Pharmacists critical to managing antimicrobials, developing infection control procedures

Abstract

Infectious diseases kill more people worldwide than any other single cause, according to the U.S. National Library of Medicine. With Ebola raising its ugly head, combined with the mysterious enterovirus D68 and the fact that we’re heading into cold and influenza season, hospital pharmacists continue to play key roles in infectious disease control, antimicrobial stewardship programs, and managing antibiotics. Infectious diseases kill more people worldwide than any other single cause, according to the U.S. National Library of Medicine. With Ebola raising its ugly head, combined with the mysterious enterovirus D68 and the fact that we’re heading into cold and influenza season, hospital pharmacists continue to play key roles in infectious disease control, antimicrobial stewardship programs, and managing antibiotics. Prominent roles“The more appropriate the antimicrobial therapy that a patient gets, the better off they are,” said Debra Goff, PharmD, FCCP, Clinical Associate Professor and infectious diseases specialty practice pharmacist at Ohio State University Medical Center. “We have clinical pharmacists available to see all of our infectious disease patients. We manage a patient’s antibiotics until they are negative and free of the disease.”In July, the American Hospital Association, the American Society of Health-System Pharmacists (ASHP), and other organizations collaborated on a quality advisory for the appropriate use of medical resources in antimicrobial stewardship. As part of the advisory, ASHP issued a statement about the pharmacist’s role. The statement explains that pharmacists have a responsibility to take prominent roles in an antimicrobial stewardship program. According to the statement, pharmacist responsibilities include promoting optimal use of antimicrobial agents, reducing the transmission of infections, and providing education about infection prevention and appropriate antimicrobial use to health professionals, patients, and others.“At our hospital, the pharmacists are quite adept at recognizing antimicrobial issues and work with the providers to get them corrected,” said Carla Walraven, PharmD, BCPS, Antimicrobial Stewardship Pharmacist at the University of New Mexico Hospital in Albuquerque. “Pharmacists have been instrumental in reducing unnecessary therapy, deescalating broad spectrum therapy, and ensuring that our hospital guidelines for appropriate antimicrobial use are adhered to.”“Patients with known or suspected Ebola will require pharmacy service and care just like any other patient. The pharmacist is a stakeholder and should be involved in developing procedures and response plans.”According to Craig Martin, PharmD, BCPS, Clinical Associate Professor at the University of Kentucky College of Pharmacy and a member of the Society of Infectious Disease Pharmacists, the key to pharmacists taking on prominent roles in antimicrobial stewardship is for pharmacists to be active participants in the entire antimicrobial use cycle.“From participation in the Pharmacy and Therapeutics Committee, to making formulary and policy decisions, to the education of prescribers on the proper use of antimicrobials, to the development of clinical decision support, to the preparation and delivery of antimicrobials and more, the pharmacist should be central to the team,” said Martin. HIGHLIGHTS■Hospital pharmacists can make important contributions to the development of hospital protocols for managing patients with infectious diseases.■Pharmacist participation in antimicrobial stewardship programs can lead to better antibiotic dosing and management.Ebola interventionThe recent Ebola case in Texas highlighted the need for hospitals to have an emergency preparedness plan in place. Hospitals need to determine whether they have the capability to care for patients with infectious diseases like Ebola, noted Walraven. “In some cases, this may require a dedicated team of health care workers who are willing to undergo specific training and quarantine procedures if needed,” she added.Because there are no approved drugs for patients infected with Ebola, hospital pharmacists may be called on to assist medical teams in other ways. “First and foremost, the pharmacist should be an advocate for proper infection control practices,” said Martin. “Preventing Ebola transmission should be the first priority for the entire health care team. Additionally, however, pharmacists should ensure that they have procedures in place in the event that an investigational drug needs to be procured.”Response protocol“Pharmacists are not usually the primary points of contact for patients coming into the hospital,” said Walraven. “Much of a pharmacist’s role in these cases is to ensure hospital policies are followed and then provide supportive care for the patient and health care staff as needed.”Health-system pharmacists can take a lead role in helping a hospital develop infection control and supportive care procedures that are part of a hospital’s Ebola response plan. “Pharmacists should be involved in the protocol development because most patients will be seen by a pharmacist at some point in their hospital stay,” explained Martin. “Patients with known or suspected Ebola will