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2.01 Core Skills: Bladder Catheterization and Interpretation of Urinalysis
Introduction
Bladder catheterization is a commonly performed procedure, typically used to collect a sterile urine sample for analysis and culture when urinary tract infection (UTI) is suspected. Bladder catheterization is also used to relieve urinary retention or obstruction, particularly in cases of anatomic abnormalities or neurogenic bladder, or to monitor urine output and overall fluid status. Pediatric hospitalists frequently encounter patients requiring bladder catheterization, and in many practice settings, may need to be adept at performing this procedure in infants, children, and adolescents. While not all pediatric hospitalists will regularly perform bladder catheterization, all will be required to interpret urinalysis (UA) in routine practice. A UA is most commonly used to diagnose UTI but can also be used to detect a wide range of pediatric conditions, including primary renal disease, trauma, diabetes, and metabolic disease. The ability to effectively interpret a urinalysis in the inpatient setting remains a core skill for the pediatric hospitalist.
Knowledge
Pediatric hospitalists should be able to:
- Review the basic anatomy of the male and female genitourinary tract.
- Discuss the indications and contraindications for bladder catheterization.
- Describe how the method used to collect a urine specimen can affect interpretation of urine culture results.
- Explain why bladder catheterization is the preferred method of collection in infants and children who cannot reliably produce a voided specimen or in whom a sterile sample is needed.
- Compare and contrast the implications of using different methods to collect a urine specimen, including the varied ability to correctly interpret the UA and culture.
- Describe the steps in performing bladder catheterization for both male and female patients, attending to aspects such as patient identification, sterile technique, patient positioning, equipment needs, and specimen handling.
- Describe the risks and complications associated with bladder catheterization, including localized trauma, creation of a false passage, and potential stricture formation.
- Discuss the indications for analgesia, sedation, or anxiolysis and the medications that may be used for each.
- Describe the indications and risks of indwelling bladder catheters and the criteria for removal.
- Describe best practices and care bundles that can minimize the risk of catheter associated urinary tract infections (CAUTIs).
- Review the indications for consultation with a urologist for bladder catheterization, including known genitourinary tract abnormality, recent genitourinary surgery, or urethral trauma.
- Define a UTI in terms of minimum bacterial colony counts needed with different methods of obtaining the sample, such as catheterization, clean catch, and clean bag.
- Discuss the importance of appropriate specimen handling and the potential effect on culture results.
- Discuss the different components of a urinalysis, including specific gravity, white and red blood cell counts, protein, casts, and glucose, including how each can be used to detect and manage different pediatric conditions.
- Compare and contrast the sensitivity, specificity, and positive or negative predictive value of the leukocyte esterase and nitrite components of a UA in the diagnosis of UTI.
Skills
Pediatric hospitalists should be able to:
- Perform a pre-procedural evaluation to determine risks and benefits of bladder catheterization.
- Demonstrate proficiency in performance of bladder catheterization on infants, children, and adolescents, when required according to local practice.
- Identify the level of pain and anxiety provoked by the procedure and provide appropriate pharmacologic or nonpharmacologic interventions when indicated.
- Employ proper techniques for holding and calming patients before, during, and after bladder catheterization and educate healthcare providers in these practices when indicated.
- Consistently adhere to infection control practices.
- Identify complications and respond with appropriate actions.
- Distinguish the need for and efficiently access appropriate consultants and support services for assistance with analgesia, sedation, anxiolysis, and performance of a bladder catheterization.
- Diagnose pediatric conditions, such as UTI, nephrotic syndrome, glomerulonephritis, diabetes mellitus, and others, through effective interpretation of a UA.
Attitudes
Pediatric hospitalists should be able to:
- Realize the importance of obtaining a sterile urine specimen to correctly diagnose urinary tract infection.
- Realize the importance of effective communication with patients and the family/caregivers regarding the indications for, risks, benefits, and steps of bladder catheterization.
