Antimicrobial-resistant and healthcare-associated pathogens cause over 2.5 million infections each year. Nearly 2% of these infections end in death. Antimicrobial stewardship, which seeks to minimize unnecessary and inappropriate antimicrobial use is a critical part of preventing illness caused by antimicrobial-resistant and healthcare-associated pathogens. Antimicrobial stewardship guidelines call for a multidisciplinary team with an infectious disease physician and infection disease-trained clinical pharmacist as core members. Unfortunately, there are insufficient infectious disease-trained specialists to staff on-site antimicrobial stewardship programs at every VA medical center (VAMC). In order to support antimicrobial stewardship throughout VA, all facilities need ready access to experts skilled with applying antimicrobial stewardship principles. The VA has existing infrastructure, the Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO), which serves to improve access to healthcare specialists.
The goal of this pilot project was to use telehealth to improve antimicrobial stewardship at VA facilities with limited access to infectious disease-trained specialists. Specifically, we used SCAN-ECHO to connect an infectious disease physician to pharmacists, infection control preventionists, nurses and clinicians at a geographically distant VA to form a videoconference antimicrobial stewardship team (VAST). This pilot study tested the feasibility of the VAST approach using 2 pairs of VA facilities.
Our central hypothesis was that an effective videoconference antimicrobial stewardship team (VAST) will lead to a decrease in antimicrobial length of therapy and to a decrease in the use of broad-spectrum antimicrobials for veterans in acute and long-term care settings. Objective 1 was to describe and assess the feasibility of implementing a VAST at 2 intervention sites. Objective 2 was to assess the outcomes of VAST implementation on antimicrobial use at the intervention sites
We conducted a prospective quasi-experimental pilot study in parallel, pairing 2 intervention sites, both VAMCs in rural areas, with an infectious disease physician at another VAMC in the same region. The project called for each VAST to hold weekly meetings for 6 months with the VAST members from the intervention site to include a multidisciplinary team of pharmacists, infection preventionists, nurses and clinical providers. The off-site VAST members were infectious disease (ID) physicians.
To assess the VAST, we measured quantitative outcomes (descriptive statistics, changes in overall antibiotic use) and qualitative outcomes (fidelity of implementation, impressions from participants).
a. Descriptive Statistics. During the planned 6-month intervention period, Site 1 discussed 74 veterans over 24 sessions (average of 3.1 veterans/session). Of those 49 (66%) were from acute care and 25 (34%) were from long-term care. The Site 1 VAST made a total of 142 recommendations; 113 (80%) were accepted. Site 2 discussed 63 veterans over 24 sessions (average of 2.6 veterans/session). Of those 21 (35%) were from acute care and 41 (65%) were from long-term care. The Site 2 VAST made a total of 100 recommendations; 64 (64%) were accepted.
b. Changes in Overall Antibiotic Use. We used VA databases to total inpatient antibiotic use and length of antibiotic therapy in the 6 months before and after VAST initiation. For Site 1, the VAST led to a substantial reduction in total antibiotic use (34%) and length of therapy (30%) for the long-term but not acute care wards. For Site 2, the VAST led to a modest reduction in total antibiotic use (10%) for the acute care but not long-term wards.
c. Fidelity of Implementation. While each VAST adapted a slightly different workflow, the basic elements were that the VAST members at the intervention site selected and reviewed the patients to be discussed and left recommendations from the VAST in the patients' medical records. Additionally, the off-site ID physicians used a templated note to complete an interfacility consult, thus enabling them to capture workload. For Site 1, the ID physician reviewed the cases prior to the VAST session, communicating recommendations during the session. For Site 2, the ID physician reviewed the cases after the session, leaving final recommendations in medical record. These differences may reflect that at Site 1, the VAST was the primary means to access ID expertise while Site 2 had recently engaged a part-time ID physician. Our findings indicate that each VAST can adapt the basic approach to suit the needs of their individual team members.
d. Impressions of Team Members. We used semi-structured interviews of team members to assess their impression of the VAST. Interview questions focused on the participant perceptions of VAST, including the barriers and facilitators to antimicrobial stewardship activities. Across both sites, participants reported enjoying attending VAST meetings. Many participants reported increased awareness of antibiotic stewardship, feeling more confident in treating illnesses differently than in the past, feeling more comfortable selecting antibiotics and asking for assistance either via the VAST, from the infection control staff, or from the VAST ID Physician. Participants reported valuing the multidisciplinary input they received from VAST participants, including having people from both acute care and long-term care units. Providers reported no increase in workload burden from VAST participation.
The project has improved the access of rural VAMCs to professionals with expertise in ID and has helped to weave antibiotic stewardship principles into the culture at both intervention sites. Decreased antibiotic use, over time, will help reduce the prevalence of antimicrobial-resistant and healthcare-associated pathogens while improving patient safety.
We are now well past the 1 year mark for our first VAST sessions. The VAST members at Sites 1 and 2 have elected to continue their programs, which is perhaps the strongest outcome measure describing the success of this pilot project.
- Wilson BM, Banks RE, Crnich CJ, Ide E, Viau RA, El Chakhtoura NG, Jones YR, Cherry JB, Anderson BA, Jump RLP. Changes in antibiotic use following implementation of a telehealth stewardship pilot program. Infection control and hospital epidemiology. 2019 Jul 1; 40(7):810-814.
- Stevenson LD, Banks RE, Stryczek KC, Crnich CJ, Ide EM, Wilson BM, Viau RA, Ball SL, Jump RLP. A pilot study using telehealth to implement antimicrobial stewardship at two rural Veterans Affairs medical centers. Infection control and hospital epidemiology. 2018 Oct 1; 39(10):1163-1169.