User login
Toxic ingestion
Introduction
In 2006, the National Data Poison System captured more than 4 million calls to poison control centers in the United States, 2.4 million of which were calls regarding human exposures. More than 50% of reported toxin exposures occur in children under age 6 years. Furthermore, ingestion accounts for 75% of all toxin exposures in younger children. In this age group, toxin ingestion is frequently unintentional and involves non‐pharmacologic agents, but therapeutic errors in the administration of pharmacologic agents do occur. In adolescents, toxin ingestion is more often intentional or associated with substance abuse, and carries with it greater morbidity and mortality, particularly when pharmacological agents are involved. Pediatric hospitalists often provide immediate care, coordinate care with subspecialists, or arrange for transfer to another facility when appropriate.
Knowledge
Pediatric hospitalists should be able to:
List the pharmacologic and non‐pharmacologic agents commonly ingested by pediatric patients and describe how the frequency of each category changes with age.
Compare and contrast the risk factors and co‐morbidities associated with unintentional versus intentional ingestion.
Describe the signs and symptoms of acute ingestion, including known toxidromes for commonly ingested agents such as salicylates, acetaminophen, narcotics, hallucinogens, stimulants, and others.
Discuss the risk factors for and presentation of acute and chronic lead poisoning.
List the laboratory tests that support or refute the diagnosis or assist with the management of common ingestions.
List the agents detected in locally available blood and urine toxicology screens and describe the benefits and limitations of this testing.
Explain the indications for and limitations of decontamination therapy, including dermal, ocular, and gastric decontamination methods.
Identify toxins that have a specific antidote available and explain the indications and limitations of each.
List local resources that provide information and advice regarding pediatric toxin ingestion management, and recognize there is a single phone number that may be used in the United States to access all regional poison center resources.
Summarize the indications and goals of hospitalization, attending to acute and chronic medical needs and psychosocial intervention.
Review the criteria for and process of discharge including psychiatric evaluation, inpatient psychiatric facility transfer, foster care and other elements important for safe discharge.
Skills
Pediatric hospitalists should be able to:
Obtain a focused history, including detailed information about potential exposures, such as the type, amount, and timing of the ingestion.
Perform a focused physical examination, with attention paid to signs and symptoms that may indicate the ingestion of a particular toxin.
Efficiently access institutional and local resources to obtain information and advice regarding the diagnosis and management of acute ingestion.
Identify patients presenting with common toxidromes and efficiently institute appropriate therapy.
Recognize life‐threatening complications such as cardiac dysrhythmias, respiratory depression, or mental status change and institute appropriate therapy in a timely fashion.
Recognize potential co‐morbidities associated with intentional ingestion, such as depression, abuse, or other mental illness.
Correctly order and interpret basic tests, such as serum chemistries, blood gases, and electrocardiograms, and identify abnormal findings that require additional testing or consultation.
Develop an appropriate treatment plan based on the presumptive or confirmed agent and provide decontamination or antidote therapy when appropriate.
Determine the appropriate level of care and duration of observation for a given toxin, recognizing that some agents may have delayed toxic effects.
Involve subspecialists when appropriate, including social work and/or psychiatric consultation for cases of non‐accidental ingestion as appropriate.
Correctly identify patients who require legal (protective or other) involvement and efficiently access appropriate agencies.
Attitudes
Pediatric hospitalists should be able to:
Counsel the family/caregiver and other professional staff on the possible etiology and outcomes of the ingestion episode.
Assess the social environment to determine the risk of future exposure and the need for mitigation of risk factors prior to discharge.
Educate caregivers regarding proactive risk reduction measures, such as the safe and effective storage, use and administration of medications.
Realize the importance of remaining vigilant regarding changes in recreational drug availability and use as well as safety profile updates on pharmacologic and non‐pharmacologic agents.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development of systems that integrate hospital, community, and national resources to provide up‐to‐date and evidence‐based information about toxin ingestions and promote timely recognition and treatment of both intentional and unintentional ingestions.
Lead, coordinate or participate in efforts to educate healthcare providers about the most common ingestions in the pediatric population.
Lead, coordinate or participate in efforts to educate healthcare providers and the community, regarding ways to mitigate medication errors.
Introduction
In 2006, the National Data Poison System captured more than 4 million calls to poison control centers in the United States, 2.4 million of which were calls regarding human exposures. More than 50% of reported toxin exposures occur in children under age 6 years. Furthermore, ingestion accounts for 75% of all toxin exposures in younger children. In this age group, toxin ingestion is frequently unintentional and involves non‐pharmacologic agents, but therapeutic errors in the administration of pharmacologic agents do occur. In adolescents, toxin ingestion is more often intentional or associated with substance abuse, and carries with it greater morbidity and mortality, particularly when pharmacological agents are involved. Pediatric hospitalists often provide immediate care, coordinate care with subspecialists, or arrange for transfer to another facility when appropriate.
Knowledge
Pediatric hospitalists should be able to:
List the pharmacologic and non‐pharmacologic agents commonly ingested by pediatric patients and describe how the frequency of each category changes with age.
Compare and contrast the risk factors and co‐morbidities associated with unintentional versus intentional ingestion.
Describe the signs and symptoms of acute ingestion, including known toxidromes for commonly ingested agents such as salicylates, acetaminophen, narcotics, hallucinogens, stimulants, and others.
Discuss the risk factors for and presentation of acute and chronic lead poisoning.
List the laboratory tests that support or refute the diagnosis or assist with the management of common ingestions.
List the agents detected in locally available blood and urine toxicology screens and describe the benefits and limitations of this testing.
Explain the indications for and limitations of decontamination therapy, including dermal, ocular, and gastric decontamination methods.
Identify toxins that have a specific antidote available and explain the indications and limitations of each.
List local resources that provide information and advice regarding pediatric toxin ingestion management, and recognize there is a single phone number that may be used in the United States to access all regional poison center resources.
Summarize the indications and goals of hospitalization, attending to acute and chronic medical needs and psychosocial intervention.
Review the criteria for and process of discharge including psychiatric evaluation, inpatient psychiatric facility transfer, foster care and other elements important for safe discharge.
Skills
Pediatric hospitalists should be able to:
Obtain a focused history, including detailed information about potential exposures, such as the type, amount, and timing of the ingestion.
Perform a focused physical examination, with attention paid to signs and symptoms that may indicate the ingestion of a particular toxin.
Efficiently access institutional and local resources to obtain information and advice regarding the diagnosis and management of acute ingestion.
Identify patients presenting with common toxidromes and efficiently institute appropriate therapy.
Recognize life‐threatening complications such as cardiac dysrhythmias, respiratory depression, or mental status change and institute appropriate therapy in a timely fashion.
Recognize potential co‐morbidities associated with intentional ingestion, such as depression, abuse, or other mental illness.
Correctly order and interpret basic tests, such as serum chemistries, blood gases, and electrocardiograms, and identify abnormal findings that require additional testing or consultation.
Develop an appropriate treatment plan based on the presumptive or confirmed agent and provide decontamination or antidote therapy when appropriate.
Determine the appropriate level of care and duration of observation for a given toxin, recognizing that some agents may have delayed toxic effects.
Involve subspecialists when appropriate, including social work and/or psychiatric consultation for cases of non‐accidental ingestion as appropriate.
Correctly identify patients who require legal (protective or other) involvement and efficiently access appropriate agencies.
Attitudes
Pediatric hospitalists should be able to:
Counsel the family/caregiver and other professional staff on the possible etiology and outcomes of the ingestion episode.
Assess the social environment to determine the risk of future exposure and the need for mitigation of risk factors prior to discharge.
Educate caregivers regarding proactive risk reduction measures, such as the safe and effective storage, use and administration of medications.
Realize the importance of remaining vigilant regarding changes in recreational drug availability and use as well as safety profile updates on pharmacologic and non‐pharmacologic agents.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development of systems that integrate hospital, community, and national resources to provide up‐to‐date and evidence‐based information about toxin ingestions and promote timely recognition and treatment of both intentional and unintentional ingestions.
Lead, coordinate or participate in efforts to educate healthcare providers about the most common ingestions in the pediatric population.
Lead, coordinate or participate in efforts to educate healthcare providers and the community, regarding ways to mitigate medication errors.
Introduction
In 2006, the National Data Poison System captured more than 4 million calls to poison control centers in the United States, 2.4 million of which were calls regarding human exposures. More than 50% of reported toxin exposures occur in children under age 6 years. Furthermore, ingestion accounts for 75% of all toxin exposures in younger children. In this age group, toxin ingestion is frequently unintentional and involves non‐pharmacologic agents, but therapeutic errors in the administration of pharmacologic agents do occur. In adolescents, toxin ingestion is more often intentional or associated with substance abuse, and carries with it greater morbidity and mortality, particularly when pharmacological agents are involved. Pediatric hospitalists often provide immediate care, coordinate care with subspecialists, or arrange for transfer to another facility when appropriate.
Knowledge
Pediatric hospitalists should be able to:
List the pharmacologic and non‐pharmacologic agents commonly ingested by pediatric patients and describe how the frequency of each category changes with age.
Compare and contrast the risk factors and co‐morbidities associated with unintentional versus intentional ingestion.
Describe the signs and symptoms of acute ingestion, including known toxidromes for commonly ingested agents such as salicylates, acetaminophen, narcotics, hallucinogens, stimulants, and others.
Discuss the risk factors for and presentation of acute and chronic lead poisoning.
List the laboratory tests that support or refute the diagnosis or assist with the management of common ingestions.
List the agents detected in locally available blood and urine toxicology screens and describe the benefits and limitations of this testing.
Explain the indications for and limitations of decontamination therapy, including dermal, ocular, and gastric decontamination methods.
Identify toxins that have a specific antidote available and explain the indications and limitations of each.
List local resources that provide information and advice regarding pediatric toxin ingestion management, and recognize there is a single phone number that may be used in the United States to access all regional poison center resources.
Summarize the indications and goals of hospitalization, attending to acute and chronic medical needs and psychosocial intervention.
Review the criteria for and process of discharge including psychiatric evaluation, inpatient psychiatric facility transfer, foster care and other elements important for safe discharge.
Skills
Pediatric hospitalists should be able to:
Obtain a focused history, including detailed information about potential exposures, such as the type, amount, and timing of the ingestion.
Perform a focused physical examination, with attention paid to signs and symptoms that may indicate the ingestion of a particular toxin.
Efficiently access institutional and local resources to obtain information and advice regarding the diagnosis and management of acute ingestion.
Identify patients presenting with common toxidromes and efficiently institute appropriate therapy.
Recognize life‐threatening complications such as cardiac dysrhythmias, respiratory depression, or mental status change and institute appropriate therapy in a timely fashion.
Recognize potential co‐morbidities associated with intentional ingestion, such as depression, abuse, or other mental illness.
Correctly order and interpret basic tests, such as serum chemistries, blood gases, and electrocardiograms, and identify abnormal findings that require additional testing or consultation.
Develop an appropriate treatment plan based on the presumptive or confirmed agent and provide decontamination or antidote therapy when appropriate.
Determine the appropriate level of care and duration of observation for a given toxin, recognizing that some agents may have delayed toxic effects.
Involve subspecialists when appropriate, including social work and/or psychiatric consultation for cases of non‐accidental ingestion as appropriate.
Correctly identify patients who require legal (protective or other) involvement and efficiently access appropriate agencies.
Attitudes
Pediatric hospitalists should be able to:
Counsel the family/caregiver and other professional staff on the possible etiology and outcomes of the ingestion episode.
Assess the social environment to determine the risk of future exposure and the need for mitigation of risk factors prior to discharge.
Educate caregivers regarding proactive risk reduction measures, such as the safe and effective storage, use and administration of medications.
Realize the importance of remaining vigilant regarding changes in recreational drug availability and use as well as safety profile updates on pharmacologic and non‐pharmacologic agents.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development of systems that integrate hospital, community, and national resources to provide up‐to‐date and evidence‐based information about toxin ingestions and promote timely recognition and treatment of both intentional and unintentional ingestions.
Lead, coordinate or participate in efforts to educate healthcare providers about the most common ingestions in the pediatric population.
Lead, coordinate or participate in efforts to educate healthcare providers and the community, regarding ways to mitigate medication errors.
Copyright © 2010 Society of Hospital Medicine
Advocacy
Introduction
Advocacy is defined as the process of speaking out in support of a specific individual, cause or program as distinct from the direct provision of material support to the individual, cause or program. In pediatric hospital medicine, advocacy can occur as an isolated event for a single patient, but is most effective when it leads to a change in an approach to a problem that supports multiple individuals in similar circumstances. Advocacy skills are part of the toolkit of both physicians and leaders. In conjunction with other healthcare professionals and organizations, pediatric hospitalists have an important role to play in advocating for both the children and the evolving field of hospital medicine. Pediatric hospitalists may also be called upon to advocate for the pediatric services or department within the hospital, as well as for children in the community.
Knowledge
Pediatric hospitalists should be able to:
Define advocacy and health policy.
Describe how advocacy impacts the care of children both in the hospital and the community.
Discuss the multiple levels of advocacy, including individual, group, institutional, community, and legislative advocacy.
Illustrate how financing of child health relates to advocacy.
Describe the relationship between pediatric quality and advocacy.
Discuss the various areas of focus for advocacy efforts, including disease process/diagnosis, age group, socio‐economic, cultural or demographic group, health systems, payment systems, and government or community agencies.
