Google hangout – the experts respond to your comments and questions

OK, we’re live. I think we’re finally online, Mark. We’re finally live, so, hello, welcome everyone. We’ve just gone for five minutes of broadcast only to work out that we weren’t actually broadcasting. So wherever you are in the world, welcome. Mark did a beautiful introduction. I’m sure this one will still be as beautiful. But, anyway, we are live on air now, finally. So welcome to the end of week two on the MOOC. I’m Mark Gilchrist and this Gavin Barlow, and we’re keenly involved and majorly involved in stewardship across our own organisations and are passionate about that. We have had lots of comments throughout the week, which has been great.

It’s been great to see the interaction between the different countries and the continents and sharing best practise, which is really what we’re trying to do– promote best practice at the grassroots levels. We’ve been learning too, haven’t we? We’ve been learning. Yeah, yeah, really, it’s been fantastic. Learned lots of things. Great ideas and stuff like that. Tweak our environment– and challenging some concepts in maybe taking away some of those old myths and cobwebs that have maybe been handed down to us and making it a better place. So thank you very much for those. We really do want you to interact with us through the next half an hour or so.

You’ve got a dashboard at the bottom that you can put in your comments. Please do put the country that you are calling from. That just helps us see the breadth of where we getting to. We do have actually 4,000 learners involved in the MOOC. Now, technology has failed us at the last minute. There’s a surprise. But this is our printout of where you all are across the globe. So there’s a lot of you out there, which is great to see. But please do send your questions. We’ve got questions that we’re going to answer over the next half an hour or so that you posted already.

We’ve got some really nice case vignettes that we’re going to talk about, and Gavin and I are going to add in some of our experience and what we’ve learned as well over the week. So we’ll start off now. We had two main areas which we were going to give you some feedback on, which was the word cloud that you were asked to help generate and also the poll, which was around who you educate, and then we’ll go onto some specific questions. So the word cloud was around topic choice and what you would prioritise in terms of education and strategy around your stewardship programmes.

And what we thought would be a little bit fun would be to hear Gavin’s point of view, my point of view, and then– Which are different. Which are different, and then we’ll tell you the results of what you all thought globally. So I guess we’ll start with you, Gavin. What are your top five in the work cloud? So I jotted my top five down very quickly on the train last night without thinking about it too much. And, interestingly, we’ve taken slightly different perspectives. So the angle I took was very much based on the video scenario we provided for you early in the week. And I think Mark’s taken a more umbrella-type approach that you’ll see from his answers.

So my top five, in no particular order by the way, no preference at the top or anything like that. But I thought it would be remiss to not mention hand washing because only that’s not a classical stewardship intervention, and it’s not– oh, it’s something that the infection prevention and control team tend to focus on. I don’t think we can separate out infection prevention and control issues from antimicrobial stewardship too much, and in some organisations, as you know, maybe where you’re working, the two interact very actively, and in some organisations they are essentially one entity.

So hand washing was certainly in my top five on the basis that if you stop the spread of resistant organisms within your institution, then you will get less health care associated infection, and you will prescribe less in the way of antimicrobials and so on and so forth.

Second on the list, but not necessarily in second place, I would want to educate about resistance, and the reason I put that is that that’s one of the major goals of stewardship is obviously to mitigate the evolution and the spread of resistant pathogens. So people at the coal face, and I took a very coal face perspective as opposed to umbrella-type perspective from the institutional aspect of things. But if you don’t understand about resistance, then I think it’s difficult to really do stewardship at all. Third on the list was duration, review, stop. I think that was specifically mentioned as an issue in the video itself– intravenous antibodies going off at 10, 14 days whatever.

So I think that’s a real issue, and one of the major themes over the years in my own organisation has been the importance of length of therapy control and even if you can’t change the patterns of your anti-microbial prescriptions within your institution, actually reducing the overall consumption of antimicrobials will hopefully be beneficial for a variety of the outcomes we’re interested in. I would be keen to teach on broad versus narrow spectrum antimicrobial therapy and the concepts around that. In this scenario, there was considerable concern about the use of very broad spectrum agents. So, again, the coal face team having some concept of what we mean by that and what the alternative prescribing strategies might be I think would be important.

