Influenza A-Associated Epiglottitis and Compensatory Pursed Lip Breathing in an Infant.

The last 3 decades have seen a shift in the epidemiology of epiglottitis. Epiglottitis was once most commonly associated with Haemophilus influenzae type B. However, with the implementation of the H. influenzae type B vaccine in 1985, the incidence has drastically declined. There are now new emerging pathogens-bacteria, viruses, and fungi-causing epiglottitis. Here, we report the first case of epiglottitis secondary to influenza A in a former full-term, vaccinated infant who presented with cough, fever, stridor, pursed lip breathing, and progressive respiratory distress and eventual respiratory failure. This case highlights the presentation and clinical course of epiglottitis and describes a rare clinical feature, pursed lip breathing, in an infant.

Continuous Albuterol in Pediatric Acute Care: Study Demonstrates Safety Outside the Intensive Care Unit.

There are little data to support the use of continuous aerosolized albuterol (CAA) in the non-intensive care unit (ICU) or non-emergency department (ED) setting for pediatric asthma patients. A 2014 study demonstrated low rates of adverse outcomes associated with administration of CAA on the acute care unit; however, the authors do not describe additional outcomes. We sought to determine whether administration of CAA within a respiratory cohort on an acute care floor was feasible and safe. METHODS: This quasi-experimental study evaluates data 1 year before and after (2014-2016) the initiation of CAA on the acute care inpatient unit for asthma patients 2-18 years of age. Outcome measures included ED and hospital length of stay (LOS), readmission rate, rapid response team activations, and transfers to ICU. Use of chest x-rays, viral studies, and hospital charges were also studied. RESULTS: Seven hundred thirty-two patients met study criteria. Population demographics and severity of acute presentation were similar pre- and poststudy. ED LOS decreased poststudy, whereas overall hospital LOS was unchanged. Fifteen-day readmission rate decreased in the poststudy group. Only 4 rapid response activations occurred in the poststudy population. The poststudy group utilized fewer chest x-rays and viral studies. There was no change in overall hospital charges. CONCLUSIONS: With appropriate resources and safety processes in place, care of pediatric patients with status asthmaticus receiving CAA on an acute care unit, outside of the ICU, resulted in improved ED LOS with evidence of lower resource utilization and rare adverse outcomes.

Improving student documentation using a feedback tool.

BACKGROUND: Medical students are often given non-standardised midpoint feedback and final evaluation on their history and physical examination documentation, despite this written communication being one of the most important aspects of patient care. This study aims to assess the effect of using a standardised feedback tool on overall student documentation performance. METHODS: A standardised written evaluation form, called the history and physical examination write-up assessment (HAPA) form, was previously developed and published in The Clinical Teacher in 2011. This form evaluates the documentation of student communication, data collection and clinical reasoning, and was used to provide midpoint documentation feedback to one group of medical students, whereas a second group received non-standardised midpoint feedback on documentation. Final written history and physical examination documentation from both groups was then evaluated using the standardised tool to assess the effect of receiving more formalised midpoint documentation feedback using the HAPA form. RESULTS: The group receiving standardised midpoint feedback using the HAPA form performed significantly better on the final evaluations of their documentation, especially when examining communication and data collection documentation. Performance in clinical reasoning documentation did not demonstrate a significant change between the two groups. Medical students are often given non-standardised midpoint feedback and final evaluation CONCLUSIONS: The use of a standardised evaluation tool, such as the HAPA form, may be associated with improved student documentation. This form provides educators with an effective tool to use when providing feedback and final evaluation of medical student documentation.

Engaging Learners Through Modules in Quality Improvement and Patient Safety.

