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Culture Keepers: Why Nurses are Key to Antibiotic Stewardship Success · The SHEA Podcast

• 0:06
  SPEAKER_01: Hi everyone, welcome to today's Shay podcast entitled Culture Keepers: Why Nurses Are Key to Antimicrobial Stewardship Success.
• 0:16
  SPEAKER_01: I'm Marissa Hullabar.
• 0:18
  SPEAKER_01: I'm a clinical professor of infectious diseases at Stanford University School of Medicine and Medical Director of our Antimicrobial Stewardship Program.
• 0:26
  SPEAKER_01: I'm also the current chair of our antimicrobial stewardship committee for SHA.
• 0:32
  SPEAKER_01: We have the privilege today of being joined by two leading experts and, frankly, awesome people to help us unpack the role of nurses in both diagnostic and antimicrobial stewardship.
• 0:43
  SPEAKER_01: I'll first introduce them.
• 0:45
  SPEAKER_01: So first, welcome Dr.
• 0:47
  SPEAKER_01: Eileen Carter.
• 0:49
  SPEAKER_01: Dr.
• 0:49
  SPEAKER_01: Carter is an emergency department nurse by training and currently serves as an assistant professor at the University of Connecticut School of Nursing.
• 0:58
  SPEAKER_01: A fellow of the American Academy of Nursing, she is nationally recognized for advancing the role of nurses in antimicrobial stewardship and for trailblazing an innovative academic practice partnership model that bridges gaps between nurses in academic and practice settings.
• 1:16
  SPEAKER_01: Eileen is also a renowned baker and reportedly loves spoiling her family with sweet treats.
• 1:22
  SPEAKER_01: At one family gathering, Eileen baked over 200 chocolate chip cookies and they vanished in no time.
• 1:28
  SPEAKER_01: Sorry that we weren't there for that.
• 1:31
  SPEAKER_01: Welcome, Eileen.
• 1:32
  SPEAKER_00: Thanks so much for having me.
• 1:34
  SPEAKER_00: It's truly an honor to be here.
• 1:36
  SPEAKER_01: Oh, it's great to talk to you.
• 1:37
  SPEAKER_01: Next, Dr.
• 1:38
  SPEAKER_01: David Ha is an infectious diseases and antimicrobial stewardship pharmacist and the manager of our Stanford Antimicrobial Safety and Sustainability Program.
• 1:48
  SPEAKER_01: His background includes launching and advancing antimicrobial stewardship programs in both the academic and community hospital settings and incorporating bedside nursing collaboratives.
• 2:00
  SPEAKER_01: And he has held various other roles in academia and public health.
• 2:04
  SPEAKER_01: He is also a longtime member and volunteer with the Society of ID Pharmacists, SIDP, and a former host of their Breakpoints podcast, where he hosted an episode on this very topic of nurses and stewardship.
• 2:18
  SPEAKER_01: Listeners, we will include a link to this in the show notes.
• 2:22
  SPEAKER_01: One thing you might not know about David is that he is also an avid gardener, particularly of tomatoes, where he is well known within our team for having a tomato growing and tasting spreadsheet.
• 2:33
  SPEAKER_01: Those of you who know David may not, you may not have known that, but you're not surprised by this information.
• 2:38
  SPEAKER_01: So welcome, David.
• 2:40
  SPEAKER_02: Wonderful.
• 2:40
  SPEAKER_02: Thank you so much, Marissa.
• 2:42
  SPEAKER_02: And thank you to Shay for the opportunity to say that like practice evidence-based medicine and evidence-based gardening as well.
• 2:51
  SPEAKER_01: I love it.
• 2:52
  SPEAKER_01: Okay, let's dive in.
• 2:54
  SPEAKER_01: So talking about the potential role nurses could play in advancing antimicrobial stewardship is not new.
• 3:01
  SPEAKER_01: In 2015, a key paper entitled The Critical Role of the Staff Nurse in Antimicrobial Stewardship, unrecognized but already there, got the community's attention.
• 3:12
  SPEAKER_01: And then in 2017, the American Nursing Association and CDC released a white paper entitled Redefining the Antimicrobial Stewardship Team: Role of Registered Nurses in Hospital Antimicrobial Stewardship.
• 3:26
  SPEAKER_01: And then in 2019, nurses were highlighted in CDC's core elements.
• 3:32
  SPEAKER_01: David, why were these papers and the inclusion of nurses in the core elements so important?
• 3:39
  SPEAKER_02: Yeah, thanks, Marissa.
• 3:41
  SPEAKER_02: So I will say I just want to start and say that Eileen is really the true expert in the room, but I'd like to, you know, really embellish this with the non-nurse perspective.
• 3:52
  SPEAKER_02: So from the non-nurse perspective, uh the ANA white paper in particular, I believe is critical.
