Ambulatory Healthcare Facilities Research Articles

Benchmarks for HIV Testing: What Is Needed to Achieve Universal Testing Coverage at U.S. Ambulatory Healthcare Facilities.

Black and Hispanic men have the highest rates of HIV diagnoses. To decrease the number of U.S. men who are unaware of their HIV status, they should be tested at least once. Our objective was to estimate the increases needed in HIV testing rates at ambulatory health care visits to achieve universal coverage. We analyzed nationally representative medical record abstraction data to estimate the number of visits per person to physician offices, emergency departments, and outpatient clinics among men aged 18-39 years during 2009-2016, and the percentage of visits with an HIV test. We calculated the increase in the percentage of visits with an HIV test needed to achieve universal testing coverage of men by age 39 years. Men had a mean of 75.3 million ambulatory visits per year and 1.67 visits per person. An HIV test was performed at 0.9% of the ambulatory visits made by white men, 2.5% by black men, and 2.4% by Hispanic men. A 3-fold increase in the percentage of visits with an HIV test would result in coverage of 46.2% of white, 100% of black, and 100% of Hispanic men; an 11-fold increase would be needed to result in coverage of 100% of white men. HIV testing rates of men at ambulatory health care visits were too low to provide HIV testing coverage of all men by aged 39 years. A 3-fold increase in the percentage of visits with an HIV test would result in universal testing coverage of black and Hispanic men by age 39 years.

The Analgesic Efficacy of Forced Coughing During Cervical Punch Biopsy: A Prospective Randomized Controlled Study

(Abstracted from Aust N Z J Obstet Gynaecol 2018;58:681–685) Cervical punch biopsies are a common procedure performed routinely in ambulatory health care facilities and are usually performed without local anesthesia. Use of local anesthesia injections alleviates the pain associated with the procedure, but has numerous disadvantages, including risk of allergies or intravascular injection, pain from the injection itself, and lengthening procedure time.

Assessing information sources to elucidate diagnostic process errors in radiologic imaging - a human factors framework.

To assess information sources that may elucidate errors related to radiologic diagnostic imaging, quantify the incidence of potential safety events from each source, and quantify the number of steps involved from diagnostic imaging chain and socio-technical factors. This retrospective, Institutional Review Board-approved study was conducted at the ambulatory healthcare facilities associated with a large academic hospital. Five information sources were evaluated: an electronic safety reporting system (ESRS), alert notification for critical result (ANCR) system, picture archive and communication system (PACS)-based quality assurance (QA) tool, imaging peer-review system, and an imaging computerized physician order entry (CPOE) and scheduling system. Data from these sources (January-December 2015 for ESRS, ANCR, QA tool, and the peer-review system; January-October 2016 for the imaging ordering system) were collected to quantify the incidence of potential safety events. Reviewers classified events by the step(s) in the diagnostic process they could elucidate, and their socio-technical factors contributors per the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Potential safety events ranged from 0.5% to 62.1% of events collected from each source. Each of the information sources contributed to elucidating diagnostic process errors in various steps of the diagnostic imaging chain and contributing socio-technical factors, primarily Person, Tasks, and Tools and Technology. Various information sources can differentially inform understanding diagnostic process errors related to radiologic diagnostic imaging. Information sources elucidate errors in various steps within the diagnostic imaging workflow and can provide insight into socio-technical factors that impact patient safety in the diagnostic process.

