Latest / The SHEA Podcast / Antibiotic Prescribing & Stewardship in Hospitals (Part 2)

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Antibiotic Prescribing & Stewardship in Hospitals (Part 2) · The SHEA Podcast

• 0:09
  SPEAKER_02: Welcome to the Social and Cultural Aspects of Infection Control and Antibiotic Stewardship Podcast Series, brought to you by the Society for Healthcare Epidemiology of America, Shay, promoting the prevention of healthcare associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:31
  SPEAKER_02: I am Hannah Wenders, antimicrobial stewardship pharmacist at Prisma Health Midlands in Columbia, South Carolina, and I will serve as today's moderator.
• 0:39
  SPEAKER_02: Shay is excited to launch this episode on social and cultural aspects of antibiotic prescribing and stewardship in hospitals.
• 0:47
  SPEAKER_02: This podcast is part two of the previous podcast that looked at key drivers of suboptimal antibiotic prescribing in hospitals based on social and cultural aspects.
• 0:58
  SPEAKER_02: We will discuss the interventions that can be implemented based on the culture at your institution or within parts of your institution.
• 1:06
  SPEAKER_02: We will also discuss communication strategies that can be most successful when talking with prescribers as a part of prospective auditing feedback based on the culture of the unit, hospital, or specialty at your institution, and the perceived social and behavioral drivers of their suboptimal prescribing.
• 1:25
  SPEAKER_02: We have the same three speakers with us today for the second part, Dr.
• 1:29
  SPEAKER_02: Asmita Chirotney, Associate Professor at the University of Cape Town, where she is undertaking a Welcome Trust Career Development Fellowship investigating intersectionality and AMR.
• 1:42
  SPEAKER_02: In the UK, she is a reader in infectious diseases, AMR, and Global Health at the University of Liverpool.
• 1:49
  SPEAKER_02: She is a visiting researcher at Hawkland University Hospital, Bergen, Norway, and adjunct professor at Amrita Institute of Medical Sciences, Kerala, India, where she is involved in helping implement and investigate national antibiotic stewardship programs.
• 2:08
  SPEAKER_02: Her work in AMR has been recognized through the Academy of Medical Sciences UK India AMR Visiting Professor Award.
• 2:18
  SPEAKER_02: She is an expert advisor to the Commonwealth Pharmacy Association and a Global Health Fellow with the Office of Chief Pharmaceutical Officer England.
• 2:27
  SPEAKER_02: She is involved in mentoring and supporting clinical pharmacists across different healthcare settings and economies in implementing antimicrobial stewardship interventions.
• 2:37
  SPEAKER_02: Her doctoral thesis investigated antimicrobial stewardship across India, Norway, France, Burkina Faso, and England.
• 2:46
  SPEAKER_03: Hi, great to be back.
• 2:48
  SPEAKER_02: Next we have Dr.
• 2:49
  SPEAKER_02: David Schwartz.
• 2:50
  SPEAKER_02: Dr.
• 2:50
  SPEAKER_02: Schwartz became chair of the NASANT Antimicrobial Stewardship Program at Cook County Hospital in Chicago shortly after completing his postgraduate medical training at the University of Washington and joining the CCH ID faculty in 1993.
• 3:10
  SPEAKER_02: He gave up this post on retiring from full-time employment in 2022.
• 3:16
  SPEAKER_02: During his tenure, a host of stewardship-related interventions were implemented and expanded at CCH and affiliated hospitals, most seeking to educate clinicians on principles of optimal infection management while making more granular treatment recommendations accessible at the point of care.
• 3:34
  SPEAKER_02: And he studied the impacts of these interventions on antimicrobial usage and appropriateness through collaborative agreements between CCH, Rush University Medical Center, and the CDC.
• 3:45
  SPEAKER_02: Always keen to understand the perspectives of antimicrobial prescribers, Dr.
• 3:50
  SPEAKER_02: Schwartz later collaborated with a medical anthropologist, Katharina Rinkowicz, PhD, who performed field work in intensive care units at Rush and CCH, now Stroger Hospital, to better understand the attitudinal, institutional, and cultural dynamics underlying day-to-day antimicrobial treatment and other infection management decisions.
• 4:14
  SPEAKER_01: Hi, Hannah, and Esmina and Brad, great to be back.
• 4:17
  SPEAKER_02: And finally, we have Dr.
• 4:19
  SPEAKER_02: Brad Spelberg.