Describe the legislative process and identify specific ways in which physicians can participate in this process to improve the health of children, especially those requiring hospitalization.
List the key national organizations (such as the American Academy of Pediatrics, the Society of Hospital Medicine and National Association of Children's Hospitals and Related Institutions and others) with which pediatric hospitalists work to advocate for hospitalized pediatric patients
Explain how private and governmental funding and oversight organizations (such as Leapfrog, Medicaid, The Joint Commission and many others) influence advocacy efforts for children's healthcare.
Identify community characteristics, demographics, needs, and assets that impact children's healthcare, including the availability of social, educational, and medical services for children and the family/caregiver.
State common barriers, especially those unique to the pediatric population, that impact hospital care for children.
Cite advocacy efforts that are unique to community hospitals such as obtaining pediatric representation on key committees, establishing a relationship with a pediatric referral center, and developing relationships with adult subspecialists.
Cite unique opportunities for advocacy in children's hospitals.
Define the medical home and understand the role of pediatric hospitalists in delivering care within a medical home.
Skills
Pediatric hospitalists should be able to:
Conduct effective family centered, interdisciplinary rounds.
Consistently engage patients and the family/caregiver in medical‐decision making.
Deliver family‐centered, comprehensive, coordinated care for medically complex children and other special populations.
Develop collaborative relationships with other pediatric healthcare providers to advocate for children within the medical home model.
Provide effective media interviews on relevant topics in various formats (such as print, radio, television, and other).
Define, articulate, and gain support for the unique health care needs of children in the hospital setting as well as the community.
Identify hospital environments or processes that lack a focus on children and take appropriate steps to advocate for pediatric‐specific needs.
Participate in the advocacy and health policy activities sponsored by local, community, and national organizations.
Attitudes
Pediatric hospitalists should be able to:
Accept responsibility for child health advocacy.
Recognize the cultural beliefs and biases of patients, family/caregiver, and healthcare providers and adapt to advocate for patients' needs.
Realize that the most effective advocacy involves creation of coalitions and teams.
Maintain awareness of political, cultural, and socio‐economic factors affecting children's healthcare and the practice of pediatric hospital medicine.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations and their communities, pediatric hospitalists should:
Incorporate the institution's mission and vision statements into daily work.
Work with key hospital leaders to assure child advocacy is fully integrated into the delivery of care on a daily basis.
Establish effective relationships with hospital leaders, community leaders and local politicians to target a specific issue and/or serve as an expert pediatric consultant.
Participate in the development of systems of care in your institution and beyond that promote effective care for hospitalized children.
Introduction
Advocacy is defined as the process of speaking out in support of a specific individual, cause or program as distinct from the direct provision of material support to the individual, cause or program. In pediatric hospital medicine, advocacy can occur as an isolated event for a single patient, but is most effective when it leads to a change in an approach to a problem that supports multiple individuals in similar circumstances. Advocacy skills are part of the toolkit of both physicians and leaders. In conjunction with other healthcare professionals and organizations, pediatric hospitalists have an important role to play in advocating for both the children and the evolving field of hospital medicine. Pediatric hospitalists may also be called upon to advocate for the pediatric services or department within the hospital, as well as for children in the community.
Knowledge
Pediatric hospitalists should be able to:
Define advocacy and health policy.
Describe how advocacy impacts the care of children both in the hospital and the community.
Discuss the multiple levels of advocacy, including individual, group, institutional, community, and legislative advocacy.
Illustrate how financing of child health relates to advocacy.
Describe the relationship between pediatric quality and advocacy.
Discuss the various areas of focus for advocacy efforts, including disease process/diagnosis, age group, socio‐economic, cultural or demographic group, health systems, payment systems, and government or community agencies.
Describe the legislative process and identify specific ways in which physicians can participate in this process to improve the health of children, especially those requiring hospitalization.
List the key national organizations (such as the American Academy of Pediatrics, the Society of Hospital Medicine and National Association of Children's Hospitals and Related Institutions and others) with which pediatric hospitalists work to advocate for hospitalized pediatric patients
Explain how private and governmental funding and oversight organizations (such as Leapfrog, Medicaid, The Joint Commission and many others) influence advocacy efforts for children's healthcare.
Identify community characteristics, demographics, needs, and assets that impact children's healthcare, including the availability of social, educational, and medical services for children and the family/caregiver.
State common barriers, especially those unique to the pediatric population, that impact hospital care for children.
Cite advocacy efforts that are unique to community hospitals such as obtaining pediatric representation on key committees, establishing a relationship with a pediatric referral center, and developing relationships with adult subspecialists.
Cite unique opportunities for advocacy in children's hospitals.
Define the medical home and understand the role of pediatric hospitalists in delivering care within a medical home.
Skills
Pediatric hospitalists should be able to:
Conduct effective family centered, interdisciplinary rounds.
Consistently engage patients and the family/caregiver in medical‐decision making.
Deliver family‐centered, comprehensive, coordinated care for medically complex children and other special populations.
Develop collaborative relationships with other pediatric healthcare providers to advocate for children within the medical home model.
Provide effective media interviews on relevant topics in various formats (such as print, radio, television, and other).
Define, articulate, and gain support for the unique health care needs of children in the hospital setting as well as the community.
Identify hospital environments or processes that lack a focus on children and take appropriate steps to advocate for pediatric‐specific needs.
Participate in the advocacy and health policy activities sponsored by local, community, and national organizations.
Attitudes
Pediatric hospitalists should be able to:
Accept responsibility for child health advocacy.
Recognize the cultural beliefs and biases of patients, family/caregiver, and healthcare providers and adapt to advocate for patients' needs.
Realize that the most effective advocacy involves creation of coalitions and teams.
Maintain awareness of political, cultural, and socio‐economic factors affecting children's healthcare and the practice of pediatric hospital medicine.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations and their communities, pediatric hospitalists should:
Incorporate the institution's mission and vision statements into daily work.
Work with key hospital leaders to assure child advocacy is fully integrated into the delivery of care on a daily basis.
Establish effective relationships with hospital leaders, community leaders and local politicians to target a specific issue and/or serve as an expert pediatric consultant.
Participate in the development of systems of care in your institution and beyond that promote effective care for hospitalized children.
Introduction
Advocacy is defined as the process of speaking out in support of a specific individual, cause or program as distinct from the direct provision of material support to the individual, cause or program. In pediatric hospital medicine, advocacy can occur as an isolated event for a single patient, but is most effective when it leads to a change in an approach to a problem that supports multiple individuals in similar circumstances. Advocacy skills are part of the toolkit of both physicians and leaders. In conjunction with other healthcare professionals and organizations, pediatric hospitalists have an important role to play in advocating for both the children and the evolving field of hospital medicine. Pediatric hospitalists may also be called upon to advocate for the pediatric services or department within the hospital, as well as for children in the community.
Knowledge
Pediatric hospitalists should be able to:
Define advocacy and health policy.
Describe how advocacy impacts the care of children both in the hospital and the community.
Discuss the multiple levels of advocacy, including individual, group, institutional, community, and legislative advocacy.
Illustrate how financing of child health relates to advocacy.
Describe the relationship between pediatric quality and advocacy.
Discuss the various areas of focus for advocacy efforts, including disease process/diagnosis, age group, socio‐economic, cultural or demographic group, health systems, payment systems, and government or community agencies.
Describe the legislative process and identify specific ways in which physicians can participate in this process to improve the health of children, especially those requiring hospitalization.
List the key national organizations (such as the American Academy of Pediatrics, the Society of Hospital Medicine and National Association of Children's Hospitals and Related Institutions and others) with which pediatric hospitalists work to advocate for hospitalized pediatric patients
Explain how private and governmental funding and oversight organizations (such as Leapfrog, Medicaid, The Joint Commission and many others) influence advocacy efforts for children's healthcare.
Identify community characteristics, demographics, needs, and assets that impact children's healthcare, including the availability of social, educational, and medical services for children and the family/caregiver.
State common barriers, especially those unique to the pediatric population, that impact hospital care for children.
Cite advocacy efforts that are unique to community hospitals such as obtaining pediatric representation on key committees, establishing a relationship with a pediatric referral center, and developing relationships with adult subspecialists.
Cite unique opportunities for advocacy in children's hospitals.
Define the medical home and understand the role of pediatric hospitalists in delivering care within a medical home.
Skills
Pediatric hospitalists should be able to:
Conduct effective family centered, interdisciplinary rounds.
Consistently engage patients and the family/caregiver in medical‐decision making.
Deliver family‐centered, comprehensive, coordinated care for medically complex children and other special populations.
Develop collaborative relationships with other pediatric healthcare providers to advocate for children within the medical home model.
Provide effective media interviews on relevant topics in various formats (such as print, radio, television, and other).
Define, articulate, and gain support for the unique health care needs of children in the hospital setting as well as the community.
Identify hospital environments or processes that lack a focus on children and take appropriate steps to advocate for pediatric‐specific needs.
Participate in the advocacy and health policy activities sponsored by local, community, and national organizations.
Attitudes
Pediatric hospitalists should be able to:
Accept responsibility for child health advocacy.
Recognize the cultural beliefs and biases of patients, family/caregiver, and healthcare providers and adapt to advocate for patients' needs.
Realize that the most effective advocacy involves creation of coalitions and teams.
Maintain awareness of political, cultural, and socio‐economic factors affecting children's healthcare and the practice of pediatric hospital medicine.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations and their communities, pediatric hospitalists should:
Incorporate the institution's mission and vision statements into daily work.
Work with key hospital leaders to assure child advocacy is fully integrated into the delivery of care on a daily basis.
Establish effective relationships with hospital leaders, community leaders and local politicians to target a specific issue and/or serve as an expert pediatric consultant.
Participate in the development of systems of care in your institution and beyond that promote effective care for hospitalized children.
Copyright © 2010 Society of Hospital Medicine
Seizures
Introduction
Seizures are the most common neurologic disorder of childhood. It is estimated that approximately 5% of all children will have at least one seizure before the age of 20. The prevalence of epilepsy, or recurrent unprovoked seizures, is about 0.5% in children. Seizures may range from self‐limited to life‐threatening events. Status epilepticus is the condition of prolonged seizure activity. Optimal management of seizures not only includes identification of the underlying cause and initiation of appropriate anticonvulsant therapy or other treatments, but also the maintenance and management of an adequate airway and circulation. Pediatric hospitalists frequently encounter patients with active seizures and underlying seizure disorders, and should render both acute care and coordination of multidisciplinary care to the ambulatory setting.
Knowledge
Pediatric hospitalists should be able to:
Describe and distinguish between the various manifestations of seizure activity including involuntary motor activity, alterations of consciousness, behavior changes, disturbances of sensation and autonomic dysfunction.
Classify seizures using appropriate descriptive terms such as generalized, partial, simple and complex.
Discuss the pathophysiology of seizure activity.
Review alternate diagnoses which may mimic the presentation of seizures including behavioral abnormalities, movement disorders, conversion disorders and others.
Compare and contrast distinguishing features of seizures versus other paroxysmal events.
List the various etiologies of seizures attending to both acute (such as electrolyte imbalance, infection, toxins, trauma and others) and chronic (such as central nervous system malformations, metabolic diseases, and others) causes.
List the most common etiologies of seizures in various age groups such as the neonate, infant, preschool aged, school aged, and adolescent.
Define simple and complex febrile seizures and discuss evaluation, treatment, prognosis, and indications for admission.
State the common complications associated with seizures and status epilepticus.
Discuss indications for hospitalization or transfer to a tertiary care facility.
Discuss indications for transfer to an intensive care unit.
Review the goals of inpatient diagnostic evaluation and therapy.
Compare and contrast commonly used anti‐epileptic drugs and therapies attending to treatments for specific seizure types, adverse drug events, and ease of use.
Compare and contrast the risk and benefits of commonly used imaging modalities.
List the indications for subspecialty consultation.
Review the management of status epilepticus, including stabilization, testing, monitoring, and patient placement.
Summarize the risks for readmission, attending to medication management (dosing, availability, pharmacokinetics, and side effect profiles), compliance, and changes in disease state.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose seizures by efficiently performing an accurate history and physical examination with particular focus on the neurologic exam.
Accurately order appropriate laboratory and radiographic evaluations to identify the etiology of the seizure and potential underlying disorders.
Interpret laboratory studies including drug levels and make therapy adjustments based on results.
Order appropriate studies for patients with chronic seizure disorders, avoiding unnecessary duplication of testing and radiation exposure.
Identify and efficiently treat the cause of the seizure where appropriate.
Identify status epilepticus and initiate appropriate evidence‐based treatment.
Recognize complications due to seizures and institute appropriate cardiorespiratory support as needed.
Identify patients at increased risk for seizure recurrence or morbidity and ensures appropriate monitoring and treatment.
Obtain appropriate consults efficiently.
Create a comprehensive evaluation and management plan addressing the unique needs of patients and the family/caregiver.
Anticipate, monitor for, identify, and treat potential side effects of treatment.
Recognize and efficiently transfer patients requiring higher level of care.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with patients, the family/caregiver, hospital staff, subspecialists and primary care provider regarding the reasons for diagnostic testing and therapy choices.
Recognize the role of patient and family/caregiver education in improving compliance with treatment and follow‐up.
