User login
Abbreviations
ABG Arterial blood gas
ACLS Advanced cardiac life support
ACS Acute coronary syndrome
ADE Adverse drug event
ARF Acute renal failures
ARR Absolute risk reduction
BLS Basic life support
CAD Coronary artery disease
CAP Community acquired pneumonia
CHF Congestive heart failure
CNS Central nervous system
COPD Chronic obstructive pulmonary disease
CPOE Computer physician order entry
CSF Cerebrospinal fluid
CT Computed tomography
CXR Chest radiograph
DKA Diabetic ketoacidosis
DSM‐IV Diagnostic and Statistical Manual of Mental Disorders (4th edition)
DVT Deep vein thrombosis
EBM Evidence based medicine
EKG Electrocardiogram
FMEA Failure mode and effects analysis
GI Gastrointestinal
HAP Hospital acquired pneumonia
HHS Hyperglycemia hyperosmolar state
ICU Intensive care unit
MRI Magnetic resonance imaging
NNT Number needed to treat
NSAIDS Nonsteroidal anti‐inflammatory drugs
NSTEMI Non‐ST‐segment elevation myocardial infarction
OTC Over‐the‐counter drugs
PBLI Practice based learning and improvement
PE Pulmonary embolus
PDI Pneumonia severity index
PORT Pneumonia patient outcomes research team
PDSA Plan Do Study Act
PSI Pneumonia Severity Index
QI Quality Improvement
RCA Root cause analysis
RRR Relative risk reduction
RVU Relative value units
STEMI ST‐elevation myocardial infarction
SIRS Systemic Inflammatory Response Syndrome
UTI Urinary tract infection
VTE Venous thromboembolism
ABG Arterial blood gas
ACLS Advanced cardiac life support
ACS Acute coronary syndrome
ADE Adverse drug event
ARF Acute renal failures
ARR Absolute risk reduction
BLS Basic life support
CAD Coronary artery disease
CAP Community acquired pneumonia
CHF Congestive heart failure
CNS Central nervous system
COPD Chronic obstructive pulmonary disease
CPOE Computer physician order entry
CSF Cerebrospinal fluid
CT Computed tomography
CXR Chest radiograph
DKA Diabetic ketoacidosis
DSM‐IV Diagnostic and Statistical Manual of Mental Disorders (4th edition)
DVT Deep vein thrombosis
EBM Evidence based medicine
EKG Electrocardiogram
FMEA Failure mode and effects analysis
GI Gastrointestinal
HAP Hospital acquired pneumonia
HHS Hyperglycemia hyperosmolar state
ICU Intensive care unit
MRI Magnetic resonance imaging
NNT Number needed to treat
NSAIDS Nonsteroidal anti‐inflammatory drugs
NSTEMI Non‐ST‐segment elevation myocardial infarction
OTC Over‐the‐counter drugs
PBLI Practice based learning and improvement
PE Pulmonary embolus
PDI Pneumonia severity index
PORT Pneumonia patient outcomes research team
PDSA Plan Do Study Act
PSI Pneumonia Severity Index
QI Quality Improvement
RCA Root cause analysis
RRR Relative risk reduction
RVU Relative value units
STEMI ST‐elevation myocardial infarction
SIRS Systemic Inflammatory Response Syndrome
UTI Urinary tract infection
VTE Venous thromboembolism
ABG Arterial blood gas
ACLS Advanced cardiac life support
ACS Acute coronary syndrome
ADE Adverse drug event
ARF Acute renal failures
ARR Absolute risk reduction
BLS Basic life support
CAD Coronary artery disease
CAP Community acquired pneumonia
CHF Congestive heart failure
CNS Central nervous system
COPD Chronic obstructive pulmonary disease
CPOE Computer physician order entry
CSF Cerebrospinal fluid
CT Computed tomography
CXR Chest radiograph
DKA Diabetic ketoacidosis
DSM‐IV Diagnostic and Statistical Manual of Mental Disorders (4th edition)
DVT Deep vein thrombosis
EBM Evidence based medicine
EKG Electrocardiogram
FMEA Failure mode and effects analysis
GI Gastrointestinal
HAP Hospital acquired pneumonia
HHS Hyperglycemia hyperosmolar state
ICU Intensive care unit
MRI Magnetic resonance imaging
NNT Number needed to treat
NSAIDS Nonsteroidal anti‐inflammatory drugs
NSTEMI Non‐ST‐segment elevation myocardial infarction
OTC Over‐the‐counter drugs
PBLI Practice based learning and improvement
PE Pulmonary embolus
PDI Pneumonia severity index
PORT Pneumonia patient outcomes research team
PDSA Plan Do Study Act
PSI Pneumonia Severity Index
QI Quality Improvement
RCA Root cause analysis
RRR Relative risk reduction
RVU Relative value units
STEMI ST‐elevation myocardial infarction
SIRS Systemic Inflammatory Response Syndrome
UTI Urinary tract infection
VTE Venous thromboembolism
Copyright © 2006 Society of Hospital Medicine
Emergency procedures
In Hospital Medicine, emergency procedures refer to advanced cardiac life support (ACLS), endotracheal intubation, and short‐term mechanical ventilation. Hospitalists care for patients admitted to the hospital with critical illnesses, as well as patients who have become critically ill during their hospital stay. In providing care to patients who have become critically ill, many Hospitalists perform or supervise these emergency procedures. Hospitalists lead efforts to provide timely, standardized response to inpatient emergencies.
