 Hi everybody. I'm Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation. Today we're joined by Dr. David Ha, who's a pharmacist in infectious diseases and antimicrobial stewardship at Stanford HealthCare. He's going to talk to us about establishing an effective antimicrobial stewardship program. Good morning, David. Thank you so much for joining us today. Good morning, Donna. Thank you so much for the invite. And as you can see, David is following appropriate protocol and wearing his PPE to keep himself and everyone else safe by wearing a mask today. So thank you again, David, for joining us at this unprecedented time in this pandemic and taking the time to talk to us. Absolutely. So I wonder if you could tell us, start by just telling us a little bit about your background. Sure. So I'll start a little earlier. I'm not sure how many folks watching this will be familiar with the background and training of pharmacists specifically, but I completed my doctorate pharmacy at the University of California in San Diego and did two years of residency in general acute care and then infectious diseases at the UC San Diego Medical Center. And after that, I spent the better part of six to seven years down in Los Angeles. I was a faculty at the Keck Graduate Institute School of Pharmacy and also served as an infectious diseases pharmacist starting and running our antimicrobial stewardship program at the Pomona Valley Medical Center, which is a community regional medical center down in eastern Los Angeles County. And about a little over a year ago now, I've moved up to the Bay Area and joined the team up here at Stanford. Excellent. Well, you know, antimicrobial stewardship programs haven't been around for that long, you know, compared to a lot of other things in medicine. Can you tell us just a little bit about why these programs are important and, you know, what do they typically look like in an organization? Yeah, you know, that's a good question. And it's kind of an interesting question and an interesting comment about how they, it's right, you're right that they haven't been around for a long time formally. But I will say that really at a fundamental level, and I'm taking this from one of our medical directors here, that antimicrobial stewardship really is just good clinical medicine in infectious diseases. And infectious diseases is one of those interesting specialties that is generalized amongst general practitioners. And so, you know, I like to use the analogy of if you have cancer and you need chemotherapy, you're not going to do that without working with an oncologist and the oncologist really is going to be driving that. You know, if you need a heart transplant, you're going to be working with a cardiologist, a cardiothoracic surgeon, and, you know, a number of other specialists. But if a patient comes in with pneumonia or a urinary infection, you're not always going to be consulting with infectious diseases. And so the vast majority of infectious diseases that we encounter in the hospital setting or in the outpatient setting, which is an even larger arena in terms of antimicrobial stewardship, you know, you have disseminated that specialty out to out to generalists. And it's a complex specialty. And so what's also interesting about infectious diseases is the tools that we use to treat them become less effective over time the more we use them. And this is relatively unique to the field of infectious disease and the, you know, the antibiotic drug class in that bacteria. And to a certain extent as well, fungi and viruses that can cause infections can develop resistance over time. And that prevalence of resistance increases in the population. The more we use antibiotics, we obviously need to use antibiotics to treat people, to cure them of their infections. But in so doing, we are increasing that resistance and making it less likely the next time either that patient or another patient who has maybe, you know, caught the pathogen that they have, you know, gets a subsequent infection makes it less likely that the antibiotics we use the first time are going to be affected the second time. And I will say if you take a walk around any intensive care units or, you know, any setting like that in a hospital, you will find the consequences of that antibiotic resistance, unfortunately. And so it's a it's a dire problem that needs to be addressed. Thankfully, organizations like yours have recognized this issue and have have really supported this. And, you know, the federal government and other entities have supported antimicrobial stewardship more recently. And so there's been a more concerted effort institutionally to improve antimicrobial use. And that has been more recent. But the concept of antimicrobial stewardship, I would say is as old as antimicrobials themselves. And so tell us a little bit about when you implemented your program. How did you get started? And who did you have to involve in the process? Sure. So I will put the caveat that mine is an experience is one person's experience and everybody's experience is quite a bit different. But I'm actually going to call back from some prior experience in starting an antimicrobial stewardship at a at a large medical center. It