VA Quality Enhancement Research Initiative (QUERI) CARRIAGE VAST

Background: Antimicrobial resistance (AMR) is a current pandemic. Access to ID physicians and pharmacists in VHA is limited and many VHA healthcare systems do not have an ID specialist. This gap in expertise is detrimental, as the presence of ID trained physicians and pharmacists in acute care is associated with improved antimicrobial utilization. Telehealth can facilitate antimicrobial stewardship in VA facilities underserved by ID expertise. The interdisciplinary Videoconference Antimicrobial Stewardship Team (VAST)consists of weekly meetings between an interdisciplinary team at a rural VAMC with an off-site ID trained physician and/or pharmacist who meet by videoconference. At each session, participants discuss patients receiving antibiotics or who may potentially receive antibiotics. Team members enter the VAST's recommendations into the electronic medical record (EMR) at the rural VAMC. The ID physicians capture their clinical effort by completing interfacility consults placed through the EMR. The aims of this hybrid effectiveness trial are to assess the implementation of VAST and antibiotic utilization outcomes.

Aim 1: Implement and evaluate the implementation of VAST, using an implementation playbook with external facilitation and tailoring. VAST will be implemented over 15 months, plus sustainability follow-up in 6 rural VAMCs using key implementation strategies of external facilitation provided by CARRIAGE, tailoring and adaptation of VAST, and use of an implementation playbook. Process maps (which informed the playbook) from the previous VAST expansion captured VAST experiences at each site and illuminated successful implementation processes, showing that tailoring and adapting the VAST program based on site-specific needs, individual clinical processes, and patient care needs was crucial to its success and sustainability. The playbook details the general process for setting up an e-consult VAST clinic and scheduling and conducting VAST sessions. Site-specific tailoring, adaptation, and facilitation of VAST will occur based on playbook information. CARRIAGE members will hold initial facilitation calls weekly with VASTs, with ad hoc support available as well. CARRIAGE will facilitate an initial kick off meeting via Teams for each VAST to encourage team building and expectations for the ensuing sessions.

Aim 2: Assess the impact of VAST on antimicrobial use and the care of Veterans with suspected and confirmed infections. Using a quasi-experimental design, the investigators will assess outcomes for new rural sites implementing VAST and for the current rural sites currently using VAST to assess sustainability. For each site, the investigators will calculate these statistics monthly for the 12 months prior to and 15 months following the first VAST session (allowing for a 3-month wash-in period), and up to 24 months to assess sustainability. The investigators will include a control group of rural sites not utilizing VAST (matched). Antibiotic use metrics including rates of total and broad-spectrum anti-biotic use, antibiotic starts, and length of antibiotic therapy will be evaluated. The primary outcome is days of antibiotic therapy per 1000 days of care (DOT/1000 DOC) to measure the overall rate of antibiotic use; key secondary outcomes include rate of broad-spectrum antibiotics, defined as agents with an Antibiotic Spectrum Index score of ≥ 8;72 rate of antibiotic starts, calculated as the number of new starts per 1000 DOC; and length of antibiotic therapy in days. Other outcomes may be evaluated including management of resistant infections including treatment selection. The investigators will use VA CDW/Millennium to obtain antimicrobial prescribing, diagnosis, comorbidity, microbiologic, laboratory, and demographic data.