Ambulatory Care Facilities Research Articles

New York University School of Medicine

New York University School of Medicine

Standard and Transmission-Based Precautions: An Update for Dentistry

BackgroundStandard Precautions are the foundation of all infection control programs and include infection control practices that apply to all patients and situations regardless of whether the infection status is suspected, confirmed or unknown.MethodsThe author reviewed Standard Precautions, including two new elements introduced by the Centers for Disease Control and Prevention in 2007: safe injection practices and respiratory hygiene and cough etiquette. Standard Precautions sometimes are referred to as the first tier of precautions because for some diseases and circumstances, transmission cannot be interrupted completely with Standard Precautions alone and it is necessary to use second-tier Transmission-Based Precautions. The author reviewed the three categories of Transmission-Based Precautions—Airborne, Droplet and Contact—with an emphasis on their use in dental health care outpatient settings.Conclusions and Clinical ImplicationsDental health care personnel (DHCP) should update their infection control programs to ensure that safe injection practices and respiratory hygiene and cough etiquette measures are used routinely. In addition, with the emergence of new pathogens, re-emergence of variant organisms and more patients seeking care in ambulatory care facilities, DHCP need to be aware of additional measures to take when treating patients in their offices who are actively infected with certain organisms to protect fully other patients, their staff members and themselves.

Improving personal health records for patient-centered care.

To assess the patient-centeredness of personal health records (PHR) and offer recommendations for best practice guidelines. Semi-structured interviews were conducted in seven large early PHR adopter organizations in 2007. Organizations were purposively selected to represent a variety of US settings, including medium and large hospitals, ambulatory care facilities, insurers and health plans, government departments, and commercial sectors. Patient-centeredness was assessed against a framework of care that includes: (1) respect for patient values, preferences, and expressed needs; (2) information and education; (3) access to care; (4) emotional support to relieve fear and anxiety; (5) involvement of family and friends; (6) continuity and secure transition between healthcare providers; (7) physical comfort; (8) coordination of care. Within this framework we used evidence for patient preferences (where it exists) to compare existing PHR policies, and propose a best practice model. Most organizations enable many patient-centered functions such as data access for proxies and minors. No organization allows patient views of clinical progress notes, and turnaround times for PHR reporting of normal laboratory results can be up to 7 days. Findings suggest patient-centeredness for personal health records can be improved, and recommendations are made for best practice guidelines.

Top Technology Issues for Ambulatory Care Facilities This Year and Beyond

ECRI Institute medical technology experts (i.e., biomedical engineers, patient safety experts, physicians, and research scientists) compiled a list of important technology-related issues that executives and clinical leaders at ambulatory care facilities should pay close attention to this year. The list presents several high-profile technologies in the context of the convergence of critical economic, patient safety, reimbursement, and regulatory pressures. Guidance is provided about key considerations regarding adoption and implementation of electronic medical records, high-end computed tomography and magnetic resonance imaging technology, the convergence of health information technology and medical technologies highlighting integrated patient alarm systems as a case in point, physician preference items such as cardiac stents, robotic-assisted technology for minimally invasive procedures, image-guided radiation technologies, and the role of radiofrequency identification technology.

Engaging the Patient as Observer to Promote Hand Hygiene Compliance in Ambulatory Care

Monitoring hand hygiene guideline compliance in an ambulatory environment can be challenging. For example, direct observation by independent observers is impractical because the sink and hand sanitizer dispensers are most often located inside the examination room. At Johns Hopkins Outpatient Center, an ambulatory care facility located on the campus of The Johns Hopkins Hospital in Baltimore, patients were engaged as an observer in monitoring hand hygiene compliance. The Johns Hopkins Hospital's ambulatory quality and patient safety (AQPS) task force, after assessing common methods of monitoring hand hygiene compliance including direct observation, self-reporting, and product usage, evaluated using the patient as an observer. Of 50 patients interviewed, 43 (86%) indicated a willingness to monitor and report providers' compliance with hand hygiene guidelines. In collaboration with providers, a patient-as-observer hand hygiene monitoring process was developed and piloted. Qualitative feedback postimplementation did not indicate that the process would inhibit the patient-provider relationship. The cost of the program to implement and maintain averages $0.17 per patient encounter. The overall patient response rate was 21.6% (range, 12%-77%), based on completed observation cards to total appointments completed. Hand hygiene compliance as measured by the patient-as-observer process averaged 88% (range, 74%-100%). Independent observation revealed 100% concurrence between the patient's recorded observation and the independent observer. Engaging the patient to report on hand hygiene compliance was found to be efficient and acceptable to patients and providers, and the results of the observations were representative of actual provider behavior.