Educate the family/caregiver regarding outcomes of febrile seizures including the risk of the child developing a seizure disorder.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with seizure disorders.
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 of hospitalized children with seizures and status epilepticus.
Collaborate with hospital administration and community partners to develop and sustain referral networks for both transport and subpsecialty services for children with seizures and chronic seizure disorders.
Collaborate with primary care providers, subspecialists and other healthcare providers to create effective discharge plans that reduce the likelihood of readmission.
Introduction
Seizures are the most common neurologic disorder of childhood. It is estimated that approximately 5% of all children will have at least one seizure before the age of 20. The prevalence of epilepsy, or recurrent unprovoked seizures, is about 0.5% in children. Seizures may range from self‐limited to life‐threatening events. Status epilepticus is the condition of prolonged seizure activity. Optimal management of seizures not only includes identification of the underlying cause and initiation of appropriate anticonvulsant therapy or other treatments, but also the maintenance and management of an adequate airway and circulation. Pediatric hospitalists frequently encounter patients with active seizures and underlying seizure disorders, and should render both acute care and coordination of multidisciplinary care to the ambulatory setting.
Knowledge
Pediatric hospitalists should be able to:
Describe and distinguish between the various manifestations of seizure activity including involuntary motor activity, alterations of consciousness, behavior changes, disturbances of sensation and autonomic dysfunction.
Classify seizures using appropriate descriptive terms such as generalized, partial, simple and complex.
Discuss the pathophysiology of seizure activity.
Review alternate diagnoses which may mimic the presentation of seizures including behavioral abnormalities, movement disorders, conversion disorders and others.
Compare and contrast distinguishing features of seizures versus other paroxysmal events.
List the various etiologies of seizures attending to both acute (such as electrolyte imbalance, infection, toxins, trauma and others) and chronic (such as central nervous system malformations, metabolic diseases, and others) causes.
List the most common etiologies of seizures in various age groups such as the neonate, infant, preschool aged, school aged, and adolescent.
Define simple and complex febrile seizures and discuss evaluation, treatment, prognosis, and indications for admission.
State the common complications associated with seizures and status epilepticus.
Discuss indications for hospitalization or transfer to a tertiary care facility.
Discuss indications for transfer to an intensive care unit.
Review the goals of inpatient diagnostic evaluation and therapy.
Compare and contrast commonly used anti‐epileptic drugs and therapies attending to treatments for specific seizure types, adverse drug events, and ease of use.
Compare and contrast the risk and benefits of commonly used imaging modalities.
List the indications for subspecialty consultation.
Review the management of status epilepticus, including stabilization, testing, monitoring, and patient placement.
Summarize the risks for readmission, attending to medication management (dosing, availability, pharmacokinetics, and side effect profiles), compliance, and changes in disease state.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose seizures by efficiently performing an accurate history and physical examination with particular focus on the neurologic exam.
Accurately order appropriate laboratory and radiographic evaluations to identify the etiology of the seizure and potential underlying disorders.
Interpret laboratory studies including drug levels and make therapy adjustments based on results.
Order appropriate studies for patients with chronic seizure disorders, avoiding unnecessary duplication of testing and radiation exposure.
Identify and efficiently treat the cause of the seizure where appropriate.
Identify status epilepticus and initiate appropriate evidence‐based treatment.
Recognize complications due to seizures and institute appropriate cardiorespiratory support as needed.
Identify patients at increased risk for seizure recurrence or morbidity and ensures appropriate monitoring and treatment.
Obtain appropriate consults efficiently.
Create a comprehensive evaluation and management plan addressing the unique needs of patients and the family/caregiver.
Anticipate, monitor for, identify, and treat potential side effects of treatment.
Recognize and efficiently transfer patients requiring higher level of care.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with patients, the family/caregiver, hospital staff, subspecialists and primary care provider regarding the reasons for diagnostic testing and therapy choices.
Recognize the role of patient and family/caregiver education in improving compliance with treatment and follow‐up.
Educate the family/caregiver regarding outcomes of febrile seizures including the risk of the child developing a seizure disorder.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with seizure disorders.
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 of hospitalized children with seizures and status epilepticus.
Collaborate with hospital administration and community partners to develop and sustain referral networks for both transport and subpsecialty services for children with seizures and chronic seizure disorders.
Collaborate with primary care providers, subspecialists and other healthcare providers to create effective discharge plans that reduce the likelihood of readmission.
Introduction
Seizures are the most common neurologic disorder of childhood. It is estimated that approximately 5% of all children will have at least one seizure before the age of 20. The prevalence of epilepsy, or recurrent unprovoked seizures, is about 0.5% in children. Seizures may range from self‐limited to life‐threatening events. Status epilepticus is the condition of prolonged seizure activity. Optimal management of seizures not only includes identification of the underlying cause and initiation of appropriate anticonvulsant therapy or other treatments, but also the maintenance and management of an adequate airway and circulation. Pediatric hospitalists frequently encounter patients with active seizures and underlying seizure disorders, and should render both acute care and coordination of multidisciplinary care to the ambulatory setting.
Knowledge
Pediatric hospitalists should be able to:
Describe and distinguish between the various manifestations of seizure activity including involuntary motor activity, alterations of consciousness, behavior changes, disturbances of sensation and autonomic dysfunction.
Classify seizures using appropriate descriptive terms such as generalized, partial, simple and complex.
Discuss the pathophysiology of seizure activity.
Review alternate diagnoses which may mimic the presentation of seizures including behavioral abnormalities, movement disorders, conversion disorders and others.
Compare and contrast distinguishing features of seizures versus other paroxysmal events.
List the various etiologies of seizures attending to both acute (such as electrolyte imbalance, infection, toxins, trauma and others) and chronic (such as central nervous system malformations, metabolic diseases, and others) causes.
List the most common etiologies of seizures in various age groups such as the neonate, infant, preschool aged, school aged, and adolescent.
Define simple and complex febrile seizures and discuss evaluation, treatment, prognosis, and indications for admission.
State the common complications associated with seizures and status epilepticus.
Discuss indications for hospitalization or transfer to a tertiary care facility.
Discuss indications for transfer to an intensive care unit.
Review the goals of inpatient diagnostic evaluation and therapy.
Compare and contrast commonly used anti‐epileptic drugs and therapies attending to treatments for specific seizure types, adverse drug events, and ease of use.
Compare and contrast the risk and benefits of commonly used imaging modalities.
List the indications for subspecialty consultation.
Review the management of status epilepticus, including stabilization, testing, monitoring, and patient placement.
Summarize the risks for readmission, attending to medication management (dosing, availability, pharmacokinetics, and side effect profiles), compliance, and changes in disease state.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose seizures by efficiently performing an accurate history and physical examination with particular focus on the neurologic exam.
Accurately order appropriate laboratory and radiographic evaluations to identify the etiology of the seizure and potential underlying disorders.
Interpret laboratory studies including drug levels and make therapy adjustments based on results.
Order appropriate studies for patients with chronic seizure disorders, avoiding unnecessary duplication of testing and radiation exposure.
Identify and efficiently treat the cause of the seizure where appropriate.
Identify status epilepticus and initiate appropriate evidence‐based treatment.
Recognize complications due to seizures and institute appropriate cardiorespiratory support as needed.
Identify patients at increased risk for seizure recurrence or morbidity and ensures appropriate monitoring and treatment.
Obtain appropriate consults efficiently.
Create a comprehensive evaluation and management plan addressing the unique needs of patients and the family/caregiver.
Anticipate, monitor for, identify, and treat potential side effects of treatment.
Recognize and efficiently transfer patients requiring higher level of care.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with patients, the family/caregiver, hospital staff, subspecialists and primary care provider regarding the reasons for diagnostic testing and therapy choices.
Recognize the role of patient and family/caregiver education in improving compliance with treatment and follow‐up.
Educate the family/caregiver regarding outcomes of febrile seizures including the risk of the child developing a seizure disorder.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with seizure disorders.
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 of hospitalized children with seizures and status epilepticus.
Collaborate with hospital administration and community partners to develop and sustain referral networks for both transport and subpsecialty services for children with seizures and chronic seizure disorders.
Collaborate with primary care providers, subspecialists and other healthcare providers to create effective discharge plans that reduce the likelihood of readmission.
Copyright © 2010 Society of Hospital Medicine
Bronchiolitis
Introduction
Bronchiolitis is the most common viral lower respiratory illness in young children and infants. It is responsible for hundreds of thousands of outpatient and emergency department visits and nearly 150,000 hospitalizations per year, costing the U.S. healthcare system more than $500 million annually. The most commonly identified etiology of bronchiolitis is respiratory syncytial virus (RSV), however bronchiolitis may be caused by many other viruses, including human metapneumovirus, adenovirus, and influenza. Despite guidelines published by the American Academy of Pediatrics on the diagnosis and management of bronchiolitis, there is significant variation in care of hospitalized patients. Pediatric hospitalists should render evidence‐based care that avoids use of unnecessary tests and procedures and improves outcomes.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the epidemiology and pathogenesis of bronchiolitis with asthma.
Describe the typical clinical presentation of viral bronchiolitis including wheezing, tachypnea, acute respiratory distress, hypoxia, cough, apnea, and/or nasal obstruction, and give examples of how presentations may vary.
Review alternate diagnoses which may mimic the presentation of bronchiolitis such as congestive heart failure, previously undiagnosed cyanotic or non‐cyanotic congenital heart disease, metabolic acidosis, sepsis, aspiration, and others.
Identify the risk factors such as prematurity, congenital heart disease, pulmonary disease, immunodeficiency, and environmental smoke exposure that predispose infants and children to severe illness or complications of bronchiolitis.
State the indications and contraindications for RSV immunoprophylaxis.
List the indications for hospital admission and cite discharge criteria.
Discuss indications for ordering viral antigen testing and chest radiographs.
Compare and contrast initial diagnostic evaluation for febrile infants of various ages presenting with bronchiolitis attending to ages less than 30 days, 31‐60 days and others.
Discuss the evidence regarding beta‐agonist and steroid therapy in routine bronchiolitis.
Discuss the evidence regarding use of supportive measures including suctioning, positioning, enteral versus intravenous fluids and nutrition, and supplemental oxygen.
Discuss the benefits and potential technical errors associated with use of various non‐invasive monitoring modalities including cardiorespiratory, oxygen saturation, and capnography.
Describe a management strategy for patients with worsening respiratory status including the use of different oxygen delivery systems and methods for positive pressure ventilation.
Describe a management strategy for patients with worsening respiratory status including use of different oxygen delivery systems and methods for positive pressure ventilation.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose bronchiolitis by efficiently performing an accurate history and physical examination; determining if key features of the disease are present.
Accurately assess clinical signs of respiratory distress and identify impending respiratory failure.
Assess nutrition and hydration status and chose appropriate methods to maintain adequate hydration and nutrition.
Order appropriate monitoring and correctly interpret monitor data.
Objectively assess the response to any medications trialed and use clinical exam and respiratory scores to determine true efficacy.
Perform careful reassessments daily and as needed, note changes in clinical status and respond with appropriate actions including discontinuation of ineffective or unnecessary therapies.
Recognize the indications for escalating level of care and initiate basic ventilatory support if indicated.
Implement appropriate oxygen weaning strategies, including the use of appropriate oxygen saturation parameters.
Engage the family/caregiver in assisting with interpreting clinical status changes and in determining care plans.
Consistently adhere to proper infection control measures.
Efficiently render care by creating a discharge plan which can be expediently activated when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Educate the family/caregiver on the etiologies and natural history of bronchiolitis, including the importance of hand washing and minimizing environmental exposure in the prevention of infection.
Discuss with the family/caregiver the importance of supportive care, as well as the limited evidence supporting other interventions.
Display proactive, engaged behavior regarding proper isolation measures particularly including hand‐washing to prevent spread of the etiologic agent in the hospital.
Educate the family/caregiver regarding the relationship between hospitalization for bronchiolitis and risk of future wheezing based on the most current evidence.
Collaborate with the primary care provider to ensure a smooth transition to the outpatient setting, and to minimize the need for readmission.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with hospital infection control practitioners to prevent nosocomial infection related to bronchiolitis.
Partner with community services to educate the public on respiratory infection preventive strategies.
Work with emergency department physicians to mutually develop and implement evidence‐based admission criteria.
Lead, coordinate or participate in multidisciplinary initiatives to develop, implement, and assess quality outcomes of evidence‐based clinical guidelines.
Introduction
Bronchiolitis is the most common viral lower respiratory illness in young children and infants. It is responsible for hundreds of thousands of outpatient and emergency department visits and nearly 150,000 hospitalizations per year, costing the U.S. healthcare system more than $500 million annually. The most commonly identified etiology of bronchiolitis is respiratory syncytial virus (RSV), however bronchiolitis may be caused by many other viruses, including human metapneumovirus, adenovirus, and influenza. Despite guidelines published by the American Academy of Pediatrics on the diagnosis and management of bronchiolitis, there is significant variation in care of hospitalized patients. Pediatric hospitalists should render evidence‐based care that avoids use of unnecessary tests and procedures and improves outcomes.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the epidemiology and pathogenesis of bronchiolitis with asthma.
Describe the typical clinical presentation of viral bronchiolitis including wheezing, tachypnea, acute respiratory distress, hypoxia, cough, apnea, and/or nasal obstruction, and give examples of how presentations may vary.
