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Division of Infectious Diseases

Even after Thanksgiving, it’s still not too late to get your FLU SHOT!

It’s already the day after Thanksgiving, but believe it or not, it is still early in the flu season! The Douglas County Department of Health has been recording influenza cases since the beginning of the flu season, designated as October 1, 2017.  To date, there have been 96 laboratory confirmed influenza cases in Douglas County.  This is more than was reported for the same time-period in the previous two influenza seasons. Learn more about influenza reporting in Nebraska here. Over 50% of hospitalizations for influenza-like illnesses were in patients under the age of 4 or over the age of 65 (the most vulnerable populations). Only 1 death has attributed to influenza in the state of Nebraska.

In September, Dr. Mark Rupp (Chair of the Division of Infectious Diseases and Medical Director of the Nebraska Medicine Department of Infection Control & Epidemiology) shared some information on this blog about this year’s flu vaccine and our institutional efforts to vaccinate our employees and students to protect our patients and each other. Already at UNMC/Nebraska Medicine, we are approaching our target of >90% compliance for multiple employee groups across campus; currently we have recorded >85% compliance among employees on inpatient units, and expect to see a significant uptick in compliance in the coming weeks.

The peak of the flu season is expected between December and March, so it is still not too late to get your flu shot!

Learn more about influenza, how to prevent the flu, why you should get your flu shot, and where you can get your flu shot if you are a patient or a student/employee.

Flu shot cartoon courtesy Beatrice the Biologist

Special thanks to members of the UNMC ID division who submitted their post-flu shot photos!

Thankful and Grateful for YOU

Sometimes in life there are moments of amazing coincidence, and this post is a very happy, unexpected, coincidence as we had not planned a post for today.

We had, however, planned a THANK YOU post to all of the amazing readers and supporters who have helped make this blog a success after we passed 10, 000 views. It just so happens that this is the week we achieved that goal, and it could not be more appropriate timing.

We are so incredibly grateful and thankful for the support from everyone in the Division of Infectious Diseases, the Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Nebraska Medicine and to each and every reader who reads a post, likes a post, and even better, shares a post!

Thank you for your support and we hope you will continue to read, contribute and share this blog.

 

“No one who achieves success does so without acknowledging the help of others. The wise and confident acknowledge this help with gratitude.”

-Alfred North Whitehead

 

A New Template for Antibiotic Stewardship in Post-Acute and Long-Term Care Settings

Antibiotic use is common in long-term care facilities (LTCF) with 70% residents receiving at least one course of systemic antibiotic every year. A significant proportion of the antibiotic use (40% to 75%) in nursing homes has been found to be unnecessary or inappropriate. Antibiotic exposure drives selection for multi-drug resistant organisms and C difficile infection. Antibiotic stewardship promotes appropriate antibiotic use and is important in combating antibiotic resistant bacteria. Centers for Medicare and Medicaid Services (CMS) will require all long-term care (LTC) facilities to have an antibiotic stewardship program by November 28, 2017 as part of the requirements for participation.

Most long-term care facilities do not have any experience in implementing antibiotic stewardship program and these facilities also lack expertise in this area. Under the leadership of Dr. Robin Jump, Infection Advisory Committee of AMDA – The society for post-acute and long-term care medicine has developed a template for antibiotic stewardship policy for post-acute and long-term care settings. Dr. Muhammad Salman Ashraf, an associate professor in the division of infectious diseases at UNMC, who is also a member of the infection advisory committee of AMDA, has also contributed in the development of this template. This template is published in November issue of JAMDA (The Journal of Post-Acute and Long-Term Care Medicine) and can be found at http://www.jamda.com/article/S1525-8610(17)30430-9/fulltext

According to Dr. Ashraf, long-term care facilities can adapt antibiotic stewardship policy mentioned in this template to meet the requirements of CMS. The template also provide some guidance on implementation of antibiotic stewardship program. Another helpful part of this document is a compiled list of many free resources that can be used for development of an antibiotic stewardship program.

