VetTeamAMR for companion animal teams

VetTeamAMR for companion animal teams
Angie Rayner BVM&S MRCVS
David Singleton BVSc MSc PhD MRCVS

RCVS Knowledge:
Welcome to this VetTeamAMR podcast from RCVS Knowledge. Leading responsible antimicrobial use in farm, companion, and equine teams.
Pam Mosedale:
Hi everyone. Today I’m going to talk to Angie Rayner and David Singleton, who are co-clinical leads of VetTeamAMR at RCVS Knowledge. Angie is also Director of QI at RCVS and David is an epidemiologist at Liverpool University. We’re going to talk about VetTeamAMR. Hi both.
Angie Rayner:
Hello.
David Singleton:
Afternoon.
Pam Mosedale:
Hi. So we’ll start with how did this VetTeamAMR thing start? What’s it all about, and how did it start?
Angie Rayner:
Well, I’ll hand this over to David, because it seemed to all start when he sent me an email about, “Angie, I’ve got an idea for a project.” And so David, how did that progress for you from there?
David Singleton:
The background to that kind of was thinking about what about a project was, I used to work at the small Animal Veterinary Surveillance Network, south net, and my kind of passion, my slight borderline obsession is AMR. And we’ve just completed a paper on treatment of acute diarrhea in dogs and sort of looked at evidence, generation and things like that and kind of got to the point of saying in terms of acute mild diarrhea, is there really any need for antibiotics at all? Quite possibly not. Felt very sort of confident about it. And then a little while later, Angie picked up the phone and said, “A practitioner within the group has read all the evidence, read your paper, and has been convinced to give it a try, of not prescribing for acute diarrhea.”
And the first, I can’t remember how many cases, it might have been in 10 cases, of having their view, gone badly, what could we do to help this practitioner understand more about their own clinical practice? Maybe convince them to stay the course and carry on. And at that point I went, oh, I don’t really have anything. I think we kind of recognize, we’re fortunate. We’re collecting large volumes of data increasingly and it can kind of start to give an overview on a population scale. But when it comes back to the practitioner having to jump the line, jump the divide almost in terms of how they’ve always prescribed for example, and they’ve moved into something new, that’s quite a leap on an individual level. And we didn’t really have any mechanisms to help them in that leap. So I guess hand back to Angie now, perhaps my involvement started a question again, well what could we do? How could we actually help practitioners in a meaningful way to prescribe antimicrobials responsibly?
Angie Rayner:
And that’s where quality improvement steps in doesn’t it, is the how do we improve? And it’s sort of gathering that sort of local knowledge of how we do that in the local context. And so we devised a plan of how, will this sort of QI approach work in promoting sort of appropriate use of antibiotics. And equally to be able to learn from each other from how we implement these approaches. And so yes, we looked at providing benchmarking data and which creates awareness around where’s my prescribing data as opposed, as compared to my peers. Equally looking at providing some clinical guidelines around prescribing but also giving people their prescribing data, which we found to be really helpful in helping people to reflect on, gosh, is there any room for improvement here with course the benefit of hindsight and what can we learn from each other and how can we support each other in that pursuit?
So that’s how we started. And being in the fortunate position of doing quality improvement work within RCVS, we were able to recruit some practices in a randomized controlled trial to be able to test these different approaches. And fortunately we were successful in doing that. And when David and I and the rest of the SAVSNET team were sitting in the University of Liverpool looking at our results and we were like, this is fantastic, how do we share this with the profession? We have to let people know that this approach can work. And that’s when we picked up the phone to RCVS Knowledge and asked for their help. And here we are, Pam. David, here we are.
Pam Mosedale:
Excellent. And it sounds like it’s going to be really, really useful for people in practices. So what is it actually going to be then VetTeamAMR? What will it consist of?
David Singleton:
So it’s a multi part tool really, we hope. Although was started with a alert impact platform, which is, how many practitioners, academics, I don’t know how many people have been involved with creating resources, but it’s an amazing resource. Spanning across from the fundamentals of antimicrobial resistance, the biology, epidemiology, etc, right through to hopefully at least practical guidance and support for prescribers. Though practice from dogs, cats, horses, but also hopefully a little bit on exotics as well. And I guess we see is kind of the basis is we’re spreading the word, spreading the learning, hopefully making a little bit easier for those busy practitioners to gain access to the relevant resources at time which suits them. However, we did want to learn from the trials that Angie and I conducted and as Angie sort of pointed out a second ago about the importance of data.
