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Diabetes mellitus
Introduction
Diabetes mellitus, a disorder of glucose homeostasis, is increasing in incidence and prevalence in pediatrics. Although Type 1 diabetes is more frequently diagnosed in children, there has recently been a significant rise in the incidence of Type 2 diabetes, particularly among adolescents in certain ethnic groups. The increasing incidence of Type 2 diabetes parallels the increasing incidence of obesity in the population. In addition to the medical complications associated with this chronic disease, both forms of diabetes have profound social and emotional impacts on the child. Pediatric hospitalists frequently encounter both children with new‐onset diabetes and known diabetics requiring hospitalization because of poor disease control, illness, or elective procedures. Pediatric hospitalists are often in the best position to provide both immediate care for children with diabetes as well as to coordinate care across multiple specialties when necessary.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the epidemiology and pathophysiology of Type 1 with Type 2 diabetes attending to differences in impairment of glucose regulation and occurrence of ketoacidosis.
List common alternate causes of hyperglycemia, such as stress, drug, or steroid‐induced hyperglycemia and give examples of situations in which insulin administration is indicated.
Discuss the importance of completing a thorough review of systems and family history and a full physical examination in order to identify polyendocrinopathies.
Describe the role of obesity in the metabolic syndrome and Type 2 diabetes.
List and explain the laboratory tests used to determine the type of diabetes, assess glucose control, and identify complications or co‐morbidities of diabetes (such as glutamic acid decarboxylase, insulin auto antibodies, islet cell antibodies, hemoglobin A1c, thyroid panel, and celiac panel).
Describe the initial management of diabetic ketoacidosis (DKA), attending to fluid delivery, electrolyte monitoring, mental status assessments, frequency of repeated blood testing, and appropriate patient placement based on local facility services.
Define criteria for escalating care in the context of severe acidosis, altered mental status, and effects of electrolyte disturbances.
Summarize the approach toward management and education after stabilization of DKA.
Discuss the importance of including cultural and ethnic practices when creating a diabetes management plan.
Discuss potential complications that may result from treatment, including hypoglycemia and electrolyte imbalances
Identify the co‐morbidities commonly associated with both Type 1 and Type 2 diabetes.
Describe the different formulations of and delivery systems for insulin.
Review the principles of carbohydrate counting.
Discuss short and long‐term prognostic factors associated with complications of poor glucose control.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose diabetes and its complications by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
Correctly recognize and determine the cause of DKA in the patient with known diabetes by efficiently performing an accurate history and physical examination and ordering appropriate diagnostic tests.
Order appropriate diagnostic testing for patients with new onset diabetes or diabetes exacerbations.
Implement an evidence‐based treatment plan.
Correctly order insulin doses and delivery systems (such as continuous infusion, subcutaneous, and others) and other classes of drugs used in the treatment of diabetes.
Recognize and manage both hyperglycemia and hypoglycemia with particular attention to complications that may arise during treatment.
Recognize the indications for escalating levels of care and promptly initiate appropriate actions.
Identify the indications for in hospital consultation and obtain prompt consultation with an endocrinologist or other subspecialist as appropriate.
Access available support services such as social work, child life, nutrition, and others to ensure a comprehensive management approach.
Clearly articulate discharge criteria and outpatient long term management strategies for patients and the family/caregiver.
Coordinate care and education for patients and the family/caregiver with other healthcare providers.
Coordinate care with subspecialists and the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with patients maintaining awareness of the unique needs of pre‐adolescent and adolescent age groups.
Discuss the importance of a healthy lifestyle in promoting optimal disease management with patients and the family/caregiver.
Recognize that acute and chronic psychosocial factors impact the ability of patients and the family/caregiver to appropriately manage the disease.
Recognize the importance of the multidisciplinary team approach in the management of diabetes in children, including involvement of the primary care provider, endocrinologist, nutritionist, social worker, psychologist, child life, and school representative.
Maintain awareness of local populations which may have multiple risk factors for diabetes
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with diabetes.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize the evaluation and management for hospitalized children with diabetes.
Work with hospital administration, hospital staff, subspecialists and community organizations to affect system‐wide processes to improve the transition of care from hospital to the ambulatory setting.
Lead, coordinate or participate in system‐wide processes within the hospital to promote therapeutic safety and vigilance in the use of hypoglycemic agents.
Lead, coordinate or participate in educational events to promote awareness of and familiarity with national guidelines for management strategies, new therapeutic and pharmacologic agents and the use of medical devices to improve and monitor glucose homeostasis.
Introduction
Diabetes mellitus, a disorder of glucose homeostasis, is increasing in incidence and prevalence in pediatrics. Although Type 1 diabetes is more frequently diagnosed in children, there has recently been a significant rise in the incidence of Type 2 diabetes, particularly among adolescents in certain ethnic groups. The increasing incidence of Type 2 diabetes parallels the increasing incidence of obesity in the population. In addition to the medical complications associated with this chronic disease, both forms of diabetes have profound social and emotional impacts on the child. Pediatric hospitalists frequently encounter both children with new‐onset diabetes and known diabetics requiring hospitalization because of poor disease control, illness, or elective procedures. Pediatric hospitalists are often in the best position to provide both immediate care for children with diabetes as well as to coordinate care across multiple specialties when necessary.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the epidemiology and pathophysiology of Type 1 with Type 2 diabetes attending to differences in impairment of glucose regulation and occurrence of ketoacidosis.
List common alternate causes of hyperglycemia, such as stress, drug, or steroid‐induced hyperglycemia and give examples of situations in which insulin administration is indicated.
Discuss the importance of completing a thorough review of systems and family history and a full physical examination in order to identify polyendocrinopathies.
Describe the role of obesity in the metabolic syndrome and Type 2 diabetes.
List and explain the laboratory tests used to determine the type of diabetes, assess glucose control, and identify complications or co‐morbidities of diabetes (such as glutamic acid decarboxylase, insulin auto antibodies, islet cell antibodies, hemoglobin A1c, thyroid panel, and celiac panel).
Describe the initial management of diabetic ketoacidosis (DKA), attending to fluid delivery, electrolyte monitoring, mental status assessments, frequency of repeated blood testing, and appropriate patient placement based on local facility services.
Define criteria for escalating care in the context of severe acidosis, altered mental status, and effects of electrolyte disturbances.
Summarize the approach toward management and education after stabilization of DKA.
Discuss the importance of including cultural and ethnic practices when creating a diabetes management plan.
Discuss potential complications that may result from treatment, including hypoglycemia and electrolyte imbalances
Identify the co‐morbidities commonly associated with both Type 1 and Type 2 diabetes.
Describe the different formulations of and delivery systems for insulin.
Review the principles of carbohydrate counting.
Discuss short and long‐term prognostic factors associated with complications of poor glucose control.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose diabetes and its complications by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
Correctly recognize and determine the cause of DKA in the patient with known diabetes by efficiently performing an accurate history and physical examination and ordering appropriate diagnostic tests.
Order appropriate diagnostic testing for patients with new onset diabetes or diabetes exacerbations.
Implement an evidence‐based treatment plan.
Correctly order insulin doses and delivery systems (such as continuous infusion, subcutaneous, and others) and other classes of drugs used in the treatment of diabetes.
Recognize and manage both hyperglycemia and hypoglycemia with particular attention to complications that may arise during treatment.
Recognize the indications for escalating levels of care and promptly initiate appropriate actions.
Identify the indications for in hospital consultation and obtain prompt consultation with an endocrinologist or other subspecialist as appropriate.
Access available support services such as social work, child life, nutrition, and others to ensure a comprehensive management approach.
Clearly articulate discharge criteria and outpatient long term management strategies for patients and the family/caregiver.
Coordinate care and education for patients and the family/caregiver with other healthcare providers.
Coordinate care with subspecialists and the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with patients maintaining awareness of the unique needs of pre‐adolescent and adolescent age groups.
Discuss the importance of a healthy lifestyle in promoting optimal disease management with patients and the family/caregiver.
Recognize that acute and chronic psychosocial factors impact the ability of patients and the family/caregiver to appropriately manage the disease.
Recognize the importance of the multidisciplinary team approach in the management of diabetes in children, including involvement of the primary care provider, endocrinologist, nutritionist, social worker, psychologist, child life, and school representative.
Maintain awareness of local populations which may have multiple risk factors for diabetes
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with diabetes.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize the evaluation and management for hospitalized children with diabetes.
Work with hospital administration, hospital staff, subspecialists and community organizations to affect system‐wide processes to improve the transition of care from hospital to the ambulatory setting.
Lead, coordinate or participate in system‐wide processes within the hospital to promote therapeutic safety and vigilance in the use of hypoglycemic agents.
Lead, coordinate or participate in educational events to promote awareness of and familiarity with national guidelines for management strategies, new therapeutic and pharmacologic agents and the use of medical devices to improve and monitor glucose homeostasis.
Introduction
Diabetes mellitus, a disorder of glucose homeostasis, is increasing in incidence and prevalence in pediatrics. Although Type 1 diabetes is more frequently diagnosed in children, there has recently been a significant rise in the incidence of Type 2 diabetes, particularly among adolescents in certain ethnic groups. The increasing incidence of Type 2 diabetes parallels the increasing incidence of obesity in the population. In addition to the medical complications associated with this chronic disease, both forms of diabetes have profound social and emotional impacts on the child. Pediatric hospitalists frequently encounter both children with new‐onset diabetes and known diabetics requiring hospitalization because of poor disease control, illness, or elective procedures. Pediatric hospitalists are often in the best position to provide both immediate care for children with diabetes as well as to coordinate care across multiple specialties when necessary.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the epidemiology and pathophysiology of Type 1 with Type 2 diabetes attending to differences in impairment of glucose regulation and occurrence of ketoacidosis.
List common alternate causes of hyperglycemia, such as stress, drug, or steroid‐induced hyperglycemia and give examples of situations in which insulin administration is indicated.
Discuss the importance of completing a thorough review of systems and family history and a full physical examination in order to identify polyendocrinopathies.
Describe the role of obesity in the metabolic syndrome and Type 2 diabetes.
List and explain the laboratory tests used to determine the type of diabetes, assess glucose control, and identify complications or co‐morbidities of diabetes (such as glutamic acid decarboxylase, insulin auto antibodies, islet cell antibodies, hemoglobin A1c, thyroid panel, and celiac panel).
Describe the initial management of diabetic ketoacidosis (DKA), attending to fluid delivery, electrolyte monitoring, mental status assessments, frequency of repeated blood testing, and appropriate patient placement based on local facility services.
Define criteria for escalating care in the context of severe acidosis, altered mental status, and effects of electrolyte disturbances.
Summarize the approach toward management and education after stabilization of DKA.
Discuss the importance of including cultural and ethnic practices when creating a diabetes management plan.
Discuss potential complications that may result from treatment, including hypoglycemia and electrolyte imbalances
Identify the co‐morbidities commonly associated with both Type 1 and Type 2 diabetes.
Describe the different formulations of and delivery systems for insulin.
Review the principles of carbohydrate counting.
Discuss short and long‐term prognostic factors associated with complications of poor glucose control.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose diabetes and its complications by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
Correctly recognize and determine the cause of DKA in the patient with known diabetes by efficiently performing an accurate history and physical examination and ordering appropriate diagnostic tests.
Order appropriate diagnostic testing for patients with new onset diabetes or diabetes exacerbations.
Implement an evidence‐based treatment plan.
Correctly order insulin doses and delivery systems (such as continuous infusion, subcutaneous, and others) and other classes of drugs used in the treatment of diabetes.
Recognize and manage both hyperglycemia and hypoglycemia with particular attention to complications that may arise during treatment.
Recognize the indications for escalating levels of care and promptly initiate appropriate actions.
Identify the indications for in hospital consultation and obtain prompt consultation with an endocrinologist or other subspecialist as appropriate.
Access available support services such as social work, child life, nutrition, and others to ensure a comprehensive management approach.
Clearly articulate discharge criteria and outpatient long term management strategies for patients and the family/caregiver.
Coordinate care and education for patients and the family/caregiver with other healthcare providers.
Coordinate care with subspecialists and the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with patients maintaining awareness of the unique needs of pre‐adolescent and adolescent age groups.
Discuss the importance of a healthy lifestyle in promoting optimal disease management with patients and the family/caregiver.
Recognize that acute and chronic psychosocial factors impact the ability of patients and the family/caregiver to appropriately manage the disease.
Recognize the importance of the multidisciplinary team approach in the management of diabetes in children, including involvement of the primary care provider, endocrinologist, nutritionist, social worker, psychologist, child life, and school representative.
Maintain awareness of local populations which may have multiple risk factors for diabetes
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with diabetes.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize the evaluation and management for hospitalized children with diabetes.
Work with hospital administration, hospital staff, subspecialists and community organizations to affect system‐wide processes to improve the transition of care from hospital to the ambulatory setting.
Lead, coordinate or participate in system‐wide processes within the hospital to promote therapeutic safety and vigilance in the use of hypoglycemic agents.
Lead, coordinate or participate in educational events to promote awareness of and familiarity with national guidelines for management strategies, new therapeutic and pharmacologic agents and the use of medical devices to improve and monitor glucose homeostasis.
Copyright © 2010 Society of Hospital Medicine
Sickle cell disease
Introduction
Sickle cell disease is the most common autosomal recessive disease in African American individuals. It occurs in 1 in 625 live births to African‐American couples. While it is most common in African Americans, it also occurs in individuals of Hispanic, Arabic, Native American and Caucasian heritage. Sickle cell disease results from a single base‐pair substitution of thymine for adenine resulting in valine instead of glutamine in the sixth position of the Beta‐globin molecule. Sickle cell disease results when this substitution occurs in a homozygous state. Less severe forms occur when the heterozygote state is combined with a second variant Beta‐globin chain such as hemoglobin C or Betao‐thalassemia. Clinical manifestations result from polymerization of the abnormal hemoglobin and sickling of the red cells. The clinical manifestations most important to pediatric hospitalists include recurrent and chronic pain from dactylitis and vaso‐occlusive crises, acute chest syndrome, increased susceptibility to infections, aplastic crisis, splenic sequestration, cerebral vascular accidents and priapism. Pediatric hospitalists commonly encounter patients with known or suspected sickle cell disease and care for the various complications associated with the disease.
Knowledge
Pediatric hospitalists should be able to:
Review the genetics and pathophysiology underlying the variants of sickle cell disease and their complications.