And then the fifth one I’ve actually got sepsis. But I think it could have been– clinical diagnosis came very close second. I think the two are highly related. So for me, at least at the coal face level when I’m managing a patient in front of me, I think there are two things that are really important critical control points in my own prescribing and for others, and that’s trying to make a clear diagnosis– not always easy to do in clinical practice. But that’s what I’m trying to do. And then, also, physiological assessments of the patient– this key question– how ill is this patient in front of you? And I think that’s really important because the principle– broadly, there are exceptions, obviously.

But broadly the principle there if you have a relatively well patient in front of you sitting up, eating their Rice Krispies, reading the newspaper who does not have severe sepsis, they either need maybe narrow spectrum oral antibody therapy or possibly even no therapy at all. Whereas if you have someone who’s hypertensive and clearly in severe sepsis, rather like the scenario we gave you, then clearly those patients are going to need intravenous antibiotics quickly after the onset of the recognition of hypertension and severe sepsis– and probably broad spectrum initially unless you have some positive microbiology already. So that was my take on the top five. Mark has a little bit different perspective.

And I think they complement really well actually because clearly here there are not necessarily right or wrong answers. We could probably have done a top 10. There is probably a need for a top 10 here because you’re going to cover many issues for this scenario if you’re trying to educate and persuade people at the coal face level. But what did you go for, Mark? [mark]I went for more of an operational-type view in terms of educating our staff and approaches to stewardship in general.

So in no particular order, I guess, one of them was around treatment guidelines and making sure that those are effective, and I think one of the things we don’t do very well is make sure that they are easy to read. And we produced 20-page documents around guidance but we forget how they’re used at the end-user level. So I think putting some importance and some impetus into making guidelines readable, accessible, and in a way that people can interpret, is important, and I guess I was thinking that those treatment guidelines encompass a lot of the things that Gavin was talking about– so treatment duration and selection and– Broad classes narrowing, yeah.

Absolutely, and putting in that context that your treatment guidelines need to be tailored to your local resistance patterns wherever that may be. So I guess I cheated slightly, and I used that as an umbrella term for a couple of others. So the clinical diagnosis that I had is one of the options, and really again, that is because treatment guidelines are only as good as your clinical diagnosis and your ability to diagnose appropriately. So you can know the pneumonia or you can do a measurement to say that your antibiotic is correct for a certain diagnosis. But actually, if your diagnosis isn’t correct, your measure is not worthwhile.

Those I guess were the clinical components, and then I switched tact to thinking about the overall organisation and that of teams and that I see on a ward level every day around clinical leadership. So leadership being effective, and if you don’t drive and push that leadership from an executive level down to your ward or your ward sister or your matron or your pharmacy teams, than there’s no real ownership of the problems that you can face with antibiotics. Teamwork I put down as critical particularly if you’re in a fast moving environment like in an acute medicine ward or emergency department. Handover– I see quite often that you make a decision during the day. Nobody writes it down.

Nobody speaks to one another, and then in the evening, you get the same call from another junior doctor going why is this patient on an antibiotic? So there’s a lot of teamwork. And in that, my last one was about communication– so bringing together those core– so many non-clinical components to education and putting some emphasis behind it because if you don’t have those, it doesn’t matter the best clinical acumen in the world, you won’t get the effective treatment if you don’t communicate. So those were my top five. We could call it our top 10, actually. We could call it our top 10. Yeah, the doctor and the pharmacy perspective of prescribing. Your toolkit to stewardship strategies. There you go.

You heard it here first. But you should post on that. You should tell us what you think. I think that’s really important because the comments that have been coming in through the week have been really interesting, excellent, give us ideas, so on and so forth. So we can see the number of viewers I can see on the screen. So those viewers are going up. So that’s good. So please do post your views. So in terms of what you guys thought of the 4,000 learners that we’ve got on the course, the top one that you spoke about in word cloud was prophylaxis, which I think both Gavin and I– It caused some controversy.

It caused some controversy because we weren’t expecting prophylaxis to come up, but actually, it’s something that’s been generated in a lot of your comments about the prophylaxis in education and when should you give it, when should you not give ti, and how long. And that’s really interesting because in the scenario, it maybe was one of the secondary markers in there. It wasn’t the primary thing that came out because it was about treatment. But, actually, it’s obviously important from a global sense that prophylaxis is there about education.

