What Really Matters in the Implementation of Evidence-based Practices in Community Mental Health? Insight and Recommendations from Experts, Providers, and Clients.

Perceptions of evidence-based practices (EBPs) and implementation are inherent drivers of implementation outcomes. Most studies on implementation perceptions have focused on direct service providers, but clients and EBP experts may offer additional meaningful information about implementing EBPs in community settings. EBP providers (n = 21), EBP experts (n = 12), and clients who received EBPs (n = 6) participated in focus groups to ascertain their perceptions of and experiences with EBP implementation, as part of a program evaluation. Thematic analysis indicated that provider and expert perceptions of EBP implementation in community settings converged around themes of implementation supports and training and client outcomes, along with several subthemes. Client perceptions centered on themes regarding the importance of their personal experiences, their impressions of EBPs, as well as their recommendation for increasing public awareness and use of EBPs. Findings suggest that the perspectives of EBP providers and experts are closely aligned, focusing on system-level, individual-level, and training issues that impact EBP implementation within a public mental health system. The themes that were important to clients were primarily related to their experiences as recipients of an EBP which produced insightful recommendations for promoting EBPs in the community.

External vs Internal Focus of Attention in Procedural Skills Learning: A Randomized Study.

PURPOSE: The Optimizing Performance Through Intrinsic Motivation and Attention for Learning theory postulates that directing attention to the intended movement effect or outcome (external focus) is more effective than directing attention to the internal body motion or body part (internal focus). This study compared external vs internal focus of attention as novice students learned ultrasound-guided peripheral cannulation. The authors hypothesized that conditions promoting an external (vs internal) focus of attention would result in better performance on immediate and delayed (retention) testing. METHOD: The authors conducted a randomized, experimental study from October 2022 to February 2023 comparing external and internal focus using ultrasound-guided peripheral venous cannulation followed by practice using an ultrasound training block. Undergraduate health science students performed 4 practice trials with instructions to focus on the needle tip (external focus) or their hands (internal focus), followed by an immediate assessment and a retention assessment 2 weeks later. The primary outcome was time to successful cannulation. Results were compared using Kaplan-Meier curves and parametric survival analysis regression (accelerated failure time) models. RESULTS: Seventy participants completed the immediate assessment. The external focus group completed successful cannulation a mean of 2.33 times faster (95% CI = 1.47, 3.67; P < .001) than those in the internal focus group (median time, 12.0 vs 29.5 seconds). Results also favored the external focus group during practice, with the external focus group successfully completing the task a mean of 1.83 times faster (95% CI = 1.04, 3.21; P = .04) than the internal focus group. In the retention assessment, the external focus group successfully completed the task a mean of 2.37 times faster (95% CI = 1.19, 4.74; P = .02) than the internal focus group. CONCLUSIONS: External focus of attention compared with internal focus of attention improves medical motor skill learning in novice learners.

Mental Health Counseling From Conversational Content With Transformer-Based Machine Learning.

Importance: Use of asynchronous text-based counseling is rapidly growing as an easy-to-access approach to behavioral health care. Similar to in-person treatment, it is challenging to reliably assess as measures of process and content do not scale. Objective: To use machine learning to evaluate clinical content and client-reported outcomes in a large sample of text-based counseling episodes of care. Design, Setting, and Participants: In this quality improvement study, participants received text-based counseling between 2014 and 2019; data analysis was conducted from September 22, 2022, to November 28, 2023. The deidentified content of messages was retained as a part of ongoing quality assurance. Treatment was asynchronous text-based counseling via an online and mobile therapy app (Talkspace). Therapists were licensed to provide mental health treatment and were either independent contractors or employees of the product company. Participants were self-referred via online sign-up and received services via their insurance or self-pay and were assigned a diagnosis from their health care professional. Exposure: All clients received counseling services from a licensed mental health clinician. Main Outcomes and Measures: The primary outcomes were client engagement in counseling (number of weeks), treatment satisfaction, and changes in client symptoms, measured via the 8-item version of Patient Health Questionnaire (PHQ-8). A previously trained, transformer-based, deep learning model automatically categorized messages into types of therapist interventions and summaries of clinical content. Results: The total sample included 166 644 clients treated by 4973 therapists (20 600 274 messages). Participating clients were predominantly female (75.23%), aged 26 to 35 years (55.4%), single (37.88%), earned a bachelor's degree (59.13%), and were White (61.8%). There was substantial variability in intervention use and treatment content across therapists. A series of mixed-effects regressions indicated that collectively, interventions and clinical content were associated with key outcomes: engagement (multiple R = 0.43), satisfaction (multiple R = 0.46), and change in PHQ-8 score (multiple R = 0.13). Conclusions and Relevance: This quality improvement study found associations between therapist interventions, clinical content, and client-reported outcomes. Consistent with traditional forms of counseling, higher amounts of supportive counseling were associated with improved outcomes. These findings suggest that machine learning-based evaluations of content may increase the scale and specificity of psychotherapy research.

