Crocker J

Gastrointestinal (GI) bleed refers to any bleeding that originates in the GI tract. Bleeding is generally defined as upper (between the mouth and the ligament of Treitz) or lower (from the ligament of Treitz to the anus). Acute GI bleeding complicates about 7% of all hospital stays in the United States and has an approximate 3% in-hospital mortality rate. Annually, more than 245,000, 130,000, and 165,000 hospital discharges occur with upper GI bleed, lower GI bleed, and unspecified GI bleed as the primary diagnosis, respectively.¹ The degree of blood loss can vary from microscopic amounts to noticeable or massive volumes that can cause hemodynamic instability. Between 19% and 28% of patients with GI bleeding have complications that require intensive care unit admission.^2-5 A well-orchestrated approach that includes prompt assessment for risk stratification, evaluation for early endoscopy, initiation of pharmacotherapy, and treatment of comorbid diseases is necessary for a favorable outcome. Hospitalists provide immediate care for patients presenting with GI bleeding while coordinating care across multiple specialties. Hospitalists lead quality improvement initiatives that optimize the efficiency and quality of care for patients with GI bleeding. 

Hospitalists should be able to:

• Explain the etiologies and pathophysiologic processes that lead to GI bleeds.

• Describe and differentiate the clinical features and presentations of upper and lower GI bleeds.

• Describe the tests required to evaluate GI bleeds.

• Explain the risk factors for upper and lower GI bleeds and clinical indicators of patients at high risk for complications.

• List the indications for early specialty consultation, which may include interventional radiology, gastroenterology, and surgery.

• Describe the approach to transfusion therapy in GI bleeds.

• Describe the treatment for concomitant coagulopathy in patients with GI bleeds.

• Compare the advantages and disadvantages of medical, endoscopic, and surgical treatments for patients with GI bleeds.

• Explain indications, contraindications, and mechanisms of action of pharmacologic agents used to treat GI bleeds.

• Identify clinical, laboratory, and imaging studies that indicate disease severity.

• Explain goals for hospital discharge including specific measures of clinical stability for safe care transition.

Hospitalists should be able to:

• Elicit a thorough and relevant history, including a directed medication, family, and social history.

• Perform a physical examination to identify the likely source of bleeding, presence of comorbid conditions (such as liver disease), and signs of clinical instability (such as organ hypoperfusion) or complications (such as intestinal perforation).

• Order and interpret results of appropriate laboratory, imaging, and endoscopic tests.

• Synthesize results of physical examination, laboratory testing, and imaging studies to determine the best management and care plan for the patient.

• Assess patients with GI bleeds for the purpose of risk stratification and determine the corresponding level of care required.

• Initiate preventive measures including avoidance of nonsteroidal anti-inflammatory agents, stress ulcer prophylaxis in critically ill patients, dietary modification, and evidence-based medical therapies.

• Formulate an evidence-based treatment plan, including nutritional recommendations, pharmacologic agents and dosing, and coordination of endoscopic and surgical interventions tailored to the individual patient.

• Determine frequency for laboratory monitoring and transfusion during hospitalization.

• Ensure adequate intravenous access to allow rapid volume and blood product resuscitation.

• Perform rapid hemodynamic resuscitation.

• Recognize and treat signs of clinical decompensation and recurrent bleeding.

• Assess patients with suspected GI bleeds in a timely manner and manage or comanage the patient with the primary requesting service.

• Communicate with patients and families to explain the disease etiology, prognosis, risk reduction strategies, and symptoms of recurrent GI bleed.

• Communicate with patients and families to explain risks, benefits, and alternatives to transfusion therapy.

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care. 

Hospitalists should be able to:

• Employ a multidisciplinary approach, which may include nursing, pharmacy and nutrition services, and specialty and referring physicians, in the care of patients with GI bleeds that begins at admission and continues through all care transitions.

• Establish and maintain an open dialogue with patients and/or families regarding goals and limitations of care, including palliative care and end-of-life wishes. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in the development and promotion of evidence-based guidelines and/or pathways for treatment of patients with GI bleeds.

• Lead, coordinate, and/or participate in multidisciplinary teams to develop quality improvement initiatives that promote early identification of GI bleeds and reduce preventable complications.

• Develop systems that provide timely reports of pending study results to outpatient providers.

• Integrate outcomes research, institution-specific laboratory policies, and hospital formulary to create indicated and cost-effective diagnostic and management strategies for patients with GI bleeds.

Gastrointestinal (GI) bleed refers to any bleeding that originates in the GI tract. Bleeding is generally defined as upper (between the mouth and the ligament of Treitz) or lower (from the ligament of Treitz to the anus). Acute GI bleeding complicates about 7% of all hospital stays in the United States and has an approximate 3% in-hospital mortality rate. Annually, more than 245,000, 130,000, and 165,000 hospital discharges occur with upper GI bleed, lower GI bleed, and unspecified GI bleed as the primary diagnosis, respectively.¹ The degree of blood loss can vary from microscopic amounts to noticeable or massive volumes that can cause hemodynamic instability. Between 19% and 28% of patients with GI bleeding have complications that require intensive care unit admission.^2-5 A well-orchestrated approach that includes prompt assessment for risk stratification, evaluation for early endoscopy, initiation of pharmacotherapy, and treatment of comorbid diseases is necessary for a favorable outcome. Hospitalists provide immediate care for patients presenting with GI bleeding while coordinating care across multiple specialties. Hospitalists lead quality improvement initiatives that optimize the efficiency and quality of care for patients with GI bleeding. 

Hospitalists should be able to:

• Explain the etiologies and pathophysiologic processes that lead to GI bleeds.

• Describe and differentiate the clinical features and presentations of upper and lower GI bleeds.

• Describe the tests required to evaluate GI bleeds.

• Explain the risk factors for upper and lower GI bleeds and clinical indicators of patients at high risk for complications.

• List the indications for early specialty consultation, which may include interventional radiology, gastroenterology, and surgery.

• Describe the approach to transfusion therapy in GI bleeds.

• Describe the treatment for concomitant coagulopathy in patients with GI bleeds.

• Compare the advantages and disadvantages of medical, endoscopic, and surgical treatments for patients with GI bleeds.

• Explain indications, contraindications, and mechanisms of action of pharmacologic agents used to treat GI bleeds.

• Identify clinical, laboratory, and imaging studies that indicate disease severity.

• Explain goals for hospital discharge including specific measures of clinical stability for safe care transition.

Hospitalists should be able to:

• Elicit a thorough and relevant history, including a directed medication, family, and social history.

• Perform a physical examination to identify the likely source of bleeding, presence of comorbid conditions (such as liver disease), and signs of clinical instability (such as organ hypoperfusion) or complications (such as intestinal perforation).

• Order and interpret results of appropriate laboratory, imaging, and endoscopic tests.

• Synthesize results of physical examination, laboratory testing, and imaging studies to determine the best management and care plan for the patient.

• Assess patients with GI bleeds for the purpose of risk stratification and determine the corresponding level of care required.

• Initiate preventive measures including avoidance of nonsteroidal anti-inflammatory agents, stress ulcer prophylaxis in critically ill patients, dietary modification, and evidence-based medical therapies.

• Formulate an evidence-based treatment plan, including nutritional recommendations, pharmacologic agents and dosing, and coordination of endoscopic and surgical interventions tailored to the individual patient.

• Determine frequency for laboratory monitoring and transfusion during hospitalization.

• Ensure adequate intravenous access to allow rapid volume and blood product resuscitation.

• Perform rapid hemodynamic resuscitation.

• Recognize and treat signs of clinical decompensation and recurrent bleeding.

• Assess patients with suspected GI bleeds in a timely manner and manage or comanage the patient with the primary requesting service.

• Communicate with patients and families to explain the disease etiology, prognosis, risk reduction strategies, and symptoms of recurrent GI bleed.

• Communicate with patients and families to explain risks, benefits, and alternatives to transfusion therapy.

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care. 

Hospitalists should be able to:

• Employ a multidisciplinary approach, which may include nursing, pharmacy and nutrition services, and specialty and referring physicians, in the care of patients with GI bleeds that begins at admission and continues through all care transitions.

• Establish and maintain an open dialogue with patients and/or families regarding goals and limitations of care, including palliative care and end-of-life wishes. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in the development and promotion of evidence-based guidelines and/or pathways for treatment of patients with GI bleeds.

• Lead, coordinate, and/or participate in multidisciplinary teams to develop quality improvement initiatives that promote early identification of GI bleeds and reduce preventable complications.

• Develop systems that provide timely reports of pending study results to outpatient providers.

• Integrate outcomes research, institution-specific laboratory policies, and hospital formulary to create indicated and cost-effective diagnostic and management strategies for patients with GI bleeds.

Gastrointestinal (GI) bleed refers to any bleeding that originates in the GI tract. Bleeding is generally defined as upper (between the mouth and the ligament of Treitz) or lower (from the ligament of Treitz to the anus). Acute GI bleeding complicates about 7% of all hospital stays in the United States and has an approximate 3% in-hospital mortality rate. Annually, more than 245,000, 130,000, and 165,000 hospital discharges occur with upper GI bleed, lower GI bleed, and unspecified GI bleed as the primary diagnosis, respectively.¹ The degree of blood loss can vary from microscopic amounts to noticeable or massive volumes that can cause hemodynamic instability. Between 19% and 28% of patients with GI bleeding have complications that require intensive care unit admission.^2-5 A well-orchestrated approach that includes prompt assessment for risk stratification, evaluation for early endoscopy, initiation of pharmacotherapy, and treatment of comorbid diseases is necessary for a favorable outcome. Hospitalists provide immediate care for patients presenting with GI bleeding while coordinating care across multiple specialties. Hospitalists lead quality improvement initiatives that optimize the efficiency and quality of care for patients with GI bleeding. 

Hospitalists should be able to:

• Explain the etiologies and pathophysiologic processes that lead to GI bleeds.

• Describe and differentiate the clinical features and presentations of upper and lower GI bleeds.

• Describe the tests required to evaluate GI bleeds.

• Explain the risk factors for upper and lower GI bleeds and clinical indicators of patients at high risk for complications.

• List the indications for early specialty consultation, which may include interventional radiology, gastroenterology, and surgery.

• Describe the approach to transfusion therapy in GI bleeds.

• Describe the treatment for concomitant coagulopathy in patients with GI bleeds.

• Compare the advantages and disadvantages of medical, endoscopic, and surgical treatments for patients with GI bleeds.

• Explain indications, contraindications, and mechanisms of action of pharmacologic agents used to treat GI bleeds.

• Identify clinical, laboratory, and imaging studies that indicate disease severity.

• Explain goals for hospital discharge including specific measures of clinical stability for safe care transition.

Hospitalists should be able to:

• Elicit a thorough and relevant history, including a directed medication, family, and social history.

• Perform a physical examination to identify the likely source of bleeding, presence of comorbid conditions (such as liver disease), and signs of clinical instability (such as organ hypoperfusion) or complications (such as intestinal perforation).

• Order and interpret results of appropriate laboratory, imaging, and endoscopic tests.

• Synthesize results of physical examination, laboratory testing, and imaging studies to determine the best management and care plan for the patient.

• Assess patients with GI bleeds for the purpose of risk stratification and determine the corresponding level of care required.

• Initiate preventive measures including avoidance of nonsteroidal anti-inflammatory agents, stress ulcer prophylaxis in critically ill patients, dietary modification, and evidence-based medical therapies.

• Formulate an evidence-based treatment plan, including nutritional recommendations, pharmacologic agents and dosing, and coordination of endoscopic and surgical interventions tailored to the individual patient.

• Determine frequency for laboratory monitoring and transfusion during hospitalization.

• Ensure adequate intravenous access to allow rapid volume and blood product resuscitation.

• Perform rapid hemodynamic resuscitation.

• Recognize and treat signs of clinical decompensation and recurrent bleeding.

• Assess patients with suspected GI bleeds in a timely manner and manage or comanage the patient with the primary requesting service.

• Communicate with patients and families to explain the disease etiology, prognosis, risk reduction strategies, and symptoms of recurrent GI bleed.

• Communicate with patients and families to explain risks, benefits, and alternatives to transfusion therapy.

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care. 

Hospitalists should be able to:

• Employ a multidisciplinary approach, which may include nursing, pharmacy and nutrition services, and specialty and referring physicians, in the care of patients with GI bleeds that begins at admission and continues through all care transitions.

• Establish and maintain an open dialogue with patients and/or families regarding goals and limitations of care, including palliative care and end-of-life wishes. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in the development and promotion of evidence-based guidelines and/or pathways for treatment of patients with GI bleeds.

• Lead, coordinate, and/or participate in multidisciplinary teams to develop quality improvement initiatives that promote early identification of GI bleeds and reduce preventable complications.

• Develop systems that provide timely reports of pending study results to outpatient providers.

• Integrate outcomes research, institution-specific laboratory policies, and hospital formulary to create indicated and cost-effective diagnostic and management strategies for patients with GI bleeds.

Heart failure (HF) is characterized by impaired cardiac function resulting in a constellation of symptoms that includes fatigue, weakness, and shortness of breath. In North America, the lifetime risk of developing HF is 20% for all persons older than 40 years; more than 5 million persons have HF in the United States.^1,2 Roughly half of those who develop HF die within 5 years of diagnosis.¹ HF exacerbation is one of the most common diagnoses leading to hospital admission, and annually more than 1 million hospital discharges occur with HF as the primary diagnosis. The average length of stay is 5.2 days.³ Direct medical costs for HF total more than $20 billion each year.⁴ Despite published guidelines for HF management, treatment of hospitalized patients varies markedly. Hospitalists can lead their institutions in the prompt diagnosis of HF, initiation of evidence-based medical therapy, and incorporation of a multidisciplinary approach to management. Hospitalists can also develop strategies to operationalize cost-effective interventions that reduce morbidity, mortality, and readmissions. 

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Hospitalists should be able to:

• Explain underlying causes of HF and precipitating factors leading to exacerbation.

• Differentiate features of systolic and diastolic dysfunction and explain the common etiologies of each.

• Identify the clinical indications for hospitalization for acute decompensated HF.

• Describe the indicated tests required to evaluate HF including assessment of both left and right ventricular function.

• Explain when reassessment of left ventricular function is indicated.

• Explain the utility and limitations of cardiac biomarkers (eg, age adjusted).

• Explain markers of disease severity and factors that influence prognosis.

• Describe risk factors for the development of HF in the hospital setting.

• Recognize indications for early cardiology consultation.

• Describe the goals of inpatient therapy for acute decompensated HF, including pre-load and after-load reduction, hemodynamic stabilization, and optimization of volume status.

• Describe the role of invasive and noninvasive ventilatory support.

• Explain evidence-based therapeutic options for management of both acute and chronic HF and list contraindications to these therapies.

• Explain indications, contraindications, and mechanisms of action of pharmacologic agents used to treat HF.

• Identify medications and interventions contraindicated in HF.

• Recognize indications for device therapy (such as implanted cardioverter defibrillator, cardiac resynchronization therapy, and left ventricular assist devices).

• Recognize indications and qualifications for cardiac transplant evaluation.

• Explain the importance of palliative care in the treatment of patients with chronic HF.

• Explain goals for hospital discharge including specific measures of clinical stability for safe care transition.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history and review the medical record to identify symptoms, comorbidities, medications, and/or social influences contributing to HF or its exacerbation.

• Recognize the clinical presentation of HF including features of exacerbation and reliability of signs and symptoms.

• Identify physical findings consistent with HF.

• Identify symptoms and signs of low perfusion states and cardiogenic shock.

