6 min read November 15, 2016 at 7:09am
I spent yesterday in Brisbane at this year's Antimicrobial Resistance Forum. As with last year, it was a joint project of the Queensland Statewide stewardship team, UQ IMB's Centre for Superbug Solutions and the Queensland Health Communicable Diseases Network. It's an excellent forum - one that I don't mind treking down to from Remotesville, FNQ - it's a great chance to catch up with people in the field, and I had grave concerns that my brain would have dribbled out my ear if I'd attempted a second all-day video conference in a week (you can see my storify from the NCAS forum last Wednesday here and here). Alas, I didn't have the wifi password until after lunch (thanks for providing it, Minyon!), so there was no live tweets from the morning sessions. You can see my tweets from the after-lunch sessions here, and I've also done a storify of the conference hashtag (although I kept getting it wrong).
I won't go back through all of the day's sessions, although I've got extensive notes, and will maybe turn them into another blog post some other time. I will talk a little about two of the morning keynotes, though. The second was from Chris Baggoley, who is an emergency physician by training, but until the middle of this year, was the Commonwealth Chief Medical Officer. His contribution to getting Australia into its world-leading position on antimicrobial stewardship can't be understated. During his time at the Commission, he was instrumental in getting antimicrobial stewardship onto the list of national hospital accreditation standards. Most of Chris' talk was a rather dry and somewhat unneccesary overview of the National Antimicrobial Resistance Strategy's Implementation plan , released last week. I read it again on the plane on the way down, and share the opinion of some of my colleagues that it's less a plan and more of a laundry list of activities in the stewardship space. He did recommend you all read the Chief Scientist's occassional paper on AMR, as an excellent introduction to the topic.
What he did that I'll share was an excellent puncturing of the oft-repeated opinion that the airline industry is ridiculously safe, why can't healthcare be just like that?These are his themes, but many of the words are mine.
The purpose of an airline is to convey passengers along a known route at a known time (give or take), without immolating, decompressing or crashing into unmoving terrain features or other moving aerial objects. It does this using well-maintained machinery which has known fuel consumption and performance given a known load and is full of extremely well-trained staff and a strong checklist culture. Passengers purchase one of a more-or-less fixed number of tickets, present themselves for processing and boarding in what sometimes could generously be described as an orderly fashion. If demand exceeds supply, customers are invited to present at another time. Excess demand is not managed by seating customers in the aisles, toilets or the baggage holds. Variables include the weather (which is forecasted as best as can be and measured on an ongoing basis), unexpected equipment failure and human error.
Contrast this with a hospital emergency department, in which an unknown and randomly distributed number of patients present with an undiagnosed complaint which may represent a number of clinical entities (or none at all). There are variable severities and rarely any 100% accurate diagnostic tests. Diagnosis is usually probablistic and heuristic, and despite this is done best by fallible humans. Management is largely based on previously accumulated experience, sometime further evaluated by clinical trials into what we call evidence (which is also fallible and frequently poorly understood). Excess demand is not deferred, but is managed by triage and by parking less acute patients in corridors, non-clinical areas, and in the worst case, by delaying their entry, leaving them to be managed by paramedics in the ambulance bay.
So please keep your airline industry analogies to yourself.
The other keynote speaker was by Matthew Ames, a consumer advocate. Matthew worked in the oil and gas industry as a safety officer, and shared with us some info about the DeepWater Horizon incident. Most (if not all) system failures occur due to an accumulation of multiple errors. One of the important errors in the DWH incident involved monitoring an important safety marker. This was sufficiently important that - although not particulary complicated, was done by a very experienced worker. On the day of the incident, the senior person was taking management on a tour of the rig to review other - less important - safety issues, leaving the monitoring of the critical process to a more junior staff member. Bad things happened, were not recognised early enough, leading to very bad things indeed.
The message was clear - stay focussed on the issues that are truly important.
Matthew then went on to share his own story with us. One day in 2012, he developed a sore throat. He saw his GP, who diagnosed a likely viral infection, reassured him and sent him on his way. When he failed to improve, he presented to another doctor and was given similar advice. By the time he presented to the emergency department, he was critically ill due to toxic shock syndrome, caused by Group A Streptococcus, and spent nine months in hospital. During this time, his wife was asked to consent to the amputation of all four of his limbs (but still with only a 10% chance of survival). He spoke to us today from his electric wheelchair, with bilateral arm prostheses and an attitude that I am still completely in awe of.
Antimicrobial stewardship is not about reducing antibiotic use. It is not about saving money, or reducing length of stay. It is not even primarily about preventing resistance, although we certainly hope that it will. Antimicrobial stewardship is about improving patient care. Improving diagnostics, so we can better predict people who truly need antibiotics, and give them the best drug, in the right dose and at the right time. It's about doing so in a way that reduces adverse effects of antimicrobials to these patients, and making sure that people who don't need them aren't exposed to that risk at all. It's about preventing infections - with vaccines, with hand hygiene and infection control and by improving people's overall health so their risk of infection is reduced.
And it's about ensuring that - if all of this is unsuccessful and the future comes to pass in which you are a patient, then we still have effective antibiotics available, which we can use to treat you, too. So thanks to Matthew for sharing his story, for reminding us why we do what we do - and why it is so very, very important.