Office-based Facility Research Articles

Communication Skills of Grandview/Southview Medical Center General Surgery Residents.

In the transition of osteopathic programs to the single-accreditation graduate medical education (GME) system, residents are required to demonstrate skill in a set of core competencies identified by the Accreditation Council of Graduate Medical Education (ACGME) prior to graduation. Included in those core competencies are interpersonal and communication skills along with professionalism. To assess strengths and weaknesses of residents' interpersonal communication skills and professionalism in the Grandview/Southview Medical Center (Dayton, OH) osteopathic general surgery program using the validated Communication Assessment Tool (CAT). From November 2014 to June 2018, all patients who presented for an appointment at the Cassano General Surgery Clinic were asked by a medical assistant to complete a CAT questionnaire following their encounter with a resident physician. Patients at Cassano, an outpatient office-based facility directed to the underserved local community, are seen first by an intern, then by a 4th or 5th year resident and later by an attending physician. Patients 18 years of age or older were included; patients were excluded if they were unable to understand or read English. Patient demographics were collected, including age, gender, race/ethnicity, and previous exposure to this resident physician. Each resident's name was replaced on the CAT with a number for data analysis. The resident variables collected for this study included year of training, gender, and native language. The mean response for all CAT items was 4.5 out of 5, indicating that responses to resident performance were largely positive. Patients responded to 4 of the 14 CAT items with only excellent, very good, or good responses and no fair or poor responses. Four items had only 1 fair or poor response. The remaining 6 items received more than 1 fair or poor response: "greeted me in a way that made me feel comfortable" (#1), "talked in terms I could understand" (#8), "encouraged me to ask questions" (#10), "involved me in decisions as much as I wanted" (#11), "showed care and concern" (#13), and "spent the right amount of time with me" (#14). Attending surgeons evaluate residents in multiple areas from a doctor's perspective, but there is a potential lack of correlation between that evaluation and a patient's experience, which is paramount in osteopathic medicine. Patient responses to the CAT questionnaire can be used by program directors to identify deficiencies in milestone/competency achievement and facilitate improvement both individually and programmatically for residents according to ACGME standards.

Inflammatory Bowel Disease Care: Development and Testing an Infusion Center Questionnaire for Continuous Quality Improvement

Introduction: Approximately 1.3 million people suffer from IBD in the United States. Intravenous biologics are an important part of treatment of IBD patients. Patients treated with biologics spend a significant amount of time in infusion centers. However, there is a lack of existing literature regarding patient perspectives of ambulatory infusion care delivery. We created a novel survey to evaluate differences in perception, comfort and satisfaction among infusion patients receiving care at an office-based infusion center. Methods: Capital Digestive Care Chevy Chase Infusion Center is an office-based facility with 4 chairs in an open space. A validated survey was offered to patients during their infusions. The survey included demographic section, overall satisfaction, statements in 5 categories (Environment, Comfort, Staff, Administration, and Privacy) evaluated with a five-point Likert scale, and open-ended comment sections. Comments were classified as positive, neutral, negative, or suggestion. Results: 100 patients participated in the survey and 82 completed all the Likert scale questions. Of these, 46 were males and 36 were females. The mean and median age were 39.2 and 34.0 yrs, respectively. The median overall satisfaction (scale 1-10) was 9 with an interquartile range of 2. In summary, statements regarding staff were rated the most positive whereas responses in comfort and privacy were mixed (Table 1). Older patients rated the decorating style as significantly less pleasant compared to the ratings of younger patients. Female and male patients had significantly different, non-identical distributions in responses regarding pleasantness of room temperature, preference of others eating in the infusion room, and perception of privacy. Of the 82 participants, 76 provided written comments. Comments about staff dominated the positive category while comments regarding environment and privacy dominated the negative and suggestion categories.1110 Figure 1. Questions and median 5-point Likert Scale responses (5 - strongly agree, 4 - agree, 3 - neutral, 2 - disagree, 1 - strongly disagree)Conclusion: In general, patients were satisfied with their infusion experience but may have differing perceptions of comfort, environment and privacy depending on characteristics such as age or sex. The results will be used to inform the development of a larger, more patient-centered infusion space. The survey can also form the basis of a model to monitor patient satisfaction over time and to assure consistent, high-quality patient care in ambulatory IBD infusion centers.