• Assess patients with suspected HF in a timely manner, identify the level of care required, and manage or comanage the patient with the primary requesting service.

• Order indicated diagnostic testing to identify precipitating factors of HF and assess cardiac function.

• Risk stratify patients admitted with HF and determine the appropriate level of care.

• Formulate an evidence-based treatment plan tailored to the individual patient, which may include pharmacologic agents, device implantation, nutritional recommendations, and patient adherence.

• Recognize symptoms and signs of acute decompensation and initiate immediate indicated therapies.

• Communicate with patients and families to explain the history and prognosis of HF.

• Communicate with patients and families to explain tests and procedures and their indications and to obtain informed consent.

• Communicate with patients and families to explain the use and potential adverse effects of pharmacologic agents.

• Communicate with patients and families to explain the importance of home self-monitoring, adherence to medication regimens, nutritional recommendations, and physical rehabilitation.

• Facilitate discharge planning early during hospitalization.

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

• Communicate to outpatient providers the relevant events of the hospitalization and postdischarge needs, including pending tests, and determine who is responsible for checking the results.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians. 

Hospitalists should be able to:

• Employ a multidisciplinary approach in the care of patients with HF that begins at admission and continues through all care transitions.

• Follow evidence-based recommendations to guide diagnosis, monitoring, and treatment of HF.

• Advocate the importance of behavioral modification to delay the progression of disease and improve quality of life.

• Responsibly address and respect end-of-life care wishes for patients with end-stage HF. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in multidisciplinary teams, which may include nursing and social services, nutrition, pharmacy, and physical therapy, early in the hospital course to facilitate patient education and discharge planning, improve patient function and outcomes, and advocate for patient outreach after discharge.

• Implement systems to ensure hospital-wide adherence to national standards and document those measures as specified by recognized organizations (eg, Joint Commission on Accreditation of Healthcare Organizations, American Heart Association, American College of Cardiology, Agency for Healthcare Research and Quality).

• Integrate outcomes research, institution-specific laboratory policies, and hospital formulary to create guideline-driven and cost-effective diagnostic and management strategies for patients with HF.

• Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize resource use.

• Advocate to hospital administrators to establish and support outpatient programs that have been shown to reduce readmissions and other unfavorable patient outcomes through outreach to patients with HF.

• Lead efforts to educate staff on the importance of smoking cessation counseling and other preventive measures.

• Lead, coordinate, and/or participate in initiatives to increase awareness and improve documentation efforts that appropriately categorize patients with HF and the impact this may have on risk-adjusted mortality and value-based purchasing.

Heart failure (HF) is characterized by impaired cardiac function resulting in a constellation of symptoms that includes fatigue, weakness, and shortness of breath. In North America, the lifetime risk of developing HF is 20% for all persons older than 40 years; more than 5 million persons have HF in the United States.^1,2 Roughly half of those who develop HF die within 5 years of diagnosis.¹ HF exacerbation is one of the most common diagnoses leading to hospital admission, and annually more than 1 million hospital discharges occur with HF as the primary diagnosis. The average length of stay is 5.2 days.³ Direct medical costs for HF total more than $20 billion each year.⁴ Despite published guidelines for HF management, treatment of hospitalized patients varies markedly. Hospitalists can lead their institutions in the prompt diagnosis of HF, initiation of evidence-based medical therapy, and incorporation of a multidisciplinary approach to management. Hospitalists can also develop strategies to operationalize cost-effective interventions that reduce morbidity, mortality, and readmissions. 

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Hospitalists should be able to:

• Explain underlying causes of HF and precipitating factors leading to exacerbation.

• Differentiate features of systolic and diastolic dysfunction and explain the common etiologies of each.

• Identify the clinical indications for hospitalization for acute decompensated HF.

• Describe the indicated tests required to evaluate HF including assessment of both left and right ventricular function.

• Explain when reassessment of left ventricular function is indicated.

• Explain the utility and limitations of cardiac biomarkers (eg, age adjusted).

• Explain markers of disease severity and factors that influence prognosis.

• Describe risk factors for the development of HF in the hospital setting.

• Recognize indications for early cardiology consultation.

• Describe the goals of inpatient therapy for acute decompensated HF, including pre-load and after-load reduction, hemodynamic stabilization, and optimization of volume status.

• Describe the role of invasive and noninvasive ventilatory support.

• Explain evidence-based therapeutic options for management of both acute and chronic HF and list contraindications to these therapies.

• Explain indications, contraindications, and mechanisms of action of pharmacologic agents used to treat HF.

• Identify medications and interventions contraindicated in HF.

• Recognize indications for device therapy (such as implanted cardioverter defibrillator, cardiac resynchronization therapy, and left ventricular assist devices).

• Recognize indications and qualifications for cardiac transplant evaluation.

• Explain the importance of palliative care in the treatment of patients with chronic HF.

• Explain goals for hospital discharge including specific measures of clinical stability for safe care transition.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history and review the medical record to identify symptoms, comorbidities, medications, and/or social influences contributing to HF or its exacerbation.

• Recognize the clinical presentation of HF including features of exacerbation and reliability of signs and symptoms.

• Identify physical findings consistent with HF.

• Identify symptoms and signs of low perfusion states and cardiogenic shock.

• Assess patients with suspected HF in a timely manner, identify the level of care required, and manage or comanage the patient with the primary requesting service.

• Order indicated diagnostic testing to identify precipitating factors of HF and assess cardiac function.

• Risk stratify patients admitted with HF and determine the appropriate level of care.

• Formulate an evidence-based treatment plan tailored to the individual patient, which may include pharmacologic agents, device implantation, nutritional recommendations, and patient adherence.

• Recognize symptoms and signs of acute decompensation and initiate immediate indicated therapies.

• Communicate with patients and families to explain the history and prognosis of HF.

• Communicate with patients and families to explain tests and procedures and their indications and to obtain informed consent.

• Communicate with patients and families to explain the use and potential adverse effects of pharmacologic agents.

• Communicate with patients and families to explain the importance of home self-monitoring, adherence to medication regimens, nutritional recommendations, and physical rehabilitation.

• Facilitate discharge planning early during hospitalization.

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

• Communicate to outpatient providers the relevant events of the hospitalization and postdischarge needs, including pending tests, and determine who is responsible for checking the results.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians. 

Hospitalists should be able to:

• Employ a multidisciplinary approach in the care of patients with HF that begins at admission and continues through all care transitions.

• Follow evidence-based recommendations to guide diagnosis, monitoring, and treatment of HF.

• Advocate the importance of behavioral modification to delay the progression of disease and improve quality of life.

• Responsibly address and respect end-of-life care wishes for patients with end-stage HF. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in multidisciplinary teams, which may include nursing and social services, nutrition, pharmacy, and physical therapy, early in the hospital course to facilitate patient education and discharge planning, improve patient function and outcomes, and advocate for patient outreach after discharge.

• Implement systems to ensure hospital-wide adherence to national standards and document those measures as specified by recognized organizations (eg, Joint Commission on Accreditation of Healthcare Organizations, American Heart Association, American College of Cardiology, Agency for Healthcare Research and Quality).

• Integrate outcomes research, institution-specific laboratory policies, and hospital formulary to create guideline-driven and cost-effective diagnostic and management strategies for patients with HF.

• Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize resource use.

• Advocate to hospital administrators to establish and support outpatient programs that have been shown to reduce readmissions and other unfavorable patient outcomes through outreach to patients with HF.

• Lead efforts to educate staff on the importance of smoking cessation counseling and other preventive measures.

• Lead, coordinate, and/or participate in initiatives to increase awareness and improve documentation efforts that appropriately categorize patients with HF and the impact this may have on risk-adjusted mortality and value-based purchasing.

Heart failure (HF) is characterized by impaired cardiac function resulting in a constellation of symptoms that includes fatigue, weakness, and shortness of breath. In North America, the lifetime risk of developing HF is 20% for all persons older than 40 years; more than 5 million persons have HF in the United States.^1,2 Roughly half of those who develop HF die within 5 years of diagnosis.¹ HF exacerbation is one of the most common diagnoses leading to hospital admission, and annually more than 1 million hospital discharges occur with HF as the primary diagnosis. The average length of stay is 5.2 days.³ Direct medical costs for HF total more than $20 billion each year.⁴ Despite published guidelines for HF management, treatment of hospitalized patients varies markedly. Hospitalists can lead their institutions in the prompt diagnosis of HF, initiation of evidence-based medical therapy, and incorporation of a multidisciplinary approach to management. Hospitalists can also develop strategies to operationalize cost-effective interventions that reduce morbidity, mortality, and readmissions. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Explain underlying causes of HF and precipitating factors leading to exacerbation.

• Differentiate features of systolic and diastolic dysfunction and explain the common etiologies of each.

• Identify the clinical indications for hospitalization for acute decompensated HF.

• Describe the indicated tests required to evaluate HF including assessment of both left and right ventricular function.

• Explain when reassessment of left ventricular function is indicated.

• Explain the utility and limitations of cardiac biomarkers (eg, age adjusted).

• Explain markers of disease severity and factors that influence prognosis.

• Describe risk factors for the development of HF in the hospital setting.

• Recognize indications for early cardiology consultation.

• Describe the goals of inpatient therapy for acute decompensated HF, including pre-load and after-load reduction, hemodynamic stabilization, and optimization of volume status.

• Describe the role of invasive and noninvasive ventilatory support.

• Explain evidence-based therapeutic options for management of both acute and chronic HF and list contraindications to these therapies.

• Explain indications, contraindications, and mechanisms of action of pharmacologic agents used to treat HF.

• Identify medications and interventions contraindicated in HF.

• Recognize indications for device therapy (such as implanted cardioverter defibrillator, cardiac resynchronization therapy, and left ventricular assist devices).

• Recognize indications and qualifications for cardiac transplant evaluation.

• Explain the importance of palliative care in the treatment of patients with chronic HF.

• Explain goals for hospital discharge including specific measures of clinical stability for safe care transition.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history and review the medical record to identify symptoms, comorbidities, medications, and/or social influences contributing to HF or its exacerbation.

• Recognize the clinical presentation of HF including features of exacerbation and reliability of signs and symptoms.

• Identify physical findings consistent with HF.

• Identify symptoms and signs of low perfusion states and cardiogenic shock.

• Assess patients with suspected HF in a timely manner, identify the level of care required, and manage or comanage the patient with the primary requesting service.

• Order indicated diagnostic testing to identify precipitating factors of HF and assess cardiac function.

• Risk stratify patients admitted with HF and determine the appropriate level of care.

• Formulate an evidence-based treatment plan tailored to the individual patient, which may include pharmacologic agents, device implantation, nutritional recommendations, and patient adherence.

• Recognize symptoms and signs of acute decompensation and initiate immediate indicated therapies.

• Communicate with patients and families to explain the history and prognosis of HF.

• Communicate with patients and families to explain tests and procedures and their indications and to obtain informed consent.

• Communicate with patients and families to explain the use and potential adverse effects of pharmacologic agents.

• Communicate with patients and families to explain the importance of home self-monitoring, adherence to medication regimens, nutritional recommendations, and physical rehabilitation.

• Facilitate discharge planning early during hospitalization.

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

• Communicate to outpatient providers the relevant events of the hospitalization and postdischarge needs, including pending tests, and determine who is responsible for checking the results.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians. 

Hospitalists should be able to:

• Employ a multidisciplinary approach in the care of patients with HF that begins at admission and continues through all care transitions.

• Follow evidence-based recommendations to guide diagnosis, monitoring, and treatment of HF.

• Advocate the importance of behavioral modification to delay the progression of disease and improve quality of life.

• Responsibly address and respect end-of-life care wishes for patients with end-stage HF. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in multidisciplinary teams, which may include nursing and social services, nutrition, pharmacy, and physical therapy, early in the hospital course to facilitate patient education and discharge planning, improve patient function and outcomes, and advocate for patient outreach after discharge.

• Implement systems to ensure hospital-wide adherence to national standards and document those measures as specified by recognized organizations (eg, Joint Commission on Accreditation of Healthcare Organizations, American Heart Association, American College of Cardiology, Agency for Healthcare Research and Quality).

• Integrate outcomes research, institution-specific laboratory policies, and hospital formulary to create guideline-driven and cost-effective diagnostic and management strategies for patients with HF.

• Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize resource use.

• Advocate to hospital administrators to establish and support outpatient programs that have been shown to reduce readmissions and other unfavorable patient outcomes through outreach to patients with HF.

• Lead efforts to educate staff on the importance of smoking cessation counseling and other preventive measures.

• Lead, coordinate, and/or participate in initiatives to increase awareness and improve documentation efforts that appropriately categorize patients with HF and the impact this may have on risk-adjusted mortality and value-based purchasing.

Hospital-acquired pneumonia (HAP) is an infection of the lung parenchyma that occurs during the course of hospitalization. HAP is a significant source of morbidity, mortality, and increased resource expenditures, including prolonged hospital length of stay by an average of 7 to 9 days.^1-3 HAP accounts for approximately 15% of all hospital-acquired infections, and the associated mortality rate ranges from 20% to 50%.^1-4 The primary risk factor for the development of HAP is mechanical ventilation, and HAP occurs in 9% to 27% of all intubated patients.^1,3 Hospitalists manage patients with HAP either as an attending physician or as a consultant to patients admitted to other services. Healthcare-associated pneumonia (HCAP) was added as a category of pneumonia in the 2005 American Thoracic Society/Infectious Diseases Society of America guidelines to identify patients at increased risk for multidrug-resistant pathogens coming from community settings. HCAP is defined as pneumonia acquired in healthcare environments outside of the traditional hospital setting and is distinct from community-acquired pneumonia (CAP), HAP, or ventilator-acquired pneumonia. HCAP more closely resembles HAP with respect to pathogens and prognosis. Quality indicators have been created around the key processes of care for patients with pneumonia, and these indicators are used to evaluate performance of states, healthcare organizations, physician groups, and individual physicians. Hospitalists apply evidence-based practice guidelines to the management of patients hospitalized with pneumonia and lead initiatives to improve quality of care and reduce practice variability. 

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Hospitalists should be able to:

• Define HAP and HCAP and differentiate them from CAP.

• List common organisms associated with HAP and HCAP.

• Describe local and national resistance patterns for HAP and HCAP.

• Identify important historical elements, medical record data, and physical examination findings consistent with HAP and HCAP.

• Differentiate the infectious causes of HAP and HCAP from those of CAP.

• Describe the tests required to evaluate HAP and HCAP.

• Identify risk factors for developing HAP and HCAP.

• Describe the role of mechanical ventilation as a risk factor for the development of HAP.

• Explain the prophylactic measures commonly used to lower the risk of HAP.

• Describe steps that can be used to limit the emergence of antibiotic resistance.

• Recognize indications for specialty consultation, which may include infectious disease and/or pulmonary services.

• Describe the role of mechanical ventilation as a potential treatment option.

• Describe infection control practices to prevent the spread of resistant organisms within the hospital.

• Describe potential complications of HAP and HCAP.

• Explain goals for hospital discharge including evidence-based measures of clinical stability for safe care transition.

• Explain implications of HAP and HCAP on discharge planning.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history to identify symptoms consistent with HAP and HCAP.

• Perform a targeted physical examination to elicit signs consistent with HAP and HCAP.

• Assess patients with suspected HAP in a timely manner and manage or comanage the patient with the primary requesting service.

• Order and interpret laboratory, microbiologic, and radiologic studies to confirm the diagnosis of HAP and HCAP and determine the etiologic agent.

