Telemedicine-Based Antimicrobial Stewardship Program Improves Prescribing, Reduces Bacterial Resistance to Antibiotics at Rural Hospital
Telemedicine-Based Antimicrobial Stewardship Program Improves Prescribing, Reduces Bacterial Resistance to Antibiotics at Rural Hospital
Sonoma Valley Hospital (an 83-bed rural hospital) operates a telemedicine-based antimicrobial stewardship program designed to improve prescribing of—and reduce bacterial resistance to—antibiotics, as required by California law. Key elements include ongoing monitoring of prescribing habits combined with various educational initiatives, including daily reviews of orders for certain classes of drugs, weekly infectious disease rounds, and periodic presentations and discussion at department meetings. All program elements are delivered via telemedicine by an offsite infectious disease specialist in collaboration with a hospital-based team of physicians, pharmacists, and other staff. The program has increased physician requests to have cultures analyzed and reduced their use of targeted classes of antibiotics, leading to less bacterial resistance to these drugs.
Date First Implemented
Inappropriate use of antibiotics and other antimicrobial agents can lead to antimicrobial resistance, drug-related adverse effects, and higher costs. Antimicrobial stewardship programs are supported by national societies and mandated by California law. Yet many hospitals have difficulty implementing them, particularly rural hospitals without an onsite infectious disease specialist .,
- Growing problem of antibiotic resistance: Antibiotics have been used liberally for 70 years to treat infectious diseases. As a result of this long-term, widespread use, infectious organisms have adapted over time, making certain antibiotics less effective. Patients infected with antimicrobial-resistant organisms tend to have longer, more expensive hospital stays and face a higher risk of death than patients with other types of infections. Each year, antibiotic-resistant organisms kill an estimated 44,000 people in North America.
- Need for antimicrobial stewardship programs: Antimicrobial stewardship programs can reduce antibiotic resistance by formally addressing, monitoring, and measuring it, as well as promoting strategies to ensure appropriate antibiotic use In fact, a policy statement released jointly by the Society for Healthcare Epidemiology of America, the Infectious Diseases Society of America, and the Pediatric Infectious Diseases Society supports the creation of such programs, and the California legislature passed a law in 2007 requiring hospitals to put in place programs to promote appropriate antibiotic prescribing.
- Unrealized potential of telemedicine-based programs: Many hospitals and long-term care facilities—particularly rural facilities without an onsite infectious disease specialist—have difficulty implementing antimicrobial stewardship programs. Telemedicine has the potential to allow facilities without onsite specialists to offer the program, yet few hospitals take advantage of this approach.
Description of the Innovative Activity
In accordance with California law, Sonoma Valley Hospital operates a telemedicine-based antimicrobial stewardship program designed to improve prescribing of, and reduce bacterial resistance to, antibiotics. Key elements include ongoing monitoring of prescribing habits combined with various educational initiatives, including daily reviews of orders for certain classes of drugs, weekly infectious disease rounds, and periodic presentations and discussion at department meetings. All program elements are delivered via telemedicine by an offsite infectious disease specialist in collaboration with hospital-based physicians, pharmacists, and other staff. Key program elements are described below:
- Monitoring to identify target drugs: A hospital-based committee (the pharmacy director, two pharmacists, a microbiologist, an infection control coordinator, a hospitalist, and a microbiologist) meets on a monthly basis via telemedicine with an offsite infectious disease specialist. Known as the Antimicrobial Stewardship Program Committee, the group reviews the hospital's antibiogram, which evaluates all bacterial cultures collected from patients and measures how susceptible different types of bacteria are to antibiotics. High susceptibility suggests the drugs will be effective; low susceptibility indicates high levels of resistance. The group also evaluates the prescribing patterns of physicians to identify areas of potential overuse and misuse. Based on this analysis, the committee designates specific classes of drugs to be targeted as well as individual physicians who may be in need of support (see below for more on education efforts). The group initially decided to target two broad-spectrum antibiotics (fluoroquinolones and piperacillin/tazobactam) and subsequently added others, including antifungal medications, medications to treat methicillin-resistant Staphylococcus aureus (more commonly known as MRSA), and carbapenems (another class of broad-spectrum antibiotics).