takes a village. It's, you know, I struggle to think about how to answer this question, because I really don't recall how we started, we just sort of started reaching out into out into thin air and kind of made things happen. But but I will say traditionally speaking, antimicrobial stewardship programs are led by infectious diseases physicians and infectious diseases pharmacists. And I think that the synergy of those two professions is kind of the special sauce, if you will, of antimicrobial stewardship. And you kind of pair that diagnostic with therapeutic expertise that really, you know, sort of serves as, you know, an important foundation for antimicrobial stewardship. There's a number of other and I know we can talk about this in a second. But, you know, there's a number of other professions that are critically involved in antimicrobial stewardship as well. But it really starts there. And that's how I started my program previously down in LA. And myself and an infectious diseases physician, actually a set of infectious diseases physicians really took on the directives of the state of California. And then later, the directives of the Joint Commission and CMS to start an antimicrobial stewardship program at our hospital. And, you know, we, I think, I think really where where we started was getting an idea of where we were. We didn't know what to do if we, you know, didn't know where we were and where we were sitting and where we wanted to go. And where we were in relation to that. So we spent a lot of time in data collection, initially, looking at our antimicrobial use doing a number of use evaluations, syndromic use evaluations, like, you know, how are we, how are we doing in terms of our treatment of urinary infections? How are we doing in our treatment of pneumonia? What does our, what do our resistance patterns look like relative to the types of antimicrobials that we were you're using? Are we using drugs that are way too, you know, big and broad spectrum when we could be using much more narrow spectrum antibiotics to save some of those broad spectrum antibiotics for the times that we actually need them. And so from that, we were able to capture really what our focus areas were going to be and using national practice guidelines and and published literature to to identify what the most appropriate therapy would be. And we came to institutional practice guidelines. We were able to disseminate a lot of education about appropriate use of antibiotics, education about our resistance rates at our center, making people aware of various providers aware of things that they had not really heard of, even in, you know, many years of practicing at the institution. And, you know, the same way you practice medicine in, in medical school or in your, you know, in your residency training is, is almost certainly not the way you should be practicing now, considering that, considering the changing nature of infectious diseases. So, you know, and that's not to fault any individual. I mean, you know, there's so many other things out there besides treatment of infectious diseases that clinicians need to keep up on. And so it makes sense that institutions spend some resources to have some individuals collate this information and provide best practices, you know, or help to provide best practices to, to frontline clinicians. So that's really how we started and, you know, started talking to a number of people. We got our microbiology laboratory involved very, very quickly. They were a key, key collaborator. You know, we started getting hospital administration involved. We, you know, we really wanted to, in terms of driving institutional practice, I'm sure a lot of folks in various areas of patient care quality will understand that it's, it's the profession of herding cats, essentially. And your ability to herd cats is directly proportional to your effectiveness, I think, in a lot of these initiatives. And, you know, so we started from the ground up and we also started from the top down at the same time. And so we, you know, we engage frontline clinicians in terms of educations and one-on-one conversations on the floors about their patient that they're taking care of today right now. And we also engaged hospital leadership as well. And we found a natural collaboration with infection prevention and control. They look at a lot of things, I mean, mainly things like clostridia odys difficile infections that are associated with a number of infection prevention issues, but also with antimicrobial stewardship and appropriate antimicrobial use. And so that being already an established, you know, an established priority of the hospital with, to be quite honest, dollars attached to it when it comes to, you know, when it comes to CMS and other agencies and regulatory issues attached, that helped to get hospital administration to, to prioritize it as well. And I think, you know, as we continue to move on, success kind of spurred more success. And so it was a, it was a nucleating effect, I guess, that we got a lot of folks involved over, over that period of time. You know, I love how you said hurting cats. That's a great term, I think. So, you know, it's way too accurate. That's right, it is, it is, you