[MUSIC] Hi everyone. My name is Esmita Charani and it's a pleasure for me to be joining you in this course to talk a little bit about our experiences in implementing antimicrobial stewardship programs in hospital settings. So in terms of the research landscape and antimicrobial stewardship we still face a lot of inequities, not only in the available funding between high income and lower middle income countries. But also inequity in funding between research and development for new antimicrobials and funding for better understanding the use of existing antimicrobials so that we can optimize their use in hospital settings. This is critical because unless we learn how we can use existing antimicrobials effectively, we're not going to be able to stem the tide of resistance regardless of the number of new agents that we bring into the market. So when we recently looked at the funding landscape for antimicrobial resistance research in human populations, we identified that the majority of the funding remains in technology development and technology evaluation. And there is still a lot of inroads to be made in research for implementation of effective interventions for better understanding, engagement with policies, policymakers and evaluating and planning for strategies to implement effective antimicrobial stewardship interventions. And for context culture and behaviors. These are extremely important, particularly when we look at the one health perspective which is what this course is about. And of course I'm focusing on antibiotic use in hospitals but the factors that I discuss are relevant across the board. So the work that we do is looking at how context and resources matter and infection prevention and control and antimicrobial stewardship in hospital settings. And just as an example of why this is important, these are just examples of some of the current innovations in practice around the world for implementing effective antimicrobial stewardship focusing on the drug chart. Now the drug chart is a foundation for antimicrobial stewardship programs because unless we understand how we're prescribing and how we are using antibiotics, we won't be able to change practices. And we won't know when and where we need to target our efforts. So the first photograph is a prescription chart from Uganda where paper printing is very expensive. So some hospitals do not have access to medication charts. And what doctors do is they innovate and they use exercise books and create their own makeshift charts. Of course this is fantastic. But it also comes with difficulties in being able to decipher the prescribed the prescriptions in safe administration of medicines for nurses, but also in surveillance. How could we measure the quality of antibiotic prescribing when we haven't got effective patient charts to start with. The second photograph is from hospital in India where we are collaborating with colleagues and they realized that the antibiotic prescriptions kept getting missed. So what they did is they created a bespoke medication chart for antibiotics by just highlighting a yellow border around the existing antibiotic medication chart. And what that did it had made it much more quicker for the nurses to identify the antibiotic chart and to be able to administer antibiotics quickly and effectively when needed. The third example is from our colleagues in University of Cape Town in South Africa, where they have been able to implement the core principles of effective antibiotic prescribing into a paper chart which guides physicians in making the right decisions when prescribing. And lastly we have the example from the hospital where I work, where we have electronic prescribing. And it's very fascinating because we thought electronic prescribing will solve a lot of our problems. But it came with its own problems. One being how we interact with patients there on the bedside now that we're working on computers. And our screen time is much more, we spend a lot more time on the screen even in front of the patient than we do in interacting with the patient and understanding what's going on. And this has shifted behaviors around the patient's bedside. So all these examples of innovation come with challenges. And one of the problems we have with designing innovations in healthcare is we often do not have enough time to understand the design process to develop smooth and seamless interventions. So this slide I always use is courtesy of Professor Peter Charles who's a Dyson School of Engineering at Imperial and he describes this design concept by describing the phases of design and often in research in healthcare. We're stuck at the research phase because we don't have the funding because we're often developing knee jerk reactions and we never have the luxury to work through the design and concept to develop a smooth and seamless intervention. And this is the challenge we have which we are constantly needing to address. And when we look at this in the bigger picture, in terms of competing priorities and messages around the antibiotic stewardship, we work in a very cluttered environment. There are lots of factors that influence decision making in antimicrobial stewardship and infection prevention and control. Particularly this is examples of interventions in the hospital where I work where in blue are the local interventions we have implemented versus in black the national guidelines and policies and then read the international guidelines and policies. So and just cluttered a noisy environment policy and intervention and guidelines for different prescribers. Often when it comes to stewardship, we have to go with the low hanging fruit and what that means is we target junior doctors, we provide limited educational opportunities and a lot of our work is means driven. We don't have the resources to be able to implement effective change. So how can we move away from this. And one way to be able to move away and progress is to understand how social science research can help us in implementing better stewardship programs in the hospital setting. And what the social sciences can do is they can help us define the problem, provide contextual insights into how we need to successfully bring about change. And help us develop theory driven systematic approaches to developing interventions and help us make sure that those interventions are sustainable. These are really important because when we look at the core elements of antimicrobial stewardship intervention. Having educational resource and having antimicrobial stewardship team members who regularly have training and education themselves, all very secure component is often missed. So we're often working in very resource limited settings with very little resources to implement the change we want. When we recently conducted a survey in one of our learning tools and platforms that we had online where we had a lot of antibiotic students from around the world involved in the process of interacting with us. We asked them what were the challenges in implementing antibiotic stewardship in the settings in which they worked. And whilst a nurse recommendations and costs of antibiotic we're sort of decision factors for them to decide what they were doing. The most important factor that they considered was antibiotic resistance, patient needs policy and senior colleague recommendations. Additional feedback that they gave us was around the fact that there isn't enough investment in training nurses and pharmacists that culture matters not microbiological culture but social cultures. Social environment in which healthcare professionals are working influences and matters in anti microbe restrictive interventions. So what we did taking this knowledge is we developed a specific course on better understanding how we can apply social science methods in implementing antimicrobial stewardship in hospital environments. And this is a part of the work that is also in this look that you are watching now which is important, looking from the one health perspective. But the three week long look that we developed before the pandemic has been very successful. And we've had over 3000 learners