Latest / The SHEA Podcast / Antibiotic Prescribing & Stewardship in Hospitals (Part 1)

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Antibiotic Prescribing & Stewardship in Hospitals (Part 1) · The SHEA Podcast

• 0:09
  SPEAKER_01: 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_01: I am Hannah Wenders, Antimicrobial Stewardship Pharmacist at Prisma Health Midlands in Columbia, South Carolina, and I will serve as today's moderator.
• 0:40
  SPEAKER_01: Shay is excited to launch this two-part episode on social and cultural aspects of antibiotic prescribing and stewardship in hospitals.
• 0:48
  SPEAKER_01: In this podcast, part one, we will discuss these key drivers of suboptimal prescribing and how they may differ within various specialties within hospitals.
• 0:58
  SPEAKER_01: In addition, speakers will discuss how to determine what behavioral domains are influencing inappropriate antibiotic prescribing, which is important for determining which interventions can be useful to implement.
• 1:12
  SPEAKER_01: I am happy to introduce our speakers for today.
• 1:14
  SPEAKER_01: First, we have Esmita Charotney.
• 1:17
  SPEAKER_01: Esmita is an associate professor at the University of Cape Town where she is undertaking a Welcome Trust Career Development Fellowship investigating intersectionality and AMR 2023 to 2027.
• 1:32
  SPEAKER_01: In the UK, she is a reader in infectious diseases, AMR, and Global Health at the University of Liverpool.
• 1:40
  SPEAKER_01: 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.
• 1:59
  SPEAKER_01: Her work in AMR has been recognized through the Academy of Medical Sciences UK India AMR Visiting Professor Award.
• 2:08
  SPEAKER_01: She is an expert advisor to the Commonwealth Pharmacy Association and a Global Health Fellow with the Office of Chief Pharmaceutical Officer England.
• 2:18
  SPEAKER_01: She is involved in mentoring and supporting clinical pharmacists across different healthcare settings and economies in implementing antimicrobial stewardship interventions.
• 2:28
  SPEAKER_01: Her doctoral thesis investigated antimicrobial stewardship across India, Norway, France, Burkina Faso, and England.
• 2:37
  SPEAKER_00: Hi, everyone.
• 2:38
  SPEAKER_00: Delighted to be here.
• 2:39
  SPEAKER_01: Next, we have David Schwartz.
• 2:41
  SPEAKER_01: Dr.
• 2:42
  SPEAKER_01: Schwartz became chair of the NASA's 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.
• 3:02
  SPEAKER_01: And he gave up this post on retiring from full-time employment in 2022.
• 3:08
  SPEAKER_01: 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.
• 3:25
  SPEAKER_01: 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.
• 3:37
  SPEAKER_01: Always keen to understand the perspectives of antimicrobial prescribers, Dr.
• 3:41
  SPEAKER_01: Schwartz later collaborated with a medical anthropologist, Katharina Rinkowitz, 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.
• 4:06
  SPEAKER_03: Thanks very much for having me.
• 4:07
  SPEAKER_03: I'm very happy to be here.
• 4:09
  SPEAKER_01: And finally, we have Brad Spelberg.
• 4:11
  SPEAKER_01: Dr.
• 4:12
  SPEAKER_01: Spelberg is chief medical officer at the Los Angeles General Medical Center, one of the largest public hospitals in the U.S.
• 4:19
  SPEAKER_01: 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.
• 4:40
  SPEAKER_01: In 2009, Dr.
• 4:42
  SPEAKER_01: Spelberg published the book Rising Plague to Inform and Educate the Public About the Crisis in Antibiotic Resistant Infection and Lack of Antibiotic Development.
• 4:53
  SPEAKER_01: His latest book, Broken, Bankrupt and Dying: How to Solve the Great American Healthcare Ripoff was published in June of 2020.
• 5:03
  SPEAKER_02: Hello, thanks for having me.
• 5:05
  SPEAKER_01: Thank you all for joining us.
• 5:07
  SPEAKER_01: Let's jump in.
• 5:08
  SPEAKER_01: With respect to behavioral and social science themes, what are key drivers of suboptimal antibiotic prescribing in hospitals?
• 5:17
  SPEAKER_01: Asmita, why don't you give us your opinion first?
• 5:20
  SPEAKER_00: Thanks, Hannah.
• 5:21
  SPEAKER_00: So when we started our research back in 2011, there wasn't much attention being given to consider antibiotic use from a social science perspective in hospital settings.
• 5:33
  SPEAKER_00: And working across disciplines and learning from the different analytical lens that social sciences research enables us to do really gave us an example of being able to see how people interact with each other in the clinical environment.