know, especially in some kind, in any kind of, you know, system improvement program. So tell us what specific barriers or maybe resistance did you, did you receive when you were trying to get this initiated? Yeah. You know, I think that there's always, you know, anyone who's an antimicrobial stewardship, anyone who's in a lot of areas of quality and quality improvement will, will kind of speak to, you know, will kind of speak to the folks that are resistant to change as, as a barrier. And, you know, there was, I will say that at my former institution, we had an excellent set of leadership. And so we didn't, thankfully, did not run into very many barriers from a leadership level. But I think from a frontline frontline clinician level, I will say for the vast majority of the time, folks were very collaborative and willing to, you know, willing to, you know, have conversations and actively try to improve their practice. But I think for some, because this idea that you have an external entity trying to come in and influence your practice, there can be some resistance there that you have, you know, you have a lot of, you've obviously spent a lot of time cultivating your practice, you put a lot of thought into it. And to be quite honest, I mean, sometimes we just don't know what we don't know. And so, you know, if you don't realize that what you're doing might be inappropriate or you're not seeing downstream consequences of the things that happened as a result of what you did because that patient is now, you know, suffering the consequences outside of, you know, outside of your immediate field of view, you know, that can be a little difficult for some people. And so I will say that while we did, while that certainly was not, you know, the majority by any means, we definitely had some clinicians that were more difficult to work with. But we were able to move the dial with a lot of those folks over time. And so overall, I think it was pretty successful. And I will say, I mean, as you can see here, the other elephant in the room more recently has been COVID-19. And, you know, COVID, you know, you can kind of extend some of the lessons that we've learned here. I mean, it's definitely a lot more dramatic than anything that we've experienced in the recent past. But, you know, you can extend it to other things like, you know, to H1N1 and other potential things, you know, anything that lies in the future, we just don't really know. And, you know, being in infectious diseases, we obviously have to, you know, we have all had to step up. I mean, you know, really everyone in the health care industry has had to step up, you know, to this pandemic and do all these extra things related to COVID, you know, in terms of managing therapeutics. And now we're, you know, sort of in the process of delivering vaccine and, you know, and other things, stepping up to do these things while also maintaining the quality of work that you were doing before. And so that is, you know, I will say that's an additional challenge. But to, you know, to kind of circle back a little bit more fundamentally, because I forgot to mention this earlier, I still think that one of the major limitations of stewardship in general, because I did some work with the county public health department down in Southern California when I was there and worked with a lot of other stewardship programs to help them, you know, to help them improve some of the things that they were doing. And, you know, I will say that the number one complaint that we've heard from folks is that they just don't have sufficient time to do what they need to do. And, you know, I know that's an easy thing for everyone to say. You know, I wish I had more time. I wish we had more staff. But I will say that, you know, there have been, you know, there have been a number of studies now that have, you know, have tried to look at what the optimal, you know, optimal number of, you know, you know, full-time equivalent staff, whether it's pharmacists or ID physicians, microbiologists, you know, infection prevention, as whomever, depending on the structure of the institution that you need to successfully engage in antimicrobial stewardship. Oh, information technology as well is very important, you know, to have dedicated support. You know, to be quite honest, most hospitals have taken on antimicrobial stewardship on top of other things that folks were doing. And so I think a lot of institutions have dedicated stewardship personnel now, which is great. But I think we are, you know, we're far from goal in terms of, you know, the numbers of those individuals that are needed. I mean, if you're, you know, if you're sitting in a 650 bed hospital and you're a single person trying to improve antimicrobial use for, you know, hundreds and hundreds of prescribers, you know, in a complex and diverse patient population, I think that's just not realistic. And you know, I think that, you know, regulatory agencies should as well look at what type, and I know they are to a degree, but I guess I would continue to advocate that they look at, you know, what type of, you know, human resource support is being given to antimicrobial stewardship programs and the diversity of that support. That's an