BILL ANALYSIS Ó
SB 361
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Date of Hearing: June 23, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
SB
361 (Hill) - As Amended April 14, 2015
SENATE VOTE: 35-0
SUBJECT: Skilled nursing facilities: antimicrobial stewardship
guidelines.
SUMMARY: Requires skilled nursing facilities (SNFs) to adopt
and implement an antimicrobial stewardship policy (ASP) by
January 1, 2017, as specified. Requires SNFs to update their
ASPs to be consistent with new guidelines established by the
federal Centers for Disease Control and Prevention (CDC) or
other professional organizations within three months of the
publication of such new guidelines. Contains an urgency clause
to ensure that the provisions of this bill go into immediate
effect upon enactment.
EXISTING LAW:
1)Defines a SNF as health facility that provides skilled nursing
care and supportive care to patients whose primary need is for
the availability of long-term skilled nursing care.
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2)Establishes the Hospital Infectious Disease Control Program
under the Department of Public Health (DPH) to determine best
practices and policies related to the prevention of healthcare
associated infections (HAIs).
3)Requires general acute care hospitals to adopt and implement
an ASP, as specified, in accordance with existing state law
and guidelines established by the federal government and
professional organizations.
FISCAL EFFECT: According to the Senate Appropriations
Committee, pursuant to Senate Rule 28.8, negligible state costs.
COMMENTS:
1)PURPOSE OF THIS BILL. According to the author, the overuse
and misuse of antibiotics in nursing homes can lead to the
development of antibiotic resistant infections, which is a
national and worldwide public health threat. The author
points to reports by the CDC which state that at least two
million Americans are infected with antibiotic resistant
infections annually, and are the cause of death to
approximately 23,000 people each year. These reports also
maintain that up to 50% of all antibiotics prescribed for
patients are unnecessary or are not optimally effective as
prescribed. The author contends that 70% of nursing home
residents throughout the nation receive an antibiotic each
year, and that 27,000 residents acquire antibiotic resistant
infections, referring to research which suggests that 25-75%
of antibiotic use in long-term care settings may be
inappropriate and may contribute to the prevalence of
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antibiotic resistance. The author concludes that ASPs are an
effective way to promote judicious antibiotic use and reduce
antibiotic resistance, and that this bill is necessary to
alleviate a deficiency in existing law by extending these
programs to SNFs.
2)BACKGROUND.
a) Antibiotics. Antimicrobial resistance is resistance of
a microorganism to an antimicrobial drug that was
originally effective for treatment of infections caused by
it. Resistant microorganisms (including bacteria, fungi,
viruses, and parasites) are able to withstand attack by
antimicrobial drugs, such as antibacterial drugs (e.g.
antibiotics), antifungals, antivirals, and antimalarials,
so that standard treatments become ineffective and
infections persist, increasing the risk of spread to
others. The evolution of resistant strains is a natural
phenomenon that occurs when microorganisms replicate
themselves erroneously or when resistant traits are
exchanged between them. The use and misuse of
antimicrobial drugs accelerates the emergence of
drug-resistant strains. Poor infection control practices,
inadequate sanitary conditions, and inappropriate
food-handling encourage the further spread of antimicrobial
resistance. According to the World Health Organization,
new resistance mechanisms currently continue to emerge and
spread globally, threatening our ability to treat common
infectious diseases, and are resulting in the death and
disability of individuals who, prior to the emergence of
these new resistance mechanisms, could continue a normal
course of life. Without effective anti-infective
treatment, many standard medical treatments will fail or
turn into very high risk procedures.
b) President's Executive Order. In September 2014,
President Barack Obama signed an Executive Order directing
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federal departments and agencies to implement a national
strategy for enhancing domestic and international capacity
to manage antibiotics and antibiotic-resistant infections.
Among other requirements, the Executive Order specifically
requires the Departments of Health and Human Services,
Defense, and Veterans Affairs to review existing
regulations governing antibiotic stewardship in hospitals
and other inpatient health care delivery facilities, and to
propose new regulations and other actions to improve
antibiotic stewardship programs in accordance with best
practices in the country, including those defined by the
CDC. The Executive Order also requires federal departments
and agencies to lead the country by example by implementing
stewardship programs in outpatient settings, emergency
departments, and institutional and long-term care
facilities such as nursing homes, pharmacies, and
correctional facilities.
c) The California Antimicrobial Stewardship Program.