• 5:47
  SPEAKER_00: And doing this research and applying social science research, including observational studies, interviewing different healthcare professionals who are involved in antibiotic use in hospital settings, and looking at how they interact with their social and with their environment, their social environment and also the actual physical environment in which they work, we were able to better understand the extent and influence of social norms, culture, and team dynamics and how this influences evidence-based practices.
• 6:14
  SPEAKER_00: Because often with stewardship and with infection prevention and control interventions and practices, you know, we rely on evidence-based practices and we often wonder why people do not adhere to policy and guidelines.
• 6:27
  SPEAKER_00: And to understand that why, really, it is important to conduct uh social science research for this exactly reason to see how people interact with the environment in which they work.
• 6:37
  SPEAKER_00: And this includes, I think we have to say, you know, our work expanded.
• 6:40
  SPEAKER_00: It wasn't just antibiotic stewardship, but also infection prevention and control, antibiotic use, and you know, diagnostic use of laboratory and diagnostics.
• 6:48
  SPEAKER_00: And it's really encouraging to see that in the last 10-15 years, there has been so much more attention given to conducting social science research alongside quantitative research and randomized controlled trials to better understand the uptake of evidence, not only in antibiotic prescribing, but generally in infection management, and that's really good to see.
• 7:09
  SPEAKER_00: Bradden, would you like to add something?
• 7:11
  SPEAKER_02: Yeah, I think there are a couple of specific factors that often play a role.
• 7:16
  SPEAKER_02: And I think actually the dominant one is the one we talk about the least, which is simply fear.
• 7:20
  SPEAKER_02: And it's not everyone's, oh, they're afraid of getting sued.
• 7:23
  SPEAKER_02: It's not fear of lawsuits.
• 7:25
  SPEAKER_02: Most doctors, yes, we do do things to protect ourselves, but most doctors are not going to knowingly do the wrong thing because they're afraid of getting sued.
• 7:33
  SPEAKER_02: They're afraid of being wrong.
• 7:34
  SPEAKER_02: They don't know what the patient has.
• 7:36
  SPEAKER_02: You can't tell by looking at a patient.
• 7:39
  SPEAKER_02: And frankly, from most tests, you can't tell whether it's a virus, a bacteria, or autoimmune, or non-infectious.
• 7:45
  SPEAKER_02: And there is a mistake in belief that antibiotics are harmless.
• 7:50
  SPEAKER_02: And therefore the risk-benefit calculus is look, I don't know what it is, but let me just be safe for the patient and give you the antibiotic.
• 7:58
  SPEAKER_02: It is fear of being wrong, I think, that drives much of the inappropriate prescriptions.
• 8:04
  SPEAKER_02: We're afraid of hurting people by under-treating them.
• 8:08
  SPEAKER_02: And that's linked to a fairly well-described, not very accurate way that doctors approach risk-benefit decision making.
• 8:17
  SPEAKER_02: We tend to fear risks of omission much more than risks of commission.
• 8:22
  SPEAKER_02: And then obviously, there are knowledge issues.
• 8:25
  SPEAKER_02: People may not know what antibiotics cover what pathogens.
• 8:29
  SPEAKER_02: So I think I think it's complex, but I actually think the dominant driver, which we talk about the least sadly, is simply fear of being wrong and therefore accidentally harming people.
• 8:39
  SPEAKER_01: Yeah, that's a good point.
• 8:41
  SPEAKER_01: And David?
• 8:42
  SPEAKER_03: I I totally agree with uh Brad's comment just now about the role of fear.
• 8:47
  SPEAKER_03: I do want to call out Asmita's work, uh, which I've enjoyed uh reviewing in preparation for this uh talk, in calling attention to various underlying dynamics of how healthcare is organized, addressing issues such as the hierarchies between the various players involved in making these decisions that Brad has referenced, and how uh the various providers also uh communicate can be critical.
• 9:15
  SPEAKER_03: Um, and I think uh that effort has opened up uh very rich veins uh that we can try to use to improve the situation.
• 9:24
  SPEAKER_03: But I I think uh as a clinician, I would echo Brad's assessment that fear does play such an important role.
• 9:33
  SPEAKER_03: This has to do also, I think, with other issues that pertain to the healthcare system writ large or systems writ large, uh, which include the fact that uh there are variable levels of training and of clinical acumen as a result in assessing people for infections and other clinical problems.
• 9:53
  SPEAKER_03: There's variable knowledge about uh infection syndromes, the organisms that cause infections, the characteristics of the antibiotics that we use, and as Brad mentioned, the harms that can be associated with the use of these drugs.
• 10:08
  SPEAKER_03: And all of this uncertainty causes uh a great deal of insecurity, and that partly relates to self-awareness about uh these deficiencies.
• 10:19
  SPEAKER_03: And it's it's interesting that the the use of antibiotics is so ubiquitous and it is uh it is used by so many different providers, but this in a context where their level of knowledge about these issues is so limited.
