Implementation of an Infectious Diseases Telehealth Consultation and Antibiotic Stewardship Program for 16 Small Community Hospitals

Abstract

Background: Telehealth improves access to infectious diseases (ID) and antibiotic stewardship (AS) services in small community hospitals (SCHs), but the optimal model has not been defined. We describe implementation and impact of an integrated ID telehealth (IDt) service for 16 SCHs in the Intermountain Healthcare system.

Methods: The Intermountain IDt service included a 24-hour advice line, eConsults, telemedicine consultations (TCs), daily AS surveillance, long-term AS program (ASP) support by an IDt pharmacist, and a monthly telementoring webinar. We evaluated program measures from November 2016 through April 2018.

Results: A total of 2487 IDt physician interactions with SCHs were recorded: 859 phone calls (35% of interactions), 761 eConsults (30%), and 867 TCs (35%). Of 1628 eConsults and TCs, 1400 (86%) were SCH provider requests, while 228 (14%) were IDt pharmacist generated. Six SCHs accounted for >95% of interactions. Median consultation times for each initial telehealth interaction type were 5 (interquartile range [IQR], 5-10) minutes for phone calls, 20 (IQR, 15-25) minutes for eConsults, and 50 (IQR, 35-60) minutes for TCs. Thirty-two percent of consults led to in-person ID clinic follow-up. Bacteremia was the most common reason for consultation (764/2487 [31%]) and Staphylococcus aureus the most common organism identified. ASPs were established at 16 facilities. Daily AS surveillance led to 2229 SCH pharmacist and 1305 IDt pharmacist recommendations. Eight projects were completed with IDt pharmacist support, leading to significant reductions in meropenem, vancomycin, and fluoroquinolone use.

Conclusions: An integrated IDt model led to collaborative ID/ASP interventions and improvements in antibiotic use at 16 SCHs. These findings provide insight into clinical and logistical considerations for IDt program implementation.

Keywords: antibiotic stewardship; community hospital; critical access hospitals; infectious diseases; telehealth.

Figure 1.

Infectious diseases telehealth (IDt) service components and workflow. *Local and central monitoring consisted of antimicrobial use surveillance, microbiological culture surveillance, and chart review for potential stewardship interventions by the small community hospital (SCH) pharmacist and IDt pharmacist, respectively. The IDt pharmacist occasionally had direct telephonic communication with local SCH providers but more often referred to the IDt physician, who provided recommendations to SCH providers by telephone. The IDt pharmacist used primarily telephone (not video) to communicate with SCHs. Abbreviations: eConsult, electronic consultation (comprehensive chart review, discussion with requesting provider, and documentation in electronic medical record); IDt, infectious diseases telehealth; SCH, small community hospital.

Figure 2.

Infectious diseases telehealth (IDt) interventions (18 months). Review: remote chart review completed by the IDt pharmacist for potential stewardship intervention. Intervention: documented change or discontinuation of antimicrobial therapy, or generation of a new IDt physician consultation resulting from IDt pharmacist recommendations.

Figure 3.

Conditions seen during first 6 months of infectious diseases telehealth (IDt) service. A, Advice line calls (n = 312). “Other” category (infection control, prophylaxis, travel, human immunodeficiency virus, central nervous system [CNS], laboratory/diagnostic interpretation, ear, nose, and throat [ENT], fever not otherwise specified [NOS], animal bite, sepsis NOS, gynecology [GYN]) (20 calls were specifically for antibiotic selection/dose; reason for call was not specified for 21 cases). B, Telehealth consultations (n = 244). Telehealth consultations includes electronic consultations and telemedicine consultations. “Other” category includes CNS, laboratory/diagnostic interpretation, ENT, sepsis NOS, GYN. Antibiotic selection/dose alone was not a reason for either electronic consultation or full telemedicine consultation visit (as these were typically addressed on IDt pharmacist review/intervention. Abbreviations: BSI, bloodstream infection; GI, gastrointestinal; GU, genitourinary; MSK, musculoskeletal; RESP, respiratory; SSSI, skin and skin structure infection.

Figure 4.

Microorganisms identified on bloodstream infections seen in infectious diseases telehealth consultation during the first 6 months. Ninety-four bloodstream infections where organism was identified: 34 Staphylococcus aureus (28 methicillin susceptible, 6 methicillin resistant); 6 coagulase-negative staphylococci; 24 gram-negative bacilli (12 Escherichia coli, 4 Pseudomonas, 8 other; Klebsiella, Moraxella, Gemella; 21 streptococci (7 group B, 3 group A, 3 viridans group, 2 Streptococcus pneumoniae, 1 group C, 5 not specified); enterococci (5 Enterococcus faecalis); 4 other (2 Leuconostoc, 1 Candida, 1 culture-negative endocarditis).