Implementation Science and Practice-Oriented Research: Convergence and Complementarity.

Implementation science is the scientific study of methods to promote the uptake of research findings and other evidence-based practices in routine care, with the goal of improving the quality and effectiveness of health services (Bauer et al., 2015). In addition to this common goal, practice-oriented psychotherapy research (and researchers) and implementation science (and scientists) share a common focus on the people and the places where treatment happens. Thus, there exists strong potential for combining these two approaches. In this article, we provide a primer on implementation science for psychotherapy researchers and highlight important areas and examples of convergence and complementarity between implementation science and practice-oriented psychotherapy research. Specifically, we (a) define and describe the core features of implementation science; (b) discuss similarities and areas of complementarity between implementation science and practice-oriented psychotherapy research; (c) discuss a case example that exemplifies the integration of implementation science and practice-oriented research; and (d) propose directions for future research and collaborations that leverage both implementation science and practice-oriented research.

Does needle positioning with magnetic field induction improve central venous catheterization performance by novice learners?

OBJECTIVE: The novel ultrasound magnetic needle navigation technique can visualize the entire needle and identify its projected trajectory. We hypothesized that this technique increases the first-attempt success rate of central venous puncture by novice learners compared with the conventional needle navigation technique. METHODS: This prospective, randomized, controlled trial with a crossover design included 50 participants with limited prior experience in US-guided procedures. Participants were randomly assigned to novel or conventional technique groups and asked to perform central venous cannulation in a phantom task trainer. After the first successful attempt, participants were allocated to the other technique group. RESULTS: Although participants in the novel technique group had a higher first-attempt success rate than did those in the conventional technique group, this difference was not statistically significant (p = 0.17). The total number of attempts also did not significantly differ (p = 0.16). The conventional technique group had more needle redirections (p = 0.01) and a longer time to successful cannulation (p = 0.01). The number of adverse effects (p = 0.32) did not differ between groups. Participant confidence levels were higher in the novel technique group (p < 0.001). CONCLUSIONS: Magnetic needle navigation can reduce the number of needle redirections, shorten the time to successful cannulation, and increase confidence levels by novice learners for successful US-guided central venous access.

Systematic Review of Procedural Skill Simulation in Health Care in Low- and Middle-Income Countries.

ABSTRACT: Low- and middle-income countries (LMICs) have adopted procedural skill simulation, with researchers increasingly investigating simulation efforts in resource-strained settings. We aim to summarize the current state of procedural skill simulation research in LMICs focusing on methodology, clinical area, types of outcomes and cost, cost-effectiveness, and overall sustainability. We performed a comprehensive literature review of original articles that assessed procedural skill simulation from database inception until April 2022.From 5371 screened articles, 262 were included in this review. All included studies were in English. Most studies were observational cohort studies (72.9%) and focused on obstetrics and neonatal medicine (32.4%). Most measured outcome was the process of task performance (56.5%). Several studies mentioned cost (38.9%) or sustainability (29.8%). However, few articles included actual monetary cost information (11.1%); only 1 article assessed cost-effectiveness. Based on our review, future research of procedural skill simulation in LMICS should focus on more rigorous research, cost assessments, and on less studied areas.

Combining attachment-based family therapy and cognitive behavioral therapy to improve outcomes for adolescents with anxiety.

