Rural Critical Access Hospitals Research Articles

Emergency Department Provider Staffing among Critical Access Hospitals in Minnesota

Background: Access to healthcare remains a challenge in many rural regions. Rural critical access hospitals (CAHs) remain essential access points. Providing 24-hour access, CAH emergency departments (EDs) rely on medical staff who can treat a wide range of problems. Family physicians/general practitioners have traditionally staffed rural EDs. However, this staffing model may be changing. This study aims to characterize the current medical staffing profiles of Minnesota’s CAH EDs. Methods: From January to February 2021, the executive leaders of all of Minnesota’s 77 CAHs were invited to complete a voluntary online survey about ED staffing patterns at their facility. Results: 37/77 of MN’s CAHs responded to the survey (48% response rate). Just over half (51.4%) of the respondents reported ED physician staffing practices that included multiple physician specialties (family medicine, internal medicine, emergency medicine) while 32.4% reported staffing exclusively with family medicine physicians. A majority, 27/37 (73%), reported including non-physicians on their ED medical staff, especially at CAHs that were part of a larger healthcare system. Discussion: CAHs often operate with limited workforce and resource options. This study demonstrates that MN’s CAHs exhibit a variety of ED staffing patterns with staffing decisions driven by multiple factors. Family medicine physicians contribute to CAH ED coverage. Future studies may expand our understanding of how ED staffing models impact community health, disease outcomes, and CAH financial viability. Conclusion: ED staffing patterns across Minnesota’s CAHs vary significantly with variable use of physicians and non-physician providers. Family physicians remain an important specialty for CAH ED coverage

"We Have Outgrown Our Space; Our Facility Is Old and Falling Apart": Physical Design Implications to Address the Needs and Priorities of a Critical Access Hospital (CAH).

This exploratory study examines a rural critical access hospital (CAH) staff's perception of current obstacles and needs concerning the physical environment. CAH intends to improve access to healthcare, coordinate with experts and providers, and serve as the rural population's healthcare hub. It is imperative to understand environmental qualities that impact the quality of care to develop effective policies and design guidelines for rural healthcare. Nevertheless, a limited number of studies have focused on user or organizational outcomes related to the physical environment of rural healthcare settings. This cross-sectional exploratory qualitative case study was conducted as part of the facility planning process for a CAH in rural North Carolina. Hospital staff participated in a survey exploring their satisfaction with the overall physical environment privacy, space allocation, and department adjacency. An open-ended question asked staff to elaborate on needed improvements and changes in their department. Findings show low satisfaction levels for space allocations for emergency department, lab, surgery, and wound care. Safety and quality were the two emerging outcomes of the physical environment's shortcomings. Two clusters emerged from the content analysis, representing facility needs (rightly sized spaces, functional needs, COVID-19 needs, and improved access) and ambient conditions (clutter, visibility, flooring quality, noise, privacy, cleanliness, aesthetics, and temperature). The findings from this study suggest that the interior and exterior facility and ambient conditions of the CAH play a key role in quality and safety outcomes.

Analysis of Telestroke Usage in Rural Critical Access Emergency Departments.

Introduction: Telestroke is an effective strategy to increase appropriate stroke treatments among patients in resource-limited environments. Despite the well-documented benefits of telestroke, there is limited literature regarding its utilization. The purposes of this study are: (1) determine the percentage of potential stroke patients who generate a telestroke consult in rural critical access hospitals (CAHs) and (2) validate an electronic medical record (EMR)-derived report as a stroke screen. Methods: This retrospective chart review analyzed patients presenting between September 1, 2020 and February 1, 2021 to three CAHs. Visits with triage complaints suggesting acute ischemic stroke (AIS)/transient ischemic attack (TIA) were pooled for analysis using an EMR-derived report. Patients with confirmed AIS/TIA at discharge over this period were used to validate the EMR tool. Results: The EMR report pooled 252 possible AIS/TIA visits out of 12,685 emergency department visits for analysis. It had a specificity of 98.78% and sensitivity of 58.06%. Of the 252 visits, 12.7% met telestroke criteria and 38.89% received telestroke evaluation. Among these, a definite diagnosis of AIS/TIA was made in 92.86%. Of the remaining population who met criteria but didn't undergo consultation, 61.11% were diagnosed with AIS/TIA at discharge. Conclusion: This study provides novel characterization of stroke presentations and telestroke in rural CAHs. The EMR-derived report is a reasonable tool to concentrate potential AIS/TIA cases for review and resource allocation but is not sensitive enough to detect stroke as a stand-alone tool. The majority (56%) of eligible patients did not undergo telestroke consultation. Future studies are critical to further understand reasons contributing to this.

