hospital ID 020 in relation to the average and to other hospitals in the network is presented in Figure 1.1 for reference. This hospital is highlighted in blue columns; For each domain, there is a horizontal line indicating the average

Figure 1.1. Assessment scores (percentage achieved) for all domains in relation to the average and other hospitals in the project network

RESULTS

Hospital Assessment of Antimicrobial Stewardship Implementation

DOMAIN 1

LEADERSHIP COMMITMENT & ACCOUNTABILITY

Item 1

Is antibiotic stewardship identified as a priority by the health-care facility management/leadership?

Score: 5 (Yes)

Based on the guidelines of the Ministry of Health, the Director of the hospital signed the decision on the establishment of the AMS committee, in which the leader of the committee in charge is a Vice Director, and there is a clear assignment of tasks for healthcare workers in the hospital to aim to provide guidelines and coordinate related AMS activities, and therefore, optimize antibiotic use in the hospital. The Board of Directors is also aware of the importance of optimal antibiotic prescriptions and the consequences of antimicrobial resistance; thus, they closely direct the implementation of AMS activities to improve the effectiveness of antibiotic prescriptions. Some activities include teaching, continuous training for healthcare workers on new treatment guidelines, optimizing antibiotic use and updating new information on antimicrobial resistance. The Board of Directors also plans to allocate human and financial resources to control hospital-acquired infections.

Item 2

Are antibiotic stewardship activities included in health-care facility annual plans with key performance indicators?

Score: 2.5 (Partially implemented)

Every year, the AMS committee holds regular meetings and agrees on action plans, including the plan to collect data related to antibiotic consumption, DDD – Defined Daily Dose, DOT – Days of Therapy, and antibiotic costs, number of hospital-acquired infections associated with ventilator pneumonia, number of catheter-associated urinary tract infections, and number of catheter-associated infections. These indicators are only being compiled during the year to describe the status of implementation, however, there is no comparison over time to understand the data trends, thereby, assessing performance.

Item 3

Is there a mechanism to regularly monitor and measure the implementation of antibiotic stewardship activities?

Score: 5 (Yes)

The Director of the hospital requests that AMS committee monitors the results of the implementation of the AMS activities and report annually. In addition, the focal points in charge of AMS activities have mechanisms to monitor the corresponding implementation. Specifically, the Department of Pharmacy is responsible for monitoring and summarizing the antibiotics use of clinical departments through an inventory of antibiotics imported, dispensed and used, and reviewing the optimal antibiotic prescriptions of clinical physicians. The Department of Microbiology is responsible for culture and antibiogram results, monitoring the new resistant mechanisms and multidrug resistance, and working closely with Department of Pharmacy and other clinical departments.

Item 4

Does your healthcare facility have an antibiotic stewardship committee that reviews policies, procedures, treatment guidelines, and operational considerations related to antibiotic stewardship?

Score: 5 (Yes)

Based on microbiology data and antibiotic use, AMS committee has reviewed and updated procedures and treatment guidelines in the hospital. In addition, AMS committee also drafts and advises the Board of Directors and the Drug and Treatment Council of the hospital on the list of antibiotics that need priority management at the hospital, and the list of restricted antibiotics that require approval by a designated team before use.

Item 5

Who are the members of the antibiotic stewardship committee at your healthcare facility (select all that apply)?

Score: 5 (≥ 7 selected)

The Board of Directors signed a decision to establish an AMS committee at the hospital with clear assignments for members representing the important roles in AMS such as Department of Microbiology, Department of Pharmacy, Department of Infection Control, clinical departments, Department of Information Technology. This AMS committee works under the management of a Vice Director.

Item 6

Does the antibiotic stewardship committee meet on a regular basis (minimum monthly or quarterly)?

Score: 5 (Yes)

Normally, AMS committee holds a regular meeting every 3 months. However, depending on unexpected needs or situations, for example, running out of essential antibiotics, or the Department of Microbiology detects a superbug bacterium, AMS committee also meets irregularly at the request of the coordinator or leader of the committee.

Item 7

Who are the members of the antibiotic stewardship team at your healthcare facility (select all that apply)?

Score: 5 (infectious diseases trained physician or clinician with experience practicing infectious diseases AND infectious diseases trained pharmacist(s) OR other clinical pharmacist(s) OR other staff pharmacist(s) (if pharmacists are present at HCF) AND clinical microbiologist) AMS committee is established at the hospital with clear assignments for members representing the important roles in AMS such as Department of Microbiology, Department of Pharmacy, Department of Infection Control, clinical departments, Department of Information Technology. However, a small group of 3-5 members, including physicians with experience practicing infectious diseases, clinical pharmacists and microbiologists is in charge of specific AMS activities weekly or monthly. The AMS committee works under the management of a Vice Director. RESULTS

Hospital Assessment of Antimicrobial Stewardship Implementation

Item 8

Does the antibiotic stewardship team meet on a regular basis?

Score: 5 (Yes)

Quarterly, the AMS committee holds a meeting on a regular basis and when unexpected events occur. However, a small group of 3-5 members, including physicians with experience practicing infectious diseases, clinical pharmacists and microbiologists is in charge of specific AMS activities and holds monthly or weekly meetings to solve issues and problems related to AMS activities.

Item 9

Does the antibiotic stewardship committee or team have authority to make decisions about policies or procedures related to antibiotic use at your healthcare facility?

Score: 5 (Yes)

Item 10

Which hospital department(s) or healthcare teams does your antibiotic stewardship committee or team collaborate with (select all that apply)?

Score: 5 (≥ 2 selected)

The AMS committee collaborates actively and closely with other departments having important roles in AMS in the hospital, such as Department of Infection Prevention and Control, Department of Infectious Diseases, Department of Quality Management, Department of Pharmacy, Department of Microbiology, Drug and Therapeutic committee, and Department of Surgery.

Item 11

Does the healthcare facility participate in any external networks (e.g., multicenter studies, research or quality improvement collaboratives, data sharing consortiums) related to antibiotic stewardship?

Score: 5 (Yes)

In addition to conducting research with the Ministry of Health, the hospital works closely with different international organizations such as OURCU, US CDC in implementing outbreak management, surveillance of infection control programs, and conducting research on antibiotics and antibiotic resistance.

Item 12

Who is involved in antibiotic formulary/procurement decisions at your healthcare facility (select all that apply)?

Item 13

Is the evidence related to the safety, efficacy, and cost of new antibiotics evaluated before adding to the formulary at your healthcare facility?

Score: 5 (Yes)

The Drug and Treatment Council is charged with evaluating the safety, efficacy, and cost of new antibiotics before they are added to the hospital’s formulary. Some criteria for evaluating antibiotics include (1) being FDA-approved antibiotics for use in patients and (2) being approved by the Vietnam Department of Pharmacy for use in Vietnam. Additionally, based on reviewing documents on adverse drug reactions (ADR), the warning of the clinical departments about the antibiotic allergy assessment, or the comparison of the effectiveness to the old antibiotics. Thereafter, the Drug and Treatment Council bases its recommendations on the above conditions to comprehensively consider both safety, efficacy and cost for the list of antibiotics used in hospitals.

RESULTS

Hospital Assessment of Antimicrobial Stewardship Implementation

DOMAIN II

RESOURCES

Item 14

Has the healthcare facility allocated human and financial resources to initiate antibiotic stewardship activities?

Score: 0 (No)

The human and financial resources for the implementation of AMS activities are not allocated separately, but are integrated with other activities of the respective departments in the hospital.

Item 15

Which of the following are physically present at your healthcare facility (select all that apply)?

Item 16

Does the antibiotic stewardship team have an office or physical space to perform antibiotic stewardship activities?

Score: 0 (No)

The staff in charge of AMS implementation is using their own office or physical space to perform AMS activities and other tasks. There is no separate office or physical space for AMS activities at the hospital.

Item 17

Does the antibiotic stewardship team have the basic equipment (e.g., telephone, computer) to perform antibiotic stewardship activities?

Score: 0 (No)

The hospital provides the basic equipment such as telephone a number of computers for each specific department, and the staff in charge of AMS implementation is using those to perform AMS activities and other tasks. No basic equipment is assigned separately for AMS activities.

Item 18

Does your healthcare facility have information and decision support systems in place to support antibiotic stewardship activities (e.g., review and optimization of antibiotic prescriptions, pre-authorization)?

Score: 5 (Yes)

The hospital information system (HIS) greatly supports current AMS activities. Clinical pharmacists have access to clinical data and antibiotic use through HIS to review antibiotic prescriptions and summarize number of antibiotics imported, dispensed and used. In addition, HIS is also an effective support tool for clinical physicians in prescribing antibiotics for patients; specifically, physicians can easily receive warnings related to restricted antibiotics that require approval before use, the system also immediately notifies when it detects cases of drug – drug interactions. 12

Item 19

Which of the following can the antibiotic stewardship team access (select all that apply)?

Score: 5 (≥2 selected)

AMS committee at this hospital have full accessibility to electronic medical records, information related to antibiotic use such as antibiotic administration records, antibiotics purchased, antibiotics dispensed, and summarize table of antibiogram.

Item 20

Which data are available electronically at your healthcare facility (select all that apply)?

Score: 5 (≥2 selected)

All information related to basic demographic or antibiotic consumption, antibiotic use, antibiotic resistance and antibiotic cost are integrated in HIS, and under control and management of the Department of IT at this hospital.