CARDIOPULMONARY RESUSCITATION
KNOWLEDGE
Hospitalists should be able to:
Describe the normal anatomy of the oral cavity, airway, thorax, heart and lungs.
Describe the clinical findings or disease processes that require implementation of cardiopulmonary resuscitation and advanced life support.
Describe clinical or cardiac rhythm findings that may impact outcomes for patients with cardiopulmonary arrest.
List the laboratory and other diagnostic tests indicated during cardiopulmonary distress or arrest and immediately following successful resuscitation.
Explain basic life support (BLS) protocols.
Explain and differentiate current ACLS protocols, including the indicated interventions, based on the clinical situation and cardiac rhythm.
Select the necessary equipment to manage the airway, identify cardiac rhythms, and perform defibrillation.
Explain which cardiac rhythms and clinical situations require immediate defibrillation.
Explain the mechanisms of action and uses of medications employed during ACLS.
Explain the indications for procedural interventions that may be employed during the course of resuscitation.
Explain the role of hyperthermia as a neuro‐protective measure in the post‐resuscitation period.
SKILLS
Hospitalists should be able to:
Promptly identify acute cardiopulmonary distress or arrest, and call for assistance.
Assess the patient, rapidly review the situation, and develop a differential diagnosis of etiology.
Elicit additional history from the patient's family, other healthcare providers, and the patient's chart when available.
Clearly and rapidly identify the event leader, and delineate other staff roles at the beginning of the resuscitation event.
Properly position the patient on a backboard to perform BLS and ACLS protocols.
Continually reassess proper patient positioning during resuscitation.
Perform BLS protocols to open the airway, use a bag‐valve‐mask ventilatory device, and perform external chest compressions.
Attach a defibrillator/pacer pads to the patient, and explain the operation of manual and automated defibrillators and external pacing systems.
Maintain clinician safety with appropriate protective wear.
Interpret cardiac rhythms and other diagnostic indicators.
Synthesize diagnostic information to deliver medications and/or defibrillation, and perform procedures required during resuscitation efforts.
ATTITUDES
Hospitalists should be able to:
Assess and respect the wishes of patients and families who desire no or limited resuscitation measures during hospitalization.
Communicate with families to explain the efforts performed as well as outcomes and next steps.
Rapidly respond to emergencies without distraction.
Facilitate interactions between healthcare professionals about the roles that each will perform during the resuscitation effort.
Review the resuscitation documentation for accuracy immediately following the event.
Recognize the indications for emergent specialty consultation when available, which may include ENT, surgery, or critical care medicine.
Appreciate the value of spiritual support services during and following resuscitation efforts.
Discontinue resuscitation efforts when interventions have been unsuccessful and continued efforts are medically futile.
Arrange for appropriate care transitions following successful resuscitation.
Address family wishes regarding organ donation and autopsy.
ENDOTRACHEAL INTUBATION
KNOWLEDGE
Hospitalists should be able to:
Describe the anatomy of the oral cavity, posterior pharynx and larynx.
Describe clinical findings or disease processes that may require securing an airway.
Describe the indications and contraindications, benefits and risks of endotracheal intubation.
Describe the necessary equipment and medications required for routine and difficult intubations.
Describe the process of endotracheal intubation from laryngoscope assembly to assessment of tube placement.
Describe and differentiate alternatives to endotracheal intubation.
SKILLS
Hospitalists should be able to:
Identify patients for whom endotracheal intubation may be required.
Utilize bag‐valve‐mask ventilation with oral or nasal airway as a bridge to intubation.
Select the appropriate laryngoscope blade for the individual patient.
Position the patient and the bed for optimal procedure success and operator comfort.
Assemble the laryngoscope and intubate the patient after visualizing the vocal cords.
Prepare the oropharynx for intubation using necessary steps that may include removal of oral hardware, suctioning, and application of cricoid pressure.
Request cricoid pressure and other maneuvers when indicated.
Place the endotracheal tube at an appropriate depth in the airway.
Confirm endotracheal tube placement by gastric and breath sounds, carbon dioxide monitor, and radiography; adjust tube position when indicated.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families regarding procedure indications and next steps in management.
Maintain high oxygen saturation prior to intubation whenever possible.
Minimize patient trauma risk during intubations.
Appreciate that bag‐valve‐mask can provide adequate oxygenation for extended periods when difficult intubations are delayed.
Maintain clinician safety with appropriate protective wear.
Use an alternative airway control device (e.g. laryngeal mask airway) for patients with difficult or unsuccessful intubations.
Request appropriate specialist consultation for difficult or unsuccessful intubations or when clinician experience level precludes intubation trial.
MECHANICAL VENTILATION
KNOWLEDGE
Hospitalists should be able to:
Describe the normal anatomy of the chest wall, thorax, and lung.
Describe disease processes that lead to respiratory failure and expected clinical findings.
Describe the indications, benefits and risks of mechanical ventilation.
Describe indications and contraindications for non‐invasive ventilation in selected patients.
