Mark Briesacher, MD: I'm Dr. Mark Briesacher, the chief physician and executive at Intermountain Healthcare. Today we have a guest host, Dr. Shannon Phillips, who's our Chief Patient Experience Officer, and she's talking with some of our caregivers about this very important topic.

Shannon Phillips, MD: Hi this is Dr. Shannon Phillips. I'm the Chief Patient Experience Officer at Intermountain Healthcare. And today our topic is antimicrobial stewardship. I'd like my colleagues to introduce themselves. Whitney.

Whitney Buckel: Hi, my name is Whitney Buckel. I'm a Clinical Infectious Diseases Pharmacist and I am the System Antibiotic Stewardship Pharmacist Manager for Intermountain Healthcare.

Eddie Stenehjem, MD: Yeah, and I'm Whitney's dyad. My name's Eddie Stenehjem. I'm an infectious disease physician. I am the Antibiotic Stewardship Medical Director in the Office of Patient Experience here and an active infectious disease physician as well.

Shannon Phillips, MD: Okay. This is an important topic not just for Intermountain but healthcare nationally and internationally. Feels like a good one to start with a story. So you got one for me? Let's talk about a patient.

Whitney Buckel: We have several examples, and a lot of what we do is prevent medical errors from occurring. And some of those stories are harder to share, but we do have stories where we also help with improving patient experience. So we had an example of a patient who is admitted with a severe bacterial infection. She had a gram negative bacteremia and because this organism was resistant to a lot of our first line agents, the plan of the team was to do a two week course of I.V. antibiotic therapy. However she was actually visiting and was not local, and she had a flight home out of the country only a week away. So there was a conundrum for the team about how to provide the best care for her but also allow her to travel home. And so we got involved and were able to find oral therapy that would work for her to complete her treatment, and she was able to make her flight home which I think improved her care a lot. I mean she was very worried about whether or not the cost and the trouble associated with missing that flight.

Shannon Phillips, MD: I think there are, you've picked the experience of the patient side where you have an infection and we have the opportunity to help you get in a restorative place. They needed to get home but be home as opposed to the hospital. A really important piece. I actually think of one of the hardest spaces because, I'll just jump right into the misery, is how do we get patients to not want antibiotics. Right. So it's not winter right now, happens not to be, but as the germs go flying, the viruses I mean, how do we engage patients effectively in a positive experience around antibiotic use or not use?

Eddie Stenehjem, MD: Right. You bring up a great point Shannon. This is incredibly challenging. There is a sentiment out that antibiotics can fix everything and-

Shannon Phillips, MD: They don't?

Eddie Stenehjem, MD: It's surprising, isn't it?

Shannon Phillips, MD: Darn.

Eddie Stenehjem, MD: And I think it's up to us as a health care system to help educate the public. This is what we consider population health. This is public health. We need to let patients know that when they come to us for an illness or for a symptom, common cold, cough, whatever it might be, we're going to take care of them. We're going to treat their symptoms and that may not include an antibiotic. And that is the best care and it's working together to have a unified message, a message that states we're committed to antibiotic stewardship. We're committed to not using our antibiotics unless we ultimately need to and we're going to communicate that in a clear effective manner and be consistent across all care continuums, whether it be in urgent care or a virtual visit or a primary care office.

Shannon Phillips, MD: So I go to an urgent care, not Intermountain of course, affiliate you know on a corner and I have a cold and I get an antibiotic and then I come back to my primary care doctor with the same symptoms six months later and I get no antibiotics. That's a hard space for a doctor or a provider, it wears you down right.

Eddie Stenehjem, MD: It absolutely does.

Shannon Phillips, MD: My resiliency feels lower just thinking about it.

Eddie Stenehjem, MD: Right. If you look at antibiotic prescribing in the outpatient area and you look at adults only, our rate of antibiotic prescribing hasn't changed, hasn't changed over 20 years. And when we look at the studies and we look at what is the biggest predictor of antibiotic prescribing, it's the prescriber. That is where we see the biggest amount of variability where one prescriber is an antibiotic steward and says "No I'm going to stick to our guns and we're not going to use antibiotics when they're not needed." But then the next one may. And you can understand how that develops an environment that it can be really challenging to practice in. And I think that's where Intermountain could lead forward on this and say within Intermountain this is not what we're going to do. This is our practice and this is best care. We're not there yet, we definitely see variability and variation across our system. But I think that's where we should go.