• 10:36
  SPEAKER_03: And that kind of imbalance between what is the the level of knowledge that a person has and the gravity of the clinical situations that they confront is really at the the root of the need for um additional assistance through stewardship programs and otherwise to help improve on this dynamic.
• 10:57
  SPEAKER_02: I just I completely agree.
• 10:59
  SPEAKER_02: The fear is so powerful that even us as experts who do this for a living are susceptible to it.
• 11:07
  SPEAKER_02: So I you can you guys can tell me if this resonates with you or not.
• 11:10
  SPEAKER_02: But countless times I've been on the phone with people, surgeons, ER, whoever, demanding Zosin or a pseudomonal coverage.
• 11:18
  SPEAKER_02: And I'm like, this is a community onset appendicitis.
• 11:21
  SPEAKER_02: You don't need pseudomonal coverage.
• 11:22
  SPEAKER_02: And there is a deep part of the brain that starts talking back to you because you just said that.
• 11:28
  SPEAKER_02: This is going to be the first ever case of pseudomonal appendicitis.
• 11:31
  SPEAKER_02: And you start thinking, oh boy, am I going to look like an idiot?
• 11:34
  SPEAKER_02: Is someone gonna get hurt because I'm holding the line on this?
• 11:38
  SPEAKER_02: Even we are susceptible to this fear, but we just have the training and experience to say, all right, well, we've recognized that that fear is there, but we know what the right thing to do is.
• 11:49
  SPEAKER_02: And there is a risk-benefit calculus, and the risk-benefit calculus is we need to preserve the pseudomonal agents for patients who actually are at risk for stigmonis.
• 11:58
  SPEAKER_02: And that's the training I think you're talking about, David, that others often lack, or or the risk-benefit that they may not fully appreciate.
• 12:05
  SPEAKER_03: Yeah, Brad, I agree.
• 12:07
  SPEAKER_03: Um, I'll be the first to admit, having been in numerous situations where you have this uh crawling sense of potential doom, you know, in addressing cases, whether as a steward or as a clinician.
• 12:20
  SPEAKER_03: And so it's it's absolutely true that we are all a prey to that kind of emotional factor.
• 12:25
  SPEAKER_03: And if we didn't have those kinds of anxieties, then in many ways it's it'd be inappropriate for us to work as clinicians.
• 12:32
  SPEAKER_03: But one important dynamic in this that we haven't brought up is that I think there is a great deal of variability, even among the so-called expert infectious disease-trained clinicians, in the way that they address these situations and the heterogeneity in practice patterns and recommendations among ID physicians uh has, in my experience, contributed to some of the difficulties in kind of translating stewardship-related guidance and recommendations.
• 13:02
  SPEAKER_00: I agree.
• 13:03
  SPEAKER_00: There's two points I want to raise in this discussion.
• 13:06
  SPEAKER_00: I'm gonna start with a second one because David just talked about it, and this is the heterogeneity in practices amongst ourselves, amongst, you know, the experts.
• 13:14
  SPEAKER_00: And this has come up a lot in our work, not only in the UK, in Norway, in India, in South Africa, you know, one of the things I've learned is how culture is so stable across professions in different countries.
• 13:26
  SPEAKER_00: And it's really fascinating to me.
• 13:28
  SPEAKER_00: So how a surgical team operates in South Africa is not that different from how they operate as a team in India or in the UK, and the norms and the social values and cultural norms that they use to drive their practices.
• 13:42
  SPEAKER_00: And one of the things that these other teams who are also, we have to remember they are also experts when it comes to looking after their patients.
• 13:49
  SPEAKER_00: And sometimes there's this battling of expertise, right?
• 13:52
  SPEAKER_00: Because one of the things is when we were speaking to respiratory consultants in France, they would tell us, well, you know, we know how to treat a chest infection in our patient cohort.
• 14:00
  SPEAKER_00: So when an ID doctor comes and tells us how to treat a chest infection, we feel that our expertise is being taken on the question because we know there's this thing about the the power of n equals one, I always say, but it's your own experiences as a physician.
• 14:13
  SPEAKER_00: And one of the things we talk a lot about in our research is this need for autonomy, that clinicians are trained to practice autonomously.
• 14:20
  SPEAKER_00: That is what you are aiming towards, is to develop this expertise and excellence and to lead your own team and to practice autonomously.
• 14:27
  SPEAKER_00: And then here we have stewardship, which is an external expertise, which is telling teams what to do, and that creates some uh tension, particularly when within the stewardship team there is heterogeneity in the advice.
• 14:38
  SPEAKER_00: But going back to what Brad was saying about fear, it's really fascinating when you look at what is driving fear and how people interpret this fear and the risks that they use to evaluate the level of fear or what they attach fear to is very different.
• 14:54
  SPEAKER_00: So, and this when we spoke to we did a study in the UK where we spoke to consultants from acute medicine and acute surgery and their teams.
