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Vaughn VM, Krein SL, Hersh AL, Buckel WR, White AT, Horowitz JK, Patel PK, Gandhi TN, Petty LA, Spivak ES, Bernstein SJ, Malani AN, Johnson LB, Neetz RA, Flanders SA, Galyean P, Kimball E, Bloomquist K, Zickmund T, Zickmund SL, Szymczak JE. Excellence in Antibiotic Stewardship: A Mixed-Methods Study Comparing High-, Medium-, and Low-Performing Hospitals. Clin Infect Dis 2024; 78:1412-1424. [PMID: 38059532 PMCID: PMC11153329 DOI: 10.1093/cid/ciad743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 11/13/2023] [Accepted: 12/01/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Despite antibiotic stewardship programs existing in most acute care hospitals, there continues to be variation in appropriate antibiotic use. While existing research examines individual prescriber behavior, contextual reasons for variation are poorly understood. METHODS We conducted an explanatory, sequential mixed-methods study of a purposeful sample of 7 hospitals with varying discharge antibiotic overuse. For each hospital, we conducted surveys, document analysis, and semi-structured interviews with antibiotic stewardship and clinical stakeholders. Data were analyzed separately and mixed during the interpretation phase, where each hospital was examined as a case, with findings organized across cases using a strengths, weaknesses, opportunities, and threats framework to identify factors accounting for differences in antibiotic overuse across hospitals. RESULTS Surveys included 85 respondents. Interviews included 90 respondents (31 hospitalists, 33 clinical pharmacists, 14 stewardship leaders, 12 hospital leaders). On surveys, clinical pharmacists at hospitals with lower antibiotic overuse were more likely to report feeling: respected by hospitalist colleagues (P = .001), considered valuable team members (P = .001), and comfortable recommending antibiotic changes (P = .02). Based on mixed-methods analysis, hospitals with low antibiotic overuse had 4 distinguishing characteristics: (1) robust knowledge of and access to antibiotic stewardship guidance; (2) high-quality clinical pharmacist-physician relationships; (3) tools and infrastructure to support stewardship; and (4) highly engaged infectious diseases physicians who advocated stewardship principles. CONCLUSIONS This mixed-methods study demonstrates the importance of organizational context for high performance in stewardship and suggests that improving antimicrobial stewardship requires attention to knowledge, interactions, and relationships between clinical teams and infrastructure that supports stewardship and team interactions.
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Affiliation(s)
- Valerie M Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Health System Innovation and Research, Department of Population Health Science, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Sarah L Krein
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Division of General Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Adam L Hersh
- Division of Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Whitney R Buckel
- Intermountain Healthcare Pharmacy Services, Taylorsville, Utah, USA
| | - Andrea T White
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jennifer K Horowitz
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Payal K Patel
- Division of Infectious Diseases, Department of Medicine, Intermountain Health, Salt Lake City, Utah, USA
| | - Tejal N Gandhi
- Division of Infectious Diseases, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Lindsay A Petty
- Division of Infectious Diseases, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Emily S Spivak
- Division of Infectious Diseases, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Steven J Bernstein
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Division of General Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Anurag N Malani
- Division of Infectious Diseases, Department of Internal Medicine, Trinity Health Michigan, Ann Arbor, Michigan, USA
| | - Leonard B Johnson
- Division of Infectious Diseases, Department of Internal Medicine, Ascension St John Hospital, Detroit, Michigan, USA
| | - Robert A Neetz
- Department of Pharmacy, MyMichigan Health, Midland, Michigan, USA
| | - Scott A Flanders
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Patrick Galyean
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Elisabeth Kimball
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Kennedi Bloomquist
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Tobias Zickmund
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Susan L Zickmund
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Informatics, Decision-Enhancement and Analytic Sciences Center, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Julia E Szymczak
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Kassamali Escobar Z, Shively NR. Health System and Tele-Antimicrobial Stewardship: The Role of Building Networks. Infect Dis Clin North Am 2023; 37:873-900. [PMID: 37657974 DOI: 10.1016/j.idc.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Abstract
Tele-antimicrobial stewardship programs (tele-ASPs) use technology and remote access to resources and clinical expertise to expand antimicrobial services within and outside of health systems. Models of tele-ASPs are workforce multiplying and workforce extending, depending on how they are structured. Building rapport and strong interpersonal networks are essential for successful ASPs. The available evidence suggests that an optimal model for tele-ASP includes hands-on involvement from remote infectious disease (ID) expertise with implementation by local pharmacists. However, this model remains limited by the available time and cost of ID-trained specialists.