Explain the role of arterial blood gas (ABG) analysis in the management of ventilated patients.
Describe available modes of ventilation, and how to select initial and subsequent ventilator settings.
Describe methods of and indications for sedation, comfort management, and/or paralysis in ventilated patients.
Describe various ventilator settings and explain the use of individual settings based on the patient's disease process and clinical condition.
SKILLS
Hospitalists should be able to:
Utilize nursing and respiratory therapy reports, physical examination, and ventilator data to identify complications due to mechanical ventilation.
Select and adjust the ventilator mode and settings based on underlying disease process, other patient factors, ventilator data, and ABG analysis.
Employ indicated interventions when complications of mechanical ventilation are identified.
Identify the components of the ventilator, assess proper functioning, and identify equipment malfunction and/or patient‐ventilator dysynchrony.
Order and interpret laboratory and imaging studies based on changes in patient's clinical status.
Order adequate sedation and other indicated interventions to treat underlying conditions leading to respiratory failure and to prevent the complications of mechanical ventilation.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and/or families to explain the risks, benefits, and alternatives to invasive ventilation.
Obtain informed consent prior to non‐emergent intubations.
Conduct regular family meetings to provide clinical updates and facilitate shared decision‐making.
Implement interventions shown to reduce risk of ventilator‐associated complications, which may include hospital acquired pneumonia, stress ulceration and bleeding, and venous thromboembolism.
Provide adequate sedation, comfort management, and paralysis when indicated for patients requiring mechanical ventilation.
Recognize the indications for specialty consultation, which may include critical care medicine.
SYSTEM ORGANIZATION AND IMPROVEMENT FOR EMERGENCY PROCEDURES
To improve efficiency and quality within their organizations, Hospitalists should:
Collaborate with critical care physicians, respiratory therapists, and critical care nurses to develop evidence based protocols or guidelines for optimal ventilator management and weaning.
Lead, coordinate or participate in evaluation of resuscitation and mechanical ventilation outcomes and identify and implement improvement initiatives.
Lead, coordinate or participate in multidisciplinary teams, which may include critical care nurses, respiratory therapists, and critical care and emergency physicians, to establish ongoing training to ensure high quality performance of emergency procedures.
Lead, coordinate or participate in multidisciplinary efforts to review antecedent events to identify changes in clinical status which, if promptly identified and acted upon, may have prevented the emergency intervention.
Facilitate appropriate organization and consolidation of equipment in multiple identifiable and accessible locations in the hospital for performance of emergency procedures.
In Hospital Medicine, emergency procedures refer to advanced cardiac life support (ACLS), endotracheal intubation, and short‐term mechanical ventilation. Hospitalists care for patients admitted to the hospital with critical illnesses, as well as patients who have become critically ill during their hospital stay. In providing care to patients who have become critically ill, many Hospitalists perform or supervise these emergency procedures. Hospitalists lead efforts to provide timely, standardized response to inpatient emergencies.
CARDIOPULMONARY RESUSCITATION
KNOWLEDGE
Hospitalists should be able to:
Describe the normal anatomy of the oral cavity, airway, thorax, heart and lungs.
Describe the clinical findings or disease processes that require implementation of cardiopulmonary resuscitation and advanced life support.
Describe clinical or cardiac rhythm findings that may impact outcomes for patients with cardiopulmonary arrest.
List the laboratory and other diagnostic tests indicated during cardiopulmonary distress or arrest and immediately following successful resuscitation.
Explain basic life support (BLS) protocols.
Explain and differentiate current ACLS protocols, including the indicated interventions, based on the clinical situation and cardiac rhythm.
Select the necessary equipment to manage the airway, identify cardiac rhythms, and perform defibrillation.
Explain which cardiac rhythms and clinical situations require immediate defibrillation.
Explain the mechanisms of action and uses of medications employed during ACLS.
Explain the indications for procedural interventions that may be employed during the course of resuscitation.
Explain the role of hyperthermia as a neuro‐protective measure in the post‐resuscitation period.
SKILLS
Hospitalists should be able to:
Promptly identify acute cardiopulmonary distress or arrest, and call for assistance.
Assess the patient, rapidly review the situation, and develop a differential diagnosis of etiology.
Elicit additional history from the patient's family, other healthcare providers, and the patient's chart when available.
Clearly and rapidly identify the event leader, and delineate other staff roles at the beginning of the resuscitation event.
Properly position the patient on a backboard to perform BLS and ACLS protocols.
Continually reassess proper patient positioning during resuscitation.
Perform BLS protocols to open the airway, use a bag‐valve‐mask ventilatory device, and perform external chest compressions.
Attach a defibrillator/pacer pads to the patient, and explain the operation of manual and automated defibrillators and external pacing systems.
Maintain clinician safety with appropriate protective wear.
Interpret cardiac rhythms and other diagnostic indicators.
Synthesize diagnostic information to deliver medications and/or defibrillation, and perform procedures required during resuscitation efforts.
ATTITUDES
Hospitalists should be able to:
Assess and respect the wishes of patients and families who desire no or limited resuscitation measures during hospitalization.
Communicate with families to explain the efforts performed as well as outcomes and next steps.
