Latest / The SHEA Podcast / Stewardship in Ambulatory Settings and The Emergency Department

Transcript

Stewardship in Ambulatory Settings and The Emergency Department · The SHEA Podcast

• 0:09
  SPEAKER_01: Welcome to our new four-part podcast series: Challenges and Innovations in Antimicrobial Stewardship, brought to you by the Society for Healthcare Epidemiology of America, or SHA, promoting the prevention of healthcare-associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:30
  SPEAKER_01: This series will focus on describing how telestewardship can be used in resource-limited settings, applying stewardship practices in the ambulatory and emergency department settings, and analyzing innovation and diagnostic stewardship, as well as discussing stewardship in the time of COVID.
• 0:47
  SPEAKER_01: I'm Rebecca Wren, the coordinator of infectious diseases pharmacy programs, co-chair of the antimicrobial stewardship and evaluation team, and director of the PGY2 Infectious Disease Residency Program at Duke University Hospital.
• 1:00
  SPEAKER_01: I'm also a junctive associate professor at Duke University, and I will serve as a moderator for this podcast.
• 1:07
  SPEAKER_01: Shay is excited to launch the first episode of the podcast series, which is entitled Stewardship in the Ambulatory Setting and in the Emergency Department.
• 1:15
  SPEAKER_01: Antibiotic stewardship is well established in many inpatient settings.
• 1:19
  SPEAKER_01: However, outpatient programs are not as common despite high volumes of inappropriate prescribing.
• 1:25
  SPEAKER_01: Literature is lacking to help guide the best interventional strategies.
• 1:29
  SPEAKER_01: And additionally, patient volumes are high and time to decision making is fast in the ambulatory and easy settings.
• 1:35
  SPEAKER_01: Thus, strategies that are successful inpatient may not be feasible, successful, or sustainable in the outpatient setting.
• 1:43
  SPEAKER_01: Finally, hospitals fund stewardship programs through pharmacy department resources or through infection prevention or quality departments.
• 1:51
  SPEAKER_01: So, how do these outpatient settings get funded?
• 1:54
  SPEAKER_01: So these are some big questions for sure.
• 1:56
  SPEAKER_01: And we are fortunate to have two very experienced researchers and clinicians in this area to provide us with their insight today.
• 2:03
  SPEAKER_01: First, we have Dr.
• 2:04
  SPEAKER_01: Larissa May, Professor of Emergency Medicine, Director of the Emergency Department and Outpatient Stewardship Programs, and Medical Director of the Learning Health System Hub at University of California, Davis Health.
• 2:17
  SPEAKER_01: Our other speaker is Dr.
• 2:19
  SPEAKER_01: Jeff Linder, the Michael A.
• 2:20
  SPEAKER_01: Gertz, Professor of Medicine, and the Chief of the Division of General Internal Medicine and Geriatrics at Northwestern University, Feinberg School of Medicine.
• 2:30
  SPEAKER_01: Thank you both for joining us today.
• 2:32
  SPEAKER_01: Hi there.
• 2:32
  SPEAKER_01: Thank you.
• 2:33
  SPEAKER_01: Thanks again.
• 2:34
  SPEAKER_01: And let's jump right into the questions.
• 2:36
  SPEAKER_01: So, what concerns you most about antibiotic use in the ambulatory or ED setting?
• 2:42
  SPEAKER_01: Dr.
• 2:42
  SPEAKER_01: May, can you provide us with your initial thoughts?
• 2:45
  SPEAKER_00: Well, I think it's most concerning that the vast majority of antibiotic use is occurring in the outpatient setting, maybe up to 90%.
• 2:51
  SPEAKER_00: And yet it's the setting that's least focused on in terms of interventions.
• 2:55
  SPEAKER_00: And also, because it's such a broad array of settings, really requires some individualized approaches that are based on adapting implementation science strategies, for example, to the local context.
• 3:06
  SPEAKER_00: So the ED is clearly a very different setting than primary care.
• 3:10
  SPEAKER_00: So more of an acute episodic care setting like urgent care.
• 3:13
  SPEAKER_00: And then obviously in outpatient clinics, I'm sure Dr.
• 3:16
  SPEAKER_00: Linder will talk about it.
• 3:17
  SPEAKER_00: There's a lot of different options and a lot of different types of settings as well.
• 3:21
  SPEAKER_02: And I agree with Larissa.
• 3:22
  SPEAKER_02: The overwhelming problem to me about antibiotic prescribing in the ambulatory setting is just the prescribing of antibiotics for conditions for which antibiotics won't help at all.
• 3:33
  SPEAKER_02: So things that seem in retrospect so obvious: colds, acute bronchitis, the flu, most sinus infections, most throat infections.
• 3:42
  SPEAKER_02: None of those need to be treated with antibiotics.
• 3:44
  SPEAKER_02: And most of them actually don't need any testing.
• 3:46
  SPEAKER_02: And yet, for decades, when we've studied antibiotic prescribing in outpatient settings, we just see somebody comes in with a cold, they get amoxicillin or, you know, the ZPAC.
• 3:58
  SPEAKER_02: And so to me, that remains the most overwhelming problem in ambulatory antibiotic prescribing.
• 4:03
  SPEAKER_01: That's really helpful.
• 4:04
  SPEAKER_01: So you kind of took us through what is the specific need in the ambulatory setting.
• 4:10
  SPEAKER_01: So, Dr.
• 4:11
  SPEAKER_01: May, what are your thoughts about the specific needs in the ED setting?