• 3:59
  SPEAKER_02: As a pharmacist or physician or any non-nurse, approaching nursing with an antibiotic stewardship agenda can be, let's just say, intimidating.
• 4:11
  SPEAKER_02: But what this creates for us is an opportunity to say, hey, it's not just us saying this is important, but nursing, i.e.
• 4:18
  SPEAKER_02: the ANA, is saying it.
• 4:19
  SPEAKER_02: And furthermore, they are advocating for the active involvement of nurses and in particular bedside nurses in antibiotic stewardship.
• 4:28
  SPEAKER_02: Furthermore, what I think many of these publications do is to provide also examples of engagement opportunities where nurses may already be involved in antibiotic stewardship.
• 4:42
  SPEAKER_02: So not just saying we should collaborate, but instead we should collaborate, and here are some ideas to start with, and here are some things that may already be happening.
• 4:50
  SPEAKER_01: Yeah, I agree.
• 4:51
  SPEAKER_01: The examples are really, really helpful.
• 4:54
  SPEAKER_01: Eileen, I know you were part of the writing group for the ANA white paper that David was referencing, and you also assessed the reaction of frontline nurses to these recommendations.
• 5:05
  SPEAKER_01: What were some of the highlights from this research?
• 5:09
  SPEAKER_00: Yeah, so you know, we've probably all experienced an initiative that seemed really great on paper, but just, you know, fell flat.
• 5:17
  SPEAKER_00: So before any sort of implementation effort, we really wanted to know, you know, what do nurses and practitioners, what do they think of these recommendations?
• 5:27
  SPEAKER_00: So fortunately, with funding from APIC, we were able to conduct a multi-site qualitative study in which we conducted, you know, interviews and focus groups with nurses, infection preventionists, nurse practitioners, and physicians.
• 5:43
  SPEAKER_00: Um, and from that work, we really had two big takeaways.
• 5:47
  SPEAKER_00: So, first, um, you know, we found that nurses they really wanted to be a part of antibiotic stewardship, especially as they felt their involvement could make a real difference in patient care and outcomes.
• 6:00
  SPEAKER_00: But also importantly, we found that, you know, dominant barriers really were perceived to stand in their way.
• 6:09
  SPEAKER_01: Yeah, that's really important.
• 6:11
  SPEAKER_01: It's great to hear that everyone was so engaged.
• 6:14
  SPEAKER_01: Um, but we'd like to hear some more about these barriers.
• 6:18
  SPEAKER_01: We know there's many places struggling to include nursing and stewardship.
• 6:22
  SPEAKER_01: And I'd like to hear from both of you your experience and why this might be still a challenge.
• 6:28
  SPEAKER_01: Let's start with you, Eileen.
• 6:30
  SPEAKER_00: Yeah, so in a couple of years ago, um, in 2023, a nice scoping review was published on nurses' engagement in hospital antibiotic stewardship programs using kind of the CDC recommendations.
• 6:45
  SPEAKER_00: And just 10 studies were identified, so you know, really not many.
• 6:50
  SPEAKER_00: Nearly all of these studies focused on nurses' participation in antibiotic timeouts.
• 6:56
  SPEAKER_00: A couple of them focused on nurses improving uh culture indications or culturing technique, and quite surprisingly, zero focused on nurses improving penicillin allergy assessments or evaluations.
• 7:11
  SPEAKER_00: Um, yeah, this is a really important question.
• 7:13
  SPEAKER_00: You know, what's limiting nurses' participation and stewardship?
• 7:18
  SPEAKER_00: So, in reviewing my research and that of others, it seems there are, you know, maybe three or four principal barriers to nurses' engagement and antibiotic stewardship.
• 7:30
  SPEAKER_00: And I think these specifically are a lack of opportunity, knowledge gaps, traditional nursing versus practitioner or physician roles and responsibilities, and lastly, competing workflows.
• 7:44
  SPEAKER_00: So I'll give you just a a little bit of an example to kind of better illustrate these barriers.
• 7:50
  SPEAKER_00: So in the qualitative study I mentioned before, we asked nurses to consider the recommendation from the CDC core elements that states, you know, nurses can facilitate the IV to PO switch.
• 8:03
  SPEAKER_00: Really excitingly, we found that nurses they tended to rally around this recommendation.
• 8:08
  SPEAKER_00: You know, they felt this was a way for them to make a meaningful difference in a patient's treatment regimen.
• 8:14
  SPEAKER_00: And they also perceived this recommendation to benefit patients.
• 8:19
  SPEAKER_00: So for instance, nurses said, you know, patients will be more comfortable because they won't be connected to an IV pool.
• 8:26
  SPEAKER_00: And also nurses said, you know what, it will help patients become more familiar with their antibiotic, you know, drug regimen when discharged to home.