Rapidly respond to emergencies without distraction.
Facilitate interactions between healthcare professionals about the roles that each will perform during the resuscitation effort.
Review the resuscitation documentation for accuracy immediately following the event.
Recognize the indications for emergent specialty consultation when available, which may include ENT, surgery, or critical care medicine.
Appreciate the value of spiritual support services during and following resuscitation efforts.
Discontinue resuscitation efforts when interventions have been unsuccessful and continued efforts are medically futile.
Arrange for appropriate care transitions following successful resuscitation.
Address family wishes regarding organ donation and autopsy.
ENDOTRACHEAL INTUBATION
KNOWLEDGE
Hospitalists should be able to:
Describe the anatomy of the oral cavity, posterior pharynx and larynx.
Describe clinical findings or disease processes that may require securing an airway.
Describe the indications and contraindications, benefits and risks of endotracheal intubation.
Describe the necessary equipment and medications required for routine and difficult intubations.
Describe the process of endotracheal intubation from laryngoscope assembly to assessment of tube placement.
Describe and differentiate alternatives to endotracheal intubation.
SKILLS
Hospitalists should be able to:
Identify patients for whom endotracheal intubation may be required.
Utilize bag‐valve‐mask ventilation with oral or nasal airway as a bridge to intubation.
Select the appropriate laryngoscope blade for the individual patient.
Position the patient and the bed for optimal procedure success and operator comfort.
Assemble the laryngoscope and intubate the patient after visualizing the vocal cords.
Prepare the oropharynx for intubation using necessary steps that may include removal of oral hardware, suctioning, and application of cricoid pressure.
Request cricoid pressure and other maneuvers when indicated.
Place the endotracheal tube at an appropriate depth in the airway.
Confirm endotracheal tube placement by gastric and breath sounds, carbon dioxide monitor, and radiography; adjust tube position when indicated.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families regarding procedure indications and next steps in management.
Maintain high oxygen saturation prior to intubation whenever possible.
Minimize patient trauma risk during intubations.
Appreciate that bag‐valve‐mask can provide adequate oxygenation for extended periods when difficult intubations are delayed.
Maintain clinician safety with appropriate protective wear.
Use an alternative airway control device (e.g. laryngeal mask airway) for patients with difficult or unsuccessful intubations.
Request appropriate specialist consultation for difficult or unsuccessful intubations or when clinician experience level precludes intubation trial.
MECHANICAL VENTILATION
KNOWLEDGE
Hospitalists should be able to:
Describe the normal anatomy of the chest wall, thorax, and lung.
Describe disease processes that lead to respiratory failure and expected clinical findings.
Describe the indications, benefits and risks of mechanical ventilation.
Describe indications and contraindications for non‐invasive ventilation in selected patients.
Explain the role of arterial blood gas (ABG) analysis in the management of ventilated patients.
Describe available modes of ventilation, and how to select initial and subsequent ventilator settings.
Describe methods of and indications for sedation, comfort management, and/or paralysis in ventilated patients.
Describe various ventilator settings and explain the use of individual settings based on the patient's disease process and clinical condition.
SKILLS
Hospitalists should be able to:
Utilize nursing and respiratory therapy reports, physical examination, and ventilator data to identify complications due to mechanical ventilation.
Select and adjust the ventilator mode and settings based on underlying disease process, other patient factors, ventilator data, and ABG analysis.
Employ indicated interventions when complications of mechanical ventilation are identified.
Identify the components of the ventilator, assess proper functioning, and identify equipment malfunction and/or patient‐ventilator dysynchrony.
Order and interpret laboratory and imaging studies based on changes in patient's clinical status.
Order adequate sedation and other indicated interventions to treat underlying conditions leading to respiratory failure and to prevent the complications of mechanical ventilation.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and/or families to explain the risks, benefits, and alternatives to invasive ventilation.
Obtain informed consent prior to non‐emergent intubations.
Conduct regular family meetings to provide clinical updates and facilitate shared decision‐making.
Implement interventions shown to reduce risk of ventilator‐associated complications, which may include hospital acquired pneumonia, stress ulceration and bleeding, and venous thromboembolism.
Provide adequate sedation, comfort management, and paralysis when indicated for patients requiring mechanical ventilation.
Recognize the indications for specialty consultation, which may include critical care medicine.
SYSTEM ORGANIZATION AND IMPROVEMENT FOR EMERGENCY PROCEDURES
To improve efficiency and quality within their organizations, Hospitalists should:
Collaborate with critical care physicians, respiratory therapists, and critical care nurses to develop evidence based protocols or guidelines for optimal ventilator management and weaning.
Lead, coordinate or participate in evaluation of resuscitation and mechanical ventilation outcomes and identify and implement improvement initiatives.
Lead, coordinate or participate in multidisciplinary teams, which may include critical care nurses, respiratory therapists, and critical care and emergency physicians, to establish ongoing training to ensure high quality performance of emergency procedures.
Lead, coordinate or participate in multidisciplinary efforts to review antecedent events to identify changes in clinical status which, if promptly identified and acted upon, may have prevented the emergency intervention.
Facilitate appropriate organization and consolidation of equipment in multiple identifiable and accessible locations in the hospital for performance of emergency procedures.
