Ambulatory Clinic Research Articles

Perspectives on implementing an ambulatory age-friendly health system pilot project

As part of our Age-Friendly Health System journey in the ambulatory setting, our team chose to address "What matters most" (WMM) to older adults with cancer. While aligning with goals of care discussions, identifying patient priorities during each clinic visit led us to this initiative. The Gero-oncology and Gastrointestinal Clinics had >60% patient populations >65years of age and were chosen for this pilot. Collaborating with our interprofessional partners within these clinics, our group presented to the Patient and Family Advisory Council our plan to ask a patient-centered question addressing WMM in the ambulatory clinics. This council helped us craft "WHAT IS MOST IMPORTANT TO YOU DURING THIS CLINIC VISIT?" This pilot started as low tech paper card in English/Spanish presented to patients at their visit. Initially the cards were hand tabulated by Geriatric Resources Nurses (GRNs) and categorized. Examples include medication refills, test review, and plans of care. Plan-Do-Study-Act rapid tests of change discussions occurred bi-monthly. Workflow revisions occurred with the evolution to nursing entering patient's answers into the electronic health record (EHR). The high-frequency categories became multi-selection checklist in the EHR. This information was used to ensure we had resources for GRNs to address these needs. Currently the team is exploring how the WMM categories can translate to provider notes to be addressed during each visit. As the project rolls out to other ambulatory clinics, Patient Experience will monitor patient satisfaction metrics such as i nclusion in treatment decision.

Hospital-based ambulatory clinic adoption of video and telephone visits before and during the COVID-19 pandemic: a convergent mixed-methods study

PurposeThe purpose of this study is to understand virtual care use (e.g. telephone and video visits) during the COVID-19 pandemic across three hospital-based ambulatory clinics (i.e. mental health, renal and respiratory care) and to describe associated patient and provider experiences.Design/methodology/approachA mixed-methods convergent study was conducted including quantitative electronic medical records data on virtual care use, electronic surveys assessing domains of experience (e.g. satisfaction, acceptance and technology use) among patient and providers and semi-structured interviews exploring the associated barriers and facilitators of virtual care adoption.FindingsVirtual care adoption rates and relative modality use (telephone vs video) varied across specialty clinics. Mental health clinics) showed the greatest use of virtual care and greater use of video over telephone, as compared to renal and respiratory care, where telephone was used almost exclusively. Patients and providers reported an overall good satisfaction and acceptance of virtual care (60–72%) across clinics, but commonly observed barriers (technical problems, behavioral adaptations needed and inequity) persisted. Good value propositions, tech support and the presence of early adopters who can support others in workflow re-design and highlight value propositions of virtual care were listed as adoption facilitators.Originality/valueThe study provides a unique opportunity to compare the rate of virtual care adoption before and during the COVID-19 pandemic across distinct specialties that operate within the same organizational and political setting. This study showed that the nature of the condition (e.g. mental health conditions) and the characteristics of the users (e.g. younger patients) may drive models of care with higher rate of video use. Focusing on removing common barriers, like providing tech support and ensuring equitable access to patients, continues to be important even in the context of high virtual care adoption rates during the pandemic.

Evaluation of antibiotic prescribing for ambulatory patients seeking primary dental care services in a public hospital in Ghana: a clinical audit study.

BackgroundOne in 10 of all antibiotic prescriptions globally are for dental conditions with 80% of them being inappropriate, making it a potential driver of antimicrobial resistance.ObjectivesTo evaluate the appropriateness of antibiotic use among ambulatory patients seeking dental care services in a public hospital in Ghana.MethodsA retrospective clinical audit was conducted by extracting the medical records of all patients seeking dental care at the ambulatory care clinic of Keta Municipal Hospital (KMH) from January 2020 to December 2020 using the hospital’s electronic database. Descriptive statistics, bivariate and multivariate analysis were performed on the data collected.ResultsOverall, 1433 patient medical records were extracted from the database within the study period. The mean age of the patients identified was 39.9 years with almost two-thirds being female. The majority (91.1%, n = 1306) of them were attended to by a dental nurse. In total, 88.6% (n = 1269) of the patients received antibiotics and 87.5% (n = 1254) of antibiotics prescribed were non-compliant with Ghana Standard Treatment Guidelines. Three-quarters of the dental conditions were managed with dual antibiotics comprising amoxicillin and metronidazole. Antibiotic prescription was associated with age, gender, type of prescriber and type of dental condition diagnosed.ConclusionsThere is a high usage of antibiotics for dental conditions managed at the outpatient section of the hospital and most are inappropriate. Development of local guidelines supported by education of dental clinicians on empirical use of antibiotics is a suitable target for the antimicrobial stewardship team to address in KMH.

