1030 — Using remote Infectious Disease physician expertise to support inpatient antibiotic stewardship activities at three VA medical centers

Lead/Presenter: Daniel Livorsi,  COIN - Iowa City
All Authors: Livorsi DJ (Center for Access and Delivery Research and Evaluation, Iowa City, IA), Hockett Sherlock S (University of Iowa, Iowa City, IA) Goedken CC (Center for Access and Delivery Research and Evaluation, Iowa City, IA) Clarke KC (Carl Vinson VA Medical Center, Dublin, GA) Goodman DA (Bath VA Medical Center, Bath, NY) Pratt S (John J Pershing VA Medical Center, Poplar Bluff, MO) Cho H (University of Iowa, Iowa City, IA) Reisinger HS (Center for Access and Delivery Research and Evaluation, Iowa City, IA) Perencevich EN (Center for Access and Delivery Research and Evaluation, Iowa City, IA)

Objectives:
Using telehealth, remote Infectious Disease (ID) physicians can provide support for antibiotic stewardship activities. We assessed the implementation and effectiveness of telehealth-supported prospective-audit-and-feedback (tele-PAF) across 3 Veterans Administration medical centers (VAMC).

Methods:
All 3 participating VAMCs lacked ID support for stewardship at baseline. During 2021, an ID physician met virtually 3 times/week with the stewardship pharmacist at each participating VAMC to perform tele-PAF. This involved reviewing patients on antibiotics in acute-care (mean census 3 per site) and nursing-homes (NHs; mean census 71 per site), then providing real-time feedback on antibiotic use to clinicians. The RE-AIM framework was used to evaluate the program. The primary outcome of effectiveness was monthly antibiotic days of therapy (DOT) per 1,000 days-present aggregated across all sites; the secondary outcome was days of antibiotic spectrum coverage (DASC) per 1,000 days-present. An interrupted time-series analysis was performed to asses these outcomes during the 1-year intervention period (2021) versus the 2-year baseline period (2019-2020). Additional clinical outcomes were gathered from the Strategic Analytics for Improvement and Learning (SAIL) dashboard. Semi-structured interviews with 20 clinicians and pharmacists were conducted to assess implementation.

Results:
Reach: Feedback was provided to nearly all inpatient clinicians (n = 23) across the 3 sites. The frequency at which recommendations were accepted varied across sites (site 1: 78%; site 2: 81%; site 3: 60%). Effectiveness: After the start of tele-PAF, antibiotic DOT and DASC immediately decreased in acute-care (-20%, p = 0.01; -22%, p < 0.01) and NHs (-28%, p = 0.03; -37%, p < 0.01). Both metrics began to rise again in acute-care (DOT: +2.7%/month, p = 0.02; DASC: +3.0%/month, p = 0.02) but remained stable in NHs (DOT: 1.0% decrease/month, p = 0.71; DASC: 0.1% decrease/month, p = 0.82). Adjusted length of stay and 30-day readmission rates were stable or declined at each site during the intervention period. Adoption: All 3 invited sites agreed to participate. All sites requested that tele-PAF be performed in both their acute-care and NH units. Implementation: Audits were consistently done three times per week; feedback was at times tailored to the specific clinician, as some clinicians were more open to applying stewardship principles while others were not (fidelity). Clinicians generally appreciated the feedback and sometimes pro-actively sought out advice from the tele-PAF team, but developing rapport was difficult with a few clinicians (acceptability). Clinicians and pharmacists found the tele-PAF process to be compatible with their workflow (appropriateness). The remote ID physician devoted an average of 3.9 hours per week to tele-PAF (cost). The mean pharmacist time commitment per week varied by site (site 1: 3.4 hours; site 2: 2.6 hours; site 3: 1.5 hours). Maintenance: After the program ended, 2 sites sought continued remote ID support through a separate funded research grant. None of the sites have established a formal contractual relationship with a remote ID physician.

Implications:
The implementation of tele-PAF was associated with sustained reductions in antibiotic use across 3 NHs but not in the studied small acute-care units. Overall, clinicians perceived the intervention as acceptable and appropriate.

Impacts:
Telehealth is an effective tool for sharing ID physician expertise to advance antibiotic stewardship. Wider implementation of telehealth-supported stewardship activities may achieve reductions in antibiotic use.