Improving Hand Hygiene in a Rural Critical Access Hospital

Improving Hand Hygiene in a Rural Critical Access Hospital

New Frontiers in Diabetes Care: Quality Improvement Study of a Population Health Team in Rural Critical Access Hospitals.

Rural populations are older, have higher diabetes prevalence, and have less improvement in diabetes-related mortality rates compared to urban counterparts. Rural communities have limited access to diabetes education and social support services. Determine if an innovative population health program that integrates medical and social care models improves clinical outcomes for patients with type 2 diabetes in a resource-constrained, frontier area. Quality improvement cohort study of 1764 patients with diabetes (September 2017-December 2021) at St. Mary's Health and Clearwater Valley Health (SMHCVH), an integrated health care delivery system in frontier Idaho. The United States Department of Agriculture's Office of Rural Health defines frontier as sparsely populated areas that are geographically isolated from population centers and services. SMHCVH integrated medical and social care through a population health team (PHT), where staff assess medical, behavioral, and social needs with annual health risk assessments and provide core interventions including diabetes self-management education, chronic care management, integrated behavioral health, medical nutritional therapy, and community health worker navigation. We categorized patients with diabetes into three groups: patients with two or more PHT encounters during the study (PHT intervention), one PHT encounter (minimal PHT), and no PHT encounters (no PHT). HbA1c, blood pressure, and LDL over time for each study group. Of the 1764 patients with diabetes, mean age was 68.3 years, 57% were male, 98% were white, 33% had three or more chronic conditions, and 9% had at least one unmet social need. PHT intervention patients had more chronic conditions and higher medical complexity. Mean HbA1c of PHT intervention patients significantly decreased from baseline to 12 months (7.9 to 7.6%, p < 0.01) and sustained reductions at 18 months, 24 months, 30 months, and 36 months. Minimal PHT patients decreased HbA1c from baseline to 12 months (7.7 to 7.3%, p < 0.05). The SMHCVH PHT model was associated with improved hemoglobin A1c among less well-controlled patients with diabetes.

Do the research priorities identified in SAGES Delphi studies resonate with rural general surgeons: a Washington state perspective.

Rural surgeons operate in an environment significantly different from that of their colleagues, and as such they face unique challenges. We hypothesized the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) research agenda (as identified in the results of the 2014 Delphi study) will differ in its priorities from those identified by rural surgeons. We aimed to pilot a study in Washington state that could be replicated in other areas of the USA and the world. We identified general surgeons working at rural critical access hospitals in the state of Washington. We then conducted virtual, semi-structured interviews and followed up with surveys and site visits. The survey included the 2014 SAGES Delphi-ranked research priorities. We asked rural surgeons to rank their top 5 of these 40 priorities and to detail any additional which were not on the list. We contacted 79 surgeons with a 30% response rate. We conducted 25 semi-structured interviews and received 18 completed follow-up surveys. These interviews were followed by site visits at 4 of the 23 sites. Of the original Delphi research priorities, those most cited by rural surgeons were #8 ("What is the best method for incorporating new techniques and technology for surgeons of variable levels of experience or training?") and #1 ("How do we best train, assess, and maintain proficiency of surgeons and surgical trainees in flexible endoscopy, laparoscopy, and open surgery?"). Four surgeons included the last SAGES priority (#40 "Is quality of life improved after ventral hernia repair?") among their top 5. This study suggests that although rural surgeons' research priorities align with the published SAGES Delphi survey, these surgeons rank the priorities differently. This may be because the predominant study population of the Delphi is SAGES membership who work in urban and academic centers. Plans for future SAGES Delphi survey could capture these unique priorities by intentional involvement of rural and community surgeons.