Item 21

Does the antibiotic stewardship team have access to updated evidence in the form of peer-reviewed scientific literature (e.g., published research)?

Score: 5 (Yes)

Members of AMS committee as well as all hospital’s healthcare workers have opportunities to take part in seminars at the hospital, regional or national level; and in weekly scientific meeting to update medical knowledge. Besides, the healthcare workers are also proactive in updating treatment guidelines on the websites such as UpToDate or Sanford Guide. In addition, when staff are trained new knowledge, they will apply it to update Treatment guidelines in the hospital and younger and less experienced physicians can use it as a resource to improve their medical knowledge.

Item 22

Does the health-care facility have access to laboratory and imaging services (on-site or off-site) that can be used to support antibiotic stewardship interventions?

Score: 5 (Yes)

The Department of Microbiology is accredited with ISO 15189 – 2012 certification by the Ministry of Science and Technology of Vietnam and is an Antibiotic Reference Laboratory for hospitals in the north of Vietnam. Therefore, they ensure to provide a full range and high - quality of laboratory and diagnostic imaging services, thereby supporting the diagnosis and the best use of antibiotics for patients. However, the recent period of chemical shortages and interrupted drug bidder has resulted in some subclinical services not being met in a timely manner; the Board of Directors has immediately coordinated with other public health facilities in the area with equivalent testing functions (for example, Bach Mai Hospital, National Obstetrics Hospital, National Children’s Hospital, and Viet Duc Hospital) to quickly return results to clinical departments.

RESULTS

Hospital Assessment of Antimicrobial Stewardship Implementation

Item 23

Is the clinical microbiology laboratory used by your healthcare facility (on-site or off-site) open 24 hours per day to receive, process, and report microbiologic specimens?

Score: 5 (Yes)

The Department of Microbiology at this hospital opens 24 hours per day to receive, process and report results for microbiologic specimens.

Item 24

Is the clinical microbiology laboratory used by your healthcare facility (on-site or off-site) accredited?

Score: 5 (Yes)

The Department of Microbiology is accredited with ISO 15189 – 2012 certification by the Ministry of Science and Technology of Vietnam in 2022. And this is also an Antibiotic Reference Laboratory for hospitals in the north of Vietnam.

Item 25

Does the clinical microbiology laboratory used by your healthcare facility (on-site or off-site) have a quality management system?

Score: 5 (Yes)

The Department of Microbiology has a quality management system to comply with ISO 15189 – 2012 which is accredited by the Ministry of Science and Technology of Vietnam in 2022.

Item 26

Does the clinical microbiology laboratory used by your healthcare facility (on-site or off-site) have an electronic laboratory information system?

Score: 5 (Yes)

The Department of Microbiology is using LIS (Laboratory Information System) to store and manage laboratory information. Specifically, the patient’s microbiological data will be automatically synchronized with HIS (Hospital Information System) system to help physicians from clinical departments tracking the results of culture testing quickly and on time.

DOMAIN III

EDUCATION & TRAINING

Item 27

Does the healthcare facility provide training on antibiotic stewardship (e.g., optimizing antibiotic use) in the staff induction training?

Score: 5 (Yes)

Depending on the professional positions of new employees, relevant departments will organize induction training with contents related to AMS in the first 1-2 working weeks as follows: • Department of Pharmacy provides training for physicians on antibiotic prescription, operation procedure for pre-authorization for list of restricted antibiotics, procedure for step-up/ or step-down antibiotics; and provides training for nurses in terms of monitoring and reporting adverse drug reaction (ADR) • Department of Microbiology trains technicians on procedure for isolations and how to interpret microbiological results according to 2 systems being applied in the Department of Microbiology are CLSI and EUCAST, and procedure of specimen sampling for microbiological tests for nurses from clinical departments • Department Infection Control provides training on procedure for infection control • Clinical departments arrange physicians with experience (usually the leader or the physicians with the most work experience) to guide the new physicians through on-the-job trainings, such as in-person clinical rounds, prescribing antibiotics, consulting difficult or severe cases • Department of Information Technology provides trainings on how to use HIS. Many functions related to antibiotic prescribing such as antibiotic resistance risk classification system and warnings about restricted antibiotics that require approval before use are integrated in HIS system and new physicians need to learn how to use it Those training activities are organized through training sessions, or weekly scientific meeting.

Item 28

Does the healthcare facility offer continuous in-service training or continuous professional development on antibiotic stewardship and IPC to staff?

Score: 5 (Yes)

In terms of AMS and IPC, staff are trained through annual continuous professional development (such as the Department of Infection Control trains on handwashing procedures and multi-resistance patient isolation procedures) or through weekly scientific meetings with specific topics (such as antibiotic prescription tools by the Department of Pharmacy or clinical departments updating new treatment guidelines). The trainers are including teachers from universities such as Hanoi University of Pharmacy, Hanoi Medical University, or healthcare workers with expertise and many years of experience working at the hospital. Because this is one of the national hospitals, therefore, leaders of clinical departments are also experts in their fields.

RESULTS

Hospital Assessment of Antimicrobial Stewardship Implementation

Item 29

Does your healthcare facility provide training on antibiotic stewardship to students or trainees rotating at your healthcare facility?

Score: 5 (Yes)

Students and trainees rotating at the hospital can directly participate in theoretical lectures led by leaders of departments or staff with most working experience. In addition, the juniors also can join clinical ward rounds and participate in consultations to gain knowledge and experience.

Item 30

Does the healthcare facility provide training for the antibiotic stewardship team on antibiotic stewardship/IPC?

Score: 5 (Yes)

In terms of AMS and IPC, AMS team members and other staff are trained through annual continuous professional development and weekly scientific meeting (such as the Department of Infection Control trains on handwashing procedures and multi-resistance patient isolation procedures) or through weekly scientific meetings with specific topics (such as antibiotic prescription tools by the Department of Pharmacy or clinical departments updating new treatment guidelines). The trainers are including teachers from universities such as Hanoi University of Pharmacy, Hanoi Medical University, or healthcare workers with expertise and many years of experience working at the hospital. Sometimes, depending on the needs and conditions at the hospital, the Board of Directors will send staff to participate in training courses outside the hospital and may provide time and financial support.

Item 31

Does your healthcare facility provide patients and/or families with education about antibiotics?

Score: 2.5 (Partially implemented)

Nurses provide information on antibiotic use for inpatients and families during weekly patient council meetings in clinical departments. However, these meetings are not currently being held regularly and information is provided mainly on the care and nutrition for patients. In addition, physicians directly advise and provide some basic information about using antibiotics in the right antibiotic, in the right dose, and on the right route before the patient is discharged from the hospital. However, due to the large number of inpatients daily, communications with patients do not take place too often. Besides, the hospital created clips on the proper use of antibiotics and showed them on the TV system located in the waiting area for patients and family members. Currently, this projection system is broken down and has no resources for maintenance; therefore, it is no longer used. At the same time, experts at the hospital are regularly invited to share information about the proper use of antibiotics as well as the dangers of suboptimal antibiotics on the media channels of Vietnamese television.

DOMAIN IV

ANTIBIOTIC STEWARDSHIP ACTIONS

Item 32

Which of the following treatment guidelines exist at your healthcare facility (select all that apply)?

Score: 5 (≥4 selected)

Several treatment guidelines are developed and updated regularly, including: • Urinary tract infection/ Sepsis/ Skin and soft tissue infection/ Central lineassociated bloodstream infection/ Surgical site infection/ Intra-abdominal infection; • Community-acquired, hospital-acquired, and ventilator-associated pneumonia; • Bacterial meningitis; • Endocarditis; • Surgical prophylaxis; • Febrile neutropenia; • Management of multidrug-resistant organisms.

Item 33

Which of the following is/are included in treatment guidelines at your healthcare facility (select all that apply)?

Score: 5 (first-line antibiotic agent, dose, duration, alternative antibiotic agents selected) The treatment guidelines always include information about (1) first-line antibiotic agent; (2) dose and (3) duration; (4) alternative antibiotic agents. However, those treatment guidelines do not categorize antibiotic agents by WHO AWaRe classification.

Item 34

Are the guidelines reviewed and updated periodically based on availability of new evidence, with changes communicated to prescribers?

Score: 2.5 (Partially implemented)

Currently, the review and update of treatment guidelines at the hospital does not take place as a routine and periodic activity. Clinical physicians actively update themselves based on the guidelines of Vietnam Ministry of Health and internationally, they also refer to the treatment results of Bach Mai Hospital, Cho Ray Hospital and sometimes, they modify guidelines based on microbiological culture results. According to the plan, the treatment guidelines at hospital are reviewed and revised annually. However, the administrative procedure to approve the council takes a long time, therefore, when there are any adjustments, the Department of General planning notifies and sends in the group of communication such as Zalo to all clinical physicians. The current update of the treatment guidelines is usually after 2-3 years, in the COVID19 epidemic, it may last every 4-5 years.

RESULTS

Hospital Assessment of Antimicrobial Stewardship Implementation

Item 35

Does the antibiotic stewardship team review the healthcare facility antibiogram on a regular basis to modify treatment guidelines?

Score: 0 (No)

The Department of Microbiology aggregates and reports to the entire AMS committee on the antibiogram. However, this microbiological report does not take place as a routine and periodic activity. Currently, the Department of Microbiology integrates into presentations at weekly scientific meetings of the hospital or at scientific conferences or results from research. The Board of Directors has not had any mechanism to use these microbiological results to modify treatment guidelines.

