Telehealth has transformed healthcare delivery, including the care of patients with infectious diseases. It can support antimicrobial stewardship efforts and regulatory compliance. Here, three infectious diseases pharmacists weigh in on the topic and identify several things to know about tele-antimicrobial stewardship programs.
Authored By: Christina Andrzejewski, PharmD, BCPS, BCIDPa, Erin K. McCreary, PharmD, BCPS, BCIDPa,b,c, & Tina Khadem, PharmD, BCPSa,b,c
aInfectious Disease Connect, Incorporated, Pittsburgh, PA, USA
bDivision of Infectious Diseases, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
cUniversity of Pittsburgh School of Medicine, Pittsburgh, PA, USA
Article Posted: 3 May 2021
1. What is a tele-antimicrobial stewardship program (TASP) and why are we doing this?
Many small community and rural hospitals do not have Infectious Diseases (ID) physicians or an ID clinical pharmacist on-site.1, 2 Several factors contribute to this shortage of specialists, including the fact that available post-graduate year-2 (PGY-2) ID pharmacy residencies do not meet demand.3 Not only is there a shortage of ID-trained specialists, but it has also become increasingly challenging for smaller hospitals to obtain funding for full time ID specialist positions. Clinical pharmacists without ID training are often tasked with the responsibility to meet regulatory requirements related to antimicrobial stewardship, but without the necessary tools and resources. Meanwhile, antimicrobial overuse and rates of multidrug-resistant pathogens are continuing to grow, with rates in the community equal to or greater than those at academic centers.4
Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) guidelines on Antimicrobial Stewardship Programs (ASPs) stress the importance of ID pharmacist and physician co-leaders,5 with participation via telehealth highlighted as an acceptable alternative to in-person expertise.6
A tele-antimicrobial stewardship program (TASP) is a force multiplier, aiming to solve this problem. With a TASP, one ID pharmacist and/or an ID physician may provide care at multiple sites, allowing for optimal utilization of personnel resources, providing education, and mentoring on-site pharmacists who have not received training and may not be comfortable in this specialty area. Additionally, TASPs expand access to specialty ID care to all geographic areas, including vulnerable and underserved populations.
2. How does a tele-antimicrobial stewardship program work?
Several TASP models have been described in the literature previously, such as those formed by Intermountain Healthcare,7, 8 the University of Washington Tele-Antimicrobial Stewardship Program (UW-TASP/ECHO),9 and the Veterans Affairs medical centers (VAMC).10, 11 We have attempted to classify programs who have developed a telehealth-based solution for antimicrobial stewardship into three overall buckets. Of note, antimicrobial stewardship strategies may overlap within these general categories. In addition, many of these models offer a regional network framework which can be leveraged to increase the amount of robust data for analysis and report on meaningful clinical outcomes.
Bucket #1: Fully Remote TASPs
Fully remote TASPs may include an off-site ID specialist conducting preauthorization of antimicrobial agents and/or prospective audit with intervention and feedback on individual patient cases at the local site. Telehealth technology described in these TASPs include a secure web application,12 telephone hotline,13 shared electronic health record14, 15 or shared clinical decision support software tool.16 In a fully remote TASP model, the remote ID specialist interacts directly with on-site prescribers through these various telehealth delivery systems.
Bucket #2: Integrated TASP Models
Integrated TASP models typically include secure video or teleconference technology to connect remote ID specialists and on-site clinicians to collaborate at least weekly to review patient information. These models provide more hands-on, individual case-based discussions and evidence-based education to support day-to-day workflow and antimicrobial stewardship recommendations.7-11, 17-22 In an integrated TASP model, the remote ID expert can communicate stewardship recommendations in two ways. First, the recommendation can be discussed with the on-site pharmacist(s) via a secure chat, stewardship electronic clinical-decision support tool, or video or teleconference. That pharmacist(s) then contacts local prescribers to make the recommendation on antimicrobial therapy. Alternatively, the remote ID expert may communicate recommendations directly to local prescribers, sharing some of the workload with the local pharmacist(s). The remote specialist team also provides local stewardship education and assistance with antimicrobial usage data, reporting, and tracking for local sites.