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Affiliation(s)
- Zahra Kassamali Escobar
- University of Washington Center for Stewardship in Medicine, Seattle, WA, USA; Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, 825 Eastlake Avenue, Mail Stop G5-900, P.O. Box 19023, Seattle, WA 98109, USA
| | - Nathan R Shively
- Division of Infectious Diseases, Allegheny Health Network, 320 E North Avenue, Fourth Floor, East Wing, Suite 406, Pittsburgh, PA 15212, USA.
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Dirjayanto VJ, Lazarus G, Geraldine P, Dyson NG, Triastari SK, Anjani JV, Wisnu NK, Sugiharta AJ. Efficacy of telemedicine-based antimicrobial stewardship program to combat antimicrobial resistance: A systematic review and meta-analysis. J Telemed Telecare 2023:1357633X231204919. [PMID: 37847852 DOI: 10.1177/1357633x231204919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
INTRODUCTION Antimicrobial resistance (AMR) is a major public health threat. Improving antimicrobial use is the main strategy against AMR, but it is challenging to implement especially in low-resource settings. Thus, this review aims to explore the efficacy of telehealth-based antimicrobial stewardship programs (ASP), which is more accessible. METHODS Registered to PROSPERO and following PRISMA guidelines, literature search was performed in databases including PubMed, Scopus, Cochrane, Science Direct, EBSCOhost, EMBASE, and Google Scholar, searching for studies implementing telehealth ASP. Critical appraisal of studies was performed using Newcastle-Ottawa Scale for Cohort Studies (NOS), Cochrane Risk-of-Bias tool (RoB) 2.0, and Risk Of Bias In Non-randomised Studies-of Interventions (ROBINS-I). We utilized inverse variance, random effects model to obtain the pooled odds ratio (OR) and mean difference (MD) estimates, as well as sensitivity and subgroup analysis. RESULTS AND DISCUSSION The search yielded 14 studies. Telehealth-based ASP was associated with better adherence to guidelines (pooled OR: 2.78 [95%CI:1.29-5.99], p = 0.009; I2 = 93%), within which streamlining yielded better odds (pooled OR: 30.54 [95%CI:10.42-89.52], p < 0.001) more than the compliance with policy subgroup (pooled OR: 1.60 [95%CI:1.02-2.51], p = 0.04). The odds of antimicrobial prescription rate reduced significantly (pooled OR: 0.60 [95%CI:0.42-0.85], p = 0.005; I2 = 94%), especially for the lower respiratory infection subgroup (pooled OR: 0.37 [95%CI:0.28-0.49], p < 0.001). Days of therapy decreased (pooled MD: -47.12 [95%CI: -85.78- -8.46], p = 0.02; I2 = 100%), with the greatest effect in acute care settings (pooled MD: -97.73 [95%CI:-147.48-47.97], p = 0.0001). Mortality did not change significantly (pooled OR: 1.20 [95%CI:0.69-2.10], p = 0.52; I2 = 63%). CONCLUSION Telehealth-based ASP was proven beneficial to increase adherence to guideline and reduce prescription rates, without significantly affecting patient clinical outcome. After further studies, we recommend more widespread use of telemedicine to combat AMR.