Treatment outcomes and lessons learned from 5134 cases of outpatient office-based endovascular procedures in a vascular surgical practice.

Introduction The office-based endovascular facility has increased in number recently due in part to expedient patient experience. This study analyzed treatment outcomes of procedures performed in our office-based endovascular suite. Methods Treatment outcomes of 5134 consecutive procedures performed in our office-based endovascular suites from 2006 to 2013 were analyzed. Five sequential groups (group I-V) of 1000 consecutive interventions were compared with regard to technical success and treatment outcomes. Results Our patients included 2856 (56%) females and 2267 (44%) males. Procedures performed included diagnostic arteriogram, arterial interventions, venous interventions, dialysis access interventions, and venous catheter management, which were 1024 (19.9%), 1568 (30.6%), and 3073 (60.0%), 621(12.1%), and 354 (6.9%), respectively. The complication rates for group I, II, III, IV, and V were 3%, 1.5%, 1%, 1.1%, and 0.7%, respectively. The complication rate was higher in group I when compared to each of the remaining four groups ( p < 0.05). Nine patients (0.18%) died within the 30-day period following their procedures, and none were procedure related. Conclusions Endovascular procedure can be performed safely in an office-based facility with excellent outcomes. Lessons learned in establishing office-based endovascular suites with efforts to reduce procedural complications and optimize quality patient care are discussed.

The next frontier of office-based inferior vena cava filter placement.

There is an increasing number of procedures that traditionally were performed in the inpatient setting that arenow becoming office-based procedures. These include peripheral endovascular procedures such as angiograms, angioplasties, dialysis access interventions, and treatment for venous insufficiency. We chose to evaluate the feasibility, safety of inferior vena cava (IVC) filter placement in the office-based setting. All procedures were performed using local anesthesia, and ultrasound guidance for puncture. All venograms were performed with manual injection of iodinated contrast. An IVC filter was placed in the cases (except one failure of placement) using fluoroscopy in the infrarenal position. Patients were observed in a recovery area and then discharged. Follow-up data were obtained through an interview, physical examination, and 24-hour postoperative phone call. Over the course of 27months, 29 Greenfield filters (Boston Scientific, Marlborough, Mass) and three Celect temporary filters (Cook, Bloomington, Ind) were placed in the infrarenal IVC for 18 women and 14 men, with an average age of 75.3± 15.6years (range, 38-97years). Twenty-four acute, 6 recent (<6months ago) and three subacute lower extremity deep vein thromboses (DVTs) wereidentified. The indications for the procedure were patients with: DVT who were to undergo surgery (n= 6),acute large free-floating iliofemoral DVT (deemed high-risk for long-term anticoagulation) (n=7), new DVTduring anticoagulation therapy (n= 6), DVT with gastrointestinal bleeding (n= 4), DVT withhematuria (n= 2), recent DVT (which extended during fulldose anticoagulation treatment) while undergoing a longflight (n= 1) (temporary filter placement), DVTwith arm hematoma (n= 1), DVT with unsteady gaitand history offalls (n= 2), DVT with nose bleeding(n= 1), DVT withdementia and inability to receive anticoagulation treatment (n= 1), DVT and receiving chemotherapy and withthrombocytopenia (n= 1), and DVT and refusal to takeanticoagulation medication(n= 1). One patient had afailure to place a filterbecause of chronic IVC occlusion found on venogram.One patient with history of gastrointestinal bleeding,acute DVT, and atrial fibrillation suffered IVC filterthrombosis 1month after the procedure. We attemptedremoval of the temporary filters in the hospital in two patients but failed to retrieve the filter in thesetwo cases.We noted no insertion site DVT, extension ofDVT, orpulmonary embolism. Our preliminary experience suggests that placement of IVC filters for treatment of venous thrombotic eventsin an office-based facility is safe and efficacious with basic endovascular equipment. Long-term outcome cannot be determined at this point.

Facial Aesthetic Surgery: The Safe Use of Oral Sedation in an Office-Based Facility.

