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Cost‐effective care
Introduction
The delivery of cost‐effective care is an important responsibility and necessary skill for pediatric hospitalists. In the United States, hospital care for children, including neonatal conditions, pediatric illness and adolescent pregnancy entails 6.3 million hospital stays and $46 billion in charges per year. Pediatric inpatient care accounts for 18% of all hospital days and 9% of total U.S. hospital charges. Of these,, three respiratory conditions ‐ pneumonia, bronchitis and asthma ‐ are responsible for nearly $3 billion in charges or 7% of the total US health care bill for children and adolescents Although some categories of hospital expenses such as nurses or equipment may be outside the control of physicians, there are a number that are driven by physician practice patterns. Physician influence on hospital costs is exerted primarily through hospital length stay, medication prescribing patterns, and utilization of laboratory and diagnostic imaging services. Pediatric hospitalists can make a significant contribution to cost management efforts by increased awareness, standardization, evaluation and modification of practice and utilization patterns.
Knowledge
Pediatric hospitalists should be able to:
List the various methods of financing health care for children and state the implications of each on patient care.
Identify and discuss the importance of the metrics used to describe hospital costs such as charges, length of stay, cost per case, and hospital expense per adjusted day.
Demonstrate knowledge of common payment mechanisms for hospital care such as case rates, percent of charges, observation status, per diem rates, and capitation.
Describe mechanisms used by health plans and hospitals to limit hospital costs including pre‐authorization and utilization review.
Name hospital care costs that are controllable by physicians.
Identify examples of how standardization of clinical care processes improves cost and quality of care.
Discuss recent trends in health care delivery that affect pediatric practice such as coordinated management of complex chronic diseases and development of integrated delivery systems.
Describe the concept of system integration and define the roles of various components of the health care system such as community health centers, academic health centers, private practices, and home care agencies.
Define the role of major federal health programs such as Medicaid, Women Infants and Children (WIC) and Vaccines for Children (VFC) in funding healthcare to children from low‐income households.
Give an example of differences in costs of commonly prescribed medications. Illustrate the importance of various considerations when prescribing drugs such as total cost, compliance, availability of pediatric formulation, and insurance formulary lists.
Skills
Pediatric hospitalists should be able to:
Apply strategies to control costs in the daily care of patients in the hospital, such as use of generic drugs, case management, and avoidance of ordering unnecessary tests, as appropriate.
Participate in hospital committees where finance and clinical care are discussed such as pharmacy and therapeutics, quality improvement, ambulatory access, and others.
Incorporate cost considerations when writing orders, and use these opportunities to educate trainees on the importance of such considerations.
Obtain information about costs of care including drugs, medical imaging, and devices.
Work with consultants to determine cost effective approaches to testing and treatment plans.
Coordinate the care of patients to reduce redundant testing or procedures.
Work effectively with home care, discharge planning nurses, care coordinators, and case managers to ensure timely and safe hospital discharge.
Provide education for patients and the family/caregiver that promotes an awareness of costs in developing treatment and discharge plans.
Develop and utilize metrics and performance reporting (such as medication usage) to improve delivery of cost effective care.
Attitudes
Pediatric hospitalists should be able to:
Assume personal responsibility for providing cost effective care.
Serve as an advocate among professional colleagues and in the community for methods to reduce costs of care.
Work collaboratively with others to continuously evaluate and improve care while reducing costs.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Support efforts to gather and disseminate cost, quality and safety data for use in monitoring quality and business improvement efforts.
Promote standard methods of clinical care that improve cost, quality and patient safety.
Work to develop benchmarks for best practices in cost effective care.
Collaborate with hospital administrators to determine and direct policies that impact healthcare utilization.
Introduction
The delivery of cost‐effective care is an important responsibility and necessary skill for pediatric hospitalists. In the United States, hospital care for children, including neonatal conditions, pediatric illness and adolescent pregnancy entails 6.3 million hospital stays and $46 billion in charges per year. Pediatric inpatient care accounts for 18% of all hospital days and 9% of total U.S. hospital charges. Of these,, three respiratory conditions ‐ pneumonia, bronchitis and asthma ‐ are responsible for nearly $3 billion in charges or 7% of the total US health care bill for children and adolescents Although some categories of hospital expenses such as nurses or equipment may be outside the control of physicians, there are a number that are driven by physician practice patterns. Physician influence on hospital costs is exerted primarily through hospital length stay, medication prescribing patterns, and utilization of laboratory and diagnostic imaging services. Pediatric hospitalists can make a significant contribution to cost management efforts by increased awareness, standardization, evaluation and modification of practice and utilization patterns.
Knowledge
Pediatric hospitalists should be able to:
List the various methods of financing health care for children and state the implications of each on patient care.
Identify and discuss the importance of the metrics used to describe hospital costs such as charges, length of stay, cost per case, and hospital expense per adjusted day.
Demonstrate knowledge of common payment mechanisms for hospital care such as case rates, percent of charges, observation status, per diem rates, and capitation.
Describe mechanisms used by health plans and hospitals to limit hospital costs including pre‐authorization and utilization review.
Name hospital care costs that are controllable by physicians.
Identify examples of how standardization of clinical care processes improves cost and quality of care.
Discuss recent trends in health care delivery that affect pediatric practice such as coordinated management of complex chronic diseases and development of integrated delivery systems.
Describe the concept of system integration and define the roles of various components of the health care system such as community health centers, academic health centers, private practices, and home care agencies.
Define the role of major federal health programs such as Medicaid, Women Infants and Children (WIC) and Vaccines for Children (VFC) in funding healthcare to children from low‐income households.
Give an example of differences in costs of commonly prescribed medications. Illustrate the importance of various considerations when prescribing drugs such as total cost, compliance, availability of pediatric formulation, and insurance formulary lists.
Skills
Pediatric hospitalists should be able to:
Apply strategies to control costs in the daily care of patients in the hospital, such as use of generic drugs, case management, and avoidance of ordering unnecessary tests, as appropriate.
Participate in hospital committees where finance and clinical care are discussed such as pharmacy and therapeutics, quality improvement, ambulatory access, and others.
Incorporate cost considerations when writing orders, and use these opportunities to educate trainees on the importance of such considerations.
Obtain information about costs of care including drugs, medical imaging, and devices.
Work with consultants to determine cost effective approaches to testing and treatment plans.
Coordinate the care of patients to reduce redundant testing or procedures.
Work effectively with home care, discharge planning nurses, care coordinators, and case managers to ensure timely and safe hospital discharge.
Provide education for patients and the family/caregiver that promotes an awareness of costs in developing treatment and discharge plans.
Develop and utilize metrics and performance reporting (such as medication usage) to improve delivery of cost effective care.
Attitudes
Pediatric hospitalists should be able to:
Assume personal responsibility for providing cost effective care.
Serve as an advocate among professional colleagues and in the community for methods to reduce costs of care.
Work collaboratively with others to continuously evaluate and improve care while reducing costs.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Support efforts to gather and disseminate cost, quality and safety data for use in monitoring quality and business improvement efforts.
Promote standard methods of clinical care that improve cost, quality and patient safety.
Work to develop benchmarks for best practices in cost effective care.
Collaborate with hospital administrators to determine and direct policies that impact healthcare utilization.
Introduction
The delivery of cost‐effective care is an important responsibility and necessary skill for pediatric hospitalists. In the United States, hospital care for children, including neonatal conditions, pediatric illness and adolescent pregnancy entails 6.3 million hospital stays and $46 billion in charges per year. Pediatric inpatient care accounts for 18% of all hospital days and 9% of total U.S. hospital charges. Of these,, three respiratory conditions ‐ pneumonia, bronchitis and asthma ‐ are responsible for nearly $3 billion in charges or 7% of the total US health care bill for children and adolescents Although some categories of hospital expenses such as nurses or equipment may be outside the control of physicians, there are a number that are driven by physician practice patterns. Physician influence on hospital costs is exerted primarily through hospital length stay, medication prescribing patterns, and utilization of laboratory and diagnostic imaging services. Pediatric hospitalists can make a significant contribution to cost management efforts by increased awareness, standardization, evaluation and modification of practice and utilization patterns.
Knowledge
Pediatric hospitalists should be able to:
List the various methods of financing health care for children and state the implications of each on patient care.
Identify and discuss the importance of the metrics used to describe hospital costs such as charges, length of stay, cost per case, and hospital expense per adjusted day.
Demonstrate knowledge of common payment mechanisms for hospital care such as case rates, percent of charges, observation status, per diem rates, and capitation.
Describe mechanisms used by health plans and hospitals to limit hospital costs including pre‐authorization and utilization review.
Name hospital care costs that are controllable by physicians.
Identify examples of how standardization of clinical care processes improves cost and quality of care.
Discuss recent trends in health care delivery that affect pediatric practice such as coordinated management of complex chronic diseases and development of integrated delivery systems.
Describe the concept of system integration and define the roles of various components of the health care system such as community health centers, academic health centers, private practices, and home care agencies.
Define the role of major federal health programs such as Medicaid, Women Infants and Children (WIC) and Vaccines for Children (VFC) in funding healthcare to children from low‐income households.
Give an example of differences in costs of commonly prescribed medications. Illustrate the importance of various considerations when prescribing drugs such as total cost, compliance, availability of pediatric formulation, and insurance formulary lists.
Skills
Pediatric hospitalists should be able to:
Apply strategies to control costs in the daily care of patients in the hospital, such as use of generic drugs, case management, and avoidance of ordering unnecessary tests, as appropriate.
Participate in hospital committees where finance and clinical care are discussed such as pharmacy and therapeutics, quality improvement, ambulatory access, and others.
Incorporate cost considerations when writing orders, and use these opportunities to educate trainees on the importance of such considerations.
Obtain information about costs of care including drugs, medical imaging, and devices.
Work with consultants to determine cost effective approaches to testing and treatment plans.
Coordinate the care of patients to reduce redundant testing or procedures.
Work effectively with home care, discharge planning nurses, care coordinators, and case managers to ensure timely and safe hospital discharge.
Provide education for patients and the family/caregiver that promotes an awareness of costs in developing treatment and discharge plans.
Develop and utilize metrics and performance reporting (such as medication usage) to improve delivery of cost effective care.
Attitudes
Pediatric hospitalists should be able to:
Assume personal responsibility for providing cost effective care.
Serve as an advocate among professional colleagues and in the community for methods to reduce costs of care.
Work collaboratively with others to continuously evaluate and improve care while reducing costs.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Support efforts to gather and disseminate cost, quality and safety data for use in monitoring quality and business improvement efforts.
Promote standard methods of clinical care that improve cost, quality and patient safety.
Work to develop benchmarks for best practices in cost effective care.
Collaborate with hospital administrators to determine and direct policies that impact healthcare utilization.
Copyright © 2010 Society of Hospital Medicine
Bladder catheterization/suprapubic bladder tap
Introduction
Bladder catheterization is a common procedure, typically used to collect a sterile urine sample for analysis and culture when urinary tract infection is suspected. Bladder catheterization is also used to relieve urinary retention or obstruction, particularly in cases of anatomic abnormalities or neurogenic bladder, or to monitor urine output and fluid status. Pediatric hospitalists frequently encounter patients requiring bladder catheterization and should be adept at performing this procedure in infants, children, and adolescents.
Knowledge
Pediatric hospitalists should be able to:
List the indications and contraindications for bladder catheterization.
Describe how the method used to collect a urine specimen can affect interpretation of urine culture results, and explain why bladder catheterization or suprapubic tap are the preferred methods of collection in infants and children that cannot reliably produce a voided specimen.
Review the basic anatomy of the male and female genitourinary tract.
Review the steps in performing bladder catheterization for both male and female patients, attending to aspects such as patient identification, sterile technique, positioning, equipment needs, and specimen handling.
Discuss the indications for analgesia, sedation, or anxiolysis and describe the medications that may be used for each.
Describe the risks and complications associated with bladder catheterization, such as localized trauma, creation of a false passage, and potential stricture formation.
List the indications for consultation with a urologist with regard to bladder catheterization, including known genitourinary tract abnormality, recent genitourinary surgery, or urethral trauma
Compare and contrast the effects of using various methods to collect a urine specimen, including interpretation of the culture and urinalysis and patient risk,
Define a UTI as obtained by various methods such as catheterization, clean catch, clean bag, and suprapubic tap.
Discuss the importance of appropriate specimen handling and the effect on culture results.
Skills
Pediatric hospitalists should be able to:
Perform a pre‐procedural evaluation to determine risks and benefits of bladder catheterization.
Demonstrate proficiency in performance of bladder catheterization on infants, children, and adolescents.
Consider the level of pain and anxiety provoked by the procedure and provide appropriate pharmacologic or non‐pharmacologic interventions when indicated.
Correctly identify the need for and efficiently offer education to healthcare providers on proper techniques for holding and calming patients before, during, and after bladder catheterization.
Consistently adhere to infection control practices.
Identify complications and respond with appropriate actions.
Identify the need for and efficiently access appropriate consultants and support services for assistance with analgesia, sedation, anxiolysis, and performance of a bladder catheterization.
