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

背景：抗菌药物管理指南呼吁成立一个患有传染病的多学科团队 (ID)作为核心成员的内科医生和经过ID培训的临床药剂师。不幸的是，没有足够的身份证- 训练有素的专家为整个退伍军人管理局的现场抗菌管理计划提供工作人员。 意义：这项建议对退伍军人和退伍军人管理局的目标具有非常重要的意义。退伍军人经历了许多 与抗菌素耐药性和医疗保健相关感染的发展相关的风险因素。 新型冠状病毒病2019(新冠肺炎)对退伍军人健康的前所未有的影响 对我们整个医疗系统的需求使得对身份识别专业知识的需求更加明显，特别是在 长期护理。此外，这项研究直接涉及退伍军人事务部的任务法案，以改善获得护理的机会， 使用远程医疗服务的及时性和护理质量。最后，该项目与以下优先事项保持一致 我们的行动伙伴：退伍军人管理局抗菌特别工作组(ASTF)，退伍军人管理局国家传染病 国家卫生服务(NDS)、退伍军人管理局药房福利管理(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 抗菌药物管理远程保健的实施障碍，这是一种尚未 在退伍军人管理局设施中实施，而不是在我们之前的试点研究中。此外，抗生素使用报告(AURS) 是对同行比较的创新适应，是在门诊患者中成功的抗生素管理策略 设置。该项目将为可扩展的模型提供发现，该模型可以在全国范围内部署到所有 适用的VAMC，继续发挥VHA在实施有重点的大规模干预方面的领导作用 关于ID和管家的预防和管理。 具体目标：我们的目标是实施一个多学科视频会议抗菌管理团队 (VASS)在VAMCs中使用扫描回波。我们的中心假设是量化设施的反馈报告- 抗生素的水平使用将提高VASS的效力，以支持抗菌药物的管理。我们提出了一个 类型2混合有效性-实施设计，比较实施 Vavar Alone(Vavar)--到实施由设备级抗生素使用报告增强的大量报告的网站 (大量)。目标是：1)确定和测试实施VASS的有效战略；2)确定 广大群众对疑似感染退伍军人护理工作的影响；3)确定 广泛性、全局性和广泛性+对每个VAMC使用抗生素的影响。 方法：我们将对没有经过ID培训的专业人员的农村VAMC进行随机化实施 大量单独(大量-)与大量+抗生素使用反馈(大量+)。目标1：我们将评估修改 以及干预地点和传染病专家的适应情况。方法将包括流程 地图和半结构化访谈，以收集关于关键的广大成员所感知的定性数据 推动者、障碍和负担阻碍了广泛的执行。我们还将评估实施成本。目标2： 我们将评估所服务的退伍军人群体、临床活动和用户对海量的看法。我们会 评估临床护理与循证临床实践建议的一致性 指导方针。将对广大成员对护理质量和及时性的看法进行评估。目标3： 主要结果衡量标准将是抗生素的总体使用率。次要结果将是 广谱抗生素使用率、抗生素开始使用和抗生素治疗持续时间。 下一步/实施：在更多的VAMC测试VAST的有效实施是一个 在急性和长期护理环境中加强抗菌药物管理的重要一步。在……里面 与退伍军人管理局临床运营合作伙伴合作，本次试验的结果将用于推出 供其他VAM以及非VA设置使用的实施攻略。

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.