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Tele-stewardship: An Emerging Tool For Resource Limited Settings · The SHEA Podcast

0:08
SPEAKER_02: Welcome to our new four-part podcast series, Challenges and Innovations in Antimicrobial Stewardship, brought to you by the Society for Healthcare Epidemiology of America, promoting the prevention of healthcare associated infections and antibiotic resistance, and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
0:27
SPEAKER_02: This series will focus on applying stewardship practices in the ambulatory and emergency department settings, describing how telestewardship can be used in resource-limited settings, analyzing innovations in diagnostic stewardship, and discussing stewardship in the times of COVID-19.
0:43
SPEAKER_02: I'm Dr.
0:44
SPEAKER_02: Christopher Cernich, Chief of Medicine and Hospital Epidemiologist at the Madison VA Hospital, an associate professor of medicine at the University of Wisconsin School of Medicine and Public Health, and I will serve as the podcast moderator today.
0:57
SPEAKER_02: Shay is excited to launch the second episode of the podcast series, which is entitled Telestewardship, an emerging tool for resource limited settings.
1:06
SPEAKER_02: This podcast will explore opportunities and strategies for supporting stewardship activities in resource-limited clinical settings, including critical access hospitals and skilled nursing facilities.
1:16
SPEAKER_02: Discussion with podcast participants will center on virtual stewardship activities with a specific focus on program design, the technologies used, and the challenges encountered.
1:26
SPEAKER_02: We're happy to introduce our two speakers for today.
1:29
SPEAKER_02: First, Dr.
1:30
SPEAKER_02: Aaron McCreary, is a clinical assistant professor of medicine, director of stewardship innovation at Infectious Diseases Connect, and an infectious disease pharmacist at the University of Pittsburgh Medical Center.
1:41
SPEAKER_02: Our other speaker is Dr.
1:43
SPEAKER_02: Eddie Stenyem, Senior Medical Director of Medical Specialties and Associate Professor of Research at Intermountain Healthcare.
1:51
unknown: Dr.
1:51
SPEAKER_02: Stenyem is an infectious disease physician and prior to taking on his new position was the medical director of antibiotic stewardship at Intermountain Healthcare.
2:00
SPEAKER_02: Thank you both for joining us today.
2:02
SPEAKER_02: First, I'd like to ask if you can both provide our listeners with your background in antibiotic stewardship and what does a day or a week in the life look like for you.
2:10
SPEAKER_02: Dr.
2:11
SPEAKER_02: McCray, I will start with you.
2:13
SPEAKER_00: Yeah, thank you.
2:14
SPEAKER_00: I love this question because I don't even know what day it is anymore.
2:17
SPEAKER_00: Um, but I would say my role as a stewardship pharmacist, a steward in general, has evolved significantly since March of 2020, which I mean has in all of our lives.
2:26
SPEAKER_00: But very briefly before the pandemic, I used to practice as an antimicrobial stewardship pharmacist at a large academic urban hospital.
2:33
SPEAKER_00: And I focused mostly on prospective audit with feedback on targeted patients.
2:37
SPEAKER_00: And so I actually was doing antifungal stewardship in transplant patients, was how kind of my position was justified and where my niche really was and the patients that I looked at every day.
2:47
SPEAKER_00: And then I worked on in an average day, in an average week, quality improvement projects for the stewardship program, letting data look at where we can improve antibiotic use.
2:57
SPEAKER_00: I would round with the ID consult service and I would precept pharmacy students, residents, and ID fellows.
3:02
SPEAKER_00: When the pandemic hit, I took over COVID therapeutics for the UPMC health system, which is a 40 hospital system across three states.
3:10
SPEAKER_00: And this was a really exciting role and interesting role because I think while the pandemic has obviously been awful for many, many reasons, it did force us to start to treat patients cohesively across the system and it forced us to leverage technology and really get into telemedicine, which is how I started on this journey.
3:28
SPEAKER_00: We started to embed routine clinical care into the electronic health record so that our community hospitals had access to the same things as the academic centers and things like that.
3:38
SPEAKER_00: So that was really where I got into like this telemedicine space.
3:41
SPEAKER_00: And a lot of my ID and my stewardship work shifted to more of a system level and to more of practicing via telemedicine.
3:48
SPEAKER_00: So at UPMC, we have a community hospital stewardship program that's led by Dr.
3:52
SPEAKER_00: Ryan Variola and Dr.
3:53
SPEAKER_00: Tina Kadem.
3:54
SPEAKER_00: And they essentially were already doing stewardship for our community sites.
3:58
SPEAKER_00: And even though we didn't call it telestewardship before the pandemic, that's what it was, because they were central in downtown Pittsburgh, but they were working with hospitals all across Western Maryland, western New York, and western Pennsylvania.
4:10
SPEAKER_00: And so when the pandemic hit, I began collaborating with them.
4:13
SPEAKER_00: And then I started working with ID Connect last June.
4:16
SPEAKER_00: And I transferred from the Department of Pharmacy to the Department of Medicine to kind of fit this more system level role.
4:21
SPEAKER_00: And so now I would say an average day, I spend about two hours working with some of the ID Connect community sites, which is four hospitals in total that I do direct prospective audit and feedback with via telestewardship.
4:33
SPEAKER_00: And then I also help with the UPMC system, telestewardship.
4:36
SPEAKER_00: And that is an alert-based system, which we'll talk more about later.
4:40
SPEAKER_00: We use a software called Illum Insight.
4:42
SPEAKER_00: 19 of our hospitals have it, and it lets us get alerts on antibiotics all throughout the system.
4:47
SPEAKER_00: And then I also work with a critical access hospital in California as kind of a consultant pharmacist.
4:52
SPEAKER_00: And I'll talk later about what that model looks like.
4:55
SPEAKER_00: I meet with that hospital for an hour a week.
4:57
SPEAKER_00: We do education, we do case conferences and kind of the echo model that University of Washington was really instrumental in piloting.
5:04
SPEAKER_00: And then I guess in all of that, I do there's always that like classic stewardship work of order set reviews and guidelines and MUEs and quality improvement and collaborating with the microlab and our infection prevention colleagues.
5:17
SPEAKER_00: And I still do work with residents and fellows at my first hospital.
5:20
SPEAKER_00: Even now I love trainees.
5:22
SPEAKER_00: So that kind of keeps it fun.
5:23
SPEAKER_00: So that was a long-winded answer to say no day looks the same, but those are kind of the core stewardship functions that I participate in.
5:30
SPEAKER_02: It doesn't sound like you have enough days in the week to get that all done.
5:34
SPEAKER_00: Luckily, every day is the same day now.
5:36
SPEAKER_00: So it's fun.
5:38
SPEAKER_00: How about you, Dr.
5:39
SPEAKER_02: Senayam?
5:41
SPEAKER_01: I don't think I can compete with Erin's three jobs that she just highlighted, but my stewardship journey started when I came here to Intermountain Healthcare after fellowship in 2012.
5:53
SPEAKER_01: I came and I started the Intermountain Medical Center Antibiotic Stewardship Program.
5:57
SPEAKER_01: Intermountain Medical Center is a big flagship hospital here for Intermountain Healthcare.
6:01
SPEAKER_01: Intermountain Healthcare is a large integrated healthcare system out in the West, predominantly in Utah, but we're now expanding into Idaho and Nevada and Colorado and some of the other Western states.
6:12
SPEAKER_01: That has evolved to develop into really an integrated system-based antibiotic stewardship program that covers all of Intermountain Healthcare.
6:21
SPEAKER_01: How we really got into the telespace is we were fortunate enough to get a grant early in my career in 2013, 2014, that allowed us to study antibiotic stewardship programs in small community hospitals.
6:34
SPEAKER_01: And we did a cluster randomized trial.
6:37
SPEAKER_01: And that was really one of the first trials that looked at stewardship in small hospitals.
6:42
SPEAKER_01: And we looked at antibiotic prescribing in small hospitals and found it to be the same as in large hospitals.
6:48
SPEAKER_01: And we started this study and found out that there was a huge need.
6:52
SPEAKER_01: There was a huge need in both infectious disease care in small hospitals and also antibiotic stewardship.
