Outpatient Environments Research Articles

A Review of Advances in Collaborative Pharmacy Practice to Improve Adherence to Standards of Care in Diabetes Management

The prevalence of diabetes in the United States is increasing and so is the need to provide diabetes care. Given the time commitment and complexity of diabetes management, an interdisciplinary approach is recommended. Pharmacists are integral members of the diabetes care team because of their accessibility and expertise in medication management. Pharmacists are receiving specialized training and becoming more involved in direct patient care through collaborative practice opportunities such as medication therapy management and collaborative drug therapy management. These collaborative practice models increase patient access to care and allow pharmacists to optimize drug therapy and provide important education to promote diabetes self-management. Studies show pharmacists practicing in a variety of outpatient environments can reduce HbA1c, LDL and BP as well as improve adherence to recommended American Diabetes Association guidelines (yearly monofilament exams, dilated eye exams, microalbumin screening, etc). Pharmacists working as part of the health care team can ensure optimal diabetes management.

Moving toward a more objective peer review process

Moving toward a more objective peer review process

S2k-Leitlinie „Diagnostik und Therapie des Schnarchens des Erwachsenen“

These guidelines aim to facilitate high quality medical care of adults with snoring problems. The guidelines were devised for application in both in- and outpatient environments and are directed primarily at all those concerned with the diagnosis and therapy of snoring. According to the AWMF three-level concept, these represent S2k guidelines.A satisfactory definition of snoring does not currently exist. Snoring is the result of vibration of soft tissue structures in narrow regions of the upper airway during breathing while asleep. Ultimately, these vibrations are caused by the sleep-associated decrease in muscle tone in the area of the upper airway dilator muscles. A multitude of risk factors for snoring have been described and its occurrence is multifactorial. Data relating to the frequency of snoring vary widely, depending on the way in which the data are collected. Snoring is usually observed in middle-aged individuals and affected males predominate. Clinical diagnosis of snoring should comprise a free evaluation of the patient's medical history. Where possible this should also involve their bed partner and the case history can be complimented by questionnaires. To determine the airflow relevant structures, a clinical examination of the nose should be performed. This examination may also include nasal endoscopy. Examination of the oropharynx is particularly important and should be performed. The larynx and the hypopharynx should be examined. The size of the tongue and the condition of the mucous membranes should be recorded as part of the oral cavity examination, as should the results of a dental assessment. Facial skeleton morphology should be assessed for orientation purposes. Technical examinations may be advisable in individual cases. In the instance of suspected sleep-related breathing disorders, relevant comorbidities or where treatment for snoring has been requested, an objective sleep medicine examination should be performed. Snoring is not-at least as we currently understand it-a disease associated with a medical threat; therefore there is currently no medical necessity to treat the condition. All overweight patients with snoring problems should strive to lose weight. If snoring is associated with the supine position, positional therapy can be considered. Some cases of snoring can be appropriately treated using an intraoral device. Selected minimally invasive surgical procedures on the soft palate can be recommended to treat snoring, provided that examinations have revealed a suitable anatomy. The choice of technique is determined primarily by the individual anatomy. At an appropriate interval after the commencement or completion a therapeutic measure, a follow-up examination should be conducted to assess the success of the therapy and to aid in the planning of any further treatments.

Artificial Pancreas: Model Predictive Control Design from Clinical Experience

The objective of this research is to develop a new artificial pancreas that takes into account the experience accumulated during more than 5000 h of closed-loop control in several clinical research centers. The main objective is to reduce the mean glucose value without exacerbating hypo phenomena. Controller design and in silico testing were performed on a new virtual population of the University of Virginia/Padova simulator. A new sensor model was developed based on the Comparison of Two Artificial Pancreas Systems for Closed-Loop Blood Glucose Control versus Open-Loop Control in Patients with Type 1 Diabetes trial AP@home data. The Kalman filter incorporated in the controller has been tuned using plasma and pump insulin as well as plasma and continuous glucose monitoring measures collected in clinical research centers. New constraints describing clinical knowledge not incorporated in the simulator but very critical in real patients (e.g., pump shutoff) have been introduced. The proposed model predictive control (MPC) is characterized by a low computational burden and memory requirements, and it is ready for an embedded implementation. The new MPC was tested with an intensive simulation study on the University of Virginia/Padova simulator equipped with a new virtual population. It was also used in some preliminary outpatient pilot trials. The obtained results are very promising in terms of mean glucose and number of patients in the critical zone of the control variability grid analysis. The proposed MPC improves on the performance of a previous controller already tested in several experiments in the AP@home and JDRF projects. This algorithm complemented with a safety supervision module is a significant step toward deploying artificial pancreases into outpatient environments for extended periods of time.

