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Business practices
Introduction
Sound business practices form a foundation for the growth and effective development of pediatric hospital medicine programs. Business practice refers to program development and growth, practice management, contract negotiation, and financial solvency. Pediatric hospitalists require fundamental business skills to enhance individual success, and facilitate growth and stability of groups, divisions, and institutions. Hospitals increasingly need physician leaders with these skills to improve operational efficiency and meet other institutional needs. Pediatric hospitalists must acquire and maintain business skills that support the ability to negotiate and define hospitalist roles within the hospital, expand practices intelligently, anticipate and respond to change, and sustain financial success.
Knowledge
Pediatric hospitalists should be able to:
Explain why clinical practice is a business that needs a sound business plan, professional management, and strategic planning. Discuss the elements of mission and vision statements.
Identify institutional financial power structures and how resources are developed to build and sustain academic and non‐academic programs.
Compare and contrast the basic structure of hospital‐employed and private practice pediatric hospital medicine models.
Define the basic components assessed during the initial planning for a pediatric hospitalist practice, such as baseline and projected census, projected revenue and expenses, and impact on current and future stakeholders.
Articulate the requirements for compliant billing and documenting when collaborating with physician extenders.
Discuss the impact of critical practice variables on creation of an effective and efficient staffing plan, including:
Anticipated census, patient acuity and length of stay
Anticipated revenue streams and volume
Need for night and/or weekend coverage
Physician‐to‐patient ratios
Compare and contrast pediatric hospitalist staffing models, including:
Rounding or patient‐based model
Shift‐based model
List potential sources of non‐clinical responsibilities, such as teaching, committee participation, administrative work, and research. Describe the impact of each on staffing models and revenue.
Distinguish between various pediatric hospitalist compensation structures, including full salary, incentive salary, and case rate models.
Define the Relative Value Unit (RVU) and its utility in tracking revenue and physician compensation.
Discuss the difference between costs versus charges.
Compare and contrast basic billing methods and revenue sources for the provider versus the hospital, and review the effect of payor mix on these.
Articulate the importance of billing and coding compliance as it relates to physician compensation and physician‐hospital contracting.
Identify key elements of compliance monitored by the Office of the Inspector General (OIG) of the Department of Health and Human Services (DHHS).
State the importance of professional credentialing, licensing and liability coverage.
Describe key features of care management organizations, such as capitation, carve‐outs, withholds, case‐, disease‐, and demand‐management and their role in promoting quality of care and cost‐control.
Skills
Pediatric hospitalists should be able to:
Review basic business data including revenue, expenses, staff and marketing costs, and accounts receivable.
Demonstrate basic negotiation skills through role play or attendance at negotiation sessions with third party payors, the institution, department chair, or other contracted entity.
Consistently document in the medical record in a manner that meets expectations for billing and coding and for external certifying agencies.
Effectively utilize a clinical documentation system with an emphasis on:
Efficient, accurate, and complete documentation to support coding and billing
Compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Compliance with trainee documentation guidelines, where applicable
Complete coding and billing processes efficiently and accurately.
Participate in group, division, and/or institutional business and finance committees.
Attitudes
Pediatric hospitalists should be able to:
Advocate for a business model that encourages retention of pediatric hospitalists and allows for adequate staffing to support patient safety, and physician wellness.
Role model accountability with regard to billing, coding and business regulations.
Support the business of pediatric hospitalists, by maintaining fiscally awareness and proactively managing stakeholder expectations.
Seek opportunities to acquire basic business skills.
Systems Organization and Improvement
In order to improve efficiency and quality in their organizations, pediatric hospitalists should:
Collaborate with colleagues and business office leaders to make sound group/division business decisions using performance feedback, peer review and quality improvement information.
Engage with hospital administrators on strategic business planning, wherever possible.
Introduction
Sound business practices form a foundation for the growth and effective development of pediatric hospital medicine programs. Business practice refers to program development and growth, practice management, contract negotiation, and financial solvency. Pediatric hospitalists require fundamental business skills to enhance individual success, and facilitate growth and stability of groups, divisions, and institutions. Hospitals increasingly need physician leaders with these skills to improve operational efficiency and meet other institutional needs. Pediatric hospitalists must acquire and maintain business skills that support the ability to negotiate and define hospitalist roles within the hospital, expand practices intelligently, anticipate and respond to change, and sustain financial success.
Knowledge
Pediatric hospitalists should be able to:
Explain why clinical practice is a business that needs a sound business plan, professional management, and strategic planning. Discuss the elements of mission and vision statements.
Identify institutional financial power structures and how resources are developed to build and sustain academic and non‐academic programs.
Compare and contrast the basic structure of hospital‐employed and private practice pediatric hospital medicine models.
Define the basic components assessed during the initial planning for a pediatric hospitalist practice, such as baseline and projected census, projected revenue and expenses, and impact on current and future stakeholders.
Articulate the requirements for compliant billing and documenting when collaborating with physician extenders.
Discuss the impact of critical practice variables on creation of an effective and efficient staffing plan, including:
Anticipated census, patient acuity and length of stay
Anticipated revenue streams and volume
Need for night and/or weekend coverage
Physician‐to‐patient ratios
Compare and contrast pediatric hospitalist staffing models, including:
Rounding or patient‐based model
Shift‐based model
List potential sources of non‐clinical responsibilities, such as teaching, committee participation, administrative work, and research. Describe the impact of each on staffing models and revenue.
Distinguish between various pediatric hospitalist compensation structures, including full salary, incentive salary, and case rate models.
Define the Relative Value Unit (RVU) and its utility in tracking revenue and physician compensation.
Discuss the difference between costs versus charges.
Compare and contrast basic billing methods and revenue sources for the provider versus the hospital, and review the effect of payor mix on these.
Articulate the importance of billing and coding compliance as it relates to physician compensation and physician‐hospital contracting.
Identify key elements of compliance monitored by the Office of the Inspector General (OIG) of the Department of Health and Human Services (DHHS).
State the importance of professional credentialing, licensing and liability coverage.
Describe key features of care management organizations, such as capitation, carve‐outs, withholds, case‐, disease‐, and demand‐management and their role in promoting quality of care and cost‐control.
Skills
Pediatric hospitalists should be able to:
Review basic business data including revenue, expenses, staff and marketing costs, and accounts receivable.
Demonstrate basic negotiation skills through role play or attendance at negotiation sessions with third party payors, the institution, department chair, or other contracted entity.
Consistently document in the medical record in a manner that meets expectations for billing and coding and for external certifying agencies.
Effectively utilize a clinical documentation system with an emphasis on:
Efficient, accurate, and complete documentation to support coding and billing
Compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Compliance with trainee documentation guidelines, where applicable
Complete coding and billing processes efficiently and accurately.
Participate in group, division, and/or institutional business and finance committees.
Attitudes
Pediatric hospitalists should be able to:
Advocate for a business model that encourages retention of pediatric hospitalists and allows for adequate staffing to support patient safety, and physician wellness.
Role model accountability with regard to billing, coding and business regulations.
Support the business of pediatric hospitalists, by maintaining fiscally awareness and proactively managing stakeholder expectations.
Seek opportunities to acquire basic business skills.
Systems Organization and Improvement
In order to improve efficiency and quality in their organizations, pediatric hospitalists should:
Collaborate with colleagues and business office leaders to make sound group/division business decisions using performance feedback, peer review and quality improvement information.
Engage with hospital administrators on strategic business planning, wherever possible.
Introduction
Sound business practices form a foundation for the growth and effective development of pediatric hospital medicine programs. Business practice refers to program development and growth, practice management, contract negotiation, and financial solvency. Pediatric hospitalists require fundamental business skills to enhance individual success, and facilitate growth and stability of groups, divisions, and institutions. Hospitals increasingly need physician leaders with these skills to improve operational efficiency and meet other institutional needs. Pediatric hospitalists must acquire and maintain business skills that support the ability to negotiate and define hospitalist roles within the hospital, expand practices intelligently, anticipate and respond to change, and sustain financial success.
Knowledge
Pediatric hospitalists should be able to:
Explain why clinical practice is a business that needs a sound business plan, professional management, and strategic planning. Discuss the elements of mission and vision statements.
Identify institutional financial power structures and how resources are developed to build and sustain academic and non‐academic programs.
Compare and contrast the basic structure of hospital‐employed and private practice pediatric hospital medicine models.
Define the basic components assessed during the initial planning for a pediatric hospitalist practice, such as baseline and projected census, projected revenue and expenses, and impact on current and future stakeholders.
Articulate the requirements for compliant billing and documenting when collaborating with physician extenders.
Discuss the impact of critical practice variables on creation of an effective and efficient staffing plan, including:
Anticipated census, patient acuity and length of stay
Anticipated revenue streams and volume
Need for night and/or weekend coverage
Physician‐to‐patient ratios
Compare and contrast pediatric hospitalist staffing models, including:
Rounding or patient‐based model
Shift‐based model
List potential sources of non‐clinical responsibilities, such as teaching, committee participation, administrative work, and research. Describe the impact of each on staffing models and revenue.
Distinguish between various pediatric hospitalist compensation structures, including full salary, incentive salary, and case rate models.
Define the Relative Value Unit (RVU) and its utility in tracking revenue and physician compensation.
Discuss the difference between costs versus charges.
Compare and contrast basic billing methods and revenue sources for the provider versus the hospital, and review the effect of payor mix on these.
Articulate the importance of billing and coding compliance as it relates to physician compensation and physician‐hospital contracting.
Identify key elements of compliance monitored by the Office of the Inspector General (OIG) of the Department of Health and Human Services (DHHS).
State the importance of professional credentialing, licensing and liability coverage.
Describe key features of care management organizations, such as capitation, carve‐outs, withholds, case‐, disease‐, and demand‐management and their role in promoting quality of care and cost‐control.
Skills
Pediatric hospitalists should be able to:
Review basic business data including revenue, expenses, staff and marketing costs, and accounts receivable.
Demonstrate basic negotiation skills through role play or attendance at negotiation sessions with third party payors, the institution, department chair, or other contracted entity.
Consistently document in the medical record in a manner that meets expectations for billing and coding and for external certifying agencies.
Effectively utilize a clinical documentation system with an emphasis on:
Efficient, accurate, and complete documentation to support coding and billing
Compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Compliance with trainee documentation guidelines, where applicable
Complete coding and billing processes efficiently and accurately.
Participate in group, division, and/or institutional business and finance committees.
Attitudes
Pediatric hospitalists should be able to:
Advocate for a business model that encourages retention of pediatric hospitalists and allows for adequate staffing to support patient safety, and physician wellness.
Role model accountability with regard to billing, coding and business regulations.
Support the business of pediatric hospitalists, by maintaining fiscally awareness and proactively managing stakeholder expectations.
Seek opportunities to acquire basic business skills.
Systems Organization and Improvement
In order to improve efficiency and quality in their organizations, pediatric hospitalists should:
Collaborate with colleagues and business office leaders to make sound group/division business decisions using performance feedback, peer review and quality improvement information.
Engage with hospital administrators on strategic business planning, wherever possible.
Copyright © 2010 Society of Hospital Medicine
Bone and joint infections
Introduction
Osteomyelitis is a pyogenic infection of the bone or periosteum, whereas septic arthritis is an infection of the joint space itself. These occur in children as a result of hematogenous spread or local invasion after soft tissue infection or trauma. Either site of infection may represent a medical emergency in children. Bone and joint infections are commonly caused by Staphylococcus aureus, Streptococcal species and Salmonella. These infections can occur at any age, with osteomyelitis occurring in as many as 1 in 5000 children every year. Males are nearly twice as likely to be affected compared to females. Prompt recognition and appropriate treatment are essential to reduce the risk of significant complications including permanent bone or cartilage destruction with life‐long disability. Pediatric hospitalists are often in the best position to render acute inpatient care and coordinate transition to outpatient care to ensure best outcomes.
Knowledge
Pediatric hospitalists should be able to:
Discuss the differential diagnosis of common presenting signs and symptoms of bone and joint infections including swollen joint, limp and bone pain.
Describe the pathophysiology of osteomyelitis including the most common site of infection in a developing bone.
Explain the pathophysiologic mechanisms involved in septic arthritis.
Compare and contrast the varied clinical presentations of bone and soft tissue infections in children of differing ages (infancy to adolescence) and underlying co‐morbidities (such as sickle cell disease, immunosuppressed, and others).
Identify indications for admission to the hospital for children with suspected osteomyelitis and septic arthritis and goals for therapy during the inpatient stay.
Classify the most likely pathogens based on age, underlying risk factors, and exposures and list appropriate antimicrobial agents for each.
State relative local antimicrobial resistance rates for the most common organisms and explain the importance of these in prescribing therapy.
Describe the relative advantages, disadvantages, and local availability of commonly used laboratory (such as C ‐ reactive protein, blood cultures, bone aspirate and other) and radiologic (such as plain film, computed tomography, bone scan, magnetic resonance imaging and other) modalities in the evaluation of bone and joint infections.
Discuss the role of various services in pain management, such as child life and the acute pain service.
State the available home care services for children in the area served and explain the role of home care in discharge decision making.
Define the role of the orthopedist and infectious diseases subspecialists in consultation, co‐management, and follow‐up care.
Compare and contrast the expertise, skill sets, and availability of orthopedists with pediatric orthopedists in the local area and list criteria for transfer to a tertiary care center attending to local context.
List the components of an efficient and effective hospital discharge, including documentation of appropriate clinical improvement, discharge planning completed, antimicrobial therapy duration and monitoring determined, and others.
Identify aspects of diagnosis and treatment that may impact prognosis.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose osteomyelitis or septic arthritis by efficiently performing an accurate history and physical examination.
Order appropriate diagnostic studies and correctly interpret study results.
Develop a cost effective diagnostic work‐up for bone and joint infections, including laboratory and radiographic testing.
Manage pain for children with bone and joint infections.
Consult appropriate subspecialists in a timely and effective manner.
Demonstrate competence in placing parenterally inserted central catheters (PICC) or efficiently obtain services for PICC placement.
Efficiently access and arrange for pediatric home care services as appropriate.
Coordinate care with subspecialists and the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with patients, the family/caregiver and healthcare providers regarding findings and care plans.
Assume responsibility for care as the primary attending or in collaboration with the orthopedic team.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize the evaluation and management for hospitalized children with bone and joint infections.
Work with hospital administration to recruit a multidisciplinary team in the care of children with bone and joint infections that may include nursing, social work, physical therapy, pharmacy and care coordinators.
Assist in creating systems to evaluate and improve pain management for children hospitalized with bone and joint infections.
Lead, coordinate or participate in efforts to increase pediatric‐specific community health care resources that allow for an efficient transition to outpatient therapy and management after inpatient goals are achieved.
Introduction
Osteomyelitis is a pyogenic infection of the bone or periosteum, whereas septic arthritis is an infection of the joint space itself. These occur in children as a result of hematogenous spread or local invasion after soft tissue infection or trauma. Either site of infection may represent a medical emergency in children. Bone and joint infections are commonly caused by Staphylococcus aureus, Streptococcal species and Salmonella. These infections can occur at any age, with osteomyelitis occurring in as many as 1 in 5000 children every year. Males are nearly twice as likely to be affected compared to females. Prompt recognition and appropriate treatment are essential to reduce the risk of significant complications including permanent bone or cartilage destruction with life‐long disability. Pediatric hospitalists are often in the best position to render acute inpatient care and coordinate transition to outpatient care to ensure best outcomes.
Knowledge
Pediatric hospitalists should be able to:
Discuss the differential diagnosis of common presenting signs and symptoms of bone and joint infections including swollen joint, limp and bone pain.
Describe the pathophysiology of osteomyelitis including the most common site of infection in a developing bone.
Explain the pathophysiologic mechanisms involved in septic arthritis.
Compare and contrast the varied clinical presentations of bone and soft tissue infections in children of differing ages (infancy to adolescence) and underlying co‐morbidities (such as sickle cell disease, immunosuppressed, and others).
Identify indications for admission to the hospital for children with suspected osteomyelitis and septic arthritis and goals for therapy during the inpatient stay.
Classify the most likely pathogens based on age, underlying risk factors, and exposures and list appropriate antimicrobial agents for each.
State relative local antimicrobial resistance rates for the most common organisms and explain the importance of these in prescribing therapy.
Describe the relative advantages, disadvantages, and local availability of commonly used laboratory (such as C ‐ reactive protein, blood cultures, bone aspirate and other) and radiologic (such as plain film, computed tomography, bone scan, magnetic resonance imaging and other) modalities in the evaluation of bone and joint infections.
Discuss the role of various services in pain management, such as child life and the acute pain service.
State the available home care services for children in the area served and explain the role of home care in discharge decision making.
Define the role of the orthopedist and infectious diseases subspecialists in consultation, co‐management, and follow‐up care.
Compare and contrast the expertise, skill sets, and availability of orthopedists with pediatric orthopedists in the local area and list criteria for transfer to a tertiary care center attending to local context.
List the components of an efficient and effective hospital discharge, including documentation of appropriate clinical improvement, discharge planning completed, antimicrobial therapy duration and monitoring determined, and others.
Identify aspects of diagnosis and treatment that may impact prognosis.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose osteomyelitis or septic arthritis by efficiently performing an accurate history and physical examination.
Order appropriate diagnostic studies and correctly interpret study results.
Develop a cost effective diagnostic work‐up for bone and joint infections, including laboratory and radiographic testing.
Manage pain for children with bone and joint infections.
Consult appropriate subspecialists in a timely and effective manner.
Demonstrate competence in placing parenterally inserted central catheters (PICC) or efficiently obtain services for PICC placement.
Efficiently access and arrange for pediatric home care services as appropriate.
Coordinate care with subspecialists and the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with patients, the family/caregiver and healthcare providers regarding findings and care plans.
Assume responsibility for care as the primary attending or in collaboration with the orthopedic team.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize the evaluation and management for hospitalized children with bone and joint infections.
Work with hospital administration to recruit a multidisciplinary team in the care of children with bone and joint infections that may include nursing, social work, physical therapy, pharmacy and care coordinators.
Assist in creating systems to evaluate and improve pain management for children hospitalized with bone and joint infections.
Lead, coordinate or participate in efforts to increase pediatric‐specific community health care resources that allow for an efficient transition to outpatient therapy and management after inpatient goals are achieved.
Introduction
Osteomyelitis is a pyogenic infection of the bone or periosteum, whereas septic arthritis is an infection of the joint space itself. These occur in children as a result of hematogenous spread or local invasion after soft tissue infection or trauma. Either site of infection may represent a medical emergency in children. Bone and joint infections are commonly caused by Staphylococcus aureus, Streptococcal species and Salmonella. These infections can occur at any age, with osteomyelitis occurring in as many as 1 in 5000 children every year. Males are nearly twice as likely to be affected compared to females. Prompt recognition and appropriate treatment are essential to reduce the risk of significant complications including permanent bone or cartilage destruction with life‐long disability. Pediatric hospitalists are often in the best position to render acute inpatient care and coordinate transition to outpatient care to ensure best outcomes.
Knowledge
Pediatric hospitalists should be able to:
Discuss the differential diagnosis of common presenting signs and symptoms of bone and joint infections including swollen joint, limp and bone pain.
Describe the pathophysiology of osteomyelitis including the most common site of infection in a developing bone.
Explain the pathophysiologic mechanisms involved in septic arthritis.
Compare and contrast the varied clinical presentations of bone and soft tissue infections in children of differing ages (infancy to adolescence) and underlying co‐morbidities (such as sickle cell disease, immunosuppressed, and others).
Identify indications for admission to the hospital for children with suspected osteomyelitis and septic arthritis and goals for therapy during the inpatient stay.
Classify the most likely pathogens based on age, underlying risk factors, and exposures and list appropriate antimicrobial agents for each.
State relative local antimicrobial resistance rates for the most common organisms and explain the importance of these in prescribing therapy.
