Division of Infectious Diseases

Celebrating Doctor’s Day

March 30th will pass by for some as any other day. However, it should not. It is a day for us to celebrate and recognize American physicians for their ongoing work to improve the health of our communities, country and world. As we have said before, in the end, we are all patients. Doctors will impact the lives of most, if not all, American’s at some point. Today, we urge you to recognize this service and say Thank You.

National Doctors’ Day has a date rich with history. March 30th is the anniversary of the first use of general anesthesia in surgery by Dr. Crawford Long in 1842 when he used ether in Jefferson, Georgia for the excision of a neck tumor. In 1933, Eudora Brown Almond (wife of Dr. Charles B. Almond), and the Barrow County Medical Auxiliary Society in Georgia commemorated this date by mailing cards to physicians and their families along with placing flowers on graves of deceased doctors.

In 1958, The US House of Representatives adopted a resolution to formally commemorate Doctors’ Day and on February 21, 1991 President George Bush proclaimed March 30th as National Doctors’ Day to recognize American physicians working to improve the health of this country through patient care, research, education and more.

The proclamation reminds us of both the honor and the cost of following the professional calling of being physician.

“More than the application of science and technology, medicine is a special calling, and those who have chosen this vocation in order to serve their fellowman understand the tremendous responsibility it entails…Accordingly, reverence for human life and individual dignity is both the hallmark of a good physician and the key to truly beneficial advances in medicine.

However, in addition to the doctors whose name we easily recognize, there are countless others who carry on the quiet work of healing each day in communities throughout the United States — indeed, throughout the world. Common to the experience of each of them, from the specialist in research to the general practitioner, are hard work, stress, and sacrifice. All those Americans who serve as licensed physicians have engaged in years of study and training, often at great financial cost. Most endure long and unpredictable hours, and many must cope with the conflicting demands of work and family life.”

Here at UNMC we are grateful for all of our physician colleagues who strive to always provide the best care for the patient and we recognize the sacrifices each has had to make in the process. The institution will be celebrating Doctors’ Day in honor of this.

But, we are also specifically grateful for our ID Division physicians who provide excellent care for patients, but also, who make sure to care for each other by stepping up to help a colleague in need, covering a shift, mentoring and sponsoring colleagues, and who truly appreciate the unique expertise of each of our faculty members.

To all physicians reading this – THANK YOU and please do thank a colleague.

If are not a physician, but you know one, say thank you today. Those two words carry phenomenal value to each and every physician.

Happy Doctors’ Day!

Breakfast with IDSA CEO Chris Busky, CAE

This morning members of our UNMC ID division had the opportunity to have breakfast with the CEO of the Infectious Diseases Society of America (IDSA), Chris Busky, CAE. Though it was early in the morning, our fellows and several faculty made an appearance at the breakfast, where we listened to a short presentation by Mr. Busky, followed by an informal question-and-answer session discussing issues that affect us all as Infectious Diseases physicians. Below is an account of our discussions.

In his presentation, Mr. Busky discussed the strategic priorities of IDSA:

Strategic Priority 1: Promote the value of the Infectious Diseases Physician/HIV Specialist

IDSA is committed to spending time and resources to communicate the value of our specialty, and help ID physicians communicate this value to the key stakeholders, including hospital administrators, payers and policy makers. This involves a strategic redefining of our brand and their messaging campaign. They have created a “Value of Infectious Diseases Specialists” toolkit which includes resources for leading Antimicrobial Stewardship Programs. Additionally, they recently produced the largest Infectious Diseases Compensation survey in history with a record 2500 responses (compared to other surveys that only included a paltry single digit percentage of ID physicians) to provide better compensation data for IDSA members. One of our fellows brought up a great point: can we add value to the Infectious Diseases Physician by including access to training for minimally invasive procedures, through point-of-care ultrasound? Think – abscess drainage, paracentesis, thoracentesis, line placement etc… Many non-proceduralists perform these kinds of tests in community hospitals, why not ID physicians? Could this be an opportunity for diagnostic stewardship? The answer to this is unclear, but there may be interest in this as many ID fellow candidates are considering ID-Critical care for this reason.