• 4:20
  SPEAKER_02: Dr.
• 4:20
  SPEAKER_02: Spelberg is Chief Medical Officer at the Los Angeles General Medical Center, one of the largest public hospitals in the U.S.
• 4:28
  SPEAKER_02: He also staffs internal medicine ward teams, infectious diseases consulting service, and the antimicrobial stewardship service at LA General, and maintains an active NIH-funded basic science laboratory that focuses on novel solutions to combating antibiotic resistant infections.
• 4:49
  SPEAKER_02: In 2009, Dr.
• 4:51
  SPEAKER_02: Spelberg published Rising Plague to inform and educate the public about the crisis in antibiotic-resistant infections and lack of antibiotic development.
• 5:01
  SPEAKER_02: His latest book, Broken, Bankrupt and Dying, How to Solve the Great American Healthcare Ripoff, was published in June of 2020.
• 5:12
  SPEAKER_02: Thank you all for joining us again.
• 5:14
  SPEAKER_02: Let's jump in.
• 5:16
  SPEAKER_02: The first question is what types of interventions are most useful for changing the culture of antibiotic prescribing in hospital settings?
• 5:25
  SPEAKER_02: And would you recommend different interventions depending on what social and cultural aspects are driving the suboptimal antibiotic prescribing that you are hoping to target?
• 5:35
  SPEAKER_02: If so, please give an example.
• 5:40
  SPEAKER_03: Thank you very much.
• 5:41
  SPEAKER_03: So we did a systematic review of interventions to optimize antibiotic use in hospital settings, a Cochrane systematic review back in 2017, looking at all the evidence at the time, which predominantly was from high-income countries at the time, there wasn't much evidence from low and middle-income countries.
• 5:57
  SPEAKER_03: And what we identified was that successful interventions are dependent on being more persuasive than restrictive.
• 6:06
  SPEAKER_03: So whilst restrictive interventions, and those are things like removing certain antibiotics from the formulary, or having stop orders, or having an authorization code for certain antibiotics, whilst they may work in the short term, they are not as effective in the long term.
• 6:22
  SPEAKER_03: For sustainability and long-term effectiveness, interventions need to be persuasive.
• 6:28
  SPEAKER_03: This means bringing people around.
• 6:30
  SPEAKER_03: And this goes back to what we were saying in the first podcast.
• 6:33
  SPEAKER_03: It's about contextualizing interventions, it's about understanding the existing hierarchies, understanding the opinion leaders, and working with people to develop interventions that are going to work in their setting.
• 6:43
  SPEAKER_03: We spend a lot of time, hours and hours, interviewing healthcare professionals, and we often hear this annoyance or frustration that policies are given to people without any consideration for their opinions or how the policy will impact their practices or why in the first place people are practicing the way they are.
• 7:02
  SPEAKER_03: And I think that's really important.
• 7:03
  SPEAKER_03: So I give you a very basic and silly example if you like.
• 7:06
  SPEAKER_03: But in the UK we had this intervention, one of the interventions we had was bare below the elbows so that everybody rolls up their sleeves, doesn't wear jewellery for hand hygiene to stop the spread of infection.
• 7:16
  SPEAKER_03: And when we spoke to surgeons, they said, you know, we're a very mobile team.
• 7:20
  SPEAKER_03: We have patients all over the hospital.
• 7:22
  SPEAKER_03: We have to go to theatre, we have don't have offices per se.
• 7:25
  SPEAKER_03: This is in the hospital I was working in at a time.
• 7:27
  SPEAKER_03: And you know, I one surgeon said, I can't tell you how many blazers I've lost because I have to have this ridiculous perhaps policy.
• 7:34
  SPEAKER_03: So it's just something as simple as understanding how that context is going to influence an individual or a group of individuals and their behaviors, and then we judge them for not practicing that.
• 7:43
  SPEAKER_03: The other thing is about less punitive interventions.
• 7:46
  SPEAKER_03: I think again it goes back to clinicians wanting their autonomy and not expecting to be told what to do.
• 7:52
  SPEAKER_03: We rely a lot on technology, and one of the key things that I learned when I was conducting my research looking at the differences in medical and surgical teams is that at the time our hospital was transitioning from paper medical records to electronic systems, and we had this computer on wheels which were wheeled around from patient to patient.