- Education via daily order review and regular meetings: The offsite infectious disease specialist uses various strategies to educate physicians on appropriate use, both for the targeted drugs and for antibiotics in general. Education emphasizes the impact of appropriate prescribing on the quality (not the costs) of care and the need to do everything possible to understand the organism before prescribing the drug (typically by sending cultures to the laboratory for evaluation). This process allows for use of narrow-spectrum antibiotics made to target the specific bacteria; it contrasts with the typical approach in which physicians prescribe broad-spectrum drugs without knowing the underlying organism. This “shot-gun” method tends to be less effective and increases the risk that the bacteria will become resistant to the drugs over time. Education occurs in a variety of ways, as outlined below:
- Daily review and as-needed interventions for targeted drugs: Each day, a pharmacist reviews all antimicrobial orders and sets aside those for drugs targeted by the program (typically 7 orders a day, ranging from 3 to 15). Via telemedicine, the pharmacist and offsite infectious disease specialist spend roughly 30 minutes discussing the appropriateness of the orders. In about 30 to 40 percent of cases, they decide that the specialist should call the prescribing physician, usually to urge consideration of a narrower spectrum drug. In some cases, the advice may be to consider different dosing or use of oral rather than intravenous drugs. Based on this discussion, the prescribing physician usually agrees to the change. In some instances, the prescribing physician requests that the patient stay on the drug for another day to see how he/she responds (with agreement to talk again the following day), or asks the offsite specialist to do a consultation with the patient by telemedicine before any changes are made. In these instances, the specialist conducts the consultation via telemedicine and then discusses his recommendations with the prescribing physician (who may or may not have participated in the consultation).
- Weekly rounds: Every Wednesday at noon, hospital- or community-based physicians can attend multidisciplinary rounds during which the offsite infectious disease specialist (participating via telemedicine) discusses general issues related to antibiotic use and provides advice to those who request it on how to manage individual patients who have or are suspected of having bacterial infections.
- Department meetings: The infectious disease specialist periodically participates via telemedicine in department-wide meetings (e.g., for the emergency department [ED] and the departments of surgery and medicine), giving presentations and answering questions on infectious disease issues, including antimicrobial resistance and appropriate use of antibiotics. Discussions often focus on options for treating specific types of infections, such as simple bladder infections or aspiration pneumonia. When the program first launched, the infectious disease specialist participated in department meetings an average of every other month for a year; at present, he attends less frequently, typically after the Antimicrobial Stewardship Program Committee identifies a specific issue that needs to be addressed and when department-based physicians request his attendance.
Context of the Innovation
Sonoma Valley Hospital is an 83-bed, full-service acute care hospital located in Sonoma, CA. As a small facility in a largely rural area, the hospital was limited in its ability to offer certain types of specialty care, and many patients requiring such care ended up being referred to tertiary care hospitals. In 2000, the only infectious disease specialist on the hospital's medical staff left, limiting its ability to provide infectious disease services.
The impetus for this program began in 2006, when hospital and physician leaders began discussing the potential to use telemedicine to increase access to specialty care. The chief medical officer, director of nursing, and hospitalists met with the infection control coordinator and decided that infectious disease services represented an excellent opportunity to introduce telemedicine at the hospital and to meet the needs of its physicians, who had been requesting the ability to provide infectious disease care to patients. Later that same year, California legislators passed Senate Bill 739, which, among many things, stipulated that, as of January 1, 2008, the California Department of Public Health require all general acute care hospitals to evaluate antibiotic use and create a quality improvement committee to monitor oversight responsibilities for this issue.
After passage of the legislation, the Department of Public Health's Healthcare-Associated Infections Program created a statewide antimicrobial stewardship collaborative to offer implementation guidance to facilities across the state. Sonoma Valley Hospital participates in this collaborative. At its launch, Sonoma Valley took part in a needs assessment survey, the results of which helped Sonoma Valley program leaders realize that its telemedicine-based program was innovative. Since that time, program leaders have periodically participated in the collaborative's Web-based meetings, in some cases presenting information designed to help other participants with their stewardship programs. (See the related profile for more information on this legislation and the Department of Health program.)