Compare and contrast common sickle crisis presentations by age group.
Explain the impact of newborn screening on preventative care.
Describe the signs and symptoms of dactylitis, vaso‐occlusive crisis, sepsis, acute chest syndrome, aplastic crisis, splenic sequestration, cerebrovascular accidents and priapism.
Describe indications for hospital admission, and escalation to intensive care.
Identify the goals of inpatient therapy, attending to both acute and chronic needs.
Summarize the roles of members of a comprehensive clinical care team, such as patients, family/caregiver, subspecialty physicians, social worker, pharmacist, physical therapist, discharge planner, psychologist and others.
Discuss the therapeutic options available for complications of sickle cell disease and describe the rationale for choosing a specific management plan.
Explain the approach toward acute and chronic pain management.
Cite reasons for transfer to a referral center in cases requiring pediatric‐specific services not available at the local facility.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose sickle cell disease and/or its complications by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
Order appropriate laboratory and radiographic testing based on history and physical examination findings.
Create a comprehensive evaluation and management plan including the use of antimicrobial therapy, intravenous fluid hydration, pain management, transfusion therapy, and initiation of cardiovascular and pulmonary supportive care measures.
Identify patients with worsening status and respond with appropriate actions.
Consult subspecialists in a timely manner when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with patients and the family/caregiver regarding the disease process, expectations of inpatient therapy and transition of care to the outpatient arena.
Collaborate with subspecialists and the primary care provider and to ensure coordinated longitudinal care for children with sickle cell disease.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with a multidisciplinary team consisting of subspecialty physicians, social workers, pharmacists, physical therapists, discharge planners and psychologists to improve quality of care, increase patient satisfaction and facilitate timely discharge from the acute care setting.
Identify existing limitations for optimal care within the current hospital setting and work with hospital administration and community partners to develop and sustain appropriate referral systems and coordinated transfers of care.
Lead, coordinate or participate in the development of coordinated discharge plans and programs in the local community.
Introduction
Sickle cell disease is the most common autosomal recessive disease in African American individuals. It occurs in 1 in 625 live births to African‐American couples. While it is most common in African Americans, it also occurs in individuals of Hispanic, Arabic, Native American and Caucasian heritage. Sickle cell disease results from a single base‐pair substitution of thymine for adenine resulting in valine instead of glutamine in the sixth position of the Beta‐globin molecule. Sickle cell disease results when this substitution occurs in a homozygous state. Less severe forms occur when the heterozygote state is combined with a second variant Beta‐globin chain such as hemoglobin C or Betao‐thalassemia. Clinical manifestations result from polymerization of the abnormal hemoglobin and sickling of the red cells. The clinical manifestations most important to pediatric hospitalists include recurrent and chronic pain from dactylitis and vaso‐occlusive crises, acute chest syndrome, increased susceptibility to infections, aplastic crisis, splenic sequestration, cerebral vascular accidents and priapism. Pediatric hospitalists commonly encounter patients with known or suspected sickle cell disease and care for the various complications associated with the disease.
Knowledge
Pediatric hospitalists should be able to:
Review the genetics and pathophysiology underlying the variants of sickle cell disease and their complications.
Compare and contrast common sickle crisis presentations by age group.
Explain the impact of newborn screening on preventative care.
Describe the signs and symptoms of dactylitis, vaso‐occlusive crisis, sepsis, acute chest syndrome, aplastic crisis, splenic sequestration, cerebrovascular accidents and priapism.
Describe indications for hospital admission, and escalation to intensive care.
Identify the goals of inpatient therapy, attending to both acute and chronic needs.
Summarize the roles of members of a comprehensive clinical care team, such as patients, family/caregiver, subspecialty physicians, social worker, pharmacist, physical therapist, discharge planner, psychologist and others.
Discuss the therapeutic options available for complications of sickle cell disease and describe the rationale for choosing a specific management plan.
Explain the approach toward acute and chronic pain management.
Cite reasons for transfer to a referral center in cases requiring pediatric‐specific services not available at the local facility.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose sickle cell disease and/or its complications by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
Order appropriate laboratory and radiographic testing based on history and physical examination findings.
Create a comprehensive evaluation and management plan including the use of antimicrobial therapy, intravenous fluid hydration, pain management, transfusion therapy, and initiation of cardiovascular and pulmonary supportive care measures.
Identify patients with worsening status and respond with appropriate actions.
Consult subspecialists in a timely manner when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with patients and the family/caregiver regarding the disease process, expectations of inpatient therapy and transition of care to the outpatient arena.
Collaborate with subspecialists and the primary care provider and to ensure coordinated longitudinal care for children with sickle cell disease.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with a multidisciplinary team consisting of subspecialty physicians, social workers, pharmacists, physical therapists, discharge planners and psychologists to improve quality of care, increase patient satisfaction and facilitate timely discharge from the acute care setting.
Identify existing limitations for optimal care within the current hospital setting and work with hospital administration and community partners to develop and sustain appropriate referral systems and coordinated transfers of care.
Lead, coordinate or participate in the development of coordinated discharge plans and programs in the local community.
Introduction
Sickle cell disease is the most common autosomal recessive disease in African American individuals. It occurs in 1 in 625 live births to African‐American couples. While it is most common in African Americans, it also occurs in individuals of Hispanic, Arabic, Native American and Caucasian heritage. Sickle cell disease results from a single base‐pair substitution of thymine for adenine resulting in valine instead of glutamine in the sixth position of the Beta‐globin molecule. Sickle cell disease results when this substitution occurs in a homozygous state. Less severe forms occur when the heterozygote state is combined with a second variant Beta‐globin chain such as hemoglobin C or Betao‐thalassemia. Clinical manifestations result from polymerization of the abnormal hemoglobin and sickling of the red cells. The clinical manifestations most important to pediatric hospitalists include recurrent and chronic pain from dactylitis and vaso‐occlusive crises, acute chest syndrome, increased susceptibility to infections, aplastic crisis, splenic sequestration, cerebral vascular accidents and priapism. Pediatric hospitalists commonly encounter patients with known or suspected sickle cell disease and care for the various complications associated with the disease.
Knowledge
Pediatric hospitalists should be able to:
Review the genetics and pathophysiology underlying the variants of sickle cell disease and their complications.
Compare and contrast common sickle crisis presentations by age group.
Explain the impact of newborn screening on preventative care.
Describe the signs and symptoms of dactylitis, vaso‐occlusive crisis, sepsis, acute chest syndrome, aplastic crisis, splenic sequestration, cerebrovascular accidents and priapism.
Describe indications for hospital admission, and escalation to intensive care.
Identify the goals of inpatient therapy, attending to both acute and chronic needs.
Summarize the roles of members of a comprehensive clinical care team, such as patients, family/caregiver, subspecialty physicians, social worker, pharmacist, physical therapist, discharge planner, psychologist and others.
Discuss the therapeutic options available for complications of sickle cell disease and describe the rationale for choosing a specific management plan.
Explain the approach toward acute and chronic pain management.
Cite reasons for transfer to a referral center in cases requiring pediatric‐specific services not available at the local facility.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose sickle cell disease and/or its complications by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
Order appropriate laboratory and radiographic testing based on history and physical examination findings.
Create a comprehensive evaluation and management plan including the use of antimicrobial therapy, intravenous fluid hydration, pain management, transfusion therapy, and initiation of cardiovascular and pulmonary supportive care measures.
Identify patients with worsening status and respond with appropriate actions.
Consult subspecialists in a timely manner when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with patients and the family/caregiver regarding the disease process, expectations of inpatient therapy and transition of care to the outpatient arena.
Collaborate with subspecialists and the primary care provider and to ensure coordinated longitudinal care for children with sickle cell disease.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with a multidisciplinary team consisting of subspecialty physicians, social workers, pharmacists, physical therapists, discharge planners and psychologists to improve quality of care, increase patient satisfaction and facilitate timely discharge from the acute care setting.
Identify existing limitations for optimal care within the current hospital setting and work with hospital administration and community partners to develop and sustain appropriate referral systems and coordinated transfers of care.
Lead, coordinate or participate in the development of coordinated discharge plans and programs in the local community.
Copyright © 2010 Society of Hospital Medicine
Procedural sedation
Introduction
Sedation is often used to minimize procedure related pain and to provide decreased motion for diagnostic studies. Control of pain, anxiety and memory may minimize negative psychological responses to treatment and also lead to a higher success rate for the therapy or diagnostic test. Safe attainment of these goals requires careful preparation and decision‐making prior to the procedure, meticulous monitoring during the procedure, and application of skills to avoid or treat the complications of sedation including ability to rescue patients from a deeper level of sedation than intended. With appropriate training and experience, pediatric hospitalists can safely provide a range of sedation services for pediatric patients.
Knowledge
Pediatric hospitalists should be able to:
Describe the goals of sedation, such as pain control, anxiolysis, amnesia, and motion control.
List commonly used single or combinations of medications, and describe how each achieves the desired goal with the minimum risk of complications and side effects.
Compare and contrast the goals of isolated anxiolysis with minimal sedation, attending to issues such as medication choice and dosing, procedure, and patient past procedural history.
Define minimal sedation, moderate sedation, deep sedation, and general anesthesia as established by the American Society of Anesthesiologists (ASA), American Academy of Pediatrics (AAP), and The Joint Commission (TJC).
Discuss the pharmacology and effects of commonly used sedation medications, including planned effects and potential side effects.
Explain why non‐pharmacologic interventions such as bundling, glucose water pacifiers, family/caregiver presence, visual imagery, deep breathing, music and others are important adjuncts to medication use in mitigating the perception of pain and anxiety.
Explain the risks inherent with administration of sedating medications, and list the proper monitoring necessary to avoid or promptly recognize instability.
Describe how age, disease process, and anatomy may increase the risk of sedation complications.
Discuss the proper level of monitoring personnel necessary to maximize safety.
Review indications for use of common reversal drugs, including anticipated results and duration of rescue effects.
Skills
Pediatric hospitalists should be able to:
Perform a pre‐sedation evaluation and appropriately assign ASA class and delineate patient‐specific risks.
Correctly recognize patients at higher risk and efficiently refer to an anesthesiologist.
Correctly obtain informed consent from the family/caregiver.
Develop a sedation plan that is based on the pre‐sedation evaluation and considers goals for the sedation and risks to patients.
Communicate effectively with the healthcare team before, during, and after the sedation to ensure that safe and efficient care is rendered.
Identify complications and respond with appropriate actions.
Manage the airway and provide pediatric advanced life support in case of known or unexpected complications.
Order appropriate monitoring and correctly interpret monitor data.
Identify when recovery criteria are met, and initiate an appropriate discharge/transfer plan.
Attitudes
Pediatric hospitalists should be able to:
Work collaboratively with hospital staff and subspecialists to ensure coordinated planning and performance of sedation.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of sedation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based procedures and policies for performance of sedation for children.
Lead, coordinate or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction into procedural strategies.
Work with hospital staff and subspecialists to develop and implement management strategies for sedation.
Lead, coordinate or participate in the development and implementation of a system for review of the efficacy, efficiency and outcomes of intravenous access procedures.
Lead, coordinate or participate in the development and implementation of a system for review of the efficacy, efficiency and outcomes of sedation procedures.
Introduction
Sedation is often used to minimize procedure related pain and to provide decreased motion for diagnostic studies. Control of pain, anxiety and memory may minimize negative psychological responses to treatment and also lead to a higher success rate for the therapy or diagnostic test. Safe attainment of these goals requires careful preparation and decision‐making prior to the procedure, meticulous monitoring during the procedure, and application of skills to avoid or treat the complications of sedation including ability to rescue patients from a deeper level of sedation than intended. With appropriate training and experience, pediatric hospitalists can safely provide a range of sedation services for pediatric patients.
Knowledge
Pediatric hospitalists should be able to:
Describe the goals of sedation, such as pain control, anxiolysis, amnesia, and motion control.
List commonly used single or combinations of medications, and describe how each achieves the desired goal with the minimum risk of complications and side effects.
Compare and contrast the goals of isolated anxiolysis with minimal sedation, attending to issues such as medication choice and dosing, procedure, and patient past procedural history.
Define minimal sedation, moderate sedation, deep sedation, and general anesthesia as established by the American Society of Anesthesiologists (ASA), American Academy of Pediatrics (AAP), and The Joint Commission (TJC).
Discuss the pharmacology and effects of commonly used sedation medications, including planned effects and potential side effects.
Explain why non‐pharmacologic interventions such as bundling, glucose water pacifiers, family/caregiver presence, visual imagery, deep breathing, music and others are important adjuncts to medication use in mitigating the perception of pain and anxiety.
Explain the risks inherent with administration of sedating medications, and list the proper monitoring necessary to avoid or promptly recognize instability.
Describe how age, disease process, and anatomy may increase the risk of sedation complications.
Discuss the proper level of monitoring personnel necessary to maximize safety.
Review indications for use of common reversal drugs, including anticipated results and duration of rescue effects.
Skills
Pediatric hospitalists should be able to:
Perform a pre‐sedation evaluation and appropriately assign ASA class and delineate patient‐specific risks.
Correctly recognize patients at higher risk and efficiently refer to an anesthesiologist.
Correctly obtain informed consent from the family/caregiver.
Develop a sedation plan that is based on the pre‐sedation evaluation and considers goals for the sedation and risks to patients.
Communicate effectively with the healthcare team before, during, and after the sedation to ensure that safe and efficient care is rendered.
Identify complications and respond with appropriate actions.
Manage the airway and provide pediatric advanced life support in case of known or unexpected complications.
Order appropriate monitoring and correctly interpret monitor data.
Identify when recovery criteria are met, and initiate an appropriate discharge/transfer plan.
Attitudes
Pediatric hospitalists should be able to:
Work collaboratively with hospital staff and subspecialists to ensure coordinated planning and performance of sedation.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of sedation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based procedures and policies for performance of sedation for children.
Lead, coordinate or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction into procedural strategies.
Work with hospital staff and subspecialists to develop and implement management strategies for sedation.
Lead, coordinate or participate in the development and implementation of a system for review of the efficacy, efficiency and outcomes of intravenous access procedures.
Lead, coordinate or participate in the development and implementation of a system for review of the efficacy, efficiency and outcomes of sedation procedures.