• 4:15
  SPEAKER_00: Well, I mean, I completely agree that there is a big need to just avoid using antibiotics when they're not indicated.
• 4:21
  SPEAKER_00: And surprisingly, despite all our efforts over the past decades, almost it seems like, that ubiquitous ZPAC is still being prescribed for viral respiratory tract infections.
• 4:30
  SPEAKER_00: So that seems to be very low-hanging fruit to me, even in the emergency department, particularly in community settings.
• 4:35
  SPEAKER_00: And then I think the other sort of big beast to tackle, which I confess I haven't done much tackling of yet because it is so complex and kind of dovetails with diagnostic stewardship.
• 4:44
  SPEAKER_00: But what about asymptomatic bacteria?
• 4:46
  SPEAKER_00: I think it's particularly hard in the ED setting because we often have limited clinical information.
• 4:51
  SPEAKER_00: We're expected to make very quick decisions with a short turnaround time.
• 4:54
  SPEAKER_00: And really, ED providers are not that much more comfortable with diagnostic uncertainty than you would think.
• 4:59
  SPEAKER_00: Also, I think the quality of care outside the ED setting and patient follow-up is a big concern.
• 5:03
  SPEAKER_00: And then I think the other elephant in the room is concerns about liability.
• 5:07
  SPEAKER_00: You know, typically people are more concerned about not prescribing antibiotics when they might be indicated than over-prescribing antibiotics when they're not indicated and really probably downplay the adverse events related to them.
• 5:18
  SPEAKER_00: I think the second piece is also, you know, we tend to prescribe antibiotics for too long as well.
• 5:22
  SPEAKER_00: So if we're going to start an antibiotic, you know, there's not a lot of evidence on duration and sometimes it seems kind of arbitrary.
• 5:28
  SPEAKER_00: We are trying to move towards the shortest duration possible, but you know, there needs to be more research into what that actually is and how it applies to specific patient populations.
• 5:36
  SPEAKER_02: And I actually want to pick up on something you said, Larissa, you alluded to this, that this is not a microbiological problem.
• 5:44
  SPEAKER_02: This is overwhelmingly a social, emotional, and behavioral problem.
• 5:49
  SPEAKER_02: So Larissa, you I mean, you mentioned ED clinicians being nervous about what's going to happen with the patient or are we missing something?
• 5:56
  SPEAKER_02: And so it's sort of that we're treating the clinician's fear, and we're treating the clinician's fear of both the patient having a bad outcome if I don't give an antibiotic and just presuming that the patient is there to get an antibiotic and worried that the patient's going to have a negative reaction or get, frankly, angry at us if we don't prescribe an antibiotic.
• 6:14
  SPEAKER_02: And so coming up with strategies to address the fear, emotion, and social factors about antibiotic prescribing is way more important to my eye in the ambulatory setting than, you know, a lot of people are talking about we just need better point of care tests.
• 6:29
  SPEAKER_02: They definitely have their place, but the vast majority of these, particularly for things like colds and most upper respiratory infections, we don't need another test.
• 6:37
  SPEAKER_00: I totally agree with you.
• 6:38
  SPEAKER_00: I mean, maybe where we do need another test might be for UTI, honestly, because there, you know, our tests are so limited.
• 6:44
  SPEAKER_00: In the ED, we end up treating a lot of asymptomatic puria.
• 6:47
  SPEAKER_00: You know, we never even get the culture done.
• 6:50
  SPEAKER_00: And, you know, obviously we can't take into account the host response.
• 6:52
  SPEAKER_00: And I still, for the life of me, I'm not sure why clinicians, you know, they love to see that UTI diagnosis based on a test when that's not actually how we diagnose UTI, which should be based on symptoms, right?
• 7:04
  SPEAKER_00: But I think clinicians love to have an answer.
• 7:06
  SPEAKER_00: And I think in the ED in particular, you know, if that elderly patient has a low sodium or like a positive urine, great, we're done.
• 7:13
  SPEAKER_00: And then we're not really thinking, like, well, what are we really missing in this patient?
• 7:16
  SPEAKER_00: Right.
• 7:16
  SPEAKER_00: So I think I think that that is a good point.
• 7:18
  SPEAKER_00: I agree about, you know, I tell my residents all the time, we're treating ourselves oftentimes when we use antibiotics for these patients.
• 7:24
  SPEAKER_00: We're not really helping the patient.
• 7:25
  SPEAKER_00: I do think there are some strategies to tackle this fear in our clinicians.
• 7:30
  SPEAKER_00: And I think also there are strategies that maybe could be targeted better towards patients.
• 7:34
  SPEAKER_00: You know, there are some settings like urgent care in particular, where the setting seems to solely exist for the purpose of providing unnecessary antibiotics.
• 7:41
  SPEAKER_00: And so I think that can become a harder thing to tackle.
• 7:43
  SPEAKER_00: Although I know there's also evidence that patient satisfaction is not necessarily related to the receipt of an antibiotic.
• 7:48
  SPEAKER_00: But I do think, especially in the ED, we make a lot of assumptions about why patients are there and what they want without actually asking them.
• 7:54
  SPEAKER_02: There's data both in the emergency department setting and in primary care that we do a terrible job of even following up the results of the test, right?
• 8:01
  SPEAKER_02: So the study of the use of CRP in emergency department for cough, that clinicians by and large didn't even follow the results of the CRP, which just sort of really brings home the point that it's not the lack of a test.
• 8:14
  SPEAKER_02: It's kind of behavioral and so forth.