Attitudes
Hospital physicians should be able to:
Recognize the importance of obtaining a sterile urine specimen in order to correctly diagnose urinary tract infection.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of bladder catheterization.
Role model and advocate for strict adherence to infection control practices
Systems organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based procedures and policies for performance of bladder catheterization in children.
Lead, coordinate or participate in the development and implementation of educational initiatives designed to teach the proper technique for bladder catheterization to learners and other healthcare providers.
Introduction
Bladder catheterization is a common procedure, typically used to collect a sterile urine sample for analysis and culture when urinary tract infection is suspected. Bladder catheterization is also used to relieve urinary retention or obstruction, particularly in cases of anatomic abnormalities or neurogenic bladder, or to monitor urine output and fluid status. Pediatric hospitalists frequently encounter patients requiring bladder catheterization and should be adept at performing this procedure in infants, children, and adolescents.
Knowledge
Pediatric hospitalists should be able to:
List the indications and contraindications for bladder catheterization.
Describe how the method used to collect a urine specimen can affect interpretation of urine culture results, and explain why bladder catheterization or suprapubic tap are the preferred methods of collection in infants and children that cannot reliably produce a voided specimen.
Review the basic anatomy of the male and female genitourinary tract.
Review the steps in performing bladder catheterization for both male and female patients, attending to aspects such as patient identification, sterile technique, positioning, equipment needs, and specimen handling.
Discuss the indications for analgesia, sedation, or anxiolysis and describe the medications that may be used for each.
Describe the risks and complications associated with bladder catheterization, such as localized trauma, creation of a false passage, and potential stricture formation.
List the indications for consultation with a urologist with regard to bladder catheterization, including known genitourinary tract abnormality, recent genitourinary surgery, or urethral trauma
Compare and contrast the effects of using various methods to collect a urine specimen, including interpretation of the culture and urinalysis and patient risk,
Define a UTI as obtained by various methods such as catheterization, clean catch, clean bag, and suprapubic tap.
Discuss the importance of appropriate specimen handling and the effect on culture results.
Skills
Pediatric hospitalists should be able to:
Perform a pre‐procedural evaluation to determine risks and benefits of bladder catheterization.
Demonstrate proficiency in performance of bladder catheterization on infants, children, and adolescents.
Consider the level of pain and anxiety provoked by the procedure and provide appropriate pharmacologic or non‐pharmacologic interventions when indicated.
Correctly identify the need for and efficiently offer education to healthcare providers on proper techniques for holding and calming patients before, during, and after bladder catheterization.
Consistently adhere to infection control practices.
Identify complications and respond with appropriate actions.
Identify the need for and efficiently access appropriate consultants and support services for assistance with analgesia, sedation, anxiolysis, and performance of a bladder catheterization.
Attitudes
Hospital physicians should be able to:
Recognize the importance of obtaining a sterile urine specimen in order to correctly diagnose urinary tract infection.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of bladder catheterization.
Role model and advocate for strict adherence to infection control practices
Systems organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based procedures and policies for performance of bladder catheterization in children.
Lead, coordinate or participate in the development and implementation of educational initiatives designed to teach the proper technique for bladder catheterization to learners and other healthcare providers.
Introduction
Bladder catheterization is a common procedure, typically used to collect a sterile urine sample for analysis and culture when urinary tract infection is suspected. Bladder catheterization is also used to relieve urinary retention or obstruction, particularly in cases of anatomic abnormalities or neurogenic bladder, or to monitor urine output and fluid status. Pediatric hospitalists frequently encounter patients requiring bladder catheterization and should be adept at performing this procedure in infants, children, and adolescents.
Knowledge
Pediatric hospitalists should be able to:
List the indications and contraindications for bladder catheterization.
Describe how the method used to collect a urine specimen can affect interpretation of urine culture results, and explain why bladder catheterization or suprapubic tap are the preferred methods of collection in infants and children that cannot reliably produce a voided specimen.
Review the basic anatomy of the male and female genitourinary tract.
Review the steps in performing bladder catheterization for both male and female patients, attending to aspects such as patient identification, sterile technique, positioning, equipment needs, and specimen handling.
Discuss the indications for analgesia, sedation, or anxiolysis and describe the medications that may be used for each.
Describe the risks and complications associated with bladder catheterization, such as localized trauma, creation of a false passage, and potential stricture formation.
List the indications for consultation with a urologist with regard to bladder catheterization, including known genitourinary tract abnormality, recent genitourinary surgery, or urethral trauma
Compare and contrast the effects of using various methods to collect a urine specimen, including interpretation of the culture and urinalysis and patient risk,
Define a UTI as obtained by various methods such as catheterization, clean catch, clean bag, and suprapubic tap.
Discuss the importance of appropriate specimen handling and the effect on culture results.
Skills
Pediatric hospitalists should be able to:
Perform a pre‐procedural evaluation to determine risks and benefits of bladder catheterization.
Demonstrate proficiency in performance of bladder catheterization on infants, children, and adolescents.
Consider the level of pain and anxiety provoked by the procedure and provide appropriate pharmacologic or non‐pharmacologic interventions when indicated.
Correctly identify the need for and efficiently offer education to healthcare providers on proper techniques for holding and calming patients before, during, and after bladder catheterization.
Consistently adhere to infection control practices.
Identify complications and respond with appropriate actions.
Identify the need for and efficiently access appropriate consultants and support services for assistance with analgesia, sedation, anxiolysis, and performance of a bladder catheterization.
Attitudes
Hospital physicians should be able to:
Recognize the importance of obtaining a sterile urine specimen in order to correctly diagnose urinary tract infection.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps of bladder catheterization.
Role model and advocate for strict adherence to infection control practices
Systems organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based procedures and policies for performance of bladder catheterization in children.
Lead, coordinate or participate in the development and implementation of educational initiatives designed to teach the proper technique for bladder catheterization to learners and other healthcare providers.
Copyright © 2010 Society of Hospital Medicine
Research
Introduction
Research is a rapidly growing aspect of inpatient medicine. The practice of evidence‐based medicine and the acute need for more evidence on inpatient conditions require that pediatric hospitalists understand and participate in research related activities. Pediatric hospitalists' role in research will vary depending on their setting and job description. This role may include many facets, from reviewing relevant patient‐based articles, to participating in multi‐institutional studies requiring enrollment of patients, to leading local or national studies. Pediatric hospitalists need to have a basic understanding of research methods and process in order to participate in and benefit from research. This understanding contributes to the effective care of hospitalized patients.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast different types of study design such as case‐control, cohort, observational, and randomized control trials. Understand the advantages and disadvantages of each study design.
Name resources available to access current or proposed studies and funding sources such as the Agency for Healthcare Research and Quality (AHRQ), the National Institutes of Health (NIH), Robert Wood Johnson Foundation, clinicaltrials.gov, and others.
Discuss what resources are required to support research components of data collection, data analysis, abstract and manuscript preparation, grant funding and others.
Explain how results from articles published in the following formats apply to clinical practice:
Case reports and case series
Retrospective chart reviews
Secondary data analyses of large data sets
Randomized controlled trials
Meta analyses and systematic reviews
Practice Guidelines
Identify and efficiently locate the best available information resources to address questions in clinical practice, and conduct computerized scientific literature searches in a planned and systematic fashion.
Define basic statistical terms such as sample, discrete and continuous data variables, measures of central tendency (mean, median, and mode) and variability (variance, standard deviation, range).
Cite the various aspects of the research process including informed consent or assent, the role of institutional review boards (IRB), and HIPAA (Health Insurance Portability and Accountability Act).
Discuss special protections needed when conducting research with vulnerable populations. Define minimal risk for a healthy child and for a child with an illness.
List common barriers to implementation of clinical studies and describe pediatric hospitalists' role in overcoming these barriers.
Skills
Pediatric hospitalists should be able to:
Demonstrate proficiency in searching the medical literature for existing relevant clinical research for their inpatients.
Generate an answerable patient‐centered clinical question that is relevant to improving patient care.
Apply the results of studies to clinical practice by determining whether the study subjects were similar to patients being treated, whether all clinically important outcomes were considered, identify threats to validity, and
For treatment studies, describe whether the likely benefits are worth the potential harm and cost.
For studies of diagnostic tests, describe whether the test is available, affordable, accurate and precise in the present clinical setting, and whether the results of the test will change the management of patients being treated.
For studies of harm, describe whether the magnitude of risk warrants an attempt to stop the exposure.
For studies of prognosis, describe whether the results of the study will lead directly to selecting therapy and/or are useful for counseling patients.
Provide effective informed consent or assent for patients participating in research studies as appropriate.
Attitudes
Pediatric hospitalists should be able to:
Appreciate the importance of full informed consent for purposes of patient participation in clinical research.
Appreciate the importance of patient assent, even in the presence of legal guardian informed consent, when involving children in clinical research.
Demonstrate highly ethical principles in participating in research studies.
Avoid conflict of interest or potential conflict of interest in participation in research studies.
Acquire, manage, and share data collected for research purposes in a responsible and professional manner, maintaining high standards for protecting confidentiality, avoiding unjustified exclusions, sharing data, and adhering to copyright law.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Encourage participation of interdisciplinary teams including nursing, social work, nutrition, pharmacy, and others in performance of research.
Advocate for thoughtful application of research findings to improve systems of healthcare delivery.
Support national multi‐center research efforts that improve the evidence base in inpatient pediatrics. Where appropriate, encourage participation local hospital involvement in these efforts.
Recognize, support and promote efforts of research team members (analyst, data collector, statistician, nursing, and others).
Introduction
Research is a rapidly growing aspect of inpatient medicine. The practice of evidence‐based medicine and the acute need for more evidence on inpatient conditions require that pediatric hospitalists understand and participate in research related activities. Pediatric hospitalists' role in research will vary depending on their setting and job description. This role may include many facets, from reviewing relevant patient‐based articles, to participating in multi‐institutional studies requiring enrollment of patients, to leading local or national studies. Pediatric hospitalists need to have a basic understanding of research methods and process in order to participate in and benefit from research. This understanding contributes to the effective care of hospitalized patients.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast different types of study design such as case‐control, cohort, observational, and randomized control trials. Understand the advantages and disadvantages of each study design.
Name resources available to access current or proposed studies and funding sources such as the Agency for Healthcare Research and Quality (AHRQ), the National Institutes of Health (NIH), Robert Wood Johnson Foundation, clinicaltrials.gov, and others.
Discuss what resources are required to support research components of data collection, data analysis, abstract and manuscript preparation, grant funding and others.
Explain how results from articles published in the following formats apply to clinical practice:
Case reports and case series
Retrospective chart reviews
Secondary data analyses of large data sets
Randomized controlled trials
Meta analyses and systematic reviews
Practice Guidelines
Identify and efficiently locate the best available information resources to address questions in clinical practice, and conduct computerized scientific literature searches in a planned and systematic fashion.
Define basic statistical terms such as sample, discrete and continuous data variables, measures of central tendency (mean, median, and mode) and variability (variance, standard deviation, range).
Cite the various aspects of the research process including informed consent or assent, the role of institutional review boards (IRB), and HIPAA (Health Insurance Portability and Accountability Act).
Discuss special protections needed when conducting research with vulnerable populations. Define minimal risk for a healthy child and for a child with an illness.
List common barriers to implementation of clinical studies and describe pediatric hospitalists' role in overcoming these barriers.
Skills
Pediatric hospitalists should be able to:
Demonstrate proficiency in searching the medical literature for existing relevant clinical research for their inpatients.
Generate an answerable patient‐centered clinical question that is relevant to improving patient care.
Apply the results of studies to clinical practice by determining whether the study subjects were similar to patients being treated, whether all clinically important outcomes were considered, identify threats to validity, and
For treatment studies, describe whether the likely benefits are worth the potential harm and cost.
For studies of diagnostic tests, describe whether the test is available, affordable, accurate and precise in the present clinical setting, and whether the results of the test will change the management of patients being treated.
For studies of harm, describe whether the magnitude of risk warrants an attempt to stop the exposure.
For studies of prognosis, describe whether the results of the study will lead directly to selecting therapy and/or are useful for counseling patients.
Provide effective informed consent or assent for patients participating in research studies as appropriate.
Attitudes
Pediatric hospitalists should be able to:
Appreciate the importance of full informed consent for purposes of patient participation in clinical research.
Appreciate the importance of patient assent, even in the presence of legal guardian informed consent, when involving children in clinical research.
Demonstrate highly ethical principles in participating in research studies.
Avoid conflict of interest or potential conflict of interest in participation in research studies.
Acquire, manage, and share data collected for research purposes in a responsible and professional manner, maintaining high standards for protecting confidentiality, avoiding unjustified exclusions, sharing data, and adhering to copyright law.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Encourage participation of interdisciplinary teams including nursing, social work, nutrition, pharmacy, and others in performance of research.
Advocate for thoughtful application of research findings to improve systems of healthcare delivery.
Support national multi‐center research efforts that improve the evidence base in inpatient pediatrics. Where appropriate, encourage participation local hospital involvement in these efforts.
