BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                            



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          |SENATE RULES COMMITTEE            |                       SB 1311|
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                                 UNFINISHED BUSINESS


          Bill No:  SB 1311
          Author:   Hill (D), et al.
          Amended:  8/7/14
          Vote:     21


           SENATE HEALTH COMMITTEE  :  8-0, 4/24/14
          AYES:  Hernandez, Morrell, Beall, DeSaulnier, Evans, Monning,  
            Nielsen, Wolk
          NO VOTE RECORDED:  De León

           SENATE APPROPRIATIONS COMMITTEE  :  Senate Rule 28.8

           SENATE FLOOR  :  35-0, 5/8/14 (Consent)
          AYES:  Anderson, Beall, Berryhill, Block, Cannella, Corbett,  
            Correa, De León, DeSaulnier, Evans, Fuller, Galgiani, Hancock,  
            Hernandez, Hill, Hueso, Huff, Jackson, Lara, Leno, Lieu, Liu,  
            Mitchell, Monning, Morrell, Nielsen, Padilla, Pavley, Roth,  
            Steinberg, Torres, Vidak, Walters, Wolk, Wyland
          NO VOTE RECORDED:  Calderon, Gaines, Knight, Wright, Yee

           ASSEMBLY FLOOR  :  78-0, 8/11/14 - See last page for vote


           SUBJECT  :    Hospital:  antimicrobial stewardship

           SOURCE  :     Author


           DIGEST  :    This bill requires all general acute care hospitals,  
          as defined, to adopt and implement, by July 1, 2015, an  
          antimicrobial stewardship policy, that includes a process to  
          evaluate the judicious use of antibiotics, as specified.  This  
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          bill requires a general acute care hospital to develop a  
          physician-supervised multidisciplinary antimicrobial stewardship  
          committee, subcommittee, or workgroup, and to appoint at least  
          one physician or pharmacist who is knowledgeable about  
          antimicrobial stewardship through prior training or attendance  
          at continuing education programs.  This bill also requires a  
          general acute care hospital to report antimicrobial stewardship  
          program activities to each appropriate hospital committee  
          undertaking clinical quality improvement activities.

          Assembly Amendments  (1) change the subject of the bill; (2) make  
          technical changes related to the membership of the antimicrobial  
          stewardship committee; and (3) require the antimicrobial  
          stewardship policy to include a process to evaluate the use of  
          antibiotics, as specified.

           ANALYSIS  :    

          Existing law:

          1.Provides for the licensure and inspection of health  
            facilities, including general acute care hospitals, by the  
            Department of Public Health (DPH). 

          2.Requires general acute care hospitals to develop a process for  
            evaluating the judicious use of antibiotics, the result of  
            which is required to be monitored by appropriate  
            representatives and committees involved in quality improvement  
            activities. 

          This bill requires each general acute care hospital, as defined,  
          to do all of the following by July 1, 2015:

          1. Adopt and implement an antimicrobial stewardship policy in  
             accordance with guidelines established by the federal  
             government and professional organizations.  Requires this  
             policy to include a process to evaluate the judicious use of  
             antibiotics, as specified. 

          2. Develop a physician-supervised multidisciplinary  
             antimicrobial stewardship committee, subcommittee, or  
             workgroup.

          3. Appoint to the physician-supervised multidisciplinary  

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             antimicrobial stewardship committee, subcommittee, or  
             workgroup, at least one physician or pharmacist who is  
             knowledgeable about the subject of antimicrobial stewardship  
             through prior training or attendance at continuing education  
             programs, including programs offered by the federal Centers  
             for Disease Control and Prevention (CDC), the Society for  
             Healthcare Epidemiology of America (SHEA), or similar  
             recognized professional organizations.

          4. Report antimicrobial stewardship program activities to each  
             appropriate hospital committee undertaking clinical quality  
             improvement activities.

