The American Academy of Pediatrics (AAP) recommends children in foster care (FC) have an initial medical evaluation within 3 days of custody initiation; however, this vulnerable population often ...suffers from disjointed care. Our aim was to improve the mean time to initial foster care evaluation (TIE) from 32 to <7 days within 12 months for children in FC in Durham County, North Carolina.
This study was a time series, quality improvement project used to target interventions within an academic clinic and a community agency. Interventions were tested through multiple plan-do-study-act cycles. Control charts of the primary outcome, the TIE, were constructed. Charts were annotated with the dates of interventions, including workshops, performance feedback, integration of state forms, identification of appointments, development of an urgent appointment pathway, and empowerment of the scheduler.
The mean TIE improved from 32 to 9 days within 12 months. Significant improvement in the following 2 process measures contributed to this: the time from custody initiation to the referral date improved from an average of 10 to 3 days, and the time from referral date to the initial evaluation improved from an average of 22 to 6 days.
Improvement interventions and increased collaboration between medical and child welfare agencies can result in significant improvement of the TIE. However, despite improvement efforts, challenges remain in meeting the AAP 3-day TIE recommendation. We recommend further assessment of the AAP guideline as it relates to implementation feasibility and health outcomes of children in FC.
Coral reef cnidarians often host crustaceans in multi-level symbioses that may cause reef-wide impacts, especially through anemoneshrimp cleaner interactions with fish clients. Despite the ubiquity ...and importance of these interactions, patterns of temporal and spatial variation in crustacean association with sea anemones remain largely unknown.We censused cork screw sea anemones Bartholomea annulata and crustacean associates (5 shrimp and 1 crab species) every 3−6 mo for 2.5 yr at 2 reef sites in St. Thomas, US Virgin Islands. Crustacean abundance per anemone varied with species and census period. Occupancy rates increased with anemone body size, more so offshore where anemones were smaller and less abundant than inshore. Four species of obligate anemoneshrimps partitioned space among 5 microhabitat zones on the host anemone body. Dynamic multi-state models revealed that anemone persistence was enhanced primarily by anemone body size, with variable secondary effects of site and anemoneshrimp species. The presence of the snapping shrimp Alpheus armatus did not enhance the persistence of host anemones. However, the presence of the dedicated cleaner shrimp Ancylomenes pedersoni enhanced the persistence of small host anemones at the inshore site but reduced the persistence of the occasional cleaner shrimp Periclimenes yucatanicus on host anemones, indicating mutualistic and competitive interactions among some partners in this system. Patterns of association among anemones and crusta ceans varied significantly at both temporal (seasonal and annual) and spatial scales (among anemones and reef sites), with implications for the ecology of client fishes that visit these Caribbean anemones to receive cleaning services fromanemoneshrimps.
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