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Affiliation(s)
- Valerie J Dirjayanto
- Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne NE1 7RU, UK
- Faculty of Medicine, Universitas Indonesia, Pondok Cina, Beji, Depok, West Java 16424, Indonesia
| | - Gilbert Lazarus
- Faculty of Medicine, Universitas Indonesia, Pondok Cina, Beji, Depok, West Java 16424, Indonesia
| | - Priscilla Geraldine
- Faculty of Medicine, Universitas Indonesia, Pondok Cina, Beji, Depok, West Java 16424, Indonesia
| | - Nathaniel G Dyson
- Faculty of Medicine, Universitas Indonesia, Pondok Cina, Beji, Depok, West Java 16424, Indonesia
| | - Stella K Triastari
- Faculty of Medicine, Universitas Indonesia, Pondok Cina, Beji, Depok, West Java 16424, Indonesia
| | - Jasmine V Anjani
- Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne NE1 7RU, UK
- Faculty of Medicine, Universitas Indonesia, Pondok Cina, Beji, Depok, West Java 16424, Indonesia
| | - Nayla Kp Wisnu
- Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne NE1 7RU, UK
- Faculty of Medicine, Universitas Indonesia, Pondok Cina, Beji, Depok, West Java 16424, Indonesia
| | - Adrianus J Sugiharta
- Faculty of Medicine, Universitas Indonesia, Pondok Cina, Beji, Depok, West Java 16424, Indonesia
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Moon SY, Lim KR, Son JS. The role of infectious disease consultations in the management of patients with fever in a long-term care facility. PLoS One 2023; 18:e0291421. [PMID: 37683019 PMCID: PMC10491299 DOI: 10.1371/journal.pone.0291421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 08/26/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Infectious disease (ID) clinicians can provide essential services for febrile patients in tertiary hospitals. The aim of this study was to evaluate the role of ID consultations (IDC) in managing hospitalized patients with infections in an oriental medical hospital (OMH), which serves as a long-term care facility. To our knowledge, this is the first study on the role of IDCs in managing patients in an OMH. METHODS This retrospective study was conducted in an OMH in Seoul, Korea, from June 2006 to June 2013. RESULTS Among the 465 cases of hospital-acquired fever, 141 (30.3%) were referred for ID. The most common cause of fever was infection in both groups. The peak body temperature of the patient was higher in IDC group (38.8±0.6°C vs. 38.6±0.5°C, p<0.001). Crude mortality at 30 days (14.6% vs. 7.8%, p = 0.043) and infection-attributable mortality (15.3% vs. 6.7%, p = 0.039) were higher in the No-IDC group. Multivariable analysis showed that infection as the focus of fever (adjusted Odd ratio [aOR] 3.49, 95% confidence interval (CI) 1.64-7.44), underlying cancer (aOR 10.32, 95% CI 4.34-24.51,), and multiorgan dysfunction syndrome (aOR 15.68, 95% CI 2.06-119.08) were associated with increased 30-day mortality. Multivariate analysis showed that in patients with infectious fever, appropriate antibiotic therapy (aOR 0.19, 95% CI 0.05-0.76) was the only factor associated with decreased infection-attributable mortality while underlying cancer (aOR 7.80, 95% CI 2.555-23.807) and severe sepsis or septic shock at the onset of fever (aOR 10.15, 95% CI 1.00-102.85) were associated with increased infection-attributable mortality. CONCLUSION Infection was the most common cause of fever in patients hospitalized for OMH. Infection as the focus of fever, underlying cancer, and MODS was associated with increased 30-day mortality in patients with nosocomial fever. Appropriate antibiotic therapy was associated with decreased infection-attributable mortality in patients with infectious fever.
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Affiliation(s)
- Soo-youn Moon
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University College of Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Kyoung Ree Lim
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University College of Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Jun Seong Son
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University College of Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Korea
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May SS, Veillette JJ, Webb BJ, Stenehjem EA, Throneberry SK, Gelman S, Pirozzi M, Stanfield V, Dustin Waters C, Grisel NA, Vento TJ. Effect of tele-COVID rounds and a tele-stewardship intervention on antibiotic use in COVID-19 patients admitted to 17 small community hospitals. J Hosp Med 2023. [PMID: 37127939 DOI: 10.1002/jhm.13118] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 05/03/2023]
Abstract
Antibiotic stewardship interventions are urgently needed to reduce antibiotic overuse in hospitalized COVID-19 patients, particularly in small community hospitals (SCHs), who often lack access to infectious diseases (ID) and stewardship resources. We implemented multidisciplinary tele-COVID rounds plus tele-antibiotic stewardship surveillance in 17 SCHs to standardize COVID management and evaluate concurrent antibiotics for discontinuation. Antibiotic use was compared in the 4 months preintervention versus 10 months postintervention. Interrupted time-series analysis demonstrated an immediate decrease in antibiotic use by 339 days of therapy/1000 COVID-19 patient days (p < .001), and an estimated 5258 antibiotic days avoided during the postintervention period. Thirty-day mortality was not significantly different, and a significant reduction in transfers was observed following the intervention (23.3% vs. 7.8%, p < .001). A novel tele-ID and tele-stewardship intervention significantly decreased antibiotic use and transfers among COVID-19 patients at 17 SCHs, demonstrating that telehealth is a feasible way to provide ID expertise in community and rural settings.