In Hospital Medicine, emergency procedures refer to advanced cardiac life support (ACLS), endotracheal intubation, and short‐term mechanical ventilation. Hospitalists care for patients admitted to the hospital with critical illnesses, as well as patients who have become critically ill during their hospital stay. In providing care to patients who have become critically ill, many Hospitalists perform or supervise these emergency procedures. Hospitalists lead efforts to provide timely, standardized response to inpatient emergencies.
CARDIOPULMONARY RESUSCITATION
KNOWLEDGE
Hospitalists should be able to:
Describe the normal anatomy of the oral cavity, airway, thorax, heart and lungs.
Describe the clinical findings or disease processes that require implementation of cardiopulmonary resuscitation and advanced life support.
Describe clinical or cardiac rhythm findings that may impact outcomes for patients with cardiopulmonary arrest.
List the laboratory and other diagnostic tests indicated during cardiopulmonary distress or arrest and immediately following successful resuscitation.
Explain basic life support (BLS) protocols.
Explain and differentiate current ACLS protocols, including the indicated interventions, based on the clinical situation and cardiac rhythm.
Select the necessary equipment to manage the airway, identify cardiac rhythms, and perform defibrillation.
Explain which cardiac rhythms and clinical situations require immediate defibrillation.
Explain the mechanisms of action and uses of medications employed during ACLS.
Explain the indications for procedural interventions that may be employed during the course of resuscitation.
Explain the role of hyperthermia as a neuro‐protective measure in the post‐resuscitation period.
SKILLS
Hospitalists should be able to:
Promptly identify acute cardiopulmonary distress or arrest, and call for assistance.
Assess the patient, rapidly review the situation, and develop a differential diagnosis of etiology.
Elicit additional history from the patient's family, other healthcare providers, and the patient's chart when available.
Clearly and rapidly identify the event leader, and delineate other staff roles at the beginning of the resuscitation event.
Properly position the patient on a backboard to perform BLS and ACLS protocols.
Continually reassess proper patient positioning during resuscitation.
Perform BLS protocols to open the airway, use a bag‐valve‐mask ventilatory device, and perform external chest compressions.
Attach a defibrillator/pacer pads to the patient, and explain the operation of manual and automated defibrillators and external pacing systems.
Maintain clinician safety with appropriate protective wear.
Interpret cardiac rhythms and other diagnostic indicators.
Synthesize diagnostic information to deliver medications and/or defibrillation, and perform procedures required during resuscitation efforts.
ATTITUDES
Hospitalists should be able to:
Assess and respect the wishes of patients and families who desire no or limited resuscitation measures during hospitalization.
Communicate with families to explain the efforts performed as well as outcomes and next steps.
Rapidly respond to emergencies without distraction.
Facilitate interactions between healthcare professionals about the roles that each will perform during the resuscitation effort.
Review the resuscitation documentation for accuracy immediately following the event.
Recognize the indications for emergent specialty consultation when available, which may include ENT, surgery, or critical care medicine.
Appreciate the value of spiritual support services during and following resuscitation efforts.
Discontinue resuscitation efforts when interventions have been unsuccessful and continued efforts are medically futile.
Arrange for appropriate care transitions following successful resuscitation.
Address family wishes regarding organ donation and autopsy.
ENDOTRACHEAL INTUBATION
KNOWLEDGE
Hospitalists should be able to:
Describe the anatomy of the oral cavity, posterior pharynx and larynx.
Describe clinical findings or disease processes that may require securing an airway.
Describe the indications and contraindications, benefits and risks of endotracheal intubation.
Describe the necessary equipment and medications required for routine and difficult intubations.
Describe the process of endotracheal intubation from laryngoscope assembly to assessment of tube placement.
Describe and differentiate alternatives to endotracheal intubation.
SKILLS
Hospitalists should be able to:
Identify patients for whom endotracheal intubation may be required.
Utilize bag‐valve‐mask ventilation with oral or nasal airway as a bridge to intubation.
Select the appropriate laryngoscope blade for the individual patient.
Position the patient and the bed for optimal procedure success and operator comfort.
Assemble the laryngoscope and intubate the patient after visualizing the vocal cords.
Prepare the oropharynx for intubation using necessary steps that may include removal of oral hardware, suctioning, and application of cricoid pressure.
Request cricoid pressure and other maneuvers when indicated.
Place the endotracheal tube at an appropriate depth in the airway.
Confirm endotracheal tube placement by gastric and breath sounds, carbon dioxide monitor, and radiography; adjust tube position when indicated.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families regarding procedure indications and next steps in management.
Maintain high oxygen saturation prior to intubation whenever possible.
Minimize patient trauma risk during intubations.
Appreciate that bag‐valve‐mask can provide adequate oxygenation for extended periods when difficult intubations are delayed.
Maintain clinician safety with appropriate protective wear.
Use an alternative airway control device (e.g. laryngeal mask airway) for patients with difficult or unsuccessful intubations.
Request appropriate specialist consultation for difficult or unsuccessful intubations or when clinician experience level precludes intubation trial.
MECHANICAL VENTILATION
KNOWLEDGE
Hospitalists should be able to:
Describe the normal anatomy of the chest wall, thorax, and lung.