Review alternate diagnoses which may mimic the presentation of bronchiolitis such as congestive heart failure, previously undiagnosed cyanotic or non‐cyanotic congenital heart disease, metabolic acidosis, sepsis, aspiration, and others.
Identify the risk factors such as prematurity, congenital heart disease, pulmonary disease, immunodeficiency, and environmental smoke exposure that predispose infants and children to severe illness or complications of bronchiolitis.
State the indications and contraindications for RSV immunoprophylaxis.
List the indications for hospital admission and cite discharge criteria.
Discuss indications for ordering viral antigen testing and chest radiographs.
Compare and contrast initial diagnostic evaluation for febrile infants of various ages presenting with bronchiolitis attending to ages less than 30 days, 31‐60 days and others.
Discuss the evidence regarding beta‐agonist and steroid therapy in routine bronchiolitis.
Discuss the evidence regarding use of supportive measures including suctioning, positioning, enteral versus intravenous fluids and nutrition, and supplemental oxygen.
Discuss the benefits and potential technical errors associated with use of various non‐invasive monitoring modalities including cardiorespiratory, oxygen saturation, and capnography.
Describe a management strategy for patients with worsening respiratory status including the use of different oxygen delivery systems and methods for positive pressure ventilation.
Describe a management strategy for patients with worsening respiratory status including use of different oxygen delivery systems and methods for positive pressure ventilation.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose bronchiolitis by efficiently performing an accurate history and physical examination; determining if key features of the disease are present.
Accurately assess clinical signs of respiratory distress and identify impending respiratory failure.
Assess nutrition and hydration status and chose appropriate methods to maintain adequate hydration and nutrition.
Order appropriate monitoring and correctly interpret monitor data.
Objectively assess the response to any medications trialed and use clinical exam and respiratory scores to determine true efficacy.
Perform careful reassessments daily and as needed, note changes in clinical status and respond with appropriate actions including discontinuation of ineffective or unnecessary therapies.
Recognize the indications for escalating level of care and initiate basic ventilatory support if indicated.
Implement appropriate oxygen weaning strategies, including the use of appropriate oxygen saturation parameters.
Engage the family/caregiver in assisting with interpreting clinical status changes and in determining care plans.
Consistently adhere to proper infection control measures.
Efficiently render care by creating a discharge plan which can be expediently activated when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Educate the family/caregiver on the etiologies and natural history of bronchiolitis, including the importance of hand washing and minimizing environmental exposure in the prevention of infection.
Discuss with the family/caregiver the importance of supportive care, as well as the limited evidence supporting other interventions.
Display proactive, engaged behavior regarding proper isolation measures particularly including hand‐washing to prevent spread of the etiologic agent in the hospital.
Educate the family/caregiver regarding the relationship between hospitalization for bronchiolitis and risk of future wheezing based on the most current evidence.
Collaborate with the primary care provider to ensure a smooth transition to the outpatient setting, and to minimize the need for readmission.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with hospital infection control practitioners to prevent nosocomial infection related to bronchiolitis.
Partner with community services to educate the public on respiratory infection preventive strategies.
Work with emergency department physicians to mutually develop and implement evidence‐based admission criteria.
Lead, coordinate or participate in multidisciplinary initiatives to develop, implement, and assess quality outcomes of evidence‐based clinical guidelines.
Introduction
Bronchiolitis is the most common viral lower respiratory illness in young children and infants. It is responsible for hundreds of thousands of outpatient and emergency department visits and nearly 150,000 hospitalizations per year, costing the U.S. healthcare system more than $500 million annually. The most commonly identified etiology of bronchiolitis is respiratory syncytial virus (RSV), however bronchiolitis may be caused by many other viruses, including human metapneumovirus, adenovirus, and influenza. Despite guidelines published by the American Academy of Pediatrics on the diagnosis and management of bronchiolitis, there is significant variation in care of hospitalized patients. Pediatric hospitalists should render evidence‐based care that avoids use of unnecessary tests and procedures and improves outcomes.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the epidemiology and pathogenesis of bronchiolitis with asthma.
Describe the typical clinical presentation of viral bronchiolitis including wheezing, tachypnea, acute respiratory distress, hypoxia, cough, apnea, and/or nasal obstruction, and give examples of how presentations may vary.
Review alternate diagnoses which may mimic the presentation of bronchiolitis such as congestive heart failure, previously undiagnosed cyanotic or non‐cyanotic congenital heart disease, metabolic acidosis, sepsis, aspiration, and others.
Identify the risk factors such as prematurity, congenital heart disease, pulmonary disease, immunodeficiency, and environmental smoke exposure that predispose infants and children to severe illness or complications of bronchiolitis.
State the indications and contraindications for RSV immunoprophylaxis.
List the indications for hospital admission and cite discharge criteria.
Discuss indications for ordering viral antigen testing and chest radiographs.
Compare and contrast initial diagnostic evaluation for febrile infants of various ages presenting with bronchiolitis attending to ages less than 30 days, 31‐60 days and others.
Discuss the evidence regarding beta‐agonist and steroid therapy in routine bronchiolitis.
Discuss the evidence regarding use of supportive measures including suctioning, positioning, enteral versus intravenous fluids and nutrition, and supplemental oxygen.
Discuss the benefits and potential technical errors associated with use of various non‐invasive monitoring modalities including cardiorespiratory, oxygen saturation, and capnography.
Describe a management strategy for patients with worsening respiratory status including the use of different oxygen delivery systems and methods for positive pressure ventilation.
Describe a management strategy for patients with worsening respiratory status including use of different oxygen delivery systems and methods for positive pressure ventilation.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose bronchiolitis by efficiently performing an accurate history and physical examination; determining if key features of the disease are present.
Accurately assess clinical signs of respiratory distress and identify impending respiratory failure.
Assess nutrition and hydration status and chose appropriate methods to maintain adequate hydration and nutrition.
Order appropriate monitoring and correctly interpret monitor data.
Objectively assess the response to any medications trialed and use clinical exam and respiratory scores to determine true efficacy.
Perform careful reassessments daily and as needed, note changes in clinical status and respond with appropriate actions including discontinuation of ineffective or unnecessary therapies.
Recognize the indications for escalating level of care and initiate basic ventilatory support if indicated.
Implement appropriate oxygen weaning strategies, including the use of appropriate oxygen saturation parameters.
Engage the family/caregiver in assisting with interpreting clinical status changes and in determining care plans.
Consistently adhere to proper infection control measures.
Efficiently render care by creating a discharge plan which can be expediently activated when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Educate the family/caregiver on the etiologies and natural history of bronchiolitis, including the importance of hand washing and minimizing environmental exposure in the prevention of infection.
Discuss with the family/caregiver the importance of supportive care, as well as the limited evidence supporting other interventions.
Display proactive, engaged behavior regarding proper isolation measures particularly including hand‐washing to prevent spread of the etiologic agent in the hospital.
Educate the family/caregiver regarding the relationship between hospitalization for bronchiolitis and risk of future wheezing based on the most current evidence.
Collaborate with the primary care provider to ensure a smooth transition to the outpatient setting, and to minimize the need for readmission.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with hospital infection control practitioners to prevent nosocomial infection related to bronchiolitis.
Partner with community services to educate the public on respiratory infection preventive strategies.
Work with emergency department physicians to mutually develop and implement evidence‐based admission criteria.
Lead, coordinate or participate in multidisciplinary initiatives to develop, implement, and assess quality outcomes of evidence‐based clinical guidelines.
Copyright © 2010 Society of Hospital Medicine
Radiographic interpretation
Introduction
Radiographic studies are commonly performed throughout a wide range of pediatric healthcare settings. Imaging can play a pivotal role in the acute and chronic medical and surgical management of ill children. The explosion of imaging technology and expertise in the past three decades has resulted in an increased array of imaging modalities from which to choose. Access to and interpretation of imaging studies for children varies greatly between facilities. Pediatric hospitalists frequently encounter patients requiring imaging studies, and should be adept at ordering and interpreting images in collaboration with radiologist and other subspecialists.
Knowledge
Pediatric hospitalists should be able to:
Review basic human anatomy and relate this to interpretation of common plain radiographs of areas such as the chest, abdomen, airway, and long bones.
Describe the indications and limitations of the common radiographic modalities such as sonography, computed tomography, magnetic resonance imaging, plain radiography, and bone scans.
Describe the risks of ionizing radiation in children and review the concept of ALARA (as low as reasonably achievable) in limiting radiation exposure.
Review the indications for and benefits and risks of oral and intravenous contrast.
Review the indications for anxiolysis, sedation, and anaesthesia attending to age, developmental stage, and procedure being performed.
Compare and contrast indications for interventional radiologist versus general surgical consultation.
Discuss the role of the radiologist as consultant.
Discuss the appropriate imaging modality selection(s) for common emergent clinical presentations such as altered mental status, stridor, potential bowel obstruction, and others.
Compare and contrast the utility, risks, and costs of different imaging modalities for presentations of complicated pneumonia and acute abdominal pain.
Skills
Pediatric hospitalists should be able to:
Correctly determine the optimal study to answer a specific clinical question in a cost‐effective manner, accounting for the limitations and risks of the study.
Accurately order radiologic studies, noting indications for the study, sedation/anaesthesia need, and other relevant information in the order.
Engage the radiologist as consultant as appropriate.
Accurately interpret plain radiographs of the chest and abdomen for children 0‐18 years of age.
Correctly identify the need for and efficiently access interventional radiologists as appropriate.
Communicate effectively with the healthcare team including radiologist and anaesthesiologist (as appropriate) to ensure safe, efficient and effective performance of radiologic studies.
Correctly interpret and apply the results of radiographic studies into clinical care plans.
Attitudes
Pediatric hospitalists should be able to:
Elicit and allay common family/caregiver concerns regarding radiation risks.
Work collaboratively with hospital staff, radiologists, and anaesthesiologists to ensure coordinated planning and performance of radiologic studies.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps involved in the radiologic procedure.
Recognize the importance of obtaining results of all studies and reviewing images in person whenever possible.
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 standards for radiology services for children.
Work with hospital administration to assure that a reliable and efficient radiographic imaging service is available for pediatric inpatients at the local facility.
Lead, coordinate or participate in development and implementation of a system to review the accuracy of readings for pediatric patients and develop local criteria for tertiary referral center consultation.
Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers that enable review of appropriately selected pediatric images.
Work with hospital administration, subspecialists, and others to review acquisition of new technologies and assess the impact on patient care.
Introduction
Radiographic studies are commonly performed throughout a wide range of pediatric healthcare settings. Imaging can play a pivotal role in the acute and chronic medical and surgical management of ill children. The explosion of imaging technology and expertise in the past three decades has resulted in an increased array of imaging modalities from which to choose. Access to and interpretation of imaging studies for children varies greatly between facilities. Pediatric hospitalists frequently encounter patients requiring imaging studies, and should be adept at ordering and interpreting images in collaboration with radiologist and other subspecialists.
Knowledge
Pediatric hospitalists should be able to:
Review basic human anatomy and relate this to interpretation of common plain radiographs of areas such as the chest, abdomen, airway, and long bones.
Describe the indications and limitations of the common radiographic modalities such as sonography, computed tomography, magnetic resonance imaging, plain radiography, and bone scans.
Describe the risks of ionizing radiation in children and review the concept of ALARA (as low as reasonably achievable) in limiting radiation exposure.
Review the indications for and benefits and risks of oral and intravenous contrast.
Review the indications for anxiolysis, sedation, and anaesthesia attending to age, developmental stage, and procedure being performed.
Compare and contrast indications for interventional radiologist versus general surgical consultation.
Discuss the role of the radiologist as consultant.
Discuss the appropriate imaging modality selection(s) for common emergent clinical presentations such as altered mental status, stridor, potential bowel obstruction, and others.
Compare and contrast the utility, risks, and costs of different imaging modalities for presentations of complicated pneumonia and acute abdominal pain.
Skills
Pediatric hospitalists should be able to:
Correctly determine the optimal study to answer a specific clinical question in a cost‐effective manner, accounting for the limitations and risks of the study.
Accurately order radiologic studies, noting indications for the study, sedation/anaesthesia need, and other relevant information in the order.
Engage the radiologist as consultant as appropriate.
Accurately interpret plain radiographs of the chest and abdomen for children 0‐18 years of age.
Correctly identify the need for and efficiently access interventional radiologists as appropriate.
Communicate effectively with the healthcare team including radiologist and anaesthesiologist (as appropriate) to ensure safe, efficient and effective performance of radiologic studies.
Correctly interpret and apply the results of radiographic studies into clinical care plans.
Attitudes
Pediatric hospitalists should be able to:
Elicit and allay common family/caregiver concerns regarding radiation risks.
Work collaboratively with hospital staff, radiologists, and anaesthesiologists to ensure coordinated planning and performance of radiologic studies.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps involved in the radiologic procedure.
Recognize the importance of obtaining results of all studies and reviewing images in person whenever possible.
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 standards for radiology services for children.
Work with hospital administration to assure that a reliable and efficient radiographic imaging service is available for pediatric inpatients at the local facility.
Lead, coordinate or participate in development and implementation of a system to review the accuracy of readings for pediatric patients and develop local criteria for tertiary referral center consultation.
Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers that enable review of appropriately selected pediatric images.
