Outpatient pharmaceutical office: access to medicines in public health

Abstract We evaluated the implementation of the outpatient pharmaceutical office in a teaching hospital regarding the access to medicines available in the Unified Health System - SUS. This is a descriptive-analytical study, based on secondary data analysis of 735 appointments performed by the pharmacist from 2015 to 2017. Of the drugs prescribed to patients attended at the outpatient pharmacist office, 86.39% were listed in the National List of Essential Medicines - RENAME, of which 95.43% belonged to the Specialized Component of Pharmaceutical Assistance. Evaluating the patient's diagnosis against the inclusion criteria of the Clinical Protocols and Therapeutic Guidelines (PCDT), that the most frequent pharmaceutical interventions were: adequacy of the medication request documents (56.4%) and examination requests for pharmacotherapeutic follow up (28.5%). When the prescribed drugs were not included in RENAME/PCDT, the intervention was accepted in 90.3% of the proposals for exchange with available drug in SUS. Still, it was possible to refer the patient to primary care for renewal of continuity of treatment in 95.1% of cases. In conclusion, the role of the clinical pharmacist contributes to the resolution of untreated health problems by promoting access to medicines within the scope of SUS and their rational use in accordance with the PCDT.

Efficacy of a pharmacist-managed diabetes clinic in high-risk diabetes patients, a randomized controlled trial - "Pharm-MD" : Impact of clinical pharmacists in diabetes care.

BACKGROUND: Diabetes mellitus affects 13% of American adults. To address the complex care requirements necessary to avoid diabetes-related morbidity, the American Diabetes Association recommends utilization of multidisciplinary teams. Research shows pharmacists have a positive impact on multiple clinical diabetic outcomes. METHODS: Open-label randomized controlled trial with 1:1 assignment that took place in a single institution resident-run outpatient medicine clinic. Patients 18-75 years old with type 2 diabetes mellitus and most recent HbA1c ≥9% were randomized to standard of care (SOC) (continued with routine follow up with their primary provider) or to the SOC + pharmacist-managed diabetes clinic PMDC group (had an additional 6 visits with the pharmacist within 6 months from enrollment). Patients were followed for 12 months after enrollment. Data collected included HbA1c, lipid panel, statin use, blood pressure control, immunization status, and evidence of diabetic complications (retinopathy, nephropathy, neuropathy). Intention-to-treat and per-protocol analysis were performed. RESULTS: Forty-four patients were enrolled in the SOC + PMDC group and 42 patients in the SOC group. Average decrease in HbA1c for the intervention compared to the control group at 6 months was - 2.85% vs. -1.32%, (p = 0.0051). Additionally, the odds of achieving a goal HbA1c of ≤8% at 6 months was 3.15 (95% CI = 1.18, 8.42, p = 0.0222) in the intervention versus control group. There was no statistically significant difference in the remaining secondary outcomes measured. CONCLUSIONS: Addition of pharmacist managed care for patients with type 2 diabetes mellitus is associated with significant improvements in HbA1c compared with standard of care alone. Missing data during follow up limited the power of secondary outcomes analyses. TRIAL REGISTRATION: ClinicalTrials.gov , ID: NCT03377127 ; first posted on 19/12/2017.

Importance of access to epilepsy monitoring units during the COVID-19 pandemic: consensus statement of the International League Against Epilepsy and the International Federation of Clinical Neurophysiology.

Restructuring of healthcare services during the COVID-19 pandemic has led to lockdown of epilepsy monitoring units (EMUs) in many hospitals. The ad-hoc taskforce of the International League Against Epilepsy (ILAE) and the International Federation of Clinical Neurophysiology (IFCN) highlights the detrimental effect of postponing video-EEG monitoring of patients with epilepsy and other paroxysmal events. The taskforce calls for action for continued functioning of EMUs during emergency situations, such as the COVID-19 pandemic. Long-term video-EEG monitoring is an essential diagnostic service. Access to video-EEG monitoring of the patients in the EMUs must be given high priority. Patients should be screened for COVID-19, before admission, according to the local regulations. Local policies for COVID-19 infection control should be adhered to during the video-EEG monitoring. In cases of differential diagnosis in which reduction of antiseizure medication is not required, home video-EEG monitoring should be considered as an alternative in selected patients.