• 15:02
  SPEAKER_00: And one of the things that was unanimously agreed to across these teams was that when something goes wrong in a medical general medicine team, often the patient is comorbid, they were elderly, they had many other issues.
• 15:15
  SPEAKER_00: So a negative outcome, death as a negative outcome, or infection as a negative outcome is more easily tolerated because of the attitudes we have towards the patient profile that we have in medicine versus in surgery.
• 15:29
  SPEAKER_00: In surgical teams, uh a lot of the fear, the fear that is driving practices is that negative outcome.
• 15:35
  SPEAKER_00: And that negative outcome is dissected.
• 15:38
  SPEAKER_00: You know, when you go to a surgical morbidity mortality meeting, you will see how the surgeons have to justify and try and understand and unpick everything they had done for individual patients to lead to a negative consequence.
• 15:50
  SPEAKER_00: So the stakes are much higher when it comes to a negative outcome in surgical clinical populations.
• 15:56
  SPEAKER_00: And you know, I have a lot more empathy, having spent a lot of time doing research with surgeons in different different countries, in what is driving their practices, what fears is foremost in their mind when they're looking after their patients.
• 16:07
  SPEAKER_00: Because they also want the best for their patients, but the way they evaluate the situation and what they attribute risk to is very different to the medical teams.
• 16:17
  SPEAKER_00: And it's very different to us as stewardship teams because we go in and expect everyone to care about AMR.
• 16:22
  SPEAKER_00: But you know, it is one of several priorities that clinicians have to contend with when they're treating patients.
• 16:27
  SPEAKER_00: And AMR may not be something that is in the future or a bit abstract and not of direct relevance to the patient in front of them who they want to give pipyrocine task backdown to because they don't want to have a negative consequence for that particular patient.
• 16:40
  SPEAKER_00: And they will weigh that versus the future harm of AMR into the population.
• 16:45
  SPEAKER_01: Really great discussion.
• 16:46
  SPEAKER_01: And I know that you guys already touched on this topic, but our second question, if you have anything to add, how do the culture and team dynamics in hospitals or within specialties affect antibiotic decision making?
• 17:00
  SPEAKER_00: I think we are very tribal in healthcare.
• 17:04
  SPEAKER_00: I guess we are as human beings, and we take that tribalism into healthcare.
• 17:08
  SPEAKER_00: And, you know, there are there are these cultures within professions, and then there are cultures within specialties.
• 17:14
  SPEAKER_00: And if you look at the ICU, the intensive care unit, they are the best performing and most efficacious or productive, effective teamwork you see in the ICU, right?
• 17:25
  SPEAKER_00: And that's because the whole team comes together and they look after the patient.
• 17:29
  SPEAKER_00: And that highly functional team is very difficult to replicate in other parts of healthcare.
• 17:33
  SPEAKER_00: And part of it is because of these hierarchies, these cultural norms that influence how we interact with each other.
• 17:40
  SPEAKER_00: I'm a pharmacist by background, and I trained as a pharmacist in the UK, and then I went into stewardship.
• 17:46
  SPEAKER_00: And I remember even in the early days when antibiotic pharmacists were being recognized as a role and we were becoming involved in influencing decision making of physicians.
• 17:55
  SPEAKER_00: I remember how difficult it was to go up to a surgeon or a consultant and tell them or give them advice about their practices because the hierarchies we're used to are that the surgical, the consultants, uh, the senior doctors are at the top, and then uh it's everybody else in the hospital.
• 18:12
  SPEAKER_00: So, you know, we're working against very entrenched hierarchies within these systems.
• 18:16
  SPEAKER_00: Then you bring in gender and you look at the gender composition of teens.
• 18:20
  SPEAKER_00: So predominantly nursing in many parts of the world is female dominated.
• 18:24
  SPEAKER_00: Pharmacy is a mixed bag of things.
• 18:26
  SPEAKER_00: In many places I've worked, is predominantly female dominated.
• 18:29
  SPEAKER_00: And you know, then you look at surgical teams, you look at medical teams and all these other allied healthcare professionals.
• 18:34
  SPEAKER_00: And the gender dynamics that also come into play.
• 18:36
  SPEAKER_00: So there was a very interesting study, and I have to you have to really forgive me.
• 18:40
  SPEAKER_00: It's my colleagues in the US, and I can't remember if Brad was on the paper or you shared it on Twitter or what is X now.
• 18:47
  SPEAKER_00: But it's about the gender dynamics within stewardship teams and how that influences the outcome.
• 18:54
  SPEAKER_00: And it was in that particular study from the US found that the antibiotic steward was a male steward, their advice was much more likely to be taken up.
• 19:02
  SPEAKER_00: And that's in the US, you know, a very progressive society when it comes to gender dynamics and maybe in multi-professionalism.