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Affiliation(s)
- Stephanie Shealy May
- Infectious Diseases Telehealth Services, Intermountain Healthcare, Murray, Utah, USA
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah, USA
| | - John J Veillette
- Infectious Diseases Telehealth Services, Intermountain Healthcare, Murray, Utah, USA
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah, USA
| | - Brandon J Webb
- Infectious Diseases Telehealth Services, Intermountain Healthcare, Murray, Utah, USA
| | - Edward A Stenehjem
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Steven K Throneberry
- Infectious Diseases Telehealth Services, Intermountain Healthcare, Murray, Utah, USA
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Stephanie Gelman
- Infectious Diseases Telehealth Services, Intermountain Healthcare, Murray, Utah, USA
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Michael Pirozzi
- Department of Hospital Medicine, Intermountain Medical Center, Murray, Utah, USA
| | | | - C Dustin Waters
- Department of Pharmacy, McKay-Dee Hospital, Ogden, Utah, USA
| | - Nancy A Grisel
- Enterprise Analytics, Intermountain Healthcare, Murray, Utah, USA
| | - Todd J Vento
- Infectious Diseases Telehealth Services, Intermountain Healthcare, Murray, Utah, USA
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, Utah, USA
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Livorsi DJ, Abdel-Massih R, Crnich CJ, Dodds-Ashley ES, Evans CT, Goedken CC, Echevarria KL, Kelly AA, Spires SS, Veillette JJ, Vento TJ, Jump RLP. An Implementation Roadmap for Establishing Remote Infectious Disease Specialist Support for Consultation and Antibiotic Stewardship in Resource-Limited Settings. Open Forum Infect Dis 2022; 9:ofac588. [PMID: 36544860 PMCID: PMC9757681 DOI: 10.1093/ofid/ofac588] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/03/2022] [Indexed: 12/23/2022] Open
Abstract
Infectious Disease (ID)-trained specialists, defined as ID pharmacists and ID physicians, improve hospital care by providing consultations to patients with complicated infections and by leading programs that monitor and improve antibiotic prescribing. However, many hospitals and nursing homes lack access to ID specialists. Telehealth is an effective tool to deliver ID specialist expertise to resource-limited settings. Telehealth services are most useful when they are adapted to meet the needs and resources of the local setting. In this step-by-step guide, we describe how a tailored telehealth program can be implemented to provide remote ID specialist support for direct patient consultation and to support local antibiotic stewardship activities. We outline 3 major phases of putting a telehealth program into effect: pre-implementation, implementation, and sustainment. To increase the likelihood of success, we recommend actively involving local leadership and other stakeholders in all aspects of developing, implementing, measuring, and refining programmatic activities.
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Affiliation(s)
- Daniel J Livorsi
- VA Office of Rural Health, Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
- Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Rima Abdel-Massih
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Infectious Disease Connect, Inc, Pittsburgh, Pennsylvania, USA
| | - Christopher J Crnich
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- William S. Middleton VA Hospital, Madison, Wisconsin, USA
| | | | - Charlesnika T Evans
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Medical Center, Hines, Illinois, USA
- Preventive Medicine and Center for Health Services and Outcomes Research, Northwestern University, Chicago, Illinois, USA
| | - Cassie Cunningham Goedken
- VA Office of Rural Health, Veterans Rural Health Resource Center-Iowa City (VRHRC-IC), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Kelly L Echevarria
- Department of Veterans Affairs, Antimicrobial Stewardship Task Force, Washington, DC, USA
| | - Allison A Kelly
- Department of Veterans Affairs, Antimicrobial Stewardship Task Force, Washington, DC, USA
- Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - S Shaefer Spires
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - John J Veillette
- Intermountain Healthcare TeleHealth Services, Murray, Utah, USA
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah, USA
| | - Todd J Vento
- Intermountain Healthcare TeleHealth Services, Murray, Utah, USA
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Medical Center, Murray, Utah, USA
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Robin L P Jump
- Geriatric Research Education and Clinical Center (GRECC) at the VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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SHEA statement on antibiotic stewardship in hospitals during public health emergencies. Infect Control Hosp Epidemiol 2022; 43:1541-1552. [PMID: 36102000 PMCID: PMC9672827 DOI: 10.1017/ice.2022.194] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Veillette JJ, May SS, Gabrellas AD, Gelman SS, Albritton J, Lyons MD, Stenehjem EA, Webb BJ, Dalto JD, Throneberry SK, Stanfield V, Grisel NA, Vento TJ. A Fully Integrated Infectious Diseases and Antimicrobial Stewardship Telehealth Service Improves Staphylococcus aureus Bacteremia Bundle Adherence and Outcomes in 16 Small Community Hospitals. Open Forum Infect Dis 2022; 9:ofac549. [PMID: 36381624 PMCID: PMC9645643 DOI: 10.1093/ofid/ofac549] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/12/2022] [Indexed: 02/03/2024] Open
