The Hospitalist

For the second consecutive year, the Mayo Clinic was named the top hospital in the country by U.S. News & World Report.

Also for the second consecutive year, the Cleveland Clinic is ranked second, while Johns Hopkins Hospital in Baltimore and Massachusetts General Hospital in Boston finished third and fourth – switching their places from last year’s ranking – and UCSF Medical Center in San Francisco is fifth after ranking seventh last year, according to the 2017-2018 Best Hospitals ranking.

[email protected]

For the second consecutive year, the Mayo Clinic was named the top hospital in the country by U.S. News & World Report.

Also for the second consecutive year, the Cleveland Clinic is ranked second, while Johns Hopkins Hospital in Baltimore and Massachusetts General Hospital in Boston finished third and fourth – switching their places from last year’s ranking – and UCSF Medical Center in San Francisco is fifth after ranking seventh last year, according to the 2017-2018 Best Hospitals ranking.

[email protected]

For the second consecutive year, the Mayo Clinic was named the top hospital in the country by U.S. News & World Report.

Also for the second consecutive year, the Cleveland Clinic is ranked second, while Johns Hopkins Hospital in Baltimore and Massachusetts General Hospital in Boston finished third and fourth – switching their places from last year’s ranking – and UCSF Medical Center in San Francisco is fifth after ranking seventh last year, according to the 2017-2018 Best Hospitals ranking.

[email protected]

“You must be the change you wish to see in the world.” This famous quote from Mahatma Gandhi has inspired many to transform their work and personal space into an eternal quest for improvement. We hospitalists are now well-recognized agents of change in our work environment, improving the quality and safety of inpatient care, striving to create increased value, and promoting the delivery of cost-effective care.

What does the “Core Competencies” represent and who should use it?

It comprises a set of competency-based learning objectives that present a shared understanding of the knowledge, skills, and attitudes expected of physicians practicing hospital medicine in the United States.

A common misconception is that every hospitalist can be expected to demonstrate proficiency in all topics in the Core Competencies. While every item in the compendium is highly relevant to the field as a whole, its significance for individual hospitalists will vary depending on their practice pattern, leadership role, and local culture.

It also is noteworthy to indicate that it is not a set of practice guidelines that provide recommendations based on the latest scientific evidence, nor does it represent any legal standard of care. Rather, the Core Competencies offers an agenda for curricular training and to broadly influence the direction of the field. It also is important to realize that the Core Competencies is not an all-inclusive list that restricts a hospitalist’s scope of practice. Instead, hospitalists should use the Core Competencies as an educational and professional benchmark with the ultimate goal of providing safe, efficient, and high-value care using interdisciplinary collaboration when necessary.

As a core set of attributes, all hospitalists can use it to reflect on their knowledge, skills, and attitudes, as well as those of their group or practice collectively. The Core Competencies highlights areas within the field that are prime for further research and quality improvement initiatives on a national, regional, and local level. Thus, they also should be of interest to health care administrators and a variety of stakeholders looking to support and fund such efforts in enhancing health care value and quality for all.

It is also a framework for the development of curricula for both education and professional development purposes for use by hospitalists, hospital medicine programs, and health care institutions. Course Directors of Continuing Medical Education programs can use the Core Competencies to identify learning objectives that fulfill the goal of the educational program. Similarly, residency and fellowship program directors and medical school clerkship directors can use it to develop course syllabi targeted to the needs of their learner groups.

The structure and format of the Core Competencies in Hospital Medicine

The 53 chapters in the 2017 revision are divided into three sections – Clinical Conditions, Procedures, and Healthcare Systems, all integral to the practice of hospital medicine. Each chapter starts with an introductory paragraph that discusses the relevance and importance of the subject. Each competency-based learning objective describes a particular concept coupled with an action verb that specifies an expected level of proficiency.

For example, the action verb “explain” that requires a mere description of a subject denotes a lower competency level, compared with the verb “evaluate,” which implies not only an understanding of the matter but also the ability to assess its value for a particular purpose. These learning objectives are further categorized into knowledge, skills, and attitudes subsections to reflect the cognitive, psychomotor, and affective domains of learning.

Because hospitalists are the experts in complex hospital systems, the clinical and procedural sections have an additional subsection, “System Organization and Improvement.” The objectives in this paragraph emphasize the critical role that hospitalists can play as leaders of multidisciplinary teams to improve the quality of care of all patients with a similar condition or undergoing the same procedure.

Examples of everyday use of the Core Competencies for practicing hospitalists

A hospitalist looking to improve her performance of bedside thoracentesis reviews the chapter on Thoracentesis. She then decides to enhance her skills by attending an educational workshop on the use of point-of-care ultrasonography.

A hospital medicine group interested in improving the rate of common hospital-acquired infections reviews the Urinary Tract Infection, Hospital-Acquired and Healthcare-Associated Pneumonia, and Prevention of Healthcare-Associated Infections and Antimicrobial Resistance chapters to identify possible gaps in practice patterns. The group also goes through the chapters on Quality Improvement, Practice-based Learning and Improvement, and Hospitalist as Educator, to further reflect upon the characteristics of their practice environment. The group then adopts a separate strategy to address identified gaps by finding suitable evidence-based content in a format that best fits their need.

An attending physician leading a team of medical residents and students reviews the chapter on Syncope to identify the teaching objectives for each learner. He decides that the medical student should be able to “define syncope” and “explain the physiologic mechanisms that lead to reflex or neurally mediated syncope.” He determines that the intern on the team should be able to “differentiate syncope from other causes of loss of consciousness,” and the senior resident should be able to “formulate a logical diagnostic plan to determine the cause of syncope while avoiding rarely indicated diagnostic tests … ”

New chapters in the 2017 revision

SHM’s Core Competencies Task Force (CCTF) considered several topics as potential new chapters for the 2017 Revision. The SHM Education Committee judged each for its value as a “core” subject by its relevance, intersection with other specialties, and its scope as a stand-alone chapter.

There are two new clinical conditions – hyponatremia and syncope – mainly chosen because of their clinical importance, the risk of complications, and management inconsistencies that offer hospitalists great opportunities for quality improvement initiatives. The CCTF also identified the use of point-of-care ultrasonography as a notable advancement in the field. A separate task force is working to evaluate best practices and develop a practice guideline that hospitalists can use. The CCTF expects to add more chapters as the field of hospital medicine continues to advance and transform the delivery of health care globally.

The 2017 Revision of the Core Competencies in Hospital Medicine is located online at www.journalofhospitalmedicine.com or using the URL shortener bit.ly/corecomp17.

Dr. Nichani is assistant professor of medicine and director of education for the division of hospital medicine at Michigan Medicine, University of Michigan, Ann Arbor. He serves as the chair of the SHM Education Committee.

“You must be the change you wish to see in the world.” This famous quote from Mahatma Gandhi has inspired many to transform their work and personal space into an eternal quest for improvement. We hospitalists are now well-recognized agents of change in our work environment, improving the quality and safety of inpatient care, striving to create increased value, and promoting the delivery of cost-effective care.

What does the “Core Competencies” represent and who should use it?

It comprises a set of competency-based learning objectives that present a shared understanding of the knowledge, skills, and attitudes expected of physicians practicing hospital medicine in the United States.

A common misconception is that every hospitalist can be expected to demonstrate proficiency in all topics in the Core Competencies. While every item in the compendium is highly relevant to the field as a whole, its significance for individual hospitalists will vary depending on their practice pattern, leadership role, and local culture.

It also is noteworthy to indicate that it is not a set of practice guidelines that provide recommendations based on the latest scientific evidence, nor does it represent any legal standard of care. Rather, the Core Competencies offers an agenda for curricular training and to broadly influence the direction of the field. It also is important to realize that the Core Competencies is not an all-inclusive list that restricts a hospitalist’s scope of practice. Instead, hospitalists should use the Core Competencies as an educational and professional benchmark with the ultimate goal of providing safe, efficient, and high-value care using interdisciplinary collaboration when necessary.

As a core set of attributes, all hospitalists can use it to reflect on their knowledge, skills, and attitudes, as well as those of their group or practice collectively. The Core Competencies highlights areas within the field that are prime for further research and quality improvement initiatives on a national, regional, and local level. Thus, they also should be of interest to health care administrators and a variety of stakeholders looking to support and fund such efforts in enhancing health care value and quality for all.

It is also a framework for the development of curricula for both education and professional development purposes for use by hospitalists, hospital medicine programs, and health care institutions. Course Directors of Continuing Medical Education programs can use the Core Competencies to identify learning objectives that fulfill the goal of the educational program. Similarly, residency and fellowship program directors and medical school clerkship directors can use it to develop course syllabi targeted to the needs of their learner groups.

The structure and format of the Core Competencies in Hospital Medicine

The 53 chapters in the 2017 revision are divided into three sections – Clinical Conditions, Procedures, and Healthcare Systems, all integral to the practice of hospital medicine. Each chapter starts with an introductory paragraph that discusses the relevance and importance of the subject. Each competency-based learning objective describes a particular concept coupled with an action verb that specifies an expected level of proficiency.

For example, the action verb “explain” that requires a mere description of a subject denotes a lower competency level, compared with the verb “evaluate,” which implies not only an understanding of the matter but also the ability to assess its value for a particular purpose. These learning objectives are further categorized into knowledge, skills, and attitudes subsections to reflect the cognitive, psychomotor, and affective domains of learning.

Because hospitalists are the experts in complex hospital systems, the clinical and procedural sections have an additional subsection, “System Organization and Improvement.” The objectives in this paragraph emphasize the critical role that hospitalists can play as leaders of multidisciplinary teams to improve the quality of care of all patients with a similar condition or undergoing the same procedure.

Examples of everyday use of the Core Competencies for practicing hospitalists

A hospitalist looking to improve her performance of bedside thoracentesis reviews the chapter on Thoracentesis. She then decides to enhance her skills by attending an educational workshop on the use of point-of-care ultrasonography.

A hospital medicine group interested in improving the rate of common hospital-acquired infections reviews the Urinary Tract Infection, Hospital-Acquired and Healthcare-Associated Pneumonia, and Prevention of Healthcare-Associated Infections and Antimicrobial Resistance chapters to identify possible gaps in practice patterns. The group also goes through the chapters on Quality Improvement, Practice-based Learning and Improvement, and Hospitalist as Educator, to further reflect upon the characteristics of their practice environment. The group then adopts a separate strategy to address identified gaps by finding suitable evidence-based content in a format that best fits their need.

