Diagnosing, assessing and managing cellulitis.

Cellulitis is an acute bacterial infection that affects the deep dermis and surrounding subcutaneous tissue. Although it is a common condition, it is often misdiagnosed because it can mimic a range of conditions that also cause inflamed, red, irritated and painful skin. Such misdiagnoses may lead to unnecessary hospital admissions and antibiotic overuse, with most alternative diagnoses being non-infectious. Undertaking a holistic patient assessment, skin assessment and thorough clinical history is important in the diagnosis of cellulitis, and it is vital to use a collaborative multidisciplinary approach in its acute management and to prevent recurrence. This article defines the term cellulitis and explores its presenting features. The author also discusses the associated risk factors, clinical assessment techniques and effective management strategies, as well as outlining the actions that nurses can take to prevent recurrence.

Physician Burnout Through the Female Lens: A Silent Crisis.

Physician burnout, the emotional exhaustion and depersonalization that arises from job fatigue and dissatisfaction, is a rapidly growing problem. Although burnout has been a recognized problem for decades, our healthcare system has yet to devise a sustainable solution. Additionally, burnout does not affect all physicians in the same way- women physicians have disproportionately higher rates of burnout than male physicians. Burnout poses a tremendous risk to our public's health with its severe and debilitating effects on both physician and patient health alike. We must intervene as early as medical school and residency at both the systemic and individual levels to combat burnout. Clinical leadership training might be one sustainable approach to begin addressing burnout in female physicians.

Implementation of a Clinical Leadership Curriculum for Pediatric Residents.

Introduction: Clinical leadership is an essential skill for physicians, empowering them to lead and coordinate teams, communicate clearly under various conditions, model positive behaviors, display emotional intelligence, and ultimately improve patient care outcomes. However, there are currently no standardized residency curricula or competency-based assessments for clinical leadership, as residents often assimilate leadership skills through trial-and-error or observation of their clinical faculty. By utilizing a comprehensive needs assessment and synthesizing evidence-based practices, we developed and implemented a longitudinal and skills-based clinical leadership curriculum for pediatric residents. Methods: We modeled our clinical leadership curriculum after Kern's 6-step approach to curricular development and the Accreditation Council for Graduate Medical Education competency requirements for professionalism. We identified topics based on a resident needs assessment and synthesized evidence from published practices. The curriculum was implemented through both monthly facilitated group sessions and independent learning modules. Results: 44 postgraduate year-2 (PGY-2) and PGY-3 pediatric residents participated in at least one monthly session of the clinical leadership curriculum. 27 (61%) completed the survey to evaluate the efficacy of the curriculum. Of the respondents, 23 (85%) residents found the leadership sessions useful, 4 (15%) were neutral, and none (0%) rated the sessions as not useful. 26 (96%) residents reported that the sessions should be continued. Conclusion: The clinical leadership curriculum has been received favorably by senior pediatric residents at our institution. Our next steps are to pilot the curriculum within residency programs of different specialties at our own institution as well as with pediatric residencies at other institutions.

Association of end-tidal carbon dioxide levels during cardiopulmonary resuscitation with survival in a large paediatric cohort.

AIM: To examine the associations between ETCO2, ROSC, and chest compression quality markers in paediatric patients during active resuscitation. METHODS: This was a single-centre cohort study of data collected as part of an institutional prospective quality initiative improvement program that included all paediatric patients who received chest compressions of any duration from January 1, 2013, through July 10, 2018, in the Johns Hopkins Children's Center. Data was collected from Zoll R Series® defibrillators. Events were included if Zoll data files contained both chest compression and ETCO2 data. 2,746 minutes corresponding to 143 events were included in the analyses. RESULTS: The median event ETCO2 for all 143 events was 16.8 [9.3-26.3] mmHg. There was a significant difference in median event ETCO2 between events that achieved ROSC and those that did not (ROSC: 19.3 [14.4-26.6] vs. NO ROSC: 13.9 [6.6-25.5] mmHg; p < 0.05). When the events were based on patient age, this relationship held in adolescents (ROSC: 18.8 [15.5-22.3] vs. NO ROSC: 9.6 [4.4-15.9] mmHg; p < 0.05), but not in children or infants. Median event ETCO2 was significantly associated with chest compression rate less than 140 (p < 0.0001) and chest compression fraction 90-100 (p < 0.0001). CONCLUSIONS: This represents the largest collection of ETCO2 and chest compression data in paediatric patients to date and unadjusted analyses suggests an association between ETCO2 and ROSC in some paediatric patients.