The desire for efficient and safe office-based facial plastic surgery procedures has continued to rise. Oral sedation is a safe and effective method to provide anesthesia for facial aesthetic surgery. This study reviewed private practice anesthesia-related outcomes using oral sedation combined with local anesthesia for office-based facial aesthetic surgery procedures. A retrospective chart review was performed on all patients who underwent office-based facial plastic surgery procedures from July 2008 to July 2014. Patient demographic data including age, gender, body mass index (BMI), past medical history, social history, surgical history, allergies, and medications were collected. Anesthesia-related data were also collected including: American Society of Anesthesia (ASA) class, type of procedure, medications administered, and major complications related to sedation were assessed. There were 199 patients (23 males and 176 females) who underwent 283 facial aesthetic surgical procedures. Mean age was 49.8 years (range, 29 to 80 years). There were 195 patients in ASA class I and 4 patients were in ASA class II. Patients underwent 44 upper blepharoplasty procedures, 35 lower blepharoplasty procedures, 5 browlifts, 43 upper blepharoplasty-browpexy, 46 facelifts, 38 neck lifts/lower facelifts, 54 fat grafting, 3 tip rhinoplasties, and 15 minor revision cases. During the study period, there were no major complications and no sedation issues. Facial aesthetic surgical procedures can be performed safely and comfortably in the office-based setting under oral sedation in appropriately selected patients. LEVEL OF EVIDENCE 4: Therapeutic.

Office-Based IVC Filter Placement: The Next Frontier

An increasing number of procedures that traditionally were performed in the inpatient setting are now becoming office-based procedures. These include peripheral endovascular procedures such as angiograms, angioplasties, dialysis-access interventions, and venous insufficiency treatments. These have been performed in the office with minimal complications. We chose to evaluate the feasibility, safety of inferior vena cava (IVC) filter placement in the office-based setting. All procedures were performed under local anesthesia and using ultrasound guidance for puncture. All venograms were performed with hand injection of dye. An IVC filter was placed in the cases (except one failure of placement) under fluoroscopy at the level of L2-L3 in the infrarenal position. Patients were observed in a recovery area and discharged to home. Follow-up data were obtained through an interview, physical examination, and 24-hour postoperative phone call. At 1 week, duplex of the IVC filter and the puncture site was performed. At the 3-month follow-up, a venous and IVC duplex scan was performed. Over the course of 27 months, 29 Greenfield filters and 3 Celect temporary filters were placed in infrarenal IVC for 18 women and 14 men, with average age of 76.1 years (range, 38-97; standard deviation, ±15.1 years). Failure to place a filter occurred in one patient due to chronic IVC occlusion. The indications for the procedure were acute free-floating DVT in 10, contraindication to anticoagulation in 13, failure of anticoagulation in 5, high-risk patients in 2, patient-related contraindication such as dementia in 2, and refusal to be anticoagulated in 1. One 89-year-old patient had IVC filter thrombosis 2 months after placement of the IVC filter. The remainder of patients did not experience any complications, including but not limited to infection, bleeding, filter thrombosis, insertion-site thrombosis, perforation of the vena cava, recurrent pulmonary embolism, admission to the hospital, and death, within 24 hours (n = 32), 1 week (n = 32), and 3 months (n = 25) of follow-up time. Our preliminary experience suggests that placement of IVC filters for treatment of venous thrombotic events in an office-based facility is safe and efficacious with basic endovascular equipment. The long-term outcome cannot be determined at this point.

Complications with office-based venoplasties and stenting and their clinical correlation.