• 8:16
  SPEAKER_02: And you also brought up what patients can do potentially, you know, if I ever get to bend the ear of somebody who's doing something in the popular press, I always sort of say for patients, you know, when you see your doctor, say something to the effect of, I only want an antibiotic if I really need it, which radically changes the thinking in the clinician's mind from a visit where, well, there's this sort of antagonistic dynamic going on where I am supposed to be preventing the patient from getting something that they really want to one of, oh, we're on the same team here.
• 8:44
  SPEAKER_02: We just need to make sure that nothing bad is going on with the patient and they really only need an antibiotic.
• 8:48
  SPEAKER_01: Those are all such great points, and I couldn't agree more.
• 8:51
  SPEAKER_01: I'd love to see the expansion from kind of URI treatment into asymptomatic bacteria, because I think that's a huge issue.
• 8:59
  SPEAKER_01: So these are big needs in the ambulatory setting and then the ED kind of the discharge from the ED patients.
• 9:07
  SPEAKER_01: So, how common are these programs focusing on stewarding these areas and how are these positions funded?
• 9:14
  SPEAKER_01: Dr.
• 9:15
  SPEAKER_01: May, can you give us your perspective?
• 9:17
  SPEAKER_00: Yeah, so from the ED side of things, my sense is they're very rare, possibly limited to a few academic settings where you actually have some key champions that are focused on research around antibiotic use, maybe.
• 9:28
  SPEAKER_00: And so those programs tend to be also like kind of unstructured and like research grant funded.
• 9:33
  SPEAKER_00: And that's the kind of work that's happening.
• 9:35
  SPEAKER_00: I think I have a unique experience at my current institution at UC Davis Health, where I was recruited to start an antibiotic stewardship research program.
• 9:42
  SPEAKER_00: But I think my chair had the foresight to see that, you know, it was necessary to have a clinical program in antibiotic stewardship.
• 9:47
  SPEAKER_00: So we started off in the ED.
• 9:49
  SPEAKER_00: And then eventually the health system, you know, as part of our efforts to tackle infection prevention, they did realize that antibiotic stewardship was a big piece of infection prevention, particularly even in the inpatient stating related to prosturoides and difficulties infections.
• 10:02
  SPEAKER_00: And so they earmarked a small piece for outpatient or ambulatory stewardship, which I was able to tack on.
• 10:08
  SPEAKER_00: Unfortunately, that program is like a one-woman show for the most part.
• 10:12
  SPEAKER_00: It's just some small percentage of my time.
• 10:14
  SPEAKER_00: And even getting pharmacy support has been a little bit challenging, although we have some great champions and we've built up our ID pharmacist program quite a bit.
• 10:21
  SPEAKER_00: So, and our ambulatory operations quite a bit.
• 10:23
  SPEAKER_00: So I can usually get support to work on these projects, but it's been a slow process.
• 10:27
  SPEAKER_00: And my sense is that there are not a lot of places that really have an outpatient antibiotic stewardship program, even though they may say they have an outpatient antibiotic stewardship program or they may say they include the ED in hospital stewardship.
• 10:39
  SPEAKER_00: The reality is because of the social behavioral components of this, if you don't have champions in the frontline settings for where the stewardship is actually taking place, you know, I feel very strongly that it's not sufficient to simply have traditional hospital antibiotic stewardship programs sort of try to get into that space because ultimately it's not going to be successful.
• 10:55
  SPEAKER_02: I think Larissa and I are both spoiled that we're at we're at systems where, you know, no accident that we're at these places.
• 11:02
  SPEAKER_02: And, you know, I would presume your Shea listenership is also going to be a little bit spoiled.
• 11:07
  SPEAKER_02: So here at Northwestern, we have a system-wide antimicrobial stewardship program, and then we have an ambulatory subcommittee of our system-wide antimicrobial stewardship committee.
• 11:16
  SPEAKER_02: And we've been very focused on actually antibiotic prescribing for respiratory infections in our our what we call our immediate care centers or urgent care practices.
• 11:24
  SPEAKER_02: And they've made really, really impressive improvements because three years ago we really started measuring and improving things.
• 11:31
  SPEAKER_02: But getting back to your original question, Rebecca, in terms of how common these are around the country, I don't think it's that common.
• 11:38
  SPEAKER_01: So there are some regulatory agencies that are starting to get interested in the.
• 11:43
  SPEAKER_01: So what are those regulations a joint commission or DMP have put into place for ambulatory care practices?
• 11:49
  SPEAKER_01: And if you can kind of separate in between those ambulatory practices that may be associated with a hospital versus those that are unaffiliated and maybe that are even outside of just strict medicine, but perhaps dental practices as well.
• 12:03
  SPEAKER_01: So, Dr.
• 12:03
  SPEAKER_01: Linder, what are your thoughts on this?
• 12:05
  SPEAKER_02: Yeah, this is one area where I feel like the pandemic, well, yet another area where the pandemic really hampered us because I think it was going into 2020 that the Joint Commission came out with their first standard about having an antimicrobial stewardship program.
• 12:19
  SPEAKER_02: The standard was not terribly, the bar was not very high.
• 12:22
  SPEAKER_02: You sort of had to have one, you had to have a goal, you had to have a couple of people named to it, and you know, doing something around antimicrobial stewardship.
• 12:30
  SPEAKER_02: So those of us who've been focused on appropriate antibiotic prescribing are really excited.
• 12:35
  SPEAKER_02: But of course, the, you know, the pandemic happens and that is far from most systems top priority now.
• 12:40
  SPEAKER_02: So I think it's helpful that they're out there, but I don't feel like it's really been a game changer, particularly in the context of the pandemic.