Dr. Ashraf, who is also the co-medical director of Nebraska ASAP (Antimicrobial Stewardship Assessment and Promotion Program), pointed out that in addition to the resources mentioned in this document, long-term care facilities can also found some other helpful tools on Nebraska ASAP website (https://asap.nebraskamed.com) which was launched after this template was already submitted to the journal. Long-term care facilities in Nebraska should feel free to contact Nebraska ASAP with any question regarding development of antibiotic stewardship program and the ASAP team will make every effort to provide the best guidance.

 

Content courtesy of Dr. Ashraf.

Infectious Diseases Clinical faculty participate in UNMC College of Medicine curriculum re-design: Training the Physicians of Tomorrow

Undergraduate medical education has long been a delicate balance between providing knowledge of basic sciences and providing experience on clinical rotations. Traditional education curricula have approached this as an even split over 4 years of medical education. The first two years of basic science education were typically classroom lectures of topics over several month semesters. However, there have been new trends in medical education to explore alternate pathways, given the realization that as adult learners, medical students require more interactive learning experiences. The UNMC College of Medicine is one place where this innovative curriculum design is being implemented.  What once were semester-long traditional Microbiology and Immunology courses have now been transformed into an integrated focused block called Defenses and Invaders (course directors: Sara Bares MD, Paul Fey PhD, Geoff Thiele PhD, and Andrea Zimmer MD).  The ingenious course name conjures up images of epic battles between brave immune system soldiers and their formidable adversaries constantly trying to infiltrate our bodies. Defenses and Invaders inspires medical students to learn more about these sneaky organisms, why they do what they do, and how our own bodies protect us from harm, sometimes even without our knowledge!

The new course design involved some traditional lectures, but had the addition of multiple small group sessions. In these sessions, 12 or fewer first year medical students had the opportunity to have intimate time with one or two faculty members, most of whom were clinical Infectious Disease faculty, in addition to Microbiology/Pathology faculty. They reviewed cases together as a group, with students learning and teaching each other through specific clinical scenarios focusing on the microbiology that clinicians use for decision making, with added pearls from faculty facilitators. This approach created an earlier opportunity for interaction between medical students and clinical faculty, and provided a way to expose students to disease processes caused by microbial pathogens to make them more relatable, interesting and memorable.

The ID faculty enjoyed their interactions with the students and the cases sparked some interesting questions and discussions within the groups. While it will be years before the effect of the curriculum can be tested by board scores, the redesign has already borne fruit of interest in Infectious Diseases, with many students feeling emboldened to directly engage the experts, arrange meetings and volunteer to shadow in the ID clinics. Though not the intent of the course, this is proof that a grass-roots effort by Infectious Diseases groups can help to increase interest in and awareness of our specialty. Infectious Diseases faculty will also be providing lectures within other block topics; and core exposure to Infectious Diseases topics will be revisited throughout the next year and a half, with plans for an Infectious Diseases synthesis block before the students’ clinical years, to review concepts for boards and wards.

 Content courtesy Dr. Andrea Zimmer, MD

Dr. Mark Rupp (Professor of Medicine and Division Chief, Infectious Diseases) teaching his small group about respiratory infections

Dr. James Wisecarver (Professor of Pathology/Microbiology and Medical Director, Clinical Laboratory) and his small group

Dr. Diana Florescu (Associate Professor of Medicine and Transplant ID physician) engaged in discussion with her group

At Nebraska Medicine, we are proud to Be Antibiotics Aware!

At Nebraska Medicine, we have been supporting Antimicrobial Stewardship activities for over a decade, and we are proud to Be Antibiotics Aware. The CDC has recognized our efforts by including the Nebraska Medicine Stewardship Program as an example for other institutions to model. We have recently partnered with the state of Nebraska to promote these activities at the state level through the Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP).

Check out our Nebraska Medicine Antimicrobial Stewardship website for more information, and meet our team below.

