Promoting antimicrobial stewardship

This transcript is the automated English captions in the recordings. The text may not align with the audio and there may be errors the transcript.

Barbara Catt: Welcome everyone. My name is Barbara Catt. I'm a senior nurse consultant with the antimicrobial resistant task force at the Public Health Agency of Canada. 

Thank you for joining the Communicable Diseases and Infection Control webinar series. We are pleased to have you join us for today's webinar. Today we are meeting on a virtual platform and I'm joining you from the town of Georgina on lands originally used and occupied by the first peoples of the Williams Treaties First Nations. 

Please take a moment to acknowledge the importance of the land which we each call home. We do this to reaffirm our commitment and responsibility in improving relationships between nations and to improving our own understanding of local Indigenous Peoples and their cultures. From coast to coast to coast, we acknowledge the ancestral and unceded territory of all the Inuit, Metis and the First Nations peoples that call this nation home. 

As we move forward with today's discussions, let us remember our commitment to walking a path of partnership and friendship with Indigenous Peoples and remain mindful of the importance of person-centered culturally safe care that honors the traditions, languages, cultures, and experiences of Indigenous Peoples.  

Short disclaimer, today's webinar includes presentations from those external to the agency which may not reflect the views of the Public Health Agency of Canada. Also, following today's webinar, a copy of the presentation decks and recording as well as a feedback form will be sent to you. 

This webinar will be conducted in English. Simultaneous interpretation in French can be accessed through selecting the interpretation button that you see at the menu at the bottom of your screen. A few technical notes. 

Your audio has been muted to reduce noise as well as your video has been disabled for this webinar. However, if you're having technical problems and need help, you can reach us through the chat function. Please feel free to communicate in either English or French. 

If you have a question for the presenter, please submit your question using the Q&A function and we look to answer them during the panel discussion at the end of this webinar. Note, you can check send anonymously if you do not want your name attached to your questions in the Q&A. I'd like to now introduce your speakers for today. 

Tyler Good has a background in network neuroscience and cognitive psychology. He works as a Senior Behavioural Science Advisor for the Public Health Agency of Canada Behavioural Science Office. He is the principal investigator to an in-field research project led by the Agency that aims to promote antimicrobial stewardship in long term care homes. 

The second speaker is Jessica Kayitesi works at Shepherd Lodge Long-Term Care, part of Shepherd Village, the largest continuum of care in Central East Toronto, supporting over 1,000 seniors. She serves as the Senior Assistant Director of Care, responsible for the operations of the infection prevention and control program, along with other clinical departments.  

I would like to now turn it over to my colleague Jennifer Selkirk who will be providing the opening remarks.  

Jennifer Selkirk: Hello.  

As Barb introduced, I'm Jenn Selkirk, one of the team members for the antimicrobial resistant task force stewardship unit. 

Welcome to today's webinar, which is going to be focused on antimicrobial stewardship in long-term care homes. Antimicrobial resistance is one of the world's pressing threats to public health. Currently, the stewardship initiatives division is working in collaboration with the behavioral science office on a project whose primary goal is to improve antimicrobial stewardship in long-term care homes. 

Like other issues affecting public health, antimicrobial resistance is linked to socioeconomic inequities. Residents of long-term care homes are vulnerable to high rates of antibiotic use as well as antimicrobial resistant infections. Long-term care homes may also be less likely to have an antimicrobial stewardship program compared to other sectors. 

This quality improvement project will describe the results and include experience from a local long-term care home leader that participated in this project. This home recently celebrated a milestone as a best practice spotlight organization. Projects like this reflect innovation and excellence in long-term care. 

We want to acknowledge the collaboration of provincial long-term care homes in advancing this evidence-based practice antimicrobial stewardship initiative. I will hand it over to Tyler and Jessica to start the presentation.  

Thank you. 

Tyler Good: Thank you very much, Jenn.  

Hello everyone. Let's take a second to get set up here. 

We're excited to share results with you today from this project. We'll start by sharing some background on AMS and Canadian long-term care homes and then provide an overview of the project structure. We'll start from the initial project scoping, move into the design and then implementation of the trial in eight long-term care homes across Canada. 

Lastly, we'll share key findings and results with you as well as some higher-level lessons learned from doing this work. So beginning with background, as Jenn mentioned, AMR is a global challenge. It was recognized in 2019 as a top 10 global public health threat by the World Health Organization. 