Pharmacist-managed multistep order transmittal for electronic specialty prescriptions reduces represcribing burden in ambulatory clinics: A retrospective cohort pilot study.

BACKGROUND: Specialty medications pose unique prescribing challenges, including complexities with drug dosing and safety monitoring, need for prior authorization and patient financial assistance, use of payer-mandated specialty pharmacies, and special requirements for storage and handling. These challenges can lead to higher rates of represcribing for specialty clinic providers, who may be operating with inadequate information or limited resources. Multistep order transmittal (MSOT) is an electronic medical record (EMR) prescription work queue functionality used by a specialty pharmacy service to support select ambulatory clinics. OBJECTIVE: To explore the relationship between an MSOT specialty pharmacy support service and represcribing burden of specialty medications for providers in an ambulatory care setting. METHODS: A retrospective cohort pilot study was performed before and after MSOT implementation. Prescription data were queried from Sanford Health's EMR for patients who were electronically issued at least 1 prescription for an injectable biologic medication at a dermatology and rheumatology clinic. The pre-intervention group included index prescriptions prescribed between October 1, 2017, and June 20, 2018. The post-intervention group included index prescriptions prescribed between October 1, 2018, and June 20, 2019. Retrospective EMR review was completed to identify any prescriptions that were represcribed and the reason for represcribing. The primary outcome was the rate of represcribing. Secondary endpoints explored reason for represcribing, when it occurred. Nominal data were compared using Pearson's chi-square tests. Regressions were performed to account for potential confounders. RESULTS: The pre-intervention group included 880 index biologic prescriptions, and the post-intervention group included 941 index biologic prescriptions. The aggregate represcribing rate decreased from 12.73% in the pre-intervention group to 9.56% in the postintervention group (P = 0.03). Represcribing directly by providers as a result of needing to modify the destination pharmacy decreased significantly from 6.25% of the pre-intervention group to 0.64% of the post-intervention group (P < 0.01). However, represcribing due to patient preferences and prescribing errors increased significantly between the pre- and post-intervention groups, with patient preferences increasing from 0.91% to 2.55% (P = 0.01) and prescribing errors from 0.68% to 1.70% (P = 0.05), respectively. Represcribing due to provider preferences and payer restrictions remained similar between groups. CONCLUSIONS: Within 2 ambulatory care clinics in an integrated health care system, the use of pharmacist-managed MSOT reduced overall represcribing burden. The need to represcribe owing to wrong destination pharmacy was nearly eliminated, while appropriate represcribing to accommodate patient preferences and correct prescribing errors increased. DISCLOSURES: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors have no conflicts of interest to disclose.

A Validated Postnatal Depression Screening Tool and Guideline to Improve Evidence-Based Screening for Postpartum Depression in Ambulatory Care

Postpartum depression is one of the most common diagnoses for maternal morbidity and mortality, affecting one in eight women in the United States. Initially, there was no universal process for the identification of postpartum depression in ambulatory clinics in a regional health system caring for obstetric patients, which puts patients and their newborns at risk for severe and potentially detrimental consequences. A quality improvement project was developed and implemented with a pilot group in the ambulatory setting.