• 12:47
  SPEAKER_00: Yeah, I do know when the joint commission came out and at our last site visit, this was pre-pandemic, they were pretty impressed with some of the outpatient work that was happening, and it seemed like they were gonna be moving a little bit in that direction, but essentially highlighting it as an innovation and you know, not really being part of what most hospitals were showing or demonstrating that they were working on.
• 13:05
  SPEAKER_00: So I thought that was kind of interesting.
• 13:07
  SPEAKER_00: You know, one of the surprising things to me when the outpatient standards came out from the joint commission is they don't actually apply to us.
• 13:13
  SPEAKER_00: So being part of a health system and having a medical center on campus, our clinics are basically accredited under the hospital joint commission.
• 13:20
  SPEAKER_00: And so, you know, unless you're a large standalone practice, you know, multi-specialty practice or, you know, surgery center, basically these regulations, they don't really, they don't really apply.
• 13:30
  SPEAKER_00: So it was a little disappointing.
• 13:31
  SPEAKER_00: I was glad that we were already moving in the direction of doing this because it's the right thing to do for patients.
• 13:35
  SPEAKER_00: But I was a little disappointed that there can't be a little bit more reach into the ambulatory setting.
• 13:40
  SPEAKER_02: And I would say we we we've had the heatest measures for years.
• 13:43
  SPEAKER_02: So avoiding antibiotic prescribing for acu bronchitis in adults and avoiding antibiotic prescribing and kids with pharyngitis and a negative strep test, or rather, the actual measure is when a strep test wasn't done because they have no way of knowing what the result is.
• 13:55
  SPEAKER_02: But that really sort of applies to health plans rather than clinics or health systems.
• 13:59
  SPEAKER_02: And so it is one step kind of removed.
• 14:02
  SPEAKER_02: But insofar as that's a lever that payers are interested in and the joint commission should be influencing clinics and practices and then the system-wide, more hospital-based joint commission standards would hopefully influence what's going on in outpatient.
• 14:17
  SPEAKER_02: You know, I think there's a few of these standards that those of us interested in ambulatory stewardship can talk to our colleagues at our local institutions about to kind of get the ball rolling.
• 14:25
  SPEAKER_00: Yeah, I agree.
• 14:25
  SPEAKER_00: On the ED side, you know, it's been partly payer-driven, but it's interesting that for the first time, the American College of Emergency Physicians a couple of years back actually adopted a resolution to focus on stewardship in the ED setting.
• 14:36
  SPEAKER_00: There's actually a couple of measures that are now being promoted or metrics.
• 14:40
  SPEAKER_00: But it's interesting that at least on the ED side, you know, we've been somewhat sheltered from the payers.
• 14:45
  SPEAKER_00: And so it's interesting that even in that setting, payers are starting to drive some of the changes that are happening related to antibiotic stewardship.
• 14:51
  SPEAKER_00: And so I do find that there is more interest on the part of EDs around the country in terms of focusing on this important topic, whereas maybe five, 10 years ago, there really was none at all.
• 15:00
  SPEAKER_02: Yeah, and I'm I'll actually run to the defense of the urgent care clinics, surprisingly.
• 15:05
  SPEAKER_02: But yeah, kind of the specialty body for urgent care clinics also recognize this as a problem and so have come out with a number of statements about us seeking to improve antibiotic prescribing in urgent cares.
• 15:16
  SPEAKER_00: Yeah, I think that was great, except that there's a large proportion of urgent care clinics that are not even members of that society.
• 15:21
  SPEAKER_00: So I think it does represent, you know, perhaps the ones that are more interested in equality.
• 15:25
  SPEAKER_00: I mean, there is a lot of pick and choose your own metric or pick or choose your own measure, right?
• 15:29
  SPEAKER_00: So I think the antibiotic stewardship one is hard.
• 15:31
  SPEAKER_00: Even our own institution decided not to pick that one when we had a Medi-Cal program that basically provides incentives to focus on certain topics because they felt that we couldn't achieve the goals for antibiotic stewardship.
• 15:42
  SPEAKER_00: So they chose to focus, you know, on other topics like opiates.
• 15:44
  SPEAKER_00: But ironically, antibiotic stewardship and avoiding antibiotics for viral URIs is one of our great success stories here at UC Davis Health, really, over the last three years.
• 15:52
  SPEAKER_01: So let's expand on that a little bit.
• 15:54
  SPEAKER_01: We've talked a lot about the challenges, but can you take us through some of the successful interventions that you have found and impacted either the ambulatory care setting or ED setting?
• 16:03
  SPEAKER_00: So I think we learned a lot from, at least in the ED, from the primary care literature and some of the groundbreaking studies that Jeff and others, Daniela Meeker and Jason Doctor, were involved in in outpatient clinics.
• 16:14
  SPEAKER_00: And we actually had a CDC funded contract to develop an antibiotic stewardship toolkit for ED and urgent care settings and to do a study looking essentially at behavioral interventions versus sort of standard education.
• 16:25
  SPEAKER_00: And so we basically took the literature in the primary care setting and then adapted it locally to the context of the emergency department and urgent care setting, and then developed a toolkit that's essentially an implementation guide using implementation science techniques for how to think about developing a program that's successful.
• 16:40
  SPEAKER_00: And, you know, we do follow the CDC core elements for outpatient settings.
• 16:44
  SPEAKER_00: I think the ED may be a little bit different, but essentially it's the same principles.
• 16:48
  SPEAKER_00: You know, you need to be able to have championship on the front lines.
