1 00:00:00,000 --> 00:00:12,760 Welcome back to another episode of the Canadian Breakpoint, a Canadian infectious disease 2 00:00:12,760 --> 00:00:16,520 podcast by Canadian infectious disease physicians. 3 00:00:16,520 --> 00:00:22,040 I'm Summer Stewart, here again with Dr. Rupeena Purewal, pediatric infectious diseases specialist 4 00:00:22,040 --> 00:00:23,600 from Saskatoon. 5 00:00:23,600 --> 00:00:28,680 In this episode, we welcome two guests, Dr. Jason Newland, pediatric infectious disease 6 00:00:28,680 --> 00:00:34,040 physician in St. Louis, Missouri, as well as Dr. Michelle Mitchell, pediatric infectious 7 00:00:34,040 --> 00:00:37,360 disease physician in Milwaukee, Wisconsin. 8 00:00:37,360 --> 00:00:40,840 Today we discuss the importance of antimicrobial stewardship. 9 00:00:40,840 --> 00:00:41,840 Dr. Purewall. 10 00:00:41,840 --> 00:00:47,600 Welcome, everyone, to another episode of our podcast at the Canadian Breakpoint. 11 00:00:47,600 --> 00:00:52,280 Today we have two very special guests, and I will be introducing them shortly here. 12 00:00:52,280 --> 00:00:57,920 Our topic that we'll be talking about today is regarding antimicrobial stewardship. 13 00:00:57,920 --> 00:01:06,040 So as most of us are aware, as our audience are pharmacists, family doctors, nurses, medical 14 00:01:06,040 --> 00:01:10,720 students and residents and fellows, all of us working with patients, we know that the 15 00:01:10,720 --> 00:01:15,800 importance of an antimicrobial stewardship program, especially in a time where resistance 16 00:01:15,800 --> 00:01:22,400 is developing, and we have a lot of antimicrobial resistance and a shortage probably of some 17 00:01:22,400 --> 00:01:26,960 novel antibiotics, I think this is a really, really important topic. 18 00:01:26,960 --> 00:01:31,440 So today we have Dr. Jason Newland and Dr. Michelle Mitchell. 19 00:01:31,440 --> 00:01:33,520 So thank you so much for being on the podcast today. 20 00:01:33,520 --> 00:01:35,520 Thanks for having me. 21 00:01:35,520 --> 00:01:37,520 Yeah, for having us. 22 00:01:37,520 --> 00:01:38,520 Perfect. 23 00:01:38,520 --> 00:01:39,520 All right. 24 00:01:39,520 --> 00:01:44,360 So Dr. Jason Newland is a professor of pediatrics at Washington University in St. Louis and 25 00:01:44,360 --> 00:01:49,120 the director of antimicrobial stewardship program at St. Louis Children's Hospital. 26 00:01:49,120 --> 00:01:54,080 His current research spotlights the use of antimicrobials and the impact of an antimicrobial 27 00:01:54,080 --> 00:01:56,680 stewardship program at Children's Hospital. 28 00:01:56,680 --> 00:02:02,800 He's a co-founder of the Sharing Antimicrobial Reports for Pediatric Stewardship, SHARPS 29 00:02:02,800 --> 00:02:08,200 Collaborative, for improving antimicrobial use in children that is comprised of over 30 00:02:08,200 --> 00:02:10,520 70 children's hospitals in the US. 31 00:02:10,520 --> 00:02:15,680 He has been the chair of the Pediatric Infectious Disease Society Committee on Antimicrobial 32 00:02:15,680 --> 00:02:21,120 Stewardship and served on the IDSA's Antibiotic Resistance Committee. 33 00:02:21,120 --> 00:02:22,800 All right. 34 00:02:22,800 --> 00:02:25,080 And then I'll introduce our second guest. 35 00:02:25,080 --> 00:02:30,520 It is Dr. Michelle Mitchell, who is an assistant professor of pediatric infectious diseases 36 00:02:30,520 --> 00:02:33,360 at the Medical College of Wisconsin. 37 00:02:33,360 --> 00:02:38,240 She received her MD and completed a pediatric residency at St. Louis University, followed 38 00:02:38,240 --> 00:02:44,560 by a fellowship in pediatric infectious diseases at University of Colorado Children's Hospital, 39 00:02:44,560 --> 00:02:45,560 Colorado. 40 00:02:45,560 --> 00:02:50,400 She is associate program director of the Pediatric Infectious Disease Fellowship Program at the 41 00:02:50,400 --> 00:02:55,320 Medical College of Wisconsin and the medical director of the antimicrobial stewardship 42 00:02:55,320 --> 00:03:00,520 program at Children's Wisconsin, where she co-led the implementation of Handshake Stewardship. 43 00:03:00,520 --> 00:03:02,160 All right. 44 00:03:02,160 --> 00:03:03,880 So thank you so much. 45 00:03:03,880 --> 00:03:07,960 We look forward to hearing some of your expertise on antimicrobial stewardship. 46 00:03:07,960 --> 00:03:13,800 Just for our listeners, we may use terms as ASP and that'll stand for Antimicrobial Stewardship 47 00:03:13,800 --> 00:03:14,800 Program. 48 00:03:14,800 --> 00:03:20,760 So if there's some acronyms used, that would be probably the most likely. 49 00:03:20,760 --> 00:03:21,960 All right. 50 00:03:21,960 --> 00:03:28,200 So I wanted to do this podcast because obviously being an infectious disease physician, it 51 00:03:28,200 --> 00:03:29,520 was important for me as well. 52 00:03:29,520 --> 00:03:37,080 And there's a lot of differences between Canada and the US in terms of resources and how much 53 00:03:37,080 --> 00:03:40,960 and how advanced we actually are in terms of the stewardship programs. 54 00:03:40,960 --> 00:03:45,240 And you guys definitely are our leading neighbors. 55 00:03:45,240 --> 00:03:50,480 So I think hearing from the experts, just to let our audience know a little bit about 56 00:03:50,480 --> 00:03:52,760 the role of an ASP physician. 57 00:03:52,760 --> 00:03:53,760 Yeah. 58 00:03:53,760 --> 00:03:56,720 I mean, this is super exciting, Rapina. 59 00:03:56,720 --> 00:03:58,680 Thank you so much for having us. 60 00:03:58,680 --> 00:04:02,280 I always love being on podcasts and trying to get the word out. 61 00:04:02,280 --> 00:04:04,320 I just have conversations. 62 00:04:04,320 --> 00:04:12,680 Obviously, we've been blessed to collaborate with people from Canada and I've been able 63 00:04:12,680 --> 00:04:18,720 to meet different people like Nicole in Ottawa and Sergio, who I know you train under in 64 00:04:18,720 --> 00:04:20,720 Manitoba and doing a lot of work. 65 00:04:20,720 --> 00:04:24,400 There's a number of folks, obviously, and we are blessed with resource compared. 66 00:04:24,400 --> 00:04:29,160 And we have hospitals that literally are mandated. 67 00:04:29,160 --> 00:04:33,120 If they want to get paid by the government, they have to have stewardship programs in 68 00:04:33,120 --> 00:04:40,240 place, which requires them to put money toward people like Michelle and I. 69 00:04:40,240 --> 00:04:46,120 And that's been in pediatrics specifically, US News and World Report, many people are 70 00:04:46,120 --> 00:04:47,120 aware of. 71 00:04:47,120 --> 00:04:50,960 In the US, we like to compete on everything. 72 00:04:50,960 --> 00:04:56,600 And so if there's anything that drives hospitals, it's US News and World Report. 73 00:04:56,600 --> 00:04:58,120 They all care about their ranking. 74 00:04:58,120 --> 00:05:04,080 And there's about 10 questions about stewardship in your hospital. 75 00:05:04,080 --> 00:05:08,240 And those questions even include what sort of funding or what amount of funding do you 76 00:05:08,240 --> 00:05:10,000 provide for a physician? 77 00:05:10,000 --> 00:05:19,200 And I can tell you, my job here in St. Louis at WashU was largely driven by that need to 78 00:05:19,200 --> 00:05:20,200 have that funding. 79 00:05:20,200 --> 00:05:27,080 And so having that backup makes it a lot easier to spend days and to have funding to say, 80 00:05:27,080 --> 00:05:31,640 OK, we're going to be an all in approach to antimicrobial stewardship. 81 00:05:31,640 --> 00:05:36,440 Meaning, not that that's what I do now as much, but when I first arrived in St. Louis, 82 00:05:36,440 --> 00:05:41,560 the only thing I had to focus on was stewardship with not as much inpatient service time so 83 00:05:41,560 --> 00:05:43,360 that I could focus on that. 84 00:05:43,360 --> 00:05:46,680 And so that day to day means I can round in the hospital, I can walk around and talk to 85 00:05:46,680 --> 00:05:55,000 all the services, I can meet with a pharmacist, I can then do guidelines and interact with 86 00:05:55,000 --> 00:05:59,640 the informatics or the electronic health record teams to try to develop the things that you 87 00:05:59,640 --> 00:06:00,640 need to develop. 88 00:06:00,640 --> 00:06:06,720 Because as we've all learned in stewardship, this is a full time plus job for one just 89 00:06:06,720 --> 00:06:07,720 physician lead. 90 00:06:07,720 --> 00:06:08,720 Right. 91 00:06:08,720 --> 00:06:09,720 Yeah. 92 00:06:09,720 --> 00:06:17,720 And so I guess, Michelle, in terms of like in terms of the antimicrobial stewardship 93 00:06:17,720 --> 00:06:21,320 program, if you want to talk a little bit about what are the benefits of it. 94 00:06:21,320 --> 00:06:27,920 So we obviously know that having a physician like Jason just mentioned, but having a team 95 00:06:27,920 --> 00:06:32,480 as well is really important in a stewardship program. 96 00:06:32,480 --> 00:06:38,400 And so as in the role of a physician, what can you tell us a little bit about ESP is 97 00:06:38,400 --> 00:06:43,780 brought up and that you think has been beneficial? 