Item 36

Antibiotic Stewardship Activities?

Score: 5 (≥9 items selected “Yes”)

Some activities are routinely conducted at this hospital including re-evaluating antibiotic choices; intravenous to oral antibiotic formulation conversion; prospective audit and feedback of specified antibiotics; prior authorization of specified antibiotics; in-person antibiotic stewardship clinical rounds; assessment and clarification of documented antibiotic allergies; alerts to prescribers about potentially duplicative antibiotic coverage; alerts to prescribers about drug-drug interactions; and management of antibiotic shortages/ stockouts.

Item 37

Is antibiotic stewardship activity performed facility-wide?

Score: Not Applicable

Due to limited human resources (such as in clinical pharmacists), some activities are currently only carried out in some key departments on the use of antibiotics to evaluate its effectiveness before being applied to the whole hospital such as Intravenous to oral antibiotic formulation conversion, Prospective audit and feedback of specified antibiotics, Restricted use of antibiotics based on formulary approval for prespecified conditions or populations

Item 38

Are there standardized operating procedures for specific antibiotic stewardship activities (e.g., audit and feedback, guideline development, testing protocols) at your healthcare facility?

Score: 2.5 (Partially implemented)

The hospital has developed several standard operation procedures for some AMS activities including: testing protocols, guideline development, procedure on infection control, guideline for infusion and use of antibiotics, and procedure for monitoring antibiotic use. However, there are still some AMS activities that have been implemented in practice but have not yet had standard operation procedures in place, such as reviewing antibiotic prescriptions and providing feedback to help the clinicians adjust their performance.

Item 39

Does the activity report produced by the antibiotic stewardship committee or team include the following (select all that apply)?

Score: 5 (≥2 selected)

Quarterly, the members in charge of specific AMS activities summarize and report to the entire AMS committee on the following: • Current antibiotic stewardship resources and activity; • Performance against process and outcome indicators for antibiotic use; • Antibiotic resistance; • Key areas of improvement, or for further improvement/ priority, or areas in which guidance or support from executive and governance units is needed

Item 40

Who is the antibiotic stewardship activity report disseminated to (select all that apply)?

Score: 5 (≥2 selected)

Currently, the AMS report is only circulated within the hospital. Periodic reports are sent to the Board of Directors and departments for reference, the hospital does not send (are not required to send) these reports to the Ministry of Health and relevant partners.

Item 41

Does the health-care facility have a formulary/ list of approved antibiotics for use based on the national formulary?

Score: 5 (Yes)

Annually, the hospital always reviews and updates their list of approved antibiotics for use based on the national formulary.

Item 42

Does the health-care facility formulary specify lists of restricted antibiotics that require approval by a designated team or person (pre-authorization)?

Score: 5 (Yes)

The hospital develops a list of restricted antibiotics that require approval before use, and there is a function on HIS to alert physicians regarding administrative tasks when they prescribe these restricted antibiotics. Specifically, when clinical physician prescribes these restricted antibiotics, all necessary forms will appear to request completion. At the same time, clinical pharmacist will review this prescription on HIS system.

RESULTS

The designated team for this approval includes: (1) physician who prescribes the antibiotic, (2) leader of clinical department, (3) one leader from Board of Directors who is responsible for reviewing both clinical and clinical pharmacy. Currently, this designated team depends on the type of antibiotic. Antibiotics in group 1 (designated as 1 star) are those that are recommended by MoH to closely monitor, these only needs to go through the approval of the leader of clinical department. Antibiotics in group 2 (designated as 2 stars) are those that are required to be closely monitored, for these the approval need to come from (1) to (3). In some cases of emergency such as outside office hours or urgent cases where it is necessary to use antibiotics immediately, the Board of Directors agrees to allow the application for approval online (via telephone), then documents need to be completed right afterwards accordingly.

Hospital Assessment of Antimicrobial Stewardship Implementation

Item 43

Does the approval of restricted antibiotics take place throughout the workday?

Score: 5 (Yes)

The approval of restricted antibiotics is taken place throughout the workday. However, in some cases of emergency such as outside office hours or urgent cases where it is necessary to use antibiotics immediately, the Board of Directors agrees to allow the application for approval online (via telephone), then staff need to complete required documents right afterwards accordingly.

Item 44

Does the healthcare facility communicate modifications to the antibiotic formulary to prescribers?

Score: 5 (Yes)

The antibiotic formulary is usually updated only once a year (in the bidding cycle). When the bidding finishes, the Department of Pharmacy sends the antibiotic formulary to the clinical departments for their reference and use. At the same time, changes to the antibiotic formulary are immediately updated on the HIS system. Expired antibiotics will be removed from the HIS and added to new one, along with accompanying forms such as the approval form for restricted antibiotics to support clinical physicians. In addition, the Department of Pharmacy can daily communicate with clinical departments to prioritize the use of near-expired/high-stock antibiotics, and limit the prescribing of drugs that are running low through pharmacy inventory activities.

Item 45

Do nurses at your healthcare facility do any of the following antibiotic stewardship activities (select all that apply)?

Score: 5 (≥ 2 selected)

Typically, nurses in clinical departments are responsible for collecting urine cultures based on appropriate criteria and send to the Department of Microbiology. Additionally, they also perform antibiotic allergy assessment during the use of antibiotics and caring for patients. Some nurses are very proactive in reminding physicians about the days of therapy of antibiotics.

Item 46

Does your healthcare facility have a policy that requires prescribers to document antibiotic dose, duration, and indication in the medical record?

Score: 5 (Yes)

Currently, prescribers in clinical departments are responsible for fully documenting information on antibiotic use for patients, such as antibiotic dose, duration, and indication in the medical record.

Item 47

Does the clinical microbiology laboratory used by your healthcare facility (on-site or off-site) utilize rapid diagnostic testing to facilitate early antibiotic adjustments?

Score: 5 (Yes)

Currently, the Department of Microbiology performs several rapid diagnostic tests for diagnosis diseases, in order to assist in determining the cause of a viral or bacterial disease; or in some cases to assist clinical departments in early antibiotic adjustments for patients.

Item 48

Does the clinical microbiology laboratory used by your healthcare facility (on-site or off-site) have technology to identify the most relevant resistance mechanisms (e.g., extended spectrum betalactamases, carbapenemases)?

Score: 5 (Yes)

The Department of Microbiology performs a variety of techniques to identify the most relevant resistance mechanisms, such as minimum inhibitory concentration (MIC), disk diffusion test, and perform genotyping to find isolated microbial resistance mechanisms such as Staphylococcus aureus methicillin resistance (MRSA).

Item 49

Does the clinical microbiology laboratory used by your healthcare facility (on-site or off-site) provide culture and susceptibility results to prescribers in a timely manner (e.g., within 72 hours)?

Score: 5 (Yes)

Normally, culture and susceptibility results are reported to the clinical departments by the Department of Microbiology very promptly (within 72 hours). The technicians directly notify clinical physicians through group of communication (such as Zalo), therefore, physicians are informed and adjust antibiotics if necessary, and the results are also immediately updated on LIS and HIS systems. However, there are some cases where their results are late due to substandard samples (e.g. contamination) and are required by the Department of Microbiology to re-sample; or some bacteria that are difficult to culture. These cases are informed in advance for information.

Item 50

Score: 0 (No)

Currently, the Department of Microbiology is reporting antibiotic susceptibility testing according to the guideline of the Clinical and Laboratory Standards Institute (CLSI).

RESULTS

Hospital Assessment of Antimicrobial Stewardship Implementation

Item 51

Does the clinical microbiology laboratory used by your healthcare facility (on-site or off-site) put comments in culture results to improve antibiotic prescribing?

Score: 5 (Yes)

Currently, the Department of Microbiology reports the results of the resistance mechanism and provides explanations on the meaning of resistance mechanisms and some suggestions on antibiotic selections to help clinical physicians properly understand and have orientation in using microbiological results to select antibiotic for patients. In addition, in some cases where contamination is suspected, microbiologists make notes about re-examination of specimen. Sometimes, the clinical microbiologist also suggests additional testing (such as determination of MIC, or identification of resistance genes) to be able to make the best selection of antibiotics for patients

Item 52

Does the antibiotic stewardship team communicate the emergence of new resistance mechanisms to prescribers?

Score: 2.5 (Partially implemented)

Currently, the microbiology department is responsible for identifying new resistance mechanisms. However, this does not take place as a routine activity in the hospital.

Item 53

Has the antibiotic stewardship team conducted an analysis of the barriers, challenges and opportunities for antibiotic stewardship implementation at your healthcare facility?

Score: 2.5 (Partially implemented)

As soon as issues related to AMS occur, AMS committee seeks guidance from the Board of Directors. In addition, all difficulties and barriers to AMS implementation are listed in the annual AMS report, however, making proposals to address those difficulties is currently not possible due to limited in time, human and financial resources.

In addition, clinical physicians can also be updated by participating in scientific conferences.

DOMAIN V

ANTIBIOTIC USE TRACKING, MONITORING & REPORTING

Item 54

Are regular prescription audits, point prevalence surveys to assess the appropriateness of antibiotic prescribing undertaken at the facility by the antibiotic stewardship committee or relevant team?

