Infectious disease specialist telephone consultations requested by general practitioners

Time is running out. No excuses to delay implementation of antimicrobial stewardship programmes: impact, sustainability, resilience and efficiency through an interrupted time series analysis (2017-2022)

Introduction

The WHO declared antimicrobial resistance (AMR) a significant concern in 2014, sparking initiatives to ensure responsible antibiotic use. In human medicine, Antimicrobial Stewardship Programmes (ASPs) in hospitals play a pivotal role in combating AMR. Although evidence supports the effectiveness of ASPs in optimizing antimicrobial use, often the lack of resources becomes an excuse to limit their dissemination and use. This paper provides a comprehensive report on a 6-year analysis of an ASP implemented in a healthcare region in north-east Italy.

Methods

A retrospective data collection was conducted to assess the programme's impact on antibiotic consumption expressed as DDDs/100 patient-days, its sustainability over time, resilience during the COVID-19 pandemic and the efficiency of the ASP (relationship between workload and human resources).

Results

A substantial overall reduction in antibiotic consumption (-14%), particularly in fluoroquinolones (-64%) and carbapenems (-68%), was demonstrated, showcasing the programme's impact. Sustainability was confirmed through enduring trends in antibiotic consumption and ecological analysis over time. The ASP demonstrates resilience by maintaining positive trends even amid the challenging COVID-19 pandemic. Efficiency was underscored by an increase in on-site consultations despite consistent human resources until 2021.

Conclusions

This study offers insights into the prolonged success of a resource-efficient ASP, emphasizing the crucial role of long-term commitment in fostering responsible antibiotic use in the context of global health challenges such as AMR.

Infectious disease hotlines to provide advice to general practitioners: a prospective study

BACKGROUND

Telephone hotlines in infectious diseases (ID) are part of antimicrobial stewardship programs designed to provide support and expertise in ID and to control antibiotic resistance. The aim of the study was to characterize the activity of the ID hotlines and estimate their usefulness for general practitioners (GPs).

METHODS

This was a multicenter prospective observational study in different French regions. ID teams involved in antimicrobial stewardship with a hotline for GPs were asked to record their advice from April 2019 to June 2022. In these regions, all GPs were informed of the ID hotline's operating procedures. The main outcome was usage rate of the hotlines by GPs.

RESULTS

Ten volunteer ID teams collected 4138 requests for advice from 2171 GPs. The proportion of GPs using the hotline varied pronouncedly by region, from 54% in the Isere department, to less than 1% in departments with the lowest usage. These differences were associated with the number of physicians in ID teams and with the age of the hotline. These results highlighted the value of working time as a means of ensuring the permanence of expertise. The main reasons for calling were: a diagnostic question (44%); choice of antibiotic (31%). The ID specialist provided advice on antibiotic therapy (43%) or a proposal for specialized consultation or hospitalization (11%).

CONCLUSIONS

ID hotlines could help to strengthen cooperation between primary care and hospital medicine. However, the deployment and perpetuation of this activity require reflection concerning its institutional and financial support.

Characteristics and Outcomes of Physician-to-Physician Telephone Consultation Programs: Environmental Scan

BACKGROUND

Telephone consultations between physicians provide quick access to medical advice, allowing patients to be cared for by calling physicians in their local settings.

OBJECTIVE

As part of a quality assurance study of a physician-to-physician consultation program in Alberta, Canada, this environmental scan aims to identify the characteristics and outcomes of physician-to-physician telephone consultation programs across several countries.

METHODS

We searched 7 databases to identify English publications in 2007-2017 describing physician-to-physician consultations using telephones as the main technology. To identify Canadian programs, the literature search was supplemented with an additional internet search.

RESULTS

The literature search yielded 2336 citations, of which 17 publications were included. Across 7 countries, 14 telephone consultation programs provided primary care providers with access to various specialists through hotlines, paging systems, or call centers. The programs reported on the avoidance of hospitalizations, emergency department visits and specialty visits, caller satisfaction with the telephone consultation, and cost avoidance.