Work with hospital administration, subspecialists, and others to review acquisition of new technologies and assess the impact on patient care.
Introduction
Radiographic studies are commonly performed throughout a wide range of pediatric healthcare settings. Imaging can play a pivotal role in the acute and chronic medical and surgical management of ill children. The explosion of imaging technology and expertise in the past three decades has resulted in an increased array of imaging modalities from which to choose. Access to and interpretation of imaging studies for children varies greatly between facilities. Pediatric hospitalists frequently encounter patients requiring imaging studies, and should be adept at ordering and interpreting images in collaboration with radiologist and other subspecialists.
Knowledge
Pediatric hospitalists should be able to:
Review basic human anatomy and relate this to interpretation of common plain radiographs of areas such as the chest, abdomen, airway, and long bones.
Describe the indications and limitations of the common radiographic modalities such as sonography, computed tomography, magnetic resonance imaging, plain radiography, and bone scans.
Describe the risks of ionizing radiation in children and review the concept of ALARA (as low as reasonably achievable) in limiting radiation exposure.
Review the indications for and benefits and risks of oral and intravenous contrast.
Review the indications for anxiolysis, sedation, and anaesthesia attending to age, developmental stage, and procedure being performed.
Compare and contrast indications for interventional radiologist versus general surgical consultation.
Discuss the role of the radiologist as consultant.
Discuss the appropriate imaging modality selection(s) for common emergent clinical presentations such as altered mental status, stridor, potential bowel obstruction, and others.
Compare and contrast the utility, risks, and costs of different imaging modalities for presentations of complicated pneumonia and acute abdominal pain.
Skills
Pediatric hospitalists should be able to:
Correctly determine the optimal study to answer a specific clinical question in a cost‐effective manner, accounting for the limitations and risks of the study.
Accurately order radiologic studies, noting indications for the study, sedation/anaesthesia need, and other relevant information in the order.
Engage the radiologist as consultant as appropriate.
Accurately interpret plain radiographs of the chest and abdomen for children 0‐18 years of age.
Correctly identify the need for and efficiently access interventional radiologists as appropriate.
Communicate effectively with the healthcare team including radiologist and anaesthesiologist (as appropriate) to ensure safe, efficient and effective performance of radiologic studies.
Correctly interpret and apply the results of radiographic studies into clinical care plans.
Attitudes
Pediatric hospitalists should be able to:
Elicit and allay common family/caregiver concerns regarding radiation risks.
Work collaboratively with hospital staff, radiologists, and anaesthesiologists to ensure coordinated planning and performance of radiologic studies.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps involved in the radiologic procedure.
Recognize the importance of obtaining results of all studies and reviewing images in person whenever possible.
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 standards for radiology services for children.
Work with hospital administration to assure that a reliable and efficient radiographic imaging service is available for pediatric inpatients at the local facility.
Lead, coordinate or participate in development and implementation of a system to review the accuracy of readings for pediatric patients and develop local criteria for tertiary referral center consultation.
Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers that enable review of appropriately selected pediatric images.
Work with hospital administration, subspecialists, and others to review acquisition of new technologies and assess the impact on patient care.
Copyright © 2010 Society of Hospital Medicine
Communication
Introduction
Communication is defined as any process in which a message containing information is transferred, especially from one person to another, via any of a number of media. Communication may be delivered verbally or non‐verbally, directly, (as in face‐to‐face conversation or with the observation of a gesture) or remotely, spanning space and time (as in writing, reading, making or playing back a recording, or using a computer). Pediatric hospitalists must be effective communicators in many venues such as when rendering direct patient care, performing hospital committee work, or educating trainees. However, the most important of these is the verbal communication that occurs at the bedside with patients, family/caregiver, and healthcare team. Successful patient care is elusive or wanting without proper communication.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the importance of listening and speaking for effective communication.
Define the components of effective expressive and receptive (listening) communication, such as introduction of team members, avoiding medical jargon, tone, word choice, allowing time for patients and the family/caregiver to speak, and body language.
List examples of common non‐listening behaviors such as allowing distractions, asking unrelated questions, jumping to conclusions, interrupting the speaker, and failing to notice the speaker's non‐verbal language.
Cite methods that can be used when faced with difficult behaviors during communication, such as asking for a behavior change and paraphrasing to diffuse emotion.
Describe patients in a cultural and spiritual context.
Explain how vulnerabilities, life situation, limitation in activities of daily living, education, language and other factors should each be addressed when communicating with patients and the family/caregiver.
Identify personal values, biases, skills, and relationships that may influence communication.
Discuss the significance of including the family/caregiver and others who are most important to patients in patient care discussions.
Explain why effective communication is central to patient care handoffs and list examples of best methods for communication both within hospitalist groups and with other healthcare providers.
Articulate how to give bad news by expressing empathy, giving patients and the family/caregiver time to ask questions, maintaining calm, and choosing a quiet, private location for the discussion.
Cite important features of effective written communication.
Compare and contrast specific examples of effective and ineffective written communication, including timing of entries, legibility, disagreements on patient care decisions, documentation of changes in clinical status and others.
Skills
Pediatric hospitalists should be able to:
Demonstrate command of a comprehensive array of expressive and receptive communication skills.
Coordinate discussions with all caregivers to ensure a single clear message is given to patients and the family/caregiver.
Actively participate in conflict resolution.
Summarize the entire process and sequence of care for patients and the family/caregiver in understandable terms following the principles of family centered care.
Maintain concise, complete written records that meet expectations of external reviewing agencies and malpractice carriers.
Develop and implement a plan for daily communication that is family centered.
Attitudes
Pediatric hospitalists should be able to:
Respect the skills and contributions of all involved in the care of patients.
Exemplify professionalism in all communications.
Seek opportunities to enhance communication skills.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with hospital administrators to improve medical record documentation systems by technical means.
Assist in the development of and/or participate in hospital and system‐wide educational programs on communication skills.
Introduction
Communication is defined as any process in which a message containing information is transferred, especially from one person to another, via any of a number of media. Communication may be delivered verbally or non‐verbally, directly, (as in face‐to‐face conversation or with the observation of a gesture) or remotely, spanning space and time (as in writing, reading, making or playing back a recording, or using a computer). Pediatric hospitalists must be effective communicators in many venues such as when rendering direct patient care, performing hospital committee work, or educating trainees. However, the most important of these is the verbal communication that occurs at the bedside with patients, family/caregiver, and healthcare team. Successful patient care is elusive or wanting without proper communication.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the importance of listening and speaking for effective communication.
Define the components of effective expressive and receptive (listening) communication, such as introduction of team members, avoiding medical jargon, tone, word choice, allowing time for patients and the family/caregiver to speak, and body language.
List examples of common non‐listening behaviors such as allowing distractions, asking unrelated questions, jumping to conclusions, interrupting the speaker, and failing to notice the speaker's non‐verbal language.
Cite methods that can be used when faced with difficult behaviors during communication, such as asking for a behavior change and paraphrasing to diffuse emotion.
Describe patients in a cultural and spiritual context.
Explain how vulnerabilities, life situation, limitation in activities of daily living, education, language and other factors should each be addressed when communicating with patients and the family/caregiver.
Identify personal values, biases, skills, and relationships that may influence communication.
Discuss the significance of including the family/caregiver and others who are most important to patients in patient care discussions.
Explain why effective communication is central to patient care handoffs and list examples of best methods for communication both within hospitalist groups and with other healthcare providers.
Articulate how to give bad news by expressing empathy, giving patients and the family/caregiver time to ask questions, maintaining calm, and choosing a quiet, private location for the discussion.
Cite important features of effective written communication.
Compare and contrast specific examples of effective and ineffective written communication, including timing of entries, legibility, disagreements on patient care decisions, documentation of changes in clinical status and others.
Skills
Pediatric hospitalists should be able to:
Demonstrate command of a comprehensive array of expressive and receptive communication skills.
Coordinate discussions with all caregivers to ensure a single clear message is given to patients and the family/caregiver.
Actively participate in conflict resolution.
Summarize the entire process and sequence of care for patients and the family/caregiver in understandable terms following the principles of family centered care.
Maintain concise, complete written records that meet expectations of external reviewing agencies and malpractice carriers.
Develop and implement a plan for daily communication that is family centered.
Attitudes
Pediatric hospitalists should be able to:
Respect the skills and contributions of all involved in the care of patients.
Exemplify professionalism in all communications.
Seek opportunities to enhance communication skills.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with hospital administrators to improve medical record documentation systems by technical means.
Assist in the development of and/or participate in hospital and system‐wide educational programs on communication skills.
Introduction
Communication is defined as any process in which a message containing information is transferred, especially from one person to another, via any of a number of media. Communication may be delivered verbally or non‐verbally, directly, (as in face‐to‐face conversation or with the observation of a gesture) or remotely, spanning space and time (as in writing, reading, making or playing back a recording, or using a computer). Pediatric hospitalists must be effective communicators in many venues such as when rendering direct patient care, performing hospital committee work, or educating trainees. However, the most important of these is the verbal communication that occurs at the bedside with patients, family/caregiver, and healthcare team. Successful patient care is elusive or wanting without proper communication.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the importance of listening and speaking for effective communication.
Define the components of effective expressive and receptive (listening) communication, such as introduction of team members, avoiding medical jargon, tone, word choice, allowing time for patients and the family/caregiver to speak, and body language.
List examples of common non‐listening behaviors such as allowing distractions, asking unrelated questions, jumping to conclusions, interrupting the speaker, and failing to notice the speaker's non‐verbal language.
Cite methods that can be used when faced with difficult behaviors during communication, such as asking for a behavior change and paraphrasing to diffuse emotion.
Describe patients in a cultural and spiritual context.
Explain how vulnerabilities, life situation, limitation in activities of daily living, education, language and other factors should each be addressed when communicating with patients and the family/caregiver.
Identify personal values, biases, skills, and relationships that may influence communication.
Discuss the significance of including the family/caregiver and others who are most important to patients in patient care discussions.
Explain why effective communication is central to patient care handoffs and list examples of best methods for communication both within hospitalist groups and with other healthcare providers.
Articulate how to give bad news by expressing empathy, giving patients and the family/caregiver time to ask questions, maintaining calm, and choosing a quiet, private location for the discussion.
Cite important features of effective written communication.
Compare and contrast specific examples of effective and ineffective written communication, including timing of entries, legibility, disagreements on patient care decisions, documentation of changes in clinical status and others.
Skills
Pediatric hospitalists should be able to:
Demonstrate command of a comprehensive array of expressive and receptive communication skills.
Coordinate discussions with all caregivers to ensure a single clear message is given to patients and the family/caregiver.
Actively participate in conflict resolution.
Summarize the entire process and sequence of care for patients and the family/caregiver in understandable terms following the principles of family centered care.
Maintain concise, complete written records that meet expectations of external reviewing agencies and malpractice carriers.
Develop and implement a plan for daily communication that is family centered.
Attitudes
Pediatric hospitalists should be able to:
Respect the skills and contributions of all involved in the care of patients.
Exemplify professionalism in all communications.
Seek opportunities to enhance communication skills.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with hospital administrators to improve medical record documentation systems by technical means.
Assist in the development of and/or participate in hospital and system‐wide educational programs on communication skills.
Copyright © 2010 Society of Hospital Medicine
Shock
Introduction
Early recognition and treatment of shock is imperative in improving the outcomes of critically ill children. The American Heart Association categorizes shock into four basic forms: hypovolemic, distributive, cardiogenic, and obstructive. Shock results from inadequate tissue perfusion to support metabolic demands. This may be caused by an inadequate supply of oxygen to the tissues or an increased demand of the tissues for oxygen. As a result, cellular hypoxia, anaerobic metabolism, and dysregulation result in irreversible cell damage and death. Pediatric hospitalists often encounter children with all forms of shock and should be adept at recognition and basic management of shock to improve outcomes.
Knowledge
Pediatric hospitalists should be able to:
Discuss the pathophysiology of tissue hypoxia including hypoxemia, anemia, and ischemia.
Describe the components of tissue oxygen delivery, focusing on cardiac output.
Describe common diseases and conditions associated with the four forms of shock.
Compare and contrast the presenting signs and symptoms of the four forms of shock, attending to differences in heart rate, blood pressure, pulses and peripheral perfusion, mental status, and urine output.
Discuss compensatory mechanisms of early shock including increased heart rate, stroke volume, and vascular smooth muscle tone.
List indications for chronotropic, inotropic, and blood pressure support and describe the mechanisms of action for these classes of medications.
State the commonly performed diagnostic studies (such as lab, radiographic, and other) which aid in determining the extent or form of shock.
Summarize the approach toward stabilization of each form of shock.
Skills
Pediatric hospitalists should be able to:
Perform an initial rapid assessment using Pediatric Advanced Life Support skills.
Recognize signs of early shock and respond with appropriate actions.
Appropriately order and correctly interpret results of common studies to determine the extent of shock such as complete blood count, chemistries, blood gas, radiography and others.
Appropriately order and correctly interpret results of studies to determine the cause of shock and respond with appropriate actions.
Order appropriate monitoring and correctly interpret monitor data.
Correctly recognize cardiomegaly and other signs of congestive heart failure on chest radiograph.
Correctly identify the form of shock from a focused history, physical examination and initial diagnostic studies.
Initiate appropriate interventions based on the form of shock.