• 8:35
  SPEAKER_00: So facilitate kind of transitions, transitions of care.
• 8:39
  SPEAKER_00: Um, and also um kind of uh, you know, this this stands out in my mind.
• 8:45
  SPEAKER_00: At the end of one focus group, one nurse said very, very excitingly, you know, if you just give us the list of antibiotics, we'll start now.
• 8:53
  SPEAKER_00: So you can see, right, there was this really high level of acceptability among nurses.
• 8:59
  SPEAKER_00: Uh, but also uh they mentioned important obstacles uh that they perceived to stand in their way.
• 9:06
  SPEAKER_00: So importantly, these obstacles included traditional nursing versus prescriber roles, you know, in which nurses anticipated receiving pushback from prescribers.
• 9:17
  SPEAKER_00: Many of them likened actually the IV to PO switch to the nurse-driven urinary catheter removal protocol.
• 9:26
  SPEAKER_00: Um, also another important barrier was you know a lack of knowledge around the antibiotics suitable for IV to PO conversion, and also workflow considerations that definitely ranged from different work settings, uh, different patient care settings, um, and so on.
• 9:44
  SPEAKER_00: So, collectively, I think these challenges they really seem to result in just a lack of opportunity for nurses to take this recommendation, specifically IV to PO conversion, but also the others and really just run with them.
• 10:01
  SPEAKER_01: Thanks, Eileen.
• 10:02
  SPEAKER_01: So much of that resonates with my experience too.
• 10:06
  SPEAKER_01: What do you think, David?
• 10:07
  SPEAKER_01: What barriers do you think prevent us from optimally involving our nursing colleagues in stewardship on the front lines?
• 10:15
  SPEAKER_02: Yeah, I think um, in addition to all of those, you know, on the part of traditional, let's say, um antibiotic stewardship leaders like physicians and pharmacists, there really is a lack of action in actively engaging nurses in these efforts.
• 10:33
  SPEAKER_02: Uh, you know, like was like we mentioned earlier, uh, nursing is typically the largest single group of healthcare professionals at a given institution with a wide variety of roles and practice settings.
• 10:45
  SPEAKER_02: And so it can be an intimidating group to engage.
• 10:48
  SPEAKER_02: Um, also as a result of their size, nursing can have a larger and more complex leadership structure that can be confusing to navigate, especially from the outside looking in.
• 10:58
  SPEAKER_02: And so it may be difficult to know who specifically to approach.
• 11:02
  SPEAKER_02: But also, and and I think most important, in the minds of, you know, again, the traditional antibiotic stewardship leaders, there is a general lack of understanding and therefore recognition of the value that nurses can and already do bring to the table.
• 11:18
  SPEAKER_02: And so we may be stopping ourselves before we even start.
• 11:22
  SPEAKER_02: But hopefully we can uh move the uh a little bit on that one.
• 11:26
  SPEAKER_01: Yeah, agreed.
• 11:28
  SPEAKER_01: So although many places are struggling to get started, others have made some real gains and published their results, including both of you.
• 11:36
  SPEAKER_01: Can you each describe some recent publications in a couple of sentences to highlight specific initiatives where people have experienced success?
• 11:44
  SPEAKER_01: Let's start with you, Eileen.
• 11:47
  SPEAKER_00: Yeah, so the CDC, you know, the um core elements, the hospital core elements for um ASPs, they state that nurses can improve the evaluation of penicillin allergies.
• 11:59
  SPEAKER_00: So this can be operationalized in many different ways.
• 12:04
  SPEAKER_00: Um we were most really interested in improving nurses' assessment and documentation of those allergies to facilitate risk stratification.
• 12:14
  SPEAKER_00: And in my prior work, nurses shared they were eager to improve their assessment of penicillin allergies, but they were unsure of the questions to ask.
• 12:23
  SPEAKER_00: So, you know, really focusing in here on those knowledge gaps.
• 12:27
  SPEAKER_00: Um, so we drew upon wonderful toolkits that were published in JAMA a few years ago by Chinoy, Blumenthal, and others that outline the management of penicillin allergies.
• 12:40
  SPEAKER_00: We use these toolkits to then develop a mnemonic to signal the questions to ask when taking a penicillin allergy assessment.
• 12:49
  SPEAKER_00: And so these papers we publish them both in Ashy and Itchy, but the mnemonic is called Story.
• 12:58
  SPEAKER_00: In nursing, we use a lot of mnemonics.
• 13:00
  SPEAKER_00: I have a terrible memory, and so I find them personally very, very helpful.
• 13:04
  SPEAKER_00: Uh, but story it stands for, right?
• 13:07
  SPEAKER_00: S, the symptoms of the allergy, T, the timing in years of the allergy, O, the onset of the reaction in relation to when penicillin was taken, R, the resolution of symptoms, and then also why has the patient used penicillin yet again?