6:58
SPEAKER_01: And then through that process, really developed really nice relationships with our 15 small hospitals that were in our system.
7:06
SPEAKER_01: And then that evolved into a business case to our organization saying, hey, we need something here permanently.
7:13
SPEAKER_01: And they said, yep, we agree.
7:15
SPEAKER_01: It was the same time joint commission was coming out with their guidelines and their requirements, and the timing was right.
7:21
SPEAKER_01: And we were able to form a tele infectious disease and antibiotic stewardship program, which was going to lay on top of a pretty robust system that was being developed at Intermountain Healthcare to support telemedicine.
7:33
SPEAKER_01: So we formed that, and we're fortunate to hire two physicians and a pharmacist to run that.
7:38
SPEAKER_01: And it's really just grown since then.
7:42
SPEAKER_01: And we've now had an active program for about five years.
7:45
SPEAKER_01: That program now is able to support 17 of our Intermountain small hospitals and now is expanding into non-intermountain facilities.
7:54
SPEAKER_01: And we cover about five different non-intermountain facilities as well.
7:58
SPEAKER_01: And then my career has evolved into forming and developing the system-wide medical director role of stewardship for intermountain healthcare, growing that and overseeing antibiotic stewardship, inpatient, outpatient, and transitions in care.
8:12
SPEAKER_01: And then just this past April, I was fortunate enough to be asked to take on a leadership role within Intermountain Healthcare where I'm now, and the senior medical director over nine different medical specialties, which includes infectious disease and antibiotic stewardship.
8:24
SPEAKER_01: And so a day in my life is much different now.
8:28
SPEAKER_01: It's not as nearly focused as I was on antibiotic stewardship and infectious disease.
8:33
SPEAKER_01: And now I oversee about 13 different medical directors that cover specialties like dermatology and rheumatology and endocrinology and the like.
8:42
SPEAKER_01: And it's just been a fascinating journey and just a privilege right now to be able to lead out in a system like Intermountain Healthcare.
8:49
SPEAKER_01: But my roots are in stewardship and certainly will never leave me.
8:53
SPEAKER_01: I'm excited to chat with you guys all today.
8:56
SPEAKER_01: That's wonderful.
8:57
SPEAKER_02: Thank you.
8:57
SPEAKER_02: So I think many of our listeners have a reasonable concept of what antibiotic stewardship is, and many have some familiarity with how it is done at their hospital, particularly if they practice in a referral hospital with dedicated antibiotic stewardship resources.
9:13
SPEAKER_02: Dr.
9:13
SPEAKER_02: McCray, can you briefly describe how the structure and practice of antibiotic stewardship differs in small hospitals and non-hospital healthcare facilities and some of the key barriers they face with implementing and doing antibiotic stewardship?
9:28
SPEAKER_00: Yeah, I think it's a really good question.
9:30
SPEAKER_00: I think one of the main differences right off the bat is that stewardship at its core has two main ways you can practice.
9:38
SPEAKER_00: You can do prospective audit with feedback, or you can have a prior authorization or a hybrid of the two.
9:42
SPEAKER_00: And I would say a main difference, very high level, is that community hospital stewardship is not going to have as much prior authorization, if any prior authorization at all.
9:51
SPEAKER_00: Some of the hospitals I work with don't have any pre-approval.
9:54
SPEAKER_00: Some have very limited, and it's really the most expensive and the most toxic of agents.
9:58
SPEAKER_00: Like there's no carpapenum restriction at community hospitals because for prior auth to work, you have to have someone answering a phone to approve the drugs.
10:06
SPEAKER_00: And then you likely need an ID consult service to refer and sustain the use of those restricted agents.
10:13
SPEAKER_00: And a lot of these hospitals don't have ready access to ID specialists.
10:17
SPEAKER_00: They may not even have an ID consult service.
10:20
SPEAKER_00: And so that is, I think, the coolest thing with telemedicine is that we're bringing this specialty service into the communities.
10:27
SPEAKER_00: A lot of the hospitals we work with, we have UPMC tele-ID consults in collaboration with the ID stewardship we provide, which I think is an important synergy.
10:36
SPEAKER_00: But that's, I guess, one of the biggest differences right off the bat.
10:40
SPEAKER_00: I would say if you're doing prospective audit with feedback, it's pretty similar.
10:43
SPEAKER_00: That function at its core is something I think you can train any pharmacist and any physician to do.
10:48
SPEAKER_00: I think everyone can and should be a good steward.
10:51
SPEAKER_00: But I would say that what you're reviewing is probably very different.
10:54
SPEAKER_00: So I'm definitely not doing antifungal stewardship in a lot of my community sites because they don't really use that many antifungal agents.
11:01
SPEAKER_00: Big believer in letting the data drive what you do.
11:03
SPEAKER_00: And so the different community sites you work with, you're going to be reviewing different antibiotics or different units or different patients based on what challenges that hospital faces, what prescribers they have that may have different practice patterns that warrant more stewardship efforts focused on that area.
11:20
SPEAKER_00: So we try to not just have the same one size fits all approach.
11:24
SPEAKER_00: You have to look at that hospital's culture and that hospital's antibiotic use and let that drive where your stewardship team is focusing.
11:32
SPEAKER_00: From the quality improvement side of stewardship, so putting systems in place that help everyone use antibiotics better, I actually think it's a lot more fun, a lot more efficient at community hospitals, which was surprising to me when I started doing this work.
11:46
SPEAKER_00: But I can get so much more done at my community sites because I don't have the red tape of the countless committees that come with a 700 plus bed hospital and all those providers' inputs.
11:57
SPEAKER_00: So at my community sites, the relationships are more intimate.
12:01
SPEAKER_00: I think leadership is closer to frontline workers.
12:04
SPEAKER_00: And we honestly just get things done faster.
12:07
SPEAKER_00: And it's really cool.
12:08
SPEAKER_00: We have an idea and in a month it's implemented and we're making positive changes for patient care.
12:13
SPEAKER_00: And I find that that's been really rewarding work.
12:16
SPEAKER_00: I don't work specifically with non-hospital healthcare facilities, so skilled nursing facilities and things like that.
12:22
SPEAKER_00: We do do consults and stewardship in those spaces, but my colleagues are assigned to those sites.
12:26
SPEAKER_00: I don't, I don't specifically work with them.
12:28
SPEAKER_00: But some challenges I know just high level are the formulary availability at those sites.
12:33
SPEAKER_00: So you might not have access to every drug you want.
12:35
SPEAKER_00: Microbiology lab resources are a huge barrier at community critical access and non-hospital healthcare facilities, delays and reporting, using outdated breakpoints, all those kinds of things are huge.
12:47
SPEAKER_00: And I think the stewardship team can make a really big difference whenever you start at a new site, just doing a microbiology lab review, meet and greet, form those relationships and start to overhaul and make some small improvements in the lab.
13:00
SPEAKER_00: That goes a really long way.
13:02
SPEAKER_00: And then I guess the last thing I would say is like clinician confidence in antimicrobial stewardship, both making recommendations and receiving them, can be a big barrier, especially if they've never had any stewardship services before.
13:15
SPEAKER_00: Culture change is hard.
13:16
SPEAKER_00: And people being familiar with those and making those recommendations.
13:20
SPEAKER_00: The other thing that you encounter at community sites, which can be a big barrier, is that the person that's doing stewardship, one may not be ID trained.
13:28
SPEAKER_00: And then two, they may do stewardship, but they also wear five other hats, which I'm like laughing.
13:34
SPEAKER_00: Eddie said I have a lot of jobs.
13:36
SPEAKER_00: He has like 17 jobs.
13:37
SPEAKER_00: But you know, we all wear a lot of hats in healthcare, of course.
13:40
SPEAKER_00: But, you know, the pharmacist that does stewardship at a community hospital may get to do stewardship, but they also may be responsible for all inpatient operations and the ORs and other things because there's just less people there.
13:52
SPEAKER_00: And so if the automated like medication dispensing cabinets go down that day, that's priority over doing antibiotic reviews.
14:01
SPEAKER_00: And so sometimes stewardship will just get canceled for the day because there's only three pharmacists in the whole hospital and you have to get meds to patients as first and foremost.