Recognize, support and promote efforts of research team members (analyst, data collector, statistician, nursing, and others).
Introduction
Research is a rapidly growing aspect of inpatient medicine. The practice of evidence‐based medicine and the acute need for more evidence on inpatient conditions require that pediatric hospitalists understand and participate in research related activities. Pediatric hospitalists' role in research will vary depending on their setting and job description. This role may include many facets, from reviewing relevant patient‐based articles, to participating in multi‐institutional studies requiring enrollment of patients, to leading local or national studies. Pediatric hospitalists need to have a basic understanding of research methods and process in order to participate in and benefit from research. This understanding contributes to the effective care of hospitalized patients.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast different types of study design such as case‐control, cohort, observational, and randomized control trials. Understand the advantages and disadvantages of each study design.
Name resources available to access current or proposed studies and funding sources such as the Agency for Healthcare Research and Quality (AHRQ), the National Institutes of Health (NIH), Robert Wood Johnson Foundation, clinicaltrials.gov, and others.
Discuss what resources are required to support research components of data collection, data analysis, abstract and manuscript preparation, grant funding and others.
Explain how results from articles published in the following formats apply to clinical practice:
Case reports and case series
Retrospective chart reviews
Secondary data analyses of large data sets
Randomized controlled trials
Meta analyses and systematic reviews
Practice Guidelines
Identify and efficiently locate the best available information resources to address questions in clinical practice, and conduct computerized scientific literature searches in a planned and systematic fashion.
Define basic statistical terms such as sample, discrete and continuous data variables, measures of central tendency (mean, median, and mode) and variability (variance, standard deviation, range).
Cite the various aspects of the research process including informed consent or assent, the role of institutional review boards (IRB), and HIPAA (Health Insurance Portability and Accountability Act).
Discuss special protections needed when conducting research with vulnerable populations. Define minimal risk for a healthy child and for a child with an illness.
List common barriers to implementation of clinical studies and describe pediatric hospitalists' role in overcoming these barriers.
Skills
Pediatric hospitalists should be able to:
Demonstrate proficiency in searching the medical literature for existing relevant clinical research for their inpatients.
Generate an answerable patient‐centered clinical question that is relevant to improving patient care.
Apply the results of studies to clinical practice by determining whether the study subjects were similar to patients being treated, whether all clinically important outcomes were considered, identify threats to validity, and
For treatment studies, describe whether the likely benefits are worth the potential harm and cost.
For studies of diagnostic tests, describe whether the test is available, affordable, accurate and precise in the present clinical setting, and whether the results of the test will change the management of patients being treated.
For studies of harm, describe whether the magnitude of risk warrants an attempt to stop the exposure.
For studies of prognosis, describe whether the results of the study will lead directly to selecting therapy and/or are useful for counseling patients.
Provide effective informed consent or assent for patients participating in research studies as appropriate.
Attitudes
Pediatric hospitalists should be able to:
Appreciate the importance of full informed consent for purposes of patient participation in clinical research.
Appreciate the importance of patient assent, even in the presence of legal guardian informed consent, when involving children in clinical research.
Demonstrate highly ethical principles in participating in research studies.
Avoid conflict of interest or potential conflict of interest in participation in research studies.
Acquire, manage, and share data collected for research purposes in a responsible and professional manner, maintaining high standards for protecting confidentiality, avoiding unjustified exclusions, sharing data, and adhering to copyright law.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Encourage participation of interdisciplinary teams including nursing, social work, nutrition, pharmacy, and others in performance of research.
Advocate for thoughtful application of research findings to improve systems of healthcare delivery.
Support national multi‐center research efforts that improve the evidence base in inpatient pediatrics. Where appropriate, encourage participation local hospital involvement in these efforts.
Recognize, support and promote efforts of research team members (analyst, data collector, statistician, nursing, and others).
Copyright © 2010 Society of Hospital Medicine
Toxic ingestion
Introduction
In 2006, the National Data Poison System captured more than 4 million calls to poison control centers in the United States, 2.4 million of which were calls regarding human exposures. More than 50% of reported toxin exposures occur in children under age 6 years. Furthermore, ingestion accounts for 75% of all toxin exposures in younger children. In this age group, toxin ingestion is frequently unintentional and involves non‐pharmacologic agents, but therapeutic errors in the administration of pharmacologic agents do occur. In adolescents, toxin ingestion is more often intentional or associated with substance abuse, and carries with it greater morbidity and mortality, particularly when pharmacological agents are involved. Pediatric hospitalists often provide immediate care, coordinate care with subspecialists, or arrange for transfer to another facility when appropriate.
Knowledge
Pediatric hospitalists should be able to:
List the pharmacologic and non‐pharmacologic agents commonly ingested by pediatric patients and describe how the frequency of each category changes with age.
Compare and contrast the risk factors and co‐morbidities associated with unintentional versus intentional ingestion.
Describe the signs and symptoms of acute ingestion, including known toxidromes for commonly ingested agents such as salicylates, acetaminophen, narcotics, hallucinogens, stimulants, and others.
Discuss the risk factors for and presentation of acute and chronic lead poisoning.
List the laboratory tests that support or refute the diagnosis or assist with the management of common ingestions.
List the agents detected in locally available blood and urine toxicology screens and describe the benefits and limitations of this testing.
Explain the indications for and limitations of decontamination therapy, including dermal, ocular, and gastric decontamination methods.
Identify toxins that have a specific antidote available and explain the indications and limitations of each.
List local resources that provide information and advice regarding pediatric toxin ingestion management, and recognize there is a single phone number that may be used in the United States to access all regional poison center resources.
Summarize the indications and goals of hospitalization, attending to acute and chronic medical needs and psychosocial intervention.
Review the criteria for and process of discharge including psychiatric evaluation, inpatient psychiatric facility transfer, foster care and other elements important for safe discharge.
Skills
Pediatric hospitalists should be able to:
Obtain a focused history, including detailed information about potential exposures, such as the type, amount, and timing of the ingestion.
Perform a focused physical examination, with attention paid to signs and symptoms that may indicate the ingestion of a particular toxin.
Efficiently access institutional and local resources to obtain information and advice regarding the diagnosis and management of acute ingestion.
Identify patients presenting with common toxidromes and efficiently institute appropriate therapy.
Recognize life‐threatening complications such as cardiac dysrhythmias, respiratory depression, or mental status change and institute appropriate therapy in a timely fashion.
Recognize potential co‐morbidities associated with intentional ingestion, such as depression, abuse, or other mental illness.
Correctly order and interpret basic tests, such as serum chemistries, blood gases, and electrocardiograms, and identify abnormal findings that require additional testing or consultation.
Develop an appropriate treatment plan based on the presumptive or confirmed agent and provide decontamination or antidote therapy when appropriate.
Determine the appropriate level of care and duration of observation for a given toxin, recognizing that some agents may have delayed toxic effects.
Involve subspecialists when appropriate, including social work and/or psychiatric consultation for cases of non‐accidental ingestion as appropriate.
Correctly identify patients who require legal (protective or other) involvement and efficiently access appropriate agencies.
Attitudes
Pediatric hospitalists should be able to:
Counsel the family/caregiver and other professional staff on the possible etiology and outcomes of the ingestion episode.
Assess the social environment to determine the risk of future exposure and the need for mitigation of risk factors prior to discharge.
Educate caregivers regarding proactive risk reduction measures, such as the safe and effective storage, use and administration of medications.
Realize the importance of remaining vigilant regarding changes in recreational drug availability and use as well as safety profile updates on pharmacologic and non‐pharmacologic agents.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development of systems that integrate hospital, community, and national resources to provide up‐to‐date and evidence‐based information about toxin ingestions and promote timely recognition and treatment of both intentional and unintentional ingestions.
Lead, coordinate or participate in efforts to educate healthcare providers about the most common ingestions in the pediatric population.
Lead, coordinate or participate in efforts to educate healthcare providers and the community, regarding ways to mitigate medication errors.
Introduction
In 2006, the National Data Poison System captured more than 4 million calls to poison control centers in the United States, 2.4 million of which were calls regarding human exposures. More than 50% of reported toxin exposures occur in children under age 6 years. Furthermore, ingestion accounts for 75% of all toxin exposures in younger children. In this age group, toxin ingestion is frequently unintentional and involves non‐pharmacologic agents, but therapeutic errors in the administration of pharmacologic agents do occur. In adolescents, toxin ingestion is more often intentional or associated with substance abuse, and carries with it greater morbidity and mortality, particularly when pharmacological agents are involved. Pediatric hospitalists often provide immediate care, coordinate care with subspecialists, or arrange for transfer to another facility when appropriate.
Knowledge
Pediatric hospitalists should be able to:
List the pharmacologic and non‐pharmacologic agents commonly ingested by pediatric patients and describe how the frequency of each category changes with age.
Compare and contrast the risk factors and co‐morbidities associated with unintentional versus intentional ingestion.
Describe the signs and symptoms of acute ingestion, including known toxidromes for commonly ingested agents such as salicylates, acetaminophen, narcotics, hallucinogens, stimulants, and others.
Discuss the risk factors for and presentation of acute and chronic lead poisoning.
List the laboratory tests that support or refute the diagnosis or assist with the management of common ingestions.
List the agents detected in locally available blood and urine toxicology screens and describe the benefits and limitations of this testing.
Explain the indications for and limitations of decontamination therapy, including dermal, ocular, and gastric decontamination methods.
Identify toxins that have a specific antidote available and explain the indications and limitations of each.
List local resources that provide information and advice regarding pediatric toxin ingestion management, and recognize there is a single phone number that may be used in the United States to access all regional poison center resources.
Summarize the indications and goals of hospitalization, attending to acute and chronic medical needs and psychosocial intervention.
Review the criteria for and process of discharge including psychiatric evaluation, inpatient psychiatric facility transfer, foster care and other elements important for safe discharge.
Skills
Pediatric hospitalists should be able to:
Obtain a focused history, including detailed information about potential exposures, such as the type, amount, and timing of the ingestion.
Perform a focused physical examination, with attention paid to signs and symptoms that may indicate the ingestion of a particular toxin.
Efficiently access institutional and local resources to obtain information and advice regarding the diagnosis and management of acute ingestion.
Identify patients presenting with common toxidromes and efficiently institute appropriate therapy.
Recognize life‐threatening complications such as cardiac dysrhythmias, respiratory depression, or mental status change and institute appropriate therapy in a timely fashion.
Recognize potential co‐morbidities associated with intentional ingestion, such as depression, abuse, or other mental illness.
Correctly order and interpret basic tests, such as serum chemistries, blood gases, and electrocardiograms, and identify abnormal findings that require additional testing or consultation.
Develop an appropriate treatment plan based on the presumptive or confirmed agent and provide decontamination or antidote therapy when appropriate.
Determine the appropriate level of care and duration of observation for a given toxin, recognizing that some agents may have delayed toxic effects.
Involve subspecialists when appropriate, including social work and/or psychiatric consultation for cases of non‐accidental ingestion as appropriate.
Correctly identify patients who require legal (protective or other) involvement and efficiently access appropriate agencies.
Attitudes
Pediatric hospitalists should be able to:
Counsel the family/caregiver and other professional staff on the possible etiology and outcomes of the ingestion episode.
Assess the social environment to determine the risk of future exposure and the need for mitigation of risk factors prior to discharge.
Educate caregivers regarding proactive risk reduction measures, such as the safe and effective storage, use and administration of medications.
Realize the importance of remaining vigilant regarding changes in recreational drug availability and use as well as safety profile updates on pharmacologic and non‐pharmacologic agents.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development of systems that integrate hospital, community, and national resources to provide up‐to‐date and evidence‐based information about toxin ingestions and promote timely recognition and treatment of both intentional and unintentional ingestions.
Lead, coordinate or participate in efforts to educate healthcare providers about the most common ingestions in the pediatric population.
Lead, coordinate or participate in efforts to educate healthcare providers and the community, regarding ways to mitigate medication errors.
Introduction
In 2006, the National Data Poison System captured more than 4 million calls to poison control centers in the United States, 2.4 million of which were calls regarding human exposures. More than 50% of reported toxin exposures occur in children under age 6 years. Furthermore, ingestion accounts for 75% of all toxin exposures in younger children. In this age group, toxin ingestion is frequently unintentional and involves non‐pharmacologic agents, but therapeutic errors in the administration of pharmacologic agents do occur. In adolescents, toxin ingestion is more often intentional or associated with substance abuse, and carries with it greater morbidity and mortality, particularly when pharmacological agents are involved. Pediatric hospitalists often provide immediate care, coordinate care with subspecialists, or arrange for transfer to another facility when appropriate.
Knowledge
Pediatric hospitalists should be able to:
List the pharmacologic and non‐pharmacologic agents commonly ingested by pediatric patients and describe how the frequency of each category changes with age.
Compare and contrast the risk factors and co‐morbidities associated with unintentional versus intentional ingestion.
Describe the signs and symptoms of acute ingestion, including known toxidromes for commonly ingested agents such as salicylates, acetaminophen, narcotics, hallucinogens, stimulants, and others.