require pharmacy service and care just like any other patient. The pharmacist is a stakeholder and should be involved in developing procedures and response plans.”Enterovirus concernsEnterovirus D68 is a nonpolio enterovirus that can cause mild to severe respiratory illness in children. “For enterovirus D68, like Ebola, there is no approved drug therapy,” said Martin. “The hospital pharmacist’s role will once again be to assist the health care team in the supportive care process.”Walraven believes that hospital pharmacists can “play a more active role in educating patients and disseminating accurate information to dispel any rumor or misconceptions patients may have about the virus.”Pediatric antimicrobial stewardshipCases of enterovirus D68 are putting antimicrobial stewardship for pediatric populations in the spotlight. This branch of stewardship has not received as much attention as adult antimicrobial stewardship. “I think this is due to the fact that adults with chronic illnesses are more likely to have received multiple courses of antibiotics and therefore harbor resistant organisms,” said Martin.According to Walraven, pediatric antimicrobial stewardship is definitely an area that needs more pharmacy support. “Many of the most common pediatric infections are caused by viruses for which antibiotics are unnecessary and inappropriate,” she added.When it comes to developing effective procedures and protocols for pediatric antimicrobial stewardship, the key is to “combine the expertise of the pediatric specialist with the infectious diseases specialist,” said Martin. “While some of our successes in adult antimicrobial stewardship will work in this population, others won’t. The pediatric pharmacist can provide much-needed perspective.”Antimicrobial resistanceAlthough Ebola and enterovirus D68 have taken center stage in the world of infectious diseases, the problem of antimicrobial resistance remains a hot topic. “Antibiotic resistance, especially in Gram-negative bacteria, is of particular concern due to the lack of antibiotics that can be used to safely and effectively treat such infections,” said Walraven. “However, pharmacists have the training and knowledge to optimize the pharmacokinetic and pharmacodynamic properties that have allowed us to maximize the efficacy of our currently available antibiotics while awaiting the development of new antibiotics. In the meantime, antimicrobial vigilance can be used to delay or thwart the development of further resistance.”According to Martin, there is still a “desperate need” for novel agents to treat multidrug-resistant, Gram-negative organisms. “The most important thing a hospital pharmacist can do to prevent further resistance is to ensure our broad-spectrum agents are used appropriately,” he said. “That doesn’t always mean restricting them. Sometimes therapy with carbapenems, for instance, is absolutely warranted. The pharmacist can make sure the most effective dose and duration [are] used, thereby maximizing the likelihood of treatment success and minimizing the likelihood of recurrence or failure.”Successful stewardshipA report published in the March 7, 2014, issue of CDC’s Morbidity and Mortality Weekly Report analyzed data from the MarketScan Hospital Drug Database and CDC’s Emerging Infections Program to assess the potential for improving antibiotic prescribing in hospitals. The researchers reported that 55.7% of patients discharged from 323 hospitals in 2010 received antibiotics during their stay. They also noted that antibiotic prescribing could possibly be improved in “37.2% of the most common scenarios that were reviewed.” The researchers concluded that antibiotic prescribing in hospitals is common and often incorrect. “There is ample opportunity to improve use and patient safety by reducing incorrect antibiotic prescribing,” the researchers wrote.CDC recommended the implementation of seven core elements that contribute to the success of antimicrobial stewardship programs. These elements include a commitment from hospital leadership; accountability; appointing a pharmacist leader to help improve antibiotic use; monitoring antimicrobial prescribing and resistance patterns; reporting information to physicians, nurses, and staff; action including at least one intervention to improve prescribing; and educating health care workers about resistance and best prescribing practices.Improving antibiotic useAnother piece to the antimicrobial resistance puzzle is overuse of antibiotics in hospitals. A recent 1-day survey of 183 hospitals found that about one-half of hospitalized patients in the survey received antimicrobial drugs, and about one-half of these patients received two or more antimicrobial agents, according to a study in the October 8, 2014, issue of JAMA.Shelley S. Magill, MD, PhD, and colleagues reported that four antimicrobial medications—parenteral vancomycin, piperacillin-tazobactam, ceftriaxone, and levofloxacin—comprised around 45% of all antimicrobial medication therapies. These four medications were the most common agents for treating health care facility-onset infections and patients in critical care units, noted the study authors. They were also the most common medications used for treating community-onset infections and patients outside of the critical care setting, the