Postoperative pulmonary complications are common, with a reported incidence of 2-40%, and are associated with adverse outcomes that include death, longer hospital stay and reduced long-term survival. Enhanced recovery is now a standard of care for patients undergoing elective major surgery. Despite the high prevalence of pulmonary complications in this population, few elements of enhanced recovery specifically address reducing these complications. In 2013, a prevalence audit confirmed a postoperative pulmonary complication rate of 16/83 (19.3%) in patients undergoing elective major surgery who were admitted to critical care postoperatively. A quality improvement team developed and implemented ERAS+, an innovative model of peri-operative care combining elements of enhanced recovery with specific measures aimed at reducing pulmonary complications. ERAS+ was introduced in June 2014, with full implementation in September 2014. Patients were screened during full ERAS+ implementation and again one year following implementation. Following ERAS+ implementation, postoperative pulmonary complications reduced to 24/228 (10.5%). Sustained improvement was evident one year after implementation, with a pulmonary complication rate of 16/183 (8.7%). Median (IQR [range]) length of hospital stay one year after implementation of ERAS+ also improved from 12 (9-15 [4-101]) to 9 (5.5-10.5 [3-81]) days. The ERAS+ pathway is applicable to patients undergoing elective major surgery and appears effective in reducing postoperative pulmonary complications.

Education and ongoing assessment of skin integrity and the use of devices that minimize pressure at the tracheostomy-skin interface effectively reduce TRPU even among a population of children at high risk. These interventions can be integrated into daily workflow and result in sustained effect.

Of 109 children admitted to a tertiary paediatric hospital with a diagnosis of invasive meningococcal disease from 2000-2011, 37.6% (n = 41) developed sequelae; for serogroup B, 41.3% developed sequelae. Independent predictors of sequelae included: fever ≥ 39 °C on hospital presentation [odds ratio (OR): 4.5; P = 0.012] and a diagnosis of septicemia with meningitis compared with septicemia alone (OR: 15.5; P < 0.001) and meningitis alone (OR: 7.8; P = 0.002).

American Indian and Alaska Native (AI/AN) cultures in the United States include a diverse group of indigenous cultures that have been affected by their contact with European Americans and have suffered adverse psychological, physical, and economic consequences. AI/AN adolescents have the highest prevalence of cigarette smoking of all U.S. ethnic groups. Culturally competent health promotion programs are needed to enhance their resiliency and help them avoid recreational, addictive use of commercial tobacco. The authors describe the diverse AI/AN populations and their unique health and social issues, including adolescent smoking. They present examples of smoking prevention programs tailored or adapted for AI/AN adolescents and make recommendations for implementation and evaluation of prototype programs. Recommendations include involving the community, respecting tribes' wishes for confidentiality, being aware of IRB issues, beginning with formative and qualitative research, using culturally appropriate measures, understanding the diversity of AI/AN cultures, and involving multiple generations of the family.

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