- Appreciate the need for collaboration with nurses, learners and other healthcare providers, to promote the use of evidence-based practices in maintenance of urinary catheters to decrease risk of CAUTIs in the inpatient setting.
- Exemplify appropriate adherence to and advocate for strict infection control practices.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based procedures and policies for performance of bladder catheterization in children.
- Lead, coordinate, or participate in the development and implementation of educational initiatives designed to teach the proper technique for bladder catheterization as well as safe catheter maintenance when prolonged catheterization is required.
1. May OW. Urine collection methods in children: which is best? Nurs Clin North Am. 2018;53(2):137-143. https://doi.org/10.1016/j.cnur.2018.01.001.
2. Davis, KF, Colebaugh AM, Eithun BL, et al. Reducing catheter-associated urinary tract infections: A quality-improvement initiative. Pediatrics. 2014;134(3): e857-864. https://doi.org/10.1542/peds.2013-3470.
3. Chase L, Lopez M, Wallace S, Ganem J, Vachani J, and Hill VL. Nephrology. In: Zaoutis LB, Chiang VW. eds. Comprehensive Pediatric Hospital Medicine, 2nd ed. New York, NY: McGraw-Hill Education, 2017:611-636.
Introduction
Bladder catheterization is a commonly performed procedure, typically used to collect a sterile urine sample for analysis and culture when urinary tract infection (UTI) is suspected. Bladder catheterization is also used to relieve urinary retention or obstruction, particularly in cases of anatomic abnormalities or neurogenic bladder, or to monitor urine output and overall fluid status. Pediatric hospitalists frequently encounter patients requiring bladder catheterization, and in many practice settings, may need to be adept at performing this procedure in infants, children, and adolescents. While not all pediatric hospitalists will regularly perform bladder catheterization, all will be required to interpret urinalysis (UA) in routine practice. A UA is most commonly used to diagnose UTI but can also be used to detect a wide range of pediatric conditions, including primary renal disease, trauma, diabetes, and metabolic disease. The ability to effectively interpret a urinalysis in the inpatient setting remains a core skill for the pediatric hospitalist.
Knowledge
Pediatric hospitalists should be able to:
- Review the basic anatomy of the male and female genitourinary tract.
- Discuss the indications and contraindications for bladder catheterization.
- Describe how the method used to collect a urine specimen can affect interpretation of urine culture results.
- Explain why bladder catheterization is the preferred method of collection in infants and children who cannot reliably produce a voided specimen or in whom a sterile sample is needed.
- Compare and contrast the implications of using different methods to collect a urine specimen, including the varied ability to correctly interpret the UA and culture.
- Describe the steps in performing bladder catheterization for both male and female patients, attending to aspects such as patient identification, sterile technique, patient positioning, equipment needs, and specimen handling.
- Describe the risks and complications associated with bladder catheterization, including localized trauma, creation of a false passage, and potential stricture formation.
- Discuss the indications for analgesia, sedation, or anxiolysis and the medications that may be used for each.
- Describe the indications and risks of indwelling bladder catheters and the criteria for removal.
- Describe best practices and care bundles that can minimize the risk of catheter associated urinary tract infections (CAUTIs).
- Review the indications for consultation with a urologist for bladder catheterization, including known genitourinary tract abnormality, recent genitourinary surgery, or urethral trauma.
- Define a UTI in terms of minimum bacterial colony counts needed with different methods of obtaining the sample, such as catheterization, clean catch, and clean bag.
- Discuss the importance of appropriate specimen handling and the potential effect on culture results.
- Discuss the different components of a urinalysis, including specific gravity, white and red blood cell counts, protein, casts, and glucose, including how each can be used to detect and manage different pediatric conditions.
- Compare and contrast the sensitivity, specificity, and positive or negative predictive value of the leukocyte esterase and nitrite components of a UA in the diagnosis of UTI.