An attending physician leading a team of medical residents and students reviews the chapter on Syncope to identify the teaching objectives for each learner. He decides that the medical student should be able to “define syncope” and “explain the physiologic mechanisms that lead to reflex or neurally mediated syncope.” He determines that the intern on the team should be able to “differentiate syncope from other causes of loss of consciousness,” and the senior resident should be able to “formulate a logical diagnostic plan to determine the cause of syncope while avoiding rarely indicated diagnostic tests … ”

New chapters in the 2017 revision

SHM’s Core Competencies Task Force (CCTF) considered several topics as potential new chapters for the 2017 Revision. The SHM Education Committee judged each for its value as a “core” subject by its relevance, intersection with other specialties, and its scope as a stand-alone chapter.

There are two new clinical conditions – hyponatremia and syncope – mainly chosen because of their clinical importance, the risk of complications, and management inconsistencies that offer hospitalists great opportunities for quality improvement initiatives. The CCTF also identified the use of point-of-care ultrasonography as a notable advancement in the field. A separate task force is working to evaluate best practices and develop a practice guideline that hospitalists can use. The CCTF expects to add more chapters as the field of hospital medicine continues to advance and transform the delivery of health care globally.

The 2017 Revision of the Core Competencies in Hospital Medicine is located online at www.journalofhospitalmedicine.com or using the URL shortener bit.ly/corecomp17.

Dr. Nichani is assistant professor of medicine and director of education for the division of hospital medicine at Michigan Medicine, University of Michigan, Ann Arbor. He serves as the chair of the SHM Education Committee.

“You must be the change you wish to see in the world.” This famous quote from Mahatma Gandhi has inspired many to transform their work and personal space into an eternal quest for improvement. We hospitalists are now well-recognized agents of change in our work environment, improving the quality and safety of inpatient care, striving to create increased value, and promoting the delivery of cost-effective care.

What does the “Core Competencies” represent and who should use it?

It comprises a set of competency-based learning objectives that present a shared understanding of the knowledge, skills, and attitudes expected of physicians practicing hospital medicine in the United States.

A common misconception is that every hospitalist can be expected to demonstrate proficiency in all topics in the Core Competencies. While every item in the compendium is highly relevant to the field as a whole, its significance for individual hospitalists will vary depending on their practice pattern, leadership role, and local culture.

It also is noteworthy to indicate that it is not a set of practice guidelines that provide recommendations based on the latest scientific evidence, nor does it represent any legal standard of care. Rather, the Core Competencies offers an agenda for curricular training and to broadly influence the direction of the field. It also is important to realize that the Core Competencies is not an all-inclusive list that restricts a hospitalist’s scope of practice. Instead, hospitalists should use the Core Competencies as an educational and professional benchmark with the ultimate goal of providing safe, efficient, and high-value care using interdisciplinary collaboration when necessary.

As a core set of attributes, all hospitalists can use it to reflect on their knowledge, skills, and attitudes, as well as those of their group or practice collectively. The Core Competencies highlights areas within the field that are prime for further research and quality improvement initiatives on a national, regional, and local level. Thus, they also should be of interest to health care administrators and a variety of stakeholders looking to support and fund such efforts in enhancing health care value and quality for all.

It is also a framework for the development of curricula for both education and professional development purposes for use by hospitalists, hospital medicine programs, and health care institutions. Course Directors of Continuing Medical Education programs can use the Core Competencies to identify learning objectives that fulfill the goal of the educational program. Similarly, residency and fellowship program directors and medical school clerkship directors can use it to develop course syllabi targeted to the needs of their learner groups.

The structure and format of the Core Competencies in Hospital Medicine

The 53 chapters in the 2017 revision are divided into three sections – Clinical Conditions, Procedures, and Healthcare Systems, all integral to the practice of hospital medicine. Each chapter starts with an introductory paragraph that discusses the relevance and importance of the subject. Each competency-based learning objective describes a particular concept coupled with an action verb that specifies an expected level of proficiency.

For example, the action verb “explain” that requires a mere description of a subject denotes a lower competency level, compared with the verb “evaluate,” which implies not only an understanding of the matter but also the ability to assess its value for a particular purpose. These learning objectives are further categorized into knowledge, skills, and attitudes subsections to reflect the cognitive, psychomotor, and affective domains of learning.

Because hospitalists are the experts in complex hospital systems, the clinical and procedural sections have an additional subsection, “System Organization and Improvement.” The objectives in this paragraph emphasize the critical role that hospitalists can play as leaders of multidisciplinary teams to improve the quality of care of all patients with a similar condition or undergoing the same procedure.

Examples of everyday use of the Core Competencies for practicing hospitalists

A hospitalist looking to improve her performance of bedside thoracentesis reviews the chapter on Thoracentesis. She then decides to enhance her skills by attending an educational workshop on the use of point-of-care ultrasonography.

A hospital medicine group interested in improving the rate of common hospital-acquired infections reviews the Urinary Tract Infection, Hospital-Acquired and Healthcare-Associated Pneumonia, and Prevention of Healthcare-Associated Infections and Antimicrobial Resistance chapters to identify possible gaps in practice patterns. The group also goes through the chapters on Quality Improvement, Practice-based Learning and Improvement, and Hospitalist as Educator, to further reflect upon the characteristics of their practice environment. The group then adopts a separate strategy to address identified gaps by finding suitable evidence-based content in a format that best fits their need.

An attending physician leading a team of medical residents and students reviews the chapter on Syncope to identify the teaching objectives for each learner. He decides that the medical student should be able to “define syncope” and “explain the physiologic mechanisms that lead to reflex or neurally mediated syncope.” He determines that the intern on the team should be able to “differentiate syncope from other causes of loss of consciousness,” and the senior resident should be able to “formulate a logical diagnostic plan to determine the cause of syncope while avoiding rarely indicated diagnostic tests … ”

New chapters in the 2017 revision

SHM’s Core Competencies Task Force (CCTF) considered several topics as potential new chapters for the 2017 Revision. The SHM Education Committee judged each for its value as a “core” subject by its relevance, intersection with other specialties, and its scope as a stand-alone chapter.

There are two new clinical conditions – hyponatremia and syncope – mainly chosen because of their clinical importance, the risk of complications, and management inconsistencies that offer hospitalists great opportunities for quality improvement initiatives. The CCTF also identified the use of point-of-care ultrasonography as a notable advancement in the field. A separate task force is working to evaluate best practices and develop a practice guideline that hospitalists can use. The CCTF expects to add more chapters as the field of hospital medicine continues to advance and transform the delivery of health care globally.

The 2017 Revision of the Core Competencies in Hospital Medicine is located online at www.journalofhospitalmedicine.com or using the URL shortener bit.ly/corecomp17.

Dr. Nichani is assistant professor of medicine and director of education for the division of hospital medicine at Michigan Medicine, University of Michigan, Ann Arbor. He serves as the chair of the SHM Education Committee.

Education and service have always been important for Harry Cho, MD, who recently joined the editorial advisory board of The Hospitalist.

From joining AmeriCorps as a fresh faced college graduate, to his ongoing work as assistant professor of medicine and director of quality, safety, and value for the division of hospital medicine at Mount Sinai in New York, and as senior fellow at the Lown Institute, Dr. Cho has found a passion in helping others learn.

Q: Why did you choose medicine as a career?

A: Right after I finished undergrad at Cornell, I spent the summer and the following year doing AmeriCorps, which is service learning work, and I worked in the inner city of Philadelphia. I worked on after-school programs and weekend programs for inner city youth and I loved it. I was organizing and developing these programs, and I thought it was fantastic. The one thing that I thought was lacking, and I think what really drove me to get into medicine, was that at the end of the day, although I felt really connected with all the kids, I felt like I was a role model, like I was a mentor, and we had a really good connection, but I wanted something a little bit more concrete on improving outcomes. I knew we made connections, but I really wanted to know more – such as, did we reduce the dropout rate in high school for these students? I think that’s why medicine was really interesting.
 

Q: How did you end up in hospital medicine?

A: I think it’s a lot of things. I love the acuity, I love playing the quarterback in a place where a lot of things are going back and forth and you have to coordinate with others. You have to make sure you see the patient from top to bottom, the whole picture, and I love that part. I also love the action and the communication and the teamwork aspect of it.
 

Q: What part of being a hospitalist do you like the most?

A: I love the education on a daily basis: the morning rounds where you walk around for an hour or two with your team, and you teach them at the bedside, and these little pearls come up along the way. My career is positioned more within quality, value improvement, and safety, so I think that participating in the education process is really helpful. I think hospital medicine has taken over that spirit in the hospital setting, and I love that.
 

Q: Which part do you like the least?

A: I think we’re in a unique time right now. Burnout is getting a little tougher to beat. People are getting a bit more tired, and I don’t think we have a good solution to solve this. With quality improvement and the electronic medical record system, a lot of us are expected to do more. I still get queries from clinical documentation saying, “I need you to document this for billing purposes” or “I need you to document this for increasing the expected length of stay,” and doctors are not quite at the point where they can balance these requirements in an effective way. There tends to be an emphasis on “one more click,” one more thing to document, just one more thing to do on the checklist. It’s getting more complex.
 

Q: What is the most rewarding part of your work?

A: Larger scale accomplishments. When you give a talk, or teach a group of residents during morning rounds, and they look at you with wonder because you have this teaching pearl they’ve never heard before, and they think you’re a great attending – that’s very instant gratification, but there's more to be done beyond that. I’ve been co-directing in the Right Care educator program, and we have a High Value Care curriculum that we’ve been implementing across the country, and we’ve just finished our second year. There are around 60 programs involved, and it’s a great feeling. You’re not seeing actual people face to face after they’ve been taught, and you’re not getting that instant gratification. But just knowing what one of those chief residents who has implemented the program is feeling, and extrapolating across the number of programs this year alone, that makes me feel good.
 

Q: Outside of hospital work, what else are you interested in?

A: High-value care is my central aim right now. I want to expand it, and I want to do things on a national scale. We formed a High Value Care committee and I’m hoping to create new guidelines to reduce overuse, overtesting, and Choosing Wisely. Outside of medicine, I like photography. Nothing professional, but I love taking pictures, especially nature and travel. Back in the day, I used to do a lot of running and martial arts too.
 

Q: Where do you see yourself in 10 years?

A: I’m not sure if I will go the chief medical officer or chief quality officer route. That’s probably where I see myself. I definitely want to continue making bigger changes on a national scale, like implementing the overuse educator program across the country.
 

Q: What do you see as the future of hospital medicine?

A: Value-based health care is always going to get bigger as the cost of health care and the cost of overuse rises, and we start to see a lot of harms outlined in research. We’re going to be on top of it much more, because the hospital setting is complex and continues to change.