Strategic Priority 2: Attract the Best and Brightest to ID/HIV

Acknowledging that (a) medical students start to decide on broad scope of specialty (Internal Medicine vs non-Internal Medicine) by their second year of medical school, and (b) Internal Medicine residents decide on subspecialty fellowship interests by their second year of residency, IDSA is increasing efforts to attract medical students and residents to our field. The society now has over 1000 resident/medical student members, and several ID interest groups directly affiliated with IDSA. The society acknowledges the need to continually engage these students/residents well into their training, so that they remain interested in Infectious Diseases when the time comes to pick their specialty. Additionally, IDSA will be piloting a new leadership institute program in 2019. This program will provide an opportunity to create a blended curriculum involving professionals to describe leadership/business core competencies tailored specifically to infectious diseases as a specialty, to promote advancement of ID physicians in leadership positions throughout their careers.

Strategic Priority 3: Promote Leadership in Antimicrobial Resistance and Stewardship

Society journals have recently released several publications outlining the need for Infectious Disease Leadership in Antimicrobial Stewardship Programs (which ties into the priority of promoting ID Physician value). Acknowledging that these programs are needed (perhaps even more critically so) in smaller communities with limited resources and worldwide, IDSA is actively exploring how to utilize Tele-Stewardship programs nationally and internationally in combination with appropriate compensation models. This tele-health program for Antimicrobial Stewardship is also applicable for long-term health care facilities. Our own Dr. M Salman Ashraf is also exploring this in Nebraska and has collaborated with the CDC and Nebraska Department of Health to create the Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP). Additionally, IDSA has piloted the Antimicrobial Stewardship Centers of Excellence Program to”promote excellence in optimizing antimicrobial use and combating antimicrobial resistance (AMR) by identifying institutions that effectively demonstrate these activities“. Finally, as part of promoting leadership in this area, IDSA is developing an Antimicrobial Stewardship curriculum for fellowship programs, including basic and advanced curricula that should be available for free to ID program directors and fellows later this year.

Strategic Priority 4: Produce Relevant Guidelines

IDSA is committed to producing high-quality guidelines, using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to standardize and improve quality of guidelines. Guideline committees will work with an ID physician guideline specialist and methodologist to have more streamlined and consistent development guidelines that address relevant clinical needs. They have also committed to rapid turn-around, high-level updates of guidelines and better coordination with international society guidelines.

Strategic Priorities 5 & 6: Promote ID/HIV Research, and Advocate for Public Health Funding in ID/HIV

IDSA has been a strong funding advocate. They advocate for funds through the National Institute of Allergy and Infectious Diseases (NIAID), Centers for Disease Control and Prevention (CDC) and Food and Drug Administration (FDA). Additionally, they advocate for Global Health through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), and United States Agency for International Development (USAID). IDSA has several ID/HIV funding programs for which members are eligible. Tied to the priority of attracting the Best and Brightest, to promote research in HIV/ID, IDSA has been funding the Medical Scholars Program. Finally, membership to the HIV Medicine Association is included in IDSA membership, and this sub-society is dedicated to promoting quality in HIV care, directing major HIV-related policies and guidelines.

Member Engagement

IDSA has >11,000 members in 100+ countries across 6 continents, and the society is constantly working on transforming their brand. They will be moving towards more personalized engagement, featuring stories of physician members, fellows, resident/students interested in ID. The annual conference has been improving in popularity each year,largely due to improved content, more opportunities for interaction and new features (ID Bug Bowl was a blast!). IDSA is being more deliberate about creating personal connections, engaging dynamics, relevant content and opportunities for networking with smaller, more interactive sessions to transform the conference.