• 8:11
  SPEAKER_03: And it was so interesting, uh, and it was actually a privilege to observe that, that transition, because we thought these computers, this electronic prescribing would solve so many of our problems, but actually it brought many issues of its own in how it changed people's behaviors and the culture of practice around the patient bedside.
• 8:30
  SPEAKER_03: What we observed is before when people had the medication chart, somebody would go and physically retrieve the medication chart and bring it to the team and people would discuss and actively look at it.
• 8:40
  SPEAKER_03: And the whole conversation happened around the patient bedside.
• 8:43
  SPEAKER_03: Once we had these computer on wheels, and I wasn't my study had nothing to do with it, but I wish I had done a study on it, we observed that people moved, everybody congregated around the computer, the patient kind of became a satellite of the wardround.
• 8:55
  SPEAKER_03: And because everything was on the screen, there were fewer instances of people actually going to look at the medication chart and reviewing the antibiotics as a result.
• 9:04
  SPEAKER_03: So what we saw is people would just go to their own team's previous entry and do another entry.
• 9:08
  SPEAKER_03: So it actually created more silos and less effective communication across and within teams.
• 9:15
  SPEAKER_03: Another thing we observed is I followed nurses as they were giving their medications and getting used to this electronic system.
• 9:22
  SPEAKER_03: And you know, you would see vancomycin flashing on the chart that you need to give this medication is out of time.
• 9:27
  SPEAKER_03: And I saw one nurse struggling for two hours to medicate four patients in a bay because they were getting used to the system.
• 9:33
  SPEAKER_03: And as this therapeutic drug monitoring drug was antibiotic, was flashing that it needs to be given on time, the nurse entered it, administered the medication to the patient, the antibiotics patient, and put in the right time that it should have been given at, as opposed to the actual time it was given.
• 9:49
  SPEAKER_03: And when I questioned, they said, you know, if we if I enter that, the system will override me and think that we haven't given the medication or it looked like a delayed dose.
• 9:56
  SPEAKER_03: So that has huge implications for therapeutic drug monitoring.
• 9:59
  SPEAKER_03: So we're actually telling the system that it was giving at the wrong dose than it actually was in reality.
• 10:03
  SPEAKER_03: It's a long answer to your question, but you know, looking at changing what interventions are most useful for changing the culture, you have to first understand the culture in which you want to implement those interventions.
• 10:13
  SPEAKER_03: It's really important.
• 10:15
  SPEAKER_03: Thank you for that thorough answer.
• 10:17
  SPEAKER_02: David, do you want to add something?
• 10:19
  SPEAKER_01: Yes, uh, thank you, Asmita.
• 10:21
  SPEAKER_01: That's a great uh overview.
• 10:23
  SPEAKER_01: I think I would kind of follow on to what Asmita has has brought out.
• 10:28
  SPEAKER_01: Um, in my experience, uh persuasive interventions uh generally they're longer lasting, have uh greater legs, and they generate greater communication, greater collaboration between stewardship and primary service teams than using a restrictive approach.
• 10:47
  SPEAKER_01: I think from an intellectual standpoint, one issue that is extremely important is that stewardship interventions be couched in almost purely patient-centered goals.
• 11:02
  SPEAKER_01: So that the goal of every stewardship intervention should be to advance the health of the patient, to mitigate against active risks against that patient's health, and that it should not be and should be made very clear that ecological issues of resistance should not be perceived as being the primary driver of stewardship recommendations.
• 11:26
  SPEAKER_01: Rather, resistance comes to bear on these issues insofar as antibiotic exposure is the most important driver of subsequent resistance.
• 11:38
  SPEAKER_01: And that obviously is part of the antibiotic-related harm that uh needs to be pointed out.
• 11:44
  SPEAKER_01: And likewise, it's certainly you will lose your audience entirely if there's a perception that what you're doing is you're trying to reduce antibiotic-related costs.
• 11:54
  SPEAKER_01: That is a non-starter and should not be part of the discussion with providers or at least only in a very tangential way, if at all.
• 12:05
  SPEAKER_01: And so we also talked about some of the impediments to teamwork, and so interventions that can acknowledge and hopefully overcome those impediments are part of this, as Ismida has pointed out.
• 12:18
  SPEAKER_01: There is, I think, the a major aspect of the persuasiveness, if we were to give it a name, would fall in a general rubric of specific recommendations, what you should do for specific syndrome in a specific context, what sort of diagnostic tests should be obtained, and what sort of empiric regimens are recommended.