Skills
Pediatric hospitalists should be able to:
- Perform a pre-procedural evaluation to determine risks and benefits of bladder catheterization.
- Demonstrate proficiency in performance of bladder catheterization on infants, children, and adolescents, when required according to local practice.
- Identify the level of pain and anxiety provoked by the procedure and provide appropriate pharmacologic or nonpharmacologic interventions when indicated.
- Employ proper techniques for holding and calming patients before, during, and after bladder catheterization and educate healthcare providers in these practices when indicated.
- Consistently adhere to infection control practices.
- Identify complications and respond with appropriate actions.
- Distinguish the need for and efficiently access appropriate consultants and support services for assistance with analgesia, sedation, anxiolysis, and performance of a bladder catheterization.
- Diagnose pediatric conditions, such as UTI, nephrotic syndrome, glomerulonephritis, diabetes mellitus, and others, through effective interpretation of a UA.
Attitudes
Pediatric hospitalists should be able to:
- Realize the importance of obtaining a sterile urine specimen to correctly diagnose urinary tract infection.
- Realize the importance of effective communication with patients and the family/caregivers regarding the indications for, risks, benefits, and steps of bladder catheterization.
- Appreciate the need for collaboration with nurses, learners and other healthcare providers, to promote the use of evidence-based practices in maintenance of urinary catheters to decrease risk of CAUTIs in the inpatient setting.
- Exemplify appropriate adherence to and advocate for strict infection control practices.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based procedures and policies for performance of bladder catheterization in children.
- Lead, coordinate, or participate in the development and implementation of educational initiatives designed to teach the proper technique for bladder catheterization as well as safe catheter maintenance when prolonged catheterization is required.
Introduction
Bladder catheterization is a commonly performed procedure, typically used to collect a sterile urine sample for analysis and culture when urinary tract infection (UTI) is suspected. Bladder catheterization is also used to relieve urinary retention or obstruction, particularly in cases of anatomic abnormalities or neurogenic bladder, or to monitor urine output and overall fluid status. Pediatric hospitalists frequently encounter patients requiring bladder catheterization, and in many practice settings, may need to be adept at performing this procedure in infants, children, and adolescents. While not all pediatric hospitalists will regularly perform bladder catheterization, all will be required to interpret urinalysis (UA) in routine practice. A UA is most commonly used to diagnose UTI but can also be used to detect a wide range of pediatric conditions, including primary renal disease, trauma, diabetes, and metabolic disease. The ability to effectively interpret a urinalysis in the inpatient setting remains a core skill for the pediatric hospitalist.
Knowledge
Pediatric hospitalists should be able to:
- Review the basic anatomy of the male and female genitourinary tract.
- Discuss the indications and contraindications for bladder catheterization.
- Describe how the method used to collect a urine specimen can affect interpretation of urine culture results.
- Explain why bladder catheterization is the preferred method of collection in infants and children who cannot reliably produce a voided specimen or in whom a sterile sample is needed.
- Compare and contrast the implications of using different methods to collect a urine specimen, including the varied ability to correctly interpret the UA and culture.
- Describe the steps in performing bladder catheterization for both male and female patients, attending to aspects such as patient identification, sterile technique, patient positioning, equipment needs, and specimen handling.
- Describe the risks and complications associated with bladder catheterization, including localized trauma, creation of a false passage, and potential stricture formation.
- Discuss the indications for analgesia, sedation, or anxiolysis and the medications that may be used for each.
- Describe the indications and risks of indwelling bladder catheters and the criteria for removal.
- Describe best practices and care bundles that can minimize the risk of catheter associated urinary tract infections (CAUTIs).
- Review the indications for consultation with a urologist for bladder catheterization, including known genitourinary tract abnormality, recent genitourinary surgery, or urethral trauma.
- Define a UTI in terms of minimum bacterial colony counts needed with different methods of obtaining the sample, such as catheterization, clean catch, and clean bag.
- Discuss the importance of appropriate specimen handling and the potential effect on culture results.