Score: 2.5 (Partially implemented)

The Department of Pharmacy regular carries out reviewing antibiotic prescription on HIS system after physician’s practice and if there is no concern about diagnosis or dose of antibiotics, clinical pharmacists will approve on system. However, due to limited number of clinical pharmacists and the large numbers of inpatients daily, this activity has not been implemented across the entire antibiotic prescriptions, but only focuses on severe and unresponsive cases, or cases when patients and family members have questions about treatment. For outpatient prescriptions, clinical pharmacist in charge of dispensing medications over the counter is responsible for a quick review of the reasonableness of antibiotic prescriptions. When problems are detected in dosage and quantity, clinical pharmacist works directly with the clinical physicians, or summarizes and presents in weekly scientific meetings with systemic issues and is common in many clinical departments. Some healthcare workers in the hospital also actively participate in research and project that has component to assess the optimal antibiotic prescriptions.

Item 55

Does the health-care facility regularly monitor and report the quantity and types of antibiotic use (purchased, prescribed, or dispensed)?

Score: 5 (Yes)

Periodic monitoring and reporting of the quantity and types of antibiotic use is carried out by the Department of Pharmacy through inventories and summarization of the number of antibiotics purchased, prescribed, or dispensed. Accordingly, the Department of Pharmacy has a mechanism to regulate the use of antibiotics in clinical departments, ensure priority for the use of near-expired/ high-stock antibiotics, and limit the prescription of antibiotics that are running low.

Item 56

What metric does the antibiotic stewardship team use to measure antibiotic use or consumption at your healthcare facility (select all that apply)?

Score: 5 (≥1 selected)

Currently, the AMS committee uses Defined Daily Dose (DDD) indicator to measure the number of days of antibiotics used or consumed.

RESULTS

Hospital Assessment of Antimicrobial Stewardship Implementation

Item 57

Does the antibiotic stewardship team develop action plans in response to problems identified related to optimization of antibiotic use (e.g., increase in the consumption of broad-spectrum antibiotics)?

Score: 5 (Yes)

The AMS committee has agreed on the mechanism to respond to an increase in the antibiotic consumption in clinical department. The mechanism is that the Department of Pharmacy (the focal point for summarize the quantity of antibiotic used and consumed) works directly and immediately with the clinical department to find out the causes of the increase in antibiotic consumption; in case of the cause coming from suboptimal antibiotic prescribing, then the clinical department needs immediate correction their performances. In addition, the supply of medicines has been interrupted due to drug bidding problems, therefore, some groups of antibiotics have run out but cannot be restoked in time, leading to a shortage of formularies. Therefore, through inventorying the number of antibiotics dispensed and used, the Department of Pharmacy has a mechanism to regulate the use of antibiotics in clinical departments, ensure priority for the use of nearexpired/high-stock antibiotics, and limit the prescription of antibiotics that are running low. In case clinical physicians tend to focus and regularly prescribe a certain antibiotic to patients of their department, clinical pharmacist reminds to ensure there is no excessive increase in the use of antibiotics in one department, while others really need but have no more antibiotics to use.

Item 58

Does the antibiotic stewardship team monitor compliance with at least one specific antibiotic stewardship activity (e.g. compliance with treatment guidelines) at the health-care facility?

Score: 5 (Yes)

Diagnosis, name of antibiotic and dosage are required to fully document in the patient’s medical records by physicians. AMS teams are responsible for monitoring the optimal antibiotic prescription using medical records as a source to assess the compliance. For example, the pharmacy department assesses the optimal antibiotic prescribing in clinical departments through the review of medical records. Moreover, HIS system at the hospital is very developed, the information related to patients is constantly updated and much supports the implementation of antibiotic use management activities. Specifically, the HIS system is integrated with many alerts when abnormal antibiotic cases are detected

Item 59

Does the antibiotic stewardship committee or team implement strategies (e.g., presentation to healthcare workers on implementation of new infectious diseases treatment guideline) to increase compliance with prioritized antibiotic stewardship activities?

Score: 5 (Yes)

The AMS committee conducts several sessions with the objective of presenting on a new treatment guideline (e.g. COVID19); or pharmacy department is the focal point and collaborates with the head of clinical departments to actively review antibiotic prescriptions to optimize the use and to increase compliance to antibiotic treatment guidelines.

Item 60

Which of the following metrics are monitored by the antibiotic stewardship team to assess the impact of antibiotic stewardship activities (select all that apply)?

Score: 5 (≥2 selected)

In the quarterly reports of the AMS committee, there are several indicators (such as the number of antibiotic consumption and use, antibiotic appropriateness (agent, dose, duration), cost-savings, length of stay and antibiotic-related adverse events). The data are disaggregated specifically by clinical departments, and there is data collection over time to identify improvements. However, this activity of monitoring is currently only implemented in some clinical departments with regular antibiotic prescriptions.

Item 61

Which data can be stratified by hospital unit/ward at your healthcare facility (select all that apply)?

Score: 5 (≥2 selected)

Information such as administration, antibiotic consumption, antibiotic use, antibiotic resistance, antibiotic cost is all compiled by each clinical department through HIS and LIS systems.

Item 62

Does the healthcare facility regularly monitor shortages/stockouts of essential antimicrobials?

Score: 2.5 (Partially implemented)

Recently, hospitals no longer have autonomy in procurement and supply of drugs but depend on the Department of Health and the Ministry of Health. Therefore, now the monitoring of shortages or stockouts of essential antibiotics is carried out by the Department of Pharmacy through the review and summary of quantity of antibiotics. The monitoring of inventories currently only stops at regulating the use of antibiotics between clinical departments and drawing up procurement lists. However, the results of procurement of drugs are beyond the hospital’s control.

RESULTS

Hospital Assessment of Antimicrobial Stewardship Implementation

Item 63

Does your healthcare facility monitor shortages/stockouts of laboratory supplies (e.g., reagents, plates)?

Score: 5 (Yes)

Monitoring the shortages/stockouts of laboratory supplies is carried out by the Department of Supplies. At the same time, Department of Microbiology actively monitors and reports the quantity if it is running low to be restocked in time.

Item 64

If there is a concern about substandard quality of antibiotics (e.g., falsified antibiotics) and diagnostics, is there a mechanism to report this at the healthcare facility?

Score: 5 (Yes)

Currently, the hospital has reporting process on substandard quality of antibiotics and diagnostics.

Item 65

Does the antibiotic stewardship committee or team regularly monitor and report antibiotic susceptibility and resistance rates for a range of key indicator bacteria?

Score: 2.5 (Partially implemented)

Item 66

Does the antibiotic stewardship team communicate findings from audits/ reviews of the quality/appropriateness of antibiotic use to prescribers along with specific action points?

Score: 5 (Yes)

The Department of Pharmacy is responsible for reviewing and assessing the optimal antibiotic prescription through in-person clinical rounds. When detecting problems related to the suboptimal antibiotic prescription, clinical pharmacists directly discuss with physicians to propose reasonable solutions. In addition, if systemic problems are found in many clinical departments, the clinical pharmacist will present at the weekly scientific meeting.

Item 67

Does the antibiotic stewardship team report metrics used to assess the impact of antibiotic stewardship activities to leadership at your healthcare facility?

Score: 0 (No)

The annual AMS report is only being compiled during the year to describe the status of AMS implementation, but there is no comparison over time to understand data trends, thereby, assessing the impact of AMS activities.

Item 68

Does the healthcare facility develop and aggregate antibiogram and regularly update it?

Score: 5 (Yes)

The Department of Microbiology is responsible for aggregation and updating antibiogram in this hospital regularly.

Knowledge, attitudes, and perceptions (KAP) survey results

The KAP survey of healthcare workers (including physicians, pharmacists, nurses) regarding antibiotic use, antibiotic stewardship program includes 41 items. Participants rated their level of agreement with each item using a scale of Strongly Agree to Strongly Disagree, and Not applicable was selected only if the statement does not apply to their practice or if the statement refers to a resource or action that is not available at this hospital. Healthcare workers who do not prescribe antibiotics only rate their level of agreement with items 1-21. A total of 20 healthcare workers participated in this survey (response rate 20/21 ~95%), and their characteristics is shown in Table 2.1.