• 19:09
  SPEAKER_00: And then you go to India and it's very different, or to South Africa, or to many other parts of the world, where the hierarchies are very strong and medical teams really rule and sort of drive decision making.
• 19:20
  SPEAKER_00: Um so I think we have to bear in mind about uh these factors when we look at culture and team dynamics within specialties, when we set expectations for stewardship, you know, nurses should do X, Y, and Z, pharmacists should do this.
• 19:33
  SPEAKER_00: Have we considered, are they able to do this?
• 19:36
  SPEAKER_00: Does the system allow them to have a voice and to be present?
• 19:40
  SPEAKER_00: And do we support them?
• 19:41
  SPEAKER_00: There's an example from the India where the team we work with in Kerala, India is very male-dominated, very medical dominated setting when it comes to hospitals.
• 19:50
  SPEAKER_00: But in this particular hospital, through the championship of the chief medical superintendent who was himself a pediatrician, they were able to support pharmacists to take on more and more active roles in stewardship.
• 20:02
  SPEAKER_00: It was a long process, it was a lot of pushback because people weren't used to pharmacists telling doctors what to do.
• 20:07
  SPEAKER_00: But with the right championship, with the right support from the organization and the leadership, over time these cultures changed.
• 20:15
  SPEAKER_00: Because we have to remember culture is not static, it's also dynamic and it can change and evolve all the time.
• 20:20
  SPEAKER_00: That was great.
• 20:21
  SPEAKER_00: David, do you have something to add?
• 20:24
  SPEAKER_03: Uh yeah, I'm I'm very interested to hear about the uh the study of gender dynamics in stewardship programs.
• 20:31
  SPEAKER_03: I think it just reflects how the U.S.
• 20:34
  SPEAKER_03: uh outwardly appears to be progressive, but um still some uh fair amount of work to go.
• 20:40
  SPEAKER_03: I think uh a couple of other comments about how team dynamics can affect uh decision making.
• 20:47
  SPEAKER_03: Pharmacists play uh do play an important role in in our hospital, um, the clinical pharmacists round often and every day, every weekday, anyhow, within the intensive care units with the physician-led teams.
• 21:05
  SPEAKER_03: But interestingly, we found in interviewing them uh that they felt constrained in speaking up during the bedside rounds when the um you know, when there was the greatest kind of gathering of clinical information and hopefully acting on uh synthesis of of that information, that it wasn't until later that the pharmacist would would talk to the prescribing physician and say, you know, recommend changes in dose or make suggestions about considering uh alternatives.
• 21:40
  SPEAKER_03: Um so uh the pharmacist's role, I think, is still evolving.
• 21:44
  SPEAKER_03: And another issue with pharmacists as it relates to antibiotic stewardship and their relationship with um the hands-on clinicians is that the the fact that pharmacists do not provide hands-on clinical.
• 22:00
  SPEAKER_03: care as physicians and nurse uh uh uh advanced practice nurses and physician assistants do, their judgment in addressing antibiotic use issues, especially as it relates to diagnosis of infection, et cetera, is often questioned by the people that they're trying to work with.
• 22:19
  SPEAKER_03: And that is that is uh uh I think a remaining problem in that dynamic.
• 22:25
  SPEAKER_03: I would also observe uh that I mean your own work as MEDA has made it very clear that the way that some of these services uh even within intensive care are organized can you can have a huge impact on how well things worked.
• 22:43
  SPEAKER_03: I mean the your paper describing the difference between the medicine and the surgical teams pointed out how the the organization of care within the surgical teams was much more prone to to gaps in communication, to the lack of accessibility among the primary decision makers so that important decisions wind up getting tossed down the the road to to uh doctors who are lower on the hierarchy.
• 23:10
  SPEAKER_03: And that too, you know, we see this uh in our hospital where for example in trauma intensive care the end of the care is is very strongly protocolized and rounds are uh a huge thing.
• 23:24
  SPEAKER_03: It's a busy place with uh very very uh sick people but that's uh a different situation from what obtains in the surgical ICU which is an open unit and where you have a primary ICU service but also you have each patient having its own primary service uh that is led by the surgeon who's attending surgeon for the problem that led to the patient's admission to the unit.
• 23:50
  SPEAKER_03: And so those things also all within those those systems have a a major impact on how you have to go about communicating your recommendations both as a steward but also as a clinician.
• 24:06
  SPEAKER_03: And so I think those are worth taking note of.
• 24:08
  SPEAKER_03: Thank you.
• 24:09
  SPEAKER_02: Thank you.
• 24:10
  SPEAKER_01: And Brad?
• 24:11
  SPEAKER_02: Yeah just very briefly I mean I think that person-to-person relationships plays a huge role here I mean I I I'm comfortable with generalizations the dynamic depends very much on how much one person trusts the other and trust is earned over time and as Mita said is dynamic.