14:09
SPEAKER_00: And so we've encountered those kinds of barriers as we're learning and developing our programs.
14:14
SPEAKER_02: That's fantastic.
14:15
SPEAKER_02: Dr.
14:16
SPEAKER_02: Stenium, can you describe to our audience what telest stewardship is at kind of a high level and how can it help overcome some of the barriers that that have been described by Dr.
14:26
SPEAKER_02: McCray and perhaps other barriers that maybe she left off?
14:30
SPEAKER_01: Yeah, I mean, I think at the simplest form is you, as the stewardship team are trying to improve antibiotic prescribing at a facility where you're not located.
14:40
SPEAKER_01: I mean, that's I think it's as simple as it is.
14:42
SPEAKER_01: You know, we're all accustomed to the traditional stewardship model where, you know, as physicians and pharmacists, we are trying to impact care and impact prescribing at our facility, where you can walk up to the floor and you can have a conversation with a clinician.
14:57
SPEAKER_01: You can do handshake stewardship.
14:59
SPEAKER_01: And, you know, that's pretty familiar to us.
15:01
SPEAKER_01: And I feel like, you know, over the past 15 years, we've we've dialed that in pretty well and have gotten pretty effective at it.
15:09
SPEAKER_01: And, you know, what tele stewardship is, is now doing that at a remote site and trying to be able to do that same type of practice, but over the internet or over a phone or over a Zoom link and really trying to impact care there.
15:23
SPEAKER_01: And you know, tele stewardship can take all sorts of different forms, which I'm sure we'll get into and all really dependent on, you know, what are the needs of the facility you're trying to assist and what are their resources.
15:36
SPEAKER_01: You know, one of the biggest barriers that we encountered initially on is the fact that, you know, all of the facilities that we were working with within Intermountain Healthcare, none of them had access to an infectious disease physician.
15:48
SPEAKER_01: Zero.
15:49
SPEAKER_01: And so if they needed to get an infectious disease counsel, if they wanted infectious disease input, they either had to have a friend that they knew was an ID doc that they called, or they would have to spend, you know, countless minutes to hours trying to call a big facility to see if they can get in touch with the ID person on call.
16:08
SPEAKER_01: That person, you know, would have varying enthusiasm to talk to them about a case that they're not involved in.
16:13
SPEAKER_01: And so, you know, one of the biggest issues we saw was that these people were amazing clinicians and taking care of really complex patients in their small facilities, but had zero backup from an infectious disease standpoint, whether it be, you know, an evaluation of drug interactions or management of staph aureospectoremia, whatever it might be.
16:35
SPEAKER_01: And so, you know, really tele stewardship is providing them a service for both reaching out to an infectious disease professional and also the day-to-day antibiotic stewardship of their um of their patients and improving antibiotic prescribing and thus improving safety and quality.
16:52
SPEAKER_01: Aaron listed a ton of barriers, and I think one of the biggest barriers is a barrier to content expertise, which is what we can now provide with um tele stewardship and tele-id.
17:02
SPEAKER_02: That's great.
17:02
SPEAKER_02: Now, I think both of you have kind of alluded to uh an aspect of stewardship that probably doesn't get enough attention.
17:11
SPEAKER_02: And it's the the issue of kind of cultivating and building relationships.
17:16
SPEAKER_02: Can either of you or both of you kind of talk about what that's like?
17:20
SPEAKER_02: How do you build and cultivate relationships, you know, using a virtual modality like telestewardship?
17:26
SPEAKER_01: I'll jump in first, and I'm sure Aaron has heard his stories as well.
17:30
SPEAKER_01: And you know, I think Aaron mentioned this is one of the fun parts of the job.
17:34
SPEAKER_01: You know, stewardship is fun, but this one is really pretty unique.
17:37
SPEAKER_01: And, you know, I was doing the tele stewardship and teleid part for Air Mountain Healthcare for my by myself for about two years.
17:45
SPEAKER_01: And I had the ability to, you know, get to know these clinicians at small community hospitals all across the state of Utah.
17:52
SPEAKER_01: And they reached me via the hotline that we had developed, and we'll talk more about that.
17:57
SPEAKER_01: They knew me, they knew my family, they they knew you know the care that they were going to receive from me when they called me and and that you know, I was gonna treat them with respect and caring and really try to help them out.
18:11
SPEAKER_01: And so, you know, these people are now my friends, and some of our stewardship staff have you know traveled to Logan to enjoy Thanksgiving dinner with some of them because we've gotten to know them so well.
18:22
SPEAKER_01: And we really feel that it's those relationships that you develop that instill trust in the stewardship group and allow us to make interventions that frankly would be hard to make otherwise.
18:36
SPEAKER_01: You know, they're now to the point where like, okay, you know, if the tele stewardship group thinks this, let's do it.
18:40
SPEAKER_01: And we've cultivated those relationships over years now.
18:44
SPEAKER_01: And part of that is just showing up.
18:45
SPEAKER_01: You know, we will make a point of driving three hours to a facility for a 20-minute meeting just because it shows to them like we're committed and we're here.
18:57
SPEAKER_01: And, you know, we think it's important to come face to face every once in a while to really shake hands and see each other face to face.
19:05
SPEAKER_01: Granted, we haven't been doing that much now with COVID, but it's developing those relationships, developing that trust that really allows your stewardship group to be successful.
19:15
SPEAKER_01: Aaron, what do you think?
19:16
SPEAKER_00: Yeah, I completely agree with everything you said.
19:18
SPEAKER_00: I actually think this is another silver lining of the pandemic in that the only way we meet people is virtually now.
19:24
SPEAKER_00: And so meeting people over Zoom to discuss patients feels less odd because that's what we were doing for a year, even with the physicians whose office is across the hall from mine.
19:34
SPEAKER_00: And so admittedly, I only started doing telestewardship in COVID-19 and have continued it.
19:40
SPEAKER_00: But I that has actually broken down that barrier for all of us moving forward.
19:44
SPEAKER_00: And I don't think we're ever going back.
19:45
SPEAKER_00: I do think telemedicine is really the way of the future for all of the reasons we've described, and that we're just treating patients where they are, and that's so, so important that the vast majority of our patients are in the community.
19:56
SPEAKER_00: But I think you form relationships virtually the same way you do in person, in that like the first week or so, whenever I start working with a new hospital, that whole week is just meet and greets and one on 30-minute one-on-one meetings, meeting with the micro lab director, meeting with the head of infection prevention or whoever is in that role.
20:12
SPEAKER_00: Again, a lot of times in these hospitals, that's not their specific title.
20:16
SPEAKER_00: They're just responsible for that content.
20:18
SPEAKER_00: Meeting one-on-one with all of the pharmacists, you know, what are your concerns?
20:22
SPEAKER_00: What is your baseline?
20:23
SPEAKER_00: We do kind of high-level educational, like what is stewardship?
20:26
SPEAKER_00: Who are we?
20:27
SPEAKER_00: How can we help?
20:28
SPEAKER_00: Kind of things before we dive in and start taking care of patients.
20:31
SPEAKER_00: And then you start small and get bigger as you go.
20:34
SPEAKER_00: We started at my one hospital site, we started looking at three patients a day just to get them used to these kinds of interventions.
20:40
SPEAKER_00: What is prospective audit and feedback?
20:42
SPEAKER_00: How do you make phone calls?
20:43
SPEAKER_00: I actually do a topic discussion with all my sites on behavioral communication of stewardship and using a lot of that IDSA and Shea curriculums on how to frame these conversations with providers.
20:54
SPEAKER_00: And then I do think that site visits are very important.
20:57
SPEAKER_00: So the virtual is absolutely something you can sustain, but I do think it's very important when safe and able to go visit the site in person.
21:05
SPEAKER_00: We try to do that now, about a year in that we've have felt a little safer and vaccinated.
21:10
SPEAKER_00: We've started doing site visits again.
21:12
SPEAKER_00: And that's been extremely, extremely rewarding to have those sit-down conversations with surgeons and say, you know, we've been working with you for a year, and here are some patterns, and how can we help?
21:22
SPEAKER_00: And what are your concerns?
21:23
SPEAKER_00: And that's just how we keep that going.