Facilitate effective transfer to a tertiary care center or intensive care setting when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with emergency room and intensive care staff to ensure appropriate care for patients in shock.
Listen effectively and respond to concerns of the family/caregiver and healthcare providers regarding changes in physiologic parameters including vital signs, mental status, physical examination, and urine output.
Provide family/caregiver support and education on the nuances and complexities of the various forms of shock and the importance of careful monitoring and evaluation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Work with hospital administration, hospital staff, subspecialists, and other services to advocate for an educational program for healthcare providers on the importance of early recognition of shock to prevent end‐organ failure and death.
Lead, coordinate or participate in the development and implementation of rapid response systems to assist in recognition and stabilization of early shock.
Collaborate with hospital administration and community partners to develop and sustain local AHA Pediatric Life Support classes where descriptions and case scenarios provide a comprehensive knowledge base and intervention plan for various types of shock.
Lead, coordinate or participate in efforts to partner with simulation centers to assist in acquiring skill sets needed for appropriate recognition and intervention for children in shock.
Introduction
Early recognition and treatment of shock is imperative in improving the outcomes of critically ill children. The American Heart Association categorizes shock into four basic forms: hypovolemic, distributive, cardiogenic, and obstructive. Shock results from inadequate tissue perfusion to support metabolic demands. This may be caused by an inadequate supply of oxygen to the tissues or an increased demand of the tissues for oxygen. As a result, cellular hypoxia, anaerobic metabolism, and dysregulation result in irreversible cell damage and death. Pediatric hospitalists often encounter children with all forms of shock and should be adept at recognition and basic management of shock to improve outcomes.
Knowledge
Pediatric hospitalists should be able to:
Discuss the pathophysiology of tissue hypoxia including hypoxemia, anemia, and ischemia.
Describe the components of tissue oxygen delivery, focusing on cardiac output.
Describe common diseases and conditions associated with the four forms of shock.
Compare and contrast the presenting signs and symptoms of the four forms of shock, attending to differences in heart rate, blood pressure, pulses and peripheral perfusion, mental status, and urine output.
Discuss compensatory mechanisms of early shock including increased heart rate, stroke volume, and vascular smooth muscle tone.
List indications for chronotropic, inotropic, and blood pressure support and describe the mechanisms of action for these classes of medications.
State the commonly performed diagnostic studies (such as lab, radiographic, and other) which aid in determining the extent or form of shock.
Summarize the approach toward stabilization of each form of shock.
Skills
Pediatric hospitalists should be able to:
Perform an initial rapid assessment using Pediatric Advanced Life Support skills.
Recognize signs of early shock and respond with appropriate actions.
Appropriately order and correctly interpret results of common studies to determine the extent of shock such as complete blood count, chemistries, blood gas, radiography and others.
Appropriately order and correctly interpret results of studies to determine the cause of shock and respond with appropriate actions.
Order appropriate monitoring and correctly interpret monitor data.
Correctly recognize cardiomegaly and other signs of congestive heart failure on chest radiograph.
Correctly identify the form of shock from a focused history, physical examination and initial diagnostic studies.
Initiate appropriate interventions based on the form of shock.
Facilitate effective transfer to a tertiary care center or intensive care setting when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with emergency room and intensive care staff to ensure appropriate care for patients in shock.
Listen effectively and respond to concerns of the family/caregiver and healthcare providers regarding changes in physiologic parameters including vital signs, mental status, physical examination, and urine output.
Provide family/caregiver support and education on the nuances and complexities of the various forms of shock and the importance of careful monitoring and evaluation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Work with hospital administration, hospital staff, subspecialists, and other services to advocate for an educational program for healthcare providers on the importance of early recognition of shock to prevent end‐organ failure and death.
Lead, coordinate or participate in the development and implementation of rapid response systems to assist in recognition and stabilization of early shock.
Collaborate with hospital administration and community partners to develop and sustain local AHA Pediatric Life Support classes where descriptions and case scenarios provide a comprehensive knowledge base and intervention plan for various types of shock.
Lead, coordinate or participate in efforts to partner with simulation centers to assist in acquiring skill sets needed for appropriate recognition and intervention for children in shock.
Introduction
Early recognition and treatment of shock is imperative in improving the outcomes of critically ill children. The American Heart Association categorizes shock into four basic forms: hypovolemic, distributive, cardiogenic, and obstructive. Shock results from inadequate tissue perfusion to support metabolic demands. This may be caused by an inadequate supply of oxygen to the tissues or an increased demand of the tissues for oxygen. As a result, cellular hypoxia, anaerobic metabolism, and dysregulation result in irreversible cell damage and death. Pediatric hospitalists often encounter children with all forms of shock and should be adept at recognition and basic management of shock to improve outcomes.
Knowledge
Pediatric hospitalists should be able to:
Discuss the pathophysiology of tissue hypoxia including hypoxemia, anemia, and ischemia.
Describe the components of tissue oxygen delivery, focusing on cardiac output.
Describe common diseases and conditions associated with the four forms of shock.
Compare and contrast the presenting signs and symptoms of the four forms of shock, attending to differences in heart rate, blood pressure, pulses and peripheral perfusion, mental status, and urine output.
Discuss compensatory mechanisms of early shock including increased heart rate, stroke volume, and vascular smooth muscle tone.
List indications for chronotropic, inotropic, and blood pressure support and describe the mechanisms of action for these classes of medications.
State the commonly performed diagnostic studies (such as lab, radiographic, and other) which aid in determining the extent or form of shock.
Summarize the approach toward stabilization of each form of shock.
Skills
Pediatric hospitalists should be able to:
Perform an initial rapid assessment using Pediatric Advanced Life Support skills.
Recognize signs of early shock and respond with appropriate actions.
Appropriately order and correctly interpret results of common studies to determine the extent of shock such as complete blood count, chemistries, blood gas, radiography and others.
Appropriately order and correctly interpret results of studies to determine the cause of shock and respond with appropriate actions.
Order appropriate monitoring and correctly interpret monitor data.
Correctly recognize cardiomegaly and other signs of congestive heart failure on chest radiograph.
Correctly identify the form of shock from a focused history, physical examination and initial diagnostic studies.
Initiate appropriate interventions based on the form of shock.
Facilitate effective transfer to a tertiary care center or intensive care setting when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with emergency room and intensive care staff to ensure appropriate care for patients in shock.
Listen effectively and respond to concerns of the family/caregiver and healthcare providers regarding changes in physiologic parameters including vital signs, mental status, physical examination, and urine output.
Provide family/caregiver support and education on the nuances and complexities of the various forms of shock and the importance of careful monitoring and evaluation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Work with hospital administration, hospital staff, subspecialists, and other services to advocate for an educational program for healthcare providers on the importance of early recognition of shock to prevent end‐organ failure and death.
Lead, coordinate or participate in the development and implementation of rapid response systems to assist in recognition and stabilization of early shock.
Collaborate with hospital administration and community partners to develop and sustain local AHA Pediatric Life Support classes where descriptions and case scenarios provide a comprehensive knowledge base and intervention plan for various types of shock.
Lead, coordinate or participate in efforts to partner with simulation centers to assist in acquiring skill sets needed for appropriate recognition and intervention for children in shock.
Copyright © 2010 Society of Hospital Medicine
Feeding tubes
Introduction
Feeding tubes are commonly used to deliver enteral nutrition and medications to pediatric inpatients. Commonly used tubes are nasogastric (NG), nasojejunal (NJ), gastric (G), gastrojejunal (GJ), or jejunal (J). They may be used instead of or in addition to oral feedings. Feeding tubes may deliver nutrition and medications into the stomach or past the pylorus. While different types of feeding tubes may be placed by a variety of practitioners ‐ nurses, radiologists, medical physicians, or surgeons ‐ it is critical for pediatric hospitalists to understand the uses, limitations, and complications of various types of feeding tubes.
Knowledge
Pediatric hospitalists should be able to:
Describe basic gastrointestinal anatomy and physiology, and relate this to commonly used feeding tubes.
Compare and contrast the indications, uses, and limitations of various types of feeding tubes, including NG, NJ, G, GJ, and J tubes.
Discuss the benefits of short term enteral feeding compared to intravenous fluid or parenteral nutrition use.
Describe the correct procedure to replace each type of feeding tube and potential complications to be avoided.
Review commonly encountered short and long term complications of feeding tubes, such as nasal irritation, granulation tissue, cellulitis, extrusion, obstruction, and others.
Compare and contrast risks and benefits of percutaneous endoscopic gastrostomy (PEG) versus surgical gastrostomy.
List the indications, risks, benefits, and alternatives for surgical gastrostomy with Nissen fundoplication.
Discuss the factors to consider when determining the optimal type of feeding tube for children with neurologic impairment, such as risk of aspiration pneumonia, social aspects of maintaining oral stimulation, complications of Nissen fundoplication, and others.
Compare and contrast the short and long term risks and benefits of gastrostomy with Nissen fundoplication versus placement of GJ tubes in patients with neurologic impairment.
Discuss the roles of primary care provider, home care, subspecialists, and the family/caregiver in the home management of feeding tubes.
Skills
Pediatric hospitalists should be able to:
Correctly institute short term NG feeding in appropriate patients.
Appropriately prescribe NG or NJ feeding, including correct starting and increasing volumes and enteral formula choice.
Correctly identify and refer appropriate patients for a G tube, GJ tube, or J tube placement.
Effectively and clearly articulate the risks and benefits of combining Nissen Fundoplication with G tube placement vs. GJ tube placement to the family/caregiver.
Accurately diagnose and treat dermatological problems associated with feeding tubes.
Accurately diagnose and initiate treatment for common complications (obstruction, extrusion, leakage) associated with feeding tubes, in collaboration with appropriate subspecialists.
Order appropriate radiological studies to assess feeding tube dysfunction.
Demonstrate basic proficiency in interpretation of radiographic studies commonly performed to assess correct tube placement.
Correctly identify the need for and efficiently access appropriate consultants.
Attitudes
Pediatric hospitalists should be able to:
Work collaboratively with patients, family/caregiver, hospital staff, subspecialists and the primary care provider in making decisions regarding feeding tubes.
Elicit and allay concerns of patients and the family/caregiver regarding the cosmetic appearance of tubes or impact on oral feeding.
Educate patients and the family/caregiver about the use and care of feeding tubes prior to discharge home.
Recognize the key role that home health care plays in the discharge planning and long term care of children with feeding tubes.
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 of feeding tubes for children.
Collaborate with hospital administration and community partners to develop and sustain local systems that organize and consolidate the feeding tube supplies and services for children in an identifiable, easily accessible location.
Lead, coordinate or participate in efforts to develop strategies to minimize institutional complication rates from feeding tube placement and use.
Lead, coordinate or participate in multidisciplinary efforts to develop an education and hospital discharge protocol to ensure that patients with feeding tubes are safely transitioned to the outpatient setting.
Introduction
Feeding tubes are commonly used to deliver enteral nutrition and medications to pediatric inpatients. Commonly used tubes are nasogastric (NG), nasojejunal (NJ), gastric (G), gastrojejunal (GJ), or jejunal (J). They may be used instead of or in addition to oral feedings. Feeding tubes may deliver nutrition and medications into the stomach or past the pylorus. While different types of feeding tubes may be placed by a variety of practitioners ‐ nurses, radiologists, medical physicians, or surgeons ‐ it is critical for pediatric hospitalists to understand the uses, limitations, and complications of various types of feeding tubes.
Knowledge
Pediatric hospitalists should be able to:
Describe basic gastrointestinal anatomy and physiology, and relate this to commonly used feeding tubes.
Compare and contrast the indications, uses, and limitations of various types of feeding tubes, including NG, NJ, G, GJ, and J tubes.
Discuss the benefits of short term enteral feeding compared to intravenous fluid or parenteral nutrition use.
Describe the correct procedure to replace each type of feeding tube and potential complications to be avoided.
Review commonly encountered short and long term complications of feeding tubes, such as nasal irritation, granulation tissue, cellulitis, extrusion, obstruction, and others.
Compare and contrast risks and benefits of percutaneous endoscopic gastrostomy (PEG) versus surgical gastrostomy.
List the indications, risks, benefits, and alternatives for surgical gastrostomy with Nissen fundoplication.
Discuss the factors to consider when determining the optimal type of feeding tube for children with neurologic impairment, such as risk of aspiration pneumonia, social aspects of maintaining oral stimulation, complications of Nissen fundoplication, and others.
Compare and contrast the short and long term risks and benefits of gastrostomy with Nissen fundoplication versus placement of GJ tubes in patients with neurologic impairment.
Discuss the roles of primary care provider, home care, subspecialists, and the family/caregiver in the home management of feeding tubes.
Skills
Pediatric hospitalists should be able to:
Correctly institute short term NG feeding in appropriate patients.
Appropriately prescribe NG or NJ feeding, including correct starting and increasing volumes and enteral formula choice.
Correctly identify and refer appropriate patients for a G tube, GJ tube, or J tube placement.
Effectively and clearly articulate the risks and benefits of combining Nissen Fundoplication with G tube placement vs. GJ tube placement to the family/caregiver.
Accurately diagnose and treat dermatological problems associated with feeding tubes.
Accurately diagnose and initiate treatment for common complications (obstruction, extrusion, leakage) associated with feeding tubes, in collaboration with appropriate subspecialists.
Order appropriate radiological studies to assess feeding tube dysfunction.