           Background
           
          According to the CDC, antibiotic resistance is a quickly  
          growing, extremely dangerous problem.  World health leaders have  
          described antibiotic-resistant bacteria as "nightmare bacteria"  
          that "pose a catastrophic threat" to people in every country in  
          the world.  Most infections occur in the community, like skin  
          infections with Methicillin-resistant Staphylococcus aureus  
          (MRSA) and sexually transmitted diseases.  However, most deaths  
          related to antibiotic resistance occur from drug-resistant  
          infections picked up in health care settings, such as hospitals  
          and nursing homes.  According to a February 2013 joint letter  
          from the Infectious Diseases Society of America and the SHEA to  
          the National Quality Forum, ample data exist from both inpatient  
          and outpatient settings demonstrating that antibiotics are often  
          prescribed sub-optimally or inappropriately.  Antibiotics are  
          misused in a variety of ways.  They are often administered when  
          they are not needed, continued when they are no longer  
          necessary, or prescribed at the wrong dose.  Broad-spectrum  
          agents may be used unnecessarily against bacteria that are very  
          susceptible or the wrong antibiotic may be given to treat a  
          particular infection.  Over the past 30 years, bacteria that are  
          extremely resistant to traditional treatments or resistant to  
          multiple drugs have spread widely among patients in health care  
          settings.  In some cases these pathogens have been  
          pan-resistant, meaning that they are resistant to all available  
          antibiotics.  The unique nature of antibiotics, in which the use  
          of the drugs in one patient can impact the effectiveness of the  
          drug in a different patient, make antibiotic overuse a serious  
          patient safety issue and public health threat.  The World Health  
          Organization has characterized antibiotic resistance as "a  

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          crisis that has been building up over decades, so that today  
          common and life-threatening infections are becoming difficult or  
          even impossible to treat."  Resistant infections not only result  
          in increased morbidity and mortality, but increased economic  
          burdens.  For example, studies have shown that  
          antibiotic-resistant infections are associated with longer  
          lengths of stay and increased mortality, both in the hospital  
          and in intensive care units. 

           California's program  .   In February 2010, the DPH Healthcare  
          Associated Infection (HAI) Program developed a statewide  
          antimicrobial stewardship program (ASP) initiative in order to  
          strengthen and promote optimization of antimicrobial utilization  
          in California health care facilities.  According to DPH, the  
          purpose of an antimicrobial stewardship program in a health care  
          facility is to measure and promote the appropriate use of  
          antimicrobials by selecting the appropriate agent, dose,  
          duration and route of administration in order to improve patient  
          outcomes, while minimizing toxicity and the emergence of  
          antimicrobial resistance. Although guidelines exist for  
          developing ASPs, there is limited information on practical  
          implementation of these guidelines, particularly in  
          resource-limited settings.  According to DPH, its partners in  
          this statewide initiative include the Division of Healthcare  
          Quality and Promotion at CDC, Infectious Disease Association of  
          California, and SHEA.

           Prior Legislation
           
          SB 158 (Florez, Chapter 294, Statutes of 2008) established an  
          infection surveillance, prevention, and control program within  
          DPH to provide oversight of hospital prevention and reporting of  
          general acute care hospital-associated infections, expanded the  
          responsibilities of DPH's Healthcare Associated Infection (HAI)  
          Advisory Committee, and requires all hospitals to institute a  
          patient safety plan for the purpose of improving the health and  
          safety of patients and reducing preventable patient safety  
          events.

          SB 1058 (Alquist, Chapter 296, Statutes of 2008) established the  
          Medical Facility Infection Control and Prevention Act, which  
          requires hospitals to implement specified procedures for  
          screening, prevention, and reporting specified health care  
          associated infections also known as HAIs.  Requires hospitals to  

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          report positive MRSA and other HAI test results to DPH and  
          requires DPH to make specified information public on its  
          Internet Web site.