- Discuss the different components of a urinalysis, including specific gravity, white and red blood cell counts, protein, casts, and glucose, including how each can be used to detect and manage different pediatric conditions.
- Compare and contrast the sensitivity, specificity, and positive or negative predictive value of the leukocyte esterase and nitrite components of a UA in the diagnosis of UTI.
Skills
Pediatric hospitalists should be able to:
- Perform a pre-procedural evaluation to determine risks and benefits of bladder catheterization.
- Demonstrate proficiency in performance of bladder catheterization on infants, children, and adolescents, when required according to local practice.
- Identify the level of pain and anxiety provoked by the procedure and provide appropriate pharmacologic or nonpharmacologic interventions when indicated.
- Employ proper techniques for holding and calming patients before, during, and after bladder catheterization and educate healthcare providers in these practices when indicated.
- Consistently adhere to infection control practices.
- Identify complications and respond with appropriate actions.
- Distinguish the need for and efficiently access appropriate consultants and support services for assistance with analgesia, sedation, anxiolysis, and performance of a bladder catheterization.
- Diagnose pediatric conditions, such as UTI, nephrotic syndrome, glomerulonephritis, diabetes mellitus, and others, through effective interpretation of a UA.
Attitudes
Pediatric hospitalists should be able to:
- Realize the importance of obtaining a sterile urine specimen to correctly diagnose urinary tract infection.
- Realize the importance of effective communication with patients and the family/caregivers regarding the indications for, risks, benefits, and steps of bladder catheterization.
- Appreciate the need for collaboration with nurses, learners and other healthcare providers, to promote the use of evidence-based practices in maintenance of urinary catheters to decrease risk of CAUTIs in the inpatient setting.
- Exemplify appropriate adherence to and advocate for strict infection control practices.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based procedures and policies for performance of bladder catheterization in children.
- Lead, coordinate, or participate in the development and implementation of educational initiatives designed to teach the proper technique for bladder catheterization as well as safe catheter maintenance when prolonged catheterization is required.
1. May OW. Urine collection methods in children: which is best? Nurs Clin North Am. 2018;53(2):137-143. https://doi.org/10.1016/j.cnur.2018.01.001.
2. Davis, KF, Colebaugh AM, Eithun BL, et al. Reducing catheter-associated urinary tract infections: A quality-improvement initiative. Pediatrics. 2014;134(3): e857-864. https://doi.org/10.1542/peds.2013-3470.
3. Chase L, Lopez M, Wallace S, Ganem J, Vachani J, and Hill VL. Nephrology. In: Zaoutis LB, Chiang VW. eds. Comprehensive Pediatric Hospital Medicine, 2nd ed. New York, NY: McGraw-Hill Education, 2017:611-636.
1. May OW. Urine collection methods in children: which is best? Nurs Clin North Am. 2018;53(2):137-143. https://doi.org/10.1016/j.cnur.2018.01.001.
2. Davis, KF, Colebaugh AM, Eithun BL, et al. Reducing catheter-associated urinary tract infections: A quality-improvement initiative. Pediatrics. 2014;134(3): e857-864. https://doi.org/10.1542/peds.2013-3470.
3. Chase L, Lopez M, Wallace S, Ganem J, Vachani J, and Hill VL. Nephrology. In: Zaoutis LB, Chiang VW. eds. Comprehensive Pediatric Hospital Medicine, 2nd ed. New York, NY: McGraw-Hill Education, 2017:611-636.
1.26 Common Clinical Diagnoses and Conditions: Toxin Ingestion and Exposure
Introduction
In 2016, the National Data Poison System captured more than 4 million calls to poison control centers in the United States, 2.2 million of which were calls regarding human exposures. Close to 50% of reported toxin exposures occur in children under age 6 years.Furthermore, ingestion accounts for 75% of all toxin exposures in younger children. In this age group, toxin ingestion is frequently unintentional and involves non-pharmacologic agents, but therapeutic errors in the administration of pharmacologic agents do occur. In adolescents, toxin ingestion is more often intentional or secondary to substance abuse and is associated with greater morbidity and mortality, particularly when pharmacological agents are involved. Pediatric hospitalists often provide immediate care, coordinate care with subspecialists, and arrange for transfer to another facility when appropriate.