• 24:29
  SPEAKER_02: Someone who doesn't trust you at first can learn to trust you over time.
• 24:32
  SPEAKER_02: Your recommendations are going to be accepted at a much higher percentage when that trust is there.
• 24:38
  SPEAKER_02: So I think we can't forget about the importance of building a trusting working relationship between the two parties over time.
• 24:45
  SPEAKER_01: Thank you guys.
• 24:46
  SPEAKER_01: And our next question is are there any social and cultural aspects relating to inappropriate antibiotic prescribing that are more common in critical care settings?
• 24:58
  SPEAKER_01: David, you want to take this one first?
• 25:00
  SPEAKER_03: Well I think if we're motivated by fear, patients in ICUs arouse more fear than than anywhere else since they almost by definition are in life and death situations where the provision of physiological support is required to prevent deterioration and death.
• 25:19
  SPEAKER_03: And when you think of the different modalities by which intensive cares provide this support manual ventilation, the mechanical ventilation, pressors, etc, well antibiotics uh I think ICU clinicians would identify also as being critical modalities of support for their patients.
• 25:40
  SPEAKER_03: And this relates to the tremendous diversity and severity of the comorbid problems, such as cancer, liver disease, et cetera, and it creates situations where when a person is crumping and they are brought into the intensive care unit, it is not within the capability of anyone often to say definitively whether infection is or is not a factor in that patient's deterioration.
• 26:11
  SPEAKER_03: And therefore that leads in turn to the very very high prevalence of antibiotic use within ICU patients.
• 26:19
  SPEAKER_03: In RMICU it's you know 70 to 75% of patients at any given time are taking intensive are taking antibiotics.
• 26:27
  SPEAKER_03: And so that creates the fear which leads to the the need for timeliness, giving antibiotics as as quickly as possible and the perceived need to use antibiotic regimens that are very broad spectrum with the the notion being that you really can't afford to miss whatever a possible infection might be caused by you can't afford to give an antibiotic that is not adequately effective against it.
• 26:56
  SPEAKER_03: The thing that about antibiotics that is perhaps unique, certainly different from other support modalities in ICUs like mechanical ventilation and pressers is that there is so much more uncertainty about the patient's need for this support and there's much less precision in how they're deployed than what you would do with the other modalities.
• 27:23
  SPEAKER_03: And that is in large part why there's a more frequent need for help among intensivists with these kinds of issues.
• 27:52
  SPEAKER_03: Within our medical intensive care unit there is a reliance kind of a reluctant reliance on clinical pharmacists for help both in making sure that the antibiotics are are administered quickly once they're ordered but also in kind of providing early post-order modifications in the regimen but they also we noticed a dynamic there that is seen in many other settings in hospitals which is that the whole clinical assessment since patients are so often so ill in a general way and since the role of infection is often as I say impossible to determine with certainty, the whole decision surrounding antibiotics can devolve in a way to just do we need antibiotics yes or no and if the answer is yes then let's give our kind of standard go-to regimen that we feel provides the sufficient effectiveness and breadth of spectrum that the patient is likely to need.
• 28:58
  SPEAKER_03: So say for example vancomycin and pipersillintazobactium is an is one very common combination.
• 29:05
  SPEAKER_03: And they do this without you know sometimes overlooking the more granular nuanced aspects of well if there is an infection what part of the body is it likely to originate from and how does that impact the way that you evaluate the infection the kinds of diagnostic testing that you perform and how might it impact actually the the choice of therapy with for example pipercylintasobactium not being a good drug for CNS infections.
• 29:34
  SPEAKER_03: And so all of that plays out on a regular basis.
• 29:39
  SPEAKER_03: The other major issue that we identified was kind of unique to our surgical ICU where it's an open unit the patients are you you don't need the approval of the SICU clinical team to admit a patient to that unit.
• 29:56
  SPEAKER_03: And once a patient is admitted the primary responsibility for that patient remains in the surgeon who first admitted and operated on the patient whereas the SICU doctors their job was even though they were with the patient much more of the time any major decisions including whether to give or to stop antibiotics or what they should consist of would need to be checked out with the primary surgeons who are often in the operating room.
• 30:27
  SPEAKER_03: And so this obviously led to difficult and and one might would say suboptimal communication on these very important issues.
• 30:38
  SPEAKER_01: Thank you for that those are some great points.
• 30:41
  SPEAKER_01: Brad do you have anything to add?
• 30:43
  SPEAKER_02: I'll just say quickly you know I completely agree that the fear factor goes up in the ICU your fear squared sicker patients.
• 30:51
  SPEAKER_02: And the challenge is to dissect out the real increase in risk, which is as David said, you can't miss something right because if you do the risk of death goes up dramatically from yes, but what is the patient actually likely to have and so the way this one common way this manifests is they're in the ICU because they're very sick from community acquired pneumonia and they want vancososin.