Education and service have always been important for Harry Cho, MD, who recently joined the editorial advisory board of The Hospitalist.

From joining AmeriCorps as a fresh faced college graduate, to his ongoing work as assistant professor of medicine and director of quality, safety, and value for the division of hospital medicine at Mount Sinai in New York, and as senior fellow at the Lown Institute, Dr. Cho has found a passion in helping others learn.

Q: Why did you choose medicine as a career?

A: Right after I finished undergrad at Cornell, I spent the summer and the following year doing AmeriCorps, which is service learning work, and I worked in the inner city of Philadelphia. I worked on after-school programs and weekend programs for inner city youth and I loved it. I was organizing and developing these programs, and I thought it was fantastic. The one thing that I thought was lacking, and I think what really drove me to get into medicine, was that at the end of the day, although I felt really connected with all the kids, I felt like I was a role model, like I was a mentor, and we had a really good connection, but I wanted something a little bit more concrete on improving outcomes. I knew we made connections, but I really wanted to know more – such as, did we reduce the dropout rate in high school for these students? I think that’s why medicine was really interesting.
 

Q: How did you end up in hospital medicine?

A: I think it’s a lot of things. I love the acuity, I love playing the quarterback in a place where a lot of things are going back and forth and you have to coordinate with others. You have to make sure you see the patient from top to bottom, the whole picture, and I love that part. I also love the action and the communication and the teamwork aspect of it.
 

Q: What part of being a hospitalist do you like the most?

A: I love the education on a daily basis: the morning rounds where you walk around for an hour or two with your team, and you teach them at the bedside, and these little pearls come up along the way. My career is positioned more within quality, value improvement, and safety, so I think that participating in the education process is really helpful. I think hospital medicine has taken over that spirit in the hospital setting, and I love that.
 

Q: Which part do you like the least?

A: I think we’re in a unique time right now. Burnout is getting a little tougher to beat. People are getting a bit more tired, and I don’t think we have a good solution to solve this. With quality improvement and the electronic medical record system, a lot of us are expected to do more. I still get queries from clinical documentation saying, “I need you to document this for billing purposes” or “I need you to document this for increasing the expected length of stay,” and doctors are not quite at the point where they can balance these requirements in an effective way. There tends to be an emphasis on “one more click,” one more thing to document, just one more thing to do on the checklist. It’s getting more complex.
 

Q: What is the most rewarding part of your work?

A: Larger scale accomplishments. When you give a talk, or teach a group of residents during morning rounds, and they look at you with wonder because you have this teaching pearl they’ve never heard before, and they think you’re a great attending – that’s very instant gratification, but there's more to be done beyond that. I’ve been co-directing in the Right Care educator program, and we have a High Value Care curriculum that we’ve been implementing across the country, and we’ve just finished our second year. There are around 60 programs involved, and it’s a great feeling. You’re not seeing actual people face to face after they’ve been taught, and you’re not getting that instant gratification. But just knowing what one of those chief residents who has implemented the program is feeling, and extrapolating across the number of programs this year alone, that makes me feel good.
 

Q: Outside of hospital work, what else are you interested in?

A: High-value care is my central aim right now. I want to expand it, and I want to do things on a national scale. We formed a High Value Care committee and I’m hoping to create new guidelines to reduce overuse, overtesting, and Choosing Wisely. Outside of medicine, I like photography. Nothing professional, but I love taking pictures, especially nature and travel. Back in the day, I used to do a lot of running and martial arts too.
 

Q: Where do you see yourself in 10 years?

A: I’m not sure if I will go the chief medical officer or chief quality officer route. That’s probably where I see myself. I definitely want to continue making bigger changes on a national scale, like implementing the overuse educator program across the country.
 

Q: What do you see as the future of hospital medicine?

A: Value-based health care is always going to get bigger as the cost of health care and the cost of overuse rises, and we start to see a lot of harms outlined in research. We’re going to be on top of it much more, because the hospital setting is complex and continues to change.

Education and service have always been important for Harry Cho, MD, who recently joined the editorial advisory board of The Hospitalist.

From joining AmeriCorps as a fresh faced college graduate, to his ongoing work as assistant professor of medicine and director of quality, safety, and value for the division of hospital medicine at Mount Sinai in New York, and as senior fellow at the Lown Institute, Dr. Cho has found a passion in helping others learn.

Q: Why did you choose medicine as a career?

A: Right after I finished undergrad at Cornell, I spent the summer and the following year doing AmeriCorps, which is service learning work, and I worked in the inner city of Philadelphia. I worked on after-school programs and weekend programs for inner city youth and I loved it. I was organizing and developing these programs, and I thought it was fantastic. The one thing that I thought was lacking, and I think what really drove me to get into medicine, was that at the end of the day, although I felt really connected with all the kids, I felt like I was a role model, like I was a mentor, and we had a really good connection, but I wanted something a little bit more concrete on improving outcomes. I knew we made connections, but I really wanted to know more – such as, did we reduce the dropout rate in high school for these students? I think that’s why medicine was really interesting.
 

Q: How did you end up in hospital medicine?

A: I think it’s a lot of things. I love the acuity, I love playing the quarterback in a place where a lot of things are going back and forth and you have to coordinate with others. You have to make sure you see the patient from top to bottom, the whole picture, and I love that part. I also love the action and the communication and the teamwork aspect of it.
 

Q: What part of being a hospitalist do you like the most?

A: I love the education on a daily basis: the morning rounds where you walk around for an hour or two with your team, and you teach them at the bedside, and these little pearls come up along the way. My career is positioned more within quality, value improvement, and safety, so I think that participating in the education process is really helpful. I think hospital medicine has taken over that spirit in the hospital setting, and I love that.
 

Q: Which part do you like the least?

A: I think we’re in a unique time right now. Burnout is getting a little tougher to beat. People are getting a bit more tired, and I don’t think we have a good solution to solve this. With quality improvement and the electronic medical record system, a lot of us are expected to do more. I still get queries from clinical documentation saying, “I need you to document this for billing purposes” or “I need you to document this for increasing the expected length of stay,” and doctors are not quite at the point where they can balance these requirements in an effective way. There tends to be an emphasis on “one more click,” one more thing to document, just one more thing to do on the checklist. It’s getting more complex.
 

Q: What is the most rewarding part of your work?

A: Larger scale accomplishments. When you give a talk, or teach a group of residents during morning rounds, and they look at you with wonder because you have this teaching pearl they’ve never heard before, and they think you’re a great attending – that’s very instant gratification, but there's more to be done beyond that. I’ve been co-directing in the Right Care educator program, and we have a High Value Care curriculum that we’ve been implementing across the country, and we’ve just finished our second year. There are around 60 programs involved, and it’s a great feeling. You’re not seeing actual people face to face after they’ve been taught, and you’re not getting that instant gratification. But just knowing what one of those chief residents who has implemented the program is feeling, and extrapolating across the number of programs this year alone, that makes me feel good.
 

Q: Outside of hospital work, what else are you interested in?

A: High-value care is my central aim right now. I want to expand it, and I want to do things on a national scale. We formed a High Value Care committee and I’m hoping to create new guidelines to reduce overuse, overtesting, and Choosing Wisely. Outside of medicine, I like photography. Nothing professional, but I love taking pictures, especially nature and travel. Back in the day, I used to do a lot of running and martial arts too.
 

Q: Where do you see yourself in 10 years?

A: I’m not sure if I will go the chief medical officer or chief quality officer route. That’s probably where I see myself. I definitely want to continue making bigger changes on a national scale, like implementing the overuse educator program across the country.
 

Q: What do you see as the future of hospital medicine?

A: Value-based health care is always going to get bigger as the cost of health care and the cost of overuse rises, and we start to see a lot of harms outlined in research. We’re going to be on top of it much more, because the hospital setting is complex and continues to change.

An age-adjusted version of the Sequential Organ Failure Assessment score for sepsis has been found to be at least as good, if not better than, other pediatric organ dysfunction scores at predicting in-hospital mortality.

Writing in the Aug. 7 online edition of JAMA Pediatrics, researchers reported the outcome of a retrospective observational cohort study in 6,303 critically ill patients aged 21 years or younger, which was used to adapt and validate a pediatric version of the Sequential Organ Failure Assessment (SOFA) score.

“One of the major limitations of the SOFA score is that it was developed for adult patients and contains measures that vary significantly with age, which makes it unsuitable for children,” wrote Travis J. Matics, DO, and L. Nelson Sanchez-Pinto, MD, of the department of pediatrics at the University of Chicago.

Several pediatric organ dysfunction scores exist, but their range, scale, and coverage are different from those of the SOFA score, which makes them difficult to use concurrently (JAMA Pediatr. 2017 Aug 7. doi: 10.1001/jamapediatrics.2017.2352).

“Fundamentally, having different definitions of sepsis for patients above or below the pediatric-adult threshold has no known physiologic justification and should therefore be avoided,” the authors wrote.

In this study, they modified the age-dependent cardiovascular and renal variables of the adult SOFA score by using validated cut-offs from the updated Pediatric Logistic Organ Dysfunction (PELOD-2) scoring system. They also expanded the respiratory subscore to incorporate the SpO₂:FiO₂ ratio as an alternative surrogate of lung injury.

The neurologic subscore, based on the Glasgow Coma Scale, was changed to a pediatric version of the scale. The coagulation and hepatic criteria remained the same as the adult version of the score.

Validating the pediatric version of the SOFA score (pSOFA) score in 8,711 hospital encounters, researchers found that nonsurvivors had a significantly higher median maximum pSOFA score, compared with survivors (13 vs. 2, P less than .001). The area under the curve (AUC) for discriminating in-hospital mortality was 0.94 (95% confidence interval, 0.92-0.95) and remained stable across sex, age groups, and admission types.

The maximum pSOFA score was as good as the PELOD and PELOD-2 scales at discriminating in-hospital mortality and better than the Pediatric Multiple Organ Dysfunction Score. It also showed “excellent” discrimination of in-hospital mortality among the 48.4% of patients who had a confirmed or suspected infection in the pediatric intensive care unit (AUC, 0.92; 95% CI, 0.91-0.94), Dr. Matics and Dr. Sanchez-Pinto reported.

Researchers also looked at the clinical utility of pSOFA on the day of admission, compared with the Pediatric Risk of Mortality (PRISM) III score, and found the two were similar, while the pSOFA outperformed other organ dysfunction scores in this setting.

Overall, 14.1% of the pediatric intensive care population met the sepsis criteria according to the adapted definitions and pSOFA scores, and this group had a mortality of 12.1%. Four percent of the population met the criteria for septic shock, with a mortality of 32.3%.