In answer to this global problem, Canada released the Pan-Canadian Action Plan on AMR in June 2023.  

And I'm just seeing that you're not seeing my screen. So I'm going to pause and just see if we can get that sorted. 

Okay. Apologies for that.  

In answer to the global problem of AMR, Canada released the Pan-Canadian Action Plan on AMR in June 2023. This is a five-year commitment between federal, provincial, and territorial ministers of health and agriculture to collectively combat AMR. In PCAP priority action items outline five pillars that include research and innovation, surveillance, infection prevention and control, leadership, and finally stewardship where our project falls under our project. 

Our project team narrowed further to long-term care given this is a sector that houses a vulnerable population to AMR and a sector where AMS programs are generally less established than other sectors like hospitals, for example. So, we saw a need and we saw an opportunity for improvement within long-term care homes. UTI is a foundational challenge to AMS. 

We see this in the high rates of testing and treatment for UTI in long-term care homes and the higher proportion of these tests that have been estimated to be avoidable in previous research. I also want to acknowledge that there's a rich literature of excellent AMS and IPC work introducing interventions in long-term care homes to support the testing treatment of UTI. This has been a persistent challenge and one that we approached humbly with the goal of moving the needle on this challenge. 

So with that I'd like to move forward and we can see that we know that in long-term care 40% of antibiotic prescriptions are given for UTI. It's the top indication for antibiotic prescriptions in this sector. Of those prescriptions for UTI, previous work has found about 50 to 70% of those prescriptions are avoidable. 

This means that the residents that receive the antibiotics did not have the minimal clinical signs and symptoms of UTI as outlined by the modified Loeb criteria. Testing for UTI through urine cultures antibiotic use is highly variable across long-term care homes and higher use of both has been tied to greater risk of antibiotic related harms like stomach upset, rash and c-difficile infection. So our project aimed to improve antimicrobial stewardship in long-term care homes. 

By decreasing testing and treatment for urinary tract infection that is not aligned with guidelines. With that, we're pleased to have Jessica here with us. She's the assistant director of care at Shephard Lodge as we've mentioned. 

Jessica, could you share some of your experiences with AMS and UTI working in long-term care?  

Jessica Kayitesi: Thank you, Tyler. It was such a pleasure for our home to be included in this initiative. 

We did realize very quickly that implementing AMS in our home would require basically more than education as the concept is was quite new based on a small survey we conducted earlier on when we first started. A significant challenge for us was many individuals including our families, our staff had limited understanding of what antimicrobial stewardship was. We found that this knowledge gap created unrealistic expectations regarding antibiotic use and urine culture prescriptions. 

And some of the other challenges we had was around prescriber variability having prescribers with different experiences, different prescribing habits and other inconsistencies to adhering to AMS protocols. There was also some misalignment between acute care, primary care, but also long-term care that resulted in conflicting recommendations. And of course our the diagnostic uncertainties that come with non-specific and atypical presentation of symptoms in older adults complicated some of the clinical decision making. 

We as a home also realized that we lacked a robust real time data auditing mechanism limited that limited our ability to monitor adherence and drive continuous improvement.  

Back to you Tyler.  

Tyler: Thank you Jessica. 

I appreciate it. and from there so we'll dive into project a look at the project structure we used the impacts project life cycle to guide our work as we used to guide all of our work here at the behavioral science office at PHAC. We started by identifying a behavioral opportunity in this case optimizing the testing and treatment for UTI in long-term care homes. 

We explored this through stakeholder interviews and literature review, formalizing our understanding of the barriers and drivers relevant to the challenge with a series of mapping exercises from a big picture system map narrowing to a behavioral map and then finally a cognitive map of key actors. Working with an advisory group of healthcare worker experts in AMS and long-term care, we then developed a protocol and piloted this in a single long-term care home. We refined our protocol based on the pilot and then launched a stepped wedge trial in eight long-term care homes across Canada to evaluate its effectiveness at decreasing testing and treatment for UTI that was not aligned with guidelines. 

This graph here is an excerpt from our high-level systems map and we're showing it because in our scoping work, we identified barriers and drivers in UTI management and long-term care homes. With our advisory group, we identified three priority barriers where we saw opportunity for behavioral science intervention. 

They were first expectations of essential care providers or ECPs. This is the name we give to the group mostly typically family and friends of residents but could also include paid care aids. 

