Pilot to policy: statewide dissemination and implementation of evidence-based treatment for traumatized youth.

BACKGROUND: A model for statewide dissemination of evidence-based treatment (EBT) for traumatized youth was piloted and taken to scale across North Carolina (NC). This article describes the implementation platform developed, piloted, and evaluated by the NC Child Treatment Program to train agency providers in Trauma-Focused Cognitive Behavioral Therapy using the National Center for Child Traumatic Stress Learning Collaborative (LC) Model on Adoption & Implementation of EBTs. This type of LC incorporates adult learning principles to enhance clinical skills development as part of training and many key implementation science strategies while working with agencies and clinicians to implement and sustain the new practice. METHODS: Clinicians (n = 124) from northeastern NC were enrolled in one of two TF-CBT LCs that lasted 12 months each. During the LC clinicians were expected to take at least two clients through TF-CBT treatment with fidelity and outcomes monitoring by trainers who offered consultation by phone and during trainings. Participating clinicians initiated treatment with 281 clients. The relationship of clinician and client characteristics to treatment fidelity and outcomes was examined using hierarchical linear regression. RESULTS: One hundred eleven clinicians completed general training on trauma assessment batteries and TF-CBT. Sixty-five clinicians met all mastery and fidelity requirements to meet roster criteria. One hundred fifty-six (55%) clients had fidelity-monitored assessment and TF-CBT. Child externalizing, internalizing, and post-traumatic stress symptoms, as well as parent distress levels, decreased significantly with treatment fidelity moderating child PTSD outcomes. Since this pilot, 11 additional cohorts of TF-CBT providers have been trained to these roster criteria. CONCLUSION: Scaling up or outcomes-oriented implementation appears best accomplished when training incorporates: 1) practice-based learning, 2) fidelity coaching, 3) clinical assessment and outcomes-oriented treatment, 4) organizational skill-building to address barriers for agencies, and 5) linking clients to trained clinicians via an online provider roster. Demonstrating clinician performance and client outcomes in this pilot and subsequent cohorts led to legislative support for dissemination of a service array of EBTs by the NC Child Treatment Program.

Ultrasound-guided angioplasty of autogenous arteriovenous fistulas in the office setting.

OBJECTIVE: There has been an increasing awareness of the superiority of native arteriovenous fistulas (AVFs) over prosthetic grafts for dialysis access. Many AVFs fail to mature, however, and others develop stenosis while in use. There is growing experience in treating these patients in the interventional suite with percutaneous balloon angioplasty. These procedures, however, are expensive, uncomfortable, and inconvenient for patients and physicians, and involve exposure to radiation and intravenous contrast in patients who are often not on dialysis. This study reviews our experience with ultrasound-guided angioplasty of AVFs in the office setting. METHODS: A retrospective review was performed of all patients treated in our practice with ultrasound-guided AVF angioplasty, from May 2009 to April 2011. The need for intervention was determined by examination and duplex ultrasound. All patients referred to the practice with failing or nonmaturing AVFs were treated in the office under ultrasound guidance, unless a central venous stenosis was suspected. All procedures were performed with the patient under local anesthesia by a single surgeon, and preprocedure, periprocedure, and postprocedure ultrasounds were performed in a single vascular laboratory. RESULTS: There were 31 AVFs in 30 patients in the study. Fifty-five interventions were performed, 48 for AVFs failing to mature and seven for stenosis in functioning AFVs. The 90-day patency was 93%. The overall complication rate was 11%. Two patients had proximal stenosis that could not be crossed (one patient required surgical revision and one patient refused further treatment and thrombosed). There were four perifistular hematomas; three of these resulted in AFV thrombosis. No patients required hospitalization or urgent surgical intervention. Eighty-five percent of patients treated for AVF failing to mature achieved a functional fistula. CONCLUSIONS: AVF intervention can be performed safely and effectively under ultrasound guidance in the office setting and is a valuable tool in the management of dialysis access patients.