• 12:38
  SPEAKER_01: Brad alluded to this, that when you're treating community acquired pneumonia, it's rare that you will need to use an antimonal drug, for example.
• 12:48
  SPEAKER_01: And so the best way to overcome the urge to give a broader than necessary regimen would be to talk about what constitutes the epidemiology of microorganisms causing pneumonia in the area where you're working with the people who have primary responsibility for their care, and winning their agreement to using a less broad-spectrum regimen from the front end and having uh agreement from the various attending physicians, from uh importantly the unit director or the division chair, and that that can then filter down through the the rest of the medical staff.
• 13:31
  SPEAKER_01: We uh have over the years made a very large effort to make recommendations that are up to date, evidence-based, and easily accessible and made available to all the clinicians in our system while they're at work, a major focus of our program over the years, and then you know, updating them and so on as events warrant.
• 13:54
  SPEAKER_01: That has also been uh very important, and I think has helped to just help primary providers feel more confident that when they follow these recommendations, their fear of doing the wrong thing can be attenuated.
• 14:07
  SPEAKER_01: I'll stop there, but there are many, many aspects in which this kind of attention to the influences uh that drive these problems can help.
• 14:15
  SPEAKER_02: Thank you, David, for that.
• 14:17
  SPEAKER_02: Brad, would you like to add anything?
• 14:18
  SPEAKER_00: The other thing I'll add, I mean, I agree that you always have better long-term success when the process is collaborative, at least to the extent that you give a voice to the people who you're stewarding and that the interactions are respectful.
• 14:34
  SPEAKER_00: Nevertheless, I have found at several hospitals, we have found in our system, restrictions work exceptionally well.
• 14:42
  SPEAKER_00: I am a big fan of restrictions.
• 14:44
  SPEAKER_00: Restrictions need not be imposed disrespectfully.
• 14:47
  SPEAKER_00: Restrictions are an effective tool to achieve appropriate antibiotic use when all parties have agreed that is a goal that the organization is striving for.
• 14:57
  SPEAKER_00: So I understand that that is likely a minority opinion.
• 15:00
  SPEAKER_00: And it also depends on the nature of the organization.
• 15:03
  SPEAKER_00: If you're in a private community hospital where the doctors are private practice and can take their patients and go anywhere they want, maybe harder to do than when you're working like I do at a government hospital where people are employed by or directly contracted with the organization.
• 15:18
  SPEAKER_00: So it will be dependent on the local structure of the organization and culture, but I would not write restrictions off.
• 15:24
  SPEAKER_00: We have found them to be extremely effective.
• 15:26
  SPEAKER_02: Thank you.
• 15:27
  SPEAKER_02: And the next question: if a hospital or unit has a culture that is used to something like prolonged durations of therapy, what are some steps antibiotic stewards can take to shifting the culture towards appropriate antibiotic prescribing?
• 15:44
  SPEAKER_02: Rod, I'm going to let you start us off on this one.
• 15:47
  SPEAKER_00: Audit and feedback, show them the data, and then show them the literature, showing that that actually results in harm and does not improve clinical cure.
• 15:55
  SPEAKER_00: So audit, feedback, data, and as we've been talking about, collaborative dialogue.
• 16:00
  SPEAKER_00: Those are the steps that we take.
• 16:02
  SPEAKER_02: Awesome.
• 16:02
  SPEAKER_02: Very straightforward.
• 16:03
  SPEAKER_02: David?
• 16:04
  SPEAKER_01: Yeah, I mean, uh, you know, the the question of what is the best duration of therapy is one largely is a question of what does the literature demonstrate in this regard?
• 16:17
  SPEAKER_01: And yet it can take a long time for people to adapt to new information, as we all know.
• 16:22
  SPEAKER_01: I think a very good example was in uh SMU's paper, she collaborated on, describing how the resistance of surgeons often to uh limit their perioperative antibiotic prophylaxis to, you know, a single dose or uh uh, you know, to stop it once the operation is over.
• 16:41
  SPEAKER_01: And how frequently these senior surgeons were like, well, it just seems like the right thing to do, and why would it be a problem, and et cetera.
• 16:49
  SPEAKER_01: And um, those questions can be directly answered, though it is a challenge when you it can be a challenge when you're dealing with people who have very definite perspectives on the issue.
• 17:01
  SPEAKER_03: Yeah, thank you.
• 17:02
  SPEAKER_03: Good point.