Knowledge
Pediatric hospitalists should be able to:
- List the pharmacologic and non-pharmacologic agents commonly ingested by pediatric patients, including how the relative frequency of each changes with age.
- Compare and contrast the risk factors and comorbidities associated with unintentional versus intentional ingestion.
- Describe the signs and symptoms of acute ingestion, including known toxidromes for commonly ingested agents such as salicylates, acetaminophen, narcotics, hallucinogens, stimulants, and others.
- Discuss the risk factors for and presentation of acute and chronic lead poisoning.
- List common laboratory tests that aid the diagnosis or assist with the management of common exposures and ingestions.
- List the agents detected in locally available blood and urine toxicology screens, including the benefits and limitations of this testing.
- Describe the benefits of comprehensive drug screens, attending to which screens are available to be sent from local institutions.
- Explain the indications for and limitations of decontamination therapy, including dermal, ocular, and gastric decontamination methods.
- Identify toxins that have a specific antidote available, including the indications and limitations of each.
- List local resources that provide information and advice regarding pediatric toxin exposure and ingestion management, acknowledging that there is a single phone number in the United States to access all regional poison center resources.
- Summarize the indications and goals of hospitalization, attending to acute and chronic medical needs and psychosocial intervention.
- Describe elements of a safe discharge for patients with toxic ingestion or exposure, including pre-discharge psychiatric and substance abuse evaluation, establishment of outpatient providers, development of a home safety plan, and others as indicated.
- Discuss risk factors for opioid and other prescription medication misuse and abuse.
- Identify locations and other local resources for safe medication disposal in the community.
Skills
Pediatric hospitalists should be able to:
- Obtain a focused history, including detailed information about the type, quantity, timing, and duration of potential exposures and ingestions.
- Perform a focused physical examination, with attention paid to signs and symptoms that may indicate exposure or ingestion of a particular toxin.
- Access institutional and local resources to obtain information and advice regarding the diagnosis and management of acute ingestion.
- Identify patients presenting with common toxidromes and efficiently institute appropriate therapy.
- Identify life-threatening complications of exposures or ingestions, such as cardiac dysrhythmias, respiratory depression, or mental status change, instituting appropriate therapy in a timely fashion.
- Recognize potential co-morbidities associated with intentional ingestion, such as depression, abuse, or other mental illness.
- Order and interpret basic tests, such as serum chemistries, blood gases, and electrocardiograms, and identify abnormal findings that require additional testing or consultation.
- Develop an appropriate treatment plan based on the presumptive or confirmed agent and provide decontamination or antidote therapy when appropriate.
- Determine the appropriate level of care and duration of observation for a given toxin, understanding that some agents may have delayed toxic effects.
- Consult subspecialists, including social work and/or psychiatry, for care of non-accidental ingestion as appropriate.
- Identify patients at high risk of opioid and other prescription medication misuse and abuse, efficiently utilizing state monitoring websites when appropriate.
- Counsel the family/caregivers in safe medication practices and disposal.
Attitudes
Pediatric hospitalists should be able to:
- Realize the importance of counseling the family/caregivers and other professional staff on the possible etiology and outcomes of an exposure or ingestion episode.
- Consider the social environment to determine the risk of future exposure or ingestion and the need for mitigation of risk factors prior to discharge.
- Reflect on the importance of educating the family/caregivers regarding proactive risk reduction measures, such as the safe and effective storage, use, and administration of medications, and potential availability of reversal agents in the home environment.