Using emollients to promote safe and effective skin care for patients.

The role of emollients in the treatment of dry skin conditions is often underestimated. Emollients promote optimal skin health and prevent skin breakdown, and their use can improve patients' quality of life. However, when advising patients on emollient use, nurses must consider the challenges involved such as the extensive choice of products and the necessity of regular applications. This article explores the development of dry skin conditions and outlines the role of emollients in maintaining the skin barrier function. The author also details optimal nursing practice in areas such as emollient prescribing and application.

Assessment of Clinical Leadership Training Needs in Senior Pediatric Residents.

INTRODUCTION: Although clinical leadership in physicians is associated with improved healthcare, leadership training is rarely integrated into residency training. Our objective was to perform a comprehensive needs assessment of our pediatric residents' existing leadership experiences and knowledge and to identify training gaps within our program. METHODS: First, we held focus groups with senior pediatric residents to understand their clinical leadership experiences and identify training needs. Notes were transcribed and independently coded by 2 researchers, with thematic saturation achieved. Next, we focused each session on 1 leadership content area identified from the aforementioned themes to better understand the specific training needs for each topic. RESULTS: Four major themes were identified: (1) Effective and timely communication with supervisors, learners, ancillary staff, and patients is indispensable in promoting safe patient care, avoiding conflict, and preventing misunderstanding. (2) Training in teaching methods is desired, especially gaining the skills needed to teach various levels of learners, in different settings and under time constraints. (3) Time management, availability of resources, and team logistics were often learned through trial-and-error. (4) Self-care, self-acceptance, emotional regulation, and peer debriefing are relied upon to manage negative emotions; rarely are resilience and wellness strategies employed in "real-time." CONCLUSION: Senior residents currently face gaps in clinical leadership training and may benefit from additional instruction in content areas related to these 4 themes. Our next steps are to utilize the identified themes to develop a longitudinal and skills-based clinical leadership curriculum to address the gap in graduate medical education.

Advancing Advocacy: Implementation of a Child Health Advocacy Curriculum in a Pediatrics Residency Program.

Introduction: ACGME program requirements for graduate medical education state that pediatric residency programs should include elements of child advocacy education. Finding readily available, easily implementable advocacy curricula for pediatric residency programs is challenging. We conducted a generalized curricular needs assessment via literature review and a targeted needs assessment with health care providers and advocacy leaders and developed and implemented a child health advocacy curriculum in a pediatrics residency program. Methods: Delivered across 9 months, the curriculum included three components: electronic resources, didactic sessions, and interactive workshops aimed at developing advocacy skills in the context of pressing child health issues. The learner audience was PGY 1 through PGY 4. The curriculum was evaluated using pre- and postcurriculum surveys. Results: Our curriculum advanced child advocacy locally by establishing partnerships with state and federal American Academy of Pediatrics and pediatric residency programs, teaching residents to generate advocacy action plans, and implanting a longitudinal advocacy curriculum in the residency program. Sixty-four of 70 residents participated in the curriculum: 33% were PGY 1, 31% were PGY 2, 30% were PGY 3, and 6% were PGY 4. Pre- and postcurriculum surveys demonstrated improved knowledge of and comfort level with advocacy after curriculum completion. Discussion: Child advocacy teaching improved resident and faculty awareness about child health issues in the community, as well as understanding of pathways to advocate for child health. The curriculum is reproducible and feasible and can assist other institutions to develop advocacy education and skill development programs.

Improved Cardiopulmonary Resuscitation Performance With CODE ACES2: A Resuscitation Quality Bundle.