• 16:52
  SPEAKER_00: You really do need administrative or higher level executive support.
• 16:55
  SPEAKER_00: So you need that executive sponsorship.
• 16:57
  SPEAKER_00: You need a way to collect and track data.
• 16:58
  SPEAKER_00: So again, the institution has to be invested in helping you do that.
• 17:01
  SPEAKER_00: And then some of the successful interventions that we found, which I've actually even applied to our outpatient setting, is, you know, in addition to having those champions, it's just providing feedback on their own data.
• 17:11
  SPEAKER_00: For the ED, we did it at the provider level.
• 17:13
  SPEAKER_00: For our outpatient clinics, it was just a little too overwhelming with 900,000 patient visits a year.
• 17:17
  SPEAKER_00: So we did it at the clinic level.
• 17:18
  SPEAKER_00: And maybe it's a Hawthorne effect, maybe it's just peer pressure, but ultimately we found a reduction in antibiotic use that, you know, has continued to decline over time, at least for viral respiratory tract infections.
• 17:29
  SPEAKER_00: We're starting to focus a little more on selection and duration.
• 17:31
  SPEAKER_00: And I do know that azithromycin and fluoroclinolone still remain a problem.
• 17:34
  SPEAKER_00: And that may be something that pairs are interested in, also, right?
• 17:37
  SPEAKER_00: Because that's an expensive, unnecessary cost.
• 17:39
  SPEAKER_02: And I would say in primary care, I'll just talk about I could go on and on, which I'll spare your listeners going on and, but just two interventions that we that we studied that that were effective.
• 17:48
  SPEAKER_02: One is what we call peer comparison, and Larissa alluded to this, where in the outpatient setting, and we've done this in a randomized controlled trial, and we've done it in our primary care practices and our urgent care practices here, but really giving people individualized feedback about their antibiotic prescribing relative to their top performing peers.
• 18:08
  SPEAKER_02: And really, so it feels really blunt, and you're giving people feedback that really sounds like you're doing a bad job, but people don't get the message if you if you're if you sort of show them where they are on the bell curve versus saying these are your colleagues who are doing well, you're not in that group.
• 18:23
  SPEAKER_02: And so, you know, our our go-to line is always you're not a top performer, and this is what the top performers are doing.
• 18:28
  SPEAKER_02: And then the other intervention that we've studied that's easy and pretty effective is commitment posters, so pre-commitment posters.
• 18:34
  SPEAKER_02: And it was really gratifying that this is actually part of the CDC core elements.
• 18:38
  SPEAKER_02: It's mentioned in there.
• 18:39
  SPEAKER_02: But the idea that you, as a practice, individual clinicians and as a practice put together a poster saying that you're committed to only prescribing antibiotics when they're absolutely necessary and you're most focused on doing what's right for patients, making a big poster, signing it, putting your picture on it, really personalizing it, putting it out in the waiting room.
• 18:58
  SPEAKER_02: That usually drops the inappropriate antibiotic prescribing rate by about 20%.
• 19:02
  SPEAKER_02: And our thinking is the, you know, the way that works is it gets the message out to patients that we're focused on what's best for them.
• 19:09
  SPEAKER_02: And that may not be an antibiotic, but even more importantly, it lets the clinician sort of know that the patient knows by the time they get together in the room.
• 19:16
  SPEAKER_02: So we found those commitment posters to be reasonably easy and pretty effective.
• 19:20
  SPEAKER_00: I should mention that for our mitigate study, as we call it, we did adapt many of these things that have been studied that Jeff is mentioning from the work that he and others did.
• 19:28
  SPEAKER_00: But it really, for the ED context, had to be modified a bit, right?
• 19:32
  SPEAKER_00: So it's hard to put up a poster when you don't have, you know, especially a signed commitment poster when you have like people working in varied shifts and we don't have specific exam rooms and there's nowhere to really hang it on a curtain.
• 19:42
  SPEAKER_00: And you know, same with some of the other, the other types of things.
• 19:45
  SPEAKER_00: So we actually had flare.
• 19:46
  SPEAKER_00: That was an idea that Jason Doctor had is, you know, people could wear their commitment too, right?
• 19:51
  SPEAKER_00: So we had like these really nice badge reels that had the at the time it was the CDC Get Smart logo, now the B antibiotics aware campaign.
• 19:58
  SPEAKER_00: I kind of miss the Get Smart logo.
• 20:00
  SPEAKER_00: And then we basically, you know, implemented some of these things in a in a similar but modified fashion, just because the realities of the context of ED and urgent care is sometimes, you know, a more chaotic environment, should I say?
• 20:11
  SPEAKER_00: There were also some interesting concerns.
• 20:12
  SPEAKER_00: Like a couple of our faculty were worried somehow that if they signed the poster and it was displayed in public, the patients would like forge their signatures.
• 20:19
  SPEAKER_00: I thought that was kind of interesting because I hadn't even thought about that.
• 20:21
  SPEAKER_00: I don't know if that's ever happened, but essentially we did make some modifications and I think it still had its intended goals of getting everyone on the same page and getting the patients on the same page too.
• 20:30
  SPEAKER_02: And I should say for listeners, if you go to the CDC website, the B Antibiotics Aware, they have templates for commitment posters that, you know, and every time we go go through and like revise it, it gets simpler and simpler every time.
• 20:42
  SPEAKER_02: But it could good to see what's there.
• 20:44
  SPEAKER_01: Those are all excellent points.
• 20:45
  SPEAKER_01: I think we took Jeff's recommendation for the poster as well and learned quickly that we need to engage the staff that is involved in decorating in the offices to make sure it was allowable to put up posters.