• 17:02
  SPEAKER_03: And Asmita?
• 17:04
  SPEAKER_03: I'm trying to think of what else I can say that will add wisdom to what has already been said.
• 17:09
  SPEAKER_03: It is about showing people data and the reasons why their behavior or their their practice may be causing more harm in the long term or not be of benefit to the patient, but also the larger population at large or for future use.
• 17:23
  SPEAKER_03: The other thing which I do wonder, and I I don't have an answer, it's really a question, is also, you know, economics always are important too, is showing the economic benefit of reducing the duration of therapy, you know, in terms of reduced length of stay, the cost to the hospital, uh, and the healthcare economy at large.
• 17:41
  SPEAKER_03: I when I started my career as a clinical pharmacist, we had to prove our value for money.
• 17:47
  SPEAKER_03: And uh the first year of my practice, all I did was support IVT oral switch for cifrofloxism, which at the time was patented and it was expensive.
• 17:56
  SPEAKER_03: And you know, economically we were able to provide evidence for why making certain changes to practice is beneficial.
• 18:03
  SPEAKER_03: So I think it's always important to also think of the economics when we develop interventions.
• 18:06
  SPEAKER_03: We often aren't trained and aren't thinking that far to look at uh the economic consequences of the interventions we implement.
• 18:13
  SPEAKER_01: Yeah, I I would add uh economics, I think often debt stewardship a foot in the door.
• 18:19
  SPEAKER_01: When I started out in the early 90s, the most expensive antibiotic was a moxicillin clavulinate or a bamentin, believe it or not.
• 18:27
  SPEAKER_01: And we kind of established ourselves by doing audits and seeing how often the drug was being used for non-infectious indications or for indications for which, you know, moxicillin or uh or other less broad spectrum or less expensive drugs were preferred.
• 18:44
  SPEAKER_01: And then that led in turn to a restriction on the use of the drug and saved a lot of money.
• 18:50
  SPEAKER_01: And so that can be very useful, but um, again, you certainly don't want that to be the sole focus of what you're trying to do.
• 18:58
  SPEAKER_02: Our next question is what role can peer comparisons play in changing behavior and culture in hospitals with respect to antibiotic prescribing?
• 19:09
  SPEAKER_02: Brad, do you want to start us off with this one too?
• 19:11
  SPEAKER_00: Yeah, I mean, it's hard to do it, just it's hard to get data broken out by individual users, particularly teaching hospitals, where the attendings are not the ones usually signing the orders and the residents are signing orders, but often it's the attendings who have the say.
• 19:26
  SPEAKER_00: And so if you can get accurate data, psychological literature across multiple fields has demonstrated repeatedly that audit and feedback is probably the single most effective way to change human behavior.
• 19:39
  SPEAKER_00: There's a reason why when you're driving on the street, there's a flashing sign that shows you your speed and you reflexively slow down.
• 19:45
  SPEAKER_00: They do that for a reason.
• 19:46
  SPEAKER_00: It's audit and feedback.
• 19:47
  SPEAKER_00: So if you can get accurate data, this is an incredibly effective way to get people to realize how they're performing relative to their peers, which intrinsically, in a non-threatening way, helps them course correct.
• 19:59
  SPEAKER_01: We haven't been able to do, well, we've done a bit of peer comparisons, uh, although we tried to study inter-attending differences, for example, in rates of antibiotic use within our intensive care units.
• 20:12
  SPEAKER_01: We were able to accomplish it, to get the data.
• 20:15
  SPEAKER_01: It is quite a challenge from an IT standpoint, and you need a lot of support to do that.
• 20:21
  SPEAKER_01: But we didn't feel as if it were, if it was usable, partly uh because of, as Brad pointed out, the uh especially initial antibiotic prescribing decisions may be made by people other than the attending physicians, but partly also because it's very difficult.
• 20:38
  SPEAKER_01: I think if the peer comparisons are on volume of antibiotic use, I think it's much harder to know what to do with that than if it pertains to how a specific syndrome is managed in a given practice.
• 20:54
  SPEAKER_01: And so I'll I'll offer two examples that that illustrate this.
• 20:58
  SPEAKER_01: One is from the University of Pennsylvania, their children's, their pediatrics group, where they studied the impact of giving feedback to pediatricians seeing uh office patients.
• 21:13
  SPEAKER_01: The intervention was to reduce the use of broader spectrum antibiotics in those practices, drugs like augmentin or azothermycin, as opposed to amoxicillin.