• 13:27
  SPEAKER_00: And if so, what was the reaction?
• 13:30
  SPEAKER_00: So we implemented uh this mnemonic along with a multifaceted implementation strategy, including dot phrases in EPIC, right?
• 13:38
  SPEAKER_00: Because we wanted to minimize any sort of documentation burden.
• 13:41
  SPEAKER_00: We also included interdisciplinary education, and so we implemented this in one periop setting, and we saw sizable improvements in nurses' comprehensive documentation of penicillin allergies.
• 13:56
  SPEAKER_01: That's very encouraging, I think, as many institutions are struggling to figure out how to productively collaborate with nursing colleagues, they're also struggling with addressing penicillin allergies.
• 14:09
  SPEAKER_01: David, tell us about your experience.
• 14:11
  SPEAKER_02: Thanks so much.
• 14:12
  SPEAKER_02: Yeah, and I have I have to agree, you know, penicillin allergies are such a such a pervasive and difficult problem to deal with.
• 14:20
  SPEAKER_02: And so, you know, levering leveraging such a large group that can be involved in so many different settings like nursing, um, you know, is a is a you know uh is a fantastic um opportunity to potentially take advantage of.
• 14:34
  SPEAKER_02: Um on our end, um this is not something that is recently published, but um probably could be again with the reassessment of outcomes.
• 14:43
  SPEAKER_02: But um but I say recent in that it's it's still ongoing today.
• 14:47
  SPEAKER_02: It's been uh an intervention that now has eight, maybe even nine years behind it at my previous institution in Los Angeles, where we implemented multiple times weekly rounds with um the ID pharmacists and infection preventionists.
• 15:02
  SPEAKER_02: But importantly, these rounds were coordinated and led by our telemetry units and their unit nurse leaders, who themselves, the nurses themselves, made interventions directly with their patients' primary teams and attending physicians.
• 15:18
  SPEAKER_02: These were interventions which were the same day by our antibiotic stewardship team, including myself and our ID physicians.
• 15:28
  SPEAKER_02: And through that effort, over the years, we saw significant decreases in antibiotic use across the board, as well as C.
• 15:35
  SPEAKER_02: diff infections and central line use.
• 15:38
  SPEAKER_02: Um, and it makes me so happy to recall when we presented um several years back, um, then three-year outcomes at ID Week.
• 15:47
  SPEAKER_02: We had six individuals attend ID Week from our hospital, four of which were nurses, three of whom were bedside nurses.
• 15:54
  SPEAKER_02: So it's just a wonderful memory that I think about all the time, and we have great pictures.
• 15:59
  SPEAKER_02: Um, another thing, though, that I will mention about this project is that really the key to our success was a one nurse by the name of Mary Bette Forte, who was then a telemetry staff nurse interested in infection prevention and antibiotic stewardship.
• 16:17
  SPEAKER_02: And we launched this project together as part of her master's thesis, and then several years later expanded it to two other telemetry units where we saw similar sustained antibiotic and HAI reduction results.
• 16:29
  SPEAKER_02: And then she subsequently evaluated, both quantitatively and qualitatively, these expanded efforts as part of her doctoral thesis several years later.
• 16:39
  SPEAKER_02: And I say this uh because, first off, Mary Bett is an amazing individual and it underscores the power of finding the stars at your institution when you're looking to pilot things, but also that many nurses may be pursuing advanced education or other internal advancement programs, usually which involve a capstone project of sorts.
• 17:02
  SPEAKER_02: And so they may be interested in collaborating on these types of implementation projects.
• 17:08
  SPEAKER_01: That's a really good point.
• 17:10
  SPEAKER_01: I don't know, Eileen, if you have anything else to respond to about that, the fact that many practicing nurses are also pursuing other educational um programs or and or even internal quality improvement projects.
• 17:24
  SPEAKER_00: Yeah, absolutely.
• 17:26
  SPEAKER_00: I mean, I think um, you know, Mary Beth Fort, while I don't know her personally, I would say um, you know, there are many, many countless numbers of individuals who are similarly highly motivated, right?
• 17:42
  SPEAKER_00: They want to improve patient care intrinsically, but then also have these extrinsic mode uh motivations.
• 17:50
  SPEAKER_00: Maybe they're trying to move up the clinical ladder, or maybe they're, you know, similarly uh pursuing, you know, a doctor, doctoral degree or a master's degree.
• 18:00
  SPEAKER_00: Certainly in the nursing profession, there is a big push for nurses to advance their education.
• 18:07
  SPEAKER_00: Um and as David had mentioned, you know, a lot of that is, you know, conducting a QI project or even a research study.
• 18:15
  SPEAKER_01: Awesome.
• 18:16
  SPEAKER_01: Thank you.