Discuss the risk factors for and presentation of acute and chronic lead poisoning.
List the laboratory tests that support or refute the diagnosis or assist with the management of common ingestions.
List the agents detected in locally available blood and urine toxicology screens and describe the benefits and limitations of this testing.
Explain the indications for and limitations of decontamination therapy, including dermal, ocular, and gastric decontamination methods.
Identify toxins that have a specific antidote available and explain the indications and limitations of each.
List local resources that provide information and advice regarding pediatric toxin ingestion management, and recognize there is a single phone number that may be used in the United States to access all regional poison center resources.
Summarize the indications and goals of hospitalization, attending to acute and chronic medical needs and psychosocial intervention.
Review the criteria for and process of discharge including psychiatric evaluation, inpatient psychiatric facility transfer, foster care and other elements important for safe discharge.
Skills
Pediatric hospitalists should be able to:
Obtain a focused history, including detailed information about potential exposures, such as the type, amount, and timing of the ingestion.
Perform a focused physical examination, with attention paid to signs and symptoms that may indicate the ingestion of a particular toxin.
Efficiently access institutional and local resources to obtain information and advice regarding the diagnosis and management of acute ingestion.
Identify patients presenting with common toxidromes and efficiently institute appropriate therapy.
Recognize life‐threatening complications such as cardiac dysrhythmias, respiratory depression, or mental status change and institute appropriate therapy in a timely fashion.
Recognize potential co‐morbidities associated with intentional ingestion, such as depression, abuse, or other mental illness.
Correctly order and interpret basic tests, such as serum chemistries, blood gases, and electrocardiograms, and identify abnormal findings that require additional testing or consultation.
Develop an appropriate treatment plan based on the presumptive or confirmed agent and provide decontamination or antidote therapy when appropriate.
Determine the appropriate level of care and duration of observation for a given toxin, recognizing that some agents may have delayed toxic effects.
Involve subspecialists when appropriate, including social work and/or psychiatric consultation for cases of non‐accidental ingestion as appropriate.
Correctly identify patients who require legal (protective or other) involvement and efficiently access appropriate agencies.
Attitudes
Pediatric hospitalists should be able to:
Counsel the family/caregiver and other professional staff on the possible etiology and outcomes of the ingestion episode.
Assess the social environment to determine the risk of future exposure and the need for mitigation of risk factors prior to discharge.
Educate caregivers regarding proactive risk reduction measures, such as the safe and effective storage, use and administration of medications.
Realize the importance of remaining vigilant regarding changes in recreational drug availability and use as well as safety profile updates on pharmacologic and non‐pharmacologic agents.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development of systems that integrate hospital, community, and national resources to provide up‐to‐date and evidence‐based information about toxin ingestions and promote timely recognition and treatment of both intentional and unintentional ingestions.
Lead, coordinate or participate in efforts to educate healthcare providers about the most common ingestions in the pediatric population.
Lead, coordinate or participate in efforts to educate healthcare providers and the community, regarding ways to mitigate medication errors.
Copyright © 2010 Society of Hospital Medicine
Advocacy
Introduction
Advocacy is defined as the process of speaking out in support of a specific individual, cause or program as distinct from the direct provision of material support to the individual, cause or program. In pediatric hospital medicine, advocacy can occur as an isolated event for a single patient, but is most effective when it leads to a change in an approach to a problem that supports multiple individuals in similar circumstances. Advocacy skills are part of the toolkit of both physicians and leaders. In conjunction with other healthcare professionals and organizations, pediatric hospitalists have an important role to play in advocating for both the children and the evolving field of hospital medicine. Pediatric hospitalists may also be called upon to advocate for the pediatric services or department within the hospital, as well as for children in the community.
Knowledge
Pediatric hospitalists should be able to:
Define advocacy and health policy.
Describe how advocacy impacts the care of children both in the hospital and the community.
Discuss the multiple levels of advocacy, including individual, group, institutional, community, and legislative advocacy.
Illustrate how financing of child health relates to advocacy.
Describe the relationship between pediatric quality and advocacy.
Discuss the various areas of focus for advocacy efforts, including disease process/diagnosis, age group, socio‐economic, cultural or demographic group, health systems, payment systems, and government or community agencies.
Describe the legislative process and identify specific ways in which physicians can participate in this process to improve the health of children, especially those requiring hospitalization.
List the key national organizations (such as the American Academy of Pediatrics, the Society of Hospital Medicine and National Association of Children's Hospitals and Related Institutions and others) with which pediatric hospitalists work to advocate for hospitalized pediatric patients
Explain how private and governmental funding and oversight organizations (such as Leapfrog, Medicaid, The Joint Commission and many others) influence advocacy efforts for children's healthcare.
Identify community characteristics, demographics, needs, and assets that impact children's healthcare, including the availability of social, educational, and medical services for children and the family/caregiver.
State common barriers, especially those unique to the pediatric population, that impact hospital care for children.
Cite advocacy efforts that are unique to community hospitals such as obtaining pediatric representation on key committees, establishing a relationship with a pediatric referral center, and developing relationships with adult subspecialists.
Cite unique opportunities for advocacy in children's hospitals.
Define the medical home and understand the role of pediatric hospitalists in delivering care within a medical home.
Skills
Pediatric hospitalists should be able to:
Conduct effective family centered, interdisciplinary rounds.
Consistently engage patients and the family/caregiver in medical‐decision making.
Deliver family‐centered, comprehensive, coordinated care for medically complex children and other special populations.
Develop collaborative relationships with other pediatric healthcare providers to advocate for children within the medical home model.
Provide effective media interviews on relevant topics in various formats (such as print, radio, television, and other).
Define, articulate, and gain support for the unique health care needs of children in the hospital setting as well as the community.
Identify hospital environments or processes that lack a focus on children and take appropriate steps to advocate for pediatric‐specific needs.
Participate in the advocacy and health policy activities sponsored by local, community, and national organizations.
Attitudes
Pediatric hospitalists should be able to:
Accept responsibility for child health advocacy.
Recognize the cultural beliefs and biases of patients, family/caregiver, and healthcare providers and adapt to advocate for patients' needs.
Realize that the most effective advocacy involves creation of coalitions and teams.
Maintain awareness of political, cultural, and socio‐economic factors affecting children's healthcare and the practice of pediatric hospital medicine.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations and their communities, pediatric hospitalists should:
Incorporate the institution's mission and vision statements into daily work.
Work with key hospital leaders to assure child advocacy is fully integrated into the delivery of care on a daily basis.
Establish effective relationships with hospital leaders, community leaders and local politicians to target a specific issue and/or serve as an expert pediatric consultant.
Participate in the development of systems of care in your institution and beyond that promote effective care for hospitalized children.
Introduction
Advocacy is defined as the process of speaking out in support of a specific individual, cause or program as distinct from the direct provision of material support to the individual, cause or program. In pediatric hospital medicine, advocacy can occur as an isolated event for a single patient, but is most effective when it leads to a change in an approach to a problem that supports multiple individuals in similar circumstances. Advocacy skills are part of the toolkit of both physicians and leaders. In conjunction with other healthcare professionals and organizations, pediatric hospitalists have an important role to play in advocating for both the children and the evolving field of hospital medicine. Pediatric hospitalists may also be called upon to advocate for the pediatric services or department within the hospital, as well as for children in the community.
Knowledge
Pediatric hospitalists should be able to:
Define advocacy and health policy.
Describe how advocacy impacts the care of children both in the hospital and the community.
Discuss the multiple levels of advocacy, including individual, group, institutional, community, and legislative advocacy.
Illustrate how financing of child health relates to advocacy.
Describe the relationship between pediatric quality and advocacy.
Discuss the various areas of focus for advocacy efforts, including disease process/diagnosis, age group, socio‐economic, cultural or demographic group, health systems, payment systems, and government or community agencies.
Describe the legislative process and identify specific ways in which physicians can participate in this process to improve the health of children, especially those requiring hospitalization.
List the key national organizations (such as the American Academy of Pediatrics, the Society of Hospital Medicine and National Association of Children's Hospitals and Related Institutions and others) with which pediatric hospitalists work to advocate for hospitalized pediatric patients
Explain how private and governmental funding and oversight organizations (such as Leapfrog, Medicaid, The Joint Commission and many others) influence advocacy efforts for children's healthcare.
Identify community characteristics, demographics, needs, and assets that impact children's healthcare, including the availability of social, educational, and medical services for children and the family/caregiver.
State common barriers, especially those unique to the pediatric population, that impact hospital care for children.
Cite advocacy efforts that are unique to community hospitals such as obtaining pediatric representation on key committees, establishing a relationship with a pediatric referral center, and developing relationships with adult subspecialists.
Cite unique opportunities for advocacy in children's hospitals.
Define the medical home and understand the role of pediatric hospitalists in delivering care within a medical home.
Skills
Pediatric hospitalists should be able to:
Conduct effective family centered, interdisciplinary rounds.
Consistently engage patients and the family/caregiver in medical‐decision making.
Deliver family‐centered, comprehensive, coordinated care for medically complex children and other special populations.
Develop collaborative relationships with other pediatric healthcare providers to advocate for children within the medical home model.
Provide effective media interviews on relevant topics in various formats (such as print, radio, television, and other).
Define, articulate, and gain support for the unique health care needs of children in the hospital setting as well as the community.
Identify hospital environments or processes that lack a focus on children and take appropriate steps to advocate for pediatric‐specific needs.
Participate in the advocacy and health policy activities sponsored by local, community, and national organizations.
Attitudes
Pediatric hospitalists should be able to:
Accept responsibility for child health advocacy.
Recognize the cultural beliefs and biases of patients, family/caregiver, and healthcare providers and adapt to advocate for patients' needs.
Realize that the most effective advocacy involves creation of coalitions and teams.
Maintain awareness of political, cultural, and socio‐economic factors affecting children's healthcare and the practice of pediatric hospital medicine.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations and their communities, pediatric hospitalists should:
Incorporate the institution's mission and vision statements into daily work.
Work with key hospital leaders to assure child advocacy is fully integrated into the delivery of care on a daily basis.
Establish effective relationships with hospital leaders, community leaders and local politicians to target a specific issue and/or serve as an expert pediatric consultant.
Participate in the development of systems of care in your institution and beyond that promote effective care for hospitalized children.
Introduction
Advocacy is defined as the process of speaking out in support of a specific individual, cause or program as distinct from the direct provision of material support to the individual, cause or program. In pediatric hospital medicine, advocacy can occur as an isolated event for a single patient, but is most effective when it leads to a change in an approach to a problem that supports multiple individuals in similar circumstances. Advocacy skills are part of the toolkit of both physicians and leaders. In conjunction with other healthcare professionals and organizations, pediatric hospitalists have an important role to play in advocating for both the children and the evolving field of hospital medicine. Pediatric hospitalists may also be called upon to advocate for the pediatric services or department within the hospital, as well as for children in the community.
Knowledge
Pediatric hospitalists should be able to:
Define advocacy and health policy.
Describe how advocacy impacts the care of children both in the hospital and the community.
Discuss the multiple levels of advocacy, including individual, group, institutional, community, and legislative advocacy.
Illustrate how financing of child health relates to advocacy.
Describe the relationship between pediatric quality and advocacy.
Discuss the various areas of focus for advocacy efforts, including disease process/diagnosis, age group, socio‐economic, cultural or demographic group, health systems, payment systems, and government or community agencies.
Describe the legislative process and identify specific ways in which physicians can participate in this process to improve the health of children, especially those requiring hospitalization.
List the key national organizations (such as the American Academy of Pediatrics, the Society of Hospital Medicine and National Association of Children's Hospitals and Related Institutions and others) with which pediatric hospitalists work to advocate for hospitalized pediatric patients
Explain how private and governmental funding and oversight organizations (such as Leapfrog, Medicaid, The Joint Commission and many others) influence advocacy efforts for children's healthcare.
Identify community characteristics, demographics, needs, and assets that impact children's healthcare, including the availability of social, educational, and medical services for children and the family/caregiver.
State common barriers, especially those unique to the pediatric population, that impact hospital care for children.
Cite advocacy efforts that are unique to community hospitals such as obtaining pediatric representation on key committees, establishing a relationship with a pediatric referral center, and developing relationships with adult subspecialists.
Cite unique opportunities for advocacy in children's hospitals.
Define the medical home and understand the role of pediatric hospitalists in delivering care within a medical home.
Skills
Pediatric hospitalists should be able to:
Conduct effective family centered, interdisciplinary rounds.
Consistently engage patients and the family/caregiver in medical‐decision making.
Deliver family‐centered, comprehensive, coordinated care for medically complex children and other special populations.
Develop collaborative relationships with other pediatric healthcare providers to advocate for children within the medical home model.
Provide effective media interviews on relevant topics in various formats (such as print, radio, television, and other).
Define, articulate, and gain support for the unique health care needs of children in the hospital setting as well as the community.
Identify hospital environments or processes that lack a focus on children and take appropriate steps to advocate for pediatric‐specific needs.
