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JK-PRACTITIONER
Ambulatory care is defined as the care provided to patients, who are not confined to bed and care can be provided at a clinic, health center or a hospital (1). Keeping in view the demographic profile, increase in per capita income and a rise in the life expectancy at birth, there is a quantitative need for inpatient beds, thus stretching the already limited funds, particularly in under developed and developing countries. What is really needed is not many additional beds, but fewer patients. Thus a good outpatient department, its services correlated with and as an adjunct to preventive health practices and medical care patterns of the community, can be a potent force towards this end. It is an economic waste to utilize inpatient care, when ambulatory care would suffice (2). At present India has one hospital bed per 1412 population, which is not sufficient to meet the challenges posed by demographic and epidemiological shifts. As against one bed/1000 population by 2000 A.D, we are still at 0.74 beds per 1000 population. According to an estimate India requires additional 1.5 lac beds from the current 15 lac hospital beds by 2012. These additional infrastructural facilities may require an estimated additional investment of anything around 10,00,000 crores (3). This is where ambulatory care, particularly in tertiary care hospitals can be of tremendous economic value. It is a recognized fact that 20-30 percent of patients admitted to hospitals do not require full professional care normally received by acutely ill inpatients (4). A study covering 300 American hospitals, Mccarrol, found that

utilization of emergency department in hospitals as an outpatient facility has resultedinanincreaseof approximately 500 percent in number of visits since second world war (5). American Hospital Association reports that from March 1964 to March 1965 this growth was 13 percent (6). The importance of ambulatory care can be recognized from the fast

that in a survey conducted by American Hospital Association in 1986, approximately 80% of 2200 responding hospitals said they plan to extend ambulatory services. Of the 7 .6 billion U.S. dollars spent on hospital construction from September, 1985 to September 1986, 2.5 billion dollars were spent on funding ambulatory care projects (7). Based on the growth of ambulatory care in the past, the projections for the future indicated that the average person will make six to eight visits as an ambulatory patient each year(4). To meet this great challenge adequately, hospitals must be developed on certain basic principles, i.e., 1. The building and its facilities must express the function of activities to take place with in it. 2. Maximum flexibility and expansibility. 3. Extra and internal patterns must be simple, clear cut, easily understood and as short as possible 4. Physical and functional separation in traffic flow of people and things as much as possible. 5. Labour saving devices must be utilized to reduce operational expenses (2). Facility planning. The hospital must establish a formal ambulatory care programme to suit its requirements. Various types of ambulatory care include integrated, separated, satellite and free standing. Defined standard and established Ambulatory care is fundamental arm of health care, as it is provided at all levels of health care system i.e., sub-center to tertiary care hospital. One of the greatest revolution in modern health care is occurring in the area of ambulatory services. policies and procedures serve as operational guidelines for providing efficient, safe care to patients. These standards include maintaining a safe controlled, and consistently monitored environment and keeping accurate records and active quality assurance programme should be achieved by organizing a defined committee to promote excellence in ambulatory care (8). Special services of ambulatory care at a tertiary care

hospital. These are also called as extended ambulatory care services. A. Day care center A day care center provides the intermediate step toward re-introduction of the patient of certain disciplines into the community. Such center can be pressed into service for physical rehabilitation, medical oncology, psychiatric patients and certain types of surgeries. Approximately 40 percent of all surgeries, can be performed on an ambulatory basis. This avoids inpatient hospitalizations and susceptibility to nosocomial infection is negligible. Six surgical procedures appropriate to ambulatory setting are: l. Biopsy 2. Dilatation and curettage 3. Excision of skin lesion 4. Tubal ligation 5. Cataract extraction 6. Inguinal herniorrhaphy Other non-surgical procedures, which can be performed on day care basis are: l. Aspiration of breast mass 2. Bladder irrigation 3. Bone marrow aspiration 4. Bronchoscopy 5. Cardiac arteriography and cath etertzatron 6. Antineoplastic and antibacterial chemotherapy 7. Cystoscopy 8. Colonoscopy 9. Esophageal variceal sclerotherapy 10. Intercostal tube drainage 11. Liver biopsy (percutaneous) 12. Lumbar puncture (Diagnostic) 13. Renal biopsy 14. Sigmoidoscopy 15 . Thoracentesis (9) B. Self care units Such units should be provided for ambulatory patients, who are convalescing or require diagnostic or therapeutic management. Such units can be used by new diabetics, who require precise dietary management, frequent laboratory tests, adjustment of insulin dosage, instructions on diet and self administration of insulin or postcoronary patient who must learn under close supervision, that how much activity patient can tolerate. In short, services provided are chiefly educational and supervisory. C. Home care services Another facet of ambulatory care that will become more and more important as our hospitals feel the impact of the trends in medical practice and of Government Health Legislation, is that of home care (10). needed services to the patient after he leaves the hospital and returns to his home in the community. This is co-ordinated through one central administrative agency. This agency should be the hospital but it may be another Community Health Agency such as Local Health Department, visiting nurse association or Primary Health Center. Scope of ambulatory care services in Indian hospitals For each hospital bed, about 500 out-patients are given service each year. This mean 30 crore out-patients are treated