And the barrier here was expectations of this group for testing and treatment when it may not be warranted. Secondly, we saw perceived risk of negative outcomes given the choice not to test or treat that staff or ECPs may feel. And finally was lack of staff capacity which we saw as an overarching barrier that affected our entire approach to the protocol. 

To address our priority barriers, we co-developed a two-pronged quality improvement approach focused on the upstream diagnostic test for UTI, the urine culture order. First, we developed educational materials for ECPs that strive to provide a positive role for these important caregivers in UTI management as allies to AMS. 

Second, we developed education and a monthly facility level feedback on rate of urine cultures in alignment with guidelines for all clinical staff. The goal here was to reinforce knowledge about the current clinical gold standard and reassure staff about perceived risk of following these guidelines. Following a pilot in a single long-term care home, we rolled out our protocol in eight large long-term care homes across five provinces in Canada, we collected one year's worth of retrospective data from the homes at as a true baseline at the onset of the project. 

And then the homes began the step wedge. All homes started in the control phase where usual care was given then moved to the transition phase where the quality improvement strategies were brought online before moving into the intervention phase proper. Lastly, we collected one month of follow-up data four months after the intervention phase was complete to give us an opportunity to assess long-term changes. 

To evaluate the success of the project, we conducted a mixed method analysis. Our key quantitative measures were monthly data on urine culture rate signs and symptoms per prompting each culture which we used to estimate alignment with guidelines antibiotics ordered and balancing measures like hospitalizations. To nuance and to extend our quantitative findings, we also collected qualitative data. 

This included optional questionnaires that were distributed to ECPs and staff as well as semi-structured interviews with three to six staff at each home in various roles including non-regulated care providers, nursing staff, administrators and physicians. We also had held two small focus groups with ECPs across the homes to understand their perspectives. Drawing from that qualitative data, there were some key contextual factors that shaped and influenced implementation of the intervention. 

First, we heard from various sources about the importance of a care team approach and positive interprofessional relationships and caring for residents and following best practices. Related to this was the importance of knowing the residents well so that a staff person could effectively identify subtle changes from baseline. Secondly, during the study period homes dealt with competing demands as you might expect. 

Our intervention began in the summer so we dealt with summer holidays. then moved into the fall where we homes worked with dealt with outbreaks vaccination campaigns, accreditation processes as well as some staff turnover. 

Our approach to implementation was to share study materials with all homes alongside suggestions for distribution, but we also encouraged homes to adapt this distribution to better match the specific needs and contexts of their homes. Although this introduces some variability in implementation specifically in terms of how the education took place on the ground, it also provides for homes to take greater ownership of the project which we felt was important. On this slide you'll see some examples of our suggested approaches for staff facing materials like our poster outlining the low year criteria and the monthly year and culture report and how and how homes adapted this these materials to their context. 

And here you see the same for ECP facing materials, these included a poster, a few different handouts, and materials to support staff educating families. You'll be able to see screenshots of all of our materials in the appendix of the deck, which we'll share after the presentation today. 

Jessica led the implementation at Shephard Lodge, and I'm wondering, Jessica, if you could speak to some of the specific challenges in implementing this project. at Shephard Lodge and how you tailored it to your home.  

Jessica: Thanks Tyler. 

So I did speak about the challenges earlier. So I'll focus on how we tailored the intervention to our home. So to build momentum for antimicrobial stewardship in our home, we began by demonstrating why it mattered. Highlighting the impact on our residents, our staff, but also the families. As most of our most of our residents do our families are actually the ones that make decisions on their behalf. 

So that was very important. We were fortunate to use some of the allocated funds to hire a team member passionate about the AMS who became very dedicated leader to support the culture at the front line as most especially for our essential care partners and to reinforce that best practice. Our approach was quite multifaceted. 

It changed as we went. We implemented tailored training collaborating with Public Health Agency of Canada to provide in-house education. This education was provided to every person that works here and lives here that could attend which was particularly impactful because long-term care is often perceived as overlooked and seeing representation from the Public Health Agency of Canada coming into the home and our family councils with their expertise on site reinforce the importance of AMS to both our staff and families fostering that engagement and buy in from the outset. 

Now education that we incorporated, we used real time scenarios open communication for our families and opportunities for our staff really to discuss. We consistently looked for ways to reinforce learning. For example, early in the project, we identified gaps in, you know, families understanding or even our staff. 