Shannon Phillips, MD: All right. So tell me why antibiotic stewardship is so important.

Eddie Stenehjem, MD: I'll give you my kind of, it's not an opinion, this is actually, you know, fact. Antibiotics are the only drug that the more you use and the less effective they become. So if I use them in one patient they could be less effective in another patient. That is unique only to antibiotics. Heart failure medications, chemotherapies, that just doesn't apply. And so our use of antibiotics essentially is preventing antibiotics to be effective for the next generation. And that's why we have antibiotic stewardship teams and people to focus on this is because this is public health. This is a public health matter where we are going to invest in antibiotic stewardship now to prevent drug resistance in the future. And we know that the development of drug resistance leads to worse outcomes or it leads to worse patient experience. It leads to higher cost of care and it leads to high rates of death. And so that's the ultimate linchpin of why is that this is public health and we need to steward these resources for generations to come. We're not going to get around this by making new drugs, we're always going to have drug resistance and so we have to slow that tide.

Whitney Buckel: That's one of the long term goals. That one's hard sometimes to see that you might in the future develop an antibiotic resistant infection.

Shannon Phillips, MD: Right. We're kind of like, “I want it now” people, aren't we.

Whitney Buckel: Right. You want some immediate, you know I'm feeling bad now, this cough or this sinus pain is bad right now. But I think there's also another part of education which is hard always to have that conversation but antibiotics do cause harm. And so we know that one in five patients who receives an antibiotic will have an adverse effect whether that be G.I., gastrointestinal, damage to the kidneys or to the bone marrow. And it can also cause a really bad diarrhea caused by an organism, C. difficile. And that's one where people just really don't appreciate it until they see it. And then once they've seen it now they know why there's this risk benefit assessment that is done when prescribing. And I think one of our main goals is to prevent resistance but also to prevent patient harm by using antibiotics appropriately.

Shannon Phillips, MD: And I bet we don't talk very often to patients about harm and antibiotics right. I mean I'm making a confession here. I feel a little bit sorry. I'm thinking of all the times in my career I've given antibiotics, and it's usually I'm pushing on the "Wow, this is a bad infection and we need to make it better and guess what, I have that for you. I got that." I can see as a pharmacist where yes meds, maybe as a provider we've not spent enough time thinking about that.

Eddie Stenehjem, MD: I think you're absolutely right. Antibiotics are the number one cause of an ED visit for adverse drug reaction in pediatrics and adolescents. It's number two most common in adults. And when you look at common conditions in the outpatient world that people get antibiotics for, sinusitis is number one. And if you look at the data for treatment of antibiotics or using antibiotics and sinusitis you're more likely to cause harm than you are to cause benefit. And that is a message we have to get out.

Shannon Phillips, MD: I don't think people know that. Or is it just me?

Eddie Stenehjem, MD: No, I don't think it's just you.

Shannon Phillips, MD: You can say it is.

Eddie Stenehjem, MD: No it's a very common misconception that sinusitis, our most common diagnosis that receives antibiotics across the U.S. and here at Intermountain, get significantly better with antibiotics. It doesn't. And in most studies, regardless where you look in the U.S. or elsewhere, it's very, very minimal effect and not using antibiotics has not been shown to worsen long term outcomes. And so we're at a point where we need to talk about these things, we need to raise this awareness to say you're more likely to cause harm with your antibiotic than you are to have any benefit. And benefit is days to get back to work, missed school, those types of things. When you look at treatment versus non-treatment, it's the same.

Shannon Phillips, MD: So I'm betting we use a lot more antibiotics in the ambulatory setting. Is my calculation right?

Whitney Buckel: Yes.

Shannon Phillips, MD: Okay good. And that was no calculation, that was a big guess. And I imagine that we have an opportunity to leverage clinical decision support, our electronic health record. Have we had any success or do you know of success in stewardship that leverages the tools that we're supposed to use every day to take care of patients in the ambulatory setting? We'll start there. That's the hard part, right. I know.