researchers added.The study highlighted a clear need for more antibiotic development and antimicrobial stewardship efforts. “Without incentives for the discovery and development of these agents, the return on investment just doesn’t allow many pharmaceutical companies to invest in infectious diseases therapies,” said Martin. “I think we’re headed in the right direction, but we’re moving very slowly.” Prominent roles“The more appropriate the antimicrobial therapy that a patient gets, the better off they are,” said Debra Goff, PharmD, FCCP, Clinical Associate Professor and infectious diseases specialty practice pharmacist at Ohio State University Medical Center. “We have clinical pharmacists available to see all of our infectious disease patients. We manage a patient’s antibiotics until they are negative and free of the disease.”In July, the American Hospital Association, the American Society of Health-System Pharmacists (ASHP), and other organizations collaborated on a quality advisory for the appropriate use of medical resources in antimicrobial stewardship. As part of the advisory, ASHP issued a statement about the pharmacist’s role. The statement explains that pharmacists have a responsibility to take prominent roles in an antimicrobial stewardship program. According to the statement, pharmacist responsibilities include promoting optimal use of antimicrobial agents, reducing the transmission of infections, and providing education about infection prevention and appropriate antimicrobial use to health professionals, patients, and others.“At our hospital, the pharmacists are quite adept at recognizing antimicrobial issues and work with the providers to get them corrected,” said Carla Walraven, PharmD, BCPS, Antimicrobial Stewardship Pharmacist at the University of New Mexico Hospital in Albuquerque. “Pharmacists have been instrumental in reducing unnecessary therapy, deescalating broad spectrum therapy, and ensuring that our hospital guidelines for appropriate antimicrobial use are adhered to.”“Patients with known or suspected Ebola will require pharmacy service and care just like any other patient. The pharmacist is a stakeholder and should be involved in developing procedures and response plans.”According to Craig Martin, PharmD, BCPS, Clinical Associate Professor at the University of Kentucky College of Pharmacy and a member of the Society of Infectious Disease Pharmacists, the key to pharmacists taking on prominent roles in antimicrobial stewardship is for pharmacists to be active participants in the entire antimicrobial use cycle.“From participation in the Pharmacy and Therapeutics Committee, to making formulary and policy decisions, to the education of prescribers on the proper use of antimicrobials, to the development of clinical decision support, to the preparation and delivery of antimicrobials and more, the pharmacist should be central to the team,” said Martin. HIGHLIGHTS■Hospital pharmacists can make important contributions to the development of hospital protocols for managing patients with infectious diseases.■Pharmacist participation in antimicrobial stewardship programs can lead to better antibiotic dosing and management. “The more appropriate the antimicrobial therapy that a patient gets, the better off they are,” said Debra Goff, PharmD, FCCP, Clinical Associate Professor and infectious diseases specialty practice pharmacist at Ohio State University Medical Center. “We have clinical pharmacists available to see all of our infectious disease patients. We manage a patient’s antibiotics until they are negative and free of the disease.” In July, the American Hospital Association, the American Society of Health-System Pharmacists (ASHP), and other organizations collaborated on a quality advisory for the appropriate use of medical resources in antimicrobial stewardship. As part of the advisory, ASHP issued a statement about the pharmacist’s role. The statement explains that pharmacists have a responsibility to take prominent roles in an antimicrobial stewardship program. According to the statement, pharmacist responsibilities include promoting optimal use of antimicrobial agents, reducing the transmission of infections, and providing education about infection prevention and appropriate antimicrobial use to health professionals, patients, and others. “At our hospital, the pharmacists are quite adept at recognizing antimicrobial issues and work with the providers to get them corrected,” said Carla Walraven, PharmD, BCPS, Antimicrobial Stewardship Pharmacist at the University of New Mexico Hospital in Albuquerque. “Pharmacists have been instrumental in reducing unnecessary therapy, deescalating broad spectrum therapy, and ensuring that our hospital guidelines for appropriate antimicrobial use are adhered to.”“Patients with known or suspected Ebola will require pharmacy service and care just like any other patient. The pharmacist is a stakeholder and should be involved in developing procedures and response plans.” According to Craig Martin, PharmD, BCPS, Clinical Associate Professor at the University of Kentucky College of Pharmacy and a member of the Society of Infectious Disease Pharmacists, the key to pharmacists taking on prominent roles in antimicrobial stewardship is for pharmacists to be active participants in the entire antimicrobial use cycle. “From participation in the Pharmacy and Therapeutics Committee, to making formulary and policy decisions, to the education of prescribers on the proper use of antimicrobials, to the development of clinical decision support, to the preparation and delivery of antimicrobials and more, the pharmacist should be central to the team,” said Martin. HIGHLIGHTS■Hospital pharmacists can make important contributions to the development of hospital protocols for managing patients with infectious diseases.