Thank you, Mr. Chair.
Good morning, Mr. Chair, and members of the committee. My name is Karey Shuhendler. I'm a registered nurse and policy adviser with the Canadian Nurses Association, the national professional voice for over 139,000 registered nurses and nurse practitioners in Canada.
I'm pleased to be here with Yoshiko Nakamachi, who is with us today as CNA's antimicrobial resistance nursing expert. She will be able to answer questions that may be more technical in nature. Yoshi currently serves as the antimicrobial stewardship program lead and program manager at the Sinai Health System and University Health Network antimicrobial stewardship program in Toronto. She has also worked with community hospitals to develop antimicrobial stewardship programs, is involved in a multicentre antimicrobial stewardship initiative in primary care, and is a member of provincial, national, and FPT antimicrobial stewardship committees.
At the outset, I'd like to thank the committee for studying this important issue and for giving CNA the opportunity to speak on behalf of registered nurses and nurse practitioners. We have a professional responsibility to advocate for federal action on antimicrobial stewardship, henceforth referred to as AMR, as it is a major threat to the health of people in Canada and is projected to worsen over time if appropriate actions are not taken. As you may know, antimicrobial resistance occurs when an organism, like a bacteria or virus, stops an antimicrobial medication from working against it. This means standard treatments no longer work, and infections can persist and spread to others. AMR leads to increased human illness, suffering, and death; increased costs and length of treatment; and increased side effects from the use of multiple and increasingly powerful medications.
Prior to outlining our two key recommendations and taking your questions, we want to paint a picture of the impact of AMR internationally, as well as providing some national context.
The director general of the WHO has referred to AMR as a “slow moving disaster”, one of the most serious threats to human health and safety. The WHO has also warned that AMR is putting the gains of the millennium development goals at risk and endangering the achievement of sustainable development goals. AMR is an issue that requires action by all areas and disciplines in health.
In its 2017 position statement on AMR, the International Council of Nurses notes:
Nurses and other healthcare workers have a vital role to play in preserving the power of antimicrobial medicines. Nurses play a central role in patient care and interdisciplinary communication and, as such, are in a key position to contribute to reducing AMR and critical for the function of antimicrobial stewardship programmes (ASP).
The statement goes on to point out that nurses contribute to assessment and diagnoses of infections, administer and may prescribe antimicrobials, monitor outcomes and report side effects, provide vaccinations, and educate patients, families, and communities.
At the national level, CNA acknowledges the planning efforts of the federal government to respond to the threat of AMR through the development of the 2014 document “Antimicrobial Resistance and Use in Canada: A Federal Framework for Action”, the 2015 document, “Federal Action Plan on Antimicrobial Resistance and Use in Canada: Building on the Federal Framework for Action”, and the 2017 draft document, “Tackling Antimicrobial Resistance and Antimicrobial Use: A Pan-Canadian Framework for Action”.
CNA has also been doing its part to combat AMR by contributing to national work on infection prevention and on stewardship. Do Bugs Need Drugs?, a community-based antimicrobial stewardship program in B.C. and Alberta, defines “stewardship” as:
...the practice of minimizing the emergence of antimicrobial resistance by using antibiotics only when necessary and, if needed, by selecting the appropriate antibiotic at the right dose, frequency and duration to optimize outcomes while minimizing adverse effects. The principles of antimicrobial stewardship apply wherever antimicrobial agents are used including hospitals, long term care facilities, community medicine, agriculture and veterinary use, and in the home and community.
CNA's efforts in this area include membership and participation on the antimicrobial stewardship or AMS Canada steering committee, and engaging in the Canadian Roundtable on AMS to develop a Canadian multidisciplinary, multi-sectoral action plan on antimicrobial stewardship.
We are also active participants in the federal-provincial-territorial AMR stewardship task team to develop a pan-Canadian framework and action plan. In addition, through partnering with Choosing Wisely Canada, a national program to engage clinicians and patients in conversations to reduce overuse, CNA has developed a broad list of nursing recommendations to reduce the use of tests, treatments, and interventions that may lack benefit or cause harm. Several of these recommendations advance the AMS agenda, including recommendations to reduce inappropriate or unnecessary use of antimicrobials.
CNA is planning to release a speciality Choosing Wisely nursing list, in partnership with Infection Prevention and Control Canada. This list includes recommendations to reduce the use of interventions that can lead to infection, as well as reducing inappropriate laboratory testing, which can lead to unnecessary use of antimicrobials. It also includes stewardship recommendations focused on reducing inappropriate antimicrobial use.
Despite work done by CNA and other partner organizations across the county, additional effort and investment is required by the federal government to further address antimicrobial use and resistance. Of particular note is the need to emphasize an interprofessional approach to stewardship that includes nurses, in collaboration with physicians, pharmacists, patients, and caregivers, as a cost-effective preventative approach to AMR.
We have two key recommendations to address the issue of AMR in Canada with a focus on stewardship. We encourage the committee to include these recommendations in your final report on this important study.
Our first recommendation encourages the federal government to support the 10 action items on antimicrobial stewardship put forward in HealthCareCAN and the National Collaborating Centre for Infectious Diseases document entitled “Putting the Pieces Together: A National Action Plan on Antimicrobial Stewardship”. The 10 items are outlined in CNA's brief, but also nicely summarized by Dr. Morris.
Our second recommendation urges that the federal government commit to providing significant funding over the next five years to support scaling up of antimicrobial stewardship programs across acute care and community-based settings in the provinces and territories, conditional on an accountability framework, and that the federal government support the role of nurses in antimicrobial use, resistance, and stewardship.
Why is funding needed? Historically, education and reform around antimicrobial use and stewardship has been targeted to physicians and pharmacists but not to regulated nurses, who make up the largest group of health care professionals in Canada.
According to the Canadian Institute for Health Information's report entitled “Regulated Nurses, 2016” and released just last week, there are more than 400,000 regulated nurses in Canada. This number represents over 100,000 licensed practical nurses, approximately 6,000 registered psychiatric nurses, and nearly 300,000 registered nurses, including 5,000 nurse practitioners. Nurses are present in every health setting. They are well positioned to contribute to antimicrobial stewardship, for the preservation of health and the improvement of health outcomes for all people in Canada.
I would like to close with the reminder that antimicrobial resistance is a national and international issue with local implications. Every person in Canada, including those who live in the ridings that each of you represent, is not immune from the evolving threat of AMR. That is why immediate action by the federal government is required.
CNA encourages the Standing Committee on Health to urge the federal government to adopt all 10 expert-developed recommendations in “Putting the Pieces Together: A National Action Plan on Antimicrobial Stewardship” as a key component of addressing antimicrobial use and resistance in Canada.
Furthermore, the federal government can take additional concrete action by investing in established AMS programs with proven results to reduce inappropriate antimicrobial use, and by investing in the education of nurses to leverage their potential as antimicrobial stewardship leaders across all health settings in Canada.
Thank you.