What we’re also trying to do is to provide a mechanism for practitioners to audit their prescribing against other practices that take part in the scheme. We think this, at least in our experience, shone quite a good light on how people prescribe. I’ve kind of got this view almost individual prescribers are often kind of an island of in their own consult room and the island might get a bit bigger within the practice, but it’s still quite isolated. I think connecting practitioners together and learning from each other is really important. The final element then is, it almost links back to our kind of original motivation for doing this is what happens when people decide to change but don’t have a mechanism for assessing that improvement. So we’ve devised a sort of owner involved approach which seeks to define clinical outcomes for a select group of patients within each practice.
For example, if someone did decide that they wanted to stop treating with antibiotics for acute diarrhea, this might give a mechanism where they recruit owners to this platform and then can follow them up 7 days, 10 days later. See actually how well the animals did, whether they were or were not prescribed antibiotics. And what we hope is that these three areas together will kind of provide the learning, the benchmarking, and then the patient, well owner reported outcomes for other client reported outcomes that might just support vets if they are deciding to make these sort of behavioral changes in practice.
Pam Mosedale:
That’s really interesting using client reported outcomes. That’s very much like the Canine Cruciate Registry that we also have at RCVS Knowledge. I think that’s great to actually involve clients and it would surely help practitioners with these discussions with clients too. So the resource, was it going to be, I mean we have Farm Vet Champions and that is lots of different webinars. Is this going to be lots of webinars online? How will it work?
Angie Rayner:
Well I think that the learning platform itself has been really wonderful in bringing together a whole host of people who’ve been working on the topic of antimicrobial stewardship for many years. And so bringing a lot of people together to bring in their knowledge and expertise, especially on very clinical, syndrome based or clinical problem based focus. And so some very sort of bite size webinars to watch, you can hone in on specific conditions that you would like to know more about. But then equally, armed with that knowledge, you can then focus in on what it is that you want to know, what it is that you want to audit.
And we’re also discussing potentially starting out with a national approach to using this audit platform to focus on specific conditions first so that we can really hone in on and focus on what we want to learn, what we want to know and how we can improve in these specific areas. But then equally people can use the platform however they choose, it’s pretty flexible as well. So we’re leaving it open to people and how they want to use it. But it’s a little bit of learning and a lot of practical application on auditing our prescribing usage.
Pam Mosedale:
Sounds like great CPD for everyone, is it just aimed at vets or other members of the team too?
David Singleton:
No, absolutely. So we very much hope that this will be vets, vet nurses, the whole practice team can get involved. I do a little bit of sort of work in the medical world and it seems to auto often be the nurses particularly that are really kind of lead enthusiasm drive for clinical audits and I think that’s something that certain profession where we’re trying to get the whole team involved. But I think that’s a real step to be taken, I guess with this project to ensure that we do involve the whole team from the very beginning because they all can have an impact on AMR.
Angie Rayner:
The reception team too, the client care team that have, are well-placed also to have to reinforce the conversations that are being had in consultation rooms. Reception, they’re the gatekeepers to everything really. So they’re really well-placed to engage clients in that conversation too.
Pam Mosedale:
Yeah, I agree. I think they’re the ones who are going to have the odd client complaining because their animal didn’t get antibiotics. So if they understand what it’s all about, I think that’s really important.
David Singleton:
Absolutely. If you also often hear the client who was nice to the vet who then turned around to the receptionist and maybe was a little bit more blunt, shall we say. It’s important to remember that, you’re right.
Pam Mosedale:
So it sounds brilliant and all that free CPD and sounds like a fantastic learning platform and resource. What do you hope that it will actually achieve? What do you hope VetTeamAMR will achieve?
Angie Rayner:
I mean I’m really excited about it because really I hope it’s a place where we can bring together the whole of the UK vet profession to really learn from each other, collaborate with each other to learn what steps can we take to improve stewardship in our practice and with our prescribing. And because there’s so much power within a group of people who are united in a shared purpose. And so for all of us to be able to do that is a pretty amazing thing. And equally when we can demonstrate the change that we’re making, what a great thing to be able to celebrate but also share with other professions, other industries who can take this, our experience and our knowledge and potentially apply it to what they’re doing and so our reach can really hopefully expand. David, what about you? What do you think?
