Thanks for joining us again at the Canadian Breakpoint, a Canadian infectious diseases
podcast by Canadian infectious diseases physicians.
I'm Summer Stewart, here with Dr. Rupeena Purewal, pediatric infectious diseases physician
from Saskatoon.
In this episode, we welcome Dr. Jennifer Grant, medical microbiologist and infectious diseases
physician in Vancouver, British Columbia, who specializes in antimicrobial stewardship.
Today we'll be discussing Aspires, the anti-infective prescription audit and feedback service system.
Dr. Purewal.
All right, welcome to another episode of our podcast at the Canadian Breakpoint.
Today we have a very special guest with us, Dr. Jennifer Grant, who's practiced medical
microbiology and infectious diseases in Vancouver since 2007.
She's been on the boards of CHICA, now IPAC Canada and AMI Canada.
Her current concentration is on antimicrobial stewardship as a medical director of Vancouver
Coastal Health's Aspires program, providing stewardship support for the coastal region
of British Columbia and occupational health during the COVID-19 pandemic.
Her research projects include quality improvement initiatives in antimicrobial utilization locally
and nationally, occupational health of physicians during the pandemic, and clinical research
into optimal use of antimicrobials.
Away from medicine, Jennifer is a mother to three, an avid skier and mountain biker, making
use of the coastal mountains whenever possible.
Welcome Dr. Grant.
Thanks, and thanks for having me.
Yeah, it's our pleasure.
So today we want to talk a lot about your program, Aspires.
So I think for our audience who we have pharmacists, nurses, physicians from really across the
world who are listening in and would love to hear and have you tell us about what Aspires
is, what it stands for and what really when was it established.
Okay, so Aspires is our antimicrobial stewardship program and it has an acronym and I can almost
never remember the precise words in the acronym.
It's antimicrobial stewardship and we're really concentrating on quality improvement and knowledge
improvement as well.
We started essentially before stewardship programs became required in the hospital system.
We knew it's something we wanted to do and our hospital system did have a lot of people
working in the stewardship space, but we didn't really have an official program.
So we partnered with infection prevention and control and we were really trying to work
on making patient experience better and smoother and safer.
So we tied the use of enhanced cleaning and reducing basically environmental spread of
resistant organisms to try and reduce their induction by using antimicrobial stewardship
and that was a trade off with reducing the need for isolation space and gowns and whatnot.
So we built it as a business case as a pilot project proof of principle to make a system
that could actually be used for our region starting out small and hoping to expand it
over time.
So we started out with myself and a pharmacist and we've worked on building the data to support
that program over time.
And currently how many centers have you expanded to in the coastal region there?
So we cover all of our communities of care.
So we have three major communities of care, the Richmond, Vancouver, and then the coastal
community of care that entails something like seven hospitals and a whole bunch of other
smaller centers that are sort of within our umbrella group.
And then in terms of kind of your goal of ASPIRES, I'm sure that goal has been changing
over time as you've had kind of your quality improvement projects and reflection on how
things have been going.
But initially when it was started, was it to combat AMR and was that the original purpose
or was the pilot started for other reasons at that time?
So I guess the first couple of years of any program is trying to justify your existence.
Yes.
So, you know, we certainly came on with a survival mode and what we were really, really
hoping that we could prove we could do is twofold.
I mean, we have the overall goal of the right drug for the right patient at the right time
by the right route.
And that's sort of our overall vision statement.
But what we were really concentrating on at that time was reducing the development of
resistance using VRE as our model organism and diminishing the side effects of antibiotics
using C. difficile as our model organism.
So those are our sort of two concentrated areas and allowed us to really follow those
two items to make sure that what we were doing was safe.
That sounds very interesting.
I mean, you now discussed some of the goals of ASPIRES in terms of, I guess we want to
talk a little bit about what is your strategy.
So for our listeners to really understand what does a day look like when you're part
of the ASPIRES program and what is the most effective strategy that you've utilized in
centers?
So I think the most sort of overall arching, most effective strategy is to listen to the
people that you're working with and do what they are interested in doing.
Really very much a positive deviance model.
We initially sort of tried to set up a program and do it.
And that actually was much less well received than sort of coming in very humbly and asking
what are your problems?
How can we help you?
And that I think is a much, it builds trust and it allows people to make use of their
expertise because there are the experts in the place that they're at, patient population.
So I guess anyone who's trying to start a program really start with things that people
want to do that where there's already enthusiasm and interest.
Yeah, that's a very good point.
In terms of when you guys were starting ASPIRES, what were some of the main obstacles that
you faced?
Like everybody else in every healthcare system known to man, the obstacle is money.
Yes, that is true.
So really trying to get that foot in the door from a financial point of view was a real
challenge.
