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Describe the workload associated with using telehealth to support Antimicrobial Stewardship efforts at Veterans Affairs Medical Centers (VAMCs) without local infectious diseases (ID) expertise.
Design:
A mixed-methods process assessment to evaluate workload and workflow associated with Videoconference Antimicrobial Stewardship Teams (VASTs).
Setting and Participants:
Rural VAMC champions paired with ID consultants at geographically distant VAMCs to form VASTs.
Methods:
Total workload estimates were based on time that champions and ID consultants allocated to VAST activities. Clinical Procedural Terminology (CPT) codes were used to estimate the workloads for clinical encounters. Role-based process maps were developed to understand variation in implementation by VAMC.
Results:
The average workload that champions and ID consultants allocated to VAST activities was 6.7% (range 1.0%–20.0%) and 8.4% (range 2.0%–12.5%) full-time equivalents (FTEs), respectively. Clinical encounters completed by ID consultants contributed an average of 1.4% (range < 0.01%–2.5%) FTEs to the workload. The average proportion of FTEs required to sustain VASTs was 13.0% (range 3.0%–31.6%). Process maps showed four phases common to each VAST’s workflow: case identification, meeting preparation, team meeting, and documentation. The tasks associated with each phase varied between VASTs. Champions carried out most tasks related to case finding and meeting preparation; the ID consultants completed most documentation tasks.
Conclusions:
The distribution of tasks within and among the VASTs indicated opportunities to improve workflow efficiency. Investing <12.5% of the FTE allocated to VA Antimicrobial Stewardship programs to support the time of an ID consultant from another VAMC can help rural VAMCs achieve staffing sustainability.
To support Antimicrobial Stewardship programs (ASPs) as well as the clinical care of patients with infections, we disseminated and implemented a Videoconference Antimicrobial Stewardship Team (VAST) to connect multidisciplinary teams from rural Veterans Affairs (VA) medical centers with geographically distant ID experts. Here, we describe the clinical syndromes discussed and the response to recommendations made during VAST sessions.
Methods:
Between September 2021 to February 2024, eight ID consultants established VASTs with ten rural VAMCs, holding regularly scheduled videoconference sessions to discuss clinical cases and provide recommendations. Data were collected on patient demographics, clinical syndromes, and recommendations. Acceptance of recommendations within one week of each session was assessed via chart review. Six months after the intervention began, we conducted semi-structured interviews to assess participants’ perceptions of VASTs.
Results:
VASTs reviewed 626 cases involving 527 unique patients. Among 763 clinical syndromes discussed, the most common were infections of the respiratory (29%) or urinary tract (21%). Overall, VASTs made 973 recommendations, of which 71% were accepted. Of 570 recommendations related to antibiotics, 459 (80%) were accepted. Among 403 other recommendations, 235 (58%) were accepted. Interviews with participants indicated the importance of building trust and strong interpersonal relationships.
Conclusions:
VASTs effectively supported Antimicrobial Stewardship in rural VA medical centers (VAMCs) without local ID expertise. High acceptance rates, particularly for antibiotic-related recommendations, suggest that telehealth-enabled provider-to-provider models enhance stewardship efforts.
Northern Ireland is no longer the relentless headline-maker in the global media it once was, when multiple killings and bombings provided a daily diet of depressing news and images. This book commences with a review of the literature on essentialism and then in the three domains: what has come to be known as 'identity politics'; the nature of nationalism; and power-sharing models for divided societies. It draws out implications for key aspects of the Northern Ireland problem. The book is based on secondary sources on Macedonia and Bosnia-Herzegovina (B-H). A key resource is the independent journalistic network in the Balkans responsible for the production of Balkan Insight, successor to the Balkan Crisis Report, a regular e-mail newsletter. The book explores how policy-makers in London and Dublin, unenlightened by the benefit of hindsight, grappled with the unfamiliar crisis that exploded in Northern Ireland in the late 1960s. It shows that a taken-for-granted communalism has had very negative effects on societies recently driven by ethnic conflict. The book argues that conflicts such as that in Northern Ireland can only be adequately understood within a broader and more complex philosophical frame, freed of the appealing simplifications of essentialism. More than a decade on from the Belfast agreement, the sectarian 'force field' of antagonism in Northern Ireland remained as strong as ever. Unionism and nationalism may be antagonistic but as individual affiliations 'Britishness' and 'Irishness', still less Protestantism and Catholicism, need not be antagonistic.
More than a decade on from the Belfast agreement, the sectarian 'force field' of antagonism in Northern Ireland remained as strong as ever. The Belfast agreement restricts north-south collaboration to twelve specified policy domains in an annexe, though the main body of the text speaks of 'at least' six implementation bodies and six areas of policy cooperation. To make the 'external' arrangements work, 'internal' governance of Northern Ireland must place a premium on dialogue and deliberation across sectarian boundaries. This can best be done through a requirement to reach cross-communal majorities on executive formation and dissolution. To implement the constitutional changes, new legislation would be required substantially amending the Northern Ireland Act 1998, passed at Westminster to implement the agreement, and the Northern Ireland Act 2006, which paved the way for renewed devolution.
