Dissemination and Implementation of a Videoconference Antimicrobial Stewardship Team (VAST)

背景：抗菌药物管理指南要求对感染性疾病进行多学科研究 (ID)医师和经过身份证培训的临床药师为核心成员。很不幸，没有足够的身份证- 经过培训的专家在整个弗吉尼亚州的现场抗菌管理计划中工作。 意义：这项建议对退伍军人和退伍军人事务部的目标具有重要意义。退伍军人经历了许多 与抗生素耐药性和卫生保健相关感染的发展相关的风险因素。 2019年新型冠状病毒病（COVID-19）对退伍军人健康的前所未有的影响 在我们的整个医疗保健系统中，对ID专业知识的需求更加明显，特别是在 长期护理。此外，这项研究直接解决了VA使命法案，以改善获得护理， 利用远程保健服务，提高护理的及时性和质量。最后，该项目符合以下优先事项： 我们的运营合作伙伴：VA抗菌药物管理工作组（ASTF）、VA国家传染病委员会 服务（NIDS），VA药房福利管理（PBM）服务和农村卫生办公室。 创新和影响：设计是创新的，因为我们将系统地测试和评估 远程医疗抗菌药物管理的实施障碍，这是一种新的方法， 在VA设施中实施，而不是在我们以前的试点研究中。抗生素使用报告（AURs） 是一种创新的适应同行比较，抗生素管理策略成功地在门诊 设置.该项目将为一个可在全国范围内向所有人推广的可扩展模式提供调查结果 适用的VAMC，继续发挥VHA作为实施大规模干预措施的领导者的作用， 关于预防和管理ID和管理。 具体目标：我们的目标是建立一个多学科视频会议抗菌管理团队 （VAST）在VAMCs中使用SCAN-ECHO。我们的中心假设是，量化设施的反馈报告- 水平的抗生素使用将提高VAST的有效性，以支持抗菌药物管理。我们提出了一个 2型混合有效性-实施设计，比较实施 仅VAST（VAST-）适用于实施VAST并通过机构级抗生素使用报告增强的研究中心 (VAST+).目标是：1）确定和测试实施VAST的有效策略; 2）确定 VAST总体和VAST+对疑似感染退伍军人护理的影响; 3）确定 VAST总体和VAST+对每个VAMC抗生素使用的影响。 方法：我们将随机选择没有受过身份证培训的专业人员的农村VAMC来实施 单独的VAST（VAST-）与VAST +抗生素使用反馈（VAST+）。目标1：我们将评估修改 以及在干预地点和传染病专家进行的调整。方法将包括过程 地图和半结构化访谈，以收集有关关键VAST成员认为 VAST实施的促进者、障碍和负担。我们还将评估实施成本。目标二： 我们将评估服务的退伍军人群体、临床活动和用户对VAST的看法。我们将 评估临床护理与循证临床实践建议的一致性 指南将评估VAST成员对护理质量和及时性的看法。目标3： 主要的结果测量将是抗生素使用的总体比率。次要结局将是 广谱抗生素使用率、抗生素开始使用率和抗生素治疗时间长度。 后续步骤/实施：在其他VAMC测试VAST的有效实施是一项 这是在急性和长期护理环境中加强抗菌管理的重要一步。在 与VA临床运营合作伙伴合作，本试验的结果将用于推出 其他VAMC以及非VA设置使用的实施行动手册。

Background: Antimicrobial stewardship guidelines call for a multidisciplinary team with an infectious disease (ID) physician and ID-trained clinical pharmacist as core members. Unfortunately, there are insufficient ID- trained specialists to staff on-site antimicrobial stewardship programs throughout VA. Significance: This proposal is highly significant for Veterans and the goals of VA. Veterans experience many of the risk factors associated with development of antimicrobial resistant and healthcare-associated infections. The unprecedented effects of the novel Coronavirus disease 2019 (COVID-19) on the health of our Veterans and on our entire healthcare system makes the demand for ID expertise even more apparent, especially in long-term care. Also, this study directly addresses the VA MISSION ACT to improve access to care, timeliness and quality of care, using telehealth services. Finally, this project is aligned with the priorities of our operation partners: VA Antimicrobial Stewardship Taskforce (ASTF), the VA National Infectious Disease Service (NIDS), VA Pharmacy Benefits Management (PBM) Services, and the Office of Rural Health. Innovation and Impact: The design is innovative because we will systematically test and assess implementation barriers to telehealth for antimicrobial stewardship, a novel approach that has not been implemented in VA facilities, other than in our previous pilot study. Further, the Antibiotic Use Reports (AURs) are an innovative adaptation of peer-comparison, an antibiotic stewardship strategy successful in outpatient settings. This project will provide findings for a scalable model that could be deployed nationally to all applicable VAMCs, continuing the role of VHA as a leader in implementing large-scale interventions focused on prevention and management of ID and stewardship. Specific Aims: Our goal is to implement a multidisciplinary videoconference antimicrobial stewardship team (VAST) in VAMCs using SCAN-ECHO. Our central hypothesis is that feedback reports that quantify facility- level antibiotic use will enhance the efficacy of VASTs to support antimicrobial stewardship. We propose a Type 2 hybrid effectiveness-implementation design, comparing clinical effectiveness in sites that implement the VAST alone (VAST-) to sites that implement the VAST augmented by facility-level Antibiotic Use Reports (VAST+). Aims are: 1) Identify and test effective strategies for implementing the VAST; 2) Determine the influence of the VAST overall and VAST+ on the care of Veterans with suspected infections; 3) Determine the influence of the VAST overall and VAST+ on antibiotic use at each VAMC. Methodology: We will randomize rural VAMCs that do not have ID-trained professionals on staff to implement the VAST alone (VAST-) versus VAST + antibiotic use feedback (VAST+). Aim 1: We will assess modification and adaptations at the intervention sites and by the infectious disease experts. Methods will include process maps and semi-structured interviews to gather qualitative data about what key VAST members perceive as facilitators, barriers and burden to VAST implementation. We will also evaluate costs of implementation. Aim 2: We will evaluate the Veteran population served, clinical activities, and user perceptions of the VAST. We will assess the concordance of clinical care with recommendations from evidence-based clinical practice guidelines. VAST members’ perceptions of the quality and timeliness of care will be evaluated. Aim 3: The primary outcome measure will be overall rates of antibiotic use. Secondary outcomes will be changes in the rates of broad-spectrum antibiotic use, antibiotic starts, and length of antibiotic therapy. Next steps/Implementation: Testing effective implementation of the VAST at additional VAMCs is an important step toward augmenting antimicrobial stewardship in both acute- and long-term care settings. In collaboration with VA clinical operation partners, outcomes from this trial will be used to roll-out an implementation playbook to be used by other VAMCs, as well as non-VA settings.