A Path FORWARD: Development of a Comprehensive Multidisciplinary Clinic to Create Health and Wellness for the Child and Adolescent with a Fontan Circulation.

Today, it is anticipated most individuals diagnosed with single-ventricle malformation will survive surgical reconstruction through a successful Fontan operation. As greater numbers of patients survive, so has the recognition that individuals with Fontan circulation face a variety of challenges. The goal of a normal quality and duration of life will not be reached by all. The hurdles fall into a variety of domains. From a cardiovascular perspective, the Fontan circulation is fundamentally flawed by its inherent nature of creating a state of chronically elevated venous pressure and congestion, accompanied by a relatively low cardiac output. Ventricular dysfunction, atrioventricular valve regurgitation, and arrhythmia may directly impact cardiac performance and can progress with time. Problems are not limited to the cardiovascular system. Fontan circulatory physiology impacts a multitude of biological processes and health parameters outside the heart. The lymphatic circulation is under strain manifesting as variable degrees of protein-rich lymph loss and immune system dysregulation. Organ system dysfunction develops through altered perfusion profiles. Liver fibrosis is ubiquitous, and a process of systemic fibrogenesis in response to circulatory stressors may affect other organs as well. Somatic growth and development can be delayed. Behavioral and mental health problems are common, presenting as clinically important levels of anxiety and depression. Most striking is the high variability in prevalence and magnitude of these complications within the population, indicating the likelihood of additional factors enhancing or mitigating their emergence. We propose that optimal care for the individual with single ventricle and a Fontan circulation is ideally offered in a comprehensive multidisciplinary manner, with attention to elements that are beyond cardiac management alone. In this report, we share the concepts, our experiences, and perspectives on development of a clinic model-the "Fontan rehabilitation, wellness and resilience development" or FORWARD program. We provide insights into the mechanics of our multidisciplinary model of care and the benefits offered serving our growing population of individuals with a Fontan circulation and their families.

Factors Associated With Pediatric Burn Clinic Follow-up After Emergency Department Discharge.

Attrition between emergency department discharge and outpatient follow-up is well documented across a variety of pediatric ailments. Given the importance of outpatient medical care and the lack of related research in pediatric burn populations, we examined sociodemographic factors and burn characteristics associated with outpatient follow-up adherence among pediatric burn patients. A retrospective review of medical records was conducted on patient data extracted from a burn registry database at an urban academic children's hospital over a 2-year period (January 2018-December 2019). All patients were treated in the emergency department and discharged with instructions to follow-up in an outpatient burn clinic within 1 week. A total of 196 patients (Mage = 5.5 years; 54% male) were included in analyses. Average % TBSA was 1.9 (SD = 1.5%). One third of pediatric burn patients (33%) did not attend outpatient follow-up as instructed. Older patients (odds ratio [OR] = 1.00; 95% confidence interval [CI]: [0.99-1.00], P = .045), patients with superficial burns (OR = 9.37; 95% CI: [2.50-35.16], P = .001), patients with smaller % TBSA (OR = 1.37; 95% CI: [1.07-1.76], P = .014), and patients with Medicaid insurance (OR = 0.22; 95% CI: [0.09-0.57], P = .002) or uninsured/unknown insurance (OR = 0.07; 95% CI: [0.02-0.26], P = .000) were less likely to follow up, respectively. Patient gender, race, ethnicity, and distance to clinic were not associated with follow-up. Follow-up attrition in our sample suggests a need for additional research identifying factors associated with adherence to follow-up care. Identifying factors associated with follow-up adherence is an essential step in developing targeted interventions to improve health outcomes in this at-risk population.

Routine Psychological Screening for Parent Depressive Symptoms in an Outpatient Pediatric Specialty Burn Clinic.

Pediatric burn injuries are stressful for parents, yet few burn clinics report screening caregivers. We evaluated psychometric properties of a two-item depression screener administered to parents of children with burns during outpatient clinic visits. We also examined associations between parent depression symptoms and child characteristics. We used a retrospective review of pediatric patients with burn injuries (n = 496, age range: 0-21 years; M = 5.0 years, SD = 4.4 years) from an outpatient specialty burn clinic. Sample was 54.8% male; ethnicity was 42.4% Black/African American and 42.2% White. Most children (94.7%) had a burn TBSA of 10% or less and partial thickness burns (87%). Depression measure was administered at two time points as part of routine care: T1 (n = 496) and T2 (n = 121). Score range was 0 to 8. The means were 1.17 (SD = 1.74) at T1 and 0.81 (SD = 1.40) at T2. The majority scored ≤3 (89.9% caregivers) at T1. The measure demonstrated satisfactory internal consistency at T1 (Cronbach α = .74) and T2 (α = .82). Scores at T1 and T2 for a subsample (n = 121) were related (r = .61, p < .001). Parents of non-White children tended to report higher depression scores at T1. At T2, being female and greater burn degree were associated with higher depression scores. This brief two-item scale used with caregivers of pediatric burn patients is a reasonable method for screening parental depression in this setting. Given the association between parental depression and child characteristics, further studies are needed, including examination of predictive validity of parental depression with pediatric outcomes.