Sterile Processing in Healthcare Facilities: Preparing for Accreditation Surveys

Sterile processing departments are a renewed focus of accreditation organizations and the Centers for Medicare & Medicaid Services (CMS), thanks to a country-wide initiative to eliminate preventable healthcare-associated infections (HAIs) and media attention on outbreaks related to the improper cleaning, disinfection, and/or sterilization of instruments, equipment or devices. In this age of unannounced visits, a sterile processing department needs to be in a constant state of readiness for an accreditation survey. It is absolutely necessary to be aware of all the accreditation standards, recommended practices, evidence-based guidelines, and best practices that will impact your sterile processing practices— whether in a teaching or community hospital, ambulatory surgery center, or the office-based setting.Audience: This book should be part of the toolkit of all novice and experienced sterile processing managers, infection preventionists, biomedical engineers, and risk managers for everyday use. There is excellent coverage of all the relevant accreditation standards, evidence-based guidelines from a variety of professional organizations, risk reduction tools, and a sample audit tool is also provided.Features: One of the key features of the book is the annexes. The annexes condense all the applicable Joint Commission standards related to the Environment of Care, Infection Prevention and Control, Human Resources, and Leadership that apply to sterile processing department in hospitals and ambulatory care facilities. The CMS Infection Survey Worksheet is a very thorough and useful tool to assess all infection prevention and related practices in the ambulatory healthcare facilities setting, and is also useful in the hospital and office-based practice setting. Author Rose Seavey has cleverly correlated the key provision of ANSI/ AAMI ST79 to the pertinent Joint Commission standards. Healthcare is all about acronyms, and the author has thought about that and has included a definitions and abbreviations section in the book. The bibliography is complete with all the references you will need for more details.Assessment: This is a user-friendly and easy-to-read book, providing all the information you need at your fingertips to ensure ongoing accreditation preparation and maintain a quality program that ensures patient safety. You will not want to skip a single chapter. The content is well organized and succinct with everything you need to develop a quality program in all sterile processing department settings. I know that there will be many sterile processing department managers breathing a sigh of relief to have everything they need to ensure and maintain compliance at their fingertips.

Rapid diagnostic tests for diagnosing uncomplicated P. falciparum malaria in endemic countries.

Rapid diagnostic tests (RDTs) for Plasmodium falciparum malaria use antibodies to detect either HRP-2 antigen or pLDH antigen, and can improve access to diagnostics in developing countries. To assess thediagnostic accuracy of RDTs for detecting P. falciparum parasitaemia in persons living in endemic areas who present to ambulatory healthcare facilities with symptoms suggestive of malaria by type and brand. We undertook a comprehensive search of the following databases: Cochrane Infectious Diseases Group Specialized Register; MEDLINE; EMBASE; MEDION; Science Citation Index; Web of Knowledge; African Index Medicus; LILACS; IndMED; to January 14, 2010. Studies comparing RDTs with a reference standard (microscopy or polymerase chain reaction) in blood samples from a random or consecutive series of patients attending ambulatory health facilities with symptoms suggestive of malaria in P. falciparum endemic areas. For each study, a standard set of data was extracted independently by two authors, using a tailored data extraction form. Comparisons were grouped hierarchically by target antigen, and type and brand of RDT, and combined in meta-analysis where appropriate. We identified 74 unique studies as eligible for this review and categorized them according to the antigens they detected. Types 1 to 3 include HRP-2 (from P. falciparum) either by itself or with other antigens. Types 4 and 5 included pLDH (from P. falciparum) either by itself or with other antigens. In comparisons with microscopy, we identified 71 evaluations of Type 1 tests, eight evaluations of Type 2 tests and five evaluations of Type 3 tests. In meta-analyses, average sensitivities and specificities (95% CI) were 94.8% (93.1% to 96.1%) and 95.2% (93.2% to 96.7%) for Type 1 tests, 96.0% (94.0% to 97.3%) and 95.3% (87.3% to 98.3%) for Type 2 tests, and 99.5% (71.0% to 100.0%) and 90.6% (80.5% to 95.7%) for Type 3 tests, respectively.Overall for HRP-2, the meta-analytical average sensitivity and specificity (95% CI) were 95.0% (93.5% to 96.2%) and 95.2% (93.4% to 99.4%), respectively.For pLDH antibody-based RDTs verified with microscopy, we identified 17 evaluations of Type 4 RDTs and three evaluations of Type 5 RDTs. In meta-analyses, average sensitivity for Type 4 tests was 91.5% (84.7% to 95.3%) and average specificity was 98.7% (96.9% to 99.5%).For Type 5 tests, average sensitivity was 98.4% (95.1% to 99.5%) and average specificity was 97.5% (93.5% to 99.1%).Overall for pLDH, the meta-analytical average sensitivity and specificity (95% CI) were 93.2% (88.0% to 96.2%) and 98.5% (96.7% to 99.4%), respectively.For both categories of test, there was substantial heterogeneity in study results. Quality of the microscopy reference standard could only be assessed in 40% of studies due to inadequate reporting, but results did not seem to be influenced by the reporting quality.Overall, HRP-2 antibody-based tests (such as the Type 1 tests) tended to be more sensitive and were significantly less specific than pLDH-based tests (such as the Type 4 tests). If the point estimates for Type 1 and Type 4 tests are applied to a hypothetical cohort of 1000 patients where 30% of those presenting with symptoms have P. falciparum, Type 1 tests will miss 16 cases, and Type 4 tests will miss 26 cases. The number of people wrongly diagnosed with P. falciparum would be 34 with Type 1 tests, and nine with Type 4 tests. The sensitivity and specificity of all RDTs issuch that they can replace or extend the access of diagnostic services for uncomplicated P. falciparum malaria. HRP-2antibody types may be more sensitive but are less specific than pLDH antibody-based tests, but the differences are small. The HRP-2 antigen persists even after effective treatment and so is not useful for detecting treatment failures.

