How Dr Barlow and Mr Gilchrist started

What’s the first step you would do to create an antimicrobial stewardship programme, depending on resource and team size? We thought that was a good one to kick off. And maybe, Gavin, you could start off with your experiences with the stewardship programme that you’re involved in and how that started. Yeah, so I thought I would just describe how we started way back in 2005 a little. And hopefully this will be of use to you, to at least some extent anyway. So, I actually started where I work at the moment in Hull at the end of 2004. And in February 2005, we had 66 cases in that month of C. diff. And it was around the time when C.

diff was becoming a huge UK priority at the governmental level and also at the patient level. And the government was levering some action, putting some funding in, but also levering some action at the chief executive and medical director level of hospitals with various thresholds that could not be gone above for C. diff and MRSA bloodstream infection as well. So it was really good timing. And I think sometimes you do need that imperative. You need that urgency. You need the political dimension, sometimes, to get your program going. And if you don’t have that, that can be really challenging. But in February, 2005, that was the most C. diff cases we’ve ever had, in fact, either before or since.

And we had to do something about that. The hospital I was working in, it had a very rudimentary stewardship framework at that time. So it didn’t have an antibiotic committee, for example. And also, didn’t really have any basic framework for stewardship, no real guidelines that were easily accessible, and just really basic stuff that would be talking about this. So the first thing we did was actually to create an antibiotic committee. And that was really important. And we got some senior pharmacists on that committee, and senior medics on that committee. And subsequently– I’m not going go into detail about, but obviously over the years that committee has evolved in one form or another. We’ve had junior doctors on it.

We have a senior nurse on it. We have members of the infection prevention control team and so on and so forth. That team has evolved. But that was really the first thing we did was set up that team. And we were really fortunate because I have to give a lot of credit to the medical director at that time. He was really engaged in this area, possibly because he was getting pressure from above and outside the hospital. But nevertheless, he was really engaged in this area. And having that person with authority within your organisation, that person, who can actually make things happen very quickly on your stewardship team initially, I think, is really, really helpful.

And so just one– I don’t know if it’s amusing– but one little anecdote that I told Mark last night, was the evidence suggests that if you want to tackle a stewardship issue, like in the scenario. If you want to try and change something very, very quickly, then restriction, at least initially, is probably better than persuasion. But in the long term, we know that restriction is no better than persuasion on an educational type approach. But we were at an antibiotic committee discussing C. diff and the overuse of cephalosporins within our organisation and other types of agents, but mainly cephalosporins in our organisation at the time.

And because we had the medical director on the committee, we were able to take a highly restrictive policy initially with authorisation from him for specific cephalosporins. We just essentially just took them out of the cupboard which is somewhat radical. And we can debate the appropriateness of that for various reasons. But at the time it seemed the right thing to do. And was really effective, amongst other things, really effective in getting our cephalosporin use right down very quickly. And indeed, a positive response in terms of C. diff. So having that authority, if you can get it, is really, really important. And one of the ways, I think, you need some leverage to get that sort of authority involved in stewardship.

One of the ways you can do that maybe initially is by showing some data, some patient safety data. Whatever it is that shows there’s a safety issue for patients. It might be C. diff. It might be something else. But whatever it is, using that sort of data to leverage some authority early on, I think, is really, really important. And then I’m not going to go into it. We’ve done a huge amount of things over the years. We’ve created antibiotic intranet sites. We’ve tried to keep the whole principle of stewardship very active within the organisation. We’ve had yearly conferences on antibiotic stewardship, infection prevention. We’ve tried various other things.

But one of the fundamental things, we’re putting that framework of guidelines– we’ve talked about guidelines already– but that framework of easily accessible guidelines, not only for the initial empiric therapy at 3 o’clock in the morning for health associated pneumonia, and so on and so forth. But also the IV to oral switch guidelines, Glycopeptide guidelines and so on and so forth. So we put those in place over the next year or so. We updated our formulary, for example. We created a list of alert antibiotics that had to be approved by either an infectious disease physician or a microbiologist. And it evolved and developed from that. I have a little, it’s almost an acronym that I find useful.

And I think it’s just worth mentioning, which is which is CECL. So that’s C-E-C-L, without the I, okay. So the C is understanding your local context. So understanding your antimicrobial epidemiology, understanding your microbial epidemiology. Just understanding how your organisation works is really, really important in generating energy and change. So understanding your locality issue is really, really important. How you function locally. Engagement is really, really important. Now, I don’t actually like the word engagement because people throw it around all over the place for medicine nowadays. But actually, for stewardship I think there is no better word. You have to get out. You have to be visible within your organisation.

You have to be talking the top of the hospital, the bottom– when I say the bottom, I don’t mean that in a derogatory way. But the coal face, people doing the hard work, you’re going to talk to undergraduates, people postgraduate, people. So you’ve really got to get out, gotta talk to people. You’ve got to communicate. So the second C is communicate. And you can actually engage, potentially, without communicating. Communicating and engagement are not the same thing. So in communication you have to listen. You have to listen. And this will be relevant to one of our next questions. You have to listen to people’s perspectives and really try to understand people’s perspectives.

When they’re not doing something you want them to do, you have to really try and understand why that is. And that’s by listening. It’s not about telling them what you think. It’s about listening. You can tell them what you think, but you listen first. I think that’s really important. And then lead. We’ve talked about it already. Mark’s touched on it in his list of five. Leadership, leadership is key. Individual leadership, that’s important. It can’t just be one person. And also, team leadership is really important. So that’s, I guess, I hope that’s useful. What about the Imperial approach, Mark? How have you develop into that?