• 20:58
  SPEAKER_01: So that was a lesson learned for us.
• 21:00
  SPEAKER_01: Can each of you talk about some other lessons learned that you've had or some unsuccessful interventions that going back, you would maybe alter a bit in your approach.
• 21:09
  SPEAKER_01: Dr.
• 21:10
  SPEAKER_01: Linder, could you start us off?
• 21:12
  SPEAKER_02: Oh, geez.
• 21:12
  SPEAKER_02: It's funny you mentioned that.
• 21:13
  SPEAKER_02: So everything I said, it took about a decade before I really landed on the, oh, this is not an information problem.
• 21:20
  SPEAKER_02: This is a social, behavioral, emotional problem.
• 21:22
  SPEAKER_02: And so I basically have a decade of my career that when I give a talk about this, I sign, you know, I have one bullet that says prior interventions have been less effective than hoped.
• 21:32
  SPEAKER_02: And some of those prior interventions were, you know, giving people too much data, you know, complicated data, pop-ups in the electronic health record.
• 21:40
  SPEAKER_02: You know, and I would say probably every three months or so, I get you know an email from somebody around the world saying, like, hey, we're thinking about having clinical decision support to tell doctors to not prescribe antibiotics for colds.
• 21:52
  SPEAKER_02: And, you know, it's like, I did that 15 years ago.
• 21:54
  SPEAKER_02: It doesn't work.
• 21:55
  SPEAKER_02: Like by the time the person's writing the prescription for the cold, like It's too late.
• 22:00
  SPEAKER_02: So, I mean, those are a couple that kind of leap to mind.
• 22:04
  SPEAKER_02: But and I think what we're alluding to also is that, you know, context is everything.
• 22:08
  SPEAKER_02: So, you know, the ED is different from the primary care practice, and each primary care practice is different in its own way.
• 22:13
  SPEAKER_02: And so you really do need to engage people locally, as Larissa said, to have a local champion to understand what's going on, be measuring things, be following things.
• 22:22
  SPEAKER_00: I was just thinking, you know, in terms of like how we gave feedback, I tried to do it the way that the studies had done it, you know, with that you're not a top performer.
• 22:31
  SPEAKER_00: And I think you're right, it worked.
• 22:33
  SPEAKER_00: But I had another study looking at skin and soft tissue stewardship where I had a kind of softer approach, like a more individualized, like personal email.
• 22:40
  SPEAKER_00: And that also seemed to be effective.
• 22:42
  SPEAKER_00: So I I guess what I've realized is, you know, in this process, since it is a social, emotional, behavioral problem, at least for viral URIs and treatment of asymptomatic bacteria, you know, it's all about the relationship building, right?
• 22:53
  SPEAKER_00: It's it's you need to have good relationships with your clinicians.
• 22:55
  SPEAKER_00: It's why it's important to have a champion that's in the environment that you're trying to make the change in.
• 23:00
  SPEAKER_00: You know, it's really that engagement and and relationships.
• 23:02
  SPEAKER_00: And it takes a while.
• 23:04
  SPEAKER_00: I remember coming into UC Davis and I've got this great study, and I'm just gonna tell everybody what to do.
• 23:08
  SPEAKER_00: You know, maybe it didn't go over the best way it could have at the outset.
• 23:11
  SPEAKER_00: Ultimately, I think we all have a collegial relationship now, but it it is interesting to be in a position where you're trying to change people's behavior and trying to figure out how much you need to kind of tiptoe around things versus like how forceful you need to be.
• 23:22
  SPEAKER_00: And I think it's finding that balance in the setting and group that you're in, but really, you know, that can take a little bit of time.
• 23:27
  SPEAKER_00: And it it really is about the human relationship, I think.
• 23:29
  SPEAKER_00: And it's even more challenging now that we're mostly virtual.
• 23:32
  SPEAKER_00: I think something's been lost in that opportunity.
• 23:34
  SPEAKER_02: I think a couple of things I've I've tried to recapture that maybe I was missing earlier on in my career was this idea of kind of coaching, empowerment, and professionalism.
• 23:43
  SPEAKER_02: So you have to replace the patient satisfaction, efficiency, my habit of just prescribing antibiotics.
• 23:50
  SPEAKER_02: You have to replace it with something else.
• 23:52
  SPEAKER_02: You can't just tell people they're doing a bad job and leave it at that.
• 23:55
  SPEAKER_02: You know, you have to convince people that you're doing right by them, even if that makes them unhappy.
• 24:00
  SPEAKER_02: So there is sort of this, it does feel a little more paternalistic, but as a professional, it's like this is our obligation to our patients to do what's right by them and to get people to feel good about doing the right thing.
• 24:11
  SPEAKER_02: So I think as much as we've sort of alluded towards like negative emotions, replacing it with these kind of positive emotions too is very helpful.
• 24:19
  SPEAKER_00: Yeah, no, I agree.
• 24:20
  SPEAKER_00: I think when, you know, we sometimes lose focus of why we're doing these things, right?
• 24:23
  SPEAKER_00: We get so entrenched in we need you to stop prescribing antibiotics, but the reality is like we're all trying to do the right thing for the patient.
• 24:30
  SPEAKER_00: And I think sometimes we kind of lose that patient focus.
• 24:32
  SPEAKER_00: I think we've been pretty successful here because there is this engagement of patients and and physicians that really has this patient-centered focus, but also is really, you know, it's a safety issue, right?