Participate in the advocacy and health policy activities sponsored by local, community, and national organizations.
Attitudes
Pediatric hospitalists should be able to:
Accept responsibility for child health advocacy.
Recognize the cultural beliefs and biases of patients, family/caregiver, and healthcare providers and adapt to advocate for patients' needs.
Realize that the most effective advocacy involves creation of coalitions and teams.
Maintain awareness of political, cultural, and socio‐economic factors affecting children's healthcare and the practice of pediatric hospital medicine.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations and their communities, pediatric hospitalists should:
Incorporate the institution's mission and vision statements into daily work.
Work with key hospital leaders to assure child advocacy is fully integrated into the delivery of care on a daily basis.
Establish effective relationships with hospital leaders, community leaders and local politicians to target a specific issue and/or serve as an expert pediatric consultant.
Participate in the development of systems of care in your institution and beyond that promote effective care for hospitalized children.
Copyright © 2010 Society of Hospital Medicine
Seizures
Introduction
Seizures are the most common neurologic disorder of childhood. It is estimated that approximately 5% of all children will have at least one seizure before the age of 20. The prevalence of epilepsy, or recurrent unprovoked seizures, is about 0.5% in children. Seizures may range from self‐limited to life‐threatening events. Status epilepticus is the condition of prolonged seizure activity. Optimal management of seizures not only includes identification of the underlying cause and initiation of appropriate anticonvulsant therapy or other treatments, but also the maintenance and management of an adequate airway and circulation. Pediatric hospitalists frequently encounter patients with active seizures and underlying seizure disorders, and should render both acute care and coordination of multidisciplinary care to the ambulatory setting.
Knowledge
Pediatric hospitalists should be able to:
Describe and distinguish between the various manifestations of seizure activity including involuntary motor activity, alterations of consciousness, behavior changes, disturbances of sensation and autonomic dysfunction.
Classify seizures using appropriate descriptive terms such as generalized, partial, simple and complex.
Discuss the pathophysiology of seizure activity.
Review alternate diagnoses which may mimic the presentation of seizures including behavioral abnormalities, movement disorders, conversion disorders and others.
Compare and contrast distinguishing features of seizures versus other paroxysmal events.
List the various etiologies of seizures attending to both acute (such as electrolyte imbalance, infection, toxins, trauma and others) and chronic (such as central nervous system malformations, metabolic diseases, and others) causes.
List the most common etiologies of seizures in various age groups such as the neonate, infant, preschool aged, school aged, and adolescent.
Define simple and complex febrile seizures and discuss evaluation, treatment, prognosis, and indications for admission.
State the common complications associated with seizures and status epilepticus.
Discuss indications for hospitalization or transfer to a tertiary care facility.
Discuss indications for transfer to an intensive care unit.
Review the goals of inpatient diagnostic evaluation and therapy.
Compare and contrast commonly used anti‐epileptic drugs and therapies attending to treatments for specific seizure types, adverse drug events, and ease of use.
Compare and contrast the risk and benefits of commonly used imaging modalities.
List the indications for subspecialty consultation.
Review the management of status epilepticus, including stabilization, testing, monitoring, and patient placement.
Summarize the risks for readmission, attending to medication management (dosing, availability, pharmacokinetics, and side effect profiles), compliance, and changes in disease state.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose seizures by efficiently performing an accurate history and physical examination with particular focus on the neurologic exam.
Accurately order appropriate laboratory and radiographic evaluations to identify the etiology of the seizure and potential underlying disorders.
Interpret laboratory studies including drug levels and make therapy adjustments based on results.
Order appropriate studies for patients with chronic seizure disorders, avoiding unnecessary duplication of testing and radiation exposure.
Identify and efficiently treat the cause of the seizure where appropriate.
Identify status epilepticus and initiate appropriate evidence‐based treatment.
Recognize complications due to seizures and institute appropriate cardiorespiratory support as needed.
Identify patients at increased risk for seizure recurrence or morbidity and ensures appropriate monitoring and treatment.
Obtain appropriate consults efficiently.
Create a comprehensive evaluation and management plan addressing the unique needs of patients and the family/caregiver.
Anticipate, monitor for, identify, and treat potential side effects of treatment.
Recognize and efficiently transfer patients requiring higher level of care.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with patients, the family/caregiver, hospital staff, subspecialists and primary care provider regarding the reasons for diagnostic testing and therapy choices.
Recognize the role of patient and family/caregiver education in improving compliance with treatment and follow‐up.
Educate the family/caregiver regarding outcomes of febrile seizures including the risk of the child developing a seizure disorder.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with seizure disorders.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective safe, evidence‐based care pathways to standardize the evaluation and management of hospitalized children with seizures and status epilepticus.
Collaborate with hospital administration and community partners to develop and sustain referral networks for both transport and subpsecialty services for children with seizures and chronic seizure disorders.
Collaborate with primary care providers, subspecialists and other healthcare providers to create effective discharge plans that reduce the likelihood of readmission.
Introduction
Seizures are the most common neurologic disorder of childhood. It is estimated that approximately 5% of all children will have at least one seizure before the age of 20. The prevalence of epilepsy, or recurrent unprovoked seizures, is about 0.5% in children. Seizures may range from self‐limited to life‐threatening events. Status epilepticus is the condition of prolonged seizure activity. Optimal management of seizures not only includes identification of the underlying cause and initiation of appropriate anticonvulsant therapy or other treatments, but also the maintenance and management of an adequate airway and circulation. Pediatric hospitalists frequently encounter patients with active seizures and underlying seizure disorders, and should render both acute care and coordination of multidisciplinary care to the ambulatory setting.
Knowledge
Pediatric hospitalists should be able to:
Describe and distinguish between the various manifestations of seizure activity including involuntary motor activity, alterations of consciousness, behavior changes, disturbances of sensation and autonomic dysfunction.
Classify seizures using appropriate descriptive terms such as generalized, partial, simple and complex.
Discuss the pathophysiology of seizure activity.
Review alternate diagnoses which may mimic the presentation of seizures including behavioral abnormalities, movement disorders, conversion disorders and others.
Compare and contrast distinguishing features of seizures versus other paroxysmal events.
List the various etiologies of seizures attending to both acute (such as electrolyte imbalance, infection, toxins, trauma and others) and chronic (such as central nervous system malformations, metabolic diseases, and others) causes.
List the most common etiologies of seizures in various age groups such as the neonate, infant, preschool aged, school aged, and adolescent.
Define simple and complex febrile seizures and discuss evaluation, treatment, prognosis, and indications for admission.
State the common complications associated with seizures and status epilepticus.
Discuss indications for hospitalization or transfer to a tertiary care facility.
Discuss indications for transfer to an intensive care unit.
Review the goals of inpatient diagnostic evaluation and therapy.
Compare and contrast commonly used anti‐epileptic drugs and therapies attending to treatments for specific seizure types, adverse drug events, and ease of use.
Compare and contrast the risk and benefits of commonly used imaging modalities.
List the indications for subspecialty consultation.
Review the management of status epilepticus, including stabilization, testing, monitoring, and patient placement.
Summarize the risks for readmission, attending to medication management (dosing, availability, pharmacokinetics, and side effect profiles), compliance, and changes in disease state.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose seizures by efficiently performing an accurate history and physical examination with particular focus on the neurologic exam.
Accurately order appropriate laboratory and radiographic evaluations to identify the etiology of the seizure and potential underlying disorders.
Interpret laboratory studies including drug levels and make therapy adjustments based on results.
Order appropriate studies for patients with chronic seizure disorders, avoiding unnecessary duplication of testing and radiation exposure.
Identify and efficiently treat the cause of the seizure where appropriate.
Identify status epilepticus and initiate appropriate evidence‐based treatment.
Recognize complications due to seizures and institute appropriate cardiorespiratory support as needed.
Identify patients at increased risk for seizure recurrence or morbidity and ensures appropriate monitoring and treatment.
Obtain appropriate consults efficiently.
Create a comprehensive evaluation and management plan addressing the unique needs of patients and the family/caregiver.
Anticipate, monitor for, identify, and treat potential side effects of treatment.
Recognize and efficiently transfer patients requiring higher level of care.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with patients, the family/caregiver, hospital staff, subspecialists and primary care provider regarding the reasons for diagnostic testing and therapy choices.
Recognize the role of patient and family/caregiver education in improving compliance with treatment and follow‐up.
Educate the family/caregiver regarding outcomes of febrile seizures including the risk of the child developing a seizure disorder.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with seizure disorders.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective safe, evidence‐based care pathways to standardize the evaluation and management of hospitalized children with seizures and status epilepticus.
Collaborate with hospital administration and community partners to develop and sustain referral networks for both transport and subpsecialty services for children with seizures and chronic seizure disorders.
Collaborate with primary care providers, subspecialists and other healthcare providers to create effective discharge plans that reduce the likelihood of readmission.
Introduction
Seizures are the most common neurologic disorder of childhood. It is estimated that approximately 5% of all children will have at least one seizure before the age of 20. The prevalence of epilepsy, or recurrent unprovoked seizures, is about 0.5% in children. Seizures may range from self‐limited to life‐threatening events. Status epilepticus is the condition of prolonged seizure activity. Optimal management of seizures not only includes identification of the underlying cause and initiation of appropriate anticonvulsant therapy or other treatments, but also the maintenance and management of an adequate airway and circulation. Pediatric hospitalists frequently encounter patients with active seizures and underlying seizure disorders, and should render both acute care and coordination of multidisciplinary care to the ambulatory setting.
Knowledge
Pediatric hospitalists should be able to:
Describe and distinguish between the various manifestations of seizure activity including involuntary motor activity, alterations of consciousness, behavior changes, disturbances of sensation and autonomic dysfunction.
Classify seizures using appropriate descriptive terms such as generalized, partial, simple and complex.
Discuss the pathophysiology of seizure activity.
Review alternate diagnoses which may mimic the presentation of seizures including behavioral abnormalities, movement disorders, conversion disorders and others.
Compare and contrast distinguishing features of seizures versus other paroxysmal events.
List the various etiologies of seizures attending to both acute (such as electrolyte imbalance, infection, toxins, trauma and others) and chronic (such as central nervous system malformations, metabolic diseases, and others) causes.
List the most common etiologies of seizures in various age groups such as the neonate, infant, preschool aged, school aged, and adolescent.
Define simple and complex febrile seizures and discuss evaluation, treatment, prognosis, and indications for admission.
State the common complications associated with seizures and status epilepticus.
Discuss indications for hospitalization or transfer to a tertiary care facility.
Discuss indications for transfer to an intensive care unit.
Review the goals of inpatient diagnostic evaluation and therapy.
Compare and contrast commonly used anti‐epileptic drugs and therapies attending to treatments for specific seizure types, adverse drug events, and ease of use.
Compare and contrast the risk and benefits of commonly used imaging modalities.
List the indications for subspecialty consultation.
Review the management of status epilepticus, including stabilization, testing, monitoring, and patient placement.
Summarize the risks for readmission, attending to medication management (dosing, availability, pharmacokinetics, and side effect profiles), compliance, and changes in disease state.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose seizures by efficiently performing an accurate history and physical examination with particular focus on the neurologic exam.
Accurately order appropriate laboratory and radiographic evaluations to identify the etiology of the seizure and potential underlying disorders.
Interpret laboratory studies including drug levels and make therapy adjustments based on results.
Order appropriate studies for patients with chronic seizure disorders, avoiding unnecessary duplication of testing and radiation exposure.
Identify and efficiently treat the cause of the seizure where appropriate.
Identify status epilepticus and initiate appropriate evidence‐based treatment.
Recognize complications due to seizures and institute appropriate cardiorespiratory support as needed.
Identify patients at increased risk for seizure recurrence or morbidity and ensures appropriate monitoring and treatment.
Obtain appropriate consults efficiently.
Create a comprehensive evaluation and management plan addressing the unique needs of patients and the family/caregiver.
Anticipate, monitor for, identify, and treat potential side effects of treatment.
Recognize and efficiently transfer patients requiring higher level of care.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with patients, the family/caregiver, hospital staff, subspecialists and primary care provider regarding the reasons for diagnostic testing and therapy choices.
Recognize the role of patient and family/caregiver education in improving compliance with treatment and follow‐up.
Educate the family/caregiver regarding outcomes of febrile seizures including the risk of the child developing a seizure disorder.
Collaborate with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with seizure disorders.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective safe, evidence‐based care pathways to standardize the evaluation and management of hospitalized children with seizures and status epilepticus.
Collaborate with hospital administration and community partners to develop and sustain referral networks for both transport and subpsecialty services for children with seizures and chronic seizure disorders.
Collaborate with primary care providers, subspecialists and other healthcare providers to create effective discharge plans that reduce the likelihood of readmission.