Community Pharmacist Services for People With Mental Illnesses: Preferences, Satisfaction, and Stigma

Community Pharmacist Services for People With Mental Illnesses: Preferences, Satisfaction, and Stigma

A Model for Infection Prevention in Ambulatory Care Facilities

A Model for Infection Prevention in Ambulatory Care Facilities

Patient Safety Climate in Primary Care

Safety climate, as a measurement in time of safety culture using a survey instrument, has been explored in inpatient units and among hospitals. Differences have been reported among professional groups in these venues. This study sought to determine if comparable differences exist among professional groups in ambulatory care settings. Four US Air Force ambulatory care facilities (clinics) from the Midwestern United States. The Safety Attitudes Questionnaire was selected as the research tool because of its published utilization in inpatient venues, its sound psychometrics (Cronbach alpha, 0.74-0.93), and its ambulatory care version. All 328 available primary care staff from 4 clinics was surveyed yielding 213 responses for a response rate of 65%. There were no significant differences among the professional groups on the total patient safety score or on 5 of the 6 subscales. There were, however, significant differences on total safety scores based on age, not professional group, with staff members younger than 31 years scoring lower on the overall safety score (mean, 64.8; P < 0.001), as compared with the 32- to 41-year age group (mean, 74.3) and those 42- to 63-year age group (mean, 73.8). The youngest age group also had the lowest scores on the subscales of teamwork climate, safety climate, perception of management, and job satisfaction (all subscales P < 0.03). These differences persisted after controlling for professional group. Growing attention has been given to the demographic groups known in the popular press as Generation Xers and Nexters, but not within the context of enhancing patient safety. Efforts that address the information, training, and job satisfaction needs of these specific age groups have the potential to strengthen health care teams and contribute to a more positive safety climate.

Medizinisches Versorgungszentrum – Ausnahmefall oder Regelversorgung der Zukunft? Eine Bestandsaufnahme

Due to governmental regulation in 2004 new options to establish ambulatory care facilities have become available and are widely used by healthcare providers. Medical service centres (Medizinische Versorgungszentren, MVZs) are characterised by the obligation for interdisciplinary teams of physicians, extended options for the employment of physicians and finally by flexible avenues of investment regarding the establishment of medical service centres. Medical service centres aim to improve ambulatory healthcare provision via an integrated service approach and offer opportunities for hospitals and third-party payers to set foot into the ambulatory healthcare sector. The rise of MVZs has therefore been closely and quite sceptically watched by the medical profession. The spread of MVZs is constant but limited to a modest growth rate. 250 MVZs are set up annually; in summer 2009 a total number of about 1300 had been reached, which is fairly small compared to 92,000 individual and group practices. The prominent specialities include general medicine, internal medicine, and surgery. The majority of MVZs are located in urban and suburban areas. Especially hospitals have, however, been using this approach to establish and operate ambulatory care centres with employed physicians. It remains to be seen whether and to what extent MVZs will improve service provision to the benefit of patients or mainly represent a new business model compromising existing structures. Continuous evaluation of trends is therefore essential for the further development of new ambulatory care structures.

The Impact of Title VII on General and Pediatric Dental Education and Training

The authors describe the impact of the Title VII, Section 747 Training in Primary Care Medicine and Dentistry (Title VII) grant program on the development, growth, and expansion of general and pediatric dentistry residency programs in the United States. They first briefly review the legislative history of the Title VII program as it pertains to dental education, followed by a historical overview of dental education in the United States, including a description of the differences between dental and medical education and the routes to professional practice. The authors then present an extensive assessment of the role of the Title VII grant program in building general and pediatric dental training capacity, diversifying the dental workforce, providing outreach and service to underserved and vulnerable populations, stimulating innovations in dental education, and engaging collaborative and interdisciplinary training with medicine. Finally, the authors call for broadening the scope of the Title VII program to allow for predoctoral training (dental student education) and faculty development in general and pediatric dentistry. In doing so, the Title VII program can more effectively address current and future challenges in dental education, dentist workforce, and disparities in oral health and access to care.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

HIV Testing in Adolescents and Young Adults Receiving STI Testing in an Urban Primary Care Setting