Does a Little Bit Really Go a Long Way? Infection Prevention in Ambulatory Healthcare Facilities

Affiliations: Hospital Epidemiology Service and Office of the Deputy Director for Clinical Care, Clinical Center, National Institutes of Health, Bethesda, Maryland. Received November 9, 2010; accepted November 10, 2010; electronically published April 7, 2011. 2011 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2011/3205-0002$15.00. DOI: 10.1086/659402 Does a little bit go a long way, as the old saying goes? The origin of the saying “A little bit goes a long way” is unclear. The relevance of the application of this old saying to various settings and situations is equally unclear. Similarly, the relevance to clinical medicine is totally “uncharted territory.” In her 2001 hit song “A Little Bit,” the pop singer Jessica Simpson sings that “a little bit goes a long way,” but her lyrics also emphasize the need for “a little less talk and a little more do.” In my opinion, the latter statement, not the former, should become the mantra for the managers and owners of US ambulatory healthcare facilities with respect to infection prevention. In this issue of the journal, Shimokura et al present their findings from a study that was designed to identify factors associated with the risk of hepatitis C virus (HCV) transmission in ambulatory dialysis centers. This important study identifies several practices that the authors found to be associated with the risk of healthcare-associated transmission of bloodborne pathogens in these centers. In the study, patient-care practices that were independently associated with a higher prevalence of HCV infection among dialysis patients included the reuse of priming receptacles from one patient to another without disinfection, staff members handling blood specimens immediately adjacent to medications and clean supplies, and the use of mobile carts to deliver injectable medications. Most experts would consider each of these practices to be inadvisable at best and substandard care at worst. Bloodborne pathogen transmission has long been a concern of the hemodialysis community, and as early as the 1970s strategies were designed to prevent hepatitis B virus (HBV) transmission in these “blood-rich” environments. HBV transmission in the dialysis setting was the subject of intense scientific scrutiny in the pre-HBV-vaccine era. Similarly, over the past decade several studies have clearly documented the occurrence of HCV transmission to patients in the dialysis setting. Furthermore, dialysis patients have been shown to have a higher prevalence of HCV infection than the population at large. Previous investigations of the instances of dialysis-related transmission identified inadequate infection prevention procedures in the settings in which transmission occurred but did not identify specific practices associated with the risk of HCV transmission. In my view, one of the most striking findings from the study by Shimokura et al is the astoundingly low level of adherence to what most of us would consider basic infection prevention strategies—virtually across the waterfront—in these dialysis centers. Interestingly, for the patients in these centers even low levels of adherence to basic infection prevention strategies were associated with decreased prevalences of HCV infection. In reading this interesting article, I was struck both by the basic infection control data and by the manner in which these data were analyzed. With respect to the analysis, for example, the cutoff for hand hygiene “success” was greater than 33% adherence, and the cutoff for “successful” changing of gloves between patients was greater than 41% of the time. Even though staff in these centers were made totally aware that observers were there to evaluate the workers’ adherence to infection control guidelines, more than 75% of centers exhibited less than 33% adherence to hand hygiene recommendations, and staff from more than 70% of the centers failed to change gloves more than 41% of the time between patients. Most strikingly, only 28% of the centers had staff who followed both the hand hygiene and gloveuse recommendations more than 17% of the time! Interestingly, although not statistically significant, for each of these comparisons patients from institutions whose staff were (only slightly) more adherent to the recommendations had consistently lower prevalences of HCV infection—demonstrating that a little bit of infection prevention may actually go a long way while simultaneously underscoring the huge need for sweeping improvement in infection prevention procedures in these centers. Thus, from these data one might readily con-