Bucket #3: Collaborative TASP models
Collaborative TASP models focus efforts on knowledge deficiencies and provide on-site clinicians with evidence-based antimicrobial stewardship education and tools, recommendations for customized strategies for action, tracking and reporting of progress based on a gap analysis, antimicrobial usage data with or without analysis, and/or consultations with ID experts as needed.23, 24 In contrast to the integrated TASP models, day-to-day synchronous support for stewardship interventions on individual patient case reviews is not usually provided. In a collaborative TASP model, the on-site team of mostly pharmacists identify patient intervention opportunities independently and contact local prescribers to make recommendations on antimicrobial therapy.
3. How often does a tele-antimicrobial stewardship program work?
Antimicrobial stewardship strategies and interventions have the greatest impact on antimicrobial use and patient outcomes when they are consistent, whether that be via prospective audit with intervention and feedback or antimicrobial restriction upfront with preauthorization.5 TASPs can dedicate resources 5-7 days per week or less depending on the size of the hospital, personnel available, and goals of the program.
Leaves of absence or extended periods of time off by team members should also be accounted for to prevent gaps in coverage of the service. The mentorship interactions between the remote and on-site teams can be as frequent as daily, weekly, or monthly.
4. Who is involved in a tele-antimicrobial stewardship program?
Similar to traditional ASP models, TASPs are typically co-led by an ID physician and ID pharmacist, but collaboration with a multidisciplinary team is critical for success. TASPs may include remote and local clinical pharmacists, physicians, infection preventionists, nurses, administrators, case managers, and care coordinators. The scope of the interaction between remote ID experts and on-site team members is often dependent on the type of TASP model.
Within the various models, TASP members can come from different institutions. An integrated TASP model can be built by central and local representatives within one health system, or ID-trained specialists from one health system can collaborate with local clinicians at another hospital or system. For standalone hospitals who do not have resources within a network, partnering with a TASP that is a consultative network or a private telehealth entity or telemedicine company could be pursued.
The on-site stewardship champion(s) is arguably the important factor in the success of a TASP. It’s important to remember that remote ID expertise does not simply replace the need to establish trusting relationships with key stakeholders and clinicians at local sites. Pharmacists are essential to building and sustaining local ASPs, and they can be mentored and supported by the remote team to build confidence, continue education, and successfully perform various stewardship activities regardless of formal residency training.
5. Where are tele-antimicrobial stewardship programs?
Many types of TASPs have been described all over the US, as well as internationally, as the problem of antimicrobial overuse and constrained resources to tackle this problem is global. With a TASP, clinicians in one country can easily collaborate with providers all over the world to improve patient care.
We have only begun to scratch the surface with exploring creative solutions to expand antimicrobial stewardship and ID expertise via telehealth. Most TASPs that have been described focus on the inpatient acute care setting, but there is tremendous opportunity to expand stewardship efforts into outpatient settings, long-term care facilities, and more.
The value of telemedicine has been demonstrated in the provider-patient and consultative space25 and is now rapidly expanding to include other services such as tele-antimicrobial stewardship. While the concept and adoption of TASPs is relatively new, the foundation exists via several publications describing some form of a telehealth-based solution to overcome the problem of antimicrobial overuse.
Importantly, TASPs face the same barriers that traditional ASPs face, and the solutions can look the same or different. For example, an effective ASP strategy of “handshake stewardship”26 may need to be creatively modified for TASPs so teams can get “face time” virtually.
The future is bright for TASPs as they are more readily adopted and new strategies and outcome metrics are explored. Targets for future TASP research should include efforts in critical access hospitals and non-acute settings, the specific role of integrating the use of clinical decision support software tools to streamline and enhance daily workflows and further descriptions of collaborative or integrated telehealth models that improve patient-centered outcomes.
