1166
Table 3. Roles of VAST Participants Who Attended at Least 1 Session During the 1-Year Study Period
Role
Intervention site Infection preventionists Nurses
Nurse practitioners and physician assistants Pharmacists Physicians Traineesb Othersc
Remote site Infectious diseases physicians Research team members Information technologist
Site A 3
10 5 3
14 Site B
2 0 2 2
1a
62 01
2 3 2
1 0 0
Note. VAST, videoconference antimicrobial stewardship team. aDuring the latter part of the 1-year assessment period, the infectious diseases physician
making rounds at site B adjusted his schedule to attend the VAST in person. bMedical resident (n=1), pharmacy residents (n=2), nurse practitioner students (n=2) and
pharmacy students (n=3). cDentist.
Lauren D. Stevenson et al
settings. Providers reported gaining more confidence in com- municating their plans of care for patients transferring from one setting to another leading to more closely aligned patient care. One provider reported less antibiotic use in patients transferred from acute-care to long-term care.
Participant responses
At site A, the interviews highlighted efforts by the local cham- pions to encourage participation in VAST. Respondents also reported that the infectious disease physician made them feel welcome, prompted questions, and encouraged them to give their opinions. Participants emphasized that they were never made to feel that they did something wrong or made a bad choice, which made them feel more comfortable about presenting cases and discussing how to improve antimicrobial stewardship. Site B respondents also reported being encouraged to participate by the specialist when they were asked questions and to contribute to case discussion even if they were unsure. Participants reported valuing the multidisciplinary input they
Tools and technology
The video component, which allowed face-to-face communica- tion, facilitated the VAST. Participants reported that it enhanced their positive experience by supporting learning and commu- nication, which in turn led to a better understanding of the recommendations. Video conferencing also facilitated discussion among participants, compared to traditional consults in which asynchronous communication between providers and specialists may be limited to reviewing content within the EMR. Further- more, the team at the intervention site and the infectious disease physician accessed the same EMR, which participants felt also advanced learning, development of recommendations, and treat- ment steps. Barriers reported by some participants included having to learn to operate the technology associated with running the videoconference system and, occasionally, technical difficulties such as audio interference.
Organizational environment
Engagement differed by site and by the participants’ roles. At site A, participants were highly engaged and attended VAST sessions whether or not they had a case to present. At site B, however, while the pharmacist and infection preventionists remained strongly engaged, providers rarely attended sessions. At site A, nurses mentioned barriers to participation, although
several regularly participated in the VAST. The nurses interviewed indicate that they learned a lot about antimicrobial stewardship by attending the VAST sessions. They also shared that they could not readily apply that knowledge clinically due to the culture of their work setting and the relationship between nursing staff and the providers making treatment decisions for patients. At site A, the organizational culture and approach to patient care sometimes differed between acute-care and long-term care
received from VAST participants and indicated more willingness to ask for assistance from the infectious disease physician or from their local colleagues. Specifically, they identified their local infection preventionists as a resource. Furthermore, they noted that the VAST sessions built the rapport with the off-site infec- tious disease physician. Site A participants discussed an increase in communication among medical providers (ie, peer-to-peer) and between providers and professionals from other disciplines (ie, pharmacists, infection preventionists and infectious diseases physicians). Notably, site A providers reported learning that their facility’s pharmacists are a knowledgeable resource for antibiotic selection and use.
Tasks
The infection preventionists at both sites helped identify appro- priate cases for discussion at the VAST sessions, notifying pro- viders of the intent to discuss one of their patients. At site A, the infection preventionists entered consults, reviewed and presented cases during the VAST session, and recorded recommendations into the patient’s EMR. At site A, some providers identified and either presented their own cases or supplemented the presenta- tions made by the infection preventionists. While providers from site A reported no increase in workload burden from VAST participation, the infection preventionists commented that they typically dedicated 8 hours each week to VAST activities. At both sites, participants reported enjoying the VAST ses-
sions and attended when it did not interfere with patient care. Despite limited time and availability site A participants reported prioritizing VAST sessions because they were interested and felt the program helped them provide better patient care. Many participants mentioned enjoyed meeting each week because it provided routine feedback on antimicrobial stewardship, allowed for follow-up on challenging cases, enhanced learning, and improved treatment. Scheduling issues, such as rotating work weeks and conflicting
times with grand rounds or other duties, were barriers to parti- cipation. VAST sessions were held in the middle of the day, typically at noon. Providers reported feeling pressure to discharge patients who needed to move to a different level of care and to address other pressing patient care issues. Some participants mitigated these barriers by arranging cross coverage or by
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