So, we created a quiz, [phone ringing] sorry, we created a quiz and structured Q&A sessions tailored to their needs. And through those meetings that Tyler was talking about, we were able to discuss some of the things that some of the questions that came out of the Q&As. [phone ringing] sorry. 

That's long-term care. We always carry so many hearts. So, sorry about that. 

AMS was integrated into staff huddles, morning risk reports, professional advisory committees and resident circle of care forums. Providing that repeated touch points for reinforcement. One of the unexpected successes we were having a hard time getting a hold. 

We wanted to capture all of our families that who have who's for whom the residents live here. It was hard to get some of us our essential care partners. So we worked with Public Health Agency of Canada but also some of got input from some family members to come up with a video that an educational video that was only 7 minutes long and one of the family members actually said, "Oh, I'm glad I watched this video because I thought I was going to be sitting down for a lecture."  

So being able to tailor and change the education just to meet the needs of our staff and families quite worked quite well and for sustain for sustainability of these changes was supported through ongoing that in-house training review of the urine culture reports that we got every month and continued reinforcement like looking at the report for the morning and looking at which residents are going to be slotted for urine cultures and making sure that actually they meet the criteria that helped when we had the staff in house. 

So by continuously identifying learning needs and adapting education need their education needs and tools were ensured that AMS principles were meaningfully integrated into the culture of our home.  

Back to you Tyler.  

Tyler: I could look at the demand of long-term care. 

So moving on to some results and lessons learned from the study. Our primary outcome measure was rate of urine cultures sent. You can see that the pre-intervention adjusted rate of orders was 1.87 per thousand resident days. 

A number which I think is relatively low compared to the literature. We did not see a statistically significant decrease in urine culture ordering during the intervention and follow-up periods compared to the pre-intervention phase as we as we expected. So it was null. 

There was moderate variability across long-term care homes in the effect of the intervention and follow-up, but no single long-term care home had a significant reduction in culture. We also investigated differences in the rate of antibiotic prescriptions for UTI across the experimental conditions. While results were again not statistically significant, the descriptive stats did show that the rates of prescribing antibiotics for UTI were lower in the intervention and follow-up phases compared to the control. 

Furthermore, we also saw a statistically non-significant 16% decline in rate of antibiotics for UTI during the intervention. So in some while the results are null we did not see significant effects of the intervention we were encouraged to see some prescribing trends that were trending in the right direction or the expected direction I should say. Our exploratory analyses considered the alignment of urine culture orders to guidelines. 

Data availabilities made this possible in seven of eight homes which we were pleased about. We estimated alignment by comparing documented signs and symptoms at the time of the order with the modified Loeb minimum signs and symptoms of UTI. The bar plot here shows average alignment across all of the homes. 

You'll see that during the control phase, 23% of cultures were aligned. Though this increased to 28% during the intervention. So it's a 5-percentage point increase in alignment. 

This was not statistically significant but encouraging another trend in the expected direction. We were also pleased to see that the percentage of cultures with insufficient data to estimate alignment decreased from control to intervention. This ran parallel to what we heard in interviews with some stakeholders that the project increased the attention to and quality of data collection. 

So though we didn't see a significant difference in alignment across experimental conditions, we did find significant variability across long-term care homes. Homes ranged from a 17-percentage point increase in alignment from controlled intervention to an 8-percentage point decrease. There was no statistically significant intervention effect at the individual long-term care home level in any of the homes. 

However, there was significant between home variability in the intervention effect. So we can say that we did see some evidence of a heterogeneous response to the intervention across the long-term care homes. We were interested in the correlates of long-term care home responsiveness to the intervention. 

So we performed some additional analyses, exploratory analyses I should qualify. First, we found that a longer intervention period was associated with larger increases in alignment from the control to intervention phase. The average difference in alignment between intervention and control is plotted here for each cluster of homes. 

The cluster one homes spent the longest time in the intervention 5 months compared to the cluster four homes that had just two months in the intervention phase. And accordingly we see the cluster one homes had greater responsiveness. This was also supported by the qualitative findings. 

A theme that emerged was that meaningful change on this issue would require culture change and we know that this is something that takes time. With a longer intervention period, we're able to reach more people. We can have more repetition of education, which is something some staff noted to us as being important. 

It can also absorb the effect of competing priorities like accreditations and outbreaks which can sideline non-essential quality improvement projects like this one. And it gives more chances for people to see the impact of the intervention and hopefully feel compelled to adopt best practices. The quote from a staff person here highlights how educating ECPs takes time and Jessica, I'm wondering if you could speak to your experiences working with ECPs on AMS and UTI.  

