Variety Of Outpatient Settings Research Articles

Development of a Novel, Reusable Task Trainer for Foreign Body Removal and Abscess Incision and Drainage.

Cutaneous abscess incision and drainage and foreign body removal are 2 common procedures in a variety of outpatient settings. The goal of this project was to create a novel, clean, reusable task trainer that could more accurately reproduce all the steps necessary to perform cutaneous abscess drainage or foreign body removal including ultrasound to identify the abscess cavity or foreign body. The novel task trainer was constructed using silicone for both the base and the top skin. Toothpaste mixed with saline was used for the abscess material as this produced an ultrasound image that mimicked purulent material. A piece of a metal paper clip was imbedded in the top skin to mimic a cutaneous foreign body. Physician assistant (PA) students given a didactic lecture then used the novel task trainer as part of a clinical skills course. After the activity, the PA students were asked to voluntarily complete a brief preretrospective/postretrospective survey comprised 8 questions that addressed their self-perceived knowledge and skills using a 5-point Likert scale. Survey data from an initial cohort of PA students at one university show effectiveness of the models when used with the associated curriculum. This study demonstrates the feasibility of constructing a practical, low-cost, non-animal-based task trainer for the purpose of training incision and drainage of cutaneous abscesses and removal of cutaneous foreign bodies. This novel task trainer allows for ultrasound skill development and provides realistic imaging experience.

Pharmacists' role in buprenorphine management for opioid use disorder: A narrative review

AbstractThe continued rise in patients treated for opioid use disorder (OUD) has called for an increase in access to OUD therapies. Pharmacists, who have previously demonstrated their value in various disease states, have begun to address gaps in OUD care by facilitating buprenorphine treatment. The objective was to review current literature and characterize the pharmacists' role in buprenorphine collaborative care models for patients with OUD. PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and Google Scholar were queried through May 2021. Studies were included if a pharmacist was part of a care model in which buprenorphine was prescribed for OUD and excluded if there was a pain management indication, a limited pharmacist role, or a survey methodology was used. Eight care models were included in this review. Key characteristics identified were (1) pharmacist role, (2) collaborating prescriber type, (3) clinic setting, (4) pharmacist practice type, and (5) outcomes. All models were located within a variety of outpatient settings. No collaborative practice model involved autonomous buprenorphine prescriptive authority by pharmacists. The majority utilized a psychiatrist as a collaborating prescriber, alongside a psychiatry‐trained pharmacist. Less than half utilized pharmacists to make dosing recommendations. Outcomes evaluating treatment retention and relapse rates were most reported. Most outcomes identified across each model were either improved or unchanged by pharmacist involvement. Pharmacists are valued members of buprenorphine care teams across a variety of settings, collaborate with various clinicians, and have a positive impact on patient outcomes such as treatment retention and relapse. Few published collaborative care models exist, suggesting pharmacists may be underutilized in caring for this growing patient population. The role of the pharmacist in buprenorphine management is not currently well‐defined; however, pharmacists are well prepared to take a more active role to help address the opioid crisis.

