Differences in implementation at sites A and B

While following the same general approach, distinct features emerged at each site. Infection preventionists championed the VAST at site A, selecting cases to discuss, presenting the cases at the sessions, and incorporating most of recommendations into the EMR. At site B, a pharmacist served as the champion, selecting cases to review and entering relevant documentation into the EMR. The infectious diseases physicians working with site A reviewed cases prior to each session, whereas for site B, the infectious disease physician learned about the cases during the VAST session, reviewing the medical record after the meeting and adding the note placed by the pharmacist.

Additional differences pertained to engagement and education. Site A benefited from leadership support; the chief of staff, the chief of medicine, the associate director for patient care, and the chief of nursing demonstrated their support of the VAST by attending several sessions. Furthermore, approximately once each month, the infectious disease physicians working with site A prepared and gave brief didactic sessions (10–15 minutes) relevant to the cases discussed. At site B, there was limited support to provide frontline providers with administrative time to attend VAST sessions. While their VAST also had a strong educational component, the content was incorporated into notes for subsequent review by clinical providers.

Quantitative results

Over a 1-year period, the VAST at site A discussed 140 cases over 40 sessions for an average of 3.5 cases per session. Similarly, site B discussed 119 cases over 38 sessions, for an average of 3.1 cases per session. Most cases for site A came from the acute-care wards (70%); most cases at site B came from the long-term care ward (50%). Pneumonia and respiratory syndromes, including acute exacerbations of chronic obstructive pulmonary disease, accounted for ~40% of the cases from both intervention sites (Table 1). The acceptance rate for actionable recommendations made by the VASTs was >65% at both intervention sites (Table 2). The most common recommendation at both sites was to stop antibiotics, which had an 82% acceptance rate (54 of 66 recommendations) at site A and a 71% acceptance rate (32 of 45 recommendations) at site B.

Table 1

Location and Diagnoses of Cases Discussed at VAST Sessions

Note. VAST, videoconference antimicrobial stewardship team.

^a Site A includes patients from outpatient clinics (n=4) and 1 case each from urgent care and home-based primary care. Site B includes urgent care (n=17) and outpatient clinics (n=12).

^b Includes respiratory viral infections and acute exacerbations of chronic obstructive pulmonary disease.

^c Site A includes bacteriuria (n=3), 2 cases each of drug-fever, dysuria, heart-failure, hematuria, ruling out Lyme disease, and 1 case each of cirrhosis, irritable bowel syndrome, lymphedema, myelodysplastic syndrome, positive blood culture (contaminant) and venous insufficiency. Site B includes bacteriuria (n=7), cough or dyspnea (n=4), fatigue (n=2), and 1 case each of abdominal tenderness, asplenia, encephalopathy, gross hematuria, nocturia, and rheumatoid arthritis.

^d Site A includes abscesses (n=2) and 1 case each of acute cholecystitis and diverticulitis. Site B includes 1 case of diverticulitis.

^e Site A includes unspecified fever (n=3), candidal esophagitis and orchitis. Site B includes urethritis (n=2), fever, lung abscess, and prostatitis.

Table 2

Recommendations Made by the VAST and Accepted by Primary Team

Note. VAST, videoconference antimicrobial stewardship team.

^a Some patients received ≥1 recommendation.

^b Site A included change remove or do not place device (3 of 4, 75%) recommendations accepted), nursing intervention (2 of 3, 67%), transfer to a tertiary care facility (2 of 2, 100%), and establish with primary care (1 of 1; 100%). Site B included antibiotic allergy rechallenge (0 of 3, 0%) and do obtain a diagnostic test (0 of 1, 0%).

Site A had a greater number and variety of attendees than site B, with ~15 and 3 attendees per session, respectively (Table 3). This difference may reflect both the individual cultures at each intervention sites and differences in access to infectious disease expertise. Specifically, at site A, the VAST was the primary means to access infectious disease expertise, whereas site B had recently engaged a part-time infectious disease physician who was available to address more complex infectious disease problems commonly encountered in the inpatient setting.

Table 3

Roles of VAST Participants Who Attended at Least 1 Session During the 1-Year Study Period

Note. VAST, videoconference antimicrobial stewardship team.

^a During the latter part of the 1-year assessment period, the infectious diseases physician making rounds at site B adjusted his schedule to attend the VAST in person.

^b Medical resident (n=1), pharmacy residents (n=2), nurse practitioner students (n=2) and pharmacy students (n=3).

^c Dentist.

Qualitative results

From sites A and B, 19 of 41 (46%) and 5 of 5 (100%) VAST members, respectively, agreed to be interviewed. Most of the qualitative findings aligned with the 5 domains of the SIEPS 2.0 human factors model (Table 4). Practice change emerged as an inductive theme outside of the SEIPS domains.

Table 4

Illustrative Quotations Identified From the Semi-Structured Interviews, Presented in the Context of the SEIPS Framework

Note. SEIPS, Systems Engineering Initiative for Patient Safety; CLC, community living center, nursing home and long-term care units at Veterans Affairs medical centers; VAST, videoconference antimicrobial stewardship team; CPRS, computerized patient record system (the VA’s electronic medical record); MD, medical doctor.