21:25
SPEAKER_02: Great.
21:26
SPEAKER_02: So I work in the VA healthcare system, and there's a common refrain among VA docs that if you've seen one VA hospital, you've seen one VA hospital.
21:34
SPEAKER_02: And I think, Dr.
21:34
SPEAKER_02: McCray, you've alluded to the fact that I think a similar thing can be stated about tele stewardship programs.
21:42
SPEAKER_02: You were recently a co author on an excellent review that I would encourage all our audience uh who has an interest in stewardship to read that was published in the Journal of the American College of Clinical Pharmacy that reviewed tele uh antimicrobial stewardship programs.
21:55
SPEAKER_02: Could you describe to our audience how you and your co authors chose to characterize?
22:00
SPEAKER_02: Different types of teller stewardship approaches that are currently being described in the literature.
22:04
SPEAKER_00: Yeah, of course.
22:05
SPEAKER_00: And thank you for that.
22:06
SPEAKER_00: I I do have to give a shout out to the lead author Christina on that paper.
22:10
SPEAKER_00: She did an absolutely phenomenal job.
22:12
SPEAKER_00: I think the first draft was like 15,000 words or something when we started reviewing it.
22:17
SPEAKER_00: And I read it and I was like, oh boy, we got to cut this down.
22:19
SPEAKER_00: But no, that was a fun paper to write because there's not a lot.
22:22
SPEAKER_00: It was actually really just reading about all the work Intermountains had done and trying to be cool like them.
22:27
SPEAKER_00: They're really pioneers in this space.
22:29
SPEAKER_00: But I think one of my favorite lines in that in that paper when we were framing telestewardship and what we're doing is actually in the first page.
22:36
SPEAKER_00: And telestewardship really is a force multiplier.
22:39
SPEAKER_00: And we've alluded to this in that you're able to take care of so many more patients.
22:43
SPEAKER_00: You're able to bring specialty services to places that never had it before.
22:47
SPEAKER_00: And you can have one ID pharmacist and one ID physician collaborating together.
22:51
SPEAKER_00: And I do, I'm, I'd say I love our model.
22:53
SPEAKER_00: I'm really fortunate.
22:54
SPEAKER_00: And all the sites I work with, I have a physician partner.
22:56
SPEAKER_00: And I think that's essential for appropriate patient care and for collaborating.
23:00
SPEAKER_00: And, you know, I'm comfortable elevating cases to that physician partner and talking through things with them.
23:05
SPEAKER_00: So I think that's really important for whatever model you're in.
23:07
SPEAKER_00: But we can, between the two of us, we take care of five, six hospitals a day.
23:12
SPEAKER_00: And it's that whole like teaching someone how to fish concept.
23:15
SPEAKER_00: Like we look at so many more patients, we make so much more of a difference because we're teaching and empowering the local pharmacists, local physicians, even nurses to do stewardship at all these smaller sites and kind of touching base with them throughout the day, but not sitting down and just reviewing a list of 30 patients.
23:30
SPEAKER_00: And so that should be the core of whatever your model looks like.
23:34
SPEAKER_00: But we break down the different telemodels into what we call either a fully remote model, an integrated model, or a collaborative approach.
23:41
SPEAKER_00: A fully remote model would be where the telespecialist, that would be like if I was offering antibiotic recommendations directly to local prescribers, I could look at those patients either asynchronously or synchronously with them, but there would be no involvement of a local clinician middleman, so to speak.
23:58
SPEAKER_00: I would just be reviewing the patients and calling the sites directly.
24:02
SPEAKER_00: So that would be least preferred because then you're just basically, again, you're not, you're not being a force multiplier in that situation, but you're providing specialty expertise to a distant site.
24:11
SPEAKER_00: So that's good in that regard.
24:13
SPEAKER_00: Integrated is what we strive for at most of our sites, where a remote specialist offers support to an on-site clinical team, whether that be a pharmacist, a physician, a nurse, whomever.
24:22
SPEAKER_00: And that can be over the phone.
24:24
SPEAKER_00: It can be over video conference.
24:26
SPEAKER_00: We prefer to have remote access into the EHR.
24:29
SPEAKER_00: We'll talk about barriers later, but that comes with, you know, credentialing and licensure and things like that.
24:35
SPEAKER_00: But prefer to look at the patients if you can.
24:37
SPEAKER_00: You might have a third-party surveillance software or something that you both can log into and look at alerts.
24:43
SPEAKER_00: And then we do education and guidance, but there is actual review of patients involved.
24:48
SPEAKER_00: But the local team is who's calling the local prescribers to make the interventions.
24:53
SPEAKER_00: And then finally, a collaborative approach is where you would provide education, maybe webinars and case conferences, data review, the review and analysis of data is essential in all of these models, but very much so in a collaborative approach and like other tools.
25:09
SPEAKER_00: And so you basically bring in the specialty education and expertise, but there's no actual patient review by the telemedicine team.
25:17
SPEAKER_00: And that's what I do with this critical access hospital that I work with in California.
25:21
SPEAKER_00: So a lot of different ways to approach it.
25:24
SPEAKER_02: Thank you for that.
25:25
SPEAKER_02: Dr.
25:25
SPEAKER_02: Stenium, we've already kind of alluded to the study that you and your team at Intermountain Health published in briefly.
25:33
SPEAKER_02: Uh it was a cluster randomized trial that was studying the effects of three different remote stewardship models in 15 under-resourced hospitals in your region.
25:43
SPEAKER_02: Can you briefly describe the different stewardship models that were employed in that study, what their impact on outcomes were, and what our audience should take away from that study?
25:55
SPEAKER_01: Yeah.
25:55
SPEAKER_01: So that was really our first kind of jump into stewardship in in small hospitals.
26:00
SPEAKER_01: And you know, what we did is, well, let's back up what the question was is how do we do stewardship in small hospitals and do we need to?
26:08
SPEAKER_01: And you know, what's that impact going to look like?
26:11
SPEAKER_01: And you know, it's not gonna be the same as our large facilities.
26:14
SPEAKER_01: And so we developed kind of three different programs.
26:17
SPEAKER_01: We had 15 hospitals, and so we randomized each hospital into one of the three programs.
26:21
SPEAKER_01: So we had five hospitals in each of the program types.
26:24
SPEAKER_01: And keep in mind, these are small hospitals.
26:26
SPEAKER_01: You know, some of them were 19 beds, 20 beds, critical access hospitals.
26:29
SPEAKER_01: So it wasn't like, yeah, we had five hospitals and that was over a thousand beds.
26:33
SPEAKER_01: You know, this was we had five hospitals and it totaled maybe 300 beds, 200 beds in each one.
26:39
SPEAKER_01: So, you know, what we did was we developed kind of a low, medium, and high approach in terms of the intensity of stewardship that we offered.
26:46
SPEAKER_01: All the facilities got a baseline education on antibiotic stewardship, what it is.
26:52
SPEAKER_01: We developed some nice educational materials, some one-pagers on IB to PO transition, what is prospective audit and feedback, you know, just really kind of basic stuff in terms of stewardship.
27:04
SPEAKER_01: And they all received that.
27:05
SPEAKER_01: They also all received their own data.
27:08
SPEAKER_01: And so they were able to see what their antimicrobial prescribing looked like, but they didn't see it in comparison to the other facility.
27:15
SPEAKER_01: You know, this wasn't a study where we wanted them to really see how they compared because we knew that one group may you know improve more.
27:23
SPEAKER_01: We didn't necessarily want that to influence, you know, how they perceived their data.
27:27
SPEAKER_01: So we gave them their data over time and they could see the different antibiotics they use and any changes that occurred during the study.
27:33
SPEAKER_01: And then they all had access to what we called the score hotline.
27:37
SPEAKER_01: It was 80150 score.
27:39
SPEAKER_01: They could dial that, they reached an ID doc 24 hours a day, seven days a week, and all facilities had access to that.
27:46
SPEAKER_01: And that was me being a very naive, very junior investigator thinking, like, nobody's gonna call this.
27:53
SPEAKER_01: This is fine.
27:54
SPEAKER_01: I'll just develop this and I'll just staff it.
