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Thanks for joining us again at the Canadian Breakpoint, a Canadian infectious diseases

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podcast by Canadian infectious diseases physicians.

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I'm Summer Stewart, here with Dr. Rupeena Purewal, pediatric infectious diseases physician

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from Saskatoon.

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In this episode, we welcome Dr. Jennifer Grant, medical microbiologist and infectious diseases

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physician in Vancouver, British Columbia, who specializes in antimicrobial stewardship.

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Today we'll be discussing Aspires, the anti-infective prescription audit and feedback service system.

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Dr. Purewal.

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All right, welcome to another episode of our podcast at the Canadian Breakpoint.

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Today we have a very special guest with us, Dr. Jennifer Grant, who's practiced medical

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microbiology and infectious diseases in Vancouver since 2007.

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She's been on the boards of CHICA, now IPAC Canada and AMI Canada.

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Her current concentration is on antimicrobial stewardship as a medical director of Vancouver

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Coastal Health's Aspires program, providing stewardship support for the coastal region

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of British Columbia and occupational health during the COVID-19 pandemic.

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Her research projects include quality improvement initiatives in antimicrobial utilization locally

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and nationally, occupational health of physicians during the pandemic, and clinical research

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into optimal use of antimicrobials.

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Away from medicine, Jennifer is a mother to three, an avid skier and mountain biker, making

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use of the coastal mountains whenever possible.

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Welcome Dr. Grant.

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Thanks, and thanks for having me.

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Yeah, it's our pleasure.

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So today we want to talk a lot about your program, Aspires.

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So I think for our audience who we have pharmacists, nurses, physicians from really across the

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world who are listening in and would love to hear and have you tell us about what Aspires

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is, what it stands for and what really when was it established.

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Okay, so Aspires is our antimicrobial stewardship program and it has an acronym and I can almost

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never remember the precise words in the acronym.

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It's antimicrobial stewardship and we're really concentrating on quality improvement and knowledge

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improvement as well.

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We started essentially before stewardship programs became required in the hospital system.

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We knew it's something we wanted to do and our hospital system did have a lot of people

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working in the stewardship space, but we didn't really have an official program.

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So we partnered with infection prevention and control and we were really trying to work

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on making patient experience better and smoother and safer.

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So we tied the use of enhanced cleaning and reducing basically environmental spread of

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resistant organisms to try and reduce their induction by using antimicrobial stewardship

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and that was a trade off with reducing the need for isolation space and gowns and whatnot.

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So we built it as a business case as a pilot project proof of principle to make a system

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that could actually be used for our region starting out small and hoping to expand it

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over time.

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So we started out with myself and a pharmacist and we've worked on building the data to support

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that program over time.

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And currently how many centers have you expanded to in the coastal region there?

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So we cover all of our communities of care.

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So we have three major communities of care, the Richmond, Vancouver, and then the coastal

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community of care that entails something like seven hospitals and a whole bunch of other

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smaller centers that are sort of within our umbrella group.

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And then in terms of kind of your goal of ASPIRES, I'm sure that goal has been changing

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over time as you've had kind of your quality improvement projects and reflection on how

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things have been going.

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But initially when it was started, was it to combat AMR and was that the original purpose

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or was the pilot started for other reasons at that time?

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So I guess the first couple of years of any program is trying to justify your existence.

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Yes.

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So, you know, we certainly came on with a survival mode and what we were really, really

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hoping that we could prove we could do is twofold.

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I mean, we have the overall goal of the right drug for the right patient at the right time

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by the right route.

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And that's sort of our overall vision statement.

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But what we were really concentrating on at that time was reducing the development of

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resistance using VRE as our model organism and diminishing the side effects of antibiotics

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using C. difficile as our model organism.

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So those are our sort of two concentrated areas and allowed us to really follow those

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two items to make sure that what we were doing was safe.

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That sounds very interesting.

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I mean, you now discussed some of the goals of ASPIRES in terms of, I guess we want to

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talk a little bit about what is your strategy.

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So for our listeners to really understand what does a day look like when you're part

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of the ASPIRES program and what is the most effective strategy that you've utilized in

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centers?

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So I think the most sort of overall arching, most effective strategy is to listen to the

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people that you're working with and do what they are interested in doing.

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Really very much a positive deviance model.

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We initially sort of tried to set up a program and do it.

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And that actually was much less well received than sort of coming in very humbly and asking

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what are your problems?

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How can we help you?

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And that I think is a much, it builds trust and it allows people to make use of their

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expertise because there are the experts in the place that they're at, patient population.

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So I guess anyone who's trying to start a program really start with things that people

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want to do that where there's already enthusiasm and interest.

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Yeah, that's a very good point.

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In terms of when you guys were starting ASPIRES, what were some of the main obstacles that

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you faced?

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Like everybody else in every healthcare system known to man, the obstacle is money.

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Yes, that is true.

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So really trying to get that foot in the door from a financial point of view was a real

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challenge.