from 150 countries. And what the learners from these countries were telling us about the challenges and antimicrobial stewardship was that there are limited roles for non physicians, healthcare professionals and the lack of resources including training of antimicrobial stewardship. And we don't engage enough with the patients and the public. And I'd be very interested to see how that fits with the experiences of the learners on this move that you are currently engaged in to see how much of that is true. So the research that we've undertaken at Imperial College specifically is looking at the complex city of antimicrobial stewardship in hospital settings. And we're using a model of culture to investigate the social environment in which decision making is being made in hospital settings. And through ethnographic research and qualitative face to face interviews with staff. We have described a set of unwritten rules around antibiotic use and hospital settings, including the influence of senior physicians and clinicians on outcomes. The neutral clinical autonomy and the fact that hierarchies often overall policies and guidelines. And these are the factors that are often overlooked in development of antibiotics use interventions. And so then, what we have done is taking this learning further. We have engaged with colleagues through grant funding in different countries. So this is an example of a study we conducted. An ethnographic study to better understand antibiotic decision making in the surgical pathway in India and South Africa. And this particular patient is that it's a 44 year old female who was diagnosed with ovarian carcinoma and had to come back for hernia repair to the hospital in India. And and with tracks using social science methods, were able to track the pathways of care in hospitals. And the sheer number of people involved. In this particular patient's case, there were over 80 for healthcare professionals who are involved in infection related care for the patient. And this is really important because often as I mentioned, antibiotic stewardship interventions focused on junior doctors. And we overlook the role of nurses, the role of all these other healthcare professionals, pharmacists, different specialties who will invariably have an impact on the decision making for patients in terms of antibiotic use. And for this patient, they ended up being for the majority of the time they were in the hospital, they were on broad spectrum antibiotics driven by cultural sensitivity tests which often were contaminated or inappropriate. So, understanding the whole care pathway and all the individuals involved is critical in us being able to develop sustainable interventions that impact all aspects of infection related care in the hospital setting. And not just one episode of care for example, just improving surgical site infection management through better antibiotic prescribing for prophylaxis. We need to understand the whole pathway. Following on from this work, we have also worked with colleagues to map the communication process to visualize how as members of teams in the hospital setting, we are communicating with each other. We have a fantastic nurse in South Africa can despondent concert who brought in her expertise in using social programs to better understand communication and teams. And socio grams is basically visually mapping not only the type of communication but who is involved in the communication in the direction of the communication. And including where people position themselves for this example of socio grams will focus on the patient bedside. And the individuals involved in the conversations are an infection related a decision making for the patient, including antibiotics, including removing lines including diagnostics. And who was involved in that decision making. And then we quantified these episodes of observation to map the communication pathways and what we described as the majority of the communication occurs between consultants and magistrates. This is on surgical pathways in South Africa. This gray line represents how much nurses and patients get involved. So very very little involvement of patients and nurse. This blue and gray line is patient and this is the nurse involvement and this is the patient involvement in in communications. And this is critical because the nurses have really important information about patient care. For example removal of lines, surgical wound healing, any output of fluids from the wound site. So these are factors that are often overlooked and we need to be better at engaging with our colleagues as members of teams in the hospital setting. And in fact as a result of this research and the engagement with the surgical teams and the ICU teams we've been able to demonstrate a significant improvement in the quality of ward rounds, particularly in the ICU. Whether ICU surgeons and consultants have now been able to reduce the time on the ward rounds by 45 minutes just by making it more efficient, the communication. So the value of social science research is showing a different lens or a different window to healthcare professionals about the way they are working and advocating for change through showing them how they are behaving. So as I mentioned, we're not very good with patient involvement. And this is important to natural careful stewardship because increasingly antibiotics are accessible through many different ways in the population. And this is important from a health perspective as well in terms of over the counter and under the counter access online access to antibiotics. And the demand that comes with it from patients. We need to be better at involving patients in infection related information and communication, particularly around antibiotic resistance. So malu who is a one of our pharmacists in the University of Cape Town in South Africa, has done a lot of research to better understand the level of engagement we currently have with patients. And she conducted a scoping review where she identified that actually we are very limited in our participation in our patient participation in infection control and anti cultural stewardship interventions. And there's very little evidence from low and middle income settings. So she is now working to identify solutions to this locally to better engage with patients and bring them into the conversation, particularly when we look across the surgical pathway. There are so many different points at which patients need to be involved both pre and post operatively in their own care for better outcomes, including wound care, including adherence to best practices for optimal outcomes. And lastly but not least, we also need to look at the bigger culture and social network around patients. So this is a serious surrendering who is our anthropologists in India and she's worked at understanding the role of carers in infection prevention and control in hospital settings. And she identified that actually to the research we have done together, we have identified that the role of carers often under looked in policy and guidelines. Particularly infection control policy and guidelines, that it is a critical role that needs to be integrated into policy and guidelines for infection prevention and control. Because often the carers our constant present in the patient environment and the patient's relies on them and they're also knowledge brokers for the patient. They have a lot of knowledge about the patients which will be critical for better outcomes. So I'm going to stop here and say thank you for listening to this talk. And really to highlight that the examples are used although they are from the hospital setting where there are lots of teams and individuals and groups of people who are trying to work together for the best outcome for the patient. Some of this learning can be applied across the one health agenda to optimize antibiotic use and to help us with the fight against antimicrobial resistance. Particularly the methodologies used in social sciences to understand the context are really important in the fight against antimicrobial resistance. Thank you very much for listening. [MUSIC]