The benefits of using a mixed methods approach – quantitative with qualitative – to identify client satisfaction and unmet needs in an HIV healthcare centre

Research into patient satisfaction with HIV ambulatory healthcare facilities is limited due to confidentiality restraints, the short history of the condition and the stigma attached. Furthermore, most satisfaction studies of this client group have not used mixed methods (quantitative with qualitative) despite its increasing use since the 1990s in healthcare research. This cross-sectional study demonstrates how a mixed methods approach is beneficial in assessing HIV client satisfaction and in identifying unmet needs in HIV healthcare. Conducted at the largest ambulatory HIV healthcare centre in Australia, this study consisted of two phases conducted sequentially: Phase One, a quantitative self-administered questionnaire survey, provided an overall statistical picture of satisfaction levels. This was followed by Phase Two, qualitative semi-structured face-to-face interviews, which enabled in-depth investigation of the reasons for satisfaction/dissatisfaction. Phase One had 166 respondents, giving a high response rate of 71%, while Phase Two had 22 participants. The study demonstrates the three advantages of using a mixed methods approach. Firstly, it increased the comprehensiveness of overall findings, by showing how qualitative data (Phase Two) provided explanations for statistical data (Phase One). Secondly, it expanded the dimensions of the research topic, as Phase Two enabled investigation of the determinants of satisfaction/dissatisfaction more broadly after assessing the client satisfaction levels in Phase One. Thirdly, it increased the methodological rigour as findings in both phases could be checked for consistency. Thus using a mixed methods approach can greatly enhance our understanding of client satisfaction in HIV/AIDS research.

Quality improvement: experience of a sexually transmitted infection clinic in Singapore

Over the past two years, the Department of Sexually Transmitted Infection Control Clinic (DSC) in Singapore has embarked on a programme to review and enhance its quality improvement programmes. A thorough review of its day-to-day operations was conducted, infection control processes and standard operating procedures. It capitalized on its use of computerized medical records to improve documentation and patient screening. DSC introduced risk-management protocols and revised patient, staff and workplace safety guidelines. These measures have resulted in benefits such as reduced prescription errors, fewer patient complaints and active clinical practice improvement programmes. In January 2008, DSC, along with its parent hospital the National Skin Centre, became the first ambulatory health-care facility in Singapore, and also among the first few outside the United States to be accredited by the Joint Commission International.

Changes in the AIDS epidemiologic situation in Puerto Rico following health care reform and the introduction of HAART

To compare the occurrence of AIDS as well as the sociodemographic and clinical profiles of AIDS patients in Puerto Rico before and after the introduction of highly active antiretroviral therapy (HAART) and the privatization of the island's public health care system. We compared the incident AIDS cases for two three-year periods, 1992-1994 and 1998-2000, in four populations: (1) entire United States, (2) Puerto Rico, (3) Bayamón Health Region (located in north-central Puerto Rico, it includes 11 of the island's 78 municipalities), and (4) an HIV cohort enrolled at the Universidad Central del Caribe (UCC) School of Medicine. The UCC is located in Bayamón, Puerto Rico, within an academic medical complex that houses the teaching hospital (Ramón Ruíz Arnaú University Hospital), the ambulatory health care facilities (Immunology Clinics) for patients with HIV, and administrative buildings. This represents the major government-sponsored health care infrastructure within the Bayamón Health Region. Incident AIDS declined substantially between the two periods in each of the four populations studied. The 48.1% decline in Puerto Rico exceeded the 40.9% decline in the United States. The decline in Puerto Rico likely resulted from increased availability and implementation of HAART and the delivery of health care to HIV/AIDS patients in an integrated fashion within each regional ambulatory clinic. In spite of this improvement, the absolute number of patients with AIDS on the island remains high. Substantial resources for treatment and prevention are required. The proportion of new AIDS cases was lower among women, persons 40 years of age or older, the less educated, and those living alone. Injection drug use remains the predominant mode of transmission in Puerto Rico. Further gains in Puerto Rico's fight against AIDS will depend on the island's ability to reduce the transmission that occurs through injection drug use; the use of HAART on a larger number of vulnerable patients, particularly intravenous drug users; educational interventions to improve medication compliance in certain risk groups; and specific measures aimed at decreasing the rate of injection drug use.

