Implementing Measurement-Based Care in a Youth Partial Hospital Setting: Leveraging Feedback for Sustainability

This paper describes the successful implementation of Measurement-Based Care (MBC) within a Partial Hospitalization Program (PHP) for children and adolescents. Measurement-based care (MBC), the practice of using patient-reported measures routinely to inform decision-making, is associated with improved clinical outcomes for behavioral health patients (Jong et al., Clinical Psychology Review 85, 2021; Fortney & Sladek, 2015). MBC holds great promise in partial hospital programs (PHP) to improve outcomes, yet implementation strategies are as complex as the setting itself. This paper provides a case study example of MBC implementation in a PHP for youth. Over the course of 18 months, an interdisciplinary staff of approximately 20 behavioral health professionals provided partial hospitalization level of care to 633 (39% in-person, 61% telehealth) youth from ages 5 to 18 years old. MBC in this setting incorporated daily patient self-report and weekly caregiver-reported measurements. This descriptive reconstruction, which includes examples of the data that were used during the implementation project, illustrates specific barriers and facilitators in a successful implementation in the local PHP setting. Implementation strategies to address workflow integration, leadership and supervision, and coaching are described, including evolution of these strategies over the course of implementation. Practical considerations for implementing MBC in youth PHP settings are discussed. Finally, the authors explore the potential relationships between the data-driven MBC model of decision making and the development of resilient organizations.

A new blue whale song-type described for the Arabian Sea and Western Indian Ocean

Blue whales Balaenoptera musculus in the Indian Ocean (IO) are currently thought to represent 2 or 3 subspecies (B. m. intermedia, B. m. brevicauda, B. m. indica), and believed to be structured into 4 populations, each with a diagnostic song-type. Here we describe a previously unreported song-type that implies the probable existence of a population that has been undetected or conflated with another population. The novel song-type was recorded off Oman in the northern IO/Arabian Sea, off the western Chagos Archipelago in the equatorial central IO, and off Madagascar in the southwestern IO. As this is the only blue whale song that has been identified in the western Arabian Sea, we label it the ‘Northwest Indian Ocean’ song-type to distinguish it from other regional song-types. Spatiotemporal variation suggested a distribution west of 70°E, with potential affinity for the northern IO/Arabian Sea, and only minor presence in the southwestern IO. Timing of presence off Oman suggested that intensive illegal Soviet whaling that took 1294 blue whales in the 1960s likely targeted this population, as opposed to the more widely distributed ‘Sri Lanka’ acoustic population as previously assumed. Based upon geographic distribution and potential aseasonal reproduction found in the Soviet catch data, we suggest that if there is a northern IO subspecies (B. m. indica), it is likely this population. Moreover, the potentially restricted range, intensive historic whaling, and the fact that the song-type has been previously undetected, suggests a small population that is in critical need of status assessment and conservation action.

Prolonging the survival of peripheral infusion sites in neonates with low dose heparin

The effect was studied of adding heparin to 10 per cent dextrose and to total parenteral nutrition (TPN) solutions infused into peripheral veins of premature babies. The median survival times of sites receiving 10 per cent dextrose and TPN solutions without heparin were 37 and 22 hours, respectively. Addition of 0. liu/ml heparin had little effect whereas adding 0.25iu/ml increased survival times to 48 and 32 hours, respectively. Adding 0.5iu/ml heparin increased survival times to 67 and 68 hours, and with liu/ml they rose further still, to 69 and 83 hours, respectively. These data suggest that 0.5iu/ml may be sufficient to prolong the survival of peripheral intravenous sites in premature babies.

Direct activation of porcine endothelial cells by human natural killer cells

Endothelial cell (EC) activation is a consistent feature of discordant xenograft rejection. Treatment of xenograft recipients with complement inhibitors and xenoreactive natural antibody depletion leads to delayed xenograft rejection associated with a cellular infiltrate comprising up to 20% natural killer (NK) cells. To determine the importance of NK cells in xenograft rejection, we studied EC activation and cytotoxicity in co-cultures containing human NK cells and porcine EC. The addition of freshly isolated NK cells to porcine EC resulted in EC cell activation, characterized by the induction of mRNA and protein for the adhesion molecule E-selectin and the chemotactic cytokine interleukin (IL)-8. The induction of E-selectin and IL-8 occurred with three separate sources of NK cells: purified CD56+ve cells, the NK cell clone B22, and the Fc receptor-deficient NK cell line NK92. Transwell cultures demonstrated that direct NK-EC contact was required for the EC induction of E-selectin and IL-8. These effects could not be inhibited with human recombinant tumor necrosis factor-alpha receptor, and the transfer of supernatants or cell lysates from activated EC to secondary cultures did not result in EC activation. The addition of human IgG enhanced the level of E-selectin expression and cellular cytotoxicity, and resulted in tumor necrosis factor-alpha and interferon-gamma secretion. Thus, human NK cells can lyse or activate EC by direct cell contact and the addition of IgG enhances EC activation and NK cell cytokine secretion. These findings implicate NK cells in EC activation and cell-mediated xenograft rejection.

Prescription for a system

Health authorities' drug budgets are large and difficult to control. Alan Willson and colleagues outline the system requirements for audit, resource management and costing reports.