• 24:43
  SPEAKER_00: And I think reframing it that way when talking to clinicians is really helpful because clinicians don't, they definitely don't want to be responsible for harming patients.
• 24:50
  SPEAKER_00: And I think if you focus on the patient safety aspects of things, that conversation with the patient may be a little bit easier to have as well because we don't want to harm you, right?
• 24:58
  SPEAKER_00: And we want, we want you to get better.
• 25:00
  SPEAKER_00: But I do think, I do think some of the communication strategies probably need to be a little bit stronger also.
• 25:04
  SPEAKER_00: But I agree with what Jeff said.
• 25:05
  SPEAKER_01: So as you're thinking forward, what are some research gaps that would really help for us to understand how to do stewardship in this setting in the best, most sustainable way?
• 25:15
  SPEAKER_01: You know, we've talked about relationships, and if you're looking across a huge setting with, you know, lots and lots of patient visits and lots of different providers, how do you build that sustainability?
• 25:26
  SPEAKER_01: So what are some areas that you guys are kind of focusing on?
• 25:29
  SPEAKER_00: You know, I think sustainability is key and it's that piece of, you know, like the implementation science, feasibility, acceptability, you know, cost.
• 25:37
  SPEAKER_00: What about sustainability?
• 25:38
  SPEAKER_00: So we've been trying to kind of look at that.
• 25:40
  SPEAKER_00: I think in our academic settings, you know, our prescribing rates are so low for viral respiratory tract infections that, you know, we really don't see that much moving.
• 25:48
  SPEAKER_00: But I think in the community settings, there has been quite a downtrend.
• 25:51
  SPEAKER_00: And so I think that's an opportunity to look at how implementation science can adapt the evidence to the local context and setting, and then following those measures over time to see how sustainable things are.
• 26:00
  SPEAKER_00: Like how much touch does the stewardship program need to continue to have, or do we need new strategies?
• 26:05
  SPEAKER_00: I think there are still some research gaps and perhaps even still some low-hanging fruit in terms of duration of antibiotic use when an antibiotic is selected, perhaps some in terms of antibiotic selection.
• 26:15
  SPEAKER_00: Again, diagnostic testing not by itself, but obviously there are some opportunities to use diagnostic testing to help reassure clinicians or kind of guide them.
• 26:23
  SPEAKER_00: And then some major gaps, I think, really for me are in UTI right now and the management of asymptomatic bacteria.
• 26:30
  SPEAKER_00: We just put out a position paper between the antibiotic resistance leadership group and the diagnostic subcommittee.
• 26:35
  SPEAKER_00: And I think one of the major gaps is we don't have good UTI diagnostics and we still overtreat asymptomatic bacteria.
• 26:42
  SPEAKER_00: And so those things I think will need to be tackled together because clinicians are obviously relying on a test that's completely inaccurate.
• 26:48
  SPEAKER_00: But it's also a social behavioral problem where you know we've got the little elderly patient that is a little weak or dizzy, and we really just want a reason to fix them, or then there's the family member who's saying last time they were like this, they had a UTI, right?
• 27:00
  SPEAKER_00: So it's sort of like the ZPAC for viral URIs where we were about 20 years ago.
• 27:04
  SPEAKER_00: It's a self-perpetuating prophecy.
• 27:06
  SPEAKER_00: So we really need to find some, I think, behavioral interventions to kind of break that.
• 27:10
  SPEAKER_00: But that's not low-hanging fruit, in my opinion, but it is very important.
• 27:13
  SPEAKER_02: Yeah, and I feel like in primary care, we still have a lot of work to do for acute respiratory infections that just don't need antibiotics.
• 27:19
  SPEAKER_02: But in places where we've been successful, it brings up kind of more measurement problems.
• 27:24
  SPEAKER_02: So I think going forward, whatever you do, like setting up some type of measurement regime or measurement system is really important.
• 27:31
  SPEAKER_02: So you can keep an eye on what you're doing.
• 27:32
  SPEAKER_02: But as, for example, the antibiotic prescribing rates for acute respiratory infections come down, one would actually hope that the visits would go down too.
• 27:39
  SPEAKER_02: So, you know, there's actually in ambulatory care, not so much in the emergency department, well, maybe in the emergency department too.
• 27:45
  SPEAKER_02: Like you really don't want a visit for a cold to happen even in the first place.
• 27:49
  SPEAKER_02: And so it mathematically you remove that from the denominator and you're just sort of left with the people who are really sick.
• 27:54
  SPEAKER_02: And you can actually see the antibiotic prescribing rate go up when in fact you're doing right by the overall amount of antibiotics coming down, because there are way fewer visits.
• 28:02
  SPEAKER_02: So to me, it's kind of this idea of visit stewardship, overall antibiotic prescribing, and our kind of next frontiers in ambulatory antibiotic stewardship to me, while we continue to work on acute respiratory infections.
• 28:14
  SPEAKER_02: And then a final thing is, and I'm I was about to use the phrase, as we come out of the COVID pandemic, I hope the idea that this is a little bit of a teachable moment.
• 28:24
  SPEAKER_02: And I'm not sure we're quite taking advantage of it.
• 28:27
  SPEAKER_02: Because I think people do, for all the craziness about hydroxychloroquine and ivermectin and whatever crazy thing people are using this week, I think there's a recognition that antibiotics don't work for COVID.
• 28:38
  SPEAKER_02: So this is one area where you know people are much more interested in the test.
• 28:42
  SPEAKER_02: What does this mean for my job, for me being around people?
• 28:45
  SPEAKER_02: And they kind of get that antibiotics aren't the answer.