27:57
SPEAKER_01: And you know, it's gonna be a minimally obtrusive into my life.
28:02
SPEAKER_01: Man, I was dead wrong on that.
28:05
SPEAKER_01: Those three things is what the low facilities got, and then the medium facilities got all those three things.
28:11
SPEAKER_01: And then in addition, we trained their local pharmacies how to do prospective audit and feedback and also restrictions on a limited number of drugs.
28:19
SPEAKER_01: And then in the high group, we expanded that prospective audit and feedback and restrictions.
28:24
SPEAKER_01: And the restrictions were held by our ID pharmacists.
28:28
SPEAKER_01: And then we let it go for about 15 months and we looked at the results.
28:31
SPEAKER_01: And you know, what we saw was the fact that the more you did, the more results you got.
28:36
SPEAKER_01: And so the more you did, the you know, the more antibiotics were reduced, the more of the restricted drugs were reduced, and the more calls you received on the ID outline.
28:45
SPEAKER_01: And so, you know, the basics of it was the more you are engaged with a facility from an ID physician and stewardship standpoint, the more results you're gonna see in terms of antibiotic prescribing and also engagement with ID consults.
29:00
SPEAKER_01: And so we really took that format of that high approach and we brought it to the rest of the facilities at the end of the study and expanded out.
29:09
SPEAKER_01: And so now all of you know our inner mountain facilities that are cared for by a tele stewardship program really has that high intensity stewardship and it's evolved over time, clearly, but that's really how we started out and um were able to offer our services to our hospitals.
29:26
SPEAKER_02: So is it fair to say that a low-touch approach probably doesn't have much impact on antibiotic use, or am I oversimplifying things?
29:37
SPEAKER_01: Yeah, it's a it's a great question.
29:39
SPEAKER_01: And I think it's a question that we need to answer in the tele stewardship arena is what is the impact of some of these lower touch programs?
29:50
SPEAKER_01: And maybe it's not, maybe we're looking at the wrong outcomes, you know, maybe it's not just DOTs that we should be looking at.
29:56
SPEAKER_01: And we should be looking at you know more quality metrics and more appropriateness metrics and safety metrics around staph aureus bacteria.
30:04
SPEAKER_01: But I think it's something we really need to evaluate because you know, not all hospitals are going to be able to get this high-intensity stewardship program.
30:11
SPEAKER_01: They're not gonna be able to link their EHR to an outside hospital.
30:15
SPEAKER_01: They're not gonna be able to afford to uh, you know, have a subscription service to either me or to Aaron's group.
30:21
SPEAKER_01: Um, you know, and maybe they can only do an echo model where they are being mentored stewardship.
30:26
SPEAKER_01: And it really is important for us to say what is the impact of you know some of these different program and program types.
30:33
SPEAKER_01: I think about UW Tasp that has this really nice echo model that reaches, you know, lots of hospitals in Washington and surrounding states.
30:41
SPEAKER_01: And what is the impact of something like that?
30:43
SPEAKER_01: And so I wouldn't say that we don't impact care.
30:46
SPEAKER_01: I do think we impact care.
30:47
SPEAKER_01: I think it's up to us to try to determine, you know, how do we measure that?
30:52
SPEAKER_01: And how can we help facilitate engagement of all small community hospitals that don't have access to stewardship to some kind of you know hub and spoke model where we can mentor them in stewardship?
31:04
SPEAKER_00: Yeah, I would just tack onto that.
31:06
SPEAKER_00: I don't have the answer, but I would agree wholeheartedly.
31:08
SPEAKER_00: One of the hospitals I work with is like is like eight beds.
31:11
SPEAKER_00: It's like that tiny critical access hospital.
31:14
SPEAKER_00: Some weeks they have whole weeks where they don't have a single patient on antibiotics.
31:17
SPEAKER_00: And so, but our stewardship services are valuable and it's hard to quantify that.
31:22
SPEAKER_00: But I think as a as a profession and as a collective whole in healthcare, we need to be better about that because you have to use antibiotics, so you're never gonna get your DOTs to zero.
31:31
SPEAKER_00: And at the end of the day, especially in these community sites, most of the antimicrobials that were being used are are pretty cost effective.
31:38
SPEAKER_00: And so you're not gonna see these million dollar gains and stewardship and drug cost savings alone.
31:43
SPEAKER_00: It's not enough to measure the value of what we're doing.
31:46
SPEAKER_00: But this is something infectious diseases struggles with across the board, right?
31:51
SPEAKER_00: As an intellectual specialty rather than a specialty that really is billing for a lot of procedures and services.
31:56
SPEAKER_00: So I think just something to keep in mind as we build these programs.
32:00
SPEAKER_02: So I think it'd be useful for our audiences to hear what your individual telestewardship programs look like.
32:05
SPEAKER_02: Dr.
32:05
SPEAKER_02: McCray, I'll start with you.
32:07
SPEAKER_02: How is the UPMC telestewardship program set up and specifically how many and what types of facilities is your program supporting?
32:15
SPEAKER_02: What are the types of services and interventions that are being offered or performed?
32:20
SPEAKER_02: And how have you kind of structured your program in order to deliver those services?
32:25
SPEAKER_02: And kind of what does that look on the originating site and perhaps the receiving site?
32:31
SPEAKER_00: Yeah, it's a great question.
32:33
SPEAKER_00: Briefly, I think so.
32:34
SPEAKER_00: Our community hospital stewardship program, as I said, started.
32:37
SPEAKER_00: We have a pharmacist and a physician co-lead that run that program and I help support that program.
32:42
SPEAKER_00: They focus on we have multiple EHRs across our health system, which is a whole nother can of worms.
32:48
SPEAKER_00: But 19 of our hospitals are on our core Cerner as the EHR.
32:52
SPEAKER_00: And then they use Alum Insight as their stewardship third-party alerting system.
32:56
SPEAKER_00: But really, you know, it could be any third-party alerting system if your stewardship isn't built into your EHR, which some EHR support better than others.
33:05
SPEAKER_00: And that is very similar to Inner Mountain in that it's this hub and spoke model.
33:09
SPEAKER_00: We have a central pharmacist that reviews patients at sites that don't have an ID trained pharmacist.
33:14
SPEAKER_00: We're actually hiring a second pharmacist now after about three years of a really successful program.
33:19
SPEAKER_00: We're able to get support for another pharmacist, which is really exciting.
33:22
SPEAKER_00: But within those 19 hospitals, those models vary.
33:25
SPEAKER_00: So about four to five of those hospitals do have an ID trained pharmacist on site.
33:30
SPEAKER_00: The about four or five others have a local pharmacist who is solely responsible for stewardship.
33:35
SPEAKER_00: They're not necessarily ID trained, but they've been doing stewardship for a long time, and that's their job, which is nice.
33:40
SPEAKER_00: But then the rest of them have a maybe a clinical pharmacist that helps look at patients, but really no formal ID training and not a hundred percent dedicated stewardship time.
33:49
SPEAKER_00: So we're all across the board and we have trained everyone in the software, and then we collaborate with everyone.
33:56
SPEAKER_00: We actually leverage Microsoft Teams a lot.
33:58
SPEAKER_00: We basically have a constant, massive system ID pharmacist group chat where people can throw a patient that they're looking at in that team's chat, and any pharmacist or physician who sees it can respond to that.
34:10
SPEAKER_00: So that's kind of a constant communication.
34:12
SPEAKER_00: We have a bi-weekly stewardship clinicians call, and then we have a monthly system stewardship subcommittee call to communicate.
34:19
SPEAKER_00: But it is this integrated model within the UPMC network.
34:23
SPEAKER_00: And then from the ID Connect end, which ID Connect started as a UPMC enterprises company, it is the for-profit sector that is a large telemedicine company now that does both consults and stewardship.
34:34
SPEAKER_00: That's where I work with hospitals external to UPMC.
34:37
SPEAKER_00: And I've touched on those models, but just to recap very briefly, I work with one three hospital health system that's all community sites.
34:46
SPEAKER_00: And I meet with those pharmacists for an hour a day via Microsoft Teams.
34:50
SPEAKER_00: I do have access to the EHR.
34:52
SPEAKER_00: We do targeted prospective audit and feedback.