Perianal Block for Open Hemorrhoidectomy: A Case Series

Introduction: Hemorrhoidectomy is one of the most common anorectal surgeries performed in a surgical room or ambulatory clinic. The procedure is linked to severe postoperative pain. Both general and regional anesthesia with spinal anesthesia is used in anorectal surgery. However, these predominantly used anesthesia methods leave postoperative side effects of nausea, vomitus, urinary retention, headache, dizziness, back pain, prolonged inferior muscle weakness, and the level of postoperative pain after the anesthesia wears off.&#x0D; Case presentation: Three cases of severe hemorrhoids were reported, and they underwent open hemorrhoidectomy with a perianal block. Postoperatively, all cases reported no side effects, minimal level of pain, and faster recovery. Recently, the perianal block has been used to curtail the side effects.&#x0D; Conclusion: Perianal block is performed by infiltrating the inferior rectal nerves innervating the anus and sphincter muscle. Sedation is sometimes performed prior to injection of the anesthetic block. This technique is considered safe and effective for hemorrhoidectomy.

Physical activity telephone coaching intervention for insufficiently physically active ambulatory hospital patients: Economic evaluation of the Healthy 4U-2 randomised controlled trial.

The Healthy 4U-2 randomised controlled trial demonstrated that a physical activity (PA) telephone coaching intervention was effective for improving objectively-measured PA and health-related outcomes. The current study reports on an economic evaluation performed alongside the trial to determine whether this effective intervention is also cost-effective from a healthcare funder perspective. Participants (N = 120) were insufficiently physically active adults recruited from an ambulatory care clinic in a public hospital in regional Australia. The primary outcome was change in moderate-to-vigorous physical activity (MVPA) measured using accelerometers. Changes in quality-adjusted life-years (QALYs) were derived from the 12-Item Short Form Health Survey Questionnaire (SF-12). Incremental cost-effectiveness ratios (ICERs) were calculated for each outcome. Uncertainty of cost-effectiveness results were estimated using non-parametric bootstrapping techniques and sensitivity analyses. The mean intervention cost was $132 per person. The control group incurred higher overall costs compared to intervention ($2,465 vs. $1,743, respectively). Relative to control, the intervention resulted in incremental improvements in MVPA and QALYs and was deemed cost-effective. Probabilistic sensitivity analysis indicated that compared to control, the intervention would be cost-effective for improving MVPA and QALYs at very low willingness to pay thresholds. Sensitivity analyses indicated that results were robust to varied assumptions. This study shows that PA telephone coaching was a low-cost strategy for increasing MVPA and QALYs in insufficiently active ambulatory hospital patients. Findings of health benefits and overall cost-savings are uncommon and PA telephone coaching offers a potentially cost-effective investment to produce important public health outcomes.

The Road to High Level Disinfection and Sterilization Competency in Ambulatory Clinics

Background In 2020, our organization added an infection prevention role for approximately 250 affiliated ambulatory clinics. A rounding assessment tool was developed and initiated. During this initial rounding, it was discovered that several locations were not performing High Level Disinfection on endocavity ultrasound probes, and those that were performing the HLD, were not following manufacturer's guidelines. Upon further investigation, similar findings were discovered for both HLD of endoscopes as well as sterilization using tabletop autoclaves. There was no official training or competency program in place for any of these processes in the ambulatory clinics. Methods First, a gap analysis was performed. Data was collected on the current processes and a complete device inventory was created. A cluster analysis was performed and revealed the infection rate among potentially affected patients over the last 3 years to be within the expected range. A 3rd party infection control consultant was brought in to validate and verify our proposed plan of creating new processes, educating staff, and developing a sustainable competency program. Results Broken processes were immediately halted and corrected. Three competency programs were developed and implemented for HLD and Sterilization, which included online modules, webinars, hands-on training (for endoscopes), and a competency check-off. This involved 175 staff members in almost 50 clinics across the state and only one IP. New logs were created and distributed to the practices as well as supply lists of necessary items to maintain compliance. Conclusions At the time of this abstract, 64% of staff had completed the competency training and were checked-off. Those who are unable to complete it by the deadline, will be unable to perform that skill. This will be a required annual competency moving forward. In 2020, our organization added an infection prevention role for approximately 250 affiliated ambulatory clinics. A rounding assessment tool was developed and initiated. During this initial rounding, it was discovered that several locations were not performing High Level Disinfection on endocavity ultrasound probes, and those that were performing the HLD, were not following manufacturer's guidelines. Upon further investigation, similar findings were discovered for both HLD of endoscopes as well as sterilization using tabletop autoclaves. There was no official training or competency program in place for any of these processes in the ambulatory clinics. First, a gap analysis was performed. Data was collected on the current processes and a complete device inventory was created. A cluster analysis was performed and revealed the infection rate among potentially affected patients over the last 3 years to be within the expected range. A 3rd party infection control consultant was brought in to validate and verify our proposed plan of creating new processes, educating staff, and developing a sustainable competency program. Broken processes were immediately halted and corrected. Three competency programs were developed and implemented for HLD and Sterilization, which included online modules, webinars, hands-on training (for endoscopes), and a competency check-off. This involved 175 staff members in almost 50 clinics across the state and only one IP. New logs were created and distributed to the practices as well as supply lists of necessary items to maintain compliance. At the time of this abstract, 64% of staff had completed the competency training and were checked-off. Those who are unable to complete it by the deadline, will be unable to perform that skill. This will be a required annual competency moving forward.