Practice change

Participants reported that the VAST sessions increased their awareness of antibiotic stewardship principles, helping them to adapt their practice patterns and engage in antimicrobial stewardship efforts. They specifically mentioned feeling greater confidence in their ability to make more targeted antibiotic choices, to reduce the time patients were on antibiotics, and to utilize more effective methods whenever possible (ie, intravenous to oral conversions). They also highlighted the educational component, including the brief didactic sessions, and being able to apply what they learned from case presentations to other patients. Providers were eager to see whether the data on antibiotics use and hospitalizations would reflect their perception of the changes. In the context of barriers, participants reported that some providers were not open to recommendations to change to their treatment plans. They attributed this resistance to ego or to the idea that some providers are set in their ways and preferred to use their established practice patterns.

Both sites reported efforts to improve antimicrobial stewardship independent of the VAST, including auditing cases to identify areas for improvement in antibiotic stewardship. At site B, decision aid tools were developed to help providers identify appropriate testing for certain illnesses and symptoms to ensure best choices for antibiotic use were made when appropriate.

Tools and technology

The video component, which allowed face-to-face communication, facilitated the VAST. Participants reported that it enhanced their positive experience by supporting learning and communication, which in turn led to a better understanding of the recommendations. Video conferencing also facilitated discussion among participants, compared to traditional consults in which asynchronous communication between providers and specialists may be limited to reviewing content within the EMR. Furthermore, the team at the intervention site and the infectious disease physician accessed the same EMR, which participants felt also advanced learning, development of recommendations, and treatment steps. Barriers reported by some participants included having to learn to operate the technology associated with running the videoconference system and, occasionally, technical difficulties such as audio interference.

Organizational environment

Engagement differed by site and by the participants’ roles. At site A, participants were highly engaged and attended VAST sessions whether or not they had a case to present. At site B, however, while the pharmacist and infection preventionists remained strongly engaged, providers rarely attended sessions.

At site A, nurses mentioned barriers to participation, although several regularly participated in the VAST. The nurses interviewed indicate that they learned a lot about antimicrobial stewardship by attending the VAST sessions. They also shared that they could not readily apply that knowledge clinically due to the culture of their work setting and the relationship between nursing staff and the providers making treatment decisions for patients.

At site A, the organizational culture and approach to patient care sometimes differed between acute-care and long-term care settings. Providers reported gaining more confidence in communicating their plans of care for patients transferring from one setting to another leading to more closely aligned patient care. One provider reported less antibiotic use in patients transferred from acute-care to long-term care.

Participant responses

At site A, the interviews highlighted efforts by the local champions to encourage participation in VAST. Respondents also reported that the infectious disease physician made them feel welcome, prompted questions, and encouraged them to give their opinions. Participants emphasized that they were never made to feel that they did something wrong or made a bad choice, which made them feel more comfortable about presenting cases and discussing how to improve antimicrobial stewardship. Site B respondents also reported being encouraged to participate by the specialist when they were asked questions and to contribute to case discussion even if they were unsure.

Participants reported valuing the multidisciplinary input they received from VAST participants and indicated more willingness to ask for assistance from the infectious disease physician or from their local colleagues. Specifically, they identified their local infection preventionists as a resource. Furthermore, they noted that the VAST sessions built the rapport with the off-site infectious disease physician. Site A participants discussed an increase in communication among medical providers (ie, peer-to-peer) and between providers and professionals from other disciplines (ie, pharmacists, infection preventionists and infectious diseases physicians). Notably, site A providers reported learning that their facility’s pharmacists are a knowledgeable resource for antibiotic selection and use.

Tasks

The infection preventionists at both sites helped identify appropriate cases for discussion at the VAST sessions, notifying providers of the intent to discuss one of their patients. At site A, the infection preventionists entered consults, reviewed and presented cases during the VAST session, and recorded recommendations into the patient’s EMR. At site A, some providers identified and either presented their own cases or supplemented the presentations made by the infection preventionists. While providers from site A reported no increase in workload burden from VAST participation, the infection preventionists commented that they typically dedicated 8 hours each week to VAST activities.

At both sites, participants reported enjoying the VAST sessions and attended when it did not interfere with patient care. Despite limited time and availability site A participants reported prioritizing VAST sessions because they were interested and felt the program helped them provide better patient care. Many participants mentioned enjoyed meeting each week because it provided routine feedback on antimicrobial stewardship, allowed for follow-up on challenging cases, enhanced learning, and improved treatment.

Scheduling issues, such as rotating work weeks and conflicting times with grand rounds or other duties, were barriers to participation. VAST sessions were held in the middle of the day, typically at noon. Providers reported feeling pressure to discharge patients who needed to move to a different level of care and to address other pressing patient care issues. Some participants mitigated these barriers by arranging cross coverage or by communicating information from the session to individuals who were not able to attend. At site A, the initial VAST sessions were on Friday afternoons, a time that made attendance difficult for several interviewees. After several weeks, the VAST for site A moved to Wednesdays, which was better but also overlapped with grand rounds once a month.

Physical environment

The physical space available for VAST sessions was a concern for participants. Initially, the setting for site A was small, hot, and noisy. The meeting was moved to a larger room with a more comfortable temperature and less ambient noise. Participants at both sites reported occasional issues with not having rooms available for the VAST session. The distance from providers’ work area and the meeting room was a barrier for some due to the large campus size. Site B overcame this barrier by allowing providers to call in from their location.