This All Facilities Letter (AFL) notifies all hospitals of new requirements resulting from the enactment of SB 1311 (Chapter 843, Statutes of 2014), which added Section 1288.85 to the Health and Safety Code (HSC), and requires general acute care hospitals (GACH) to adopt and implement Antimicrobial Stewardship Programs (ASPs).

Current law requires hospitals to have infection control programs (Title 22, California Code of Regulations Section 70739) and to develop a process for evaluating the judicious use of antibiotics in their facility (HSC Section 1288.8(a)(3)). In addition to existing requirements, SB 1311 requires GACHs to complete all of the following by July 1, 2015:

• Adopt and implement an antimicrobial stewardship policy in accordance with guidelines established by the federal government and professional organizations that includes a process to evaluate the judicious use of antibiotics.
• Develop a physician supervised multidisciplinary antimicrobial stewardship committee, subcommittee, or workgroup with at least one physician or pharmacist who is knowledgeable about the subject of antimicrobial stewardship through prior training or attendance at continuing education programs.
• Report ASP activities to each appropriate hospital committee undertaking clinical quality improvement activities.

The California Department of Public Health (CDPH) has an initiative that describes specific activities comprising hospital ASPs. Additionally, the Centers for Disease Control and Prevention (CDC) have developed information on ASP implementation. Resources on ASPs are available at the following links:

• The California Antimicrobial Stewardship Program Initiative, CDPH: (https://www.cdph.ca.gov/Programs/CHCQ/HAI/Pages/CA_AntimicrobialStewardshipProgramInitiative.aspx) 
• Get Smart for Healthcare Campaign: Implementation Resources, CDC:
  (http://www.cdc.gov/getsmart/healthcare/implementation.html)  

The information in this AFL is a brief summary of the changes that SB 1311 makes to the HSC. Facilities are responsible for following all applicable laws. Any failure of CDPH to expressly notify facilities of statutory or regulatory requirements does not relieve facilities of their responsibility for following all laws and regulations. Facilities should refer to the full text of all applicable sections of the HSC and Title 22 of the California Code of Regulations.

If you have any questions, please contact your respective Licensing & Certification District Office.

Sincerely,

Original signed by Scott Vivona for

Jean Iacino
Interim Deputy Director