We might come on to that when we talk about who’s involved in stewardship, and there’s a little bit about surgeons and anaesthetists and things like that that have been brought out from your conversations. Clinical diagnosis and teamwork were the second and third one. So they marry up a little bit. Duration, review of therapy and putting stop dates was important. That was number four. And then the fifth one was around treatment guidelines. So all of the things that we’ve discussed in our top 10 and the you’ve have still discussed in the top five. And hand washing, the sixth . And hand washing, sixth and IPC strategy there, but important in the overall stewardship strategies.

So you’ll see that the themes are– there are principles and themes there that I think are crossing over all of our selections, which are around making sure we have right decision, right clinical guidelines, right treatment algorithms etc.– and then a little bit about teamwork and leadership and other metrics. And that is just determined by your resource and your setting and how you implement stewardship , even if you’re at the naive stage, or you’re at a very experienced stage as well. So I am going to hand it over to Gavin. He’s got a poll results. No, I don’t. No, you don’t. We’re going to say, no we don’t. No, we don’t, but we are going to talk about the poll.

So the poll focused on not so much the content in terms of education, but on who to educate, again, thinking about that. I think they asked you about the scenario, but also about your own environments. But I’m really sorry we don’t have the results. It’s quite actually complex analyse, but we’re going to post those next week. So if you’re interested in those results, we’ll post them next week. But I think we give gave you five potential staff groups to educate– junior doctors, senior doctors, the ward nurses, ward pharmacists, and then the infection prevention and control nurses. And Mark and I had a chat about this a little bit earlier. We had slightly different views, but I think broadly the same.

I think looking at some of the posts online and quite a few posts online outside of the poll telling us what your top five would be. And, actually, those posts have been very variable, and I think that probably reflects the different environments people are working in and the different resources available to each of you out there, and obviously, Mark and I have quite a UK perspective, and even within the UK, our experience in local environments are quite different. So what did you have down as your top five there, Mark?

So I had influencing the ward medical staff and the pharmacy staff, and then going third, it would be educating your nursing staff around– nursing staff giving the antibiotics, pharmacy-making decisions about selection and then the medics with that diagnostic element. And, actually, one of the comments we got back, actually. So this is from Kevin Cahill, who put a post up about this was talking about “the senior doctor needs to have good habits and the ability to communicate those in terms antibiotic prescribing. The SHOs need to feel confident about challenging senior prescribing, particularly if it’s out of date. The pharmacist needs to challenge all prescribing that’s out of guidance.

The nurse is responsible for administering the antibiotics, and therefore, they need to ensure it’s correct as per local policy,” which I found that that’s really a good point to make, and I’m not sure in all organisations if that happens. So that’s a really good aspiration, I think. And then the infection control nurses about responsibility for and hygiene aseptic technique, minimal input, I guess, around antimicrobial selection. But it’s coming at it within wider stewardship sense. We had a little bit of debate ourselves about, I mean, obviously, your target both for education, but about who was more important in terms of the senior doctors or the junior doctors.

They obviously compliment each other on the basis that obviously targeting senior doctors is really important in terms of leadership and that percolation down that has been mentioned. But certainly, in my own environment, junior doctors are really important because they are at the coal face and actually, a lot of the prescribing and the monitoring of prescribing tends to be left in their hands sometimes. But perhaps that emphasises the need for the senior leadership. Yeah. Absolutely. And I think probably both of us both agree that the nursing staff group as a group of health care professionals are increasingly recognised as being potentially important in stewardship, not just in initiating antimicrobial therapy, but also in terms of monitoring.

I think nurses are a really good province for doctors, potentially. Absolutely. And also, in terms of my own organisation, that review, stop date issue, I think that’s a really key role for the nursing staff amongst other roles as well, and here in Dundee there’s a specialist nurse now in antimicrobial stewardship, which some of you have posted on, and I think it’s a really interesting role, a quite innovative role, and it’ll be interesting to see if that model expands elsewhere in the UK and across the globe. OK, so I think we’re going to– those were the two big questions that we asked you in the week.