Jessica: So it was it's new. So I have I have to say that it's new. 

One of the challenges we encountered and still encounter was shifting that long held belief about urinary tract infections and antibiotic use in general. In one case, I had an essential care provider insist that their family member needed antibiotics because they always get them when the urine looks cloudy. It took three separate visits from one from our IPAC assistant, then we had to speak to the NP, even our social worker to get to use that gentle, you know, using visuals, our story boards, cloudy urine does not meet the criteria, right? 

But over time like it took this is someone who was on prophylaxis within over time that ECP later changed their mind and told a social worker I didn't realize antibiotics could actually make her weaker. Making a breakthrough in trust in long-term care. 

We are a village and having that this education accessible not just to you know to our staff but also ECPs and everybody work so we're all speaking the same language helps at the home we navigated some family and prescriber pressure in one Q&A huddle discussing urine culture results an ECP One of the ECP strongly advocated for antibiotics because their father seemed more confused than usual. The physician at the time reported they almost had no choice but to prescribe them, but consulted with the NP who had a previous relationship with their family and explained that maybe we could try hydration. Give it a few days and within 48 hours of close monitoring and hydration the resident felt better. 

So this case became a teaching example in subsequent sessions illustrating how empathy and sometimes collaboration using those evidence-based practices can change outcomes. So there it is challenge it's something that we have to keep our pulse on and integrating these principles into huddles advisory meetings and resident forums do reinforce the learning and support the culture of change.  

Back to you. 

Tyler: The next variable we investigated was the incidence of dementia at each home. We found that homes with a lower percentage of residents that had dementia tended to have larger improvements in alignment. here we show a negative correlation between the percentage of residents with dementia which was measured as a point estimate at baseline with the difference in alignment between the intervention and control phase. 

It illustrated one of the most consistent and clear messages from the qualitative data which we heard from staff and from ECPS which was a feeling that it was difficult or even impossible to apply the modified Loeb minimum criteria to residents with dementia. The reasoning for this was typically the non-verbal residents were unable to report signs and symptoms. Coupled with the perception that some symptoms for example fever with a common example may present differently or not at all in these residents. 

This set up a perceived tension between strict adherence to the clinical criteria and using one's clinical judgment. Given the challenge of identifying UTI symptoms and residents with limited ability to communicate them verbally, both staff and ECPs shared the feeling that accurate assessment relies on knowing the resident well enough to notice relevant changes to their behavior, cognition, or emotional state. Staff turnover can present a challenge to this as well. 

As can increased reliance on agency staff. It may be less familiar with the home and its policies and it's importantly its residents.  

Jessica, could you share some challenges you and your team faced in caring for residents with dementia in regard to identifying UTI? 

Jessica: Absolutely. You did mention some of them but I will give some of the examples. because it is not always easy to distinguish between UTI and changes related to dementia. 

So we had some of our staff admit an uncertainty about when to escalate concerns. Like one of my staff said sometimes they are just so sleepy. I don't know if it's the infection or their dementia. 

Residents with dementia often present with atypical for atypical symptoms. For example, during one evening rounds, a resident became unusually restless and became started kind of pacing the halls. Staff initially suspected a UTI and considered ordering a urine test and good thing our IPAC assistant was around and further assessment revealed that they were actually constipated and in discomfort. 

This case really highlights how easily behavior changes can be misinterpreted as infection and risking of course unnecessary testing and treatment. and you know education and recognizing atypical presentation often requires staff that are consistent like you said and families who know the resident well and able to advocate on their behalf in that realm. there's also that communication barrier that you mentioned. 

Residents with advanced dementia. One of the resident was grimacing during a transfer prompting a nurse to suspect. Oh, is there a change? 

Closer assessment revealed, you know, arthritis pain. With careful evaluation, these scenarios could have led in the past could have led to inappropriate prescription. And that familiarity with the residents baseline sometimes is very helpful because they when you when they know the residents they are able to interpret some subtle signs that you know an agency staff that just came in for that day would not be able to notice. 

Back to you Tyler.  

Tyler: Thanks Jessica. I'd like to present three other key themes that emerged from interviews with staff from focus groups with ECPs and observations working with local implementation teams. 

First, among ECPs, there are still some persistent beliefs around antibiotics being a panacea, an answer to many ailments. We also heard mostly from ECPs but occasionally from staff some misconceptions around AMR. Notably that AMR should not be a concern given the elderly population. 