Rapid Design and Implementation of Post-COVID-19 Clinics.

Survivors of COVID-19 are a vulnerable population, with complex needs because of lingering symptoms and complications across multiple organ systems. Those who required hospitalization or intensive care are also at risk for post-hospital syndrome and post-ICU syndromes, with attendant cognitive, psychological, and physical impairments, and high levels of health care utilization. Effective ambulatory care for COVID-19 survivors requires coordination across multiple subspecialties, which can be burdensome if not well coordinated. With growing recognition of these needs, post-COVID-19 clinics are being created across the country. We describe the design and implementation of multidisciplinary post-COVID-19 clinics at two academic health systems, Johns Hopkins and the University of California-San Francisco. We highlight components of the model which should be replicated across sites, while acknowledging opportunities to tailor offerings to the local institutional context. Our goal is to provide a replicable framework for others to create these much-needed care delivery models for survivors of COVID-19.

A retrospective study comparing interventions by oncology and non-oncology pharmacists in outpatient chemotherapy.

BACKGROUND: The differences in the clinical pharmacy services (CPS) provided by oncology and non-oncology pharmacists have not been sufficiently explained. AIM: This study aimed to demonstrate the differences in direct CPS provided by oncology and non-oncology pharmacists for patients and physicians, and to assess the potential impact of these services on medical costs. METHODS: We retrospectively examined CPS provided by oncology and non-oncology pharmacists for outpatients who underwent chemotherapy between January and December 2016. RESULTS: In total, 1177 and 1050 CPS provided by oncology and non-oncology pharmacists, respectively, were investigated. The rates of interventions performed by oncology and non-oncology pharmacists for physicians-determined treatment were 18.5% and 11.3%, respectively (p < .001). The rates of oncology and non-oncology pharmacist interventions accepted by physicians were 84.6 and 78.8%, respectively (p = .12). Level 4 and Level 5 interventions accounted for 64.6% of all oncology pharmacist interventions and 53.0% of all non-oncology pharmacist interventions (p = .03). The rates of improvement in symptoms from adverse drug reactions among patients resulting from interventions by oncology and non-oncology pharmacists were 89.4 and 72.1%, respectively (p = .02). Conservative assessments of medical cost impact showed that a single intervention by an oncology and by a non-oncology pharmacist saved ¥6355 and ¥3604, respectively. CONCLUSION: The results of the present study suggested that CPS by oncology pharmacists enable safer and more effective therapy for patients with cancer and indirectly contribute to reducing health care fees.

Children's Hospital Ambulatory Response to the 2019 Novel Coronavirus Disease (COVID-19) Pandemic.

The 2019 novel coronavirus disease (COVID-19) pandemic produced an abrupt and near shutdown of nonemergent patient care. Children's National Hospital (CNH) mounted a multidisciplinary, coordinated ambulatory response that included supply chain management, human resources, risk management, infection control, and information technology. To ensure patient access, CNH expanded telemedicine and instituted operational innovations for outpatient procedures. While monthly in-person ambulatory subspecialty visits decreased from 25 889 pre-COVID-19 to 4484 at nadir of the COVID-19 pandemic, telemedicine visits increased from 70 to 13 539. Further studies are needed to assess the impact of innovations in health care delivery and operations that the crisis prompted.

Effects of a physician- and pharmacist-managed clinic on pain management in cancer patients in China.