So we’re now going to pick up some of the questions that have been asked, and as I say, please feel free to check in and give us some questions online. We’re on Twitter as well. So if you do– Tweet away. If you do have any tweets, then our technical team to the left and right of us are on standby. So the first question I guess it came up, which has been echoed by a number of people, is really about the notion of how do you set up a stewardship programme, and one of the comments was, “I’m faced with obstacles such as gaining participation from my consultant colleagues. Time issues within the trust, or hospital, are very stretched.

So do you have any pointers between how you set that up?” And that’s a good discussion group that’s going on at the moment. And then there’s another one from Pilar Ramatar. He says, he’s in infectious diseases in charge of an antimicrobial stewardship team and any time they participate in an AS course where people have no experience about antimicrobial stewardship they ask how do you start that team? What’s the first step you would do to create an anti-microbial stewardship programme depending on resource and team size? So we thought that was a good one to kick off, and maybe, Gavin, you could start off with maybe your experiences of 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 of 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 the patient level. And the government was levering some action.

Putting in 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 MSA 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 programme going. If you don’t have that, that can be really challenging, I think. But in February, 2005, that was 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 had a very rudimentary stewardship framework at that time.

So they didn’t have an antibiotic committee, for example. And also, they didn’t really have any basic framework for stewardship, no real guidelines that were easily accessible and just the really basic stuff that we’ve been talking about this week. 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 to go into detail, but essentially 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 the members of the infection prevention control team. That team has evolved.

But that was really the first thing we did was set up a team, and we were really fortunate because I have to give a lot of credit to the medical director at the time. He was really engaged in this area possibly because he was getting pressure from above and outside the hospital, but nevertheless, he’s 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.

So just one, I don’t know if it’s amusing, but one little anecdote that I told Mark last night was that very– I mean, the evidence suggests that if you want to tackle a stewardship issue like in the scenario– if you want to try to change something very, very quickly, then restriction of these initiatives is probably better with persuasion. But in the long term, we know that stewardship was no better than persuasion or an educational-type approach. But we ran an antibiotic committee discussing C. diff and the overuse of cephalosporins within our organisation– I know there are other active agents, but mainly cephalosporins in our own 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 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 it was really effective in getting, 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 to, I think, you need some leverage to get that 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 it’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– 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, and 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 three o’clock in the morning for healthcare-associated pneumonia– but also the IV to oral switch guidelines– the aminoglycoside guidelines. 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. It’s almost an acronym that I find useful and I think is worth mentioning, which is CECL. So that’s C-E-C-L without the I.

So the C is understanding your local context– so understanding your antimicrobial epidemiology, understanding your microbial epidemiology, and just understanding how your organisation works is really, really important in generating energy and change. So understanding your locality issues is really, really important– how you function locally. Engagements is really, really important. And I don’t actually like the word engagement because people throw it around the way in the place in medicine nowadays. But, actually, for stewardship, I think there is no better way. You have to get out there. You have to visible within your organisation. You have to be talking to the top of the hospital or the bottom.

When I say the bottom, I don’t mean that in a derogatory way, but I mean, the coal face the people doing the hard work. You’re going to talk to undergraduates, people postgraduate people. So you really got to get out there and talk to people. You got to communicate. The second C is communicate. And you can actually engage potentially without communication. Communication and engagement is 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 and understand people’s perspectives.

When they’re not doing something you want them to do, you have to really try to understand why that is. And that’s why listening is not about telling them what you think. It’s about listening. You can tell them what you think, but if you listen first, I think that’s really important. And then lead– we talked about it already in Mark’s introduction is leadership. Leadership is key. Individual leadership– that’s important. You 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 any sort of Imperial approach, Mark? How have you developed into that?

I think the really interesting thing, and I was fortunate because 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 programmes and things?

And I think actually for us, that’s about understanding your landscape, and 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– 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 look at our resistance rates. Those turn into guidelines. We look at the appropriateness of our antibiotics that we use across the organisation. We monitor those against our guidelines and see where the areas that need maybe some help in discussion. But the idea of creating guidelines is about a balance.

And I’m going to use the word engagement again. It’s a good word. It’s a good word for stewardship. It’s about talking to the people that want to use your guidelines. So 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 and 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 rate for X. And it’s having that data and having that, 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.