Don't Jump to Conclusions, a Central Line-associated Bloodstream Infection Pseudo-Outbreak Investigation

<h3>Background</h3> Central-line associated bloodstream infections (CLABSI) are serious infections that have significant morbidity and mortality. Our institution tracks CLABSIs in all settings. Between February 2021 to March 2021, surveillance by our Infection Prevention and Control Department identified five Portacath (PAC) CLABSIs with methicillin susceptible Staphylococcus aureus (MSSA) in pediatric oncology patients. This was a significant increase from our baseline of 3 MSSA PAC CLABSI in the 12 months prior, initiating an outbreak investigation. <h3>Methods</h3> A line list was created and identified two epidemiologic links: all PAC were placed in interventional radiology (IR), and primary points of access were ambulatory oncology clinics. There was no common product used. Four of the five infections had identical antimicrobial susceptibility profiles. Pulsed-field Gel Electrophoresis (PFGE) was performed to discriminate between isolates. Observations in IR for line placement were performed with attention to skin preparation. Ambulatory oncology observations were performed to review skin preparation for PAC access and hand hygiene practices. We confirmed with the PAC manufacturer there were no recalls of the PAC lot numbers. <h3>Results</h3> All 5 isolates were unrelated by PFGE and, therefore excluded a true outbreak. Observations in IR revealed variabilities in skin preparation and recommendations were made to standardize practices to align with those in our operating rooms. Although no variations in practice were noted in ambulatory oncology this was used as an opportunity to re-educate staff on the attention to detail for PAC access. <h3>Conclusions</h3> Outbreak identification by traditional epidemiologic methods are complemented with technology such as PFGE to identify conclusive links between patients and can demonstrate when an apparent outbreak is not due to a single pathogen. Obtaining PFGE data supported broad-based interventions including observations of practice at the time of line insertion and access, as well as reeducation to providers performing these roles, to reduce CLABSI in our institution.

Psychosocial characteristics of chronic pain in cancer survivors referred to an Australian multidisciplinary pain clinic.

To describe the clinical and psychosocial characteristics of chronic pain in cancer survivors referred to one Australian hospital's ambulatory pain clinic over a 7-year period (2013-19), and to compare cancer treatment-related pain with comorbid non-malignant pain. Retrospective chart review including responses to standardized self-report questionnaires (Brief Pain Inventory, Depression Anxiety Stress Scale, Pain Self-Efficacy Questionnaire, Pain Catastrophizing Scale), routinely collected in all patients referred to pain clinics at Australian and New Zealand hospitals. Of 3510 new referrals during the study period, 267 (7.5%) had a history of cancer and 176 (5.0%) met the study's eligibility criteria. Their average age was 63±13years, with 55% female. Breast cancer survivors were commonest, followed by hematological, prostate, melanoma, and colorectal, a median of 3years post-diagnosis. Pain was attributed to cancer treatment in 87 (49%), surgery being the commonest modality. Multimodal treatment (n=89, 58%) was significantly commoner in the treatment-related pain group (p&lt;0.001). Average pain severity was moderate, as was pain-related disability and distress. Pain cognitions were often maladaptive (low pain self-efficacy, high pain catastrophizing), predicted by pre-existing anxiety and depression. Associations between pain cognitions and outcomes were medium-to-large. Differences between treatment pain and comorbid pain were small-to-medium. Their scores were similar to Australian pain clinic norms. Cancer treatment causes tissue damage, but pain-related distress and disability in survivors is associated with maladaptive pain cognitions. Survivors with poor pain outcomes should be evaluated for unhelpful thoughts and beliefs especially when they have pre-existing depression or anxiety.