     Nebraska Medicine Stewardship Team
Front Row L-R: Jasmine Marcelin MD (Associate Medical Director), Philip Chung, PharmD, Scott Bergman PharmD (Pharmacy Coordinator)
Back Row L-R: Salman Ashraf MBBS, Mark Rupp MD, Trevor Van Schooneveld MD (Medical Director)

Celebrating Nurse Practitioner’s Week – Spotlight on Solid Organ Transplant ID NP’s!

As part of our Nurse Practitioner’s week feature, our third spotlight features Heather Chambers, Lisa Hill, and Jennifer Hrbek, who serve our Solid Organ Transplant ID patients.

 

Heather Chambers

A graduate of Pensacola Christian College (BSN) and the University of Nebraska Medical Center for her Masters and Doctor of Nursing Practice, Heather joined the nursing field because of her desire to help others. While Heather was unit nurse, she knew that she wanted to do more with her knowledge and expertise. The drive for knowledge and continual growth attracted her to pursue Nurse Practitioner school.

As a Nurse Practitioner with the Solid Organ Transplant ID team, Heather loves helping our patients. She finds it very rewarding to help patients improve and guide families along the care process. Heather enjoys the comradery that comes from collaborating with other services and the knowledge that she gains with every patient she treats to help her become a better clinician.

 

Lisa Hill

A graduate from the University of Nebraska Medical Center (BSN) and Creighton University (MSN-FNP), Lisa was drawn to healthcare from the guidance from a friend. As a nurse, Lisa found the care she provided to her patients to be extremely rewarding. However, she desired more and pursued Nurse Practitioner school.

As a Nurse Practitioner with the Solid Organ Transplant ID team, Lisa finds gratification in the care she provides as part of the team for our complex patients. Lisa develops a strong rapport with the patients and families, making the best interest of our patients her priority.

 

Jennifer Hrbek (photo unavailable)

A graduate from Auburn University, Clarkson College (BSN) and Creighton University (MSN-FNP), Jennifer was inspired to be a Nurse Practitioner by the birth of her brother. Her mother’s provider, an OB/GYN Nurse Practitioner, delivered her brother that left a profound impact on Jennifer’s journey. As a nurse, Jennifer knew she wanted to increase her skills and expertise and pursued Nurse Practitioner school.

As a Nurse Practitioner with the Solid Organ Transplant ID team, Jennifer finds rewarding the comradery from working with her colleagues. She enjoys the complex patient population that she serves and the continual learning each and every day.

Content courtesy of Jonathan Nguyen.

Be Antibiotics Aware…in the Outpatient Clinics

Nebraska Medicine and Antimicrobial Stewardship in the Outpatient Setting

Antimicrobial stewardship is not only about inpatient prescribing. Recent studies measuring antibiotic use in ambulatory settings have estimated that antibiotics are prescribed inappropriately 30-77% of visits(1).  Despite being one of the leaders in implementing antimicrobial stewardship in hospitals, Nebraska ranks 44th (out of 50 states and District of Columbia) in outpatient antibiotic prescriptions dispensed. The practice of inappropriate antibiotic prescribing is one of the factors that has led to world-wide spread of antibiotic resistant bacteria. Due to the ongoing issue of antibiotic resistance, in 2014 the president called for a 50% reduction in appropriate outpatient antibiotic use in his National Action Plan for Combating Antibiotic-Resistant Bacteria. In 2016, the Centers for Disease Control and Prevention (CDC) outlined the Core Elements of Outpatient Antibiotic Stewardship(2).  

The CDC suggested that in order for an outpatient antimicrobial stewardship program to be successful, it needs leadership commitment within healthcare institutions, definitive action by implementation of policies to improve prescribing practices, accurate tracking of prescribing and individual reporting to prescribers, education of healthcare professionals and patients/families, and finally access to experts in antimicrobial stewardship. Put simply, the goal of these elements, when implemented, are to improve patient care by treating infections with antibiotics when needed, avoiding patient adverse effects (like drug toxicities or C. difficile infections) from unnecessary antibiotic treatment, and avoiding the development of antimicrobial resistance in the community.