• 18:17
  SPEAKER_01: Okay, so now let's go back to IV to PO.
• 18:21
  SPEAKER_01: The stewardship community has been talking about this literally forever.
• 18:25
  SPEAKER_01: There's so many reasons to do IV2PO, and yet this these projects tend to fizzle out or hit a wall.
• 18:33
  SPEAKER_01: But maybe a nursing PharmD collaboration will be the key to moving this forward.
• 18:38
  SPEAKER_01: What do you think, David?
• 18:40
  SPEAKER_02: I I completely agree with that, and I'm going to say with confidence and gusto that in I'm saying 2026, I know we're recording this in 2025, but it's December, so it's effectively 2026.
• 18:52
  SPEAKER_02: In 2026, IVPO is cool again.
• 18:55
  SPEAKER_02: So clinical pharmacists and nurses, many of us already know this.
• 19:00
  SPEAKER_02: They're already collaborating on a daily basis.
• 19:03
  SPEAKER_02: Many institutions employ decentralized pharmacists who are physically present in, say, your ICU or your medical ward or the emergency department.
• 19:13
  SPEAKER_02: And this enables face-to-face connection between pharmacists and nurses, and various qualitative studies have found that this drives more collaboration and interprofessionalism and ultimately improves patient care as a result.
• 19:27
  SPEAKER_02: These are studies from both inside and outside of infectious diseases, mostly outside, actually.
• 19:32
  SPEAKER_02: But something that we encountered in some of our work is that our nurses in some of Mary Bett's qualitative evaluations expressed more comfort with talking to their unit pharmacist or with me as their ID pharmacist about their patient's antibiotics before approaching their primary medical team.
• 19:52
  SPEAKER_02: So there's a natural connection there that can potentially be leveraged.
• 19:56
  SPEAKER_02: Now, on the pharmacist side, many institutions have established IV to PO protocols in place where a pharmacist can independently change certain antimicrobials from an IV route to an oral route, provided that certain clinical criteria are met.
• 20:12
  SPEAKER_02: I'm sure that many, many of our listeners have are at institutions that have these protocols in place.
• 20:18
  SPEAKER_02: However, on the practical side, a unit-based pharmacist may be covering 20 or 40 plus patients.
• 20:26
  SPEAKER_02: And between their clinical rounds, dosing protocols, ordering TPNs, et cetera, et cetera, et cetera, they may not have the time to evaluate all of their patients every day for IV to PO readiness.
• 20:40
  SPEAKER_02: So, and also on top of that, there are some commonly used antibiotics like, say, ceftriaxone or piparicillin tasal bactam that are IV antibiotics that don't have direct oral equivalents.
• 20:53
  SPEAKER_02: And so they may not exist on some of these automatic IV to oral interchange protocols.
• 20:59
  SPEAKER_02: However, if say a bedside nurse or a nurse manager or a collapse prevention team or combination thereof is routinely evaluating patients for IV to PO readiness, say, tolerating important other oral medications and informing their unit pharmacist of this, that pharmacist can assist in making those IV to PO transitions themselves, say, if on protocol, or if off protocol, reaching out to the primary team to suggest some oral options.
• 21:29
  SPEAKER_02: So, like you mentioned, Marissa, this has been, we've been talking about IV to PO for what seems like forever.
• 21:36
  SPEAKER_02: And there have been already lots of positive outcomes that have been described, like reduced length of stay, improved clinical outcomes, decreased cost.
• 21:46
  SPEAKER_02: But there are other outcomes that may be further valued by our nursing colleagues.
• 21:51
  SPEAKER_02: So, first, um IV antibiotics are more complex and more time intensive to prepare and administer the this has been looked at in a A couple of studies, one time in motion study in particular, found on average that an IV antibiotic takes 12 minutes of nursing time versus only two minutes of nursing time for an oral antibiotic.
• 22:11
  SPEAKER_02: Multiply that further for antibiotics that are given multiple times per day.
• 22:16
  SPEAKER_02: So you could see in my mind, better clinical care while saving nursing time is a slam dunk.
• 22:24
  SPEAKER_02: There's also evidence that less IV versus PO antibiotics minimizes IV catheter use and IV catheter complications.
• 22:32
  SPEAKER_02: These are outcomes of interest for our infection prevention colleagues and their nursing partners.
• 22:38
  SPEAKER_02: And there are also some clear sustainability benefits as IV antibiotics create much more medical waste than their oral equivalents.
• 22:45
  SPEAKER_02: So I'll say it again.
• 22:47
  SPEAKER_02: In 2026, IV2PO is cool again.
• 22:49
  SPEAKER_02: And I think it is a great opportunity for nursing collaboration with pharmacists.
• 22:54
  SPEAKER_01: I love it.
• 22:55
  SPEAKER_01: You've convinced me.