CONCLUSIONS

Telephone consultation programs between health care providers have facilitated access to specialist care and prevented acute care use. .

Telephone consultations with otolaryngology - head and neck surgery reduced emergency visits and specialty consultations in northern Alberta

Background

RAAPID (Referral, Access, Advice, Placement, Information, and Destination) is a 24-h call center in Alberta, Canada, facilitating urgent telephone consultations between physicians and specialists. We evaluated the extent to which RAAPID calls to Otolaryngology-Head and Neck Surgery (OHNS) reduced visits to the emergency department and specialty clinics.

Methods

This was a cross-sectional study evaluating all telephone consultations to OHNS from physicians in northern Alberta between 2013 and 2014 (T1) (where consultations by residents occurred) and 2015 to 2017 (T2) (where consultations were done by consultants during office hours and residents during after hours). Outcomes of the calls included medical advice, specialty clinic referrals, and emergency department (ED) referrals. Differences in the reduction of ED visits and costs, overall as well as in T1 and T2, were assessed using multivariate logistic regression.

Results

Overall, 62.3% (1064/1709) of telephone consultations reduced ED visits consisting of advice being provided (n = 884; 83.1%) and referral to specialty clinics (n = 180; 16.9%). The adjusted odds ratio of calls reducing emergency visits in T2 as compared to T1 was 2.47 (95% CI 1.99 to 3.08). The adjusted odds ratio of reducing ED visits during office hours compared to after-hours 2.54 (95% CI 1.77–3.64). The estimated direct costs avoided from ED visits in T1 and T2 were $42,224.22 and $114,393.86, respectively.

Conclusion

RAAPID telephone consultations to OHNS were effective in reducing ED visits and healthcare costs. This model should be considered in other areas to improve efficiencies within the health system.

Fast track consultation in the infectious diseases department of a French university hospital: evaluation of the service delivered to the general practitioner

PURPOSE

Since 2010, the Infectious Diseases (ID) department of the Nice university hospital (France) has implemented a fast track consultation (FTC): it allows General Practitioners (GP) to directly reach an ID specialist through a dedicated phone number for initial advice. Depending on the first observation, a formal consultation can be planned within 48 h. Our aim was to evaluate in a pilot study, the contribution of the FTC regarding the management of patients 28 days after the first phone contact.

METHODS

This prospective current care study was conducted between November 2014 and January 2015 in our ID department. The GP indicates the most likely diagnosis, the therapeutic strategy and the patient's management he would have applied. After the formal consultation, ID specialist provides his diagnosis, therapeutic strategy and patient's management. An adjudicative committee has evaluated the benefit of the FTC after 28 days of follow-up.

RESULTS

Fifty-one patients referred by 49 GP were included. ID specialists modified the diagnosis in 22 (43%) patients, antibiotic treatment in 35 (68%) and treatment plan in 30 patients (59%). FTC provided at least one service for 41/51 patients (94%): antibiotic treatment was reassessed for 11 (22%) patients, averted for 9 (18%) patients, unnecessary hospitalization was avoided for 8 (16%) of them and emergency room visit averted for 5 (10%) patients.

CONCLUSIONS

FTC can provide significant improvement in the management of the patients in terms of decrease in unnecessary hospitalization, emergency room visit averted and appropriate use of antibiotics.

Infectious diseases consultations at an Australian tertiary hospital: a review of 11,511 inpatient consultations

BACKGROUND

Infectious diseases (ID) clinicians provide an important service within tertiary hospitals. However, as a largely consultation-based service, their value can be difficult to evaluate.

AIMS

A review of 13.5 years of consultations was undertaken to define the scope of the service and any changes over time.

METHODS

ID consultations at the Princess Alexandra Hospital are tracked on a database, recording information including the requesting team, indication for and outcome of the consult. Incident formal inpatient consultations between July 1999 and December 2012 were reviewed retrospectively. Phone consultations, repeat consultations and ID admissions were excluded.