Characteristics Professional role [n/N (%)] Nurse Pharmacist Physician

5/20 (25%) 1/20 (5%) 14/20 (70%)

Prescriber [n/N (%)] No Yes

7/20 (35%) 13/20 (65%)

Number of years working in this hospital [mean (min – max)]

10 (1-20)

Number of years working in this professional role [mean (min – max)]

10 (1-20)

Table 2.1. Patient characteristics in KAP survey (N=20)

RESULTS

Hospital Assessment of Antimicrobial Stewardship Implementation

Knowledge, attitudes, and perceptions to AMS programs and practice of antibiotic prescribing at Hospital ID 020 (Figure 2.1; 2.2) 19/20 participants were familiar with the term antibiotic stewardship (item 3), and they were aware of the responsibility of their hospital leaders in the AMS program, including 19/20 participants who scored that optimizing antibiotic use was a priority (item 1) and was discussed at multidisciplinary team meetings (item 2 & 4). All antibiotic prescribers (13/13) also agreed that the practice of prescribing antibiotics could be improved by having more guidelines from AMS committee (item 8), by optimizing antibiotic use and infection prevention and control (items 11 & 12), and by obtaining approval prior to prescribing antibiotics (item 13). 5/20 participants disagreed that using broad-spectrum antibiotics when equally effective narrower spectrum antibiotics are available increases antibiotic resistance (item 9), including 3/7 were non-prescribers and 2/13 was prescriber. However, there were most of participants determined that antibiotics were overused at this hospital (4/20 were neutral, 12/20 agreed and strongly agreed) (item 14) and 16/20 participants also agreed that antibiotic resistance was a problem at this hospital (item 15). When comparing between prescribers and non-prescribers, a higher proportion (5/7 and 6/7) stated that antibiotics were overused and antibiotic resistance was a problem in the hospital in the group of healthcare workers who were not prescribed antibiotics, compared with 7/13 and 10/13 prescribers. 9/11 clinical physicians in this KAP survey stated that when they often obtained cultures before starting an antibiotic therapy in patients with suspected infection (item 32); or 12/12 physicians modified antibiotic treatment after receiving culture and antibiotic susceptibility results when appropriate (item 33). They were not only considering adverse events (item 34), drug interactions (item 35), kidney function (item 36) when selecting an antibiotic regimen for patients, but also thinking about the risk of development of antibiotic resistance (item 37). Additionally, 9/13 physicians considered the opinion of non-physician staff (such as nurses) in antibiotic decisionmaking (item 38). Decisions on antibiotic prescribing were mainly influenced by AMS committee (item 25) and by the scientific literature (item 28) – agreed by 10/13 physicians. However, there were 3/12 physicians being under pressure by their patients (item 26) and 1/13 were under pressure by their colleagues (item 27) when they prescribed antibiotics for patients, and 3/13 were influenced of pharmaceutical companies (item 29). Most of participants agreed that they received much support when prescribing antibiotics for patients. Regarding microbiology, 19/20 participants trusted in microbiological test at their hospital (item 5); 4/13 physicians did not receive or see the updated antibiogram, while this in non-prescribers were 1/7 (item 7). All participants were alerted about positive culture result by the Department of Microbiology (item 6). However, there was 1/13 stayed neutral to the statement that they had timely access to microbiology test results to guide their use of antibiotics (item 22). Additionally, 17/20 participants agreed that they were supported by a multidisciplinary team (item 16) and infectious disease expertise (item 19 & 31); mostly received useful recommendations from the AMS committee (item 17), and accessing to locally endorsed infectious diseases treatment guidelines (item 18 & 30).

Figure 2.1. Rating of participants for each item of KAP survey, item 22-41 for prescribers only This figure does not include “Not applicable” answers

Figure 2.2. Rating of participants for each item of KAP survey grouping by prescribers and non-prescribers This figure does not include “Not applicable” answers

Hospital Assessment of Antimicrobial Stewardship Implementation

Summary of qualitative data from in-depth interviews and focus group discussions

3.1. Strengths of and opportunities for AMS implementation The Board of Directors has made the use of antibiotics a priority for the hospital and assigns personnel to carry out AMS activities. Whereby, based on the guidelines of Ministry of Health, the Director signed a decision on the establishment of AMS committee in the hospital, in which the leader of the committee in charge is a Vice Director, and there is a clear assignment of tasks for healthcare workers in the hospital to aim to provide guidelines and coordinate related AMS activities. In addition, there is close coordination between AMS committee and other departments in implementing AMS activities. The clinical departments, clinical pharmacists and clinical microbiologists have a very close and timely relationship. The clinical pharmacists provide information about antibiotics to be used in the most optimal way according to the patient’s condition and microbiologists promptly perform and report culture results for clinical physicians to consider and adjust antibiotics accordingly. Hospital ID 020 is one of the central hospitals specializing in infectious diseases in Vietnam and brings together many infectious disease specialists and experts. Therefore, it is a very favorable condition to support clinical physicians in optimizing the use of antibiotics for patients. The Department of Microbiology is accredited with ISO 15189 – 2012 certification by the Ministry of Science and Technology of Vietnam and is an Antibiotic Reference Laboratory for hospitals in the north of Vietnam. Therefore, they ensure to provide a full range and high - quality of laboratory and diagnostic imaging services, thereby supporting the diagnosis and the best use of antibiotics for patients. Besides, according to participants who took part in this research, there is enough supply and variety of antibiotic groups most of the time to help physicians in antibiotic decision-making.

3.2. Weaknesses of and barriers for AMS implementation According to the opinions of the research participants, the hospital currently has a mechanism to monitor the AMS implementation such as monitoring and summarizing the antibiotic use by clinical departments through inventory of antibiotics imported, dispensed, and used, and reviewing antibiotic prescriptions. However, these indicators are only being compiled during the year to describe the status of implementation, but there is no comparison over time to understand the data trend and assess the impact of AMS activities. The disruption of the supply of antibiotics by bidding is also a barrier to implementing AMS activities. For example, the inability to be proactive in procurement of antibiotics can be a factor affecting the optimization of antibiotic prescribing for patients. Besides, the Board of Directors also does not have a mechanism to update treatment guidelines and report antibiotic susceptibility and antibiotic resistance rates more frequently and periodically.

RESULTS

Hospital Assessment of Antimicrobial Stewardship Implementation

3.3. Factors influencing antibiotic prescribing practices Recently, the supply of medicines has been interrupted due to drug bidding problems, therefore, some groups of antibiotics have run out but cannot be restoked in time, leading to a shortage of formularies, making it difficult for clinical physicians to select antibiotics for patients for the best treatment results. Along with sometimes there are differences between culture testing or AST results and clinical symptoms; therefore, it leads to difficulty for physicians in antibiotic decision-making. In addition, a small number of physicians are under pressure from patients and their families in their decisions to use antibiotics. Moreover, Hospital ID 020 is one of the central hospitals, which means that patients may have been admitted to lower-level hospitals before admission here. Along with this, the storage of medical information, including information on antibiotic use, at health facilities in Vietnam is not transparent, which makes it difficult for physicians to accurately exploit the patient’s history of antibiotic use.

Summary of quantitative antibiotic use indicators

Figure 4.1 shows the average number of antibiotics per patient reported on the PPS day of all hospitals in the project network. At Hospital ID 020, an average daily use of 1 to 2 antibiotics ranged from oral or parenteral or intramuscular – higher than the average of all hospitals participating in the study and the highest at the time of the study.

Figure 4.1. Average number of antibiotics per patient reported on the PPS day by hospital This hospital is highlighted in blue column; Horizontal line indicating the average.

According to World Health Organization (WHO), the AWaRe chemical subgroup classification consists of Access group (which are first- or second- line antibiotics agents for empirical treatment, and should be widely available in health settings), Watch group (which is an antibiotic for use when the first or second option is no longer available), and Reserve group (are antibiotics that should be considered last-resort options), the rest are antibiotics not classified by WHO AWaRe classification. At the hospital, on the PPS day on November 9, 2022, 67.5% of antibiotics prescribed to patients were in the watch group, followed by 19.2% of access-group antibiotics, 10.9% of reserve antibiotics and 2.4% of current antibiotics not classified by WHO AWaRe classification were used for patients on the day of the survey (Figure 4.2).

RESULTS

Hospital Assessment of Antimicrobial Stewardship Implementation

Figure 4.2. Percentage of all antibiotics reported on the PPS day classified by WHO AWaRe subgroups by hospital This hospital is highlighted in blue column; Horizontal line indicating the average.

On the day of PPS survey, approximately 61.9% of patients were assigned at least one microbiological culture test when antibiotics were used. In which, about 28% of patient samples tested positive (Figures 4.3 and 4.4).

Figure 4.3. Percentage of patients having microbiological culture before using antibiotics reported on the PPS day by hospital This hospital is highlighted in blue column Horizontal line indicating the average

Figure 4.4. Percentage of culture tests with a positive result reported on the PPS dway by hospital This hospital is highlighted in blue column Horizontal line indicating the average

Regarding the use of invasive devices on the PPS day, the patients of Hospital ID 020 primarily used peripheral vascular catheters, followed by urinary catheter, endotracheal intubation and central vascular catheter; inserted tubes and drains was also used but were not common on the day of the survey (Figure 4.5).

