Purpose: Examine outpatient providers' perceptions of palliative care education in increasing their understanding, knowledge of resources, and intent to refer. Research questions/goals: 1) Increase provider understanding about palliative care and the benefits that patients can receive as a result of early referral; 2) Increase provider knowledge of palliative care facilities and resources within VHSO; 3) Increase provider intent to use the referral process for patients in need of palliative care. Setting: Veterans Healthcare System of the Ozarks, Fayetteville, Arkansas. Participants: 14 outpatient providers within VHSO; 8 MDs, 4 NPs, and 2 PAs. Methods: Descriptive research study consisting of an education session, discussion, and completion of a demographics form and evaluation questionnaire. Results: Questionnaire scores: Goal 1) 4.9 (SD=1.27)/6; Goal 2) 5.07 (SD=1.1)/6; Goal 3) 5.1 (SD=1.1)/6. Open ended question themes: 1) 21.4%: palliative care was an "umbrella"; 35.7%: early referral improves outcomes; 21.4%: treatment plan can include curative therapies; 2) 28.6%: open group discussion; 14.3%: training opportunities; 21.4%: multidisciplinary team approach. 3) 35.7%: screenshots of the referral process; 14.3%: individual comments for the care plan; 21.4%: open discussion regarding referrals. 4) 14.3%: more about how to accommodate homebound Veterans; 28.6%: more about telehealth opportunities; 21.4%: more information on communication tactics. Conclusions: There is a knowledge deficit among outpatient care providers in regards to palliative care. The providers found this education session informative, beneficial, and increased their intent to initiate palliative care referrals.

OBJECTIVES: Penicillin allergies are the most commonly reported drug allergy. However, recent research has supported the concept that reported penicillin allergy does not equal true allergy. False penicillin allergies and associated alternative antibiotic use can result in inferior clinical outcomes. Determination of true versus self-reported allergy can be determined through skin testing to penicillin and oral challenge to amoxicillin. Penicillin allergy evaluations improve antibiotic utilization but penicillin skin testing (PST) requires more resources than oral amoxicillin challenge alone. Because amoxicillin challenge without preceding PST may be safe in low-risk patients, we assessed a risk stratification tool for outpatient penicillin allergy evaluations that stratify low-risk patients to receive amoxicillin challenge without prior skin testing. METHODS: The patient population was identified using the Massachusetts General Hospital Allergy Associates clinic schedule in EPIC from the beginning of January 2017 through the end of July 2018. Patients were classified into one of two evaluation methods based on allergy history, using the MGH Allergy Associates Outpatient Penicillin Allergy Pathway. Patients deemed low-risk were evaluated with direct 2-step oral amoxicillin challenge. Intermediate-risk patients were evaluated with PST and subsequent oral amoxicillin challenge. Skin testing (ST) was performed using epi-cutaneous prick tests with a major and minor determinate of penicillin, histamine (positive) and saline (negative) controls, followed by intradermal injections of the same reagents. ST was followed by one oral dose of 500mg amoxicillin. Direct oral challenge involved doses of 50mg of amoxicillin in the first step or 500mg of amoxicillin in the second step. These patients’ charts were retrospectively reviewed for information regarding the initial antibiotic allergic reaction, type of allergy testing administered, and outcomes of the outpatient allergy testing. Analysis was performed to assess and significant differences in patient characteristics, safety, and outcomes in patients given preceding skin testing or direct oral amoxicillin challenge. RESULTS: Overall, 509 eligible patients were reviewed. Four hundred twenty-six patients underwent PST with subsequent oral amoxicillin challenge. The remaining 83 patients received direct, two-step oral amoxicillin challenge. Across both groups, 43 adverse drug reactions (ADRs) were observed, 26 of which were considered hypersensitivity reactions (HSRs). The proportion of patients in each testing group that experienced ADRs was near equal, 8.5% of the skin tested group and 8.4% of the direct challenge group. One patient in each group had an HSR requiring treatment with epinephrine. Using multivariate logarithmic analysis to evaluate potential predictors for ADRs and HSRs, female sex was the only variable associated with significant increased odds for an ADR. There were no significant findings for increased odds for HSRs, including evaluation method with direct drug challenge. The proportion of patients considered to have a true penicillin allergy was similar in the two groups. DISCUSSION: PST is a vitally important aspect of antibiotic stewardship, especially when conducted before antibiotic treatment is required. Though the standard procedure is skin testing with penicillin, followed by oral amoxicillin challenge, direct oral challenges can be considered for appropriately selected low-risk patients presenting for penicillin allergy evaluation. PST is nonetheless advisable for patients with higher risk allergy histories, pregnant patients, and patients with tenuous cardiac or pulmonary status.