In China, pharmacists have started to manage cancer pain at outpatient clinics. This retrospective study performed at a tertiary teaching hospital was aimed to evaluate the effects of a physician-pharmacist joint clinic for cancer pain management. The study was performed between December 2016 and August 2019 and included 113 outpatients with moderate to severe cancer-related pain. Patients were divided into two groups according to the clinic each patient visited: the physician-pharmacist joint clinic (joint group, n = 59) or physician-only clinic (usual group, n = 54). Brief Pain Inventory (BPI) and Morisky Medication Adherence Measure (MMAM) were used to collect data on pain intensity, interference and medication adherence. Pain Management Index (PMI) was also calculated. BPI, MMAM and PMI were assessed at baseline (patients' first visit, week 0) and week 4 follow-up. The Chinese version of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) was used to assess patients' health-related quality of life (HRQoL) at week 4. The primary outcomes were the improvement in pain intensity, adequacy of pain management and medication adherence. The secondary outcome was the improvement in HRQoL. At week 4, compared to the usual group, the BPI pain intensity categories except the pain right now were significantly lower in the joint group: worst pain, 4 (3-7) vs 6 (4-8), P = .020; least pain, 1 (0-2) vs 2 (1-3), P = .010; average pain, 3 (2-4) vs 4 (2-5), P = .023; pain right now, 2 (1-3) vs 2 (0-4), P = .796. For the seven pain interference categories, there were no significant improvements in the joint group (P > .05). Significantly more patients achieved adequate pain control in the joint group than the usual group ((P = .002). There was also a significant difference in medication adherence between the two groups (P = .001). There were no significant differences in HRQoL between the two groups. The study suggests that pharmacist participation in outpatient cancer pain management is associated with improvement of patients' pain control and medication adherence.

Optimizing Throughput in Clinical Practice: Lean Management and Efficient Care in Plastic and Reconstructive Surgery.

BACKGROUND: As the cost of health care continues to rise, the role of medical providers has evolved to include the duties of an operations manager. Two theories of operations management can be readily applied to health care-lean management, the process of identifying and eliminating waste; and Little's law, the idea that throughput is maximized by changing the capacity to host patients or the time they spend in the system. Equipped with theories of operations management, providers are better able to identify and address flow limitations in their own practices. METHODS: Operations flow data were collected from three areas of care-clinic, surgical booking, and the operating room-for one provider. Variables of interest included visit or procedure characteristics and operations flow characteristics, such as different time points involved in the sector of care. RESULTS: Clinic data were collected from 48 patients. Variables with a significant relationship to total clinic visit time included afternoon appointments (p = 0.0080) and visit type (p = 0.0114). Surgical booking data were collected for 127 patients. Shorter estimated procedure length (p = 0.0211) decreased time to surgery. Operating room data were collected for 65 cases. Variables with a significant relationship to total operating room time were patient age (p = 0.0325), Charlson Comorbidity Index (p = 0.0039), flap type (p = 0.0153), and number of flaps (p < 0.0001). CONCLUSIONS: This brief single-provider study provides examples of how to apply operations management theories to each point of care within one's own practice. Although longitudinal data following patients through each point of care are the next step in operations flow analysis, this work lays the foundation for evaluation at each time point with the goal of developing practical strategies to improve throughput in one's practice.

COVID-19 pandemic: an Italian single institution's experience and lessons learned by public health residents' workforce.

Methods: We hereby provide a systematic description of the response actions in which the public health residents' workforce was pivotal, in a large tertiary hospital. Background: The Coronavirus Disease 2019 pandemic has posed incredible challenges to healthcare workers worldwide. The residents have been affected by an almost complete upheaval of the previous setting of activities, with a near total focus on service during the peak of the emergency. In our Institution, residents in public health were extensively involved in leading activities in the management of Coronavirus Disease 2019 pandemic. Results: The key role played by residents in the response to Coronavirus Disease 2019 pandemic is highlighted by the diversity of contributions provided, from cooperation in the rearrangement of hospital paths for continuity of care, to establishing and running new services to support healthcare professionals. Overall, they constituted a workforce that turned essential in governing efficiently such a complex scenario. Conclusions: Despite the difficulties posed by the contingency and the sacrifice of many training activities, Coronavirus Disease 2019 pandemic turned out to be a unique opportunity of learning and measuring one's capabilities and limits in a context of absolute novelty and uncertainty.

A qualitative study on the development of pharmacist-managed clinics in Taiwan.