■Pharmacist participation in antimicrobial stewardship programs can lead to better antibiotic dosing and management. HIGHLIGHTS■Hospital pharmacists can make important contributions to the development of hospital protocols for managing patients with infectious diseases.■Pharmacist participation in antimicrobial stewardship programs can lead to better antibiotic dosing and management. HIGHLIGHTS■Hospital pharmacists can make important contributions to the development of hospital protocols for managing patients with infectious diseases.■Pharmacist participation in antimicrobial stewardship programs can lead to better antibiotic dosing and management. ■Hospital pharmacists can make important contributions to the development of hospital protocols for managing patients with infectious diseases.■Pharmacist participation in antimicrobial stewardship programs can lead to better antibiotic dosing and management. Ebola interventionThe recent Ebola case in Texas highlighted the need for hospitals to have an emergency preparedness plan in place. Hospitals need to determine whether they have the capability to care for patients with infectious diseases like Ebola, noted Walraven. “In some cases, this may require a dedicated team of health care workers who are willing to undergo specific training and quarantine procedures if needed,” she added.Because there are no approved drugs for patients infected with Ebola, hospital pharmacists may be called on to assist medical teams in other ways. “First and foremost, the pharmacist should be an advocate for proper infection control practices,” said Martin. “Preventing Ebola transmission should be the first priority for the entire health care team. Additionally, however, pharmacists should ensure that they have procedures in place in the event that an investigational drug needs to be procured.” The recent Ebola case in Texas highlighted the need for hospitals to have an emergency preparedness plan in place. Hospitals need to determine whether they have the capability to care for patients with infectious diseases like Ebola, noted Walraven. “In some cases, this may require a dedicated team of health care workers who are willing to undergo specific training and quarantine procedures if needed,” she added. Because there are no approved drugs for patients infected with Ebola, hospital pharmacists may be called on to assist medical teams in other ways. “First and foremost, the pharmacist should be an advocate for proper infection control practices,” said Martin. “Preventing Ebola transmission should be the first priority for the entire health care team. Additionally, however, pharmacists should ensure that they have procedures in place in the event that an investigational drug needs to be procured.” Response protocol“Pharmacists are not usually the primary points of contact for patients coming into the hospital,” said Walraven. “Much of a pharmacist’s role in these cases is to ensure hospital policies are followed and then provide supportive care for the patient and health care staff as needed.”Health-system pharmacists can take a lead role in helping a hospital develop infection control and supportive care procedures that are part of a hospital’s Ebola response plan. “Pharmacists should be involved in the protocol development because most patients will be seen by a pharmacist at some point in their hospital stay,” explained Martin. “Patients with known or suspected Ebola will require pharmacy service and care just like any other patient. The pharmacist is a stakeholder and should be involved in developing procedures and response plans.” “Pharmacists are not usually the primary points of contact for patients coming into the hospital,” said Walraven. “Much of a pharmacist’s role in these cases is to ensure hospital policies are followed and then provide supportive care for the patient and health care staff as needed.” Health-system pharmacists can take a lead role in helping a hospital develop infection control and supportive care procedures that are part of a hospital’s Ebola response plan. “Pharmacists should be involved in the protocol development because most patients will be seen by a pharmacist at some point in their hospital stay,” explained Martin. “Patients with known or suspected Ebola will require pharmacy service and care just like any other patient. The pharmacist is a stakeholder and should be involved in developing procedures and response plans.” Enterovirus concernsEnterovirus D68 is a nonpolio enterovirus that can cause mild to severe respiratory illness in children. “For enterovirus D68, like Ebola, there is no approved drug therapy,” said Martin. “The hospital pharmacist’s role will once again be to assist the health care team in the supportive care process.”Walraven believes that hospital pharmacists