IDWeek 2018 will be in San Francisco October 3-7 (UNMC_ID will be there!). There are also additional opportunities for fellows to get involved, and Open Forum Infectious Diseases is an opportunity for ID fellows to submit their work for publication. There are clinical and research meetings for fellows occurring in April and June 2018 respectively. IDSA encourages active membership engagement, and the society is committed to providing volunteering roles for all who want to be involved-advocacy, website content, media core (be a content expert), journal club, education, mentorship etc. Regarding engagement in political advocacy, the society had record engagement (>4000) from members in 2017 with face to face meetings, action alerts, member visits in local communities. Mr. Busky emphasized that the society’s role in advocacy is never complete – engagement with congress is ongoing, building and strengthening relationships on Capitol Hill to advance the priorities of the society representing its individual physician members. He encouraged physician members to be a consistent voice reaching out to Congressional representatives with the message to prioritize ID/HIV concerns.

Burnout/Stress

Mr. Busky wanted to know what we are doing to address stress/burnout here. Our general ID service is our busiest clinical inpatient service. Acknowledging this, our Division Chief Dr. Mark Rupp has already made plans to split this service into two. This will significantly reduce the patient census and make a difference in reducing stress. Of course, time spent documenting in the EMR (universal problem for all medical specialties) contributes to stress/burnout, when physicians are spending 2-3 hrs after care is provided to document in EMR. The group felt that one of the biggest contributors to burnout/stress in our specialty is the struggle with with communicating value of ID outside our division – many ID physicians find themselves engaged in several different activities to “prove their worth”, compared to some proceduralist specialties which may be able to focus more on what they actually trained to do for the same (but usually higher) compensation. In the same thread, we discussed how to communicate the value of ID sub specialties such as Oncology-ID, Ortho-ID, or Transplant-ID to the related medical specialties in promoting this niche care. Mr. Busky shared that IDSA is part of the “Cognitive Care Alliance” of specialties, collectively working towards advocating for value of these cognitive specialties.

Diversity

IDSA acknowledges there are gender and racial disparities within our ID workforce. Their first goal was to evaluate it to see what the gaps are as described in this publication. Now that the extent of the gap has been identified, IDSA has committed to integrating principles of Diversity, Inclusion & Equity into the core values of the society. The IDSA board will go through training to define these principles and model to the society, with the goal of not only recruiting more women and under-represented minorities, but improving visibility this commitment to membership by ensuring that women and People of Color are represented on leadership committees, award recipients, ID week speakers and society representatives. Additionally, the society aims to diversify the membership and leadership geographically, to ensure that there is representation of more individuals from Midwest/mountain regions. Finally, they recognize that there is a need for more clinical representation on leadership committees and are working to diversify their boards in this way also.

Today, Mr. Busky came to us and by just having a conversation with us, showed us that IDSA is working for us, dedicated to personalizing its connection with members and pursuing our common interests. Thank you for sharing!

Congratulations to UNMC ID Faculty designated as Top Teachers for 2017!

After every rotation, medical students and Internal Medicine Residents at UNMC submit evaluations on their faculty members. The Department of Internal Medicine pools all of the evaluation data and designates the faculty with the top 33% of evaluation scores as “Top Teachers”. For the year 2017, four of our Infectious Disease faculty members who attend on the General ID Service and participate in Medical Student Education were awarded this honor.

Meet our Internal Medicine 2017 Top Teachers from UNMC ID!