RESULTS

Eleven thousand five hundred and eleven consultations were identified, with annual consultations increasing significantly during this period. Overall, formal consultations were performed on 1.3% of admissions. Consultations were most commonly requested by orthopaedics (14.3%) and general medicine (11.4%). The two most common syndromes triggering a consult were bloodstream infection (13.9%) and complicated soft tissue infection (7.8%). The final diagnosis was most frequently osteomyelitis (7.9%). Staphylococcus aureus (19.4%) and Pseudomonas aeruginosa (8.3%) were the most commonly identified pathogens.

CONCLUSION

The demand for ID consultations has increased over time and there are likely to be many drivers of this increase. Information derived from this audit can enhance the ID service by guiding service delivery, trainee education and informing funding or accreditation applications.

Spectrum of advice and curbside consultations of infectious diseases specialists

OBJECTIVES

Curbside consultation (CC) of infectious diseases specialists for advice is very frequent but the corresponding workload has rarely been assessed. This activity is mostly oral (phone or direct contact) and poorly quantifiable because it is not charged. We had for aim to evaluate this activity in a French teaching hospital.

METHODS

We recorded all CCs given during a 2.5-year period, from mid-2011 to the end of 2013.

RESULTS

During the study period, 6789 CCs were recorded (2715 per year), or slightly more than 10 per day. These CCs were divided in 676 travel recommendations and 6113 for other reasons. They were mostly given by phone (77.4%). Most demands came from our hospital (61.4%), followed by community family physicians and specialist (27.1%), other local hospitals (6.5%) and clinics (4.3%). All the departments in our hospital consulted us for advice at least once and answers were mainly given by phone (70.1%) and at bedside (30.5%). The answers were principally advice (50.8%), modification of antibiotic prescription (22.9%), initiation of antibiotic course (14.8%), maintaining the same treatment (6.2%), and stopping antibiotics (4.3%). CCs accounted for 20% of clinical work for 1 physician. If the CCs in our hospital had been paid, our department would have received an additional 77,000€ in revenue.

CONCLUSION

This curbside activity is very important and time-consuming for infectious diseases specialists, but it is currently not acknowledged or rewarded.

Professional networks and EBM use: a study of inter-physician interaction across levels of care

Physicians around the globe are increasingly encouraged to adopt guidelines, protocols and other scientific material when making clinical decisions. Extant research suggests that the clinicians' propensity to use evidence-based medicine (EBM) is strongly associated with the professional collaborative networks they establish and maintain with peers. In this paper we explore whether and how the connectedness of primary care physicians with colleagues working in hospital settings is related to their frequency of EBM use in clinical practice. We used survey data from 104 pediatricians working in five local health authorities in the Italian NHS. Social network and attributional data concerning single physicians, as well as their self-reported frequency of EBM use, were collected for three major pathologies in pediatric care: asthmatic, gastro-enteric and urinary pathologies. Ordered regression analysis was employed. Our findings documented a positive association between the number of physicians' relationships with hospital colleagues and the frequency of use EBM. Results also indicated that physicians' organizational affiliations influence the frequency of EBM use. Finally, contrary to our expectations, it was found that clinicians' affiliation to formal collaborative arrangements is at odds with the likelihood of reporting higher frequency of EBM use.

Informal consultation at a teaching hospital infectious diseases department

INTRODUCTION

Informal consultations for advice in the infectious diseases department (IDD) induce a significant workload for physicians. Our aim was to retrospectively quantify and describe this activity in our institution.

METHOD

The data was obtained from files documented and faxed by physicians from October 2009 to May 2012. One thousand nine hundred and seventy-two files were included. The file was faxed to the IDD specialist, analyzed, then a telephone conversation allowed making precisions, and the documented form was faxed back.

