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Inguinal hernias are often repaired before hospital discharge if they are noted in the neonatal period. Infants presenting with hernias after discharge should be sent promptly for surgical consultation. If repair under general anesthesia is performed before the infant reaches the age of three months past the due date, inpatient monitoring is advised because of the increased risk of postoperative apnea.

In contrast to inguinal hernias, umbilical hernias rarely incarcerate. They can safely be managed with observation and usually resolve spontaneously by the time the child reaches three to five years of age. If an umbilical hernia persists beyond then, surgical repair should be considered. Of course, the folk practice of placing a silver dollar or 50-cent piece over the hernia does not increase the chance of closure. This practice should be discouraged through parental education.

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Anemia is common but can be minimized by using iron supplements. Careful physical examinations and monitoring of developmental milestones help identify cerebral palsy or other developmental abnormalities. The presence of developmental abnormalities signals the need for multidisciplinary evaluation. Chronic medical problems can be managed by the family physician along with the neonatologist. Surgical referral for hernias and cryptorchidism must be obtained in a timely fashion. By performing frequent examinations, coordinating the infant's medical care and monitoring the needs of the parents, the family physician can make effective interventions on behalf of the premature infant.

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1. Jones MD Jr. Postnatal anemia. In: Jones MD Jr, Gleason CA, Lipstein SU, eds. Hospital care of the recovering NICU infant. Baltimore: Williams Wilkins, 1991:49–60. ...

Once patients agree to participate, staff and charge nurses evaluate them for venous accessibility for peripheral blood specimens, and laboratory specimens are bundled and drawn by phlebotomy or nursing staff. We created a process flow chart to provide a visual guide for all staff. (See Making the right decision: The No Central Line Blood Draw decision tree .)

In addition to the steps and exceptions identified in the flow chart, if a specimen can’t be obtained after four attempts or if the patient is identified as having difficult venous access, we evaluate him or her for a foot or capillary blood specimen. If a patient refuses peripheral blood draws despite CLABSI prevention awareness education, or if the patient meets one of the exceptions, the physician orders central line collection. The charge nurse documents this information in the unit charge nurse’s resource book, which contains patients who have had a specimen drawn from their central line and why the line was accessed.

Success

Since implementing No Central Line Blood Draw in October 2014, no participating patient has acquired a CLABSI, down from 2.99 infections per 1,000 central line days. In addition, the number of times central lines were accessed for specimen collection decreased from an average of 6 to 1.4 times per day, and mislabeled or contaminated specimens sent to the laboratory were significantly reduced.

Implementation of this innovative process allowed for interprofessional collaboration and decreased the risk of patients acquiring CLABSIs. The process is now standard practice on the unit, and it’s being evaluated for implementation in other medical-surgical units.

All authors work at Penn State Hershey Medical Center in Hershey, Pennsylvania. Krista Williamson is a nurse manager, Lorie Gonzalez is a nurse educator, Ashley Neusbaum is a clinical head nurse, and Jaime Messing is a staff nurse.

Centers for Disease Control and Prevention. Bloodstream infection event (central line-associated bloodstream infection and non-central line–associated bloodstream infection) . January 2016.

Centers for Disease Control and Prevention. FAQs about catheter-associated bloodstream infections. (n.d.).

Centers for Disease Control and Prevention. Vital signs: Central line–associated blood stream infections—United States, 2001, 2008, and 2009. MMWR Morb Mortal Wkly Rep . 2011;60(8):243-8.

Marschall J, Mermel LA, Fakih M, et al. Strategies to prevent central line–associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol . 2014;35(7):753-71.

Wilson MZ, Rafferty C, Deeter D, Comito MA, Hollenbeak CS. Attributable costs of central line–associated bloodstream infections in a pediatric hematology/oncology population. Am J Infect Control . 2014; 42(11):1157-60.

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