Dr. Sara Bares, MD Assistant Professor of Medicine; Associate Director of the Specialty Care Clinic; Director of the UNMC COM HIV Enhanced Medical Education Track; Co-Director of UNMC COM Defenses & Invaders Microbiology Course

Dr. Angela Hewlett, MD, MS Associate Professor of Medicine; Medical Director, Nebraska Biocontainment Unit; Associate Medical Director, Nebraska Medicine Infection Control & Epidemiology; Director, Infectious Diseases Outpatient Clinics; Faculty Adviser, Medical Student Infectious Disease Interest Group

Dr. Mark Rupp, MD Professor of Medicine; Chief, Division of Infectious Diseases; Medical Director, Nebraska Medicine Department of Infection Control & Epidemiology

Dr. Trevor Van Schooneveld, MD Associate Professor of Medicine; Medical Director, Nebraska Medicine Antimicrobial Stewardship Program; Program Director, UNMC Infectious Disease Fellowship; Associate Medical Director, Nebraska Medicine Infection Control & Epidemiology

The UNMC ID Division would like to congratulate Drs. Sara Bares, Angela Hewlett, Mark Rupp and Trevor Van Schooneveld for being awarded Top Teachers in 2017. All four of them have been awarded this honor in the past – this is the 3rd for Dr. Bares, 8th for Dr. Hewlett and 9th for Drs. Rupp and Van Schooneveld.

Drs. Sara Bares and Angela Hewlett were among only 19 faculty members in the Department of Internal Medicine who were designated 2017 Top Teachers by both medical students and residents.

This is yet another testament to our Division’s commitment to Medical Education and growing the next generation of Infectious Disease Doctors!

Nebraska Medicine to Host Emerging Infectious Disease Preparedness Workshop March 27-28

Nebraska Medicine has been home to one of the few Biocontainment Units in the country, and was one of three selected to care for citizens affected by the Ebola outbreak. Dr. Angela Hewlett, one of our own UNMC Infectious Disease Physicians, is the Medical Director of the Nebraska Biocontainment Unit (NBU) and Associate Medical Director of Infection Control & Epidemiology at Nebraska Medicine.

Our NBU is one of several training sites for Emerging Infectious Disease Preparedness training, and Dr. Hewlett shared an upcoming training event with us.

“The National Ebola Training and Education Center (NETEC) is a collaborative effort between UNMC, Emory Medicine, and NYC Health Hospitals Bellevue in New York City; in that effort we host training courses here on [UNMC] campus, we attend training courses on the campuses of our collaborators and we also visit a variety of medical facilities to enhance preparedness for highly infectious diseases. We will be hosting a course on campus here at UNMC on March 27 and 28, where we will have over 130 attendees from multiple disciplines, from all over the United States to come and learn about preparedness efforts.”

The workshop target audience includes healthcare workers and public health professionals. The workshop will be free of charge, but will provide continuing education credits. Course offerings include Pathogens of concern, Emergency Management, Laboratory and Clinical Lab Skills, Leadership Strategies, and EMS/Pre-Hospital Operations, with additional skills stations utilizing their own personal protective equipment and protocols.

For more information about the NETEC education and training offerings, click here.

Josh Havens, PharmD on “Why I Love ID”

Why I Love ID:

Infectious diseases, in general, is quite interesting, but I can really only speak from an HIV perspective. My initial career interests were not in infectious diseases and it was not until I threw myself into this niche world of HIV that I started to recognize a true affinity toward the field. It is rare to find an infection that is such long-lived and durable despite enormous efforts to cure it. I find the complexity and evasive nature of the HIV virus is fascinating. I love the challenge that the treatment of HIV can often provide. In most cases, the majority of your patients create a small portion of your work/effort yet it’s that 10% that can often require 95% of your time. I love the 10% because of the upside. The challenges to get these patients better are multifaceted and generally difficult, but the smallest changes in their medical care can result in noticeable positive changes. There are many other reasons I love this field but the struggles it can present are sometimes what I enjoy the most.

–Josh Havens, PharmD

Learn more about the UNMC ID Division here.

World Social Work Day – Meet our HIV Case Management Team

The official theme for Social Work Month in March 2018 is “Social Workers: Leaders. Advocates. Champions.”

Social workers are the glue that keeps clinical practices together as we balance the need to care for patients with the socioeconomic needs of the individual patients.