Noise in the ambulatory health care setting. How loud is too loud?

A study was conducted to assess noise levels at the Sycamore Primary Care Center, an ambulatory health care facility. It is hypothesized that the building design led to an unusually quiet environment. Noise levels were sampled over a two-week period at two locations within the center, with a range of between 49.2 and 53.2 decibels. A comprehensive literature review failed to find comparison data at other ambulatory care facilities. However, when comparing the results to those of a typical business office environment, the building is unusually quiet. This should result in a positive environment for employees, by increasing productivity and reducing stress.

The "Sherman effect": decreased ambulatory care volumes in Atlanta during the 1996 Summer Olympic Games.

To estimate the effect of the 1996 Atlanta Summer Olympic Games on visits to local ambulatory healthcare facilities. Comparison of median visit rates by time period, obtained from retrospective review of administrative data. The emergency department of the designated athletes' hospital, the public hospital's adult emergency department and adult walk-in clinics, and the adult and paediatric outpatient facilities of a large health maintenance organisation. All 132,826 visitors to the designated facilities during the study interval. Daily visit frequencies at each facility. Our informal observations had suggested that volumes were not as high as expected. In all but the athletes' designated hospital, there was a decrease in average volumes the week before the opening ceremonies, ranging from zero to 8.4% of baseline. Average daily volumes in these non-venue facilities varied from 3.2% above to 16.1% below baseline during the two weeks of the Games, but all experienced an increase in volumes the week after the closing ceremonies, ranging from 3.0% to 13.7% of baseline. Unlike the venue-related facility, community ambulatory care sites did not encounter a significant rise in volumes until after the closing ceremonies. Although confirmation from other events is needed, our data suggest that, in addition to increased preparedness for sudden volume surges, overtime staffing of local facilities during planned mass gatherings should occur not during, but immediately after, the event.

Peer Review for Anesthesia and Emergency Care

SUMMARY Within a very short time, all 50 states in the United States will have enacted dental anesthesia and sedation acts. It is reasonable to have standardized implementation of the oral/maxillofacial surgery peer review as the standard of care for surgeons and all other professionals providing anesthesia. Watered-down versions of the examination neither protect the public's welfare nor ensure safe and sane anesthesia provided by competent doctors. If a doctor does not perform satisfactorily during the examination, provisions are made for a re-examination. Compliance with both the initial examination and the re-examination has been high because of the new vertical orientation of the component state societies in the AAMOS and the legal action by the state board of dental examination in states where his evaluation is mandatory. Unlike other one-time examinations of competency, anesthesia evaluations need to be on the forefront with considerations for re-examination after 5 years. All who practice anesthesia on a day-to-day basis have seen pharmacology changes as well as an explosion in monitoring technology. It behooves all who practice anesthesia in either an inpatient or an outpatient facility to keep abreast of these changes. Although this article discusses only the involvement of oral and maxillofacial surgeons in the examining process, the National Institutes of Health has adopted a Consensus Statement on Anesthesia that includes a directive concerning anesthesia training for the use of conscious sedation techniques.4 The American Dental Association and the American Dental Society of Anesthesiology have been supportive of this increased training for dental students, general dentists, and other dental specialists. At one time there was a movement for dental anesthesiology residencies, but, for a variety of political, economic, and practical reasons, these programs are few in number. An adjunct program that helps the anesthesia assistant in the office setting has been the development of the Oral and Maxillofacial Surgery Anesthesia Assistants' Program (OMAAP), founded in 1988. This program consists of a 6-month home-study course with five different areas of emphasis that in large part parallel the anesthesia evaluation sections. The five basic study modules consist of basic sciences, drugs, anesthetic techniques, monitoring, and medical emergencies. The surgeon works closely with the assistant, monitoring progress, giving quizzes, and being a resource person prior to the final examination. This is administered by the American College Testing Program (ACT) and is given periodically throughout the United States and Canada. Because this is not a pass or fail examination, it is meant to be used as an learning and evaluating instrument for the assistant. One further developing trend that augments the anesthesia evaluation is accreditation by the Accreditation Association for Ambulatory Health Care (AAAHC). In a recent article in an AAOMS publication,1 this accreditation process is viewed as a means of establishing an oral and maxillofacial surgery office as an appropriate facility for the delivery of outpatient surgery similar to an am-bulatory surgical center. AAAHC was founded in 1979 to assist ambulatory health care facilities in achieving accreditation for compliance with their guidelines. These standards include quality assurance, medical record evaluation, clinical and pharmaceutical services, environmental safety, and administration and professional development. Although AAAHC was founded to help standardize and measure performance of outpatient surgical facilities, AAOMS became a corporate member in November of 1989 with the expectation that some private practice offices might like to participate in an evaluation for accreditation. Unlike the office an-esthesia evaluation, this process is entirely voluntary. The cost of the examination, which takes an average of 1.5 days, is paid by the examinee and can run between $4000 and $4500. Because this alliance is new, the trend of the examination is not known. Finally, the field of oral and maxillofacial surgery has been blessed with foresighted visionaries who correctly determined and guided the future of the safe practice of anesthesia in the office setting for the benefit of patient and doctor. This “win-win” situation has helped practitioners control their professional destinies and serves as a reminder of the necessity for involvement as an organized and united group.