Whitney Buckel: There's been a lot of interventions. Some of them are really creative as far as just having providers sign a sheet that says they're committed to using antibiotics appropriately and posting it on the wall or providing feedback about their prescribing and comparing them to their peers. So there's been a lot of great studies in the outpatient setting.

Shannon Phillips, MD: To shift culture, that sounds like, right?

Whitney Buckel: To shift culture.

Shannon Phillips, MD: And then not to be understated, if it's what you've done all your life, it's hard to move. Right. So those commitments, I think, are important probably insufficient.

Eddie Stenehjem, MD: Absolutely. To get back to your initial estimate or calculation. Yes, 80 percent is the number.

Shannon Phillips, MD: Oh, wasn't even close.

Eddie Stenehjem, MD: Wasn't even close.

Shannon Phillips, MD: OK. Alright.

Eddie Stenehjem, MD: We think this is hard to measure, but we think approximately 80 percent of all antibiotics used in humans are in outpatients. That being said, they're very different antibiotics than the inpatient and the impact that they have on resistance and the like may be different, we just don't know. But if you look at all antibiotics the lion's share is in the outpatient world. Now trying to integrate clinical decision support in terms of improving antibiotic use has been done in some studies. But I don't think it's been done well and I think we have a long way to go on this to really integrate clinical decision support into clinical workflow where it's effective and easy for physicians and also advance practice clinicians that prescribe a lot of antibiotics. I think it's an area where there's movement, but I would not say that there's best practice yet to say this is a tool that consistently delivers best outcomes.

Shannon Phillips, MD: Do you have any ideas about where we get started?

Eddie Stenehjem, MD: Yeah, I think we've talked with a number of physicians in the community, both urgent care and primary care. And their biggest desire is to build it into clinical workflow, build it into documentation and build it for those key areas that they see commonly. So sinusitis, otitis media, ear infections, pharyngitis, sore throats. And if we can effectively build it into their clinical workflow and provide patients symptomatic therapies aside from just antibiotics, then I think we can be successful, but it's going to take some iteration and a lot of work with the frontline clinicians to say what is effective and how does this improve your workflow and how does this improve the ability for you to communicate with patients.

Shannon Phillips, MD: Are we working on that here at Intermountain?

Whitney Buckel: Yes we are. We will be having a big intervention going forward in 2018 to 2019 to really focus on this. We want to measure where we're currently at, and we want to do a number of the things that Whitney said in conjunction with engaging the patient, engaging our frontline caregivers, building these clinical decision support tools, integrating them into clinical care and then measuring the impact. We have to move the needle in Utah on antibiotic prescribing. We are a low prescribing state. We're doing OK compared to other states, but we can do better. We know that we don't need to use this many antibiotics for sinusitis or even bronchitis. So more to come.

Shannon Phillips, MD: Okay. So most of the work of infectious disease is actually on the hospital side. Well I guess there are probably more pharmacists in the ambulatory space but certainly, as a hospitalist, I spend a lot more time with both of you guys on the inpatient side. Are we any better in the hospital-based use of antibiotics than the ambulatory side? Are any of the tools that we were just talking about in the ambulatory side in play and working for hospital based stewardship?

Whitney Buckel: Yeah, so in hospital-based stewardship we have done a lot more. We've established antibiotic stewardship programs in all of our 22 hospitals. And what that means is we have a group of committed people that work together and they do one—or several, in reality—actions to improve antibiotic use via usually a review by a pharmacist and a discussion with the provider or also different policies and procedures about what's the best route, what's the right agent to pick. A lot of those are aided by computer decision support programs. So we've done a lot working with the order sets to be able to help pick the right one initially, tools and trigger functions so that we know when to switch patients from an intravenous to an oral, or to adjust their dose.

Shannon Phillips, MD: So you're saying because both the providers and the patient are a captive audience, you have a lot more control as a pharmacist over what we do which is a good thing. I don't mean that in a bad way.

Whitney Buckel: Yes. And there's-

Shannon Phillips, MD: And the computer can help.