The SOFA score incorporates respiratory, coagulation, renal, hepatic, cardiovascular, and neurologic variables. The authors, however, argued that it does not account for age-related variability, in particular in renal criteria and the detrimental effects of kidney dysfunction in younger patients.

“In addition, the respiratory subscore criteria – based on the ratio of PaO₂ to the fraction of inspired oxygen (FiO₂) – have not been modified in previous adaptations of the SOFA score even though the decreased use of arterial blood gases in children is a known limitation,” they wrote.

“Having a harmonized definition of sepsis across age groups while recognizing the importance of the age-based variation of its measures can have many benefits, including better design of clinical trials, improved accuracy of reported outcomes, and better translation of the research and clinical strategies in the management of sepsis,” Dr. Matics and Dr. Sanchez-Pinto said.

They acknowledged, however, that their findings were limited because they were generated using retrospective data and needed to be validated in a large multicenter sample of critically ill children. They also pointed out that they did not evaluate the performance of pSOFA as a longitudinal biomarker and suggested that such studies would improve understanding of pSOFA’s clinical utility.

No conflicts of interest were reported.

[email protected]

An age-adjusted version of the Sequential Organ Failure Assessment score for sepsis has been found to be at least as good, if not better than, other pediatric organ dysfunction scores at predicting in-hospital mortality.

Writing in the Aug. 7 online edition of JAMA Pediatrics, researchers reported the outcome of a retrospective observational cohort study in 6,303 critically ill patients aged 21 years or younger, which was used to adapt and validate a pediatric version of the Sequential Organ Failure Assessment (SOFA) score.

“One of the major limitations of the SOFA score is that it was developed for adult patients and contains measures that vary significantly with age, which makes it unsuitable for children,” wrote Travis J. Matics, DO, and L. Nelson Sanchez-Pinto, MD, of the department of pediatrics at the University of Chicago.

Several pediatric organ dysfunction scores exist, but their range, scale, and coverage are different from those of the SOFA score, which makes them difficult to use concurrently (JAMA Pediatr. 2017 Aug 7. doi: 10.1001/jamapediatrics.2017.2352).

“Fundamentally, having different definitions of sepsis for patients above or below the pediatric-adult threshold has no known physiologic justification and should therefore be avoided,” the authors wrote.

In this study, they modified the age-dependent cardiovascular and renal variables of the adult SOFA score by using validated cut-offs from the updated Pediatric Logistic Organ Dysfunction (PELOD-2) scoring system. They also expanded the respiratory subscore to incorporate the SpO₂:FiO₂ ratio as an alternative surrogate of lung injury.

The neurologic subscore, based on the Glasgow Coma Scale, was changed to a pediatric version of the scale. The coagulation and hepatic criteria remained the same as the adult version of the score.

Validating the pediatric version of the SOFA score (pSOFA) score in 8,711 hospital encounters, researchers found that nonsurvivors had a significantly higher median maximum pSOFA score, compared with survivors (13 vs. 2, P less than .001). The area under the curve (AUC) for discriminating in-hospital mortality was 0.94 (95% confidence interval, 0.92-0.95) and remained stable across sex, age groups, and admission types.

The maximum pSOFA score was as good as the PELOD and PELOD-2 scales at discriminating in-hospital mortality and better than the Pediatric Multiple Organ Dysfunction Score. It also showed “excellent” discrimination of in-hospital mortality among the 48.4% of patients who had a confirmed or suspected infection in the pediatric intensive care unit (AUC, 0.92; 95% CI, 0.91-0.94), Dr. Matics and Dr. Sanchez-Pinto reported.

Researchers also looked at the clinical utility of pSOFA on the day of admission, compared with the Pediatric Risk of Mortality (PRISM) III score, and found the two were similar, while the pSOFA outperformed other organ dysfunction scores in this setting.

Overall, 14.1% of the pediatric intensive care population met the sepsis criteria according to the adapted definitions and pSOFA scores, and this group had a mortality of 12.1%. Four percent of the population met the criteria for septic shock, with a mortality of 32.3%.

The SOFA score incorporates respiratory, coagulation, renal, hepatic, cardiovascular, and neurologic variables. The authors, however, argued that it does not account for age-related variability, in particular in renal criteria and the detrimental effects of kidney dysfunction in younger patients.

“In addition, the respiratory subscore criteria – based on the ratio of PaO₂ to the fraction of inspired oxygen (FiO₂) – have not been modified in previous adaptations of the SOFA score even though the decreased use of arterial blood gases in children is a known limitation,” they wrote.

“Having a harmonized definition of sepsis across age groups while recognizing the importance of the age-based variation of its measures can have many benefits, including better design of clinical trials, improved accuracy of reported outcomes, and better translation of the research and clinical strategies in the management of sepsis,” Dr. Matics and Dr. Sanchez-Pinto said.

They acknowledged, however, that their findings were limited because they were generated using retrospective data and needed to be validated in a large multicenter sample of critically ill children. They also pointed out that they did not evaluate the performance of pSOFA as a longitudinal biomarker and suggested that such studies would improve understanding of pSOFA’s clinical utility.

No conflicts of interest were reported.

[email protected]

An age-adjusted version of the Sequential Organ Failure Assessment score for sepsis has been found to be at least as good, if not better than, other pediatric organ dysfunction scores at predicting in-hospital mortality.

Writing in the Aug. 7 online edition of JAMA Pediatrics, researchers reported the outcome of a retrospective observational cohort study in 6,303 critically ill patients aged 21 years or younger, which was used to adapt and validate a pediatric version of the Sequential Organ Failure Assessment (SOFA) score.

“One of the major limitations of the SOFA score is that it was developed for adult patients and contains measures that vary significantly with age, which makes it unsuitable for children,” wrote Travis J. Matics, DO, and L. Nelson Sanchez-Pinto, MD, of the department of pediatrics at the University of Chicago.

Several pediatric organ dysfunction scores exist, but their range, scale, and coverage are different from those of the SOFA score, which makes them difficult to use concurrently (JAMA Pediatr. 2017 Aug 7. doi: 10.1001/jamapediatrics.2017.2352).

“Fundamentally, having different definitions of sepsis for patients above or below the pediatric-adult threshold has no known physiologic justification and should therefore be avoided,” the authors wrote.

In this study, they modified the age-dependent cardiovascular and renal variables of the adult SOFA score by using validated cut-offs from the updated Pediatric Logistic Organ Dysfunction (PELOD-2) scoring system. They also expanded the respiratory subscore to incorporate the SpO₂:FiO₂ ratio as an alternative surrogate of lung injury.

The neurologic subscore, based on the Glasgow Coma Scale, was changed to a pediatric version of the scale. The coagulation and hepatic criteria remained the same as the adult version of the score.

Validating the pediatric version of the SOFA score (pSOFA) score in 8,711 hospital encounters, researchers found that nonsurvivors had a significantly higher median maximum pSOFA score, compared with survivors (13 vs. 2, P less than .001). The area under the curve (AUC) for discriminating in-hospital mortality was 0.94 (95% confidence interval, 0.92-0.95) and remained stable across sex, age groups, and admission types.

The maximum pSOFA score was as good as the PELOD and PELOD-2 scales at discriminating in-hospital mortality and better than the Pediatric Multiple Organ Dysfunction Score. It also showed “excellent” discrimination of in-hospital mortality among the 48.4% of patients who had a confirmed or suspected infection in the pediatric intensive care unit (AUC, 0.92; 95% CI, 0.91-0.94), Dr. Matics and Dr. Sanchez-Pinto reported.

Researchers also looked at the clinical utility of pSOFA on the day of admission, compared with the Pediatric Risk of Mortality (PRISM) III score, and found the two were similar, while the pSOFA outperformed other organ dysfunction scores in this setting.

Overall, 14.1% of the pediatric intensive care population met the sepsis criteria according to the adapted definitions and pSOFA scores, and this group had a mortality of 12.1%. Four percent of the population met the criteria for septic shock, with a mortality of 32.3%.

The SOFA score incorporates respiratory, coagulation, renal, hepatic, cardiovascular, and neurologic variables. The authors, however, argued that it does not account for age-related variability, in particular in renal criteria and the detrimental effects of kidney dysfunction in younger patients.

“In addition, the respiratory subscore criteria – based on the ratio of PaO₂ to the fraction of inspired oxygen (FiO₂) – have not been modified in previous adaptations of the SOFA score even though the decreased use of arterial blood gases in children is a known limitation,” they wrote.

“Having a harmonized definition of sepsis across age groups while recognizing the importance of the age-based variation of its measures can have many benefits, including better design of clinical trials, improved accuracy of reported outcomes, and better translation of the research and clinical strategies in the management of sepsis,” Dr. Matics and Dr. Sanchez-Pinto said.

They acknowledged, however, that their findings were limited because they were generated using retrospective data and needed to be validated in a large multicenter sample of critically ill children. They also pointed out that they did not evaluate the performance of pSOFA as a longitudinal biomarker and suggested that such studies would improve understanding of pSOFA’s clinical utility.

No conflicts of interest were reported.

[email protected]

NASHVILLE, TENN. – Young children with acute bronchiolitis do not need to be admitted to the pediatric ICU for high-flow nasal cannula treatment of up to 6 L/min and 50% oxygen; it is safe to administer it on the floor, according to a review of 6,804 acute bronchiolitis cases in children younger than 2 years treated at the University of Texas Southwestern Medical Center, Dallas.

Use of high-flow nasal cannulas (HFNC) has increased dramatically in recent years at UT Southwestern and elsewhere. It soothes children and can rapidly improve breathing without the nasal edema and nose bleeds common with cooler, drier, 100% oxygen. At Southwestern, HFNC use on the pediatric wards increased from 5% of acute bronchiolitis cases in the September 2010 to April 2011 season to 60% in the 2015-2016 season. Use for bronchiolitis in the PICU increased from 82% to 98% over the same period.

[email protected]
 

NASHVILLE, TENN. – Young children with acute bronchiolitis do not need to be admitted to the pediatric ICU for high-flow nasal cannula treatment of up to 6 L/min and 50% oxygen; it is safe to administer it on the floor, according to a review of 6,804 acute bronchiolitis cases in children younger than 2 years treated at the University of Texas Southwestern Medical Center, Dallas.