Copyright © 2010 Society of Hospital Medicine
Bronchiolitis
Introduction
Bronchiolitis is the most common viral lower respiratory illness in young children and infants. It is responsible for hundreds of thousands of outpatient and emergency department visits and nearly 150,000 hospitalizations per year, costing the U.S. healthcare system more than $500 million annually. The most commonly identified etiology of bronchiolitis is respiratory syncytial virus (RSV), however bronchiolitis may be caused by many other viruses, including human metapneumovirus, adenovirus, and influenza. Despite guidelines published by the American Academy of Pediatrics on the diagnosis and management of bronchiolitis, there is significant variation in care of hospitalized patients. Pediatric hospitalists should render evidence‐based care that avoids use of unnecessary tests and procedures and improves outcomes.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the epidemiology and pathogenesis of bronchiolitis with asthma.
Describe the typical clinical presentation of viral bronchiolitis including wheezing, tachypnea, acute respiratory distress, hypoxia, cough, apnea, and/or nasal obstruction, and give examples of how presentations may vary.
Review alternate diagnoses which may mimic the presentation of bronchiolitis such as congestive heart failure, previously undiagnosed cyanotic or non‐cyanotic congenital heart disease, metabolic acidosis, sepsis, aspiration, and others.
Identify the risk factors such as prematurity, congenital heart disease, pulmonary disease, immunodeficiency, and environmental smoke exposure that predispose infants and children to severe illness or complications of bronchiolitis.
State the indications and contraindications for RSV immunoprophylaxis.
List the indications for hospital admission and cite discharge criteria.
Discuss indications for ordering viral antigen testing and chest radiographs.
Compare and contrast initial diagnostic evaluation for febrile infants of various ages presenting with bronchiolitis attending to ages less than 30 days, 31‐60 days and others.
Discuss the evidence regarding beta‐agonist and steroid therapy in routine bronchiolitis.
Discuss the evidence regarding use of supportive measures including suctioning, positioning, enteral versus intravenous fluids and nutrition, and supplemental oxygen.
Discuss the benefits and potential technical errors associated with use of various non‐invasive monitoring modalities including cardiorespiratory, oxygen saturation, and capnography.
Describe a management strategy for patients with worsening respiratory status including the use of different oxygen delivery systems and methods for positive pressure ventilation.
Describe a management strategy for patients with worsening respiratory status including use of different oxygen delivery systems and methods for positive pressure ventilation.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose bronchiolitis by efficiently performing an accurate history and physical examination; determining if key features of the disease are present.
Accurately assess clinical signs of respiratory distress and identify impending respiratory failure.
Assess nutrition and hydration status and chose appropriate methods to maintain adequate hydration and nutrition.
Order appropriate monitoring and correctly interpret monitor data.
Objectively assess the response to any medications trialed and use clinical exam and respiratory scores to determine true efficacy.
Perform careful reassessments daily and as needed, note changes in clinical status and respond with appropriate actions including discontinuation of ineffective or unnecessary therapies.
Recognize the indications for escalating level of care and initiate basic ventilatory support if indicated.
Implement appropriate oxygen weaning strategies, including the use of appropriate oxygen saturation parameters.
Engage the family/caregiver in assisting with interpreting clinical status changes and in determining care plans.
Consistently adhere to proper infection control measures.
Efficiently render care by creating a discharge plan which can be expediently activated when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Educate the family/caregiver on the etiologies and natural history of bronchiolitis, including the importance of hand washing and minimizing environmental exposure in the prevention of infection.
Discuss with the family/caregiver the importance of supportive care, as well as the limited evidence supporting other interventions.
Display proactive, engaged behavior regarding proper isolation measures particularly including hand‐washing to prevent spread of the etiologic agent in the hospital.
Educate the family/caregiver regarding the relationship between hospitalization for bronchiolitis and risk of future wheezing based on the most current evidence.
Collaborate with the primary care provider to ensure a smooth transition to the outpatient setting, and to minimize the need for readmission.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with hospital infection control practitioners to prevent nosocomial infection related to bronchiolitis.
Partner with community services to educate the public on respiratory infection preventive strategies.
Work with emergency department physicians to mutually develop and implement evidence‐based admission criteria.
Lead, coordinate or participate in multidisciplinary initiatives to develop, implement, and assess quality outcomes of evidence‐based clinical guidelines.
Introduction
Bronchiolitis is the most common viral lower respiratory illness in young children and infants. It is responsible for hundreds of thousands of outpatient and emergency department visits and nearly 150,000 hospitalizations per year, costing the U.S. healthcare system more than $500 million annually. The most commonly identified etiology of bronchiolitis is respiratory syncytial virus (RSV), however bronchiolitis may be caused by many other viruses, including human metapneumovirus, adenovirus, and influenza. Despite guidelines published by the American Academy of Pediatrics on the diagnosis and management of bronchiolitis, there is significant variation in care of hospitalized patients. Pediatric hospitalists should render evidence‐based care that avoids use of unnecessary tests and procedures and improves outcomes.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the epidemiology and pathogenesis of bronchiolitis with asthma.
Describe the typical clinical presentation of viral bronchiolitis including wheezing, tachypnea, acute respiratory distress, hypoxia, cough, apnea, and/or nasal obstruction, and give examples of how presentations may vary.
Review alternate diagnoses which may mimic the presentation of bronchiolitis such as congestive heart failure, previously undiagnosed cyanotic or non‐cyanotic congenital heart disease, metabolic acidosis, sepsis, aspiration, and others.
Identify the risk factors such as prematurity, congenital heart disease, pulmonary disease, immunodeficiency, and environmental smoke exposure that predispose infants and children to severe illness or complications of bronchiolitis.
State the indications and contraindications for RSV immunoprophylaxis.
List the indications for hospital admission and cite discharge criteria.
Discuss indications for ordering viral antigen testing and chest radiographs.
Compare and contrast initial diagnostic evaluation for febrile infants of various ages presenting with bronchiolitis attending to ages less than 30 days, 31‐60 days and others.
Discuss the evidence regarding beta‐agonist and steroid therapy in routine bronchiolitis.
Discuss the evidence regarding use of supportive measures including suctioning, positioning, enteral versus intravenous fluids and nutrition, and supplemental oxygen.
Discuss the benefits and potential technical errors associated with use of various non‐invasive monitoring modalities including cardiorespiratory, oxygen saturation, and capnography.
Describe a management strategy for patients with worsening respiratory status including the use of different oxygen delivery systems and methods for positive pressure ventilation.
Describe a management strategy for patients with worsening respiratory status including use of different oxygen delivery systems and methods for positive pressure ventilation.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose bronchiolitis by efficiently performing an accurate history and physical examination; determining if key features of the disease are present.
Accurately assess clinical signs of respiratory distress and identify impending respiratory failure.
Assess nutrition and hydration status and chose appropriate methods to maintain adequate hydration and nutrition.
Order appropriate monitoring and correctly interpret monitor data.
Objectively assess the response to any medications trialed and use clinical exam and respiratory scores to determine true efficacy.
Perform careful reassessments daily and as needed, note changes in clinical status and respond with appropriate actions including discontinuation of ineffective or unnecessary therapies.
Recognize the indications for escalating level of care and initiate basic ventilatory support if indicated.
Implement appropriate oxygen weaning strategies, including the use of appropriate oxygen saturation parameters.
Engage the family/caregiver in assisting with interpreting clinical status changes and in determining care plans.
Consistently adhere to proper infection control measures.
Efficiently render care by creating a discharge plan which can be expediently activated when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Educate the family/caregiver on the etiologies and natural history of bronchiolitis, including the importance of hand washing and minimizing environmental exposure in the prevention of infection.
Discuss with the family/caregiver the importance of supportive care, as well as the limited evidence supporting other interventions.
Display proactive, engaged behavior regarding proper isolation measures particularly including hand‐washing to prevent spread of the etiologic agent in the hospital.
Educate the family/caregiver regarding the relationship between hospitalization for bronchiolitis and risk of future wheezing based on the most current evidence.
Collaborate with the primary care provider to ensure a smooth transition to the outpatient setting, and to minimize the need for readmission.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with hospital infection control practitioners to prevent nosocomial infection related to bronchiolitis.
Partner with community services to educate the public on respiratory infection preventive strategies.
Work with emergency department physicians to mutually develop and implement evidence‐based admission criteria.
Lead, coordinate or participate in multidisciplinary initiatives to develop, implement, and assess quality outcomes of evidence‐based clinical guidelines.
Introduction
Bronchiolitis is the most common viral lower respiratory illness in young children and infants. It is responsible for hundreds of thousands of outpatient and emergency department visits and nearly 150,000 hospitalizations per year, costing the U.S. healthcare system more than $500 million annually. The most commonly identified etiology of bronchiolitis is respiratory syncytial virus (RSV), however bronchiolitis may be caused by many other viruses, including human metapneumovirus, adenovirus, and influenza. Despite guidelines published by the American Academy of Pediatrics on the diagnosis and management of bronchiolitis, there is significant variation in care of hospitalized patients. Pediatric hospitalists should render evidence‐based care that avoids use of unnecessary tests and procedures and improves outcomes.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the epidemiology and pathogenesis of bronchiolitis with asthma.
Describe the typical clinical presentation of viral bronchiolitis including wheezing, tachypnea, acute respiratory distress, hypoxia, cough, apnea, and/or nasal obstruction, and give examples of how presentations may vary.
Review alternate diagnoses which may mimic the presentation of bronchiolitis such as congestive heart failure, previously undiagnosed cyanotic or non‐cyanotic congenital heart disease, metabolic acidosis, sepsis, aspiration, and others.
Identify the risk factors such as prematurity, congenital heart disease, pulmonary disease, immunodeficiency, and environmental smoke exposure that predispose infants and children to severe illness or complications of bronchiolitis.
State the indications and contraindications for RSV immunoprophylaxis.
List the indications for hospital admission and cite discharge criteria.
Discuss indications for ordering viral antigen testing and chest radiographs.
Compare and contrast initial diagnostic evaluation for febrile infants of various ages presenting with bronchiolitis attending to ages less than 30 days, 31‐60 days and others.
Discuss the evidence regarding beta‐agonist and steroid therapy in routine bronchiolitis.
Discuss the evidence regarding use of supportive measures including suctioning, positioning, enteral versus intravenous fluids and nutrition, and supplemental oxygen.
Discuss the benefits and potential technical errors associated with use of various non‐invasive monitoring modalities including cardiorespiratory, oxygen saturation, and capnography.
Describe a management strategy for patients with worsening respiratory status including the use of different oxygen delivery systems and methods for positive pressure ventilation.
Describe a management strategy for patients with worsening respiratory status including use of different oxygen delivery systems and methods for positive pressure ventilation.
Skills
Pediatric hospitalists should be able to:
Correctly diagnose bronchiolitis by efficiently performing an accurate history and physical examination; determining if key features of the disease are present.
Accurately assess clinical signs of respiratory distress and identify impending respiratory failure.
Assess nutrition and hydration status and chose appropriate methods to maintain adequate hydration and nutrition.
Order appropriate monitoring and correctly interpret monitor data.
Objectively assess the response to any medications trialed and use clinical exam and respiratory scores to determine true efficacy.
Perform careful reassessments daily and as needed, note changes in clinical status and respond with appropriate actions including discontinuation of ineffective or unnecessary therapies.
Recognize the indications for escalating level of care and initiate basic ventilatory support if indicated.
Implement appropriate oxygen weaning strategies, including the use of appropriate oxygen saturation parameters.
Engage the family/caregiver in assisting with interpreting clinical status changes and in determining care plans.
Consistently adhere to proper infection control measures.
Efficiently render care by creating a discharge plan which can be expediently activated when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Educate the family/caregiver on the etiologies and natural history of bronchiolitis, including the importance of hand washing and minimizing environmental exposure in the prevention of infection.
Discuss with the family/caregiver the importance of supportive care, as well as the limited evidence supporting other interventions.
Display proactive, engaged behavior regarding proper isolation measures particularly including hand‐washing to prevent spread of the etiologic agent in the hospital.
Educate the family/caregiver regarding the relationship between hospitalization for bronchiolitis and risk of future wheezing based on the most current evidence.
Collaborate with the primary care provider to ensure a smooth transition to the outpatient setting, and to minimize the need for readmission.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with hospital infection control practitioners to prevent nosocomial infection related to bronchiolitis.
Partner with community services to educate the public on respiratory infection preventive strategies.
Work with emergency department physicians to mutually develop and implement evidence‐based admission criteria.
Lead, coordinate or participate in multidisciplinary initiatives to develop, implement, and assess quality outcomes of evidence‐based clinical guidelines.
Copyright © 2010 Society of Hospital Medicine
Radiographic interpretation
Introduction
Radiographic studies are commonly performed throughout a wide range of pediatric healthcare settings. Imaging can play a pivotal role in the acute and chronic medical and surgical management of ill children. The explosion of imaging technology and expertise in the past three decades has resulted in an increased array of imaging modalities from which to choose. Access to and interpretation of imaging studies for children varies greatly between facilities. Pediatric hospitalists frequently encounter patients requiring imaging studies, and should be adept at ordering and interpreting images in collaboration with radiologist and other subspecialists.