• 21:24
  SPEAKER_01: And so when every time the doctor made a prescription, they would be given information about the frequency of the use of the broader spectrum drugs within their practice and for themselves as compared to the overall network.
• 21:38
  SPEAKER_01: And it was shown that as with the sign causing you to slow down when you're driving, that this brought about a substantial reduction in the use of the broader spectrum drugs.
• 21:50
  SPEAKER_01: Uh, but then the project had to be stopped, the funding was lost, and follow up showed that the rates of broader spectrum antibiotics went right.
• 22:00
  SPEAKER_01: Back up.
• 22:01
  SPEAKER_01: And when there was mixed methods, qualitative analysis of the reaction of the providers to this, they were upset about it.
• 22:10
  SPEAKER_01: Julie Simzak published a nice paper that provided that information.
• 22:15
  SPEAKER_01: As a contrast, I would offer a study that was done within a neonatal intensive care unit that illustrated the impacts of a very carefully thought out and negotiated set of antibiotic stewardship principles for managing the neonates.
• 22:33
  SPEAKER_01: And they found one thing that was very helpful to the neonatologists was to see the frequency with which they initiated antibiotics for late onset sepsis as compared to their peers, because there was huge variation.
• 22:51
  SPEAKER_01: It was like four to fivefold variation in the frequency with which they did this.
• 22:56
  SPEAKER_01: And after they saw this, the level of variation in this regard fell.
• 23:01
  SPEAKER_01: And so it is, I think, easier to look at something that's more tangible, like how often do you pull the trigger on treating a given set of worrying circumstances versus what is the total tonnage of antibiotics that you've given over a period of time?
• 23:17
  SPEAKER_02: Those are great examples.
• 23:18
  SPEAKER_02: Shifting gears, what communication strategies can be used when making recommendations as a part of prospective audit and feedback?
• 23:28
  SPEAKER_02: And are they different depending on who you are talking to or who is making the recommendation based on the culture at your institution?
• 23:38
  SPEAKER_02: And would this differ at other institutions?
• 23:41
  SPEAKER_02: David, why don't you start us off?
• 23:44
  SPEAKER_01: Sure.
• 23:44
  SPEAKER_01: Well, I think it is different depending on who you talk to.
• 23:47
  SPEAKER_01: As we've discussed, as the stewardship team needs to understand the people that they are working with, the context that they're working in.
• 23:56
  SPEAKER_01: And I think in particular for audit and feedback, I think we've alluded to this before, but the goals, the infection treatment problems that you're hoping to improve upon need to be made explicit at the outset.
• 24:10
  SPEAKER_01: And so the scope of it and the basis and the evidence for the direction in the antibiotic use that you want to go, whether it's use of non-antiseudomonal regimens for intraabdominal infections among surgical patients or something else that needs to be made clear from the outset and discussed with as many of the people who actually do the work as possible, giving them the opportunity to look at it in the abstract to provide their reactions to these recommendations before they are actually implemented in the audit and feedback effort.
• 24:50
  SPEAKER_01: And beyond that, you know, an underpinning for being able to do this is the stewardship team needs to have on it, you know, very good clinicians, clinicians who are very well respected, and clinicians who have a great deal of experience in doing day-to-day clinical work within the environment that they're doing the audits and feedback at.
• 25:14
  SPEAKER_01: And things will go much more smoothly when that happens.
• 25:18
  SPEAKER_01: And likewise, the people who do the patient-by-patient assessments and uh contact primary services to give their recommendations, you know, that you need to be clear that their assessments and recommendations are consistent with the rubric that is established at the outset.
• 25:36
  SPEAKER_01: And the experts on the stewardship service, or say not even experts, because they're all experts, but those who have more credibility with the clinicians, who are most often the doctors on the stewardship team, need to be available for patients where it doesn't fit in an obvious way, where or where the considerations are more nuanced than they uh are for most.
• 26:01
  SPEAKER_01: And so, you know, ideally then the stewardship physician at least should be someone who works uh well and frequently with the audited clinicians in whatever role they play as uh most often in infectious disease as a consultant.
• 26:15
  SPEAKER_01: And and of course, as I mentioned earlier, the other ID people who see patients should uh make their recommendations consistent with the goals of the audit and feedback program.
• 26:26
  SPEAKER_01: And finally, uh, when these recommendations are made, again, you want to emphasize the benefit to the patient for the recommendation as opposed to uh other less salient objectives.