34:54
SPEAKER_00: And I also do a lot of project work with them.
34:57
SPEAKER_00: So I do about 10 to 20 hours a month of MUE kind of things, implementing protocols, microbiology lab work, et cetera.
35:04
SPEAKER_00: I have another hospital.
35:05
SPEAKER_00: It's about a 400-bed community hospital that's about an hour outside of Pittsburgh.
35:10
SPEAKER_00: I meet with them 30 minutes a day and I also have access to that EHR.
35:14
SPEAKER_00: I talk to those pharmacists and coach them, and then they make local interventions.
35:18
SPEAKER_00: And then the critical access hospital I work with in California is pure echo model, and that we do a monthly case conference and then weekly touch bases and educational topics and things like that.
35:29
SPEAKER_00: I was laughing.
35:30
SPEAKER_00: I think I don't know if we've mentioned this, but a barrier is definitely as you start to work with all these sites, like we are people that are naturally like, here's my cell phone number.
35:39
SPEAKER_00: Call me about all your patients.
35:40
SPEAKER_00: I'm totally interested.
35:41
SPEAKER_00: I want to help you all the time.
35:42
SPEAKER_00: I think everyone in Pittsburgh has my cell phone number.
35:45
SPEAKER_00: Like I think every single soul across the UPMC enterprises has my cell phone number.
35:50
SPEAKER_00: And, you know, that's fine to a degree.
35:53
SPEAKER_00: But as you start working with more and more sites, because telemedicine is such a cool force multiplier in that I can work with so many pharmacists and physicians at so many sites and so many different models.
36:04
SPEAKER_00: There has to be some kind of boundary.
36:06
SPEAKER_00: And so I don't have the perfect solution to that yet.
36:08
SPEAKER_00: But constantly being on your cell phone and email for all of these patients can get a little taxing.
36:14
SPEAKER_00: So I think that's just something that people have to watch out for.
36:17
unknown: Dr.
36:17
SPEAKER_02: Sthenny, can you describe how the program Intermountain Health is set up?
36:21
SPEAKER_01: Yeah, happy to gross.
36:23
SPEAKER_01: I'm I'm just laughing about Aaron's comment about everybody having her cell phone.
36:27
SPEAKER_01: Everybody in the state of Utah had had mine, which is probably similar to the size of your town.
36:32
SPEAKER_01: So it's, you know, it's similar.
36:34
SPEAKER_01: But yeah, so Intermountain is set up.
36:36
SPEAKER_01: So we now cover 17 Intermountain facilities, and we all share the same EHR.
36:41
SPEAKER_01: We're all on Cerner, and we all um have access to Vigilance, which is our real-time monitoring software.
36:47
SPEAKER_01: And so we now have two tele stewardship pharmacists that are on to serve those two hospitals and our outreach hospitals.
36:55
SPEAKER_01: And then we also have a tele ID physician that's on as well.
36:59
SPEAKER_01: And you know, from our standpoint, it's really critical to have that ID physician doing tele ID consults in addition to having the telepharmacist doing the stewardship because they're incredibly linked and integrated.
37:12
SPEAKER_01: And so, in terms of just the stewardship, we are fully integrated with the local teams.
37:17
SPEAKER_01: And so the local team will be monitoring their vigilance alerts, their prospective audit and feedback, their restricted drugs, their blood culture monitoring, you know, all of that will be done at the local site.
37:28
SPEAKER_01: And then the ID pharmacist will essentially be backing them up.
37:32
SPEAKER_01: Granted, the ID pharmacist now has 17 hospitals as opposed to the local team having one.
37:37
SPEAKER_01: And so they're not reviewing all the alerts that the local team are reviewing, but they're reviewing the alerts that are really these kind of high-risk, high safety alerts that we've designated.
37:47
SPEAKER_01: And so they're looking at every blood culture, they're looking at carbapenamuse and specific antimicrobials.
37:53
SPEAKER_01: And so they're doing that as just kind of routine work on a daily basis.
37:57
SPEAKER_01: When they see something, staph aureuspectoremia, for example, and they see that the local team hasn't called the teleid team, they'll intervene and they'll kick that up to the teleid doc on call, and we'll you know essentially invite ourselves to the party.
38:12
SPEAKER_01: At this point, most people know that, okay, staph aureuspectoremia, fungemia, I'm calling teleid.
38:18
SPEAKER_01: But you know, we'll get involved earlier through our stewardship program.
38:21
SPEAKER_01: And then other you know, diagnostic cases that the pharmacist will review and say, hey, this just doesn't fit right.
38:27
SPEAKER_01: I'm gonna bump this up and review it with my doc, or those patients that are being evaluated by telecritical care, which we offer as well, we'll have that collaborative conversation either between the pharmacist and the telecritical care doc or the teleid physician and the critical care doc.
38:42
SPEAKER_01: And so all that is kind of happening as routine work across our facility.
38:46
SPEAKER_01: And then the other thing that the telepharmacist does is really these collaborative projects.
38:51
SPEAKER_01: And so we encourage all of our sites to have at least one focused stewardship project each year.
38:56
SPEAKER_01: Many times that is, you know, a project that's the same across all sites and will help develop case report forms and data collecting tools and the like.
39:04
SPEAKER_01: Our telepharmacists will be essentially mentoring the pharmacists on the other end to be really working hard on these projects and looking at our outcomes.
39:12
SPEAKER_01: And then we also have a monthly echo that we put on as a time to really gather as a community of stewards across uh intermountain healthcare, have a topic of discussion, and then allow people to ask questions and answers of our leadership team.
39:26
SPEAKER_01: For the outreach sites, it's a little different because we don't necessarily have access to their EHR for all of these sites.
39:32
SPEAKER_01: And so we're not doing the stewardship for them.
39:34
SPEAKER_01: We're not fully integrated.
39:36
SPEAKER_01: We're available, obviously, in a mentorship role and they meet with them on a cadence and they help them set up their programs and there in terms of mentorship and guidance.
39:45
SPEAKER_01: Our ID physicians are available via a hotline to talk to them for challenging cases, but it definitely looks different than our inner mountain facilities.
39:53
SPEAKER_01: And that's really most of it's based on the fact that we don't have direct access to their EHR.
39:57
SPEAKER_01: So that's really kind of in a nutshell what we're doing for our facilities.
40:01
SPEAKER_02: I know that both of you already kind of have alluded to a number of the challenges that that you faced with implementing and sustaining your telestewardship programs.
40:11
SPEAKER_02: If you were to kind of step back and kind of pick, you know, maybe the the top three or the common, you know, barriers, challenges that that people may encounter as they're looking to build or expand their telestewardship program, what would each of you highlight?
40:25
SPEAKER_02: And Dr.
40:26
SPEAKER_02: McCray, I'll start with you.
40:28
SPEAKER_00: Okay.
40:28
SPEAKER_00: In addition to things I guess I already said, I'll I'll I guess piggyback on how we ended.
40:32
SPEAKER_00: I do think access to the EHR, if you're reviewing patients, is essential.
40:37
SPEAKER_00: If you're in a model where you're not providing direct patient review, then of course, and we've talked about how education can work.
40:45
SPEAKER_00: But if the expectation of your stewardship services and the model you're trying to build is that you're going to be doing some kind of prospective audit and feedback, it's really helpful to actually read the notes.
40:56
SPEAKER_00: You get to know the local prescriber style.
40:59
SPEAKER_00: I mean, there's only so much someone can read to over the phone until you're like, I just need to look at this chest x-ray myself.
41:04
SPEAKER_00: And so I think that has been important.
41:07
SPEAKER_00: That's also a barrier, though, especially as a pharmacist.
41:10
SPEAKER_00: So figuring out what it even meant to get credentialed as a pharmacist at these hospitals, whether or not we need licensure.
41:16
SPEAKER_00: I'll pause and say, I think it's absurd that medical professionals need a different license in all 50 states to practice medicine.
41:22
SPEAKER_00: So that nationally is a huge barrier to providing care.
41:25
SPEAKER_00: And if we're going to start to structurally address a lot of the health disparities in our country, we have to make it easier for physicians and nurses and pharmacists to take care of patients in other states.