Delivering Monoclonal Antibody Infusions to Novel Outpatient Settings

Summary In November 2020, monoclonal antibody infusions became the first available treatment for outpatients with Covid-19. The logistics of administering the drug, however, necessitated novel approaches to health care delivery to maximize the effectiveness in Geisinger’s patient community. To overcome these challenges, Geisinger quickly set up a process to identify the patients at highest risk and to proactively reach out to them for treatment scheduling. For most patients, an ambulatory clinic was the appropriate setting for infusions. For patients living in a skilled nursing facility or a residential facility for the developmentally disabled, Geisinger deployed mobile units to deliver care treatment to them. Additionally, to serve imprisoned patients, the health system arranged for secure access to select ambulatory clinics at designated times. Using this agile approach, nearly 3,000 patients have been treated by Geisinger since monoclonal antibody treatments were first granted Emergency Use Authorization by the FDA. In this article, the authors describe how Geisinger designed and executed this innovative approach to care delivery.

Challenges in virtual collection of patient-reported data: a prospective cohort study conducted in COVID-19 era.

Prior to the COVID-19 pandemic, patients attending ambulatory clinics at cancer centers in Ontario completed the Edmonton Symptom Assessment Scale (ESAS) at each visit. At our center, completion was via touchpad, with assistance from clinic volunteers. As of March 2020, clinic appointments were conducted virtually when possible and touch pads removed. We anticipated a negative impact on the collection of patient-reported outcomes (PROs) and the recognition of severe symptoms.MethodsWe performed a prospective cross-sectional cohort study to investigate remote ESAS completion by patients with appointments at a weekly surgical oncology clinic. Patients in the initial study cohort were asked to complete and return the ESAS virtually (V). Given low completion rates, the ensuing cohort was asked to complete a hard-copy (HC) ESAS. For the final cohort, we provided remote, personal mentorship by a member of the care team to support virtual electronic ESAS completion (virtual-mentored (VM) cohort).ResultsBetween May and July 2020, a total of 174 patient encounters were included in the study. For the V cohort, 20/46 patients (44%) successfully completed and returned the electronic ESAS, compared to 49/50 (98%) for the HC cohort. For the VM cohort, the overall completion rate was 74% (58/78); however, 12 of these 58 patients did not independently complete a virtual ESAS. Virtual questionnaire completion was not predicted by age, sex, or tumor site, although patients who completed the ESAS were more likely to be in active management rather than surveillance (p = 0.04). Of all completed forms, 42% revealed a depression score of ≥2, and 27% an anxiety score of ≥4.ConclusionsWe identified significant barriers to the virtual completion of ESAS forms, with a lack of predictive variables. The severe degree of psychological distress reported by ~50% of respondents demonstrates the need for ongoing regular collection/review of these data. Innovative solutions are required to overcome barriers to the virtual collection of PROs.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00520-022-07191-3.