LEVERAGING THE STRENGTH OF UNIQUE PARTNERS TO IMPROVE GERIATRIC EMERGENCY CARE IN RURAL CRITICAL ACCESS HOSPITALS

Abstract Developing a level 1 accredited geriatric emergency department during the pandemic was challenging. The greater challenge has been to support rural critical access hospitals on their journey of becoming level 2 accredited geriatric emergency departments. This has been accomplished through a novel collaborative approach between the level 1 accredited emergency department, a newly established Geriatric Center of Excellence at Dartmouth-Hitchcock Health and a HRSA funded Geriatric Workforce Enhancement Program. This talk will focus on bringing together system partners and funders who have a history of success through: (a) development, testing and dissemination of tool kits and implementation guides; (b) boot camp training that includes interprofessional team training, QI and specific geriatric content training; (c) implementation support and coaching using data and QI methodology through learning collaboratives; (d) scaling successful models of evidence based geriatric care; (e) expertise in implementation science; (f) expertise in evaluation and (g) disseminating findings to achieve our goals.

Perspectives About Emergency Department Care Encounters Among Adults With Opioid Use Disorder

Emergency departments (EDs) are increasingly initiating treatment for patients with untreated opioid use disorder (OUD) and linking them to ongoing addiction care. To our knowledge, patient perspectives related to their ED visit have not been characterized and may influence their access to and interest in OUD treatment. To assess the experiences and perspectives regarding ED-initiated health care and OUD treatment among US patients with untreated OUD seen in the ED. This qualitative study, conducted as part of 2 studies (Project ED Health and ED-CONNECT), included individuals with untreated OUD who were recruited during an ED visit in EDs at 4 urban academic centers, 1 public safety net hospital, and 1 rural critical access hospital in 5 disparate US regions. Focus groups were conducted between June 2018 and January 2019. Data collection and thematic analysis were grounded in the Promoting Action on Research Implementation in Health Services (PARIHS) implementation science framework with evidence (perspectives on ED care), context (ED), and facilitation (what is needed to promote change) elements. A total of 31 individuals (mean [SD] age, 43.4 [11.0] years) participated in 6 focus groups. Twenty participants (64.5%) identified as male and most 13 (41.9%) as White; 17 (54.8%) reported being unemployed. Themes related to evidence included patients' experience of stigma and perceived minimization of their pain and medical problems by ED staff. Themes about context included the ED not being seen as a source of OUD treatment initiation and patient readiness to initiate treatment being multifaceted, time sensitive, and related to internal and external patient factors. Themes related to facilitation of improved care of patients with OUD seen in the ED included a need for on-demand treatment and ED staff training. In this qualitative study, patients with OUD reported feeling stigmatized and minimized when accessing care in the ED and identified several opportunities to improve care. The findings suggest that strategies to address stigma, acknowledge and treat pain, and provide ED staff training should be implemented to improve ED care for patients with OUD and enhance access to life-saving treatment.

Using Appreciative Inquiry to Optimize a Person-Centered Care Training Program for Clinical Champions in Rural Critical Access Hospitals.

Person-centered care (PCC) involves shared decision-making between the individual and provider and is widely recognized as the gold standard of care. However, not all organizations have successfully implemented PCC, especially those in rural settings with limited resources. Implementation strategies, such as clinical champions, are key to PCC uptake. The purpose of the current article is to illustrate how Appreciative Inquiry, a strengths-based framework for transformational change, can be used to optimize a successful PCC champion training program. Appreciative Inquiry employs the quality improvement processes of (a) define, (b) discover, (c) dream, (d) design, and (e) deliver/destiny. Using Appreciative Inquiry, we were able to identify three new long-term goals and add supporting features to an existing champion training program. The methods developed herein could be implemented by researchers and evidence-based practice councils to improve the care of older adults in any care setting to make it more person-centered. [Journal of Gerontological Nursing, 47(8), 7-12.].

Characteristics of U.S. Acute Care Hospitals That Have Implemented Telemedicine Critical Care.