Increases in adolescent anxiety over the past several years suggest a need for trauma-informed, culturally responsive interventions that help teens cope with environmental stressors like those associated with the COVID-19 pandemic. Although abundant evidence supports the efficacy of cognitive behavioral therapy (CBT) in treating adolescent anxiety, not all teens respond positively to CBT. CBT does not typically include strategies that address important family factors that may be impacting the teen's functioning, such as the attachment relationship. Attachment-based family therapy (ABFT) addresses the attachment relationship and other factors that contribute to the adolescent's anxiety and related distress. By enhancing positive parenting behaviors, such as acceptance and validation of the adolescent's distress and promotion of their autonomy, ABFT sessions may repair the attachment relationship and increase the family's ability and willingness to engage in CBT tasks aimed at reducing anxiety. This theoretical paper describes the ABFT model and proposes that implementing ABFT sessions prior to CBT could result in better clinical outcomes for adolescents with anxiety disorders by improving the context within which the anxiety symptoms and treatment are experienced. Given that ABFT is sensitive and responsive to family and other contextual factors, adolescents from marginalized communities and those from less individualistic cultures may find the model to be more acceptable and appropriate for addressing factors related to their anxiety. Thus, a combined ABFT+CBT model might result in better outcomes for adolescents who have not historically responded well to CBT alone.

Enhancing the quality of cognitive behavioral therapy in community mental health through artificial intelligence generated fidelity feedback (Project AFFECT): a study protocol.

BACKGROUND: Each year, millions of Americans receive evidence-based psychotherapies (EBPs) like cognitive behavioral therapy (CBT) for the treatment of mental and behavioral health problems. Yet, at present, there is no scalable method for evaluating the quality of psychotherapy services, leaving EBP quality and effectiveness largely unmeasured and unknown. Project AFFECT will develop and evaluate an AI-based software system to automatically estimate CBT fidelity from a recording of a CBT session. Project AFFECT is an NIMH-funded research partnership between the Penn Collaborative for CBT and Implementation Science and Lyssn.io, Inc. ("Lyssn") a start-up developing AI-based technologies that are objective, scalable, and cost efficient, to support training, supervision, and quality assurance of EBPs. Lyssn provides HIPAA-compliant, cloud-based software for secure recording, sharing, and reviewing of therapy sessions, which includes AI-generated metrics for CBT. The proposed tool will build from and be integrated into this core platform. METHODS: Phase I will work from an existing software prototype to develop a LyssnCBT user interface geared to the needs of community mental health (CMH) agencies. Core activities include a user-centered design focus group and interviews with community mental health therapists, supervisors, and administrators to inform the design and development of LyssnCBT. LyssnCBT will be evaluated for usability and implementation readiness in a final stage of Phase I. Phase II will conduct a stepped-wedge, hybrid implementation-effectiveness randomized trial (N = 1,875 clients) to evaluate the effectiveness of LyssnCBT to improve therapist CBT skills and client outcomes and reduce client drop-out. Analyses will also examine the hypothesized mechanism of action underlying LyssnCBT. DISCUSSION: Successful execution will provide automated, scalable CBT fidelity feedback for the first time ever, supporting high-quality training, supervision, and quality assurance, and providing a core technology foundation that could support the quality delivery of a range of EBPs in the future. TRIAL REGISTRATION: ClinicalTrials.gov; NCT05340738 ; approved 4/21/2022.

An Automated Quality Evaluation Framework of Psychotherapy Conversations with Local Quality Estimates.

Text-based computational approaches for assessing the quality of psychotherapy are being developed to support quality assurance and clinical training. However, due to the long durations of typical conversation based therapy sessions, and due to limited annotated modeling resources, computational methods largely rely on frequency-based lexical features or dialogue acts to assess the overall session level characteristics. In this work, we propose a hierarchical framework to automatically evaluate the quality of transcribed Cognitive Behavioral Therapy (CBT) interactions. Given the richly dynamic nature of the spoken dialog within a talk therapy session, to evaluate the overall session level quality, we propose to consider modeling it as a function of local variations across the interaction. To implement that empirically, we divide each psychotherapy session into conversation segments and initialize the segment-level qualities with the session-level scores. First, we produce segment embeddings by fine-tuning a BERT-based model, and predict segment-level (local) quality scores. These embeddings are used as the lower-level input to a Bidirectional LSTM-based neural network to predict the session-level (global) quality estimates. In particular, we model the global quality as a linear function of the local quality scores, which allows us to update the segment-level quality estimates based on the session-level quality prediction. These newly estimated segment-level scores benefit the BERT fine-tuning process, which in turn results in better segment embeddings. We evaluate the proposed framework on automatically derived transcriptions from real-world CBT clinical recordings to predict session-level behavior codes. The results indicate that our approach leads to improved evaluation accuracy for most codes when used for both regression and classification tasks.