• 31:15
  SPEAKER_02: Okay, it's community acquired pneumonia.
• 31:18
  SPEAKER_02: It's not going to be pseudomonas and outside of pretty specific risk factors, it's not going to be MRS.
• 31:24
  SPEAKER_02: And they say yeah but the patient's very sick and you're like yes I understand that I'm giving the most effective rugs possible for the pathogens that are almost certainly causing the infection.
• 31:36
  SPEAKER_02: People tend to spill the fear of illness over to broadening out the likely pathogens and that's not the problem.
• 31:44
  SPEAKER_02: And so I think that that's the challenge in the ICU is respecting that you really do need to be more aggressive, but you need to be aggressive rationally based on the organisms likely to be causing disease and don't give Lenezolidaptamycinum amycin and ivermectin to everyone because anything could cause anything in anyone at any time when that actually is not the case.
• 32:08
  SPEAKER_02: And and you know could have added Bory in there too.
• 32:12
  SPEAKER_00: Ismita do you have something else to add?
• 32:14
  SPEAKER_00: I think from from the work that has been done by colleagues and also by us one of the things is I go back to the the team efficiency and the team dynamics within ICU teams.
• 32:26
  SPEAKER_00: So the matching Michigan intervention that was very successful in the USA in preventing bloodstream bacteria was replicated in the UK and colleagues of ours did a multi-center qualitative research to understand the success of implementing an intervention that worked in another setting in the USA in in the ICUs in the UK and they did this meta ethnography work of observing and interviewing observing practices and interviewing people in working in ICU teams across England.
• 32:55
  SPEAKER_00: And what they identified is that the key to successful implementation of this intervention was in how the ICU teams operated.
• 33:03
  SPEAKER_00: And the successful ICU teams were those that implemented the the intervention um successfully were those that were the intervention was locally owned.
• 33:12
  SPEAKER_00: There was flexibility for it to adapt to the needs of the local population as in the team that work was working in the unit.
• 33:20
  SPEAKER_00: And so these and anyway the unsuccessful um sites were those that didn't have this flexibility that it was the external teams that were coming in and telling the ICU teams how to work and so it's really interesting it's important to always contextualize interventions.
• 33:34
  SPEAKER_00: And I mentioned this at the beginning I think for me the ICU team is one of the most effective teams within healthcare to look at and learn from but of course it's not easily replicable because of the high level of staff resources in the ICU which cannot be replicated in other settings.
• 33:48
  SPEAKER_00: And then we have a a study that we have conducted in South Africa where Candice Bonaconsa my colleague who's a research nurse led this study and is now looking at communication in the ICU team but she used socio so we use sociograms which is a way of mapping communication in any given setting and we mapped the communication on ward rounds and what we observed is even by where people place themselves on a ward round so we found the nurses are often on the periphery.
• 34:16
  SPEAKER_00: They're not really engaged with the wardround they're already made a decision that they're not going to be part of the team and that's partially because of learned behavior but also the boundaries they set themselves because of the hierarchies that they've experienced.
• 34:27
  SPEAKER_00: But actually the nursing team are one of the most important members in terms of the information they have particularly for all patients but in surgery we saw you know they have so much information about uh surgical drain about the wound site about uh whether the patients had their antibiotics or not and so when we fed this back to the ICU teams what was really interesting was how receptive they were to this visualization of their communication and how much they took on board where there were gaps and now this whole intervention is owned by the team and it is being driven by the team themselves and they turned around the way they do their ward rounds.
• 35:02
  SPEAKER_00: They not only reduced it by four to five minutes to made it more efficient but now proactively always ensured that nurses are involved in discussions at the patient bedside.
• 35:11
  SPEAKER_00: So it was just an interesting observation for me to see how when you bring people on board on the journey of the research with you when they feel they have a stake in it, they're much more receptive to actually making it work and it's kind of for me validated the the findings of the the matching Michigan study that was on the UK.
• 35:30
  SPEAKER_00: That was by Mary Dixon Woodson colleagues and they they wrote a report for the Health Foundation about it.
• 35:35
  SPEAKER_00: Really it comes down to contextualizing and understanding the the strengths of the team that you're working with and I think the ICU is a very good example of really effective teamwork which we can learn from.
• 35:46
  SPEAKER_01: Thank you.
• 35:47
  SPEAKER_01: And I think you touched on this last question that we have a little bit when describing your previous studies but how would you recommend determining what behavioral domains such as social influences, beliefs about consequences, goals of care, etc, are influencing the suboptimal antibiotic prescribing that you might see for a specific disease state or patient population or even with a certain group of prescribers at your institution.
• 36:15
  SPEAKER_01: Zamida?