Abstract
Background Infectious diseases (ID) and antimicrobial stewardship (AS) improve Staphylococcus aureus bacteremia (SAB) outcomes. However, many small community hospitals (SCHs) lack on-site access to these services, and it is not known if ID telehealth (IDt) offers the same benefit for SAB. We evaluated the impact of an integrated IDt service on SAB outcomes in 16 SCHs. Methods An IDt service offering IDt physician consultation plus IDt pharmacist surveillance was implemented in October 2016. Patients treated for SAB in 16 SCHs between January 2009 and August 2019 were identified for review. We compared SAB bundle adherence and outcomes between patients with and without an IDt consult (IDt group and control group, respectively). Results A total of 423 patients met inclusion criteria: 157 in the IDt group and 266 in the control group. Baseline characteristics were similar between groups. Among patients completing their admission at an SCH, IDt consultation increased SAB bundle adherence (79% vs 23%; odds ratio [OR], 16.9; 95% CI, 9.2-31.0). Thirty-day mortality and 90-day SAB recurrence favored the IDt group, but the differences were not statistically significant (5% vs 9%; P = .2; and 2% vs 6%; P = .09; respectively). IDt consultation significantly decreased 30-day SAB-related readmissions (9% vs 17%; P = .045) and increased length of stay (median [IQR], 5 [5-8] days vs 5 [3-7] days; P = .04). In a subgroup of SAB patients with a controllable source, IDt appeared to have a mortality benefit (2% vs 9%; OR, 0.12; 95% CI, 0.01-0.98). Conclusions An integrated ID/AS telehealth service improved SAB management and outcomes at 16 SCHs. These findings provide important insights for other IDt programs.
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Affiliation(s)
- John J Veillette
- Infectious Diseases TeleHealth Service, Intermountain Medical Center, Murray, Utah, USA
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah, USA
| | - Stephanie S May
- Infectious Diseases TeleHealth Service, Intermountain Medical Center, Murray, Utah, USA
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah, USA
| | - Alithea D Gabrellas
- Division of Infectious Diseases, University of Utah, Salt Lake City, Utah, USA
| | - Stephanie S Gelman
- Infectious Diseases TeleHealth Service, Intermountain Medical Center, Murray, Utah, USA
- Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Murray, Utah, USA
| | - Jordan Albritton
- TeleHealth Services, Intermountain Healthcare, Midvale, Utah, USA
- RTI International, Durham, North Carolina, USA
| | - Michael D Lyons
- TeleHealth Services, Intermountain Healthcare, Midvale, Utah, USA
| | - Edward A Stenehjem
- Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Murray, Utah, USA
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Brandon J Webb
- Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Murray, Utah, USA
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Joseph D Dalto
- TeleHealth Services, Intermountain Healthcare, Midvale, Utah, USA
| | - S Kyle Throneberry
- Infectious Diseases TeleHealth Service, Intermountain Medical Center, Murray, Utah, USA
- Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Murray, Utah, USA
| | - Valoree Stanfield
- Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Murray, Utah, USA
| | - Nancy A Grisel
- Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Murray, Utah, USA
| | - Todd J Vento
- Infectious Diseases TeleHealth Service, Intermountain Medical Center, Murray, Utah, USA
- Division of Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, Murray, Utah, USA
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Lam PW, Schwartz IS, Medford RJ. Use of virtual care by infectious disease specialists in Canada: A national survey. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e106. [PMID: 36483399 PMCID: PMC9726522 DOI: 10.1017/ash.2022.246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE The aim of this study was to characterize the type and extent of virtual care use among infectious disease specialists in Canada, with a focus on the clinical factors that influence the decision to provide virtual versus in-person care. METHODS Infectious disease physicians practicing in Canada were invited to complete a survey regarding their experiences with virtual care. The survey included 14 vignettes depicting new outpatient and post-hospital-discharge referrals. Participants were asked to select which (if any) virtual care modalities they would feel comfortable using and to specify a reason if they did not feel comfortable providing care virtually. Machine learning and natural language processing techniques were used to identify themes. RESULTS In total, 57 infectious disease physicians completed the survey. Respondents reported devoting 36.5% (SD, 18.4%) of their infectious disease practice to outpatient care, with 44.2% (SD, 23.2%) of it being delivered virtually. Respondents were more comfortable providing virtual care to post-hospital-discharge referrals who had been seen by an infectious disease physician compared to new outpatient referrals. When respondents were not comfortable with using any virtual care modality, the following common themes emerged: the need for physical examination, the importance of establishing a therapeutic relationship, the need for additional in-person tests or diagnostics, and patient counselling. CONCLUSION This study provides a glimpse into the current state of virtual care use in Canada and some of the major themes that affect decision making for virtual versus in-person care.