• Initiate an empiric antibiotic regimen on the basis of patient history, underlying comorbid conditions, likely organisms, and local resistance patterns.

• Tailor antibiotic regimens on the basis of microbiologic culture and sensitivity data as soon as available.

• Manage complications of HAP and HCAP, which may include respiratory failure, pleural effusions, and empyema.

• Coordinate care for patients requiring mechanical ventilation.

• Identify patients who require thoracentesis, perform or coordinate the procedure, and interpret the results.

• Communicate with patients and families to explain the tests, procedures, and their indications, and to obtain informed consent.

• Communicate with patients and families to explain the etiology, management plan, and potential outcomes of HAP and HCAP.

• Facilitate discharge planning early during hospitalization.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians. 

Hospitalists should be able to:

• Employ a multidisciplinary approach, which may include nursing, respiratory therapy, nutrition, and pharmacy services, to the care of patients with HAP and HCAP through all care transitions.

• Follow evidence-based recommendations, protocols, and risk stratification tools for the treatment of HAP.

• Work collaboratively with primary care physicians and emergency physicians in making admission decisions. 

To improve efficiency and quality within their organizations, hospitalists should:

• Collaborate with local infection control practitioners to reduce the spread of resistant organisms within the institution.

• Lead, coordinate, and/or participate in multidisciplinary initiatives, which may include collaboration with critical care specialists and pulmonologists, to reduce the incidence of HAP in ventilated patients.

• Lead, coordinate, and/or participate in quality improvement initiatives to reduce ventilator days, rates of HAP, and variance in antibiotic use.

• Implement systems to ensure hospital-wide adherence to national standards for empiric antibiotic use and document those measures as specified by recognized organizations.

• Lead efforts to educate staff on the importance of smoking cessation counseling and other preventive measures.

Hospital-acquired pneumonia (HAP) is an infection of the lung parenchyma that occurs during the course of hospitalization. HAP is a significant source of morbidity, mortality, and increased resource expenditures, including prolonged hospital length of stay by an average of 7 to 9 days.^1-3 HAP accounts for approximately 15% of all hospital-acquired infections, and the associated mortality rate ranges from 20% to 50%.^1-4 The primary risk factor for the development of HAP is mechanical ventilation, and HAP occurs in 9% to 27% of all intubated patients.^1,3 Hospitalists manage patients with HAP either as an attending physician or as a consultant to patients admitted to other services. Healthcare-associated pneumonia (HCAP) was added as a category of pneumonia in the 2005 American Thoracic Society/Infectious Diseases Society of America guidelines to identify patients at increased risk for multidrug-resistant pathogens coming from community settings. HCAP is defined as pneumonia acquired in healthcare environments outside of the traditional hospital setting and is distinct from community-acquired pneumonia (CAP), HAP, or ventilator-acquired pneumonia. HCAP more closely resembles HAP with respect to pathogens and prognosis. Quality indicators have been created around the key processes of care for patients with pneumonia, and these indicators are used to evaluate performance of states, healthcare organizations, physician groups, and individual physicians. Hospitalists apply evidence-based practice guidelines to the management of patients hospitalized with pneumonia and lead initiatives to improve quality of care and reduce practice variability. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Define HAP and HCAP and differentiate them from CAP.

• List common organisms associated with HAP and HCAP.

• Describe local and national resistance patterns for HAP and HCAP.

• Identify important historical elements, medical record data, and physical examination findings consistent with HAP and HCAP.

• Differentiate the infectious causes of HAP and HCAP from those of CAP.

• Describe the tests required to evaluate HAP and HCAP.

• Identify risk factors for developing HAP and HCAP.

• Describe the role of mechanical ventilation as a risk factor for the development of HAP.

• Explain the prophylactic measures commonly used to lower the risk of HAP.

• Describe steps that can be used to limit the emergence of antibiotic resistance.

• Recognize indications for specialty consultation, which may include infectious disease and/or pulmonary services.

• Describe the role of mechanical ventilation as a potential treatment option.

• Describe infection control practices to prevent the spread of resistant organisms within the hospital.

• Describe potential complications of HAP and HCAP.

• Explain goals for hospital discharge including evidence-based measures of clinical stability for safe care transition.

• Explain implications of HAP and HCAP on discharge planning.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history to identify symptoms consistent with HAP and HCAP.

• Perform a targeted physical examination to elicit signs consistent with HAP and HCAP.

• Assess patients with suspected HAP in a timely manner and manage or comanage the patient with the primary requesting service.

• Order and interpret laboratory, microbiologic, and radiologic studies to confirm the diagnosis of HAP and HCAP and determine the etiologic agent.

• Initiate an empiric antibiotic regimen on the basis of patient history, underlying comorbid conditions, likely organisms, and local resistance patterns.

• Tailor antibiotic regimens on the basis of microbiologic culture and sensitivity data as soon as available.

• Manage complications of HAP and HCAP, which may include respiratory failure, pleural effusions, and empyema.

• Coordinate care for patients requiring mechanical ventilation.

• Identify patients who require thoracentesis, perform or coordinate the procedure, and interpret the results.

• Communicate with patients and families to explain the tests, procedures, and their indications, and to obtain informed consent.

• Communicate with patients and families to explain the etiology, management plan, and potential outcomes of HAP and HCAP.

• Facilitate discharge planning early during hospitalization.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians. 

Hospitalists should be able to:

• Employ a multidisciplinary approach, which may include nursing, respiratory therapy, nutrition, and pharmacy services, to the care of patients with HAP and HCAP through all care transitions.

• Follow evidence-based recommendations, protocols, and risk stratification tools for the treatment of HAP.

• Work collaboratively with primary care physicians and emergency physicians in making admission decisions. 

To improve efficiency and quality within their organizations, hospitalists should:

• Collaborate with local infection control practitioners to reduce the spread of resistant organisms within the institution.

• Lead, coordinate, and/or participate in multidisciplinary initiatives, which may include collaboration with critical care specialists and pulmonologists, to reduce the incidence of HAP in ventilated patients.

• Lead, coordinate, and/or participate in quality improvement initiatives to reduce ventilator days, rates of HAP, and variance in antibiotic use.

• Implement systems to ensure hospital-wide adherence to national standards for empiric antibiotic use and document those measures as specified by recognized organizations.

• Lead efforts to educate staff on the importance of smoking cessation counseling and other preventive measures.

Hospital-acquired pneumonia (HAP) is an infection of the lung parenchyma that occurs during the course of hospitalization. HAP is a significant source of morbidity, mortality, and increased resource expenditures, including prolonged hospital length of stay by an average of 7 to 9 days.^1-3 HAP accounts for approximately 15% of all hospital-acquired infections, and the associated mortality rate ranges from 20% to 50%.^1-4 The primary risk factor for the development of HAP is mechanical ventilation, and HAP occurs in 9% to 27% of all intubated patients.^1,3 Hospitalists manage patients with HAP either as an attending physician or as a consultant to patients admitted to other services. Healthcare-associated pneumonia (HCAP) was added as a category of pneumonia in the 2005 American Thoracic Society/Infectious Diseases Society of America guidelines to identify patients at increased risk for multidrug-resistant pathogens coming from community settings. HCAP is defined as pneumonia acquired in healthcare environments outside of the traditional hospital setting and is distinct from community-acquired pneumonia (CAP), HAP, or ventilator-acquired pneumonia. HCAP more closely resembles HAP with respect to pathogens and prognosis. Quality indicators have been created around the key processes of care for patients with pneumonia, and these indicators are used to evaluate performance of states, healthcare organizations, physician groups, and individual physicians. Hospitalists apply evidence-based practice guidelines to the management of patients hospitalized with pneumonia and lead initiatives to improve quality of care and reduce practice variability. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Define HAP and HCAP and differentiate them from CAP.

• List common organisms associated with HAP and HCAP.

• Describe local and national resistance patterns for HAP and HCAP.

• Identify important historical elements, medical record data, and physical examination findings consistent with HAP and HCAP.

• Differentiate the infectious causes of HAP and HCAP from those of CAP.

• Describe the tests required to evaluate HAP and HCAP.

• Identify risk factors for developing HAP and HCAP.

• Describe the role of mechanical ventilation as a risk factor for the development of HAP.

• Explain the prophylactic measures commonly used to lower the risk of HAP.

• Describe steps that can be used to limit the emergence of antibiotic resistance.

• Recognize indications for specialty consultation, which may include infectious disease and/or pulmonary services.

• Describe the role of mechanical ventilation as a potential treatment option.

• Describe infection control practices to prevent the spread of resistant organisms within the hospital.

• Describe potential complications of HAP and HCAP.

• Explain goals for hospital discharge including evidence-based measures of clinical stability for safe care transition.

• Explain implications of HAP and HCAP on discharge planning.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history to identify symptoms consistent with HAP and HCAP.

• Perform a targeted physical examination to elicit signs consistent with HAP and HCAP.

• Assess patients with suspected HAP in a timely manner and manage or comanage the patient with the primary requesting service.

• Order and interpret laboratory, microbiologic, and radiologic studies to confirm the diagnosis of HAP and HCAP and determine the etiologic agent.

• Initiate an empiric antibiotic regimen on the basis of patient history, underlying comorbid conditions, likely organisms, and local resistance patterns.

• Tailor antibiotic regimens on the basis of microbiologic culture and sensitivity data as soon as available.

• Manage complications of HAP and HCAP, which may include respiratory failure, pleural effusions, and empyema.

• Coordinate care for patients requiring mechanical ventilation.

• Identify patients who require thoracentesis, perform or coordinate the procedure, and interpret the results.

• Communicate with patients and families to explain the tests, procedures, and their indications, and to obtain informed consent.

• Communicate with patients and families to explain the etiology, management plan, and potential outcomes of HAP and HCAP.

• Facilitate discharge planning early during hospitalization.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians. 

Hospitalists should be able to:

• Employ a multidisciplinary approach, which may include nursing, respiratory therapy, nutrition, and pharmacy services, to the care of patients with HAP and HCAP through all care transitions.

• Follow evidence-based recommendations, protocols, and risk stratification tools for the treatment of HAP.

• Work collaboratively with primary care physicians and emergency physicians in making admission decisions. 

To improve efficiency and quality within their organizations, hospitalists should:

• Collaborate with local infection control practitioners to reduce the spread of resistant organisms within the institution.

• Lead, coordinate, and/or participate in multidisciplinary initiatives, which may include collaboration with critical care specialists and pulmonologists, to reduce the incidence of HAP in ventilated patients.

• Lead, coordinate, and/or participate in quality improvement initiatives to reduce ventilator days, rates of HAP, and variance in antibiotic use.

• Implement systems to ensure hospital-wide adherence to national standards for empiric antibiotic use and document those measures as specified by recognized organizations.

• Lead efforts to educate staff on the importance of smoking cessation counseling and other preventive measures.

Hyponatremia, defined as a serum sodium value less than 135 mEq/L, is the most common electrolyte disorder observed in hospitalized patients in the United States, occurring in up to 60% of patients.¹ The disorder may develop within 48 hours of, or during, hospitalization (acute), or may be subacute or chronic. When it develops in the hospital, hyponatremia is associated with increased length of stay, increased cost of hospitalization, increased in-hospital mortality, and increased postdischarge mortality. Even chronic hyponatremia present at hospital admission adversely affects outcomes—such patients have a 30% higher risk of mortality and are hospitalized 14% longer than patients without hyponatremia at admission.^2,3Hospitalists can facilitate the evaluation and management of hyponatremia to improve patient outcomes, as well as decrease healthcare costs and length of stay. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Distinguish acute from chronic hyponatremia.

• Identify hospitalized patients at risk of developing hyponatremia and institute monitoring measures to increase early recognition.

• Describe the symptoms of mild and severe hyponatremia.

• Describe the indicated serum and urine laboratory tests used to evaluate the causes of hyponatremia.

• Differentiate among hypertonic, isotonic, and hypotonic forms of hyponatremia.

• Identify the likely pathophysiologic process underlying a patient’s hyponatremia on the basis of urine osmolality and electrolyte concentrations.

• Identify the likely pathophysiologic process underlying a patient’s hyponatremia on the basis of the clinical volume status and urine sodium value.

• Explain how concurrent fluid administration or diuresis may affect urinary tests used in the evaluation of hyponatremia.

• Explain the physiology leading to development of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and describe how it is diagnosed.

• Recognize indications for specialty consultation, such as endocrinology or nephrology.

• Describe an appropriate treatment strategy for patients with asymptomatic, mildly symptomatic, and severely symptomatic hyponatremia, including the risks of treatment.

• Explain the appropriate rate of correction for acute or chronic hyponatremia, adjusted to the needs of the individual patient.

• Explain the indications for water restriction in hyponatremia.

• Explain the indications of isotonic sodium chloride fluid administration in hyponatremia.

• Explain the indications for hypertonic sodium chloride fluid administration in hyponatremia.

• Explain the role, limitations, risks, and contraindications of vasopressin receptor agonists in the treatment of hyponatremia.

• Predict how concurrent correction of other electrolyte disorders (eg, hypokalemia) may affect sodium correction.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history, perform a physical examination, and review the medical record for factors contributing to the development of hyponatremia.

• Accurately assess the relevant volume status and neurologic examination findings of a patient with hyponatremia.

• Order and interpret indicated diagnostic studies that may include serum electrolytes, serum and urine osmolality, serum blood urea nitrogen, creatinine, uric acid, urine sodium, thyrotropin, and early-morning cortisol.

• Formulate and implement the most appropriate intervention tailored to the individual patient’s etiology of hyponatremia while minimizing potential complications from overcorrection or undercorrection.

• Identify the most appropriate care setting to monitor patients with hyponatremia, including indications to transfer to the intensive care unit.

• Recognize symptoms and signs of severe hyponatremia and osmotic demyelination syndrome.

• Communicate with patients and families to explain the significance, etiology, and importance of recognizing and treating hyponatremia.

• Communicate with patients and families to explain the risks, monitoring, and appropriate management of hyponatremia.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians.

• Facilitate coordination of transitional monitoring of recurrent hyponatremia after hospital discharge. 

Hospitalists should be able to:

• Follow evidence-based recommendations when managing hospitalized patients with hyponatremia.

• Acknowledge the opportunity to decrease mortality, length of stay, and healthcare costs by addressing hyponatremia, even when asymptomatic. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize management strategies for hyponatremia.

• Participate in initiatives to articulate, manage, or restrict the use of high-risk therapies, such as hypertonic saline.

Hyponatremia, defined as a serum sodium value less than 135 mEq/L, is the most common electrolyte disorder observed in hospitalized patients in the United States, occurring in up to 60% of patients.¹ The disorder may develop within 48 hours of, or during, hospitalization (acute), or may be subacute or chronic. When it develops in the hospital, hyponatremia is associated with increased length of stay, increased cost of hospitalization, increased in-hospital mortality, and increased postdischarge mortality. Even chronic hyponatremia present at hospital admission adversely affects outcomes—such patients have a 30% higher risk of mortality and are hospitalized 14% longer than patients without hyponatremia at admission.^2,3Hospitalists can facilitate the evaluation and management of hyponatremia to improve patient outcomes, as well as decrease healthcare costs and length of stay. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Distinguish acute from chronic hyponatremia.

• Identify hospitalized patients at risk of developing hyponatremia and institute monitoring measures to increase early recognition.

• Describe the symptoms of mild and severe hyponatremia.

• Describe the indicated serum and urine laboratory tests used to evaluate the causes of hyponatremia.

• Differentiate among hypertonic, isotonic, and hypotonic forms of hyponatremia.