WHAT IS KNOWN AND OBJECTIVE: Pharmacist-managed clinics (PMCs) are established to solve drug-related problems and enhance the quality of care of ambulatory patients. Although the benefits of such services have been demonstrated, little is known about PMC operations, especially outside the United States. The aim of this study was to explore how PMCs were established and to discuss implementation issues of PMCs in Taiwan. METHODS: A purposive sample of pharmacists, pharmacy administrators and physicians involved with PMCs was recruited from hospitals of varying scales across Taiwan. Semi-structured, individual interviews were conducted to understand the perceptions of the clinical service of PMCs. Interviews were transcribed verbatim and analysed by thematic analysis to find underlying themes. RESULTS: A total of 12 pharmacists, 5 pharmacy administrators and 3 physicians from 8 institutions were interviewed. Pharmacists spent 4 to 20 h per week at PMCs, and the practice experiences of PMC ranged from 1 to 6 years. PMCs have been provided in these institutions for 4 to 11 years with an average volume of 28 h and 25 patient visits weekly. Study participants described influential factors in establishing PMCs, including clinical expertise, attitude towards patient care and trust building with collaborating physicians. Operational concerns in implementing PMCs included role clarifications, manpower shortage, inadequate advanced training or certification, regulatory issues and a lack of service promotion. WHAT IS NEW AND CONCLUSION: This research broadens the understanding of operating PMC services and reveals key requirements and concerns regarding the care model, which can be useful for other countries. Resolving perceived barriers and collecting other stakeholders' perspectives may reinforce the integration of PMCs into patient care in the future.

The implementation cost of a safety-net hospital program addressing social needs in Atlanta.

OBJECTIVE: To describe the cost of integrating social needs activities into a health care program that works toward health equity by addressing socioeconomic barriers. DATA SOURCES/STUDY SETTING: Costs for a heart failure health care program based in a safety-net hospital were reported by program staff for the program year May 2018-April 2019. Additional data sources included hospital records, invoices, and staff survey. STUDY DESIGN: We conducted a retrospective, cross-sectional, case study of a program that includes health education, outpatient care, financial counseling and free medication; transportation and home services for those most in need; and connections to other social services. Program costs were summarized overall and for mutually exclusive categories: health care program (fixed and variable) and social needs activities. DATA COLLECTION: Program cost data were collected using a activity-based, micro-costing approach. In addition, we conducted a survey that was completed by key staff to understand time allocation. PRINCIPAL FINDINGS: Program costs were approximately $1.33 million, and the annual per patient cost was $1455. Thirty percent of the program costs was for social needs activities: 18% for 30-day supply of medications and addressing socioeconomic barriers to medication adherence, 18% for mobile health services (outpatient home visits), 53% for navigating services through a financial counselor and community health worker, and 12% for transportation to visits and addressing transportation barriers. Most of the program costs were for personnel: 92% of the health care program fixed, 95% of the health care program variable, and 78% of social needs activities. DISCUSSION: Historically, social and health care services are funded by different systems and have not been integrated. We estimate the cost of implementing social needs activities into a health care program. This work can inform implementation for hospitals attempting to address social determinants of health and social needs in their patient population.

Improving hepatitis B vaccination rates for advanced chronic kidney disease patients: a quality improvement initiative.

INTRODUCTION: Chronic kidney disease (CKD) patients are vulnerable to hepatitis B, and immunization prior to end stage kidney disease is recommended to optimize seroconversion. Our institution undertook a process improvement approach to increase hepatitis B vaccination in stage 4 and 5 CKD patients. METHODS: Four strategies were utilized such as: (1) Electronic health record (EHR)-based CKD registry to identify patients, (2) EHR-based physician/nurse reminders, (3) a co-located nurse appointment for vaccine administration, and (4) information sharing and provider awareness effort. The CKD registry was utilized to identify patients with stage 4 or 5 CKD, with at least two clinic visits in the prior 2 years, who had not received the hepatitis B vaccine or did not have serologic evidence of immunity. Target monthly vaccination rate was set at 75%, based on clinic leadership, nephrologist, and nurse consensus. RESULTS: A total of 239 patients were included in the study period, from November 2018 to January 2019 (observation period) and from February 2019 to September 2019 (intervention period). Monthly vaccination rate improved from 48% in November 2018 to the target rate of 75% by the end of the intervention (August and September 2019). There was a statistically significant increase from the rate of vaccination at a unique patient level in the first month of the baseline period, compared to the last month of the intervention period (51 vs. 75% p = 0.03). CONCLUSIONS: Utilizing a nurse-led approach to hepatitis B vaccination, coupled with EHR-based tools, along with continuous monitoring of performance, helped to improve hepatitis B vaccination among CKD stage 4 and 5 patients.