And I really have to thank my colleague, Elizabeth Bryce, who had been working here for quite
a while and had all the connections within the system to allow us to talk to the people
who had the money and to build the business case to be able to do it and to have some
collateral with the infection prevention program and some proof of former success.
So being able to pair with somebody like that is very helpful.
And then really having to just repeatedly put our successes on the table, put our hard
results on the table and just keep bringing it back and saying, look, we're doing good
work.
We'd like more resources.
This is what we'll do with them.
And some of that is serendipity.
You just have to hit the anvil at the right moment.
And so that we finally managed to get that done probably after about four years of trying
to really expand the program to where we are now.
Okay.
Definitely a commendable approach and difficult always to initiate, but I think definitely
a success story from that side.
So we're really excited to hear more about this.
And so some of the, I guess, being the medical director currently, what are some of the ongoing
projects, quality improvement?
You mentioned your initiatives and quality improvement.
And you mentioned some of them while you were starting the program.
So are there some ongoing projects that you guys are currently working on?
Yeah.
What we try and do is we try and find learners who have an interest and do some, I'm much
more of an iterative person than a big boil the ocean kind of person.
So we start on really small projects and have our learners gather the data and then work
with the people whose patients it applies to and trying to sort of do the PDSA cycles
and improve.
So we do a lot of that and all of those are small but important.
Some of our bigger projects are around penicillin allergy.
People have an absolute fear of penicillin allergy.
And the truth is most people who think they're penicillin allergic are not.
And so we've done a lot of work in terms of trying to delabel those people who are really
easy to delabel.
I don't know what my reaction was.
I was five when you're speaking to an 85 year old.
My mom told me I was allergic to penicillin and a lot of those either they weren't truly
penicillin allergies.
They were an allergy to an impurity in the formulation or they were truly a penicillin
allergic but that's not something that actually goes away over time.
So that sort of group of people and then recognizing that the cross reactivity is much less than
people think and that most of the cephalosporins are generally safe with a few notable exceptions
and that you can just start using the cephalosporins and stopping people from jumping up to the
next level like the carpet pens or whatever they might choose to use rather than going
for a penicillin product.
And so is Aspires working both in hospital and community aspects or is this something
that's hospital driven?
This is hospital driven.
We don't have the funding or the mandate for community and there are people doing really,
really great work in that space like Dr. David Patrick and Dr. Edith Blundell Hill both of
them really have wonderful community stewardship programs.
There's a bit of a hole for long-term care and I suspect that we'll be asked to move
on to that at some point but right now we really want to stick to what we're funded
to do which is acute care.
Yeah, fair.
And so I'm sure a lot of our listeners would have watched or listened to our first episode
of the season on the CARS report and there's definitely a lot of changes.
We had some data come out kind of peri-peak pandemic.
So I wonder in terms of, so I won't go through all those details due to time because I'm
more interested in hearing your approach and your thoughts on how do you think things have
kind of changed either locally or nationally in these hospital kind of infection settings
with like multi-drug resistance but in the era of having aspires.
Do you think, like do you want to comment a little bit and tell us a little bit about
how this has probably influenced prescribers?
Well I think there's so many, there's a lot of moving parts and the pandemic really was
sort of a blow to the whole system and we watched our antiviral microbial use go through
the roof for a number of reasons.
Obviously we had more people with respiratory infections and it's very hard to know if that's
bacterial or viral.
So despite the fact that we knew we were probably over treating, we didn't know whom we were
over treating and that's really challenging.
And the other challenge is that it was all hands on deck and we had a lot of people who
don't have the habit of managing inpatients who don't have that 20 years of experience
looking at someone like, yeah I think they'll probably be okay without antibiotics.
So we had people who predominantly had outpatient practices managing our inpatient COVID patients
and they are naturally more conservative as anyone would be when they're in an unfamiliar
environment.
So the pandemic was a real blow but what I think it allows us to do is just to step back,
refocus, reset and reset priorities and really sort of work on those priority interventions
that will make a big difference and sort of stop being lost in the weeds a little bit
which happens if you've been at it for a while.
And then in terms of, so definitely with AMR being a huge topic of discussion in this day
and age and for I guess in terms of your thoughts about ASP programs, now I really do appreciate
that ASPIRES is actually looking at more than antimicrobial use and you're really angling
it and looking at even infection control kind of measures, for instance like your C diff
projects and et cetera.
And so I think there's multiple angles that you guys are looking at it but overall, how
do you think this phase is in terms of like battling AMR with ASPIRES and what benefits
have you already seen?
So hospital antimicrobial stewardship programs are necessary but not sufficient for reducing
AMR and I do want to sort of point out that Canada is actually in a very enviable position
with respect to antimicrobial resistance.