Autonomy and focus of attention in medical motor skills learning: a randomized experiment.

BACKGROUND: The 'OPTIMAL' (Optimizing Performance Through Intrinsic Motivation and Attention for Learning) theory of motor learning suggests that autonomy, external focus of attention, and perceived competence can improve learning of simple motor tasks. The authors hypothesized that enhanced (vs. routine) autonomy and external (vs. internal) focus of attention would improve first-try performance of two medical motor tasks. METHODS: The authors conducted a randomized two-by-two factorial design study with high school students as participants. Task instructions promoted either enhanced or routine autonomy, and either external or internal focus of attention. These conditions were replicated in a crossover design for two common medical tasks (chest compressions on a manikin and a Fundamentals of Laparoscopic Surgery peg transfer task). Primary outcomes were objective measures of task performance (chest compression deviation from target depth; peg transfer time with penalties for errors). Secondary outcomes included subjective perceptions of confidence, autonomy, and workload. RESULTS: One hundred thirty-three high school students participated in this study. The primary outcomes concerning enhanced vs. routine autonomy demonstrated no statistically significant difference in either task (chest compression depth deviation: difference -0.7 mm [score range 0 to 37.5 mm]; 95% confidence interval (CI95) -3.85, 2.41; p = .65; peg transfer penalized time: rate ratio 1.03; CI95 0.91, 1.31; p = .79). The authors likewise found no statistically significant difference for external vs. internal focus of attention (depth deviation: difference 1.1 mm; CI95 -2.04, 4.17; p = .50; penalized time: rate ratio 0.89; CI95 0.75, 1.13; p = .33). The authors found no statistically significant differences for either comparison in confidence, autonomy and workload (p > .09; differences ranged from -0.83 to 0.79 [scale range 0 to 10]). CONCLUSIONS: First-try performance of chest compressions and peg transfer by novice learners is not significantly affected by enhanced (vs. routine) autonomy or external (vs. internal) focus of attention.

Addressing Barriers to Telemedicine Use in Rural Emergency Medicine: Leveraging In Situ Simulation.

Introduction: Acute care telemedicine is a critical resource for rural and community Emergency Medicine (EM) providers. To address potential barriers and promote use of these services throughout our health system Emergency Departments (EDs), we embed telemedicine consultations within in situ simulations. Materials and Methods: Care teams in health system EDs participated in multidisciplinary in situ simulations that focused on Difficult Airway management or Obstetric Emergencies. Physicians in EM and Neonatology at the referral center were available for assistance via telemedicine consultation. Participants were then surveyed regarding their experience with the telemedicine consultation during the simulations. Results: Participants reported increased likelihood to use telemedicine as well as increased understanding of the technology, awareness of available consultation services, and comfort interacting with the consultant. Conclusions: Embedding telemedicine consultations into in situ EM simulations is an effective approach to address implementation barriers and may promote increased use of telemedicine services among rural and community EM providers.

Knowledge and Attitudes Toward an Artificial Intelligence-Based Fidelity Measurement in Community Cognitive Behavioral Therapy Supervision.