Endovenous therapy by venoplasty and stenting is rapidly gaining momentum and popularity in treatment of chronic venous insufficiency (nonthrombotic iliac vein lesions, in particular). The purpose of this study was to examine the results of office-based venoplasty and stenting procedures that were performed at our office-based facility from July 28, 2012, until April 28, 2013. The study focused on any complications during and after the procedure. From July 2012 to April 2013, 245 patients underwent venography for the correction of suspected iliac vein stenosis in the office setting. Data included 74 patients undergoing bilateral iliac procedures and 137 patients undergoing unilateral procedures. The remaining 34 patients underwent venography only, without any intervention. The remaining 285 limbs were classified according to the Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) classification as follows: C1, n = 0; C2, n = 84; C3, n = 97; C4, n = 34; C5, n = 53, and C6, n = 17. Postprocedure pain was assessed with a Likert scale of 0 to 10, and scores were collected in 108 patients in the latter portion of the study once this was established to be our primary complication. Pain was considered to be significant if ≥ 5 (n = 20) and insignificant if <5 (n = 88). Pearson correlation was used to evaluate any correlation between pain and gender, age, laterality, CEAP scores (2-6), stent size, and balloon size. Fourteen patients had a history of prior deep venous thrombosis (DVT). Out of the series, 90 women and 47 men underwent unilateral intervention, and 23 women and 14 men underwent bilateral intervention. The average age was 69 years (range, 22-96; standard deviation [SD], ± 13). In 20 patients with significant pain, the average pain score was 6 (range, 5-10; SD, ± 1.4). In 88 patients with insignificant pain, the average pain score was 1.15 (range, 0-4; SD, ± 1.5). The overall average pain score for 108 cases was 2 (range, 0-10; SD, ± 2.4). Five patients (2%) who underwent intervention developed thrombosis of the iliac stent either <30 days (n = 4) or >30 days (n = 1); all five patients had history of DVT. No statistically significant correlation of pain to age, gender, laterality, CEAP scores (2-6), or stent and balloon size was found. No correlation was found between stent thrombosis and gender, age, laterality, CEAP scores (2-6), or stent and balloon size. No complications were reported, such as pseudoaneurysm formation, infection, and insertion site DVT, within 5 days. Iliac fossa hematoma developed 30 days after the procedure in one patient, who required hospital admission for evaluation and treatment. The correction of iliac vein outflow obstruction in office-based settings results in a low incidence of complications, such as thrombosis (2%), and average pain score of 2 of 10 on the Likert scale. The procedure is minimally invasive with minimal complications.

A national study of out-of-pocket expenditures for mammography screening.

To identify variations in screening mammography expenditures, primarily out-of-pocket and total expenditures, of women 40-64 years of age in the United States and factors associated with variations. Retrospective analysis of data collected from the 2007 and 2008 Medical Expenditure Panel Survey (MEPS). The sample included 2020 women 40-64 years of age who received one mammogram in 2007 or 2008. Ordinary least squares regression was used to describe relationships among out-of-pocket mammography expenditures, total mammography expenditures, and out-of-pocket mammography expenditures as a percentage of total mammography expenditures and such independent variables as insurance status and type, income, region of the United States, and type of facility where a mammogram was received. The average out-of-pocket expenditure for a mammogram in 2007 or 2008 was $33, representing 14.1% of the total mammogram expenditure ($266). After controlling for demographic and health factors, women who were uninsured, were from the Midwest, and had a mammogram at an office-based facility had greater out-of-pocket mammography expenditures. Women who were uninsured, lived in the South, and received their mammogram at an office-based facility had out-of-pocket mammography expenditures that represented a greater proportion of the total mammography expenditures. Large variations in out-of-pocket expenditures were observed among women with and without insurance and between insurance types, geographic regions of the United States, and types of facilities where mammograms were received. A higher financial burden of mammography screening among some subgroups of women may act as a barrier to future mammography screening.

Organizational prerequisites for anesthesia outside the operating room

The purpose of this review is to define the responsibility and designation of anesthesia personnel to nonoperating room location anesthesia and their education in this regard. The review will also define the safety standards, guidelines, physical environment, equipment, accreditation, the quality of care and patient and procedural selection. Anesthesia outside the operating room continues to be a challenging field. With the advances in surgical and anesthetic technology, there is an increasing need for research in the area of office-based anesthetic techniques and for improvement in terms of adherence to safety standards in aiming to decrease morbidity and mortality and increase patient satisfaction. Complications of anesthesia outside the operating room still persist even in American Society of Anesthesiologists (ASA) status I patients and in accredited facilities with board-certified physicians. The department of anesthesiology taking care of the in-hospital office-based facility has the responsibility to define safe practice standards according to the ASA guidelines regarding education, documentation, guidelines preparation, equipment, standards monitoring, collaboration with other facilities, backup for the personnel in case of emergencies and prolongation of observation of a complicated patient in the postanesthesia care unit. Office-based facilities outside the hospital should comply with all federal, state, local laws and regulations. Such precautions will enhance safety, efficiency and reliability of office-based anesthesia inside and outside the hospital.