Introduction
Sedation is often used to minimize procedure related pain and to provide decreased motion for diagnostic studies. Control of pain, anxiety and memory may minimize negative psychological responses to treatment and also lead to a higher success rate for the therapy or diagnostic test. Safe attainment of these goals requires careful preparation and decision‐making prior to the procedure, meticulous monitoring during the procedure, and application of skills to avoid or treat the complications of sedation including ability to rescue patients from a deeper level of sedation than intended. With appropriate training and experience, pediatric hospitalists can safely provide a range of sedation services for pediatric patients.
Knowledge
Pediatric hospitalists should be able to:
Describe the goals of sedation, such as pain control, anxiolysis, amnesia, and motion control.
List commonly used single or combinations of medications, and describe how each achieves the desired goal with the minimum risk of complications and side effects.
Compare and contrast the goals of isolated anxiolysis with minimal sedation, attending to issues such as medication choice and dosing, procedure, and patient past procedural history.
Define minimal sedation, moderate sedation, deep sedation, and general anesthesia as established by the American Society of Anesthesiologists (ASA), American Academy of Pediatrics (AAP), and The Joint Commission (TJC).
Discuss the pharmacology and effects of commonly used sedation medications, including planned effects and potential side effects.
Explain why non‐pharmacologic interventions such as bundling, glucose water pacifiers, family/caregiver presence, visual imagery, deep breathing, music and others are important adjuncts to medication use in mitigating the perception of pain and anxiety.
Explain the risks inherent with administration of sedating medications, and list the proper monitoring necessary to avoid or promptly recognize instability.
Describe how age, disease process, and anatomy may increase the risk of sedation complications.
Discuss the proper level of monitoring personnel necessary to maximize safety.
Review indications for use of common reversal drugs, including anticipated results and duration of rescue effects.
Skills
Pediatric hospitalists should be able to:
Perform a pre‐sedation evaluation and appropriately assign ASA class and delineate patient‐specific risks.
Correctly recognize patients at higher risk and efficiently refer to an anesthesiologist.
Correctly obtain informed consent from the family/caregiver.
Develop a sedation plan that is based on the pre‐sedation evaluation and considers goals for the sedation and risks to patients.
Communicate effectively with the healthcare team before, during, and after the sedation to ensure that safe and efficient care is rendered.
Identify complications and respond with appropriate actions.
Manage the airway and provide pediatric advanced life support in case of known or unexpected complications.
Order appropriate monitoring and correctly interpret monitor data.
Identify when recovery criteria are met, and initiate an appropriate discharge/transfer plan.
Attitudes
Pediatric hospitalists should be able to:
Work collaboratively with hospital staff and subspecialists to ensure coordinated planning and performance of sedation.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of sedation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based procedures and policies for performance of sedation for children.
Lead, coordinate or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction into procedural strategies.
Work with hospital staff and subspecialists to develop and implement management strategies for sedation.
Lead, coordinate or participate in the development and implementation of a system for review of the efficacy, efficiency and outcomes of intravenous access procedures.
Lead, coordinate or participate in the development and implementation of a system for review of the efficacy, efficiency and outcomes of sedation procedures.
Copyright © 2010 Society of Hospital Medicine
Pain management
Introduction
Acute pain (pain) is a common complaint in the pediatric inpatient setting and is most often associated with exacerbations of chronic diseases, trauma, burns or surgical and diagnostic procedures. Children with acute pain may also have chronic pain due to an underlying illness or previous injury. Chronic pain complicates effective control of acute pain and may be associated with neuropsychological changes that impact pain perception. Despite advances in understanding of the pathophysiology and management of pain in children, several barriers to effective pain management exist, such as fear of harmful side effects and drug dependency. Pediatric hospitalists should enhance pain management services through the direct provision of effective care, and are often in the best position to lead development of a systematic approach to pain management in institutions and communities.
Knowledge
Pediatric hospitalists should be able to:
Describe the pathophysiology and multidimensional aspects of pain in children of various ages.
Explain how pain, anxiety, and fear interrelate and discuss strategies for addressing each.
List the indications and contraindications for the main classes of drugs used for pain management, such as opioids, non‐steroidal anti‐inflammatory drugs, and topical and local anesthetics.
Discuss the pharmacology of medications commonly used for analgesia, including route of administration, dosing range, and expected side effects.
Discuss the pharmacology of medications used for anxiolysis, including route of administration, dosing range, and expected side effects.
Describe the effects of age, anatomy, and disease process on the pharmacology of medications used for analgesia and anxiolysis.
Compare and contrast the risks and benefits of various modalities of drug delivery attending to drug delivery, side effects, and invasiveness and safety of delivery methods/devices.
List appropriate monitoring techniques for patients receiving analgesics, anxiolytics, and other associated medications.
Describe the pharmacology of and indications for reversal agents for specific classes of drugs used for pain management.
Discuss how use of adjuvant medications, such as antidepressants, anticonvulsants, anxiolytics, and sleep medications can be used most appropriately for pain management.
Discuss how complementary techniques such as behavioral therapy, play therapy, and physical therapy can be utilized to manage pain and anxiety.
Describe the role of the pediatric pain consultant/pain management team and discuss barriers to local availability.
Skills
Pediatric hospitalists should be able to:
Accurately assess the presence and level of pain in children regardless of developmental level utilizing history, physical examination, physiologic parameters, and validated pediatric pain scales.
Appropriately prescribe doses of analgesic medication that ameliorate pain while avoiding untoward side effects.
Demonstrate proficiency in adjusting drug doses in the face of breakthrough pain.
Safely prescribe equi‐analgesic doses or adjust doses appropriately when changing from intravenous to oral therapy or when switching from one medication to another.
Select and order pain and anxiety medications in safe and cost‐effective manner.
Correctly calculate and order a pain and anxiolytic medication tapering regimen that avoids withdrawal symptoms or breakthrough pain.
Perform careful reassessments daily and as needed, note changes in clinical status, pain, side effects, and withdrawal symptoms and respond with appropriate actions.
Order appropriate monitoring and correctly interpret monitor data.
Anticipate and recognize potential side effects of analgesic and anxiolytic medications and respond with appropriate actions.
Consistently utilize non‐pharmacologic methods as part of a pain management plan.
Identify patients likely to have chronic pain, and involve appropriate consultants to assist with long term management.
Identify patients with neuropathic pain and develop a treatment plan with assistance from appropriate consultants.
Correctly identify discharge needs and create a comprehensive discharge plan attending to equipment, medications, and specialty services required.
Attitudes
Pediatric hospitalists should be able to:
Educate patients and the family/caregiver on various aspects of pain, including etiologies, management, and impact on the healing process.
Involve the primary care provider in the therapeutic process early in the hospitalization and work together to coordinate appropriate follow‐up care.
Recognize the impact of uncontrolled pain has on patients' emotional and physical well‐being.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children receiving chronic pain management services.
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 others to implement a comprehensive, systematic approach to pain management across the continuum of care.
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care to standardize the evaluation and management for hospitalized children with pain.
Educate other healthcare providers who may work with children on pediatric pain assessment and safe medication use.
Work in consultation with surgical staff to prioritize and improve the management of pain in pediatric surgical patients.
Introduction
Acute pain (pain) is a common complaint in the pediatric inpatient setting and is most often associated with exacerbations of chronic diseases, trauma, burns or surgical and diagnostic procedures. Children with acute pain may also have chronic pain due to an underlying illness or previous injury. Chronic pain complicates effective control of acute pain and may be associated with neuropsychological changes that impact pain perception. Despite advances in understanding of the pathophysiology and management of pain in children, several barriers to effective pain management exist, such as fear of harmful side effects and drug dependency. Pediatric hospitalists should enhance pain management services through the direct provision of effective care, and are often in the best position to lead development of a systematic approach to pain management in institutions and communities.
Knowledge
Pediatric hospitalists should be able to:
Describe the pathophysiology and multidimensional aspects of pain in children of various ages.
Explain how pain, anxiety, and fear interrelate and discuss strategies for addressing each.
List the indications and contraindications for the main classes of drugs used for pain management, such as opioids, non‐steroidal anti‐inflammatory drugs, and topical and local anesthetics.
Discuss the pharmacology of medications commonly used for analgesia, including route of administration, dosing range, and expected side effects.
Discuss the pharmacology of medications used for anxiolysis, including route of administration, dosing range, and expected side effects.
Describe the effects of age, anatomy, and disease process on the pharmacology of medications used for analgesia and anxiolysis.
Compare and contrast the risks and benefits of various modalities of drug delivery attending to drug delivery, side effects, and invasiveness and safety of delivery methods/devices.
List appropriate monitoring techniques for patients receiving analgesics, anxiolytics, and other associated medications.
Describe the pharmacology of and indications for reversal agents for specific classes of drugs used for pain management.
Discuss how use of adjuvant medications, such as antidepressants, anticonvulsants, anxiolytics, and sleep medications can be used most appropriately for pain management.
Discuss how complementary techniques such as behavioral therapy, play therapy, and physical therapy can be utilized to manage pain and anxiety.
Describe the role of the pediatric pain consultant/pain management team and discuss barriers to local availability.
Skills
Pediatric hospitalists should be able to:
Accurately assess the presence and level of pain in children regardless of developmental level utilizing history, physical examination, physiologic parameters, and validated pediatric pain scales.
Appropriately prescribe doses of analgesic medication that ameliorate pain while avoiding untoward side effects.
Demonstrate proficiency in adjusting drug doses in the face of breakthrough pain.
Safely prescribe equi‐analgesic doses or adjust doses appropriately when changing from intravenous to oral therapy or when switching from one medication to another.
Select and order pain and anxiety medications in safe and cost‐effective manner.
Correctly calculate and order a pain and anxiolytic medication tapering regimen that avoids withdrawal symptoms or breakthrough pain.
Perform careful reassessments daily and as needed, note changes in clinical status, pain, side effects, and withdrawal symptoms and respond with appropriate actions.
Order appropriate monitoring and correctly interpret monitor data.
Anticipate and recognize potential side effects of analgesic and anxiolytic medications and respond with appropriate actions.
Consistently utilize non‐pharmacologic methods as part of a pain management plan.
Identify patients likely to have chronic pain, and involve appropriate consultants to assist with long term management.
Identify patients with neuropathic pain and develop a treatment plan with assistance from appropriate consultants.
Correctly identify discharge needs and create a comprehensive discharge plan attending to equipment, medications, and specialty services required.
Attitudes
Pediatric hospitalists should be able to:
Educate patients and the family/caregiver on various aspects of pain, including etiologies, management, and impact on the healing process.
Involve the primary care provider in the therapeutic process early in the hospitalization and work together to coordinate appropriate follow‐up care.
Recognize the impact of uncontrolled pain has on patients' emotional and physical well‐being.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children receiving chronic pain management services.
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 others to implement a comprehensive, systematic approach to pain management across the continuum of care.
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care to standardize the evaluation and management for hospitalized children with pain.
Educate other healthcare providers who may work with children on pediatric pain assessment and safe medication use.
Work in consultation with surgical staff to prioritize and improve the management of pain in pediatric surgical patients.
Introduction
Acute pain (pain) is a common complaint in the pediatric inpatient setting and is most often associated with exacerbations of chronic diseases, trauma, burns or surgical and diagnostic procedures. Children with acute pain may also have chronic pain due to an underlying illness or previous injury. Chronic pain complicates effective control of acute pain and may be associated with neuropsychological changes that impact pain perception. Despite advances in understanding of the pathophysiology and management of pain in children, several barriers to effective pain management exist, such as fear of harmful side effects and drug dependency. Pediatric hospitalists should enhance pain management services through the direct provision of effective care, and are often in the best position to lead development of a systematic approach to pain management in institutions and communities.
Knowledge
Pediatric hospitalists should be able to:
Describe the pathophysiology and multidimensional aspects of pain in children of various ages.
Explain how pain, anxiety, and fear interrelate and discuss strategies for addressing each.
List the indications and contraindications for the main classes of drugs used for pain management, such as opioids, non‐steroidal anti‐inflammatory drugs, and topical and local anesthetics.
Discuss the pharmacology of medications commonly used for analgesia, including route of administration, dosing range, and expected side effects.
Discuss the pharmacology of medications used for anxiolysis, including route of administration, dosing range, and expected side effects.
Describe the effects of age, anatomy, and disease process on the pharmacology of medications used for analgesia and anxiolysis.
Compare and contrast the risks and benefits of various modalities of drug delivery attending to drug delivery, side effects, and invasiveness and safety of delivery methods/devices.
List appropriate monitoring techniques for patients receiving analgesics, anxiolytics, and other associated medications.
Describe the pharmacology of and indications for reversal agents for specific classes of drugs used for pain management.
Discuss how use of adjuvant medications, such as antidepressants, anticonvulsants, anxiolytics, and sleep medications can be used most appropriately for pain management.
Discuss how complementary techniques such as behavioral therapy, play therapy, and physical therapy can be utilized to manage pain and anxiety.
Describe the role of the pediatric pain consultant/pain management team and discuss barriers to local availability.
Skills
Pediatric hospitalists should be able to:
Accurately assess the presence and level of pain in children regardless of developmental level utilizing history, physical examination, physiologic parameters, and validated pediatric pain scales.
Appropriately prescribe doses of analgesic medication that ameliorate pain while avoiding untoward side effects.
Demonstrate proficiency in adjusting drug doses in the face of breakthrough pain.
Safely prescribe equi‐analgesic doses or adjust doses appropriately when changing from intravenous to oral therapy or when switching from one medication to another.
Select and order pain and anxiety medications in safe and cost‐effective manner.
Correctly calculate and order a pain and anxiolytic medication tapering regimen that avoids withdrawal symptoms or breakthrough pain.
Perform careful reassessments daily and as needed, note changes in clinical status, pain, side effects, and withdrawal symptoms and respond with appropriate actions.
Order appropriate monitoring and correctly interpret monitor data.
Anticipate and recognize potential side effects of analgesic and anxiolytic medications and respond with appropriate actions.
Consistently utilize non‐pharmacologic methods as part of a pain management plan.
Identify patients likely to have chronic pain, and involve appropriate consultants to assist with long term management.
Identify patients with neuropathic pain and develop a treatment plan with assistance from appropriate consultants.
Correctly identify discharge needs and create a comprehensive discharge plan attending to equipment, medications, and specialty services required.
Attitudes
Pediatric hospitalists should be able to:
Educate patients and the family/caregiver on various aspects of pain, including etiologies, management, and impact on the healing process.