To capitalize on investments in evidence-based practices, technology is needed to scale up fidelity assessment and supervision. Stakeholder feedback may facilitate adoption of such tools. This evaluation gathered stakeholder feedback and preferences to explore whether it would be fundamentally feasible or possible to implement an automated fidelity-scoring supervision tool in community mental health settings. A partially mixed, sequential research method design was used including focus group discussions with community mental health therapists (n = 18) and clinical leadership (n = 12) to explore typical supervision practices, followed by discussion of an automated fidelity feedback tool embedded in a cloud-based supervision platform. Interpretation of qualitative findings was enhanced through quantitative measures of participants' use of technology and perceptions of acceptability, appropriateness, and feasibility of the tool. Initial perceptions of acceptability, appropriateness, and feasibility of automated fidelity tools were positive and increased after introduction of an automated tool. Standard supervision was described as collaboratively guided and focused on clinical content, self-care, and documentation. Participants highlighted the tool's utility for supervision, training, and professional growth, but questioned its ability to evaluate rapport, cultural responsiveness, and non-verbal communication. Concerns were raised about privacy and the impact of low scores on therapist confidence. Desired features included intervention labeling and transparency about how scores related to session content. Opportunities for asynchronous, remote, and targeted supervision were particularly valued. Stakeholder feedback suggests that automated fidelity measurement could augment supervision practices. Future research should examine the relations among use of such supervision tools, clinician skill, and client outcomes.

Assessing Causal Pathways and Targets of Implementation Variability for EBP use (Project ACTIVE): a study protocol.

BACKGROUND: Advancing causal implementation theory is critical for designing tailored implementation strategies that target specific mechanisms associated with evidence-based practice (EBP) use. This study will test the generalizability of a conceptual model that integrates organizational constructs and behavioral theory to predict clinician use of cognitive-behavioral therapy (CBT) techniques in community mental health centers. CBT is a leading psychosocial EBP for psychiatric disorders that remains underused despite substantial efforts to increase its implementation. METHODS: We will leverage ongoing CBT implementation efforts in two large public health systems (Philadelphia and Texas) to recruit 300 mental health clinicians and 600 of their clients across 40 organizations. Our primary implementation outcomes of interest are clinician intentions to use CBT and direct observation of clinician use of CBT. As CBT comprises discrete components that vary in complexity and acceptability, we will measure clinician use of six discrete components of CBT. After finishing their CBT training, participating clinicians will complete measures of organizational and behavior change constructs delineated in the model. Clinicians also will be observed twice via audio recording delivering CBT with a client. Within 48 h of each observation, theorized moderators of the intention-behavior gap will be collected via survey. A subset of clinicians who report high intentions to use CBT but demonstrate low use will be purposively recruited to complete semi-structured interviews assessing reasons for the intention-behavior gap. Multilevel path analysis will test the extent to which intentions and determinants of intention predict the use of each discrete CBT component. We also will test the extent to which theorized determinants of intention that include psychological, organizational, and contextual factors explain variation in intention and moderate the association between intentions and CBT use. DISCUSSION: Project ACTIVE will advance implementation theory, currently in its infancy, by testing the generalizability of a promising causal model of implementation. These results will inform the development of implementation strategies targeting modifiable factors that explain substantial variance in intention and implementation that can be applied broadly across EBPs.

Feature Fusion Strategies for End-to-End Evaluation of Cognitive Behavior Therapy Sessions.

Cognitive Behavioral Therapy (CBT) is a goal-oriented psychotherapy for mental health concerns implemented in a conversational setting. The quality of a CBT session is typically assessed by trained human raters who manually assign pre-defined session-level behavioral codes. In this paper, we develop an end-to-end pipeline that converts speech audio to diarized and transcribed text and extracts linguistic features to code the CBT sessions automatically. We investigate both word-level and utterance-level features and propose feature fusion strategies to combine them. The utterance level features include dialog act tags as well as behavioral codes drawn from another well-known talk psychotherapy called Motivational Interviewing (MI). We propose a novel method to augment the word-based features with the utterance level tags for subsequent CBT code estimation. Experiments show that our new fusion strategy outperforms all the studied features, both when used individually and when fused by direct concatenation. We also find that incorporating a sentence segmentation module can further improve the overall system given the preponderance of multi-utterance conversational turns in CBT sessions.

Automated quality assessment of cognitive behavioral therapy sessions through highly contextualized language representations.