And so we need to make sure they’re easy to use– that we have buy-in from the clinicians at a senior level. And also the junior level– 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 I first started in stewardship, we only targeted the orthopaedic ward. 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 a measurement. You show consumption values and the impact. What’s missing is the outcome measures and quality measures that you use to measure a service, and we’re not going to go into that because that is coming. Week three.

[Mark] For week three, which is we’re teeing that up nicely for our colleagues in week three. But 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 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 fruits and strategies can be? So IV to oral I just mentioned was the classic one that we did in 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 the big. So one of the responses we’ve had is that they’ve got a very engaged microbiologist that spends a week– 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 now is if you don’t publicise it enough and get engagement from that team, you might annoy them by just going in the ward and saying, this is what you should do.

So there’s a little bit about communication and getting that strategy right so that you can contain continue with that . 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, I think it’s really important they don’t become office based and don’t become data based entirely and 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 time, obviously but you can get maybe a couple of hours a week that you get benefit.

And also, that’s one of the things I found from our joint pharmacy doctor ward rounds, infectious disease ward rounds, and the microbiology ward rounds is that you really start to understand your locality much better. You can pull out and slice it up many different ways all that data and reflect on DDDs and this and that and next thing. But, actually, just sometimes getting out of the ward and really understanding 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 staff have with antibiotics. Is it because they can’t get them? Is it because they don’t understand or they can’t have access to the policy? What do the junior doctors feel when they are at midnight, and they are trying to make a prescribing decision? And, again, your pharmacy colleagues. One of questions we 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 maybe leads into some other questions.

Even if you don’t have a specialist, and many hospitals around the world who don’t have a specialist infection pharmacist or antibiotic pharmacist– 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. It 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 multidisciplinary team.

Where now? Where now? Where now? I think we’ve got some more questions. More questions. Yeah, so we got a list of questions that we hold from your polls– quite a long list. And I noticed we didn’t really want a lot of questions. We’re 40 minutes in already. So we haven’t dried up. So it’s looking good.

We haven’t had a drop in viewers. So that’s a good thing. Well, yeah, not too many.

I think the question has been asked more than once this week, several times, I think, is how to engage– well, most people I’m afraid, no bias here, but most people have said surgeons. But I’m going to say difficult groups. So how do you engage the belligerent in antimicrobial stewardship? What are your thoughts on that, Mark? So I think we’ve maybe touched a little bit about this in terms of engagement previously. But if we take the surgical approach, from my experience,

surgeons do their rounds 7:30 in the morning before theatre. I’m still in bed then. What time do you start? 8 o’clock. They don’t start work. That they have a theater list, maybe a break at lunch time, and then they do things in the evening when the day-to-day stewards ship teams or when you are around, your 9 to 5 office days are. So the daily lives of those groups are not compatible. And we could put anaesthetists in that bracket as well in terms those tend to be the people that give the antibiotic prophylaxis or tend to be people who administer things in theatre. So you do unfortunately then have to say, well,

let me– shall I go in at 7:30 in the morning and go on their round and start to make a difference in terms of increasing the visibility of stewardship and the agenda and being there to ask questions. And I found that successful in going to meet them at their times. You can’t do it all the time, and it’s not sustainable. But, actually, if you build up that rapport, and you build up that evidence base with them and see what their challenges are, then can help improve how you manage stewardship within those areas.

So the example that you would give is if you have problems with surgical prophylaxis, one of the things we find is that where we want to give vancomycin to surgical patients, it takes two hours to administer to a patient before they get to theatre. And we were just finding that we kept on saying why not– whey are you not improving your compliance with policy? And the big thing was they just don’t have time. They don’t have to get it. And so we think about switching it to another agency. So in the UK, I know it’s not available globally. We have teicoplanin.

And we use that agent sometimes in surgical prophylaxis because it’s a bolus and because we’re able to do it. So it sometimes comes at a cost, and the cost– we haven’t touched upon that yet in terms of stewardship, but it is important, particularly if you’re choosing new and novel antibiotics or different antibiotics that maybe work better for you in a service delivery mode but maybe have a cost implication. So this comes part and parcel. But you can’t understand the difficult patient groups until you go and speak to them– until you go into their land and their environment and take out plus points, but also try and help them improve.