The program increased physician requests to have cultures analyzed and reduced use of targeted broad-spectrum antibiotics, leading to less bacterial resistance to the drugs. The program's impact on length of stay (LOS) and costs is currently being evaluated.
- More cultures sent for analysis: Since the program began, physicians have significantly increased the number of urine, sputum, and blood cultures they send for analysis, thus allowing for the identification of the specific bacterial organism a patient has in advance of prescribing treatment. Between 2007 and 2011, the annual number of cultures sent by physicians that turned out to be Escherichia coli more than doubled (from 279 to 735), while the number that turned out to be Pseudomonas aeruginosa tripled (from 45 to 135).
- Less use of targeted drugs: Between 2008 and 2011, use of the two initial target classes of broad-spectrum drugs fell significantly, as outlined below:
- Fluoroquinolones: Annual hospital expenditures for this class of drug fell by 77 percent, from $10,169 to $2,359. (The impact on overall drug costs cannot be determined, as physicians often prescribed different, narrower-spectrum drugs instead.) Adjusting for price declines due to increased prescribing of generic drugs, use of these drugs is estimated to have declined by over 60 percent.
- Piperacillin/tazobactam: Annual hospital expenditures fell by 72 percent, from $51,363 to $14,624. Adjusting for price declines due to greater use of generic drugs and for the impact of periodic national shortages during the early years of the analysis, use of these drugs fell by an estimated 56 to 59 percent.
- Less bacterial resistance to drugs: An analysis of the hospital's antibiogram found that E. coli and P. aeruginosa became more susceptible (and hence less resistant) to the targeted drugs. Between 2007 and 2011, the susceptibility of E. coli to piperacillin/tazobactam rose from 96 percent to 100 percent, while its susceptibility to fluoroquinolones remained basically the same (85 to 84 percent). The susceptibility of P. aeruginosa to these drugs also increased, from 79 to 91 percent for fluoroquinolones and from 93 to 96 percent for piperacillin/tazobactam.
- Impact on LOS, costs to be determined: Program leaders are currently conducting an analysis to determine the impact on LOS and overall hospital costs.
Planning and Development Process
As noted, the program evolved over time; key steps included the following:
- Gauging stakeholder interest: In exploring economical ways to enhance access to specialty care, the chief medical officer met with key stakeholders within the hospital to discuss the merits of bringing infectious disease services to the hospital via telemedicine. Further discussions with the infection control coordinator, pharmacists, and several hospitalists found broad-based support for the proposed program.
- Forging agreement with specialist: The hospital contracted with an infectious disease specialist through the University of California at Davis, Center for Health and Technology in Fall 2006. This physician now provides the same services through an independent medical practice he founded; see the Innovator Disclosures section for more details.
- Initial launch on small scale: An infectious disease telemedicine program began in January 2007, with inpatient consults occurring during the weekly lunchtime sessions and on an as-needed basis.
- Expansion over time: Relatively quickly, it became clear that the weekly conversations often focused on common themes related to overuse of broad-spectrum antibiotics, driven in part by the failure to first determine the organism being targeted. It also became clear that these sessions alone were not adequate to stimulate meaningful, sustained improvement in antibiotic prescribing patterns at the hospital. Consequently, over time, the specialist and hospital-based team introduced other antimicrobial stewardship program elements (described earlier) to address the identified themes and to provide greater support to physicians in making prescribing decisions.
Resources Used and Skills Needed
- Staffing: The hospital did not hire additional staff for the program. One pharmacist spends roughly an hour a day reviewing the orders for the targeted drugs and discussing them with the specialist. Other hospital staff participate in the monthly meetings and the weekly lunchtime consultations as part of their regular duties. The infectious disease specialist spends approximately 10 hours a week overseeing issues related to antimicrobial stewardship. He spends another 10 hours a week providing other infectious disease services, such as wound consultations.