Involve the primary care provider in the therapeutic process early in the hospitalization and work together to coordinate appropriate follow‐up care.
Recognize the impact of uncontrolled pain has on patients' emotional and physical well‐being.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children receiving chronic pain management services.
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 others to implement a comprehensive, systematic approach to pain management across the continuum of care.
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care to standardize the evaluation and management for hospitalized children with pain.
Educate other healthcare providers who may work with children on pediatric pain assessment and safe medication use.
Work in consultation with surgical staff to prioritize and improve the management of pain in pediatric surgical patients.
Copyright © 2010 Society of Hospital Medicine
Acute abdominal pain and the acute abdomen
Introduction
Acute abdominal pain is a common presenting symptom of children and adolescents and prompts the consideration of an extensive differential diagnosis. Although it is frequently due to common, self‐limited medical conditions related to the abdomen such as gastroenteritis, it may also be a signal of systemic illness or referred from problems elsewhere in the body. Acute abdominal pain may or may not be accompanied by signs and symptoms of an acute abdomen such as loss of bowel sounds or evidence of obstruction. Identifying children with a true medical or surgical emergency is critical. Children with peritonitis and other surgical conditions need prompt evaluation by a surgeon with pediatric expertise. Early diagnosis and treatment reduces morbidity, mortality, and length of hospital stay. Pediatric hospitalists frequently encounter children with acute abdominal pain in a variety of clinical settings and should assist in the timely and effective evaluation and management either alone or in conjunction with a surgeon.
Knowledge
Pediatric hospitalists should be able to:
Recognize features of the medical history and physical examination that prompt specific diagnostic evaluation.
Describe the differential diagnosis of acute abdominal pain as well the acute abdomen for children of varying chronological and developmental ages.
List gender‐specific etiologies of acute abdominal pain, such as testicular torsion and ovarian cyst rupture.
Identify the role congenital anomalies may play in the child with an acute abdomen.
Discuss the principles of stabilization of the child with an acute abdomen, such as volume resuscitation, antibiotics, and bowel decompression.
List conditions that may mimic the acute abdomen, such as lower lobe pneumonia and diabetic ketoacidosis.
State the importance of, and indications for, early surgical consultation in the child with an acute abdomen.
Compare and contrast benefits versus limitations of various commonly performed studies such as acute abdominal series, sonography, computed tomography, nuclear medicine scans, and magnetic resonance imaging. State the benefits of and barriers to use of contrast enhancement for these studies.
Provide indications for hospital admission and cite the reasons for admission to various locations in the hospital system, such as a short‐stay unit, surgical or medical ward, step‐down intensive care unit, or intensive care unit.
Cite reasons for patient transfer to a referral center in cases requiring pediatric‐specific services not available at the local facility.
Identify specific evaluation and treatment needs for technology dependent children who present with an acute abdomen, including children with feeding and drainage tubes (gastrostomy, jejunostomy, ileosotomy, and others), long term vascular access devices (ports, Hickman catheters, and others), shunts (ventricular, other), ventilator dependence, and other implanted devices.
Summarize the approach toward pain control in patients presenting with acute abdominal pain, attending to medication choice, delivery method, and impact on exam re‐assessments.
Skills
Pediatric hospitalists should be able to:
Obtain an accurate history and perform a thorough physical examination.
Formulate a targeted differential diagnosis based on elements from the history and physical examination, prior to ordering studies.
Identify the child with an acute abdomen.
Identify and manage the child with concomitant hypovolemia or sepsis.
Direct an appropriate and cost‐effective evaluation to identify the cause of the abdominal pain or the acute abdomen.
Access radiology services efficiently, for both performance and interpretation of studies.
Order and correctly interpret commonly performed basic diagnostic imaging studies and laboratory studies.
Consult surgeons effectively and efficiently when indicated.
Identify the child requiring emergent surgical consultation.
Provide pre‐ and post‐operative general pediatric care for the child requiring surgery, as appropriate, including pain management.
Coordinate care with the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Assume responsibility for care of patients as the primary attending or in collaboration with the surgical team.
Communicate effectively with patients, the family/caregiver, and healthcare providers regarding findings and care plans.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Educate healthcare providers, trainees, the family/caregiver regarding the signs and symptoms of the acute abdomen to encourage early detection and prompt evaluation.
Lead, coordinate or participate in a multidisciplinary team to provide optimal care for children with acute abdominal pain with and without acute abdomen.
Incorporate knowledge of outcomes research and cost management strategies into the evaluation and treatment of patients with an acute abdomen.
Lead, coordinate or participate in institutional efforts to improve the expediency of diagnostic laboratory and radiographic studies, availability of specialty care, and other resources for patients with acute abdominal pain and acute abdomen.
Introduction
Acute abdominal pain is a common presenting symptom of children and adolescents and prompts the consideration of an extensive differential diagnosis. Although it is frequently due to common, self‐limited medical conditions related to the abdomen such as gastroenteritis, it may also be a signal of systemic illness or referred from problems elsewhere in the body. Acute abdominal pain may or may not be accompanied by signs and symptoms of an acute abdomen such as loss of bowel sounds or evidence of obstruction. Identifying children with a true medical or surgical emergency is critical. Children with peritonitis and other surgical conditions need prompt evaluation by a surgeon with pediatric expertise. Early diagnosis and treatment reduces morbidity, mortality, and length of hospital stay. Pediatric hospitalists frequently encounter children with acute abdominal pain in a variety of clinical settings and should assist in the timely and effective evaluation and management either alone or in conjunction with a surgeon.
Knowledge
Pediatric hospitalists should be able to:
Recognize features of the medical history and physical examination that prompt specific diagnostic evaluation.
Describe the differential diagnosis of acute abdominal pain as well the acute abdomen for children of varying chronological and developmental ages.
List gender‐specific etiologies of acute abdominal pain, such as testicular torsion and ovarian cyst rupture.
Identify the role congenital anomalies may play in the child with an acute abdomen.
Discuss the principles of stabilization of the child with an acute abdomen, such as volume resuscitation, antibiotics, and bowel decompression.
List conditions that may mimic the acute abdomen, such as lower lobe pneumonia and diabetic ketoacidosis.
State the importance of, and indications for, early surgical consultation in the child with an acute abdomen.
Compare and contrast benefits versus limitations of various commonly performed studies such as acute abdominal series, sonography, computed tomography, nuclear medicine scans, and magnetic resonance imaging. State the benefits of and barriers to use of contrast enhancement for these studies.
Provide indications for hospital admission and cite the reasons for admission to various locations in the hospital system, such as a short‐stay unit, surgical or medical ward, step‐down intensive care unit, or intensive care unit.
Cite reasons for patient transfer to a referral center in cases requiring pediatric‐specific services not available at the local facility.
Identify specific evaluation and treatment needs for technology dependent children who present with an acute abdomen, including children with feeding and drainage tubes (gastrostomy, jejunostomy, ileosotomy, and others), long term vascular access devices (ports, Hickman catheters, and others), shunts (ventricular, other), ventilator dependence, and other implanted devices.
Summarize the approach toward pain control in patients presenting with acute abdominal pain, attending to medication choice, delivery method, and impact on exam re‐assessments.
Skills
Pediatric hospitalists should be able to:
Obtain an accurate history and perform a thorough physical examination.
Formulate a targeted differential diagnosis based on elements from the history and physical examination, prior to ordering studies.
Identify the child with an acute abdomen.
Identify and manage the child with concomitant hypovolemia or sepsis.
Direct an appropriate and cost‐effective evaluation to identify the cause of the abdominal pain or the acute abdomen.
Access radiology services efficiently, for both performance and interpretation of studies.
Order and correctly interpret commonly performed basic diagnostic imaging studies and laboratory studies.
Consult surgeons effectively and efficiently when indicated.
Identify the child requiring emergent surgical consultation.
Provide pre‐ and post‐operative general pediatric care for the child requiring surgery, as appropriate, including pain management.
Coordinate care with the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Assume responsibility for care of patients as the primary attending or in collaboration with the surgical team.
Communicate effectively with patients, the family/caregiver, and healthcare providers regarding findings and care plans.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Educate healthcare providers, trainees, the family/caregiver regarding the signs and symptoms of the acute abdomen to encourage early detection and prompt evaluation.
Lead, coordinate or participate in a multidisciplinary team to provide optimal care for children with acute abdominal pain with and without acute abdomen.
Incorporate knowledge of outcomes research and cost management strategies into the evaluation and treatment of patients with an acute abdomen.
Lead, coordinate or participate in institutional efforts to improve the expediency of diagnostic laboratory and radiographic studies, availability of specialty care, and other resources for patients with acute abdominal pain and acute abdomen.
Introduction
Acute abdominal pain is a common presenting symptom of children and adolescents and prompts the consideration of an extensive differential diagnosis. Although it is frequently due to common, self‐limited medical conditions related to the abdomen such as gastroenteritis, it may also be a signal of systemic illness or referred from problems elsewhere in the body. Acute abdominal pain may or may not be accompanied by signs and symptoms of an acute abdomen such as loss of bowel sounds or evidence of obstruction. Identifying children with a true medical or surgical emergency is critical. Children with peritonitis and other surgical conditions need prompt evaluation by a surgeon with pediatric expertise. Early diagnosis and treatment reduces morbidity, mortality, and length of hospital stay. Pediatric hospitalists frequently encounter children with acute abdominal pain in a variety of clinical settings and should assist in the timely and effective evaluation and management either alone or in conjunction with a surgeon.
Knowledge
Pediatric hospitalists should be able to:
Recognize features of the medical history and physical examination that prompt specific diagnostic evaluation.
Describe the differential diagnosis of acute abdominal pain as well the acute abdomen for children of varying chronological and developmental ages.
List gender‐specific etiologies of acute abdominal pain, such as testicular torsion and ovarian cyst rupture.
Identify the role congenital anomalies may play in the child with an acute abdomen.
Discuss the principles of stabilization of the child with an acute abdomen, such as volume resuscitation, antibiotics, and bowel decompression.
List conditions that may mimic the acute abdomen, such as lower lobe pneumonia and diabetic ketoacidosis.
State the importance of, and indications for, early surgical consultation in the child with an acute abdomen.
Compare and contrast benefits versus limitations of various commonly performed studies such as acute abdominal series, sonography, computed tomography, nuclear medicine scans, and magnetic resonance imaging. State the benefits of and barriers to use of contrast enhancement for these studies.
Provide indications for hospital admission and cite the reasons for admission to various locations in the hospital system, such as a short‐stay unit, surgical or medical ward, step‐down intensive care unit, or intensive care unit.
Cite reasons for patient transfer to a referral center in cases requiring pediatric‐specific services not available at the local facility.
Identify specific evaluation and treatment needs for technology dependent children who present with an acute abdomen, including children with feeding and drainage tubes (gastrostomy, jejunostomy, ileosotomy, and others), long term vascular access devices (ports, Hickman catheters, and others), shunts (ventricular, other), ventilator dependence, and other implanted devices.
Summarize the approach toward pain control in patients presenting with acute abdominal pain, attending to medication choice, delivery method, and impact on exam re‐assessments.
Skills
Pediatric hospitalists should be able to:
Obtain an accurate history and perform a thorough physical examination.
Formulate a targeted differential diagnosis based on elements from the history and physical examination, prior to ordering studies.
Identify the child with an acute abdomen.
Identify and manage the child with concomitant hypovolemia or sepsis.
Direct an appropriate and cost‐effective evaluation to identify the cause of the abdominal pain or the acute abdomen.
Access radiology services efficiently, for both performance and interpretation of studies.
Order and correctly interpret commonly performed basic diagnostic imaging studies and laboratory studies.
Consult surgeons effectively and efficiently when indicated.
Identify the child requiring emergent surgical consultation.
Provide pre‐ and post‐operative general pediatric care for the child requiring surgery, as appropriate, including pain management.
Coordinate care with the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
Assume responsibility for care of patients as the primary attending or in collaboration with the surgical team.
Communicate effectively with patients, the family/caregiver, and healthcare providers regarding findings and care plans.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Educate healthcare providers, trainees, the family/caregiver regarding the signs and symptoms of the acute abdomen to encourage early detection and prompt evaluation.
Lead, coordinate or participate in a multidisciplinary team to provide optimal care for children with acute abdominal pain with and without acute abdomen.
Incorporate knowledge of outcomes research and cost management strategies into the evaluation and treatment of patients with an acute abdomen.
Lead, coordinate or participate in institutional efforts to improve the expediency of diagnostic laboratory and radiographic studies, availability of specialty care, and other resources for patients with acute abdominal pain and acute abdomen.
Copyright © 2010 Society of Hospital Medicine
Newborn care and delivery room management
Introduction
Pediatric hospitalists are often asked to support delivery and newborn services. For those who provide these services, the components vary and may include any combination of normal newborn examination and discharge, emergency delivery care, level II neonatal intensive care stabilization, level II neonatal care, or neonatal intensive care transport services. Rendering this care requires medical and procedural skills, as well as leadership and team skills while working with obstetricians, nurses, nurse midwives, advanced practice nurses, primary care providers, neonatologists, and families. Pediatric hospitalists are well positioned to provide care for the immediate newborn and assure effective transition of care at transport or discharge home.
Knowledge
Pediatric hospitalists should be able to:
Describe the role of each team member commonly involved in newborn care, including the obstetrician, prenatal ultrasonographers/radiologists, primary care providers, nurses, lactation consultants, and others.
Review the basic physiologic differences between the preterm and term infant, attending to cardiopulmonary needs, respiratory control, feeding issues, and other elements.
Discuss the impact of maternal factors on the fetus and newborn, including abnormal pre‐natal labs, maternal diabetes, thyroid disorders, and prescription, non‐prescription and illicit drug use.
Define nursery care levels and give an example of infants should be cared for at each level.
Describe the normal delivery process and the physiologic transitions of a newborn infant.
Describe the skills needed to be an effective resuscitation team leader, including critical thinking, evidence‐based decision‐making, and use of continuous quality improvement principles.
Describe the benefits of breast milk, formulas and supplements (Vitamin D, Iron) in infant nutrition for term and preterm infants.
Review the components of newborn screening, and state which tests are performed locally.
Discuss factors influencing bilirubin levels and summarize current guidelines for treatment of jaundice.