Describe disease processes that lead to respiratory failure and expected clinical findings.
Describe the indications, benefits and risks of mechanical ventilation.
Describe indications and contraindications for non‐invasive ventilation in selected patients.
Explain the role of arterial blood gas (ABG) analysis in the management of ventilated patients.
Describe available modes of ventilation, and how to select initial and subsequent ventilator settings.
Describe methods of and indications for sedation, comfort management, and/or paralysis in ventilated patients.
Describe various ventilator settings and explain the use of individual settings based on the patient's disease process and clinical condition.
SKILLS
Hospitalists should be able to:
Utilize nursing and respiratory therapy reports, physical examination, and ventilator data to identify complications due to mechanical ventilation.
Select and adjust the ventilator mode and settings based on underlying disease process, other patient factors, ventilator data, and ABG analysis.
Employ indicated interventions when complications of mechanical ventilation are identified.
Identify the components of the ventilator, assess proper functioning, and identify equipment malfunction and/or patient‐ventilator dysynchrony.
Order and interpret laboratory and imaging studies based on changes in patient's clinical status.
Order adequate sedation and other indicated interventions to treat underlying conditions leading to respiratory failure and to prevent the complications of mechanical ventilation.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and/or families to explain the risks, benefits, and alternatives to invasive ventilation.
Obtain informed consent prior to non‐emergent intubations.
Conduct regular family meetings to provide clinical updates and facilitate shared decision‐making.
Implement interventions shown to reduce risk of ventilator‐associated complications, which may include hospital acquired pneumonia, stress ulceration and bleeding, and venous thromboembolism.
Provide adequate sedation, comfort management, and paralysis when indicated for patients requiring mechanical ventilation.
Recognize the indications for specialty consultation, which may include critical care medicine.
SYSTEM ORGANIZATION AND IMPROVEMENT FOR EMERGENCY PROCEDURES
To improve efficiency and quality within their organizations, Hospitalists should:
Collaborate with critical care physicians, respiratory therapists, and critical care nurses to develop evidence based protocols or guidelines for optimal ventilator management and weaning.
Lead, coordinate or participate in evaluation of resuscitation and mechanical ventilation outcomes and identify and implement improvement initiatives.
Lead, coordinate or participate in multidisciplinary teams, which may include critical care nurses, respiratory therapists, and critical care and emergency physicians, to establish ongoing training to ensure high quality performance of emergency procedures.
Lead, coordinate or participate in multidisciplinary efforts to review antecedent events to identify changes in clinical status which, if promptly identified and acted upon, may have prevented the emergency intervention.
Facilitate appropriate organization and consolidation of equipment in multiple identifiable and accessible locations in the hospital for performance of emergency procedures.
Copyright © 2006 Society of Hospital Medicine
Prevention of healthcare‐associated infections and antimicrobial resistance
Healthcare‐associated infections impose a significant burden on the healthcare system in the Unites States, both economically and in terms of patient outcomes. The Centers for Disease Control and Prevention (CDC) estimate that nearly 2 million patients develop healthcare‐associated infections each year, and approximately 88,000 die as a direct or indirect result of their infections. These infections often lead to increases in length of hospitalization, and result in about $4.5 billion in excess costs annually. The central aim of infection control is to prevent healthcare‐associated infections and the emergence of resistant organisms. Hospitalists work in concert with other members of the healthcare organization to reduce healthcare‐associated infections, develop institutional initiatives for prevention, and promote and implement evidence based infection control measures.
KNOWLEDGE
Hospitalists should be able to:
Describe acceptable methods of hand hygiene technique and timing in relationship to patient contact.
Describe the prophylactic measures required for all types of isolation precautions, which include Standard, Contact, Droplet, and Airborne Precautions, and list the indications for implementing each type of precaution.
List common types of healthcare‐associated infections, and describe the risk factors associated with urinary tract infections, surgical site infections, hospital‐acquired pneumonia, and blood stream infections.
Explain the utility of the hospital antibiogram in delineating antimicrobial resistance patterns for bacterial isolates, and how it should be used to make empiric antibiotic selections.
Identify major resources for infection control information, including hospital infection control staff, hospital infection control policies and procedures, local and state public health departments, and CDCP guidelines.
Describe the indicated prevention measures necessary to perform hospital‐based procedures in a sterile fashion.
SKILLS
Hospitalists should be able to:
Perform consistent and optimal hand hygiene techniques at all indicated points of care.
Implement indicated isolation precautions for patients with high risk transmissible diseases or highly resistant infections.
Identify and utilize local hospital resources, including antibiograms and infection control officers.
Perform indicated infection control and prevention technique during all procedures.
Implement precautions and infection control practices to protect patients from acquiring healthcare‐associated infections.
ATTITUDES
Hospitalists should be able to:
Appreciate that specific infection control practices and engineering controls are required to protect very high risk patient populations, which may include hematopoietic stem cell transplant or solid organ transplant recipients, from healthcare associated infections.
Serve as a role model in adherence to recommended hand hygiene and infection control practices.
Communicate effectively the rationale and importance of infection control practices to patients, families, visitors, other health care providers and hospital staff.
Communicate appropriate patient information to infection control staff regarding potentially transmissible diseases.