1536. Impact of Type of Provider on Appropriateness of Treatment for Gonorrhea and Chlamydia in Outpatient Clinics

BackgroundPatients with sexually transmitted infections (STIs) receive care in a variety of outpatient settings with medical providers of different levels of training and expertise, especially regarding STIs. We aimed to determine the impact of type of provider on the appropriateness of treatment for chlamydia and gonorrhea in a large integrated health system.MethodsWe conducted a retrospective cohort study of adult patients diagnosed with chlamydia and/or gonorrhea at any outpatient clinic within an integrated health system in Des Moines, Iowa. Nucleic-acid amplification tests were used for diagnosis, and all samples were processed at the same laboratory. Adequate treatment was defined as prescription for appropriate antibiotic, dose and duration within 7 days of the positive test. Logistic regression models with robust standard errors and adjusting for clustering by clinic were built.ResultsWe identified 481 unique patients and a total of 515 unique encounters. Considering unique patients only, the median patient age was 23 years (IQR 20-26), 466/481 (96.9%) were female (96.9%), 15/481 (3.1%) were male, and 79/481 (16.4%) were pregnant. Table 1 shows the patient demographic and provider characteristics by appropriateness of treatment for individual visits.A total of 53 patients had inappropriate treatment, some with multiple errors which are described in Table 2.Provider type, age, type of infection, and pregnancy status were significantly associated with appropriateness of treatment. After adjusting for type of infection, pregnancy status and clustering by clinic, compared to physicians, certified nurse midwives (CNMs) had 33% lower odds of prescribing appropriate treatment (95% CI 0.49-0.91; p-value = 0.010), with no difference in appropriateness of prescribing by mid-level providers (OR 1.61, 95% CI 0.82-3.17; p-value = 0.167). Pregnancy was independently associated with lower odds of appropriate treatment (OR 0.35, 95% CI 0.24-0.52; p-value < 0.001), as was infection with gonorrhea (OR 0.29, 95% CI 0.12-0.68; p-value = 0.004).Table 1. Demographic characteristics of adult patients diagnosed with chlamydia and/or gonorrhea in outpatient clinics by appropriateness of treatment. Des Moines, Iowa, January 1, 2019 to December 31, 2019 Table 2. Type of therapeutic errors encountered among patients diagnosed with chlamydia or gonorrhea ConclusionCNMs had lower odds of prescribing appropriate treatment for STIs. Efforts aimed at improving prescribing by healthcare providers should actively engage with this group.Disclosures All Authors: No reported disclosures

A COVID-19 screening tool for oncology telephone triage.

PurposeSymptoms associated with COVID-19 infection have made the assessment and triage of cancer patients extremely complicated. The purpose of this paper is to describe the development and implementation of a COVID-19 screening tool for oncology telephone triage.MethodsAn Ambulatory Oncology Clinical Nurse Educator and three faculty members worked on the development of an oncology specific triage tool based on the challenges that oncology nurses were having with the generic COVID triage tool. A thorough search of the published literature, as well as pertinent websites, verified that no screening tool for oncology patients was available.ResultsThe screening tool met a number of essential criteria: (1) simple and easy to use, (2) included the most common signs and symptoms as knowledge of COVID-19 infection changed, (3) was congruent with the overall screening procedures of the medical center, (4) included questions about risk factors for and environmental exposures related to COVID-19, and (5) assessed patient’s current cancer history and treatment status. Over a period of 3 weeks, the content and specific questions on the tool were modified based on information obtained from a variety of sources and feedback from the triage nurses.ConclusionWithin 1 month, the tool was developed and implemented in clinical practice. Oncology clinicians can modify this tool to triage patients as well as to screen patients in a variety of outpatient settings (e.g., chemotherapy infusion units, radiation therapy departments). The tool will require updates and modifications based on available resources and individual health care organizations’ policies and procedures.

Tu1065 OUTPATIENT ENDOSCOPIC SEDATION REVERSAL TRENDS AT A TERTIARY CARE ACADEMIC AMBULATORY ENDOSCOPY DIGESTIVE HEALTH CENTER (AEC-DHC) VS IN-HOSPITAL AMBULATORY PROCEDURE CENTER (APC) USING A TRIAGE PROTOCOL