Describe the relative advantages, disadvantages, and local availability of commonly used laboratory (such as C ‐ reactive protein, blood cultures, bone aspirate and other) and radiologic (such as plain film, computed tomography, bone scan, magnetic resonance imaging and other) modalities in the evaluation of bone and joint infections.
Discuss the role of various services in pain management, such as child life and the acute pain service.
State the available home care services for children in the area served and explain the role of home care in discharge decision making.
Define the role of the orthopedist and infectious diseases subspecialists in consultation, co‐management, and follow‐up care.
Compare and contrast the expertise, skill sets, and availability of orthopedists with pediatric orthopedists in the local area and list criteria for transfer to a tertiary care center attending to local context.
List the components of an efficient and effective hospital discharge, including documentation of appropriate clinical improvement, discharge planning completed, antimicrobial therapy duration and monitoring determined, and others.
Identify aspects of diagnosis and treatment that may impact prognosis.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose osteomyelitis or septic arthritis by efficiently performing an accurate history and physical examination.
Order appropriate diagnostic studies and correctly interpret study results.
Develop a cost effective diagnostic work‐up for bone and joint infections, including laboratory and radiographic testing.
Manage pain for children with bone and joint infections.
Consult appropriate subspecialists in a timely and effective manner.
Demonstrate competence in placing parenterally inserted central catheters (PICC) or efficiently obtain services for PICC placement.
Efficiently access and arrange for pediatric home care services as appropriate.
Coordinate care with subspecialists and the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with patients, the family/caregiver and healthcare providers regarding findings and care plans.
Assume responsibility for care as the primary attending or in collaboration with the orthopedic team.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize the evaluation and management for hospitalized children with bone and joint infections.
Work with hospital administration to recruit a multidisciplinary team in the care of children with bone and joint infections that may include nursing, social work, physical therapy, pharmacy and care coordinators.
Assist in creating systems to evaluate and improve pain management for children hospitalized with bone and joint infections.
Lead, coordinate or participate in efforts to increase pediatric‐specific community health care resources that allow for an efficient transition to outpatient therapy and management after inpatient goals are achieved.
Copyright © 2010 Society of Hospital Medicine
Education
Introduction
Pediatric hospitalists can serve many roles in education, from educating hospital staff, trainees (medical students, residents, and fellows), community clinicians and organizations and colleagues, to investing in self‐education. Many hospitalists derive their academic identity from their pivotal role in teaching trainees or ancillary staff on the hospital wards and in directing training programs. Training future hospitalists and directing continuing medical education programs to enable current hospitalists to update their knowledge and skills are educational opportunities which are emerging as core competencies for the field are defined. Competencies listed below should be addressed in the context of the specific learner‐educator environment.
Knowledge
Pediatric hospitalists should be able to:
Discuss how the principles of adult learning theory, such as those listed below, can be used in leading daily learning activities.
Assessment of learning needs
Case‐based approach building on the learner's previous experiences or encounters
Reflection
Recognition of the teachable moment
Active learning
Provide an effective learning environment
Self‐directed learning
Modeling
Establish learning goals
Describe one's own preferred teaching and learning style and discuss how this may affect learners with different learning styles.
Identify the steps involved in designing a learning activity, curriculum or program which include:
Conduct a needs assessment to determine learner needs
Write competency‐based goals and objectives based upon learner needs to define what is to be accomplished.
Define and secure resources (personnel, readings, handouts, computer programs, and time)
Actively involve learners in attaining competencies
Evaluate the learners' attainment of competencies
Evaluate the effectiveness of the activity, curriculum or program
Define competencies, performance indicators, goals and objectives, and explain their role in the evaluation of physicians.
Describe the pediatric competencies currently required by regulatory agencies such as the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Pediatrics (ABP). Explain why a continuum of competencies throughout a professional career is required, and illustrate the benefits and challenges of this expectation.
Give illustrative examples of resident performance that fall within each of the six mandated ACGME competency domains: patient care, medical knowledge, practice‐based learning and improvement, interpersonal skills and communications, professionalism, and systems‐based practice.
List specific examples of how pediatric hospitalists can educate to each of the six core competencies, attending to the role on the ward and in the larger healthcare system.
Explain how learners benefit from knowing their learning goals at the start of an educational experience.
Compare the strengths and weaknesses of the following evaluation methods: oral exams, written tests, global evaluations, direct observations with checklists, and multi‐source (360 degree) evaluations.
Compare and contrast formative feedback with summative evaluation.
Describe the typical effects of evaluation on the motivation and learning priorities of both medical students and residents.
Identify how key concepts of evidence‐based medicine literature review should be used to create a plan of evaluation and management for patients.
List resources and activities for continuous learning to maintain current knowledge and skills.
Skills
Pediatric hospitalists should be able to:
Orient trainees to inpatient ward rotation expectations, including learning goals and objectives, patient care and team responsibilities, systems, policies and procedures for the rotation.
Identify the educational objectives and the learner's educational needs in various settings. Use this information to direct selection of content and teaching methods.
Demonstrate efficient and flexible use of time when teaching, adapting the mix of teaching and independent learning activities to optimize use of the time available.
Develop a repertoire of teaching and supervision methods that enhance a learner's knowledge base, clinical skills, and attitudes/behaviors, including:
Bedside teaching
Teaching during work rounds
Lectures or case‐based discussions using multimedia presentation methods
Teaching a specific skill or procedure
Affirm competency when learner masters a skill
Role modeling for learners, with articulation of thought process
Written instruction
Provide frequent, effective feedback based upon direct observation of trainee's clinical, communication, and technical skills and professionalism.
Teach effectively in large group settings, such as hospital or community setting conferences.
Teach effectively in small groups using a case‐based format.
Use different types of questioning (broadening, justifying, hypothetical, and alternative)
Address learning needs of trainees of different levels of experience
Teach patients and the family/caregiver about the diagnosis, planned investigation, management plan and prognosis in an interactive, family centered manner.
Attitudes
Pediatric hospitalists should be able to:
Promote a climate of continuous learning by acknowledging one's own knowledge gaps and prompting learners to teach each other.
Model effective and empathetic communication with patients and the family/caregiver when educating.
Encourage trainees to be self‐directed and to learn independently.
Model professional behavior by being prompt, prepared, available, and approachable in educational efforts.
Build and maintain teamwork by providing reinforcing as well as corrective feedback.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Partner with training programs to create, maintain, and implement inpatient hospital medicine education.
Work with hospital administrators to maintain adequate trainee supervision to ensure patient safety, while encouraging development of autonomous practice.
Through educational efforts, promote quality improvement, patient safety, cost effective care, evidence based medicine and effective communication around inpatient pediatric care.
Integrate and explain the rationale behind established clinical pathways and prompt trainees to use them consistently.
Address the balance of teaching and patient care responsibilities with hospital administration and training program directors to maximize the effectiveness of both.
Collaborate with hospital administration to ensure adequate teaching facilities.
Introduction
Pediatric hospitalists can serve many roles in education, from educating hospital staff, trainees (medical students, residents, and fellows), community clinicians and organizations and colleagues, to investing in self‐education. Many hospitalists derive their academic identity from their pivotal role in teaching trainees or ancillary staff on the hospital wards and in directing training programs. Training future hospitalists and directing continuing medical education programs to enable current hospitalists to update their knowledge and skills are educational opportunities which are emerging as core competencies for the field are defined. Competencies listed below should be addressed in the context of the specific learner‐educator environment.
Knowledge
Pediatric hospitalists should be able to:
Discuss how the principles of adult learning theory, such as those listed below, can be used in leading daily learning activities.
Assessment of learning needs
Case‐based approach building on the learner's previous experiences or encounters
Reflection
Recognition of the teachable moment
Active learning
Provide an effective learning environment
Self‐directed learning
Modeling
Establish learning goals
Describe one's own preferred teaching and learning style and discuss how this may affect learners with different learning styles.
Identify the steps involved in designing a learning activity, curriculum or program which include:
Conduct a needs assessment to determine learner needs
Write competency‐based goals and objectives based upon learner needs to define what is to be accomplished.
Define and secure resources (personnel, readings, handouts, computer programs, and time)
Actively involve learners in attaining competencies
Evaluate the learners' attainment of competencies
Evaluate the effectiveness of the activity, curriculum or program
Define competencies, performance indicators, goals and objectives, and explain their role in the evaluation of physicians.
Describe the pediatric competencies currently required by regulatory agencies such as the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Pediatrics (ABP). Explain why a continuum of competencies throughout a professional career is required, and illustrate the benefits and challenges of this expectation.
Give illustrative examples of resident performance that fall within each of the six mandated ACGME competency domains: patient care, medical knowledge, practice‐based learning and improvement, interpersonal skills and communications, professionalism, and systems‐based practice.
List specific examples of how pediatric hospitalists can educate to each of the six core competencies, attending to the role on the ward and in the larger healthcare system.
Explain how learners benefit from knowing their learning goals at the start of an educational experience.
Compare the strengths and weaknesses of the following evaluation methods: oral exams, written tests, global evaluations, direct observations with checklists, and multi‐source (360 degree) evaluations.
Compare and contrast formative feedback with summative evaluation.
Describe the typical effects of evaluation on the motivation and learning priorities of both medical students and residents.
Identify how key concepts of evidence‐based medicine literature review should be used to create a plan of evaluation and management for patients.
List resources and activities for continuous learning to maintain current knowledge and skills.
Skills
Pediatric hospitalists should be able to:
Orient trainees to inpatient ward rotation expectations, including learning goals and objectives, patient care and team responsibilities, systems, policies and procedures for the rotation.
Identify the educational objectives and the learner's educational needs in various settings. Use this information to direct selection of content and teaching methods.
Demonstrate efficient and flexible use of time when teaching, adapting the mix of teaching and independent learning activities to optimize use of the time available.
Develop a repertoire of teaching and supervision methods that enhance a learner's knowledge base, clinical skills, and attitudes/behaviors, including:
Bedside teaching
Teaching during work rounds
Lectures or case‐based discussions using multimedia presentation methods
Teaching a specific skill or procedure
Affirm competency when learner masters a skill
Role modeling for learners, with articulation of thought process
Written instruction
Provide frequent, effective feedback based upon direct observation of trainee's clinical, communication, and technical skills and professionalism.
Teach effectively in large group settings, such as hospital or community setting conferences.
Teach effectively in small groups using a case‐based format.
Use different types of questioning (broadening, justifying, hypothetical, and alternative)
Address learning needs of trainees of different levels of experience
Teach patients and the family/caregiver about the diagnosis, planned investigation, management plan and prognosis in an interactive, family centered manner.
Attitudes
Pediatric hospitalists should be able to:
Promote a climate of continuous learning by acknowledging one's own knowledge gaps and prompting learners to teach each other.
Model effective and empathetic communication with patients and the family/caregiver when educating.
Encourage trainees to be self‐directed and to learn independently.
Model professional behavior by being prompt, prepared, available, and approachable in educational efforts.
Build and maintain teamwork by providing reinforcing as well as corrective feedback.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Partner with training programs to create, maintain, and implement inpatient hospital medicine education.
Work with hospital administrators to maintain adequate trainee supervision to ensure patient safety, while encouraging development of autonomous practice.
Through educational efforts, promote quality improvement, patient safety, cost effective care, evidence based medicine and effective communication around inpatient pediatric care.
Integrate and explain the rationale behind established clinical pathways and prompt trainees to use them consistently.
Address the balance of teaching and patient care responsibilities with hospital administration and training program directors to maximize the effectiveness of both.
Collaborate with hospital administration to ensure adequate teaching facilities.
Introduction
Pediatric hospitalists can serve many roles in education, from educating hospital staff, trainees (medical students, residents, and fellows), community clinicians and organizations and colleagues, to investing in self‐education. Many hospitalists derive their academic identity from their pivotal role in teaching trainees or ancillary staff on the hospital wards and in directing training programs. Training future hospitalists and directing continuing medical education programs to enable current hospitalists to update their knowledge and skills are educational opportunities which are emerging as core competencies for the field are defined. Competencies listed below should be addressed in the context of the specific learner‐educator environment.
Knowledge
Pediatric hospitalists should be able to:
Discuss how the principles of adult learning theory, such as those listed below, can be used in leading daily learning activities.
Assessment of learning needs
Case‐based approach building on the learner's previous experiences or encounters
Reflection
Recognition of the teachable moment
Active learning
Provide an effective learning environment
Self‐directed learning
Modeling
Establish learning goals
Describe one's own preferred teaching and learning style and discuss how this may affect learners with different learning styles.
Identify the steps involved in designing a learning activity, curriculum or program which include:
Conduct a needs assessment to determine learner needs
Write competency‐based goals and objectives based upon learner needs to define what is to be accomplished.
Define and secure resources (personnel, readings, handouts, computer programs, and time)
Actively involve learners in attaining competencies
Evaluate the learners' attainment of competencies
Evaluate the effectiveness of the activity, curriculum or program
Define competencies, performance indicators, goals and objectives, and explain their role in the evaluation of physicians.
Describe the pediatric competencies currently required by regulatory agencies such as the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Pediatrics (ABP). Explain why a continuum of competencies throughout a professional career is required, and illustrate the benefits and challenges of this expectation.
Give illustrative examples of resident performance that fall within each of the six mandated ACGME competency domains: patient care, medical knowledge, practice‐based learning and improvement, interpersonal skills and communications, professionalism, and systems‐based practice.
List specific examples of how pediatric hospitalists can educate to each of the six core competencies, attending to the role on the ward and in the larger healthcare system.
Explain how learners benefit from knowing their learning goals at the start of an educational experience.
Compare the strengths and weaknesses of the following evaluation methods: oral exams, written tests, global evaluations, direct observations with checklists, and multi‐source (360 degree) evaluations.
Compare and contrast formative feedback with summative evaluation.
Describe the typical effects of evaluation on the motivation and learning priorities of both medical students and residents.
Identify how key concepts of evidence‐based medicine literature review should be used to create a plan of evaluation and management for patients.
List resources and activities for continuous learning to maintain current knowledge and skills.
Skills
Pediatric hospitalists should be able to:
Orient trainees to inpatient ward rotation expectations, including learning goals and objectives, patient care and team responsibilities, systems, policies and procedures for the rotation.
Identify the educational objectives and the learner's educational needs in various settings. Use this information to direct selection of content and teaching methods.
Demonstrate efficient and flexible use of time when teaching, adapting the mix of teaching and independent learning activities to optimize use of the time available.
Develop a repertoire of teaching and supervision methods that enhance a learner's knowledge base, clinical skills, and attitudes/behaviors, including:
Bedside teaching
Teaching during work rounds
Lectures or case‐based discussions using multimedia presentation methods
Teaching a specific skill or procedure
Affirm competency when learner masters a skill
Role modeling for learners, with articulation of thought process
Written instruction
Provide frequent, effective feedback based upon direct observation of trainee's clinical, communication, and technical skills and professionalism.
Teach effectively in large group settings, such as hospital or community setting conferences.
Teach effectively in small groups using a case‐based format.
Use different types of questioning (broadening, justifying, hypothetical, and alternative)
Address learning needs of trainees of different levels of experience
Teach patients and the family/caregiver about the diagnosis, planned investigation, management plan and prognosis in an interactive, family centered manner.
Attitudes
Pediatric hospitalists should be able to:
Promote a climate of continuous learning by acknowledging one's own knowledge gaps and prompting learners to teach each other.
Model effective and empathetic communication with patients and the family/caregiver when educating.
Encourage trainees to be self‐directed and to learn independently.
Model professional behavior by being prompt, prepared, available, and approachable in educational efforts.
Build and maintain teamwork by providing reinforcing as well as corrective feedback.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Partner with training programs to create, maintain, and implement inpatient hospital medicine education.
Work with hospital administrators to maintain adequate trainee supervision to ensure patient safety, while encouraging development of autonomous practice.
Through educational efforts, promote quality improvement, patient safety, cost effective care, evidence based medicine and effective communication around inpatient pediatric care.
Integrate and explain the rationale behind established clinical pathways and prompt trainees to use them consistently.
Address the balance of teaching and patient care responsibilities with hospital administration and training program directors to maximize the effectiveness of both.
Collaborate with hospital administration to ensure adequate teaching facilities.
Copyright © 2010 Society of Hospital Medicine
Failure to thrive
Introduction
Failure to thrive (FTT) is a descriptive term that refers to a child with relative undernutrition and subsequent inadequate growth over time, when compared to other children of similar age, gender, and ethnicity. Several definitions have been proposed based on abnormal anthropometric criteria, but none is uniformly accepted. The etiology of FTT is often multifactorial and results from a complex interplay between psychosocial, behavioral, and physiological factors. Ultimately, this interaction leads to one of three outcomes inadequate caloric intake (in the setting of normal or excessive metabolic demands), inadequate absorption of calories, or impaired utilization of absorbed calories. FTT is often successfully managed in the outpatient setting. However, hospitalization may be necessary for very complex situations, when a child's safety is in question, or when outpatient management has not been successful. It is estimated that FTT accounts for 1 to 5% of all pediatric hospitalizations. Pediatric hospitalists should use evidence‐based approaches to guide evaluation and management, provide leadership for multidisciplinary teams, and coordinate care to optimize outcomes.
Knowledge
Pediatric hospitalists should be able to:
Describe the differential diagnosis of FTT for children of varying chronological and developmental ages recognizing that most children with FTT do not have an underlying medical disorder.
Explain why infants and toddlers are at greater risk for FTT than older children.
Describe the association between FTT and child abuse and neglect.
Describe normal growth patterns for children and the sequential effect of undernutrition on weight velocity, height velocity, and head growth.
Describe the key historical or physical examination findings that may indicate a psychosocial, behavioral, or physiological factor contributing to poor growth.
Provide indications for admission to the hospital and state criteria for determining the appropriate level of care (ward vs. intensive care unit).
Describe the goals of hospitalization including stabilization, diagnosis, treatment, observation, and education.
Discuss the importance of observation of feeding behaviors and recording of nutritional intake over time in the evaluation of FTT.
State the indications for laboratory, radiographic, or other testing in the evaluation of FTT.
Discuss the indications for consultation with a pediatric speech or occupational therapist, nutritionist, gastroenterologist or other subspecialist.
Discuss the need for catch‐up calories in FTT, as well as the methods by which to achieve adequate caloric supplementation.
Define the refeeding syndrome, and describe methods to prevent it or lead to its early detection.
Discuss potential sequelae of FTT (such as behavioral or developmental abnormalities, increased susceptibility to infections, and others) and list the risk factors for worse outcomes.
Summarize the literature on the impact of hospitalization on the evaluation, management, and outcomes for FTT.
Skills
Pediatric hospitalists should be able to:
Stabilize patients presenting with metabolic abnormalities, cardiopulmonary compromise, or other urgent problems as a result of dehydration, malnutrition, or an abnormal pathophysiological state.
Obtain a thorough patient history, including a detailed social, family, dietary and feeding history, attending to markers of abnormal behavioral or psychosocial factors.
Perform a directed physical examination, including careful measurement of anthropometric data, attending to findings that may indicate an underlying medical condition or child abuse and neglect.
Correctly utilize standardized growth charts to identify isolated growth abnormalities and to assess the growth pattern over time.
Directly observe and correctly interpret a feeding session, with attention paid to feeding behavior and the child‐caregiver interactions.
Critically assess the level of evidence and risk/benefit ratio for an expanded diagnostic evaluation.
Interpret basic tests and identify abnormal findings that require further testing or consultation.
Correctly calculate caloric needs and adjust feeding regimens to maximize weight gain while avoiding gastrointestinal compromise.
Correctly identify the need for and efficiently access appropriate consultants and support services needed to provide comprehensive care.
Coordinate care with subspecialists, the primary care provider and other services and arrange for an appropriate transition plan with detailed follow‐up plans for after hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Consider the concerns of the family/caregiver when obtaining a history, developing a diagnostic approach, and offering anticipatory guidance and management options.