Avoid devices that are more likely to cause hospital‐acquired infections if alternatives are safe, effective and available.
Encourage removal of invasive devices, especially central venous catheters and urinary catheters, early during hospital stay and as soon as clinically safe to do so.
Collaborate with multidisciplinary teams, which may include infection control, nursing service, and infectious disease consultants, to rapidly implement and maintain isolation precautions.
Collaborate with multidisciplinary teams that may include infection control, nursing service, care coordination, long term care facilities, home health care staff, and public health personnel to plan for hospital discharge of patients with transmissible infectious diseases.
Lead, coordinate or participate in efforts to educate other health care personnel and hospital staff about necessary infection control prevention measures.
Lead, coordinate or participate in multidisciplinary teams that organize, implement, and study infection control protocols, guidelines or pathways, using evidence based systematic methods.
Lead, coordinate or participate in multidisciplinary efforts to develop empiric antibiotic regimens to minimize the development of resistance within a particular hospital or region.
Healthcare‐associated infections impose a significant burden on the healthcare system in the Unites States, both economically and in terms of patient outcomes. The Centers for Disease Control and Prevention (CDC) estimate that nearly 2 million patients develop healthcare‐associated infections each year, and approximately 88,000 die as a direct or indirect result of their infections. These infections often lead to increases in length of hospitalization, and result in about $4.5 billion in excess costs annually. The central aim of infection control is to prevent healthcare‐associated infections and the emergence of resistant organisms. Hospitalists work in concert with other members of the healthcare organization to reduce healthcare‐associated infections, develop institutional initiatives for prevention, and promote and implement evidence based infection control measures.
KNOWLEDGE
Hospitalists should be able to:
Describe acceptable methods of hand hygiene technique and timing in relationship to patient contact.
Describe the prophylactic measures required for all types of isolation precautions, which include Standard, Contact, Droplet, and Airborne Precautions, and list the indications for implementing each type of precaution.
List common types of healthcare‐associated infections, and describe the risk factors associated with urinary tract infections, surgical site infections, hospital‐acquired pneumonia, and blood stream infections.
Explain the utility of the hospital antibiogram in delineating antimicrobial resistance patterns for bacterial isolates, and how it should be used to make empiric antibiotic selections.
Identify major resources for infection control information, including hospital infection control staff, hospital infection control policies and procedures, local and state public health departments, and CDCP guidelines.
Describe the indicated prevention measures necessary to perform hospital‐based procedures in a sterile fashion.
SKILLS
Hospitalists should be able to:
Perform consistent and optimal hand hygiene techniques at all indicated points of care.
Implement indicated isolation precautions for patients with high risk transmissible diseases or highly resistant infections.
Identify and utilize local hospital resources, including antibiograms and infection control officers.
Perform indicated infection control and prevention technique during all procedures.
Implement precautions and infection control practices to protect patients from acquiring healthcare‐associated infections.
ATTITUDES
Hospitalists should be able to:
Appreciate that specific infection control practices and engineering controls are required to protect very high risk patient populations, which may include hematopoietic stem cell transplant or solid organ transplant recipients, from healthcare associated infections.
Serve as a role model in adherence to recommended hand hygiene and infection control practices.
Communicate effectively the rationale and importance of infection control practices to patients, families, visitors, other health care providers and hospital staff.
Communicate appropriate patient information to infection control staff regarding potentially transmissible diseases.
Avoid devices that are more likely to cause hospital‐acquired infections if alternatives are safe, effective and available.
Encourage removal of invasive devices, especially central venous catheters and urinary catheters, early during hospital stay and as soon as clinically safe to do so.
Collaborate with multidisciplinary teams, which may include infection control, nursing service, and infectious disease consultants, to rapidly implement and maintain isolation precautions.
Collaborate with multidisciplinary teams that may include infection control, nursing service, care coordination, long term care facilities, home health care staff, and public health personnel to plan for hospital discharge of patients with transmissible infectious diseases.
Lead, coordinate or participate in efforts to educate other health care personnel and hospital staff about necessary infection control prevention measures.
Lead, coordinate or participate in multidisciplinary teams that organize, implement, and study infection control protocols, guidelines or pathways, using evidence based systematic methods.
Lead, coordinate or participate in multidisciplinary efforts to develop empiric antibiotic regimens to minimize the development of resistance within a particular hospital or region.
Healthcare‐associated infections impose a significant burden on the healthcare system in the Unites States, both economically and in terms of patient outcomes. The Centers for Disease Control and Prevention (CDC) estimate that nearly 2 million patients develop healthcare‐associated infections each year, and approximately 88,000 die as a direct or indirect result of their infections. These infections often lead to increases in length of hospitalization, and result in about $4.5 billion in excess costs annually. The central aim of infection control is to prevent healthcare‐associated infections and the emergence of resistant organisms. Hospitalists work in concert with other members of the healthcare organization to reduce healthcare‐associated infections, develop institutional initiatives for prevention, and promote and implement evidence based infection control measures.
KNOWLEDGE
Hospitalists should be able to:
Describe acceptable methods of hand hygiene technique and timing in relationship to patient contact.