- Realize the importance of remaining vigilant regarding changes in recreational drug availability and use, as well as safety profile updates on pharmacologic and non-pharmacologic agents.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in the development of systems that integrate hospital, community, and national resources to provide up-to-date and evidence-based information about toxin exposures and ingestions, promoting timely recognition and treatment of both intentional and unintentional events.
- Lead, coordinate, or participate in efforts to educate healthcare providers about the most common exposures and ingestions in the pediatric population.
- Lead, coordinate, or participate in efforts to educate healthcare providers and the community regarding ways to mitigate medication errors.
- Lead, coordinate, or participate in efforts to educate healthcare providers and the community in safe opioid prescribing during the transition of care from the hospital to outpatient setting.
1. Current annual report. National Poison Data System. The American Association of Poison Control. 2017. http://www.aapcc.org/. Accessed August 20, 2019.
2. Bryant S, Singer J. Management of toxic exposure in children. Emerg Med Clin North Am. 2003;21:101-119. https://doi.org/10.1016/s0733-8627(02)00083-4.
3. Osterhoudt K. Pediatric Toxicology. New York, NY: Elsevier Mosby 2019.
Introduction
In 2016, the National Data Poison System captured more than 4 million calls to poison control centers in the United States, 2.2 million of which were calls regarding human exposures. Close to 50% of reported toxin exposures occur in children under age 6 years.Furthermore, ingestion accounts for 75% of all toxin exposures in younger children. In this age group, toxin ingestion is frequently unintentional and involves non-pharmacologic agents, but therapeutic errors in the administration of pharmacologic agents do occur. In adolescents, toxin ingestion is more often intentional or secondary to substance abuse and is associated with greater morbidity and mortality, particularly when pharmacological agents are involved. Pediatric hospitalists often provide immediate care, coordinate care with subspecialists, and arrange for transfer to another facility when appropriate.
Knowledge
Pediatric hospitalists should be able to:
- List the pharmacologic and non-pharmacologic agents commonly ingested by pediatric patients, including how the relative frequency of each changes with age.
- Compare and contrast the risk factors and comorbidities associated with unintentional versus intentional ingestion.
- Describe the signs and symptoms of acute ingestion, including known toxidromes for commonly ingested agents such as salicylates, acetaminophen, narcotics, hallucinogens, stimulants, and others.
- Discuss the risk factors for and presentation of acute and chronic lead poisoning.
- List common laboratory tests that aid the diagnosis or assist with the management of common exposures and ingestions.
- List the agents detected in locally available blood and urine toxicology screens, including the benefits and limitations of this testing.
- Describe the benefits of comprehensive drug screens, attending to which screens are available to be sent from local institutions.
- Explain the indications for and limitations of decontamination therapy, including dermal, ocular, and gastric decontamination methods.
- Identify toxins that have a specific antidote available, including the indications and limitations of each.
- List local resources that provide information and advice regarding pediatric toxin exposure and ingestion management, acknowledging that there is a single phone number in the United States to access all regional poison center resources.
- Summarize the indications and goals of hospitalization, attending to acute and chronic medical needs and psychosocial intervention.
- Describe elements of a safe discharge for patients with toxic ingestion or exposure, including pre-discharge psychiatric and substance abuse evaluation, establishment of outpatient providers, development of a home safety plan, and others as indicated.
- Discuss risk factors for opioid and other prescription medication misuse and abuse.
- Identify locations and other local resources for safe medication disposal in the community.
Skills
Pediatric hospitalists should be able to:
- Obtain a focused history, including detailed information about the type, quantity, timing, and duration of potential exposures and ingestions.
- Perform a focused physical examination, with attention paid to signs and symptoms that may indicate exposure or ingestion of a particular toxin.
- Access institutional and local resources to obtain information and advice regarding the diagnosis and management of acute ingestion.
- Identify patients presenting with common toxidromes and efficiently institute appropriate therapy.