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Affiliation(s)
- Philip W. Lam
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, TorontoOntario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ilan S. Schwartz
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Richard J. Medford
- Division of Infectious Diseases & Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, United States
- Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, United States
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Khadem TM, Ergen HJ, Salata HJ, Andrzejewski C, McCreary EK, Abdel Massih RC, Bariola JR. Impact of Clinical Decision Support System Implementation at a Community Hospital with an Existing Tele-Antimicrobial Stewardship Program. Open Forum Infect Dis 2022; 9:ofac235. [PMID: 35836746 PMCID: PMC9274440 DOI: 10.1093/ofid/ofac235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 05/06/2022] [Indexed: 11/15/2022] Open
Abstract
Background Lack of on-site antimicrobial stewardship expertise is a barrier to establishing successful programs. Tele-antimicrobial stewardship programs (TASPs) utilizing a clinical decision support system (CDSS) can address these challenges. Methods This interrupted time series study reports the impact of CDSS implementation (February 2020) within an existing TASP on antimicrobial usage in a community hospital. Segmented regression analysis was used to assess differences in antimicrobial usage from January 2018 through December 2021. Pre- and post-CDSS frequencies of intravenous vs oral antimicrobials, time to optimal therapy (TTOT), pharmacist efficiency (number of documented interventions per month), and percentage of hospitalized patients receiving antimicrobials were compared with descriptive statistics. Results Implementation of a CDSS into an existing TASP was associated with an immediate 11% reduction in antimicrobial usage (level change, P < .0001). Antimicrobial usage was already trending down by 0.25% per month (pre-CDSS slope, P < .0001) and continued to trend down at a similar rate after implementation (post-CDSS slope, P = .0129). Frequency of use of select oral agents increased from 38% to 57%. Median TTOT was 1 day faster (2.9 days pre-CDSS vs 1.9 days post-CDSS). On average, pharmacists documented 2.2-fold more interventions per month (198 vs 90) and patients received 1.03 fewer days of antimicrobials per admission post-CDSS. Conclusions Implementation of a CDSS within an established TASP at a community hospital resulted in decreased antimicrobial usage, higher rates of oral usage, faster TTOT, and improved pharmacist efficiency.