98 00:06:43,780 --> 00:06:50,600 So I think everybody knows that there's ample data that tells us that antibiotics can be 99 00:06:50,600 --> 00:06:57,480 pretty harmful to a lot of people, you know, 20% serious adverse event rate for hospitalized 100 00:06:57,480 --> 00:07:02,240 patients receiving antibiotics, about one in three kids that are placed on antibiotic 101 00:07:02,240 --> 00:07:04,880 at some sort of adverse event. 102 00:07:04,880 --> 00:07:06,740 So we know that's happening. 103 00:07:06,740 --> 00:07:12,960 We know that a lot of our antibiotic use is completely unnecessary. 104 00:07:12,960 --> 00:07:17,440 Those antibiotics that are considered necessary, a lot of them are either dose suboptimally 105 00:07:17,440 --> 00:07:19,940 or given for the wrong duration. 106 00:07:19,940 --> 00:07:24,000 So there's unfortunately a lot that we do wrong. 107 00:07:24,000 --> 00:07:30,980 So that's low hanging fruit to correct that, make it better. 108 00:07:30,980 --> 00:07:34,840 We know the antibiotic use is the main driver of antibiotic resistance, right? 109 00:07:34,840 --> 00:07:44,920 So with 2.8 million antibiotic resistant infections in the US per year, 35,000 deaths, you know, 110 00:07:44,920 --> 00:07:47,680 and on our current track record, that's only going to increase. 111 00:07:47,680 --> 00:07:58,000 So unless we do something to curb that trend, you know, we're causing harm, which is exactly 112 00:07:58,000 --> 00:08:01,680 what we're supposed to be avoiding as physicians. 113 00:08:01,680 --> 00:08:08,560 So those are the potential benefits and we can also save the hospital a lot of money. 114 00:08:08,560 --> 00:08:12,640 So there's a lot of data out there that suggests you can invest in stewardship, but you get 115 00:08:12,640 --> 00:08:14,080 much more than what you invest. 116 00:08:14,080 --> 00:08:16,440 I mean, let's face it as ID physicians. 117 00:08:16,440 --> 00:08:20,560 We do not cost as much as a surgeon. 118 00:08:20,560 --> 00:08:28,240 So, you know, I mean, we don't come all that expensive, but we can build those relationships. 119 00:08:28,240 --> 00:08:30,560 We can get people to change. 120 00:08:30,560 --> 00:08:32,840 And so you get a lot of return on investment. 121 00:08:32,840 --> 00:08:33,840 Yeah. 122 00:08:33,840 --> 00:08:34,920 No, that's fair. 123 00:08:34,920 --> 00:08:40,680 I mean, I think the economic impact of inappropriate antibiotic use has not been, you know, looked 124 00:08:40,680 --> 00:08:41,800 at enough. 125 00:08:41,800 --> 00:08:45,920 And I think just, if you just look at the inpatient side, I mean, you know, you're preventing 126 00:08:45,920 --> 00:08:51,160 a case of acute kidney injury that required, you know, an extra day or two of hospitalization 127 00:08:51,160 --> 00:08:55,040 because someone continued on vancomycin and pipersilentazobactam. 128 00:08:55,040 --> 00:08:57,600 I mean, there's enough stuff there. 129 00:08:57,600 --> 00:09:04,000 And I think we in the antimicrobial stewardship world have failed to demonstrate value at 130 00:09:04,000 --> 00:09:09,440 that level because it's hard to determine a value when something doesn't happen. 131 00:09:09,440 --> 00:09:10,440 Right. 132 00:09:10,440 --> 00:09:17,520 And if you don't have the negative consequence of an antibiotic, how do you value that? 133 00:09:17,520 --> 00:09:20,120 And that's just going to require some other work. 134 00:09:20,120 --> 00:09:24,560 And let's not, I mean, the outpatient world is that in the same boat. 135 00:09:24,560 --> 00:09:31,520 I mean, we in collaboration with a woman, a great epidemiologist, Anne Butler, we were 136 00:09:31,520 --> 00:09:36,360 able to publish a paper and JAMA open just this past couple of weeks that suggested, 137 00:09:36,360 --> 00:09:41,560 you know, inappropriate antibiotics in the outpatient setting cost us an excess of $74 138 00:09:41,560 --> 00:09:42,560 million. 139 00:09:42,560 --> 00:09:49,480 I mean, that's a lot of money just from what people are like, oh, oxacillin for that, you 140 00:09:49,480 --> 00:09:52,600 know, cold is probably not that big of a deal. 141 00:09:52,600 --> 00:09:57,360 Well, in the end it is because the excess healthcare costs and the back to the hospital 142 00:09:57,360 --> 00:09:59,560 or back to the clinic because of the adverse events. 143 00:09:59,560 --> 00:10:05,160 I mean, it's a lot greater when you take the totality of excess antibiotics as it being 144 00:10:05,160 --> 00:10:06,640 prescribed. 145 00:10:06,640 --> 00:10:07,640 Yeah, definitely. 146 00:10:07,640 --> 00:10:11,160 And I think it's one of those things like you talked about, Jason, is that it's just 147 00:10:11,160 --> 00:10:15,840 so difficult when you're trying to like, you're on the preventative side, right? 148 00:10:15,840 --> 00:10:21,840 So whereas like most of the time an ID, you know, we're coming in afterwards and, and 149 00:10:21,840 --> 00:10:25,360 really treating like we're on the treatment side and that's usually when we get called. 150 00:10:25,360 --> 00:10:30,760 So having that kind of forefront person being part of our team and ID, you know, most people 151 00:10:30,760 --> 00:10:36,200 think of ID physicians as antibiotic doctors, which I usually walk in and I, you know, sometimes 152 00:10:36,200 --> 00:10:39,920 the parents you say that, but then I also like kind of step back and let them know, 153 00:10:39,920 --> 00:10:44,800 like I will, I'm also somebody who's probably going to pull off the antibiotics faster than 154 00:10:44,800 --> 00:10:49,880 then like another team member, just because I know that there are adverse events and we 155 00:10:49,880 --> 00:10:50,880 see those. 156 00:10:50,880 --> 00:10:55,960 And so those are, you know, and part of having stewardship and having that role, I think, 157 00:10:55,960 --> 00:11:00,220 and I think you brought up a really good point is that it's not just in the inpatient setting. 158 00:11:00,220 --> 00:11:05,560 And I think when we think about ASP, we commonly think about that because that's where the 159 00:11:05,560 --> 00:11:11,320 bulk of the stewardship program exists, that really having kind of that outlook that yeah, 160 00:11:11,320 --> 00:11:15,880 most of the antibiotics are actually prescribed outpatient and for those colds, for those 161 00:11:15,880 --> 00:11:19,800 milder, you know, ear infections that maybe would have improved in 72 hours and didn't 162 00:11:19,800 --> 00:11:21,960 require antibiotics, right? 163 00:11:21,960 --> 00:11:28,160 So, so I think there's definitely that now we talked a little bit about resources and 164 00:11:28,160 --> 00:11:32,920 you mentioned that obviously there's a lot of funding in the US that goes to towards 165 00:11:32,920 --> 00:11:39,320 this position now, unfortunately, in Canada, there, we don't have as much funding that's 166 00:11:39,320 --> 00:11:42,460 well established for this role. 167 00:11:42,460 --> 00:11:48,080 And so, you know, in terms of setting up a stewardship program, a lot of ID physicians 168 00:11:48,080 --> 00:11:54,480 don't actually have more than 15 to 20% of their actual role that they can dedicate to 169 00:11:54,480 --> 00:11:55,480 this. 170 00:11:55,480 --> 00:12:00,160 And in this position, it's almost a full time position to have somebody in this role. 171 00:12:00,160 --> 00:12:06,080 So can we talk a little bit about the reason I'm really interested in this is because we 172 00:12:06,080 --> 00:12:11,320 are currently in our children's hospital here, you know, in the process of we've tried to 173 00:12:11,320 --> 00:12:16,680 set up a program, it's just been more difficult because we don't have pharmacists support. 174 00:12:16,680 --> 00:12:22,420 And so what is some advice that you would give to somebody, let's say a physician like 175 00:12:22,420 --> 00:12:32,600 myself or my colleagues here to set up a program if you're in a resource limited area? 176 00:12:32,600 --> 00:12:34,200 I think that can be really difficult. 177 00:12:34,200 --> 00:12:36,120 I'll just say that. 178 00:12:36,120 --> 00:12:42,180 First off, I mean, you're making me think about all the resources that I have that helped 179 00:12:42,180 --> 00:12:46,240 me in my job and making me appreciate those resources for sure. 180 00:12:46,240 --> 00:12:51,620 But I think, you know, even before I have all these resources, I think, you know, guidelines 181 00:12:51,620 --> 00:12:54,640 in general are less labor intensive, right? 182 00:12:54,640 --> 00:12:59,520 If you're not able to do prospective audit and feedback, you might be able to at least 183 00:12:59,520 --> 00:13:04,680 have a select group of antibiotics that you can do prior authorization on, right? 184 00:13:04,680 --> 00:13:10,280 When you do have to have a person that has to be called or notified, but you could potentially 185 00:13:10,280 --> 00:13:15,680 set that up through your hospital pharmacist or the ID physician that's on call, you know, 186 00:13:15,680 --> 00:13:17,720 if they're willing to participate in that. 187 00:13:17,720 --> 00:13:20,480 And those phone calls don't have to be super labor intensive. 