Demonstrate basic proficiency in interpretation of radiographic studies commonly performed to assess correct tube placement.
Correctly identify the need for and efficiently access appropriate consultants.
Attitudes
Pediatric hospitalists should be able to:
Work collaboratively with patients, family/caregiver, hospital staff, subspecialists and the primary care provider in making decisions regarding feeding tubes.
Elicit and allay concerns of patients and the family/caregiver regarding the cosmetic appearance of tubes or impact on oral feeding.
Educate patients and the family/caregiver about the use and care of feeding tubes prior to discharge home.
Recognize the key role that home health care plays in the discharge planning and long term care of children with feeding tubes.
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 of feeding tubes for children.
Collaborate with hospital administration and community partners to develop and sustain local systems that organize and consolidate the feeding tube supplies and services for children in an identifiable, easily accessible location.
Lead, coordinate or participate in efforts to develop strategies to minimize institutional complication rates from feeding tube placement and use.
Lead, coordinate or participate in multidisciplinary efforts to develop an education and hospital discharge protocol to ensure that patients with feeding tubes are safely transitioned to the outpatient setting.
Introduction
Feeding tubes are commonly used to deliver enteral nutrition and medications to pediatric inpatients. Commonly used tubes are nasogastric (NG), nasojejunal (NJ), gastric (G), gastrojejunal (GJ), or jejunal (J). They may be used instead of or in addition to oral feedings. Feeding tubes may deliver nutrition and medications into the stomach or past the pylorus. While different types of feeding tubes may be placed by a variety of practitioners ‐ nurses, radiologists, medical physicians, or surgeons ‐ it is critical for pediatric hospitalists to understand the uses, limitations, and complications of various types of feeding tubes.
Knowledge
Pediatric hospitalists should be able to:
Describe basic gastrointestinal anatomy and physiology, and relate this to commonly used feeding tubes.
Compare and contrast the indications, uses, and limitations of various types of feeding tubes, including NG, NJ, G, GJ, and J tubes.
Discuss the benefits of short term enteral feeding compared to intravenous fluid or parenteral nutrition use.
Describe the correct procedure to replace each type of feeding tube and potential complications to be avoided.
Review commonly encountered short and long term complications of feeding tubes, such as nasal irritation, granulation tissue, cellulitis, extrusion, obstruction, and others.
Compare and contrast risks and benefits of percutaneous endoscopic gastrostomy (PEG) versus surgical gastrostomy.
List the indications, risks, benefits, and alternatives for surgical gastrostomy with Nissen fundoplication.
Discuss the factors to consider when determining the optimal type of feeding tube for children with neurologic impairment, such as risk of aspiration pneumonia, social aspects of maintaining oral stimulation, complications of Nissen fundoplication, and others.
Compare and contrast the short and long term risks and benefits of gastrostomy with Nissen fundoplication versus placement of GJ tubes in patients with neurologic impairment.
Discuss the roles of primary care provider, home care, subspecialists, and the family/caregiver in the home management of feeding tubes.
Skills
Pediatric hospitalists should be able to:
Correctly institute short term NG feeding in appropriate patients.
Appropriately prescribe NG or NJ feeding, including correct starting and increasing volumes and enteral formula choice.
Correctly identify and refer appropriate patients for a G tube, GJ tube, or J tube placement.
Effectively and clearly articulate the risks and benefits of combining Nissen Fundoplication with G tube placement vs. GJ tube placement to the family/caregiver.
Accurately diagnose and treat dermatological problems associated with feeding tubes.
Accurately diagnose and initiate treatment for common complications (obstruction, extrusion, leakage) associated with feeding tubes, in collaboration with appropriate subspecialists.
Order appropriate radiological studies to assess feeding tube dysfunction.
Demonstrate basic proficiency in interpretation of radiographic studies commonly performed to assess correct tube placement.
Correctly identify the need for and efficiently access appropriate consultants.
Attitudes
Pediatric hospitalists should be able to:
Work collaboratively with patients, family/caregiver, hospital staff, subspecialists and the primary care provider in making decisions regarding feeding tubes.
Elicit and allay concerns of patients and the family/caregiver regarding the cosmetic appearance of tubes or impact on oral feeding.
Educate patients and the family/caregiver about the use and care of feeding tubes prior to discharge home.
Recognize the key role that home health care plays in the discharge planning and long term care of children with feeding tubes.
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 of feeding tubes for children.
Collaborate with hospital administration and community partners to develop and sustain local systems that organize and consolidate the feeding tube supplies and services for children in an identifiable, easily accessible location.
Lead, coordinate or participate in efforts to develop strategies to minimize institutional complication rates from feeding tube placement and use.
Lead, coordinate or participate in multidisciplinary efforts to develop an education and hospital discharge protocol to ensure that patients with feeding tubes are safely transitioned to the outpatient setting.
Copyright © 2010 Society of Hospital Medicine
Apparent life‐threatening event
Introduction
Apparent Life‐Threatening Event (ALTE) is defined by the NIH Consensus Development Conference on Infantile Apnea and Home Monitoring as an episode that is frightening to the observer and that is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking, or gagging. Because ALTE is a description of symptoms rather than a diagnosis, epidemiologic data is imprecise. It is estimated that 1‐3% of infants will have an episode that can be described as an ALTE and that most of these infants present before 2 months of life. Pediatric hospitalists can provide a valuable service to the family/caregiver by reconciling the potentially life threatening nature of ALTE with an infant who often appears normal on physical examination. Pediatric hospitalists should approach the broad differential diagnosis in a logical, systematic manner.
Knowledge
Pediatric hospitalists should be able to:
Describe the differential diagnosis of ALTE (such as gastroesophageal reflux disease, seizure, apnea of prematurity, infection [sepsis, meningitis, pertussis, bronchiolitis], toxin, breath‐holding spell, cardiac arrhythmia, obstructive sleep apnea, inborn errors of metabolism, central hypoventilation syndrome, hydrocephalus, child abuse, Munchausen's Syndrome by Proxy, and others) and the key historical or physical findings specifically associated with each diagnosis.
Provide indications for admission to the hospital and determine the appropriate level of care required.
Describe the goals of hospitalization including stabilization, diagnosis, treatment, reassurance, and education.
Compare and contrast Sudden Infant Death Syndrome (SIDS) versus ALTE,
Discuss current hypotheses regarding the etiology of SIDS and relate this to the spectrum of disorders that may cause ALTE.
Describe a basic approach toward the work‐up for ALTE and list the factors that may warrant an increased level of laboratory, radiographic, or other testing.
Summarize the literature on the impact of home monitors on morbidity and mortality and identify the benefits and limitations of home monitoring.
Skills
Pediatric hospitalists should be able to:
Resuscitate and stabilize an infant with ALTE who presents in an unstable state.
Obtain an accurate patient history and perform a thorough physical examination eliciting features to narrow the differential diagnosis of ALTE.
Critically assess the level of evidence and risk/benefit ratio for the diagnostic work‐up and management plan.
Interpret basic tests (such as laboratory tests, chest x‐rays, and electrocardiograms) and identify abnormal findings that require further testing or consultation.
Order appropriate monitoring and correctly interpret monitor data.
Engage consultants and support staff (such as subspecialty physicians and social workers) efficiently and appropriately.
Use the ALTE admission as an opportunity to educate the family/caregiver on proper sleep positioning and risk factors for SIDS.
Impart basic resuscitation skills to the family/caregiver, using a teach‐back method.
Coordinate care with the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with the family/caregiver, and healthcare providers regarding findings and care plans.
Ensure a safe and supportive atmosphere for the patient and family during the period of observation and evaluation of a child admitted following an ALTE.
Counsel the family/caregiver on the valid use of home monitors in a limited population, noting the features which support or refute use of a home monitor for their child.
Realize the impact of an ALTE on the family/caregiver and the implications for discharge planning and follow‐up.
Role model professional behavior when addressing issues related to potential social concerns and child abuse evaluation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in multidisciplinary initiatives to develop and implement evidence‐based clinical guidelines to improve quality of care for infants with ALTE.
Advocate for preventive education regarding sudden infant death syndrome in the hospital system and community.
Introduction
Apparent Life‐Threatening Event (ALTE) is defined by the NIH Consensus Development Conference on Infantile Apnea and Home Monitoring as an episode that is frightening to the observer and that is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking, or gagging. Because ALTE is a description of symptoms rather than a diagnosis, epidemiologic data is imprecise. It is estimated that 1‐3% of infants will have an episode that can be described as an ALTE and that most of these infants present before 2 months of life. Pediatric hospitalists can provide a valuable service to the family/caregiver by reconciling the potentially life threatening nature of ALTE with an infant who often appears normal on physical examination. Pediatric hospitalists should approach the broad differential diagnosis in a logical, systematic manner.
Knowledge
Pediatric hospitalists should be able to:
Describe the differential diagnosis of ALTE (such as gastroesophageal reflux disease, seizure, apnea of prematurity, infection [sepsis, meningitis, pertussis, bronchiolitis], toxin, breath‐holding spell, cardiac arrhythmia, obstructive sleep apnea, inborn errors of metabolism, central hypoventilation syndrome, hydrocephalus, child abuse, Munchausen's Syndrome by Proxy, and others) and the key historical or physical findings specifically associated with each diagnosis.
Provide indications for admission to the hospital and determine the appropriate level of care required.
Describe the goals of hospitalization including stabilization, diagnosis, treatment, reassurance, and education.
Compare and contrast Sudden Infant Death Syndrome (SIDS) versus ALTE,
Discuss current hypotheses regarding the etiology of SIDS and relate this to the spectrum of disorders that may cause ALTE.
Describe a basic approach toward the work‐up for ALTE and list the factors that may warrant an increased level of laboratory, radiographic, or other testing.
Summarize the literature on the impact of home monitors on morbidity and mortality and identify the benefits and limitations of home monitoring.
Skills
Pediatric hospitalists should be able to:
Resuscitate and stabilize an infant with ALTE who presents in an unstable state.
Obtain an accurate patient history and perform a thorough physical examination eliciting features to narrow the differential diagnosis of ALTE.
Critically assess the level of evidence and risk/benefit ratio for the diagnostic work‐up and management plan.
Interpret basic tests (such as laboratory tests, chest x‐rays, and electrocardiograms) and identify abnormal findings that require further testing or consultation.
Order appropriate monitoring and correctly interpret monitor data.
Engage consultants and support staff (such as subspecialty physicians and social workers) efficiently and appropriately.
Use the ALTE admission as an opportunity to educate the family/caregiver on proper sleep positioning and risk factors for SIDS.
Impart basic resuscitation skills to the family/caregiver, using a teach‐back method.
Coordinate care with the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with the family/caregiver, and healthcare providers regarding findings and care plans.
Ensure a safe and supportive atmosphere for the patient and family during the period of observation and evaluation of a child admitted following an ALTE.
Counsel the family/caregiver on the valid use of home monitors in a limited population, noting the features which support or refute use of a home monitor for their child.
Realize the impact of an ALTE on the family/caregiver and the implications for discharge planning and follow‐up.
Role model professional behavior when addressing issues related to potential social concerns and child abuse evaluation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in multidisciplinary initiatives to develop and implement evidence‐based clinical guidelines to improve quality of care for infants with ALTE.
Advocate for preventive education regarding sudden infant death syndrome in the hospital system and community.
Introduction
Apparent Life‐Threatening Event (ALTE) is defined by the NIH Consensus Development Conference on Infantile Apnea and Home Monitoring as an episode that is frightening to the observer and that is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking, or gagging. Because ALTE is a description of symptoms rather than a diagnosis, epidemiologic data is imprecise. It is estimated that 1‐3% of infants will have an episode that can be described as an ALTE and that most of these infants present before 2 months of life. Pediatric hospitalists can provide a valuable service to the family/caregiver by reconciling the potentially life threatening nature of ALTE with an infant who often appears normal on physical examination. Pediatric hospitalists should approach the broad differential diagnosis in a logical, systematic manner.
Knowledge
Pediatric hospitalists should be able to:
Describe the differential diagnosis of ALTE (such as gastroesophageal reflux disease, seizure, apnea of prematurity, infection [sepsis, meningitis, pertussis, bronchiolitis], toxin, breath‐holding spell, cardiac arrhythmia, obstructive sleep apnea, inborn errors of metabolism, central hypoventilation syndrome, hydrocephalus, child abuse, Munchausen's Syndrome by Proxy, and others) and the key historical or physical findings specifically associated with each diagnosis.
Provide indications for admission to the hospital and determine the appropriate level of care required.
Describe the goals of hospitalization including stabilization, diagnosis, treatment, reassurance, and education.
Compare and contrast Sudden Infant Death Syndrome (SIDS) versus ALTE,
Discuss current hypotheses regarding the etiology of SIDS and relate this to the spectrum of disorders that may cause ALTE.
Describe a basic approach toward the work‐up for ALTE and list the factors that may warrant an increased level of laboratory, radiographic, or other testing.
Summarize the literature on the impact of home monitors on morbidity and mortality and identify the benefits and limitations of home monitoring.
Skills
Pediatric hospitalists should be able to:
Resuscitate and stabilize an infant with ALTE who presents in an unstable state.
Obtain an accurate patient history and perform a thorough physical examination eliciting features to narrow the differential diagnosis of ALTE.
Critically assess the level of evidence and risk/benefit ratio for the diagnostic work‐up and management plan.