Establishing a Cardiac Amyloidosis Clinic: A Practical Primer for Cardiologists.

Cardiac amyloidosis is an emerging and important cause of heart failure, arrhythmia, and other cardiovascular disease in Canada. In this context, many centres have expressed interest in the development of effective care pathways for screening, evaluating, and treating this rapidly growing patient population. In October 2019, a group of Canadian stakeholders met, including specialists in cardiac amyloidosis, experts in heart failure and chronic disease management, and academic and community-based cardiologists at various stages of cardiac amyloidosis clinic development. Objectives of the meetings included discussion of existing care pathways, consideration of barriers to program development, and achieving a consensus on essential and desirable components of a best-practice cardiac amyloidosis program. Topics discussed included optimal settings for cardiac amyloidosis clinics and integration with other specialty clinics, funding limitations that act as barriers to program development and potential solutions to these barriers, the roles of the multidisciplinary team and specialist physicians in amyloidosis care, and diagnostic pathways and strategies for the identification of patients with cardiac amyloidosis. In this report, we summarize the discussion points and key recommendations for the development of a cardiac amyloidosis clinic that emerged from this meeting, focused on program integration and care coordination, human resource elements, access to care, and quality improvement and outcome measures in cardiac amyloidosis.

Fatores de riscos psicossociais e dimensões do trabalho em profissionais de Enfermagem de ambulatório universitário / Psychosocial risk factors and dimensions of work in Nursing professionals at a university outpatient clinic

Objetivo: Analisar as dimensões do trabalho que constituem fatores de risco psicossocial e suas repercussões no sofrimento e adoecimento das profissionais de enfermagem de ambulatório de hospitais universitários. Método: Estudo quantitativo, transversal, realizado nos 11 ambulatórios dos hospitais universitários localizados no município do Rio de Janeiro. Foram participantes da pesquisa 388 profissionais atuantes na assistência de enfermagem dessas unidades. O instrumento de coleta de dados contemplou um questionário para caracterização sociodemográfica, ocupacional e de saúde e o Protocolo de Avaliação dos Riscos Psicossociais Relacionados ao Trabalho. Os dados foram organizados, processados e analisados com o auxílio do programa Statistical Package for the Social Sciences, versão 21.0. As análises bivariadas foram realizadas utilizando a razão de chances, odds ratio (OR), com intervalo de confiança de 95%, com um nível de significância de 5% para verificar a associação entre as variáveis. A coleta de dados orientou-se pela obediência aos princípios éticos da pesquisa com seres humanos, sendo aprovado por oito comitês de Ética em Pesquisa. Resultados: A equipe de enfermagem ambulatorial aponta para um perfil de feminilidade maior que em outras unidades, profissionais mais velhas, casadas, com filhos, negras e com qualificação superior às exigidas para o cargo. Dentre as características ocupacionais, destacou-se o vínculo permanente, sendo um percentual significativo com mais de um vínculo, exercendo uma carga horária superior a 30 horas semanais. A maioria era de técnicas de enfermagem e já havia trabalhado em outro setor dentro da instituição, sendo no turno diurno independente do vínculo. Em relação ao tempo de trabalho, a média foi de 23,7 anos na enfermagem, 17,8 anos na instituição e 8,3 anos no ambulatório. No que diz respeito às características relacionadas à saúde, a maioria apresentou autoavaliação positiva da saúde, não apresentou afastamento por doença no último ano, possuía problema de saúde relacionado ao trabalho e apresentava doenças crônicas. A organização do trabalho em ambulatórios de hospitais universitários foi avaliada como risco médio pelos respondentes, o que significa um estado de alerta/situação limite para os riscos psicossociais no trabalho dos profissionais de enfermagem. Para esses profissionais há presença moderada dos estilos de gestão gerencialista e coletivo nos ambulatórios universitários. Em relação ao sofrimento patogênico, os fatores falta de sentido no trabalho e falta de reconhecimento apresentaram baixo risco psicossocial, enquanto o fator esgotamento mental apresentou risco médio. Os danos físicos foram avaliados como risco médio, já os danos psicológicos e sociais apresentaram resultado positivo, representando baixos riscos psicossociais. Conclusões: A partir do entendimento de que a natureza do trabalho da enfermagem não é passível de mudanças, e que esta, por si, já expõe o trabalhador a riscos com potencial de causar danos à sua saúde, medidas interventivas devem ser realizadas nas dimensões do trabalho que se constituem fatores de risco psicossocial e se apresentaram nesta pesquisa relacionados à organização do trabalho e gestão dessas unidades, a fim de minorar o sofrimento e os danos dos profissionais de enfermagem que atuam nos ambulatórios universitários. Contribuições para a enfermagem: A partir desses resultados, pretende-se sensibilizar os gestores das unidades para a necessidade de implementar ações que foquem nas condições desfavoráveis de trabalho, visando sua adequação, possibilitando melhoria no desempenho da equipe de enfermagem, com vista à prestação de serviços de qualidade, mas também à preservação de sua saúde. Atenção deve ser dada aos modelos hierarquizados, hegemônicos nos serviços de saúde, que impedem a autonomia no trabalho da enfermagem, dificultam o estabelecimento de relações cooperativas e o sentimento de valorização e reconhecimento, essenciais para a transformação do sofrimento em prazer no trabalho.