Knowledge
Pediatric hospitalists should be able to:
Review basic human anatomy and relate this to interpretation of common plain radiographs of areas such as the chest, abdomen, airway, and long bones.
Describe the indications and limitations of the common radiographic modalities such as sonography, computed tomography, magnetic resonance imaging, plain radiography, and bone scans.
Describe the risks of ionizing radiation in children and review the concept of ALARA (as low as reasonably achievable) in limiting radiation exposure.
Review the indications for and benefits and risks of oral and intravenous contrast.
Review the indications for anxiolysis, sedation, and anaesthesia attending to age, developmental stage, and procedure being performed.
Compare and contrast indications for interventional radiologist versus general surgical consultation.
Discuss the role of the radiologist as consultant.
Discuss the appropriate imaging modality selection(s) for common emergent clinical presentations such as altered mental status, stridor, potential bowel obstruction, and others.
Compare and contrast the utility, risks, and costs of different imaging modalities for presentations of complicated pneumonia and acute abdominal pain.
Skills
Pediatric hospitalists should be able to:
Correctly determine the optimal study to answer a specific clinical question in a cost‐effective manner, accounting for the limitations and risks of the study.
Accurately order radiologic studies, noting indications for the study, sedation/anaesthesia need, and other relevant information in the order.
Engage the radiologist as consultant as appropriate.
Accurately interpret plain radiographs of the chest and abdomen for children 0‐18 years of age.
Correctly identify the need for and efficiently access interventional radiologists as appropriate.
Communicate effectively with the healthcare team including radiologist and anaesthesiologist (as appropriate) to ensure safe, efficient and effective performance of radiologic studies.
Correctly interpret and apply the results of radiographic studies into clinical care plans.
Attitudes
Pediatric hospitalists should be able to:
Elicit and allay common family/caregiver concerns regarding radiation risks.
Work collaboratively with hospital staff, radiologists, and anaesthesiologists to ensure coordinated planning and performance of radiologic studies.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps involved in the radiologic procedure.
Recognize the importance of obtaining results of all studies and reviewing images in person whenever possible.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based standards for radiology services for children.
Work with hospital administration to assure that a reliable and efficient radiographic imaging service is available for pediatric inpatients at the local facility.
Lead, coordinate or participate in development and implementation of a system to review the accuracy of readings for pediatric patients and develop local criteria for tertiary referral center consultation.
Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers that enable review of appropriately selected pediatric images.
Work with hospital administration, subspecialists, and others to review acquisition of new technologies and assess the impact on patient care.
Introduction
Radiographic studies are commonly performed throughout a wide range of pediatric healthcare settings. Imaging can play a pivotal role in the acute and chronic medical and surgical management of ill children. The explosion of imaging technology and expertise in the past three decades has resulted in an increased array of imaging modalities from which to choose. Access to and interpretation of imaging studies for children varies greatly between facilities. Pediatric hospitalists frequently encounter patients requiring imaging studies, and should be adept at ordering and interpreting images in collaboration with radiologist and other subspecialists.
Knowledge
Pediatric hospitalists should be able to:
Review basic human anatomy and relate this to interpretation of common plain radiographs of areas such as the chest, abdomen, airway, and long bones.
Describe the indications and limitations of the common radiographic modalities such as sonography, computed tomography, magnetic resonance imaging, plain radiography, and bone scans.
Describe the risks of ionizing radiation in children and review the concept of ALARA (as low as reasonably achievable) in limiting radiation exposure.
Review the indications for and benefits and risks of oral and intravenous contrast.
Review the indications for anxiolysis, sedation, and anaesthesia attending to age, developmental stage, and procedure being performed.
Compare and contrast indications for interventional radiologist versus general surgical consultation.
Discuss the role of the radiologist as consultant.
Discuss the appropriate imaging modality selection(s) for common emergent clinical presentations such as altered mental status, stridor, potential bowel obstruction, and others.
Compare and contrast the utility, risks, and costs of different imaging modalities for presentations of complicated pneumonia and acute abdominal pain.
Skills
Pediatric hospitalists should be able to:
Correctly determine the optimal study to answer a specific clinical question in a cost‐effective manner, accounting for the limitations and risks of the study.
Accurately order radiologic studies, noting indications for the study, sedation/anaesthesia need, and other relevant information in the order.
Engage the radiologist as consultant as appropriate.
Accurately interpret plain radiographs of the chest and abdomen for children 0‐18 years of age.
Correctly identify the need for and efficiently access interventional radiologists as appropriate.
Communicate effectively with the healthcare team including radiologist and anaesthesiologist (as appropriate) to ensure safe, efficient and effective performance of radiologic studies.
Correctly interpret and apply the results of radiographic studies into clinical care plans.
Attitudes
Pediatric hospitalists should be able to:
Elicit and allay common family/caregiver concerns regarding radiation risks.
Work collaboratively with hospital staff, radiologists, and anaesthesiologists to ensure coordinated planning and performance of radiologic studies.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps involved in the radiologic procedure.
Recognize the importance of obtaining results of all studies and reviewing images in person whenever possible.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based standards for radiology services for children.
Work with hospital administration to assure that a reliable and efficient radiographic imaging service is available for pediatric inpatients at the local facility.
Lead, coordinate or participate in development and implementation of a system to review the accuracy of readings for pediatric patients and develop local criteria for tertiary referral center consultation.
Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers that enable review of appropriately selected pediatric images.
Work with hospital administration, subspecialists, and others to review acquisition of new technologies and assess the impact on patient care.
Introduction
Radiographic studies are commonly performed throughout a wide range of pediatric healthcare settings. Imaging can play a pivotal role in the acute and chronic medical and surgical management of ill children. The explosion of imaging technology and expertise in the past three decades has resulted in an increased array of imaging modalities from which to choose. Access to and interpretation of imaging studies for children varies greatly between facilities. Pediatric hospitalists frequently encounter patients requiring imaging studies, and should be adept at ordering and interpreting images in collaboration with radiologist and other subspecialists.
Knowledge
Pediatric hospitalists should be able to:
Review basic human anatomy and relate this to interpretation of common plain radiographs of areas such as the chest, abdomen, airway, and long bones.
Describe the indications and limitations of the common radiographic modalities such as sonography, computed tomography, magnetic resonance imaging, plain radiography, and bone scans.
Describe the risks of ionizing radiation in children and review the concept of ALARA (as low as reasonably achievable) in limiting radiation exposure.
Review the indications for and benefits and risks of oral and intravenous contrast.
Review the indications for anxiolysis, sedation, and anaesthesia attending to age, developmental stage, and procedure being performed.
Compare and contrast indications for interventional radiologist versus general surgical consultation.
Discuss the role of the radiologist as consultant.
Discuss the appropriate imaging modality selection(s) for common emergent clinical presentations such as altered mental status, stridor, potential bowel obstruction, and others.
Compare and contrast the utility, risks, and costs of different imaging modalities for presentations of complicated pneumonia and acute abdominal pain.
Skills
Pediatric hospitalists should be able to:
Correctly determine the optimal study to answer a specific clinical question in a cost‐effective manner, accounting for the limitations and risks of the study.
Accurately order radiologic studies, noting indications for the study, sedation/anaesthesia need, and other relevant information in the order.
Engage the radiologist as consultant as appropriate.
Accurately interpret plain radiographs of the chest and abdomen for children 0‐18 years of age.
Correctly identify the need for and efficiently access interventional radiologists as appropriate.
Communicate effectively with the healthcare team including radiologist and anaesthesiologist (as appropriate) to ensure safe, efficient and effective performance of radiologic studies.
Correctly interpret and apply the results of radiographic studies into clinical care plans.
Attitudes
Pediatric hospitalists should be able to:
Elicit and allay common family/caregiver concerns regarding radiation risks.
Work collaboratively with hospital staff, radiologists, and anaesthesiologists to ensure coordinated planning and performance of radiologic studies.
Communicate effectively with patients and the family/caregiver regarding the indications for, risks, benefits, and steps involved in the radiologic procedure.
Recognize the importance of obtaining results of all studies and reviewing images in person whenever possible.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Lead, coordinate or participate in the development and implementation of cost‐effective, safe, evidence‐based standards for radiology services for children.
Work with hospital administration to assure that a reliable and efficient radiographic imaging service is available for pediatric inpatients at the local facility.
Lead, coordinate or participate in development and implementation of a system to review the accuracy of readings for pediatric patients and develop local criteria for tertiary referral center consultation.
Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers that enable review of appropriately selected pediatric images.
Work with hospital administration, subspecialists, and others to review acquisition of new technologies and assess the impact on patient care.
Copyright © 2010 Society of Hospital Medicine
Communication
Introduction
Communication is defined as any process in which a message containing information is transferred, especially from one person to another, via any of a number of media. Communication may be delivered verbally or non‐verbally, directly, (as in face‐to‐face conversation or with the observation of a gesture) or remotely, spanning space and time (as in writing, reading, making or playing back a recording, or using a computer). Pediatric hospitalists must be effective communicators in many venues such as when rendering direct patient care, performing hospital committee work, or educating trainees. However, the most important of these is the verbal communication that occurs at the bedside with patients, family/caregiver, and healthcare team. Successful patient care is elusive or wanting without proper communication.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the importance of listening and speaking for effective communication.
Define the components of effective expressive and receptive (listening) communication, such as introduction of team members, avoiding medical jargon, tone, word choice, allowing time for patients and the family/caregiver to speak, and body language.
List examples of common non‐listening behaviors such as allowing distractions, asking unrelated questions, jumping to conclusions, interrupting the speaker, and failing to notice the speaker's non‐verbal language.
Cite methods that can be used when faced with difficult behaviors during communication, such as asking for a behavior change and paraphrasing to diffuse emotion.
Describe patients in a cultural and spiritual context.
Explain how vulnerabilities, life situation, limitation in activities of daily living, education, language and other factors should each be addressed when communicating with patients and the family/caregiver.
Identify personal values, biases, skills, and relationships that may influence communication.
Discuss the significance of including the family/caregiver and others who are most important to patients in patient care discussions.
Explain why effective communication is central to patient care handoffs and list examples of best methods for communication both within hospitalist groups and with other healthcare providers.
Articulate how to give bad news by expressing empathy, giving patients and the family/caregiver time to ask questions, maintaining calm, and choosing a quiet, private location for the discussion.
Cite important features of effective written communication.
Compare and contrast specific examples of effective and ineffective written communication, including timing of entries, legibility, disagreements on patient care decisions, documentation of changes in clinical status and others.
Skills
Pediatric hospitalists should be able to:
Demonstrate command of a comprehensive array of expressive and receptive communication skills.
Coordinate discussions with all caregivers to ensure a single clear message is given to patients and the family/caregiver.
Actively participate in conflict resolution.
Summarize the entire process and sequence of care for patients and the family/caregiver in understandable terms following the principles of family centered care.
Maintain concise, complete written records that meet expectations of external reviewing agencies and malpractice carriers.
Develop and implement a plan for daily communication that is family centered.
Attitudes
Pediatric hospitalists should be able to:
Respect the skills and contributions of all involved in the care of patients.
Exemplify professionalism in all communications.
Seek opportunities to enhance communication skills.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with hospital administrators to improve medical record documentation systems by technical means.
Assist in the development of and/or participate in hospital and system‐wide educational programs on communication skills.
Introduction
Communication is defined as any process in which a message containing information is transferred, especially from one person to another, via any of a number of media. Communication may be delivered verbally or non‐verbally, directly, (as in face‐to‐face conversation or with the observation of a gesture) or remotely, spanning space and time (as in writing, reading, making or playing back a recording, or using a computer). Pediatric hospitalists must be effective communicators in many venues such as when rendering direct patient care, performing hospital committee work, or educating trainees. However, the most important of these is the verbal communication that occurs at the bedside with patients, family/caregiver, and healthcare team. Successful patient care is elusive or wanting without proper communication.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the importance of listening and speaking for effective communication.
Define the components of effective expressive and receptive (listening) communication, such as introduction of team members, avoiding medical jargon, tone, word choice, allowing time for patients and the family/caregiver to speak, and body language.
List examples of common non‐listening behaviors such as allowing distractions, asking unrelated questions, jumping to conclusions, interrupting the speaker, and failing to notice the speaker's non‐verbal language.
Cite methods that can be used when faced with difficult behaviors during communication, such as asking for a behavior change and paraphrasing to diffuse emotion.
Describe patients in a cultural and spiritual context.
Explain how vulnerabilities, life situation, limitation in activities of daily living, education, language and other factors should each be addressed when communicating with patients and the family/caregiver.
Identify personal values, biases, skills, and relationships that may influence communication.
Discuss the significance of including the family/caregiver and others who are most important to patients in patient care discussions.
Explain why effective communication is central to patient care handoffs and list examples of best methods for communication both within hospitalist groups and with other healthcare providers.
Articulate how to give bad news by expressing empathy, giving patients and the family/caregiver time to ask questions, maintaining calm, and choosing a quiet, private location for the discussion.
Cite important features of effective written communication.
Compare and contrast specific examples of effective and ineffective written communication, including timing of entries, legibility, disagreements on patient care decisions, documentation of changes in clinical status and others.