Provide education to the family/caregiver on FTT, with specific focus on patient‐specific underlying diagnoses.
Communicate effectively with the family/caregiver and healthcare providers regarding findings and care plans.
Maintain the continuum of care by effectively coordinating the discharge with the primary care provider.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Coordinate the care of professional staff (including social work, nursing, speech or occupational therapists) and consultants to improve the quality and efficiency of care.
Work with healthcare providers and community leaders to develop a system for effective and safe transitions of care from the inpatient to outpatient healthcare providers, preserving the multidisciplinary nature of the care team when appropriate.
Lead, coordinate or participate in efforts to develop evidence‐based guidelines for the evaluation and management of FTT in the hospital.
Introduction
Failure to thrive (FTT) is a descriptive term that refers to a child with relative undernutrition and subsequent inadequate growth over time, when compared to other children of similar age, gender, and ethnicity. Several definitions have been proposed based on abnormal anthropometric criteria, but none is uniformly accepted. The etiology of FTT is often multifactorial and results from a complex interplay between psychosocial, behavioral, and physiological factors. Ultimately, this interaction leads to one of three outcomes inadequate caloric intake (in the setting of normal or excessive metabolic demands), inadequate absorption of calories, or impaired utilization of absorbed calories. FTT is often successfully managed in the outpatient setting. However, hospitalization may be necessary for very complex situations, when a child's safety is in question, or when outpatient management has not been successful. It is estimated that FTT accounts for 1 to 5% of all pediatric hospitalizations. Pediatric hospitalists should use evidence‐based approaches to guide evaluation and management, provide leadership for multidisciplinary teams, and coordinate care to optimize outcomes.
Knowledge
Pediatric hospitalists should be able to:
Describe the differential diagnosis of FTT for children of varying chronological and developmental ages recognizing that most children with FTT do not have an underlying medical disorder.
Explain why infants and toddlers are at greater risk for FTT than older children.
Describe the association between FTT and child abuse and neglect.
Describe normal growth patterns for children and the sequential effect of undernutrition on weight velocity, height velocity, and head growth.
Describe the key historical or physical examination findings that may indicate a psychosocial, behavioral, or physiological factor contributing to poor growth.
Provide indications for admission to the hospital and state criteria for determining the appropriate level of care (ward vs. intensive care unit).
Describe the goals of hospitalization including stabilization, diagnosis, treatment, observation, and education.
Discuss the importance of observation of feeding behaviors and recording of nutritional intake over time in the evaluation of FTT.
State the indications for laboratory, radiographic, or other testing in the evaluation of FTT.
Discuss the indications for consultation with a pediatric speech or occupational therapist, nutritionist, gastroenterologist or other subspecialist.
Discuss the need for catch‐up calories in FTT, as well as the methods by which to achieve adequate caloric supplementation.
Define the refeeding syndrome, and describe methods to prevent it or lead to its early detection.
Discuss potential sequelae of FTT (such as behavioral or developmental abnormalities, increased susceptibility to infections, and others) and list the risk factors for worse outcomes.
Summarize the literature on the impact of hospitalization on the evaluation, management, and outcomes for FTT.
Skills
Pediatric hospitalists should be able to:
Stabilize patients presenting with metabolic abnormalities, cardiopulmonary compromise, or other urgent problems as a result of dehydration, malnutrition, or an abnormal pathophysiological state.
Obtain a thorough patient history, including a detailed social, family, dietary and feeding history, attending to markers of abnormal behavioral or psychosocial factors.
Perform a directed physical examination, including careful measurement of anthropometric data, attending to findings that may indicate an underlying medical condition or child abuse and neglect.
Correctly utilize standardized growth charts to identify isolated growth abnormalities and to assess the growth pattern over time.
Directly observe and correctly interpret a feeding session, with attention paid to feeding behavior and the child‐caregiver interactions.
Critically assess the level of evidence and risk/benefit ratio for an expanded diagnostic evaluation.
Interpret basic tests and identify abnormal findings that require further testing or consultation.
Correctly calculate caloric needs and adjust feeding regimens to maximize weight gain while avoiding gastrointestinal compromise.
Correctly identify the need for and efficiently access appropriate consultants and support services needed to provide comprehensive care.
Coordinate care with subspecialists, the primary care provider and other services and arrange for an appropriate transition plan with detailed follow‐up plans for after hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Consider the concerns of the family/caregiver when obtaining a history, developing a diagnostic approach, and offering anticipatory guidance and management options.
Provide education to the family/caregiver on FTT, with specific focus on patient‐specific underlying diagnoses.
Communicate effectively with the family/caregiver and healthcare providers regarding findings and care plans.
Maintain the continuum of care by effectively coordinating the discharge with the primary care provider.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Coordinate the care of professional staff (including social work, nursing, speech or occupational therapists) and consultants to improve the quality and efficiency of care.
Work with healthcare providers and community leaders to develop a system for effective and safe transitions of care from the inpatient to outpatient healthcare providers, preserving the multidisciplinary nature of the care team when appropriate.
Lead, coordinate or participate in efforts to develop evidence‐based guidelines for the evaluation and management of FTT in the hospital.
Introduction
Failure to thrive (FTT) is a descriptive term that refers to a child with relative undernutrition and subsequent inadequate growth over time, when compared to other children of similar age, gender, and ethnicity. Several definitions have been proposed based on abnormal anthropometric criteria, but none is uniformly accepted. The etiology of FTT is often multifactorial and results from a complex interplay between psychosocial, behavioral, and physiological factors. Ultimately, this interaction leads to one of three outcomes inadequate caloric intake (in the setting of normal or excessive metabolic demands), inadequate absorption of calories, or impaired utilization of absorbed calories. FTT is often successfully managed in the outpatient setting. However, hospitalization may be necessary for very complex situations, when a child's safety is in question, or when outpatient management has not been successful. It is estimated that FTT accounts for 1 to 5% of all pediatric hospitalizations. Pediatric hospitalists should use evidence‐based approaches to guide evaluation and management, provide leadership for multidisciplinary teams, and coordinate care to optimize outcomes.
Knowledge
Pediatric hospitalists should be able to:
Describe the differential diagnosis of FTT for children of varying chronological and developmental ages recognizing that most children with FTT do not have an underlying medical disorder.
Explain why infants and toddlers are at greater risk for FTT than older children.
Describe the association between FTT and child abuse and neglect.
Describe normal growth patterns for children and the sequential effect of undernutrition on weight velocity, height velocity, and head growth.
Describe the key historical or physical examination findings that may indicate a psychosocial, behavioral, or physiological factor contributing to poor growth.
Provide indications for admission to the hospital and state criteria for determining the appropriate level of care (ward vs. intensive care unit).
Describe the goals of hospitalization including stabilization, diagnosis, treatment, observation, and education.
Discuss the importance of observation of feeding behaviors and recording of nutritional intake over time in the evaluation of FTT.
State the indications for laboratory, radiographic, or other testing in the evaluation of FTT.
Discuss the indications for consultation with a pediatric speech or occupational therapist, nutritionist, gastroenterologist or other subspecialist.
Discuss the need for catch‐up calories in FTT, as well as the methods by which to achieve adequate caloric supplementation.
Define the refeeding syndrome, and describe methods to prevent it or lead to its early detection.
Discuss potential sequelae of FTT (such as behavioral or developmental abnormalities, increased susceptibility to infections, and others) and list the risk factors for worse outcomes.
Summarize the literature on the impact of hospitalization on the evaluation, management, and outcomes for FTT.
Skills
Pediatric hospitalists should be able to:
Stabilize patients presenting with metabolic abnormalities, cardiopulmonary compromise, or other urgent problems as a result of dehydration, malnutrition, or an abnormal pathophysiological state.
Obtain a thorough patient history, including a detailed social, family, dietary and feeding history, attending to markers of abnormal behavioral or psychosocial factors.
Perform a directed physical examination, including careful measurement of anthropometric data, attending to findings that may indicate an underlying medical condition or child abuse and neglect.
Correctly utilize standardized growth charts to identify isolated growth abnormalities and to assess the growth pattern over time.
Directly observe and correctly interpret a feeding session, with attention paid to feeding behavior and the child‐caregiver interactions.
Critically assess the level of evidence and risk/benefit ratio for an expanded diagnostic evaluation.
Interpret basic tests and identify abnormal findings that require further testing or consultation.
Correctly calculate caloric needs and adjust feeding regimens to maximize weight gain while avoiding gastrointestinal compromise.
Correctly identify the need for and efficiently access appropriate consultants and support services needed to provide comprehensive care.
Coordinate care with subspecialists, the primary care provider and other services and arrange for an appropriate transition plan with detailed follow‐up plans for after hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Consider the concerns of the family/caregiver when obtaining a history, developing a diagnostic approach, and offering anticipatory guidance and management options.
Provide education to the family/caregiver on FTT, with specific focus on patient‐specific underlying diagnoses.
Communicate effectively with the family/caregiver and healthcare providers regarding findings and care plans.
Maintain the continuum of care by effectively coordinating the discharge with the primary care provider.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Coordinate the care of professional staff (including social work, nursing, speech or occupational therapists) and consultants to improve the quality and efficiency of care.
Work with healthcare providers and community leaders to develop a system for effective and safe transitions of care from the inpatient to outpatient healthcare providers, preserving the multidisciplinary nature of the care team when appropriate.
Lead, coordinate or participate in efforts to develop evidence‐based guidelines for the evaluation and management of FTT in the hospital.
Copyright © 2010 Society of Hospital Medicine
Electrocardiogram interpretation
Introduction
Cardiorespiratory monitoring is used commonly during hospitalization, and electrocardiograms (ECGs) are often obtained to screen for or diagnose cardiac pathology. Cardiac arrhythmias in the hospital setting can be of clinical significance and may be life‐threatening. Early recognition of a clinically significant arrhythmia will result in rapid implementation of appropriate and life‐saving interventions. Pediatric hospitalists are often in the best position to recognize, diagnose, and provide the initial treatment for cardiac arrhythmias and other cardiac problems. Pediatric hospitalists should be skilled at obtaining and interpreting ECGs.
Knowledge
Pediatric hospitalists should be able to:
Describe the normal electrical cardiac cycle and the corresponding wave forms on an ECG tracing.
Review the steps in performing an ECG, attending to lead placement and other technical aspects of the procedure.
Summarize a general approach to the interpretation of pediatric ECGs, attending to evaluation of heart rate, rhythm, QRS axis, wave form durations and intervals, and chamber hypertrophy.
Compare and contrast the features of the newborn ECG to those of older children and adults.
Describe the common ECG changes associated with specific electrolyte disturbances.
List the medications associated with potentially serious arrhythmias (e.g. cisapride and prolonged QT syndrome).
Describe the appropriate treatment for specific cardiac arrhythmias (e.g. medications, electrical cardioversion, or defibrillation).
List the ECG findings that should prompt consultation with a cardiologist, including life‐threatening or unstable cardiac arrhythmia.
Skills
Pediatric hospitalists should be able to:
Obtain an ECG using the standard number and placement of leads, recording speed, and sensitivity.
Differentiate between a normal sinus rhythm and other rhythms by evaluating the presence and relationship of the P wave to the QRS complex.
Determine the heart rate, considering both the atrial and ventricular rates if different.
Determine the PR and QT intervals, P and QRS durations, and QRS axis.
Calculate the corrected QT interval (QTc) for the evaluation of prolonged QT syndrome.
Use the calculated intervals, durations, and amplitudes to evaluate for chamber hypertrophy and to screen for ischemia.
Recognize patterns that are pathognomonic for certain diagnoses (e.g., delta waves in Wolff‐Parkinson‐White syndrome).
Correctly identify abnormal cardiac rhythms and respond with appropriate actions and interventions, including medications, electrical cardioversion, and defibrillation.
Order appropriate monitoring and correctly interpret monitor data.
Consult a pediatric cardiologist when indicated.
Attitudes
Pediatric hospitalists should be able to:
Assume responsibility for the need to obtain an ECG and provide an accurate interpretation.
Communicate effectively with patients, the family/caregivers and other healthcare providers regarding the need to obtain an ECG, findings, and care plan.
Collaborate with the primary care provider and subspecialists to ensure coordinated longitudinal care for children with cardiac pathology.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, Pediatric Hospitalists should:
Lead, coordinate, or participate in the development and implementation of cost‐effective and evidence‐based policies regarding the indications for obtaining an ECG.
Work with pediatric cardiologists, hospital staff, and others to ensure timely, reliable and accurate pediatric ECG interpretation.
Lead, coordinate, or participate in efforts directed at educating healthcare providers about risk factors for cardiac arrhythmia, early identification of abnormal rhythms, and implementation of appropriate resuscitative efforts.
Introduction
Cardiorespiratory monitoring is used commonly during hospitalization, and electrocardiograms (ECGs) are often obtained to screen for or diagnose cardiac pathology. Cardiac arrhythmias in the hospital setting can be of clinical significance and may be life‐threatening. Early recognition of a clinically significant arrhythmia will result in rapid implementation of appropriate and life‐saving interventions. Pediatric hospitalists are often in the best position to recognize, diagnose, and provide the initial treatment for cardiac arrhythmias and other cardiac problems. Pediatric hospitalists should be skilled at obtaining and interpreting ECGs.
Knowledge
Pediatric hospitalists should be able to:
Describe the normal electrical cardiac cycle and the corresponding wave forms on an ECG tracing.
Review the steps in performing an ECG, attending to lead placement and other technical aspects of the procedure.
Summarize a general approach to the interpretation of pediatric ECGs, attending to evaluation of heart rate, rhythm, QRS axis, wave form durations and intervals, and chamber hypertrophy.
Compare and contrast the features of the newborn ECG to those of older children and adults.
Describe the common ECG changes associated with specific electrolyte disturbances.
List the medications associated with potentially serious arrhythmias (e.g. cisapride and prolonged QT syndrome).
Describe the appropriate treatment for specific cardiac arrhythmias (e.g. medications, electrical cardioversion, or defibrillation).
List the ECG findings that should prompt consultation with a cardiologist, including life‐threatening or unstable cardiac arrhythmia.
Skills
Pediatric hospitalists should be able to:
Obtain an ECG using the standard number and placement of leads, recording speed, and sensitivity.
Differentiate between a normal sinus rhythm and other rhythms by evaluating the presence and relationship of the P wave to the QRS complex.
Determine the heart rate, considering both the atrial and ventricular rates if different.
Determine the PR and QT intervals, P and QRS durations, and QRS axis.
Calculate the corrected QT interval (QTc) for the evaluation of prolonged QT syndrome.
Use the calculated intervals, durations, and amplitudes to evaluate for chamber hypertrophy and to screen for ischemia.
Recognize patterns that are pathognomonic for certain diagnoses (e.g., delta waves in Wolff‐Parkinson‐White syndrome).
Correctly identify abnormal cardiac rhythms and respond with appropriate actions and interventions, including medications, electrical cardioversion, and defibrillation.
Order appropriate monitoring and correctly interpret monitor data.
Consult a pediatric cardiologist when indicated.
Attitudes
Pediatric hospitalists should be able to:
Assume responsibility for the need to obtain an ECG and provide an accurate interpretation.
Communicate effectively with patients, the family/caregivers and other healthcare providers regarding the need to obtain an ECG, findings, and care plan.
Collaborate with the primary care provider and subspecialists to ensure coordinated longitudinal care for children with cardiac pathology.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, Pediatric Hospitalists should:
Lead, coordinate, or participate in the development and implementation of cost‐effective and evidence‐based policies regarding the indications for obtaining an ECG.
Work with pediatric cardiologists, hospital staff, and others to ensure timely, reliable and accurate pediatric ECG interpretation.
Lead, coordinate, or participate in efforts directed at educating healthcare providers about risk factors for cardiac arrhythmia, early identification of abnormal rhythms, and implementation of appropriate resuscitative efforts.
Introduction
Cardiorespiratory monitoring is used commonly during hospitalization, and electrocardiograms (ECGs) are often obtained to screen for or diagnose cardiac pathology. Cardiac arrhythmias in the hospital setting can be of clinical significance and may be life‐threatening. Early recognition of a clinically significant arrhythmia will result in rapid implementation of appropriate and life‐saving interventions. Pediatric hospitalists are often in the best position to recognize, diagnose, and provide the initial treatment for cardiac arrhythmias and other cardiac problems. Pediatric hospitalists should be skilled at obtaining and interpreting ECGs.
Knowledge
Pediatric hospitalists should be able to:
Describe the normal electrical cardiac cycle and the corresponding wave forms on an ECG tracing.
Review the steps in performing an ECG, attending to lead placement and other technical aspects of the procedure.
Summarize a general approach to the interpretation of pediatric ECGs, attending to evaluation of heart rate, rhythm, QRS axis, wave form durations and intervals, and chamber hypertrophy.
Compare and contrast the features of the newborn ECG to those of older children and adults.
Describe the common ECG changes associated with specific electrolyte disturbances.
List the medications associated with potentially serious arrhythmias (e.g. cisapride and prolonged QT syndrome).
Describe the appropriate treatment for specific cardiac arrhythmias (e.g. medications, electrical cardioversion, or defibrillation).
List the ECG findings that should prompt consultation with a cardiologist, including life‐threatening or unstable cardiac arrhythmia.
Skills
Pediatric hospitalists should be able to:
Obtain an ECG using the standard number and placement of leads, recording speed, and sensitivity.
Differentiate between a normal sinus rhythm and other rhythms by evaluating the presence and relationship of the P wave to the QRS complex.
Determine the heart rate, considering both the atrial and ventricular rates if different.
Determine the PR and QT intervals, P and QRS durations, and QRS axis.
Calculate the corrected QT interval (QTc) for the evaluation of prolonged QT syndrome.
Use the calculated intervals, durations, and amplitudes to evaluate for chamber hypertrophy and to screen for ischemia.
Recognize patterns that are pathognomonic for certain diagnoses (e.g., delta waves in Wolff‐Parkinson‐White syndrome).
Correctly identify abnormal cardiac rhythms and respond with appropriate actions and interventions, including medications, electrical cardioversion, and defibrillation.
Order appropriate monitoring and correctly interpret monitor data.
Consult a pediatric cardiologist when indicated.
Attitudes
Pediatric hospitalists should be able to:
Assume responsibility for the need to obtain an ECG and provide an accurate interpretation.
Communicate effectively with patients, the family/caregivers and other healthcare providers regarding the need to obtain an ECG, findings, and care plan.
Collaborate with the primary care provider and subspecialists to ensure coordinated longitudinal care for children with cardiac pathology.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, Pediatric Hospitalists should:
Lead, coordinate, or participate in the development and implementation of cost‐effective and evidence‐based policies regarding the indications for obtaining an ECG.
Work with pediatric cardiologists, hospital staff, and others to ensure timely, reliable and accurate pediatric ECG interpretation.
Lead, coordinate, or participate in efforts directed at educating healthcare providers about risk factors for cardiac arrhythmia, early identification of abnormal rhythms, and implementation of appropriate resuscitative efforts.