So that would be my experience is you have to go to them and understand them. Yeah, I know. We had a something similar in our organisation. For an anaesthetist, during an elective, but also an emergency caesarean section, is big duelling act. And then if you ask them to be trying to draw up some challenging to draw an antibiotic and it needs to be administered as an infusion and try to time that and all the other things they’re doing in an emergency caesarean section is really challenging. That I think goes back to the communication when we’re talking about that communication issue is really important.

The other thing that has stretched our views quite a bit over the years is– and some people might say this is a little bit disingenuous. But what I do, try and do is get people to come up with ideas to solve their own problems because if you try and enforce something on someone then generally– we all do that. I do that. You go, oh, I’m not going to do that type of approach.

But if you can get people to generate the ideas you want them to generate– and if you can get them to talk about the direction you actually want them to go in, and they believe it’s theirs, and they have ownership of it, I think that really a useful thing that I have found very useful ideas.

And also, certainly in my own organisation when I first started in terms of prophylaxis, for example, some procedures were getting really prolonged post-operative surgical prophylaxis, and a piece of advice I’d give you there about that is don’t try and reduce the surgeon from using five days of prophylaxis post-operatively to using more days of induction because I can guarantee that won’t work, or it’s going to be very, very challenging unless you’ve got real authority and enforcer to do that, which many of us won’t.

So what you can do is maybe take the strategy that you bring them down to three days and audit, bring them down to one day, 24 hours, and then audit, and then maybe down to an induction dose only. So don’t try and be belligerent yourself. You have to sometimes compromise, and that’s really important. Gavin, the other thing I was going to say is really the partnership that you’re trying to establish, if you haven’t got that already. And so your example of the anaesthetist and having caesarean section– when you have that penicillin-allergic patient, and you have to give an aminoglycoside and something else, and something that takes and hour to give, there’s a little bit of, yes, it’s important.

But actually, from the anaesthetist point of view, getting the spinal block in place is as important. Yes, totally. And that procedure. So there’s a bit of compromise, and that’s the whole thing about stewardship. You have to believe in your principles and make sure they’re OK but deliver the partnership to get it right. And sometimes things might not be perfect, and I think stewardship programmes need to be a little bit flexible to allow how they mould and how they move to the organisation and patient flow. Yeah, right, so that’s probably enough on that question. Shall we move to the next one?

So the next one is what to do if you don’t have an infectious disease physician or a microbiologist or pharmacist within your organisation– an ID type pharmacist, antibiotic pharmacist? What do you think? I guess the pharmacist who are specialists in antibiotics or infectious diseases, and the terminology has change depending where you are globally, they are a limited resource. And I think we know that from a UK and wider perspective that 30% of our patients are on antibiotics at any one time, if not a little bit more. So pharmacists in general are coming into contact with these patients and need to know how to manage them.

And all you need is a champion who has a passion, who has an interest in that field, to start doing a little bit of work in championing it and moving it forward. And a lot of the rules, particularly in the UK, even for an ID, or an antibiotic specialist pharmacist, are not full time. They are half time or they are a third of their time and they are linked to other areas like intensive care or respiratory medicine.

And so you need to find someone who can champion it, and I think it’s a little bit the same with the medics as well in terms of you can have a respiratory position who has an interest in antibiotics who wants to take and champion that a little bit more. And between those partnerships and getting together, you can then create some data, create some value, and then put business cases together for full-time posts. So that would be my take. Yeah, and I think the nursing staff, again, I’m not going to– we discussed that in a little bit of detail already. But think about how the role of the nursing staff in the limited resource environment I think is potentially fruitful.

OK, so the next question is all about sustainability of stewardship. How do you keep this going over the years? So this is really hard. And I don’t think we’ll be able to answer all of the concerns globally. But creating a programme that has a sustainable future is difficult because you need to keep people with momentum and engagement as things go on now.

Interestingly, in the US and in the UK and in Australia there are legislation in motion and specific guidelines there that try and promote best practise within hospital organisations and talk about quality improvement measures and the measures that you’ll hear about in the next couple of weeks– creating the right results, the right format, how you display them, how you promote them. Is it once a week? Is it once a month? And deliver those in an easy format for people to digest and take up.

