Discussion
This study demonstrates the benefit of participating in a regional ASP collaborative for individual facilities and the region. Some products from the collaborative include the development of regionwide guidance for the use of antimicrobials in COVID-19, interfacility collaborative initiatives, a COVID-19 dashboard, improvement in metrics, and several publications. Importantly, this expansion occurred during the COVID-19 pandemic when many ASP members were spread thin. Moreover, despite 4 sites not meeting VA-recommended ASP staffing requirements for both pharmacists and physicians, productivity increased within the VISN as facilities worked together sharing local challenges and successful paths in removing ASP barriers. The collaborative shared QI strategies, advocated for technological support (ie, Theradoc and dashboards) to maximize available ASP human capital, standardized metric reporting, and made continued efforts sustainable. VA ASTF disseminates evidence-based practice but is not designed to develop tailored site-specific interventions, which has led to the support of VISN-level collaboratives to serve local facilities’ needs. We postulate the use of a collaborative as a beneficial strategy to increase productivity and achieve local goals with limited resources.
Previous reports in the literature have found ASP collaboratives to be an effective model for long-term program growth.3 Two collaboratives found improved adherence to the Centers for Disease Control and Prevention core elements for ASP.4,5 Similar to our findings, other collaboratives noted a reduction in AU after implementation, although statistical analysis of improvement over time was not performed to verify significance.3-5,7 One VA study reviewed the use of dashboards with a monthly learning collaborative and identified a reduction in AU.7 However, the structure of our ASP collaborative was through joint meetings and projects, as defined by Buckel and colleagues.6
Our findings highlight that ASP collaboratives can help answer the recent call to action from McGregor, Fitzpatrick, and Suda who advocated for ASPs to take the next steps in stewardship, which include standardization of evaluating metrics and the use of robust QI frameworks.11 Moving forward, an area for research could include a comparison of ASP collaborative infrastructures and productivity to identify optimal fit dependent on facility structure and setting. Parallel to our experience, other reports cite heterogeneous ASP metrics and a lack of benchmarking, spotlighting the need for standardization.8,11,12 The VA and other health care facilities would benefit from national benchmarking of AU metrics to make comparisons across sites beneficial.
Limitations
Using annual reports was a limitation for analyzing and reporting the full impact of the collaborative. Local facility-level discretion of content inclusion led to many facilities only reporting on the forefront of new initiatives that they had developed and may have led to the omission of other ongoing work. Further, time invested into the ASP regional collaborative was not captured within annual reports; therefore, the opportunity cost cannot be determined.
Conclusions
The VA has an advantage that many private health care facilities do not: the ability to work across systems to ease the burden of duplicative work and more readily disseminate effective strategies. The regional ASP collaborative bred innovation and the tearing down of silos. The implementation of the collaborative aided in robust QI infrastructure, standardization of reporting and metrics, and greater support through facility alignments with regional guidance. ASP interfacility collaboratives provide a sustainable solution in a resource-limited landscape.
Acknowledgments
This work was made possible by the resources provided through the Antimicrobial Stewardship Programs in the Veterans Integrated Services Network (VISN) 9.