- Costs: Upfront costs consist primarily of the telemedicine units, with each unit costing roughly $12,000 to $15,000. Sonoma Valley has three units, although they are used for many other purposes as well, including pediatric emergency and stroke care. Ongoing operating costs consist of payments to the infectious disease specialist for time spent on program-related activities; further details are not available.
Payments to the infectious disease specialist come out of the hospital's operating budget. The hospital received grant funding to cover the costs of the three telemedicine units. The first came from University of California at Davis for an ED-based unit used initially for pediatric emergency care. The second grant, from the Blue Shield of California Foundation, covered the purchase of an additional unit and wireless capabilities. The hospital recently received a grant from the California Telehealth Network to cover the costs of a third unit.
Getting Started with This Innovation
- Identify hospital-based physician and administrative champions: The program requires a reasonably large time commitment from several hospital staff (pharmacists, microbiologists, infection control coordinators) and physicians. Physician and administrative champions need to convince these stakeholders of the merits of allocating this time. At Sonoma Valley, the chief medical officer proved to be a major proponent of this and other telemedicine-based programs because he saw them as a way to bring critical specialty care to rural patients for a fraction of the cost of sending them to a distant medical center. One hospitalist also served as a major proponent, as he wanted access to an infectious disease physician to help in caring for patients.
- Involve key stakeholders from the outset: Pharmacists, microbiologists, infection control specialists, and others bring an important perspective to the issue of infection control and antibiotic resistance. Including these stakeholders from the beginning not only helps to ensure their buy-in, but also leads to a more effective program, with new knowledge gained at almost every meeting.
- Start small, targeting areas with potential for improvement: Begin by targeting a few areas that represent “low-hanging fruit” and then expand the program over time. This approach will likely lead to quick, visible successes that can generate broad support for the program and will also give the infectious disease specialist time to build rapport with key stakeholders in the hospital.
- Build program based on education: Many antimicrobial stewardship programs prohibit or automatically override prescriptions for certain drugs. These restrictive approaches may be effective in the short term, but their benefits often fade as physicians rebel against being told how to practice medicine. Education tends to be more effective, as it helps physicians understand the need to improve and hence is more likely to result in lasting changes in culture and prescribing habits.
Sustaining This Innovation
- Keep initial targets and monthly meetings in place: Even after several years, the Antimicrobial Stewardship Program Committee continues to identify new issues to be addressed, including lingering problems with the initial target classes of drugs. For example, after two new ED physicians joined the hospital, the committee quickly discovered that they frequently prescribed the targeted drug classes to address organisms of unknown origin. The team intervened with educational outreach that succeeded in bringing their prescribing habits in line with the rest of the medical staff.
- Continually review program, adapt over time: The program needs to remain a “living, breathing” entity that changes over time. As noted, this program began with only the weekly lunchtime sessions, but then expanded over time to address systematic prescribing problems.
- Monitor and share data on program impact: To maintain enthusiasm for the program, the director of pharmacy regularly shares data with hospital administration and relevant medical staff committees that demonstrate its impact on prescribing habits and antimicrobial resistance. Once available, data on LOS and costs will also be shared.
Contact the Innovator
Note: Innovator contact information is no longer being updated and may not be current.
Infection Control Coordinator
Sonoma Valley Hospital
347 Andrieux Street
Sonoma, CA 95476
Phone: (707) 935-5180
Fax: (707) 935-5143
Javeed Siddiqui MD, MPH
The Telemedicine Group
Phone: (916) 740-3721
Director of Pharmacy
Sonoma Valley Hospital
347 Andrieux Street
Sonoma, CA 95476
Phone: (707) 935-5340
Fax: (707) 935-5337
Siddiqui is the founder and owner of Telem2U, an independent for-profit medical practice that provides services to Sonoma Valley Hospital as part of this program and offers similar services to other hospitals; in addition, information on funders is available in the Funding Sources section.
McMahon and Kutza reported having no financial interests or business/professional affiliations relevant to the work described in this profile other than the funders listed in the Funding Sources section.
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