1. (1) The REH shall provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There shall be an active program for the prevention, control, and investigation of infections and communicable diseases supervised and administered by the hospital. The REH shall be governed by the Board's Rules for Hospitals, Chapter 420-5-7, Ala. Admin. Code.
2. (2) An individual (or individuals) qualified through education, training, or experience in infectious diseases and/or antibiotic stewardship, must be appointed by the governing authority as the leader(s) of the infection prevention and control and antibiotic stewardship programs, based on the recommendations of medical staff leadership and pharmacy leadership.

3. (3) The facility-wide antibiotic stewardship program:

   1. (a) Demonstrates coordination among all components of the REH responsible for antibiotic use and resistance, including, but not limited to, the infection prevention and control program, the QAPI Program, the medical staff, nursing services, and pharmacy services;
   2. (b) Documents the evidence-based use of antibiotics in all departments and services of the REH; and
   3. (c) Documents any improvements, including sustained improvements, in proper antibiotic use.
4. (4) The antibiotic stewardship program adheres to nationally recognized guidelines, as well as best practices, for improving antibiotic use; and
5. (5) The antibiotic stewardship program reflects the scope and complexity of the services furnished by an REH.

6. (6) The leader(s) of the antibiotic stewardship program is responsible for:

   1. (a) The development and implementation of a facility-wide antibiotic stewardship program, based on nationally recognized guidelines, to monitor and improve the use of antibiotics.
   2. (b) All documentation, written or electronic, of antibiotic stewardship program activities.
   3. (c) Communication and collaboration with medical staff, nursing, and pharmacy leadership, as well as the REH's infection prevention and control and QAPI Programs, on antibiotic use issues.
   4. (d) Competency-based training and education of REH personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the REH, on the practical applications of antibiotic stewardship guidelines, policies, and procedures.

7. (7) If an REH is part of a system consisting of multiple separately certified hospitals, CAHs, and/or REHs using a system governing body that is legally responsible for the conduct of 2 or more hospitals, CAHs, and/or REHs, the system governing body can elect to have unified and integrated infection prevention and control and antibiotic stewardship programs for all of its member facilities after determining that such a decision is in accordance with all applicable state and local laws. The system governing body is responsible and accountable for ensuring that each of its separately certified REHs meets all of the requirements of this section. Each separately certified REH subject to the system governing body must demonstrate that:

   1. (a) The unified and integrated infection prevention and control and antibiotic stewardship programs are established in a manner that takes into account each member REH's unique circumstances and any significant differences in patient populations and services offered in each REH;
   2. (b) The unified and integrated infection prevention and control and antibiotic stewardship programs establish and implement policies and procedures to ensure that the needs and concerns of each of its separately certified REHs, regardless of practice or location, are given due consideration;
   3. (c) The unified and integrated infection prevention and control and antibiotic stewardship programs have mechanisms in place to ensure that issues localized to particular REHs are duly considered and addressed; and
   4. (d) A qualified individual (or individuals) with expertise in infection prevention and control and in antibiotic stewardship has been designated at the REH as responsible for communicating with the unified infection prevention and control and antibiotic stewardship programs, for implementing and maintaining the policies and procedures governing infection prevention and control and antibiotic stewardship as directed by the unified infection prevention and control and antibiotic stewardship programs, and for providing education and training on the practical applications of infection prevention and control and antibiotic stewardship to REH staff.

Author: Dana H. Billingsley

Statutory Authority: Code of Ala. 1975, §§22-21-20, et seq.

History: New Rule: Published August 31, 2023; effective October 15, 2023.