Ambulatory Exam 1

What are the defining features of ambulatory care nursing when compared with in-patient nursing?

• Locus of control is with the patient

• Different types of technology: telehealth and virtual visits

• Breadth and depth of care coordination

  • Multiple elements of impact and constraint

  • Essential role of teamwork

• More emphasis on preventative care

What are the main challenges specific to ambulatory nursing?

• insurance/”payer” bigger issue and factor in treatment/adherence outcomes

  • Can make care coordination and follow-ups more difficult 

• Encounters are shorter; if you don’t have all the information you need, you cannot return to the patient

• Workload could theoretically be unlimited, or at least less defined 

• Less defined responsibilities

What is the role of RNs in ambulatory care?

• Role definition less clearly defined: triage, assessment, medication/vaccine administration

• important in coordination of care

  • Coming up with complete plan of care; virtual care and telehealth

What is the role of MAs in ambulatory care?

• much larger role in ambulatory care

  • Rooming of the client, other responsibilities as assigned

  • Under the responsibility of the MD

  • Certification is available; not always required

What is the role of LPNs in ambulatory care?

• often overlaps with RN roles

  • State regulations may keep RN in an oversight role when cost considerations are an issue

  • Like RNs, LPNs are subject to state licensure practice

Who created the organization that evolved into the Visiting Nurse Service?

Lillian Wald; originally the Henry Street Settlement 

primordial prevention

• prevents emergence/development of disease risk factors by addressing SDOH and promoting good health habits or discouraging bad ones

  • Examples: promoting healthy behaviors at childhood, preventing high blood pressure

primary prevention

• promote health and prevent disease

  • Examples: vaccinations, smoking prevention programs, water fluoridation

secondary prevention

• early detection and intervention to reduce severity

  • Examples: mammograms, colonoscopy, pap smear

tertiary prevention

• reduce disability and help rehabilitate patients who have already been diagnosed with a disease

  • Examples: insulin therapy/diet management, rehab programs, surgery/treatments

How would an RN find good and reliable screening tests?

• Test be capable of detecting a high proportion of disease in its preclinical state (high sensitivity and specificity)

• be safe to administer

• be reasonable in cost

• Be acceptable to the population

• lead to demonstrated improved health outcomes

  • Reduction in incidence and mortality

  • Increase in average life expectancy

• be widely available, as must the interventions that follow a positive result

What are the principles of appropriate screening? What makes something an effective screening tool?

• The condition should be an important health problem.

• There should be a treatment for the condition.

• Facilities for diagnosis and treatment should be available.

• There should be a latent stage of the disease.

• There should be a test or examination for the condition.

• The natural history of the disease should be adequately understood.

• There should be an agreed policy on whom to treat.

What might be the disadvantages of simply screening for every possible issue?

• Higher prevalence of false positives causing unnecessary stress or costs

• Higher prevalence of false negatives

• Expensive, stressful, uncomfortable

• Might not have effective treatment if positive 

• Radiation exposure

• Adverse side effects

• overdiagnosis

Specificity

•  the ability of a test to correctly identify people without the disease

  • Ex: A pregnancy test with 98% specificity means that 98% of non-pregnant individuals will correctly test negative, but 2% might incorrectly test positive (false positives).

Sensitivity

the ability of a test to correctly identify patients with a disease– how well a test can identify true positives

Ex: A COVID-19 rapid test with 95% sensitivity means that 95% of infected people will correctly test positive, but 5% might incorrectly test negative (false negatives).

review the USPSTF levels of confidence (A,B,C,D,I) and what they mean

• A: strongly recommended, benefits substantially outweigh harms

• B: recommended, benefits outweigh harms

• C: selective recommendation, benefits and harms closely balanced

• D: not recommended, ineffective interventions or harms outweigh potential benefits

• I: insufficient evidence, providers should use judgement

Describe the impact of COVID on telehealth and virtual care, both positive and negative.

• Arguably greater on telehealth/telemedicine than on any other part of healthcare delivery.

• Obtaining an adequate history is very important/helpful

• Comfort zones got pushed!

• CMS (Centers for Medicare & Medicaid Services) changed reimbursement to provide more for telemedicine, and relaxed previous requirements about the proportion of face-to-face and virtual

  • Downsides: more fraud and digital divide issues

What are the patient care and legal considerations for an RN who delivers virtual or telehealth care?

• Have to consider interstate/international laws: your license versus where you’re calling

• Must have completely secure technology in a private area and be able to confirm patient identity 

Understand the principles of triage

• Triage: assess for severity first

  • Virtual or in-person

  • Choices for referral: ED, urgent care, walk-in clinic, PCP

  • Challenges with protocol and dedicated space/time

Understand the principles of prioritization.

• Prioritization 

  • If multiple issues, just focus on the most important at this time

    • Limited time

  • ABCs first, but then less clear– use judgement and experience

  • Protocols and Decision Support Tools (DST)

What are the benefits and limitations of protocols/DSTs?