David Singleton:
I was thinking personally, I’m really interested in seeing what happens with the client’s involvement, particularly. I think although the Canon Cruciate Registry is a really good example of this journey beginning almost of involving clients in clinical quality improvement. I think it’s still quite relatively, it’s been quite uncharted waters and understanding more about, I think what I hope to be at least an untapped enthusiasm for bringing clients along to the betterment of canine, and well, animal welfare in general. I think that’s going to be something that could be very interesting and we certainly do hope we’ll be successful.
Pam Mosedale:
So is antimicrobial resistance a big problem in companion animal practice do you think?
David Singleton:
Oh, very, very good question Pam. I almost want to start answering by, I guess considering the global picture and maybe slightly frustrating, normally go straight to humans, we do know that resistance is a building problem in humans. At the moment there’s quite recent estimates from 2019 of around 1.2 million people per year die from resistance infections, which is almost an unimaginable number to be honest. And that is predicted and indeed on course to rise to 10 billion people per year by 2050, which would place resistance as the leading cause of death globally. That of course those are some scary figures, aren’t they? But I think what we do know is that any prescription of antibiotics is a risk factor for development and dissemination of resistance. And we should come with the bigger global view of saying that actually whether or not almost, resistance is the individual problem in the animals that you treat.
We all have a collective responsibility to ensure the antimicrobials are used responsibly. I guess that’s the global picture. If you go down to companion animals, perhaps the water does get a little bit more muddy at this point because in many respects the burden of resistive infection in animals and companion animals are kind of unknown, I guess. There are various sort of factors that surround that, such as a relatively low rate of undertaking bacterial, cultural, and susceptibility in practice for quite often pragmatic reasons. But it does underline an issue of us actually saying, okay, what is the burden of resistant infections in these species. That said, there are increasing reports of resistant infections in dogs and cats and other companion animals and they are causing a building level of concern. I think people in practice would recognize it, pick up more of maybe a daily or weekly feature of the practice life rather than a monthly or annual feature that practice life, for example. I don’t know, Angie, if you want to say anything from your perspective.
Angie Rayner:
I think, not sure of the prevalence, I think that’s more your area of expertise, David, but I think certainly, we know it’s the overuse and misuse of antibiotics that really contribute to resistance and what can we do as individuals to really try and do our best to prevent that from happening and use antibiotics responsibly. And when we do that we’ll either we have something to learn or something to share and so we have then a responsibility to do one of those things. And so by reflecting on our prescribing, if there’s room for improvement, great, let’s learn on how best to do that. If we’ve done it, then let’s share that learning. So yes, for me, I suppose it’s knowing that look, this is, as you said David, it’s a global health threat that will likely touch every single one of us in some way or another in the coming decade or decades and we have an opportunity to try and do something about that. So that’s why we’re here.
David Singleton:
Absolutely. But perhaps there’s another slightly different perspective as well, which is almost wider than AMR, but at least in my sort of experience it’s proven to be quite a good, you could kind of call it a use case almost for quality improvement because of this fairly dire predictions I guess for the future. It’s focused minds and focused efforts across professions to really try to make improvements. And I think that can almost, in terms of a more of positive message, I guess that can be understated, that with improvements in prescribe, in comes improvements in infection control, isolation procedures, I won’t list all the areas of practice it could also improve. But there are improvements I think that can kind of be catalyzed by the issue of AMR.
Angie Rayner:
Yes, yes. And we know we’ve shown that we can affect change, we can do it. And having those focused minds, and as you say David is really beneficial on that respect. And this is a way to, I guess this platform is, learning platform and on platforms are a way to facilitate that.
Pam Mosedale:
Yeah, absolutely. And that’s really interesting because I think people think about using antibiotics, but infection control is so, so important. I think that’s something that we learned during the COVID pandemic too. So it’s not just about the antibiotics and it’s not about not using them, is it? It’s about reducing and using them responsibly.