At the Specialty Care Center, our Case Management team works tirelessly to ensure that patients’ needs are met; they enroll patients in insurance, review Ryan White eligibility, and provide gift cards/coupons for extra monetary support. They are a valuable resource to the clinicians, providing insight into patients’ current living situations, relationship struggles, or drug abuse, all of which can affect adherence and treatment effectiveness.

Meet our Case Management Team:

Tacy Slater, MSW, MPH joined the HIV team in July of 1999 after being employed as a case manager with the Nebraska AIDS Project for five years. She received her Master’s degree in Social Work and Public administration from the University of Nebraska at Omaha. Tacy is a clinic social worker, patient services coordinator and the coordinator for the Ryan White Parts C and D Programs. She is strongly committed to quality care and access for our patients and always goes the extra-mile for patients.

Jeremy Johnson, MSW joined the HIV team in October 2005 as a social worker and coordinator for the Nebraska AIDS Drug Assistance Program (ADAP). He received his Master’s degree in Social Work from the University of Denver, Colorado. Prior to working with us, he was the Southwest Iowa case manager for Nebraska AIDS Project. He is committed to working with this population of clients and greatly enjoys being a part of the team.

Renae Furl, MPH joined the HIV team in August 2007 after being employed as a case manager with the Nebraska AIDS Project for nearly five years. She received her Master’s degree in Public Health from the University of Nebraska Medical Center. Renae is committed to helping patients find ways to pay for their care and medications, and coordinates the insurance program through Nebraska ADAP. Her position is titled “Healthcare Access Coordinator”.

Laura Krajewski, MPA joined the HIV team in 2013 as the Patient Outreach Specialist. Behind the scenes, Laura coordinates quality assurance efforts for the Ryan White Parts C and D Programs. A Nebraska native, Laura returned to Omaha after working at an AIDS Service Organization in Massachusetts for eight years. She received her master’s degree from Clark University and also served in the Peace Corps in Kazakhstan teaching English to high school students. She is interested in the social impact HIV/AIDS has on individuals living with the disease.

Samantha L. Jones, BSW joined the HIV team in May 2016. She received her BSW from the University of Iowa and was employed with Goodwill for over five years. Most recently she was the Intake Coordinator under the Federal Workforce Innovation and Opportunity Act (WIOA), working to provide outreach and access to employment and training opportunities in order to assist individuals in becoming self-sufficient. Samantha works with the AIDS Drug Assistance Program (ADAP) participants to access and maintain insurance coverage through the Affordable Care Act, help navigate insurance plans, and increase insurance literacy among recipients. Behind the scenes, Samantha coordinates quality assurance efforts for processing pharmaceutical claims, medical co-pays, and tax reconciliation efforts, while ensuring ADAP meets program requirements.

L-R: Samantha L. Jones BSW , Renae Furl MPH, Jeremy Johnson MSW, Tacy Slater MSW, MPH, Laura Krajewski MPA

Many clinics are not as fortunate as we are to have social workers integrated into the team, let alone a whole group of social workers. Together, they are a force to be reckoned with, and UNMC ID is grateful for their dedication to their craft and to our patients.

Learn more about UNMC HIV care at the Specialty Care Clinic here.

ID Journal Club Presents… Molecular Rapid Diagnostic Tests Improve Clinical Outcome

Bloodstream infections are associated with high mortality. Blood cultures are a reliable and accurate method for the identification of bloodstream infections but can take up to 5 days or even more being finalized, leading to delays in initiation of effective antibiotic therapy. The Infectious Disease Society of America (IDSA) recommends the use of rapid diagnostic testing with support of antimicrobial stewardship for better clinical outcomes, and President Obama include development of rapid diagnostic tests as one of the five overarching goals of the “National Action Plan for Combating Antibiotic Resistant Bacteria”.

