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(SCAN‑ECHO), this program is an effective healthcare delivery model that integrates patient care with provider education, improving access to specialty care from a distance.9–11 To improve antimicrobial stewardship at VA facilities with
limited access to infectious diseases specialists, we developed a pilot project using telehealth. Specifically, we used SCAN-ECHO to connect pharmacists, infection preventionists, staff nurses, and other clinicians at a rural VAMCs with an infectious disease physician at a geographically distant VA to form a video- conference antimicrobial stewardship team (VAST). Staff from acute-care and long-term care settings participated. Here, we describe program implementation at 2 VAs, and we report related qualitative results based on interviews with participating clinical staff.
Methods Intervention
We conducted a 1-year prospective quasi‑experimental study in parallel at 2 intervention sites, starting in August 2016 for site A and in October 2016 for site B. The intervention sites were rural Veterans Affairs medical centers (VAMCs) without a trained infectious disease professional on staff. Site A has 27 acute-care beds and 162 long-term care beds; site B has 10 acute-care beds and 180 long-term care beds. Medical providers, pharmacists, infection preventionists, and staff nurses from each intervention site who were interested in participating were paired with an off-site infectious disease physician from another VAMC for weekly telehealth sessions. Together, these individuals formed the videoconference antimicrobial stewardship team (VAST), and they discussed concerns related to infections and anti- microbial use among patients at the intervention site. Each week, staff at the intervention sites selected cases for
discussion; patients could come from any setting, including acute care, long-term care, urgent care, and outpatient clinics. During the 1-hour meetings, a VAST member from the inter- vention site presented cases for discussion, recorded the team’s recommendations, and entered them into the electronic medical record (EMR) at the intervention site. The VAST member also placed an interfacility consult to the VAMC of the infectious disease physicians, who used a templated note to complete the consult and capture workload. The clinical providers for the patient being discussed did not need to be present for the VAST meeting to formulate recommendations. The infectious disease physicians were also available outside of the VAST session for brief or urgent questions, some of which were answered using e-consults. Before initiating the VAST sessions, the research team agreed
on a general approach and process for workload capture in the EMR. The 2-month difference in the start dates permitted the personnel working with site B to anticipate problems and adapt solutions implemented by the research team working with site A.
Quantitative results
We recorded the number of patients discussed, their infectious syndromes, their location (acute, long-term, or urgent care), the recommendations made by the VAST, and whether they provide followed through on those recommendations within 7 days. We also noted the number and roles of participants at each VAST session.
Qualitative results
Six months after the intervention began, we conducted semi- structured interviews to assess participants’ perceptions of the VAST (detailed in Appendix 1). Individuals who participated in at least 1 VAST session were approached for an interview, primarily through e-mail. Telephone interviews (20–60 min- utes) were digitally recorded, transcribed, and analyzed using NVivo software (QSR International, Melbourne, Australia). Inductive and deductive content analysis identified salient themes, with deductive codes based on domains from the Sys- tems Engineering Initiative for Patient Safety (SEIPS 2.0), a human factors model geared toward improving patient safety, which proposes that the following 5 components of a work system continuously interact and influence one another: (1) tools and technologies, (2) organizational conditions, (3) par- ticipant(s), (4) tasks, and (5) the physical environment.12 Qualitative data were analyzed as an aggregate, and site-level comparisons were not made.
Results Differences in implementation at sites A and B
While following the same general approach, distinct features emerged at each site. Infection preventionists championed the VAST at site A, selecting cases to discuss, presenting the cases at the sessions, and incorporating most of recommendations into the EMR. At site B, a pharmacist served as the champion, selecting cases to review and entering relevant documentation into the EMR. The infectious diseases physicians working with site A reviewed cases prior to each session, whereas for site B, the infectious disease physician learned about the cases during the VAST session, reviewing the medical record after the meeting and adding the note placed by the pharmacist. Additional differences pertained to engagement and education.
Site A benefited from leadership support; the chief of staff, the chief of medicine, the associate director for patient care, and the chief of nursing demonstrated their support of the VAST by attending several sessions. Furthermore, approximately once each month, the infectious disease physicians working with site A prepared and gave brief didactic sessions (10–15 minutes) rele- vant to the cases discussed. At site B, there was limited support to provide frontline providers with administrative time to attend VAST sessions. While their VAST also had a strong educational component, the content was incorporated into notes for sub- sequent review by clinical providers.
Quantitative results
Over a 1-year period, the VAST at site A discussed 140 cases over 40 sessions for an average of 3.5 cases per session. Similarly, site B discussed 119 cases over 38 sessions, for an average of 3.1 cases per session. Most cases for site A came from the acute-care wards (70%); most cases at site B came from the long-term care ward (50%). Pneumonia and respiratory syndromes, including acute exacerbations of chronic obstructive pulmonary disease, accoun- ted for ~40% of the cases from both intervention sites (Table 1). The acceptance rate for actionable recommendations made by the VASTs was >65% at both intervention sites (Table 2). The most common recommendation at both sites was to stop antibiotics, which had an 82% acceptance rate (54 of 66 recommendations) at
Lauren D. Stevenson et al
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