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And I really have to thank my colleague, Elizabeth Bryce, who had been working here for quite

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a while and had all the connections within the system to allow us to talk to the people

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who had the money and to build the business case to be able to do it and to have some

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collateral with the infection prevention program and some proof of former success.

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So being able to pair with somebody like that is very helpful.

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And then really having to just repeatedly put our successes on the table, put our hard

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results on the table and just keep bringing it back and saying, look, we're doing good

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work.

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We'd like more resources.

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This is what we'll do with them.

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And some of that is serendipity.

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You just have to hit the anvil at the right moment.

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And so that we finally managed to get that done probably after about four years of trying

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to really expand the program to where we are now.

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Okay.

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Definitely a commendable approach and difficult always to initiate, but I think definitely

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a success story from that side.

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So we're really excited to hear more about this.

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And so some of the, I guess, being the medical director currently, what are some of the ongoing

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projects, quality improvement?

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You mentioned your initiatives and quality improvement.

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And you mentioned some of them while you were starting the program.

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So are there some ongoing projects that you guys are currently working on?

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Yeah.

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What we try and do is we try and find learners who have an interest and do some, I'm much

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more of an iterative person than a big boil the ocean kind of person.

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So we start on really small projects and have our learners gather the data and then work

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with the people whose patients it applies to and trying to sort of do the PDSA cycles

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and improve.

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So we do a lot of that and all of those are small but important.

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Some of our bigger projects are around penicillin allergy.

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People have an absolute fear of penicillin allergy.

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And the truth is most people who think they're penicillin allergic are not.

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And so we've done a lot of work in terms of trying to delabel those people who are really

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easy to delabel.

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I don't know what my reaction was.

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I was five when you're speaking to an 85 year old.

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My mom told me I was allergic to penicillin and a lot of those either they weren't truly

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penicillin allergies.

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They were an allergy to an impurity in the formulation or they were truly a penicillin

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allergic but that's not something that actually goes away over time.

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So that sort of group of people and then recognizing that the cross reactivity is much less than

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people think and that most of the cephalosporins are generally safe with a few notable exceptions

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and that you can just start using the cephalosporins and stopping people from jumping up to the

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next level like the carpet pens or whatever they might choose to use rather than going

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for a penicillin product.

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And so is Aspires working both in hospital and community aspects or is this something

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that's hospital driven?

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This is hospital driven.

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We don't have the funding or the mandate for community and there are people doing really,

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really great work in that space like Dr. David Patrick and Dr. Edith Blundell Hill both of

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them really have wonderful community stewardship programs.

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There's a bit of a hole for long-term care and I suspect that we'll be asked to move

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on to that at some point but right now we really want to stick to what we're funded

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to do which is acute care.

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Yeah, fair.

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And so I'm sure a lot of our listeners would have watched or listened to our first episode

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of the season on the CARS report and there's definitely a lot of changes.

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We had some data come out kind of peri-peak pandemic.

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So I wonder in terms of, so I won't go through all those details due to time because I'm

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more interested in hearing your approach and your thoughts on how do you think things have

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kind of changed either locally or nationally in these hospital kind of infection settings

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with like multi-drug resistance but in the era of having aspires.

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Do you think, like do you want to comment a little bit and tell us a little bit about

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how this has probably influenced prescribers?

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Well I think there's so many, there's a lot of moving parts and the pandemic really was

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sort of a blow to the whole system and we watched our antiviral microbial use go through

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the roof for a number of reasons.

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Obviously we had more people with respiratory infections and it's very hard to know if that's

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bacterial or viral.

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So despite the fact that we knew we were probably over treating, we didn't know whom we were

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over treating and that's really challenging.

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And the other challenge is that it was all hands on deck and we had a lot of people who

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don't have the habit of managing inpatients who don't have that 20 years of experience

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looking at someone like, yeah I think they'll probably be okay without antibiotics.

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So we had people who predominantly had outpatient practices managing our inpatient COVID patients

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and they are naturally more conservative as anyone would be when they're in an unfamiliar

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environment.

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So the pandemic was a real blow but what I think it allows us to do is just to step back,

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refocus, reset and reset priorities and really sort of work on those priority interventions

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that will make a big difference and sort of stop being lost in the weeds a little bit

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which happens if you've been at it for a while.

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And then in terms of, so definitely with AMR being a huge topic of discussion in this day

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and age and for I guess in terms of your thoughts about ASP programs, now I really do appreciate

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that ASPIRES is actually looking at more than antimicrobial use and you're really angling

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it and looking at even infection control kind of measures, for instance like your C diff

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projects and et cetera.

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And so I think there's multiple angles that you guys are looking at it but overall, how

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do you think this phase is in terms of like battling AMR with ASPIRES and what benefits

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have you already seen?

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So hospital antimicrobial stewardship programs are necessary but not sufficient for reducing

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AMR and I do want to sort of point out that Canada is actually in a very enviable position

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with respect to antimicrobial resistance.

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We sort of take our lead from the US but if you look at our resistance rates compared

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to the US resistance rates, they're not comparable.