Objective: To analyze the work dimensions that represent psychosocial risk factors and their repercussion in the suffering and illness of the Nursing professionals working in outpatient clinics of university hospitals. Method: A quantitative and cross-sectional study conducted in the 11 outpatient services of the university hospitals located in the city of Rio de Janeiro. The research participants were 388 professionals working in the Nursing assistance sector of these units. The data collection instrument included a questionnaire for sociodemographic, occupational and health characterization, as well as the Protocol for the Evaluation of the Work- Related Psychosocial Risks. The data were organized, processed and analyzed with the aid of the Statistical Package for the Social Sciences program, version 21.0. The bivariate analyses were performed using Odds Ratio (OR), with a 95% confidence interval and a 5% significance level to verify the association between the variables. Data collection was guided by observance of the ethical principles of research with human beings, being approved by eight Research Ethics committees. Results: The outpatient Nursing team points to a greater female profile than in other units, older professionals, married, with children, black-skinned and with higher qualifications than those required for the position. Among the occupational characteristics, permanent employment contract stood out, with a significant percentage of people having more than one contract, representing an hour load of over 30 hours a week. Most of the participants were nursing technicians and had already worked in another sector within the institution, in the day shift regardless of the contract. In relation to the working time, the mean values were 23.7 years in Nursing, 17.8 years in the institution, and 8.3 years in the outpatient service. Regarding the characteristics related to health, most of them presented a positive health self- assessment, did not take medical leaves in the past year, had some work-related health problem, and presented chronic diseases. Work organization in the outpatient services of university hospitals was assessed as with medium risk by the respondents, which means a state of alert/borderline situation for the psychosocial risks in the Nursing professionals' work. For these professionals, there is moderate presence of the managerial and collective management styles in the university outpatient services. In relation to pathogenic suffering, the "lack of meaning in work" and "lack of recognition" factors presented low psychosocial risk, while the "mental exhaustion" factor presented medium risk. The physical harms were assessed as with medium risk; on the other hand, the psychological and social harms presented a positive result, representing low psychosocial risks. Conclusions: Based on the understanding that the nature of the Nursing work is not subjectable to changes, and that such nature per se already exposes workers to risks with the potential to cause harms to their health, intervention measures must be implemented in the work dimensions that constitute psychosocial risk factors and were presented in this research as related to the work organization and management of these units, in order to mitigate distress and harms in the Nursing professionals working in the outpatient services of university hospitals. Contributions to Nursing: Based on these results, the intention is to sensitize the units' managers regarding the need to implement actions focused on the unfavorable working conditions, aiming at their adaptation, enabling an improvement in the performance of the Nursing team, with a view to quality in the provision of services, but also to preserving their health. Attention must be paid to the hierarchical models, hegemonic in the health services, which preclude autonomy in the Nursing work, hinder the institution of cooperative relationships and of a feeling of appreciation and recognition, essential to transform suffering into pleasure at work.