188 00:13:20,480 --> 00:13:27,120 But you know, if you want to protect things like Mirapenem or septariline, you know, some 189 00:13:27,120 --> 00:13:30,400 of your really broad spectrum antibiotics, you know, those phone calls, I don't think 190 00:13:30,400 --> 00:13:34,200 are going to get too onerous unless you're in a really large hospital system. 191 00:13:34,200 --> 00:13:39,840 And again, the guidelines, I think, just building those relationships with other groups of physicians 192 00:13:39,840 --> 00:13:45,180 in the hospital, they can do a lot of the bulk work behind the guideline. 193 00:13:45,180 --> 00:13:51,240 But if you're able to kind of influence the antibiotic use, the dosing, the duration, 194 00:13:51,240 --> 00:13:57,320 you can work with your hospital pharmacist on IV to PO protocols that they can help enforce, 195 00:13:57,320 --> 00:14:01,160 standardizing dosing throughout your hospital, you know, I think those are some low hanging 196 00:14:01,160 --> 00:14:03,560 fruit that don't require a whole lot of resources. 197 00:14:03,560 --> 00:14:07,480 Other, you have other thoughts, Jason, those are the ones that I... 198 00:14:07,480 --> 00:14:11,520 Yeah, no, I think that's all I mean, I guess the first thing is, and I like to, I know 199 00:14:11,520 --> 00:14:13,720 you mentioned this, that you don't have pharmacy support. 200 00:14:13,720 --> 00:14:20,120 I just, I think that if there's been anything that I would fight for is pharmacy support. 201 00:14:20,120 --> 00:14:22,760 Like if someone's going to say, okay, what's a must? 202 00:14:22,760 --> 00:14:28,320 I think anymore, if you can get the must to be pharmacy support, that's what I go for. 203 00:14:28,320 --> 00:14:35,000 Now, people that are listening have to understand that I'm married to a ID pharmacist who does 204 00:14:35,000 --> 00:14:36,000 stewardship. 205 00:14:36,000 --> 00:14:42,640 And so, yes, I am very biased, but you know, you can see over time that, you know, everyone 206 00:14:42,640 --> 00:14:48,600 realizes this and that's why the CDC and their, as they changed their core elements said, 207 00:14:48,600 --> 00:14:50,400 look, it needs to be co-led. 208 00:14:50,400 --> 00:14:54,820 It needs to be co-led by a physician and a pharmacist because pharmacists have really 209 00:14:54,820 --> 00:14:58,040 driven the impact in a lot of our programs. 210 00:14:58,040 --> 00:14:59,440 So I guess that's the one thing. 211 00:14:59,440 --> 00:15:01,520 I think you got to do everything you can to get pharmacy support. 212 00:15:01,520 --> 00:15:04,760 And then I think the second thing, and Michelle mentioned all the things that you can, these 213 00:15:04,760 --> 00:15:05,760 things you can do. 214 00:15:05,760 --> 00:15:11,720 I really strongly believe in in-person interactions and I think as you're limited, you know, then 215 00:15:11,720 --> 00:15:14,960 you pick some spots and go talk to people. 216 00:15:14,960 --> 00:15:18,840 Because then, as Michelle said, then you're trying to find your advocates within each 217 00:15:18,840 --> 00:15:19,880 of these groups, right? 218 00:15:19,880 --> 00:15:24,560 So there's probably someone in neonatology that actually gets the fact that antibiotics 219 00:15:24,560 --> 00:15:28,200 are bad and gets the fact that, I mean, neonatologists get it better than most, right? 220 00:15:28,200 --> 00:15:32,320 Because they realize that excess antibiotics leads to neck and they don't like cephalosporins. 221 00:15:32,320 --> 00:15:36,120 Like I mean, these guys are, you know, they have their own, they come up with their own 222 00:15:36,120 --> 00:15:39,000 early sepsis score to make it easier not to do antibiotics. 223 00:15:39,000 --> 00:15:43,240 So, you know, there's these people that are there and I think they're there in neonatology, 224 00:15:43,240 --> 00:15:47,800 they're in intensive care medicine and, you know, they're there in surgery and it can 225 00:15:47,800 --> 00:15:53,800 you identify that because then they become your, the people that kind of get the job 226 00:15:53,800 --> 00:15:56,200 done as you're moving forward. 227 00:15:56,200 --> 00:15:59,840 And, you know, and then with that all being said, you're always going to have the people 228 00:15:59,840 --> 00:16:04,360 that just aren't going to want to pay attention, but I always say kill them with kindness, 229 00:16:04,360 --> 00:16:06,400 keep me happy around them and kill them with kindness. 230 00:16:06,400 --> 00:16:09,320 And eventually like, why are these people so nice? 231 00:16:09,320 --> 00:16:13,800 I just continue with other people, like working with other people too. 232 00:16:13,800 --> 00:16:18,360 And then like over time they're like, well, that person's not very threatening and they're 233 00:16:18,360 --> 00:16:21,800 getting resources there and then they maybe get a little bit jealous, like, well, why 234 00:16:21,800 --> 00:16:23,800 don't you come help us out? 235 00:16:23,800 --> 00:16:24,800 Exactly. 236 00:16:24,800 --> 00:16:25,800 Yeah. 237 00:16:25,800 --> 00:16:29,760 And you build small wins with the people and you're there and you're there and you're present. 238 00:16:29,760 --> 00:16:34,520 I think that part of it's just having a presence. 239 00:16:34,520 --> 00:16:40,120 And that's if I was in your shoes, that's probably, I'd probably pick a unit and I'd 240 00:16:40,120 --> 00:16:43,040 probably go there two to three times a week. 241 00:16:43,040 --> 00:16:45,920 And I would say, here on the stewardship program, I've looked at these patients, just wanted 242 00:16:45,920 --> 00:16:46,920 to know this one thing. 243 00:16:46,920 --> 00:16:47,920 And do you have any questions? 244 00:16:47,920 --> 00:16:48,920 Right. 245 00:16:48,920 --> 00:16:51,120 And even I had nothing and I would just start with that. 246 00:16:51,120 --> 00:16:54,400 And I would probably make sure that I'm talking to as many people as I can. 247 00:16:54,400 --> 00:17:00,480 Because I think in the end, and we've said this a lot, I think there's the medicine side 248 00:17:00,480 --> 00:17:05,800 and we can argue about tracheitis and the ICU people understand where they come from. 249 00:17:05,800 --> 00:17:08,080 They actually understand where we come from. 250 00:17:08,080 --> 00:17:13,000 The surgeons that want to do drain prophylaxis have their reasons and we disagree and we 251 00:17:13,000 --> 00:17:14,000 have our reasons. 252 00:17:14,000 --> 00:17:17,360 And there's not a, I mean, you can debate it all you want, but we all know each other's 253 00:17:17,360 --> 00:17:18,360 side, honestly. 254 00:17:18,360 --> 00:17:20,640 But when it comes down to it, it's a social game. 255 00:17:20,640 --> 00:17:24,520 And then having all the skills to be a social scientist is necessary. 256 00:17:24,520 --> 00:17:25,880 How do you do conflict resolution? 257 00:17:25,880 --> 00:17:27,160 How do you do communication management? 258 00:17:27,160 --> 00:17:28,720 I mean, all these different things. 259 00:17:28,720 --> 00:17:30,040 That's what stewardship becomes. 260 00:17:30,040 --> 00:17:31,040 Great. 261 00:17:31,040 --> 00:17:32,040 Yeah. 262 00:17:32,040 --> 00:17:33,040 It's key about communication. 263 00:17:33,040 --> 00:17:40,080 So like them being aware, knowing you, having, and I think that's where the handshake approach 264 00:17:40,080 --> 00:17:43,000 comes in play when you talk about that model. 265 00:17:43,000 --> 00:17:49,280 So why don't we talk a little bit about, I know Michelle obviously has co-led that initiative 266 00:17:49,280 --> 00:17:55,120 there and she previously told me that she's had some training under you, Jason, for helping 267 00:17:55,120 --> 00:17:57,460 establish her stewardship program there. 268 00:17:57,460 --> 00:18:04,960 So why don't we hear it from Michelle first to see how setting up your program there and 269 00:18:04,960 --> 00:18:10,440 when you co-led the handshake stewardship model, kind of what were some challenges and 270 00:18:10,440 --> 00:18:16,200 what were some things that maybe you weren't anticipating when you started that program 271 00:18:16,200 --> 00:18:17,200 out there? 272 00:18:17,200 --> 00:18:24,440 Well, so for better or for worse, we, you know, Tracy Zumbels, who's the, you know, 273 00:18:24,440 --> 00:18:31,080 my pharmacist co-lead, you know, we just decided we picked a date and said, we're just going 274 00:18:31,080 --> 00:18:33,080 to start going out there and just doing this. 275 00:18:33,080 --> 00:18:39,480 We didn't really give anybody a whole lot of warning because we thought, well, if we 276 00:18:39,480 --> 00:18:43,440 give them warning, then, you know, then they have an opportunity to push back. 277 00:18:43,440 --> 00:18:48,640 So we'll just kind of see what happens and you'll have to gauge your center and if that's 278 00:18:48,640 --> 00:18:54,320 a worthy approach or not, but, you know, fortunately it worked out, but we did have to survive a 279 00:18:54,320 --> 00:19:00,400 year of, you know, sort of rehashing kind of who we are, what we're doing. 280 00:19:00,400 --> 00:19:02,680 You know, we're not the antibiotic police. 281 00:19:02,680 --> 00:19:06,080 We're just, you know, we're just trying to optimize care for patients. 