Copyright © 2010 Society of Hospital Medicine
Pediatric Hospital Medicine Core Competencies
Introduction
The Society of Hospital Medicine (SHM) defines hospitalists as physicians whose primary professional focus is the comprehensive general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.1 It is estimated that there are up to 2500 pediatric hospitalists in the United States, with continued growth due to the converging needs for a dedicated focus on patient safety, quality improvement, hospital throughput, and inpatient teaching.2‐9 (Pediatric Hospital Medicine (PHM), as defined today, has been practiced in the United States for at least 30 years10 and continues to evolve as an area of specialization, with the refinement of a distinct knowledgebase and skill set focused on the provision of high quality general pediatric care in the inpatient setting. PHM is the latest site‐specific specialty to emerge from the field of general pediatrics it's development analogous to the evolution of critical care or emergency medicine during previous decades.11 Adult hospital medicine has defined itself within the field of general internal medicine12 and has recently received approval to provide a recognized focus of practice exam in 2010 for those re‐certifying with the American Board of Internal Medicine,13 PHM is creating an identity as a subspecialty practice with distinct focus on inpatient care for children within the larger context of general pediatric care.8, 14
The Pediatric Hospital Medicine Core Competencies were created to help define the roles and expectations for pediatric hospitalists, regardless of practice setting. The intent is to provide a unified approach toward identifying the specific body of knowledge and measurable skills needed to assure delivery of the highest quality of care for all hospitalized pediatric patients. Most children requiring hospitalization in the United States are hospitalized in community settings where subspecialty support is more limited and many pediatric services may be unavailable. Children with complex, chronic medical problems, however, are more likely to be hospitalized at a tertiary care or academic institutions. In order to unify pediatric hospitalists who work in different practice environments, the PHM Core Competencies were constructed to represent the knowledge, skills, attitudes, and systems improvements that all pediatric hospitalists can be expected to acquire and maintain.
Furthermore, the content of the PHM Core Competencies reflect the fact that children are a vulnerable population. Their care requires attention to many elements which distinguishes it from that given to the majority of the adult population: dependency, differences in developmental physiology and behavior, occurrence of congenital genetic disorders and age‐based clinical conditions, impact of chronic disease states on whole child development, and weight‐based medication dosing often with limited guidance from pediatric studies, to name a few. Awareness of these needs must be heightened when a child enters the hospital where diagnoses, procedures, and treatments often include use of high‐risk modalities and require coordination of care across multiple providers.
Pediatric hospitalists commonly work to improve the systems of care in which they operate and therefore both clinical and non‐clinical topics are included. The 54 chapters address the fundamental and most common components of inpatient care but are not an extensive review of all aspects of inpatient medicine encountered by those caring for hospitalized children. Finally, the PHM Core Competencies are not intended for use in assessing proficiency immediately post‐residency, but do provide a framework for the education and evaluation of both physicians‐in‐training and practicing hospitalists. Meeting these competencies is anticipated to take from one to three years of active practice in pediatric hospital medicine, and may be reached through a combination of practice experience, course work, self‐directed work, and/or formalized training.
Methods
Timeline
In 2002, SHM convened an educational summit from which there was a resolution to create core competencies. Following the summit, the SHM Pediatric Core Curriculum Task Force (CCTF) was created, which included 12 pediatric hospitalists practicing in academic and community facilities, as well as teaching and non‐teaching settings, and occupying leadership positions within institutions of varied size and geographic location. Shortly thereafter, in November 2003, approximately 130 pediatric hospitalists attended the first PHM meeting in San Antonio, Texas.11 At this meeting, with support from leaders in pediatric emergency medicine, first discussions regarding PHM scope of practice were held.
Formal development of the competencies began in 2005 in parallel to but distinct from SHM's adult work, which culminated in The Core Competencies in Hospital Medicine: A Framework for Curriculum Development published in 2006. The CCTF divided into three groups, focused on clinical, procedural, and systems‐based topics. Face‐to‐face meetings were held at the SHM annual meetings, with most work being completed by phone and electronically in the interim periods. In 2007, due to the overlapping interests of the three core pediatric societies, the work was transferred to leaders within the APA. In 2008 the work was transferred back to the leadership within SHM. Since that time, external reviewers were solicited, new chapters created, sections re‐aligned, internal and external reviewer comments incorporated, and final edits for taxonomy, content, and formatting were completed (Table 1).
| Date | Event |
|---|---|
| Feb 2002 | SHM Educational Summit held and CCTF created |
| Oct 2003 | 1st PHM meeting held in San Antonio |
| 2003‐2007 | Chapter focus determined; contributors engaged |
| 2007‐2008 | APA PHM Special Interest Group (SIG) review; creation of separate PHM Fellowship Competencies (not in this document) |
| Aug 2008‐Oct 2008 | SHM Pediatric Committee and CCTF members resume work; editorial review |
| Oct 2008‐Mar 2009 | Internal review: PHM Fellowship Director, AAP, APA, and SHM section/committee leader, and key national PHM leader reviews solicited and returned |
| Mar 2009 | PHM Fellowship Director comments addressed; editorial review |
| Mar‐Apr 2009 | External reviewers solicited from national agencies and societies relevant to PHM |
| Apr‐July 2009 | External reviewer comments returned |
| July‐Oct 2009 | Contributor review of all comments; editorial review, sections revised |
| Oct 2009 | Final review: Chapters to SHM subcommittees and Board |
Areas of Focused Practice
The PHM Core Competencies were conceptualized similarly to the SHM adult core competencies. Initial sections were divided into clinical conditions, procedures, and systems. However as content developed and reviewer comments were addressed, the four final sections were modified to those noted in Table 2. For the Common Clinical Diagnoses and Conditions, the goal was to select conditions most commonly encountered by pediatric hospitalists. Non‐surgical diagnosis‐related group (DRG) conditions were selected from the following sources: The Joint Commission's (TJC) Oryx Performance Measures Report15‐16 (asthma, abdominal pain, acute gastroenteritis, simple pneumonia); Child Health Corporation of America's Pediatric Health Information System Dataset (CHCA PHIS, Shawnee Mission, KS), and relevant publications on common pediatric hospitalizations.17 These data were compared to billing data from randomly‐selected practicing hospitalists representing free‐standing children's and community hospitals, teaching and non‐teaching settings, and urban and rural locations. The 22 clinical conditions chosen by the CCTF were those most relevant to the practice of pediatric hospital medicine.
| Common Clinical Diagnoses and Conditions | Specialized Clinical Services | Core Skills | Healthcare Systems: Supporting and Advancing Child Health | |
|---|---|---|---|---|
| Acute abdominal pain and the acute abdomen | Neonatal fever | Child abuse and neglect | Bladder catheterization/suprapubic bladder tap | Advocacy |
| Apparent life‐threatening event | Neonatal Jaundice | Hospice and palliative care | Electrocardiogram interpretation | Business practices |
| Asthma | Pneumonia | Leading a healthcare team | Feeding Tubes | Communication |
| Bone and joint infections | Respiratory Failure | Newborn care and delivery room management | Fluids and Electrolyte Management | Continuous quality improvement |
| Bronchiolitis | Seizures | Technology dependent children | Intravenous access and phlebotomy | Cost‐effective care |
| Central nervous system infections | Shock | Transport of the critically ill child | Lumbar puncture | Education |
| Diabetes mellitus | Sickle cell disease | Non‐invasive monitoring | Ethics | |
| Failure to thrive | Skin and soft tissue infection | Nutrition | Evidence based medicine | |
| Fever of unknown origin | Toxic ingestion | Oxygen delivery and airway management | Health Information Systems | |
| Gastroenteritis | Upper airway infections | Pain management | Legal issues/risk management | |
| Kawasaki disease | Urinary Tract infections | Pediatric Advanced Life Support | Patient safety |
The Specialized Clinical Servicessection addresses important components of care that are not DRG‐based and reflect the unique needs of hospitalized children, as assessed by the CCTF, editors, and contributors. Core Skillswere chosen based on the HCUP Factbook 2 Procedures,18 billing data from randomly‐selected practicing hospitalists representing the same settings listed above, and critical input from reviewers. Depending on the individual setting, pediatric hospitalists may require skills in areas not found in these 11 chapters, such as chest tube placement or ventilator management. The list is therefore not exhaustive, but rather representative of skills most pediatric hospitalists should maintain.
The Healthcare Systems: Supporting and Advancing Child Healthchapters are likely the most dissimilar to any core content taught in traditional residency programs. While residency graduates are versed in some components listed in these chapters, comprehensive education in most of these competencies is currently lacking. Improvement of healthcare systems is an essential element of pediatric hospital medicine, and unifies all pediatric hospitalists regardless of practice environment or patient population. Therefore, this section includes chapters that not only focus on systems of care, but also on advancing child health through advocacy, research, education, evidence‐based medicine, and ethical practice. These chapters were drawn from a combination of several sources: expectations of external agencies (TJC, Center for Medicaid and Medicare) related to the specific nonclinical work in which pediatric hospitalists are integrally involved; expectations for advocacy as best defined by the AAP and the National Association of Children's Hospitals and Related Institutions (NACHRI); the six core competency domains mandated by the Accrediting Council on Graduate Medical Education (ACGME), the American Board of Pediatrics (ABP), and hospital medical staff offices as part of Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE)16; and assessment of responsibilities and leadership roles fulfilled by pediatric hospitalists in all venues. In keeping with the intent of the competencies to be timeless, the competency elements call out the need to attend to the changing goals of these groups as well as those of the Institute of Healthcare Improvement (IHI), the Alliance for Pediatric Quality (which consists of ABP, AAP, TJC, CHCA, NACHRI), and local hospital systems leaders.
Contributors and Review
The CCTF selected section (associate) editors from SHM based on established expertise in each area, with input from the SHM Pediatric and Education Committees and the SHM Board. As a collaborative effort, authors for various chapters were solicited in consultation with experts from the AAP, APA, and SHM, and included non‐hospitalists with reputations as experts in various fields. Numerous SHM Pediatric Committee and CCTF conference calls were held to review hospital and academic appointments, presentations given, and affiliations relevant to the practice of pediatric hospital medicine. This vetting process resulted in a robust author list representing diverse geographic and practice settings. Contributors were provided with structure (Knowledge, Skills, Attitudes, and Systems subsections) and content (timeless, competency based) guidelines.
The review process was rigorous, and included both internal and external reviewers. The APA review in 2007 included the PHM Special Interest Group as well as the PHM Fellowship Directors (Table 1). After return to SHM and further editing, the internal review commenced which focused on content and scope. The editors addressed the resulting suggestions and worked to standardize formatting and use of Bloom's taxonomy.19 A list of common terms and phrases were created to add consistency between chapters. External reviewers were first mailed a letter requesting interest, which was followed up by emails, letters, and phone calls to encourage feedback. External review included 29 solicited agencies and societies (Table 3), with overall response rate of 66% (41% for Groups I and II). Individual contributors then reviewed comments specific to their chapters, with associate editor overview of their respective sections. The editors reviewed each chapter individually multiple times throughout the 2007‐2009 years, contacting individual contributors and reviewers by email and phone. Editors concluded a final comprehensive review of all chapters in late 2009.
| I. Academic and Certifying Societies |
| Academic Pediatric Association |
| Accreditation Council for Graduate Medical Education, Pediatric Residency Review Committee |
| American Academy of Family Physicians |
| American Academy of Pediatrics Board |
| American Academy of Pediatrics National Committee on Hospital Care |
| American Association of Critical Care Nursing |
| American Board of Family Medicine |
| American Board of Pediatrics |
| American College of Emergency Physicians |
| American Pediatric Society |
| Association of American Medical Colleges |
| Association of Medical School Pediatric Department Chairs (AMSPDC) |
| Association of Pediatric Program Directors |
| Council on Teaching Hospitals |
| Society of Pediatric Research |
| II. Stakeholder agencies |
| Agency for Healthcare Research and Quality |
| American Association of Critical Care Nursing |
| American College of Emergency Physicians |
| American Hospital Association (AHA) |
| American Nurses Association |
| American Society of Health‐System Pharmacists |
| Child Health Corporation of America (CHCA) |
| Institute for Healthcare Improvement |
| National Association for Children's Hospitals and Related Institutions (NACHRI) |
| National Association of Pediatric Nurse Practitioners (NAPNAP) |
| National Initiative for Children's Healthcare Quality (NICHQ) |
| National Quality Forum |
| Quality Resources International |
| Robert Wood Johnson Foundation |
| The Joint Commission for Accreditation of Hospitals and Organizations (TJC) |
| III. Pediatric Hospital Medicine Fellowship Directors |
| Boston Children's |
| Children's Hospital Los Angeles |
| Children's National D.C. |
| Emory |
| Hospital for Sick Kids Toronto |
| Rady Children's San Diego University of California San Diego |
| Riley Children's Hospital Indiana |
| University of South Florida, All Children's Hospital |
| Texas Children's Hospital, Baylor College of Medicine |
| IV. SHM, APA, AAP Leadership and committee chairs |
| American Academy of Pediatrics Section on Hospital Medicine |
| Academic Pediatric Association PHM Special Interest Group |
| SHM Board |
| SHM Education Committee |
| SHM Family Practice Committee |
| SHM Hospital Quality and Patient Safety Committee |
| SHM IT Task Force |
| SHM Journal Editorial Board |
| SHM Palliative Care Task Force |
| SHM Practice Analysis Committee |
| SHM Public Policy Committee |
| SHM Research Committee |
Chapter Content
Each of the 54 chapters within the four sections of these competencies is presented in the educational theory of learning domains: Knowledge, Skills, Attitudes, with a final Systems domain added to reflect the emphasis of hospitalist practice on improving healthcare systems. Each chapter is designed to stand alone, which may assist with development of curriculum at individual practice locations. Certain key phrases are apparent throughout, such as lead, coordinate, or participate in and work with hospital and community leaders to which were designed to note the varied roles in different practice settings. Some chapters specifically comment on the application of competency bullets given the unique and differing roles and expectations of pediatric hospitalists, such as research and education. Chapters state specific proficiencies expected wherever possible, with phrases and wording selected to help guide learning activities to achieve the competency.
Application and Future Directions
Although pediatric hospitalists care for children in many settings, these core competencies address the common expectations for any venue. Pediatric hospital medicine requires skills in acute care clinical medicine that attend to the changing needs of hospitalized children. The core of pediatric hospital medicine is dedicated to the care of children in the geographic hospital environment between emergency medicine and tertiary pediatric and neonatal intensive care units. Pediatric hospitalists provide care in related clinical service programs that are linked to hospital systems. In performing these activities, pediatric hospitalists consistently partner with ambulatory providers and subspecialists to render coordinated care across the continuum for a given child. Pediatric hospital medicine is an interdisciplinary practice, with focus on processes of care and clinical quality outcomes based in evidence. Engagement in local, state, and national initiatives to improve child health outcomes is a cornerstone of pediatric hospitalists' practice. These competencies provide the framework for creation of curricula that can reflect local issues and react to changing evidence.
As providers of systems‐based care, pediatric hospitalists are called upon more and more to render care and provide leadership in clinical arenas that are integral to healthcare organizations, such as home health care, sub‐acute care facilities, and hospice and palliative care programs. The practice of pediatric hospital medicine has evolved to its current state through efforts of many represented in the competencies as contributors, associate editors, editors, and reviewers. Pediatric hospitalists are committed to leading change in healthcare for hospitalized children, and are positioned well to address the interests and needs of community and urban, teaching and non‐teaching facilities, and the children and families they serve. These competencies reflect the areas of focused practice which, similar to pediatric emergency medicine, will no doubt be refined but not fundamentally changed in future years. The intent, we hope, is clear: to provide excellence in clinical care, accountability for practice, and lead improvements in healthcare for hospitalized children.
- Society of Hospital Medicine (SHM). Definition of a Hospitalist. http://www.hospitalmedicine.org/AM/Template.cfm?Section=General_Information 2009.
- Todd von Deak MBA CAE Vice President Membership and Marketing.Pediatric Hospitalists Membership Numbers. In.Philadelphia:Society of Hospital Medicine National Office 1500 Spring Garden, Suite 501, Philadelphia, PA 19130;2009.
- ,.The emerging role of “hospitalists” in the American health care system.N Engl J Med.1996;335:514–517.
- .The future of hospital medicine: evolution or revolution?Am J Med.2004;117:446–450.
- ,.The hospitalist movement 5 years later.JAMA.2002;287:487–494.
- ,,,,.Variation in pediatric hospitalists' use of proven and unproven therapies: A study from the Pediatric Research in Inpatient Settings (PRIS) network.Journal of Hospital Medicine.2008;3(4):292–298.
- ,,.Pediatric hospitalists: Training, current practice, and career goals.Journal of Hospital Medicine.2009;4(3):179–186.
- ,.Standardize to Excellence: Improving the Quality and Safety of Care with Clinical Pathways.Pediatric Clinics of North America.2009;56(4):893–904.
- .Evolution of a new specialty ‐ a twenty year pediatric hospitalist experience [Abstract]. In:National Association of Inpatient Physicians (now Society of Hospital Medicine).New Orleans, Louisiana;1999.
- ,,,,,, et al.Pediatric Hospitalists: Report of a Leadership Conference.Pediatrics.2006;117(4):1122–1130.
- ,,,, e.The Core Competencies in Hospital Medicine: A Framework for Curriculum Development.J Hosp Med.2006;1(Suppl 1).
- American Board of Internal Medicine. Questions and Answers regarding ABIM Recognition of Focused Practice in Hospital Medicine through Maintenance of Certification. http://www.abim.org/news/news/focused‐practice‐hospital‐medicine‐qa.aspx. Published 2010. Accessed January 6,2010.
- .Comprehensive Pediatric Hospital Medicine.N Engl J Med.2008;358(21):2301–2302.
- The Joint Commission. Performance Measurement Initiatives. http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/. Published 2010. Accessed December 5,2010.
- The Joint Commission. Standards Frequently Asked Questions: Comprehensive Accreditation Manual for Critical Access Hospitals (CAMCAH). http://www.jointcommission.org/AccreditationPrograms/CriticalAccessHospitals/Standards/09_FAQs/default.htm. Accessed December 5,2008; December 14, 2009.
- ,,,,.Infectious Disease Hospitalizations Among Infants in the United States.Pediatrics.2008;121(2):244–252.
- ,,,.Procedures in U.S. Hospitals, 1997.HCUP Fact Book No. 2. In:Agency for Healthcare Research and Quality,Rockville, MD;2001.
- Anderson L,Krathwohl DR,Airasian PW,Cruikshank KA,Mayer RE,Pintrich PR, et al., editors.A Taxonomy for Learning, Teaching, and Assessing — A Revision of Bloom's Taxonomy of Educational Objectives.Addison Wesley Longman, Inc.Pearson Education USA, One Lake Street Upper Saddle River, NJ; (2001).
Introduction
The Society of Hospital Medicine (SHM) defines hospitalists as physicians whose primary professional focus is the comprehensive general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.1 It is estimated that there are up to 2500 pediatric hospitalists in the United States, with continued growth due to the converging needs for a dedicated focus on patient safety, quality improvement, hospital throughput, and inpatient teaching.2‐9 (Pediatric Hospital Medicine (PHM), as defined today, has been practiced in the United States for at least 30 years10 and continues to evolve as an area of specialization, with the refinement of a distinct knowledgebase and skill set focused on the provision of high quality general pediatric care in the inpatient setting. PHM is the latest site‐specific specialty to emerge from the field of general pediatrics it's development analogous to the evolution of critical care or emergency medicine during previous decades.11 Adult hospital medicine has defined itself within the field of general internal medicine12 and has recently received approval to provide a recognized focus of practice exam in 2010 for those re‐certifying with the American Board of Internal Medicine,13 PHM is creating an identity as a subspecialty practice with distinct focus on inpatient care for children within the larger context of general pediatric care.8, 14
The Pediatric Hospital Medicine Core Competencies were created to help define the roles and expectations for pediatric hospitalists, regardless of practice setting. The intent is to provide a unified approach toward identifying the specific body of knowledge and measurable skills needed to assure delivery of the highest quality of care for all hospitalized pediatric patients. Most children requiring hospitalization in the United States are hospitalized in community settings where subspecialty support is more limited and many pediatric services may be unavailable. Children with complex, chronic medical problems, however, are more likely to be hospitalized at a tertiary care or academic institutions. In order to unify pediatric hospitalists who work in different practice environments, the PHM Core Competencies were constructed to represent the knowledge, skills, attitudes, and systems improvements that all pediatric hospitalists can be expected to acquire and maintain.