in out-patient department of the hospitals. Each person in one year suffers 2-4 episodes of sickness, varying from a mild to moderate to severe nature (11). If on an average only twice a person attends for medical help that exposes the nation¶s outpatient departments to 200 crore episodes. But in reality only l/6th. Of these patients manage to seek medical care in outpatient departments of health care centers and hospitals. Others seek help from private practitioners, traditional healers and health workers. However, the share of general hospitals is more than tertiary care hospitals as only complicated cases are referred to higher centres. Clinical management and ambulatory care. In the Indian scenario, the outpatient departments of both general and tertiary care hospitals face two main problems as: 1. Too many patients 2. Inadequate hospital facilities Both these problems lead to conflicts, mutual mistrust, poor quality of services and poor public relations and image (l2). However this is not always true. Studies conducted at Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Srinagar, reveal fairly good number of patients are satisfied with physical facilities and waiting time for consultation (2) Quite contrary is the result of the study conducted in outpatient department of associated hospitals of Amritsar city(13). It has been observed that most important factor for determining patient satisfaction in outpatient departments is waiting time at registration counter and consultation chamber(2) Hospital management has tried various appointment models like ,,Block,, and ³:Individual´ appointment systems to make outpatient services user friendly(14). Regarding the utilization of the outpatient services, our study conducted at SKIMS µreveals that situation is not disappointing, however corrective technical and administrative measures are needed to. l. Have sound referral system, between the hospitals on one side and, rural/ urban based hearth care system on the other side. 2. Institution of health education and awareness, particularly in rural areas, so that urban based out-patient services are not taxed. out-patient department providing ambulatory care in a teaching hospital, is a link between the users and providers of health care delivery system. Its fu1 potential and exploitation will go a long way in providing cost-effective outpatient based health care compared to more costly inpatient based hearth care (2). Conclusion Ambulatory care is emerging as the epicentre and focal point(3). Demographic, epidemiological and quality pressures coupled with resource constraints demand a costeffective¶ accessible and affordable health facility to vast majority of people. Ambul atory care¶ obviously is the alternative approach health planners and policy-makers must consider.
References
1. Sakharkar BM. Principles of hospital administration and planing; First edition

(reprint) 1999;Page 1,5,6,53. 2. Rangrez Shah RA. Utilization of outpatient department at a large teaching hospital; MD thesis, Sher-i-Kashmir Institute of Medical Sciences, Sriangar2000. 3. Tabish SA. Health of the Nation. Reflections of passion. In the Future of Health. Paras Medical Publishers. 2004 pp 789-815. 4. Alden B Mills. Functional planning of general hospital, American Association of Hospital Cosultants 1969; page183, 184,187,186. 5. Scudder Paul A, Mccarroll James R, Wade Preston A. Hospital Emergency facilities and services: A survey. Bull. Amer Coll surg 1961; 46-52 6. Hospital indicators, Hospital 1965;39(12): 23-24. 7. Chersilov M. Hospital Design follows the crown to ambulatory care hospitals. HJA 1990;61(4):58-72. 8. Tabish SA. Planning Tommorrow's Hospitals Today. JAHA 2(2);714:1990. 9. Tabish SA. Hospital and nursing homs planning, organisations and management; First edition 2003;page 477,479,481. 10. Littauer, David, Flance, I Jerome and Wesser Albert F. Home care. Hospital Monograph S. No. 9 Chicago, America n Hospital Association 1961. 11. Marker MD. Developing an evaluation schedule for OPD. MHA thesis Pune University 1985. 12. Agrawal AK. Planning and organizaion of ambulatory care. Health administration 1989;7(1):38. 13. Mohan Virender, Pada AS, Deepti SS, Dhanjal Rajinder Singh, Mahajan Sham Lal, Lal Monohar. Level of patient satisfaction at the OPDs of hospital Administration 1999;11(2): 29-35. 14. Rudi Van-De-Velde. Hospital Information Systems. The next generation 1992;13:156. 50

Facts about Ambulatory Care Accreditation
The Joint Commission¶s Ambulatory Care Accreditation Program was established in 1975, and today more than 1,600 freestanding ambulatory care organizations are Joint Commissionaccredited. These organizations generally fall into the broad categories of surgical, medical/dental and diagnostic/therapeutic services, and represent a variety of settings, including:
y y y y y y y y y y Ambulatory surgery centers Audiology Cancer therapy Catheterization labs Chiropractic practices College/University health Community health centers Convenient care centers Correctional health facilities Dental practices y y y y y y Group medical practices In vitro fertilization clinics Indian Health Services Imaging centers Infusion therapy services Laser surgery centers y y y Plastic/cosmeti c surgery Podiatric services Pain management centers Radiation oncology Rehabilitative and physical

y y

y y y y y y

Dermatology practices Dialysis centers Ear, nose and throat practices Endoscopy centers Family practices Gastroenterology services

y y y y y y y

Accreditati on Handbook for Ambulator y Care
What you need to know about obtaining accreditation

y y

Lithotripsy services Military clinics Mobile imaging Occupational health Ophthalmology practices Optometry Oral and maxillofacial surgery Orthotics/prosthetic s Orthopedic services

y y y y y y y y

therapy Recovery care/short stay Sleep centers Teleradiology Telemedicine diagnostics Urgent care centers Urology services VA clinics Women¶s health centers

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