Whitney Buckel: The drugs are local and it's not going out to other pharmacies or being handled over the phone rather than in person right there.

Shannon Phillips, MD: Well there's something to be said for just in time support, right, where you are now seeing the patient and somebody can bring wisdom and data and great ideas to the fore for you and help you make the right decisions for your patient. That's pretty powerful. Maybe we need like an Avatar pharmacist in the ambulatory setting. If that works, it's mine. Just saying. But I mean I have appreciated as a hospitalist pretty much my entire career having a pharmacist who quietly or not watched over my practice, and that's a great thing. You learn iteratively. You know you don't want to make the same mistake twice or you learn it and you're like, I'm going to do it before they tell me. And that really reinforces the right behaviors. It's making me realize that we may have an even larger mountain to climb, since it's Utah, in the ambulatory space right because you're not sitting there whispering in my ear telling me how to do better.

Eddie Stenehjem, MD: Absolutely. The amount of patient encounters we see in ambulatory setting far exceeds the ability of one pharmacist or even a team of pharmacists to be right there talking to you. It doesn't fit in that kind of method of care in the outpatient and so it's utilizing these things in the outpatient to their fullest extent.

Shannon Phillips, MD: I'm feeling like artificial intelligence or something's got to work there right. I'm on to something. I don't know what it but it feels like it could help.

Eddie Stenehjem, MD: I think when you look at the trend in antibiotic stewardship the focus has been on inpatient care and there is no government regulation and recommendations to have stewardship programs. The Joint Commission, part of their accreditation process is that you have a stewardship program. CDC recommends that every hospital regardless of size has a stewardship program.

Shannon Phillips, MD: Right. And so in Utah we have some frontier medicine going on, right. We have places that take care of rural critical access hospitals, and while stewardship applies to any patient, that's hard to reach. I bet not every rural hospital, I can speak for Intermountain, doesn't have an infectious disease doctor who lives in the neighborhood. So how are we transporting stewardship to even our very smallest hospitals?

Eddie Stenehjem, MD: Right, you're absolutely spot on. When Whitney and I came here in 2012, we had started stewardship programs in our large facilities, and what we saw when we looked around is that our 15 small community hospitals, those that had less than 150 beds, had no stewardship programs, period, and there was no plan to develop them. And when you look nationally, of our approximately 5000 U.S. hospitals, 70 percent of them are less than 200 beds. And when you look at the likelihood to have a stewardship program, you are least likely to have a stewardship program if you have less than 200 beds. And if you're a critical access hospital, one in five have a stewardship program.

And so we thought that that was an opportunity for us, and we went forward and we did a big study that looked at how do you actually do this in small hospitals, because there had been no studies on stewardship in small hospitals, these remote isolated facilities that don't have I.D. consultation, don't have any access to infection disease pharmacies. And we underwent a two year study and what we found is that if you centralize resources from an infectious disease physician and infectious disease pharmacist and you provide them data, they reduce antibiotic prescribing at no harm to patient outcomes. And it was with that data that we developed the Infectious Disease Telehealth Program and we now have our own separate telemedicine stewardship program that provides antibiotic stewardship support and infectious disease consultation to 16 of our small hospitals. And that is really how we reach out to those frontier hospitals that you call them to say antibiotic use in those facilities are just the same in our large, they need to be part of our mission and this is how we do it.

Shannon Phillips, MD: And how was that received when you reach in from a distance?

Eddie Stenehjem, MD: Initially there was some resistance, and that resistance went away immediately when the clinicians recognized that we provided value. And so part of this was being available to those small hospitals, those clinicians, those emergency departments and saying "We're here to help you." And once they realized that we could add value to their system and their program and their patients and their community they welcomed us with open arms. And now we're an integral part of their teams all the way from Burley, Idaho, down to Garfield, Utah. And we're welcome there and we're part of the clinical care.

Whitney Buckel: We've also really empowered the local pharmacists and physicians to be involved. And I think getting that local buy-in and having them teach them to learn, to be able to make some of those interventions themselves so they're not all coming from some remote person that's calling in.

Shannon Phillips, MD: Got you.