We sort of take our lead from the US but if you look at our resistance rates compared
to the US resistance rates, they're not comparable.
For example, for hospital acquired pneumonia, there's a 30% pseudomonas rate in the US,
while we are under 4% and I can tell you exactly which patients are at risk for it.
So it's not something that's happening generally on our words.
And a lot of that, I don't know the explanation.
My theory is that warmer environments tend to breed more antimicrobial resistance just
because there's more mixing in outside environment and soils but that sort of brings us to the
point that most of the antibiotics that our environment sort of contains are not used
for human health.
They're used for animal health, for animal growth and we're also using them for a whole
bunch of other things that aren't directly related to human health.
So while humans do have our own ecosystem and we do have our own microbiome, we are
interchanging it constantly with the world around us and so really this needs to be concerted
one health approach where we look at veterinary medicine, agriculture, human health, what's
in the environment, what we're doing to mitigate antibiotics ending up in the environment so
that they're not interacting with the environmental organisms that come back to us in our food
and in our interactions with the environment.
And I think again, the benefits of looking at it from multiple angles and really appreciating
that it is an entirety, like it's a full circle.
We have to do everything right in the full circle to ensure that we can see these reduction
rates.
In terms of Aspires, what is the future goal of Aspires?
I would like to see Aspires really be able to take that full circle of health and not
only looking at antimicrobial use, but looking at patient journey from start to finish, including
looking at diagnostic stewardship because a lot of what we do, once you turn a rock
over, you have to deal with whatever's under it.
And sometimes those rocks are best not turned over.
So trying to limit the number of unnecessary investigations, trying to make sure that we're
doing the right thing for the right person and not over investigating, not over treating.
There's a whole lot of other issues for patients that come from that when we find things that
we're never going to bother them and they probably be better off not knowing.
And then in terms of other centers, so I'm out in Saskatchewan here and like we mentioned
earlier in this conversation, that funding is sometimes a rate limiting step for a lot
of us when we're running our antimicrobial stewardship programs.
But despite that, I feel there's a lot of other challenges that we face, just manpower,
having the expertise from, because ASP hasn't been around for that long, and especially
Canadian centers and a lot of us don't have extra training to run such programs.
Is there opportunities for other provinces to liaise with ASPIRES and for it to expand
nationally?
So I think that there's absolutely opportunity for people involved in stewardship to work
together and I want to push back gently on the idea that you have to have expertise to
be involved in antimicrobial stewardship.
I would say that essentially if somebody's interested and willing, a good GP, a good
internist, a good surgeon, if they're super interested in it, would be a wonderful person
to do it.
Really it has to do with the interest and taking the time to think about things and
work through things.
So I mean, ID expertise is nice, but it's not necessary.
In terms of ASPIRES, the program itself, we are a Vancouver Coastal Health program, so
that would probably not expand, but there are lots of opportunities for different provinces
to liaise either through PHAC and CNESP, who are doing a lot of good work, or through AMI
Canada, who also sort of is involved in working with certain national people and creating
our own little networks of people who work together.
So it's nice to kind of know what our resources are out there and definitely a lot of us can
reflect on that.
And you're absolutely right.
I think most of us don't really have a guidebook or anything that you use and really it is
interesting.
I think a lot of us on a day-to-day basis are actually practicing as good stewards and
trying to do that and reflecting on that.
And I think another approach would be doing a quality improvement project, entertaining
idea of having trainees at your center, starting some of those projects and really looking
at it from different angles.
So it was really great all the work that you've done out there.
We're grateful to hear about it.
So for your listeners out there, what is one of the things that you kind of wanted to,
what's the key kind of message you'd want to send out to pharmacists, nurses, physicians
of all kinds, trainees in terms of anything that either that inspired you to do this and
continue to kind of motivate others as well?
So I really like to end my discussions when I'm talking to med students with more is not
better, more is often worse.
And that it really takes true knowledge and true courage to be the person who says, no,
we don't need to do this next highest, greatest thing.
The patient is good as they are and simple care is the best care.
It gets people home.
It gets people back to what they care about, which is living whatever life they've chosen
to live.
And that more intervention really does cause more harm than benefit.
And we have to be very selective about what we choose to do.
That's great advice.
Thank you.
And I'm really appreciated that you're able to take the time out today to talk to us about
the program, give us your expertise and insight on a lot of great thoughts.
I'm sure a lot of listeners are going to be excited to hear more about this.
Thank you.
Thanks for having me again.
And it's been lovely to talk to you.
Have a great day.
Thank you.
Thank you, Dr. Purwall.
And a special thank you to Dr. Grant.
Thanks for joining us.
If you have a topic suggestion, email us at thecanadianbreakpoint at gmail.com or tweet
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See you again soon at the Canadian Breakpoint.