Infection Control & Hospital Epidemiology
Table 4. Illustrative Quotations Identified From the Semi-Structured Interviews, Presented in the Context of the SEIPS Framework SEIPS Elements
Illustrative Quotation(s)
Tools and technology “I think it’s a lot better than just a phone call.” “You see part of the communication is through body language through facial expressions…having the visual experience enhances the process”
“Better with teleconference and working as a group to come up with a treatment plan than e-consult.”
Organizational environment
“Idon’t have time. I squeeze in time because I’m interested.” “It does take time to do a quality review… It needs to be something dedicated as someone’s work duties as opposed to ad hoc…” “[Nurses] generally cannot get away [from the floor] because of care duties. I think a lot of times…they don’t have empowerment in terms of guiding MDs as far as not using antibiotics.”
“I see [the VAST] as screening for inappropriate or potentially inappropriate antibiotic use and bringing that to the attention of the ID physician and other VAST group members and / or and the primary prescriber. And making appropriate recommendations for change when warranted.”
“[The team members] interact well. They offer their opinions and clarify histories and it encourages discussion and learning…. A lot of times we don’t have a lot of opportunity for that to happen especially among physicians and nurses in a multidisciplinary group.” “I think that it builds a little better rapport, especially between the CLC providers and acute medical providers”
Person(s)
“I think there are some physicians that can be a little prideful at times and maybe not so open to everything or feel the need to maybe defend themselves….”
“I think that some people are very set in their ways from probably years and year of practice. A lot of the resistant strains of bugs came along and they threw everything but the kitchen sink at people, so I think it’s just going to take some time.”
“Sometimes the physicians make the patients wait until after that VAST meeting to determine if they can go home.” “When we were meeting on Fridays, people were very uncomfortable with changing [antibiotics] on a Friday afternoon.”
Tasks
“It doesn’t always give you time…to review those cases and prepare. When you are in a collaborative session like that you feel silly if you don’t have anything to add because you don’t know that patient.”
Physical environment “It’s our busy time during the middle of the day” “We can get bumped to another room and [then] you get different set up and different buttons to push. That has been an annoyance or a hampering of our work flow on a couple of occasions”
“We can get real time data. Everybody congregates around the table in the room and patient is presented by myself or the MD, and we discuss over the teleconference with the specialist and the group.”
Note. SEIPS, Systems Engineering Initiative for Patient Safety; CLC, community living center, nursing home and long-term care units at Veterans Affairs medical centers; VAST, video- conference antimicrobial stewardship team; CPRS, computerized patient record system (the VA’s electronic medical record); MD, medical doctor.
communicating information from the session to individuals who were not able to attend. At site A, the initial VAST sessions were on Friday afternoons, a time that made attendance difficult for several interviewees. After several weeks, the VAST for site A moved to Wednesdays, which was better but also overlapped with grand rounds once a month.
Physical environment
The physical space available for VAST sessions was a concern for participants. Initially, the setting for site A was small, hot, and noisy. The meeting was moved to a larger room with a more comfortable temperature and less ambient noise. Participants at both sites reported occasional issues with not having rooms available for the VAST session. The distance from providers’ work area and the meeting room was a barrier for some due to the large campus size. Site B overcame this barrier by allowing providers to call in from their location.
Discussion
This pilot study has demonstratedsuccessfulimplementationofa telehealth antimicrobial stewardship programat 2 rural VAMCs. The initial protocol called for a 6-month trial of the VAST. At the requests of participants from both sites, the VAST sessions continued well beyond the planned intervention period, permitting us to report outcomes from the first year of implementation. To our knowledge, this is the first description of a telehealth program focused on
antimicrobial stewardship in the VA. Additionally, the VAST dis- cussed cases from both acute-care and long-term care units, pro- viding team members from these different settings an opportunity to interact and address antimicrobial stewardship at transitions of care. Previous telehealth antimicrobial stewardship programs have
used both synchronous and asynchronous approaches, with the latter relying upon a linked EMR or dedicated web application for communication.13,14 Synchronous programs used technology to permit a multidisciplinary team of professionals to discuss cases in real time and also allowed for consultation to occur outside of scheduled sessions.15–18 In addition to infectious disease physicians and pharmacists, team members included epidemiologists, micro- biologists, administrators, information technology specialists, infection control staff members, as well as other physicians. To help broaden the inclusion of antimicrobial stewardship principles across clinical disciplines, the VAST specifically involved staff nurses.19 Similar to the program described by Zhou et al,18 the VAST began with a site visit, and subsequent meetings included brief didactic sessions on topics relevant to the cases addressed. The VAST approach represents a successful implementation of
the SCAN-ECHO model, demonstrated by continuation of the program and acceptance of most VAST recommendations at both sites. Contributing factors aligned with those previously described by Stevenson et al,20 including a design built around VA infra- structure, compatibility with existing workflow processes for doc- umentation and workload capture, as well as increased knowledge and competency reported by participants. These factors may also account for some of the differences in implementation between the 2 intervention sites. At site A, leaders from both medicine and
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