Telemedicine critical care is associated with improved efficiency, quality, and cost-effectiveness. As of 2010, fewer than 5% of U.S. hospitals had telemedicine critical care, and fewer than 10% of ICU beds were covered. We evaluated recent telemedicine critical care implementation and bed coverage rates in the United States and compared characteristics of hospitals with and without telemedicine critical care. Cross-sectional study of 2018 American Hospital Association Annual Survey Database. U.S. hospitals. None. None. We obtained data regarding telemedicine critical care implementation, ICU capability (defined as ≥ 1 ICU bed), other hospital characteristics, and the Herfindahl-Hirschman Index, a measure of ICU market competition based on hospital referral regions. Among 4,396 hospitals (response rate 71%), 788 (17.9%) had telemedicine critical care, providing potential coverage to 27,624 (28% of total) ICU beds. Among 306 hospital referral regions, 197 (64%) had a respondent hospital with telemedicine critical care. Telemedicine critical care implementation was associated with being a nonprofit (odds ratio, 7.75; 95% CI, 5.18-11.58) or public (odds ratio, 4.16 [2.57-6.73]) compared with for-profit hospital; membership in a health system (odds ratio, 3.83 [2.89-5.08]; stroke telemedicine presence (odds ratio, 6.87 [5.35-8.81]); ICU capability (odds ratio, 1.68 [1.25-2.26]); and more competitive ICU markets (odds ratio per 1,000-point decrease in Herfindahl-Hirschman Index 1.11 [1.01-1.22]). Notably, rural critical access hospitals had lower odds of telemedicine critical care implementation (odds ratio, 0.49 [0.34-0.70]). Teaching status, geographic region, and rurality were not associated with telemedicine critical care implementation. About one fifth of respondent hospitals had telemedicine critical care by 2018, providing potential coverage of nearly one third of reported ICU beds. This represents a substantial increase in telemedicine critical care implementation over the last decade. Future expansion to include more rural hospitals that could benefit most may be aided by addressing hospital financial and market barriers to telemedicine critical care implementation.

Abstract P278: Improving Stroke Systems of Care in Nebraska

Introduction: Stroke is a leading cause of disability in the United States. Disparities in stroke care between metropolitan and rural areas have long been recognized. Access to high-level timely stroke expertise improves outcomes, but in rural areas this is limited by sparse availability of stroke specialists. Since 2006, the Nebraska Stroke Advisory Council, a statewide coalition of stroke experts and stakeholders, began implementing strategies to improve stroke care. In 2016, the Nebraska legislature approved Bill 722, mandating the development of stroke systems of care. In 2018, the AHA and the Helmsley Charitable Trust launched Mission: Lifeline Stroke, a coordinated 3-year program to enhance stroke systems of care in Nebraska. Purpose: To assess advances in acute stroke care in Nebraska after implementing a statewide stroke system of care focused on rural areas. Methods: The Council joined with AHA to expand public and professional stroke education offerings including workshops, conferences, and EMS trainings. They developed state specific treatment guidelines and created educational reinforcement materials. From 2016 to 2019 Get With The Guidelines® (GWTG) was used for stroke data collection and quality improvement in Nebraska. GWTG participating hospitals expanded from 7 to 40 sites (21 critical access). Results: The number of stroke and Transient Ischemic Attack cases reported more than doubled from 2016 to 2019 (1848 to 3987 cases). The door to CT initiated in &lt; 25 minutes improved by 13%. IV alteplase therapy gains included: utilization increased from 8.7% to 11.3%; median door to drug time reduced from 54 to 42 minutes; and door to drug within 60 minutes of arrival increased from 67% to 80.4%.The number of alteplase monitored patients doubled and mechanical thrombectomy cases increased from 77 in 2017 to 138 in 2019. Conclusion: Implementation of strategies in Nebraska, with an emphasis on rural critical access hospitals, led to significant improvements in acute stroke care. This work represents the authors’ independent analysis of local or multicenter data gathered using the AHA Get With The Guidelines® Patient Management Tool but is not an analysis of the national GWTG dataset and does not represent findings from the AHA GWTG National Program

The Implementation of a Collaborative Pediatric Telesimulation Intervention in Rural Critical Access Hospitals.