Routine outpatient endoscopy is performed across a variety of outpatient settings. A known risk of performing endoscopy under moderate sedation is the potential for over sedation requiring use of reversal agents. Little has been reported on rates of reversal across different outpatient settings. At our academic tertiary care center we utilize a triage tool (Figure 1) which directs higher risk patients to the in-hospital ambulatory procedure center (APC) for their procedure. Here, we report data on outpatient sedation reversal rates for endoscopy performed at an in-hospital APC vs. at a free standing Ambulatory Endoscopy Digestive Health Center (AEC-DHC) following risk stratification with a triage tool. A retrospective analysis of all outpatient endoscopy procedures performed at AEC-DHC and APC from April 2013 to September 2019 was conducted. Procedures were stratified by their respective sites. We evaluated each procedure for which sedation reversal with flumazenil and/or naloxone was recorded. Demographics and characteristics recorded include procedure type, reason for sedation reversal, patient age, American Society of Anesthesiologists (ASA) classification, body mass index (BMI), and gender. A total of 97,366 endoscopic procedures were performed at AEC-DHC and 22,494 procedures at the APC during the study period. During this period, 17 patients at AEC-DHC were given reversal agents vs. 9 sedation reversals at APC (0.017 % vs. 0.04%, p=0.068). At AEC-DHC, indications for sedation reversal included hypoxia in 13/17 patients (76%), excessive somnolence in 3/17 patients (18%) and hypotension in one patient (6%). At APC, sedation reversal indications included hypoxia in 7/9 patients (78%) and hypotension in 2/9 patients (22%). Demographics for those requiring reversal at AEC-DHC vs. APC included mean age of 53.5 vs. 60.4 years old (p=0.23), ASA class of 1.66 vs. 2.25 (p=0.20), BMI of 27.7 vs. 24.3 (p=0.23), and females 66% vs. 22% (p=0.10). Procedures at AEC-DHC requiring sedation reversal included 6 colonoscopies, 9 EGDs, and 2 EGD/colonoscopies. APC procedures requiring sedation reversals included 2 EGDs, 1 EGD with gastrostomy tube placement, 2 ERCPs and 4 EUS’s. This accounted for 0.03% of ERCPs (5694 total) and 0.07% of EUS’s (5715 total). No sedation related deaths or long term post-sedation reversal adverse outcomes occurred at either site. We demonstrate that through use of a triage tool, low rates of sedation reversal can be achieved in two outpatient ambulatory settings for EGD and colonoscopy. Triaging procedures for higher risk patients to an in-hospital ambulatory setting appears to be safe with low rates of sedation reversal for all procedures. Overall, there was no significant difference in sedation reversal rates or patient demographics of those requiring reversal at both outpatient sites.

Outpatient antimicrobial stewardship: Optimizing patient care via pharmacist led microbiology review

Cultures are often taken in the outpatient setting but results are not acted upon, leading to unnecessary re-presentations to the health care setting. This study was a prospective study with interventions made between January 1, 2018, and January 1, 2019. Cultures were reviewed to ensure appropriate antimicrobial coverage. The objective was to compare outcomes with accepted versus rejected interventions. Descriptive statistics were used to summarize data. A total of 7,360 antibiotic orders were reviewed by the infectious diseases pharmacists. Pharmacists intervened on 20.1% (n = 194) of encounters with related cultures. Interventions were most frequent in the emergency department (42%). Ciprofloxacin required the most interventions (26%), followed by third-generation cephalosporins (22%). The intervention acceptance rate was 76%, which was associated with decreased rates of 30-day treatment failure (5% vs 28%, P < .001) and 30-day admission (0.7% vs 11%, P = .001), when interventions were accepted rather than rejected. Approximately 20% of patients required intervention. Culture review services may be beneficial in a variety of outpatient settings. Outpatient stewardship literature is limited, and our study found a decrease in admission and treatment failure. Microbiology review and intervention positively impacted care for outpatients. Intervention was associated with significantly decreased rates of treatment failure and admission when interventions were accepted.

Exploring best practices for transitioning to outpatient miscarriage management

Objectives: Many women experience miscarriage in their lifetime. Though miscarriage can safely be managed expectantly, medically or surgically in a variety of outpatient settings, it is most often treated surgically in an operating room. We aimed to understand the facilitators and barriers to providing comprehensive miscarriage care in a variety of clinical settings and to identify best practices for moving toward a model of outpatient, comprehensive care.

Intensive alternating 6-drug chemotherapy for high-risk nonmetastatic rhabdomyosarcoma in children and adolescents: Impact on survival.