Dog Training Intervention Shows Social-Cognitive Change in the Journals of Incarcerated Youth.

There is limited research assessing the effectiveness of Animal-Assisted Therapy in at-risk adolescent populations. In a recent study, 138 adjudicated adolescents participated in a randomized controlled trial of an animal-assisted intervention, in which participants either trained shelter dogs (Teacher's Pet group) or walked the dogs (control group), with both groups participating in classroom work related to dogs (1). Journal writing was a part of class activities for all youth in the study. Conventional assessments of youth behavior made by staff or youth themselves did not demonstrate the expected differences between the groups favoring the dog training group, as youth in both groups showed a significant increase in staff and youth rated internalizing behavior problems and empathy from the beginning to the end of the project (1). However, subsequent analysis of the journal content from 73 of the adjudicated youth reported here, did reveal significant differences between treatment and control groups, favoring the Teacher's Pet group. Youth participating in the dog training intervention showed through their journal writing greater social-cognitive growth, more attachment, and more positive attitudes toward the animal-assisted intervention compared to youth in the control group. The 73 youth whose journals were available were very similar to youth in the larger group. Their results illustrate that journaling can be a useful method of assessing effects of similar animal-assisted interventions for at-risk youth. Writing done by youth receiving therapy appeared to promote self-reflection, desirable cognitive change, and prosocial attitudes that may signify improving quality of life for such youth. The expressive writing of participants could reveal important effects of treatment beyond the behavioral changes that are often the targeted outcomes of animal-assisted interventions.

Animal Assisted Therapy for Incarcerated Youth: A Randomized Controlled Trial.

Teacher's Pet, an animal assisted therapy (AAT) was assessed in a randomized controlled trial with incarcerated youth from two Midwestern United States detention facilities. The AAT was expected to increase empathy and reduce behavior problems. Participants trained dogs one hour, twice weekly for 10 weeks. A control group walked but did not train dogs for the same duration. Both groups attended one hour, twice weekly animal didactics. Of 138 participants, 117 provided complete data, and 21 had some missing data imputed. Contrary to expectation, both groups increased slightly in self-reported empathy, and staff and youth rated internalizing problems. The time youth spent with dogs plus animal didactics may have increased empathy. Increased internalizing problems could be attributed to youth gaining greater emotional awareness. Alternately, this brief intervention may not have any immediate effects, given the small changes observed. Additional follow-up of these youth and other comparison groups are needed.

Patients' views of teamwork in the emergency department offer insights about team performance.

BACKGROUND: Research into efforts to engage patients in the assessment of health-care teams is limited. OBJECTIVE: To explore, through qualitative methods, patient awareness of teamwork-related behaviours observed during an emergency department (ED) visit. DESIGN: Researchers used semi-structured question guides for audio-recorded interviews and analysed their verbatim transcripts. SETTING AND PARTICIPANTS: Researchers conducted individual phone interviews with 6 teamwork subject matter experts (SMEs) and held 5 face-to-face group interviews with patients and caregivers (n = 25) about 2 weeks after discharge from the emergency department (ED). RESULTS: SMEs suggested that a range of factors influence patient perspectives of teams. Many patients perceived the health-care team within the context of their expectations of an ED visit and their treatment plan. Four themes emerged: (i) patient-centred views highlight gaps in coordination and communication; (ii) team processes do concern patients; (iii) patients are critical observers of ways that team members present their team roles; (iv) patients' observations of team members relate to patients' views of team effectiveness. Analysis also indicated that patients viewed health-care team members' interactions with each other as proxy for how team members actually felt about patients. DISCUSSION: Results from both sets of interviews (SME and patient) indicated that patient observations of teamwork could add to assessment of team processes/frameworks. Patients' understanding about teamwork organization seemed helpful and witnessed interteam communication appeared to influence patient confidence in the team. CONCLUSION: Patients perspectives are an important part of assessment in health care and suggest potential areas for improvement through team training.

A rater training protocol to assess team performance.