41:35
SPEAKER_00: So that's something I kind of just put forth an advocacy in general that I think we need to support that a little bit better.
41:41
SPEAKER_00: And then I the other biggest one, of course, is culture changes really hard.
41:45
SPEAKER_00: We've talked about this a lot, but some of the hospitals you go into may have had some semblance of some kind of stewardship program.
41:52
SPEAKER_00: At this point, we're four or five years out from a lot of the regulatory requirements surrounding stewardship.
41:58
SPEAKER_00: So we have a little bit in that people at least have heard this word before.
42:01
SPEAKER_00: But a lot of these hospitals too aren't under joint commission requirements.
42:04
SPEAKER_00: If they're teeny tiny community hospitals, they might not need to meet those regulatory measures at this point in time.
42:11
SPEAKER_00: And so going in and giving unsolicited advice as a steward is always challenging to a degree, but it's especially challenging when you are a stranger across a computer.
42:23
SPEAKER_00: And so again, forming those relationships in order to start to break down these barriers and meet people where they are, help them achieve their goals will in the long run just help you achieve your goals.
42:35
SPEAKER_00: I do think connecting your sites as much as possible is really valuable.
42:38
SPEAKER_00: So I love the monthly case conference discussion type things.
42:42
SPEAKER_00: And like I said at UPMC across our 19 hospitals, we're just constantly in communication on teams and like however you can connect people so they don't feel like they're alone.
42:50
SPEAKER_00: I think that's all very helpful, especially with the state of healthcare right now.
42:54
SPEAKER_01: Eddie, anything you'd like to add?
42:56
SPEAKER_01: Yeah, I mean, I just am laughing because I don't know how many times you know I've had a conversation about enterococcus, and then you look at the chart and it's enterobacter, you know.
43:07
SPEAKER_00: Yes.
43:08
SPEAKER_00: And you're like, yes, that is so true.
43:11
SPEAKER_00: And you're like, like, wait, what?
43:16
SPEAKER_00: My favorite is like, oh, they have a history of ESPL like from last week, and you're like, oh no.
43:21
SPEAKER_00: And then you look and it was like 2017.
43:24
SPEAKER_00: You're like, dates are important.
43:27
SPEAKER_01: Or one more is the oh, they're two out of two blood cultures for coag negative staff.
43:32
SPEAKER_01: And you're like, two out of two, really?
43:34
SPEAKER_01: Like, oh yeah.
43:35
SPEAKER_01: And then you look and it's one out of two sets.
43:37
SPEAKER_01: And in that one set, they had two cultures positive, and you know, these things that are you know, we laugh about it, but like this is just an example of like this is the value we add.
43:47
SPEAKER_01: And it's not that we're better doctors, it's just that we're much more comfortable in this space, just like other specialists are more comfortable in their space.
43:55
SPEAKER_01: And but it's you know, it's just an example where looking at the chart so critical, you know.
44:00
SPEAKER_01: I'll talk about the kind of the elephant in the room.
44:02
SPEAKER_01: It's funding.
44:03
SPEAKER_01: The biggest barrier, I think, is funding.
44:05
SPEAKER_01: I would say that healthcare networks, so integrated healthcare networks, have an obligation to provide the service to all of their facilities.
44:14
SPEAKER_01: Period.
44:14
SPEAKER_01: Blanket statement.
44:15
SPEAKER_01: We know this adds value.
44:17
SPEAKER_01: We know we can do it through models, you know, that Aaron's talked about, like Intermountain has accession health, HCA, you know, all these places can do this.
44:25
SPEAKER_01: And so if you're in a healthcare network and you're not reaching your small facilities, that needs to be a priority and that needs to be prioritized at your healthcare network level, at that leadership level.
44:35
SPEAKER_01: And so that doesn't have anything to do with funding.
44:37
SPEAKER_01: That's just resourcing it and providing the care that you need to provide your care to your communities.
44:43
SPEAKER_01: I think the real challenge is those independent small community hospitals, critical access hospitals, that may not be part of a system.
44:51
SPEAKER_01: And we've seen through COVID how taxed they are.
44:54
SPEAKER_01: We're seeing them close because they don't have the funding.
44:57
SPEAKER_01: They don't have necessarily the patients and the revenue to keep them open.
45:00
SPEAKER_01: And so then how are we supposed to come in and say, hey, I want you to pay me to give you this service?
45:07
SPEAKER_01: And, you know, they'll look at you and say, well, that's great, Eddie.
45:11
SPEAKER_01: Are you also can provide psychiatric care and cardiology care and rheumatology?
45:17
SPEAKER_01: And, you know, so we are just one aspect of care that these small community hospitals need.
45:22
SPEAKER_01: It happens to be that, you know, CMS requires it and joint commission requires it and the like, but they don't have any extra money to be able to facilitate, you know, some of these types of programs that they desperately need.
45:35
SPEAKER_01: And so I think it's you know something we need to be thinking about.
45:39
SPEAKER_01: We, the greater we of healthcare, is how do we provide this service free of charge?
45:43
SPEAKER_01: You know, should these be state-based public health run initiatives that then potentially contract with organizations like ID Connect or Inner Mountain or UWE Task or any of these different organizations that have been doing this now for a number of years and doing it well?
45:59
SPEAKER_01: But how do we ensure that we can provide this service to all facilities across the United States?
46:06
SPEAKER_01: And I think that's you know a really challenging ask, especially for those really small community hospitals that you know desperately need this service, that have no access to infectious disease care.
46:17
SPEAKER_01: So I'll just tack that on to the list that Aaron already mentioned.
46:21
SPEAKER_02: Well, you you segued right into my next question, and and you you did a wonderful job answering that.
46:26
SPEAKER_02: Aaron, do you have anything else that you want to add to that from you know on the financial aspects, which I agree is such a critical aspect of this?
46:34
SPEAKER_00: No, that was beautifully put.
46:37
SPEAKER_00: I just got back from a site visit at my uh 400 bed hospital, standalone community hospital I work with, and it was the best day.
46:44
SPEAKER_00: I haven't, it was a really great day to go there in person and meet with everyone.
46:48
SPEAKER_00: And it was it was great.
46:49
SPEAKER_00: But at the end of the day, the CMO sat us down and was basically like, I love y'all, you've made a difference, it's great.
46:58
SPEAKER_00: But without hard dollars, like we cannot sustain this service.
47:03
SPEAKER_00: So go home and come back to me and tell me how you're actually saving me money so I can keep paying you.
47:09
SPEAKER_00: And I mean, we know that is the cold hard truth, and but it's hard, and I've said it before, but metronitizal is dirt cheap, whether it's IV or PO.
47:17
SPEAKER_00: And like, yes, IV to PO flagell is important.
47:19
SPEAKER_00: Stopping flagell when they're on Zosin is important.
47:22
SPEAKER_00: Like, I can't use that to cost justify the entire program.
47:27
SPEAKER_00: And because you're not gonna, again, you're not gonna get it to zero and it's really not that much in hard drug dollars.
47:32
SPEAKER_00: And then again, just a fatal error of our healthcare system is that cost avoidance and and harm avoidance is not something you get credit for in hard dollars.
47:42
SPEAKER_00: Or if you do, you've worked really, really hard to come up with a way to prove that to your C-suite.
47:48
SPEAKER_00: And that's all that we do in stewardship and in pharmacy practice and in a lot of things is the most of what I do is you know prevent drugs from ever getting to the patient.
47:57
SPEAKER_00: That actually, in a lot of reimbursement models, actively hurts my profession because we are valued on how many doses we dispense.
48:05
SPEAKER_00: And so when I stop patients from getting unnecessary medication, I'm actually shooting myself in the foot based on reimbursement models, which is insanity.
48:12
SPEAKER_00: And so I don't know if I have the perfect solution.
48:15
SPEAKER_00: I mean, obviously, we we put together a lot of data.
48:18
SPEAKER_00: We do a lot of QI projects, we try to show decreased adverse events, decreased AKI and vancomycin use kind of things, you know, less need for renal replacement therapies, shorter hospital length of stay.
48:30
SPEAKER_00: If you can show that, that goes a long way.