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This thesis is an ethnographic account of the daily life of an outpatient centre for the treatment of non-psychotic patients. The centre is located in a university setting and is nominally attached to a university mental hospital. The setting is described and the case is made that it normally allows for only two categories of participant: patients and therapists. The situated activity of these two groups in structuring the setting is a major focus of the work. The roles embodied in the two categories are described in detail and the way in which these roles interlock to create the social reality that is understood by the participants as a "therapeutic community" is set out. A belief system which is embedded in, and a determinant of each role is proposed. The practice of "doing therapy" is described and a preliminary formulation of this practice as a situated activity which depends on the social structure of the setting is attempted. A section which describes the observer's experiences in the setting is included as an appendix. It is argued that because the setting allows for only two classes of participant, the observer role is seen as deviant and that this leads to mistrust on the part of both sets of participants. / Arts, Faculty of / Anthropology, Department of / Graduate

published_or_final_version / Public Health / Master / Master of Public Health

The purpose of this research was the development of an instrument to measure the complexity of nursing care requirements in ambulatory care settings. Charles Perrow's sociological theory of organizations was adapted to nursng in order to define the complexity concept. Four research questions were investigated in this study. These questions related first, to the construct validity of the instrument's activity category system; second, to the criterion validity of the complexity weighting system; third, to the equivalent reliability to the instrument and fourth, to the instrument's clinical generalizability. Construct validity was evaluated through the regression of subjective estimations of complexity on the individual categories which make up the 154 ratings that contained measurement error, 641 independent client ratings remained for analysis. This data indicated that the classification instrument accounted for 52 percent of the total nursing care complexity in the ambulatory setting. An 18 variable equation was as statistically effective in explaining complexity as was the original 44 variable equation. Criterion validity was examined by comparing empirical complexity weights established through the regression of subjective complexity estimations on activity categories with theoretical weights determined by nurse experts in a Delphi exercise. Kendall's tau, a measure of rank association, was used for analysis. This examination revealed no statistically significant direct association between empirical and theoretical sets of complexity weights. Equivalent reliability was investigated by looking at the percent agreement among six trained raters using the classification instrument. The data indicated agreement on ratings was above 90 percent which met the criterion pre-established for interrater reliability. Finally, by a graphical analysis of residuals from regression equations, instrument generalizability across clinical services was examined. The Ambulatory Care Client Classification Instrument was not found to be generalizable in explaining the complexity of nursing care requirements across the clinical services used in this research.

Class of 2009 Abstract / OBJECTIVES: The purpose of this study is to describe clinical pharmacist services in a nurse practitioner (NP) run clinic and how clinical pharmacists might influence prescribing. METHODS: The description of the clinical pharmacist services is based on a 12-week experience of a clinical pharmacist and senior student pharmacist working with the nurse practitioner and nurse practitioner students. A questionaire was developed and consisted of items relating to the nurse practitioners ability to identify possible interactions of OTC medications, herbals and prescription medications. In addition, the questionnare assessed the comfort level of NP’s taking a prescription medication history, checking a patient’s prescription formulary, and selecting appropriate medication therapies. The questionaire uses a retrospective pretest format and was tested as a method of collecting data on how a pharmacist influenced NP prescribing. The site selected for this study was the Arizona State University Center for Healthcare Innovation (ASU Center) located in the heart of Downtown Phoenix (3rd Ave and Van Buren). RESULTS: Only one nurse practitioner worked at the ASU Center. The facility is new to the neighborhood and does not see many patients. The nurse practitioner partner in this project responded that working with a clinical pharmacist on a regular basis, with more patients would definitely help her hone skills necessary to identify interactions and prescribe according to a patients formulary. CONCLUSIONS: Pharmacists provide value-added services in an ambulatory care clinic run by nurse practitioners and provide valuable education and consultation on drug interactions. Pharmacist influence can be measured successfully to using a questionnaire in a retrospective pretest-posttest study design.

Thesis (M.S.)--Boston University

No description available.