And that we should be focused on end of life comfort care with this group. Trying to do everything we can to make residents comfortable. Even if this comes at the expense of running a test or prescribing an antibiotic that might not be necessary. 

These point to the need for continued education of all stakeholders using multiple channels and modalities recognizing that a culture change needs to take place and that culture change can't happen overnight. So sustained efforts are needed here. We also heard some specific suggestions from both staff and ECPs for areas for future work. 

First was the need for more training but specific to implementing the Loeb criteria in residents with dementia and neurological conditions like MS for example. There were suggestions for revising algorithms to include explicit inclusion of using clinical judgment. next staff and next was a suggestion that we emphasize prevention of UTI. 

This came from staff and ECPs with specific suggestions for volunteer-based hydration programs and education about proper toileting care as a potential area for focus. So we'll start to wrap up. 

I'd like to finish with three key takeaways. First, was that diagnosing UTI in residents with dementia is a core barrier here. We saw there was a need for continued education and training on the applicability and application of guidelines. 

And we need to address concerns that strict adherence to criteria might lead to untreated UTI with severe consequences. We also saw that while there is evidence in the literature and in our own data of tremendous pressure from ECPs as a driver of avoidable testing and treatment, this project with all of its intensity made education for ECPs one of its main focuses and still we saw the rates of urine culture ordering didn't change. I think that this could indicate that culture change in the home is key and we know that this takes this takes time.  

We saw some evidence that longer intervention times were associated with more positive results. UTI management and long-term care is a long-standing challenge with deeply ingrained habits. 

For many making meaningful progress here will take time and engagement from everyone from all stakeholders. Lastly, in doing this work, we were encouraged to see enthusiasm for change. Education was largely warmly received from ECPs and they engaged and made requests for education in varied mediums and channels for education using accessible language that was free of technical terminology.  

Similarly, staff took ownership of the project. They make customizations to tailor materials to their own environment in ways like Jessica described. 

If we zoom out and look more broadly, there is also visible support from many professional organizations like Choosing Wisely Canada, IPAC Canada and many others that I won't I won't name all of there's been some new emphasis on AMS and some training. For example, there was some recent work done by the Canadian Nurses Association. And this along with clear alignment on guidelines that we see internationally is encouraging that we'll see a shift on this issue over time. 

So with that back to you Jessica could you share some takeaways from the project? Could you tell us a little bit about what's next for Shepherd Lodge in terms of AMS and UTI?  

Jessica: Yeah, so this project was very eye-open for our team. It really showed the importance of antimicrobial stewardship and in UTI management. It works best when practices are consistent, collaborative and supported at all levels. tools like the low criteria guide evidence-based decisions while team discussions help staff confidently assess residents and also that in education constant education for our essential care providers has to be included. 

We also learned that AMS education presents you know that culture change for our home. We identified that during the intervention period, this was very much apparent. Inappropriate UTI prescription decreased very significantly compared to our data in 2022 and 2023. 

And so we've decided to keep the project going for us incorporating it into our move in which is people call it admission orientation. It's part of our IPAC orientation for our ECPs as they you know and residents when they move into the home. We've included it on our onboarding orientation ongoing staff training as well as our family education program because we see the impact we see we now have our IPAC assistants leading chart reviews, staff huddles you using real time data. For example when recently we had a staff collect urine sample because it looked cloudy news newer staff and but they called the IPAC person and we went through they went through the criteria with them. 

So this continuing these practices and sharing outcomes with our families, our residents on a quarterly basis, we aim to strengthen stewardship here at the lodge and improve residents care and support that lasting change hopefully.  

Thank you.  

Tyler: Thank you Jessica. I appreciate the insight. hearing from someone like you on the ground helps to bring it to life so thank you for that. 

I also want to acknowledge that there's a small but mighty team here at the Public Health Agency that made the work possible. So I’d like to thank our external advisory group who provided invaluable guidance throughout the entire process of the project. And finally, of course to all of the people, at the participating homes who ultimately made this project happen. 

Thank you to all of you.  

I believe we have time for questions. So I'll pass over to Barb to lead that. 

If there are a few other questions or comments or you're interested in getting in touch with us, we'd love to hear from you. We'd be happy to chat. Feel please to reach out. 

You can see our office’s email address here. We'll do our best to get back to you as soon as we can.