9566 Background: Both 5-year overall survival (OS) and event free survival (EFS) for pediatric rhabdomyosarcoma (RMS) has increased in the last 3 decades through multimodality, risk-adapted management. The reported EFS for high risk RMS in children treated at the NCI in Egypt during the 1990s was 50%. Using an intensive 6 drug alternating chemotherapy regimen in addition to local control measures was our aim to improve the outcome for this group of patients. Methods: Forty-six previously untreated patients, younger than 21 years of age, with localized high risk RMS received this regimen. High risk criteria included: (1) Localized tumors (T1) biopsied or incompletely resected, ortumors extending beyond the tissue or organ of origin (T2) completely or incompletely resected at any site (excluding orbit, uterus, vagina, and paratestis); (2)All node positive patients with primary tumor at any site; and (3) All RMS with alveolar histology at any site. Chemotherapy regimen comprised 27 weeks of alternating 6 drugs (carboplatin, doxorubicin hydrochloride, ifosfamide, actinomycin D, etoposide, vincristine). Local therapy (surgery, radiotherapy, or both) was offered at week 9. Results: Forty-six patients meeting high-risk criteria were recruited from September 2000 to November 2005. Median follow-up of survivors was 62 months. The 5-year OS and EFS for the whole group was 64% ± 10% and 47% ± 8% respectively. The EFS was significantly affected by: the size of the tumor (≤5 cm vs. &gt; 5 cm, p= 0.03), SIOP UICC clinical stage (p = 0.004), IRS stage (p = 0.01), lymph node status (p = 0.02), surgery vs. incisional biopsy (p=0.01) and overall duration of time in which therapy was delivered (p = 0.04). There was significant toxicity, mainly hematologic, but only one treatment related fatality. Conclusions: The use of intensified alternating 6-drug CT did not improve the EFS compared with historical control although it was feasible to be delivered safely in a variety of outpatient settings. Surgical resection of the tumor is essential. Delivering therapy in a timely fashion appears to impact outcome and future investigations will focus on impediments to administering chemotherapy as scheduled.

Point of care testing in a large urban academic medical center: Evolving test menu and clinical applications

Introduction There have been many reports describing individual POCT technologies but there are no recent studies describing the organizational scope and impact of a POCT program. Methods Our menu of POCT tests has increased to 26 and the test volume to 664,287 tests/year equivalent to 14.5% of the volume of the central core laboratory. POCT is performed in nearly all inpatient units and in a variety of outpatient settings. Results Cumulatively 84.6% of the test volume and most testing sites can be accounted for by 4 traditional tests (bedside glucose testing, fecal occult blood, dipstick urinalysis and activated clotting time). Most POCT tests are not performed because of a true medical necessity but rather to improve the efficiency of clinical operations. Conclusion We are experiencing a significant increase in requests for new POCT tests. Unlike established high volume conventional POC tests, these new requests originate from specialized services seeking to improve the efficiency of clinical operations.

Technical Aspects of Duplex Ultrasound-Guided Angioplasty of Arteriovenous Fistulae

Introduction Up to one-third of autologous arteriovenous fistulae (AVF) created for hemodialysis access will require additional interventions to maintain patency or promote maturation. We describe the technical aspects of duplex ultrasound-guided AVF angioplasty as an alternative to traditional contrast fistulogram and angioplasty. Methods The procedure can be performed either in the operating room, interventional procedures suite, or in an outpatient office setting. It is done in a sterile fashion under local anesthesia and light intravenous sedation. With the use of a 12-MHz linear probe and color Doppler imaging, the AVF is surveyed in both the longitudinal and transverse planes, with velocity measurements for identification of areas of stenosis and measurement of AVF blood flow to examine for failure of maturation. Specific areas of stenosis are marked with a skin marker. Percutaneous access into the AVF, guidewire advancement, angioplasty balloon inflation, and deflation are all performed under direct ultrasound visualization. Successful angioplasty is achieved when the vessel diameter, flow, and velocity improve to acceptable ranges. Results We have found that duplex ultrasound provides accurate diagnosis of AVF stenosis and non-maturation. Ultrasound information assisted us in the selection of angioplasty balloon sizes and the process of balloon inflation-deflation. Available real-time hemodynamic assessment of lesions before and after interventions provided immediate feedback on the efficacy of treatment. Additional information such as vessel wall recoil, residual stenosis, or plaque dissection after angioplasty guided the upsizing of balloons or deployment of intravascular stents. Conclusions Duplex ultrasonography offers the potential for a less expensive and more informative treatment of stenotic or non-maturing arteriovenous fistulas in a variety of outpatient settings. One such future potential location includes the Vascular Laboratory. It offers additional benefits of the avoidance of ionizing radiation and nephrotoxic contrast.