• 28:47
  SPEAKER_02: So using this teachable moment to sort of say, hey, you have a cold, this is caused by a virus, and like COVID, it doesn't respond to antibiotics and you just need to get better.
• 28:56
  SPEAKER_02: So I think keeping an eye on what's happened with antibiotic prescribing, as you know, again, we hopefully we're in the latter phases of the COVID pandemic, but it's gonna be around for a little while.
• 29:05
  SPEAKER_02: But can we use this teachable moment?
• 29:07
  SPEAKER_00: Well, we just need to convince our colleagues, I guess, that antibiotics don't work for COVID.
• 29:11
  SPEAKER_02: Right.
• 29:12
  SPEAKER_00: At least in the hospital setting, right?
• 29:14
  SPEAKER_00: So I think there is still like, I'm gonna make myself feel better because I don't know, but I I agree.
• 29:19
  SPEAKER_00: Like I think for outpatients or discharge patients with, you know, COVID, most of them sort of get like, this is not something I can just treat with an antibiotic, right?
• 29:27
  SPEAKER_00: So it's it's just different and new.
• 29:28
  SPEAKER_00: And maybe you're right, that is the teachable moment to kind of go back to square one.
• 29:32
  SPEAKER_00: I mean, I think it'll be interesting to see what happens with urgent care because I know there have been some studies, you know, for example, highlighting that retail health and urgent care actually drive visits for respiratory tract infections.
• 29:41
  SPEAKER_00: They don't actually solve our crisis of access to care.
• 29:44
  SPEAKER_00: They tend to pop up in places where patients are more affluent.
• 29:47
  SPEAKER_00: It certainly doesn't really help our underserved patients.
• 29:49
  SPEAKER_00: And then we're basically driving more visits, you know, for these types of complaints.
• 29:53
  SPEAKER_00: I think within our health system, we've looked at, you know, video visits over the last year for respiratory infections or we have a virtual express care.
• 30:00
  SPEAKER_00: And we haven't found that the antibiotic prescribing in in those settings in telehealth is greater than it is in face-to-face visits.
• 30:06
  SPEAKER_00: So I thought that was really interesting.
• 30:07
  SPEAKER_00: I was expecting the opposite based on some of the literature that's out there, but we haven't found it at least within our own system.
• 30:12
  SPEAKER_00: So maybe that's just part of the culture change.
• 30:14
  SPEAKER_00: You know, when you have a health system that's supporting stewardship and focused on stewardship and you have champions that get it, maybe over time that is what happens.
• 30:22
  SPEAKER_00: And maybe we will see fewer visits for the common cold once the patients start to get it as well.
• 30:26
  SPEAKER_01: Those are all excellent points and such a great conversation.
• 30:30
  SPEAKER_01: I'd like to open it to both of you guys for just some final thoughts before we close out this episode of the podcast.
• 30:36
  SPEAKER_02: I'm just going to reiterate what I said before.
• 30:37
  SPEAKER_02: I mean, and and that Larissa picked up on about, you know, this is all about what's doing right for patients.
• 30:42
  SPEAKER_02: And, you know, the phrase I often use with patients is this is a drug that has no chance of helping you and has a real chance of hurting you, and to kind of keep it focused on patients and doing the right thing by patients.
• 30:53
  SPEAKER_00: You said it perfectly, Jeff.
• 30:54
  SPEAKER_00: I think the other thing I would add is, you know, that we're sort of in a diagnostic testing revolution now.
• 30:59
  SPEAKER_00: And I think highlighted by COVID, you know, we've got PCR and antigen tests and all these new tests popping up for a variety of infectious diseases, conditions.
• 31:06
  SPEAKER_00: And yet, you know, really the bottom line is if they are not implemented, considering workflow in mind or considering overall stewardship strategy, simply implementing a test is just not going to be effective.
• 31:16
  SPEAKER_00: So, as important as I think diagnostics are, I think the reality is we really need to focus first on robust antibiotic stewardship.
• 31:23
  SPEAKER_00: And I think the viral respiratory tract infection place is a great place to work because it's much easier to kind of tackle.
• 31:28
  SPEAKER_00: You don't need an antibiotic, then which antibiotic should I use?
• 31:31
  SPEAKER_01: Thank you so much, Dr.
• 31:32
  SPEAKER_01: May and Dr.
• 31:33
  SPEAKER_01: Lennon, for such a great conversation.
• 31:35
  SPEAKER_01: It's been really informative to give us both perspective on kind of what you both have done in the past as well as what you're looking forward to to doing and others researching in the future.
• 31:44
  SPEAKER_01: So thank you so much.
• 31:46
  SPEAKER_02: Thanks for having me.
• 31:47
  SPEAKER_01: Thank you.
• 31:48
  SPEAKER_01: As a reminder, this is episode one in a four-part series.
• 31:51
  SPEAKER_01: Be on the lookout for our remainder episodes: innovation and diagnostic stewardship with a focus on bacterium and sputa urea, which you've heard about a little bit today.
• 32:00
  SPEAKER_01: Telestewardship, an emerging tool for resource limited settings, and antibiotic stewardship in the time of COVID-19, which we've also kind of touched on today as well.
• 32:10
  SPEAKER_01: These will launch in the upcoming weeks.
• 32:12
  SPEAKER_01: You can find more educational content like this podcast on Shay's online educational center, the learning CE, at www.learningce.shay online.org.
• 32:23
  SPEAKER_01: This concludes episode one of the challenges and innovations in antimicrobial stewardship series.
• 32:28
  SPEAKER_01: Thank you for tuning in.