48:32
SPEAKER_00: But at the end of the day, that kind of stuff and mortality benefits for sure are hard to show, especially with observational studies.
48:39
SPEAKER_00: And so you have to make your program cost effective and you have to cost justify it.
48:44
SPEAKER_00: And that is hard.
48:45
SPEAKER_00: I will say a value though that we show is we do intervene on some sites are really eager to purchase things that are probably unnecessary.
48:54
SPEAKER_00: And so we actually just with one of my community sites, they were going to bring on a pretty expensive rapid diagnostic platform for gram-negative bacteremias.
49:03
SPEAKER_00: They had three pseudomonas bacteremias in an entire calendar year.
49:07
SPEAKER_00: So they just don't have that many patients or that many positive blood cultures.
49:10
SPEAKER_00: And so it's not worth it for them to bring on that platform despite how cool it sounds and despite how it would have improved the care for those three patients.
49:19
SPEAKER_00: Unfortunately, I can't cost justify that for three patients.
49:22
SPEAKER_00: And so we help with those kinds of counseling things, but again, that's cost avoidance.
49:26
SPEAKER_00: They didn't spend money, but I don't get to take credit for that in a lot of ways.
49:30
SPEAKER_00: So I think something we all struggle with.
49:33
SPEAKER_01: Chris, can I just tag on to that a little bit?
49:35
SPEAKER_01: Yeah, please.
49:37
SPEAKER_01: Yes, completely.
49:38
SPEAKER_01: That's not what I was gonna add.
49:40
SPEAKER_00: Um thank you though.
49:42
SPEAKER_01: I feel yeah, you know, you know, one thing that I think you know, we as a stewardship community needs to start focusing on is in this realization that payers are moving much more to a value-based care contracting, so at-risk dollars.
49:59
SPEAKER_01: And so payers are essentially offering a capitated platform for their lives that they're serving under that, you know, insurance plan.
50:07
SPEAKER_01: And we need to be thinking about how do we influence population health on the individual member?
50:14
SPEAKER_01: And you know, that then turns a focus to ambulatory stewardship.
50:18
SPEAKER_01: And we haven't even talked about, you know, the fact that in these small hospitals that you're offering tele stewardship to a hospital, those are the same doctors, those are the same APPs that are taking care of the patients in the clinic.
50:29
SPEAKER_01: And so, you know, how can we think about moving upstream and influencing the care of the patient before they get to the hospital?
50:38
SPEAKER_01: And how do we contextualize that?
50:40
SPEAKER_01: How do we verbalize and show that in some kind of business case that not only are we gonna help you, like Aaron said, change the metronidazole prescribing, which is pennies, but how do we move upstream and say, we're gonna help prevent a hospitalization, which under at-risk care plans is what you need to do.
50:57
SPEAKER_01: It's absolutely critical that you do that to save those folks money.
51:01
SPEAKER_01: So I think that's one thing is turning our attention to population health and value-based care, and how can we articulate that?
51:07
SPEAKER_01: And then the other thing is what else can we provide small hospitals?
51:11
SPEAKER_01: You know, we're very good at stewardship of drugs, of antibiotics, but it turns out those same principles apply to lab diagnostic stewardship.
51:21
SPEAKER_01: It applies to stewardship of radiologic imaging.
51:24
SPEAKER_01: And can we market ourselves as like, yeah, we're gonna do your antibiotic stewardship, but we're also gonna, you know, lead something called lab stewardship and we're gonna help you reduce your lab costs.
51:34
SPEAKER_01: I think Aaron's point is great in terms of unnecessary molecular tests.
51:38
SPEAKER_01: Like that is, you know, a huge aspect for some of these facilities.
51:41
SPEAKER_01: And so, you know, how can we leverage our skills in other areas to make ourselves more marketable for these small hospitals that need us and be able to then show them the financial benefit of our skills?
51:52
SPEAKER_01: So just you know, I think a future directions idea of like we can be, you know, engaged in other aspects of stewardship besides antibiotics.
52:01
SPEAKER_02: Well, this has been an amazing talk, and I feel like I could talk to both of you for another couple hours, but we do have to end up our conversation today.
52:09
SPEAKER_02: But before we kind of leave, do either of you have any additional thoughts or comments that we didn't touch on that you feel are uh would be important for our audience to hear?
52:19
SPEAKER_02: Dr.
52:19
SPEAKER_02: McCray, I'll start with you.
52:21
SPEAKER_00: No, I think we've covered a lot of it.
52:22
SPEAKER_00: This was really fun.
52:23
SPEAKER_00: I appreciate both of you.
52:25
SPEAKER_00: And I think this is a conversation we're gonna keep having.
52:27
SPEAKER_00: And I and again, I just want to reinforce like telemedicine isn't going anywhere.
52:30
SPEAKER_00: It's something I never thought I'd be doing, and now I can't really see myself doing anything else.
52:34
SPEAKER_00: And I think it's just so, so cool that we are spreading our specialty to the communities and again treating patients where they are.
52:41
SPEAKER_00: So thanks for the thanks for the opportunity.
52:44
SPEAKER_01: Yeah, Chris, I mean, what a delightful way to start your morning at 6:30.
52:50
SPEAKER_01: Um I think this is a conversation like Aaron said that we're gonna continue to have.
52:56
SPEAKER_01: Tele stewardship, teleid is here to stay.
52:59
SPEAKER_01: COVID has showed us that.
53:00
SPEAKER_01: You know, we've had the same experience as Aaron has in terms of really integrating our COVID therapeutics algorithm across our system.
53:08
SPEAKER_01: And so that's not gonna go away.
53:10
SPEAKER_01: We've we've shown our value time and time again over these past 19 months, and we've generated such goodwill, it's upon us to really capture that and move forward.
53:20
SPEAKER_01: And people see infectious disease clinicians in a brand new light.
53:24
SPEAKER_01: It's our opportunity now to really kind of lead out on that.
53:27
SPEAKER_01: And to the listeners, I would say if you're not involved in stewardship in a small hospital, get involved.
53:33
SPEAKER_01: Get out, get on the road, meet with people, understand what they need, have a cup of coffee, shake hands, do the things that you should to really start meeting people.
53:42
SPEAKER_01: And if your system isn't engaged in this and you have hospitals in your system that don't have stewardship, you know, that's on you to escalate that and make sure that you are pushing your leaders to say, hey, this is something that they need.
53:55
SPEAKER_01: And I'd say get involved.
53:56
SPEAKER_01: Everybody's got Aaron's cell phone number, just give her a call, you know, and she'll walk you through it.
54:01
SPEAKER_00: Happy to talk.
54:02
SPEAKER_00: You can DM me on Twitter.
54:04
SPEAKER_01: No, there's, and I I mean that in all seriousness, is that there are this community of stewards that have been focused on tele stewardship, and there's a number of us are great people that are willing to chat and willing to share and provide you the resources that you need to get going.
54:19
SPEAKER_01: And I would just say, you know, reach out.
54:22
SPEAKER_01: We are happy to set up a call and have an initial conversation.
54:25
SPEAKER_01: And we just need more people involved in this area of stewardship.
54:29
SPEAKER_02: Well, thank you to you both, Dr.
54:30
SPEAKER_02: McCray and Dr.
54:31
SPEAKER_02: Stiniam.
54:32
SPEAKER_02: This has been such a great conversation.
54:34
SPEAKER_02: I feel like I've learned a ton and it was a pleasure having you both here today.
54:38
SPEAKER_01: Thanks, Chris, for having me.
54:39
SPEAKER_01: Really pleasure.
54:40
SPEAKER_00: Yeah, thank you so much.
54:42
SPEAKER_02: As a reminder, this is episode two of a four-part series.
54:45
SPEAKER_02: Be on the lookout for our remaining episodes, innovations and diagnostic stewardship, a focus on bacteria and bacteria spudia and antibiotic stewardship in the time of COVID-19, which will launch in the upcoming weeks.
54:57
SPEAKER_02: You can find more educational content like this podcast on Shay's online education center, Learning CE, at www.learningce.shayonline.org.
55:08
SPEAKER_02: This concludes episode two of the challenges and innovations in antibiotic stewardship series.
55:15
SPEAKER_02: Thank you for tuning in.