Here at Nebraska Medicine we have several ongoing projects geared towards improving our antibiotic use in the outpatient setting. We have been working with hospital and ambulatory clinic leadership to improve vaccination protocols, particularly with an inpatient nurse-driven influenza protocol that identifies patients who need the flu vaccine and administers prior to discharging from the hospital. Alerts have also been developed in our electronic health record which prompt clinicians when vaccines are indicated. Additionally, we partnered with the Nebraska Health Network to develop evidence-based guidance documents for the treatment of sinusitis and C. difficile infections in the outpatient setting. Additional guidance documents focused on the inpatient setting are also applicable to outpatient encounters, such as Acute Exacerbations of Chronic Obstructive Pulmonary Disease (AECOPD), Urinary Tract Infections (UTI), Skin/Soft Tissue Infections (SSTIs), and Community Acquired Pneumonia (CAP).

Finally, we have partnered with the  Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP) to create a large-scale antimicrobial stewardship education program for ambulatory clinics.  Through this program, we hope to implement several educational strategies for providers and patients, evaluate and measure the effectiveness of these strategies, and improve on them to achieve our goal of 50% reduction of inappropriate outpatient antibiotic use by 2020.

References:

  1.  Fleming-Dutra KE et al, JAMA. 2016;315(17):1864., Antimicrob Agents Chemother. 2015;59(7):3848. Epub 2015 Apr 13.
  2.  Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core Elements of Outpatient Antibiotic Stewardship. MMWR Recomm Rep 2016;65(No. RR-6):1–12

Be Antibiotics Aware Logos Courtesy Centers for Disease Control and Prevention

 

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

Celebrating Nurse Practitioner’s Week – Spotlight on Specialty Care Clinic NP’s!

As part of our Nurse Practitioner’s week feature, our second spotlight features Ann Fitzgerald, Nikki Regan, and Christine Tran, who serve our Specialty Care Clinic patients.

 

Nikki Regan (on left)

A graduate from the University of Nebraska Medical Center College of Nursing – Lincoln for both her Bachelor and Masters of Science in Nursing, Nikki’s journey originally started towards biochemistry until she realized a lab environment did not provide her the opportunity serve others. She quickly found nursing, which provided the perfect combination of her love for science and caring for others. For many years, during nursing school and after, Nikki volunteered at Camp Kindle, which provides camps free of cost for kids and teens with HIV. The time spent at Camp Kindle would inspire Nikki to go to Nurse Practitioner school to increase her autonomy and skill set.

As a Nurse Practitioner at the Specialty Care Clinic, Nikki enjoys the collaborative environment with the faculty that constantly provides teaching moments. Nikki embraces the challenges that come with her role but finds her ability to serve our patients to be rewarding and gratifying.

 

Ann Fitzgerald (middle)

A graduate from the University of Nebraska Medical Center (BSN) and the University of California, Los Angeles (MSN-FNP), Ann was drawn to healthcare from her desire to help people and passion for science. Ann’s mother was also a nurse, which solidified her decision to join the field. Ann contemplated between Medical School and Nurse Practitioner School and chose Nurse Practitioner School because of her love of nursing.

As a Nurse Practitioner at our Specialty Care Clinic, Ann enjoys the collaborative environment she participates in every day serving our patients. She finds it rewarding to use her skills and talents with the Specialty Care team to improve the health of the patients in our community.

 

Christine Tran (on right)

A graduate from Marquette University (BSN), Creighton University (MSN) and UNMC(DNP), Christine’s journey originally started toward business but was redirected to nursing in part from her love of science, working with others, and her two aunts who were nurses that she admired. Immediately after graduation, Christine volunteered as an RN with the Jesuit Volunteer Corps (JVC), where she served the homeless in Cleveland, OH. During her time with JVC, Christine valued the independence and patient continuity the role provided that it was apparent she wanted to be a Nurse Practitioner.