• 26:39
  SPEAKER_02: Thank you.
• 26:39
  SPEAKER_02: Those are some great points.
• 26:41
  SPEAKER_02: Brad, would you like to add anything?
• 26:43
  SPEAKER_00: I would just say in agreement, there are a couple of core principles that are going to be generally used when you do this kind of audit and feedback, but you're always gonna have to customize it, depending not at just on the institution, not just on the service, but the individual doctor you're talking to, depending on the nature of your relationship with that person.
• 27:02
  SPEAKER_00: The core principles, I think, are to explain what you are measuring, how you are measuring it, and why you are measuring it.
• 27:10
  SPEAKER_00: You have to explain those three things to people when you show them these data.
• 27:13
  SPEAKER_00: How you do that depends, is this your bud who you've known for years and trusts you?
• 27:18
  SPEAKER_00: Is this someone brand new to the institution?
• 27:21
  SPEAKER_00: Is this someone who's already pissed off at the stewardship team?
• 27:24
  SPEAKER_00: And we all know those people are out there.
• 27:26
  SPEAKER_00: They're gonna adjust your approach, how you approach those three core principles, depending on the nature of your relationship with the individual.
• 27:34
  SPEAKER_03: Thank you.
• 27:34
  SPEAKER_03: And Ismita?
• 27:36
  SPEAKER_03: I agree to all of that.
• 27:37
  SPEAKER_03: And um the other things, you know, in just in relation to communicating strategies around audit and feedback.
• 27:44
  SPEAKER_03: One of the things we hear a lot about in our research is that you know, the data you show me is not relevant to my practice or it's it's out of date and it's difficult, it's very labor-intensive to do audit and feedback.
• 27:54
  SPEAKER_03: You need resources, but it's really important that we do this in a timely fashion so that the data we present back to the teams is relevant to their practice.
• 28:02
  SPEAKER_03: What I've seen often is you know, a year later we show surgical site infection rates or antibiotic use rates, and people have moved on, you know, the teams have changed.
• 28:10
  SPEAKER_03: So I think being timely is very important.
• 28:13
  SPEAKER_03: The other thing is having people involved in the process of the data collection.
• 28:16
  SPEAKER_03: When we had interns and and junior members of the team who want to do projects, we would bring them on board the stewardship team, and they would be responsible for monitoring the performance of their own team.
• 28:24
  SPEAKER_03: And we found that very effective as well because then they own the process.
• 28:28
  SPEAKER_03: And although there isn't continuity because people change, but you are training and you're educating people and they take that with them to their next practice.
• 28:35
  SPEAKER_03: I think it's important to keep that engagement going, don't just turn up with data to to teams that aren't part of the process of the data gathering and analysis.
• 28:43
  SPEAKER_03: I think it's that's also relevant.
• 28:45
  SPEAKER_03: And I really agree with what I think David said about, or was it Brad, or both of you may have touched on it, is this it has to be from someone that they respect.
• 28:52
  SPEAKER_03: It has to be peer-to-peer, it's really important.
• 28:54
  SPEAKER_03: Having spoken about hierarchies now, I'm being hierarchical, but it is really important.
• 28:59
  SPEAKER_03: If you go to a consultant, they have to feel that they're speaking to a peer, someone who's at the same level of training as themselves.
• 29:04
  SPEAKER_03: And I think that is an etiquette, part of the etiquette of how we communicate with each other is really important.
• 29:09
  SPEAKER_02: Thank you all for such a fantastic conversation.
• 29:13
  SPEAKER_02: We appreciate you joining us today.
• 29:15
  SPEAKER_02: Thank you so much.
• 29:16
  SPEAKER_03: I really enjoyed the conversation.
• 29:18
  SPEAKER_01: I I did as well.
• 29:19
  SPEAKER_01: It was a pleasure to meet Brad and Esmita, and hopefully we'll talk again, hopefully in person at some point.
• 29:25
  SPEAKER_00: Nice to meet you all as well, and to all you stewards out there, may the force be with you.
• 29:30
  SPEAKER_02: You can find more educational content like this podcast on Shay's online education center, Learning CE, at www.learningce.shay dash online.org.
• 29:44
  SPEAKER_02: This concludes today's episode of the social and cultural aspects of infection control and antibiotic stewardship series.
• 29:51
  SPEAKER_02: Thank you for tuning in.