Changes in Patient Reported Outcome Measure Scores From Initial Presentation to Day-of-Surgery in Patients Undergoing Hip and Knee Arthroplasty

BackgroundIt is not well understood how patient reported outcome measures (PROMs) change from initial presentation to day-of-surgery (DOS). This study sought to quantify preoperative PROM changes for hip and knee arthroplasty patients. MethodsA retrospective review was performed on primary total hip, total knee, and partial knee arthroplasty patients from October 2020 through January 2021. Trends in preoperative Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR), and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) scores were compared using scores at initial presentation in the ambulatory clinic and at a time near the date-of-surgery. A total of 497 patients possessed 2 preoperative PROMIS-PF (497/497), HOOS-JR (152/497), or KOOS-JR (258/497) surveys. ResultsThere was no significant statistical difference in mean PROM scores between initial presentation and DOS PROMIS-PF or HOOS-JR scores. Only KOOS-JR demonstrated a significant statistical difference of 2 ± 14 (P = .002) when comparing initial versus preoperative scores. Partial knee arthroplasty patients saw a strong positive correlation (r = 0.77) between initial PROMIS-PF and DOS scores. However, mean absolute value changes on an individual level were 4 ± 4, 11 ± 39, and 11 ± 10 for PROMIS-PF, HOOS-JR, and KOOS-JR, respectively, indicating the presence of meaningful patient-level score changes as based on previously published anchor-based minimal clinically important differences. ConclusionPROMs collected during the preoperative period demonstrated wide variability at an individual level, but not at a population level. Collection at both time points may be necessary in order to understand the clinical impact of surgery on these patients.

Utility of On-Treatment Viral Loads During Treatment With Direct-Acting Antivirals in Patients Infected With Chronic Viral Hepatitis C.

Background: Direct-acting antiviral (DAA) agents have revolutionized the treatment of chronic hepatitis C virus (HCV) infection. Current data regarding the utility of on-treatment HCV viral load (VL) monitoring are conflicting and limited data are available in HIV-coinfected patients. Objective: The objective of the study was to determine whether on-treatment VLs are predictive of HCV cure in a real-world population. Method: A single-center, retrospective cohort study was conducted using patients who received a prescription for DAA therapy for HCV treatment at a large, tertiary ambulatory care clinic. Results: A total of 219 patients were included in the final analysis. The average age was 56 years. Most patients were male (64.4%), African American (73.1%), and insured by Medicaid (61.6%). Most patients were treatment-naive, noncirrhotic, and infected with HCV genotype 1a (73.1%). About 22.4% of patients were coinfected with HIV. The most common regimen was 12 weeks of ledipasvir/sofosbuvir (53.9%). On-treatment VLs were most commonly obtained at treatment week 4 (42.5%), of which 45.2% of patients were detectable. Sustained virologic response (SVR) was achieved in 96.8% of the total population and 95.9% of HIV-coinfected patients. Of the 7 patients who did not achieve SVR, 3 patients had undetectable on-treatment VLs in the first 8 weeks of therapy. Conclusion: Sustained virologic response rates were similar between HCV-monoinfected patients and HCV-HIV-coinfected patients. This research further supports that on-treatment VLs may not be a valuable indicator of treatment failure but may be helpful to engage patients in care and ensure treatment adherence and ultimately cure.

AuduBon-Bons: Bite-Sized Learning for Residents in the Ambulatory Obstetrics and Gynecology Clinic.

While most medical education happens in the inpatient setting, the vast majority of medicine is practiced in the outpatient setting. Graduates from our obstetrics and gynecology (OB/GYN) program consistently report lower confidence and comfort in the ambulatory, as opposed to inpatient, setting. To describe and evaluate a novel curriculum, delivered in an ambulatory clinic covering ambulatory care topics, and to assess its feasibility in a single site OB/GYN residency program. We created an ambulatory curriculum, comprising short modules delivered in the ambulatory clinic during the first 15 minutes of every half-day clinic session. Modules were delivered using a flipped classroom format with pre-session assignments during the 2019-2020 academic year. Outcomes were residents' pre- and post-session comfort and confidence and module developers' time to create the curriculum. Time tracking was performed. On average, 11 residents were present for the teaching session weekly. Twenty-four residents and 6 faculty were eligible to complete pre- and post-session surveys. For every weekly session, the average resident comfort level and the average resident confidence level with the module's topic increased from the pre-module survey to the post-module survey. Residents completed pre-module assignments 64.8% (236 of 364) of the time, and of residents who completed the pre-work, 89.4% (211 of 236) reported it was useful. Average survey completion rate was 70.5% (1398 of 1984). We showed that it is feasible to create and implement an ambulatory curriculum for residents in OB/GYN, and this curriculum increased resident's comfort and confidence with ambulatory practice.