Figure 4.5. Percentage of patients with an invasive device reported on the PPS day by hospital This hospital is highlighted in blue column; Horizontal line indicating the average

RESULTS

Hospital Assessment of Antimicrobial Stewardship Implementation

Figure 4.6. Percentage of patients with antibiotic use by month in the assessment year by hospital ward; data extracted from hospital information system

Figure 4.7. Percentage of antibiotic use by days of therapy by month in the assessment year by hospital ward; data extracted from hospital information system

Recommendations for the next AMS action plan

Overall, the hospital has an established and active AMS program with a relatively methodical and clear action plan. The Board of Directors dedicated healthcare workers identified as part of the hospital AMS annual plan. The hospital can improve the impact of their AMS activities by considering the following actions in their next AMS action plan:

Short – term priority (the next 6 months) • • • • •

Expand the audit and feedback activity to another clinical department with regular use of antibiotics Increase education activities for patients and family members to raise their awareness on the use of antibiotics only when needed and prescribed by physicians Plan for updating and revising the existing treatment guidelines, and adding new emerging diseases routinely and periodically. Routinely and periodically report antibiotic susceptibility, resistance rates and antibiogram; and plan to use microbiological data to support and adjust antibiotic prescribing in clinical departments Standardize procedures for AMS activities and extend modules on the current HIS and LIS to support clinical pharmacists in performing AMS activities

Medium – term priority (the next 1 – 2 years) • • •

Enhance the organization of annual training, raise awareness of antibiotic resistance and the application of principles of optimal antibiotic use to prescribers and other relevant AMS team members Organize discussions from clinical microbiologists and clinical physicians to investigate on the cases with apparently contradicting results between clinical and antibiotic susceptibility profiles; can be done as part of AMS team/clinical ward rounds and hospital-wide consultations for difficult cases Review antibiotic supply and plan for prioritizing the distribution of drugs to clinical departments to improve optimal antibiotic use in patients

Long – term priority (the next 3 – 5 years) • • •

Develop indicators to evaluate the effectiveness of AMS implementation, thereby, identifying the achievements and the difficulties and barriers to plan priorities for improvement Develop a specific plan for the allocation of human and financial resources, integrating with existing programs to optimize the use of resources to implement AMS activities Implement selective/ cascading report of AST results to clinical physicians

RESULTS

Hospital Assessment of Antimicrobial Stewardship Implementation

Point Prevalence Survey at Grande International Hospital in Nepal

APPENDIX Photo: In-depth interview with member of Antimicrobial Stewardship committee at B.P. Koirala Institute of Health Sciences in Nepal

Hospital Assessment of Antimicrobial Stewardship Implementation

Appendix 1

Antibiotic Stewardship Survey for Healthcare Workers

This survey assesses the knowledge, attitudes, and perceptions of various healthcare workers (e.g., physicians, pharmacists, nurses) regarding antibiotic use, antibiotic stewardship, and antibiotic resistance. Please select your healthcare profession:

☐ physician ☐ nurse or technician

Are you currently in training (e.g., residency, fellowship)?

☐ pharmacist ☐ other, please specify: _____ ☐ yes

☐ no

Please enter the number of years of experience that you have in the selected healthcare profession: ________ Please enter the number of years that you have worked at this healthcare facility: ________ Do you prescribe antibiotics? ☐ yes ☐ no

=> please rate your agreement with ALL items => please rate your agreement with items 1-21

FOR ALL HEALTHCARE WORKERS: Please rate your Notes/ agreement with each of the following statements below. Comments 1

Optimizing antibiotic use is a priority at my healthcare facility.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

Antibiotic use is discussed at facility-wide multidisciplinary team meetings.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

I am familiar with the term antibiotic stewardship.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

The importance of antibiotic stewardship is communicated (e.g., via posters, emails) at my healthcare facility.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

I trust the microbiology test results that I receive at my healthcare facility.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

My healthcare facility promptly alerts prescribers about relevant positive culture results (e.g., organism identified in blood culture) to modify antibiotic therapy.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

I am able to access my healthcare facility’s updated antibiogram.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

I am able to access my healthcare facility’s updated antibiogram.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

Use of broad-spectrum antibiotics when equally effective narrower spectrum antibiotics are available increases antibiotic resistance.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

10 Inappropriate antibiotic use can harm patients.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

The incidence of antibiotic-resistant organisms can be reduced by optimizing antibiotic 11 prescribing patterns and infection prevention and control practices.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

APPENDIX

Hospital Assessment of Antimicrobial Stewardship Implementation

Appropriate use of antibiotics may reduce antibiotic resistance.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

Requiring clinicians to obtain approval prior 13 to prescribing certain antibiotics is a way to improve antibiotic use.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

Antibiotics are overused (e.g., antibiotics 14 are used when not clinically indicated) at my healthcare facility.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

Antibiotic resistance is a problem at my healthcare facility.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

There is multidisciplinary teamwork for 16 antibiotic decision-making activities at my healthcare facility.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

I value recommendations from the antibiotic stewardship team at my healthcare facility.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

I have access to locally endorsed infectious 18 diseases treatment guidelines used at my healthcare facility.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

I have adequate access to infectious diseases expertise (e.g., infectious diseases trained 19 physician or clinician with experience practicing infectious diseases) at my healthcare facility.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

☐ strongly agree ☐ agree I feel comfortable recommending an ☐ neutral 20 intervention to my colleagues on antibiotic use. ☐ disagree ☐ strongly disagree ☐ not applicable Healthcare workers (e.g., physicians, pharmacists, or nurses) educate patients and/ 21 or their families on the use of antibiotics at discharge at my healthcare facility.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

FOR PRESCRIBERS ONLY: Please rate your agreement with each of the following statements below.

Notes/ Comments

☐ strongly agree ☐ agree I have timely access to microbiology test results ☐ neutral 22 and diagnostic information to guide my use of ☐ disagree antibiotics. ☐ strongly disagree ☐ not applicable Receiving more education on appropriate selection of antibiotic agent, duration of 23 therapy, and dose could improve my antibiotic prescribing practices at my healthcare facility.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

I receive education on how to select the most appropriate antibiotic for treatment 24 based on microbiology test results at my healthcare facility.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

☐ strongly agree The antibiotic stewardship team can impact ☐ agree ☐ neutral 25 my decisions on antibiotic initiation and ☐ disagree continuation at my healthcare facility. ☐ strongly disagree ☐ not applicable

I am pressured to prescribe antibiotics by patients or their families.

APPENDIX

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

Hospital Assessment of Antimicrobial Stewardship Implementation

I am pressured to prescribe antibiotics by my colleagues.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

Scientific literature (e.g., published research) influences my decisions on 28 antibiotic prescribing at my healthcare facility.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

Pharmaceutical companies influence some 29 of my decisions on antibiotic prescribing at my healthcare facility.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

I use locally endorsed infectious diseases treatment guidelines when I am making 30 decisions about antibiotic prescribing at my healthcare facility.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

I prescribe certain empiric antibiotics based on consultation with a clinician with experience practicing infectious diseases, 31 infectious diseases trained physician, or the antibiotic stewardship team at my healthcare facility.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

I routinely obtain cultures before starting antibiotic therapy in patients with 32 suspected infection at my healthcare facility.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

33 after receiving culture and antibiotic

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

I consider adverse events when selecting an 34 antibiotic regimen for patients at my healthcare facility.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

I modify my patient’s antibiotic treatment susceptibility results when appropriate.

I consider drug interactions when selecting 35 an antibiotic regimen for a defined patient population at my healthcare facility.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

I consider my patient’s kidney function when dosing antibiotics at my healthcare facility.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

I consider the risk of development of antibiotic 37 resistance in my patients when I prescribe antibiotics.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

I consider the opinion of non-physician staff 38 (e.g., nursing, pharmacy) in antibiotic decisionmaking at my healthcare facility.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

Receiving feedback about appropriateness of 39 antibiotics that I prescribe could improve my antibiotic prescribing practices.

☐ strongly agree ☐ agree ☐ neutral ☐ disagree ☐ strongly disagree ☐ not applicable

☐ strongly agree

Receiving feedback on how my antibiotic ☐ agree prescribing practices compares to my peers ☐ neutral 40 ☐ disagree could improve my antibiotic prescribing ☐ strongly disagree practices. ☐ not applicable

☐ strongly agree ☐ agree I am aware of changes that are needed to my ☐ neutral 41 current antibiotic prescribing practices based on ☐ disagree feedback received at my healthcare facility. ☐ strongly disagree ☐ not applicable

APPENDIX

Hospital Assessment of Antimicrobial Stewardship Implementation

Appendix 2

Self-Assessment for Antibiotic Stewardship Team in Inpatient Healthcare Facilities

This tool assesses core elements, structure, education and training, facility processes, and the presence or absence of activities related to antibiotic stewardship practices. To complete the assessment tool, members of the antibiotic stewardship team at the HCF should provide one response per question based on the following options: • • •

Yes = the activity/core element is in place and is fully implemented Partially implemented = the activity/core element is in place but is only partially implemented requiring further action or strengthening No = the activity/core element is not in place or has not been implemented

OR Members of the antibiotic stewardship team at the HCF should “select all that apply” based on the provided answer choices for relevant questions.

Facility Characteristics Facility Name Number of Licensed Beds

Respondent name

Department/ Unit

Preferred Contact (Email/Phone)

Domain Completed

Date of Completion

Item

Assessment

Score (points)

Notes

DOMAIN I: LEADERSHIP COMMITMENT & ACCOUNTABILITY 1

Is antibiotic stewardship identified as a priority by the health-care facility management/leadership?

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

Are antibiotic stewardship activities included in healthcare facility annual plans with key performance indicators?

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

Is there a mechanism to regularly monitor and measure the implementation of antibiotic stewardship activities?

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

Does your healthcare facility have an antibiotic stewardship committee that reviews ☐ Yes policies, procedures, treatment ☐ Partially implemented guidelines, and operational ☐ No considerations related to antibiotic stewardship?

Yes = 5 Partially implemented = 2.5 No = 0

APPENDIX

Hospital Assessment of Antimicrobial Stewardship Implementation

Who are the members of the antibiotic stewardship committee at your healthcare facility (select all that apply)?

SELECT ALL THAT APPLY: ☐ infection prevention and control (IPC) physician(s) ☐ IPC nurse(s) ☐ non-IPC nurse(s) ☐ infectious diseases trained physician(s) or clinician(s) with experience practicing infectious diseases ☐ intensive care unit physician(s) ☐ surgeon ☐ general medicine physician(s) ☐ other physician(s) ☐ infectious diseases trained pharmacist(s) or pharmacist with experience practicing infectious diseases ☐ other clinical pharmacist(s) ☐ other staff pharmacist(s) ☐ senior healthcare facility leader(s) ☐ clinical microbiologist(s) ☐ information technology specialist(s) ☐ not applicable ☐ other, please specify:

5 points = ≥7 healthcare professionals selected 2.5 points = 1-7 healthcare professionals selected 0 points = none or not applicable

If other physician(s) or clinical pharmacist(s) were selected, indicate specialty: 6

Does the antibiotic stewardship ☐ Yes committee meet on a regular ☐ Partially implemented basis (minimum monthly or ☐ No quarterly)?