Furthermore, the content of the PHM Core Competencies reflect the fact that children are a vulnerable population. Their care requires attention to many elements which distinguishes it from that given to the majority of the adult population: dependency, differences in developmental physiology and behavior, occurrence of congenital genetic disorders and age‐based clinical conditions, impact of chronic disease states on whole child development, and weight‐based medication dosing often with limited guidance from pediatric studies, to name a few. Awareness of these needs must be heightened when a child enters the hospital where diagnoses, procedures, and treatments often include use of high‐risk modalities and require coordination of care across multiple providers.
Pediatric hospitalists commonly work to improve the systems of care in which they operate and therefore both clinical and non‐clinical topics are included. The 54 chapters address the fundamental and most common components of inpatient care but are not an extensive review of all aspects of inpatient medicine encountered by those caring for hospitalized children. Finally, the PHM Core Competencies are not intended for use in assessing proficiency immediately post‐residency, but do provide a framework for the education and evaluation of both physicians‐in‐training and practicing hospitalists. Meeting these competencies is anticipated to take from one to three years of active practice in pediatric hospital medicine, and may be reached through a combination of practice experience, course work, self‐directed work, and/or formalized training.
Methods
Timeline
In 2002, SHM convened an educational summit from which there was a resolution to create core competencies. Following the summit, the SHM Pediatric Core Curriculum Task Force (CCTF) was created, which included 12 pediatric hospitalists practicing in academic and community facilities, as well as teaching and non‐teaching settings, and occupying leadership positions within institutions of varied size and geographic location. Shortly thereafter, in November 2003, approximately 130 pediatric hospitalists attended the first PHM meeting in San Antonio, Texas.11 At this meeting, with support from leaders in pediatric emergency medicine, first discussions regarding PHM scope of practice were held.
Formal development of the competencies began in 2005 in parallel to but distinct from SHM's adult work, which culminated in The Core Competencies in Hospital Medicine: A Framework for Curriculum Development published in 2006. The CCTF divided into three groups, focused on clinical, procedural, and systems‐based topics. Face‐to‐face meetings were held at the SHM annual meetings, with most work being completed by phone and electronically in the interim periods. In 2007, due to the overlapping interests of the three core pediatric societies, the work was transferred to leaders within the APA. In 2008 the work was transferred back to the leadership within SHM. Since that time, external reviewers were solicited, new chapters created, sections re‐aligned, internal and external reviewer comments incorporated, and final edits for taxonomy, content, and formatting were completed (Table 1).
| Date | Event |
|---|---|
| Feb 2002 | SHM Educational Summit held and CCTF created |
| Oct 2003 | 1st PHM meeting held in San Antonio |
| 2003‐2007 | Chapter focus determined; contributors engaged |
| 2007‐2008 | APA PHM Special Interest Group (SIG) review; creation of separate PHM Fellowship Competencies (not in this document) |
| Aug 2008‐Oct 2008 | SHM Pediatric Committee and CCTF members resume work; editorial review |
| Oct 2008‐Mar 2009 | Internal review: PHM Fellowship Director, AAP, APA, and SHM section/committee leader, and key national PHM leader reviews solicited and returned |
| Mar 2009 | PHM Fellowship Director comments addressed; editorial review |
| Mar‐Apr 2009 | External reviewers solicited from national agencies and societies relevant to PHM |
| Apr‐July 2009 | External reviewer comments returned |
| July‐Oct 2009 | Contributor review of all comments; editorial review, sections revised |
| Oct 2009 | Final review: Chapters to SHM subcommittees and Board |
Areas of Focused Practice
The PHM Core Competencies were conceptualized similarly to the SHM adult core competencies. Initial sections were divided into clinical conditions, procedures, and systems. However as content developed and reviewer comments were addressed, the four final sections were modified to those noted in Table 2. For the Common Clinical Diagnoses and Conditions, the goal was to select conditions most commonly encountered by pediatric hospitalists. Non‐surgical diagnosis‐related group (DRG) conditions were selected from the following sources: The Joint Commission's (TJC) Oryx Performance Measures Report15‐16 (asthma, abdominal pain, acute gastroenteritis, simple pneumonia); Child Health Corporation of America's Pediatric Health Information System Dataset (CHCA PHIS, Shawnee Mission, KS), and relevant publications on common pediatric hospitalizations.17 These data were compared to billing data from randomly‐selected practicing hospitalists representing free‐standing children's and community hospitals, teaching and non‐teaching settings, and urban and rural locations. The 22 clinical conditions chosen by the CCTF were those most relevant to the practice of pediatric hospital medicine.
| Common Clinical Diagnoses and Conditions | Specialized Clinical Services | Core Skills | Healthcare Systems: Supporting and Advancing Child Health | |
|---|---|---|---|---|
| Acute abdominal pain and the acute abdomen | Neonatal fever | Child abuse and neglect | Bladder catheterization/suprapubic bladder tap | Advocacy |
| Apparent life‐threatening event | Neonatal Jaundice | Hospice and palliative care | Electrocardiogram interpretation | Business practices |
| Asthma | Pneumonia | Leading a healthcare team | Feeding Tubes | Communication |
| Bone and joint infections | Respiratory Failure | Newborn care and delivery room management | Fluids and Electrolyte Management | Continuous quality improvement |
| Bronchiolitis | Seizures | Technology dependent children | Intravenous access and phlebotomy | Cost‐effective care |
| Central nervous system infections | Shock | Transport of the critically ill child | Lumbar puncture | Education |
| Diabetes mellitus | Sickle cell disease | Non‐invasive monitoring | Ethics | |
| Failure to thrive | Skin and soft tissue infection | Nutrition | Evidence based medicine | |
| Fever of unknown origin | Toxic ingestion | Oxygen delivery and airway management | Health Information Systems | |
| Gastroenteritis | Upper airway infections | Pain management | Legal issues/risk management | |
| Kawasaki disease | Urinary Tract infections | Pediatric Advanced Life Support | Patient safety |
The Specialized Clinical Servicessection addresses important components of care that are not DRG‐based and reflect the unique needs of hospitalized children, as assessed by the CCTF, editors, and contributors. Core Skillswere chosen based on the HCUP Factbook 2 Procedures,18 billing data from randomly‐selected practicing hospitalists representing the same settings listed above, and critical input from reviewers. Depending on the individual setting, pediatric hospitalists may require skills in areas not found in these 11 chapters, such as chest tube placement or ventilator management. The list is therefore not exhaustive, but rather representative of skills most pediatric hospitalists should maintain.
The Healthcare Systems: Supporting and Advancing Child Healthchapters are likely the most dissimilar to any core content taught in traditional residency programs. While residency graduates are versed in some components listed in these chapters, comprehensive education in most of these competencies is currently lacking. Improvement of healthcare systems is an essential element of pediatric hospital medicine, and unifies all pediatric hospitalists regardless of practice environment or patient population. Therefore, this section includes chapters that not only focus on systems of care, but also on advancing child health through advocacy, research, education, evidence‐based medicine, and ethical practice. These chapters were drawn from a combination of several sources: expectations of external agencies (TJC, Center for Medicaid and Medicare) related to the specific nonclinical work in which pediatric hospitalists are integrally involved; expectations for advocacy as best defined by the AAP and the National Association of Children's Hospitals and Related Institutions (NACHRI); the six core competency domains mandated by the Accrediting Council on Graduate Medical Education (ACGME), the American Board of Pediatrics (ABP), and hospital medical staff offices as part of Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE)16; and assessment of responsibilities and leadership roles fulfilled by pediatric hospitalists in all venues. In keeping with the intent of the competencies to be timeless, the competency elements call out the need to attend to the changing goals of these groups as well as those of the Institute of Healthcare Improvement (IHI), the Alliance for Pediatric Quality (which consists of ABP, AAP, TJC, CHCA, NACHRI), and local hospital systems leaders.
Contributors and Review
The CCTF selected section (associate) editors from SHM based on established expertise in each area, with input from the SHM Pediatric and Education Committees and the SHM Board. As a collaborative effort, authors for various chapters were solicited in consultation with experts from the AAP, APA, and SHM, and included non‐hospitalists with reputations as experts in various fields. Numerous SHM Pediatric Committee and CCTF conference calls were held to review hospital and academic appointments, presentations given, and affiliations relevant to the practice of pediatric hospital medicine. This vetting process resulted in a robust author list representing diverse geographic and practice settings. Contributors were provided with structure (Knowledge, Skills, Attitudes, and Systems subsections) and content (timeless, competency based) guidelines.
The review process was rigorous, and included both internal and external reviewers. The APA review in 2007 included the PHM Special Interest Group as well as the PHM Fellowship Directors (Table 1). After return to SHM and further editing, the internal review commenced which focused on content and scope. The editors addressed the resulting suggestions and worked to standardize formatting and use of Bloom's taxonomy.19 A list of common terms and phrases were created to add consistency between chapters. External reviewers were first mailed a letter requesting interest, which was followed up by emails, letters, and phone calls to encourage feedback. External review included 29 solicited agencies and societies (Table 3), with overall response rate of 66% (41% for Groups I and II). Individual contributors then reviewed comments specific to their chapters, with associate editor overview of their respective sections. The editors reviewed each chapter individually multiple times throughout the 2007‐2009 years, contacting individual contributors and reviewers by email and phone. Editors concluded a final comprehensive review of all chapters in late 2009.
| I. Academic and Certifying Societies |
| Academic Pediatric Association |
| Accreditation Council for Graduate Medical Education, Pediatric Residency Review Committee |
| American Academy of Family Physicians |
| American Academy of Pediatrics Board |
| American Academy of Pediatrics National Committee on Hospital Care |
| American Association of Critical Care Nursing |
| American Board of Family Medicine |
| American Board of Pediatrics |
| American College of Emergency Physicians |
| American Pediatric Society |
| Association of American Medical Colleges |
| Association of Medical School Pediatric Department Chairs (AMSPDC) |
| Association of Pediatric Program Directors |
| Council on Teaching Hospitals |
| Society of Pediatric Research |
| II. Stakeholder agencies |
| Agency for Healthcare Research and Quality |
| American Association of Critical Care Nursing |
| American College of Emergency Physicians |
| American Hospital Association (AHA) |
| American Nurses Association |
| American Society of Health‐System Pharmacists |
| Child Health Corporation of America (CHCA) |
| Institute for Healthcare Improvement |
| National Association for Children's Hospitals and Related Institutions (NACHRI) |
| National Association of Pediatric Nurse Practitioners (NAPNAP) |
| National Initiative for Children's Healthcare Quality (NICHQ) |
| National Quality Forum |
| Quality Resources International |
| Robert Wood Johnson Foundation |
| The Joint Commission for Accreditation of Hospitals and Organizations (TJC) |
| III. Pediatric Hospital Medicine Fellowship Directors |
| Boston Children's |
| Children's Hospital Los Angeles |
| Children's National D.C. |
| Emory |
| Hospital for Sick Kids Toronto |
| Rady Children's San Diego University of California San Diego |
| Riley Children's Hospital Indiana |
| University of South Florida, All Children's Hospital |
| Texas Children's Hospital, Baylor College of Medicine |
| IV. SHM, APA, AAP Leadership and committee chairs |
| American Academy of Pediatrics Section on Hospital Medicine |
| Academic Pediatric Association PHM Special Interest Group |
| SHM Board |
| SHM Education Committee |
| SHM Family Practice Committee |
| SHM Hospital Quality and Patient Safety Committee |
| SHM IT Task Force |
| SHM Journal Editorial Board |
| SHM Palliative Care Task Force |
| SHM Practice Analysis Committee |
| SHM Public Policy Committee |
| SHM Research Committee |
Chapter Content
Each of the 54 chapters within the four sections of these competencies is presented in the educational theory of learning domains: Knowledge, Skills, Attitudes, with a final Systems domain added to reflect the emphasis of hospitalist practice on improving healthcare systems. Each chapter is designed to stand alone, which may assist with development of curriculum at individual practice locations. Certain key phrases are apparent throughout, such as lead, coordinate, or participate in and work with hospital and community leaders to which were designed to note the varied roles in different practice settings. Some chapters specifically comment on the application of competency bullets given the unique and differing roles and expectations of pediatric hospitalists, such as research and education. Chapters state specific proficiencies expected wherever possible, with phrases and wording selected to help guide learning activities to achieve the competency.
Application and Future Directions
Although pediatric hospitalists care for children in many settings, these core competencies address the common expectations for any venue. Pediatric hospital medicine requires skills in acute care clinical medicine that attend to the changing needs of hospitalized children. The core of pediatric hospital medicine is dedicated to the care of children in the geographic hospital environment between emergency medicine and tertiary pediatric and neonatal intensive care units. Pediatric hospitalists provide care in related clinical service programs that are linked to hospital systems. In performing these activities, pediatric hospitalists consistently partner with ambulatory providers and subspecialists to render coordinated care across the continuum for a given child. Pediatric hospital medicine is an interdisciplinary practice, with focus on processes of care and clinical quality outcomes based in evidence. Engagement in local, state, and national initiatives to improve child health outcomes is a cornerstone of pediatric hospitalists' practice. These competencies provide the framework for creation of curricula that can reflect local issues and react to changing evidence.
As providers of systems‐based care, pediatric hospitalists are called upon more and more to render care and provide leadership in clinical arenas that are integral to healthcare organizations, such as home health care, sub‐acute care facilities, and hospice and palliative care programs. The practice of pediatric hospital medicine has evolved to its current state through efforts of many represented in the competencies as contributors, associate editors, editors, and reviewers. Pediatric hospitalists are committed to leading change in healthcare for hospitalized children, and are positioned well to address the interests and needs of community and urban, teaching and non‐teaching facilities, and the children and families they serve. These competencies reflect the areas of focused practice which, similar to pediatric emergency medicine, will no doubt be refined but not fundamentally changed in future years. The intent, we hope, is clear: to provide excellence in clinical care, accountability for practice, and lead improvements in healthcare for hospitalized children.
Introduction
The Society of Hospital Medicine (SHM) defines hospitalists as physicians whose primary professional focus is the comprehensive general medical care of hospitalized patients. Their activities include patient care, teaching, research, and leadership related to Hospital Medicine.1 It is estimated that there are up to 2500 pediatric hospitalists in the United States, with continued growth due to the converging needs for a dedicated focus on patient safety, quality improvement, hospital throughput, and inpatient teaching.2‐9 (Pediatric Hospital Medicine (PHM), as defined today, has been practiced in the United States for at least 30 years10 and continues to evolve as an area of specialization, with the refinement of a distinct knowledgebase and skill set focused on the provision of high quality general pediatric care in the inpatient setting. PHM is the latest site‐specific specialty to emerge from the field of general pediatrics it's development analogous to the evolution of critical care or emergency medicine during previous decades.11 Adult hospital medicine has defined itself within the field of general internal medicine12 and has recently received approval to provide a recognized focus of practice exam in 2010 for those re‐certifying with the American Board of Internal Medicine,13 PHM is creating an identity as a subspecialty practice with distinct focus on inpatient care for children within the larger context of general pediatric care.8, 14
The Pediatric Hospital Medicine Core Competencies were created to help define the roles and expectations for pediatric hospitalists, regardless of practice setting. The intent is to provide a unified approach toward identifying the specific body of knowledge and measurable skills needed to assure delivery of the highest quality of care for all hospitalized pediatric patients. Most children requiring hospitalization in the United States are hospitalized in community settings where subspecialty support is more limited and many pediatric services may be unavailable. Children with complex, chronic medical problems, however, are more likely to be hospitalized at a tertiary care or academic institutions. In order to unify pediatric hospitalists who work in different practice environments, the PHM Core Competencies were constructed to represent the knowledge, skills, attitudes, and systems improvements that all pediatric hospitalists can be expected to acquire and maintain.
Furthermore, the content of the PHM Core Competencies reflect the fact that children are a vulnerable population. Their care requires attention to many elements which distinguishes it from that given to the majority of the adult population: dependency, differences in developmental physiology and behavior, occurrence of congenital genetic disorders and age‐based clinical conditions, impact of chronic disease states on whole child development, and weight‐based medication dosing often with limited guidance from pediatric studies, to name a few. Awareness of these needs must be heightened when a child enters the hospital where diagnoses, procedures, and treatments often include use of high‐risk modalities and require coordination of care across multiple providers.
Pediatric hospitalists commonly work to improve the systems of care in which they operate and therefore both clinical and non‐clinical topics are included. The 54 chapters address the fundamental and most common components of inpatient care but are not an extensive review of all aspects of inpatient medicine encountered by those caring for hospitalized children. Finally, the PHM Core Competencies are not intended for use in assessing proficiency immediately post‐residency, but do provide a framework for the education and evaluation of both physicians‐in‐training and practicing hospitalists. Meeting these competencies is anticipated to take from one to three years of active practice in pediatric hospital medicine, and may be reached through a combination of practice experience, course work, self‐directed work, and/or formalized training.
Methods
Timeline
In 2002, SHM convened an educational summit from which there was a resolution to create core competencies. Following the summit, the SHM Pediatric Core Curriculum Task Force (CCTF) was created, which included 12 pediatric hospitalists practicing in academic and community facilities, as well as teaching and non‐teaching settings, and occupying leadership positions within institutions of varied size and geographic location. Shortly thereafter, in November 2003, approximately 130 pediatric hospitalists attended the first PHM meeting in San Antonio, Texas.11 At this meeting, with support from leaders in pediatric emergency medicine, first discussions regarding PHM scope of practice were held.
Formal development of the competencies began in 2005 in parallel to but distinct from SHM's adult work, which culminated in The Core Competencies in Hospital Medicine: A Framework for Curriculum Development published in 2006. The CCTF divided into three groups, focused on clinical, procedural, and systems‐based topics. Face‐to‐face meetings were held at the SHM annual meetings, with most work being completed by phone and electronically in the interim periods. In 2007, due to the overlapping interests of the three core pediatric societies, the work was transferred to leaders within the APA. In 2008 the work was transferred back to the leadership within SHM. Since that time, external reviewers were solicited, new chapters created, sections re‐aligned, internal and external reviewer comments incorporated, and final edits for taxonomy, content, and formatting were completed (Table 1).
| Date | Event |
|---|---|
| Feb 2002 | SHM Educational Summit held and CCTF created |
| Oct 2003 | 1st PHM meeting held in San Antonio |
| 2003‐2007 | Chapter focus determined; contributors engaged |
| 2007‐2008 | APA PHM Special Interest Group (SIG) review; creation of separate PHM Fellowship Competencies (not in this document) |
| Aug 2008‐Oct 2008 | SHM Pediatric Committee and CCTF members resume work; editorial review |
| Oct 2008‐Mar 2009 | Internal review: PHM Fellowship Director, AAP, APA, and SHM section/committee leader, and key national PHM leader reviews solicited and returned |
| Mar 2009 | PHM Fellowship Director comments addressed; editorial review |
| Mar‐Apr 2009 | External reviewers solicited from national agencies and societies relevant to PHM |
| Apr‐July 2009 | External reviewer comments returned |
| July‐Oct 2009 | Contributor review of all comments; editorial review, sections revised |
| Oct 2009 | Final review: Chapters to SHM subcommittees and Board |
Areas of Focused Practice
The PHM Core Competencies were conceptualized similarly to the SHM adult core competencies. Initial sections were divided into clinical conditions, procedures, and systems. However as content developed and reviewer comments were addressed, the four final sections were modified to those noted in Table 2. For the Common Clinical Diagnoses and Conditions, the goal was to select conditions most commonly encountered by pediatric hospitalists. Non‐surgical diagnosis‐related group (DRG) conditions were selected from the following sources: The Joint Commission's (TJC) Oryx Performance Measures Report15‐16 (asthma, abdominal pain, acute gastroenteritis, simple pneumonia); Child Health Corporation of America's Pediatric Health Information System Dataset (CHCA PHIS, Shawnee Mission, KS), and relevant publications on common pediatric hospitalizations.17 These data were compared to billing data from randomly‐selected practicing hospitalists representing free‐standing children's and community hospitals, teaching and non‐teaching settings, and urban and rural locations. The 22 clinical conditions chosen by the CCTF were those most relevant to the practice of pediatric hospital medicine.
| Common Clinical Diagnoses and Conditions | Specialized Clinical Services | Core Skills | Healthcare Systems: Supporting and Advancing Child Health | |
|---|---|---|---|---|
| Acute abdominal pain and the acute abdomen | Neonatal fever | Child abuse and neglect | Bladder catheterization/suprapubic bladder tap | Advocacy |
| Apparent life‐threatening event | Neonatal Jaundice | Hospice and palliative care | Electrocardiogram interpretation | Business practices |
| Asthma | Pneumonia | Leading a healthcare team | Feeding Tubes | Communication |
| Bone and joint infections | Respiratory Failure | Newborn care and delivery room management | Fluids and Electrolyte Management | Continuous quality improvement |
| Bronchiolitis | Seizures | Technology dependent children | Intravenous access and phlebotomy | Cost‐effective care |
| Central nervous system infections | Shock | Transport of the critically ill child | Lumbar puncture | Education |
| Diabetes mellitus | Sickle cell disease | Non‐invasive monitoring | Ethics | |
| Failure to thrive | Skin and soft tissue infection | Nutrition | Evidence based medicine | |
| Fever of unknown origin | Toxic ingestion | Oxygen delivery and airway management | Health Information Systems | |
| Gastroenteritis | Upper airway infections | Pain management | Legal issues/risk management | |
| Kawasaki disease | Urinary Tract infections | Pediatric Advanced Life Support | Patient safety |
The Specialized Clinical Servicessection addresses important components of care that are not DRG‐based and reflect the unique needs of hospitalized children, as assessed by the CCTF, editors, and contributors. Core Skillswere chosen based on the HCUP Factbook 2 Procedures,18 billing data from randomly‐selected practicing hospitalists representing the same settings listed above, and critical input from reviewers. Depending on the individual setting, pediatric hospitalists may require skills in areas not found in these 11 chapters, such as chest tube placement or ventilator management. The list is therefore not exhaustive, but rather representative of skills most pediatric hospitalists should maintain.