Interpret basic tests (such as laboratory tests, chest x‐rays, and electrocardiograms) and identify abnormal findings that require further testing or consultation.
Order appropriate monitoring and correctly interpret monitor data.
Engage consultants and support staff (such as subspecialty physicians and social workers) efficiently and appropriately.
Use the ALTE admission as an opportunity to educate the family/caregiver on proper sleep positioning and risk factors for SIDS.
Impart basic resuscitation skills to the family/caregiver, using a teach‐back method.
Coordinate care with the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with the family/caregiver, and healthcare providers regarding findings and care plans.
Ensure a safe and supportive atmosphere for the patient and family during the period of observation and evaluation of a child admitted following an ALTE.
Counsel the family/caregiver on the valid use of home monitors in a limited population, noting the features which support or refute use of a home monitor for their child.
Realize the impact of an ALTE on the family/caregiver and the implications for discharge planning and follow‐up.
Role model professional behavior when addressing issues related to potential social concerns and child abuse evaluation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in multidisciplinary initiatives to develop and implement evidence‐based clinical guidelines to improve quality of care for infants with ALTE.
Advocate for preventive education regarding sudden infant death syndrome in the hospital system and community.
Copyright © 2010 Society of Hospital Medicine
Hospice and palliative care
Introduction
Pediatric palliative and/or hospice care are increasingly important components of the continuum of care for hospitalized children. As both a philosophy and an organized method for delivering care, these approaches to care focus on the relief of physical, psychosocial, and spiritual suffering experienced by infants, children and adolescents and the family/caregiver who face a life‐threatening condition. The guiding philosophy includes comfort and quality of life, while at the same time sustaining hope despite the likelihood of death. The goals of this type of care include enhancing choices, relieving pain and suffering and ensuring the best quality of care for the child and family/caregiver during the stages of living, dying and grief and bereavement. Care may be provided at home, in an inpatient hospice setting or within a traditional hospital setting. Palliative care services are most easily accessible in the traditional intensive care and hospital settings. Resources for treatment of dying children outside of these settings may be quite limited and vary by geographic location. Pediatric hospitalists therefore are often in the best position to provide both leadership and clinical roles for children requiring these services. Pediatric hospitalists should be able to access available palliative and hospice services and must be comfortable managing ethical dilemmas encountered in the inpatient setting related to care of the dying patient.
Knowledge
Pediatric hospitalists should be able to:
Define the terms palliative and hospice care and describe the similarities and differences between them.
Give examples of children who may be appropriate for hospice and palliative care services.
Describe why pediatric hospice and palliative care are optimally provided by an interdisciplinary team consisting of a pediatrician, pediatric nurse, social worker, chaplain, home health aide, and others.
Compare and contrast multidisciplinary with interdisciplinary team dynamics.
Describe why the decision related to forgoing potentially life‐sustaining treatments or the withdrawal of life support often are best made before a child becomes critically ill.
Discuss the elements of a treatment plan for relief of suffering, including appropriate consultations (such as palliative care, pain service, physiatrists, and others) and therapies (such as complementary medicine, pain medications, and others).
Explain how elements of palliative treatment and curative treatment may simultaneously occur during the course of treatment of a child's life limiting illness.
Identify local, regional, and national resources for pediatric palliative and hospice care that are accessible to patients, the family/caregiver, and healthcare providers.
Describe the role and composition of a hospital Ethics Committee as it relates to patient and family/caregiver decisions regarding end‐of‐life decisions.
Describe the processes involved in writing Allow Natural Death (AND) orders, pronouncing a person dead, completing a death certificate, discussing autopsy and donor mandates and options, and accessing immediate support for family/caregiver and staff.
Skills
Pediatric hospitalists should be able to:
Proactively identify opportunities for appropriate referral to and utilization of hospice and palliative care services.
Communicate bad news effectively and provide opportunities for patients and the family/caregiver to be introduced to palliative care or hospice services when appropriate.
Manage ethical dilemmas encountered in the inpatient setting related to care of the dying patient.
Integrate cultural issues in discussions and management of end of life issues.
Effectively adapt communication methods to varying age and developmental stages to assure understanding of chronic illness, death and dying.
Recognize and manage pain and other common symptoms causing distress for patients and the family/caregiver at the end of life.
Correctly prescribe medication and non‐medication therapies in collaboration with appropriate consultants.
Attitudes
Pediatric hospitalists should be able to:
Create awareness for the importance of pediatric palliative and hospice care.
Demonstrate awareness and acceptance of palliative care approaches, which may include alternative and/or complementary medical therapies.
Role model ethical behavior at all times.
Identify personal attitudes toward end of life care from a physical, psychosocial and spiritual perspective.
Recognize when personal perspective and bias may influence care for dying patients.
Identify gaps in personal knowledge, skills and attitudes regarding palliative care and utilize opportunities for professional education to address them.
Collaborate with the interdisciplinary team, subspecialists and the primary care provider to ensure coordinated longitudinal care for children receiving palliative or hospice services.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Engage in organizational efforts to provide pediatric hospice and palliative care education for interdisciplinary teams.
Create or help sustain a pediatric perspective for hospital Ethics Committees.
Collaborate with hospital administration and community partners to ensure efficient access to appropriate consultants necessary for success of these programs for children.
Advocate for development of pediatric hospice and palliative care resources in their hospital and their community.
Introduction
Pediatric palliative and/or hospice care are increasingly important components of the continuum of care for hospitalized children. As both a philosophy and an organized method for delivering care, these approaches to care focus on the relief of physical, psychosocial, and spiritual suffering experienced by infants, children and adolescents and the family/caregiver who face a life‐threatening condition. The guiding philosophy includes comfort and quality of life, while at the same time sustaining hope despite the likelihood of death. The goals of this type of care include enhancing choices, relieving pain and suffering and ensuring the best quality of care for the child and family/caregiver during the stages of living, dying and grief and bereavement. Care may be provided at home, in an inpatient hospice setting or within a traditional hospital setting. Palliative care services are most easily accessible in the traditional intensive care and hospital settings. Resources for treatment of dying children outside of these settings may be quite limited and vary by geographic location. Pediatric hospitalists therefore are often in the best position to provide both leadership and clinical roles for children requiring these services. Pediatric hospitalists should be able to access available palliative and hospice services and must be comfortable managing ethical dilemmas encountered in the inpatient setting related to care of the dying patient.
Knowledge
Pediatric hospitalists should be able to:
Define the terms palliative and hospice care and describe the similarities and differences between them.
Give examples of children who may be appropriate for hospice and palliative care services.
Describe why pediatric hospice and palliative care are optimally provided by an interdisciplinary team consisting of a pediatrician, pediatric nurse, social worker, chaplain, home health aide, and others.
Compare and contrast multidisciplinary with interdisciplinary team dynamics.
Describe why the decision related to forgoing potentially life‐sustaining treatments or the withdrawal of life support often are best made before a child becomes critically ill.
Discuss the elements of a treatment plan for relief of suffering, including appropriate consultations (such as palliative care, pain service, physiatrists, and others) and therapies (such as complementary medicine, pain medications, and others).
Explain how elements of palliative treatment and curative treatment may simultaneously occur during the course of treatment of a child's life limiting illness.
Identify local, regional, and national resources for pediatric palliative and hospice care that are accessible to patients, the family/caregiver, and healthcare providers.
Describe the role and composition of a hospital Ethics Committee as it relates to patient and family/caregiver decisions regarding end‐of‐life decisions.
Describe the processes involved in writing Allow Natural Death (AND) orders, pronouncing a person dead, completing a death certificate, discussing autopsy and donor mandates and options, and accessing immediate support for family/caregiver and staff.
Skills
Pediatric hospitalists should be able to:
Proactively identify opportunities for appropriate referral to and utilization of hospice and palliative care services.
Communicate bad news effectively and provide opportunities for patients and the family/caregiver to be introduced to palliative care or hospice services when appropriate.
Manage ethical dilemmas encountered in the inpatient setting related to care of the dying patient.
Integrate cultural issues in discussions and management of end of life issues.
Effectively adapt communication methods to varying age and developmental stages to assure understanding of chronic illness, death and dying.
Recognize and manage pain and other common symptoms causing distress for patients and the family/caregiver at the end of life.
Correctly prescribe medication and non‐medication therapies in collaboration with appropriate consultants.
Attitudes
Pediatric hospitalists should be able to:
Create awareness for the importance of pediatric palliative and hospice care.
Demonstrate awareness and acceptance of palliative care approaches, which may include alternative and/or complementary medical therapies.
Role model ethical behavior at all times.
Identify personal attitudes toward end of life care from a physical, psychosocial and spiritual perspective.
Recognize when personal perspective and bias may influence care for dying patients.
Identify gaps in personal knowledge, skills and attitudes regarding palliative care and utilize opportunities for professional education to address them.
Collaborate with the interdisciplinary team, subspecialists and the primary care provider to ensure coordinated longitudinal care for children receiving palliative or hospice services.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Engage in organizational efforts to provide pediatric hospice and palliative care education for interdisciplinary teams.
Create or help sustain a pediatric perspective for hospital Ethics Committees.
Collaborate with hospital administration and community partners to ensure efficient access to appropriate consultants necessary for success of these programs for children.
Advocate for development of pediatric hospice and palliative care resources in their hospital and their community.
Introduction
Pediatric palliative and/or hospice care are increasingly important components of the continuum of care for hospitalized children. As both a philosophy and an organized method for delivering care, these approaches to care focus on the relief of physical, psychosocial, and spiritual suffering experienced by infants, children and adolescents and the family/caregiver who face a life‐threatening condition. The guiding philosophy includes comfort and quality of life, while at the same time sustaining hope despite the likelihood of death. The goals of this type of care include enhancing choices, relieving pain and suffering and ensuring the best quality of care for the child and family/caregiver during the stages of living, dying and grief and bereavement. Care may be provided at home, in an inpatient hospice setting or within a traditional hospital setting. Palliative care services are most easily accessible in the traditional intensive care and hospital settings. Resources for treatment of dying children outside of these settings may be quite limited and vary by geographic location. Pediatric hospitalists therefore are often in the best position to provide both leadership and clinical roles for children requiring these services. Pediatric hospitalists should be able to access available palliative and hospice services and must be comfortable managing ethical dilemmas encountered in the inpatient setting related to care of the dying patient.
Knowledge
Pediatric hospitalists should be able to:
Define the terms palliative and hospice care and describe the similarities and differences between them.
Give examples of children who may be appropriate for hospice and palliative care services.
Describe why pediatric hospice and palliative care are optimally provided by an interdisciplinary team consisting of a pediatrician, pediatric nurse, social worker, chaplain, home health aide, and others.
Compare and contrast multidisciplinary with interdisciplinary team dynamics.
Describe why the decision related to forgoing potentially life‐sustaining treatments or the withdrawal of life support often are best made before a child becomes critically ill.
Discuss the elements of a treatment plan for relief of suffering, including appropriate consultations (such as palliative care, pain service, physiatrists, and others) and therapies (such as complementary medicine, pain medications, and others).
Explain how elements of palliative treatment and curative treatment may simultaneously occur during the course of treatment of a child's life limiting illness.
Identify local, regional, and national resources for pediatric palliative and hospice care that are accessible to patients, the family/caregiver, and healthcare providers.
Describe the role and composition of a hospital Ethics Committee as it relates to patient and family/caregiver decisions regarding end‐of‐life decisions.
Describe the processes involved in writing Allow Natural Death (AND) orders, pronouncing a person dead, completing a death certificate, discussing autopsy and donor mandates and options, and accessing immediate support for family/caregiver and staff.
Skills
Pediatric hospitalists should be able to:
Proactively identify opportunities for appropriate referral to and utilization of hospice and palliative care services.
Communicate bad news effectively and provide opportunities for patients and the family/caregiver to be introduced to palliative care or hospice services when appropriate.
Manage ethical dilemmas encountered in the inpatient setting related to care of the dying patient.
Integrate cultural issues in discussions and management of end of life issues.
Effectively adapt communication methods to varying age and developmental stages to assure understanding of chronic illness, death and dying.
Recognize and manage pain and other common symptoms causing distress for patients and the family/caregiver at the end of life.
Correctly prescribe medication and non‐medication therapies in collaboration with appropriate consultants.
Attitudes
Pediatric hospitalists should be able to:
Create awareness for the importance of pediatric palliative and hospice care.
Demonstrate awareness and acceptance of palliative care approaches, which may include alternative and/or complementary medical therapies.
Role model ethical behavior at all times.
Identify personal attitudes toward end of life care from a physical, psychosocial and spiritual perspective.
Recognize when personal perspective and bias may influence care for dying patients.
Identify gaps in personal knowledge, skills and attitudes regarding palliative care and utilize opportunities for professional education to address them.
Collaborate with the interdisciplinary team, subspecialists and the primary care provider to ensure coordinated longitudinal care for children receiving palliative or hospice services.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Engage in organizational efforts to provide pediatric hospice and palliative care education for interdisciplinary teams.
Create or help sustain a pediatric perspective for hospital Ethics Committees.
Collaborate with hospital administration and community partners to ensure efficient access to appropriate consultants necessary for success of these programs for children.
Advocate for development of pediatric hospice and palliative care resources in their hospital and their community.
Copyright © 2010 Society of Hospital Medicine