Periodic-Zone Model Predictive Control for Diurnal Closed-Loop Operation of an Artificial Pancreas

The objective of this research is an artificial pancreas (AP) that performs automatic regulation of blood glucose levels in people with type 1 diabetes mellitus. This article describes a control strategy that performs algorithmic insulin dosing for maintaining safe blood glucose levels over prolonged, overnight periods of time and furthermore was designed with outpatient, multiday deployment in mind. Of particular concern is the prevention of nocturnal hypoglycemia, because during sleep, subjects cannot monitor themselves and may not respond to alarms. An AP intended for prolonged and unsupervised outpatient deployment must strategically reduce the risk of hypoglycemia during times of sleep, without requiring user interaction. A diurnal insulin delivery strategy based on predictive control methods is proposed. The so-called "periodic-zone model predictive control" (PZMPC) strategy employs periodically time-dependent blood glucose output target zones and furthermore enforces periodically time-dependent insulin input constraints to modulate its behavior based on the time of day. The proposed strategy was evaluated through an extensive simulation-based study and a preliminary clinical trial. Results indicate that the proposed method delivers insulin more conservatively during nighttime than during daytime while maintaining safe blood glucose levels at all times. In clinical trials, the proposed strategy delivered 77% of the amount of insulin delivered by a time-invariant control strategy; specifically, it delivered on average 1.23 U below, compared with 0.31 U above, the nominal basal rate overnight while maintaining comparable, and safe, blood glucose values. The proposed PZMPC algorithm strategically prevents nocturnal hypoglycemia and is considered a significant step toward deploying APs into outpatient environments for extended periods of time in full closed-loop operation.

The emergence of community-onset Clostridium difficile infection in a tertiary hospital in Singapore: A cause for concern

Increasing rates of Clostridium difficile infection (CDI) among those without traditional risk factors have been reported mainly in Europe and North America. Here we describe the epidemiology, clinical features and ribotypes of CDI at National University Hospital (NUH), a 1000-bed tertiary care hospital in Singapore, from December 2011 to May 2012. All laboratory-confirmed CDI cases ≥21 years old who gave informed consent were included. Clinical data were collected prospectively and participants underwent an interviewer-administered questionnaire. Cases were classified by healthcare facility exposure and severity according to the SHEA guidelines. Included cases were also subjected to PCR and were classified by ribotype. In total, 66 patients participated in the study, of which 33 (50.0%) were healthcare-facility-associated hospital onset (HCFA-HO). Of the 33 community-onset (CO) cases, 14 (42.4%) were HCFA-CO, 10 (30.3%) were indeterminate and 9 (27.3%) were community-associated (CA). Of the CA cases, a majority (90.9%) had prior exposure to a healthcare facility within the last 12 weeks. Clinical characteristics, exposures and outcomes were not different between HO-CDI and CO-CDI. Diagnosis was delayed in CO-CDI compared with HO-CDI (4 days vs. 1 day; P=0.014). There was no difference in distribution of ribotypes between CO-CDI and HO-CDI, with 053 being most prevalent in both groups. CO-CDI increasingly contributes to the burden of CDI in NUH. This may reflect a trend in other parts of Asia. Healthcare professionals should be aware of the possible role of outpatient healthcare environments to CDI risk and thus extend control measures to outpatient settings.

Survey of Transplant-Related Pharmacy Services at Large Comprehensive Transplant Centers in the United States

United Network for Organ Sharing (UNOS) 2011 bylaws and Centers for Medicare and Medicaid Services (CMS) regulations require a transplant pharmacist to be an active participant in the care of transplant patients. Transplant centers must be members in good standing with UNOS in order to perform transplants and must be certified by CMS to participate with Medicare. To identify characteristics of transplant-related pharmacy services at comprehensive transplant centers. Survey regarding number of full-time equivalent (FTE) transplant pharmacists relative to number of annual transplants, transplant pharmacy model, roles in inpatient and clinic environments, training and specialization, funding sources, and expansion plans.Participants-Surveys were received from 14 (74%) of 19 identified centers that performed 200 to 400 kidney, liver, pancreas, simultaneous kidney/pancreas, heart, and lung transplants in 2010, representing 55 transplant pharmacists. A mean of 325 transplants were performed in 2010 at the surveyed centers. The mean number of pharmacist FTEs was 4.25, which yielded a transplant-to-pharmacist ratio of 76.5. Nine centers (64%) practiced in a pharmacy specialist-only model, 12 (86%) practiced in a service-based fashion, and 10 (71%) saw patients in clinic. Fifty-four pharmacists (98%) had obtained a PharmD degree, 45 (82%) had completed 1 postgraduate year, and 28 (51%) had completed 2 postgraduate years of training. Nine centers (64%) funded FTEs solely through the pharmacy department. Ten centers (71%) plan to expand transplant pharmacist staff by a mean of 1.4 FTEs. Large comprehensive transplant centers use multiple transplant pharmacists to perform patient care in the inpatient and outpatient environments. Most centers plan to expand FTEs. Further characterization of transplant pharmacists appears warranted.