Rapid diagnostic tests in bloodstream infections were discussed at a recent UNMC infectious disease journal club. “The effects of Molecular Rapid Diagnostic Testing on clinical outcomes in Bloodstream Infections systemic review and meta-analysis” published in Clinical Infectious Disease in Jan 2017 was presented by infectious disease fellow Dr. Rajendra Karnatak, with enthusiastic discussion among the group.

Recent advances in rapid diagnostic tests like PCR, Matrix-assisted Laser Desorption/Ionization Time of Flight (MALDI-TOF) Mass Spectrometry, and PNA-FISH have significantly reduced time to identification of microorganisms in bloodstream infections. The effect of molecular rapid diagnostic tests on important clinical outcomes like mortality, time to effective therapy, length of stay, and reduction of treatment cost has not been well established.

The article Dr. Karnatak reviewed studied the effects of utility of molecular rapid diagnostic tests on mortality, time to effective therapy, and length of stay (LOS). 31 studies met inclusion criteria for systemic review/meta-analysis and 5920 bloodstream infections were studied. All included studies compared conventional microbiological methods to molecular rapid diagnostic tests. Results indicated molecular rapid diagnostics would need to be used 20 times to prevent 1 death within 30-day period, and a statistically significant overall reduction in mortality with use of rapid diagnostics in combination with antimicrobial stewardship (ASP). There was a mean difference of -5.03 hours in time to effective therapy in the molecular rapid diagnostic tests group as compared to conventional microbiological methods. Time to effective therapy was most pronounced in bloodstream infections due to Enterococcus spp. The rapid diagnostic test group demonstrated a shorter LOS by 2.48 days compared to conventional microbiologic methods.

The included enterococcal bloodstream infection study contributed to some heterogeneity of the meta-analysis, with respect time-to-effective therapy. When the enterococcal bloodstream infection study was excluded from analysis, there was only 1.89 hours mean difference in time-to-effective therapy. Without the support of antimicrobial stewardship, results favored mortality benefit with the use of molecular rapid diagnostic tests but failed to demonstrate statistical significance. These findings further support 2016 IDSA recommendations for use of rapid diagnostic tests with support of ASP for better clinical outcome.

Use of rapid diagnostic tests is one step in a multi-step process that includes appropriate ASP structure, appropriate laboratory notification process, timely intervention and availability of resources for ASP. The majority of studies included in this meta-analysis did not have 24/7 support of ASP. Although this study clearly demonstrated benefit in reduction of LOS, it did not mention overall cost benefit. Molecular rapid diagnostic tests can revolutionize patient care, allowing for initiation of appropriate tailored therapy earlier during the treatment of critically ill patients. ASP and molecular rapid diagnostic tests together can have significant impact on fight against increasing antimicrobial resistance.

Content provided by Dr. Rajendra Karnatak, UNMC ID fellow

M4 Students in our HIV Enhanced Education Track present Capstone Projects…and Today is MATCH DAY!

The UNMC College of Medicine offers a unique Enhanced Medical Education Track (EMET) program which provides an opportunity for medical students to delve into particular disciplines of interest in the field of medicine throughout their four year degree program. Track students attend seminars, preceptorships and complete a research project culminating in a poster or conference presentation.

Yesterday, on the eve of their Match Day, our two M4 Students, Rebecca Osborn and Daniel Cloonan (under the mentorship of Dr. Sara Bares) presented their Capstone Projects at UNMC College of Medicine.

Today, after years of hard work, months of interviews, weeks of decision and the most anxiety-filled week of their lives, they found out where they will be spending the next few years of their lives as newly minted doctors.

Rebecca’s project focused on a collaborative care program to help with medication adherence in patients living with HIV. This collaborative worked with a local community pharmacy to create a program of direct engagement between pharmacists and patients in order to improve adherence. She will be submitting her work for presentation at a national conference and for publication. Rebecca will be continuing her medical training with Internal Medicine Residency at Yale. We wish her all the best and hope to see her again in the future for ID fellowship!