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Affiliation(s)
- Tina M. Khadem
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, PA USA
- UPMC Centralized Health-System Antimicrobial Stewardship Efforts, Pittsburgh PA USA
- Infectious Disease Connect Inc., Pittsburgh PA USA
| | | | | | | | - Erin K. McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, PA USA
- Infectious Disease Connect Inc., Pittsburgh PA USA
| | - Rima C. Abdel Massih
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, PA USA
- Infectious Disease Connect Inc., Pittsburgh PA USA
| | - J. Ryan Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, PA USA
- UPMC Centralized Health-System Antimicrobial Stewardship Efforts, Pittsburgh PA USA
- Infectious Disease Connect Inc., Pittsburgh PA USA
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Cantey JB, Correa CC, Dugi DD, Huff E, Olaya JE, Farner R. Remote Stewardship for Medically Underserved Nurseries: A Stepped-Wedge, Cluster Randomized Study. Pediatrics 2022; 149:e2021055686. [PMID: 35411402 PMCID: PMC9648107 DOI: 10.1542/peds.2021-055686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Antibiotic overuse is associated with adverse neonatal outcomes. Many medically underserved centers lack pediatric antibiotic stewardship program (ASP) support. Telestewardship may mitigate this disparity. Authors of this study aimed to determine the effectiveness and safety of a nursery-specific ASP delivered remotely. METHODS Remote ASP was implemented in 8 medically underserved newborn nurseries using a stepped-wedge, cluster-randomized design over 3 years. This included a 15-month baseline period, a 9-month "step-in" period using random nursery order, and a 12-month postintervention period. The program consisted of education, audit, and feedback; and 24/7 infectious diseases provider-to-provider phone consultation availability. Outcomes included each center's volume of antibiotic use and the proportion of infants exposed to any antibiotics. Safety measures included length of stay, transfer to another facility, sepsis, and mortality. RESULTS During the study period, there were 9277 infants born (4586 preintervention, 4691 postintervention). Infants exposed to antibiotics declined from 6.2% pre-ASP to 4.2% post-ASP (relative risk 0.68 [95% confidence interval, 0.63% to 0.75%]). Total antibiotic use declined from 117 to 84.1 days of therapy per 1000 patient-days (-28% [95% confidence interval -22% to -34%]. No safety signals were observed. Most provider-to-provider consultations were <5 minutes in duration and occurred during normal business hours. CONCLUSIONS The number of infants exposed to antibiotics and total antibiotic use declined in medically underserved nurseries after implementing a remote ASP. No adverse safety events were seen, and the remote ASP time demands were manageable. Remote stewardship may be a safe and effective strategy for optimizing antibiotic use in medically underserved newborn nurseries.
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Affiliation(s)
- Joseph B. Cantey
- Department of Pediatrics, Divisions of Neonatology and
Allergy, Immunology, and Infectious Diseases, University of Texas Health San
Antonio, San Antonio, Texas
| | - Cynthia C. Correa
- Department of Obstetrics and Gynecology, Dimmit Regional
Hospital, Carrizo Springs, Texas
| | - Daniel D. Dugi
- Department of Family Medicine, Cuero Regional Hospital,
Cuero, Texas
| | - Erin Huff
- Department of Obstetrics and Gynecology, Hill Country
Memorial Hospital, Fredericksburg, Texas
| | - Jorge E. Olaya
- Division of Neonatology, Department of Pediatrics,
University of Texas Health San Antonio, San Antonio, Texas
| | - Rachael Farner
- Department of Pediatrics, Divisions of Neonatology and
Allergy, Immunology, and Infectious Diseases, University of Texas Health San
Antonio, San Antonio, Texas
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12
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Khadem TM, Nguyen MH, Mellors JW, Bariola JR. Development of a Centralized Antimicrobial Stewardship Program Across a Diverse Health System and Early Antimicrobial Usage Trends. Open Forum Infect Dis 2022; 9:ofac168. [PMID: 35615296 PMCID: PMC9126488 DOI: 10.1093/ofid/ofac168] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/28/2022] [Indexed: 11/16/2022] Open
Abstract
Background Expanding antimicrobial stewardship to community hospitals is vital and now required by regulatory agencies. UPMC instituted the Centralized Health system Antimicrobial Stewardship Efforts (CHASE) Program to expand antimicrobial stewardship to all UPMC hospitals regardless of local resources. For hospitals with few local stewardship resources, we used a model integrating local non-Infectious Diseases (ID) trained pharmacists with centralized ID experts. Methods Thirteen hospitals were included. Eleven were classified as robust (4) or nonrobust (7) depending on local stewardship resources and fulfillment of Centers for Disease Control and Prevention core elements of hospital antimicrobial stewardship. In addition to general stewardship oversight at all UPMC hospitals, the centralized team interacted regularly with nonrobust hospitals for individual patient reviews and local projects. We compared inpatient antimicrobial usage rates at nonrobust versus robust hospitals and at 2 UPMC academic medical centers. Results The CHASE Program expanded in scope between 2018 and 2020. During this period, antimicrobial usage at these 13 hospitals decreased by 16% with a monthly change of −4.7 days of therapy (DOT)/1000 patient days (PD) (95% confidence interval [CI], −5.5 to −3.9; P < .0001). Monthly decrease at nonrobust hospitals was −3.3 DOT/1000 PD per month (−4.5 to −2.0, P < .0001), similar to rates of decline at both robust hospitals (−3.3 DOT/1000 PD) and academic medical centers (−4.8 DOT/1000 PD) (P = .167). Conclusions Coordinated antimicrobial stewardship can be implemented across a large and diverse health system. Our hybrid model incorporating a central team of experts with local community hospital pharmacists led to usage decreases over 3 years at a rate comparable to that seen in larger hospitals with more established stewardship programs.