282 00:19:06,080 --> 00:19:07,080 We're on the same side. 283 00:19:07,080 --> 00:19:12,760 We got a lot of like deer in headlight looks of like, you know, what am I doing wrong? 284 00:19:12,760 --> 00:19:16,680 Like what are these people doing here? 285 00:19:16,680 --> 00:19:19,720 And we still get a little bit of that every July, right? 286 00:19:19,720 --> 00:19:25,440 And the new residents come in and, and so they're a little bit scared when they see 287 00:19:25,440 --> 00:19:31,920 us, but, you know, we bring around candy and pass it out and, you know, try and do like 288 00:19:31,920 --> 00:19:32,920 nice things. 289 00:19:32,920 --> 00:19:37,800 You know, we, we read a room, so things look really busy and chaotic, like in the ICU workroom, 290 00:19:37,800 --> 00:19:39,680 we just, you know, back off. 291 00:19:39,680 --> 00:19:41,280 So we're really looking at the long game. 292 00:19:41,280 --> 00:19:48,200 We're trying to change the culture, make our visibility, you know, have a positive connotation 293 00:19:48,200 --> 00:19:49,200 with it. 294 00:19:49,200 --> 00:19:54,040 So, so yeah, we just went out there and we started giving feedback and we stopped by 295 00:19:54,040 --> 00:19:59,040 all the workrooms, regardless if we have an intervention or not. 296 00:19:59,040 --> 00:20:00,040 Do you have any questions? 297 00:20:00,040 --> 00:20:02,920 You know, is there anything we can help you out with? 298 00:20:02,920 --> 00:20:07,120 And a lot of the times it's the questions that then they ask us that were totally not 299 00:20:07,120 --> 00:20:08,120 on our radar. 300 00:20:08,120 --> 00:20:09,120 Right. 301 00:20:09,120 --> 00:20:15,600 That ended up being some of the best things that we can help with, you know, you know, 302 00:20:15,600 --> 00:20:20,160 it may turn out that the patient, you know, they had it like a suspected CNS infection. 303 00:20:20,160 --> 00:20:25,000 It's like, well, the drug you're on doesn't even penetrate there or, you know, maybe they 304 00:20:25,000 --> 00:20:30,400 weren't even thinking about a certain diagnosis or something that touches like in the ID world. 305 00:20:30,400 --> 00:20:34,960 And so I can recommend an ID consultant, you know, could completely change the management 306 00:20:34,960 --> 00:20:35,960 of a patient. 307 00:20:35,960 --> 00:20:43,160 And I know other hospitals have similar examples to that, but, but it's really been a door 308 00:20:43,160 --> 00:20:46,080 opener for a lot of that, like relationship building. 309 00:20:46,080 --> 00:20:51,600 So again, if you want to change the culture, like Jason had mentioned before, you got to 310 00:20:51,600 --> 00:20:57,640 start just building those relationships with different people, building that trust. 311 00:20:57,640 --> 00:21:02,760 And over time, you know, you sort of, yeah, you kill them with kindness or you wear on 312 00:21:02,760 --> 00:21:06,000 them, you know, nudges are good, but you don't want to get pushy. 313 00:21:06,000 --> 00:21:08,640 You know, you don't want to burn any bridges. 314 00:21:08,640 --> 00:21:10,640 So we just try and stay positive. 315 00:21:10,640 --> 00:21:14,200 Like we get a door slammed in our face, so to speak, we haven't actually had any doors 316 00:21:14,200 --> 00:21:20,000 slammed in our faces, but you know, figuratively, if that happens, then we just kind of back 317 00:21:20,000 --> 00:21:25,440 off and, you know, we may approach it from a more global standpoint of like looking at, 318 00:21:25,440 --> 00:21:30,560 you know, can we, can we get on the same page maybe with a guideline or, or, you know, we 319 00:21:30,560 --> 00:21:33,840 just give it, give it some time and then we kind of circle back. 320 00:21:33,840 --> 00:21:39,200 So, you know, I wish I had a minor or major in psychology after doing this for a while. 321 00:21:39,200 --> 00:21:41,280 Yeah, it sounds like it. 322 00:21:41,280 --> 00:21:45,960 Well, I mean, Michelle trained at Colorado, right? 323 00:21:45,960 --> 00:21:49,760 So she trained where they, where they actually developed Handshake Stewardship under Sarah 324 00:21:49,760 --> 00:21:50,760 Parker. 325 00:21:50,760 --> 00:21:51,760 I mean, she's the one that coined it. 326 00:21:51,760 --> 00:21:53,520 And so, I mean, I think she hit on it. 327 00:21:53,520 --> 00:21:54,760 I think, and Michelle mentioned it, right? 328 00:21:54,760 --> 00:21:57,120 I mean, what ends up happening is you develop the relationships. 329 00:21:57,120 --> 00:22:01,520 And I think, I think for the people listening, I mean, the person to actually read stuff 330 00:22:01,520 --> 00:22:04,160 about her, try to listen to is Julie Simczak. 331 00:22:04,160 --> 00:22:09,520 And the way you spell her last name is S-Z-Y-M-C-Z-A-K. 332 00:22:09,520 --> 00:22:14,120 I mean, her work is really fascinating in the number of quotes and stuff. 333 00:22:14,120 --> 00:22:18,760 And she's followed stewardship teams around and done a lot of stuff on communication. 334 00:22:18,760 --> 00:22:22,720 And she now has developed kind of a communication model that suggests, you know, you have to 335 00:22:22,720 --> 00:22:26,320 understand the context, then you have to have your communication strategies and you have 336 00:22:26,320 --> 00:22:27,320 to have your collaboration. 337 00:22:27,320 --> 00:22:30,240 And these are the three C's of kind of the important thing. 338 00:22:30,240 --> 00:22:31,920 And I think that's exactly what Michelle just mentioned, right? 339 00:22:31,920 --> 00:22:33,600 I mean, you understand the context. 340 00:22:33,600 --> 00:22:37,340 You mentioned that like sometimes you don't, when the ICU is in the middle of rounding 341 00:22:37,340 --> 00:22:41,680 on an ECMO patient, like talking about the ANSA, if they're on for the two, well, you 342 00:22:41,680 --> 00:22:44,520 might not agree with this, probably like the last thing they want to hear about. 343 00:22:44,520 --> 00:22:45,520 Right? 344 00:22:45,520 --> 00:22:46,520 That's the content. 345 00:22:46,520 --> 00:22:47,520 You have to understand that content. 346 00:22:47,520 --> 00:22:52,440 That's the social part of this versus the kids on ECMO and they don't have them on vancomycin 347 00:22:52,440 --> 00:22:55,560 because they, and they have MRSA and they have horrible pneumonia. 348 00:22:55,560 --> 00:22:59,040 And you're like, guys, why aren't you, you know, like that's another side of stewardship 349 00:22:59,040 --> 00:23:00,040 people don't talk about. 350 00:23:00,040 --> 00:23:03,560 But when you have that relationship, you can have that conversation because they know you're 351 00:23:03,560 --> 00:23:07,480 only going to talk when, or you're going to speak when it's really important in that regard. 352 00:23:07,480 --> 00:23:10,120 So I mean, I think that's the part of this. 353 00:23:10,120 --> 00:23:14,960 That's why to me, as Michelle mentioned, like a psychology or social science degree, all 354 00:23:14,960 --> 00:23:19,960 of these things, these social, the social game of stewardship, I think is the most important 355 00:23:19,960 --> 00:23:24,000 thing in what you do as you move forward in it. 356 00:23:24,000 --> 00:23:25,000 Right? 357 00:23:25,000 --> 00:23:26,480 No, that's, that's a really good point. 358 00:23:26,480 --> 00:23:32,200 And I think, you know, bringing up, you know, the type, the communication, I mean, it just 359 00:23:32,200 --> 00:23:33,880 goes back to medicine, right? 360 00:23:33,880 --> 00:23:35,880 Like that is what we are trained to do. 361 00:23:35,880 --> 00:23:38,440 We are, you know, working in a collaboration. 362 00:23:38,440 --> 00:23:44,160 And I think sometimes, you know, and Michelle mentioned that antibiotic police, the policing, 363 00:23:44,160 --> 00:23:45,160 you know, role. 364 00:23:45,160 --> 00:23:49,640 And so I think sometimes it's taken as like, we're, you know, somebody who'd be walking 365 00:23:49,640 --> 00:23:54,200 in and having that role, but really it's more working as a team. 366 00:23:54,200 --> 00:23:58,120 And the interest at the end of the day is the best interest for the patient, right? 367 00:23:58,120 --> 00:24:03,440 Because as all of us know, the ASP programs, you know, we're changing inappropriate use 368 00:24:03,440 --> 00:24:10,040 of antibiotics, but also modifying so that there is appropriate use of antibiotics. 369 00:24:10,040 --> 00:24:14,440 And there has been great studies out there letting us know that there's decreased morbidity 370 00:24:14,440 --> 00:24:19,560 and mortality with when you're working on all aspects of it. 371 00:24:19,560 --> 00:24:24,660 And so, and so that's, I think most of our listeners probably are aware of all of that. 372 00:24:24,660 --> 00:24:29,480 And so I think the next kind of thing I want to talk about is highlighting. 373 00:24:29,480 --> 00:24:32,520 So we talked about this handshake model. 374 00:24:32,520 --> 00:24:35,600 Maybe we can touch a little bit about, is this the same model like currently that you 375 00:24:35,600 --> 00:24:37,320 guys are using in ASP? 376 00:24:37,320 --> 00:24:41,560 Is this pretty much been a bit modified since the beginning? 