Review guidelines for common neonatal care such as immunizations, Vitamin K, eye prophylaxis, hearing screening, car seat trials and electrolyte and bilirubin screening.
Discuss the role of maternal group B streptococcal screen, and presence or absence of chorioamnionitis in the management of the newborn.
Describe the diagnostic and therapeutic approach toward newborns with common dysmorphisms, including features associated with trisomies, ear pits, cleft‐lip/palate, supranummary digits, and clubfoot.
Describe the approach toward the diagnosis and treatment of common infections and toxic exposures of newborns.
Describe the pathophysiology of persistent fetal circulation/pulmonary hypertension.
Describe stabilization techniques and list the differential diagnoses for newborns with seizures.
Review the role of pre‐natal ultrasounds and describe appropriate post‐birth follow‐up of common findings, such as umbilical cord anomalies, renal abnormalities and heart lesions.
List the clinical indications for an acute metabolic or endocrine work‐up in newborns.
Compare and contrast the characteristics of benign versus pathologic cardiac murmurs, and describe the role of oxygen saturation testing.
Discuss the appropriate interventions for a cardiac murmur, including indications for and timing of cardiology consultation
Describe the elements of a safe discharge, attending to timing and follow‐up plans.
Skills
Pediatric hospitalists should be able to:
Maintain Neonatal Resuscitation Program (NRP) certification.
Provide care that incorporates current best practices for oxygen at delivery, infant warming, and treatment of asphyxia.
Correctly order and manage enteral and parenteral nutrition for neonates.
Perform a comprehensive exam and document normal and abnormal variants, including complications of delivery.
Initiate an NRP‐based infant resuscitation, effectively leading the team in the resuscitation of an extremely premature to term infant.
Provide leadership for a normal newborn or level II nursery in partnership with neonatologists and other subspecialists as indicated.
Identify infants with respiratory and cardiac problems and appropriately initiate cardiorespiratory support.
Accurately perform procedures such as lumbar puncture, placement of enteral tubes, umbilical catheters, venous access, intraosseous placement, exchange transfusion and needle thoracotomy or chest tube placement.
Correctly identify newborns requiring subspecialty consultation and counseling such as those with ambiguous genitalia, dysmorphisms, and others and effectively coordinate the referral and subsequent care as indicated.
Recognize and provide initial care for newborns with surgical emergencies, such as infants with gastrointestinal obstruction, diaphragmatic hernia, and others.
Attitudes
Pediatric hospitalists should be able to:
Demonstrate a consistent level of commitment, responsibility, and accountability in rendering patient care for newborns
Role model professional behavior, demonstrating compassion for women and families during the delivery process, when discussing care options, and consultation or referral need, as indicated.
Communicate effectively with patients, the family/caregiver and healthcare providers regarding findings and care plans including post‐discharge needs.
Recognize and respect decisions of the family/caregiver regarding care of extremely premature infants or infants with anomalies.
Systems Organization and Improvement
In order to improve efficiency and quality in their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, evidence‐based care pathways to standardize the evaluation, management and discharge process for newborns.
Work with hospital administration, hospital staff, subspecialists, and other services/consultants to provide appropriate newborn resuscitation services.
Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers for newborns requiring tertiary care.
Introduction
Pediatric hospitalists are often asked to support delivery and newborn services. For those who provide these services, the components vary and may include any combination of normal newborn examination and discharge, emergency delivery care, level II neonatal intensive care stabilization, level II neonatal care, or neonatal intensive care transport services. Rendering this care requires medical and procedural skills, as well as leadership and team skills while working with obstetricians, nurses, nurse midwives, advanced practice nurses, primary care providers, neonatologists, and families. Pediatric hospitalists are well positioned to provide care for the immediate newborn and assure effective transition of care at transport or discharge home.
Knowledge
Pediatric hospitalists should be able to:
Describe the role of each team member commonly involved in newborn care, including the obstetrician, prenatal ultrasonographers/radiologists, primary care providers, nurses, lactation consultants, and others.
Review the basic physiologic differences between the preterm and term infant, attending to cardiopulmonary needs, respiratory control, feeding issues, and other elements.
Discuss the impact of maternal factors on the fetus and newborn, including abnormal pre‐natal labs, maternal diabetes, thyroid disorders, and prescription, non‐prescription and illicit drug use.
Define nursery care levels and give an example of infants should be cared for at each level.
Describe the normal delivery process and the physiologic transitions of a newborn infant.
Describe the skills needed to be an effective resuscitation team leader, including critical thinking, evidence‐based decision‐making, and use of continuous quality improvement principles.
Describe the benefits of breast milk, formulas and supplements (Vitamin D, Iron) in infant nutrition for term and preterm infants.
Review the components of newborn screening, and state which tests are performed locally.
Discuss factors influencing bilirubin levels and summarize current guidelines for treatment of jaundice.
Review guidelines for common neonatal care such as immunizations, Vitamin K, eye prophylaxis, hearing screening, car seat trials and electrolyte and bilirubin screening.
Discuss the role of maternal group B streptococcal screen, and presence or absence of chorioamnionitis in the management of the newborn.
Describe the diagnostic and therapeutic approach toward newborns with common dysmorphisms, including features associated with trisomies, ear pits, cleft‐lip/palate, supranummary digits, and clubfoot.
Describe the approach toward the diagnosis and treatment of common infections and toxic exposures of newborns.
Describe the pathophysiology of persistent fetal circulation/pulmonary hypertension.
Describe stabilization techniques and list the differential diagnoses for newborns with seizures.
Review the role of pre‐natal ultrasounds and describe appropriate post‐birth follow‐up of common findings, such as umbilical cord anomalies, renal abnormalities and heart lesions.
List the clinical indications for an acute metabolic or endocrine work‐up in newborns.
Compare and contrast the characteristics of benign versus pathologic cardiac murmurs, and describe the role of oxygen saturation testing.
Discuss the appropriate interventions for a cardiac murmur, including indications for and timing of cardiology consultation
Describe the elements of a safe discharge, attending to timing and follow‐up plans.
Skills
Pediatric hospitalists should be able to:
Maintain Neonatal Resuscitation Program (NRP) certification.
Provide care that incorporates current best practices for oxygen at delivery, infant warming, and treatment of asphyxia.
Correctly order and manage enteral and parenteral nutrition for neonates.
Perform a comprehensive exam and document normal and abnormal variants, including complications of delivery.
Initiate an NRP‐based infant resuscitation, effectively leading the team in the resuscitation of an extremely premature to term infant.
Provide leadership for a normal newborn or level II nursery in partnership with neonatologists and other subspecialists as indicated.
Identify infants with respiratory and cardiac problems and appropriately initiate cardiorespiratory support.
Accurately perform procedures such as lumbar puncture, placement of enteral tubes, umbilical catheters, venous access, intraosseous placement, exchange transfusion and needle thoracotomy or chest tube placement.
Correctly identify newborns requiring subspecialty consultation and counseling such as those with ambiguous genitalia, dysmorphisms, and others and effectively coordinate the referral and subsequent care as indicated.
Recognize and provide initial care for newborns with surgical emergencies, such as infants with gastrointestinal obstruction, diaphragmatic hernia, and others.
Attitudes
Pediatric hospitalists should be able to:
Demonstrate a consistent level of commitment, responsibility, and accountability in rendering patient care for newborns
Role model professional behavior, demonstrating compassion for women and families during the delivery process, when discussing care options, and consultation or referral need, as indicated.
Communicate effectively with patients, the family/caregiver and healthcare providers regarding findings and care plans including post‐discharge needs.
Recognize and respect decisions of the family/caregiver regarding care of extremely premature infants or infants with anomalies.
Systems Organization and Improvement
In order to improve efficiency and quality in their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, evidence‐based care pathways to standardize the evaluation, management and discharge process for newborns.
Work with hospital administration, hospital staff, subspecialists, and other services/consultants to provide appropriate newborn resuscitation services.
Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers for newborns requiring tertiary care.
Introduction
Pediatric hospitalists are often asked to support delivery and newborn services. For those who provide these services, the components vary and may include any combination of normal newborn examination and discharge, emergency delivery care, level II neonatal intensive care stabilization, level II neonatal care, or neonatal intensive care transport services. Rendering this care requires medical and procedural skills, as well as leadership and team skills while working with obstetricians, nurses, nurse midwives, advanced practice nurses, primary care providers, neonatologists, and families. Pediatric hospitalists are well positioned to provide care for the immediate newborn and assure effective transition of care at transport or discharge home.
Knowledge
Pediatric hospitalists should be able to:
Describe the role of each team member commonly involved in newborn care, including the obstetrician, prenatal ultrasonographers/radiologists, primary care providers, nurses, lactation consultants, and others.
Review the basic physiologic differences between the preterm and term infant, attending to cardiopulmonary needs, respiratory control, feeding issues, and other elements.
Discuss the impact of maternal factors on the fetus and newborn, including abnormal pre‐natal labs, maternal diabetes, thyroid disorders, and prescription, non‐prescription and illicit drug use.
Define nursery care levels and give an example of infants should be cared for at each level.
Describe the normal delivery process and the physiologic transitions of a newborn infant.
Describe the skills needed to be an effective resuscitation team leader, including critical thinking, evidence‐based decision‐making, and use of continuous quality improvement principles.
Describe the benefits of breast milk, formulas and supplements (Vitamin D, Iron) in infant nutrition for term and preterm infants.
Review the components of newborn screening, and state which tests are performed locally.
Discuss factors influencing bilirubin levels and summarize current guidelines for treatment of jaundice.
Review guidelines for common neonatal care such as immunizations, Vitamin K, eye prophylaxis, hearing screening, car seat trials and electrolyte and bilirubin screening.
Discuss the role of maternal group B streptococcal screen, and presence or absence of chorioamnionitis in the management of the newborn.
Describe the diagnostic and therapeutic approach toward newborns with common dysmorphisms, including features associated with trisomies, ear pits, cleft‐lip/palate, supranummary digits, and clubfoot.
Describe the approach toward the diagnosis and treatment of common infections and toxic exposures of newborns.
Describe the pathophysiology of persistent fetal circulation/pulmonary hypertension.
Describe stabilization techniques and list the differential diagnoses for newborns with seizures.
Review the role of pre‐natal ultrasounds and describe appropriate post‐birth follow‐up of common findings, such as umbilical cord anomalies, renal abnormalities and heart lesions.
List the clinical indications for an acute metabolic or endocrine work‐up in newborns.
Compare and contrast the characteristics of benign versus pathologic cardiac murmurs, and describe the role of oxygen saturation testing.
Discuss the appropriate interventions for a cardiac murmur, including indications for and timing of cardiology consultation
Describe the elements of a safe discharge, attending to timing and follow‐up plans.
Skills
Pediatric hospitalists should be able to:
Maintain Neonatal Resuscitation Program (NRP) certification.
Provide care that incorporates current best practices for oxygen at delivery, infant warming, and treatment of asphyxia.
Correctly order and manage enteral and parenteral nutrition for neonates.
Perform a comprehensive exam and document normal and abnormal variants, including complications of delivery.
Initiate an NRP‐based infant resuscitation, effectively leading the team in the resuscitation of an extremely premature to term infant.
Provide leadership for a normal newborn or level II nursery in partnership with neonatologists and other subspecialists as indicated.
Identify infants with respiratory and cardiac problems and appropriately initiate cardiorespiratory support.
Accurately perform procedures such as lumbar puncture, placement of enteral tubes, umbilical catheters, venous access, intraosseous placement, exchange transfusion and needle thoracotomy or chest tube placement.
Correctly identify newborns requiring subspecialty consultation and counseling such as those with ambiguous genitalia, dysmorphisms, and others and effectively coordinate the referral and subsequent care as indicated.
Recognize and provide initial care for newborns with surgical emergencies, such as infants with gastrointestinal obstruction, diaphragmatic hernia, and others.
Attitudes
Pediatric hospitalists should be able to:
Demonstrate a consistent level of commitment, responsibility, and accountability in rendering patient care for newborns
Role model professional behavior, demonstrating compassion for women and families during the delivery process, when discussing care options, and consultation or referral need, as indicated.
Communicate effectively with patients, the family/caregiver and healthcare providers regarding findings and care plans including post‐discharge needs.
Recognize and respect decisions of the family/caregiver regarding care of extremely premature infants or infants with anomalies.
Systems Organization and Improvement
In order to improve efficiency and quality in their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, evidence‐based care pathways to standardize the evaluation, management and discharge process for newborns.
Work with hospital administration, hospital staff, subspecialists, and other services/consultants to provide appropriate newborn resuscitation services.
Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers for newborns requiring tertiary care.
Copyright © 2010 Society of Hospital Medicine
Lumbar puncture
Introduction
Lumbar puncture is a common typically performed procedure to confirm clinical suspicion of meningitis. Other common indications include the evaluation and diagnosis of pseudotumor cerebri, complex migraine headaches, altered mental status, subarachnoid hemorrhage, neurologic deterioration, and demyelinating diseases such as Guillan Barr. A lumbar puncture or spinal tap often elicits great concern from both patients and the family/caregiver due to a misunderstanding of risk to the spinal cord. Adequate discussion with patients and the family/caregiver, and appropriate use of topical anesthesia, anxiolysis, or sedation can create the environment needed for a successful procedure. Pediatric hospitalists frequently encounter patients requiring lumbar puncture and should be adept at performing lumbar puncture in all appropriately selected pediatric patients.
Knowledge
Pediatric hospitalists should be able to:
List the indications for lumbar puncture, such as confirmation of pleocytosis, aiding initial antimicrobial selection, therapeutic removal of fluid, assessment of response to treatment, performance of neurometabolic studies, and others.
Review the basic anatomy of the spine and spinal column.
List the indications for obtaining an imaging study of the brain or spinal cord prior to performing a lumbar puncture.
Describe the relative contraindications to lumbar puncture such as pre‐existing ventriculoperitoneal shunt or previous spinal surgeries and discuss the options for safely obtaining cerebrospinal fluid in these patients
List the absolute contraindications to lumbar puncture, such as increased intracranial pressure, unstable cardiorespiratory status, unstable coagulopathies, and others.
Describe the risks and complications of lumbar puncture attending to infection, bleeding, nerve injury, pain, post‐procedure headache, and others.
Summarize factors that may increase risk for complications such as age, disease process, and anatomy.
Review the steps in performing a lumbar puncture, attending to aspects such as infection control, patient identification, positioning options, monitoring, family/caregiver presence and others.