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For example, for hospital acquired pneumonia, there's a 30% pseudomonas rate in the US,

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while we are under 4% and I can tell you exactly which patients are at risk for it.

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So it's not something that's happening generally on our words.

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And a lot of that, I don't know the explanation.

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My theory is that warmer environments tend to breed more antimicrobial resistance just

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because there's more mixing in outside environment and soils but that sort of brings us to the

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point that most of the antibiotics that our environment sort of contains are not used

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for human health.

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They're used for animal health, for animal growth and we're also using them for a whole

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bunch of other things that aren't directly related to human health.

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So while humans do have our own ecosystem and we do have our own microbiome, we are

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interchanging it constantly with the world around us and so really this needs to be concerted

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one health approach where we look at veterinary medicine, agriculture, human health, what's

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in the environment, what we're doing to mitigate antibiotics ending up in the environment so

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that they're not interacting with the environmental organisms that come back to us in our food

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and in our interactions with the environment.

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And I think again, the benefits of looking at it from multiple angles and really appreciating

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that it is an entirety, like it's a full circle.

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We have to do everything right in the full circle to ensure that we can see these reduction

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rates.

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In terms of Aspires, what is the future goal of Aspires?

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I would like to see Aspires really be able to take that full circle of health and not

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only looking at antimicrobial use, but looking at patient journey from start to finish, including

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looking at diagnostic stewardship because a lot of what we do, once you turn a rock

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over, you have to deal with whatever's under it.

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And sometimes those rocks are best not turned over.

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So trying to limit the number of unnecessary investigations, trying to make sure that we're

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doing the right thing for the right person and not over investigating, not over treating.

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There's a whole lot of other issues for patients that come from that when we find things that

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we're never going to bother them and they probably be better off not knowing.

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And then in terms of other centers, so I'm out in Saskatchewan here and like we mentioned

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earlier in this conversation, that funding is sometimes a rate limiting step for a lot

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of us when we're running our antimicrobial stewardship programs.

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But despite that, I feel there's a lot of other challenges that we face, just manpower,

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having the expertise from, because ASP hasn't been around for that long, and especially

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Canadian centers and a lot of us don't have extra training to run such programs.

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Is there opportunities for other provinces to liaise with ASPIRES and for it to expand

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nationally?

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So I think that there's absolutely opportunity for people involved in stewardship to work

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together and I want to push back gently on the idea that you have to have expertise to

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be involved in antimicrobial stewardship.

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I would say that essentially if somebody's interested and willing, a good GP, a good

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internist, a good surgeon, if they're super interested in it, would be a wonderful person

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to do it.

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Really it has to do with the interest and taking the time to think about things and

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work through things.

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So I mean, ID expertise is nice, but it's not necessary.

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In terms of ASPIRES, the program itself, we are a Vancouver Coastal Health program, so

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that would probably not expand, but there are lots of opportunities for different provinces

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to liaise either through PHAC and CNESP, who are doing a lot of good work, or through AMI

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Canada, who also sort of is involved in working with certain national people and creating

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our own little networks of people who work together.

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So it's nice to kind of know what our resources are out there and definitely a lot of us can

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reflect on that.

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And you're absolutely right.

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I think most of us don't really have a guidebook or anything that you use and really it is

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interesting.

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I think a lot of us on a day-to-day basis are actually practicing as good stewards and

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trying to do that and reflecting on that.

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And I think another approach would be doing a quality improvement project, entertaining

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idea of having trainees at your center, starting some of those projects and really looking

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at it from different angles.

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So it was really great all the work that you've done out there.

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We're grateful to hear about it.

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So for your listeners out there, what is one of the things that you kind of wanted to,

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what's the key kind of message you'd want to send out to pharmacists, nurses, physicians

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of all kinds, trainees in terms of anything that either that inspired you to do this and

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continue to kind of motivate others as well?

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So I really like to end my discussions when I'm talking to med students with more is not

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better, more is often worse.

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And that it really takes true knowledge and true courage to be the person who says, no,

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we don't need to do this next highest, greatest thing.

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The patient is good as they are and simple care is the best care.

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It gets people home.

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It gets people back to what they care about, which is living whatever life they've chosen

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to live.

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And that more intervention really does cause more harm than benefit.

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And we have to be very selective about what we choose to do.

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That's great advice.

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Thank you.

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And I'm really appreciated that you're able to take the time out today to talk to us about

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the program, give us your expertise and insight on a lot of great thoughts.

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I'm sure a lot of listeners are going to be excited to hear more about this.

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Thank you.

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Thanks for having me again.

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And it's been lovely to talk to you.

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Have a great day.

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Thank you.

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Thank you, Dr. Purwall.

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And a special thank you to Dr. Grant.

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Thanks for joining us.

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If you have a topic suggestion, email us at thecanadianbreakpoint at gmail.com or tweet

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us on Twitter at CABbreakpoint.

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See you again soon at the Canadian Breakpoint.