VA pilot study finds telehealth could aid stewardship

A pilot study conducted at two rural Veterans Affairs (VA) medical centers suggests that telehealth could be a helpful tool for implementing antibiotic stewardship in hospitals that lack infectious disease (ID) specialists.

In the 1-year prospective study, published today in Infection Control & Hospital Epidemiology, staff members at two rural VA medical centers without a trained ID professional formed teams that discussed infections and antimicrobial use among their patients during a weekly1-hour videoconference with an offsite ID physician at another VA hospital. At both sites, participants in the videoconference antimicrobial stewardship team (VAST) discussed and made recommendations on roughly three cases per session, then entered those recommendations into the electronic medical record at the intervention site.

Over the 1-year intervention period, 140 cases were discussed at site A and 119 at site B. Most of the cases came from acute care and long-term care wards, and roughly 40% at both sites involved pneumonia and respiratory syndromes, including acute exacerbations of chronic obstructive pulmonary disease.

The results showed that providers accepted and implemented more than two thirds of the actionable recommendations (73% at site A, 65% at site B). The most common recommendation at both sites—to stop antibiotics—had an 82% acceptance rate at site A and a 71% acceptance rate at site B.

While the study did not assess whether the intervention reduced overall antibiotic use at either hospital, interviews with 24 VAST participants—who included physicians, nurses, pharmacists, infection preventionists, and trainees—indicated that the videoconference sessions increased their awareness of antimicrobial stewardship principles and gave them greater confidence in their ability to make more targeted antibiotic choices and reduce the time that patients are on antibiotics.

AST members also said that the video component facilitated the process by allowing for face-to-face communication, and that it helped build rapport with the offsite ID physician.

"I think it's a lot better than just a phone call," one participant told researchers in an interview.

Shortage of ID expertise a problem

The findings of the study are important, because across all healthcare settings, including the VA system, there aren't enough ID physicians and pharmacists to staff antimicrobial stewardship programs (ASPs). The authors of the study cite a 2012 survey that found that only 52 of 130 VA hospitals providing inpatient care had a full-time ID physician on staff. And help doesn't appear to be on the way: a 2017 paper in Clinical Infectious Diseases found that the number of medical students training to become ID physicians has plummeted since 2011.

The shortage of ID expertise is most acutely felt in small, rural hospitals. Surveys show that only slightly more than half of small community hospitals even have access to an ID specialist. This means that the task of implementing ASPs in these facilities is often left to physicians, pharmacists, and nurses who lack ID and stewardship training.

"When antibiotic stewardship programs are left to those who are not trained to run them, they are more susceptible to issues and can ultimately be ineffective," study co-author Laura Stevens, PhD, a researcher at the Louis Stokes Cleveland VA Medical Center, said in a press release from the Society for Healthcare Epidemiology of America (SHEA—publisher of the journal).

Guidelines from SHEA and the Infectious Diseases Society of America recommend that ASPs be led by ID physicians with advanced stewardship training or co-directed by an ID physician and a clinical pharmacist who have advanced ID training.

Stevens and her co-authors say the results suggest telehealth could be part of the solution. "Telehealth can be a low-cost and effective way to provide facilities with the expertise needed to implement these initiatives—eliminating some of the barriers that have typically thwarted these efforts," said senior author Robin Jump, MD, PhD, a physician at Louis Stokes Cleveland VA Medical Center.

The researchers say the next step will be to measure antibiotic use at the two intervention sites and expand the program to other VA hospitals with limited access to ID expertise.

See also:

Sep 6 Infect Control Hosp Epidemiol abstract

Sep 6 SHEA press release

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