- Identify life-threatening complications of exposures or ingestions, such as cardiac dysrhythmias, respiratory depression, or mental status change, instituting appropriate therapy in a timely fashion.
- Recognize potential co-morbidities associated with intentional ingestion, such as depression, abuse, or other mental illness.
- Order and interpret basic tests, such as serum chemistries, blood gases, and electrocardiograms, and identify abnormal findings that require additional testing or consultation.
- Develop an appropriate treatment plan based on the presumptive or confirmed agent and provide decontamination or antidote therapy when appropriate.
- Determine the appropriate level of care and duration of observation for a given toxin, understanding that some agents may have delayed toxic effects.
- Consult subspecialists, including social work and/or psychiatry, for care of non-accidental ingestion as appropriate.
- Identify patients at high risk of opioid and other prescription medication misuse and abuse, efficiently utilizing state monitoring websites when appropriate.
- Counsel the family/caregivers in safe medication practices and disposal.
Attitudes
Pediatric hospitalists should be able to:
- Realize the importance of counseling the family/caregivers and other professional staff on the possible etiology and outcomes of an exposure or ingestion episode.
- Consider the social environment to determine the risk of future exposure or ingestion and the need for mitigation of risk factors prior to discharge.
- Reflect on the importance of educating the family/caregivers regarding proactive risk reduction measures, such as the safe and effective storage, use, and administration of medications, and potential availability of reversal agents in the home environment.
- Realize the importance of remaining vigilant regarding changes in recreational drug availability and use, as well as safety profile updates on pharmacologic and non-pharmacologic agents.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in the development of systems that integrate hospital, community, and national resources to provide up-to-date and evidence-based information about toxin exposures and ingestions, promoting timely recognition and treatment of both intentional and unintentional events.
- Lead, coordinate, or participate in efforts to educate healthcare providers about the most common exposures and ingestions in the pediatric population.
- Lead, coordinate, or participate in efforts to educate healthcare providers and the community regarding ways to mitigate medication errors.
- Lead, coordinate, or participate in efforts to educate healthcare providers and the community in safe opioid prescribing during the transition of care from the hospital to outpatient setting.
Introduction
In 2016, the National Data Poison System captured more than 4 million calls to poison control centers in the United States, 2.2 million of which were calls regarding human exposures. Close to 50% of reported toxin exposures occur in children under age 6 years.Furthermore, ingestion accounts for 75% of all toxin exposures in younger children. In this age group, toxin ingestion is frequently unintentional and involves non-pharmacologic agents, but therapeutic errors in the administration of pharmacologic agents do occur. In adolescents, toxin ingestion is more often intentional or secondary to substance abuse and is associated with greater morbidity and mortality, particularly when pharmacological agents are involved. Pediatric hospitalists often provide immediate care, coordinate care with subspecialists, and arrange for transfer to another facility when appropriate.
Knowledge
Pediatric hospitalists should be able to:
- List the pharmacologic and non-pharmacologic agents commonly ingested by pediatric patients, including how the relative frequency of each changes with age.
- Compare and contrast the risk factors and comorbidities associated with unintentional versus intentional ingestion.
- Describe the signs and symptoms of acute ingestion, including known toxidromes for commonly ingested agents such as salicylates, acetaminophen, narcotics, hallucinogens, stimulants, and others.
- Discuss the risk factors for and presentation of acute and chronic lead poisoning.
- List common laboratory tests that aid the diagnosis or assist with the management of common exposures and ingestions.
- List the agents detected in locally available blood and urine toxicology screens, including the benefits and limitations of this testing.
- Describe the benefits of comprehensive drug screens, attending to which screens are available to be sent from local institutions.
- Explain the indications for and limitations of decontamination therapy, including dermal, ocular, and gastric decontamination methods.
- Identify toxins that have a specific antidote available, including the indications and limitations of each.
- List local resources that provide information and advice regarding pediatric toxin exposure and ingestion management, acknowledging that there is a single phone number in the United States to access all regional poison center resources.