You need to involve the staff at the front end whether that’s data collection, whether that’s promoting the results and key results, have all your members of your team singing the same song and then determining where you need to focus your efforts to sustain your programme. So in our organisation, we’d look at our antibiotic prevalence, I guess, two to four times a year, depending on the various patient populations. But in our acute admissions area, we know that that is the place that antibiotics get prescribed commonly. And if they get prescribed wrong, they then go off to the different divisions of medicine and surgery.

So we need to concentrate effort to get our acute admissions physicians and pharmacists and nurses prescribing the right dose, the right duration, the right drug. And so we monitor them weekly. And we then feed that back in various methodologies. So I’m trying not to give too many things away week three. But that’s our sustainability strategy and then having an overarching stewardship strategy. So it’s what works for you and how you can engage. And I don’t know. Have you done it within Hull? I think one of the points made earlier was about leadership. I think having that ongoing leadership, you need individuals providing leadership, and that can be challenging to maintain the energy, but also team leadership as well.

That’s key importance. And that sort of measurement issue, I think, is important. One of the issues with stewardship is about sustainability of resource. Certainly in some organisations maybe five years they had more resource than they do now– pharmacists are thin on the ground so they get pulled back to general pharmacy issues. And I think in terms of trying to continue to get the adequate resource both in terms of finances but also in terms of human resource, which is possibly as important then showing positive outcomes I think is very, very important. But we want tread on week three. We won’t tread on week three too much.

OK, so this is a question that I thought was quite interesting and it’s cropped up in a few different formats. So we thought we’d mentioned it. What about the nature of antibiotic guidelines, Mark, within your organisation? A little bit like the scenario. What about the nature of those guidelines when you know you have a lot of resistant infections out there, ESBL producers in some places in the world who will be carbopenamase producers, of course. So what would your approach be to developing an antimicrobial guideline in that context? So I guess this comes back to a little bit what we said earlier about having guidelines that are maybe not completely empiric for everyone.

So within specific populations that maybe have high antibiotic use because they are more vulnerable populations so that may be haematology. It may renal. It may be transplantation. It’s around developing or putting processes in place to use maybe less broad spectrum agents, more carbapenem-sparing agents– looking at your own sensitivity patterns and thinking can we get away with using a different antibiotic and different combinations than the rest of the hospital to try and reduce the resistance impact on that population? So I think you need data. You definitely need data to form your guideline choice. But there has to be this, I guess, safety net about putting in these other agents or using older agents more wisely.

I don’t think we use– the older agents sometimes come with less knowledge about the drugs. So we need to upskill people about those agents and drugs so the Septrins and co-trimoxazoles of this world or the chloramphenicols that we use– And up skill that knowledge, puts the safety nets in place and then create guidelines that are very carefully monitored because these agents are useful when we go away from the norm. But if we’re not careful, that norm will become the same as where we are now if we let those agents get out of control. It’s a monitoring the antibiotic approach and linking that to your guidelines and how those guidelines evolve and change. Yeah. I completely agree with all that.

The things that would go through my head in this sort of scenario is that one has to try and avoid or reduce the use of broader spectrum agents that are likely to select for these resistant organisms. So in the UK that would be agents like co-amoxiclav, pipercillin tazobactam, fluoroquinolones, cephalosporins if we’re dealing with, say, an ESBL, for example. And then we have to think back, exploiting, as Mark said, some of these agents that perhaps were not used quite as often in the recent past– aminoglycosides, phosphomycin, tardocillin, tegecylcline, chloramphenicol, co-trimoxazole. There are many of these different agents that we could potentially use in somewhat different ways to how we’ve used previously and more often than we’ve used previously.

But that very much depends on the antibiogram for the resistant pathogens. And of course, when you’re in the carbapenemase-producing setting, I think it becomes a real major challenge. And I think when you’re looking at guidelines overall for me, my view on this has evolved over the years. I think in terms of the classes of antibiotics one is using, we should probably be going more diverse now and really mixing it up a bit like what Mark said. And I think in the UK in the past, perhaps we focused on a relatively small number of antibiotic classes and used those as backbone antibiotics. But that can create its own problems. But it’s a really challenging question to answer.