ABOUT THE AUTHORS
Christina Andrzejewski, PharmD, BCPS, BCIDP
Christina Andrzejewski, PharmD, BCPS, BCIDP is a Clinical Intelligence Specialist for Infectious Disease Connect, Inc. Prior to joining the ID Connect team in 2020, she worked as an Infectious Diseases Clinical Pharmacist and Antimicrobial Stewardship Program co-director for UPMC Mercy (Pittsburgh, PA), where she served as preceptor and educator for students, residents, and pharmacists. She received her PharmD from Duquesne University Mylan School of Pharmacy (Pittsburgh, PA) in 2008 and completed her PGY1 Pharmacy Practice residency and subsequent Infectious Diseases training at UPMC Mercy.
Areas of interest include antimicrobial stewardship, the expansion of tele-antimicrobial stewardship, clinical pharmacy practice, and HIV pharmacotherapy.
You can find her on Twitter @ChristinaAndrz1
Erin McCreary, PharmD, BCPS, BCIDP is a Clinical Assistant Professor within the University of Pittsburgh Department of Medicine, Division of Infectious Diseases (ID), an ID pharmacist at UPMC, and the Director of Stewardship Innovation for ID Connect. Prior to joining the UPMC team, she worked as an adult and pediatric infectious diseases pharmacist and served as the Education and Development Coordinator for the University of Wisconsin (UW) Health, where she oversaw the training and professional growth of students, residents, and pharmacists. She received her PharmD from the Auburn University Harrison School of Pharmacy (War Eagle!) and completed her PGY1 Pharmacy and PGY2 Infectious Diseases residencies at UW Health.
Dr. McCreary chairs the UPMC System COVID-19 Therapeutics Committee and serves as a co-investigator for the REMAP-CAP trial, a global, adaptive, clinical trial evaluating multiple therapies for COVID-19. She has published numerous peer-reviewed manuscripts in the areas of antimicrobial stewardship and infectious diseases. She also serves on the Society of Infectious Diseases Pharmacists (SIDP) Executive Board and as a member of the ASM Microbe Planning Committee. She is a host of Breakpoints, the SIDP Podcast.
Her practice interests include infectious diseases and antimicrobial stewardship in immunocompromised hosts, antimicrobial resistance and combination therapies, antimicrobial pharmacokinetic/pharmacodynamic optimization, and convincing people to get vaccinated. She is also passionate about professional leadership, mentorship, and preceptorship.
You can find her on Twitter @erinmccreary
Tina Khadem, PharmD, BCPS
Tina Khadem, PharmD, BCPS is a Clinical Assistant Professor at the University of Pittsburgh Department of Medicine, Division of Infectious Diseases. She also serves as the co-director of the Community Hospital Antimicrobial Stewardship Efforts (CHASE) Program at UPMC and the Antimicrobial Stewardship Telehealth Program at Infectious Disease Connect with Dr. Ryan Bariola, MD.
She received her Doctor of Pharmacy Degree from the University of Pittsburgh School of Pharmacy in 2010. Subsequently, she completed a PGY1 Pharmacy Practice residency at the Portland VA Medical Center in Portland OR and a PGY2 Infectious Diseases pharmacy residency at the University of Rochester Medical Center in Rochester NY. In 2014, she completed a research fellowship in outcomes research and epidemiology at St. John Fisher College in Rochester NY. Upon completion of her post-graduate training, she served as an Infectious Diseases Clinical Pharmacy Specialist at Highland Hospital and Strong Memorial Hospital in Rochester NY until 2017 when she accepted current position with UPMC.
Areas of interest include implementing and developing antimicrobial stewardship best practices in acute care settings using data-driven interventions, particularly in community hospitals with limited local antimicrobial stewardship resources and expertise.
You can find her on Twitter @TinaKhadem
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