Over 5.8 million pediatric visits to rural emergency department (EDs) occur each year in the United States. Most rural EDs care for less than five pediatric patients per day and are not well prepared for pediatrics. Simulation has been associated with improvements in pediatric preparedness. The implementation of pediatric simulation in rural settings is challenging due to limited access to equipment and pediatric specialists. Telesimulation involves a remote facilitator interacting with onsite learners. This article aims to describe the implementation experiences and participant feedback of a 1-year remotely facilitated pediatric emergency telesimulation program in three critical-access hospitals. Three hospitals were recruited to participate with a nurse manager serving as the on-site lead. The managers worked with a study investigator to set up the simulation technology during an in-person pilot testing visit with the off-site facilitators. A curriculum consisting of eight pediatric telesimulations and debriefings was conducted over a 12-month period. Participant feedback was collected via a paper survey after each simulation. Implementation metrics were collected after each session including technical and logistic issues. Of 147 participant feedback surveys 90% reported that pediatric simulations should be conducted on a regular basis and overall feedback was positive. Forty-seven of 48 simulations were completed on the first attempt with few major technologic issues. The most common issue encountered related to the simulator not working correctly locally and involved the facilitator running the session without the heart and lung sounds. All debriefings occurred without any issues. This replicable telesimulation program can be used in the small, rural hospital setting, overcoming time and distance barriers and lending pediatric emergency medicine expertise to the education of critical-access hospital providers.

An Observational Study of Telemental Care Delivery and the Context for Involuntary Commitment for Mental Health Patients in a Group of Rural Emergency Departments

Background: Rates for all-cause U.S. emergency department (ED) visits to rural critical access hospitals (CAHs) have increased by 50% since 2005. During the same time period, total number of U.S. hospital admissions for a mental health (MH) crisis has increased by 12.2%, with rural counties demonstrating the largest suicide rate increases overall.Introduction: Increasing number of rural patients are reporting need for MH care in the region's four rural EDs. Characteristics of ED telemental health services were evaluated, including MH diagnostic category, voluntary vs. involuntary commitment (IC), forensic vs. nonforensic presentation, ED throughput, disposition, and payor reimbursement.Materials and Methods: Observational 2.5-year program evaluation of telemental health care delivery for children (n = 114) and adults (n = 417) who were evaluated by a rural ED physician and received an MH diagnosis. Participants (N = 531) were treated by a licensed psychiatrist through telemental care delivery from September 2017 to April 2020.Results: Noncommitted ED MH patients (86%; n = 455) were distributed across three major diagnostic groups: (1) depression, anxiety, or other mental illness (35%); (2) substance abuse (33%); or (3) suicide risk (32%), with 47% admitted inpatients (IPs), 47% referred outpatient (OPs), and 6% admitted to CAH. Fourteen percent (n = 76/531) of ED MH patients were subsequently IC, with 67% of those assessed as needing IP care. Forty-nine percent (n = 37) of IC patients presented in police custody. Most common diagnosis for IC patients was suicidal ideation/attempt (χ2 [2, N = 452] = 12.884, p = 0.002). Admitted patients experienced significantly longer length of stay than those with OP referral (p = 0.001). Mean total payor reimbursements for ED MH care were significantly lower than actual ED costs (p < 0.001).Discussion: Innovative approaches to telemental care for IC and non-IC patients need to be piloted and comparatively evaluated in rural CAHs.Conclusion: As the gateway to critically needed MH care, rural CAHs and public services pivotal to care access (e.g., law enforcement) need additional resources and support.

Spatial association patterns between post-acute care services and acute care facilities in the United States.

BackgroundThere is increasing demand for post-acute care services, which is amplified by the COVID-19 pandemic.AimsWe studied the pattern of spatial association between post-acute care services and acute care facilities and evaluated how geographic variability could influence their use.MethodsWe compiled data on CMS-certified acute care and critical access hospitals and post-acute health care services (nursing homes, home health care services, inpatient rehabilitation facilities, long-term care hospitals, and hospice facilities). We used the colocation quotient (CLQ) to measure the magnitude and direction of association (clustering or segregation) between post-acute care providers and hospitals. This metric allows pairwise comparison of categorical data; a value <1 indicates spatial segregation and a value >1 spatial clustering. Unity marks the lack of spatial dependence (random distribution).ResultsWith the exception of nursing homes (CLQ 1.26), all other types of post-acute care providers are spatially segregated from rural critical access hospitals. Long-term care facilities ranked first (had the lowest global CLQ, 0.06), hospice facilities ranked last (had the highest global CLQ estimate, 0.54). Instead, post-acute care services either clustered with (inpatient rehabilitation 2.76, long-term care 2.10, nursing homes 1.37) or were only weakly segregated (home health care 0.86) from acute care hospitals. Home health care (1.44), hospice services (1.46), and nursing homes (1.08) spatially clustered with the same category of services. Results were robust in the sensitivity analysis and we provided illustrative examples of local variation for the states of MA and IA.ConclusionPost-acute care services are isolated from critical access hospitals, and have a clustering pattern with the same category services and acute care hospitals. Such misdistribution of resources may result in both underuse and a substitution effect on the type of post-acute care between rural and urban areas and undermine public health during increasing demand, such as the COVID-19 pandemic.