377 00:24:41,560 --> 00:24:45,960 And I wonder if Jason, since you've been in this a little bit longer than the rest of 378 00:24:45,960 --> 00:24:53,200 us in ASP and you're kind of, you know, on and by a lot of the committees, and if there's 379 00:24:53,200 --> 00:24:56,520 ongoing talk about what is the best kind of model. 380 00:24:56,520 --> 00:25:00,640 Well, yeah, you know, so I trained all age myself. 381 00:25:00,640 --> 00:25:04,760 I trained from 2003 to 2006 and trained at Children's Hospital of Philadelphia, where 382 00:25:04,760 --> 00:25:06,640 we just did prior approval, right? 383 00:25:06,640 --> 00:25:13,840 So we held a pager if you wanted ceftriaxone, Amsobactam, you know, you got to call us to 384 00:25:13,840 --> 00:25:14,840 get it. 385 00:25:14,840 --> 00:25:21,000 Now you can imagine getting a call for ceftriaxone like at seven o'clock at night, you know, 386 00:25:21,000 --> 00:25:24,200 like that, you're like, man, really, especially now. 387 00:25:24,200 --> 00:25:25,200 But that was what we did. 388 00:25:25,200 --> 00:25:26,200 That was fine. 389 00:25:26,200 --> 00:25:29,360 I mean, I stopped a lot of ceftriaxone for community acquired pneumonia back in 2003. 390 00:25:29,360 --> 00:25:32,920 And I know you can do ampicillin, you're fine, right? 391 00:25:32,920 --> 00:25:34,080 But that was there. 392 00:25:34,080 --> 00:25:37,440 So that was why one of your first papers was on that, right? 393 00:25:37,440 --> 00:25:40,440 You're so sick of getting that call. 394 00:25:40,440 --> 00:25:41,440 That is exactly right. 395 00:25:41,440 --> 00:25:43,840 Switch to the ampicillin, please. 396 00:25:43,840 --> 00:25:48,840 So and so when I first, so when I took, when I moved to Kansas City, my first 10 years 397 00:25:48,840 --> 00:25:52,240 of my career was in Kansas City. 398 00:25:52,240 --> 00:25:55,880 And I was like, I'm not coming to Kansas City, gonna make them call me because I don't think 399 00:25:55,880 --> 00:25:58,120 that's going to go well. 400 00:25:58,120 --> 00:26:04,480 And so we, so we started a prospective audit, but we only looked at those people who had, 401 00:26:04,480 --> 00:26:08,120 you know, we only went and talked to those that we had a recommendation. 402 00:26:08,120 --> 00:26:11,720 And then Sarah came along, right, and did a handshake stewardship. 403 00:26:11,720 --> 00:26:13,440 And it and that made sense to me, right? 404 00:26:13,440 --> 00:26:18,560 I mean, the reality of it is, is communication and collaboration is what sustains a program. 405 00:26:18,560 --> 00:26:20,800 The more you can communicate, the more you can collaborate, the better you're going to 406 00:26:20,800 --> 00:26:21,800 be. 407 00:26:21,800 --> 00:26:22,800 And we kind of talked about that. 408 00:26:22,800 --> 00:26:29,600 And so it then has become clear that you need, I think you need to have some sort of in person 409 00:26:29,600 --> 00:26:32,680 conversation relationship building time. 410 00:26:32,680 --> 00:26:34,760 And that's what handshake stewardship allows you. 411 00:26:34,760 --> 00:26:36,320 I'm on the side of the fence. 412 00:26:36,320 --> 00:26:40,280 So that still thinks there needs to be some, I still think there needs to be some prior 413 00:26:40,280 --> 00:26:41,280 approval. 414 00:26:41,280 --> 00:26:43,800 Now, some places don't, some people still don't do it. 415 00:26:43,800 --> 00:26:47,240 And probably because they have the ability that they're not going to use the Ceptaz AV 416 00:26:47,240 --> 00:26:54,360 Bactams or Ceptola Zantazo Bactams or the Daptomycin in a inappropriate use that where you only 417 00:26:54,360 --> 00:26:56,360 find out about it after they started it. 418 00:26:56,360 --> 00:26:59,120 Because I do think that there are some things, right? 419 00:26:59,120 --> 00:27:05,640 Like when do you ever really need to start empirically, you know, Ceptazenem AV Bactams? 420 00:27:05,640 --> 00:27:06,640 Not very often. 421 00:27:06,640 --> 00:27:10,520 And if you do need to start it, you probably need to have an ID console because there's 422 00:27:10,520 --> 00:27:14,360 probably something really bad in some highly resistant that's going to take a lot more 423 00:27:14,360 --> 00:27:18,040 than just a stewardship conversation. 424 00:27:18,040 --> 00:27:21,640 So I still am thinking that prior approval needs to be a part of our programs. 425 00:27:21,640 --> 00:27:22,640 And that's how we have it. 426 00:27:22,640 --> 00:27:28,200 So we now, so when I moved to St. Louis in 2016, the program started here was really 427 00:27:28,200 --> 00:27:30,000 based off of handshake stewardship. 428 00:27:30,000 --> 00:27:32,760 So we do the rounding with the pharmacist. 429 00:27:32,760 --> 00:27:36,560 We now have trainees that join us, which is always fun because it's a, because handshake 430 00:27:36,560 --> 00:27:38,560 stewardship is a perfect opportunity to educate, right? 431 00:27:38,560 --> 00:27:40,600 Like you get to chat with people. 432 00:27:40,600 --> 00:27:42,720 You can quiz the residents. 433 00:27:42,720 --> 00:27:44,280 You can have fun in that. 434 00:27:44,280 --> 00:27:48,960 You can also learn everything about them, which is also, as Michelle can tell you, I 435 00:27:48,960 --> 00:27:52,200 usually like to do a lot of chit chatting about all kinds of things. 436 00:27:52,200 --> 00:27:58,840 It might be the latest Netflix show or something else, but I think that builds relationship. 437 00:27:58,840 --> 00:28:02,520 And so I think that's the way, but I think those are like your core features on a day 438 00:28:02,520 --> 00:28:03,520 to day thing. 439 00:28:03,520 --> 00:28:09,800 But what often gets missed is that while that might be your morning, your afternoons are 440 00:28:09,800 --> 00:28:14,400 trying to develop a guideline because it gets kind of old to go by the same surgeon over 441 00:28:14,400 --> 00:28:18,080 and over saying, you don't need the post-op drains because that's kind of annoying to 442 00:28:18,080 --> 00:28:19,460 them and for you. 443 00:28:19,460 --> 00:28:20,720 So that's a different, right? 444 00:28:20,720 --> 00:28:25,520 That's working on something else or trying to get the set tracks on the ampicillin switch 445 00:28:25,520 --> 00:28:27,760 without having to have the conversation every time. 446 00:28:27,760 --> 00:28:28,760 Well, that's a big guideline. 447 00:28:28,760 --> 00:28:31,440 And so I think those are the other parts. 448 00:28:31,440 --> 00:28:33,000 Oh, that's fair. 449 00:28:33,000 --> 00:28:34,000 Yeah. 450 00:28:34,000 --> 00:28:38,040 And then I guess just touching on, because we talked a little bit about guidelines and 451 00:28:38,040 --> 00:28:44,560 developing, I guess, like order sets or guidelines that have helped clinical pathways basically 452 00:28:44,560 --> 00:28:46,520 that can assist. 453 00:28:46,520 --> 00:28:53,600 So when I just for my own knowledge, locally on our adult side, we do have a more well 454 00:28:53,600 --> 00:29:00,680 established stewardship program because funding is obviously at larger hospitals, more patients. 455 00:29:00,680 --> 00:29:03,600 And so funding is kind of shifted there. 456 00:29:03,600 --> 00:29:08,920 In our pediatric side, there's a couple of things lacking. 457 00:29:08,920 --> 00:29:13,620 We are just kind of moving into more of a proper EMR system. 458 00:29:13,620 --> 00:29:18,920 So we don't actually have a lot of order sets to begin with. 459 00:29:18,920 --> 00:29:27,920 And so kind of even implementing clinical pathways in your guys' experience to get approved, 460 00:29:27,920 --> 00:29:35,360 like get them hospital approved or authority approved, once you have an established ASD 461 00:29:35,360 --> 00:29:42,960 program, is it much easier, do you feel, to kind of be able to, I guess, have more clinical 462 00:29:42,960 --> 00:29:47,980 pathways introduced at a quicker pace than because there's times when I've had to. 463 00:29:47,980 --> 00:29:55,160 So we have more than just, I guess, certain infectious diseases, but a lot of congenital 464 00:29:55,160 --> 00:29:59,760 infections, some things that could be more protocolized and things like that. 465 00:29:59,760 --> 00:30:03,400 So just my experience with that, it's been a little bit tough to release some of these 466 00:30:03,400 --> 00:30:04,400 clinical pathways. 467 00:30:04,400 --> 00:30:08,680 So do you think that comes along with having the funding for a stewardship program? 468 00:30:08,680 --> 00:30:09,680 Is it much easier? 469 00:30:09,680 --> 00:30:14,200 I think the time commitment certainly helps. 470 00:30:14,200 --> 00:30:22,880 I mean, at least before there was physician support in our institution, you're sort of 471 00:30:22,880 --> 00:30:27,480 asking one of the ID physicians to kind of, you know, for a little bit more altruistic 472 00:30:27,480 --> 00:30:29,680 behavior, you know, it's sort of on their own personal time. 473 00:30:29,680 --> 00:30:32,240 They didn't have dedicated time. 474 00:30:32,240 --> 00:30:37,920 So at least, you know, those guidelines are probably still getting formed, from what I 475 00:30:37,920 --> 00:30:42,920 can tell, but they weren't having input from people that were the most knowledgeable about 476 00:30:42,920 --> 00:30:48,520 the antibiotics, which includes a pharmacist and an ID physician. 