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 “:Individual”
appointment systems to make outpatient services user
friendly(14).
Regarding the utilization of the outpatient services, our
study conducted at SKIMS ‘reveals 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. Ambulatory 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, American 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 Commission-
accredited. These organizations generally fall into the broad categories of surgical,
medical/dental and diagnostic/therapeutic services, and represent a variety of settings,
including:  

 Ambulatory surgery centers  Group medical  Plastic/cosmeti

 Audiology practices c surgery
 Cancer therapy  In vitro fertilization  Podiatric
clinics  services
 Catheterization labs
 Indian Health  Pain
 Chiropractic practices
Services management
 College/University health
 Imaging centers centers
 Community health centers
 Infusion therapy  Radiation
 Convenient care centers services oncology
  Correctional health facilities  Laser surgery  Rehabilitative
 Dental practices centers and physical
 Dermatology practices  Lithotripsy services therapy
 Military clinics  Recovery
 Dialysis centers
care/short stay
 Ear, nose and throat practices  Mobile imaging
 Sleep centers
 Endoscopy centers  Occupational
health  Teleradiology
 Family practices
 Telemedicine
 Ophthalmology
 Gastroenterology services
practices diagnostics
 Optometry  Urgent care

Accreditati
centers
 Oral and
maxillofacial  Urology
surgery services
 Orthotics/prosthetic  VA clinics


on
s Women’s
 Orthopedic health centers
services

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