There’s maybe not a correct answer as such, and what you do in different localities might be different. But it would be interesting to hear your posts on that as well. So we’ve got about five minutes, I think, left of this– four minutes now before we get cut off. And we haven’t even finished our question list. But I think one of the questions that I’m going to pick right at the very last. It was about the public and what can the public do in the hospital sector to address antibiotic stewardship, which I think is important to your patients and the public there because we haven’t touched on that. But it’s equally important.

And then I’m going to come onto medical students just before we finish as well because that’s another area that’s been touched on. So what can the public do to do more about stewardship in hospital settings? Yeah, so when we’re thinking about stewardship, traditionally the public had been much more involved I think, certainly in the UK, at the primary care community end of the spectrum. And there are some evidence-based strategies such as forward-dated prescribing, which we know will reduce overall antimicrobial consumption. But when we’re thinking about the hospital and this MOOC is focused on hospital stewardship. I know a lot of you have been interested in the primary care aspect of things.

But that’s almost important to integrate the two primary care, secondary, obviously. That’s always a different MOOC, a different challenge, I think. But I think traditionally in the UK, patients haven’t been really very involved in the secondary care setting, but there’s this concept in medicine there about joint decision making between the patient and the doctor. I think that’s really important in being up front with the patient about what you’re intending to prescribe and informing them. That’s important. I think particularly in the outpatient setting– particularly if you’re about to start on a very long course of antimicrobial therapy for some reason maybe to prophylax recurrent UTIs or something like that, for example, so being upfront in terms of the pros and cons.

And actually, interestingly, I deal with a lot of orthopaedic infection, Mark. I also see a lot of patients with very complex scenarios– pre renal transplants and things like this with recurrent urinary tract infection. And when I talk to patients and give them the pros and cons, a lot of patients don’t actually want to take long-term antimicrobials. So it’s really interesting, their perspective. If you don’t get their perspective, then I think you wouldn’t necessarily make the optimal prescribing decisions. And then I think patients need to question doctors even in secondary care, tertiary care settings.

It’s really important to question the approach in a positive way, obviously, it’s going back to that drug decision making type thing, and also, I think about here we’ve been really bad at this. And I think this is something for the future. I think we need to have patients on our antibody committees, don’t we? A patient representative who can give a patient perspective when we’re thinking about implementing certain interventions. I think patient representation is really important, and I think as it goes forward, particularly as health care systems move forward, having the patient view is really important. I think we’re just about there. I’ve got a minute left on the counter. We talked for an hour. We talked for an hour.

How did we do that? I don’t know. Maybe that says a lot. We’ve come up with some themes really for the week, and I’m going to end then on an email very quickly that we received. It says, we’ve got a lot on education. There’s a lot on education awareness about resource and resource implications and settings– multi-disciplinary team working, which is important, having a global nature in the global resistance aspect and the impact on that. And then around communications and engagement. And I think everyone will probably agree of the 4,000 active learners as we have, the principles of all this are the same. But how we do it is slightly different. And that’s not wrong.

It’s just because we have local challenges and barriers that we have to negotiate. And some of those questions are difficult, and we have to use the knowledge we have across the globe to share best practise. And, really, one of the things that is from a student who’s doing this course at the moment said, thanks for developing the resource. They had an opportunity to discuss the learning from week two on the ward yesterday. Our patient was placed on three broad spectrum antibiotics for cellulitis and haematoma of the leg by the surgical team. Wow! This went against everything I’ve learned in the course. So we alerted the team, reviewed the patient, and switched them to monotherapy flucloxacillin.

So I think that’s a really good example to end on. We’ve had some success. We’ve had success in one person at the moment. But I’m hoping that 4,000 active learners will follow suit. So from Dundee, that’s really it from us. Thanks to all the technologists and everyone behind the scenes who’ve made this happen and the weak happen and for all of you for participating. The two ladies here handing us questions– very important. To Gavin, thanks very much. But most importantly to you.

So we’re learning from you too. So that’s really important. And we’ll see you on another Google Hangout or another edition of the MOOC at a later stage in 2016. So thanks very much, and we’ll see you later on. Take care.