Use of high-flow nasal cannulas (HFNC) has increased dramatically in recent years at UT Southwestern and elsewhere. It soothes children and can rapidly improve breathing without the nasal edema and nose bleeds common with cooler, drier, 100% oxygen. At Southwestern, HFNC use on the pediatric wards increased from 5% of acute bronchiolitis cases in the September 2010 to April 2011 season to 60% in the 2015-2016 season. Use for bronchiolitis in the PICU increased from 82% to 98% over the same period.

[email protected]
 

NASHVILLE, TENN. – Young children with acute bronchiolitis do not need to be admitted to the pediatric ICU for high-flow nasal cannula treatment of up to 6 L/min and 50% oxygen; it is safe to administer it on the floor, according to a review of 6,804 acute bronchiolitis cases in children younger than 2 years treated at the University of Texas Southwestern Medical Center, Dallas.

Use of high-flow nasal cannulas (HFNC) has increased dramatically in recent years at UT Southwestern and elsewhere. It soothes children and can rapidly improve breathing without the nasal edema and nose bleeds common with cooler, drier, 100% oxygen. At Southwestern, HFNC use on the pediatric wards increased from 5% of acute bronchiolitis cases in the September 2010 to April 2011 season to 60% in the 2015-2016 season. Use for bronchiolitis in the PICU increased from 82% to 98% over the same period.

[email protected]
 

NASHVILLE, TENN. – Development of a medical educator’s portfolio is a necessary, but daunting, task for clinician educators when they enter the promotion process, according to an expert panel at Pediatric Hospital Medicine 2017, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Session

Promote yourself: Demonstrating teaching excellence with an educator’s portfolio

Presenters

Michael Ryan, MD, MEHP; Ashlie Tseng, MD; Jocelyn Schiller, MD; Rebecca Tenney-Soeiro, MD, MEd; Michele Long, MD; Corki Lehmann, MD, MEd; Amy Fleming, MD; and H. Barrett Fromme, MD, MHPE

Session summary

Development of an educator’s portfolio is a necessary, but daunting, task for clinician educators when they enter the promotion process. Each institution has its own specific requirements for the educator’s portfolio, but there are several general themes that should be considered for inclusion:

1. Develop an educational philosophy. This is a personal statement that frames the rest of the portfolio and describes how this philosophy is used by the educator in his/her approach to education.

2. Teaching. Include teaching activities that are both formal (i.e. lectures) and sessions that encourage more active participation (i.e. small group discussions). This can be accomplished by generating a teaching activities report, which helps to categorize these activities. This will not only demonstrate the volume of teaching experience, but also help to demonstrate the diversity of an educator’s teaching activities. In this section, an educator also should include teaching awards received.

3. Learner evaluations. A qualitative summary of comments will provide a narrative of the educator’s teaching skills. This section also may include summaries of annual reviews of teaching.

4. Curriculum development. Demonstrate the educator’s active engagement in the development of a novel curriculum or the improvement of a pre-existing curriculum and the successful outcomes of those improvements.

5. Mentoring and advising. Generating a list of advisees and highlighting their accomplishments reflects on the ability of the educator to guide and promote success in his/her learners.

6. Educational leadership and administration. This is a description of the past and present leadership roles that the educator has held, including courses or clerkships directed. This should allow the educator the opportunity to provide a narrative description of his/her involvement beyond what is typically stated on the curriculum vitae.

7. Professional development. The educator should develop a list of activities, including formal degree programs, certificate programs, and educational workshops, in which he/she has participated as a learner and have enhanced his/her skills as an educator.

8. Products of educational scholarship. Generate a list of education-related peer-reviewed publications authored, other educational products (such as a syllabus or curriculum) developed, and educational workshops that the educator was invited to give.

For clinician educators interested in developing an educator’s portfolio, there are several resources available, including the Academic Pediatric Association’s website and several MedEdPORTAL publications.

Key takeaways for Pediatric HM

• While each institution has its own specific requirements, there are general themes to consider including in an educator’s portfolio.

• Resources such as the Academic Pediatric Association’s website can help guide an educator in the development of his/her portfolio.
 

Dr. Player is a pediatric hospitalist at Children’s Hospital of Wisconsin and assistant professor at the Medical College of Wisconsin, Milwaukee.

NASHVILLE, TENN. – Development of a medical educator’s portfolio is a necessary, but daunting, task for clinician educators when they enter the promotion process, according to an expert panel at Pediatric Hospital Medicine 2017, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Session

Promote yourself: Demonstrating teaching excellence with an educator’s portfolio

Presenters

Michael Ryan, MD, MEHP; Ashlie Tseng, MD; Jocelyn Schiller, MD; Rebecca Tenney-Soeiro, MD, MEd; Michele Long, MD; Corki Lehmann, MD, MEd; Amy Fleming, MD; and H. Barrett Fromme, MD, MHPE

Session summary

Development of an educator’s portfolio is a necessary, but daunting, task for clinician educators when they enter the promotion process. Each institution has its own specific requirements for the educator’s portfolio, but there are several general themes that should be considered for inclusion:

1. Develop an educational philosophy. This is a personal statement that frames the rest of the portfolio and describes how this philosophy is used by the educator in his/her approach to education.

2. Teaching. Include teaching activities that are both formal (i.e. lectures) and sessions that encourage more active participation (i.e. small group discussions). This can be accomplished by generating a teaching activities report, which helps to categorize these activities. This will not only demonstrate the volume of teaching experience, but also help to demonstrate the diversity of an educator’s teaching activities. In this section, an educator also should include teaching awards received.

3. Learner evaluations. A qualitative summary of comments will provide a narrative of the educator’s teaching skills. This section also may include summaries of annual reviews of teaching.

4. Curriculum development. Demonstrate the educator’s active engagement in the development of a novel curriculum or the improvement of a pre-existing curriculum and the successful outcomes of those improvements.

5. Mentoring and advising. Generating a list of advisees and highlighting their accomplishments reflects on the ability of the educator to guide and promote success in his/her learners.

6. Educational leadership and administration. This is a description of the past and present leadership roles that the educator has held, including courses or clerkships directed. This should allow the educator the opportunity to provide a narrative description of his/her involvement beyond what is typically stated on the curriculum vitae.

7. Professional development. The educator should develop a list of activities, including formal degree programs, certificate programs, and educational workshops, in which he/she has participated as a learner and have enhanced his/her skills as an educator.

8. Products of educational scholarship. Generate a list of education-related peer-reviewed publications authored, other educational products (such as a syllabus or curriculum) developed, and educational workshops that the educator was invited to give.

For clinician educators interested in developing an educator’s portfolio, there are several resources available, including the Academic Pediatric Association’s website and several MedEdPORTAL publications.

Key takeaways for Pediatric HM

• While each institution has its own specific requirements, there are general themes to consider including in an educator’s portfolio.

• Resources such as the Academic Pediatric Association’s website can help guide an educator in the development of his/her portfolio.
 

Dr. Player is a pediatric hospitalist at Children’s Hospital of Wisconsin and assistant professor at the Medical College of Wisconsin, Milwaukee.

NASHVILLE, TENN. – Development of a medical educator’s portfolio is a necessary, but daunting, task for clinician educators when they enter the promotion process, according to an expert panel at Pediatric Hospital Medicine 2017, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Session

Promote yourself: Demonstrating teaching excellence with an educator’s portfolio

Presenters

Michael Ryan, MD, MEHP; Ashlie Tseng, MD; Jocelyn Schiller, MD; Rebecca Tenney-Soeiro, MD, MEd; Michele Long, MD; Corki Lehmann, MD, MEd; Amy Fleming, MD; and H. Barrett Fromme, MD, MHPE

Session summary

Development of an educator’s portfolio is a necessary, but daunting, task for clinician educators when they enter the promotion process. Each institution has its own specific requirements for the educator’s portfolio, but there are several general themes that should be considered for inclusion:

1. Develop an educational philosophy. This is a personal statement that frames the rest of the portfolio and describes how this philosophy is used by the educator in his/her approach to education.

2. Teaching. Include teaching activities that are both formal (i.e. lectures) and sessions that encourage more active participation (i.e. small group discussions). This can be accomplished by generating a teaching activities report, which helps to categorize these activities. This will not only demonstrate the volume of teaching experience, but also help to demonstrate the diversity of an educator’s teaching activities. In this section, an educator also should include teaching awards received.

3. Learner evaluations. A qualitative summary of comments will provide a narrative of the educator’s teaching skills. This section also may include summaries of annual reviews of teaching.

4. Curriculum development. Demonstrate the educator’s active engagement in the development of a novel curriculum or the improvement of a pre-existing curriculum and the successful outcomes of those improvements.

5. Mentoring and advising. Generating a list of advisees and highlighting their accomplishments reflects on the ability of the educator to guide and promote success in his/her learners.

6. Educational leadership and administration. This is a description of the past and present leadership roles that the educator has held, including courses or clerkships directed. This should allow the educator the opportunity to provide a narrative description of his/her involvement beyond what is typically stated on the curriculum vitae.

7. Professional development. The educator should develop a list of activities, including formal degree programs, certificate programs, and educational workshops, in which he/she has participated as a learner and have enhanced his/her skills as an educator.

8. Products of educational scholarship. Generate a list of education-related peer-reviewed publications authored, other educational products (such as a syllabus or curriculum) developed, and educational workshops that the educator was invited to give.

For clinician educators interested in developing an educator’s portfolio, there are several resources available, including the Academic Pediatric Association’s website and several MedEdPORTAL publications.

Key takeaways for Pediatric HM

• While each institution has its own specific requirements, there are general themes to consider including in an educator’s portfolio.

• Resources such as the Academic Pediatric Association’s website can help guide an educator in the development of his/her portfolio.
 

Dr. Player is a pediatric hospitalist at Children’s Hospital of Wisconsin and assistant professor at the Medical College of Wisconsin, Milwaukee.

Condition Help: A patient- and family-initiated rapid response system

Implementation of a patient/family-initiated rapid response system at an academic, urban medical center resulted in 367 calls over 3½ years with 83.4% of them being for “nonsafety” issues and 11.4% being for “safety” issues.

Citation: Elizabeth L. Eden, MD, Laurie L. Rack, DNP, RN, Ling-Wan Chen, MS, Bump GM, Condition Help: A patient- and family-initiated rapid response system. J Hosp Med. 2017;3;157-161. doi: 10.12788/jhm.2697.

Association between U.S. norepinephrine shortage and mortality among patients with septic shock

Patient mortality during unannounced accreditation surveys at U.S. hospitals

An evaluation of quasi-randomized Medicare admissions at 1,984 hospitals demonstrated that 30-day mortality decreased by 0.18% in all hospitals and 0.48% at major teaching hospitals during The Joint Commission survey periods; both changes were greater than could be attributed to chance alone when compared to other, similar time periods.