Cardiac Resuscitation

Over 1,000 people suffer sudden cardiac death every day in the United States. About half occur in the hospital, the remainder occurring in the home, outpatient medical environments, or public spaces. The ultimate goal of cardiac resuscitation is survival with full neurologic recovery. Interventions that have the greatest potential to provide this outcome are often those interventions that can be performed by trained laypersons. Delay in the initiation of compressions in a cardiac arrest is one of the leading predictors of mortality. This chapter deliberately opens with a discussion of one of the most vital, yet relatively under-appreciated aspects of cardiac resuscitation—teamwork. Following an overview of cardiac arrest, the chapter covers epidemiology and recognition of cardiac arrest, then activation of the emergency response system. Chest compressions, defibrillation and airway management are discussed, then end-tidal CO2, vascular access, rhythm analysis during cardiac arrest, and drugs used during cardiac resuscitation. The chapter concludes with a look at postresuscitation care, special considerations in cardiac arrest, and future directions. Figures include the foundations of cardiac resuscitation, a management algorithm for the initial treatment of cardiac arrest, coronary perfusion pressure as a function of time, an impedance threshold device incorporated into a bag-valve mask, a colorimetric CO2 detector, four basic phases of a capnogram, sample capnographs, a battery-powered intraosseous drill, electrocardiogram readouts of ventricular arrhythmias, a sonogram of large pericardial effusion, and electrocardiographic appearance of varying degrees of hyperkalemia. Tables summarize recommendations from the American Heart Association, the components of optimal and suboptimal chest compressions, and underlying causes of nonshockable rhythms and their management. This chapter contains 11 highly rendered figures, 3 tables, 138 references, 5 MCQs.

Towards the creation of a flexible classification scheme for voluntarily reported transfusion and laboratory safety events.

BackgroundTransfusion and clinical laboratory services are high-volume activities involving complicated workflows across both ambulatory and inpatient environments. As a result, there are many opportunities for safety lapses, leading to patient harm and increased costs. Organizational techniques such as voluntary safety event reporting are commonly used to identify and prioritize risk areas across care settings. Creation of functional, standardized safety data structures that facilitate effective exploratory examination is therefore essential to drive quality improvement interventions. Unfortunately, voluntarily reported adverse event data can often be unstructured or ambiguously defined.ResultsTo address this problem, we sought to create a “best-of-breed” patient safety classification for data contained in the Duke University Health System Safety Reporting System (SRS). Our approach was to implement the internationally recognized World Health Organization International Classification for Patient Safety Framework, supplemented with additional data points relevant to our organization. Data selection and integration into the hierarchical framework is discussed, as well as placement of the classification into the SRS. We evaluated the impact of the new SRS classification on system usage through comparisons of monthly average report rates and completion times before and after implementation. Monthly average inpatient transfusion reports decreased from 102.1 ± 14.3 to 91.6 ± 11.2, with the proportion of transfusion reports in our system remaining consistent before and after implementation. Monthly average transfusion report rates in the outpatient and homecare environments were not significantly different. Significant increases in clinical lab report rates were present across inpatient and outpatient environments, with the proportion of lab reports increasing after implementation. Report completion times increased modestly but not significantly from a practical standpoint.ConclusionsA common safety vocabulary can facilitate integration of information from disparate systems and processes to permit meaningful measurement and interpretation of data to improve safety within and across organizations. Formation of a “best-of-breed” classification for voluntary reporting necessitates an internal examination of localized data needs and workflow in order to design a product that enables comprehensive data capture. A team of clinical, safety, and information technology experts is necessary to integrate the data structures into the reporting system. We have found that a “best-of-breed” patient safety classification provides a solid, extensible model for adverse event analysis, healthcare leader communication, and intervention identification.

Accuracy of point-of-care glucose measurements.