IN THE UNITED STATES, an estimated 1 million people are infected with the humanimmunodeficiency virus (HIV) and one-quarter are unaware of their infection. 1 Rates of newinfections have increased among young persons with nearly half of all new HIV infections inthe US occurring in black adolescents and young adults aged 13 to 24.1-4Despite evidence that early diagnosis may have potential advantages in promoting prevention,5-8 improving immune restoration, and linking HIV-infected persons with care9 HIV testinghas been a controversial and difficult area to define and produce relevant guidelines. In 2001,the Centers for Disease Control and Prevention 10 (CDC) recommended universal HIV testingfor all persons who (a) live in communities with an HIV prevalence >1%; (b) have known riskfactors for HIV infection; and (c) request HIV testing. In September 2006, the guidelines forhealth care settings were modified to recommend that all persons aged 13 to 64 years be testedfor HIV.11Understanding risk-based care delivery patterns of providers who care for vulnerablepopulations is salient to understanding the acceptance of the current guidelines. The purposeof this study was to determine if care-seeking adolescents and young adults who were receivingsexually transmitted infection (STI) testing and living in a high-HIV–prevalent communitywere being tested for HIV according to CDC guidelines.To select adolescents who fall in the special CDC risk categories, medical records ofadolescents and young adults aged 11 to 24 years who were evaluated for an STI in a largeacademic ambulatory care facility in Baltimore, MD, between July 2003 and June 2004 werereviewed. This time frame was used to include time points in all seasons. This multidisciplinarypractice provides general pediatric care, adolescent medicine primary and subspecialty care,and HIV primary and specialty care as a 3-team structure. Most of the patients served by thisclinic are from the Baltimore metropolitan area. Baltimore is a large city on the east coast ofthe United States that is 64% black, has 23% of the population living below poverty level,12and an estimated community HIV incidence of 166.8 per 100,000 persons.13 The clinic isprimarily staffed by resident, fellow, and nurse practitioner providers supervised by attendingphysicians. Counselors are also available on-site to provide pre/posttest HIV counseling andgeneral STI/HIV risk reduction counseling to adolescents.Quality assurance (QA) laboratory logs were used to randomly identify patients who had STIand/or HIV testing during the study period. Inclusion criteria for chart review included (a) agebetween 11 and 24 years and (b) evidence of STI screening or testing at the visit during the

Involvement of trainees in routine unsedated colonoscopy: review of a pilot experience

Unsedated colonoscopy is not required by the Accreditation Council of Graduate Medical Education in the curriculum of GI trainees. We describe our pilot experience with trainee participation in unsedated colonoscopy. A retrospective review of a performance improvement program to provide access to colonoscopy. A Veteran's Affair ambulatory care facility that discontinued sedated colonoscopy because of a nursing shortage. A total of 145 of 483 patients who chose unsedated colonoscopy after both sedated and unsedated options were discussed. GI fellows performed unsedated colonoscopy under the supervision of the attending physician. Cecal intubation rate, patient assessment of the reasons for the choice, the unsedated experience, willingness to have another colonoscopy, and the rate of return for unsedated colonoscopy among eligible patients. Cecal intubation was achieved in 112 of 145 patients. The adjusted success rate (excluding inadequate bowel preparation and an obstructing lesion) was 81%. The most frequently acknowledged reason for the choice was the ability to communicate with the colonoscopist. Eighty-six patients reported a good experience and were likely to accept another unsedated colonoscopy. To date, all 8 patients eligible for 3-year follow-up successfully completed another unsedated examination. An uncontrolled, nonrandomized review in predominantly male older veterans. An unsedated colonoscopy might be acceptable to some populations, particularly when communication with clinicians and procedural convenience are highly valued. Involvement of trainees is feasible. Randomized controlled comparisons of sedated and unsedated options in terms of safety (eg, sedation and procedure-related complications) and cost in settings with and without a nursing shortage deserve to be considered.

Measuring patient assessments of the quality of outpatient care: a systematic review

The aim of the study was to answer three questions: first, what methods have been used to measure patient assessments of the quality of care? Second, how do outpatients rate their care? And third, what needs to be taken into account in measuring patient assessments of the quality of care? Systematic review of the literature. Electronic searches were conducted on Medline, CINAHL and the Cochrane Database of Systematic Reviews. To be included, articles were to deal with patients' assessments of health care in ambulatory units for somatic adult patients. They were to have been published between January 2000 and May 2005, written in English, Swedish or Finnish with an English abstract, and the research was to have been conducted in Europe. The search terms used were: ambulatory care, ambulatory care facilities, outpatient, outpatients, patient satisfaction and quality of health care. The articles were screened by two independent reviewers in three phases. Thirty-five articles were included. The quality of care was measured using both quantitative and qualitative methods. Only a few studies relied on the single criterion of patient satisfaction for quality measurements. It is easy to identify common sources of dissatisfaction in different studies. Sources of satisfaction are more closely dependent on the target population, the context and research design. Patient satisfaction is widely used as one indicator among others in assessing the quality of outpatient care. However, there is no single, universally accepted method for measuring this.