Improving Quality With Emergency Department Throughput in a Critical Access Hospital.

The study objective was to determine the impact of specific measures to reduce the length of stay (LOS) in an emergency department (ED) in a critical access hospital (CAH). Despite mandates to reduce bottlenecks by increasing throughput, many EDs are not successful. Strategies available to larger hospitals may not be feasible for resource-limited CAHs. Interventions were implemented to decrease ED LOS in a rural CAH. Through retrospective chart reviews from time periods both preimplementation and postimplementation, the LOS was determined and compared using 2-sample t tests. Significant decreases were found between the groups in mean LOS times, as well as specific time intervals within the overall LOS time for nursing-centric activities and incidence of patients leaving prior to treatment completion. A significant decrease in LOS resulted from numerous actions taken to improve patient flow. Results may be used to enhance patient flow and decrease LOS in other CAHs, improving quality and access to care.

Patient and Care Team Perspectives of Telemedicine in Critical Access Hospitals.

Telemedicine acute care may address issues facing critical access hospitals. This evaluation used web, mail, and telephone surveys to quantitatively and qualitatively assess patient and care team experience with telemedicine in 3 rural critical access hospitals and a large metropolitan tertiary care hospital. Results show that patients, nurses, and clinicians perceived quality of care as high, and they offered feasible recommendations to enhance communication and otherwise improve the experience. Continued work to improve, test, and publish findings on patient and care team experience with telemedicine is critical to providing quality services in often underserved communities.

The Effect of an Evidence-Based Practice Education and Mentoring Program on Increasing Knowledge, Practice, and Attitudes Toward Evidence-Based Practice in a Rural Critical Access Hospital.

The aim of this study was to determine the effect of an evidence-based practice (EBP) education and mentoring program on the knowledge, practice, and attitudes toward EBP among staff nurses and clinicians in a rural critical access hospital. While rural nurses value EBP, they often have more limited resources to engage in EBP activities compared with urban-based nurses. Direct care nurses and clinicians participated in a 5-month EBP education and mentoring program following the Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Health Care. The Evidence-Based Practice Questionnaire was used to assess pretest-posttest knowledge, practice, and attitudes toward EBP. Knowledge and practice of EBP increased significantly (P = .008 and P = .015, respectively) after the EBP education and mentoring intervention. Attitudes toward EBP also increased, although the increase was not statistically significant (P = .106). Education and mentoring of healthcare clinicians in rural settings are crucial to the translation of evidence-based research into practice to improve patient outcomes.

A cross-sectional survey of measles preparedness in critical-access hospitals of Idaho

Patients with measles can precipitate outbreaks in health care facilities where they seek care. Rural critical-access hospitals (CAHs) may be at higher risk of outbreaks given their size and potentially limited infection prevention resources. We surveyed CAHs in Idaho to ascertain their levels of preparedness for managing measles cases. A 25-item questionnaire was sent to infection preventionists at all 27 Idaho CAHs. The questionnaire covered organizational structure, resources for managing measles cases, and hospital policies for ensuring immunity among health care workers. A total of 22 (82%) CAHs responded, reporting varying availability of facilities and resources for managing measles cases and disparate procedures for testing clinical samples and providing vaccines to nonimmune, exposed staff. With measles incidence on the rise in the United States, our survey found that most of the responding hospitals had the basic organizational structure for facility-wide prevention and management efforts in case a patient with suspected or confirmed measles presented to that facility. Most of the hospitals also had at least some available resources to manage measles cases, as well as policies for ensuring immunity to measles among at least some groups of health care workers. This study provides initial perspectives on measles preparedness among Idaho CAHs, despite limited generalizability. Future studies should explore whether self-reported preparedness measures reflect the ability of the CAHs to control measles spread when cases present for care.