The Healthcare Systems: Supporting and Advancing Child Healthchapters are likely the most dissimilar to any core content taught in traditional residency programs. While residency graduates are versed in some components listed in these chapters, comprehensive education in most of these competencies is currently lacking. Improvement of healthcare systems is an essential element of pediatric hospital medicine, and unifies all pediatric hospitalists regardless of practice environment or patient population. Therefore, this section includes chapters that not only focus on systems of care, but also on advancing child health through advocacy, research, education, evidence‐based medicine, and ethical practice. These chapters were drawn from a combination of several sources: expectations of external agencies (TJC, Center for Medicaid and Medicare) related to the specific nonclinical work in which pediatric hospitalists are integrally involved; expectations for advocacy as best defined by the AAP and the National Association of Children's Hospitals and Related Institutions (NACHRI); the six core competency domains mandated by the Accrediting Council on Graduate Medical Education (ACGME), the American Board of Pediatrics (ABP), and hospital medical staff offices as part of Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE)16; and assessment of responsibilities and leadership roles fulfilled by pediatric hospitalists in all venues. In keeping with the intent of the competencies to be timeless, the competency elements call out the need to attend to the changing goals of these groups as well as those of the Institute of Healthcare Improvement (IHI), the Alliance for Pediatric Quality (which consists of ABP, AAP, TJC, CHCA, NACHRI), and local hospital systems leaders.
Contributors and Review
The CCTF selected section (associate) editors from SHM based on established expertise in each area, with input from the SHM Pediatric and Education Committees and the SHM Board. As a collaborative effort, authors for various chapters were solicited in consultation with experts from the AAP, APA, and SHM, and included non‐hospitalists with reputations as experts in various fields. Numerous SHM Pediatric Committee and CCTF conference calls were held to review hospital and academic appointments, presentations given, and affiliations relevant to the practice of pediatric hospital medicine. This vetting process resulted in a robust author list representing diverse geographic and practice settings. Contributors were provided with structure (Knowledge, Skills, Attitudes, and Systems subsections) and content (timeless, competency based) guidelines.
The review process was rigorous, and included both internal and external reviewers. The APA review in 2007 included the PHM Special Interest Group as well as the PHM Fellowship Directors (Table 1). After return to SHM and further editing, the internal review commenced which focused on content and scope. The editors addressed the resulting suggestions and worked to standardize formatting and use of Bloom's taxonomy.19 A list of common terms and phrases were created to add consistency between chapters. External reviewers were first mailed a letter requesting interest, which was followed up by emails, letters, and phone calls to encourage feedback. External review included 29 solicited agencies and societies (Table 3), with overall response rate of 66% (41% for Groups I and II). Individual contributors then reviewed comments specific to their chapters, with associate editor overview of their respective sections. The editors reviewed each chapter individually multiple times throughout the 2007‐2009 years, contacting individual contributors and reviewers by email and phone. Editors concluded a final comprehensive review of all chapters in late 2009.
| I. Academic and Certifying Societies |
| Academic Pediatric Association |
| Accreditation Council for Graduate Medical Education, Pediatric Residency Review Committee |
| American Academy of Family Physicians |
| American Academy of Pediatrics Board |
| American Academy of Pediatrics National Committee on Hospital Care |
| American Association of Critical Care Nursing |
| American Board of Family Medicine |
| American Board of Pediatrics |
| American College of Emergency Physicians |
| American Pediatric Society |
| Association of American Medical Colleges |
| Association of Medical School Pediatric Department Chairs (AMSPDC) |
| Association of Pediatric Program Directors |
| Council on Teaching Hospitals |
| Society of Pediatric Research |
| II. Stakeholder agencies |
| Agency for Healthcare Research and Quality |
| American Association of Critical Care Nursing |
| American College of Emergency Physicians |
| American Hospital Association (AHA) |
| American Nurses Association |
| American Society of Health‐System Pharmacists |
| Child Health Corporation of America (CHCA) |
| Institute for Healthcare Improvement |
| National Association for Children's Hospitals and Related Institutions (NACHRI) |
| National Association of Pediatric Nurse Practitioners (NAPNAP) |
| National Initiative for Children's Healthcare Quality (NICHQ) |
| National Quality Forum |
| Quality Resources International |
| Robert Wood Johnson Foundation |
| The Joint Commission for Accreditation of Hospitals and Organizations (TJC) |
| III. Pediatric Hospital Medicine Fellowship Directors |
| Boston Children's |
| Children's Hospital Los Angeles |
| Children's National D.C. |
| Emory |
| Hospital for Sick Kids Toronto |
| Rady Children's San Diego University of California San Diego |
| Riley Children's Hospital Indiana |
| University of South Florida, All Children's Hospital |
| Texas Children's Hospital, Baylor College of Medicine |
| IV. SHM, APA, AAP Leadership and committee chairs |
| American Academy of Pediatrics Section on Hospital Medicine |
| Academic Pediatric Association PHM Special Interest Group |
| SHM Board |
| SHM Education Committee |
| SHM Family Practice Committee |
| SHM Hospital Quality and Patient Safety Committee |
| SHM IT Task Force |
| SHM Journal Editorial Board |
| SHM Palliative Care Task Force |
| SHM Practice Analysis Committee |
| SHM Public Policy Committee |
| SHM Research Committee |
Chapter Content
Each of the 54 chapters within the four sections of these competencies is presented in the educational theory of learning domains: Knowledge, Skills, Attitudes, with a final Systems domain added to reflect the emphasis of hospitalist practice on improving healthcare systems. Each chapter is designed to stand alone, which may assist with development of curriculum at individual practice locations. Certain key phrases are apparent throughout, such as lead, coordinate, or participate in and work with hospital and community leaders to which were designed to note the varied roles in different practice settings. Some chapters specifically comment on the application of competency bullets given the unique and differing roles and expectations of pediatric hospitalists, such as research and education. Chapters state specific proficiencies expected wherever possible, with phrases and wording selected to help guide learning activities to achieve the competency.
Application and Future Directions
Although pediatric hospitalists care for children in many settings, these core competencies address the common expectations for any venue. Pediatric hospital medicine requires skills in acute care clinical medicine that attend to the changing needs of hospitalized children. The core of pediatric hospital medicine is dedicated to the care of children in the geographic hospital environment between emergency medicine and tertiary pediatric and neonatal intensive care units. Pediatric hospitalists provide care in related clinical service programs that are linked to hospital systems. In performing these activities, pediatric hospitalists consistently partner with ambulatory providers and subspecialists to render coordinated care across the continuum for a given child. Pediatric hospital medicine is an interdisciplinary practice, with focus on processes of care and clinical quality outcomes based in evidence. Engagement in local, state, and national initiatives to improve child health outcomes is a cornerstone of pediatric hospitalists' practice. These competencies provide the framework for creation of curricula that can reflect local issues and react to changing evidence.
As providers of systems‐based care, pediatric hospitalists are called upon more and more to render care and provide leadership in clinical arenas that are integral to healthcare organizations, such as home health care, sub‐acute care facilities, and hospice and palliative care programs. The practice of pediatric hospital medicine has evolved to its current state through efforts of many represented in the competencies as contributors, associate editors, editors, and reviewers. Pediatric hospitalists are committed to leading change in healthcare for hospitalized children, and are positioned well to address the interests and needs of community and urban, teaching and non‐teaching facilities, and the children and families they serve. These competencies reflect the areas of focused practice which, similar to pediatric emergency medicine, will no doubt be refined but not fundamentally changed in future years. The intent, we hope, is clear: to provide excellence in clinical care, accountability for practice, and lead improvements in healthcare for hospitalized children.
- Society of Hospital Medicine (SHM). Definition of a Hospitalist. http://www.hospitalmedicine.org/AM/Template.cfm?Section=General_Information 2009.
- Todd von Deak MBA CAE Vice President Membership and Marketing.Pediatric Hospitalists Membership Numbers. In.Philadelphia:Society of Hospital Medicine National Office 1500 Spring Garden, Suite 501, Philadelphia, PA 19130;2009.
- ,.The emerging role of “hospitalists” in the American health care system.N Engl J Med.1996;335:514–517.
- .The future of hospital medicine: evolution or revolution?Am J Med.2004;117:446–450.
- ,.The hospitalist movement 5 years later.JAMA.2002;287:487–494.
- ,,,,.Variation in pediatric hospitalists' use of proven and unproven therapies: A study from the Pediatric Research in Inpatient Settings (PRIS) network.Journal of Hospital Medicine.2008;3(4):292–298.
- ,,.Pediatric hospitalists: Training, current practice, and career goals.Journal of Hospital Medicine.2009;4(3):179–186.
- ,.Standardize to Excellence: Improving the Quality and Safety of Care with Clinical Pathways.Pediatric Clinics of North America.2009;56(4):893–904.
- .Evolution of a new specialty ‐ a twenty year pediatric hospitalist experience [Abstract]. In:National Association of Inpatient Physicians (now Society of Hospital Medicine).New Orleans, Louisiana;1999.
- ,,,,,, et al.Pediatric Hospitalists: Report of a Leadership Conference.Pediatrics.2006;117(4):1122–1130.
- ,,,, e.The Core Competencies in Hospital Medicine: A Framework for Curriculum Development.J Hosp Med.2006;1(Suppl 1).
- American Board of Internal Medicine. Questions and Answers regarding ABIM Recognition of Focused Practice in Hospital Medicine through Maintenance of Certification. http://www.abim.org/news/news/focused‐practice‐hospital‐medicine‐qa.aspx. Published 2010. Accessed January 6,2010.
- .Comprehensive Pediatric Hospital Medicine.N Engl J Med.2008;358(21):2301–2302.
- The Joint Commission. Performance Measurement Initiatives. http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/. Published 2010. Accessed December 5,2010.
- The Joint Commission. Standards Frequently Asked Questions: Comprehensive Accreditation Manual for Critical Access Hospitals (CAMCAH). http://www.jointcommission.org/AccreditationPrograms/CriticalAccessHospitals/Standards/09_FAQs/default.htm. Accessed December 5,2008; December 14, 2009.
- ,,,,.Infectious Disease Hospitalizations Among Infants in the United States.Pediatrics.2008;121(2):244–252.
- ,,,.Procedures in U.S. Hospitals, 1997.HCUP Fact Book No. 2. In:Agency for Healthcare Research and Quality,Rockville, MD;2001.
- Anderson L,Krathwohl DR,Airasian PW,Cruikshank KA,Mayer RE,Pintrich PR, et al., editors.A Taxonomy for Learning, Teaching, and Assessing — A Revision of Bloom's Taxonomy of Educational Objectives.Addison Wesley Longman, Inc.Pearson Education USA, One Lake Street Upper Saddle River, NJ; (2001).
- Society of Hospital Medicine (SHM). Definition of a Hospitalist. http://www.hospitalmedicine.org/AM/Template.cfm?Section=General_Information 2009.
- Todd von Deak MBA CAE Vice President Membership and Marketing.Pediatric Hospitalists Membership Numbers. In.Philadelphia:Society of Hospital Medicine National Office 1500 Spring Garden, Suite 501, Philadelphia, PA 19130;2009.
- ,.The emerging role of “hospitalists” in the American health care system.N Engl J Med.1996;335:514–517.
- .The future of hospital medicine: evolution or revolution?Am J Med.2004;117:446–450.
- ,.The hospitalist movement 5 years later.JAMA.2002;287:487–494.
- ,,,,.Variation in pediatric hospitalists' use of proven and unproven therapies: A study from the Pediatric Research in Inpatient Settings (PRIS) network.Journal of Hospital Medicine.2008;3(4):292–298.
- ,,.Pediatric hospitalists: Training, current practice, and career goals.Journal of Hospital Medicine.2009;4(3):179–186.
- ,.Standardize to Excellence: Improving the Quality and Safety of Care with Clinical Pathways.Pediatric Clinics of North America.2009;56(4):893–904.
- .Evolution of a new specialty ‐ a twenty year pediatric hospitalist experience [Abstract]. In:National Association of Inpatient Physicians (now Society of Hospital Medicine).New Orleans, Louisiana;1999.
- ,,,,,, et al.Pediatric Hospitalists: Report of a Leadership Conference.Pediatrics.2006;117(4):1122–1130.
- ,,,, e.The Core Competencies in Hospital Medicine: A Framework for Curriculum Development.J Hosp Med.2006;1(Suppl 1).
- American Board of Internal Medicine. Questions and Answers regarding ABIM Recognition of Focused Practice in Hospital Medicine through Maintenance of Certification. http://www.abim.org/news/news/focused‐practice‐hospital‐medicine‐qa.aspx. Published 2010. Accessed January 6,2010.
- .Comprehensive Pediatric Hospital Medicine.N Engl J Med.2008;358(21):2301–2302.
- The Joint Commission. Performance Measurement Initiatives. http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/. Published 2010. Accessed December 5,2010.
- The Joint Commission. Standards Frequently Asked Questions: Comprehensive Accreditation Manual for Critical Access Hospitals (CAMCAH). http://www.jointcommission.org/AccreditationPrograms/CriticalAccessHospitals/Standards/09_FAQs/default.htm. Accessed December 5,2008; December 14, 2009.
- ,,,,.Infectious Disease Hospitalizations Among Infants in the United States.Pediatrics.2008;121(2):244–252.
- ,,,.Procedures in U.S. Hospitals, 1997.HCUP Fact Book No. 2. In:Agency for Healthcare Research and Quality,Rockville, MD;2001.
- Anderson L,Krathwohl DR,Airasian PW,Cruikshank KA,Mayer RE,Pintrich PR, et al., editors.A Taxonomy for Learning, Teaching, and Assessing — A Revision of Bloom's Taxonomy of Educational Objectives.Addison Wesley Longman, Inc.Pearson Education USA, One Lake Street Upper Saddle River, NJ; (2001).
Asthma
Introduction
Asthma is the most common childhood chronic disease and is the third leading cause of hospital admission for children less than 15 years of age. Prevalence and mortality rates have increased over the past decade, along with costs, the latter predominantly associated with hospital based care. The Department of Health and Human Services (DHHS), through the National Institutes of Health (NIH), coordinated the National Asthma Education and Prevention Program designed to provide up‐to‐date evidence‐based guidelines for the diagnosis, treatment and prevention of asthma. The DHHS also identified asthma as one of the key elements of the Healthy People 2010 initiative with several specific health objectives related directly to inpatient management. Due to the chronic nature of this disease, pediatric hospitalists should not only treat the acute exacerbation resulting in status asthmaticus, but also create or re‐affirm long term management plans.
Knowledge
Pediatric hospitalists should be able to:
Discuss the pathophysiology of asthma addressing both bronchoconstrictive and inflammatory components and state how each impacts pharmacologic treatment choices.
Compare and contrast the pathophysiology of asthma with other common small airway illnesses in children such as bronchiolitis, viral pneumonia with bronchospasm, or chronic lung disease.
List the differential diagnosis of wheezing for various age groups and delineate the defining features leading to a diagnosis of asthma.
Summarize evaluation, monitoring, and treatment options for patients with worsening cardiorespiratory status including mental status assessment, capnography, inhaled and intravenous medications, respiratory support and others.
Describe the signs and symptoms of impending respiratory failure and list criteria for transfer to an intensive care unit.
Cite the common complications of asthma or asthma treatment, including pneumothorax, atelectasis, lobar collapse, poor cardiac output, dysrhythmias and others.
State the basic pharmacology, safety profile and potential adverse effects of commonly used medications.
Discuss the impact of risk factors (such as genetic predisposition and family history) associated chronic co‐morbidities (such as atopic dermatitis and allergic rhinitis) and exacerbating factors (such as gastroesophageal reflux and smoke exposure) on morbidity, treatment and prognosis.
Define asthma groups by symptom severity and frequency based on current classification guidelines.
Explain the significance of environmental controls and trigger avoidance in minimizing asthma exacerbations.
Describe the utility of using asthma action plans to both monitor and treat asthma via pulmonary function testing (spirometry and/or peak flow) and proper use of controller and reliever medications.
Discuss the goals of asthma management, including the maintenance of normal activity levels and pulmonary function, the prevention of chronic symptoms, recurrent exacerbations, and hospitalizations, and the provision of optimal pharmacotherapy while minimizing adverse events.
Give examples of specific indications for referral to an asthma subspecialist.
Illustrate why proper coding for asthma is critical to assure proper local resource use, accurate billing, and appropriate national comparisons of asthma data.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose and classify asthma by efficiently performing an accurate history and physical examination.
Recognize signs and symptoms of serious complications of asthma such as pneumothorax or impending respiratory failure.
Direct an evidence‐based treatment plan for status asthmaticus.
Order and interpret objective measures of pulmonary function, including peak flow monitoring and spirometry.
Order and interpret results of basic diagnostic tools such as chest radiograph and blood gas as indicated.
Order appropriate monitoring and correctly interpret monitor data.
Provide supplemental oxygen therapy and advanced airway management as necessary.
Recognize indications for hospital admission and discharge, and for transfer to a higher level of care or tertiary care facility.
Modify the medication regimen based upon accurate assessment of changes in disease severity.
Efficiently render care by creating a discharge plan which can be expediently activated when appropriate.
Consistently initiate patient and family/caregiver asthma education as soon after admission as possible, as appropriate for the clinical context.
Coordinate care with the primary care provider including discharge medications and instructions, and follow‐up plans.
Complete a written asthma action plan and use it to educate patients and the family/caregiver on trigger avoidance, medication adherence, and disease control.
Attitudes
Pediatric hospitalists should be able to:
Reinforce the role and responsibility of patients and the family/caregiver regarding self‐care, recognition of symptoms, and disease management.