So I think, the really interesting thing– and I was fortunate as I came in when the infrastructure of stewardship and the seeds of stewardship programmes had been set by colleagues. But I think one of the things that is immediately clear is your point about listening, and your point about where– One of the questions we’ve had here is where do you start? What can you suggest as startup activities for an AMS team and programs and things? And I think, actually, for us that’s about understanding your landscape. You’re going to be hearing in week three and week four about how you develop strategies for measurement and looking at what you don’t know. So, how do you know what you don’t know?

And looking at your consumption rates and looking at your antibiotic rates. And that informs you to then make guidelines. So, we’ve looked at our consumption and use. We’ve looked at our resistance rates. Those turn into guidelines. We’ve looked at the appropriateness of our antibiotics that we use across the organisation. And we monitor those against our guidelines, see where the areas that need some help and discussion. But the idea of creating guidelines is a balance– and I’m going to use the word engagement again– but it’s– It’s a good word for it. It’s a good word for stewardship. It is about talking to the people that want to use your guidelines.

If you’re developing an empiric policy that’s going to cover respiratory, and gastro, and renal, and all of these other complicated areas, there is an argument for saying you shouldn’t have empiric policy for everyone. Because one of the questions that came out this week was about the diversity of people and patients and the organisms and how we should treat those within the different patient populations. But at the coal face, you need something for your junior doctors to use out of hours and in emergency situations. And so, this is about talking to your respiratory physicians, saying what do you think in your guidelines you want to use?

And then you come in from the stewardship angle and say, well I would suggest we use this because of our resistance rates are X. And it’s having that data and having the information available to speak and provide the evidence base for. And if you can do that– and within our organisation we have lots of different specialties, and they’re competing with everyone’s time. And antibiotic stewardship has to compete with the time for surgery, and the outcomes, and the processing of patients, et cetera. And so we need to make sure they are easy to use. That we have buy in from the clinicians at senior level and also the junior level.

That the antibiotics that we want to use are readily available for the nursing staff. That the pharmacy have an idea of what these guidelines are so they can monitor and have surveillance. And so, it’s really what I would describe as a partnership. So you start off very small. And I do remember when we started. When I first started in stewardship, we only targeted orthopaedic wards. And we did that because they had a high use of intravenous antibiotics. And by placing a pharmacist on the ward, we reduced the percentage of patients on IV antibiotics from about 70% down to 10%. And that was just converting people from IV to oral, getting lines out and demonstrating the value.

So you don’t need to start big. You start small and you build up your programme. Then you have a strategy every year to be building a little bit more to your programme as you get success. Then you get buy in. You show measurement. You show consumption values and the impact. What’s missing is the outcome measures and quality measures that you’d use to measure a service. And we’re not going into that, because that is coming. –week three. That’s for week three. We’re teeing that up nicely for our colleagues in week three. And that’s why you need to keep going with this course, that you understand the value of the metrics that you use.

But I think, you’re starting small, building the programme up. –low hanging fruit. –low hanging fruit. –low hanging fruit. So, you’ll have seen the paper that we asked you to look at about what do you think these low hanging fruit strategies can be. So IV-to-oral, I’ve just mentioned, was the classic one that we did within orthopaedics. And there are other things about formula restriction, and looking at days of therapy, and seeing how you can reduce that duration. So, there are lots of things you can do that are small. And don’t tackle them big. One of the responses we’ve had is that they’ve got a very engaged microbiologist that spends a day a week looking at stewardship interventions with their antimicrobial pharmacist.

So maybe that’s an angle that you pick a pocket of your organisation that you’re concerned about, through data or through just conversation. And you go and do a stewardship round. And you look at the antibiotics. The danger of that is that if you don’t publicise it enough and get engagement from that team, you might annoy them by just going to a ward and saying, this is what you should do. So there is a little bit about communication and getting that strategy right so that you can continue that for them.

But those are some of the questions– That’s great, a microbiologist and a pharmacist maybe getting– I think when you’ve got someone engaged like that, and you’ve got a pharmacist working together, that team, I think it’s really important they don’t become office based and don’t become data based entirely. They need to get out there and be available, and on the wards, and chatting to people, and doing academic detailing on the wards. That’s really important. You can’t do that all the time, obviously. But you can get them, even if it’s just a couple of hours a week, you’ve got benefit.

And also, one of the things I found from our joint pharmacy-doctor ward rounds, infectious disease ward rounds, microbiology ward rounds, is that you really start to understand your locality much better. You can slice it up in many different ways, all that data that we collect on DDDs and this and that. But just sometimes getting out on the ward and really understanding the locality is really, really key, I think. And I would say, sometimes you don’t necessarily need to collect data from day one. As Gavin said, get on the wards and understand what’s happening. Go and shadow a ward round. Go shadow the nursing staff. What problems do the nursing have with antibiotics? Is it because they can’t get them?

Is it because they don’t understand and they can’t have access to the policy? What do the junior doctors feel when they’re at midnight and they’re trying to make a prescribing decision? And again, your pharmacy crews– one of the questions we’ve had from Toby is “how do you see the role of a pharmacist in antibiotic stewardship?” So, I think hopefully by the week’s course, Toby, you’ve seen how integral medicine, and pharmacy, and nursing is in stewardship. But go and speak to your colleagues and see how you can make a difference.

And that may be linked into some other questions that we’ve– Because even if you don’t have a specialist– many hospitals working around the world who don’t have a specialist infection pharmacist or antibiotic pharmacist. You know, general ward pharmacists can do a lot. They may not have too much time or resource to do much. But they can do just a little bit each week. And over time it just evolves over time, generates a culture of people thinking about antibiotics and not just writing up the big-gun antibiotic. Actually is this appropriate? And maybe chatting to other people, and working as a multi-disciplinary team.