• Identify the likely pathophysiologic process underlying a patient’s hyponatremia on the basis of urine osmolality and electrolyte concentrations.

• Identify the likely pathophysiologic process underlying a patient’s hyponatremia on the basis of the clinical volume status and urine sodium value.

• Explain how concurrent fluid administration or diuresis may affect urinary tests used in the evaluation of hyponatremia.

• Explain the physiology leading to development of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and describe how it is diagnosed.

• Recognize indications for specialty consultation, such as endocrinology or nephrology.

• Describe an appropriate treatment strategy for patients with asymptomatic, mildly symptomatic, and severely symptomatic hyponatremia, including the risks of treatment.

• Explain the appropriate rate of correction for acute or chronic hyponatremia, adjusted to the needs of the individual patient.

• Explain the indications for water restriction in hyponatremia.

• Explain the indications of isotonic sodium chloride fluid administration in hyponatremia.

• Explain the indications for hypertonic sodium chloride fluid administration in hyponatremia.

• Explain the role, limitations, risks, and contraindications of vasopressin receptor agonists in the treatment of hyponatremia.

• Predict how concurrent correction of other electrolyte disorders (eg, hypokalemia) may affect sodium correction.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history, perform a physical examination, and review the medical record for factors contributing to the development of hyponatremia.

• Accurately assess the relevant volume status and neurologic examination findings of a patient with hyponatremia.

• Order and interpret indicated diagnostic studies that may include serum electrolytes, serum and urine osmolality, serum blood urea nitrogen, creatinine, uric acid, urine sodium, thyrotropin, and early-morning cortisol.

• Formulate and implement the most appropriate intervention tailored to the individual patient’s etiology of hyponatremia while minimizing potential complications from overcorrection or undercorrection.

• Identify the most appropriate care setting to monitor patients with hyponatremia, including indications to transfer to the intensive care unit.

• Recognize symptoms and signs of severe hyponatremia and osmotic demyelination syndrome.

• Communicate with patients and families to explain the significance, etiology, and importance of recognizing and treating hyponatremia.

• Communicate with patients and families to explain the risks, monitoring, and appropriate management of hyponatremia.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians.

• Facilitate coordination of transitional monitoring of recurrent hyponatremia after hospital discharge. 

Hospitalists should be able to:

• Follow evidence-based recommendations when managing hospitalized patients with hyponatremia.

• Acknowledge the opportunity to decrease mortality, length of stay, and healthcare costs by addressing hyponatremia, even when asymptomatic. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize management strategies for hyponatremia.

• Participate in initiatives to articulate, manage, or restrict the use of high-risk therapies, such as hypertonic saline.

Hyponatremia, defined as a serum sodium value less than 135 mEq/L, is the most common electrolyte disorder observed in hospitalized patients in the United States, occurring in up to 60% of patients.¹ The disorder may develop within 48 hours of, or during, hospitalization (acute), or may be subacute or chronic. When it develops in the hospital, hyponatremia is associated with increased length of stay, increased cost of hospitalization, increased in-hospital mortality, and increased postdischarge mortality. Even chronic hyponatremia present at hospital admission adversely affects outcomes—such patients have a 30% higher risk of mortality and are hospitalized 14% longer than patients without hyponatremia at admission.^2,3Hospitalists can facilitate the evaluation and management of hyponatremia to improve patient outcomes, as well as decrease healthcare costs and length of stay. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Distinguish acute from chronic hyponatremia.

• Identify hospitalized patients at risk of developing hyponatremia and institute monitoring measures to increase early recognition.

• Describe the symptoms of mild and severe hyponatremia.

• Describe the indicated serum and urine laboratory tests used to evaluate the causes of hyponatremia.

• Differentiate among hypertonic, isotonic, and hypotonic forms of hyponatremia.

• Identify the likely pathophysiologic process underlying a patient’s hyponatremia on the basis of urine osmolality and electrolyte concentrations.

• Identify the likely pathophysiologic process underlying a patient’s hyponatremia on the basis of the clinical volume status and urine sodium value.

• Explain how concurrent fluid administration or diuresis may affect urinary tests used in the evaluation of hyponatremia.

• Explain the physiology leading to development of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and describe how it is diagnosed.

• Recognize indications for specialty consultation, such as endocrinology or nephrology.

• Describe an appropriate treatment strategy for patients with asymptomatic, mildly symptomatic, and severely symptomatic hyponatremia, including the risks of treatment.

• Explain the appropriate rate of correction for acute or chronic hyponatremia, adjusted to the needs of the individual patient.

• Explain the indications for water restriction in hyponatremia.

• Explain the indications of isotonic sodium chloride fluid administration in hyponatremia.

• Explain the indications for hypertonic sodium chloride fluid administration in hyponatremia.

• Explain the role, limitations, risks, and contraindications of vasopressin receptor agonists in the treatment of hyponatremia.

• Predict how concurrent correction of other electrolyte disorders (eg, hypokalemia) may affect sodium correction.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history, perform a physical examination, and review the medical record for factors contributing to the development of hyponatremia.

• Accurately assess the relevant volume status and neurologic examination findings of a patient with hyponatremia.

• Order and interpret indicated diagnostic studies that may include serum electrolytes, serum and urine osmolality, serum blood urea nitrogen, creatinine, uric acid, urine sodium, thyrotropin, and early-morning cortisol.

• Formulate and implement the most appropriate intervention tailored to the individual patient’s etiology of hyponatremia while minimizing potential complications from overcorrection or undercorrection.

• Identify the most appropriate care setting to monitor patients with hyponatremia, including indications to transfer to the intensive care unit.

• Recognize symptoms and signs of severe hyponatremia and osmotic demyelination syndrome.

• Communicate with patients and families to explain the significance, etiology, and importance of recognizing and treating hyponatremia.

• Communicate with patients and families to explain the risks, monitoring, and appropriate management of hyponatremia.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians.

• Facilitate coordination of transitional monitoring of recurrent hyponatremia after hospital discharge. 

Hospitalists should be able to:

• Follow evidence-based recommendations when managing hospitalized patients with hyponatremia.

• Acknowledge the opportunity to decrease mortality, length of stay, and healthcare costs by addressing hyponatremia, even when asymptomatic. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize management strategies for hyponatremia.

• Participate in initiatives to articulate, manage, or restrict the use of high-risk therapies, such as hypertonic saline.

Pain is a very common presenting or accompanying symptom in hospitalized patients. Pain management relies on the use of various modalities to alleviate suffering and restore patient function. Proper assessment and treatment of pain can improve clinical outcomes, discharge planning, and patient and family satisfaction. Managing pain in inpatients necessitates understanding the various mechanisms that cause pain, properties of analgesic pharmacologic and nonpharmacologic modalities, and accurate assessment of severity and treatment response. Hospitalists assess and manage patients experiencing pain. This role requires that hospitalists be aware of current issues and controversies in pain management. Opioid therapy, for example, is a well-established approach for treating severe acute pain and cancer-related pain, and opioids are the most commonly prescribed drug class in the United States.¹ However, the continued increase in opioid prescription coincides with an increased number of poisoning deaths. Poisoning deaths involving opioid analgesics have more than tripled since 1999.^2,3 To best manage patients’ pain, hospitalists must demonstrate empathy, clinical excellence, and an understanding of the myriad obstacles, cautions, specific knowledge, skills, and attitudes necessary for appropriate pain management. Hospitalists serve as leaders of multidisciplinary teams to develop policies and protocols to improve pain management in their healthcare system. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Describe the mechanisms that cause pain.

• Describe the symptoms and signs of pain.

• Differentiate acute, chronic, somatic, neuropathic, referred, and visceral pain syndromes.

• Differentiate tolerance, dependence, addiction, and pseudoaddiction.

• Describe the value and limitations of the physical examination and various validated pain intensity assessment scales.

• Recognize indications for specialty consultation, which may include pain service, anesthesiology, and physical and rehabilitation medicine.

• Explain the relationship among physical, cultural, and psychological factors and pain and pain thresholds.

• Describe the indications and limitations of opioid pharmacotherapy.

• Discuss the genetic, social, and psychological factors that may contribute to opioid addiction.

• Describe the indications and limitations of other analgesics including tramadol, tricyclic agents, and anticonvulsant medications in the treatment of various pain syndromes.

• Describe the indications and limitations of nonopioids including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and topical agents.

• Describe specific factors that affect dosing regimens such as drug half-life, renal function, and hepatic function.

• Describe the indications and limitations of nonpharmacologic methods of pain control available in the inpatient setting.

• Establish functional criteria for discharge.

Hospitalists should be able to:

• Elicit a thorough and relevant history and description of pain and review the medical record to determine the likely source and acuity of pain.

• Review patient pharmacologic and psychosocial history and identify factors contributing to pain or factors that might affect its management.

• Perform a physical examination to determine the likely source of pain.

• Order and interpret diagnostic studies to determine the source of pain when underlying acute illness is suspected.

• Assess pain severity using validated measurement tools.

• Formulate an initial pain management plan.

• Determine the appropriate route, dosage, and frequency of dosing for pharmacologic agents on the basis of patient-specific factors.

• Reassess pain severity and determine the need for escalating therapy and/or adjuvant therapies.

• Determine equianalgesic dosing for pharmacologic therapy when needed.

• Titrate short- and long-acting opioids to desired effect.

• Predict and counteract as needed expected analgesic adverse effects, including use of reversal and specific agents, especially in older patients.

• Anticipate and manage adverse effects of pain medications including respiratory depression and sedation, nausea, vomiting, and pruritis.

• Initiate appropriate therapies to prevent and treat constipation when a patient is taking opioid analgesics.

• Assess and communicate the need for pain management during medical consultation.

• Recognize the signs and symptoms of addiction and assess patients for prescription drug abuse when appropriate.

• Educate patients on the adverse effects of prescription drug abuse.

• Educate patients and physicians on the importance of appropriate use of opioids in pain management and explain the rarity of opioid addiction in the setting of appropriate pain management.

• Establish and maintain an open dialogue with patients and families regarding care goals and limitations, which may include palliative care and end-of-life wishes.

• Document treatment plans, provide clear discharge instructions, and communicate with the outpatient clinician responsible for follow-up to ensure a safe transition. 

Hospitalists should be able to:

• Employ a multidisciplinary approach to the assessment and management of patients with pain that begins at admission and continues through all care transitions.

• Follow evidence-based recommendations, including the World Health Organization (WHO) step approach to pain management.

• Promote the ethical imperative of frequent pain assessment and adequate control.

• Appreciate that all pain is subjective and acknowledge patients’ self-reports of pain.

• Appreciate the value of patient-controlled analgesia.

• Appreciate the importance of a patient/family-centered approach for establishing the goals for pain management strategies and setting targets for pain control. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in efforts to develop educational modules, order sets, and/or pathways that facilitate effective pain management in the hospital setting, with goals of improving outcomes and patient satisfaction, decreasing length of stay, and reducing rehospitalization rates.

• Lead, coordinate, and/or participate in efforts to measure quality of inpatient pain control, operationalize system improvements, and reduce barriers to adequate pain control.

• Lead, coordinate, and/or participate in efforts to establish or support existing multidisciplinary pain control teams.

Pain is a very common presenting or accompanying symptom in hospitalized patients. Pain management relies on the use of various modalities to alleviate suffering and restore patient function. Proper assessment and treatment of pain can improve clinical outcomes, discharge planning, and patient and family satisfaction. Managing pain in inpatients necessitates understanding the various mechanisms that cause pain, properties of analgesic pharmacologic and nonpharmacologic modalities, and accurate assessment of severity and treatment response. Hospitalists assess and manage patients experiencing pain. This role requires that hospitalists be aware of current issues and controversies in pain management. Opioid therapy, for example, is a well-established approach for treating severe acute pain and cancer-related pain, and opioids are the most commonly prescribed drug class in the United States.¹ However, the continued increase in opioid prescription coincides with an increased number of poisoning deaths. Poisoning deaths involving opioid analgesics have more than tripled since 1999.^2,3 To best manage patients’ pain, hospitalists must demonstrate empathy, clinical excellence, and an understanding of the myriad obstacles, cautions, specific knowledge, skills, and attitudes necessary for appropriate pain management. Hospitalists serve as leaders of multidisciplinary teams to develop policies and protocols to improve pain management in their healthcare system. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Describe the mechanisms that cause pain.

• Describe the symptoms and signs of pain.

• Differentiate acute, chronic, somatic, neuropathic, referred, and visceral pain syndromes.

• Differentiate tolerance, dependence, addiction, and pseudoaddiction.

• Describe the value and limitations of the physical examination and various validated pain intensity assessment scales.

• Recognize indications for specialty consultation, which may include pain service, anesthesiology, and physical and rehabilitation medicine.

• Explain the relationship among physical, cultural, and psychological factors and pain and pain thresholds.

• Describe the indications and limitations of opioid pharmacotherapy.

• Discuss the genetic, social, and psychological factors that may contribute to opioid addiction.

• Describe the indications and limitations of other analgesics including tramadol, tricyclic agents, and anticonvulsant medications in the treatment of various pain syndromes.

• Describe the indications and limitations of nonopioids including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and topical agents.

• Describe specific factors that affect dosing regimens such as drug half-life, renal function, and hepatic function.

• Describe the indications and limitations of nonpharmacologic methods of pain control available in the inpatient setting.

• Establish functional criteria for discharge.

Hospitalists should be able to:

• Elicit a thorough and relevant history and description of pain and review the medical record to determine the likely source and acuity of pain.

• Review patient pharmacologic and psychosocial history and identify factors contributing to pain or factors that might affect its management.

• Perform a physical examination to determine the likely source of pain.

• Order and interpret diagnostic studies to determine the source of pain when underlying acute illness is suspected.

• Assess pain severity using validated measurement tools.

• Formulate an initial pain management plan.

• Determine the appropriate route, dosage, and frequency of dosing for pharmacologic agents on the basis of patient-specific factors.

• Reassess pain severity and determine the need for escalating therapy and/or adjuvant therapies.

• Determine equianalgesic dosing for pharmacologic therapy when needed.

• Titrate short- and long-acting opioids to desired effect.

• Predict and counteract as needed expected analgesic adverse effects, including use of reversal and specific agents, especially in older patients.

• Anticipate and manage adverse effects of pain medications including respiratory depression and sedation, nausea, vomiting, and pruritis.

• Initiate appropriate therapies to prevent and treat constipation when a patient is taking opioid analgesics.

• Assess and communicate the need for pain management during medical consultation.

• Recognize the signs and symptoms of addiction and assess patients for prescription drug abuse when appropriate.

• Educate patients on the adverse effects of prescription drug abuse.

• Educate patients and physicians on the importance of appropriate use of opioids in pain management and explain the rarity of opioid addiction in the setting of appropriate pain management.

• Establish and maintain an open dialogue with patients and families regarding care goals and limitations, which may include palliative care and end-of-life wishes.

• Document treatment plans, provide clear discharge instructions, and communicate with the outpatient clinician responsible for follow-up to ensure a safe transition. 

Hospitalists should be able to:

• Employ a multidisciplinary approach to the assessment and management of patients with pain that begins at admission and continues through all care transitions.

• Follow evidence-based recommendations, including the World Health Organization (WHO) step approach to pain management.

• Promote the ethical imperative of frequent pain assessment and adequate control.

• Appreciate that all pain is subjective and acknowledge patients’ self-reports of pain.

• Appreciate the value of patient-controlled analgesia.

• Appreciate the importance of a patient/family-centered approach for establishing the goals for pain management strategies and setting targets for pain control. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in efforts to develop educational modules, order sets, and/or pathways that facilitate effective pain management in the hospital setting, with goals of improving outcomes and patient satisfaction, decreasing length of stay, and reducing rehospitalization rates.

