Get your sticks together

This is article twenty-six in an RCVS Knowledge series of features on patient safety, clinical human factors, and the principles and associated themes of Quality Improvement (QI).

‘Sticks in a bundle are unbreakable’ – Bondei proverb.

Tom is a vet on a mission - to improve antimicrobial stewardship in his practice. Lately it seemed that the cats in the local area were having a turf war and he noticed that a great deal of them were being prescribed long-acting injectable antibiotics, that were considered highest priority-critically important antibiotics (HPCIAs), for cat bite abscesses.  Fair enough, he thought, it’s easily done when treating cats – clients like to avoid the sharp ends of animals.  The more he looked, the more he found that all cats with cat bite abscesses (CBAs) had received some type of antibiotic.

A recent webinar, that was promoted by the quality improvement department, rang alarm bells about the current threat of antimicrobial resistance (AMR) to human and animal health, and he had started to question if this common approach to CBAs was the right one. It was important to avoid the misuse and overuse of antibiotics.  But if this current method wasn’t right, then what was? He reached out to a specialist in this area who helped him develop a clinical guideline that outlined when antibiotics were indicated and importantly, when they were not. 

Tom had also accessed RCVS Knowledge resources on clinical audit and thought that this would be the best method to affect change, as he wanted to build his confidence using a different course of treatment, and this would provide him with the necessary data to do so. In order to meet the standard as outlined in the guideline, he thought about what ideas to test that would influence change and decided that the first one would be to involve clients in the conversation about the risks of AMR when discussing the need (or no need) for antibiotics.  He already knew that he was starting from a benchmark of zero when meeting the standard, so he set a goal of achieving it 80% of the time and planned to reassess his progress in a month’s time.

Tom tried out his new approach in one patient, and then another with good success, he found that these two cases didn’t require antibiotics and clients had been happy with this approach. He spoke to a couple of his colleagues about his experience – but they didn’t bite. N=2 was not enough to change their mind; surely clients expect antibiotics, and the cats would be back in a few days needing them anyway. Tom shrugged and carried on. Several patients later, he knew he was on to something, but who would join him? He knew that he needed roughly 25% of his colleagues to adopt the new standard for change to gain momentum.¹

He then thought of his colleague Emma, who shared his passion for responsible stewardship. ‘If Emma will join me – then we can learn from this together and double our influence’. Thankfully, Emma enthusiastically said yes.

A few months later, the turf war had escalated, and they had seen a larger number of cases. Tom and Emma shared their results of their audit with the whole team. Encouraged by these results, the rest of the team decided to give the new approach a try. Having a process in place for assessing patient outcomes gave them the confidence to ensure that any negative effects would be quickly addressed.

The team decided to test a few more ideas. To encourage more conversations about AMR, they decided to hang a poster in each consulting room; 'Ask us about our cat bite audit'. This had an additional benefit of clients asking what the audit was about without any prompt from the clinician. The team also valued clinical case discussions and decided to expand this peer support aspect to include the whole team in talking about antibiotic use. Nurses played a key role in the audit when seeing the cats back for rechecks to evaluate their recovery and the reception team got involved too by supporting the AMR message with clients in their post-consultation chats. 

Results: In the 6-month period of the audit, implementation of the new clinical guidelines was successful. Clinicians had grown their confidence in not using antibiotics for cat bite abscesses and the team had become stronger in the process.  An added benefit was that long term injectable antibiotic use had decreased.

Tom and Emma’s practice was part of a large veterinary group and news of the audit traveled to nearby practices.  Now two more practices had joined forces, increasing the impact three-fold.  Tom started to dream big about the influence this audit could have across the group and even more widely across the profession.  He reached out to the quality improvement community for help in sharing learnings and recruiting more participants and applied for an RCVS Knowledge QI Award in AMR to celebrate what they had accomplished. 

Tom, being very proud of these results, looked back on the start of this audit. This was a real example of a community coming together for a shared purpose. Starting from a webinar that sparked an idea, that drew in collaborators, to the whole practice team - which included clients, whose reach grew even farther to the wider profession. Without the collaboration of the people involved, he would have never achieved alone, what they had achieved together.  The team, or community, is stronger than the individual just as sticks, when gathered in a bundle, are unbreakable.

There are many examples of people coming together with a common goal; building a community and using it to realise the change they want to see in the world.  A local community who wants to have a positive effect on the environment will plant trees.  Not only does this benefit itself through natural beauty and fresh air, but there are also wider, indirect effects such as helping to reduce global warming.   

When you see the need for change, it may be easier and feel safer to not shake up the status quo, but the most likely way of reaching our destination, of a world where AMR is no longer a major health threat, is to join forces with those around us.  There is always help out there, you just need to look for it, and it often comes from the people with the same ideals as you.  Bundle your sticks and build your community, there is incredible power to be harnessed when we choose to work together. 

Checklist: What can you do next?

• Read about a trial published in Nature in 2021 which demonstrated effective strategies for reducing the prescription of ‘last resort’ antibiotics in veterinary practice. These findings are being used to inform RCVS Knowledge's VetTeamAMR project. 

• Learn more about VetTeamAMR, a major collaborative project, kindly sponsored by the Veterinary Medicines Directorate, that aims to reduce the development and spread of antimicrobial resistance by uniting and empowering companion, farm, and equine veterinary teams in the responsible use of antimicrobials.
• Visit the AMR Hub, where you can find freely accessible evidence-based knowledge, tools and resources about the responsible use of antimicrobials and support for embedding good antimicrobial stewardship in your practice.
• Download and use the RCVS Knowledge Antibiotics: Self-assessment checklist. Adapted from the Public Health England and Royal Collage of General Practitioners framework, this checklist aims to help vets better understand their antibiotic usage.
• Access our free Managing Veterinary Medicines: Staying Legal and Promoting Safety course in collaboration with the Veterinary Medicines Directorate (VMD), offering 6 hours of CPD for veterinary teams to improve their medication safety in practice.
• Listen to The Knowledge Session: Antimicrobial Resistance. Recorded for World Antibiotic Awareness Week in 2019, this roundtable discussion focuses on the challenges we face and the ways we can tackle antimicrobial resistance for the benefit of our patients, and society.
• Read our previous QI Feature ‘Maximising welfare benefits by contextualising case management’. Contextualised care refers to an approach to cases within the context of the patient and owner/caregiver circumstances, combined with clinical expertise and the most relevant and best available scientific evidence. This partnership between the client and the veterinary team focuses on maximising the welfare of the patient.

References:

1.     Centola, D. et al. (2018)  Experimental evidence for tipping points in social convention.  Science. 360 (6393),  pp. 1116-1119 https://doi.org/10.1126/science.aas8827

About the author

Angela Rayner BVM&S MScPSHCF MRCVS

Angela is a Quality Improvement Advisor for RCVS Knowledge, Director of Quality Improvement for CVS, and is an RCVS Knowledge Champion for her role in improving CVS’ systems for controlled drugs auditing.

In 2021, Angela completed a MSc in Patient Safety and Clinical Human Factors at the University of Edinburgh. The programme supports healthcare professionals in using evidence-based tools and techniques to improve the reliability and safety of healthcare systems.

It includes how good teamwork influences patient outcomes, key concepts around learning from adverse events and teaching safety, understanding the speciality of clinical human factors, as well as the concept of implementing, observing and measuring change, monitoring for safety, and it focusses on quality improvement research and methodologies.