excellent point. So what have your outcomes been and how did you sustain the program? Yeah. So, you know, I think that outcomes is an interesting thing in antimicrobial stewardship. I think that for, I always relate things, you know, to some other outcomes that we look at in infection prevention like, like C. difficile or, you know, catheter associated urinary infections where we're trying to get down to as close to zero as possible. With antibiotics, it's quite a bit different and, you know, zero antibiotic use would obviously be not what we want. I think the tendency in the absence of formal stewardship programs of clinicians is to over prescribe because they, you know, it's about the taking care of the individual now versus the, you know, larger population and that's it. It's a challenging thing to think about for really anybody. And so the, you know, the typical outcome, initial outcome at least of a stewardship program is to reduce antimicrobial use. But I think that, and that's certainly what, you know, what we've seen. But, you know, I think the challenge is really trying to get to a level of optimal antimicrobial use. And that is a much, much harder thing to measure because there are so many factors that go into the choice of an antimicrobial, even simple things like allergies or, you know, other types of potential side effects that a drug may have that to a particular patient that may make another drug more optimal, even if it is maybe less optimal from a, you know, broader narrow spectrum perspective. And without reviewing every single patient in the hospital in detail, it is hard to get to what that appropriate number is. But, you know, suffice it to say, I think that, you know, we're getting more and more sophisticated metrics over time. The CDC has made a lot of movements to capture antimicrobial use between hospitals and also try to get some semblance of a benchmark for various hospitals. And then, of course, the goal is not zero, but perhaps the goal is to look similar to other institutions that look similar to you. All the caveats, you know, notwithstanding, of course. And so, you know, I think that, you know, you ask about sustainability, and that's a really important question. You know, I think that what's challenging about stewardship is that it's always changing, right? Or the appropriate, you know, the appropriate use of antibiotics or the definition of appropriate use is always changing. And it will be different next year than it is this year. And how do you hurt all your cats and make sure that they're, you know, they're there when, you know, when those practice guidelines change or, you know, when more evidence suggests that, you know, this type of practice is, you know, more optimal than this type of practice. And that's a tough one. And it means that you need continued involvement from your antimicrobial stewards, like myself and others, to kind of keep this moving, because it is a naturally moving target. But the other thing is you don't want, in my opinion, you don't want your antimicrobial stewards to be doing the same thing today that they were doing five years ago. And I'm a huge, huge fan of decentralizing antimicrobial stewardship and that there is no way that I or even 10 of me could look at all the patients in my hospital in a day and provide recommendations on appropriate antimicrobial therapy. It's just not, it's just not realistic. It's not sustainable. And it's not reasonable because you, with appropriate education, with appropriate partnerships, you can empower frontline clinicians to make those, you know, to help to make those assessments, make those decisions, educating physicians, educating pharmacists, educating microbiologists, educating nurses. I think nurses are a huge, untapped force in antimicrobial stewardship. And we, we haven't even hit the tip of the ice, we haven't even found the iceberg yet in terms of, you know, in terms of engaging nurses. And, and I think, you know, there's, there's a lot to be said about, you know, the, the efforts of, you know, what is that 1% of 100 people's efforts versus 100% of one person's efforts. And in trying to, in trying to disseminate that knowledge and disseminate the activity of antimicrobial stewardship, because again, it's really, it's really just good clinical medicine. And so, you know, we're really trying to help to support people to practice good clinical medicine. And so I think if you can, you can push the culture of your institution to be sort of a continued learning, you know, a learning model. And that naturally we will change the way that I prescribe today will not be the way that I prescribed in two years. I know that and I'm expecting that. That is certainly not the narrative that has existed in the past. It's really been more so that this is how I treated a urinary infection back in 1976. And so that's how I'm going to treat it today. And so I think, I think those types of efforts are really important. It's hard to be specific in that regard. But I think that, but that is probably one of the most valuable things that that an antimicrobial stewardship program can do. The last thing I'll say on that is just to quote a qualitative researcher in antimicrobial stewardship. And