- Summarize the indications and goals of hospitalization, attending to acute and chronic medical needs and psychosocial intervention.
- Describe elements of a safe discharge for patients with toxic ingestion or exposure, including pre-discharge psychiatric and substance abuse evaluation, establishment of outpatient providers, development of a home safety plan, and others as indicated.
- Discuss risk factors for opioid and other prescription medication misuse and abuse.
- Identify locations and other local resources for safe medication disposal in the community.
Skills
Pediatric hospitalists should be able to:
- Obtain a focused history, including detailed information about the type, quantity, timing, and duration of potential exposures and ingestions.
- Perform a focused physical examination, with attention paid to signs and symptoms that may indicate exposure or ingestion of a particular toxin.
- Access institutional and local resources to obtain information and advice regarding the diagnosis and management of acute ingestion.
- Identify patients presenting with common toxidromes and efficiently institute appropriate therapy.
- Identify life-threatening complications of exposures or ingestions, such as cardiac dysrhythmias, respiratory depression, or mental status change, instituting appropriate therapy in a timely fashion.
- Recognize potential co-morbidities associated with intentional ingestion, such as depression, abuse, or other mental illness.
- Order and interpret basic tests, such as serum chemistries, blood gases, and electrocardiograms, and identify abnormal findings that require additional testing or consultation.
- Develop an appropriate treatment plan based on the presumptive or confirmed agent and provide decontamination or antidote therapy when appropriate.
- Determine the appropriate level of care and duration of observation for a given toxin, understanding that some agents may have delayed toxic effects.
- Consult subspecialists, including social work and/or psychiatry, for care of non-accidental ingestion as appropriate.
- Identify patients at high risk of opioid and other prescription medication misuse and abuse, efficiently utilizing state monitoring websites when appropriate.
- Counsel the family/caregivers in safe medication practices and disposal.
Attitudes
Pediatric hospitalists should be able to:
- Realize the importance of counseling the family/caregivers and other professional staff on the possible etiology and outcomes of an exposure or ingestion episode.
- Consider the social environment to determine the risk of future exposure or ingestion and the need for mitigation of risk factors prior to discharge.
- Reflect on the importance of educating the family/caregivers regarding proactive risk reduction measures, such as the safe and effective storage, use, and administration of medications, and potential availability of reversal agents in the home environment.
- Realize the importance of remaining vigilant regarding changes in recreational drug availability and use, as well as safety profile updates on pharmacologic and non-pharmacologic agents.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in the development of systems that integrate hospital, community, and national resources to provide up-to-date and evidence-based information about toxin exposures and ingestions, promoting timely recognition and treatment of both intentional and unintentional events.
- Lead, coordinate, or participate in efforts to educate healthcare providers about the most common exposures and ingestions in the pediatric population.
- Lead, coordinate, or participate in efforts to educate healthcare providers and the community regarding ways to mitigate medication errors.
- Lead, coordinate, or participate in efforts to educate healthcare providers and the community in safe opioid prescribing during the transition of care from the hospital to outpatient setting.
1. Current annual report. National Poison Data System. The American Association of Poison Control. 2017. http://www.aapcc.org/. Accessed August 20, 2019.
2. Bryant S, Singer J. Management of toxic exposure in children. Emerg Med Clin North Am. 2003;21:101-119. https://doi.org/10.1016/s0733-8627(02)00083-4.
3. Osterhoudt K. Pediatric Toxicology. New York, NY: Elsevier Mosby 2019.
1. Current annual report. National Poison Data System. The American Association of Poison Control. 2017. http://www.aapcc.org/. Accessed August 20, 2019.
2. Bryant S, Singer J. Management of toxic exposure in children. Emerg Med Clin North Am. 2003;21:101-119. https://doi.org/10.1016/s0733-8627(02)00083-4.
3. Osterhoudt K. Pediatric Toxicology. New York, NY: Elsevier Mosby 2019.