Control of blood glucose (BG) in an acceptable range is a major therapy target for diabetes patients in both the hospital and outpatient environments. This review focuses on the state of point-of-care (POC) glucose monitoring and the accuracy of the measurement devices. The accuracy of the POC glucose monitor depends on device methodology and other factors, including sample source and collection and patient characteristics. Patient parameters capable of influencing measurements include variations in pH, blood oxygen, hematocrit, changes in microcirculation, and vasopressor therapy. These elements alone or when combined can significantly impact BG measurement accuracy with POC glucose monitoring devices (POCGMDs). In general, currently available POCGMDs exhibit the greatest accuracy within the range of physiological glucose levels but become less reliable at the lower and higher ranges of BG levels. This issue raises serious safety concerns and the importance of understanding the limitations of POCGMDs. This review will discuss potential interferences and shortcomings of the current POCGMDs and stress when these may impact the reliability of POCGMDs for clinical decision-making.

Making Patient-Centered Care Reliable

Multiple reports have concluded that healthcare does not reliably meet patient needs and can even cause harm. The Institute for Healthcare Improvement (IHI) has adapted reliability principles and methods from other industries and applied them in healthcare with promising results in hospital settings. This article describes how one outpatient system successfully applied the IHI reliability methods to multiple clinical and administrative processes. How the application may differ in outpatient environments is also discussed. In particular, the patient role is much more central, and a strong collaborative engagement with the patient is likely necessary to achieve high reliability. Applying reliability principles to patient-centered processes is a critical and undeveloped area.

Drug labeling and its impact on patient safety

Adverse drug events (ADE) are defined as any medication error with significant potential to harm a patient [13]. Often times, ADE occur due to inadequate or ineffective systems of labeling. These ADE often result in mistakes in prescription adherence (compliance) with the prescription instructions. These mistakes are costly and can be deadly. Potential problems with drug labeling can occur in both in-patient and out-patient environments. This paper discusses some of the key issues to consider in drug labeling and its impact on patient safety.

Drug Labeling and its Impact on Patient Safety

Adverse drug events (ADE) are defined as any medication errors with significant potential to harm a patient. ADE frequently occur due to inadequate or ineffective systems of medication labeling. These ADE often result from mistakes in adherence (compliance) with the prescription instructions. Potential problems with drug labeling can occur in both in-patient and out-patient environments. This paper discusses some of the key issues to consider in drug labeling and its impact on patient safety.

Evidence-Based Design for Healthcare in Post-Katrina New Orleans: Current Dilemmas

New Orleans continues to struggle to rebuild from the devastation inflicted by Hurricane Katrina in 2005. More than 1,800 perished in its aftermath. Katrina stands as the costliest catastrophe in U.S. history, and the city's healthcare infrastructure is similarly striving to resuscitate itself. The incorporation of evidence-based design and research (EBD&R) in the reconstitution of the city's healthcare infrastructure offers a promising direction to improve healthcare outcomes. Recent efforts to incorporate EBD&R in New Orleans' recovery are summarized. EBD&R interventions are needed that take certain key dilemmas into consideration-embracing the adaptive reuse possibilities of historic healthcare facilities, private-public sector collaborations in acute care and in neighborhood-based outpatient care environments, and interventions to serve the city's growing population of medically underserved residents.

<h4>Influenza Vaccination Administration by Junior and Senior Nursing Students</h4>

<h4>Influenza Vaccination Administration by Junior and Senior Nursing Students</h4> <p>Auburn University Montgomery School of Nursing faculty are committed to exposing baccalaureate nursing students to a broad spectrum of experiences that promote critical thinking, caring, and clinical competence. Although rotations at the junior and senior levels offered many traditional experiences in acute and outpatient environments, when the opportunity arose to be part of a massive effort to provide influenza vaccines to the community and university employees, faculty were eager to blend experiential learning with community service. [more...]</p>

Letting the Outsiders In! A Postgraduate Certificate in Diagnostic Ultrasound for Emergency Medicine Clinicians

Diagnostic Ultrasound has a well recognized role in the evaluation of patients across the spectrum of clinical practice. Technological advances have improved image quality, while making the functionality and ease of use better. This has resulted in more compact systems becoming available at more affordable prices. Over the past 10 years there has been an increase in the development of the point of care application of this skill, in particular at the bedside by clinicians looking to complement their traditional forms of patient assessment. This has been most evident in some of the acute specialist practices, such as Emergency Medicine, and other critical care practices, as well as some out-patient and primary care environments. In this article we describe some of the training and educational challenges inherent in the development of imaging skills by non-traditional practitioners. We describe an innovative post-graduate award (Postgraduate Certificate) that has been specifically designed to provide a suitable educational structure for clinicians wishing to develop focused ultrasound skills. In particular we concentrate on the experience of the first cohort of students from Emergency Medicine who have completed the course successfully. We describe the experience related to the development of the course and the lessons learned from its provision. We argue that there is an increasing need for such courses across the spectrum of clinician ultrasound at the bedside and we look forward to further evaluation in the years ahead.