Daniel’s project looked at the gender affirming hormone therapy taken by transgender patients and possible interactions with Pre-exposure prophylaxis (PrEP), which is recommended to help prevent HIV infection in persons at high risk for acquiring the disease. Because of a fear of drug-drug interactions, many transgender individuals may avoid PrEP when they are at high risk, fearing an interruption in their hormone therapy. Daniel’s study is part of a larger study being led by Kim Scarsi, PharmD (HIV Clinical Pharmacist at the Specialty Care Center and Associate Professor in the College of Pharmacy) and Lauren Cirinccione, PharmD (Pharmacy Practice Fellow). The project, collaborating with the UNMC College of Pharmacy, hopes to answer this question and by doing so, remove some barriers to PrEP engagement when needed. Daniel will be continuing his medical training with a General Surgery Residency at Beth Israel Deaconess Medical Center. We wish him all the best in the future!

Each year, our UNMC HIV clinic takes two medical students into the EMET track, and we look forward to working with them over the course of their undergraduate medical training to immerse them in HIV care and Infectious Diseases. We will soon be announcing our new M1 EMET students, who will start working with us over the coming summer.

Congratulations again to Becky and Daniel, we are proud of you! And congratulations to all M4s out there who found out where they matched today!

More information about the EMET program can be found here.

What Patient Safety Means to Us – Part 2

In endeavoring to give you a real flavor of how important patient safety is to all of us, we have more comments today from our team. Patient safety is important to all of us and we wish we could highlight the all of important work everyone in our Division is doing to provide the best possible care while still preventing harm.

Adrienne Sy, RN, BSN; Quality Lead for CLABSI & CAUTI reduction starts us off today:

Patient safety means protecting someone’s loved one from harm. My grandmother passed away after a fall two weeks before I took the NCLEX, and my mother-in-law passed away after a bloodstream infection three months after I got to marry her eldest son.

Two things that I am very excited to help run/coordinate are the CAUTI and CLABSI Roundups. It gives me a chance to work with the nursing units, and I believe that these have been very helpful in identifying what is done well and what our areas of opportunity are.

Michelle Schwedhelm, RN adds a great global view of safety at Nebraska Medicine/UNMC:

Patient Safety is creating a safe zone and processes for patients seeking care at Nebraska Medicine.

One project is doing Fire and Severe Weather Drills with our staff to assure they know how to evacuate and how to mitigate danger for our patients. Another is our new Daily Shout Out meeting where we identify safety issues for patients and staff and encourage prompt resolution. Visibility is at the highest levels of the organization.

Dr. Kelly Cawcutt on preventing harm in the ICU:

Dr. Kelly Cawcutt, Associate Director of Infection Control and Epidemiology

Patient safety is about always providing the best patient-centered care while preventing harm, for all patients. I work in the ICU also, and there we are providing care to the sickest patients in the hospital and often have to use invasive procedures and devices for life support measures. Providing excellent clinical care is one component of patient safety, but through working in Infection Control, I can also focus on preventing harm are a larger scale from how we prevent the spread of infections in the hospital to which types of devices we use in the ICU.

Some examples of projects I have worked on are developing a vascular access algorithm to ensure we use the right device at the right time for our patients – whether that is a peripheral IV, midline, central venous catheter or another type of device. I also am working on how to address and prevent ventilator-associated events, including pneumonia, for our patients who require mechanical ventilation in the ICU. These projects reduce harm, prevent adverse events and in the end, I believe this work helps save lives.

To me, patient safety is about imagining yourself as each patient or family member being cared for in the hospital, and asking “is the care I’m delivering what I would want for myself or my family?”, and if the answer to that is “no”, personally seeking ways to improve that care for our patients.