During a psychotherapy session, the counselor typically adopts techniques which are codified along specific dimensions (e.g., 'displays warmth and confidence', or 'attempts to set up collaboration') to facilitate the evaluation of the session. Those constructs, traditionally scored by trained human raters, reflect the complex nature of psychotherapy and highly depend on the context of the interaction. Recent advances in deep contextualized language models offer an avenue for accurate in-domain linguistic representations which can lead to robust recognition and scoring of such psychotherapy-relevant behavioral constructs, and support quality assurance and supervision. In this work, we propose a BERT-based model for automatic behavioral scoring of a specific type of psychotherapy, called Cognitive Behavioral Therapy (CBT), where prior work is limited to frequency-based language features and/or short text excerpts which do not capture the unique elements involved in a spontaneous long conversational interaction. The model focuses on the classification of therapy sessions with respect to the overall score achieved on the widely-used Cognitive Therapy Rating Scale (CTRS), but is trained in a multi-task manner in order to achieve higher interpretability. BERT-based representations are further augmented with available therapy metadata, providing relevant non-linguistic context and leading to consistent performance improvements. We train and evaluate our models on a set of 1,118 real-world therapy sessions, recorded and automatically transcribed. Our best model achieves an F1 score equal to 72.61% on the binary classification task of low vs. high total CTRS.

Changes in Community Clinicians' Attitudes and Competence following a Transdiagnostic Cognitive Behavioral Therapy Training.

BACKGROUND: Although the literature suggest that attitudes toward evidence-based practices (EBPs) are associated with provider use of EBPs, less is known about the association between attitudes and how competently EBPs are delivered. This study examined how initial attitudes and competence relate to improvements in attitudes and competence following EBP training. METHODS: Program evaluation data was collected during implementation of an EBP in a large community mental health network. Clinicians (N=891) received intensive training in cognitive behavioral therapy followed by six months of consultation. Attitudes were assessed using the Evidence-Based Practice Attitude Scale, and competence was assessed using the Cognitive Therapy Rating Scale. Data were analyzed by fitting three latent change score models to examine the relationship between changes in attitudes and competence across the training and within its two phases (workshop phase, consultation phase). RESULTS: Latent change models identified significant improvement in attitudes (Ms latent change≥1.03, SEs≤ 0.18, zs≥6.55, ps< .001) and competence (Ms latent change ≥14.16, SEs≤3.10, zs≥2.82, ps<.001) across the full training and in each phase. Higher pre-workshop attitudes predicted significantly greater change in competence in the workshop and across training (bs≥1.62, SEs≤0.90, z≥1.09, p<.04, ß≥0.10); however, contrary to our hypothesis, post-workshop attitudes did not significantly predict change in competence in consultation (b=1.62, SE=0.86, z=1.87, p=.06, ß=0.09). Change in attitudes and change in competence in the training period and within the two phases were not significantly correlated. CONCLUSIONS: Results indicate that pre-training attitudes about EBPs present a target for implementation interventions, given their relation to changes in both attitudes and competence throughout training. Following participation in in itial training workshops, other factors such as subjective norms, implementation culture, or system-level policy shifts may be more predictive of change in competence through consultation.

Comparison of dyad versus individual simulation-based training on stress, anxiety, cognitive load, and performance: a randomized controlled trial.

BACKGROUND: Dyad learning has been shown to be an effective tool for teaching procedural skills, but little is known about how dyad learning may impact the stress, anxiety, and cognitive load that a student experiences when learning in this manner. In this pilot study, we investigate the relationship between dyad training on stress, anxiety, cognitive load, and performance in a simulated bradycardia scenario. METHODS: Forty-one fourth-year medical school trainees were randomized as dyads (n = 24) or individuals (n = 17) for an education session on day 1. Reassessment occurred on day 4 and was completed as individuals for all trainees. Primary outcomes were cognitive load (Paas scale), stress (Cognitive Appraisal Ratio), and anxiety levels (abbreviated State-Trait Anxiety Inventory). Secondary outcomes were time-based performance metrics. RESULTS: On day 1 we observed significant differences for change in anxiety and stress measured before and after the training scenario between groups. Individuals compared to dyads had larger mean increases in anxiety, (19.6 versus 7.6 on 80-point scale, p = 0.02) and stress ratio (1.8 versus 0.9, p = 0.045). On the day 4 post-intervention assessment, no significant differences were observed between groups. Secondary outcomes were significant for shorter time to diagnosis of bradycardia (p = 0.01) and time to initiation of pacing (p = 0.04) in the dyad group on day 1. On day 4, only time to recognizing the indication for pacing was significantly shorter for individual training (hazard ratio [HR] = 2.26, p = 0.02). CONCLUSIONS: Dyad training results in lower stress and anxiety levels with similar performance compared to individual training.