Comparability of the standing and supine standard electrocardiograms and standing sitting and supine stress electrocardiograms

The aim of this study was to evaluate whether change in the patients' position during the electrocardiogram (ECG) recording alters the various components of the ECG curve. Concerns whether ECGs in medically compromised patients recorded in a sitting position should be considered “standard” tracings and whether ECGs recorded in the supine and standing positions and ECGs recorded in different positions in the Exercise Laboratory are interchangeable provided the impetus for this study. The ECG was recorded in the supine and standing positions in 10 patients using standard electrode placement and in the sitting, standing, and supine positions in 16 patients using the Mason-Likar electrode system. Comparisons of sums of P waves and QRS complexes of various combinations of ECG leads from recordings in different positions and amplitudes of Q, R, and S waves of all 12 ECG leads revealed stability in the standard and stress ECGs, although few statistically significant but minor changes were noted in some comparisons, which, however, could not be expected to have any diagnostic significance. Comparison of standard ECGs recorded in patients in the supine and standing positions and stress ECGs recorded in the sitting, standing, and supine positions are interchangeable; this should allay concerns about recording the standard ECG in unconventional positions and may facilitate and make more cost-effective ECG recording in busy outpatient clinic environments.

The Business of Hospital Care of Diabetic Patients: 2. A New Model for Inpatient Support Services

What is the ideal model for inpatient diabetes support services in the present environment? How should organizations and financial systems be structured for the educational, counseling, and other support services relevant to the self-care of diabetes? At present, the only model that has official endorsement is the model for diabetes support services and education of the American Diabetes Association (ADA).1 As noted in the first article in this series,2 this model was designed for application in both the outpatient and inpatient environments. The changes that have occurred in the hospital care environment since the ADA Education Recognition Program (ERP) guidelines were originally designed in the early 1980s make this model inapplicable to today’s inpatient environment. At present, no other model is available to serve as a reference. One problem is a lack of definition regarding the characteristics and needs of diabetic inpatients. Available studies demonstrate that diabetic inpatients are usually hospitalized for complications of diabetes or for problems unrelated to their diabetes.3 Only a minority of diabetic admissions are caused by problems with glycemic control. Nevertheless, all or most hospitalized diabetic patients may require or benefit from diabetes support services regardless of the cause of admission.4 If the admission is related to issues with diabetes self-care or to problems in maintaining self-care for other related medical problems, such as hypertension, the need for diabetes support services is more clearly defined. Studies do suggest that patients who are admitted for issues involving glycemic control do represent a subpopulation that often requires the vigorous application of a variety of diabetes support services. The majority of these admissions are attributable to a minority of patients, who have repeated and multiple admissions for problems with diabetic crisis.5–7 Psychosocial, financial, and case management issues arise with these patients, …

A qualitative study of outpatient environments and experiences from the adolescent perspective

A qualitative study of outpatient environments and experiences from the adolescent perspective

Occurrence ofBurkholderia cepacia in the hospital environment

To determine the prevalence of Burkholderia cepacia from the environment in a regional adult cystic fibrosis (CF) care centre. Two hundred and eighty-five environmental samples were taken from inpatient and outpatient environments within the CF centre. Following a non-selective enrichment step, broths were plated onto a selective medium and B. cepacia isolates were confirmed by phenotypic tests and also genotypically by species specific 16S rRNA PCR. B. cepacia was not detected from commonly shared items of equipment, staff hands, staff uniforms or toilets. In addition, the organism was not detected in toilet bowls, even in the B. cepacia unit. With regard to positive environments for B. cepacia, 4/10 (40%) of the outside surfaces and inner rims of patients' plastic disposable sputum collection containers and 4/17 (23.5%) of air from patients' rooms, following physiotherapy, were positive. All positive samples originated in the B. cepacia segregation area of the inpatient wards and B. cepacia was not detected in the non-cepacia area of the CF centre. Consequently, these two positive sites should therefore be treated as high risk, where organisms may be potentially transmitted from environment to patient. As there is now evidence to suggest differences in the virulence and hence clinical outcome of certain of the genomovars of this organism, this study may be important in highlighting the areas that patients who are B. cepacia positive should avoid, to minimise the risk of transmission and acquisition of this organism within the CF cepacia population. These results indicate that effective infection control procedures are required in patients' rooms following physiotherapy, for prevention of B. cepacia transmission and to avoid the transmission of different genomovar types within CF patients, who are already colonised with this pathogen.