Yes = 5 Partially implemented = 2.5 No = 0

7-7D SUPPLEMENTAL TABLE A

Score only Question 7: 5 points = infectious diseases trained physician or clinician with experience practicing infectious diseases AND infectious diseases trained pharmacist(s) OR other clinical pharmacist(s) OR other staff pharmacist(s) (if pharmacists are present at HCF) AND clinical microbiologist (if microbiologist is present at HCF) 2.5 points = anything selected that does not meet criteria for 5 points 0 points = none or not applicable

The antibiotic stewardship team is an individual or team of healthcare workers who work to routinely implement antibiotic stewardship activities.

☐ Yes Does the antibiotic stewardship ☐ Partially implemented team meet on a regular basis? ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

Does the antibiotic stewardship committee or team have ☐ Yes authority to make decisions ☐ Partially implemented about policies or procedures ☐ No related to antibiotic use at your healthcare facility?

Yes = 5 Partially implemented = 2.5 No = 0

Which hospital department(s) or healthcare teams does your antibiotic stewardship committee or team collaborate with (select all that apply)?

APPENDIX

SELECT ALL THAT APPLY: ☐ infection prevention and control ☐ infectious diseases ☐ patient safety ☐ quality ☐ pharmacy ☐ microbiology ☐ drug and therapeutics committee ☐ HIV/tuberculosis (TB) team ☐ surgery or operating theater ☐ not applicable ☐ other, please specify:

5 points = ≥2 selected 2.5 points = 1 selected 0 points = none or not applicable

☐ Yes ☐ Partially implemented ☐ No

SELECT ALL THAT APPLY: ☐ infectious diseases trained physician(s) or clinician(s) with experience practicing infectious diseases ☐ infectious diseases trained pharmacist(s) or pharmacist with experience practicing infectious diseases ☐ other clinical pharmacist(s) ☐ other staff pharmacist(s) ☐ member(s) of antibiotic stewardship team ☐ clinical microbiologist(s) ☐ not applicable ☐ other, please specify:

Yes = 5 Partially implemented = 2.5 No = 0 5 points = infectious diseases trained physician or clinician with experience practicing infectious diseases AND infectious diseases trained pharmacist(s) OR other clinical pharmacist(s) OR other staff pharmacist(s) (if pharmacists are present at HCF) AND clinical microbiologist (if microbiologist is present at HCF) 2.5 points = some selected but does not meet criteria for 5 points 0 points = none or not applicable

Who is involved in antibiotic formulary/procurement decisions at your healthcare facility (select all that apply)?

Is the evidence related to the safety, efficacy, and cost of new ☐ Yes antibiotics evaluated before ☐ Partially implemented adding to the formulary at your ☐ No healthcare facility?

Yes = 5 Partially implemented = 2.5 No = 0

Has the healthcare facility allocated human and financial resources to initiate antibiotic stewardship activities?

Yes = 5 Partially implemented = 2.5 No = 0

DOMAIN II: RESOURCES 14

☐ Yes ☐ Partially implemented ☐ No

SELECT ALL THAT APPLY: ☐ infectious diseases trained physician(s) or clinician(s) with experience practicing infectious diseases ☐ infectious diseases trained pharmacist(s) or pharmacist with experience practicing infectious diseases ☐ other clinical pharmacist(s) ☐ other staff pharmacist(s) ☐ clinical microbiologist(s) ☐ not applicable ☐ other, please specify:

5 points = infectious diseases trained physician or clinician with experience practicing infectious diseases AND infectious diseases trained pharmacist(s) OR other clinical pharmacist(s) OR other staff pharmacist(s) (if pharmacists are present at HCF) AND clinical microbiologist (if microbiologist is present at HCF) 2.5 points = anything selected that does not meet criteria for 5 points 0 points = none or not applicable

Which of the following are physically present at your healthcare facility (select all that apply)?

Does the antibiotic stewardship ☐ Yes team have an office or physical ☐ Partially implemented space to perform antibiotic ☐ No stewardship activities?

Yes = 5 Partially implemented = 2.5 No = 0

Does the antibiotic stewardship team have the basic equipment ☐ Yes (e.g., telephone, computer) to ☐ Partially implemented perform antibiotic stewardship ☐ No activities?

Yes = 5 Partially implemented = 2.5 No = 0

APPENDIX

☐ Yes ☐ Partially implemented ☐ No

Hospital Assessment of Antimicrobial Stewardship Implementation

Which of the following can the antibiotic stewardship team access (select all that apply)?

SELECT ALL THAT APPLY: ☐ electronic medical record ☐ antibiotics purchased ☐ antibiotics dispensed ☐ antibiotic administration records ☐ syndromic antibiogram (e.g., antibiogram with urine cultures) ☐ cumulative antibiogram ☐ not applicable SELECT ALL THAT APPLY: ☐ antibiotic consumption ☐ antibiotic use ☐ antibiotic resistance ☐ antibiotic cost ☐ administrative data (e.g., patient days, discharges) ☐ not applicable ☐ other, please specify:

5 points = ≥2 selected 2.5 points = 1 selected 0 points = none or not applicable

Which data are available electronically at your healthcare facility (select all that apply)?

Does the antibiotic stewardship team have access to updated ☐ Yes evidence in the form of peer☐ Partially implemented reviewed scientific literature ☐ No (e.g., published research)?

Yes = 5 Partially implemented = 2.5 No = 0

Does the health-care facility have access to laboratory and imaging services (on-site or off-site) that can be used to support antibiotic stewardship interventions?

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

Is the clinical microbiology laboratory used by your healthcare facility (on-site or off-site) open 24 hours per day to receive, process, and report microbiologic specimens?

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

Is the clinical microbiology laboratory used by your healthcare facility (on-site or off-site) accredited?

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

Does the clinical microbiology laboratory used by your healthcare facility (on-site or off-site) have a quality management system?

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

Does the clinical microbiology laboratory used by your ☐ Yes healthcare facility (on-site or ☐ Partially implemented off-site) have an electronic ☐ No laboratory information system?

Yes = 5 Partially implemented = 2.5 No = 0

Does the healthcare facility provide training on antibiotic stewardship (e.g., optimizing antibiotic use) in the staff induction training?

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

Does the healthcare facility offer continuous in-service training or continuous professional development on antibiotic stewardship and IPC to staff?

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

Does your healthcare facility provide training on antibiotic stewardship to students or trainees rotating at your healthcare facility?

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

Does the healthcare facility provide training for the antibiotic stewardship team on antibiotic stewardship/IPC?

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

Does your healthcare facility provide patients and/or families with education about antibiotics?

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

DOMAIN III: EDUCATION & TRAINING

DOMAIN IV: ANTIBIOTIC STEWARDSHIP ACTIONS

APPENDIX

Hospital Assessment of Antimicrobial Stewardship Implementation

Which of the following treatment guidelines exist at your healthcare facility (select all that apply)?

SELECT ALL THAT APPLY: ☐ urinary tract infection ☐ community-acquired pneumonia ☐ hospital-acquired pneumonia ☐ ventilator-associated pneumonia ☐ sepsis ☐ skin and soft tissue infection ☐ surgical site infection ☐central line-associated bloodstream infection ☐ surgical prophylaxis ☐ intra-abdominal infection ☐ febrile neutropenia ☐ management of multidrugresistant organisms ☐ bacterial meningitis ☐ endocarditis ☐ not applicable (no treatment guidelines exist at my healthcare facility) ☐ other, please specify: SELECT ALL THAT APPLY: ☐ first-line antibiotic agent ☐ dose ☐ duration ☐ alternative antibiotic agents (e.g., penicillin allergy, pregnant women, oral antibiotics) ☐ antibiotic agents categorized by WHO AWaRe classification ☐ not applicable ☐ other, please specify:

5 points = ≥4 selected 2.5 points = 1-3 selected 0 points = none or not applicable

5 points = first-line antibiotic agent, dose, duration, alternative antibiotic agents selected 2.5 points = anything selected that does not meet criteria for 5 points 0 points = none or not applicable

Which of the following is/ are included in treatment guidelines at your healthcare facility (select all that apply)?

Are the guidelines reviewed and updated periodically based ☐ Yes on availability of new evidence, ☐ Partially implemented with changes communicated to ☐ No prescribers?

Yes = 5 Partially implemented = 2.5 No = 0

Does the antibiotic stewardship team review the healthcare ☐ Yes facility antibiogram on a ☐ Partially implemented regular basis to modify ☐ No treatment guidelines?

Yes = 5 Partially implemented = 2.5 No = 0

Only score Question 36: 5 points = ≥9 “yes” selected 2.5 points = 1-8 “yes” selected 0 points = none

3637

SUPPLEMENTAL TABLE B

Are there standardized operating procedures for specific antibiotic ☐ Yes stewardship activities (e.g., ☐ Partially implemented audit and feedback, guideline ☐ No development, testing protocols) at your healthcare facility?