• Lead, coordinate, and/or participate in efforts to measure quality of inpatient pain control, operationalize system improvements, and reduce barriers to adequate pain control.

• Lead, coordinate, and/or participate in efforts to establish or support existing multidisciplinary pain control teams.

Pain is a very common presenting or accompanying symptom in hospitalized patients. Pain management relies on the use of various modalities to alleviate suffering and restore patient function. Proper assessment and treatment of pain can improve clinical outcomes, discharge planning, and patient and family satisfaction. Managing pain in inpatients necessitates understanding the various mechanisms that cause pain, properties of analgesic pharmacologic and nonpharmacologic modalities, and accurate assessment of severity and treatment response. Hospitalists assess and manage patients experiencing pain. This role requires that hospitalists be aware of current issues and controversies in pain management. Opioid therapy, for example, is a well-established approach for treating severe acute pain and cancer-related pain, and opioids are the most commonly prescribed drug class in the United States.¹ However, the continued increase in opioid prescription coincides with an increased number of poisoning deaths. Poisoning deaths involving opioid analgesics have more than tripled since 1999.^2,3 To best manage patients’ pain, hospitalists must demonstrate empathy, clinical excellence, and an understanding of the myriad obstacles, cautions, specific knowledge, skills, and attitudes necessary for appropriate pain management. Hospitalists serve as leaders of multidisciplinary teams to develop policies and protocols to improve pain management in their healthcare system. 

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Hospitalists should be able to:

• Describe the mechanisms that cause pain.

• Describe the symptoms and signs of pain.

• Differentiate acute, chronic, somatic, neuropathic, referred, and visceral pain syndromes.

• Differentiate tolerance, dependence, addiction, and pseudoaddiction.

• Describe the value and limitations of the physical examination and various validated pain intensity assessment scales.

• Recognize indications for specialty consultation, which may include pain service, anesthesiology, and physical and rehabilitation medicine.

• Explain the relationship among physical, cultural, and psychological factors and pain and pain thresholds.

• Describe the indications and limitations of opioid pharmacotherapy.

• Discuss the genetic, social, and psychological factors that may contribute to opioid addiction.

• Describe the indications and limitations of other analgesics including tramadol, tricyclic agents, and anticonvulsant medications in the treatment of various pain syndromes.

• Describe the indications and limitations of nonopioids including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and topical agents.

• Describe specific factors that affect dosing regimens such as drug half-life, renal function, and hepatic function.

• Describe the indications and limitations of nonpharmacologic methods of pain control available in the inpatient setting.

• Establish functional criteria for discharge.

Hospitalists should be able to:

• Elicit a thorough and relevant history and description of pain and review the medical record to determine the likely source and acuity of pain.

• Review patient pharmacologic and psychosocial history and identify factors contributing to pain or factors that might affect its management.

• Perform a physical examination to determine the likely source of pain.

• Order and interpret diagnostic studies to determine the source of pain when underlying acute illness is suspected.

• Assess pain severity using validated measurement tools.

• Formulate an initial pain management plan.

• Determine the appropriate route, dosage, and frequency of dosing for pharmacologic agents on the basis of patient-specific factors.

• Reassess pain severity and determine the need for escalating therapy and/or adjuvant therapies.

• Determine equianalgesic dosing for pharmacologic therapy when needed.

• Titrate short- and long-acting opioids to desired effect.

• Predict and counteract as needed expected analgesic adverse effects, including use of reversal and specific agents, especially in older patients.

• Anticipate and manage adverse effects of pain medications including respiratory depression and sedation, nausea, vomiting, and pruritis.

• Initiate appropriate therapies to prevent and treat constipation when a patient is taking opioid analgesics.

• Assess and communicate the need for pain management during medical consultation.

• Recognize the signs and symptoms of addiction and assess patients for prescription drug abuse when appropriate.

• Educate patients on the adverse effects of prescription drug abuse.

• Educate patients and physicians on the importance of appropriate use of opioids in pain management and explain the rarity of opioid addiction in the setting of appropriate pain management.

• Establish and maintain an open dialogue with patients and families regarding care goals and limitations, which may include palliative care and end-of-life wishes.

• Document treatment plans, provide clear discharge instructions, and communicate with the outpatient clinician responsible for follow-up to ensure a safe transition. 

Hospitalists should be able to:

• Employ a multidisciplinary approach to the assessment and management of patients with pain that begins at admission and continues through all care transitions.

• Follow evidence-based recommendations, including the World Health Organization (WHO) step approach to pain management.

• Promote the ethical imperative of frequent pain assessment and adequate control.

• Appreciate that all pain is subjective and acknowledge patients’ self-reports of pain.

• Appreciate the value of patient-controlled analgesia.

• Appreciate the importance of a patient/family-centered approach for establishing the goals for pain management strategies and setting targets for pain control. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in efforts to develop educational modules, order sets, and/or pathways that facilitate effective pain management in the hospital setting, with goals of improving outcomes and patient satisfaction, decreasing length of stay, and reducing rehospitalization rates.

• Lead, coordinate, and/or participate in efforts to measure quality of inpatient pain control, operationalize system improvements, and reduce barriers to adequate pain control.

• Lead, coordinate, and/or participate in efforts to establish or support existing multidisciplinary pain control teams.

Perioperative medicine refers to the medical evaluation and management of patients before, during, and after surgical intervention. Hospitalists perform general medical consultation preoperatively and provide postoperative medical management. During perioperative consultation, internists and hospitalists often identify conditions related to surgical outcomes and make relevant recommendations, such as delaying surgery so the patient’s medical condition can be optimized.^1,2 In orthopedic surgery patients, for example, the hospitalist care model may be associated with shortened time to surgery, decreased length of stay, and lower hospital costs.^3,4 Optimal care for the surgical patient is realized with a team approach that coordinates the expertise of the hospitalist and the surgical team. Hospitalists apply practice guidelines to medical consultation and lead initiatives to improve the quality of care and patient safety in the perioperative period. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Explain the physiologic effects of anesthesia and surgery.

• Describe the goals, components, and role of cardiovascular preoperative risk assessment.

• Describe the goals, components, and role of pulmonary preoperative risk assessment.

• Describe risk factors for perioperative cardiovascular, pulmonary, infectious, hematologic, neurologic, venous thromboembolic, and other complications.

• Identify pharmacologic therapies that may need to be modified or held before surgery including analgesics, antihypertensive agents, immunosuppressive therapy, anticoagulants, and complementary/alternative medicines.

• List widely accepted risk assessment tools and explain their value and limitations in patients undergoing nonvascular surgery.

• Describe the evidence surrounding prophylactic perioperative interventions such as β-blockade or incentive spirometry.

Hospitalists should be able to:

• Elicit a thorough history, review the medical record, and inquire about functional capacity in patients undergoing surgery.

• Perform a targeted physical examination focused on the cardiovascular and pulmonary systems and other systems on the basis of patient history.

• Assess pain levels in perioperative patients and make recommendations for pain management when indicated.

• Perform a directed and cost-effective diagnostic evaluation on the basis of the patient’s relevant history and physical examination findings.

• Use published algorithms and validated clinical scoring systems, when available, to assess and risk stratify patients.

• Assess the urgency of the requested evaluation and provide feedback and evaluation in an appropriate timeframe.

• Identify medical conditions that increase risk for perioperative complications and make specific evidence-based recommendations to optimize outcomes in the perioperative period.

• Determine the perioperative medical management strategies required to address specific disease states.

• Develop a comprehensive perioperative plan.

• Initiate indicated perioperative preventive strategies.

• Reassess patients for postoperative complications and make medical recommendations as indicated.

• Communicate with patients and families to explain the hospitalist’s role in perioperative medical care, any indicated preoperative testing related to their medical conditions or risk assessment, and any adjustment of pharmacologic therapies.

• Communicate with patients and families to explain any indicated perioperative prophylactic measures.

• Facilitate discharge planning early in the hospitalization, including communicating with the primary care provider and presenting the patient and family with contact information for follow-up care. 

Hospitalists should be able to:

• Follow evidence-based recommendations for the evaluation and treatment of patients in the perioperative period.

• Serve as an advocate for patients.

• Promote a collaborative relationship with surgical services, which includes effective communication. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in multidisciplinary efforts to develop clinical guidelines, protocols, and pathways to improve the timing and quality of perioperative care from initial preoperative evaluation through all care transitions.

• Lead, coordinate, and/or participate in efforts to improve the efficiency and quality of care through innovative models, which may include comanagement of surgical patients in the perioperative period.

• Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize diagnostic and management strategies for surgical patients requiring medical evaluation.

• Lead, coordinate, and/or participate in multidisciplinary protocols to promote the rapid identification, triage, and expeditious evaluation of patients requiring urgent operations.

Perioperative medicine refers to the medical evaluation and management of patients before, during, and after surgical intervention. Hospitalists perform general medical consultation preoperatively and provide postoperative medical management. During perioperative consultation, internists and hospitalists often identify conditions related to surgical outcomes and make relevant recommendations, such as delaying surgery so the patient’s medical condition can be optimized.^1,2 In orthopedic surgery patients, for example, the hospitalist care model may be associated with shortened time to surgery, decreased length of stay, and lower hospital costs.^3,4 Optimal care for the surgical patient is realized with a team approach that coordinates the expertise of the hospitalist and the surgical team. Hospitalists apply practice guidelines to medical consultation and lead initiatives to improve the quality of care and patient safety in the perioperative period. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Explain the physiologic effects of anesthesia and surgery.

• Describe the goals, components, and role of cardiovascular preoperative risk assessment.

• Describe the goals, components, and role of pulmonary preoperative risk assessment.

• Describe risk factors for perioperative cardiovascular, pulmonary, infectious, hematologic, neurologic, venous thromboembolic, and other complications.

• Identify pharmacologic therapies that may need to be modified or held before surgery including analgesics, antihypertensive agents, immunosuppressive therapy, anticoagulants, and complementary/alternative medicines.

• List widely accepted risk assessment tools and explain their value and limitations in patients undergoing nonvascular surgery.

• Describe the evidence surrounding prophylactic perioperative interventions such as β-blockade or incentive spirometry.

Hospitalists should be able to:

• Elicit a thorough history, review the medical record, and inquire about functional capacity in patients undergoing surgery.

• Perform a targeted physical examination focused on the cardiovascular and pulmonary systems and other systems on the basis of patient history.

• Assess pain levels in perioperative patients and make recommendations for pain management when indicated.

• Perform a directed and cost-effective diagnostic evaluation on the basis of the patient’s relevant history and physical examination findings.

• Use published algorithms and validated clinical scoring systems, when available, to assess and risk stratify patients.

• Assess the urgency of the requested evaluation and provide feedback and evaluation in an appropriate timeframe.

• Identify medical conditions that increase risk for perioperative complications and make specific evidence-based recommendations to optimize outcomes in the perioperative period.

• Determine the perioperative medical management strategies required to address specific disease states.

• Develop a comprehensive perioperative plan.

• Initiate indicated perioperative preventive strategies.

• Reassess patients for postoperative complications and make medical recommendations as indicated.

• Communicate with patients and families to explain the hospitalist’s role in perioperative medical care, any indicated preoperative testing related to their medical conditions or risk assessment, and any adjustment of pharmacologic therapies.

• Communicate with patients and families to explain any indicated perioperative prophylactic measures.

• Facilitate discharge planning early in the hospitalization, including communicating with the primary care provider and presenting the patient and family with contact information for follow-up care. 

Hospitalists should be able to:

• Follow evidence-based recommendations for the evaluation and treatment of patients in the perioperative period.

• Serve as an advocate for patients.

• Promote a collaborative relationship with surgical services, which includes effective communication. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in multidisciplinary efforts to develop clinical guidelines, protocols, and pathways to improve the timing and quality of perioperative care from initial preoperative evaluation through all care transitions.

• Lead, coordinate, and/or participate in efforts to improve the efficiency and quality of care through innovative models, which may include comanagement of surgical patients in the perioperative period.

• Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize diagnostic and management strategies for surgical patients requiring medical evaluation.

• Lead, coordinate, and/or participate in multidisciplinary protocols to promote the rapid identification, triage, and expeditious evaluation of patients requiring urgent operations.

Perioperative medicine refers to the medical evaluation and management of patients before, during, and after surgical intervention. Hospitalists perform general medical consultation preoperatively and provide postoperative medical management. During perioperative consultation, internists and hospitalists often identify conditions related to surgical outcomes and make relevant recommendations, such as delaying surgery so the patient’s medical condition can be optimized.^1,2 In orthopedic surgery patients, for example, the hospitalist care model may be associated with shortened time to surgery, decreased length of stay, and lower hospital costs.^3,4 Optimal care for the surgical patient is realized with a team approach that coordinates the expertise of the hospitalist and the surgical team. Hospitalists apply practice guidelines to medical consultation and lead initiatives to improve the quality of care and patient safety in the perioperative period. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Explain the physiologic effects of anesthesia and surgery.

• Describe the goals, components, and role of cardiovascular preoperative risk assessment.

• Describe the goals, components, and role of pulmonary preoperative risk assessment.

• Describe risk factors for perioperative cardiovascular, pulmonary, infectious, hematologic, neurologic, venous thromboembolic, and other complications.

• Identify pharmacologic therapies that may need to be modified or held before surgery including analgesics, antihypertensive agents, immunosuppressive therapy, anticoagulants, and complementary/alternative medicines.

• List widely accepted risk assessment tools and explain their value and limitations in patients undergoing nonvascular surgery.

• Describe the evidence surrounding prophylactic perioperative interventions such as β-blockade or incentive spirometry.

Hospitalists should be able to:

• Elicit a thorough history, review the medical record, and inquire about functional capacity in patients undergoing surgery.

• Perform a targeted physical examination focused on the cardiovascular and pulmonary systems and other systems on the basis of patient history.

• Assess pain levels in perioperative patients and make recommendations for pain management when indicated.

• Perform a directed and cost-effective diagnostic evaluation on the basis of the patient’s relevant history and physical examination findings.

• Use published algorithms and validated clinical scoring systems, when available, to assess and risk stratify patients.

• Assess the urgency of the requested evaluation and provide feedback and evaluation in an appropriate timeframe.

• Identify medical conditions that increase risk for perioperative complications and make specific evidence-based recommendations to optimize outcomes in the perioperative period.

• Determine the perioperative medical management strategies required to address specific disease states.

• Develop a comprehensive perioperative plan.

• Initiate indicated perioperative preventive strategies.

• Reassess patients for postoperative complications and make medical recommendations as indicated.

• Communicate with patients and families to explain the hospitalist’s role in perioperative medical care, any indicated preoperative testing related to their medical conditions or risk assessment, and any adjustment of pharmacologic therapies.

• Communicate with patients and families to explain any indicated perioperative prophylactic measures.

• Facilitate discharge planning early in the hospitalization, including communicating with the primary care provider and presenting the patient and family with contact information for follow-up care. 

Hospitalists should be able to:

• Follow evidence-based recommendations for the evaluation and treatment of patients in the perioperative period.

• Serve as an advocate for patients.

• Promote a collaborative relationship with surgical services, which includes effective communication. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in multidisciplinary efforts to develop clinical guidelines, protocols, and pathways to improve the timing and quality of perioperative care from initial preoperative evaluation through all care transitions.

• Lead, coordinate, and/or participate in efforts to improve the efficiency and quality of care through innovative models, which may include comanagement of surgical patients in the perioperative period.

• Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize diagnostic and management strategies for surgical patients requiring medical evaluation.

• Lead, coordinate, and/or participate in multidisciplinary protocols to promote the rapid identification, triage, and expeditious evaluation of patients requiring urgent operations.

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.¹ Sepsis has various etiologies and clinical presentations. It accounts for substantial morbidity and mortality and is a leading cause of hospitalization in the United States. More than 1 million hospital discharges occur with sepsis as the primary diagnosis, and the incidence continues to rise.^2-4 Sepsis is the most expensive condition treated in US hospitals, and length of stay is roughly 75% longer than it is for other conditions.^5,6 Sepsis requires expeditious diagnosis and standardized treatment plans to favorably influence patient morbidity and mortality. The in-hospital mortality rate for sepsis varies depending on disease severity and is approximately 16%.⁵ Septic shock is a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.¹Hospitalists have a key role in the early identification of patients with sepsis, and they practice evidence-based evaluation and interventions such as early goal-directed therapy for patients with sepsis and septic shock. Hospitalists lead their institutions to implement early diagnostic strategies, initiate evidence-based medical therapies, and incorporate multidisciplinary approaches to the care of patients with sepsis. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Define and differentiate sepsis and septic shock from uncomplicated infection.

• Describe prognostic scoring tools used to assess morbidity and mortality in patients with sepsis, such as the Sequential Organ Failure Assessment (SOFA) and Quick SOFA (qSOFA) scores, and the systemic inflammatory response syndrome (SIRS) criteria.

• Describe the pathobiology that leads to sepsis and septic shock.

• Differentiate septic shock from other causes of shock.

• Recognize the value and limitations of the history and physical examination in determining the cause of sepsis.

• Recognize the indications for specialty consultations, which may include critical care medicine.

• Identify patient groups with increased risk for the development of sepsis, increased morbidity or mortality, or uncommon etiologic organisms.

• Describe the elements and efficacy of early goal-directed therapy for the treatment of sepsis and septic shock.

• Describe the mechanism of action, indications, contraindications, and adverse effects of therapeutic agents, including intravenous fluids, vasopressors, and antimicrobials, in the treatment of sepsis.

• Describe the indications for and limitations of central venous access and its value for hemodynamic monitoring and administration of vasoactive agents.

• Explain patient characteristics that on admission portend poor prognosis.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

Hospitalists should be able to:

• Use all available information, including medical records and history provided by the patient and caregivers, to identify factors that contribute to the development of sepsis.

• Perform a rapid and targeted physical examination to identify potential sources of sepsis.

• Order indicated diagnostic testing to identify the source of sepsis and determine severity of organ dysfunction.

• Rapidly identify patients with septic shock and aggressively treat in parallel with transfer to a critical care setting.

• Assess cardiopulmonary stability and implement aggressive fluid resuscitation, airway maintenance, and circulatory support.

• Measure and interpret indicated hemodynamic monitoring parameters.

• Initiate empiric antimicrobial therapy on the basis of the suspected etiologic source of infection.

• Assess the need for central venous access and monitoring; when needed, coordinate or establish central venous access.

• Determine or coordinate appropriate nutritional and metabolic interventions.

• Support organ function and correct metabolic derangements when indicated.

• Implement measures to ensure optimal glycemic control.

• Adopt measures to prevent complications, which may include aspiration precautions, stress ulcer and venous thromboembolism prophylaxis, and decubitus ulcer prevention.

• Communicate with patients and families to explain the history and prognosis of sepsis and indicators of functional improvement or decline.

• Communicate with patients and families to explain tests and procedures and their indications and to obtain informed consent.

• Address resuscitation status early during hospital stay and discuss and implement end-of-life decisions by patient or family when indicated or desired.

• Communicate with patients and families to explain the goals of care, clinical stability criteria, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care. 

Hospitalists should be able to:

• Employ an early and multidisciplinary approach, which may include respiratory therapy, nursing, pharmacy, nutrition, rehabilitation and social services, that begins at admission and continues through all care transitions.

• Follow evidence-based recommendations to guide diagnosis, monitoring, and treatment of sepsis.

• Establish and maintain an open dialogue with patients and families regarding care goals and limitations, including palliative care and end-of-life wishes.

• Value good communication with patients and receiving physicians during care transitions. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in multidisciplinary teams, which may include nutrition, pharmacy, rehabilitation, social services, and respiratory therapy, early in the hospital course to improve patient function and outcomes.

• Lead, coordinate, and/or participate in the development and promotion of guidelines and/or pathways that facilitate efficient and timely evaluation and treatment of patients with sepsis.

• Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize resource use.

• Lead, coordinate, and/or participate in intrainstitutional and interinstitutional efforts to develop protocols for the rapid identification and transfer of patients with sepsis to appropriate facilities.

• Implement systems to ensure hospital-wide adherence to national standards and document those measures as specified by recognized organizations.

• Integrate outcomes research, institution-specific laboratory policies, and hospital formulary to create indicated and cost-effective diagnostic and management strategies for patients with sepsis.

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.¹ Sepsis has various etiologies and clinical presentations. It accounts for substantial morbidity and mortality and is a leading cause of hospitalization in the United States. More than 1 million hospital discharges occur with sepsis as the primary diagnosis, and the incidence continues to rise.^2-4 Sepsis is the most expensive condition treated in US hospitals, and length of stay is roughly 75% longer than it is for other conditions.^5,6 Sepsis requires expeditious diagnosis and standardized treatment plans to favorably influence patient morbidity and mortality. The in-hospital mortality rate for sepsis varies depending on disease severity and is approximately 16%.⁵ Septic shock is a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.¹Hospitalists have a key role in the early identification of patients with sepsis, and they practice evidence-based evaluation and interventions such as early goal-directed therapy for patients with sepsis and septic shock. Hospitalists lead their institutions to implement early diagnostic strategies, initiate evidence-based medical therapies, and incorporate multidisciplinary approaches to the care of patients with sepsis. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Define and differentiate sepsis and septic shock from uncomplicated infection.

• Describe prognostic scoring tools used to assess morbidity and mortality in patients with sepsis, such as the Sequential Organ Failure Assessment (SOFA) and Quick SOFA (qSOFA) scores, and the systemic inflammatory response syndrome (SIRS) criteria.

• Describe the pathobiology that leads to sepsis and septic shock.

• Differentiate septic shock from other causes of shock.

• Recognize the value and limitations of the history and physical examination in determining the cause of sepsis.

• Recognize the indications for specialty consultations, which may include critical care medicine.

• Identify patient groups with increased risk for the development of sepsis, increased morbidity or mortality, or uncommon etiologic organisms.

• Describe the elements and efficacy of early goal-directed therapy for the treatment of sepsis and septic shock.

• Describe the mechanism of action, indications, contraindications, and adverse effects of therapeutic agents, including intravenous fluids, vasopressors, and antimicrobials, in the treatment of sepsis.

• Describe the indications for and limitations of central venous access and its value for hemodynamic monitoring and administration of vasoactive agents.

• Explain patient characteristics that on admission portend poor prognosis.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

Hospitalists should be able to:

• Use all available information, including medical records and history provided by the patient and caregivers, to identify factors that contribute to the development of sepsis.

• Perform a rapid and targeted physical examination to identify potential sources of sepsis.

• Order indicated diagnostic testing to identify the source of sepsis and determine severity of organ dysfunction.

• Rapidly identify patients with septic shock and aggressively treat in parallel with transfer to a critical care setting.

• Assess cardiopulmonary stability and implement aggressive fluid resuscitation, airway maintenance, and circulatory support.

• Measure and interpret indicated hemodynamic monitoring parameters.

• Initiate empiric antimicrobial therapy on the basis of the suspected etiologic source of infection.

• Assess the need for central venous access and monitoring; when needed, coordinate or establish central venous access.

• Determine or coordinate appropriate nutritional and metabolic interventions.

• Support organ function and correct metabolic derangements when indicated.

• Implement measures to ensure optimal glycemic control.

• Adopt measures to prevent complications, which may include aspiration precautions, stress ulcer and venous thromboembolism prophylaxis, and decubitus ulcer prevention.

• Communicate with patients and families to explain the history and prognosis of sepsis and indicators of functional improvement or decline.

• Communicate with patients and families to explain tests and procedures and their indications and to obtain informed consent.

• Address resuscitation status early during hospital stay and discuss and implement end-of-life decisions by patient or family when indicated or desired.

• Communicate with patients and families to explain the goals of care, clinical stability criteria, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care. 

Hospitalists should be able to:

• Employ an early and multidisciplinary approach, which may include respiratory therapy, nursing, pharmacy, nutrition, rehabilitation and social services, that begins at admission and continues through all care transitions.

• Follow evidence-based recommendations to guide diagnosis, monitoring, and treatment of sepsis.

• Establish and maintain an open dialogue with patients and families regarding care goals and limitations, including palliative care and end-of-life wishes.

• Value good communication with patients and receiving physicians during care transitions. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in multidisciplinary teams, which may include nutrition, pharmacy, rehabilitation, social services, and respiratory therapy, early in the hospital course to improve patient function and outcomes.

• Lead, coordinate, and/or participate in the development and promotion of guidelines and/or pathways that facilitate efficient and timely evaluation and treatment of patients with sepsis.

• Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize resource use.

• Lead, coordinate, and/or participate in intrainstitutional and interinstitutional efforts to develop protocols for the rapid identification and transfer of patients with sepsis to appropriate facilities.

• Implement systems to ensure hospital-wide adherence to national standards and document those measures as specified by recognized organizations.

• Integrate outcomes research, institution-specific laboratory policies, and hospital formulary to create indicated and cost-effective diagnostic and management strategies for patients with sepsis.

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.¹ Sepsis has various etiologies and clinical presentations. It accounts for substantial morbidity and mortality and is a leading cause of hospitalization in the United States. More than 1 million hospital discharges occur with sepsis as the primary diagnosis, and the incidence continues to rise.^2-4 Sepsis is the most expensive condition treated in US hospitals, and length of stay is roughly 75% longer than it is for other conditions.^5,6 Sepsis requires expeditious diagnosis and standardized treatment plans to favorably influence patient morbidity and mortality. The in-hospital mortality rate for sepsis varies depending on disease severity and is approximately 16%.⁵ Septic shock is a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.¹Hospitalists have a key role in the early identification of patients with sepsis, and they practice evidence-based evaluation and interventions such as early goal-directed therapy for patients with sepsis and septic shock. Hospitalists lead their institutions to implement early diagnostic strategies, initiate evidence-based medical therapies, and incorporate multidisciplinary approaches to the care of patients with sepsis. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Define and differentiate sepsis and septic shock from uncomplicated infection.

• Describe prognostic scoring tools used to assess morbidity and mortality in patients with sepsis, such as the Sequential Organ Failure Assessment (SOFA) and Quick SOFA (qSOFA) scores, and the systemic inflammatory response syndrome (SIRS) criteria.

• Describe the pathobiology that leads to sepsis and septic shock.

• Differentiate septic shock from other causes of shock.

• Recognize the value and limitations of the history and physical examination in determining the cause of sepsis.

• Recognize the indications for specialty consultations, which may include critical care medicine.

• Identify patient groups with increased risk for the development of sepsis, increased morbidity or mortality, or uncommon etiologic organisms.

• Describe the elements and efficacy of early goal-directed therapy for the treatment of sepsis and septic shock.

• Describe the mechanism of action, indications, contraindications, and adverse effects of therapeutic agents, including intravenous fluids, vasopressors, and antimicrobials, in the treatment of sepsis.

• Describe the indications for and limitations of central venous access and its value for hemodynamic monitoring and administration of vasoactive agents.

• Explain patient characteristics that on admission portend poor prognosis.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

Hospitalists should be able to:

• Use all available information, including medical records and history provided by the patient and caregivers, to identify factors that contribute to the development of sepsis.

• Perform a rapid and targeted physical examination to identify potential sources of sepsis.

• Order indicated diagnostic testing to identify the source of sepsis and determine severity of organ dysfunction.

• Rapidly identify patients with septic shock and aggressively treat in parallel with transfer to a critical care setting.

• Assess cardiopulmonary stability and implement aggressive fluid resuscitation, airway maintenance, and circulatory support.

• Measure and interpret indicated hemodynamic monitoring parameters.

• Initiate empiric antimicrobial therapy on the basis of the suspected etiologic source of infection.

• Assess the need for central venous access and monitoring; when needed, coordinate or establish central venous access.

• Determine or coordinate appropriate nutritional and metabolic interventions.

• Support organ function and correct metabolic derangements when indicated.

• Implement measures to ensure optimal glycemic control.

• Adopt measures to prevent complications, which may include aspiration precautions, stress ulcer and venous thromboembolism prophylaxis, and decubitus ulcer prevention.

• Communicate with patients and families to explain the history and prognosis of sepsis and indicators of functional improvement or decline.

• Communicate with patients and families to explain tests and procedures and their indications and to obtain informed consent.

• Address resuscitation status early during hospital stay and discuss and implement end-of-life decisions by patient or family when indicated or desired.

• Communicate with patients and families to explain the goals of care, clinical stability criteria, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care. 

Hospitalists should be able to:

• Employ an early and multidisciplinary approach, which may include respiratory therapy, nursing, pharmacy, nutrition, rehabilitation and social services, that begins at admission and continues through all care transitions.

• Follow evidence-based recommendations to guide diagnosis, monitoring, and treatment of sepsis.

• Establish and maintain an open dialogue with patients and families regarding care goals and limitations, including palliative care and end-of-life wishes.

• Value good communication with patients and receiving physicians during care transitions. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in multidisciplinary teams, which may include nutrition, pharmacy, rehabilitation, social services, and respiratory therapy, early in the hospital course to improve patient function and outcomes.

• Lead, coordinate, and/or participate in the development and promotion of guidelines and/or pathways that facilitate efficient and timely evaluation and treatment of patients with sepsis.

• Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize resource use.

• Lead, coordinate, and/or participate in intrainstitutional and interinstitutional efforts to develop protocols for the rapid identification and transfer of patients with sepsis to appropriate facilities.

• Implement systems to ensure hospital-wide adherence to national standards and document those measures as specified by recognized organizations.

• Integrate outcomes research, institution-specific laboratory policies, and hospital formulary to create indicated and cost-effective diagnostic and management strategies for patients with sepsis.

Cellulitis is a bacterial infection of the skin and subcutaneous tissues. It is a common, potentially serious medical condition that can result in significant morbidity and hospitalization. Annually, more than 620,000 hospital discharges occur with skin and soft tissue infection as the primary diagnosis.¹ Potential complications include abscess formation. Hospitalists can lead efforts to standardize care delivery, promote antibiotic stewardship, improve discharge planning, and promptly identify and address severe cases of cellulitis to minimize complications and improve patient outcomes. 

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Hospitalists should be able to:

• Describe the clinical presentation of cellulitis and distinguish between routine and complicated cellulitis.

• Differentiate cellulitis from chronic venous stasis changes and other mimicking skin conditions and discuss the accuracy of common signs and symptoms in patients with suspected cellulitis.

• Describe the tests used to evaluate cellulitis.

• Discuss possible causative organisms on the basis of classic associations with characteristic host exposures.

• Describe factors associated with an increased risk of worsening disease severity and complications.

• Recognize indications for early specialty consultation in patients with complications, misdiagnosis, or lack of response to therapy.

• Differentiate empiric antibiotic regimens for uncomplicated and complicated types of cellulitis.

• Explain indications for outpatient treatment and need for hospital admission.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

Hospitalists should be able to:

• Elicit a focused medical history to identify precipitating causes of cellulitis and comorbid conditions that may affect clinical management.