1069. Implementation and Results of a Health-System Antimicrobial Stewardship (AMS) Program

BackgroundAMS expansion initiative was implemented in fiscal year 18 (FY18) across a 14-member health system (~1,000 average daily census combined) consisting of 8 community hospitals, 5 rural critical access hospitals and 1 academic medical center.MethodsThe expansion initiative included a 0.5 full-time equivalent (FTE) infectious diseases (ID) physician and 2.5 FTE ID-trained clinical pharmacists to support daily AMS activities. Clinical decision support software (Theradoc) had previously been implemented across the health system. Here we report our continuation results for the first 9 months of year 2 (FYTD19) of the expansion initiative.ResultsAMS personnel documented an average of 319.8 and 313.2 interventions per month in FY18 vs. FYTD19, respectively. Mean acceptance rate of AMS interventions by providers was 87.9% and 89.4% in FY18 vs. FYTD19. Provider groups with the highest acceptance rate were Hospital Medicine, Pulmonary/Critical Care and Infectious Disease. Highest interventions in FYTD19 included recommending other diagnostic testing (17%) followed by de-escalating/targeting therapy based on culture results and recommending alternative therapy (both at 11%). Most common ID disease states AMS intervened included bacteremias (29%), pneumonias (ventilator-associated or community-acquired) 13% each, and UTIs 13%. AMS interventions generated 168 ID consults in FYTD19. The financial impact of AMS across the health system was a cumulative saving in antimicrobial expenditures of $1.29 million and $1.27 million in FY18 and FYTD19, respectively.ConclusionThe ability to review offsite electronic medical records daily for antimicrobial optimization with ID pharmacist and physician support, identify facility-specific needs and opportunities, and collect available data endpoints to determine program effectiveness has helped to ensure program success.Disclosures All authors: No reported disclosures.

2095. Antimicrobial Stewardship (ASP) in Rural and Critical Access Hospitals (CAHs) Using TeleStewardship® Services

BackgroundMDstewardship® is a physician-owned company that uses TeleStewardship® services, which consist of telephone and HIPPA-compliant teleconferencing and texting, to provide rural and critical access hospital (CAH) ASP services, ensuring facilities remain compliant with Joint Commission ASP requirements. MDstewardship® also provides monthly webinars to all participating hospital personnel for continuing education. Webinars are live, interactive, and contain topics based on IDSA guidelines. MDstewardship® personnel discuss antibiotics with the hospital staff using a HIPPA-compliant secure audio-video feed, phone conference, or secure-text. CAH pharmacists discuss the antibiotics currently being given in their institution and MDstewardship® personnel provide further ASP recommendations. ASP recommendations are provided by MDstewardship® clinically-trained infectious disease pharmacists and infectious disease physicians, and are communicated to on-site pharmacists or directly with providers.MethodsMDstewardship® is active with many rural CAHs in Nebraska, and over 20 hospitals nationally. Here we report our ASP results for 10 CAHs in Nebraska from August 2018 to April 2019. A total of 401 ASP recommendations were given over that time.ResultsThe top three most common infectious diseases diagnoses involving recommendations were UTI (16.7%), pneumonia (15.2%), and bacteremia (13.7%). Most common ASP interventions included alternative therapy (15.7%), additional therapy (13.7%), oral step-down therapy (12.7%), and further laboratory monitoring (12.5%). Additional daily antimicrobial stewardship assistance includes: development of hospital protocols, order-sets, antibiograms and guideline adherence. Total acceptance of ASP recommendations averages > 90%. Reimbursement is based on a contract over 12 months.ConclusionThe use of TeleStewardship® services allow CAHs to have 24/7 infectious disease specialist and clinically trained antimicrobial stewardship pharmacist support with a high number of interventions and a high acceptance of recommendations. The goal of this program is to give the right antibiotic, right dose, for the right duration, for each patient.Disclosures All authors: No reported disclosures.