this may be a quote from somebody else, but, but culture eats strategy for breakfast, lunch, and dinner. And so you can have all the strategy you want. But if you don't have the culture change in your institution, you're going to be, you're going to be walking uphill for a very long time. That's such a great point about culture. And, you know, it's funny, I always used to say culture eats strategy for lunch, but I really like the breakfast, lunch, and dinner. That's great. You've given me two things to say. So, so David, you know, before we go, any other final advice or recommendations for organizations who are trying to get their programs off the ground? You know, I would say that just to just keep at it and make partners. You know, the, the, the interesting thing about stewardship is it's, it's very rewarding and it can be very taxing at the same time. And I'm sure this will, you know, this will resonate with a lot of folks who are in any sort of quality improvement initiative that, you know, if you spend all day hurting cats, I mean, it's hard to, it's, it's really hard. It can be tough sometimes, and it can be disheartening sometimes, you know, if you're, you know, if your efforts aren't making their way up the chain or you're not seeing the outcomes that, you know, you would like to see. But, you know, I would say that one thing that certainly has kept me going is the people within stewardship. And so, you know, if you can make, if you can help to kind of push people towards being your allies, and it's not necessarily always about just thinking that you know it all and pushing that, pushing your own agenda, that you're coming in and, you know, you for some reason have all the knowledge that nobody else has. I think that, that's certainly a big fellacy. But, you know, talking to people and, you know, getting to understand what issues they're dealing with, with antibiotics and trying to think about ways that folks can be involved in big or small ways is, you know, is really helpful. And it kind of, it really humanizes that antimicrobial stewardship approach and does start to change your culture or improve your culture. And, you know, every institution can stand to improve its culture in lots of ways, particularly with regard to embracing change and embracing fluidity in terms of what they do. And, yeah, so that's probably, that's probably what I would say, you know, get lots of folks involved, make lots of, make lots of friends, try to make as little enemies as possible, and, you know, get folks on, you know, get folks on your side. And a lot of times that means getting on, you know, getting on everyone else's team, you know, trying to help with other initiatives that maybe relate to some of the things that you're doing, you know, some of the things that come to mind certainly would be, like I mentioned, infection prevention efforts. Anything that's going on in the microbiology laboratory is going to be very, very important. You know, certainly making pharmacy your allies because a lot of institutions will have pharmacists that are, you know, kind of zoned in on the drugs, antibiotics being one of the many, and, you know, getting them to, you know, to recognize patterns of maybe suboptimal use and, you know, making recommendations right there on their primary services. I keep saying this over and over again, but I think nurses really are extremely important. They are the, you know, they are truly the last line of defense when it comes to administering antibiotics, and they're the first line of defense when it comes to recognizing any adverse drug reactions and any maybe suboptimal outcomes. Perhaps the antibiotic we're using is not working to treat the infection. The nurse is going to be the first one to know about that, not the physician, not the pharmacist. So, you know, can we, you know, can we provide our nurses with more training and things, you know, specific things to be, you know, to be looking out for? Can we make nurses more critical assessors of antimicrobial therapy to capture more of the relevant information upfront, like drug allergies? I can't tell you how many times I've looked at a chart and it just says allergy to penicillin unknown or the patient vomited or something like that. And, you know, and that leads somebody to prescribe something different down the line, kind of, you know, bringing that full circle and having people recognize, you know, the, you know, maybe unexpected consequences of some of the things that might happen as a result of, you know, some of the things that they cannot even realize that they have done initially. And so, yeah, I think making, making a lot of friends, making a lot of allies, getting a lot of folks on your team as much as possible, and really trying to invest your pro, you know, their initiatives into your outcomes and your initiatives into theirs, I think really helps to, again, you know, improve that culture and really drive, drive lasting change. Wow. Well, David, this has been so incredibly helpful. We really, really appreciate your time and we will let you get back to fighting the pandemic there on the front lines and thank you again so much for joining us. Thank you so much, Donna. Have a great day. You too.