The University of Nebraska Medical Center Specialty Care Clinic (SCC) provides comprehensive care of persons living with HIV, at all stages of the disease, as well as specialty Transgender clinics. The team is composed of Physicians, Pharmacists & Pharmacy Assistants, Nurse Practitioners, Registered Nurses, Social Workers & Case Managers, Medical Assistants, Front Desk Assistants, Patient Resource Specialists, Administrative Staff, and an in-house Laboratory technician. We are located at 804 S 52nd Street, Omaha, NE 68016.
When you enter, you will be greeted by the Front Desk Staff at the Specialty Care Center. The Front Desk is staffed by Rachelle Carr, MA – Operational Lead, Adele Haas, MA and Genie Shumaker, Medical Receptionist. Rachelle and Adele are the ‘spokes in the wheel’ of this busy front desk. We deliver outstanding patient care to the patients and cover a wide variety of duties. In our years of service at the SCC, we have established relationships with the patients, which puts the patients at ease during their appointment. Rachelle and Adele keep busy rooming patients, answering phones, managing the provider schedules, treating Sexually Transmitted Infections. They also order supplies, administer vaccines, draw labs, make follow up appointments and monitor patient flow through the clinic. Genie primarily checks in patients, answers phones, registers and schedules patients. We all enjoy establishing relationships with the patients. Each of us has the opportunity to set the tone for the patients’ visits. We are frequently the first face in their patient experience to Nebraska Medicine. Our commitment is to deliver Patient First Care to each patient we serve. We strive to make it a positive visit where they are assured they are getting the best care with Nebraska Medicine.
For more information about the SCC, please call (402) 559-2666 or (866) 632-2437; or visit our website online.
World AIDS Day represents an opportunity for reflection – how far we’ve come since the beginning of the epidemic with unprecedented advances in treatment, and also reflection about the early days of fear and confusion.
I have a vivid memory of the first patient I took care of with HIV infection. It was 1986 and I was living in Columbus Ohio and working in a primary care clinic for people who were uninsured. The patient was a 30-year-old man working as a waiter, and he had been losing weight and had a recent bout of pneumonia. He had taken this new test for HIV, which was positive, and he came to me for help. He was very scared, and I remember him looking at me and asking me what was I going to do? At the time, there was no available antiretroviral therapy, and very little was known about this strange new disease. There were no treatment guidelines, no hotline to call or Up-To-Date to turn to. Instead, we had fear and anxiety about this strange new disease. My nurses were very nervous about taking care of people with HIV infection, as were the staff of many hospitals. I had small children at home, and was worried about what I might inadvertently carry home to them. Some doctors were refusing to take care of HIV-infected patients at all, which led the AMA to take an unprecedented step in the form of a statement about the ethical issues involved in the growing AIDS crisis, which basically said that “a physician may not ethically refuse to treat a patient…solely because the patient is seropositive”.
It is a rare event in clinical practice to be at a complete loss as to how to proceed; brand new diseases do not come along very often. I looked at my patient and with some dread, and thought to myself, what am I going to do? Something had to be done, so I fell back on the basic tenets of patient care – I took a careful history, did a physical exam and told him that we would work through this together. At the time, we were just beginning to understand the kind of infections that people with HIV were susceptible to, so I gave him a prescription for trimethoprim sulfa, which made most of both of us feel better.
Unfortunately, this young man did not survive his disease, which was the case for very many of my patients in the early years. As more patients with HIV infection started coming to my clinic in Ohio, my regular primary care patients started going elsewhere as they were worried about being in the same waiting room. This is how I turned into an “AIDS specialist”. I used to say this is because I was in the wrong place at the wrong time, but in fact it was the right place at the right time, and has led to a incredibly productive and rewarding career.
Since the 1980’s, we have seen steady innovation and progress at a remarkable pace. This has led to improved HIV diagnostic testing, identification of viral resistance, new antiretrovirals with fewer side effects or drug interactions, medications to prevent transmission of HIV to infants and uninfected partners, and to date, one person has been cured. We still have a long way to go to achieve reproducible cure, but there is hope, and where hope is, innovation will follow.
Editorial note: Dr. Swindells has devoted her life to the care of persons living with HIV. She has published over 100 peer-reviewed journal articles, numerous book chapters and is a member of the AIDS Clinical Trials Group (ACTG), which is a global network of expert clinician-scientists dedicated to the study of HIV. In 2013, she received the UNMC Innovation, Development and Engagement Award (IDEA) for her commitment to the community of persons living with HIV, as demonstrated through her development of the Specialty Care Clinic, personal care of her patients and securing funding for ongoing clinical and research activities.
At the Specialty Care Clinic, we are proud to have Dr. Swindells as our Director, as through ongoing innovation, we boldly march into a future that may one day be HIV-free. Over the next several weeks, stay tuned to this blog for more opportunities to learn more about advances in HIV medicine, the lives touched by HIV, and our work at the Specialty Care Clinic.
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. More information about the EMET program can be found here.
One of these tracks is HIV medicine, and we are always excited to have track students come through our HIV clinic. This month we have been fortunate to have a phenomenal M4 student, Rebecca Osborn, in our HIV clinic. She has a keen interest in Infectious Diseases and HIV medicine, particularly linkage to care and barriers to antiretroviral therapy adherence. Together with her mentor Dr. Sara Bares, Rebecca worked on a research project aimed at evaluating adherence to antiretroviral therapy in the HIV clinic, which she expertly presented to the HIV team at the Specialty Care Clinic on October 17, 2017. She provided us with a summary of her research below:
With the advent of effective antiretroviral therapy, consistent medication adherence has become the backbone of HIV Care. My study evaluated the impact of a collaborative care program between the Nebraska Medicine HIV team and a community pharmacy adjacent to the clinic to offer specialized services, including provision of customized adherence packaging, adherence checks, and the option of home delivery of medications, to a group of patients at high risk for poor adherence. Many of these patients had a history of viremia and uncontrolled HIV for several years prior to taking part in the program. We found that a collaborative pharmacy-led initiative to improve medication adherence led to improved virologic suppression in our selected patient population.
Rebecca plans to present her findings at an upcoming conference and will be submitting for publication shortly. We wish her success with her upcoming residency interviews and know she will be an invaluable addition to the residency program of her choice!
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!
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.”
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.
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.
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).
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)
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.
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.
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