INTRODUCTION: Residents are on the front lines of medical care in academic institutions. Their daily interactions are crucial to the quality of care received by patients in these settings, and thus, knowledge of patient safety and quality improvement is essential. The Accreditation Council for Graduate Medical Education requires all residents to participate in quality improvement and patient safety programs as part of their residency training. To meet this need, we developed a curriculum in patient safety and quality improvement for pediatric residents. METHODS: This curriculum describes four short modules focused on quality improvement, patient safety, evidence-based practice, and other quality improvement-related topics. These modules can be given during one rotation, throughout residency, or partnered with a practical application, such as a project. A 17-question quality improvement and patient safety knowledge test was developed after an extensive literature review to reflect module goals and objectives. A validated, 12-question attitudes survey was administered before and after the modules. RESULTS: Of the 57 eligible residents, 42 completed the knowledge pretest, and 20 completed the posttest. Mean posttest results (M = 91.00 [± 9.12]) were considerably higher than mean pretest scores (M = 75.24 [± 11.74]) when utilizing the independent t test (p < .001). Of the 57 eligible residents, 11 completed the attitude presurvey, and 13 completed the attitude postsurvey. Median responses from the survey mostly fell within the 2-3 range of slightly to moderately comfortable. Significant differences showing improvement between presurvey and postsurvey time frames were found in identifying and comparing best practices (p = .02), using the PDSA model (p = .002), and identifying how data are linked (p = .001). DISCUSSION: Knowledge and perception surveys suggest that resident knowledge and attitudes statistically improved, and faculty and residents participated in even more quality improvement initiatives after completing the curriculum.

Impact of a Longitudinal Quality Improvement and Patient Safety Curriculum on Pediatric Residents.

INTRODUCTION: The effectiveness of longitudinal quality/safety resident curricula is uncertain. We developed and tested our longitudinal quality improvement (QI) and patient safety (PS) curriculum (QIPSC) to improve resident competence in QI/PS knowledge, skills, and attitudes. METHODS: Using core features of adult education theory and QI/PS methodology, we developed QIPSC that includes self-paced online modules, an interactive conference series, and mentored projects. Curriculum evaluation included knowledge and attitude assessments at 3 points in time (pre- and posttest in year 1 and end of curriculum [EOC] survey in year 3 upon completion of all curricular elements) and skill assessment at the EOC. RESULTS: Of 57 eligible residents in cohort 1, variable numbers of residents completed knowledge (n = 42, 20, and 31) and attitude (n = 11, 13, and 37) assessments in 3 points in time; 37 residents completed the EOC skills assessment. For knowledge assessments, there were significant differences between pre- and posttest and pretest and EOC scores, however, not between the posttest and EOC scores. In the EOC self-assessment, residents' attitudes and skills improved for all areas evaluated. Additional outcomes from project work included dissemination of QI projects to hospital-wide quality/safety initiatives and in peer-reviewed national conferences. CONCLUSIONS: Successful implementation of a QIPSC must be responsive to a number of learners, faculties, and institutional needs and integrate adult learning theory and QI/PS methodology. QIPSC is an initial effort to address this need; follow-up results from subsequent learner cohorts will be necessary to measure the true impact of this curriculum: behavior change and practice improvements.

Congenital left paraduodenal hernia causing chronic abdominal pain and abdominal catastrophe.

Paraduodenal hernias are the most common type of congenital internal hernia. Because of its overall rare incidence, this entity is often overlooked during initial assessment of the patient. Lack of specific diagnostic criteria also makes diagnosis exceedingly difficult, and the resulting diagnostic delays can lead to tragic outcomes for patients. Despite these perceived barriers to timely diagnosis, there may be specific radiographic findings that, when combined with the appropriate constellation of clinical symptoms, would aid in diagnosis. This patient first presented at 8 years of age with vague symptoms of postprandial emesis, chronic abdominal pain, nausea, and syncope. Over the span of 6 years he was evaluated 2 to 3 times a year with similar complaints, all of which quickly resolved spontaneously. He underwent multiple laboratory, imaging, and endoscopic studies, which were nondiagnostic. It was not until he developed signs of a high-grade obstruction and extremis that he was found to have a large left paraduodenal hernia that had volvulized around the superior mesenteric axis. This resulted in the loss of the entire superior mesenteric axis distribution of the small and large intestine and necrosis of the duodenum. In cases of chronic intermittent obstruction without clear etiology, careful attention and consideration should be given to the constellation of symptoms, imaging studies, and potential use of diagnostic laparoscopy. Increased vigilance by primary care and consulting physicians is necessary to detect this rare but readily correctable condition.