The Automated External Defibrillator

Sudden death claims 250,000 lives annually in the U.S. The vast majority of such events are due to ventricular fibrillation and ventricular tachycardia. Even though these arrhythmias can be converted if treated promptly, less than 5% of victims of out-of-hospital cardiac arrest survive to hospitalization. This poor survival is often due to delay in the initiation of quality CPR and defibrillation. Several clinical studies have evaluated the use of an AED by nontraditional emergency medical providers and by laypersons in Public Access Defibrillation programs. These studies have demonstrated a significant improvement in survival due to earlier access to defibrillation provided by the AED. The AED has proven to be safe, reliable, and efficacious in the diagnosis and treatment of ventricular arrhythmias when employed by lay providers/rescuers in a variety of outpatient settings. Society has embraced these data and legislation has been passed that supports the implementation of PAD programs into communities and protects lay rescuers and organizations implementing these programs from liability. Concerns about cost versus benefit still serve as barriers to widespread implementation of PAD programs, but with the declining cost of AEDs and increased public awareness, many communities have initiated PAD programs. We encourage widespread implementation of PAD programs and enhanced public awareness about basic life support, with the expectation that such efforts will enhance survival of out of hospital cardiac arrest.

Acute pancreatitis following gastrostomy tube replacement: a rarely reported occurrence

Gastrostomy tube (g-tube) replacement following initial percutaneous endoscopic placement is a common procedure and is performed routinely in emergency departments and a variety of outpatient settings. Local infection, false tract formation, and peritonitis are well-recognized complications of this procedure. We report the case of a patient developing acute pancreatitis as a result of gastrostomy replacement.

Nursing Education in a Home Health Care Practicum

As our health care delivery system has undergone profound change in the past decade, providers are expanding services from inpatient facilities to a variety of alternative settings, including home health care. Academic programs offering nursing education are recognizing the need to parallel this trend and have been placing student nurses in community-based and home care settings for clinical experience. Careful attention to curriculum development and effective management of students in a home care practicum can help ensure adequate preparation of graduate nurses who are likely to be employed in a variety of outpatient settings, including home health care.

Screening for psychosocial dysfunction in pediatric inpatients.

Screening pediatric inpatients for psychosocial dysfunction offers physicians an opportunity to identify emotional and behavioral problems that might otherwise go unrecognized. In this study, the Pediatric Symptom Checklist (PSC), a brief, parent-completed questionnaire, which has been validated in a variety of outpatient settings, was used to screen 98 pediatric inpatients. Results indicated that the PSC can be easily administered in a busy inpatient setting and is well-tolerated by both house staff and patients' parents as a routine part of the admissions process. The percentage of children who screened positive with the PSC in this inpatient setting was similar to the percentages generated by using the PSC in outpatient settings. Routine use of the PSC in inpatient settings serves to heighten house staff awareness of psychosocial concerns and facilitate parent-physician discussion of pediatric mental health issues.

Consumers' Attitudes Toward Psychotherapy, Hospitalization, and Aftercare

A sample of 204 chronically mentally ill patients from a variety of outpatient settings was surveyed on their attitudes toward psychotherapy, hospitalization, aftercare, and their condition in life. Generally, they felt various types of psychotherapy and aftercare were helpful and reported good relationships with their therapists. However, their goals focused more on quality of life than on symptom reduction. Patients also were concerned about the perceived power of providers over their lives; unfair treatment, discrimination, and lack of respect because of their illness; and anger over their illness and its consequences. Consumers in advocacy groups showed a slightly higher rate of concern than those not in advocacy groups. However, significantly more consumers in advocacy groups reported anger over their experiences with mental illnesses.