Objetivo: Analizar las dimensiones del trabajo que constituyen factores de riesgo psicosocial y sus repercusiones en el sufrimiento y las enfermedades de los profesionales de Enfermería de los servicios ambulatorios de hospitales universitarios. Método: Estudio cuantitativo y transversal realizado en los 11 servicios ambulatorios de los hospitales universitarios situados en el municipio de Rio de Janeiro. Los participantes del estudio de investigación fueron 388 profesionales de Enfermería de estas unidades. El instrumento para la recolección de datos incluyó un cuestionario para la caracterización sociodemográfica, ocupacional y de salud y el Protocolo de Evaluación de los Riesgos Psicosociales Relacionados con el Trabajo. Los datos se organizaron, procesaron y analizaron con la ayuda del programa Statistical Package for the Social Sciences, versión 21.0. Los análisis bivariados se realizaron utilizando Odds Ratio (OR), con intervalo de confianza del 95% y nivel de significancia del 5% para verificar la asociación entre las variables. La recolección de datos se basó en la obediencia de los principios éticos de la investigación con seres humanos. Resultados: El equipo de Enfermería ambulatoria apunta a un perfil femenino mayor que en otras unidades, profesionales de más edad, casadas, con hijos, de raza negra y con calificaciones superiores a las exigidas para el cargo. Entre las características ocupacionales, se destacó el vínculo permanente, donde un porcentaje significativo de las profesionales poseía más de un vínculo laboral, con una carga horaria superior a 30 horas semanales. La mayoría de las participantes eran técnicas de Enfermería y ya habían trabajado en otro sector de la institución, en el turno diurno e independientemente del vínculo laboral. En relación con el tiempo de trabajo, los valores medios fueron 23,7 años en Enfermería, 17,8 años en la institución y 8,3 años en el servicio ambulatorio. Con respecto a las características relacionadas con la salud, la mayoría presentó una autoevaluación positiva de la salud, no tuvo que tomar licencia por enfermedad durante el último año, tuvo problemas de salud relacionados con el trabajo y presentó enfermedades crónicas. Las entrevistadas evaluaron la organización del trabajo en los servicios ambulatorios de hospitales universitarios como de riesgo medio, lo que significa un estado de alerta/situación límite para los riesgos psicosociales en el trabajo de los profesionales de Enfermería. En el caso de estos profesionales, se registra una moderada presencia de los estilos de gestión gerencialista y colectivo en los servicios ambulatorios universitarios. En relación con el sufrimiento patogénico, los factores «falta de sentido en el trabajo¼ y «falta de reconocimiento¼ presentaron un riesgo psicosocial reducido, mientras que el factor «agotamiento mental¼ presentó riesgo medio. Los perjuicios físicos se evaluaron como de riesgo medio, mientras que los psicológicos y sociales presentaron un resultado positivo, representando así riesgos psicosociales reducidos. Conclusiones: Sobre la base de comprender que la naturaleza del trabajo de Enfermería no es pasible de mudanzas y que, de por sí, dicha naturaleza ya expone al trabajador a riesgos con potencial de causar daños a su salud, deben implementarse medidas de intervención en las dimensiones del trabajo que representan factores de riesgo psicosocial y que, en esta investigación, se presentan relacionados con la organización del trabajo y la gestión de estas unidades, a fin de mitigar el sufrimiento y los perjuicios de los profesionales de Enfermería que se desempeñan en los servicios ambulatorios de hospitales universitarios. Contribuciones para la Enfermería: A partir de estos resultados, se pretende sensibilizar a los gerentes de las unidades con respecto a la necesidad de implementar acciones enfocadas en las condiciones desfavorables del trabajo, en pos de su adecuación, posibilitando así una mejora en el desempeño del equipo de Enfermería, con vistas a una prestación de servicios de calidad, como así también a preservar su salud. Debe prestarse atención a los modelos jerarquizados, hegemónicos en los servicios de salud, que impiden la autonomía en el trabajo de Enfermería, dificultan el establecimiento de relaciones de cooperación y el sentimiento de valorización y reconocimiento, esenciales para transformar el sufrimiento en placer laboral.

Outpatient vascular clinic management in COVID-19 pandemic.