477 00:30:48,520 --> 00:30:52,680 So I think that was the thing that at least in our institution was lacking before there 478 00:30:52,680 --> 00:30:57,360 was that dedicated time for both the pharmacist and physician. 479 00:30:57,360 --> 00:31:02,920 Yeah, I think when it comes to the, I think from an approval process, you still have to 480 00:31:02,920 --> 00:31:04,800 have the stakeholders and all the buy-in. 481 00:31:04,800 --> 00:31:10,360 And so whether that having a formal stewardship program kind of allows that to be easier, 482 00:31:10,360 --> 00:31:12,400 and they know that this is what it's coming from. 483 00:31:12,400 --> 00:31:17,200 But you know, like for pneumonia, you're still going to need pulmonology to have some way 484 00:31:17,200 --> 00:31:21,120 the hospitalists, you know, are going to have to have some way in this, because they're 485 00:31:21,120 --> 00:31:27,760 going to be the ones really executing the actual guideline and wanting to follow what 486 00:31:27,760 --> 00:31:31,480 you're saying should be the appropriate piece. 487 00:31:31,480 --> 00:31:36,160 I think one of the biggest challenges we have is that we can develop these guidelines. 488 00:31:36,160 --> 00:31:40,000 The problem is, is version control? 489 00:31:40,000 --> 00:31:41,840 And then where do they all land? 490 00:31:41,840 --> 00:31:46,540 And so, right, you can have neonatology, they might already have some guidelines on neck 491 00:31:46,540 --> 00:31:53,720 and early onset sepsis and HSV and all kinds of stuff, and you might not even realize it. 492 00:31:53,720 --> 00:31:58,200 And then over time, you might have actually developed a couple and forgot about them. 493 00:31:58,200 --> 00:32:01,200 And then you get a new colleague that comes in trying to make things better. 494 00:32:01,200 --> 00:32:05,040 Not that this has ever happened, by the way. 495 00:32:05,040 --> 00:32:06,520 And then they're like, oh, what about this? 496 00:32:06,520 --> 00:32:09,000 Like, oh, yeah, totally forgot about that, right? 497 00:32:09,000 --> 00:32:13,160 Because we get really good about developing a guideline and then like, okay, we're good, 498 00:32:13,160 --> 00:32:14,160 we got it, here you go. 499 00:32:14,160 --> 00:32:17,840 And then we forget that a guideline is only a guideline. 500 00:32:17,840 --> 00:32:22,280 Once you get in the guideline business, you need to be in the business for good, which 501 00:32:22,280 --> 00:32:27,240 means updating it, reviewing it, making sure people can see it. 502 00:32:27,240 --> 00:32:31,240 And that is so much, that's so hard. 503 00:32:31,240 --> 00:32:36,000 I just want to say that is a real hard side of it, but is a necessary side to keep a guideline 504 00:32:36,000 --> 00:32:37,000 relevant. 505 00:32:37,000 --> 00:32:38,000 That's fair. 506 00:32:38,000 --> 00:32:39,000 That's a really good point. 507 00:32:39,000 --> 00:32:43,520 I think definitely over the years and things change, right? 508 00:32:43,520 --> 00:32:48,920 So there's obviously a management, more research comes out. 509 00:32:48,920 --> 00:32:54,920 And so definitely remembering that if you have the guideline and also not having to 510 00:32:54,920 --> 00:32:56,600 reinvent the wheel, right? 511 00:32:56,600 --> 00:33:01,160 So important to, and this goes back to, I think what we're talking about today is collaboration, 512 00:33:01,160 --> 00:33:02,160 right? 513 00:33:02,160 --> 00:33:08,580 So reach out to your colleagues, reach out to areas where they may already have something 514 00:33:08,580 --> 00:33:13,160 in the unit that's functioning and you can just modify. 515 00:33:13,160 --> 00:33:16,680 I'd say we know one of the biggest opportunities we have in antibiotic use, right? 516 00:33:16,680 --> 00:33:17,920 Is limiting durations. 517 00:33:17,920 --> 00:33:21,200 And those studies are just coming out, right? 518 00:33:21,200 --> 00:33:22,200 Pneumonia, right? 519 00:33:22,200 --> 00:33:28,160 Like our national guideline or national, so in the U S right, the IDSA guideline for pediatrics 520 00:33:28,160 --> 00:33:32,760 still says 10 days and it actually flat out says expert opinion based. 521 00:33:32,760 --> 00:33:36,360 What there has been papers, Dr. Rebecca same, who now I get to work with, who is at Hopkins 522 00:33:36,360 --> 00:33:37,800 show that five days is fine. 523 00:33:37,800 --> 00:33:41,560 The adults have been doing five days for inpatient pneumonia for ages. 524 00:33:41,560 --> 00:33:42,560 Right. 525 00:33:42,560 --> 00:33:45,960 Like you, we need to be updating that. 526 00:33:45,960 --> 00:33:49,200 And we need to get ourselves to those sorts of durations. 527 00:33:49,200 --> 00:33:53,320 And that's, that's why I think that update is so key because there's so much opportunity 528 00:33:53,320 --> 00:33:56,920 from a stewardship perspective to limit durations that we haven't done yet. 529 00:33:56,920 --> 00:33:57,920 Yeah. 530 00:33:57,920 --> 00:33:58,920 And that's a really key point. 531 00:33:58,920 --> 00:34:03,760 I mean, to be honest, there's a lot of variance within even different ID specialists. 532 00:34:03,760 --> 00:34:04,760 Oh yeah. 533 00:34:04,760 --> 00:34:06,760 So we might be the worst offenders. 534 00:34:06,760 --> 00:34:07,760 Yeah. 535 00:34:07,760 --> 00:34:08,760 In many cases. 536 00:34:08,760 --> 00:34:09,760 Yeah. 537 00:34:09,760 --> 00:34:10,760 I mean, I, all right. 538 00:34:10,760 --> 00:34:16,040 So here's like, so one of my, we had a fellow Jason, like fabulous a PID ID person. 539 00:34:16,040 --> 00:34:17,040 Michelle, do you know Jason? 540 00:34:17,040 --> 00:34:18,040 I don't think so. 541 00:34:18,040 --> 00:34:19,040 Okay. 542 00:34:19,040 --> 00:34:25,000 So Jason, like he went off to Utah and he did a survey and we, we surveyed people on 543 00:34:25,000 --> 00:34:28,000 the emerging infestation network and we, we divided it. 544 00:34:28,000 --> 00:34:33,400 It was just ID people and, and it was, and it was mainly just physicians because the 545 00:34:33,400 --> 00:34:37,480 EIN doesn't have as many pharmacists, which I would wish we had pharmacists in this, but 546 00:34:37,480 --> 00:34:41,720 essentially we divided the group into whether you do stewardship or you don't do stewardship, 547 00:34:41,720 --> 00:34:43,720 they self-selected. 548 00:34:43,720 --> 00:34:49,680 And then we, one of the questions we asked was, should you steward your ID colleagues? 549 00:34:49,680 --> 00:34:50,680 Oh yeah. 550 00:34:50,680 --> 00:34:51,680 Right. 551 00:34:51,680 --> 00:34:53,200 That's an elephant in the room. 552 00:34:53,200 --> 00:34:56,680 Like everyone on this call should be like, oh, Jason, that's really fascinating. 553 00:34:56,680 --> 00:35:00,440 And I mean, I have this strong belief that we should be stewarding each other. 554 00:35:00,440 --> 00:35:04,120 Like when you're on service, you should actually have someone kind of saying, are you sure 555 00:35:04,120 --> 00:35:05,760 you really need that mural pin them? 556 00:35:05,760 --> 00:35:08,600 Do you think you need that for culture negative sepsis? 557 00:35:08,600 --> 00:35:15,520 And interestingly, we, even in the stewardship group, it was like 45% said we should steward 558 00:35:15,520 --> 00:35:16,520 each other. 559 00:35:16,520 --> 00:35:21,520 Like most of us won't steward our own colleagues because we're worried about what that's going 560 00:35:21,520 --> 00:35:22,520 to happen. 561 00:35:22,520 --> 00:35:26,840 But I, but I think as a, and I'm going to use this as a platform to say, look, if we're 562 00:35:26,840 --> 00:35:32,680 going to do this and expect our ICU colleagues to stop antibiotics for tracheitis, well, 563 00:35:32,680 --> 00:35:36,560 then we should, they should have the also know that, well, the only reason they're using 564 00:35:36,560 --> 00:35:39,120 is because your colleagues recommended it. 565 00:35:39,120 --> 00:35:41,120 Like we got to be able to do it with each other. 566 00:35:41,120 --> 00:35:42,120 Right. 567 00:35:42,120 --> 00:35:45,440 And if we're really going to push forward, but I think it's an elephant in the room that 568 00:35:45,440 --> 00:35:46,440 we, I mean, right. 569 00:35:46,440 --> 00:35:47,440 Like, oh yeah. 570 00:35:47,440 --> 00:35:48,440 Yeah. 571 00:35:48,440 --> 00:35:52,000 I know, I know who we work with. 572 00:35:52,000 --> 00:35:53,000 Sometimes you're like, really? 573 00:35:53,000 --> 00:35:55,000 I got to talk to that person. 574 00:35:55,000 --> 00:35:58,680 But I think it's how we have to move forward. 575 00:35:58,680 --> 00:36:01,680 It's all about those communications, psychology. 576 00:36:01,680 --> 00:36:02,680 Yeah, that's right. 577 00:36:02,680 --> 00:36:03,680 Sorry. 578 00:36:03,680 --> 00:36:06,680 Had to jump on that soapbox for a second. 579 00:36:06,680 --> 00:36:07,680 Sorry, Rukina. 