Discuss the roles of each member of the healthcare team, attending to proper level of monitoring to maximize safety, timeout, documentation, specimen labeling and transport to the laboratory, and communication with patients and the family/caregiver.
Skills
Pediatric hospitalists should be able to:
Perform a pre‐procedural evaluation to determine risks and benefits of lumbar puncture.
Correctly obtain informed consent from the family/caregiver.
Correctly order and ensure proper performance of procedural sedation if indicated, including assurance of adequate number of staff present for both the lumbar puncture and the sedation.
Demonstrate proficiency in performance of lumbar puncture on infants, children, and adolescents.
Correctly identify the need for and efficiently offer education to healthcare providers on proper techniques for holding and calming patients before, during, and after lumbar puncture attempts.
Consistently adhere to infection control practices.
Order appropriate monitoring and correctly interpret monitor data.
Identify complications and respond with appropriate actions.
Accurately use the pressure manometer as appropriate.
Correctly identify the need for and efficiently access appropriate consultants and support services for assistance with pain management, sedation, and performance of a lumbar puncture.
Attitudes
Pediatric hospitalists should be able to:
Work collaboratively with hospital staff and subspecialists to ensure coordinated planning and performance of lumbar punctures.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of the procedure.
Role model and advocate for strict adherence to infection control practices.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based procedures and policies for performance of lumbar punctures for children.
Work with hospital administration, hospital staff and others to develop and implement standardized documentation tools for the procedure.
Lead, coordinate or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction into procedural strategies.
Introduction
Lumbar puncture is a common typically performed procedure to confirm clinical suspicion of meningitis. Other common indications include the evaluation and diagnosis of pseudotumor cerebri, complex migraine headaches, altered mental status, subarachnoid hemorrhage, neurologic deterioration, and demyelinating diseases such as Guillan Barr. A lumbar puncture or spinal tap often elicits great concern from both patients and the family/caregiver due to a misunderstanding of risk to the spinal cord. Adequate discussion with patients and the family/caregiver, and appropriate use of topical anesthesia, anxiolysis, or sedation can create the environment needed for a successful procedure. Pediatric hospitalists frequently encounter patients requiring lumbar puncture and should be adept at performing lumbar puncture in all appropriately selected pediatric patients.
Knowledge
Pediatric hospitalists should be able to:
List the indications for lumbar puncture, such as confirmation of pleocytosis, aiding initial antimicrobial selection, therapeutic removal of fluid, assessment of response to treatment, performance of neurometabolic studies, and others.
Review the basic anatomy of the spine and spinal column.
List the indications for obtaining an imaging study of the brain or spinal cord prior to performing a lumbar puncture.
Describe the relative contraindications to lumbar puncture such as pre‐existing ventriculoperitoneal shunt or previous spinal surgeries and discuss the options for safely obtaining cerebrospinal fluid in these patients
List the absolute contraindications to lumbar puncture, such as increased intracranial pressure, unstable cardiorespiratory status, unstable coagulopathies, and others.
Describe the risks and complications of lumbar puncture attending to infection, bleeding, nerve injury, pain, post‐procedure headache, and others.
Summarize factors that may increase risk for complications such as age, disease process, and anatomy.
Review the steps in performing a lumbar puncture, attending to aspects such as infection control, patient identification, positioning options, monitoring, family/caregiver presence and others.
Discuss the roles of each member of the healthcare team, attending to proper level of monitoring to maximize safety, timeout, documentation, specimen labeling and transport to the laboratory, and communication with patients and the family/caregiver.
Skills
Pediatric hospitalists should be able to:
Perform a pre‐procedural evaluation to determine risks and benefits of lumbar puncture.
Correctly obtain informed consent from the family/caregiver.
Correctly order and ensure proper performance of procedural sedation if indicated, including assurance of adequate number of staff present for both the lumbar puncture and the sedation.
Demonstrate proficiency in performance of lumbar puncture on infants, children, and adolescents.
Correctly identify the need for and efficiently offer education to healthcare providers on proper techniques for holding and calming patients before, during, and after lumbar puncture attempts.
Consistently adhere to infection control practices.
Order appropriate monitoring and correctly interpret monitor data.
Identify complications and respond with appropriate actions.
Accurately use the pressure manometer as appropriate.
Correctly identify the need for and efficiently access appropriate consultants and support services for assistance with pain management, sedation, and performance of a lumbar puncture.
Attitudes
Pediatric hospitalists should be able to:
Work collaboratively with hospital staff and subspecialists to ensure coordinated planning and performance of lumbar punctures.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of the procedure.
Role model and advocate for strict adherence to infection control practices.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based procedures and policies for performance of lumbar punctures for children.
Work with hospital administration, hospital staff and others to develop and implement standardized documentation tools for the procedure.
Lead, coordinate or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction into procedural strategies.
Introduction
Lumbar puncture is a common typically performed procedure to confirm clinical suspicion of meningitis. Other common indications include the evaluation and diagnosis of pseudotumor cerebri, complex migraine headaches, altered mental status, subarachnoid hemorrhage, neurologic deterioration, and demyelinating diseases such as Guillan Barr. A lumbar puncture or spinal tap often elicits great concern from both patients and the family/caregiver due to a misunderstanding of risk to the spinal cord. Adequate discussion with patients and the family/caregiver, and appropriate use of topical anesthesia, anxiolysis, or sedation can create the environment needed for a successful procedure. Pediatric hospitalists frequently encounter patients requiring lumbar puncture and should be adept at performing lumbar puncture in all appropriately selected pediatric patients.
Knowledge
Pediatric hospitalists should be able to:
List the indications for lumbar puncture, such as confirmation of pleocytosis, aiding initial antimicrobial selection, therapeutic removal of fluid, assessment of response to treatment, performance of neurometabolic studies, and others.
Review the basic anatomy of the spine and spinal column.
List the indications for obtaining an imaging study of the brain or spinal cord prior to performing a lumbar puncture.
Describe the relative contraindications to lumbar puncture such as pre‐existing ventriculoperitoneal shunt or previous spinal surgeries and discuss the options for safely obtaining cerebrospinal fluid in these patients
List the absolute contraindications to lumbar puncture, such as increased intracranial pressure, unstable cardiorespiratory status, unstable coagulopathies, and others.
Describe the risks and complications of lumbar puncture attending to infection, bleeding, nerve injury, pain, post‐procedure headache, and others.
Summarize factors that may increase risk for complications such as age, disease process, and anatomy.
Review the steps in performing a lumbar puncture, attending to aspects such as infection control, patient identification, positioning options, monitoring, family/caregiver presence and others.
Discuss the roles of each member of the healthcare team, attending to proper level of monitoring to maximize safety, timeout, documentation, specimen labeling and transport to the laboratory, and communication with patients and the family/caregiver.
Skills
Pediatric hospitalists should be able to:
Perform a pre‐procedural evaluation to determine risks and benefits of lumbar puncture.
Correctly obtain informed consent from the family/caregiver.
Correctly order and ensure proper performance of procedural sedation if indicated, including assurance of adequate number of staff present for both the lumbar puncture and the sedation.
Demonstrate proficiency in performance of lumbar puncture on infants, children, and adolescents.
Correctly identify the need for and efficiently offer education to healthcare providers on proper techniques for holding and calming patients before, during, and after lumbar puncture attempts.
Consistently adhere to infection control practices.
Order appropriate monitoring and correctly interpret monitor data.
Identify complications and respond with appropriate actions.
Accurately use the pressure manometer as appropriate.
Correctly identify the need for and efficiently access appropriate consultants and support services for assistance with pain management, sedation, and performance of a lumbar puncture.
Attitudes
Pediatric hospitalists should be able to:
Work collaboratively with hospital staff and subspecialists to ensure coordinated planning and performance of lumbar punctures.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of the procedure.
Role model and advocate for strict adherence to infection control practices.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based procedures and policies for performance of lumbar punctures for children.
Work with hospital administration, hospital staff and others to develop and implement standardized documentation tools for the procedure.
Lead, coordinate or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction into procedural strategies.
Copyright © 2010 Society of Hospital Medicine
Central nervous system infections
Introduction
Central nervous system (CNS) infections in children vary widely in incidence and severity. Enteroviral meningitis is relatively common and usually resolves without sequelae. In contrast, viral encephalitides and suppurative CNS infections are less common, but are associated with significant mortality and long‐term morbidity in survivors. Children with CNS implanted devices are particularly diagnostically challenging. All of these infections require prompt diagnosis and initiation of therapy which may require coordination of care with neurologists, neurosurgeons, infectious diseases, neuroradiologists and other subspecialists for optimal outcomes. Pediatric hospitalists are often in the best position to render both coordinated acute care and transition to outpatient care or rehabilitation facility.
Knowledge
Pediatric hospitalists should be able to:
Describe the features of the history (such as back pain, trauma, sinus disease, emesis and others) that suggest CNS infections for varied age groups, including those features that differentiate encephalitis, meningitis, brain abscess, and spinal epidural abscess.
List the physical examination findings (such as focal neurologic findings, rash, mental status changes and others) that suggest CNS infections for varied age groups, including those features that differentiate encephalitis, meningitis, brain abscess, and spinal epidural abscess.
List key elements to obtain in the history such as travel, environmental exposures, animal and insect bites, water sources, and explain how each assists with development of a differential diagnosis for potential etiologic pathogens.
Identify the elements of the history and physical examination that may present in a different manner in patients with underlying co‐morbidities such as ventricular shunts/reservoirs, implanted CNS devices, immunosuppressant use, developmental delay and others.
Compare and contrast the cerebrospinal fluid (CSF) analysis values found in viral, bacterial, atypical bacterial and fungal meningitis, encephalitis, brain abscesses, ventricular infections, and suppurative parameningeal foci.
Identify conditions that predispose to focal, suppurative CNS infections.
Discuss the risks, benefits, and indications for lumbar puncture.
State appropriate microbiologic, virologic, and serologic tests utilized to establish a diagnosis.
Compare and contrast the value of computed tomography versus magnetic resonance for imaging possible CNS infections of the head, neck, and spine, attending to sedation needs, local availability, radiation exposure, and value of contrast versus non‐contrast images.
Summarize the indications for imaging for meningitis, encephalitis, brain abscess, ventricular infections, and parameningeal infections stating modality of choice for each diagnosis.
Describe the approach toward initial antimicrobial therapy for CNS infections, attending to age, likely pathogens, and site of infection.
Explain the importance of CNS drug penetration, microbial drug resistance, and age on initial antimicrobial therapy choice.
Name the most common significant complications of CNS infections such as fluid and electrolyte imbalance, seizures, and increase intracranial pressure.
Skills
Pediatric hospitalists should be able to:
Elicit key historical data that may distinguish between types of CNS infections.
Demonstrate proficiency in performing a careful global physical examination to document features to support or refute various infectious etiologies.
Perform a thorough neurologic examination to identify global or focal neurologic deficits.
Efficiently and effectively perform a lumbar puncture.
Determine best patient placement (bed or ward assignment) based on local monitoring and nursing capabilities and patient clinical status.
Initiate appropriate empiric therapy for CNS infections and modify therapy based on proper interpretation of microbiologic, virologic and serologic data.
Anticipate, recognize, and manage acute complications of CNS infections.
Recognize the indications for transfer to higher level of care and effectively coordinate the transfer.
Obtain and coordinate appropriate consults in a timely manner.
Identify patients with neurologic sequelae and make appropriate referrals for therapy and rehabilitation services.
Coordinate care with subspecialists and the primary care provider and arrange an appropriate transition plan for hospital discharge inclusive of therapies, school needs, and psychosocial support.
Consistently adhere to proper infection control practices.
Attitudes
Pediatric hospitalists should be able to:
Engage consultants in sensitive and clear communications with the family/caregiver regarding potential long term neurologic sequelae as appropriate.
Realize the impact of the illness on the family/caregiver, and maintain empathy at all times.
Recognize that the family/caregiver may not assimilate information during times of stress, and that delivering a clear, coherent assessment and plan on repeated occasions may be needed.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with CNS infection.
Collaborate with public health officials when indicated.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize the evaluation and management for hospitalized children with CNS infections.
Collaborate with hospital administration, hospital staff, and others to create a multidisciplinary approach toward care and support for children with CNS infections.
Work with hospital and community leaders to assure proper services are available for children requiring short and long term support services.
Introduction
Central nervous system (CNS) infections in children vary widely in incidence and severity. Enteroviral meningitis is relatively common and usually resolves without sequelae. In contrast, viral encephalitides and suppurative CNS infections are less common, but are associated with significant mortality and long‐term morbidity in survivors. Children with CNS implanted devices are particularly diagnostically challenging. All of these infections require prompt diagnosis and initiation of therapy which may require coordination of care with neurologists, neurosurgeons, infectious diseases, neuroradiologists and other subspecialists for optimal outcomes. Pediatric hospitalists are often in the best position to render both coordinated acute care and transition to outpatient care or rehabilitation facility.
Knowledge
Pediatric hospitalists should be able to:
Describe the features of the history (such as back pain, trauma, sinus disease, emesis and others) that suggest CNS infections for varied age groups, including those features that differentiate encephalitis, meningitis, brain abscess, and spinal epidural abscess.
List the physical examination findings (such as focal neurologic findings, rash, mental status changes and others) that suggest CNS infections for varied age groups, including those features that differentiate encephalitis, meningitis, brain abscess, and spinal epidural abscess.
List key elements to obtain in the history such as travel, environmental exposures, animal and insect bites, water sources, and explain how each assists with development of a differential diagnosis for potential etiologic pathogens.
Identify the elements of the history and physical examination that may present in a different manner in patients with underlying co‐morbidities such as ventricular shunts/reservoirs, implanted CNS devices, immunosuppressant use, developmental delay and others.
Compare and contrast the cerebrospinal fluid (CSF) analysis values found in viral, bacterial, atypical bacterial and fungal meningitis, encephalitis, brain abscesses, ventricular infections, and suppurative parameningeal foci.
Identify conditions that predispose to focal, suppurative CNS infections.
Discuss the risks, benefits, and indications for lumbar puncture.
State appropriate microbiologic, virologic, and serologic tests utilized to establish a diagnosis.
Compare and contrast the value of computed tomography versus magnetic resonance for imaging possible CNS infections of the head, neck, and spine, attending to sedation needs, local availability, radiation exposure, and value of contrast versus non‐contrast images.
