Infection Control & Hospital Epidemiology
Table 1. Location and Diagnoses of Cases Discussed at VAST Sessions Characteristics
Site A
Unique patients, no. Cases discussed, no. Acute care, no. (%)
Long-term care, no. (%) Other, no. (%)a
Diagnoses, no.
Pneumonia/Respiratory syndrome, no. (%)b Noninfectious syndrome, no. (%)c Skin and skin structure, no. (%)
Bone, joint or muscle infection, no. (%) Bacteremia or sepsis, no. (%) Urinary tract, no. (%)
Intraabdominal infection, no. (%)d Ear or eye infections, no. (%) Infectious diarrhea, no. (%) Other infections, no. (%)e
121 140
98 (70) 36 (26) 6 (4)
140
58 (41) 19 (13) 18 (12) 15 (11) 10 (7) 8 (6) 4 (3) 2 (1) 1 (1) 5 (4)
1165 Table 2. Recommendations Made by the VAST and Accepted by Primary Team Site B
106 119
30 (25) 60 (50) 29 (24)
119
41 (35) 19 (16) 23 (20) 2 (2) 3 (3)
19 (16) 1 (1) 2 (2) 4 (3) 5 (4)
Note. VAST, videoconference antimicrobial stewardship team. aSite A includes patients from outpatient clinics (n=4) and 1 case each from urgent care and home-based primary care. Site B includes urgent care (n=17) and outpatient clinics
(n=12). bIncludes respiratory viral infections and acute exacerbations of chronic obstructive pul-
monary disease. cSite A includes bacteriuria (n=3), 2 cases each of drug-fever, dysuria, heart-failure, hematuria, ruling out Lyme disease, and 1 case each of cirrhosis, irritable bowel syndrome, lymphedema, myelodysplastic syndrome, positive blood culture (contaminant) and venous insufficiency. Site B includes bacteriuria (n=7), cough or dyspnea (n=4), fatigue (n=2), and 1 case each of abdominal tenderness, asplenia, encephalopathy, gross hematuria,
nocturia, and rheumatoid arthritis. dSite A includes abscesses (n=2) and 1 case each of acute cholecystitis and diverticulitis.
Site B includes 1 case of diverticulitis. eSite A includes unspecified fever (n=3), candidal esophagitis and orchitis. Site B includes urethritis (n=2), fever, lung abscess, and prostatitis.
site A and a 71% acceptance rate (32 of 45 recommendations) at site B. Site A had a greater number and variety of attendees than
site B, with ~15 and 3 attendees per session, respectively (Table 3). This difference may reflect both the individual cultures at each intervention sites and differences in access to infectious disease expertise. Specifically, at site A, the VAST was the primary means to access infectious disease expertise, whereas site B had recently engaged a part-time infectious disease physician who was available to address more complex infectious disease problems commonly encountered in the inpatient setting.
Qualitative results
From sites A and B, 19 of 41 (46%) and 5 of 5 (100%) VAST members, respectively, agreed to be interviewed. Most of the qualitative findings aligned with the 5 domains of the SIEPS 2.0 human factors model (Table 4). Practice change emerged as an inductive theme outside of the SEIPS domains.
Recommendations, No. Accepted of Those Made (%)
All recommendationsa
Recommendations about antibiotics Stop antibiotic(s)
Continue antibiotic(s)
Change antibiotic agent, dose or length of therapy
Start new antibiotic Do not start or renew antibiotic Other recommendations
Diagnostic imaging or labs Obtain consult
Nonpharmacologic intervention (eg, wound care, change urinary catheter)
Further evaluation pending results of diagnostics tests or other records
Education to patient and/or caregivers
Start or stop medication other than an antibiotic
Otherb Site A Site B
186/256 (73) 99/153 (65) 111/137 (81) 72/104 (69) 54/66 (82) 32/45 (71) 28/31 (90)
5/6 (83) 15/25 (60) 22/40 (55) 9/10 (90) 7/7 (100)
5/5 (100) 6/6 (100) 81/119 (68) 27/49 (55) 35/48 (73) 12/18 (67) 15/25 (60) 7/14 (50) 8/18 (44)
4/7 (57) 8/9 (89)
4/5 (80) 3/4 (75)
8/10 (80) … … 4/6 (67) 0/4 (0)
Note. VAST, videoconference antimicrobial stewardship team. aSome patients received ≥1 recommendation. bSite A included change remove or do not place device (3 of 4, 75%) recommendations
accepted), nursing intervention (2 of 3, 67%), transfer to a tertiary care facility (2 of 2, 100%), and establish with primary care (1 of 1; 100%). Site B included antibiotic allergy rechallenge (0 of 3, 0%) and do obtain a diagnostic test (0 of 1, 0%).
Practice change
Participants reported that the VAST sessions increased their awareness of antibiotic stewardship principles, helping them to adapt their practice patterns and engage in antimicrobial stew- ardship efforts. They specifically mentioned feeling greater con- fidence in their ability to make more targeted antibiotic choices, to reduce the time patients were on antibiotics, and to utilize more effective methods whenever possible (ie, intravenous to oral conversions). They also highlighted the educational component, including the brief didactic sessions, and being able to apply what they learned from case presentations to other patients. Providers were eager to see whether the data on antibiotics use and hos- pitalizations would reflect their perception of the changes. In the context of barriers, participants reported that some providers were not open to recommendations to change to their treatment plans. They attributed this resistance to ego or to the idea that some providers are set in their ways and preferred to use their established practice patterns. Both sites reported efforts to improve antimicrobial steward-
ship independent of the VAST, including auditing cases to identify areas for improvement in antibiotic stewardship. At site B, decision aid tools were developed to help providers identify appropriate testing for certain illnesses and symptoms to ensure best choices for antibiotic use were made when appropriate.
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