As a Nurse Practitioner at the Specialty Care Clinic, Christine finds her role rewarding through the holistic care, physical, emotional, and social, provided for the patients of the Specialty Care Clinic. Christine enjoys the camaraderie and collaboration that the Specialty Care Clinic provides, but also the independence that her role enables her to serve patients. Christine acknowledges that she is very fortunate that her patients let her into their lives in such as personal way.

 

Thank you Nikki, Ann and Christine for your excellent care of patients!

 

Content courtesy of Jonathan Nguyen. 

Be Antibiotics Aware…in Small and Critical Access Hospitals

In 2014, the CDC published The Core Elements of Hospital Antibiotic Stewardship Programs to assist acute care facilities implement antimicrobial stewardship program (ASP).  While these efforts were relatively successful in hospitals with more than 50 beds, they were less successful in hospitals with 25 beds or less.  In response to this disparity based on hospital size, the CDC published The Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals to assist these smaller acute care facilities implement stewardship activities.

In the spring of 2017, using the antimicrobial stewardship content expertise from UNMC/Nebraska Medicine, Nebraska ASAP also partnered with 1 small and 4 critical access hospitals to guide and assist the implementation of antimicrobial stewardship programs in these facilities. Learn more about these efforts here.

 

Be Antibiotics Aware and Stewardship logos courtesy Centers for Disease Control and Prevention

Content provided by Philip Chung PharmD, Pharmacy Coordinator for Nebraska ASAP

Celebrating Nurse Practitioner’s Week – Spotlight on Oncology Infectious Diseases NP’s!

Nurse Practitioner’s Week runs from November 12 to November 18. During this week, the ID wants to recognize and extend our appreciation to our Nurse Practitioner’s that provide extraordinary care to our patients at Nebraska Medicine. Our first spotlight features Whitney Knuth and Jolene Tijerina, who serve our Oncology ID patients.

 

Whitney Knuth (on right)

A graduate of the University of Iowa (BSN) and Clarkson College (MSN-FNP), Whitney was drawn to the healthcare field from her desire to help others. Nursing provided Whitney the opportunity to make a difference in her patients’ lives in a challenging and rewarding field. As Whitney’s nursing career progressed, she had a drive for greater clinical knowledge and professional autonomy. With her foundation as a nurse, Whitney knew pursuing her dream to become a nurse practitioner would allow her to continue to advocate for her patients and provide advanced holistic care.

As a Nurse Practitioner with the Oncology ID team, Whitney enjoys the ability to work with the patients and their families. With a background as a nurse in Oncology & Hematology, being able to work with this patient population with the Infectious Diseases team has been extremely rewarding. Many of the patients served by Oncology ID team are immunocompromised, that when the team is able to prevent, diagnose, and treat an infectious complication, is extremely gratifying.

 

Jolene Tijerina (on left)

A graduate of Creighton University (BSN) and the University of Nebraska Medical Center (MSN-FNP), Jolene was drawn to the healthcare field from family experiences with Oncology. From these experiences, Jolene started in healthcare apart of the research team and quickly built relationships with the patients. Because of these meaningful relationships, Jolene pursued her nursing degree. As a nurse, Jolene loved the role that she served with caring of patients. However, she was drawn to increase her responsibility in the care process related to treatment plans.

As a Nurse Practitioner with the Oncology ID team, Jolene loves that she learns something new every day. The patient population cared by the Oncology ID team is complex and requires Jolene to dive deeper, at times playing detective, with their patient’s background. Jolene finds her role as part of the team rewarding from rapport she is able to build with their patients through the care she provides every day.

 

Thank you Whitney and Jolene for all you do everyday to provide excellent care to our patients!

 

Content courtesy of Jonathan Nguyen.

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