580 00:36:07,680 --> 00:36:11,400 No, I think, you know, it's a great point that you bring that up because there's times 581 00:36:11,400 --> 00:36:17,360 even in our center when, you know, I'm on call and I do get a call from my ESP colleague 582 00:36:17,360 --> 00:36:19,000 and I actually appreciate it. 583 00:36:19,000 --> 00:36:24,240 I'm not actually against it because sometimes you do get a bit of tunnel vision once you're, 584 00:36:24,240 --> 00:36:28,360 you know, been following somebody, especially if you're on service for a few days or two 585 00:36:28,360 --> 00:36:33,000 weeks at a time, you know, occasionally you will have like this kind of two week run. 586 00:36:33,000 --> 00:36:37,320 And there's times when you're, you're just kind of, you know, doing the day to day and 587 00:36:37,320 --> 00:36:40,080 nobody even have a time to step back. 588 00:36:40,080 --> 00:36:42,000 And I think that's the bedside too, right? 589 00:36:42,000 --> 00:36:46,280 When you're caring for the patient, the fear factor is different. 590 00:36:46,280 --> 00:36:51,200 Objectivity can leave the room sometimes, you know, like, you just got to be willing 591 00:36:51,200 --> 00:36:52,200 to be questioned. 592 00:36:52,200 --> 00:36:53,200 I think that's right. 593 00:36:53,200 --> 00:36:54,960 You have to be willing to be questioned. 594 00:36:54,960 --> 00:36:56,720 That's how you make medicine better. 595 00:36:56,720 --> 00:36:58,000 And you don't have to agree. 596 00:36:58,000 --> 00:37:02,400 Like we know that, but have the conversation and that's the key. 597 00:37:02,400 --> 00:37:05,840 And I feel like we're just too into, I'm not allowed to question my colleague because then 598 00:37:05,840 --> 00:37:08,120 they're going to be mad at me and then they're not going to support me. 599 00:37:08,120 --> 00:37:09,480 Well, we got to get over that. 600 00:37:09,480 --> 00:37:14,560 I mean, I think that's, and I think, I think stewardship programs will be better off if 601 00:37:14,560 --> 00:37:17,480 we're willing to steward each other. 602 00:37:17,480 --> 00:37:18,960 Each other being ID people. 603 00:37:18,960 --> 00:37:19,960 Right. 604 00:37:19,960 --> 00:37:20,960 Yeah. 605 00:37:20,960 --> 00:37:22,280 I think, I mean, there should be no different, right? 606 00:37:22,280 --> 00:37:24,880 Like we are just like the rest of our colleagues. 607 00:37:24,880 --> 00:37:29,840 So, and sometimes like, and what Michelle was saying right now is like, you're at bedside 608 00:37:29,840 --> 00:37:33,720 and, and there are times when, you know, if, if you have somebody kind of question your 609 00:37:33,720 --> 00:37:37,800 antibiotic approach, but you've kind of thought about the process and just explaining that, 610 00:37:37,800 --> 00:37:42,400 I think sometimes just going through the thought process with, with another colleague, an ID 611 00:37:42,400 --> 00:37:44,400 colleague, it's just what you need. 612 00:37:44,400 --> 00:37:45,400 Right. 613 00:37:45,400 --> 00:37:48,760 And so, and it shouldn't be that, you know, we shouldn't, and again, we should always 614 00:37:48,760 --> 00:37:53,600 remember for our listeners as well, is that ASP is not designed to say that you're doing 615 00:37:53,600 --> 00:37:54,600 something wrong. 616 00:37:54,600 --> 00:37:59,600 It's actually designed to look at what we're doing and if it's the best thing that we're 617 00:37:59,600 --> 00:38:01,320 doing at that time. 618 00:38:01,320 --> 00:38:03,320 And maybe it's different in every scenario, right? 619 00:38:03,320 --> 00:38:06,600 That's why it's not a blanket kind of approach. 620 00:38:06,600 --> 00:38:08,920 You have to have a case by case approach. 621 00:38:08,920 --> 00:38:13,200 And, and I think just highlighting that point is really important today. 622 00:38:13,200 --> 00:38:14,200 Yeah. 623 00:38:14,200 --> 00:38:15,200 Love it. 624 00:38:15,200 --> 00:38:16,200 Perfect. 625 00:38:16,200 --> 00:38:19,520 So we have a few more minutes and I want to talk a little bit about what does the future 626 00:38:19,520 --> 00:38:20,520 hold? 627 00:38:20,520 --> 00:38:27,880 So, you know, there is there a lot of ongoing research and ASP, is there other models that 628 00:38:27,880 --> 00:38:32,840 are, you know, and, and, and are there older models that, you know, how you mentioned Jason, 629 00:38:32,840 --> 00:38:38,560 like we're bringing in some, you know, different types of approaches and, and what is the research 630 00:38:38,560 --> 00:38:39,560 like saying right now? 631 00:38:39,560 --> 00:38:46,120 Are there newer technologies for us physicians to kind of use in ASP? 632 00:38:46,120 --> 00:38:48,800 I think the future holds. 633 00:38:48,800 --> 00:38:54,600 So I think technology will always be looked at in regards to can we automate things? 634 00:38:54,600 --> 00:38:57,160 Can we use guidelines for the better? 635 00:38:57,160 --> 00:38:58,880 Excuse me. 636 00:38:58,880 --> 00:39:02,680 I think that some of the big stuff is implementation science. 637 00:39:02,680 --> 00:39:08,240 What are the implementation strategies that seem to be most effective at different phases 638 00:39:08,240 --> 00:39:13,160 of stewardship or different issues you're trying to address? 639 00:39:13,160 --> 00:39:19,200 For example, we're trying to address post-op antibiotic prescribing and trying to eliminate 640 00:39:19,200 --> 00:39:20,200 unnecessary antibiotics. 641 00:39:20,200 --> 00:39:26,640 So we're utilizing facilitation training versus just changing your order sets or, you know, 642 00:39:26,640 --> 00:39:29,080 or using facilitation to get orders set change. 643 00:39:29,080 --> 00:39:31,440 I mean, these sorts of things I think are the future. 644 00:39:31,440 --> 00:39:33,320 I also think the future is value. 645 00:39:33,320 --> 00:39:37,600 I mean, if people in stewardship should, we should all be thinking about how we're going 646 00:39:37,600 --> 00:39:38,600 to demonstrate our value. 647 00:39:38,600 --> 00:39:41,120 We talk about it all the time. 648 00:39:41,120 --> 00:39:46,080 We got it, we have to try to hone that in as best we can because that's going to sustain 649 00:39:46,080 --> 00:39:47,080 our programs. 650 00:39:47,080 --> 00:39:50,800 I mean, I think about you, Rapina, and where you are, like, you need to have someone that's 651 00:39:50,800 --> 00:39:55,800 saying to your hospital administrators and everyone to say, look, this is the value in 652 00:39:55,800 --> 00:39:57,800 the Canadian system. 653 00:39:57,800 --> 00:39:59,080 This is why this is important. 654 00:39:59,080 --> 00:40:03,680 This is why we need to have a pharmacist to be a part of that. 655 00:40:03,680 --> 00:40:06,760 And stewardship is not, I mean, I'd say we're in our toddlerhood, right? 656 00:40:06,760 --> 00:40:10,960 Like, if you look back, I mean, people are doing some sort of stewardship in the 80s and 657 00:40:10,960 --> 00:40:14,640 some would say in the 70s when they had some initial antibiotics. 658 00:40:14,640 --> 00:40:19,040 So we're, but we're, I feel like we're beyond, we need to be starting to really push things 659 00:40:19,040 --> 00:40:20,040 forward. 660 00:40:20,040 --> 00:40:21,320 And that also means metrics. 661 00:40:21,320 --> 00:40:22,320 Metrics have to improve. 662 00:40:22,320 --> 00:40:26,320 I mean, days of therapy is fine, whatever. 663 00:40:26,320 --> 00:40:29,320 But it's not like a central line infection where you're trying to go to zero. 664 00:40:29,320 --> 00:40:31,160 You're not trying to go to zero antibiotics. 665 00:40:31,160 --> 00:40:33,800 You're trying to go to zero inappropriate use. 666 00:40:33,800 --> 00:40:36,320 We don't have a good way of determining that. 667 00:40:36,320 --> 00:40:42,520 And mind you, we tried and it was painstaking to quarterly review every patient in your 668 00:40:42,520 --> 00:40:45,480 hospital to see how, what percentage of inappropriate use was. 669 00:40:45,480 --> 00:40:46,480 Oh my gosh. 670 00:40:46,480 --> 00:40:51,360 It was hours and hours of work that seemed like, I'm not even sure it was the best use 671 00:40:51,360 --> 00:40:53,360 of our time. 672 00:40:53,360 --> 00:41:02,240 So to me, I guess in summary, then his future is best implementation strategy, value, and 673 00:41:02,240 --> 00:41:03,240 then better metrics. 674 00:41:03,240 --> 00:41:10,680 And one of those metrics needs to be a quick and easy ability to assess your hospital or 675 00:41:10,680 --> 00:41:12,280 your outpatient appropriateness. 676 00:41:12,280 --> 00:41:13,280 Right. 677 00:41:13,280 --> 00:41:14,280 That's fair. 678 00:41:14,280 --> 00:41:20,640 I think there are some cool diagnostics that are going to come our way too that, you know, 679 00:41:20,640 --> 00:41:27,840 like I think over time, you know, rapid direct identification through PCR, next gen sequencing 680 00:41:27,840 --> 00:41:34,040 through sterilized fluid is going to become a little more like accessible and mainstream. 681 00:41:34,040 --> 00:41:38,320 But the trick is we're going to have to be able to figure out how to utilize it. 682 00:41:38,320 --> 00:41:39,320 Right. 683 00:41:39,320 --> 00:41:42,320 Cause like everything else, we're going to get some of it's going to be information that 684 00:41:42,320 --> 00:41:45,720 we have to cut through the noise and, and find the signal. 