523-P: The Results of Virtual Diabetic “Boot Camp”

Introduction: The use of telemedicine exponentially increased during the COVID-pandemic as it provided easier access as well as the provision of safety via social distancing. A 12-week intense telemedicine diabetic Bootcamp was therefore launched for patients with uncontrolled DM intended for high-quality outpatient diabetic care. Methods: Patients with DM seen at ambulatory clinics with HbA1c &amp;gt; 8.0%, were voluntarily enrolled from September 2020 to November 2021. The dietitians and diabetic educators conducted biweekly visits via telehealth. Patient demographics, HbA1c, BMI, BP were compared before and after the intervention. Results: A total of 134 patients were included for analysis and 94 patients (70.2%) completed the visits. Mean HbA1c change was -2.09% ± 2.4%, and HbA1c reduction was similarly observed across different age groups, gender, ethnicity, BMI, referred clinic types [Table 1]. A greater HbA1c reduction in patients who completed the visits was noted although it was not statistically significant. We found a negative correlation between the initial HbA1c and the change of HbA1c (coefficient -0.7709, p&amp;lt;0.0001, r2= 0.3899) . No significant BMI or MAP change was observed. Conclusions: This quality improvement project demonstrated an improvement in HbA1c for all poorly controlled diabetic patients, regardless of patient characteristics. Moreover, higher initial HbA1c was associated with a greater HbA1c reduction. Disclosure Y.Chen: None. U.C.Udeh: None. K.Rajak: None. A.Amirian: None. A.Atrash: None. K.Yari: None. R.Joshi: n/a.

Cancer Clinic Redesign: Opportunities for Resource Optimization.

Ambulatory cancer centers face a fluctuating patient demand and deploy specialized personnel who have variable availability. This undermines operational stability through the misalignment of resources to patient needs, resulting in overscheduled clinics, budget deficits, and wait times exceeding provincial targets. We describe the deployment of a Learning Health System framework for operational improvements within the entire ambulatory center. Known methods of value stream mapping, operations research and statistical process control were applied to achieve organizational high performance that is data-informed, agile and adaptive. We transitioned from a fixed template model by an individual physician to a caseload management by disease site model that is realigned quarterly. We adapted a block schedule model for the ambulatory oncology clinic to align the regional demand for specialized services with optimized human and physical resources. We demonstrated an improved utilization of clinical space, increased weekly consistency and improved distribution of activity across the workweek. The increased value, represented as the ratio of monthly encounters per nursing worked hours, and the increased percentage of services delivered by full-time nurses were benefits realized in our cancer system. The creation of a data-informed demand capacity model enables the application of predictive analytics and business intelligence tools that will further enhance clinical responsiveness.

An educational intervention to improve nurses’ knowledge and self-confidence: An integrated literature review

Purpose: To provide educational intervention to improve the knowledge and self-confidence of nurses in ambulatory and urgent care clinics in detecting early deterioration, intervening, and evaluating changes in patient condition using a consistent assessment tool. A review of the organization policy indicated a process to call the medical alert response team (MAR). However, there was no established algorithm for nurses to escalate or implement interventions when they noticed a change in a patient condition. An informal survey of ten assistant nurse managers in the ambulatory and urgent care clinics asked about their calling process for MAR and what interventions are used yielded inconsistent practices across the board. An unofficial survey of clinic nurses suggested a lack of knowledge and self-confidence in nurses for recognizing and implementing appropriate intervention when there is a change in a patient condition. Method: Extensive literature search using CINAHL and PubMed databases for peer-reviewed articles relevant to the topic. Results: An educational intervention that enhances nurses’ knowledge and self-confidence in recognizing and activating appropriate intervention empowers nurses to utilize critical thinking and clinical judgment to provide high quality and safe care to their patients, thus decreasing failure to resuscitate. Conclusions and Implications to practice: There is a need to provide educational intervention to improve the knowledge and self-confidence of nurses in ambulatory and urgent care clinics in detecting early deterioration, intervening, and evaluating changes in patient condition using a consistent assessment tool.