• 22:56
  SPEAKER_01: What about you, Eileen?
• 22:57
  SPEAKER_01: What do you think?
• 22:58
  SPEAKER_00: Yeah, David, I agree.
• 23:01
  SPEAKER_00: I love the idea of nurses and unit pharmacists working on this together.
• 23:05
  SPEAKER_00: And I also think this would be a really good way to address some of the social and professional barriers that we mentioned before.
• 23:13
  SPEAKER_00: I think it's really clear nurses need to feel empowered and supported in tackling these initiatives.
• 23:20
  SPEAKER_00: One caveat though, around time.
• 23:24
  SPEAKER_00: What I had heard in the qualitative study is that time saving, while it's very apparent in the adult setting, in the pediatric setting, it um, you know, preparing oral antibiotics, depending on, you know, how it's tolerated for the child, it might actually increase time.
• 23:43
  SPEAKER_00: So I think that's also kind of an important workflow consideration and something to kind of tease out.
• 23:48
  SPEAKER_00: So it's really important, I would say, uh, when implementing such recommendations, uh, you know, active nurse participation is really, really critical.
• 23:58
  SPEAKER_01: Yeah, agreed.
• 24:00
  SPEAKER_01: Agreed.
• 24:01
  SPEAKER_01: Okay, so I think that really leads into our next question here pretty well of how stewardship programs can effectively engage nursing in stewardships and where should we go from here.
• 24:14
  SPEAKER_01: So, Eileen, what what advice do you have for us?
• 24:17
  SPEAKER_00: So, one of the things I love about antibiotic stewardship is it's so versatile, right?
• 24:23
  SPEAKER_00: It can connect to so much of what's already going on in nursing.
• 24:27
  SPEAKER_00: So, from a patient safety perspective to infection prevention to efforts to reduce waste, right?
• 24:33
  SPEAKER_00: As David mentioned throughout time preparing, you know, Ivy antibiotics.
• 24:37
  SPEAKER_00: Um, I think it's important for stewardship leaders to really understand the motivations of nursing leaders and how stewardship can propel current priorities from a nursing perspective.
• 24:51
  SPEAKER_00: So, you know, for instance, um many hospitals are journeying towards magnet, magnet or seeking magnet redesignation.
• 25:01
  SPEAKER_00: So, as part of the magnet application, institutions must demonstrate that nurses are actually conducting research, nurses are actively participating in quality improvement, and nurses are using evidence-based practice.
• 25:17
  SPEAKER_00: So I think, you know, nurses' engagement and antibiotic stewardship, when you think about, you know, some of those recommendations that were included in the CDC core elements, you pick any one of those.
• 25:28
  SPEAKER_00: Um, it could easily serve as a win-win, both for ASPs and also for nurse leaders.
• 25:34
  SPEAKER_01: How interesting.
• 25:36
  SPEAKER_01: We we hear about Magnet, but we're not really sure what that means.
• 25:39
  SPEAKER_01: So can you tell us just a little bit more about what Magnet is and why so many institutions are seeking redesignation?
• 25:47
  SPEAKER_00: Yeah, yeah.
• 25:48
  SPEAKER_00: So Magnet, it's um designated by the American Nurses Credentialing Center.
• 25:54
  SPEAKER_00: Um and it started when they actually, you know, um, back I believe in the 80s, they found that there were these institutions where nurses were flocking to these institutions, not away from them.
• 26:07
  SPEAKER_00: And so researchers, they studied, you know, what was so special about these institutions.
• 26:13
  SPEAKER_00: Um and a big part of it was around kind of this aspect of shared governance, um, where, you know, nurses at the front lines were given kind of structures and processes to kind of take initiatives to identify kind of where there's gaps, where there's opportunities, and to run with them.
• 26:34
  SPEAKER_00: So Magnet, it's designated by the American Nurses Credentialing Center.
• 26:39
  SPEAKER_00: It recognizes institutions that have reached pinnacle levels of nursing excellence.
• 26:45
  SPEAKER_00: Right now in this country, I believe there's only about 10% of hospitals that have current magnet designation.
• 26:54
  SPEAKER_00: Many more are journeying towards magnet.
• 26:57
  SPEAKER_00: But even if, let's say, your institution isn't necessarily on this journey, um, hospitals are very much aware of their performance in nurse-sensitive quality indicators, you know, cowdy, collabsy prevention.
• 27:11
  SPEAKER_00: This is another great avenue to make inroads with nursing leaders.
• 27:15
  SPEAKER_00: I think a lot of this is about how are you messaging, how are you framing stewardship and kind of finding, you know, alignment opportunities.
• 27:25
  SPEAKER_01: Sounds like there's a lot of potential alignment and easy opportunities to align.
• 27:30
  SPEAKER_01: Is there anything else you think we need to know about partnering with frontline nurses and managers?