Background Over 6000 children have an in-hospital cardiac arrest in the United States annually. Most will not survive to discharge, with significant variability in survival across hospitals suggesting improvement in resuscitation performance can save lives. Methods and Results A prospective observational study of quality of chest compressions ( CC ) during pediatric in-hospital cardiac arrest associated with development and implementation of a resuscitation quality bundle. Objectives were to: 1) implement a debriefing program, 2) identify impediments to delivering high quality CC , 3) develop a resuscitation quality bundle, and 4) measure the impact of the resuscitation quality bundle on compliance with American Heart Association ( AHA ) Pediatric Advanced Life Support CC guidelines over time. Logistic regression was used to assess the relationship between compliance and year of event, adjusting for age and weight. Over 3 years, 317 consecutive cardiac arrests were debriefed, 38% (119/317) had CC data captured via defibrillator-based accelerometer pads, data capture increasing over time: (2013:13% [12/92] versus 2014:43% [44/102] versus 2015:51% [63/123], P<0.001). There were 2135 1-minute cardiopulmonary resuscitation (CPR) epoch data available for analysis, (2013:152 versus 2014:922 versus 2015:1061, P<0.001). Performance mitigating themes were identified and evolved into the resuscitation quality bundle entitled CPR Coaching, Objective-Data Evaluation, Action-linked-phrases, Choreography, Ergonomics, Structured debriefing and Simulation (CODE ACES2). The adjusted marginal probability of a CC epoch meeting the criteria for excellent CPR (compliant for rate, depth, and chest compression fraction) in 2015, after CPR Coaching, Objective-Data Evaluation, Action-linked-phrases, Choreography, Ergonomics, Structured debriefing and Simulation was developed and implemented, was 44.3% (35.3-53.3) versus 19.9%(6.9-32.9) in 2013; (odds ratio 3.2 [95% confidence interval:1.3-8.1], P=0.01). Conclusions CODE ACES2 was associated with progressively increased compliance with AHA CPR guidelines during in-hospital cardiac arrest.

Prevention of medical errors and malpractice: Is creating resilience in physicians part of the answer?

In this article, we present key concepts regarding physician and resident resilience and burnout, the legal and educational context for these distinctions, and the effects of improved physician resilience through self-care on a reduction in medical errors and malpractice. Resilience here indicates the mental processes and behaviors that enable an individual to overcome the potential negative effects of stressors. In order to explore the multiple factors that contribute to physician resilience, the authors approached the topic from a variety of perspectives, including the current ways of thinking about medical malpractice in the United States, physician resilience and medical errors, and building resilience during postgraduate medical education. The authors review steps taken and in process to mitigate physician burnout and enhance physician resilience.

Design and Deployment of a Pediatric Cardiac Arrest Surveillance System.

OBJECTIVE: We aimed to increase detection of pediatric cardiopulmonary resuscitation (CPR) events and collection of physiologic and performance data for use in quality improvement (QI) efforts. MATERIALS AND METHODS: We developed a workflow-driven surveillance system that leveraged organizational information technology systems to trigger CPR detection and analysis processes. We characterized detection by notification source, type, location, and year, and compared it to previous methods of detection. RESULTS: From 1/1/2013 through 12/31/2015, there were 2,986 unique notifications associated with 2,145 events, 317 requiring CPR. PICU and PEDS-ED accounted for 65% of CPR events, whereas floor care areas were responsible for only 3% of events. 100% of PEDS-OR and >70% of PICU CPR events would not have been included in QI efforts. Performance data from both defibrillator and bedside monitor increased annually. (2013: 1%; 2014: 18%; 2015: 27%). DISCUSSION: After deployment of this system, detection has increased ∼9-fold and performance data collection increased annually. Had the system not been deployed, 100% of PEDS-OR and 50-70% of PICU, NICU, and PEDS-ED events would have been missed. CONCLUSION: By leveraging hospital information technology and medical device data, identification of pediatric cardiac arrest with an associated increased capture in the proportion of objective performance data is possible.

Intensivist Presence at Code Events Is Associated with High Survival and Increased Documentation Rates.

To better support the highest function of the Johns Hopkins Hospital adult code and rapid response teams, a team leadership role was created for a faculty intensivist, with the intention to integrate improve processes of care delivery, documentation, and decision-making. This article examines process and outcomes associated with the introduction of this role. It demonstrates that an intensivist has the potential to improve patient care while offsetting costs through improved billing capture.

Role of slough and biofilm in delaying healing in chronic wounds.

The management of biofilms with maintenance desloughing and antimicrobial therapy is fast becoming the accepted treatment strategy for chronic wounds.

Cost-effective wound management: a survey of 1717 nurses.

Delivering high-quality wound care requires a mix of knowledge and skills, which nurses aim to update by attending educational events such as conferences and study days. This article describes the data obtained from 30 educational study days, which took place across England, Scotland and Wales. It will explore nurses' knowledge in relation to the cost-effectiveness and clinical efficacy of current wound care practices, based on the answers of 1717 delegates that attended the events. It will also outline the results in relation to reducing expenditure on wound dressings and the importance of performing an accurate wound assessment.

A 6 month evaluation of a non-powered hybrid mattress replacement system.

