Kerry P. Mychaliska

Leadership at the front line: a clinical partnership model on general care inpatient units.

Hospitals strive to provide all their patients with quality care that is safe, timely, efficient, equitable, effective, and patient centered. Although hospitals have developed technology- and industry-based quality improvement models, there remains a need to better engage the frontline health care workers at the site of care to enhance communication and coordination of care. To foster the work environment and relationships in the general acute care units, the authors describe a leadership model that partners a nurse manager with a physician director to build a local clinical care environment that seeks to enhance the whole patient care experience.

Neonatal Circumcision: Is Feeding Behavior Altered?

BACKGROUND The effect of circumcision on feeding behavior in the newborn period is unknown. We hypothesized that circumcision would not have a significant effect on newborn feeding. METHODS This prospective study analyzed the effect of circumcision on neonatal feeding behavior. Inclusion criteria were healthy male infants WHO were exclusively bottle-fed and underwent a circumcision before discharge from the newborn nursery. We collected data (N = 42) on gestational age, birth weight, Apgar scores, maternal age, gravid status, anesthesia used during delivery, analgesia used after circumcision, time of circumcision, and volume and frequency of feeding before and after circumcision. Data were analyzed by using paired t tests, multivariable regression analysis, and analysis of variance (with SPSS version 18). Significance was P < .05 (2-tailed α). RESULTS Descriptive statistics for the entire group (N = 42) are as follows: mean ± SD gestational age: 38.7 ± 1.2 weeks; mean birth weight: 3.3 ± 0.4 kg; maternal age: 26.7 ± 6.3 years; baseline feeding (mean of first 2 feedings before circumcision): 24.5 ± 9.9 mL; mean first feeding after circumcision: 21.7 ± 11.9 mL; and mean second feeding: 26.7 ± 13.5 mL. Forty-eight percent of patients increased their feeding volume after circumcision compared with baseline, and 52% of patients decreased their feeding volume, which persisted with the second feeding. There was no statistical difference between the baseline and first feeding (P = .11) or second feeding (P = .22). CONCLUSIONS Our data suggest that circumcision does not alter feeding after circumcision. This information will be useful in counseling families regarding circumcision in the newborn period.

On Target: A Case of Acute Hemorrhagic Edema of Infancy

Case: A 16-month-old female presented to a referring emergency department with a 2-day history of a progressive rash and swelling that started on her right lower extremity and spread to her upper extremities, trunk, and face (Fig 1). The patient had recently been hospitalized at the referring hospital for bronchiolitis caused by respiratory syncytial virus and was being treated with amoxicillin for otitis media. Her mother had stopped the antibiotic 1 day before presentation after development of a rash and had given the patient diphenhydramine, with no improvement. The patient had a fever with the preceding illness but on admission to the emergency department was afebrile. She had received hepatitis B and diphtheria-tetanus-acellular pertussis vaccines at her 15-month well-child examination 3 weeks before the onset of the rash. The patient had 1 day of decreased oral intake and decreased urine output and a 2-day history of loose stools. Family history is significant for multiple maternal family members with reaction to penicillin causing hives and edema. At the referring hospital, intraosseous (IO) access was obtained after multiple attempts to place intravascular access were unsuccessful, secondary to diffuse body edema. In our emergency department, the medical team attempted to obtain intravascular access with ultrasound guidance; however, they were also unsuccessful because of the patient’s persistent edema. The patient received normal saline via the IO line in addition to oral acetaminophen and diphenhydramine. FIGURE 1 A 16-month-old female with rash and swelling. Physical examination revealed a fussy but consolable, well-nourished toddler with diffuse body edema, scratching at her arms and thighs. She was afebrile, tachycardic to 134 beats per minute, and hypertensive to 126/97 mm Hg. Erythematous annular lesions surrounded the patients …

Haemophilus influenzae Serotype f Epiglottitis: A Case Report and Review

An otherwise healthy, full-term, fully immunized 5-year-old boy presented to the emergency department after he developed decreased energy, decreased appetite, sore throat, drooling, refusal to speak, and a fever to 102°F over a period of 6 hours in the setting of 5 days of rhinorrhea and a “croupy” cough. On presentation, his weight was 22 kg and blood pressure was 102/56 mm Hg, with a respiratory rate of 32 breaths per minute, a heart rate of 132 beats per minute, a pulse oxygen saturation (Spo2) of 99% in ambient air, and a temperature of 38°C (100.4°F). He was ill-appearing and was noted to be in moderate respiratory distress, with refusal to speak and sitting with his neck extended in his mother’s lap. Physical examination revealed an erythematous posterior oropharynx with diffuse anterior and posterior cervical lymphadenopathy. His lungs were clear to auscultation bilaterally, without stridor or sterter. The rest of the physical examination was unremarkable. Laboratory analysis including a complete blood count was notable for a white blood cell count of 27.2 with 83.8% neutrophils. A rapid mononucleosis test was negative, and blood cultures were drawn. Radiographs of his neck were obtained, which revealed inflammation of the supraglottic area, epiglottis, and subglottic areas (Fig 1). A dose of nebulized racemic epinephrine was given without clinical improvement. A pediatric otolaryngologist was consulted, who performed a bedside flexible laryngoscopy, which revealed significant edema and erythema of the epiglottis extending down the bilateral aryepiglottic folds and involving the arytenoid towers. The supraglottis was significantly edematous, and the false vocal cords were edematous and erythematous. Intubation of the patient’s trachea was …