• 27:36
  SPEAKER_00: Yeah, so I would say um get to know and partner with frontline nurses and nurse managers.
• 27:43
  SPEAKER_00: I definitely, you know, I echo David's suggestion to find the stars at your institution because there's so many.
• 27:50
  SPEAKER_00: There's so many, and they need not be in a leadership position to effectuate change.
• 27:56
  SPEAKER_00: So, as I mentioned earlier, many hospitals they've adopted a model of shared governance.
• 28:02
  SPEAKER_00: It's a framework in which frontline nurses are empowered, they're supported to lead change on their units or hospital-wide.
• 28:09
  SPEAKER_00: And so, usually, as part of shared governance, there's unit practice committees, there's QI councils.
• 28:17
  SPEAKER_00: And so the ideas to engage nurses in stewardship can be brought right to these committees and you know, really lead to lasting change.
• 28:28
  SPEAKER_00: And also, um just to kind of uh revisit David's experiences, many nurses, nurse managers, nurse leaders, they're returning to school, they're looking to start a QI or research project.
• 28:41
  SPEAKER_00: And really, I would encourage you to find kind of some alignment of interests uh that can help foster these fruitful collaborations.
• 28:50
  SPEAKER_01: Great recommendations.
• 28:52
  SPEAKER_01: Anything else to add, David?
• 28:55
  SPEAKER_02: Yeah, um, of course, I agree with all of that.
• 28:57
  SPEAKER_02: And and um I guess I want to again address the, you know, uh pharmacists, physicians, other non-nurse listeners that we may have here who may be thinking, okay, this is all great, but I don't have Dr.
• 29:11
  SPEAKER_02: Carter at my institution, right?
• 29:13
  SPEAKER_02: I don't have relationships with nursing.
• 29:15
  SPEAKER_02: I don't know if they've even heard of the words antibiotic stewardship.
• 29:19
  SPEAKER_02: Um, what can I realistically do?
• 29:21
  SPEAKER_02: And, you know, I think one way to start is to take inventory of the connections and the connectors that you already have around you.
• 29:30
  SPEAKER_02: So while not every stewardship program is formally plugged in with nursing, as we've described earlier, sort of the lack of you know, overall engagement um with this, um uh almost all of our programs are going to be deeply connected with other collaborators, like, say, infection prevention.
• 29:51
  SPEAKER_02: So ask your infection prevention friends.
• 29:54
  SPEAKER_02: They likely have knowledge of some of the shared governance structure, like Eileen had mentioned at your institution.
• 30:02
  SPEAKER_02: Um, they may be able to connect you with key point people.
• 30:05
  SPEAKER_02: Um, and you may be able to leverage shared goals like HAI prevention and patient advocacy as a means to engage with nursing on antibiotic stewardship priorities.
• 30:17
  SPEAKER_02: I would share with them the ANA white paper and some of the papers that um Eileen has mentioned and some of the studies that she herself has conducted and you know, see see where that takes you.
• 30:29
  SPEAKER_01: Great.
• 30:30
  SPEAKER_01: All of this discussion really brings to light that nurses are uniquely positioned to help with other big institutional difficult goals like diagnostic stewardship.
• 30:40
  SPEAKER_01: So I'd love to hear, Eileen, what you think about nurses' role in that arena.
• 30:46
  SPEAKER_00: Yeah, I think there's just tremendous opportunity for nurses to lead improvements in diagnostic stewardship, but particularly through a de-implementation science lens.
• 30:59
  SPEAKER_00: There are many myths, as we know, and outdated practices that drive waste and patient harm in healthcare.
• 31:06
  SPEAKER_00: So, for instance, you know, like believing C.
• 31:08
  SPEAKER_00: diff can be detected by stool odor or sending urine cultures based solely on appearance.
• 31:15
  SPEAKER_00: Um, we know that nurses have tremendously heavy workloads.
• 31:19
  SPEAKER_00: And I think de-implementation science offers a very powerful way to help nurses do less while optimizing patient care.
• 31:28
  SPEAKER_01: Oh, I agree with that.
• 31:30
  SPEAKER_01: Um, taking things away that are not useful is a good opportunity.
• 31:36
  SPEAKER_01: David, other opportunities for which nurses are uniquely positioned to help.
• 31:41
  SPEAKER_02: Yeah, thanks for that.
• 31:42
  SPEAKER_02: I and I I have to say I couldn't agree with that more.
• 31:45
  SPEAKER_02: I feel sometimes like 90% of our job is just deconstructing dogma on a day-to-day basis.
• 31:52
  SPEAKER_02: Um, but um actually tied to what Eileen had mentioned, um, sort of on the de-implementation science side of things and the diagnostic stewardship side of things, I wanted to touch on antimicrobial stewardship outside of the acute care setting, um, specifically in skilled nursing facilities.