Increasing the Involvement of Specialist Physicians in Chronic Disease Management

The Capital Health (CH) region in Alberta serves the population of the Edmonton area as well as a large referral population in western Canada. CH is responsible for the delivery of the spectrum of patient care, from inpatient to outpatient services. Growth in outpatient care, in particular, has led to the development of several ambulatory care facilities from which the delivery of care to several populations with a chronic disease will be coordinated. The traditional model of care delivery is unsuited to the management of chronic diseases. Physicians must be part of the planning and implementation of new models if they are to be successful and sustainable. The concept of integration into a delivery team is not well understood or practised. This is not conducive to the integration of specialist physicians into multidisciplinary teams in ambulatory care that serves the needs of patients from a large geographic area. Chronic disease management using the Chronic Care Model has proven to be an effective method of delivering care to this wide population. Specialist physicians have not always taken advantage of opportunities to be involved in the planning and development of such new health care projects. In CH, physician integration in the planning, development and implementation of this new model has proven vital to its success. We based our strategy for change on Wagner's Chronic Care Model. This involved eight steps, the first four of which have been completed and the fifth and sixth are underway. Five factors contributed to the successful integration of specialist physicians in chronic disease management: collaboration between disciplines and organizations; creating patient-centred services; organizational commitments; strong clinical leadership; and early involvement of clinicians.

The Problem of Commercialism in Medicine

Commercialism first became a major problem for medicine in the decade of the 1970s, when huge quantities of new money began to flow into the healthcare system, as a result of Medicaid and Medicare, and the rapid expansion of private, employer-based insurance. Of course, physicians benefited, but most of this new money went to insurance plans and medical care delivery institutions, like hospitals, nursing homes, diagnostic services, and ambulatory care facilities of many kinds. Many of these were newly established for-profit businesses. A vast number of satellite enterprises sprang up to serve the growing needs of the new businesses by providing services like marketing and advertising, brokering, consulting, information technology, financial services, case and disease management, billing and collecting, and so forth.

Group Versus Individual Appointments and Their Impact on Kidney Disease Progression of Type 2 Diabetes Patients Who Attend an Ambulatory Care Facility

Group Versus Individual Appointments and Their Impact on Kidney Disease Progression of Type 2 Diabetes Patients Who Attend an Ambulatory Care Facility

The Gastroenterology Core Curriculum, Third Edition

The Gastroenterology Core Curriculum, Third Edition

Self-management program in treatment of asthma

Recently published national and international guidelines stress the importance of self-management in asthma. They have recommended that self-management plans should be an essential part of the long-term management of asthmatic patients. These plans essentially focus on the early recognition of unstable or deteoriorating asthma, by monitoring peak flow or symptoms. The aim of our one-year study was to compare the efficacy of peak-flow based self-management of asthma with traditional treatment. Sixty clinically stable adult patients with mild and moderate persistent asthma were randomly allocated to peak-flow based self-management (Group A, n=30) or to conventional treatment (Group B, n=30), with no significant difference between groups in terms of age, sex distribution and initial lung function. The recorded measurements were: lung function, asthma exacerbations, unscheduled ambulatory care facilities (hospital-based emergency department, consultations with general practitioner or pulmonologist), courses of oral prednisolone, courses of antibiotics, days off work. There was a significant difference between groups in number of asthma exacerbations (p < 0.05), unscheduled visits to ambulatory care facilities (p < 0.005), days off work (p < 0.0001), courses of oral prednisolone (p < 0.001) and antibiotics (p < 0.05). At the final visit, there was a significant improvement in some measurements of asthma severity in group A (reduced unscheduled visits for ambulatory care, reduced treatment requirements for oral corticosteroids and antibiotics, reduced days off work), but a lack of statistical difference in lung function and the maintenance-inhaled corticosteroid dose. There was no significant change in group B. These results suggest that peak-flow based self-management is more effective than traditonal treatment in mild and moderate persistent asthma.

Hospital disaster preparedness: Mental and behavioral health interventions for infectious disease outbreaks and bioterrorism incidents

Despite an increasing reliance on outpatient clinics and other ambulatory care facilities, traditional hospitals play a crucial role in the US healthcare system. They provide emergency services on a walk-in basis and are staffed to address issues related to triage. In an era of heightened concern over bioterrorism and a potential influenza pandemic, hospital preparedness for responding to infectious disease outbreaks is essential. During such outbreaks, mental and behavioral health problems may constitute an important part of the demand placed on hospitals. There is now sufficient clinical experience regarding such problems, and tested recommendations are available for hospitals to implement in disaster planning and practice. This paper summarizes available literature addressing hospital preparedness for mental and behavioral health interventions in the event of an infectious disease outbreak and identifies the barriers to improvement. A systematic literature review using the MEDLINE database was carried out. Additional articles were selected from the references of the identified sources, and Web sites of relevant agencies and organizations were searched. The review indicates that little literature documents recent hospital performance in or readiness for disaster mental and behavioral health interventions. The available evidence suggests a poor state of hospital readiness for providing such interventions. The problems related to financing such preparedness are likely contributors to this finding and must be overcome if improvements are to be made. More research is needed to categorically examine the preparedness of hospitals for mental and behavioral health interventions during times of disaster.

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