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Affiliation(s)
- Tina M Khadem
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh PA USA
- UPMC Centralized Health system Antimicrobial Stewardship Efforts, Pittsburgh PA USA
| | - M Hong Nguyen
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh PA USA
| | - John W Mellors
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh PA USA
| | - J Ryan Bariola
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh PA USA
- UPMC Centralized Health system Antimicrobial Stewardship Efforts, Pittsburgh PA USA
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Andrzejewski C, McCreary EK, Khadem T, Abdel‐Massih RC, Bariola JR. Tele‐antimicrobial
stewardship programs: A review of the literature and the role of the pharmacist. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1489] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
| | - Erin K. McCreary
- Infectious Disease Connect, Incorporated Pittsburgh Pennsylvania USA
- Division of Infectious Diseases, Department of Medicine UPMC Pittsburgh Pennsylvania USA
- University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Tina Khadem
- Infectious Disease Connect, Incorporated Pittsburgh Pennsylvania USA
- Division of Infectious Diseases, Department of Medicine UPMC Pittsburgh Pennsylvania USA
- UPMC Community Hospital Antimicrobial Stewardship Efforts Pittsburgh Pennsylvania USA
| | - Rima C. Abdel‐Massih
- Infectious Disease Connect, Incorporated Pittsburgh Pennsylvania USA
- Division of Infectious Diseases, Department of Medicine UPMC Pittsburgh Pennsylvania USA
- University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - J. Ryan Bariola
- Infectious Disease Connect, Incorporated Pittsburgh Pennsylvania USA
- Division of Infectious Diseases, Department of Medicine UPMC Pittsburgh Pennsylvania USA
- UPMC Community Hospital Antimicrobial Stewardship Efforts Pittsburgh Pennsylvania USA
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14
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Opportunities and challenges in improving antimicrobial use during the era of telehealth expansion: A narrative review. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2021; 1:e26. [PMID: 36168461 PMCID: PMC9495641 DOI: 10.1017/ash.2021.191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/11/2021] [Indexed: 11/24/2022]
Abstract
Efforts to improve antimicrobial prescribing are occurring within a changing healthcare landscape, which includes the expanded use of telehealth technology. The wider adoption of telehealth presents both challenges and opportunities for promoting antimicrobial stewardship. Telehealth provides 2 avenues for remote infectious disease (ID) specialists to improve inpatient antimicrobial prescribing: telehealth-supported antimicrobial stewardship and tele-ID consultations. Those 2 activities can work separately or synergistically. Studies on telehealth-supported antimicrobial stewardship have reported a reduction in inpatient antimicrobial prescribing, cost savings related to less antimicrobial use, a decrease in Clostridioides difficile infections, and improved antimicrobial susceptibility patterns for common organisms. Tele-ID consultation is associated with fewer hospital transfers, a shorter length of hospital stay, and decreased mortality. The implementation of these activities can be flexible depending on local needs and available resources, but several barriers may be encountered. Opportunities also exist to improve antimicrobial use in outpatient settings. Telehealth provides a more rapid mechanism for conducting outpatient ID consultations, and increasing use of telehealth for routine and urgent outpatient visits present new challenges for antimicrobial stewardship. In primary care, urgent care, and emergency care settings, unnecessary antimicrobial use for viral acute respiratory tract infections is common during telehealth encounters, as is the case for fact-to-face encounters. For some diagnoses, such as otitis media and pharyngitis, antimicrobials are further overprescribed via telehealth. Evidence is still lacking on the optimal stewardship strategies to improve antimicrobial prescribing during telehealth encounters in ambulatory care, but conventional outpatient stewardship strategies are likely transferable. Further work is warranted to fill this knowledge gap.
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