685 00:41:45,720 --> 00:41:47,760 So, so I don't know. 686 00:41:47,760 --> 00:41:48,760 Yeah. 687 00:41:48,760 --> 00:41:50,960 I'm glad you brought that up. 688 00:41:50,960 --> 00:41:54,120 Cause the other thing I should have said, and people should yell at me for not saying 689 00:41:54,120 --> 00:41:58,640 this earlier is the fact diagnostic stewardship is definitely an impactful thing. 690 00:41:58,640 --> 00:42:04,840 I think if you look at the work that done out of Hopkins with, with my Charlie Woods 691 00:42:04,840 --> 00:42:11,240 Hill, her paper on eliminating unnecessary blood cultures that was just published recently 692 00:42:11,240 --> 00:42:13,680 is fantastic. 693 00:42:13,680 --> 00:42:19,280 The same Hopkins group now under the leadership of Anna six Samuels is doing some on respiratory 694 00:42:19,280 --> 00:42:24,560 cultures in the ICU about, you know, not dealing so many respiratory cultures, these sort of 695 00:42:24,560 --> 00:42:29,120 diagnostic stewardship on the side of let's not do all this testing that leads to a lot 696 00:42:29,120 --> 00:42:30,360 of unnecessary use. 697 00:42:30,360 --> 00:42:34,240 Cause yeah, the results don't make any sense. 698 00:42:34,240 --> 00:42:39,840 I think as it is a definitely future focus for many people that it's going to impact 699 00:42:39,840 --> 00:42:40,840 antibiotic use tremendously. 700 00:42:40,840 --> 00:42:44,920 And it has, has been shown to value too. 701 00:42:44,920 --> 00:42:47,160 I mean, all of that leads to waste, right? 702 00:42:47,160 --> 00:42:53,640 So I think the waste factor is going to increasingly be looked at, you know, what, what is the 703 00:42:53,640 --> 00:42:58,720 hospital having to dispose of the environmental effects of all of that and all the, all the 704 00:42:58,720 --> 00:43:05,640 diagnostic tools, like the actual like physical, you know, material that we're using and having 705 00:43:05,640 --> 00:43:10,360 to dispose of from doing all of these tests and, you know, disposing of all these antibiotics. 706 00:43:10,360 --> 00:43:12,920 I think that's going to be looked at a lot more too. 707 00:43:12,920 --> 00:43:13,920 Yeah. 708 00:43:13,920 --> 00:43:14,920 That's a great point, Michelle. 709 00:43:14,920 --> 00:43:15,920 Right. 710 00:43:15,920 --> 00:43:21,280 And I think, you know, Preeti Jaggi from, from Emory down at Children's Hospital of Atlanta, 711 00:43:21,280 --> 00:43:26,400 talk about all her work around, and she's big into climate change and sustainability. 712 00:43:26,400 --> 00:43:30,040 And I mean, some amazing work about just dose waste dosage, right? 713 00:43:30,040 --> 00:43:31,800 Like not using it. 714 00:43:31,800 --> 00:43:35,160 And I think we think of it on a sense of, oh my gosh, we've charged people. 715 00:43:35,160 --> 00:43:36,160 It's no, no, no. 716 00:43:36,160 --> 00:43:38,880 I mean, this has impact because now that's going to impact, cause that's waste. 717 00:43:38,880 --> 00:43:40,280 Instead of it being used. 718 00:43:40,280 --> 00:43:44,640 Now you just had something you never used and you've added to waste that's unnecessary. 719 00:43:44,640 --> 00:43:49,160 And I mean, it has a larger impact than just our patients. 720 00:43:49,160 --> 00:43:52,960 I think if we, if you think beyond, and I think that's what Preeti has shown us a lot 721 00:43:52,960 --> 00:43:54,520 with some of her conversations. 722 00:43:54,520 --> 00:43:57,360 She'd be a good conversation for a podcast. 723 00:43:57,360 --> 00:44:01,080 I'm just saying, that would be a good one. 724 00:44:01,080 --> 00:44:02,080 That's what we like. 725 00:44:02,080 --> 00:44:04,280 We like when people recommend others. 726 00:44:04,280 --> 00:44:05,280 She'd be fantastic. 727 00:44:05,280 --> 00:44:06,280 Trust me. 728 00:44:06,280 --> 00:44:07,280 Nice. 729 00:44:07,280 --> 00:44:10,200 No, I would definitely reach out to her. 730 00:44:10,200 --> 00:44:16,000 So I think that's, you know, looking at the approach and having so many different angles, 731 00:44:16,000 --> 00:44:19,800 you know, for an ASP or just in general in medicine, I think things have changed. 732 00:44:19,800 --> 00:44:21,840 You know, we have to look at it that way. 733 00:44:21,840 --> 00:44:24,320 We have to look at kind of what, what are we doing initially? 734 00:44:24,320 --> 00:44:28,200 What are the investigations comes back to like choosing wisely, right? 735 00:44:28,200 --> 00:44:31,720 So there's a lot of initiatives around that as well. 736 00:44:31,720 --> 00:44:37,800 And I think overall, you know, huge impacts on costs, like we've known for years, but 737 00:44:37,800 --> 00:44:39,520 also looking at it in the environment. 738 00:44:39,520 --> 00:44:44,080 I think that's a key factor to, to know. 739 00:44:44,080 --> 00:44:45,520 So that's great. 740 00:44:45,520 --> 00:44:51,200 I'm honestly so appreciative to have both of you on our podcast today. 741 00:44:51,200 --> 00:44:52,960 It's been great. 742 00:44:52,960 --> 00:44:58,720 Just have nice conversation with some nice colleagues and just see from the expert side, 743 00:44:58,720 --> 00:45:02,920 you know, what are things that maybe we could change here? 744 00:45:02,920 --> 00:45:08,920 We're always reaching out to our US colleagues for, you know, it's kind of our, it's almost 745 00:45:08,920 --> 00:45:10,200 foreshadowing for us. 746 00:45:10,200 --> 00:45:11,200 So it's nice. 747 00:45:11,200 --> 00:45:13,960 We're a little bit behind on certain things in Canada sometimes. 748 00:45:13,960 --> 00:45:17,480 And so it's nice to see what others are doing. 749 00:45:17,480 --> 00:45:21,320 But also nice to share kind of what we have done locally here. 750 00:45:21,320 --> 00:45:25,960 And, and, and I think everybody has a lot to learn in terms of stewardship. 751 00:45:25,960 --> 00:45:30,200 And like you mentioned, we're kind of in that toddler herd times of this. 752 00:45:30,200 --> 00:45:36,720 So so what's one thing we have a few minutes, what's one kind of key point that or highlight 753 00:45:36,720 --> 00:45:41,360 that you would want to give us, I think each of you like a tip or anything that you would 754 00:45:41,360 --> 00:45:49,400 think that would be a take home message from a stewardship standpoint? 755 00:45:49,400 --> 00:45:52,760 Communication and collaboration are essential. 756 00:45:52,760 --> 00:45:56,360 I'd focus on that and things, things go well. 757 00:45:56,360 --> 00:45:57,360 Perfect. 758 00:45:57,360 --> 00:46:04,680 I say it's a, it's a marathon, not a sprint, you know, like, kind of like politics, right? 759 00:46:04,680 --> 00:46:07,760 You want to make culture change. 760 00:46:07,760 --> 00:46:09,240 You got to look at the long game. 761 00:46:09,240 --> 00:46:10,240 Yeah. 762 00:46:10,240 --> 00:46:14,280 Everything that Jason said about collaboration and communication, building relationships. 763 00:46:14,280 --> 00:46:15,280 That's great. 764 00:46:15,280 --> 00:46:16,280 Yeah. 765 00:46:16,280 --> 00:46:22,040 And I think the other key point is for smaller centers like us, I think starting, right? 766 00:46:22,040 --> 00:46:28,340 So having the initiative to start somewhere is where I would say is what I learned from 767 00:46:28,340 --> 00:46:32,080 this all because obviously everybody's in a different stage. 768 00:46:32,080 --> 00:46:36,140 Everybody has different resources, but really looking at what you can do for your center 769 00:46:36,140 --> 00:46:41,000 and having a starting point and then slowly kind of going from there, whether it's one 770 00:46:41,000 --> 00:46:46,320 unit that you start in and then go from there and make it a hospital wide approach. 771 00:46:46,320 --> 00:46:47,320 So right. 772 00:46:47,320 --> 00:46:48,320 Just do something. 773 00:46:48,320 --> 00:46:49,320 Do something. 774 00:46:49,320 --> 00:46:50,320 Yeah. 775 00:46:50,320 --> 00:46:51,320 Yeah. 776 00:46:51,320 --> 00:46:52,320 No, that's fair. 777 00:46:52,320 --> 00:46:53,320 Awesome. 778 00:46:53,320 --> 00:46:54,320 Well, thank you so much. 779 00:46:54,320 --> 00:46:56,520 I really appreciate both of you being on the podcast. 780 00:46:56,520 --> 00:47:04,040 Is there any kind of last words that anybody's itching to share with our audience? 781 00:47:04,040 --> 00:47:06,040 I love Canada and I'm glad we could do this together. 782 00:47:06,040 --> 00:47:10,920 And you guys are way far ahead, much further ahead than you might think, because you guys 783 00:47:10,920 --> 00:47:11,920 have taught us a ton. 784 00:47:11,920 --> 00:47:15,320 So I appreciate us being able to continue to collaborate. 785 00:47:15,320 --> 00:47:16,320 That's great. 786 00:47:16,320 --> 00:47:17,320 Thanks so much. 787 00:47:17,320 --> 00:47:21,800 Thank you to Dr. Newland and Dr. Mitchell for joining us. 788 00:47:21,800 --> 00:47:23,440 Have a topic suggestion? 789 00:47:23,440 --> 00:47:31,000 Email us at thecanadianbreakpoint at gmail.com and follow us on Twitter at CA Breakpoint. 790 00:47:31,000 --> 00:47:58,040 See you again soon at the Canadian Breakpoint.