Whitney Buckel: So having that sort of model, I think, has also really improved-

Shannon Phillips, MD: So they're gaining some mastery in stewardship that they can just apply right there before somebody from the system has to come in and help, and I don't mean that in a bad way.

Whitney Buckel: Yeah. We're happy to help, but we also know that everybody there is really bright and smart and talented and they're capable. And so I think putting that trust and responsibility on them as well to be engaged has led to some of the successes at many of our sites.

Eddie Stenehjem, MD: Absolutely, we want them to own their program. And that's been what our tele- leadership has been saying from the get go. This is your program. We're here to help and to support. We're the content experts but we want you to own this, and that's what we've seen. And we've had hospitals step up to the plate, and we guide them in the right direction, our tele staff guides them in the right direction. And we're here to support them.

Whitney Buckel: So this is the tele-I.D and tele-stewardship has gotten some national attention. Do you see others replicating this?

Eddie Stenehjem, MD: We do. We have seen this use of application of telemedicine now in multiple other areas and there's an ongoing national discussion of how do we use telemedicine capabilities to get into all of the critical access hospitals across the U.S., and there are thousands of them and people point to our study to say, if you really want to impact care, this is how you need to do it. And it's now up to us—and by us, I mean the royal us—those in healthcare networks to say how do we do this, how do we reach out to hospitals that may not be in our network but we need to provide them care in terms of population health. We know that if antibiotic resistance develops in Montana it ends up in our hospitals, it ends up in our communities. So it really is taking a much more global look at this in terms of, this is all of our issue, and how do we help in terms of getting into these communities.

Shannon Phillips, MD: If I asked you to think about what it should look like five years from now because this feels like such a very tip of the sphere issue in health care today and we need to bend the curve. So what's it look like in five years?

Eddie Stenehjem, MD: I feel that Intermountain's in an incredible position to really, like you say, bend the curve. And we need to focus both on outpatient, inpatient, and also the community in terms of culture. And I think Intermountain is well poised to do that. I think from the outpatient standpoint we need to change the culture and the discussion around antibiotics. We need to reach the community but at the same time we need to be consistent and have a standard within all of our Intermountain practices whether it be our Intermountain clinics or the clinically integrated network. We all need to be practicing the same. And we need to measure that, and we need to ensure that the patients understand why we're doing this. And I hope that that would then filter into other hospitals, other clinics that may not be part of Intermountain.

I think Intermountain also needs to be a leader in development of stewardship program in the Mountain West. There're nine rural hospitals in Utah that could use their help. There're 40 in Idaho. There're many in Wyoming and Montana that don't have access to a system like this. And I think we can grow—and smartly grow—to be there to help them and provide them stewardship support. Maybe not at the patient level, but we can be there to mentor them and we can help them. And I think that's where I'd love to see this go. And then we partner with health care networks in Seattle, for example, or down south and we form an integrated network that does this for community hospitals in the West and we work with our national partners to grow this, measure it, and talk about it. That's where I'd like it to go. I think it'll take more than five years but…

Shannon Phillips, MD: Come on. Five years is like forever. Whitney now you can be the realist if you want. Where are we in five years?

Whitney Buckel: I feel like five years is sooner than you think. I really think that we are well positioned. We've done so much in the inpatient setting, although I feel like we have a lot more to do to have consistency. We're expanding our team. We've hired several very talented infectious disease pharmacists that are starting this fall. So we're actually doubling the size of our I.D. pharmacists which is great. And so, yes, I think that's important. I want to build and be a model in the inpatient setting and then, like Eddie mentioned, we need to start in the outpatient space, which we haven't done, and with 80 percent of antibiotics being used in the outpatient setting, I really think that we can start to be a model in that setting, as well, and really be a learning organization in terms of creating sustainable changes. Not just these one off things, but like trying to develop a good system for consistently making things better and better for our patients.

Eddie Stenehjem, MD: I think we showed the U.S. how to do stewardship in small hospitals. We're a leader in that field. I think it's now time that we show them how to do it in our outpatient practices as well. And I think we're poised to do that.

Shannon Phillips, MD: Well two of my favorite public health warriors, Eddie and Whitney. Thanks for talking today.

Eddie Stenehjem, MD: Thanks for having us, Shannon.