Unmet Needs in Patients With Heart Failure: The Importance of Palliative Care in a Heart Failure Clinic.

BackgroundThere are increasing calls to establish heart failure (HF) clinics due to their effectiveness in the interdisciplinary management of people living with HF. However, although a recommendation exists for palliative care (PC) providers to be part of the interdisciplinary team, few of the established HF clinics include them in their teams. Therefore, in this qualitative study, we aimed to understand the unmet PC needs of patients with HF attending an already established HF clinic.MethodsSecondary qualitative analysis of structured interviews undertaken within a larger study to validate the German version of the Needs Assessment Tool: Progressive Disease—Heart Failure (NAT: PD-HF). The NAT: PD-HF is a tool that aims to assess unmet needs in patients with HF. The interviews took place between January and March 2020 with patients from the ambulatory HF Clinic of a University Hospital in Switzerland. For this analysis, we transcribed and thematically analyzed the longest and most content-rich interviews until we reached data saturation at 31 participants. The interviews lasted 31 min on average (24–48 min).ResultsParticipants (n = 31) had a median age of 64 years (IQR 56–77), the majority had reduced ejection fraction, were men, and were classified as having a New York Heart Association functional class II. Participants were in general satisfied with the treatment and information received at the HF clinic. However, they reported several unmet needs. We therefore identified three ambivalences as main themes: (I) “feeling well-informed but missing essential discussions”, (II) “although feeling mostly satisfied with the care, remaining with unmet care needs”, and (III) “fearing a referral to palliative care but acknowledging its importance”.ConclusionAlthough patients who are receiving multidisciplinary management in ambulatory HF clinics are generally satisfied with the care received, they remain with unmet needs. These unmet needs, such as the need for advance care planning or the need for timely and tactful end-of-life discussions, can be fulfilled by PC providers. Including personnel trained in PC as part of the multidisciplinary team could help to address patients' needs, thus improving the quality of care and the quality of life of people living with HF.

Phyto Antitussive Medicines Affect the Cough Treatment for Covid-19’s Children’s Patients

Introductions: Cough was one of the most troubling symptoms for Covid-19 s patients treated at home. Pandemic years of Covid-19 brought a novel approach to the use of medicinal plants. Cough is not only distressing to patients, but also increases the risk of community transmission by respiratory droplets. Stigmatization of patients with cough can occur, leading to social isolation, particularly during the infections with covid-19. Identifying ways to control Covid -19-associated cough could help to prevent community transmission and disease spread, as well as removing the stigma of this symptom. The aim of our survey was to know the cough treatments with Covid-19 children patients treated home with simple and moderate symptoms. The behaviors of pharmacist and doctors’ community for treating these symptoms with Phyto preparations. This is a survey study conducted in open big ten network pharmacy of Tirana and to the 3 main ambulatory clinics of during of Tirana during the pandemic year 2021 for the period October -December 2021. We collected information concerning the use of antitussive medicine s in this period from a questionnaire distributed to pharmacist and doctors which consisting open and closed questions. The biostatistical expert suggested to includes a combination of original question containing both the qualitative and quantitative data to the questionnaire. Data received from the questionnaire had two type of questions 1) multiple choice and 2) open questions. Results shown that antitussive medicinal plants were preferred compare with other alternatives. Mostly of the patients used in the wrong way in terms of frequency and durations. From the total 240 patients only 195 (81.25%) has given corrects to the pharmacists or have completed all the questions. From all the plants althea officinalis was the most used with 66% followed, by thymes vulgaris 29% the rest where different medicinal plants. In conclusions is necessary knowledge to orients pediatrician for the right use of Phyto medicine. Plants Althea officinalis, Thymus Vulgaris can demonstrate the same efficacy compare with synthetic antitussive medicine, but less side effects. They must be well known through educations program. Side effects of medicinal Herbs are lower, and they may be used with their proper efficacy that they have and can use longer than synthetic ones.