Tele-antimicrobial stewardship programs change the game

ByJennifer Ross, PharmD, BCIDP

Fact checked byShenaz Bagha

The term “antimicrobial stewardship” was first described in 1996 by John E. McGowan Jr., MD, and Dale N. Gerding, MD.

Inspired by a Sunday homily about the “good steward,” McGowan and Gerding thought of antimicrobial stewardship as a causal association between antimicrobial use and the development of resistance. Today, antimicrobial stewardship can be found in many different settings, including hospitals and community clinics.

One Health antimicrobial stewardship collaboratives incorporate animal and environmental perspectives. A novel term not even 30 years ago, antimicrobial stewardship has evolved differently in diverse environments. Local interpretations of antimicrobial stewardship have shaped perceptions and assumptions, moving away from a technical definition of the right drug, dose and duration toward concepts centered on responsibilities and strategy.

In the late 1990s and 2000s, antimicrobial stewardship in health care was mostly seen in the narrow context of hospital programs, often at large academic medical centers. However, small hospitals (fewer than 200 beds) make up a significant proportion of hospitals across the U.S.

Antimicrobial use, Clostridioides difficile infection and drug-resistant bacteria rates in smaller hospitals have been shown to be similar when compared with larger institutions but are less likely to have formal antimicrobial stewardship programs (ASPs) that meet all of the CDC Core Elements. Adequate staffing, information technology and financial resources are frequent barriers to successful ASP implementation and sustainability at small hospitals.

Tele-antimicrobial stewardship programs (TASPs) are a method for smaller hospitals to meet regulatory requirements and optimize antimicrobial use.

Several TASP models have been described in the literature and many overlap in their strategies. Most include remote ID expert support, either with an ID physician and/or ID pharmacist, but may or may not include targeted involvement of tele-site pharmacists. Fully remote TASPs include an off-site ID specialist who conducts prospective audit with intervention and feedback on patient cases and interacts with on-site prescribers through various telehealth communication systems. In fully remote models, on-site pharmacist involvement is minimal. In contrast, integrated TASP models bring together remote ID specialists and on-site providers at least once weekly to review patients, with most of the day-to-day ASP activities being led by on-site pharmacists. A collaborative TASP focuses on building antimicrobial stewardship education and resources longitudinally with the on-site pharmacist leading all the daily ASP work.² Three T’s have emerged across all TASP models: team, technology and trust.

The team

All ASPs have a core team element. ID expertise is critical to successful antimicrobial stewardship. An added challenge that TASPs often face is a lack of on-site ID specialists or workflows for formal ID consultation. In 2017, Medicare data showed nearly 80% of counties in the United States did not have an ID provider.⁵ This correlates to an estimated 208 million people living in a county with low or no ID provider coverage.

A systematic review examined the effectiveness of telehealth and ID consultation in which comparable efficacy was seen to in-person consultation.Other outpatient settings for patients with hepatitis C virus, HIV, or tuberculosis have shown similar outcomes whether clinic visits were conducted in-person or via teleconference. The literature describing the optimal structure of TASPs is limited.

Pierce and Stevens performed a systematic review on tele-antimicrobial stewardship that included 12 studies. The majority were observational, and one was a randomized controlled trial. In 10 of 12 studies, TASPs consisted of a remote ID provider. Three of the 12 programs included a remote pharmacist. Across the studies, there was variation amongst TASPs with a local ASP team and those in which local providers communicated with the remote ASP team.

The suggested number of ID experts per hospital beds for ASPs ranges from one provider or pharmacist for every 100 to roughly 230 beds. To quote Andrzejewski and colleagues, “A TASP is a force multiplier, where one ID pharmacist and/or ID physician deliver care at multiple sites, allowing for optimal utilization of personnel resources.”

The technology

Technology resources and remote access to the local electronic health record are essential. Technological capabilities are often linked to TASP structure and sourcing of ID expertise, either being within a health system to support smaller hospitals or acquired from a non-affiliated private practice, hospital or private telehealth entity to provide contracted consultative services.² Communication modalities, clinical decision support systems, and antimicrobial use data analytics are technology considerations. Reliable technology — such as telephone or video conferencing — for frequent communication with TASP sites tends to be more effective than passive communication methods (for example, automatic alerts).

Various technologies and their impact on TASPs have not been well described in the literature. Clinical decision support systems tools may play a greater role in integrated and collaborative TASPs in which remote ID expert involvement is more limited. Integrating internal resources — like antibiogram data and guidelines — into antimicrobial orders offers additional support. An experience of a centralized TASP supporting 15 small hospitals — none with on-site ID consult — within the same health system leveraged robust technology to provide on-site providers and pharmacists access to stewardship resources. They assessed the effectiveness of implementing three different levels of support for the local ASPs. The most intensive level, which combined on-site and remote ID expertise with advanced antimicrobial stewardship education, daily prospective audit with intervention and feedback from an ID expert on select patients, frequent use of the telephone hotline and remote ID expert review of prioritized cultures resulted in an 11% reduction in total antimicrobial usage and 24% reduction in broad-spectrum antimicrobial usage. The less intense levels did not result in a decrease in antimicrobial use.

It is evident that a multipronged technological approach is needed for successful TASPs. A lot more is coming with technology and antimicrobial stewardship implications, including incorporation of artificial intelligence into routine patient care.

The trust

The people making up the TASP are the most important element. Establishing relationships and building trust with TASP sites were frequently cited among the published literature. Rapport grows through routine communication, ideally face-to-face. Periodic visits to local sites further acquaint key antimicrobial stewardship leaders with local clinicians.

Antimicrobial stewardship initiatives based on technology do not reach full potential without trust. Trust is hard to measure, takes time and is continuous. Tracking TASP intervention acceptance rates is one way to gauge trust. Reported TASP acceptance rates vary widely. Notably, the TASPs with the lowest acceptance rates tended to lack face-to-face communication.

TASP is not only a strategy to meet antimicrobial stewardship regulatory requirements and optimize antimicrobial use; it is a game changer. With a team, technology and trust, TASPs are here to stay.

References:

For more information:

Jennifer Ross, PharmD, BCIDP, is an infectious diseases clinical pharmacist at M Health Fairview – University of Minnesota Medical Center. Ross can be reached at jross13@fairview.org.

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Disclosures: Ross reports no relevant financial disclosures.

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