A Comprehensive Departmental Care Review Model: Requirements, Structure, and Flow.

BACKGROUND: The Institute of Medicine, the National Patient Safety Foundation, and The Joint Commission have advocated for increased systematic care review to inform future quality improvement. Developing a system to efficiently gather meaningful feedback, review care, and identify areas for improvement can take years to construct. Yet, these systems are vital to reducing future medical error. CONTEXT, HISTORY, AND DEVELOPMENT: In this article, the authors present a refined intradepartmental system of retrospective care review. The team created and iteratively improved this model for more than 10 years. Herein, key aspects and benefits of the system are described. CARE REVIEW SYSTEM: A successful care review system should include a broad catchment for cases to review, direct input from multidisciplinary staff involved in each case, a standardized evaluation and feedback process, a system to translate identified gaps into practice improvement, and development of a psychologically safe space for discussions to occur. Resources required to build this system include a quality specialist, a panel of physician and nurse reviewers, and administrative assistance. Blinding cases and electronic blinded polling technology can enhance participation and reduce bias in case assessment. CONCLUSION: The authors believe that this process for care review can help hospital systems of varying resource levels produce high-quality case review and thereby activate practice improvement to prevent downstream medical errors.

Barrier Enclosure for Endotracheal Intubation in a Simulated COVID-19 Scenario: A Crossover Study.

INTRODUCTION: Barrier enclosures have been developed to reduce the risk of COVID-19 transmission to healthcare providers during intubation, but little is known about their impact on procedure performance. We sought to determine whether a barrier enclosure delays time to successful intubation by experienced airway operators. METHODS: We conducted a crossover simulation study at a tertiary academic hospital. Participants watched a four-minute video, practiced one simulated intubation with a barrier enclosure, and then completed one intubation with and one without the barrier enclosure (randomized to determine order). The primary outcome measure was time from placement of the video laryngoscope at the lips to first delivered ventilation. Secondary outcomes were periprocedural complications and participant responses to a post-study survey. RESULTS: Proceduralists (n = 50) from emergency medicine and anesthesiology had median intubation times of 23.6 seconds with practice barrier enclosure, 20.5 seconds with barrier enclosure, and 16.7 seconds with no barrier. Intubation with barrier enclosure averaged 4.5 seconds longer (95% confidence interval, 2.7-6.4, p < .001) than without, but was less than the predetermined clinical significance threshold of 10 seconds. Three complications occurred, all during the practice intubation. Barrier enclosure made intubation more challenging according to 48%, but 90% indicated they would consider using it in clinical practice. CONCLUSION: Experienced airway operators performed intubation using a barrier enclosure with minimal increased time to procedure completion in this uncomplicated airway model. Given potential to reduce droplet spread, use of a barrier enclosure may be an acceptable adjunct to endotracheal intubation for those familiar with its use.

Variability in clinician intentions to implement specific cognitive-behavioral therapy components.

BACKGROUND: CBT comprises many discrete components that vary in complexity, but implementation and training efforts often approach CBT as a single entity. We examined variability in clinician intentions to use different structural and interventional components of CBT for three different clinical groups: clients receiving CBT, clients with depression, and clients with anxiety. METHODS: Clinicians (n = 107) trained in CBT completed a one-time electronic survey. Clinicians' intentions were measured using established item stems from social psychology adapted to examine intentions to use six specific CBT components: exposure therapy, cognitive restructuring, behavioral activation, planning homework, reviewing homework, and agenda-setting. RESULTS: Intentions were weakest, on average, for exposure. They were strongest, on average, for reviewing homework. A series of ANOVAs with Tukey's post-hoc tests revealed that participants intended to use exposure with clients receiving CBT (p = .015) and clients with anxiety (p < .001) significantly more than for clients with depression. Participants intended to use behavioral activation with clients with depression (p = .01) significantly more than for clients with anxiety. No other intentions to use CBT components differed among these three clinical populations. CONCLUSIONS: When studying determinants of CBT use and designing interventions to increase use, implementers should consider that different CBT components may require different implementation strategies. TRIAL REGISTRATION: Not applicable.