Summarize the indications for imaging for meningitis, encephalitis, brain abscess, ventricular infections, and parameningeal infections stating modality of choice for each diagnosis.
Describe the approach toward initial antimicrobial therapy for CNS infections, attending to age, likely pathogens, and site of infection.
Explain the importance of CNS drug penetration, microbial drug resistance, and age on initial antimicrobial therapy choice.
Name the most common significant complications of CNS infections such as fluid and electrolyte imbalance, seizures, and increase intracranial pressure.
Skills
Pediatric hospitalists should be able to:
Elicit key historical data that may distinguish between types of CNS infections.
Demonstrate proficiency in performing a careful global physical examination to document features to support or refute various infectious etiologies.
Perform a thorough neurologic examination to identify global or focal neurologic deficits.
Efficiently and effectively perform a lumbar puncture.
Determine best patient placement (bed or ward assignment) based on local monitoring and nursing capabilities and patient clinical status.
Initiate appropriate empiric therapy for CNS infections and modify therapy based on proper interpretation of microbiologic, virologic and serologic data.
Anticipate, recognize, and manage acute complications of CNS infections.
Recognize the indications for transfer to higher level of care and effectively coordinate the transfer.
Obtain and coordinate appropriate consults in a timely manner.
Identify patients with neurologic sequelae and make appropriate referrals for therapy and rehabilitation services.
Coordinate care with subspecialists and the primary care provider and arrange an appropriate transition plan for hospital discharge inclusive of therapies, school needs, and psychosocial support.
Consistently adhere to proper infection control practices.
Attitudes
Pediatric hospitalists should be able to:
Engage consultants in sensitive and clear communications with the family/caregiver regarding potential long term neurologic sequelae as appropriate.
Realize the impact of the illness on the family/caregiver, and maintain empathy at all times.
Recognize that the family/caregiver may not assimilate information during times of stress, and that delivering a clear, coherent assessment and plan on repeated occasions may be needed.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with CNS infection.
Collaborate with public health officials when indicated.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize the evaluation and management for hospitalized children with CNS infections.
Collaborate with hospital administration, hospital staff, and others to create a multidisciplinary approach toward care and support for children with CNS infections.
Work with hospital and community leaders to assure proper services are available for children requiring short and long term support services.
Introduction
Central nervous system (CNS) infections in children vary widely in incidence and severity. Enteroviral meningitis is relatively common and usually resolves without sequelae. In contrast, viral encephalitides and suppurative CNS infections are less common, but are associated with significant mortality and long‐term morbidity in survivors. Children with CNS implanted devices are particularly diagnostically challenging. All of these infections require prompt diagnosis and initiation of therapy which may require coordination of care with neurologists, neurosurgeons, infectious diseases, neuroradiologists and other subspecialists for optimal outcomes. Pediatric hospitalists are often in the best position to render both coordinated acute care and transition to outpatient care or rehabilitation facility.
Knowledge
Pediatric hospitalists should be able to:
Describe the features of the history (such as back pain, trauma, sinus disease, emesis and others) that suggest CNS infections for varied age groups, including those features that differentiate encephalitis, meningitis, brain abscess, and spinal epidural abscess.
List the physical examination findings (such as focal neurologic findings, rash, mental status changes and others) that suggest CNS infections for varied age groups, including those features that differentiate encephalitis, meningitis, brain abscess, and spinal epidural abscess.
List key elements to obtain in the history such as travel, environmental exposures, animal and insect bites, water sources, and explain how each assists with development of a differential diagnosis for potential etiologic pathogens.
Identify the elements of the history and physical examination that may present in a different manner in patients with underlying co‐morbidities such as ventricular shunts/reservoirs, implanted CNS devices, immunosuppressant use, developmental delay and others.
Compare and contrast the cerebrospinal fluid (CSF) analysis values found in viral, bacterial, atypical bacterial and fungal meningitis, encephalitis, brain abscesses, ventricular infections, and suppurative parameningeal foci.
Identify conditions that predispose to focal, suppurative CNS infections.
Discuss the risks, benefits, and indications for lumbar puncture.
State appropriate microbiologic, virologic, and serologic tests utilized to establish a diagnosis.
Compare and contrast the value of computed tomography versus magnetic resonance for imaging possible CNS infections of the head, neck, and spine, attending to sedation needs, local availability, radiation exposure, and value of contrast versus non‐contrast images.
Summarize the indications for imaging for meningitis, encephalitis, brain abscess, ventricular infections, and parameningeal infections stating modality of choice for each diagnosis.
Describe the approach toward initial antimicrobial therapy for CNS infections, attending to age, likely pathogens, and site of infection.
Explain the importance of CNS drug penetration, microbial drug resistance, and age on initial antimicrobial therapy choice.
Name the most common significant complications of CNS infections such as fluid and electrolyte imbalance, seizures, and increase intracranial pressure.
Skills
Pediatric hospitalists should be able to:
Elicit key historical data that may distinguish between types of CNS infections.
Demonstrate proficiency in performing a careful global physical examination to document features to support or refute various infectious etiologies.
Perform a thorough neurologic examination to identify global or focal neurologic deficits.
Efficiently and effectively perform a lumbar puncture.
Determine best patient placement (bed or ward assignment) based on local monitoring and nursing capabilities and patient clinical status.
Initiate appropriate empiric therapy for CNS infections and modify therapy based on proper interpretation of microbiologic, virologic and serologic data.
Anticipate, recognize, and manage acute complications of CNS infections.
Recognize the indications for transfer to higher level of care and effectively coordinate the transfer.
Obtain and coordinate appropriate consults in a timely manner.
Identify patients with neurologic sequelae and make appropriate referrals for therapy and rehabilitation services.
Coordinate care with subspecialists and the primary care provider and arrange an appropriate transition plan for hospital discharge inclusive of therapies, school needs, and psychosocial support.
Consistently adhere to proper infection control practices.
Attitudes
Pediatric hospitalists should be able to:
Engage consultants in sensitive and clear communications with the family/caregiver regarding potential long term neurologic sequelae as appropriate.
Realize the impact of the illness on the family/caregiver, and maintain empathy at all times.
Recognize that the family/caregiver may not assimilate information during times of stress, and that delivering a clear, coherent assessment and plan on repeated occasions may be needed.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with CNS infection.
Collaborate with public health officials when indicated.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based care pathways to standardize the evaluation and management for hospitalized children with CNS infections.
Collaborate with hospital administration, hospital staff, and others to create a multidisciplinary approach toward care and support for children with CNS infections.
Work with hospital and community leaders to assure proper services are available for children requiring short and long term support services.
Copyright © 2010 Society of Hospital Medicine
Respiratory failure
Introduction
Respiratory failure is defined by the inability to provide adequate gas exchange, resulting in ineffective alveolar ventilation and/or oxygenation. The respiratory system includes the upper and lower airways, central and peripheral control mechanisms, nerves and muscles. The differential diagnosis for respiratory failure in children is extensive; failure may stem from any portion of the respiratory system. Children with respiratory conditions are frequently hospitalized and may deteriorate, requiring initiation of rapid response teams or transfer to the critical care unit. Pediatric hospitalists frequently encounter children with conditions affecting the respiratory system, and should be able to recognize and treat those who progress to respiratory failure.
Knowledge
Pediatric hospitalists should be able to:
Describe the basic components of the respiratory system, including the upper and lower airways, the central and peripheral regulation systems, peripheral nerves, accessory muscles and diaphragm.
Discuss the basic principles of respiratory physiology such as the alveolar gas equation, minute ventilation, ventilation‐perfusion mismatch, alveolar‐arterial gradient, and others.
Explain the role of the diaphragm and chest wall compliance in development of respiratory failure.
List causes of poor respiratory muscle function, attending to age, neuromuscular disorders, central nervous system dysfunction, nerve injury, and others.
Review the anatomy of the upper airway and discuss why progression to respiratory failure can be rapid in young children.
Describe the differential diagnosis of respiratory distress for children of varying chronological and developmental ages.
State risk factors and diagnostic categories at higher risk for respiratory failure, attending to acute exposures or events and underlying co‐morbidities.
Summarize the modalities commonly available to support the airway and breathing in children with worsening respiratory distress, such as nasopharyngeal or oropharyngeal airways, bag‐valve‐mask ventilation, and endotracheal intubation.
Describe complications due to endotracheal intubation, and state strategies to reduce these risks.
Summarize evaluation, monitoring, and treatment options for patients with worsening respiratory status including mental status assessment, capnography, medications, respiratory support and others.
Describe the signs and symptoms of impending respiratory failure and list criteria for transfer to an intensive care unit.
Skills
Pediatric hospitalists should be able to:
Recognize early warning signs of acute respiratory distress and institute corrective actions to avert further deterioration.
Efficiently stabilize the airway, using effective non‐invasive and invasive airway management techniques in collaboration with other services as appropriate.
Identify patients with risk factors for progression to respiratory failure and assure proper monitoring and patient placement.
Recognize signs of impending respiratory failure and transfer patients to a critical care unit in an efficient and safe manner.
Appropriately order, and interpret oxygenation and ventilation testing results.
Order appropriate monitoring and correctly interpret monitor data.
Correctly diagnose and initiate medical management for systemic causes of respiratory failure.
Demonstrate proficiency in basic management of patients with chronic respiratory support needs.
Identify patients requiring subspecialty care and obtain timely consults.
Attitudes
Pediatric hospitalists should be able to:
Collaborate with patients, the family/caregiver, hospital staff, and subspecialists to ensure coordinated hospital care for children with conditions at risk for respiratory failure.
Provide consultation for healthcare providers in community ambulatory or inpatient settings to ensure proper patient placement and transport of patients to higher acuity settings as needed.
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 others to develop, implement, and assess outcomes of intervention strategies (rapid response, early warning) for hospitalized patients with deterioration in respiratory status in order to prevent adverse outcomes.
Lead, coordinate or participate in creating educational programs for the family/caregiver, hospital staff, and other healthcare providers regarding recognition of signs and symptoms of respiratory distress in children, particularly those at higher risk for respiratory failure.
Introduction
Respiratory failure is defined by the inability to provide adequate gas exchange, resulting in ineffective alveolar ventilation and/or oxygenation. The respiratory system includes the upper and lower airways, central and peripheral control mechanisms, nerves and muscles. The differential diagnosis for respiratory failure in children is extensive; failure may stem from any portion of the respiratory system. Children with respiratory conditions are frequently hospitalized and may deteriorate, requiring initiation of rapid response teams or transfer to the critical care unit. Pediatric hospitalists frequently encounter children with conditions affecting the respiratory system, and should be able to recognize and treat those who progress to respiratory failure.
Knowledge
Pediatric hospitalists should be able to:
Describe the basic components of the respiratory system, including the upper and lower airways, the central and peripheral regulation systems, peripheral nerves, accessory muscles and diaphragm.
Discuss the basic principles of respiratory physiology such as the alveolar gas equation, minute ventilation, ventilation‐perfusion mismatch, alveolar‐arterial gradient, and others.
Explain the role of the diaphragm and chest wall compliance in development of respiratory failure.
List causes of poor respiratory muscle function, attending to age, neuromuscular disorders, central nervous system dysfunction, nerve injury, and others.
Review the anatomy of the upper airway and discuss why progression to respiratory failure can be rapid in young children.
Describe the differential diagnosis of respiratory distress for children of varying chronological and developmental ages.
State risk factors and diagnostic categories at higher risk for respiratory failure, attending to acute exposures or events and underlying co‐morbidities.
Summarize the modalities commonly available to support the airway and breathing in children with worsening respiratory distress, such as nasopharyngeal or oropharyngeal airways, bag‐valve‐mask ventilation, and endotracheal intubation.
Describe complications due to endotracheal intubation, and state strategies to reduce these risks.
Summarize evaluation, monitoring, and treatment options for patients with worsening respiratory status including mental status assessment, capnography, medications, respiratory support and others.
Describe the signs and symptoms of impending respiratory failure and list criteria for transfer to an intensive care unit.
Skills
Pediatric hospitalists should be able to:
Recognize early warning signs of acute respiratory distress and institute corrective actions to avert further deterioration.
Efficiently stabilize the airway, using effective non‐invasive and invasive airway management techniques in collaboration with other services as appropriate.
Identify patients with risk factors for progression to respiratory failure and assure proper monitoring and patient placement.
Recognize signs of impending respiratory failure and transfer patients to a critical care unit in an efficient and safe manner.
Appropriately order, and interpret oxygenation and ventilation testing results.
Order appropriate monitoring and correctly interpret monitor data.
Correctly diagnose and initiate medical management for systemic causes of respiratory failure.
Demonstrate proficiency in basic management of patients with chronic respiratory support needs.
Identify patients requiring subspecialty care and obtain timely consults.
Attitudes
Pediatric hospitalists should be able to:
Collaborate with patients, the family/caregiver, hospital staff, and subspecialists to ensure coordinated hospital care for children with conditions at risk for respiratory failure.
Provide consultation for healthcare providers in community ambulatory or inpatient settings to ensure proper patient placement and transport of patients to higher acuity settings as needed.
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 others to develop, implement, and assess outcomes of intervention strategies (rapid response, early warning) for hospitalized patients with deterioration in respiratory status in order to prevent adverse outcomes.
Lead, coordinate or participate in creating educational programs for the family/caregiver, hospital staff, and other healthcare providers regarding recognition of signs and symptoms of respiratory distress in children, particularly those at higher risk for respiratory failure.
Introduction
Respiratory failure is defined by the inability to provide adequate gas exchange, resulting in ineffective alveolar ventilation and/or oxygenation. The respiratory system includes the upper and lower airways, central and peripheral control mechanisms, nerves and muscles. The differential diagnosis for respiratory failure in children is extensive; failure may stem from any portion of the respiratory system. Children with respiratory conditions are frequently hospitalized and may deteriorate, requiring initiation of rapid response teams or transfer to the critical care unit. Pediatric hospitalists frequently encounter children with conditions affecting the respiratory system, and should be able to recognize and treat those who progress to respiratory failure.
Knowledge
Pediatric hospitalists should be able to:
Describe the basic components of the respiratory system, including the upper and lower airways, the central and peripheral regulation systems, peripheral nerves, accessory muscles and diaphragm.
Discuss the basic principles of respiratory physiology such as the alveolar gas equation, minute ventilation, ventilation‐perfusion mismatch, alveolar‐arterial gradient, and others.