In 2013, the Royal Cornwall Hospitals NHS Trust undertook a 6-week evaluation of the AtmosAir 4000 non-powered reactive pressure redistribution mattress replacement system to determine its suitability in supporting the prevention of pressure ulcers in high-risk patients (phase one). The results demonstrated that the AtmosAir 4000 mattress system, together with skin assessment and repositioning regimes, met the pressure ulcer preventative needs of patients at high and very high risk of developing pressure ulcers. It also resulted in a notable reduction in the use of dynamic air mattresses. Consequently, 50 AtmosAir 4000 mattresses were purchased for two acute medical wards in the evaluation site, where the majority of patients are elderly with an acute medical condition. This article discusses the second phase where an audit compares the number of hospital-acquired pressure ulcers reported over a 6-month period with the equivalent time period in 2014. Results show that the number of pressure ulcers reduced by 65% and 50% in the two wards. The number of dynamic mattresses used on the two wards reduced significantly from 28 to 7, which represents a 75% reduction in usage.

Evaluating a pressure-redistribution mattress replacement system.

Pressure ulcer prevention is high on the quality agenda and provision of pressure-relieving equipment to meet patients' needs is an essential part of this process. This can be challenging in today's NHS and this article explores the evaluation process that supported the procurement of the AtmosAir™ 4000 pressure-redistributing mattress replacement system. Outcomes suggest that, when combined with a robust repositioning and skin assessment regime, the AtmosAir 4000 performed well and dynamic mattress usage was reduced. Further evaluation over a longer period of time will be undertaken in future.

Management of a black leopard (Panthera pardus) with seasonal atopy and cutaneous adverse food reaction by using transmucosal immunotherapy.

An 11-yr-old female black leopard (Panthera pardus) was presented with pruritus and intermittent gastrointestinal distress for a duration of 18 mo. Dietary elimination trial and challenge confirmed food hypersensitivity. Milder and persistent pruritus, while consuming a strict elimination diet, confirmed atopic dermatitis also was related to airborne environmental triggers identified by intradermal allergy testing. Ultimately, atopy was controlled successfully by antihistamines and transmucosal immunotherapy for 7 yr after diagnosis.

The economics of pain management.

Using castration and dehorning as the test base, this article evaluates whether pain management is associated with increased production and whether this motivates producers. The literature supporting increased production parameters is limited. Studies have evaluated short periods and often use few animals. Few studies are repeated and the potential for publication bias is high. There is little evidence that pain management is associated with increased production. This is a concern because survey data suggest producers are partly motivated based on economic factors. The unanswered question is whether economic incentive programs would be greater motivators than increased production.

The Excite Trial: relationship of intensity of constraint induced movement therapy to improvement in the wolf motor function test.

PURPOSE: To examine the relationship between change scores on the log mean Wolf Motor Function Test (lmWMFT) and the intensity of supervised Constraint Induced Movement Therapy (CIMT) in participants with subacute and chronic stroke. METHODS: A retrospective analysis of data from 169 EXCITE participants who received CIMT either immediately after randomization or one year later was undertaken. During waking hours, participants wore a restraining mitt on the less affected extremity. The lmWMFT was administered before and after the two week treatment block. RESULTS: Significant relationships were seen between the intensity of training and functional score in the immediate, lower functional group for whom more training in adaptive task practice resulted in poorer outcomes (p=0.01) and in the immediate, higher functioning group for whom more training in repetitive task practice resulted in poorer outcomes (p=0.02). Female participants in the immediate group showed less progress in lmWMFT scores with greater amounts of total training (p=0.01). Functional level, gender, and concordance did not modify any other relationship. Both higher functioning participants who trained within the normal ratio (N=50) and who were exposed to more than the prescribed adaptive task practice (N=11) experienced a significant improvement in the lmWMFT score (p=0.03 and p=0.02, respectively) compared to those higher functioning participants who experienced excessive repetitive task practice. CONCLUSION: Applying CIMT to a large sample of participants with stroke resulted in directionally inappropriate but significant relationships between intensity and lmWMFT scores in the immediate but not the delayed group. Our data also suggest that functional improvements observed in the EXCITE Trial might be attributable to training components other than the designated ratio of training approaches (adaptive and repetitive task practice).

Telemedicine in educational settings.

The use of telemedicine to enhance patient care is well documented in the literature (Currell et al 2001); however, its use in educational settings requires further exploration. Technological advances in electronic communication have been the catalyst for enabling the transmission and storage of large volumes of data. This, in turn, has allowed still and video images to be used for clinical consultation and the advancement of healthcare professionals' knowledge and skills. This article discusses the use of telemedicine in healthcare practices and explores its value as an educational tool, particularly in the field of wound care.