Angie Rayner:
Yes, that’s right. I think David and I have had long conversations about this, David, about even when we’re thinking about benchmarking, because benchmarking is something to sort of gauge progress by potentially, but equally there’s really value in knowing your data and understanding it. Why do you have the results that you do? And getting below the benchmark may not always be the right thing for you. It’s about understanding what’s appropriate. And this is what we’ve really tried to build into the audit platform is can we demonstrate appropriateness and facilitate people knowing whether or not it’s appropriate in a fairly straightforward way. David, what do you think?
David Singleton:
Absolutely. It’s funny you’ve touched on this, Pam, really because it was part of the underlying thinking between the client reported outcomes feature of VetTeamAMR. Because yes, we could look at outcomes following prescribing, but that can also involve safety related outcomes as well, as I think I’m certainly not going to attempt to mind read a profession. That would be a bad, very unwise thing to do. But I think in at least many, many vets minds when they’re deciding not to prescribe, it’s the risk balance, isn’t it? What happens if I do? What happens if I don’t? And at the moment I think possibly the scales are slightly more balanced towards the risk being perceived as being lower if you do prescribe just in case. And that’s considering not having guaranteed follow up and other features of practices is understandable, but I can’t see it as at least part of our job to try to rebalance those scales to help vets in practice.
Angie Rayner:
And close the loop. That loop of understanding and learning around, okay, I’ve prescribed or I’ve not prescribed what happened, and be able to use that learning potentially next time when you’re faced with a similar situation.
Pam Mosedale:
And quality healthcare, veterinary healthcare should obviously be safe and effective, but it’s also got to be sustainable, hasn’t it? And there’s an intersection here a little bit I think was sustainability and animal welfare really, majorly because if these antibiotics start not working for the animals, then we have an animal welfare issue too.
Angie Rayner:
Yes.
David Singleton:
You’re right. I was almost quite surprised, there was a meeting last year which was representative of various practice groups and it was interesting that I think largely independently, they put AMR within their sustainability goals within their practice vision or strategy, whatever word you want to use. I think it’s interesting because I’ve kind of always equated environmental causes with AMR a little bit in my mind. And it’s interesting to see that actually taking place at a business level as well, I guess.
Pam Mosedale:
So how can practices actually get involved in this? When will they be able to access these things?
Angie Rayner:
Well to get involved, currently what we’re asking practices is to register their details on the website to be kept up to date with what’s happening and they can go to rcvsknowledge.org/VetTeamAMR there is a date for the equine platform to be launched and that is June 6th. And there’ll be some more details forthcoming for those who are interested in the equine platform, but equally then for companion animal, there is a date in the books for June 20th and there will be more details coming out then. So if you register your interest, you’ll be sent that information, equally of course on RCVS Knowledge social media channels that it will also be promoted there.
Pam Mosedale:
And I suppose we just want everybody to get involved. It’s obvious that both of you are so enthusiastic about this and it’s such a massively important subject mean those figures that you quoted David were so scary, but it’s really, really important. And the thing we maybe haven’t mentioned is these resources are free because of the help that we’ve had. RCVS Knowledge, we’re a charity and also from CMD that have financed this work too. So the resources are free, so why wouldn’t people want to access them?
Angie Rayner:
Yes, exactly. And access the information and talk to your team about it. How can each person on your team get involved and talk about why it’s important and that usually motivates people to get involved.
Pam Mosedale:
David, have you got any last words for our listeners?
David Singleton:
I’m tempted to go very inspiration, go VetTeamAMR. And keep it simple. Keep it simple like that.
Pam Mosedale:
Go VetTeamAMR.
David Singleton:
I think in truth, I couldn’t say it better than Angie just has. I think particularly that whole team involvement, I think it’s something that maybe we didn’t touch on very much with the trial that inspired this, I guess it did seem that’s starting those practice conversations, giving people time to consider cases and reflect and move forward. That I think as much as the data, I think it’s bringing the team together, which is important.
Angie Rayner:
Absolutely.
David Singleton:
We’ve seen in other areas of life that when you bring minds together, you bring enthusiasm together, you can make real impact on what we really hope is that VetTeamAMR is going to be one of those.
Pam Mosedale:
Excellent. So everyone together, we can make a difference to this.
Angie Rayner:
We can.
RCVS Knowledge:
Thank you for listening to this VetTeamAMR podcast from RCVS Knowledge. Visit rcvsknowledge.org/amr for free CPD, benchmarking and audit tools to improve your antimicrobial use.