INTRODUCTION: The recent Sars-CoV2 pandemic has dramatically slowed patients' access to our clinic for vascular pathology when the contagion curve peaked. The need to restore the assistance activity has led us to adopt new individual prophylaxis and hygiene measures. METHODS: Doctors and staff must wear dedicated clothes. Mask and gloves are mandatory for patients. A visit is scheduled every 60 minutes to allow the sanitation of the rooms. The day before the visit patients are contacted by telephone for the Covid-19 risk triage. In the presence of symptoms the visit is postponed. In the presence of other risk factors a IgG/IgM Rapid Test for Covid-19 is performed on admission to the clinic. In the presence of fever, if an extraordinary rapid test cannot be performed, the visit must be postponed. Rapid test positive patients cannot be visited: they are placed in solitary confinement at their home waiting for a nasopharyngeal swab for Covid-19. When the rapid test is positive, immediate room sanitation also occurs. The rooms dedicated to the outpatient clinic as well as medical and not medical instruments are disinfected. CONCLUSION: The one adopted can be a useful management model for any type of care activity in order to guarantee the safety of patients and all the staff. KEY WORDS: COVID-19, Management, vascular, Outpatient clinic.

Managing patient flows in radiation oncology during the COVID-19 pandemic : Reworking existing treatment designs to prevent infections at a German hot spot area University Hospital.

PURPOSE: The described work aimed to avoid cancellations of indispensable treatments by implementing active patient flow management practices and optimizing infrastructure utilization in the radiation oncology department of a large university hospital and regional COVID-19 treatment center close to the first German SARS-CoV­2 hotspot region Heinsberg in order to prevent nosocomial infections in patients and personnel during the pandemic. PATIENTS AND METHODS: The study comprised year-to-date intervention analyses of in- and outpatient key procedures, machine occupancy, and no-show rates in calendar weeks 12 to 19 of 2019 and 2020 to evaluate effects of active patient flow management while monitoring nosocomial COVID-19 infections. RESULTS: Active patient flow management helped to maintain first-visit appointment compliance above 85.5%. A slight appointment reduction of 10.3% daily (p = 0.004) could still significantly increase downstream planning CT scheduling (p = 0.00001) and performance (p = 0.0001), resulting in an absolute 20.1% (p = 0.009) increment of CT performance while avoiding overbooking practices. Daily treatment start was significantly increased by an absolute value of 18.5% (p = 0.026). Hypofractionation and acceleration were significantly increased (p = 0.0043). Integrating strict testing guidelines, a distancing regimen for staff and patients, hygiene regulations, and precise appointment scheduling, no SARS-CoV­2 infection in 164 tested radiation oncology service inpatients was observed. CONCLUSION: In times of reduced medical infrastructure capacities and resources, controlling infrastructural time per patient as well as optimizing facility utilization and personnel workload during treatment evaluation, planning, and irradiation can help to improve appointment compliance and quality management. Avoiding recurrent and preventable exposure to healthcare infrastructure has potential health benefits and might avert cross infections during the pandemic. Active patient flow management in high-risk COVID-19 regions can help Radiation Oncologists to continue and initiate treatments safely, instead of cancelling and deferring indicated therapies.

Models of outpatient neuropalliative care for patients with amyotrophic lateral sclerosis.

OBJECTIVE: To describe some current models of outpatient neuropalliative care (NPC) available to patients with amyotrophic lateral sclerosis at different institutions within the United States. METHODS: Six NPC physicians were asked to contribute written descriptions about the PC available in their ALS clinics. Descriptions were then compiled and assessed for similarities and differences. RESULTS: All clinics are multidisciplinary, with regular appointments every 3 months and similar appointment times for new visits (60-120 minutes) and follow-up visits (20-45 minutes). Four clinics have an NPC specialist embedded within the ALS clinic, 1 institution has a separate clinic for NPC, and 1 institution has both. The NPC physician at 5 institutions is a neurologist with formal palliative care training and at 1 institution is an internist with formal palliative care training. NPC is part of routine care for all patients at 2 institutions, and the primary reasons for consultation are goals of care (GOC) and severe symptom management. CONCLUSION: NPC is provided to patients with ALS heterogeneously throughout the United States with some variation in services and delivery, but all clinics are addressing similar core needs. Given the poor prognosis and high PC needs, those with ALS are the ideal patients to receive NPC. Future studies are necessary given the paucity of data available to determine best practices and to better define meaningful outcomes.