Dissemination and implementation of a telehealth program to deliver effective antibiotic stewardship support to rural or medically underserved newborn nurseries.

PROJECT ABSTRACT __
Antibiotic exposure in newborns is associated with significant morbidity and mortality, including infection with
antibiotic-resistant organisms, asthma, obesity, metabolic syndrome, and diabetes among others. Despite this,
antibiotics are misused in neonates at alarming rates and remain the most-prescribed medications in the
nursery. Antibiotic stewardship programs (ASPs) can significantly reduce antibiotic exposure but require
specialist support to be effective. Like many evidence-based interventions, a gap remains between research
and widespread implementation. Most well-baby nurseries – particularly those in rural or medically
underserved areas – do not have access to ASP support, which is a major health disparity. Scalable
approaches to increase implementation of evidence-based practices, such as ASPs, are needed to address
such disparities. Telehealth has been used successfully to deliver other aspects of newborn care, such as
complex care coordination and health screening. Telehealth strategies have been used in adult and pediatric
ASP efforts, and telehealth for infectious diseases support has been endorsed by the Infectious Diseases
Society of America. Our preliminary study, ASSIST-1, was the first to utilize telehealth to deliver ASP support
specifically for newborn nurseries. The ASSIST-1 study of 8 rural nurseries showed that telehealth ASP was
safe and effective, reducing unnecessary antibiotic use by 32%. In this R18 health services research
demonstration and dissemination grant, we aim to use dissemination and implementation (D&I) science to
accelerate delivery of our evidence-based telehealth ASP to additional level 1 and 2 nurseries (N=40) in rural
or medically underserved areas throughout Texas. Our hypothesis is that nursery telehealth is a scalable
approach to increase access to infectious diseases care and reduce unnecessary antibiotic exposure among
newborns born in medically underserved areas. We will test our hypothesis using an effectiveness-
implementation hybrid type 2 design based on the Reach, Effectiveness, Adoption, Implementation,
Maintenance (RE-AIM) and Consolidated Framework for Implementation Research (CFIR) models to measure
uptake, efficacy, and sustainability of the telehealth ASP. Our specific aims are to evaluate (1) the adoption, (2)
the effectiveness, cost, and value, and (3) the maintenance and sustainability of the telehealth ASP. The study
team includes content experts in neonatal infectious diseases (Drs. Cantey and Duchon), D&I science (Drs.
Stevens and Kilpela), and patient-centered outcomes and cost-effectiveness research (Dr. Tsevat). The
proposed research is innovative in its use of telehealth strategies to link rural hospitals with pediatric infectious
diseases specialists, improve care for infants with suspected or proven infection, and minimize adverse effects
of unnecessary antibiotic exposure. In addition, successful implementation of our study could subsequently
serve as the platform for linking rural nurseries to other pediatric subspecialists, thus relieving access-to-care
disparities and improving the quality, equity, and value of care for infants born in medically underserved areas.

Grant Number: 5R18HS027756-04
NIH Institute/Center: AHRQ
Principal Investigator: Joseph Cantey