• Assess patients with cellulitis in a timely manner and manage or comanage patients with the primary requesting service.

• Accurately identify routine cellulitis borders and signs of complications, which may include crepitus and abscess.

• Recommend an appropriate, cost-effective initial diagnostic evaluation of cellulitis, including laboratory and radiologic studies.

• Initiate empiric antibiotic treatment of cellulitis on the basis of host exposures, predisposing underlying systemic illness, history and physical examination findings, presumptive bacterial pathogens, and evidence-based recommendations.

• Treat coexisting fungal infection, edema, and other conditions that may exacerbate cellulitis.

• Formulate a subsequent treatment plan that includes narrowing antibiotic therapies on the basis of available culture data and the patient’s response to treatment.

• Determine appropriate timing for transition from intravenous to oral therapy and duration of antibiotic treatment.

• Initiate preventive measures for minimizing risk of recurrent cellulitis.

• Communicate with patients and families to explain the history and prognosis of cellulitis.

• Communicate with patients and families to explain tests and procedures and their indications and to obtain informed consent.

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

• Facilitate discharge planning early during hospitalization.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians. 

Hospitalists should be able to:

• Employ a multidisciplinary approach in the care of patients with cellulitis that begins at admission and continues through all care transitions.

• Follow evidence-based recommendations to guide diagnosis, monitoring, and treatment of cellulitis.

• Consider cost-effectiveness (including formulary availability), risk of potential adverse effects, and ease of conversion to outpatient treatment when choosing among therapeutic options. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in multidisciplinary initiatives, which may include collaborative efforts with infectious disease physicians, to promote patient safety and optimize cost-effective diagnostic and management strategies for patients with cellulitis.

• Implement systems to ensure hospital-wide adherence to national standards and document those measures as specified by recognized organizations.

Cellulitis is a bacterial infection of the skin and subcutaneous tissues. It is a common, potentially serious medical condition that can result in significant morbidity and hospitalization. Annually, more than 620,000 hospital discharges occur with skin and soft tissue infection as the primary diagnosis.¹ Potential complications include abscess formation. Hospitalists can lead efforts to standardize care delivery, promote antibiotic stewardship, improve discharge planning, and promptly identify and address severe cases of cellulitis to minimize complications and improve patient outcomes. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Describe the clinical presentation of cellulitis and distinguish between routine and complicated cellulitis.

• Differentiate cellulitis from chronic venous stasis changes and other mimicking skin conditions and discuss the accuracy of common signs and symptoms in patients with suspected cellulitis.

• Describe the tests used to evaluate cellulitis.

• Discuss possible causative organisms on the basis of classic associations with characteristic host exposures.

• Describe factors associated with an increased risk of worsening disease severity and complications.

• Recognize indications for early specialty consultation in patients with complications, misdiagnosis, or lack of response to therapy.

• Differentiate empiric antibiotic regimens for uncomplicated and complicated types of cellulitis.

• Explain indications for outpatient treatment and need for hospital admission.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

Hospitalists should be able to:

• Elicit a focused medical history to identify precipitating causes of cellulitis and comorbid conditions that may affect clinical management.

• Assess patients with cellulitis in a timely manner and manage or comanage patients with the primary requesting service.

• Accurately identify routine cellulitis borders and signs of complications, which may include crepitus and abscess.

• Recommend an appropriate, cost-effective initial diagnostic evaluation of cellulitis, including laboratory and radiologic studies.

• Initiate empiric antibiotic treatment of cellulitis on the basis of host exposures, predisposing underlying systemic illness, history and physical examination findings, presumptive bacterial pathogens, and evidence-based recommendations.

• Treat coexisting fungal infection, edema, and other conditions that may exacerbate cellulitis.

• Formulate a subsequent treatment plan that includes narrowing antibiotic therapies on the basis of available culture data and the patient’s response to treatment.

• Determine appropriate timing for transition from intravenous to oral therapy and duration of antibiotic treatment.

• Initiate preventive measures for minimizing risk of recurrent cellulitis.

• Communicate with patients and families to explain the history and prognosis of cellulitis.

• Communicate with patients and families to explain tests and procedures and their indications and to obtain informed consent.

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

• Facilitate discharge planning early during hospitalization.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians. 

Hospitalists should be able to:

• Employ a multidisciplinary approach in the care of patients with cellulitis that begins at admission and continues through all care transitions.

• Follow evidence-based recommendations to guide diagnosis, monitoring, and treatment of cellulitis.

• Consider cost-effectiveness (including formulary availability), risk of potential adverse effects, and ease of conversion to outpatient treatment when choosing among therapeutic options. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in multidisciplinary initiatives, which may include collaborative efforts with infectious disease physicians, to promote patient safety and optimize cost-effective diagnostic and management strategies for patients with cellulitis.

• Implement systems to ensure hospital-wide adherence to national standards and document those measures as specified by recognized organizations.

Cellulitis is a bacterial infection of the skin and subcutaneous tissues. It is a common, potentially serious medical condition that can result in significant morbidity and hospitalization. Annually, more than 620,000 hospital discharges occur with skin and soft tissue infection as the primary diagnosis.¹ Potential complications include abscess formation. Hospitalists can lead efforts to standardize care delivery, promote antibiotic stewardship, improve discharge planning, and promptly identify and address severe cases of cellulitis to minimize complications and improve patient outcomes. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Describe the clinical presentation of cellulitis and distinguish between routine and complicated cellulitis.

• Differentiate cellulitis from chronic venous stasis changes and other mimicking skin conditions and discuss the accuracy of common signs and symptoms in patients with suspected cellulitis.

• Describe the tests used to evaluate cellulitis.

• Discuss possible causative organisms on the basis of classic associations with characteristic host exposures.

• Describe factors associated with an increased risk of worsening disease severity and complications.

• Recognize indications for early specialty consultation in patients with complications, misdiagnosis, or lack of response to therapy.

• Differentiate empiric antibiotic regimens for uncomplicated and complicated types of cellulitis.

• Explain indications for outpatient treatment and need for hospital admission.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

Hospitalists should be able to:

• Elicit a focused medical history to identify precipitating causes of cellulitis and comorbid conditions that may affect clinical management.

• Assess patients with cellulitis in a timely manner and manage or comanage patients with the primary requesting service.

• Accurately identify routine cellulitis borders and signs of complications, which may include crepitus and abscess.

• Recommend an appropriate, cost-effective initial diagnostic evaluation of cellulitis, including laboratory and radiologic studies.

• Initiate empiric antibiotic treatment of cellulitis on the basis of host exposures, predisposing underlying systemic illness, history and physical examination findings, presumptive bacterial pathogens, and evidence-based recommendations.

• Treat coexisting fungal infection, edema, and other conditions that may exacerbate cellulitis.

• Formulate a subsequent treatment plan that includes narrowing antibiotic therapies on the basis of available culture data and the patient’s response to treatment.

• Determine appropriate timing for transition from intravenous to oral therapy and duration of antibiotic treatment.

• Initiate preventive measures for minimizing risk of recurrent cellulitis.

• Communicate with patients and families to explain the history and prognosis of cellulitis.

• Communicate with patients and families to explain tests and procedures and their indications and to obtain informed consent.

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

• Facilitate discharge planning early during hospitalization.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians. 

Hospitalists should be able to:

• Employ a multidisciplinary approach in the care of patients with cellulitis that begins at admission and continues through all care transitions.

• Follow evidence-based recommendations to guide diagnosis, monitoring, and treatment of cellulitis.

• Consider cost-effectiveness (including formulary availability), risk of potential adverse effects, and ease of conversion to outpatient treatment when choosing among therapeutic options. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in multidisciplinary initiatives, which may include collaborative efforts with infectious disease physicians, to promote patient safety and optimize cost-effective diagnostic and management strategies for patients with cellulitis.

• Implement systems to ensure hospital-wide adherence to national standards and document those measures as specified by recognized organizations.

Stroke is defined as damage to brain tissue resulting from interruption in blood flow. This condition accounts for significant morbidity and mortality in hospitalized patients. Annually in the United States, approximately 1 million hospital discharges occur with cerebrovascular disease as the primary diagnosis.^1,2 The average length of stay is 6.1 days.^1,2 Stroke care is a rapidly evolving field in which expeditious and careful inpatient care significantly affects outcome. For example, intravenous thrombolytic therapy administered within the recommended time window from symptom onset is associated with more favorable outcomes.³Therefore, it is incumbent on hospitalists to develop the knowledge and skills to identify and manage strokes, coordinate specialty and primary care resources, and guide patients safely through the acute hospitalization and back into the outpatient setting. 

Hospitalists should be able to:

• Describe causes of ischemic and hemorrhagic stroke.

• Describe the relationship between the anatomic location of stroke and clinical presentation.

• List risk factors for ischemic and hemorrhagic stroke.

• Describe appropriate imaging techniques and laboratory testing to evaluate patients with suspected stroke.

• Recognize the indications for early specialty consultation, which may include neurology, neurosurgery, and interventional radiology.

• Describe indications, contraindications, and mechanisms of action of pharmacologic agents used to treat stroke.

• Describe indications and contraindications for thrombolytic therapy in the setting of acute stroke.

• Explain blood pressure control strategies for patients presenting with different types of stroke.

• List indications for early surgical and endovascular interventions.

• Explain the spectrum of functional outcomes of different types of stroke and how these relate to the initial presentation.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history to assess for symptoms that are typical of stroke.

• Perform an appropriate physical examination to diagnose stroke and to help guide further management.

• Assess patients with stroke in a timely manner.

• Diagnose the etiology of stroke through interpretation of initial testing including history, physical examination, electrocardiogram, neurologic imaging, and laboratory results.

• Initiate indicated acute therapies to improve the prognosis of stroke.

• Identify patients at risk for acute decompensation, which may include those with signs of increased intracranial pressure and posterior circulation disease.

• Identify patients at risk for aspiration following stroke and address nutritional issues.

• Manage the airway, temperature, blood pressure, and glycemic status of patients with stroke when indicated.

• Address resuscitation status early during hospital stay; implement end-of-life decisions by patients and/or families when indicated or desired.

• Initiate prophylaxis against common complications, which may include urinary tract infection, aspiration pneumonia, and venous thromboembolism.

• Initiate secondary stroke prevention.

• Communicate with patients and families to explain the history and prognosis of stroke.

• Communicate with patients and families to explain the tests and procedures and their indications and to obtain informed consent.

• Communicate with patients and families to explain the use and potential adverse effects of pharmacologic agents.

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

• Recognize barriers to follow-up care of patients who have had a stroke and involve multidisciplinary hospital staff to accordingly tailor medications and transition of care plans.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians, which may include outpatient rehabilitation. 

Hospitalists should be able to:

• Employ an early and multidisciplinary approach to the care of patients who have had a stroke that begins at admission and continues through all care transitions.

• Follow evidence-based recommendations, protocols, and risk stratification tools for the treatment of stroke.

• Work collaboratively with allied health professionals (eg, physical therapy, occupational therapy) to develop comprehensive care plans to address deficits or limitations that result from stroke. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in multidisciplinary teams, which may include neurology, rehabilitation medicine, nursing, physical and occupational therapy, speech pathology, and other allied health professionals, early in the hospital course to reduce complications, facilitate patient education, and coordinate discharge planning.

• Lead, coordinate, and/or participate in multidisciplinary efforts to develop protocols to rapidly identify patients with stroke who have indications for acute interventions and to minimize time to intervention.

• Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize resource use, including aggressive treatment of risk factors and rehabilitation.

Stroke is defined as damage to brain tissue resulting from interruption in blood flow. This condition accounts for significant morbidity and mortality in hospitalized patients. Annually in the United States, approximately 1 million hospital discharges occur with cerebrovascular disease as the primary diagnosis.^1,2 The average length of stay is 6.1 days.^1,2 Stroke care is a rapidly evolving field in which expeditious and careful inpatient care significantly affects outcome. For example, intravenous thrombolytic therapy administered within the recommended time window from symptom onset is associated with more favorable outcomes.³Therefore, it is incumbent on hospitalists to develop the knowledge and skills to identify and manage strokes, coordinate specialty and primary care resources, and guide patients safely through the acute hospitalization and back into the outpatient setting. 

Hospitalists should be able to:

• Describe causes of ischemic and hemorrhagic stroke.

• Describe the relationship between the anatomic location of stroke and clinical presentation.

• List risk factors for ischemic and hemorrhagic stroke.

• Describe appropriate imaging techniques and laboratory testing to evaluate patients with suspected stroke.

• Recognize the indications for early specialty consultation, which may include neurology, neurosurgery, and interventional radiology.

• Describe indications, contraindications, and mechanisms of action of pharmacologic agents used to treat stroke.

• Describe indications and contraindications for thrombolytic therapy in the setting of acute stroke.

• Explain blood pressure control strategies for patients presenting with different types of stroke.

• List indications for early surgical and endovascular interventions.

• Explain the spectrum of functional outcomes of different types of stroke and how these relate to the initial presentation.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history to assess for symptoms that are typical of stroke.

• Perform an appropriate physical examination to diagnose stroke and to help guide further management.

• Assess patients with stroke in a timely manner.

• Diagnose the etiology of stroke through interpretation of initial testing including history, physical examination, electrocardiogram, neurologic imaging, and laboratory results.

• Initiate indicated acute therapies to improve the prognosis of stroke.

• Identify patients at risk for acute decompensation, which may include those with signs of increased intracranial pressure and posterior circulation disease.

• Identify patients at risk for aspiration following stroke and address nutritional issues.

• Manage the airway, temperature, blood pressure, and glycemic status of patients with stroke when indicated.

• Address resuscitation status early during hospital stay; implement end-of-life decisions by patients and/or families when indicated or desired.

• Initiate prophylaxis against common complications, which may include urinary tract infection, aspiration pneumonia, and venous thromboembolism.

• Initiate secondary stroke prevention.

• Communicate with patients and families to explain the history and prognosis of stroke.

• Communicate with patients and families to explain the tests and procedures and their indications and to obtain informed consent.

• Communicate with patients and families to explain the use and potential adverse effects of pharmacologic agents.

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

• Recognize barriers to follow-up care of patients who have had a stroke and involve multidisciplinary hospital staff to accordingly tailor medications and transition of care plans.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians, which may include outpatient rehabilitation. 

Hospitalists should be able to:

• Employ an early and multidisciplinary approach to the care of patients who have had a stroke that begins at admission and continues through all care transitions.

• Follow evidence-based recommendations, protocols, and risk stratification tools for the treatment of stroke.

• Work collaboratively with allied health professionals (eg, physical therapy, occupational therapy) to develop comprehensive care plans to address deficits or limitations that result from stroke. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in multidisciplinary teams, which may include neurology, rehabilitation medicine, nursing, physical and occupational therapy, speech pathology, and other allied health professionals, early in the hospital course to reduce complications, facilitate patient education, and coordinate discharge planning.

• Lead, coordinate, and/or participate in multidisciplinary efforts to develop protocols to rapidly identify patients with stroke who have indications for acute interventions and to minimize time to intervention.

• Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize resource use, including aggressive treatment of risk factors and rehabilitation.

Stroke is defined as damage to brain tissue resulting from interruption in blood flow. This condition accounts for significant morbidity and mortality in hospitalized patients. Annually in the United States, approximately 1 million hospital discharges occur with cerebrovascular disease as the primary diagnosis.^1,2 The average length of stay is 6.1 days.^1,2 Stroke care is a rapidly evolving field in which expeditious and careful inpatient care significantly affects outcome. For example, intravenous thrombolytic therapy administered within the recommended time window from symptom onset is associated with more favorable outcomes.³Therefore, it is incumbent on hospitalists to develop the knowledge and skills to identify and manage strokes, coordinate specialty and primary care resources, and guide patients safely through the acute hospitalization and back into the outpatient setting. 

