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Woman on phone at deskThe advent of COVID-19 catalyzed a still-evolving and radical shift in healthcare delivery, especially in hospitals that were already on the front lines of caring for the sickest patients. In March, as University of North Carolina Hospitals’ non-critical employees were sent to work from home, Carolina Antimicrobial Stewardship Program (CASP) Medical Director Nikolaos Mavrogiorgos knew everyone would have to adapt to new realities. That’s when he and CASP’s Pharmacy Lead, Lindsay Daniels, put their heads together with the CASP team see how they might adapt interventions to the times, with more physicians and pharmacists doing at least some of their work from home, and those in the hospital with infectious diseases expertise being tapped for the hospitals’ COVID-19 response.

“There is a growing body of literature that demonstrates that tele-antimicrobial stewardship programs can effectively improve appropriate antimicrobial use, just as their traditional bricks-and-mortar counterparts do,” Mavrogiorgos explained. “I was curious to explore how incorporating approaches such as video or teleconferencing might make our stewardship activities more nimble, given the changes brought with COVID.”

National professional societies as well as regulatory and accreditation bodies now require or strongly recommend that all hospitals put in place an antimicrobial stewardship program. Tele-antimicrobial stewardship programs (tele-ASPs) are a practical option for expanding stewardship to smaller, rural facilities that often lack infectious diseases expertise available at larger, urban hospitals. Electronic medical record systems, the near-universal penetration of smartphones, secure chat and conferencing platforms, and strong, reliable internet make tele-ASPs feasible in hospitals that do not yet have the resources for a fully in-house stewardship program.

A cornerstone intervention of antimicrobial stewardship is prospective audit and feedback, during which a member of the CASP team review inpatient medical records to ensure antimicrobial therapy is optimal based on available evidence. This intervention is mostly carried out using standard telemedicine communication tools embedded within the electronic medical record system such as secure messaging, and supplemented through use of pagers, phones, or a combination of these.

A critical component of any effective antimicrobial stewardship program is building trusted working relationships between members of the stewardship team and members of the various treatment teams who interface directly with patients. “Handshake stewardship”, a term coined by Parker, Hurst, Child, Palmer, and Pearce in 2015, refers to face-to-face feedback with clinicians about their patients who are being treated with antimicrobials using an informal, collegial, and collaborative approach to share recommendations. With face-to-face meetings and handshakes left by the wayside in the age of highly communicable COVID-19, it is likely that while the nomenclature and delivery of handshake stewardship may change, the characteristics that it embodies will be maintained through new pathways.

CASP uses a secure, HIPAA-compliant platform for video conferencing to review patients on antimicrobial therapy to identify opportunities to optimize therapy. Then, in place of in-person visits and handshakes with colleagues on the front lines of patient care, Mavrogiorgos, Daniels, and others on the antimicrobial stewardship team, initiate a secure chat in the electronic medical record system.

“After we identify a patient whose therapy may be optimized,” Daniels explained, “we use a secure group chat to connect with the patient’s care team.” While it is not face-to-face communication as with handshake stewardship, because CASP team members typically have previously built trust and rapport with patient care teams, group chatting is a good substitute. It also has advantages over face-to-face interactions: it relieves some pressure when a treatment decision is being questioned, and the patient care team members can respond when it is convenient. Additionally, using secure chats gives the attending antimicrobial stewardship physician or supervising antimicrobial stewardship pharmacist a chance to supervise fellows and pharmacy residents in training, even from a distance. “In a few cases, speaking or meeting in real time is needed to work through unusually complex situations. But the majority of the time, tele-antimicrobial stewardship is the next best thing to being there,” said Daniels.