          SB 739 (Speier, Chapter 526, Statutes of 2006) created a state  
          HAI advisory committee to make recommendations regarding  
          reporting cases of HAI in hospitals.   Requires each general  
          acute care hospital, after January 1, 2008, to implement and  
          annually report to DPH its implementation of infection  
          surveillance and infection prevention process measures that have  
          been recommended by CDC Healthcare Infection Control Practices  
          Advisory Committee, as suitable for a mandatory public reporting  
          program.  Requires DPH, in consultation with the HAI advisory  
          committee, to make this information public no later than six  
          months after receiving the data.  Required that general acute  
          care hospitals develop a process for evaluating the judicious  
          use of antibiotics, the results of which shall be monitored  
          jointly by appropriate representatives and committees involved  
          in quality improvement activities.

          SB 1487 (Speier of 2004) would have required specified hospitals  
          to have written infection control plans and report to Office of  
          Statewide Health Planning and Development (OSHPD) data,  
          including the rate of HAIs and risk-adjusted infection rate data  
          according to the risk-adjustment methodology determined by CDC.   
          SB 1487 was vetoed by Governor Schwarzenegger, whose veto  
          message suggested that it was unnecessary because of other  
          national efforts, which could call into question the quality and  
          validity of the data without proper auditing, and because it  
          would impose significant costs to hospitals and OSHPD.

           FISCAL EFFECT  :    Appropriation:  No   Fiscal Com.:  Yes    
          Local:  Yes

          According to the Assembly Appropriations Committee: 

           One-time costs of approximately $50,000, likely in 2017, to  
            aggregate data collected through enforcement and prepare a  
            report on compliance (Licensing and Certification Fund).

           Minor and absorbable ongoing costs to DPH to oversee  
            compliance among licensed hospitals (Licensing and  
            Certification Fund).


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           SUPPORT :   (Verified  8/12/14)

          California Academy of Preventive Medicine
          California Hospital Association
          California Pharmacists Association
          San Francisco Bay Area Physicians for Social Responsibility
          Stanford Hospital and Clinics

           ARGUMENTS IN SUPPORT  :    The California Hospital Association  
          (CHA) states that improving the use of antibiotics is an  
          important patient safety and public health issue as well as a  
          national priority.  CHA states that ASPs can both optimize the  
          treatment of infections and reduce adverse events associated  
          with antibiotic use.

          San Francisco Bay Area Physicians for Social Responsibility  
          states, one of the most important actions that can be taken to  
          slow the development of antibiotic resistance is to ensure that  
          antibiotics are used judiciously through the establishment of  
          ASP.  ASPs represent a commitment to always use antibiotics only  
          when they are necessary; to choose the right antibiotics; and to  
          administer them in the right way.

           ASSEMBLY FLOOR :  78-0, 8/11/14
          AYES:  Achadjian, Alejo, Allen, Ammiano, Bigelow, Bloom,  
            Bocanegra, Bonilla, Bonta, Bradford, Brown, Buchanan, Ian  
            Calderon, Campos, Chau, Chávez, Chesbro, Conway, Cooley,  
            Dababneh, Dahle, Daly, Dickinson, Eggman, Fong, Fox, Frazier,  
            Beth Gaines, Garcia, Gatto, Gomez, Gonzalez, Gordon, Gorell,  
            Gray, Grove, Hagman, Hall, Harkey, Roger Hernández, Holden,  
            Jones, Jones-Sawyer, Levine, Linder, Logue, Lowenthal,  
            Maienschein, Mansoor, Medina, Melendez, Mullin, Muratsuchi,  
            Nazarian, Nestande, Olsen, Pan, Patterson, Perea, John A.  
            Pérez, V. Manuel Pérez, Quirk, Quirk-Silva, Rendon,  
            Ridley-Thomas, Rodriguez, Salas, Skinner, Stone, Ting, Wagner,  
            Waldron, Weber, Wieckowski, Wilk, Williams, Yamada, Atkins
          NO VOTE RECORDED:  Donnelly, Vacancy


          JL:de  8/12/14   Senate Floor Analyses 

                           SUPPORT/OPPOSITION:  SEE ABOVE

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