California is the first, and remains the only state, to
enact an antimicrobial stewardship program. DPH states the
major objectives of antimicrobial stewardship are to
optimize clinical outcomes for patients while minimizing
toxicity and other adverse events associated with
antimicrobial use. Since 2008, California has required
general acute care hospitals to develop a process for
monitoring the judicious use of antibiotics, and has
mandated that the results are monitored by quality
improvement committees. Studies have shown that ASPs are
particularly active in community settings. DPH currently
offers an ASP toolkit to the public, to provide hospital
leadership and support staff with guidelines, resources,
and practical examples of how best to implement ASP
practices.
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3)SUPPORT. The Health Officers Association of California
supports this bill stating it is imperative for SNFs to adopt
policies that reduce the consequences of antibiotic resistance
because residents are often elderly or disabled patients with
underlying health conditions that make them more vulnerable to
contracting disease. Blue Shield of California supports,
contending that it has been well documented by the CDC that
antibiotics are grossly overused in nursing homes and can lead
to the development of antibiotic resistant infections. Blue
Shield also contends antibiotic resistant infections add
considerable and avoidable costs to the already overburdened
healthcare system, as these infections require prolonged and
costlier treatments. The California Optometric Association
and CALPIRG support, stating that each year at least two
million Americans are infected with - and at least 23,000
Americans die from - antibiotic resistant infections. The
California Long-Term Care Ombudsman Association also supported
a previous version of this bill, asserting that the current
practice of giving SNF residents antimicrobial medications
prior to confirmation or test results recommending such
medications puts residents at risk.
4)PREVIOUS LEGISLATION.
a) SB 1311 (Hill), Chapter 843, Statutes of 2014, requires
all general acute care hospitals to adopt and implement, by
July 1, 2015, an ASP, that includes a process to evaluate
the judicious use of antibiotics.
b) SB 158 (Florez), Chapter 294, Statutes of 2008,
establishes an infection surveillance, prevention, and
control program within DPH to provide oversight of hospital
prevention and reporting of general acute care HAIs,
expands the responsibilities of DPH's 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
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safety events.
c) SB 1058 (Alquist), Chapter 296, Statutes of 2008,
establishes the Medical Facility Infection Control and
Prevention Act, which requires hospitals to implement
specified procedures for screening, prevention, and
reporting specified HAIs. Requires hospitals to report
positive Methicillin-resistant Staphylococcus aureus and
other HAI test results to DPH and requires DPH to make
specified information public on its website.
d) SB 739 (Speier), Chapter 526, Statutes of 2006, creates
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,
initially, these process measures to include the CDC
guidelines for central line insertion practices, surgical
antimicrobial prophylaxis, and influenza vaccination of
patients and healthcare personnel. Requires DPH, in
consultation with the HAI Advisory Committee, to make this
information public no later than six months after receiving
the data. Requires 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.
5)POLICY COMMENT. This bill requires SNFs to establish and
implement an ASP. Existing law requires each general acute
care hospital to establish and implement an ASP; in addition,
the hospitals are required to develop a physician-supervised
multidisciplinary antimicrobial stewardship committee,
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subcommittee, or workgroup, and to appoint at least one
physician or pharmacist to the committee who is knowledgeable
about antimicrobial stewardship through specified training.
This bill's language is currently silent as to how the policy
must be implemented within each SNF and does not specifically
require SNFs to form an antimicrobial stewardship committee.
The author may wish to consider amending this bill's
provisions to be consistent with existing statutory
requirements regarding ASPs for general acute care hospitals.
REGISTERED SUPPORT / OPPOSITION:
Support
Blue Shield of California
California Long-Term Care Ombudsman Association (prior version)
California Optometric Association
CALPIRG (prior version)
Health Officers Association of California
Opposition
None on file.
Analysis Prepared by:An-Chi Tsou / HEALTH / (916)
319-2097
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