On his first full day in office as US President in January 2009, Barack Obama appointed the chair of the talks leading to the 1998 Belfast agreement, George Mitchell, as his Middle East envoy. Anticipating the decision, the Washington Post reported that the former Senate majority leader was 'highly regarded as a negotiator for his work in the successful Northern Ireland peace process'. As the former president of the International Criminal Tribunal for former Yugoslavia complained, the US administration interpreted the Goldstone report, scrupulously framed by international standards of human rights and humanitarian law, as an obstacle to progress on the Israeli-Palestinian conflict. The Israeli State had pre-empted Obama's inauguration with the invasion of Gaza, committing war crimes, echoed by its enemy Hamas, according to a 575-page report for the United Nations Human Rights Council by a distinguished team led by Justice Richard Goldstone.
In his 1990 survey of literature on the Northern Ireland conflict, John Whyte suggested that, in proportion to its size, the region represented 'the most heavily researched area on earth'. He estimated that some 7,000 books and articles might have been written on the Northern Ireland conflict. The essentialist conception of the Northern Ireland 'problem' which has predominated within the British State dovetails neatly with the argument of those who would offer consociationalism as the appropriate political 'solution'. Moreover, essentialism lends itself to an excessive readiness to hand over power to the very ethnopolitical entrepreneurs, taken to be merely the passive representatives of ethnic 'communities', whose protagonism has driven the conflict itself. Ethnic protagonism in the name of identity came to be articulated in terms of the 'politics of recognition'. 'Nationalist politics' is indeed incurious at best about working 'across communities'.
This chapter explores how official discourse, in London and Dublin, came over time to define the Northern Ireland 'problem'. It also explores how only certain solutions were conceivable, notably excluding those based on universal norms, even if these were to prove unsustainable or, at best, sub-optimal. The stereotypical conceptual grid applied to Northern Ireland prevented the logical conclusion, of flexible power-sharing arrangements, based on equal citizens rather than 'communities' as the social unit, from being drawn. Within the stereotyped perspective, of course, the British State saw itself as passive and reactive, rather than its interventions framing concrete outcomes in Northern Ireland. James Callaghan as Home Secretary had recognised that British military intervention would have political implications and he commissioned contingency plans for direct rule as early as the winter of 1968.
At their summit on the western Balkans in Thessaloniki in June 2003, European Union (EU) leaders declared: 'Fragmentation and divisions along ethnic lines are incompatible with the European perspective, which should act as a catalyst for addressing problems within the region'. This chapter is based on secondary sources on Macedonia and Bosnia-Herzegovina (B-H). In B-H an amoral approach was adopted, notably by the UK, based on minimising intervention, particularly by refusing to commit troops to a peace-enforcing role. B-H might seem a more successful power-sharing case than Northern Ireland, in as much as the State institutions, however dysfunctional, have at least been in being ever since the Dayton accords. In Macedonia importantly, interethnic dialogue after the outbreak of civil conflict could be presented instead, as Brussels was keen to do, as an integral part of the path to eventual EU membership, via an Stabilisation and Association Agreement (SAA).
Substantial claims made by British ministers for the achievements of the Belfast agreement, notably had 'solved' Northern Ireland's constitutional crisis. The first serious attempt to re-establish power-sharing after the 'rolling devolution' initiative was essayed by Peter Brooke, as soon as he became Northern Ireland's Secretary in July 1989. Following the April election, and with a new Conservative Northern Ireland Secretary, Sir Patrick Mayhew, talks were initiated once more. But immediately the difficulties were apparent. Four years on from the Belfast agreement, the then Northern Ireland Secretary, John Reid, spoke of 'looking beyond the agreement' and of 'building a society free from the burden of history and liberated from the curse of sectarianism'. Josias Cunningham concludes his three-decades-long survey of UK Government policy on Northern Ireland by denying that the agreement would herald a 'post-national' politics in which ideas of 'nation, state and identity' were critically interrogated.
The International Survey of Family Law is the annual review of the International Society of Family Law. It brings together reliable and clearly structured insights into the latest and most notable developments in family law from all around the globe.
Many post-acute and long-term care settings (PALTCs) struggle to measure antibiotic use via the standard metric, days of therapy (DOT) per 1000 days of care (DOC). Our objective was to develop antibiotic use metrics more tailored to PALTCs.
Design:
Retrospective cohort study with a validation cohort.
Setting:
PALTC settings within the same network.
Methods:
We obtained census data and pharmacy dispensing data for 13 community PALTCs (January 2020–December 2023). We calculated antibiotic DOT/1000 DOC, DOT per unique residents, and antibiotic starts per unique residents, at monthly intervals for community PALTCs. The validation cohort was 135 Veterans Affairs Community Living Centers (VA CLCs). For community PALTCs only, we determined the DOT and antibiotics starts per unique residents cared for by individual prescribers.
Results:
For community PALTCs, the correlation between facility-level antibiotic DOT/1000 DOC and antibiotic DOT/unique residents and antibiotic courses/unique residents was 0.97 (P < 0.0001) and 0.84 (P < 0.0001), respectively. For VA CLCs, those values were 0.96 (P < 0.0001) and 0.85 (P < 0.0001), respectively. At community PALTCs, both novel metrics permitted assessment and comparison of antibiotic prescribing among practitioners.
Conclusion:
At the facility level, the novel metric antibiotic DOT/unique residents demonstrated strong correlation with the standard metric. In addition to supporting tracking and reporting of antibiotic use among PALTCs, antibiotic DOT/unique residents permits visualization of the antibiotic prescribing rates among individual practitioners, and thus peer comparison, which in turn can lead to actionable feedback that helps improve antibiotic use in the care of PALTC residents.