Citation: Barnett ML, Olenski AR, Jena AB. Patient Mortality During Unannounced Accreditation Surveys at US Hospitals. JAMA Intern Med. 2017;177(5):693-700. doi: 10.1001/jamainternmed.2016.9685

Association between a virtual glucose management service and glycemic control in hospitalized adult patients

Institution of a virtual glucose management system resulted in a 39% decrease in hyperglycemic patients and a 36% decrease in hypoglycemic patients per 100 patient-days at three major teaching hospitals.

Citation: Rushakoff RJ, Sullivan MM, MacMaster HW, Shah AD, Rajkomar A, Glidden DV, et al. Association Between a Virtual Glucose Management Service and Glycemic Control in Hospitalized Adult Patients: An Observational Study. Ann Intern Med. 2017;166:621-627. doi: 10.7326/M16-1413

Dr. Imber is assistant professor in the division of hospital medicine at the University of New Mexico.

Condition Help: A patient- and family-initiated rapid response system

Implementation of a patient/family-initiated rapid response system at an academic, urban medical center resulted in 367 calls over 3½ years with 83.4% of them being for “nonsafety” issues and 11.4% being for “safety” issues.

Citation: Elizabeth L. Eden, MD, Laurie L. Rack, DNP, RN, Ling-Wan Chen, MS, Bump GM, Condition Help: A patient- and family-initiated rapid response system. J Hosp Med. 2017;3;157-161. doi: 10.12788/jhm.2697.

Association between U.S. norepinephrine shortage and mortality among patients with septic shock

Patient mortality during unannounced accreditation surveys at U.S. hospitals

An evaluation of quasi-randomized Medicare admissions at 1,984 hospitals demonstrated that 30-day mortality decreased by 0.18% in all hospitals and 0.48% at major teaching hospitals during The Joint Commission survey periods; both changes were greater than could be attributed to chance alone when compared to other, similar time periods.

Citation: Barnett ML, Olenski AR, Jena AB. Patient Mortality During Unannounced Accreditation Surveys at US Hospitals. JAMA Intern Med. 2017;177(5):693-700. doi: 10.1001/jamainternmed.2016.9685

Association between a virtual glucose management service and glycemic control in hospitalized adult patients

Institution of a virtual glucose management system resulted in a 39% decrease in hyperglycemic patients and a 36% decrease in hypoglycemic patients per 100 patient-days at three major teaching hospitals.

Citation: Rushakoff RJ, Sullivan MM, MacMaster HW, Shah AD, Rajkomar A, Glidden DV, et al. Association Between a Virtual Glucose Management Service and Glycemic Control in Hospitalized Adult Patients: An Observational Study. Ann Intern Med. 2017;166:621-627. doi: 10.7326/M16-1413

Dr. Imber is assistant professor in the division of hospital medicine at the University of New Mexico.

Condition Help: A patient- and family-initiated rapid response system

Implementation of a patient/family-initiated rapid response system at an academic, urban medical center resulted in 367 calls over 3½ years with 83.4% of them being for “nonsafety” issues and 11.4% being for “safety” issues.

Citation: Elizabeth L. Eden, MD, Laurie L. Rack, DNP, RN, Ling-Wan Chen, MS, Bump GM, Condition Help: A patient- and family-initiated rapid response system. J Hosp Med. 2017;3;157-161. doi: 10.12788/jhm.2697.

Association between U.S. norepinephrine shortage and mortality among patients with septic shock

Patient mortality during unannounced accreditation surveys at U.S. hospitals

An evaluation of quasi-randomized Medicare admissions at 1,984 hospitals demonstrated that 30-day mortality decreased by 0.18% in all hospitals and 0.48% at major teaching hospitals during The Joint Commission survey periods; both changes were greater than could be attributed to chance alone when compared to other, similar time periods.

Citation: Barnett ML, Olenski AR, Jena AB. Patient Mortality During Unannounced Accreditation Surveys at US Hospitals. JAMA Intern Med. 2017;177(5):693-700. doi: 10.1001/jamainternmed.2016.9685

Association between a virtual glucose management service and glycemic control in hospitalized adult patients

Institution of a virtual glucose management system resulted in a 39% decrease in hyperglycemic patients and a 36% decrease in hypoglycemic patients per 100 patient-days at three major teaching hospitals.

Citation: Rushakoff RJ, Sullivan MM, MacMaster HW, Shah AD, Rajkomar A, Glidden DV, et al. Association Between a Virtual Glucose Management Service and Glycemic Control in Hospitalized Adult Patients: An Observational Study. Ann Intern Med. 2017;166:621-627. doi: 10.7326/M16-1413

Dr. Imber is assistant professor in the division of hospital medicine at the University of New Mexico.

NASHVILLE, TENN. – Various instructional tools and techniques can help hospitalists teach medical learners at a variety of levels, according to experts who spoke at Pediatric Hospital Medicine 2017, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Session

Tools for Engaging Learners of All Levels: Multilevel Teaching Techniques & Cognitive Apprenticeship

Presenters

Session summary

Hospitalists are commonly charged with teaching learners at a variety of levels. There are various tools that can be used to accomplish this including multilevel teaching and cognitive apprenticeship.

Multilevel teaching is defined as teaching multiple levels of learners simultaneously. The goal is to maintain engagement without being boring or teaching over any learner’s head. Examples include:

1. Broadening: Change the case to make it more challenging or interesting such as asking what to do if the patient was a different age or had a comorbid condition.

2. Targeting: Target questions at specific team members depending on difficulty such as asking students common causes of bacterial meningitis and asking residents about admission criteria.

3. Novelty: Provide new data such as a recent journal article.

4. Up the Ladder: Ask the same question to all team members, starting with the most junior.

5. Student as Teacher: Ask a senior learner to teach a junior learner.

6. Multi-Answer: Seek multiple answers to one question such as asking each learner to contribute an item to a differential diagnosis.

7. No Right Answer: Ask questions that do not have a single correct answer such as how to approach a difficult conversation.

8. Teaching to the Top: Teach to the level of the most senior learner.

9. Extreme Challenge: Teach at a level above all learners on the team.

Laura Certain, MD, PhD, et al¹ found that most trainees feel Targeting, Up the Ladder, Student as Teacher, and Multi-Answer are most effective. No Right Answer, Teaching to the Top, and Extreme Challenge were felt to be least effective.

Another concept for engaging learners at all levels is cognitive apprenticeship, which is an instructional model whereby teachers make explicit their generally tacit cognitive processes. Examples include:

1. Modeling: Actively demonstrate skills such as performing a procedure while verbalizing the steps and thought processes.

2. Couching: Observe learners and provide feedback on their performance.

3. Scaffolding: Inquire about past experiences and provide opportunity for independent activities, while also providing help for activities that are difficult for learners.

4. Articulation: Ask learners to explain their thought processes.

5. Reflection: Prompt students to deliberately consider their strengths and weaknesses.

6. Exploration: Encourage students to set personal learning goals.

Coaching and articulation have been found to be more useful for novice learners. Reflection and exploration are more useful for advanced learners.

Key takeaways for Pediatric HM

• Multilevel teaching can be used to engage a variety of learners simultaneously. Targeting, Up the Ladder, Student as Teacher, and Multi-Answer are effective methods to achieve this goal.

• Cognitive apprenticeship can be used in clinical teaching to make a tacit cognitive process explicit. Methods such as coaching and articulation have been found to be more useful for novice learners. Reflection and exploration are more useful for advanced learners.

• Regardless of the method used, teachers should demonstrate interest in the learners’ education and treat them with respect.

Dr. Rogers is assistant professor of pediatrics and Section of Hospital Medicine associate program director, Pediatric Residency Program, at the Medical College of Wisconsin, Milwaukee.

References

1. Certain LK, Guarino AJ, Greenwald JL. Effective multilevel teaching techniques on attending rounds: a pilot survey and systematic review of the literature. Med Teach. 2011;33(12),e644-650. doi: 10.3109/0142159X.2011.610844.


 

NASHVILLE, TENN. – Various instructional tools and techniques can help hospitalists teach medical learners at a variety of levels, according to experts who spoke at Pediatric Hospital Medicine 2017, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Session

Tools for Engaging Learners of All Levels: Multilevel Teaching Techniques & Cognitive Apprenticeship

Presenters

Session summary

Hospitalists are commonly charged with teaching learners at a variety of levels. There are various tools that can be used to accomplish this including multilevel teaching and cognitive apprenticeship.

Multilevel teaching is defined as teaching multiple levels of learners simultaneously. The goal is to maintain engagement without being boring or teaching over any learner’s head. Examples include:

1. Broadening: Change the case to make it more challenging or interesting such as asking what to do if the patient was a different age or had a comorbid condition.

2. Targeting: Target questions at specific team members depending on difficulty such as asking students common causes of bacterial meningitis and asking residents about admission criteria.

3. Novelty: Provide new data such as a recent journal article.

4. Up the Ladder: Ask the same question to all team members, starting with the most junior.

5. Student as Teacher: Ask a senior learner to teach a junior learner.

6. Multi-Answer: Seek multiple answers to one question such as asking each learner to contribute an item to a differential diagnosis.

7. No Right Answer: Ask questions that do not have a single correct answer such as how to approach a difficult conversation.

8. Teaching to the Top: Teach to the level of the most senior learner.

9. Extreme Challenge: Teach at a level above all learners on the team.

Laura Certain, MD, PhD, et al¹ found that most trainees feel Targeting, Up the Ladder, Student as Teacher, and Multi-Answer are most effective. No Right Answer, Teaching to the Top, and Extreme Challenge were felt to be least effective.

Another concept for engaging learners at all levels is cognitive apprenticeship, which is an instructional model whereby teachers make explicit their generally tacit cognitive processes. Examples include:

1. Modeling: Actively demonstrate skills such as performing a procedure while verbalizing the steps and thought processes.

2. Couching: Observe learners and provide feedback on their performance.

3. Scaffolding: Inquire about past experiences and provide opportunity for independent activities, while also providing help for activities that are difficult for learners.

4. Articulation: Ask learners to explain their thought processes.

5. Reflection: Prompt students to deliberately consider their strengths and weaknesses.

6. Exploration: Encourage students to set personal learning goals.

Coaching and articulation have been found to be more useful for novice learners. Reflection and exploration are more useful for advanced learners.

Key takeaways for Pediatric HM

• Multilevel teaching can be used to engage a variety of learners simultaneously. Targeting, Up the Ladder, Student as Teacher, and Multi-Answer are effective methods to achieve this goal.