RESULTS

The requests for advice concerned 39% of female and 61% of male patients with a mean age of 64±21 years. Twenty-nine percent of requests came from surgical departments and 71% from medical departments (P<0.01). The departments most frequently concerned were cardiology (10%), gastro-enterology (10%) and cardiovascular surgery (9.7%). The most frequent infections were urogenital (19%), osteoarticular (14%), and cardiovascular (11%). Forty-nine percent were considered as nosocomial and 25.3% were bacteremic. The requests concerned diagnostic aid in 16.2% of cases and therapeutic issues in 95.6%. The IDD specialist made therapeutic recommendation in 96.5% of cases and gave diagnostic advice in 43.7%. Treatment modification was suggested in 38.5% of cases. Twenty-two percent of consultations required a second one.

CONCLUSION

This study documented the importance of antibiotic changes among medical and surgical units, the increasing need of these units to be helped, and also the complexity of the medical cases, all requiring the advice of an ID specialist. Our fax-phone-fax procedure seems to prevent the bias associated with informal consultations by phone, which is the most commonly used in other institutions.

A national network of infectious diseases experts

OBJECTIVES

The aim of this study was to consider the implementation of a network of infectious diseases (ID) experts to optimize the antibiotic prescriptions of community and hospital practitioners.

METHODS

An observational prospective study was conducted among ID experts in the Pays-de-la-Loire Region to evaluate the number of calls and to determine the practitioner's reasons for soliciting ID expertise. For each phone consultation, four criteria were recorded during 5 days: origin of the call (internal/external), kind of question (diagnostic/therapeutic) time spent for the advice provided, type of advice.

RESULTS

A total of 386 phone consultations for 20 infectious disease specialists were recorded during the study period (5 days); 81% were internal to the hospital, 7.7% from another hospital, and 11.3% from private practice, 56.3% of the questions concerned a therapeutic strategy, 21% a diagnostic advice, and 22.6% concerned both diagnosis and therapy. Two third of the questions were answered within 10minutes. In 68.7% of cases, the ID specialist answered immediately, 19.8% of calls required following-up the patient, 6% led to refer the patient to an ID consultation, and 5.5% to hospitalization.

CONCLUSION

The survey results stress the important need for such ID expertise, both in hospitals and in ambulatory medicine. Collaboration of ID specialists in a regional network would allow an easy and permanent access to antibiotic therapy advice for prescribers. This network would improve the quality and safety of care.

Telephone consultation cannot replace bedside infectious disease consultation in the management of Staphylococcus aureus Bacteremia

BACKGROUND

Infectious disease specialist (IDS) consultation improves the outcome of Staphylococcus aureus bacteremia (SAB). Although telephone consultations constitute a substantial part of IDS consultations, their impact on treatment outcome lacks evaluation.

METHODS

We retrospectively followed 342 SAB episodes with 90-day follow-up, excluding 5 methicillin-resistant S. aureus SAB cases. Patients were grouped according to bedside, telephone, or no IDS consultation within the first week. Patients with fatal outcome within 3 days after onset of SAB were excluded to allow for the possibility of death occurring before IDS consultation.

RESULTS

Seventy-two percent of patients received bedside, 18% telephone, and 10% no IDS consultation. Patients with bedside consultation were less often treated in an intensive care unit during the first 3 days compared to those with telephone consultation (odds ratio [OR], 0.53; 95% confidence interval [CI], .29-.97; P = .037; 21% vs 34%), with no other initial differences between these groups. Patients with bedside consultation more often had deep infection foci localized as compared to patients with telephone consultation (OR, 3.11; 95% CI, 1.74-5.57; P < .0001; 78% vs 53%). Patients with bedside consultation had lower mortality than patients with telephone consultation at 7 days (OR, 0.09; 95% CI, .02-.49; P = .001; 1% vs 8%), at 28 days (OR, 0.27; 95% CI, .11-.65; P = .002; 5% vs 16%) and at 90 days (OR, 0.25; 95% CI, .13-.51; P < .0001; 9% vs 29%). Considering all prognostic markers, 90-day mortality for telephone-consultation patients was higher (OR, 2.31; CI, 95% 1.22-4.38; P = .01) as compared to bedside consultation.

CONCLUSIONS

Telephone IDS consultation is inferior to bedside IDS consultation.