Communicate effectively with patients, the family/caregiver and healthcare providers regarding care plans.
Engage in a multi‐disciplinary approach to the prevention, diagnosis, and treatment of asthma, involving when appropriate, social workers or case managers, respiratory therapists, and subspecialists.
Collaborate with primary care providers and subspecialists to ensure coordinated longitudinal care for children with asthma.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in local and national initiatives to further the development and implementation of evidence‐based clinical guidelines to promote effective resource utilization and improve quality of care for hospitalized children with asthma.
Work with hospital administrators to implement and utilize performance feedback and quality improvement measures to assess outcomes of instituted guidelines for the management of inpatient asthma.
Collaborate with primary care providers, subspecialists, social workers, and case managers to ensure a smooth transition to the outpatient setting, and to minimize the need for readmission.
Introduction
Asthma is the most common childhood chronic disease and is the third leading cause of hospital admission for children less than 15 years of age. Prevalence and mortality rates have increased over the past decade, along with costs, the latter predominantly associated with hospital based care. The Department of Health and Human Services (DHHS), through the National Institutes of Health (NIH), coordinated the National Asthma Education and Prevention Program designed to provide up‐to‐date evidence‐based guidelines for the diagnosis, treatment and prevention of asthma. The DHHS also identified asthma as one of the key elements of the Healthy People 2010 initiative with several specific health objectives related directly to inpatient management. Due to the chronic nature of this disease, pediatric hospitalists should not only treat the acute exacerbation resulting in status asthmaticus, but also create or re‐affirm long term management plans.
Knowledge
Pediatric hospitalists should be able to:
Discuss the pathophysiology of asthma addressing both bronchoconstrictive and inflammatory components and state how each impacts pharmacologic treatment choices.
Compare and contrast the pathophysiology of asthma with other common small airway illnesses in children such as bronchiolitis, viral pneumonia with bronchospasm, or chronic lung disease.
List the differential diagnosis of wheezing for various age groups and delineate the defining features leading to a diagnosis of asthma.
Summarize evaluation, monitoring, and treatment options for patients with worsening cardiorespiratory status including mental status assessment, capnography, inhaled and intravenous medications, respiratory support and others.
Describe the signs and symptoms of impending respiratory failure and list criteria for transfer to an intensive care unit.
Cite the common complications of asthma or asthma treatment, including pneumothorax, atelectasis, lobar collapse, poor cardiac output, dysrhythmias and others.
State the basic pharmacology, safety profile and potential adverse effects of commonly used medications.
Discuss the impact of risk factors (such as genetic predisposition and family history) associated chronic co‐morbidities (such as atopic dermatitis and allergic rhinitis) and exacerbating factors (such as gastroesophageal reflux and smoke exposure) on morbidity, treatment and prognosis.
Define asthma groups by symptom severity and frequency based on current classification guidelines.
Explain the significance of environmental controls and trigger avoidance in minimizing asthma exacerbations.
Describe the utility of using asthma action plans to both monitor and treat asthma via pulmonary function testing (spirometry and/or peak flow) and proper use of controller and reliever medications.
Discuss the goals of asthma management, including the maintenance of normal activity levels and pulmonary function, the prevention of chronic symptoms, recurrent exacerbations, and hospitalizations, and the provision of optimal pharmacotherapy while minimizing adverse events.
Give examples of specific indications for referral to an asthma subspecialist.
Illustrate why proper coding for asthma is critical to assure proper local resource use, accurate billing, and appropriate national comparisons of asthma data.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose and classify asthma by efficiently performing an accurate history and physical examination.
Recognize signs and symptoms of serious complications of asthma such as pneumothorax or impending respiratory failure.
Direct an evidence‐based treatment plan for status asthmaticus.
Order and interpret objective measures of pulmonary function, including peak flow monitoring and spirometry.
Order and interpret results of basic diagnostic tools such as chest radiograph and blood gas as indicated.
Order appropriate monitoring and correctly interpret monitor data.
Provide supplemental oxygen therapy and advanced airway management as necessary.
Recognize indications for hospital admission and discharge, and for transfer to a higher level of care or tertiary care facility.
Modify the medication regimen based upon accurate assessment of changes in disease severity.
Efficiently render care by creating a discharge plan which can be expediently activated when appropriate.
Consistently initiate patient and family/caregiver asthma education as soon after admission as possible, as appropriate for the clinical context.
Coordinate care with the primary care provider including discharge medications and instructions, and follow‐up plans.
Complete a written asthma action plan and use it to educate patients and the family/caregiver on trigger avoidance, medication adherence, and disease control.
Attitudes
Pediatric hospitalists should be able to:
Reinforce the role and responsibility of patients and the family/caregiver regarding self‐care, recognition of symptoms, and disease management.
Communicate effectively with patients, the family/caregiver and healthcare providers regarding care plans.
Engage in a multi‐disciplinary approach to the prevention, diagnosis, and treatment of asthma, involving when appropriate, social workers or case managers, respiratory therapists, and subspecialists.
Collaborate with primary care providers and subspecialists to ensure coordinated longitudinal care for children with asthma.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in local and national initiatives to further the development and implementation of evidence‐based clinical guidelines to promote effective resource utilization and improve quality of care for hospitalized children with asthma.
Work with hospital administrators to implement and utilize performance feedback and quality improvement measures to assess outcomes of instituted guidelines for the management of inpatient asthma.
Collaborate with primary care providers, subspecialists, social workers, and case managers to ensure a smooth transition to the outpatient setting, and to minimize the need for readmission.
Introduction
Asthma is the most common childhood chronic disease and is the third leading cause of hospital admission for children less than 15 years of age. Prevalence and mortality rates have increased over the past decade, along with costs, the latter predominantly associated with hospital based care. The Department of Health and Human Services (DHHS), through the National Institutes of Health (NIH), coordinated the National Asthma Education and Prevention Program designed to provide up‐to‐date evidence‐based guidelines for the diagnosis, treatment and prevention of asthma. The DHHS also identified asthma as one of the key elements of the Healthy People 2010 initiative with several specific health objectives related directly to inpatient management. Due to the chronic nature of this disease, pediatric hospitalists should not only treat the acute exacerbation resulting in status asthmaticus, but also create or re‐affirm long term management plans.
Knowledge
Pediatric hospitalists should be able to:
Discuss the pathophysiology of asthma addressing both bronchoconstrictive and inflammatory components and state how each impacts pharmacologic treatment choices.
Compare and contrast the pathophysiology of asthma with other common small airway illnesses in children such as bronchiolitis, viral pneumonia with bronchospasm, or chronic lung disease.
List the differential diagnosis of wheezing for various age groups and delineate the defining features leading to a diagnosis of asthma.
Summarize evaluation, monitoring, and treatment options for patients with worsening cardiorespiratory status including mental status assessment, capnography, inhaled and intravenous medications, respiratory support and others.
Describe the signs and symptoms of impending respiratory failure and list criteria for transfer to an intensive care unit.
Cite the common complications of asthma or asthma treatment, including pneumothorax, atelectasis, lobar collapse, poor cardiac output, dysrhythmias and others.
State the basic pharmacology, safety profile and potential adverse effects of commonly used medications.
Discuss the impact of risk factors (such as genetic predisposition and family history) associated chronic co‐morbidities (such as atopic dermatitis and allergic rhinitis) and exacerbating factors (such as gastroesophageal reflux and smoke exposure) on morbidity, treatment and prognosis.
Define asthma groups by symptom severity and frequency based on current classification guidelines.
Explain the significance of environmental controls and trigger avoidance in minimizing asthma exacerbations.
Describe the utility of using asthma action plans to both monitor and treat asthma via pulmonary function testing (spirometry and/or peak flow) and proper use of controller and reliever medications.
Discuss the goals of asthma management, including the maintenance of normal activity levels and pulmonary function, the prevention of chronic symptoms, recurrent exacerbations, and hospitalizations, and the provision of optimal pharmacotherapy while minimizing adverse events.
Give examples of specific indications for referral to an asthma subspecialist.
Illustrate why proper coding for asthma is critical to assure proper local resource use, accurate billing, and appropriate national comparisons of asthma data.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose and classify asthma by efficiently performing an accurate history and physical examination.
Recognize signs and symptoms of serious complications of asthma such as pneumothorax or impending respiratory failure.
Direct an evidence‐based treatment plan for status asthmaticus.
Order and interpret objective measures of pulmonary function, including peak flow monitoring and spirometry.
Order and interpret results of basic diagnostic tools such as chest radiograph and blood gas as indicated.
Order appropriate monitoring and correctly interpret monitor data.
Provide supplemental oxygen therapy and advanced airway management as necessary.
Recognize indications for hospital admission and discharge, and for transfer to a higher level of care or tertiary care facility.
Modify the medication regimen based upon accurate assessment of changes in disease severity.
Efficiently render care by creating a discharge plan which can be expediently activated when appropriate.
Consistently initiate patient and family/caregiver asthma education as soon after admission as possible, as appropriate for the clinical context.
Coordinate care with the primary care provider including discharge medications and instructions, and follow‐up plans.
Complete a written asthma action plan and use it to educate patients and the family/caregiver on trigger avoidance, medication adherence, and disease control.
Attitudes
Pediatric hospitalists should be able to:
Reinforce the role and responsibility of patients and the family/caregiver regarding self‐care, recognition of symptoms, and disease management.
Communicate effectively with patients, the family/caregiver and healthcare providers regarding care plans.
Engage in a multi‐disciplinary approach to the prevention, diagnosis, and treatment of asthma, involving when appropriate, social workers or case managers, respiratory therapists, and subspecialists.
Collaborate with primary care providers and subspecialists to ensure coordinated longitudinal care for children with asthma.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in local and national initiatives to further the development and implementation of evidence‐based clinical guidelines to promote effective resource utilization and improve quality of care for hospitalized children with asthma.
Work with hospital administrators to implement and utilize performance feedback and quality improvement measures to assess outcomes of instituted guidelines for the management of inpatient asthma.
Collaborate with primary care providers, subspecialists, social workers, and case managers to ensure a smooth transition to the outpatient setting, and to minimize the need for readmission.
Copyright © 2010 Society of Hospital Medicine
Cost‐effective care
Introduction
The delivery of cost‐effective care is an important responsibility and necessary skill for pediatric hospitalists. In the United States, hospital care for children, including neonatal conditions, pediatric illness and adolescent pregnancy entails 6.3 million hospital stays and $46 billion in charges per year. Pediatric inpatient care accounts for 18% of all hospital days and 9% of total U.S. hospital charges. Of these,, three respiratory conditions ‐ pneumonia, bronchitis and asthma ‐ are responsible for nearly $3 billion in charges or 7% of the total US health care bill for children and adolescents Although some categories of hospital expenses such as nurses or equipment may be outside the control of physicians, there are a number that are driven by physician practice patterns. Physician influence on hospital costs is exerted primarily through hospital length stay, medication prescribing patterns, and utilization of laboratory and diagnostic imaging services. Pediatric hospitalists can make a significant contribution to cost management efforts by increased awareness, standardization, evaluation and modification of practice and utilization patterns.
Knowledge
Pediatric hospitalists should be able to:
List the various methods of financing health care for children and state the implications of each on patient care.
Identify and discuss the importance of the metrics used to describe hospital costs such as charges, length of stay, cost per case, and hospital expense per adjusted day.
Demonstrate knowledge of common payment mechanisms for hospital care such as case rates, percent of charges, observation status, per diem rates, and capitation.
Describe mechanisms used by health plans and hospitals to limit hospital costs including pre‐authorization and utilization review.
Name hospital care costs that are controllable by physicians.
Identify examples of how standardization of clinical care processes improves cost and quality of care.
Discuss recent trends in health care delivery that affect pediatric practice such as coordinated management of complex chronic diseases and development of integrated delivery systems.
Describe the concept of system integration and define the roles of various components of the health care system such as community health centers, academic health centers, private practices, and home care agencies.
Define the role of major federal health programs such as Medicaid, Women Infants and Children (WIC) and Vaccines for Children (VFC) in funding healthcare to children from low‐income households.
Give an example of differences in costs of commonly prescribed medications. Illustrate the importance of various considerations when prescribing drugs such as total cost, compliance, availability of pediatric formulation, and insurance formulary lists.
Skills
Pediatric hospitalists should be able to:
Apply strategies to control costs in the daily care of patients in the hospital, such as use of generic drugs, case management, and avoidance of ordering unnecessary tests, as appropriate.
Participate in hospital committees where finance and clinical care are discussed such as pharmacy and therapeutics, quality improvement, ambulatory access, and others.
Incorporate cost considerations when writing orders, and use these opportunities to educate trainees on the importance of such considerations.
Obtain information about costs of care including drugs, medical imaging, and devices.
Work with consultants to determine cost effective approaches to testing and treatment plans.
Coordinate the care of patients to reduce redundant testing or procedures.
Work effectively with home care, discharge planning nurses, care coordinators, and case managers to ensure timely and safe hospital discharge.
Provide education for patients and the family/caregiver that promotes an awareness of costs in developing treatment and discharge plans.
Develop and utilize metrics and performance reporting (such as medication usage) to improve delivery of cost effective care.
Attitudes
Pediatric hospitalists should be able to:
Assume personal responsibility for providing cost effective care.
Serve as an advocate among professional colleagues and in the community for methods to reduce costs of care.
Work collaboratively with others to continuously evaluate and improve care while reducing costs.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Support efforts to gather and disseminate cost, quality and safety data for use in monitoring quality and business improvement efforts.
Promote standard methods of clinical care that improve cost, quality and patient safety.
Work to develop benchmarks for best practices in cost effective care.
Collaborate with hospital administrators to determine and direct policies that impact healthcare utilization.
Introduction
The delivery of cost‐effective care is an important responsibility and necessary skill for pediatric hospitalists. In the United States, hospital care for children, including neonatal conditions, pediatric illness and adolescent pregnancy entails 6.3 million hospital stays and $46 billion in charges per year. Pediatric inpatient care accounts for 18% of all hospital days and 9% of total U.S. hospital charges. Of these,, three respiratory conditions ‐ pneumonia, bronchitis and asthma ‐ are responsible for nearly $3 billion in charges or 7% of the total US health care bill for children and adolescents Although some categories of hospital expenses such as nurses or equipment may be outside the control of physicians, there are a number that are driven by physician practice patterns. Physician influence on hospital costs is exerted primarily through hospital length stay, medication prescribing patterns, and utilization of laboratory and diagnostic imaging services. Pediatric hospitalists can make a significant contribution to cost management efforts by increased awareness, standardization, evaluation and modification of practice and utilization patterns.
Knowledge
Pediatric hospitalists should be able to:
List the various methods of financing health care for children and state the implications of each on patient care.
Identify and discuss the importance of the metrics used to describe hospital costs such as charges, length of stay, cost per case, and hospital expense per adjusted day.
Demonstrate knowledge of common payment mechanisms for hospital care such as case rates, percent of charges, observation status, per diem rates, and capitation.
Describe mechanisms used by health plans and hospitals to limit hospital costs including pre‐authorization and utilization review.
Name hospital care costs that are controllable by physicians.
Identify examples of how standardization of clinical care processes improves cost and quality of care.
Discuss recent trends in health care delivery that affect pediatric practice such as coordinated management of complex chronic diseases and development of integrated delivery systems.
Describe the concept of system integration and define the roles of various components of the health care system such as community health centers, academic health centers, private practices, and home care agencies.
Define the role of major federal health programs such as Medicaid, Women Infants and Children (WIC) and Vaccines for Children (VFC) in funding healthcare to children from low‐income households.
Give an example of differences in costs of commonly prescribed medications. Illustrate the importance of various considerations when prescribing drugs such as total cost, compliance, availability of pediatric formulation, and insurance formulary lists.
Skills
Pediatric hospitalists should be able to:
Apply strategies to control costs in the daily care of patients in the hospital, such as use of generic drugs, case management, and avoidance of ordering unnecessary tests, as appropriate.
Participate in hospital committees where finance and clinical care are discussed such as pharmacy and therapeutics, quality improvement, ambulatory access, and others.
Incorporate cost considerations when writing orders, and use these opportunities to educate trainees on the importance of such considerations.
Obtain information about costs of care including drugs, medical imaging, and devices.
Work with consultants to determine cost effective approaches to testing and treatment plans.
Coordinate the care of patients to reduce redundant testing or procedures.
Work effectively with home care, discharge planning nurses, care coordinators, and case managers to ensure timely and safe hospital discharge.
Provide education for patients and the family/caregiver that promotes an awareness of costs in developing treatment and discharge plans.
Develop and utilize metrics and performance reporting (such as medication usage) to improve delivery of cost effective care.
Attitudes
Pediatric hospitalists should be able to:
Assume personal responsibility for providing cost effective care.
Serve as an advocate among professional colleagues and in the community for methods to reduce costs of care.
Work collaboratively with others to continuously evaluate and improve care while reducing costs.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Support efforts to gather and disseminate cost, quality and safety data for use in monitoring quality and business improvement efforts.
Promote standard methods of clinical care that improve cost, quality and patient safety.
Work to develop benchmarks for best practices in cost effective care.
Collaborate with hospital administrators to determine and direct policies that impact healthcare utilization.
Introduction
The delivery of cost‐effective care is an important responsibility and necessary skill for pediatric hospitalists. In the United States, hospital care for children, including neonatal conditions, pediatric illness and adolescent pregnancy entails 6.3 million hospital stays and $46 billion in charges per year. Pediatric inpatient care accounts for 18% of all hospital days and 9% of total U.S. hospital charges. Of these,, three respiratory conditions ‐ pneumonia, bronchitis and asthma ‐ are responsible for nearly $3 billion in charges or 7% of the total US health care bill for children and adolescents Although some categories of hospital expenses such as nurses or equipment may be outside the control of physicians, there are a number that are driven by physician practice patterns. Physician influence on hospital costs is exerted primarily through hospital length stay, medication prescribing patterns, and utilization of laboratory and diagnostic imaging services. Pediatric hospitalists can make a significant contribution to cost management efforts by increased awareness, standardization, evaluation and modification of practice and utilization patterns.
Knowledge
Pediatric hospitalists should be able to:
List the various methods of financing health care for children and state the implications of each on patient care.
Identify and discuss the importance of the metrics used to describe hospital costs such as charges, length of stay, cost per case, and hospital expense per adjusted day.
Demonstrate knowledge of common payment mechanisms for hospital care such as case rates, percent of charges, observation status, per diem rates, and capitation.
Describe mechanisms used by health plans and hospitals to limit hospital costs including pre‐authorization and utilization review.
Name hospital care costs that are controllable by physicians.
Identify examples of how standardization of clinical care processes improves cost and quality of care.
Discuss recent trends in health care delivery that affect pediatric practice such as coordinated management of complex chronic diseases and development of integrated delivery systems.
Describe the concept of system integration and define the roles of various components of the health care system such as community health centers, academic health centers, private practices, and home care agencies.
Define the role of major federal health programs such as Medicaid, Women Infants and Children (WIC) and Vaccines for Children (VFC) in funding healthcare to children from low‐income households.
Give an example of differences in costs of commonly prescribed medications. Illustrate the importance of various considerations when prescribing drugs such as total cost, compliance, availability of pediatric formulation, and insurance formulary lists.
Skills
Pediatric hospitalists should be able to:
Apply strategies to control costs in the daily care of patients in the hospital, such as use of generic drugs, case management, and avoidance of ordering unnecessary tests, as appropriate.
Participate in hospital committees where finance and clinical care are discussed such as pharmacy and therapeutics, quality improvement, ambulatory access, and others.
Incorporate cost considerations when writing orders, and use these opportunities to educate trainees on the importance of such considerations.
Obtain information about costs of care including drugs, medical imaging, and devices.
Work with consultants to determine cost effective approaches to testing and treatment plans.
Coordinate the care of patients to reduce redundant testing or procedures.