• Cognitive apprenticeship can be used in clinical teaching to make a tacit cognitive process explicit. Methods such as coaching and articulation have been found to be more useful for novice learners. Reflection and exploration are more useful for advanced learners.

• Regardless of the method used, teachers should demonstrate interest in the learners’ education and treat them with respect.

Dr. Rogers is assistant professor of pediatrics and Section of Hospital Medicine associate program director, Pediatric Residency Program, at the Medical College of Wisconsin, Milwaukee.

References

1. Certain LK, Guarino AJ, Greenwald JL. Effective multilevel teaching techniques on attending rounds: a pilot survey and systematic review of the literature. Med Teach. 2011;33(12),e644-650. doi: 10.3109/0142159X.2011.610844.


 

NASHVILLE, TENN. – Various instructional tools and techniques can help hospitalists teach medical learners at a variety of levels, according to experts who spoke at Pediatric Hospital Medicine 2017, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Session

Tools for Engaging Learners of All Levels: Multilevel Teaching Techniques & Cognitive Apprenticeship

Presenters

Session summary

Hospitalists are commonly charged with teaching learners at a variety of levels. There are various tools that can be used to accomplish this including multilevel teaching and cognitive apprenticeship.

Multilevel teaching is defined as teaching multiple levels of learners simultaneously. The goal is to maintain engagement without being boring or teaching over any learner’s head. Examples include:

1. Broadening: Change the case to make it more challenging or interesting such as asking what to do if the patient was a different age or had a comorbid condition.

2. Targeting: Target questions at specific team members depending on difficulty such as asking students common causes of bacterial meningitis and asking residents about admission criteria.

3. Novelty: Provide new data such as a recent journal article.

4. Up the Ladder: Ask the same question to all team members, starting with the most junior.

5. Student as Teacher: Ask a senior learner to teach a junior learner.

6. Multi-Answer: Seek multiple answers to one question such as asking each learner to contribute an item to a differential diagnosis.

7. No Right Answer: Ask questions that do not have a single correct answer such as how to approach a difficult conversation.

8. Teaching to the Top: Teach to the level of the most senior learner.

9. Extreme Challenge: Teach at a level above all learners on the team.

Laura Certain, MD, PhD, et al¹ found that most trainees feel Targeting, Up the Ladder, Student as Teacher, and Multi-Answer are most effective. No Right Answer, Teaching to the Top, and Extreme Challenge were felt to be least effective.

Another concept for engaging learners at all levels is cognitive apprenticeship, which is an instructional model whereby teachers make explicit their generally tacit cognitive processes. Examples include:

1. Modeling: Actively demonstrate skills such as performing a procedure while verbalizing the steps and thought processes.

2. Couching: Observe learners and provide feedback on their performance.

3. Scaffolding: Inquire about past experiences and provide opportunity for independent activities, while also providing help for activities that are difficult for learners.

4. Articulation: Ask learners to explain their thought processes.

5. Reflection: Prompt students to deliberately consider their strengths and weaknesses.

6. Exploration: Encourage students to set personal learning goals.

Coaching and articulation have been found to be more useful for novice learners. Reflection and exploration are more useful for advanced learners.

Key takeaways for Pediatric HM

• Multilevel teaching can be used to engage a variety of learners simultaneously. Targeting, Up the Ladder, Student as Teacher, and Multi-Answer are effective methods to achieve this goal.

• Cognitive apprenticeship can be used in clinical teaching to make a tacit cognitive process explicit. Methods such as coaching and articulation have been found to be more useful for novice learners. Reflection and exploration are more useful for advanced learners.

• Regardless of the method used, teachers should demonstrate interest in the learners’ education and treat them with respect.

Dr. Rogers is assistant professor of pediatrics and Section of Hospital Medicine associate program director, Pediatric Residency Program, at the Medical College of Wisconsin, Milwaukee.

References

1. Certain LK, Guarino AJ, Greenwald JL. Effective multilevel teaching techniques on attending rounds: a pilot survey and systematic review of the literature. Med Teach. 2011;33(12),e644-650. doi: 10.3109/0142159X.2011.610844.


 

Title: 2017 ACC/AHA/HRS guidelines for patients with syncope

Clinical Question: What are the key points from the 2017 ACC/AHA/HRS guidelines for the evaluation and management of adult patients with syncope?

Background: Syncope is a common condition for which patients present to a hospital setting. Updated guidance and recommendations on the evaluation and management of syncope are provided.

 

Study Design: Evidence-based guidelines.

Setting: Panel of experts.

Synopsis: A detailed history and physical should be performed. A 12-lead ECG should be obtained. Short- and long-term morbidity and mortality risk of syncope should be assessed. Inpatient evaluation and treatment is recommended for patients presenting with syncope and who have serious medical condition relevant to the cause of syncope. Lab tests are not useful. Routine cardiac imaging is not useful unless a cardiac etiology of syncope is suspected. Carotid artery imaging is not useful in the absence of focal neurologic findings. Continuous telemetry is indicated for inpatients suspected of syncope due to a cardiac etiology.

The most common cause of syncope is vasovagal. Medication therapy has modest effect, and patient education is recommended. Dual chamber pacing may be reasonable in select patients over the age of 40 with recurrent vasovagal syncope and prolonged spontaneous pauses. If orthostatic hypotension is suspected as the cause of syncope due to dehydration, then fluid resuscitation is recommended. Removing medications causing hypotension may be appropriate for select patients with syncope.

Cardiac syncope requires expert directed care and may include life-style changes, medication therapy and/or procedural intervention.

Bottom Line: The 2017 syncope guidelines provide updated and concise recommendations on the management of syncope.

Citation: Shen W-K, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: executive summary. Journal of the American College of Cardiology. 2017; doi: 10.1016/ j.jacc.2017.03.002.

Dr. Burns is assistant professor in the division of hospital medicine at the University of New Mexico.

Title: 2017 ACC/AHA/HRS guidelines for patients with syncope

Clinical Question: What are the key points from the 2017 ACC/AHA/HRS guidelines for the evaluation and management of adult patients with syncope?

Background: Syncope is a common condition for which patients present to a hospital setting. Updated guidance and recommendations on the evaluation and management of syncope are provided.

 

Study Design: Evidence-based guidelines.

Setting: Panel of experts.

Synopsis: A detailed history and physical should be performed. A 12-lead ECG should be obtained. Short- and long-term morbidity and mortality risk of syncope should be assessed. Inpatient evaluation and treatment is recommended for patients presenting with syncope and who have serious medical condition relevant to the cause of syncope. Lab tests are not useful. Routine cardiac imaging is not useful unless a cardiac etiology of syncope is suspected. Carotid artery imaging is not useful in the absence of focal neurologic findings. Continuous telemetry is indicated for inpatients suspected of syncope due to a cardiac etiology.

The most common cause of syncope is vasovagal. Medication therapy has modest effect, and patient education is recommended. Dual chamber pacing may be reasonable in select patients over the age of 40 with recurrent vasovagal syncope and prolonged spontaneous pauses. If orthostatic hypotension is suspected as the cause of syncope due to dehydration, then fluid resuscitation is recommended. Removing medications causing hypotension may be appropriate for select patients with syncope.

Cardiac syncope requires expert directed care and may include life-style changes, medication therapy and/or procedural intervention.

Bottom Line: The 2017 syncope guidelines provide updated and concise recommendations on the management of syncope.

Citation: Shen W-K, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: executive summary. Journal of the American College of Cardiology. 2017; doi: 10.1016/ j.jacc.2017.03.002.

Dr. Burns is assistant professor in the division of hospital medicine at the University of New Mexico.

Title: 2017 ACC/AHA/HRS guidelines for patients with syncope

Clinical Question: What are the key points from the 2017 ACC/AHA/HRS guidelines for the evaluation and management of adult patients with syncope?

Background: Syncope is a common condition for which patients present to a hospital setting. Updated guidance and recommendations on the evaluation and management of syncope are provided.

 

Study Design: Evidence-based guidelines.

Setting: Panel of experts.

Synopsis: A detailed history and physical should be performed. A 12-lead ECG should be obtained. Short- and long-term morbidity and mortality risk of syncope should be assessed. Inpatient evaluation and treatment is recommended for patients presenting with syncope and who have serious medical condition relevant to the cause of syncope. Lab tests are not useful. Routine cardiac imaging is not useful unless a cardiac etiology of syncope is suspected. Carotid artery imaging is not useful in the absence of focal neurologic findings. Continuous telemetry is indicated for inpatients suspected of syncope due to a cardiac etiology.

The most common cause of syncope is vasovagal. Medication therapy has modest effect, and patient education is recommended. Dual chamber pacing may be reasonable in select patients over the age of 40 with recurrent vasovagal syncope and prolonged spontaneous pauses. If orthostatic hypotension is suspected as the cause of syncope due to dehydration, then fluid resuscitation is recommended. Removing medications causing hypotension may be appropriate for select patients with syncope.

Cardiac syncope requires expert directed care and may include life-style changes, medication therapy and/or procedural intervention.

Bottom Line: The 2017 syncope guidelines provide updated and concise recommendations on the management of syncope.

Citation: Shen W-K, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: executive summary. Journal of the American College of Cardiology. 2017; doi: 10.1016/ j.jacc.2017.03.002.

Dr. Burns is assistant professor in the division of hospital medicine at the University of New Mexico.

NASHVILLE, TENN. – A panel of experts discussed highlights from the 2017 AHA Kawasaki Guidelines at Pediatric Hospital Medicine, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Session

Kawasaki Disease Reconsidered: New AHA Guidelines
 

Presenters

John Darby, MD, Marietta DeGuzman, MD, Kristen Sexson, MD, PhD, MPH, Stanford Shulman, MD, Nisha Tamaskar, MD
 

Session summary

For the second year in a row, the session highlighting American Heart Association updates on Kawasaki disease did not disappoint and again attracted a large crowd of community and academic pediatric hospitalists. The newly-revised 2017 AHA Kawasaki Guidelines hot off the press by McCrindle et al. was reviewed in detail.

Pathophysiology

• Cause is likely to be a common ubiquitous agent that in genetically inclined children will lead to a particular inflammatory response that manifests clinically as KD.

• A new theory about how the “ubiquitous agent” is spread by wind patterns.
 

Diagnosis

• Confirmed that infants younger than 1 year of age are more difficult to diagnose because they don’t present classically so it must be on the differential.

• The new algorithm makes it clearer that infants with fever for 7 days without symptoms should get lab screening tests for KD.