• 32:11
  SPEAKER_02: So in some of my previous roles, our stewardship efforts overlapped with these types of facilities.
• 32:17
  SPEAKER_02: And what was readily apparent in having conversations every day with representatives from these facilities is that nurses, namely the LVNs, uh, the RNs, and directors of nursing, were the cornerstone of patient care.
• 32:32
  SPEAKER_02: They were doing everything, they were responding to all of the patient and family issues and triaging all of that.
• 32:39
  SPEAKER_02: Now, one, I'll just take one example here that Eileen had kind of alluded to just now.
• 32:44
  SPEAKER_02: Um, one of the most challenging stewardship concerns there is, and I say this in really big air quotes, uh, UTIs, right?
• 32:54
  SPEAKER_02: So many of these facilities have nurse-driven protocols for UTI evaluation, including collecting cultures, notifying the treating physician, who, let's be honest, may not be the easiest person to get a quick response from in those settings, um, or even calling for an ambulance for ED triage.
• 33:13
  SPEAKER_02: Now, there are a variety of more evidence-based tools like the McGear criteria for UTI assessment that can be protocolized and implemented by the nursing staff to reduce overcalling UTIs.
• 33:25
  SPEAKER_02: And these were some of the interventions that we had established that made a fairly significant impact in those institutions.
• 33:35
  SPEAKER_02: Furthermore, again, kind of, you know, um going back to to continue to go back to what Eileen had mentioned, um, the nursing staff were can be very, very valuable in educating patients and sometimes even more importantly, their families in these settings on UTI myths like what Eileen mentioned, um, you know, discolored urine or malodorous urine, or things like altered mental status, meaning there's definitely a UTI.
• 34:02
  SPEAKER_02: This can definitely be ingrained in the minds of patients, their families, um, and even certain healthcare professionals.
• 34:09
  SPEAKER_02: Um, there have been a variety of studies that have showed the value of implementing nurse-driven strategies like this for diagnostic and antibiotic stewardship in these settings with pretty significant outcomes.
• 34:21
  SPEAKER_01: Yeah, great points to highlight, especially the roles nursing have in terms of educating patients, families about dogmas, as you said before.
• 34:35
  SPEAKER_01: Okay, you guys, we're out of time, but let's end with one big take-home point from each of you.
• 34:41
  SPEAKER_01: David, let's start with you.
• 34:44
  SPEAKER_02: Okay, I'll go back to something that I said earlier, but that is that you really already have connections and may not realize it.
• 34:52
  SPEAKER_02: Take inventory of your existing nursing partners or those that have nursing connection within your institution.
• 35:01
  SPEAKER_02: And also I'll just add that um, like with a lot of things in the stewardship space, it may not always be possible to do something large scale or institution-wide right from the get-go.
• 35:12
  SPEAKER_02: Um, but use your network, find the stars, maybe pilot something, uh, maybe pilot something small on an individual unit.
• 35:19
  SPEAKER_02: I think um Eileen had given some examples of this earlier.
• 35:23
  SPEAKER_02: And um, and very, very importantly, um, don't forget to publish or present your work as much as possible.
• 35:30
  SPEAKER_02: We really need more success stories in this place to build um the evidence um for best practices here.
• 35:38
  SPEAKER_00: Yeah, David, I I absolutely agree with you.
• 35:41
  SPEAKER_00: Um, I would say similarly to David, um, you know, find common ground and initiate a conversation.
• 35:49
  SPEAKER_00: Whether that conversation be with a nurse leader, a nurse manager, or a frontline nurse.
• 35:54
  SPEAKER_00: Also, please be sure to really measure and report on the impact of nurses in in this space.
• 36:02
  SPEAKER_00: Um, so much of what nurses do directly relates to stewardship.
• 36:07
  SPEAKER_00: And I think it's really about time that we have robust empirical evidence to demonstrate our impact.
• 36:13
  SPEAKER_01: What a great way to end.
• 36:15
  SPEAKER_01: So I want to first thank both of our guests.
• 36:18
  SPEAKER_01: Thank you, Dr.
• 36:19
  SPEAKER_01: Carter and Dr.
• 36:20
  SPEAKER_01: Ha, for this really enlightening conversation.
• 36:24
  SPEAKER_01: I am not surprised, but as always, I've learned so much from talking with each of you.
• 36:29
  SPEAKER_01: And thank you to our listeners.
• 36:31
  SPEAKER_01: We hope that you feel inspired to go out and have a conversation with the nursing stars and leaders at your institutions.
• 36:41
  SPEAKER_01: And as a final note, all of the articles and resources that we've talked about on today's podcast will be linked in the show notes.
• 36:49
  SPEAKER_01: So go out and have a conversation.
• 36:52
  SPEAKER_01: Thank you.