• 36:16
  SPEAKER_00: It's uh I thought about this question it's it's not straightforward to answer because again it comes back to contextualizing things and and conducting some understanding the context in which you're working, understanding who the opinion leaders are, who the key decision makers are and the uh existing systems within which one is working is really important.
• 36:39
  SPEAKER_00: And and looking at the hierarchies, the the team dynamics that are operating and these aren't easy you know it's it's not like you can just go and it may come easy to some people but it's something that it is it is a method.
• 36:51
  SPEAKER_00: It is a study just like it if you were doing a statistical study or a randomized conservative trial.
• 36:56
  SPEAKER_00: But I think it's really about integrating qualitative research methods into research when we look at stewardship and what works and what doesn't work.
• 37:04
  SPEAKER_00: One of the challenges though we often face is only being pushed to consider uh research that is statistically powered.
• 37:11
  SPEAKER_00: So we're always interested in studies that have a significant level, you know, less than 0.05.
• 37:17
  SPEAKER_00: And whilst uh those studies are very important, uh we can't lose sight of the fact that qualitative research works alongside quantitative research.
• 37:26
  SPEAKER_00: And what qualitative research does is that it allows us enables us to be able to develop theories that can be tested quantitatively if if we want but it also helps us contextualize.
• 37:38
  SPEAKER_00: Now I say this because I've always had the privilege of working in institutions that were academically affiliated.
• 37:45
  SPEAKER_00: So we have the access to grant resources to researchers that we work with to be able to do research alongside clinical service delivery.
• 37:53
  SPEAKER_00: This is not practical everywhere and is something that I'm acutely aware of.
• 37:57
  SPEAKER_00: But again I think it's important even where we are not conducting research but just implementing and and providing clinical services that we want to be optimal how we would go about determining behavioral domains is to look at again what are the the opinion leaders, what are the decision makers within those teams how do we help people from their perspective you have to meet people halfway in stewardship and this close to what Brad was saying about diplomacy, about the relationships that we build it's really important.
• 38:28
  SPEAKER_00: I think a lot of the work is actually diplomacy and it goes back to what our work about you know autonomy and understanding people's expertise understanding that we're all there to look after the patient and the patient's best interest in mind but we come from very different analytical lenses we come from very different priorities that we have and it's being able to speak a language of risk to different healthcare professionals in a way that they can relate to it.
• 38:52
  SPEAKER_00: You know when you're there's that saying when you're a hammer everything is a nail I don't think it it helps us to always just talk about antibiotic resistance.
• 39:00
  SPEAKER_00: We have to talk about many different other outcomes that are related to infection and resistance that make sense and are of more urgent relevance to the clinical teams that we work with.
• 39:11
  SPEAKER_00: Thank you for that answer.
• 39:12
  SPEAKER_02: Brad Yeah I mean locally what we do is use data to determine where higher than normal or higher than average use is occurring.
• 39:23
  SPEAKER_02: We just go talk to people what's up why is this happening?
• 39:27
  SPEAKER_02: And you'll learn they're worried about X, Y, or Z or they've seen a rash of X, Y, or Z recently that's a local issue, right?
• 39:35
  SPEAKER_02: That's not something you can necessarily cookie cut or replicate around, but our general process is use data to identify where we think overuse may be occurring and then go talk to the people in that area and see what's up and what common solutions you can find.
• 39:50
  SPEAKER_01: That's definitely a simple and straightforward way to do it.
• 39:53
  SPEAKER_01: David, any final thoughts?
• 39:55
  SPEAKER_03: I appreciate Asmita and and Brad's comments I I do think Asmida and her colleagues in their work have have made huge contributions by pointing out how the hierarchies as they're variably deployed influence antibiotic prescribing so hierarchies of seniority of rank of career that is physician versus pharmacist versus nurse and of gender and it's not that stewardship programs can by themselves go into a unit and say you guys aren't organized properly but it is in a kind of a larger meta way to point out how a more horizontal structure of care, a more patient-centered level of care where people are really focused more on the patients and less on their own reputations and their own positions within these hierarchies are going to be very helpful.
• 40:52
  SPEAKER_01: Thank you all for such a fantastic conversation we appreciate you joining us today.
• 40:58
  SPEAKER_01: Thank you.
• 40:59
  SPEAKER_01: Thanks very much Hannah stay tuned for part two of this episode where we will discuss interventions that can be implemented based on the culture at your institution or within parts of your institution in addition to communication strategies that can be most successful when talking with prescribers as a part of prospective audit and 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.
• 41:30
  SPEAKER_01: You can find more educational content like this podcast on Shay's online education center learningce at www dot learningce dash online dot org This concludes today's episode of the social and cultural aspects of infection control and antibiotic stewardship series.
• 41:51
  SPEAKER_01: Thank you for tuning in