Skills
Pediatric hospitalists should be able to:
Demonstrate command of a comprehensive array of expressive and receptive communication skills.
Coordinate discussions with all caregivers to ensure a single clear message is given to patients and the family/caregiver.
Actively participate in conflict resolution.
Summarize the entire process and sequence of care for patients and the family/caregiver in understandable terms following the principles of family centered care.
Maintain concise, complete written records that meet expectations of external reviewing agencies and malpractice carriers.
Develop and implement a plan for daily communication that is family centered.
Attitudes
Pediatric hospitalists should be able to:
Respect the skills and contributions of all involved in the care of patients.
Exemplify professionalism in all communications.
Seek opportunities to enhance communication skills.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with hospital administrators to improve medical record documentation systems by technical means.
Assist in the development of and/or participate in hospital and system‐wide educational programs on communication skills.
Introduction
Communication is defined as any process in which a message containing information is transferred, especially from one person to another, via any of a number of media. Communication may be delivered verbally or non‐verbally, directly, (as in face‐to‐face conversation or with the observation of a gesture) or remotely, spanning space and time (as in writing, reading, making or playing back a recording, or using a computer). Pediatric hospitalists must be effective communicators in many venues such as when rendering direct patient care, performing hospital committee work, or educating trainees. However, the most important of these is the verbal communication that occurs at the bedside with patients, family/caregiver, and healthcare team. Successful patient care is elusive or wanting without proper communication.
Knowledge
Pediatric hospitalists should be able to:
Compare and contrast the importance of listening and speaking for effective communication.
Define the components of effective expressive and receptive (listening) communication, such as introduction of team members, avoiding medical jargon, tone, word choice, allowing time for patients and the family/caregiver to speak, and body language.
List examples of common non‐listening behaviors such as allowing distractions, asking unrelated questions, jumping to conclusions, interrupting the speaker, and failing to notice the speaker's non‐verbal language.
Cite methods that can be used when faced with difficult behaviors during communication, such as asking for a behavior change and paraphrasing to diffuse emotion.
Describe patients in a cultural and spiritual context.
Explain how vulnerabilities, life situation, limitation in activities of daily living, education, language and other factors should each be addressed when communicating with patients and the family/caregiver.
Identify personal values, biases, skills, and relationships that may influence communication.
Discuss the significance of including the family/caregiver and others who are most important to patients in patient care discussions.
Explain why effective communication is central to patient care handoffs and list examples of best methods for communication both within hospitalist groups and with other healthcare providers.
Articulate how to give bad news by expressing empathy, giving patients and the family/caregiver time to ask questions, maintaining calm, and choosing a quiet, private location for the discussion.
Cite important features of effective written communication.
Compare and contrast specific examples of effective and ineffective written communication, including timing of entries, legibility, disagreements on patient care decisions, documentation of changes in clinical status and others.
Skills
Pediatric hospitalists should be able to:
Demonstrate command of a comprehensive array of expressive and receptive communication skills.
Coordinate discussions with all caregivers to ensure a single clear message is given to patients and the family/caregiver.
Actively participate in conflict resolution.
Summarize the entire process and sequence of care for patients and the family/caregiver in understandable terms following the principles of family centered care.
Maintain concise, complete written records that meet expectations of external reviewing agencies and malpractice carriers.
Develop and implement a plan for daily communication that is family centered.
Attitudes
Pediatric hospitalists should be able to:
Respect the skills and contributions of all involved in the care of patients.
Exemplify professionalism in all communications.
Seek opportunities to enhance communication skills.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Collaborate with hospital administrators to improve medical record documentation systems by technical means.
Assist in the development of and/or participate in hospital and system‐wide educational programs on communication skills.
Copyright © 2010 Society of Hospital Medicine
Shock
Introduction
Early recognition and treatment of shock is imperative in improving the outcomes of critically ill children. The American Heart Association categorizes shock into four basic forms: hypovolemic, distributive, cardiogenic, and obstructive. Shock results from inadequate tissue perfusion to support metabolic demands. This may be caused by an inadequate supply of oxygen to the tissues or an increased demand of the tissues for oxygen. As a result, cellular hypoxia, anaerobic metabolism, and dysregulation result in irreversible cell damage and death. Pediatric hospitalists often encounter children with all forms of shock and should be adept at recognition and basic management of shock to improve outcomes.
Knowledge
Pediatric hospitalists should be able to:
Discuss the pathophysiology of tissue hypoxia including hypoxemia, anemia, and ischemia.
Describe the components of tissue oxygen delivery, focusing on cardiac output.
Describe common diseases and conditions associated with the four forms of shock.
Compare and contrast the presenting signs and symptoms of the four forms of shock, attending to differences in heart rate, blood pressure, pulses and peripheral perfusion, mental status, and urine output.
Discuss compensatory mechanisms of early shock including increased heart rate, stroke volume, and vascular smooth muscle tone.
List indications for chronotropic, inotropic, and blood pressure support and describe the mechanisms of action for these classes of medications.
State the commonly performed diagnostic studies (such as lab, radiographic, and other) which aid in determining the extent or form of shock.
Summarize the approach toward stabilization of each form of shock.
Skills
Pediatric hospitalists should be able to:
Perform an initial rapid assessment using Pediatric Advanced Life Support skills.
Recognize signs of early shock and respond with appropriate actions.
Appropriately order and correctly interpret results of common studies to determine the extent of shock such as complete blood count, chemistries, blood gas, radiography and others.
Appropriately order and correctly interpret results of studies to determine the cause of shock and respond with appropriate actions.
Order appropriate monitoring and correctly interpret monitor data.
Correctly recognize cardiomegaly and other signs of congestive heart failure on chest radiograph.
Correctly identify the form of shock from a focused history, physical examination and initial diagnostic studies.
Initiate appropriate interventions based on the form of shock.
Facilitate effective transfer to a tertiary care center or intensive care setting when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with emergency room and intensive care staff to ensure appropriate care for patients in shock.
Listen effectively and respond to concerns of the family/caregiver and healthcare providers regarding changes in physiologic parameters including vital signs, mental status, physical examination, and urine output.
Provide family/caregiver support and education on the nuances and complexities of the various forms of shock and the importance of careful monitoring and evaluation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Work with hospital administration, hospital staff, subspecialists, and other services to advocate for an educational program for healthcare providers on the importance of early recognition of shock to prevent end‐organ failure and death.
Lead, coordinate or participate in the development and implementation of rapid response systems to assist in recognition and stabilization of early shock.
Collaborate with hospital administration and community partners to develop and sustain local AHA Pediatric Life Support classes where descriptions and case scenarios provide a comprehensive knowledge base and intervention plan for various types of shock.
Lead, coordinate or participate in efforts to partner with simulation centers to assist in acquiring skill sets needed for appropriate recognition and intervention for children in shock.
Introduction
Early recognition and treatment of shock is imperative in improving the outcomes of critically ill children. The American Heart Association categorizes shock into four basic forms: hypovolemic, distributive, cardiogenic, and obstructive. Shock results from inadequate tissue perfusion to support metabolic demands. This may be caused by an inadequate supply of oxygen to the tissues or an increased demand of the tissues for oxygen. As a result, cellular hypoxia, anaerobic metabolism, and dysregulation result in irreversible cell damage and death. Pediatric hospitalists often encounter children with all forms of shock and should be adept at recognition and basic management of shock to improve outcomes.
Knowledge
Pediatric hospitalists should be able to:
Discuss the pathophysiology of tissue hypoxia including hypoxemia, anemia, and ischemia.
Describe the components of tissue oxygen delivery, focusing on cardiac output.
Describe common diseases and conditions associated with the four forms of shock.
Compare and contrast the presenting signs and symptoms of the four forms of shock, attending to differences in heart rate, blood pressure, pulses and peripheral perfusion, mental status, and urine output.
Discuss compensatory mechanisms of early shock including increased heart rate, stroke volume, and vascular smooth muscle tone.
List indications for chronotropic, inotropic, and blood pressure support and describe the mechanisms of action for these classes of medications.
State the commonly performed diagnostic studies (such as lab, radiographic, and other) which aid in determining the extent or form of shock.
Summarize the approach toward stabilization of each form of shock.
Skills
Pediatric hospitalists should be able to:
Perform an initial rapid assessment using Pediatric Advanced Life Support skills.
Recognize signs of early shock and respond with appropriate actions.
Appropriately order and correctly interpret results of common studies to determine the extent of shock such as complete blood count, chemistries, blood gas, radiography and others.
Appropriately order and correctly interpret results of studies to determine the cause of shock and respond with appropriate actions.
Order appropriate monitoring and correctly interpret monitor data.
Correctly recognize cardiomegaly and other signs of congestive heart failure on chest radiograph.
Correctly identify the form of shock from a focused history, physical examination and initial diagnostic studies.
Initiate appropriate interventions based on the form of shock.
Facilitate effective transfer to a tertiary care center or intensive care setting when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with emergency room and intensive care staff to ensure appropriate care for patients in shock.
Listen effectively and respond to concerns of the family/caregiver and healthcare providers regarding changes in physiologic parameters including vital signs, mental status, physical examination, and urine output.
Provide family/caregiver support and education on the nuances and complexities of the various forms of shock and the importance of careful monitoring and evaluation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Work with hospital administration, hospital staff, subspecialists, and other services to advocate for an educational program for healthcare providers on the importance of early recognition of shock to prevent end‐organ failure and death.
Lead, coordinate or participate in the development and implementation of rapid response systems to assist in recognition and stabilization of early shock.
Collaborate with hospital administration and community partners to develop and sustain local AHA Pediatric Life Support classes where descriptions and case scenarios provide a comprehensive knowledge base and intervention plan for various types of shock.
Lead, coordinate or participate in efforts to partner with simulation centers to assist in acquiring skill sets needed for appropriate recognition and intervention for children in shock.
Introduction
Early recognition and treatment of shock is imperative in improving the outcomes of critically ill children. The American Heart Association categorizes shock into four basic forms: hypovolemic, distributive, cardiogenic, and obstructive. Shock results from inadequate tissue perfusion to support metabolic demands. This may be caused by an inadequate supply of oxygen to the tissues or an increased demand of the tissues for oxygen. As a result, cellular hypoxia, anaerobic metabolism, and dysregulation result in irreversible cell damage and death. Pediatric hospitalists often encounter children with all forms of shock and should be adept at recognition and basic management of shock to improve outcomes.
Knowledge
Pediatric hospitalists should be able to:
Discuss the pathophysiology of tissue hypoxia including hypoxemia, anemia, and ischemia.
Describe the components of tissue oxygen delivery, focusing on cardiac output.
Describe common diseases and conditions associated with the four forms of shock.
Compare and contrast the presenting signs and symptoms of the four forms of shock, attending to differences in heart rate, blood pressure, pulses and peripheral perfusion, mental status, and urine output.
Discuss compensatory mechanisms of early shock including increased heart rate, stroke volume, and vascular smooth muscle tone.
List indications for chronotropic, inotropic, and blood pressure support and describe the mechanisms of action for these classes of medications.
State the commonly performed diagnostic studies (such as lab, radiographic, and other) which aid in determining the extent or form of shock.
Summarize the approach toward stabilization of each form of shock.
Skills
Pediatric hospitalists should be able to:
Perform an initial rapid assessment using Pediatric Advanced Life Support skills.
Recognize signs of early shock and respond with appropriate actions.
Appropriately order and correctly interpret results of common studies to determine the extent of shock such as complete blood count, chemistries, blood gas, radiography and others.
Appropriately order and correctly interpret results of studies to determine the cause of shock and respond with appropriate actions.
Order appropriate monitoring and correctly interpret monitor data.
Correctly recognize cardiomegaly and other signs of congestive heart failure on chest radiograph.
Correctly identify the form of shock from a focused history, physical examination and initial diagnostic studies.
Initiate appropriate interventions based on the form of shock.
Facilitate effective transfer to a tertiary care center or intensive care setting when appropriate.
Attitudes
Pediatric hospitalists should be able to:
Communicate effectively with emergency room and intensive care staff to ensure appropriate care for patients in shock.
Listen effectively and respond to concerns of the family/caregiver and healthcare providers regarding changes in physiologic parameters including vital signs, mental status, physical examination, and urine output.
Provide family/caregiver support and education on the nuances and complexities of the various forms of shock and the importance of careful monitoring and evaluation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
Work with hospital administration, hospital staff, subspecialists, and other services to advocate for an educational program for healthcare providers on the importance of early recognition of shock to prevent end‐organ failure and death.
Lead, coordinate or participate in the development and implementation of rapid response systems to assist in recognition and stabilization of early shock.
Collaborate with hospital administration and community partners to develop and sustain local AHA Pediatric Life Support classes where descriptions and case scenarios provide a comprehensive knowledge base and intervention plan for various types of shock.
Lead, coordinate or participate in efforts to partner with simulation centers to assist in acquiring skill sets needed for appropriate recognition and intervention for children in shock.
Copyright © 2010 Society of Hospital Medicine