• Protocols: 

  • allow for independent and specific action within parameters

• DSTs:

  • Pros: safety, credibility, security

  • Cons: unnecessary control, less helpful in complex care with co-morbidities, age, gender, social & structural DOH not always addressed.

What are the key elements of primary care?

• health promotion

  • Vaccines, health education, screenings

• Chronic disease management

  • Diabetes, HTN, heart failure, depression

• Gateway to referral

• Ongoing relationship

What are the challenges of primary care?

• Administrative and clinical responsibilities

• Need clear protocols and supportive education

• Lack of understanding by administrative and clinical leaders

• Clarity of responsibilities

• Initiative within nursing leadership to support expanded roles

• “Hamster healthcare” (Sullivan, 2016): constant state of mental exhaustion

• Time constraints

• Need for continuity of caregivers

• Lack of financial incentives

• System obstacles

What are the facilitators of primary care?

• Change in national attitude

• Cost of acute care

• Renewed interest in team-based care

• increased availability/use of NPs, PAs

Annual Wellness Visit

• RN reviews overall health, medications, prevention measures, cognitive function, and home safety with patient

• Develops plan with patient; provider reviews and signs off

  • Physical and any problem-focused visits are performed by the provider

“Flipped” Visit or Co-Visit

• RN begins the visit

  • Medication discussion

  • Reviews current primary issue/concern

  • Remind them of Ask Me 3

• Provider visits; RN reports SBAR to the provider in the client’s room

• RN returns at end of visit

  • Provider explains next steps

  • Asks RN to provide needed education or tx

• RN completes the visit

  • Reviews the provider plan, checks for understanding

  • Asks if all questions answered

What is ask me 3?

• What is my main problem?

• What do I need to do?

• Why is it important for me to do this?

Schools: what are the challenges in school nursing?

• Chronic illness: diabetes, asthma, epilepsy

• Increasing awareness of allergies

• Learning, mental health, or behavioral issues

• Physical challenges: obesity or mobility issues

• Legal and societal challenges: abuse issues and vaccination

Schools: what are the concerns/goals in school nursing?

• Reduce needless trips home– keep kids in school

• Savings in parent loss of work, teacher time, and use of more costly healthcare

• Principal in charge

Work: how has occupational health changed over time, and what does that mean for the occupational health nurse?

Workforce has become majority older people over time, meaning that the health issues in worker populations has grown

Rn responsibilities include:

• Promote restoration of health

• prevention of illness/injury

• protection from work-related and environmental hazards

Chronic Care Model

• Interaction between health system and community

  • Health care organization of care– prioritize chronic disease management

  • Delivery system design– proactive and team-based care

  • Clinical information systems– EHRs

  • Decision support– evidence-based guidelines

  • Self-management support– empower patients

  • Community resources and policies

• Productive interactions between patient and team: goal of improved outcomes

  • Patient is informed and activated

  • Team is prepared and proactive

Health Belief Model

• Used to explain/predict health behaviors based on an individual’s beliefs/perceptions

• Demographic variables and psychological characteristics will inform:

  • Perceived susceptibility and severity

  • Health motivation

  • And perceived benefits and barriers

• These factors will inform what actions are taken, if any (self-efficacy)

• Nurses can also influence action using cues to action

Transitional Care Model and key components for ambulatory care

• Initially designed as an APRN care model for patients transitioning from hospital to home, focus on older adults.

• Key ambulatory care components:

  • Home visits by the transitional care nurse (TCN) coupled with ongoing telephone support for about 2 months post discharge

  • Continuity of medical care between hospital and primary care physicians facilitated by the TCN

  • Comprehensive focus on each patient’s needs

  • Active engagement of patients and their family caregivers with focus on education and support

  • Emphasis on early identification and response to health care risks and symptoms to achieve longer-term positive outcomes and avoid adverse events contributing to hospital readmissions

  • Multidisciplinary approach that includes the patient, family caregivers, and providers as part of a team

  • Communication to, between, and among the patient, family caregivers, and health care providers

What are the key ambulatory care considerations in the ambulatory setting for UTI

• First test: dipstick analysis in urine

• Treatment: antibiotics

• Other considerations: infection spreading to the kidneys

• Education: drink lots of water, pee before and after sex, avoid spermicides, wipe front to back

What are the key ambulatory care considerations in the ambulatory setting for Strep?

• First test: rapid strep test (swab) (sensitivity ~86% and specificity~95%)

  • If positive: antibiotics

  • If negative: could be mono (or flu or cold)

• Treatment: salt water gargle, (warm) fluids, pain relievers 

• Education: stay home, should feel better after 1-2 days on antibiotics, can return to work when no fever

Vaccines that adults should be up to date on

• Covid, flu, Tdap booster, MMR, Varicella, HPV, Hep B, polio

• If over 50: zoster recombinant, pneumococcal

• If over 65: RSV

Screening guidelines for an adult over the age of 60 with no significant co-morbidities

• Colonoscopy every 10 years until 75

• Mammogram every 1-2 years until age 74

• pap smear every 3 years until 74 if necessary

• PSA optional

• cholesterol every 4-6 years