can “play a more active role in educating patients and disseminating accurate information to dispel any rumor or misconceptions patients may have about the virus.” Enterovirus D68 is a nonpolio enterovirus that can cause mild to severe respiratory illness in children. “For enterovirus D68, like Ebola, there is no approved drug therapy,” said Martin. “The hospital pharmacist’s role will once again be to assist the health care team in the supportive care process.” Walraven believes that hospital pharmacists can “play a more active role in educating patients and disseminating accurate information to dispel any rumor or misconceptions patients may have about the virus.” Pediatric antimicrobial stewardshipCases of enterovirus D68 are putting antimicrobial stewardship for pediatric populations in the spotlight. This branch of stewardship has not received as much attention as adult antimicrobial stewardship. “I think this is due to the fact that adults with chronic illnesses are more likely to have received multiple courses of antibiotics and therefore harbor resistant organisms,” said Martin.According to Walraven, pediatric antimicrobial stewardship is definitely an area that needs more pharmacy support. “Many of the most common pediatric infections are caused by viruses for which antibiotics are unnecessary and inappropriate,” she added.When it comes to developing effective procedures and protocols for pediatric antimicrobial stewardship, the key is to “combine the expertise of the pediatric specialist with the infectious diseases specialist,” said Martin. “While some of our successes in adult antimicrobial stewardship will work in this population, others won’t. The pediatric pharmacist can provide much-needed perspective.” Cases of enterovirus D68 are putting antimicrobial stewardship for pediatric populations in the spotlight. This branch of stewardship has not received as much attention as adult antimicrobial stewardship. “I think this is due to the fact that adults with chronic illnesses are more likely to have received multiple courses of antibiotics and therefore harbor resistant organisms,” said Martin. According to Walraven, pediatric antimicrobial stewardship is definitely an area that needs more pharmacy support. “Many of the most common pediatric infections are caused by viruses for which antibiotics are unnecessary and inappropriate,” she added. When it comes to developing effective procedures and protocols for pediatric antimicrobial stewardship, the key is to “combine the expertise of the pediatric specialist with the infectious diseases specialist,” said Martin. “While some of our successes in adult antimicrobial stewardship will work in this population, others won’t. The pediatric pharmacist can provide much-needed perspective.” Antimicrobial resistanceAlthough Ebola and enterovirus D68 have taken center stage in the world of infectious diseases, the problem of antimicrobial resistance remains a hot topic. “Antibiotic resistance, especially in Gram-negative bacteria, is of particular concern due to the lack of antibiotics that can be used to safely and effectively treat such infections,” said Walraven. “However, pharmacists have the training and knowledge to optimize the pharmacokinetic and pharmacodynamic properties that have allowed us to maximize the efficacy of our currently available antibiotics while awaiting the development of new antibiotics. In the meantime, antimicrobial vigilance can be used to delay or thwart the development of further resistance.”According to Martin, there is still a “desperate need” for novel agents to treat multidrug-resistant, Gram-negative organisms. “The most important thing a hospital pharmacist can do to prevent further resistance is to ensure our broad-spectrum agents are used appropriately,” he said. “That doesn’t always mean restricting them. Sometimes therapy with carbapenems, for instance, is absolutely warranted. The pharmacist can make sure the most effective dose and duration [are] used, thereby maximizing the likelihood of treatment success and minimizing the likelihood of recurrence or failure.” Although Ebola and enterovirus D68 have taken center stage in the world of infectious diseases, the problem of antimicrobial resistance remains a hot topic. “Antibiotic resistance, especially in Gram-negative bacteria, is of particular concern due to the lack of antibiotics that can be used to safely and effectively treat such infections,” said Walraven. “However, pharmacists have the training and knowledge to optimize the pharmacokinetic and pharmacodynamic properties that have allowed us to maximize the efficacy of our currently available antibiotics while awaiting the development of new antibiotics. In the meantime, antimicrobial vigilance can be used to delay or thwart the development of further resistance.” According to Martin, there is still a “desperate need” for novel agents to treat multidrug-resistant, Gram-negative organisms. “The most important thing a hospital pharmacist can do to prevent further resistance is to ensure our broad-spectrum agents are used appropriately,” he said. “That doesn’t always mean restricting them. Sometimes therapy with carbapenems, for instance, is absolutely warranted. The pharmacist can make sure the most effective dose and duration [are] used, thereby