One Nurseʼs Experience in Obtaining Joint Commission Accreditation for Office-Based Surgery Centers

Obtaining and maintaining Joint Commission accreditation for the office-based facility can be a positive learning experience for nurses, doctors, and ancillary staff. The advantages of such accreditation to the organization and the patients under its care are extensive. This article outlines why offices undergo accreditation and provides insight into how it can be achieved.

Safety and efficacy in an accredited outpatient plastic surgery facility: a review of 5316 consecutive cases.

Advances in medicine have improved the delivery of health care, making it more technologically superior than ever and, at the same time, more complex. Nowhere is this more evident than in the surgical arena. Plastic surgeons are able to perform procedures safely in office-based facilities that were once reserved only for hospital operating rooms or ambulatory surgery centers. Performing procedures in the office is a convenience to both the surgeon and the patient. Some groups have challenged that performing plastic surgery procedures in an office-based facility compromises patient safety. Our study was done to determine whether outcomes are adversely affected by performing plastic surgery procedures in an accredited outpatient surgical center. A retrospective review was performed on 5316 consecutive cases completed between 1995 and 2000 at Dallas Day Surgical Center, Dallas, Texas, an outpatient surgical facility. Most cases were cosmetic procedures. All cases were analyzed for any potential morbidity or mortality. Complications requiring a return to the operating room were determined, as were infection rates. Events leading to inpatient hospitalization were also included. During this 6-year period, 35 complications (0.7 percent) and no deaths were reported. Most complications were secondary to hematoma formation (77 percent). The postoperative infection rate for patients requiring a return to the operating room was 0.11 percent. Seven patients required inpatient hospitalization following their procedure secondary to arrhythmias, angina, and pulmonary emboli. Patient safety must take precedence over cost and convenience. Any monetary savings or time gained is quickly lost if safety is compromised and complications are incurred. The safety profile of the outpatient facility must meet and even exceed that of the traditional hospital-based or ambulatory care facility. After reviewing our experience over the last 6 years that indicated few complications and no deaths, we continue to support the judicious use of accredited outpatient surgical facilities by board-certified plastic surgeons in the management of plastic surgery patients.

In-field entry of geotechnical data in borehole logging to a hand-held portable computer system

Abstract A series of BASIC programs is described to allow entry, validation and checking of coded lithological descriptions, additional prose-form notes and quantitative geotechnical data to a hand-held portable computer during on-site logging of geological drill holes for engineering purposes. The programs also permit the production of a written borehole log, in the field if necessary, along with tabulations of geotechnical data and a comprehensive graphic representation of the drill hole. Use of such a system avoids some of the errors that may arise in procedures which involve transcription from written notes in a later keypunch operation. The information can be transferred from the portable unit to an office-based facility, when required, for further processing by a more comprehensive installation.

Office-based intraocular surgery in Australia.

Office-based intraocular surgery has been carried out for three years and over 1400 procedures have been performed. There have been no systemic complications or infections. The establishment of an office-based facility is a complex venture. Apart from medicolegal, ethical and financial considerations there are regulations relating to structural requirements, sterilisation of instruments, air-conditioning, electrical hazards and other technical matters. Office-based surgery is convenient for both the patient and the surgeon. The patient remains calm and relaxed from the time of initial counselling to the end of postoperative convalescence. We have borrowed systems used in the United States for management of ambulatory surgical patients, in particular the counselling techniques. This, in our opinion, has been a significant factor for calm relaxed surgery. Patient acceptance and preference for ambulatory surgery will ensure that it is here to stay. A case can be made out for an economic and ethical obligation for this form of surgery to be implemented on a more widespread basis. It is not, however, the universal solution to ocular surgery. There are still specific indications and contraindications, in terms of both the doctor and the patient. At a time when government involvement is being felt more and more in the practice of medicine, any proven alternative method of health care delivery, provided entirely by the private sector, must be worthy of serious consideration.