INTRODUCTION: Simulation-based methodologies are increasingly used to assess teamwork and communication skills and provide team training. Formative feedback regarding team performance is an essential component. While effective use of simulation for assessment or training requires accurate rating of team performance, examples of rater-training programs in health care are scarce. We describe our rater training program and report interrater reliability during phases of training and independent rating. METHODS: We selected an assessment tool shown to yield valid and reliable results and developed a rater training protocol with an accompanying rater training handbook. The rater training program was modeled after previously described high-stakes assessments in the setting of 3 facilitated training sessions. Adjacent agreement was used to measure interrater reliability between raters. RESULTS: Nine raters with a background in health care and/or patient safety evaluated team performance of 42 in-situ simulations using post-hoc video review. Adjacent agreement increased from the second training session (83.6%) to the third training session (85.6%) when evaluating the same video segments. Adjacent agreement for the rating of overall team performance was 78.3%, which was added for the third training session. Adjacent agreement was 97% 4 weeks posttraining and 90.6% at the end of independent rating of all simulation videos. DISCUSSION: Rater training is an important element in team performance assessment, and providing examples of rater training programs is essential. Articulating key rating anchors promotes adequate interrater reliability. In addition, using adjacent agreement as a measure allows differentiation between high- and low-performing teams on video review.

Failure mode effects and criticality analysis: innovative risk assessment to identify critical areas for improvement in emergency department sepsis resuscitation.

BACKGROUND: Sepsis is an increasing problem in the practice of emergency medicine as the prevalence is increasing and optimal care to reduce mortality requires significant resources and time. Evidence-based septic shock resuscitation strategies exist, and rely on appropriate recognition and diagnosis, but variation in adherence to the recommendations and therefore outcomes remains. Our objective was to perform a multi-institutional prospective risk-assessment, using failure mode effects and criticality analysis (FMECA), to identify high-risk failures in ED sepsis resuscitation. METHODS: We conducted a FMECA, which prospectively identifies critical areas for improvement in systems and processes of care, across three diverse hospitals. A multidisciplinary group of participants described the process of emergency department (ED) sepsis resuscitation to then create a comprehensive map and table listing all process steps and identified process failures. High-risk failures in sepsis resuscitation from each of the institutions were compiled to identify common high-risk failures. RESULTS: Common high-risk failures included limited availability of equipment to place the central venous catheter and conduct invasive monitoring, and cognitive overload leading to errors in decision-making. Additionally, we identified great variability in care processes across institutions. DISCUSSION: Several common high-risk failures in sepsis care exist: a disparity in resources available across hospitals, a lack of adherence to the invasive components of care, and cognitive barriers that affect expert clinicians' decision-making capabilities. Future work may concentrate on dissemination of non-invasive alternatives and overcoming cognitive barriers in diagnosis and knowledge translation.

Use of risk assessment analysis by failure mode, effects, and criticality to reduce door-to-balloon time.

STUDY OBJECTIVE: The Centers for Medicare & Medicaid Services currently endorses a door-to-balloon time of 90 minutes or less for patients presenting to the emergency department (ED) with ST-segment elevation myocardial infarction. Recent evidence shows that a door-to-balloon time of 60 minutes significantly decreases inhospital mortality. We seek to use a proactive risk assessment method of failure mode, effects, and criticality analysis (FMECA) to evaluate door-to-balloon time process, to investigate how each component failure may affect the performance of a system, and to evaluate the frequency and the potential severity of harm of each failure. METHODS: We conducted a 2-part study: FMECA of the door-to-balloon time system and process of care, and evaluation of a single institution's door-to-balloon time operational data using a retrospective observational cohort design. A multidisciplinary group of FMECA participants described the door-to-balloon time process to then create a comprehensive map and table listing all process steps and identified process failures, including their frequency, consequence, and causes. Door-to-balloon time operational data were assessed by "on" versus "off" hours. RESULTS: Fifty-one failure points were identified across 4 door-to-balloon time phases. Of the 12 high-risk failures, 58% occurred between ECG and catheterization laboratory activation. Total door-to-balloon time during on hours had a median time of 55 minutes (95% confidence interval 46 to 60 minutes) compared with 77 minutes (95% confidence interval 68 to 83 minutes) during off hours. CONCLUSION: The FMECA revealed clear areas of potential delay and vulnerability that can be addressed to decrease door-to-balloon time from 90 to 60 minutes. FMECAs can provide a robust assessment of potential risks and can serve as the platform for significant process improvement and system redesign for door-to-balloon time.

Expressive flexibility.

Previous research has examined the consequences of either expressing or suppressing emotion using between-subjects designs. However, emotion theorists have argued that adaptation depends not so much on one regulatory process but rather on the ability to flexibly regulate emotion in accord with situational demands. To test this idea, Bonanno, Papa, Lalande, Westphal, and Coifman (2004) developed a within-subjects experimental paradigm to measure expressive flexibility (EF) and showed that EF predicted better self-reported adjustment over a 2-year period. The current investigation extends this research by (1) demonstrating the stability of EF across a 3-year period, (2) replicating the association between EF and positive adjustment using a more objective measure of adjustment (obtained from participants' close friends rather than based on self-report), and (3) by showing that the positive relation between EF and adjustment was particularly salient in the context of high levels of cumulative life stress when EF was measured under conditions of immediate threat (presence of a subliminal threat prime).