maximizing the likelihood of treatment success and minimizing the likelihood of recurrence or failure.” Successful stewardshipA report published in the March 7, 2014, issue of CDC’s Morbidity and Mortality Weekly Report analyzed data from the MarketScan Hospital Drug Database and CDC’s Emerging Infections Program to assess the potential for improving antibiotic prescribing in hospitals. The researchers reported that 55.7% of patients discharged from 323 hospitals in 2010 received antibiotics during their stay. They also noted that antibiotic prescribing could possibly be improved in “37.2% of the most common scenarios that were reviewed.” The researchers concluded that antibiotic prescribing in hospitals is common and often incorrect. “There is ample opportunity to improve use and patient safety by reducing incorrect antibiotic prescribing,” the researchers wrote.CDC recommended the implementation of seven core elements that contribute to the success of antimicrobial stewardship programs. These elements include a commitment from hospital leadership; accountability; appointing a pharmacist leader to help improve antibiotic use; monitoring antimicrobial prescribing and resistance patterns; reporting information to physicians, nurses, and staff; action including at least one intervention to improve prescribing; and educating health care workers about resistance and best prescribing practices. A report published in the March 7, 2014, issue of CDC’s Morbidity and Mortality Weekly Report analyzed data from the MarketScan Hospital Drug Database and CDC’s Emerging Infections Program to assess the potential for improving antibiotic prescribing in hospitals. The researchers reported that 55.7% of patients discharged from 323 hospitals in 2010 received antibiotics during their stay. They also noted that antibiotic prescribing could possibly be improved in “37.2% of the most common scenarios that were reviewed.” The researchers concluded that antibiotic prescribing in hospitals is common and often incorrect. “There is ample opportunity to improve use and patient safety by reducing incorrect antibiotic prescribing,” the researchers wrote. CDC recommended the implementation of seven core elements that contribute to the success of antimicrobial stewardship programs. These elements include a commitment from hospital leadership; accountability; appointing a pharmacist leader to help improve antibiotic use; monitoring antimicrobial prescribing and resistance patterns; reporting information to physicians, nurses, and staff; action including at least one intervention to improve prescribing; and educating health care workers about resistance and best prescribing practices. Improving antibiotic useAnother piece to the antimicrobial resistance puzzle is overuse of antibiotics in hospitals. A recent 1-day survey of 183 hospitals found that about one-half of hospitalized patients in the survey received antimicrobial drugs, and about one-half of these patients received two or more antimicrobial agents, according to a study in the October 8, 2014, issue of JAMA.Shelley S. Magill, MD, PhD, and colleagues reported that four antimicrobial medications—parenteral vancomycin, piperacillin-tazobactam, ceftriaxone, and levofloxacin—comprised around 45% of all antimicrobial medication therapies. These four medications were the most common agents for treating health care facility-onset infections and patients in critical care units, noted the study authors. They were also the most common medications used for treating community-onset infections and patients outside of the critical care setting, the researchers added.The study highlighted a clear need for more antibiotic development and antimicrobial stewardship efforts. “Without incentives for the discovery and development of these agents, the return on investment just doesn’t allow many pharmaceutical companies to invest in infectious diseases therapies,” said Martin. “I think we’re headed in the right direction, but we’re moving very slowly.” Another piece to the antimicrobial resistance puzzle is overuse of antibiotics in hospitals. A recent 1-day survey of 183 hospitals found that about one-half of hospitalized patients in the survey received antimicrobial drugs, and about one-half of these patients received two or more antimicrobial agents, according to a study in the October 8, 2014, issue of JAMA. Shelley S. Magill, MD, PhD, and colleagues reported that four antimicrobial medications—parenteral vancomycin, piperacillin-tazobactam, ceftriaxone, and levofloxacin—comprised around 45% of all antimicrobial medication therapies. These four medications were the most common agents for treating health care facility-onset infections and patients in critical care units, noted the study authors. They were also the most common medications used for treating community-onset infections and patients outside of the critical care setting, the researchers added. The study highlighted a clear need for more antibiotic development and antimicrobial stewardship efforts. “Without incentives for the discovery and development of these agents, the return on investment just doesn’t allow many pharmaceutical companies to invest in infectious diseases therapies,” said Martin. “I think we’re headed in the right direction, but we’re moving very slowly.”