Does the activity report produced by the antibiotic stewardship committee or team include the following (select all that apply)?

Who is the antibiotic stewardship activity report disseminated to (select all that apply)?

SELECT ALL THAT APPLY: ☐ current antibiotic stewardship resources and activity ☐ performance against process and outcome indicators for antibiotic use ☐ antibiotic appropriateness ☐ antibiotic resistance ☐ key areas of improvement ☐ areas for further improvement or priority ☐ areas in which guidance or support from executive and governance units is needed ☐ not applicable (my healthcare facility does not produce an antibiotic stewardship activity report) ☐ other, please specify: SELECT ALL THAT APPLY: ☐ healthcare facility management ☐ other healthcare facility teams members ☐ national authorities (e.g., ministry of health) ☐ other, please specify: ☐ not applicable (my healthcare facility does not produce an antibiotic stewardship activity report)

Does the health-care facility have a formulary/ list of approved antibiotics for use based on the national formulary?

APPENDIX

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

5 points = ≥2 selected 2.5 points = 1 selected 0 points = none or not applicable

Yes = 5 Partially implemented = 2.5 No = 0 55

Hospital Assessment of Antimicrobial Stewardship Implementation

Does the health-care facility formulary specify lists of restricted antibiotics that require approval by a designated team or person (pre-authorization)?

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

Does the approval of restricted antibiotics take place throughout the workday?

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

Does the healthcare facility communicate modifications to the antibiotic formulary to prescribers?

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

SELECT ALL THAT APPLY: ☐ collect urine and/or respiratory cultures based on appropriate criteria Do nurses at your healthcare ☐ initiate discussions about facility do any of the following converting from intravenous to antibiotic stewardship activities oral formulation (select all that apply)? ☐ initiate antibiotic “time outs” ☐ antibiotic allergy assessment ☐ not applicable ☐ other, please specify:

5 points = ≥2 selected 2.5 points = 1 selected 0 points = none or not applicable

Does your healthcare facility have a policy that requires prescribers to document antibiotic dose, duration, and indication in the medical record?

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

Does the clinical microbiology laboratory used by your healthcare facility (on-site or off-site) utilize rapid diagnostic testing to facilitate early antibiotic adjustments?

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

Does the clinical microbiology laboratory used by your healthcare facility (on-site or off-site) provide culture and susceptibility results to prescribers in a timely manner (e.g., within 72 hours)?

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

Does the clinical microbiology laboratory used by your healthcare facility (on-site or off-site) utilize selective or cascading antibiotic ☐ Yes susceptibility testing reporting ☐ Partially implemented (e.g., not reporting an antibiotic ☐ No that would not be appropriate for the source, not reporting a broad-spectrum antibiotic when a narrower spectrum is available)?

Yes = 5 Partially implemented = 2.5 No = 0

Does the clinical microbiology laboratory used by your healthcare facility (on-site or off-site) put comments in culture results to improve antibiotic prescribing?

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

Does the antibiotic stewardship ☐ Yes team communicate the ☐ Partially implemented emergence of new resistance ☐ No mechanisms to prescribers?

Yes = 5 Partially implemented = 2.5 No = 0

Has the antibiotic stewardship team conducted an analysis of ☐ Yes the barriers, challenges and ☐ Partially implemented opportunities for antibiotic ☐ No stewardship implementation at your healthcare facility?

Yes = 5 Partially implemented = 2.5 No = 0

Are regular prescription audits, point prevalence surveys to assess the appropriateness of antibiotic prescribing undertaken at the facility by the antibiotic stewardship committee or relevant team?

Yes = 5 Partially implemented = 2.5 No = 0

DOMAIN V: ANTIBIOTIC USE TRACKING, MONITORING & REPORTING

APPENDIX

☐ Yes ☐ Partially implemented ☐ No

Hospital Assessment of Antimicrobial Stewardship Implementation

Does the health-care facility regularly monitor and report the quantity and types of antibiotic use (purchased, prescribed, or dispensed)?

What metric does the antibiotic stewardship team use to measure antibiotic use or consumption at your healthcare facility (select all that apply)?

☐ Yes ☐ Partially implemented ☐ No SELECT ALL THAT APPLY: ☐ days of therapy ☐ defined daily doses ☐ not applicable ☐ other, please specify:

Yes = 5 Partially implemented = 2.5 No = 0 5 points = ≥1 selected 0 points = none or not applicable

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

Does the antibiotic stewardship team monitor compliance with at least one specific antibiotic ☐ Yes stewardship activity (e.g. ☐ Partially implemented compliance with treatment ☐ No guidelines) at the health-care facility?

Yes = 5 Partially implemented = 2.5 No = 0

Does the antibiotic stewardship committee or team implement strategies (e.g., presentation to healthcare workers on ☐ Yes implementation of new ☐ Partially implemented infectious diseases treatment ☐ No guideline) to increase compliance with prioritized antibiotic stewardship activities?

Yes = 5 Partially implemented = 2.5 No = 0

Which of the following metrics are monitored by the antibiotic stewardship team to assess the impact of antibiotic stewardship activities (select all that apply)?

SELECT ALL THAT APPLY: ☐ antibiotic use or consumption ☐ antibiotic appropriateness (agent, dose, duration) ☐ time to appropriate antibiotic therapy ☐ cost-savings ☐ in-hospital mortality ☐ length of stay ☐ Clostridioides difficile infection rates ☐ rehospitalization ☐ antibiotic-related adverse events ☐ antibiotic-related near misses (e.g., an error that could have led to an adverse event but did not result in clinical harm) ☐ antibiotic costs (e.g., purchase price and expenditure) ☐ not applicable ☐ other, please specify: SELECT ALL THAT APPLY: ☐ antibiotic consumption ☐ antibiotic use ☐ antibiotic resistance ☐ antibiotic cost ☐ administrative data (e.g., patient days, discharges) ☐ not applicable ☐ other, please specify

5 points = ≥2 selected 2.5 points = 1 selected 0 points = none or not applicable

Which data can be stratified by hospital unit/ward at your healthcare facility (select all that apply)?

Does the healthcare facility regularly monitor shortages/ stockouts of essential antimicrobials?

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

Does your healthcare facility monitor shortages/stockouts of laboratory supplies (e.g., reagents, plates)?

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

If there is a concern about substandard quality of antibiotics (e.g., falsified antibiotics) and diagnostics, is there a mechanism to report this at the healthcare facility?

☐ Yes ☐ Partially implemented ☐ No

Yes = 5 Partially implemented = 2.5 No = 0

APPENDIX

Hospital Assessment of Antimicrobial Stewardship Implementation

Does the antibiotic stewardship committee or team regularly ☐ Yes monitor and report antibiotic ☐ Partially implemented susceptibility and resistance ☐ No rates for a range of key indicator bacteria?

Yes = 5 Partially implemented = 2.5 No = 0

Does the antibiotic stewardship team communicate findings from audits/reviews of the ☐ Yes quality/appropriateness of ☐ Partially implemented ☐ No antibiotic use to prescribers along with specific action points?

Yes = 5 Partially implemented = 2.5 No = 0

Does the antibiotic stewardship team report metrics used to assess the impact of antibiotic ☐ Yes ☐ Partially implemented stewardship activities to ☐ No leadership at your healthcare facility?

Yes = 5 Partially implemented = 2.5 No = 0

Does the healthcare facility develop and aggregate antibiogram and regularly update it?

Yes = 5 Partially implemented = 2.5 No = 0

☐ Yes ☐ Partially implemented ☐ No

SUPPLEMENTAL TABLE A

Item 7-7D. Antibiotic Stewardship Team Members

7. Who are the members of the antibiotic stewardship team at your healthcare facility (select all that apply)?

7A. For each role listed below, how many are part of the team?

7B. Are any within this role an antibiotic stewardship team leader?

☐ Not applicable (My healthcare facility does not have an antibiotic stewardship team) ☐ Infectious diseases trained physician(s) or clinician(s) with experience practicing infectious diseases

☐ Yes ☐ No

☐ Other physician(s) If yes, specify specialty(ies):

☐ Yes ☐ No

☐ Infectious diseases trained pharmacist(s) or pharmacist with experience practicing infectious diseases

☐ Yes ☐ No

☐ Other clinical pharmacist(s) If yes, specify specialty(ies):

☐ Yes ☐ No

☐ Other staff pharmacist

☐ Yes ☐ No

☐ Infection prevention and control (IPC) physician

☐ Yes ☐ No

☐ IPC Nurse(s)

☐ Yes ☐ No

☐ Non- IPC Nurse(s)

☐ Yes ☐ No

☐ Clinical microbiologist(s)

☐ Yes ☐ No

☐ Information technology specialist(s)

☐ Yes ☐ No

☐ Administrative support

☐ Yes ☐ No

☐ Other(s) If yes, please specify:

☐ Yes ☐ No

APPENDIX

Hospital Assessment of Antimicrobial Stewardship Implementation

7C. What percent time for antibiotic stewardship activities is specified in this role’s job description or contract (if more than one person within this role, average the percent time)?

7D. Are the persons within this role financially compensated for the time spent specifically on antibiotic stewardship activities?

☐ 1-25% ☐ 26-50% ☐ 51-75% ☐ 76-100% ☐ no dedicated time for antibiotic stewardship activities

☐ Yes, all staff within this role ☐ Yes, some staff within this role ☐ No, none within this role