First operation of the medical research facility at the NSLS for coronary angiography

The Synchrotron Medical Research Facility (SMERF) at the National Synchrotron Light Source has been completed and is operational for human coronary angiography experiments. The imaging system and hardware have been brought to SMERF from the Stanford Synchrotron Radiation Laboratory where prior studies were carried out. SMERF consists of a suite of rooms at the end of the high-field superconducting wiggler X17 beam line and is classified as an Ambulatory Health Care Facility. Since October of 1990 the coronary arteries of five patients have been imaged. Continuously improving image quality has shown that a large part of both the right coronary artery and the left anterior descending coronary artery can be imaged following a venous injection of contrast agent.

Developing and Implementing a Quality Assurance Program in a U.S. Coast Guard Ambulatory Health Care Facility

Developing and Implementing a Quality Assurance Program in a U.S. Coast Guard Ambulatory Health Care Facility

Quality Assurance in Ambulatory Health Care Facilities

Quality Assurance in Ambulatory Health Care Facilities

Recursive optimization-simulation modeling for the analysis of ambulatory health care facilities

The overall planning problem of an ambulatory health care facility is often attacked using either linear programming or simulation models. This paper discusses each method and then describes a third method -- recursive modeling -- which capitalizes on the advantages and minimizes the disadvantages of the other two methods. Methods of variance reduction and data analysis are also discussed.

Effects of Manpower Utilization on Cost and Productivity of a Neighborhood Health Center

Manpower is a major cost component in today's health care system, absorbing at least one half of the average health care dollar. Growing pressures to achieve cost containment and rationalization of scarce health manpower will force health care institutions to rely increasingly on management techniques for examination of choices, for guidance of activities and for evaluation of outcomes. In recent years much effort has gone into developing analytic and quantitative techniques for application to the health field, an effort that has produced a rapidly growing literature. Some of the tools are still subjects of pilot testing and further refinement; but others, whose usefulness has been demonstrated, are available for implementation by management of health facilities.l-4 This paper describes a methodology for evaluating manpower utilization in ambulatory health care facilities and illustrates its uses as a management tool. Several applications of the methodology will be discussed: (a) development of staffing standards; (b) assessment of resource allocations relative to objectives; (c) allocation of departmental costs between patient care and non-patient care services; and (d) assessment of cost-effective-

Otolaryngology and family practice.

Patients seek medical care for ENT disorders more than any other illness. Usually these patients are seen by primary care physicians, internists, pediatricians, or family physicians. Yet residents in these areas and medical students have little training in treating upper respiratory disease. The need for otolaryngologists to participate in the teaching of these groups requires their participation in ambulatory health care facilities. These include the hospital outpatient clinics, rural and urban health centers, and the model family practice units required in family practice residencies. A major contribution of otolaryngology is the training of nonspecialists to treat the common ENT disorders.