• Those who have classic symptoms and lab abnormalities consistent with KD but in whom fever is still at 3-4 days may be diagnosed with KD prior to the “5 days of fever rule” because these tend to be a sicker cohort of patients with higher rate of complications. Pretest probability and suspicion for KD must be high to treat before 5 days.

• Importance of the Z-score when evaluating an echocardiogram completed on a patient with suspected KD was stressed with a score greater than or equal to 2.5 reaching a level of significance for the patient’s body size.
 

Management

• It is still agreed that IVIG is first line therapy.

• For refractory KD (not responsive within 36 hours of first dose IVIG), management is more controversial. Experts on the panel agreed that they would likely provide a second dose of IVIG before thinking about steroids.

• Moderate dose aspirin is just as effective as high dose aspirin in the acute phase of KD.

• For more detailed information regarding the role of corticosteroids in KD, refer to Dr. Carl Galloway’s article in The Hospitalist July 2017 issue.

• A certain subset of patients may benefit from steroids if given early in the disease course, including those who present in shock syndrome. Steroids would still be in conjunction with IVIG treatment.

• Even though the new guidelines recommend a longer course of steroids for those refractory cases of KD in high-risk patients, panel experts are still unsure about evidence behind the claim.



The RAISE study was referenced and indicates there are significantly different outcomes for patients with severe disease placed on steroid therapy in combination with IVIG. In this group of patients, the incidence of coronary artery aneurysms was 23% in the IVIG-only group compared to 3% in the IVIG + steroid group (P less than .0001). This study and a recent Cochrane review that supported use of steroids in KD were completed in a homogeneous population of Japanese children and may not be generalizable to children in the United States.

Hyponatremia has been used as a diagnostic criterion for severe KD in Japanese children and was referenced as an indicator for addition of steroid therapy. Also, studies investigating the necessity of ASA at 80-100 mg/kg/d, a common practice for patients with KD treated in the United States, were compared to medium-dose ASA (30-50 mg/kg/d). There was no clinically significant difference in patient outcome or development of aneurysm formation between these two dosing regimens.
 

Key takeaways for Pediatric HM

• Diagnosis of classic KD remains unchanged and includes 5 or more days of fever and at least four clinical features (extremity changes, rash, conjunctivitis, oral changes, and cervical lymphadenopathy).

• Infants with fever of 7 days or more without other explanation should be evaluated for KD.

• Echocardiographic findings should be adjusted for body surface area and are significant if Z-score greater than or equal to 2.5.

• Moderate- to high-dose ASA is appropriate as an adjunct to IVIG until the patient is afebrile.

• Steroid therapy (for a total of 14 days) should be considered for high-risk patients.
 

Dr. King is associate program director, University of Minnesota Pediatric Residency Program. Dr. Hopkins is assistant professor of pediatrics, Johns Hopkins All Children’s Hospital.

NASHVILLE, TENN. – A panel of experts discussed highlights from the 2017 AHA Kawasaki Guidelines at Pediatric Hospital Medicine, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Session

Kawasaki Disease Reconsidered: New AHA Guidelines
 

Presenters

John Darby, MD, Marietta DeGuzman, MD, Kristen Sexson, MD, PhD, MPH, Stanford Shulman, MD, Nisha Tamaskar, MD
 

Session summary

For the second year in a row, the session highlighting American Heart Association updates on Kawasaki disease did not disappoint and again attracted a large crowd of community and academic pediatric hospitalists. The newly-revised 2017 AHA Kawasaki Guidelines hot off the press by McCrindle et al. was reviewed in detail.

Pathophysiology

• Cause is likely to be a common ubiquitous agent that in genetically inclined children will lead to a particular inflammatory response that manifests clinically as KD.

• A new theory about how the “ubiquitous agent” is spread by wind patterns.
 

Diagnosis

• Confirmed that infants younger than 1 year of age are more difficult to diagnose because they don’t present classically so it must be on the differential.

• The new algorithm makes it clearer that infants with fever for 7 days without symptoms should get lab screening tests for KD.

• Those who have classic symptoms and lab abnormalities consistent with KD but in whom fever is still at 3-4 days may be diagnosed with KD prior to the “5 days of fever rule” because these tend to be a sicker cohort of patients with higher rate of complications. Pretest probability and suspicion for KD must be high to treat before 5 days.

• Importance of the Z-score when evaluating an echocardiogram completed on a patient with suspected KD was stressed with a score greater than or equal to 2.5 reaching a level of significance for the patient’s body size.
 

Management

• It is still agreed that IVIG is first line therapy.

• For refractory KD (not responsive within 36 hours of first dose IVIG), management is more controversial. Experts on the panel agreed that they would likely provide a second dose of IVIG before thinking about steroids.

• Moderate dose aspirin is just as effective as high dose aspirin in the acute phase of KD.

• For more detailed information regarding the role of corticosteroids in KD, refer to Dr. Carl Galloway’s article in The Hospitalist July 2017 issue.

• A certain subset of patients may benefit from steroids if given early in the disease course, including those who present in shock syndrome. Steroids would still be in conjunction with IVIG treatment.

• Even though the new guidelines recommend a longer course of steroids for those refractory cases of KD in high-risk patients, panel experts are still unsure about evidence behind the claim.



The RAISE study was referenced and indicates there are significantly different outcomes for patients with severe disease placed on steroid therapy in combination with IVIG. In this group of patients, the incidence of coronary artery aneurysms was 23% in the IVIG-only group compared to 3% in the IVIG + steroid group (P less than .0001). This study and a recent Cochrane review that supported use of steroids in KD were completed in a homogeneous population of Japanese children and may not be generalizable to children in the United States.

Hyponatremia has been used as a diagnostic criterion for severe KD in Japanese children and was referenced as an indicator for addition of steroid therapy. Also, studies investigating the necessity of ASA at 80-100 mg/kg/d, a common practice for patients with KD treated in the United States, were compared to medium-dose ASA (30-50 mg/kg/d). There was no clinically significant difference in patient outcome or development of aneurysm formation between these two dosing regimens.
 

Key takeaways for Pediatric HM

• Diagnosis of classic KD remains unchanged and includes 5 or more days of fever and at least four clinical features (extremity changes, rash, conjunctivitis, oral changes, and cervical lymphadenopathy).

• Infants with fever of 7 days or more without other explanation should be evaluated for KD.

• Echocardiographic findings should be adjusted for body surface area and are significant if Z-score greater than or equal to 2.5.

• Moderate- to high-dose ASA is appropriate as an adjunct to IVIG until the patient is afebrile.

• Steroid therapy (for a total of 14 days) should be considered for high-risk patients.
 

Dr. King is associate program director, University of Minnesota Pediatric Residency Program. Dr. Hopkins is assistant professor of pediatrics, Johns Hopkins All Children’s Hospital.

NASHVILLE, TENN. – A panel of experts discussed highlights from the 2017 AHA Kawasaki Guidelines at Pediatric Hospital Medicine, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

Session

Kawasaki Disease Reconsidered: New AHA Guidelines
 

Presenters

John Darby, MD, Marietta DeGuzman, MD, Kristen Sexson, MD, PhD, MPH, Stanford Shulman, MD, Nisha Tamaskar, MD
 

Session summary

For the second year in a row, the session highlighting American Heart Association updates on Kawasaki disease did not disappoint and again attracted a large crowd of community and academic pediatric hospitalists. The newly-revised 2017 AHA Kawasaki Guidelines hot off the press by McCrindle et al. was reviewed in detail.

Pathophysiology

• Cause is likely to be a common ubiquitous agent that in genetically inclined children will lead to a particular inflammatory response that manifests clinically as KD.

• A new theory about how the “ubiquitous agent” is spread by wind patterns.
 

Diagnosis

• Confirmed that infants younger than 1 year of age are more difficult to diagnose because they don’t present classically so it must be on the differential.

• The new algorithm makes it clearer that infants with fever for 7 days without symptoms should get lab screening tests for KD.

• Those who have classic symptoms and lab abnormalities consistent with KD but in whom fever is still at 3-4 days may be diagnosed with KD prior to the “5 days of fever rule” because these tend to be a sicker cohort of patients with higher rate of complications. Pretest probability and suspicion for KD must be high to treat before 5 days.

• Importance of the Z-score when evaluating an echocardiogram completed on a patient with suspected KD was stressed with a score greater than or equal to 2.5 reaching a level of significance for the patient’s body size.
 

Management

• It is still agreed that IVIG is first line therapy.

• For refractory KD (not responsive within 36 hours of first dose IVIG), management is more controversial. Experts on the panel agreed that they would likely provide a second dose of IVIG before thinking about steroids.

• Moderate dose aspirin is just as effective as high dose aspirin in the acute phase of KD.

• For more detailed information regarding the role of corticosteroids in KD, refer to Dr. Carl Galloway’s article in The Hospitalist July 2017 issue.

• A certain subset of patients may benefit from steroids if given early in the disease course, including those who present in shock syndrome. Steroids would still be in conjunction with IVIG treatment.

• Even though the new guidelines recommend a longer course of steroids for those refractory cases of KD in high-risk patients, panel experts are still unsure about evidence behind the claim.



The RAISE study was referenced and indicates there are significantly different outcomes for patients with severe disease placed on steroid therapy in combination with IVIG. In this group of patients, the incidence of coronary artery aneurysms was 23% in the IVIG-only group compared to 3% in the IVIG + steroid group (P less than .0001). This study and a recent Cochrane review that supported use of steroids in KD were completed in a homogeneous population of Japanese children and may not be generalizable to children in the United States.

Hyponatremia has been used as a diagnostic criterion for severe KD in Japanese children and was referenced as an indicator for addition of steroid therapy. Also, studies investigating the necessity of ASA at 80-100 mg/kg/d, a common practice for patients with KD treated in the United States, were compared to medium-dose ASA (30-50 mg/kg/d). There was no clinically significant difference in patient outcome or development of aneurysm formation between these two dosing regimens.
 

Key takeaways for Pediatric HM

• Diagnosis of classic KD remains unchanged and includes 5 or more days of fever and at least four clinical features (extremity changes, rash, conjunctivitis, oral changes, and cervical lymphadenopathy).

• Infants with fever of 7 days or more without other explanation should be evaluated for KD.

• Echocardiographic findings should be adjusted for body surface area and are significant if Z-score greater than or equal to 2.5.

• Moderate- to high-dose ASA is appropriate as an adjunct to IVIG until the patient is afebrile.

• Steroid therapy (for a total of 14 days) should be considered for high-risk patients.
 

Dr. King is associate program director, University of Minnesota Pediatric Residency Program. Dr. Hopkins is assistant professor of pediatrics, Johns Hopkins All Children’s Hospital.