Work effectively with home care, discharge planning nurses, care coordinators, and case managers to ensure timely and safe hospital discharge.
Provide education for patients and the family/caregiver that promotes an awareness of costs in developing treatment and discharge plans.
Develop and utilize metrics and performance reporting (such as medication usage) to improve delivery of cost effective care.
Attitudes
Pediatric hospitalists should be able to:
Assume personal responsibility for providing cost effective care.
Serve as an advocate among professional colleagues and in the community for methods to reduce costs of care.
Work collaboratively with others to continuously evaluate and improve care while reducing costs.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Support efforts to gather and disseminate cost, quality and safety data for use in monitoring quality and business improvement efforts.
Promote standard methods of clinical care that improve cost, quality and patient safety.
Work to develop benchmarks for best practices in cost effective care.
Collaborate with hospital administrators to determine and direct policies that impact healthcare utilization.
Copyright © 2010 Society of Hospital Medicine
Bladder catheterization/suprapubic bladder tap
Introduction
Bladder catheterization is a common procedure, typically used to collect a sterile urine sample for analysis and culture when urinary tract infection is suspected. Bladder catheterization is also used to relieve urinary retention or obstruction, particularly in cases of anatomic abnormalities or neurogenic bladder, or to monitor urine output and fluid status. Pediatric hospitalists frequently encounter patients requiring bladder catheterization and should be adept at performing this procedure in infants, children, and adolescents.
Knowledge
Pediatric hospitalists should be able to:
List the indications and contraindications for bladder catheterization.
Describe how the method used to collect a urine specimen can affect interpretation of urine culture results, and explain why bladder catheterization or suprapubic tap are the preferred methods of collection in infants and children that cannot reliably produce a voided specimen.
Review the basic anatomy of the male and female genitourinary tract.
Review the steps in performing bladder catheterization for both male and female patients, attending to aspects such as patient identification, sterile technique, positioning, equipment needs, and specimen handling.
Discuss the indications for analgesia, sedation, or anxiolysis and describe the medications that may be used for each.
Describe the risks and complications associated with bladder catheterization, such as localized trauma, creation of a false passage, and potential stricture formation.
List the indications for consultation with a urologist with regard to bladder catheterization, including known genitourinary tract abnormality, recent genitourinary surgery, or urethral trauma
Compare and contrast the effects of using various methods to collect a urine specimen, including interpretation of the culture and urinalysis and patient risk,
Define a UTI as obtained by various methods such as catheterization, clean catch, clean bag, and suprapubic tap.
Discuss the importance of appropriate specimen handling and the effect on culture results.
Skills
Pediatric hospitalists should be able to:
Perform a pre‐procedural evaluation to determine risks and benefits of bladder catheterization.
Demonstrate proficiency in performance of bladder catheterization on infants, children, and adolescents.
Consider the level of pain and anxiety provoked by the procedure and provide appropriate pharmacologic or non‐pharmacologic interventions when indicated.
Correctly identify the need for and efficiently offer education to healthcare providers on proper techniques for holding and calming patients before, during, and after bladder catheterization.
Consistently adhere to infection control practices.
Identify complications and respond with appropriate actions.
Identify the need for and efficiently access appropriate consultants and support services for assistance with analgesia, sedation, anxiolysis, and performance of a bladder catheterization.
Attitudes
Hospital physicians should be able to:
Recognize the importance of obtaining a sterile urine specimen in order to correctly diagnose urinary tract infection.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of bladder catheterization.
Role model and advocate for strict adherence to infection control practices
Systems organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based procedures and policies for performance of bladder catheterization in children.
Lead, coordinate or participate in the development and implementation of educational initiatives designed to teach the proper technique for bladder catheterization to learners and other healthcare providers.
Introduction
Bladder catheterization is a common procedure, typically used to collect a sterile urine sample for analysis and culture when urinary tract infection is suspected. Bladder catheterization is also used to relieve urinary retention or obstruction, particularly in cases of anatomic abnormalities or neurogenic bladder, or to monitor urine output and fluid status. Pediatric hospitalists frequently encounter patients requiring bladder catheterization and should be adept at performing this procedure in infants, children, and adolescents.
Knowledge
Pediatric hospitalists should be able to:
List the indications and contraindications for bladder catheterization.
Describe how the method used to collect a urine specimen can affect interpretation of urine culture results, and explain why bladder catheterization or suprapubic tap are the preferred methods of collection in infants and children that cannot reliably produce a voided specimen.
Review the basic anatomy of the male and female genitourinary tract.
Review the steps in performing bladder catheterization for both male and female patients, attending to aspects such as patient identification, sterile technique, positioning, equipment needs, and specimen handling.
Discuss the indications for analgesia, sedation, or anxiolysis and describe the medications that may be used for each.
Describe the risks and complications associated with bladder catheterization, such as localized trauma, creation of a false passage, and potential stricture formation.
List the indications for consultation with a urologist with regard to bladder catheterization, including known genitourinary tract abnormality, recent genitourinary surgery, or urethral trauma
Compare and contrast the effects of using various methods to collect a urine specimen, including interpretation of the culture and urinalysis and patient risk,
Define a UTI as obtained by various methods such as catheterization, clean catch, clean bag, and suprapubic tap.
Discuss the importance of appropriate specimen handling and the effect on culture results.
Skills
Pediatric hospitalists should be able to:
Perform a pre‐procedural evaluation to determine risks and benefits of bladder catheterization.
Demonstrate proficiency in performance of bladder catheterization on infants, children, and adolescents.
Consider the level of pain and anxiety provoked by the procedure and provide appropriate pharmacologic or non‐pharmacologic interventions when indicated.
Correctly identify the need for and efficiently offer education to healthcare providers on proper techniques for holding and calming patients before, during, and after bladder catheterization.
Consistently adhere to infection control practices.
Identify complications and respond with appropriate actions.
Identify the need for and efficiently access appropriate consultants and support services for assistance with analgesia, sedation, anxiolysis, and performance of a bladder catheterization.
Attitudes
Hospital physicians should be able to:
Recognize the importance of obtaining a sterile urine specimen in order to correctly diagnose urinary tract infection.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of bladder catheterization.
Role model and advocate for strict adherence to infection control practices
Systems organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based procedures and policies for performance of bladder catheterization in children.
Lead, coordinate or participate in the development and implementation of educational initiatives designed to teach the proper technique for bladder catheterization to learners and other healthcare providers.
Introduction
Bladder catheterization is a common procedure, typically used to collect a sterile urine sample for analysis and culture when urinary tract infection is suspected. Bladder catheterization is also used to relieve urinary retention or obstruction, particularly in cases of anatomic abnormalities or neurogenic bladder, or to monitor urine output and fluid status. Pediatric hospitalists frequently encounter patients requiring bladder catheterization and should be adept at performing this procedure in infants, children, and adolescents.
Knowledge
Pediatric hospitalists should be able to:
List the indications and contraindications for bladder catheterization.
Describe how the method used to collect a urine specimen can affect interpretation of urine culture results, and explain why bladder catheterization or suprapubic tap are the preferred methods of collection in infants and children that cannot reliably produce a voided specimen.
Review the basic anatomy of the male and female genitourinary tract.
Review the steps in performing bladder catheterization for both male and female patients, attending to aspects such as patient identification, sterile technique, positioning, equipment needs, and specimen handling.
Discuss the indications for analgesia, sedation, or anxiolysis and describe the medications that may be used for each.
Describe the risks and complications associated with bladder catheterization, such as localized trauma, creation of a false passage, and potential stricture formation.
List the indications for consultation with a urologist with regard to bladder catheterization, including known genitourinary tract abnormality, recent genitourinary surgery, or urethral trauma
Compare and contrast the effects of using various methods to collect a urine specimen, including interpretation of the culture and urinalysis and patient risk,
Define a UTI as obtained by various methods such as catheterization, clean catch, clean bag, and suprapubic tap.
Discuss the importance of appropriate specimen handling and the effect on culture results.
Skills
Pediatric hospitalists should be able to:
Perform a pre‐procedural evaluation to determine risks and benefits of bladder catheterization.
Demonstrate proficiency in performance of bladder catheterization on infants, children, and adolescents.
Consider the level of pain and anxiety provoked by the procedure and provide appropriate pharmacologic or non‐pharmacologic interventions when indicated.
Correctly identify the need for and efficiently offer education to healthcare providers on proper techniques for holding and calming patients before, during, and after bladder catheterization.
Consistently adhere to infection control practices.
Identify complications and respond with appropriate actions.
Identify the need for and efficiently access appropriate consultants and support services for assistance with analgesia, sedation, anxiolysis, and performance of a bladder catheterization.
Attitudes
Hospital physicians should be able to:
Recognize the importance of obtaining a sterile urine specimen in order to correctly diagnose urinary tract infection.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of bladder catheterization.
Role model and advocate for strict adherence to infection control practices
Systems organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based procedures and policies for performance of bladder catheterization in children.
Lead, coordinate or participate in the development and implementation of educational initiatives designed to teach the proper technique for bladder catheterization to learners and other healthcare providers.
Copyright © 2010 Society of Hospital Medicine
Research
Introduction
Research is a rapidly growing aspect of inpatient medicine. The practice of evidence‐based medicine and the acute need for more evidence on inpatient conditions require that pediatric hospitalists understand and participate in research related activities. Pediatric hospitalists' role in research will vary depending on their setting and job description. This role may include many facets, from reviewing relevant patient‐based articles, to participating in multi‐institutional studies requiring enrollment of patients, to leading local or national studies. Pediatric hospitalists need to have a basic understanding of research methods and process in order to participate in and benefit from research. This understanding contributes to the effective care of hospitalized patients.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast different types of study design such as case‐control, cohort, observational, and randomized control trials. Understand the advantages and disadvantages of each study design.
Name resources available to access current or proposed studies and funding sources such as the Agency for Healthcare Research and Quality (AHRQ), the National Institutes of Health (NIH), Robert Wood Johnson Foundation, clinicaltrials.gov, and others.
Discuss what resources are required to support research components of data collection, data analysis, abstract and manuscript preparation, grant funding and others.
Explain how results from articles published in the following formats apply to clinical practice:
Case reports and case series
Retrospective chart reviews
Secondary data analyses of large data sets
Randomized controlled trials
Meta analyses and systematic reviews
Practice Guidelines
Identify and efficiently locate the best available information resources to address questions in clinical practice, and conduct computerized scientific literature searches in a planned and systematic fashion.
Define basic statistical terms such as sample, discrete and continuous data variables, measures of central tendency (mean, median, and mode) and variability (variance, standard deviation, range).
Cite the various aspects of the research process including informed consent or assent, the role of institutional review boards (IRB), and HIPAA (Health Insurance Portability and Accountability Act).
Discuss special protections needed when conducting research with vulnerable populations. Define minimal risk for a healthy child and for a child with an illness.
List common barriers to implementation of clinical studies and describe pediatric hospitalists' role in overcoming these barriers.
Skills
Pediatric hospitalists should be able to:
Demonstrate proficiency in searching the medical literature for existing relevant clinical research for their inpatients.
Generate an answerable patient‐centered clinical question that is relevant to improving patient care.
Apply the results of studies to clinical practice by determining whether the study subjects were similar to patients being treated, whether all clinically important outcomes were considered, identify threats to validity, and
For treatment studies, describe whether the likely benefits are worth the potential harm and cost.
For studies of diagnostic tests, describe whether the test is available, affordable, accurate and precise in the present clinical setting, and whether the results of the test will change the management of patients being treated.
For studies of harm, describe whether the magnitude of risk warrants an attempt to stop the exposure.
For studies of prognosis, describe whether the results of the study will lead directly to selecting therapy and/or are useful for counseling patients.
Provide effective informed consent or assent for patients participating in research studies as appropriate.
Attitudes
Pediatric hospitalists should be able to:
Appreciate the importance of full informed consent for purposes of patient participation in clinical research.
Appreciate the importance of patient assent, even in the presence of legal guardian informed consent, when involving children in clinical research.
Demonstrate highly ethical principles in participating in research studies.
Avoid conflict of interest or potential conflict of interest in participation in research studies.
Acquire, manage, and share data collected for research purposes in a responsible and professional manner, maintaining high standards for protecting confidentiality, avoiding unjustified exclusions, sharing data, and adhering to copyright law.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Encourage participation of interdisciplinary teams including nursing, social work, nutrition, pharmacy, and others in performance of research.
Advocate for thoughtful application of research findings to improve systems of healthcare delivery.
Support national multi‐center research efforts that improve the evidence base in inpatient pediatrics. Where appropriate, encourage participation local hospital involvement in these efforts.
Recognize, support and promote efforts of research team members (analyst, data collector, statistician, nursing, and others).
Introduction
Research is a rapidly growing aspect of inpatient medicine. The practice of evidence‐based medicine and the acute need for more evidence on inpatient conditions require that pediatric hospitalists understand and participate in research related activities. Pediatric hospitalists' role in research will vary depending on their setting and job description. This role may include many facets, from reviewing relevant patient‐based articles, to participating in multi‐institutional studies requiring enrollment of patients, to leading local or national studies. Pediatric hospitalists need to have a basic understanding of research methods and process in order to participate in and benefit from research. This understanding contributes to the effective care of hospitalized patients.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast different types of study design such as case‐control, cohort, observational, and randomized control trials. Understand the advantages and disadvantages of each study design.
Name resources available to access current or proposed studies and funding sources such as the Agency for Healthcare Research and Quality (AHRQ), the National Institutes of Health (NIH), Robert Wood Johnson Foundation, clinicaltrials.gov, and others.
Discuss what resources are required to support research components of data collection, data analysis, abstract and manuscript preparation, grant funding and others.
Explain how results from articles published in the following formats apply to clinical practice:
Case reports and case series
Retrospective chart reviews
Secondary data analyses of large data sets
Randomized controlled trials
Meta analyses and systematic reviews
Practice Guidelines
Identify and efficiently locate the best available information resources to address questions in clinical practice, and conduct computerized scientific literature searches in a planned and systematic fashion.
Define basic statistical terms such as sample, discrete and continuous data variables, measures of central tendency (mean, median, and mode) and variability (variance, standard deviation, range).
Cite the various aspects of the research process including informed consent or assent, the role of institutional review boards (IRB), and HIPAA (Health Insurance Portability and Accountability Act).
Discuss special protections needed when conducting research with vulnerable populations. Define minimal risk for a healthy child and for a child with an illness.
List common barriers to implementation of clinical studies and describe pediatric hospitalists' role in overcoming these barriers.
Skills
Pediatric hospitalists should be able to:
Demonstrate proficiency in searching the medical literature for existing relevant clinical research for their inpatients.
Generate an answerable patient‐centered clinical question that is relevant to improving patient care.
Apply the results of studies to clinical practice by determining whether the study subjects were similar to patients being treated, whether all clinically important outcomes were considered, identify threats to validity, and
For treatment studies, describe whether the likely benefits are worth the potential harm and cost.
For studies of diagnostic tests, describe whether the test is available, affordable, accurate and precise in the present clinical setting, and whether the results of the test will change the management of patients being treated.
For studies of harm, describe whether the magnitude of risk warrants an attempt to stop the exposure.
For studies of prognosis, describe whether the results of the study will lead directly to selecting therapy and/or are useful for counseling patients.
Provide effective informed consent or assent for patients participating in research studies as appropriate.
Attitudes
Pediatric hospitalists should be able to:
Appreciate the importance of full informed consent for purposes of patient participation in clinical research.
Appreciate the importance of patient assent, even in the presence of legal guardian informed consent, when involving children in clinical research.
Demonstrate highly ethical principles in participating in research studies.
Avoid conflict of interest or potential conflict of interest in participation in research studies.
Acquire, manage, and share data collected for research purposes in a responsible and professional manner, maintaining high standards for protecting confidentiality, avoiding unjustified exclusions, sharing data, and adhering to copyright law.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Encourage participation of interdisciplinary teams including nursing, social work, nutrition, pharmacy, and others in performance of research.
Advocate for thoughtful application of research findings to improve systems of healthcare delivery.
Support national multi‐center research efforts that improve the evidence base in inpatient pediatrics. Where appropriate, encourage participation local hospital involvement in these efforts.
Recognize, support and promote efforts of research team members (analyst, data collector, statistician, nursing, and others).
Introduction
Research is a rapidly growing aspect of inpatient medicine. The practice of evidence‐based medicine and the acute need for more evidence on inpatient conditions require that pediatric hospitalists understand and participate in research related activities. Pediatric hospitalists' role in research will vary depending on their setting and job description. This role may include many facets, from reviewing relevant patient‐based articles, to participating in multi‐institutional studies requiring enrollment of patients, to leading local or national studies. Pediatric hospitalists need to have a basic understanding of research methods and process in order to participate in and benefit from research. This understanding contributes to the effective care of hospitalized patients.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast different types of study design such as case‐control, cohort, observational, and randomized control trials. Understand the advantages and disadvantages of each study design.
Name resources available to access current or proposed studies and funding sources such as the Agency for Healthcare Research and Quality (AHRQ), the National Institutes of Health (NIH), Robert Wood Johnson Foundation, clinicaltrials.gov, and others.
Discuss what resources are required to support research components of data collection, data analysis, abstract and manuscript preparation, grant funding and others.
Explain how results from articles published in the following formats apply to clinical practice:
Case reports and case series
Retrospective chart reviews
Secondary data analyses of large data sets
Randomized controlled trials
Meta analyses and systematic reviews
Practice Guidelines
Identify and efficiently locate the best available information resources to address questions in clinical practice, and conduct computerized scientific literature searches in a planned and systematic fashion.
Define basic statistical terms such as sample, discrete and continuous data variables, measures of central tendency (mean, median, and mode) and variability (variance, standard deviation, range).
Cite the various aspects of the research process including informed consent or assent, the role of institutional review boards (IRB), and HIPAA (Health Insurance Portability and Accountability Act).
Discuss special protections needed when conducting research with vulnerable populations. Define minimal risk for a healthy child and for a child with an illness.
List common barriers to implementation of clinical studies and describe pediatric hospitalists' role in overcoming these barriers.
Skills
Pediatric hospitalists should be able to:
Demonstrate proficiency in searching the medical literature for existing relevant clinical research for their inpatients.
Generate an answerable patient‐centered clinical question that is relevant to improving patient care.
Apply the results of studies to clinical practice by determining whether the study subjects were similar to patients being treated, whether all clinically important outcomes were considered, identify threats to validity, and
For treatment studies, describe whether the likely benefits are worth the potential harm and cost.
For studies of diagnostic tests, describe whether the test is available, affordable, accurate and precise in the present clinical setting, and whether the results of the test will change the management of patients being treated.
For studies of harm, describe whether the magnitude of risk warrants an attempt to stop the exposure.
For studies of prognosis, describe whether the results of the study will lead directly to selecting therapy and/or are useful for counseling patients.
Provide effective informed consent or assent for patients participating in research studies as appropriate.
Attitudes
Pediatric hospitalists should be able to:
Appreciate the importance of full informed consent for purposes of patient participation in clinical research.
Appreciate the importance of patient assent, even in the presence of legal guardian informed consent, when involving children in clinical research.
Demonstrate highly ethical principles in participating in research studies.
Avoid conflict of interest or potential conflict of interest in participation in research studies.
Acquire, manage, and share data collected for research purposes in a responsible and professional manner, maintaining high standards for protecting confidentiality, avoiding unjustified exclusions, sharing data, and adhering to copyright law.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Encourage participation of interdisciplinary teams including nursing, social work, nutrition, pharmacy, and others in performance of research.
Advocate for thoughtful application of research findings to improve systems of healthcare delivery.
Support national multi‐center research efforts that improve the evidence base in inpatient pediatrics. Where appropriate, encourage participation local hospital involvement in these efforts.
Recognize, support and promote efforts of research team members (analyst, data collector, statistician, nursing, and others).
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