Dr. Jasmine Riviere Marcelin is the Associate Medical Director, Nebraska Medicine Antimicrobial Stewardship Program

Much of my work in Antimicrobial Stewardship is focused on reduction of antibiotic use, primarily with a patient safety mission. Antibiotics are the only drugs where an individual prescriber’s use can affect patients s/he never even cared for. For example, when patients are prescribed antibiotics for viral illnesses which do not require them, this may lead to development of bacteria resistant to antibiotics. When a patient in that community then develops a serious bacterial infection with this resistant organism, they may face grave complications from the actual bacteria or from use of alternative antibiotics with serious adverse effects or toxicities. Collaborating with the Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP) and Nebraska Health Network (NHN), I created several educational materials for outpatient prescribers on appropriate use of antibiotics in upper respiratory illnesses.

Additionally, skin/soft tissue infections are another area where antibiotics are overused, and I personally have seen patients develop kidney failure from combination treatment with vancomycin and piperacillin-tazobactam for cellulitis when only cefazolin was indicated. I am currently working on updating our institutional skin/soft tissue infection guidance document which will help antibiotic prescribers make the right treatment choices for specific skin/soft tissue infections. These are just two of the many projects our Antimicrobial Stewardship Team are working on to decrease antibiotic overuse and misuse, keeping patients safe by reducing adverse effects, drug toxicities and antibiotic resistance.

Antimicrobial Stewardship Program Takes Patient Safety Personally

At Nebraska Medicine, our Antimicrobial Stewardship Program’s (ASP) clinical mission is to optimize the utilization of antimicrobial agents, thereby improving patient outcomes (by reducing the risk of adverse events and Clostridium difficile infection) and limiting the spread of antimicrobial resistance. These Antimicrobial Stewardship activities have been mandated by the Joint Commission and our program has been expanding its reach to include our satellite hospitals and our outpatient clinics to achieve this mission. Since a large majority of inappropriate antibiotic use occurs outside of the hospital, our outpatient initiatives are currently focused on education of clinic providers and patients on not using antibiotics for conditions that do not require them.

On the inpatient side, our stewardship activities have many impacts on patient safety. First, many studies have demonstrated the benefit of early Infectious Disease consultation for patients with Staphylococcus aureus bloodstream infection (SAB). When ID doctors are involved, patients are less likely to die or suffer complications, respond faster to therapy and will have fewer adverse effects. At Nebraska Medicine, we review approximately 150 SAB cases per year to prompt ID consultation. In addition, the discussion between the ASP reviewer and the primary team ensures the appropriate antibiotic is started immediately, even in advance of the ID consultation.

Last year, our ASP program documented over 2500 reviews of patients for appropriate antibiotic use, with 381 interventions to reduce antibiotic use by either discontinuing or de-escalating therapy, with a 90% acceptance rate of interventions. Not only did we assist with narrowing antibiotic use, 97 patients with untreated or resistant infections were identified and subsequently initiated on therapy as a result of ASP review, and nearly 200 ID consult requests were implemented in highly complex cases.

Furthermore, our ASP interventions have also resulted in reductions of vancomycin and piperacillin/tazobactam combination therapy when unnecessary. The combination of these two antibiotics has been shown to increase risk of kidney failure (which leads to worse clinical outcomes for patients), and the simple act of switching to alternative antibiotics to avoid this risk has tangible patient safety benefits.

In 2016, new initiatives were introduced to improve timing and redosing of antibiotic prophylaxis for surgery, in an effort to reduce the risk for surgical site infections (SSI). Coupled with the new SSI prophylaxis guidance, the program developed guidance on how to manage patients with beta-lactam allergies. This is important for patient safety because many patients receive 2^nd or 3^rd line antibiotics inappropriately in the context of remote penicillin allergies. Sometimes, like in the case of surgical prophylaxis, the data is clear that use of antibiotics other than cefazolin can lead to increased SSI risk. Providing evidence-based guidance in collaboration with our allergists empowers physicians to provide best care for their patients without perceived harm of allergic reactions.