Hospitalists should be able to:

• Describe causes of ischemic and hemorrhagic stroke.

• Describe the relationship between the anatomic location of stroke and clinical presentation.

• List risk factors for ischemic and hemorrhagic stroke.

• Describe appropriate imaging techniques and laboratory testing to evaluate patients with suspected stroke.

• Recognize the indications for early specialty consultation, which may include neurology, neurosurgery, and interventional radiology.

• Describe indications, contraindications, and mechanisms of action of pharmacologic agents used to treat stroke.

• Describe indications and contraindications for thrombolytic therapy in the setting of acute stroke.

• Explain blood pressure control strategies for patients presenting with different types of stroke.

• List indications for early surgical and endovascular interventions.

• Explain the spectrum of functional outcomes of different types of stroke and how these relate to the initial presentation.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history to assess for symptoms that are typical of stroke.

• Perform an appropriate physical examination to diagnose stroke and to help guide further management.

• Assess patients with stroke in a timely manner.

• Diagnose the etiology of stroke through interpretation of initial testing including history, physical examination, electrocardiogram, neurologic imaging, and laboratory results.

• Initiate indicated acute therapies to improve the prognosis of stroke.

• Identify patients at risk for acute decompensation, which may include those with signs of increased intracranial pressure and posterior circulation disease.

• Identify patients at risk for aspiration following stroke and address nutritional issues.

• Manage the airway, temperature, blood pressure, and glycemic status of patients with stroke when indicated.

• Address resuscitation status early during hospital stay; implement end-of-life decisions by patients and/or families when indicated or desired.

• Initiate prophylaxis against common complications, which may include urinary tract infection, aspiration pneumonia, and venous thromboembolism.

• Initiate secondary stroke prevention.

• Communicate with patients and families to explain the history and prognosis of stroke.

• Communicate with patients and families to explain the tests and procedures and their indications and to obtain informed consent.

• Communicate with patients and families to explain the use and potential adverse effects of pharmacologic agents.

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

• Recognize barriers to follow-up care of patients who have had a stroke and involve multidisciplinary hospital staff to accordingly tailor medications and transition of care plans.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians, which may include outpatient rehabilitation. 

Hospitalists should be able to:

• Employ an early and multidisciplinary approach to the care of patients who have had a stroke that begins at admission and continues through all care transitions.

• Follow evidence-based recommendations, protocols, and risk stratification tools for the treatment of stroke.

• Work collaboratively with allied health professionals (eg, physical therapy, occupational therapy) to develop comprehensive care plans to address deficits or limitations that result from stroke. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in multidisciplinary teams, which may include neurology, rehabilitation medicine, nursing, physical and occupational therapy, speech pathology, and other allied health professionals, early in the hospital course to reduce complications, facilitate patient education, and coordinate discharge planning.

• Lead, coordinate, and/or participate in multidisciplinary efforts to develop protocols to rapidly identify patients with stroke who have indications for acute interventions and to minimize time to intervention.

• Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize resource use, including aggressive treatment of risk factors and rehabilitation.

Syncope is defined as a transient loss of consciousness that results from cerebral hypoperfusion. Characteristically, it is abrupt in onset, short-lived, and resolves spontaneously. Presyncope is a term used to describe a near-syncopal event involving identical pathophysiology as syncope; however, the patient does not fully lose consciousness. Syncope affects approximately 1 million Americans every year and accounts for 6% of all hospital admissions.^1-4 Approximately 1 in 3 persons will experience a syncopal event at least once in their lifetime.^2,4,5 The condition reflects the end-point of myriad processes ultimately leading to a disruption in the oxygen supply to the brain. It is most commonly caused by systemic hypotension accompanied by cerebral hypoperfusion. Syncope-related mortality varies depending on the etiology and is higher in persons with underlying cardiovascular disease.^3,6Although many etiologies of syncope are self-limited and benign, hospitalists must be able to identify patients who may have serious underlying diseases, as well as those at high risk for complications from a syncopal event. Hospitalists should evaluate whether diagnostic tests are indicated and curtail their routine use in patients with simple syncope for whom there is little clinical value.⁷ Furthermore, hospitalists must balance the tempo and depth of an inpatient evaluation to safely assess patients before effectively transitioning them to the outpatient environment. Hospitalists can facilitate the evaluation and management of syncope to improve patient outcomes and decrease healthcare costs associated with identifying and managing this condition. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Define syncope.

• Differentiate syncope from other causes of loss of consciousness, such as seizure.

• Explain the physiologic mechanisms that lead to reflex or neurally mediated syncope.

• Identify common causes of neurally mediated syncope such as neurocardiogenic, carotid sinus, and situational syncope.

• Identify conditions associated with orthostatic hypotension that may result in syncope.

• Identify medications that may contribute to, or cause, syncope.

• Identify common cardiac etiologies for syncope, including structural heart disease or dysrhythmia.

• Identify uncommon pulmonary or vascular etiologies for syncope, such as pulmonary embolism or vertebrobasilar insufficiency.

• Recognize associated metabolic conditions that may trigger loss of consciousness such as hypoglycemia.

• Describe risk factors that place patients at higher risk for poorer outcomes and/or complications secondary to syncope.

• List the indications that require inpatient evaluation of syncope.

• Recognize indications for specialty consultation, such as cardiology or neurology.

• Outline an evidence-based strategic process to evaluate patients with syncope.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history, perform a physical examination, and review the medical record to identify factors that led to the development of syncope.

• Accurately assess patients’ volume status and use appropriate special maneuvers to complement the physical examination to identify underlying etiologies of syncope or other causes that may mimic syncope.

• Determine which patients require evaluation of syncope as an inpatient.

• Identify the most appropriate care setting and monitoring requirements for patients admitted for a syncope evaluation (with judicious but appropriate use of continuous telemetry, pulse oximetry, and seizure precautions).

• Formulate a logical diagnostic plan to determine the cause of syncope, while avoiding diagnostic tests that are rarely indicated (such as carotid ultrasonography) except in selected circumstances.

• Order and interpret indicated laboratory studies to evaluate for underlying conditions that may contribute to, or cause, syncope.

• Appropriately order more advanced diagnostic studies to guide a syncope evaluation, seeking guidance from specialists when necessary to interpret the results.

• Determine an appropriate plan to manage syncope once the etiology has been identified.

• Communicate with nursing teams and implement appropriate precautions to prevent inpatient falls in patients admitted with syncope.

• Communicate with patients and families to explain the etiology of syncope and the importance of recognizing and preventing recurrent syncope.

• Communicate with patients and families to explain the associated risks, required monitoring, and appropriate management of syncope.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians. 

Hospitalists should be able to:

• Follow evidence-based recommendations when managing hospitalized patients with syncope.

• Work collaboratively with primary care physicians and emergency physicians in making admission decisions.

• Acknowledge the opportunity to decrease mortality, length of stay, and healthcare costs by identifying and managing complications of syncope. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize diagnostic and management strategies for syncope.

• Lead, coordinate, and/or participate in efforts to apply high-value care to the evaluation of a patient with uncomplicated syncope (eg, avoidance of neuroimaging and carotid ultrasonography).

Syncope is defined as a transient loss of consciousness that results from cerebral hypoperfusion. Characteristically, it is abrupt in onset, short-lived, and resolves spontaneously. Presyncope is a term used to describe a near-syncopal event involving identical pathophysiology as syncope; however, the patient does not fully lose consciousness. Syncope affects approximately 1 million Americans every year and accounts for 6% of all hospital admissions.^1-4 Approximately 1 in 3 persons will experience a syncopal event at least once in their lifetime.^2,4,5 The condition reflects the end-point of myriad processes ultimately leading to a disruption in the oxygen supply to the brain. It is most commonly caused by systemic hypotension accompanied by cerebral hypoperfusion. Syncope-related mortality varies depending on the etiology and is higher in persons with underlying cardiovascular disease.^3,6Although many etiologies of syncope are self-limited and benign, hospitalists must be able to identify patients who may have serious underlying diseases, as well as those at high risk for complications from a syncopal event. Hospitalists should evaluate whether diagnostic tests are indicated and curtail their routine use in patients with simple syncope for whom there is little clinical value.⁷ Furthermore, hospitalists must balance the tempo and depth of an inpatient evaluation to safely assess patients before effectively transitioning them to the outpatient environment. Hospitalists can facilitate the evaluation and management of syncope to improve patient outcomes and decrease healthcare costs associated with identifying and managing this condition. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Define syncope.

• Differentiate syncope from other causes of loss of consciousness, such as seizure.

• Explain the physiologic mechanisms that lead to reflex or neurally mediated syncope.

• Identify common causes of neurally mediated syncope such as neurocardiogenic, carotid sinus, and situational syncope.

• Identify conditions associated with orthostatic hypotension that may result in syncope.

• Identify medications that may contribute to, or cause, syncope.

• Identify common cardiac etiologies for syncope, including structural heart disease or dysrhythmia.

• Identify uncommon pulmonary or vascular etiologies for syncope, such as pulmonary embolism or vertebrobasilar insufficiency.

• Recognize associated metabolic conditions that may trigger loss of consciousness such as hypoglycemia.

• Describe risk factors that place patients at higher risk for poorer outcomes and/or complications secondary to syncope.

• List the indications that require inpatient evaluation of syncope.

• Recognize indications for specialty consultation, such as cardiology or neurology.

• Outline an evidence-based strategic process to evaluate patients with syncope.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history, perform a physical examination, and review the medical record to identify factors that led to the development of syncope.

• Accurately assess patients’ volume status and use appropriate special maneuvers to complement the physical examination to identify underlying etiologies of syncope or other causes that may mimic syncope.

• Determine which patients require evaluation of syncope as an inpatient.

• Identify the most appropriate care setting and monitoring requirements for patients admitted for a syncope evaluation (with judicious but appropriate use of continuous telemetry, pulse oximetry, and seizure precautions).

• Formulate a logical diagnostic plan to determine the cause of syncope, while avoiding diagnostic tests that are rarely indicated (such as carotid ultrasonography) except in selected circumstances.

• Order and interpret indicated laboratory studies to evaluate for underlying conditions that may contribute to, or cause, syncope.

• Appropriately order more advanced diagnostic studies to guide a syncope evaluation, seeking guidance from specialists when necessary to interpret the results.

• Determine an appropriate plan to manage syncope once the etiology has been identified.

• Communicate with nursing teams and implement appropriate precautions to prevent inpatient falls in patients admitted with syncope.

• Communicate with patients and families to explain the etiology of syncope and the importance of recognizing and preventing recurrent syncope.

• Communicate with patients and families to explain the associated risks, required monitoring, and appropriate management of syncope.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians. 

Hospitalists should be able to:

• Follow evidence-based recommendations when managing hospitalized patients with syncope.

• Work collaboratively with primary care physicians and emergency physicians in making admission decisions.

• Acknowledge the opportunity to decrease mortality, length of stay, and healthcare costs by identifying and managing complications of syncope. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize diagnostic and management strategies for syncope.

• Lead, coordinate, and/or participate in efforts to apply high-value care to the evaluation of a patient with uncomplicated syncope (eg, avoidance of neuroimaging and carotid ultrasonography).

Syncope is defined as a transient loss of consciousness that results from cerebral hypoperfusion. Characteristically, it is abrupt in onset, short-lived, and resolves spontaneously. Presyncope is a term used to describe a near-syncopal event involving identical pathophysiology as syncope; however, the patient does not fully lose consciousness. Syncope affects approximately 1 million Americans every year and accounts for 6% of all hospital admissions.^1-4 Approximately 1 in 3 persons will experience a syncopal event at least once in their lifetime.^2,4,5 The condition reflects the end-point of myriad processes ultimately leading to a disruption in the oxygen supply to the brain. It is most commonly caused by systemic hypotension accompanied by cerebral hypoperfusion. Syncope-related mortality varies depending on the etiology and is higher in persons with underlying cardiovascular disease.^3,6Although many etiologies of syncope are self-limited and benign, hospitalists must be able to identify patients who may have serious underlying diseases, as well as those at high risk for complications from a syncopal event. Hospitalists should evaluate whether diagnostic tests are indicated and curtail their routine use in patients with simple syncope for whom there is little clinical value.⁷ Furthermore, hospitalists must balance the tempo and depth of an inpatient evaluation to safely assess patients before effectively transitioning them to the outpatient environment. Hospitalists can facilitate the evaluation and management of syncope to improve patient outcomes and decrease healthcare costs associated with identifying and managing this condition. 

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Hospitalists should be able to:

• Define syncope.

• Differentiate syncope from other causes of loss of consciousness, such as seizure.

• Explain the physiologic mechanisms that lead to reflex or neurally mediated syncope.

• Identify common causes of neurally mediated syncope such as neurocardiogenic, carotid sinus, and situational syncope.

• Identify conditions associated with orthostatic hypotension that may result in syncope.

• Identify medications that may contribute to, or cause, syncope.

• Identify common cardiac etiologies for syncope, including structural heart disease or dysrhythmia.

• Identify uncommon pulmonary or vascular etiologies for syncope, such as pulmonary embolism or vertebrobasilar insufficiency.

• Recognize associated metabolic conditions that may trigger loss of consciousness such as hypoglycemia.

• Describe risk factors that place patients at higher risk for poorer outcomes and/or complications secondary to syncope.

• List the indications that require inpatient evaluation of syncope.

• Recognize indications for specialty consultation, such as cardiology or neurology.

• Outline an evidence-based strategic process to evaluate patients with syncope.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history, perform a physical examination, and review the medical record to identify factors that led to the development of syncope.

• Accurately assess patients’ volume status and use appropriate special maneuvers to complement the physical examination to identify underlying etiologies of syncope or other causes that may mimic syncope.

• Determine which patients require evaluation of syncope as an inpatient.

• Identify the most appropriate care setting and monitoring requirements for patients admitted for a syncope evaluation (with judicious but appropriate use of continuous telemetry, pulse oximetry, and seizure precautions).

• Formulate a logical diagnostic plan to determine the cause of syncope, while avoiding diagnostic tests that are rarely indicated (such as carotid ultrasonography) except in selected circumstances.

• Order and interpret indicated laboratory studies to evaluate for underlying conditions that may contribute to, or cause, syncope.

• Appropriately order more advanced diagnostic studies to guide a syncope evaluation, seeking guidance from specialists when necessary to interpret the results.

• Determine an appropriate plan to manage syncope once the etiology has been identified.

• Communicate with nursing teams and implement appropriate precautions to prevent inpatient falls in patients admitted with syncope.

• Communicate with patients and families to explain the etiology of syncope and the importance of recognizing and preventing recurrent syncope.

• Communicate with patients and families to explain the associated risks, required monitoring, and appropriate management of syncope.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians. 

Hospitalists should be able to:

• Follow evidence-based recommendations when managing hospitalized patients with syncope.

• Work collaboratively with primary care physicians and emergency physicians in making admission decisions.

• Acknowledge the opportunity to decrease mortality, length of stay, and healthcare costs by identifying and managing complications of syncope. 

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize diagnostic and management strategies for syncope.

• Lead, coordinate, and/or participate in efforts to apply high-value care to the evaluation of a patient with uncomplicated syncope (eg, avoidance of neuroimaging and carotid ultrasonography).