Explain the role of the diaphragm and chest wall compliance in development of respiratory failure.
List causes of poor respiratory muscle function, attending to age, neuromuscular disorders, central nervous system dysfunction, nerve injury, and others.
Review the anatomy of the upper airway and discuss why progression to respiratory failure can be rapid in young children.
Describe the differential diagnosis of respiratory distress for children of varying chronological and developmental ages.
State risk factors and diagnostic categories at higher risk for respiratory failure, attending to acute exposures or events and underlying co‐morbidities.
Summarize the modalities commonly available to support the airway and breathing in children with worsening respiratory distress, such as nasopharyngeal or oropharyngeal airways, bag‐valve‐mask ventilation, and endotracheal intubation.
Describe complications due to endotracheal intubation, and state strategies to reduce these risks.
Summarize evaluation, monitoring, and treatment options for patients with worsening respiratory status including mental status assessment, capnography, medications, respiratory support and others.
Describe the signs and symptoms of impending respiratory failure and list criteria for transfer to an intensive care unit.
Skills
Pediatric hospitalists should be able to:
Recognize early warning signs of acute respiratory distress and institute corrective actions to avert further deterioration.
Efficiently stabilize the airway, using effective non‐invasive and invasive airway management techniques in collaboration with other services as appropriate.
Identify patients with risk factors for progression to respiratory failure and assure proper monitoring and patient placement.
Recognize signs of impending respiratory failure and transfer patients to a critical care unit in an efficient and safe manner.
Appropriately order, and interpret oxygenation and ventilation testing results.
Order appropriate monitoring and correctly interpret monitor data.
Correctly diagnose and initiate medical management for systemic causes of respiratory failure.
Demonstrate proficiency in basic management of patients with chronic respiratory support needs.
Identify patients requiring subspecialty care and obtain timely consults.
Attitudes
Pediatric hospitalists should be able to:
Collaborate with patients, the family/caregiver, hospital staff, and subspecialists to ensure coordinated hospital care for children with conditions at risk for respiratory failure.
Provide consultation for healthcare providers in community ambulatory or inpatient settings to ensure proper patient placement and transport of patients to higher acuity settings as needed.
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 others to develop, implement, and assess outcomes of intervention strategies (rapid response, early warning) for hospitalized patients with deterioration in respiratory status in order to prevent adverse outcomes.
Lead, coordinate or participate in creating educational programs for the family/caregiver, hospital staff, and other healthcare providers regarding recognition of signs and symptoms of respiratory distress in children, particularly those at higher risk for respiratory failure.
Copyright © 2010 Society of Hospital Medicine
Upper airway infections
Introduction
As a group, upper respiratory tract infections in children are responsible for approximately 22 million days of school absence and contribute to work loss due to absence of the family/caregiver caring for ill children. Children under six years of age average six to eight upper respiratory tract infections per year. Although these infections are usually self‐limited, they can be associated with airway obstruction and may be life‐threatening. Laryngotracheobronchitis (croup) is a common cause of upper airway obstruction in children, affecting up to 6% of children under six years of age. Although less than 5% of children with croup are hospitalized, croup account for 35,000 hospital admissions annually and results in the need for endotracheal intubation for 1‐2% of those hospitalized. Other upper airway infections that may lead to airway obstruction include epiglottitis, bacterial tracheitis, severe tonsillitis, and deep neck abscesses. Pediatric hospitalists commonly encounter these patients and are often in the best position to coordinate care across multiple specialties when necessary. Pediatric hospitalists should be able to recognize signs and symptoms of impending or actual airway obstruction, provide immediate care, and arrange for the appropriate subsequent level of care.
Knowledge
Pediatric hospitalists should be able to:
Describe the anatomy of the upper respiratory tract and discuss how abnormalities in airflow in different locations may alter clinical presentation.
Compare and contrast the airway anatomy of neonates, infants, toddlers, preschoolers, school aged children, and adolescents.
Differentiate between the common infectious etiologies of upper airway obstruction in children of various ages.
Review alternate diagnoses which may mimic the presentation of acute upper respiratory infection such as allergic reaction, toxic inhalant exposure, and others.
Describe the signs and symptoms of upper airway obstruction, such as stertor, stridor, tripod positioning, dysphagia, drooling, trismus and others.
List the types of radiographic studies available to assess the upper airway (such as plain radiographs, ultrasonography, computed tomography, and magnetic resonance imaging) and discuss the risks, benefits, and indications for each.
Discuss the indications for nebulized epinephrine, glucocorticoids, antibiotics, and other medications in the treatment of upper respiratory tract infections.
Compare and contrast the benefits and limitations of various modalities of airway stabilization and respiratory support in patients with varying degrees of upper airway obstruction.
List the indications for hospital admission, and explain the utility of various monitoring options.
Discuss the changes in clinical status that indicate need for escalation of care, such as worsening stridor or work of breathing, decreased air entry, cyanosis, altered mental status and others.
Describe the criteria for management in an intensive care unit or transfer to a tertiary care facility.
Review the indications for emergent surgical consultation.
List the criteria for hospital discharge, attending to change in symptoms, oxygenation, hydration, and education.
Skills
Pediatric hospitalists should be able to:
Perform an appropriately focused medical history, attending to symptoms of potential airway obstruction.
Conduct an appropriate physical examination in children with upper respiratory tract infection, attending to signs and symptoms that may indicate the etiology or severity of the infection.
Consistently adhere to infection control practices.
Correctly identify patients with co‐morbidities or potential underlying anatomic abnormalities and order appropriate testing and treatment.
Identify complications of the infection and respond with appropriate actions.
Perform an evidence‐based, cost‐effective diagnostic evaluation and treatment plan, avoiding unnecessary testing as appropriate.
Order appropriate monitoring and correctly interpret monitor data.
Perform careful reassessments daily and as needed, note changes in clinical status and respond with appropriate actions and escalation of care as appropriate.
Stabilize the airway and provide appropriate respiratory support for patients with impending or actual airway obstruction or respiratory failure, or arrange for the appropriate personnel to perform the procedure in a timely and safe manner.
Recognize the indications for and efficiently obtain subspecialty consultation.
Attitudes
Pediatric hospitalists should be able to:
Role model and advocate for strict adherence to infection control practices.
Communicate effectively with patients and the family/caregiver regarding the diagnosis, management plan, and follow‐up needs.
Collaborate with the primary care provider and subspecialists to ensure a coordinated discharge.
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 within a multidisciplinary team for hospitalized children with upper respiratory tract infections.
Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers for hospitalized patients with upper respiratory tract infections.
Introduction
As a group, upper respiratory tract infections in children are responsible for approximately 22 million days of school absence and contribute to work loss due to absence of the family/caregiver caring for ill children. Children under six years of age average six to eight upper respiratory tract infections per year. Although these infections are usually self‐limited, they can be associated with airway obstruction and may be life‐threatening. Laryngotracheobronchitis (croup) is a common cause of upper airway obstruction in children, affecting up to 6% of children under six years of age. Although less than 5% of children with croup are hospitalized, croup account for 35,000 hospital admissions annually and results in the need for endotracheal intubation for 1‐2% of those hospitalized. Other upper airway infections that may lead to airway obstruction include epiglottitis, bacterial tracheitis, severe tonsillitis, and deep neck abscesses. Pediatric hospitalists commonly encounter these patients and are often in the best position to coordinate care across multiple specialties when necessary. Pediatric hospitalists should be able to recognize signs and symptoms of impending or actual airway obstruction, provide immediate care, and arrange for the appropriate subsequent level of care.
Knowledge
Pediatric hospitalists should be able to:
Describe the anatomy of the upper respiratory tract and discuss how abnormalities in airflow in different locations may alter clinical presentation.
Compare and contrast the airway anatomy of neonates, infants, toddlers, preschoolers, school aged children, and adolescents.
Differentiate between the common infectious etiologies of upper airway obstruction in children of various ages.
Review alternate diagnoses which may mimic the presentation of acute upper respiratory infection such as allergic reaction, toxic inhalant exposure, and others.
Describe the signs and symptoms of upper airway obstruction, such as stertor, stridor, tripod positioning, dysphagia, drooling, trismus and others.
List the types of radiographic studies available to assess the upper airway (such as plain radiographs, ultrasonography, computed tomography, and magnetic resonance imaging) and discuss the risks, benefits, and indications for each.
Discuss the indications for nebulized epinephrine, glucocorticoids, antibiotics, and other medications in the treatment of upper respiratory tract infections.
Compare and contrast the benefits and limitations of various modalities of airway stabilization and respiratory support in patients with varying degrees of upper airway obstruction.
List the indications for hospital admission, and explain the utility of various monitoring options.
Discuss the changes in clinical status that indicate need for escalation of care, such as worsening stridor or work of breathing, decreased air entry, cyanosis, altered mental status and others.
Describe the criteria for management in an intensive care unit or transfer to a tertiary care facility.
Review the indications for emergent surgical consultation.
List the criteria for hospital discharge, attending to change in symptoms, oxygenation, hydration, and education.
Skills
Pediatric hospitalists should be able to:
Perform an appropriately focused medical history, attending to symptoms of potential airway obstruction.
Conduct an appropriate physical examination in children with upper respiratory tract infection, attending to signs and symptoms that may indicate the etiology or severity of the infection.
Consistently adhere to infection control practices.
Correctly identify patients with co‐morbidities or potential underlying anatomic abnormalities and order appropriate testing and treatment.
Identify complications of the infection and respond with appropriate actions.
Perform an evidence‐based, cost‐effective diagnostic evaluation and treatment plan, avoiding unnecessary testing as appropriate.
Order appropriate monitoring and correctly interpret monitor data.
Perform careful reassessments daily and as needed, note changes in clinical status and respond with appropriate actions and escalation of care as appropriate.
Stabilize the airway and provide appropriate respiratory support for patients with impending or actual airway obstruction or respiratory failure, or arrange for the appropriate personnel to perform the procedure in a timely and safe manner.
Recognize the indications for and efficiently obtain subspecialty consultation.
Attitudes
Pediatric hospitalists should be able to:
Role model and advocate for strict adherence to infection control practices.
Communicate effectively with patients and the family/caregiver regarding the diagnosis, management plan, and follow‐up needs.
Collaborate with the primary care provider and subspecialists to ensure a coordinated discharge.
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 within a multidisciplinary team for hospitalized children with upper respiratory tract infections.
Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers for hospitalized patients with upper respiratory tract infections.
Introduction
As a group, upper respiratory tract infections in children are responsible for approximately 22 million days of school absence and contribute to work loss due to absence of the family/caregiver caring for ill children. Children under six years of age average six to eight upper respiratory tract infections per year. Although these infections are usually self‐limited, they can be associated with airway obstruction and may be life‐threatening. Laryngotracheobronchitis (croup) is a common cause of upper airway obstruction in children, affecting up to 6% of children under six years of age. Although less than 5% of children with croup are hospitalized, croup account for 35,000 hospital admissions annually and results in the need for endotracheal intubation for 1‐2% of those hospitalized. Other upper airway infections that may lead to airway obstruction include epiglottitis, bacterial tracheitis, severe tonsillitis, and deep neck abscesses. Pediatric hospitalists commonly encounter these patients and are often in the best position to coordinate care across multiple specialties when necessary. Pediatric hospitalists should be able to recognize signs and symptoms of impending or actual airway obstruction, provide immediate care, and arrange for the appropriate subsequent level of care.
Knowledge
Pediatric hospitalists should be able to:
Describe the anatomy of the upper respiratory tract and discuss how abnormalities in airflow in different locations may alter clinical presentation.
Compare and contrast the airway anatomy of neonates, infants, toddlers, preschoolers, school aged children, and adolescents.
Differentiate between the common infectious etiologies of upper airway obstruction in children of various ages.
Review alternate diagnoses which may mimic the presentation of acute upper respiratory infection such as allergic reaction, toxic inhalant exposure, and others.
Describe the signs and symptoms of upper airway obstruction, such as stertor, stridor, tripod positioning, dysphagia, drooling, trismus and others.
List the types of radiographic studies available to assess the upper airway (such as plain radiographs, ultrasonography, computed tomography, and magnetic resonance imaging) and discuss the risks, benefits, and indications for each.
Discuss the indications for nebulized epinephrine, glucocorticoids, antibiotics, and other medications in the treatment of upper respiratory tract infections.
Compare and contrast the benefits and limitations of various modalities of airway stabilization and respiratory support in patients with varying degrees of upper airway obstruction.
List the indications for hospital admission, and explain the utility of various monitoring options.
Discuss the changes in clinical status that indicate need for escalation of care, such as worsening stridor or work of breathing, decreased air entry, cyanosis, altered mental status and others.
Describe the criteria for management in an intensive care unit or transfer to a tertiary care facility.
Review the indications for emergent surgical consultation.
List the criteria for hospital discharge, attending to change in symptoms, oxygenation, hydration, and education.
Skills
Pediatric hospitalists should be able to:
Perform an appropriately focused medical history, attending to symptoms of potential airway obstruction.
Conduct an appropriate physical examination in children with upper respiratory tract infection, attending to signs and symptoms that may indicate the etiology or severity of the infection.
Consistently adhere to infection control practices.
Correctly identify patients with co‐morbidities or potential underlying anatomic abnormalities and order appropriate testing and treatment.
Identify complications of the infection and respond with appropriate actions.
Perform an evidence‐based, cost‐effective diagnostic evaluation and treatment plan, avoiding unnecessary testing as appropriate.
Order appropriate monitoring and correctly interpret monitor data.
Perform careful reassessments daily and as needed, note changes in clinical status and respond with appropriate actions and escalation of care as appropriate.
Stabilize the airway and provide appropriate respiratory support for patients with impending or actual airway obstruction or respiratory failure, or arrange for the appropriate personnel to perform the procedure in a timely and safe manner.
Recognize the indications for and efficiently obtain subspecialty consultation.
Attitudes
Pediatric hospitalists should be able to:
Role model and advocate for strict adherence to infection control practices.
Communicate effectively with patients and the family/caregiver regarding the diagnosis, management plan, and follow‐up needs.
Collaborate with the primary care provider and subspecialists to ensure a coordinated discharge.
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 within a multidisciplinary team for hospitalized children with upper respiratory tract infections.
Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers for hospitalized patients with upper respiratory tract infections.
Copyright © 2010 Society of Hospital Medicine