Describe the prophylactic measures required for all types of isolation precautions, which include Standard, Contact, Droplet, and Airborne Precautions, and list the indications for implementing each type of precaution.
List common types of healthcare‐associated infections, and describe the risk factors associated with urinary tract infections, surgical site infections, hospital‐acquired pneumonia, and blood stream infections.
Explain the utility of the hospital antibiogram in delineating antimicrobial resistance patterns for bacterial isolates, and how it should be used to make empiric antibiotic selections.
Identify major resources for infection control information, including hospital infection control staff, hospital infection control policies and procedures, local and state public health departments, and CDCP guidelines.
Describe the indicated prevention measures necessary to perform hospital‐based procedures in a sterile fashion.
SKILLS
Hospitalists should be able to:
Perform consistent and optimal hand hygiene techniques at all indicated points of care.
Implement indicated isolation precautions for patients with high risk transmissible diseases or highly resistant infections.
Identify and utilize local hospital resources, including antibiograms and infection control officers.
Perform indicated infection control and prevention technique during all procedures.
Implement precautions and infection control practices to protect patients from acquiring healthcare‐associated infections.
ATTITUDES
Hospitalists should be able to:
Appreciate that specific infection control practices and engineering controls are required to protect very high risk patient populations, which may include hematopoietic stem cell transplant or solid organ transplant recipients, from healthcare associated infections.
Serve as a role model in adherence to recommended hand hygiene and infection control practices.
Communicate effectively the rationale and importance of infection control practices to patients, families, visitors, other health care providers and hospital staff.
Communicate appropriate patient information to infection control staff regarding potentially transmissible diseases.
Avoid devices that are more likely to cause hospital‐acquired infections if alternatives are safe, effective and available.
Encourage removal of invasive devices, especially central venous catheters and urinary catheters, early during hospital stay and as soon as clinically safe to do so.
Collaborate with multidisciplinary teams, which may include infection control, nursing service, and infectious disease consultants, to rapidly implement and maintain isolation precautions.
Collaborate with multidisciplinary teams that may include infection control, nursing service, care coordination, long term care facilities, home health care staff, and public health personnel to plan for hospital discharge of patients with transmissible infectious diseases.
Lead, coordinate or participate in efforts to educate other health care personnel and hospital staff about necessary infection control prevention measures.
Lead, coordinate or participate in multidisciplinary teams that organize, implement, and study infection control protocols, guidelines or pathways, using evidence based systematic methods.
Lead, coordinate or participate in multidisciplinary efforts to develop empiric antibiotic regimens to minimize the development of resistance within a particular hospital or region.
Copyright © 2006 Society of Hospital Medicine
Diabetes mellitus
Diabetes mellitus is a disease characterized by abnormal insulin production or disordered glucose metabolism and is a co‐morbid condition of many hospitalized patients. diabetic ketoacidosis (dka) and hyperglycemia hyperosmolar state (hhs) are extreme presentations of diabetes mellitus that require hospitalization. there were 577,000 hospital discharges for diabetes mellitus in 2002, according to the american heart association. the prevalence of physician‐diagnosed diabetes mellitus was 13.9 million or 6.7 percent of the united states population. another 5.9 million americans are believed to have undiagnosed diabetes mellitus. the healthcare cost and utilization project (hcup) reports an average length‐of‐stay of 4.1 days and mean charges of $11,761 per patient for the diagnosis related group (drg) for diabetes mellitus. the estimated economic cost of diabetes in 2002 was $132 billion, of which $92 billion was direct medical costs. hospitalists care for diabetic patients and optimize glycemic control in the hospital setting. they stabilize and treat dka and hhs. the inpatient setting provides an opportunity to institute therapies to slow disease progression, prevent disease complications, and provide diabetic education to improve quality of life and limit complications leading to readmission. hospitalists use evidence based approaches to optimize care and lead multidisciplinary teams to develop institutional guidelines or care pathways to optimize glycemic control.
KNOWLEDGE
Hospitalists should be able to:
Define diabetes mellitus and explain the pathophysiologic processes that can lead to hyperglycemia, dka and hhs.
Describe the impact of hyperglycemia on immune function and wound healing.
Describe the effect of dka and hhs on intravascular volume status, electrolytes and acid‐base balance.
Describe the clinical presentation and laboratory findings of dka and hhs.
Describe the indicated tests to evaluate and diagnose dka and hhs.
Explain physiologic stressors and medications that adversely impact glycemic control.
Explain the precipitating factors of dka and hss.
Identify the goals of glycemic control in hospitalized patients in various settings, including critically ill and surgical patients, and cite supporting evidence.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat diabetes mellitus.
Explain the rationale of strict glycemic control and its effects on morbidity and mortality in hospitalized patients.
Recognize factors that indicate severity of disease in patients with dka or hhs.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a thorough and relevant history, and review the medical record to identify symptoms suggestive of acute co‐morbid illness that can impact glycemic control.
Estimate the level of outpatient glycemic control, adherence to medication regimen, and social influences that may impact glycemic control.
Perform a comprehensive physical examination to identify possible precipitants of hyperglycemia, dka or hhs.
Identify precipitating factors for dka and hhs, including infection, myocardial ischemia, and adherence to medication regimen.
Select and interpret indicated studies in patients suspected of having dka or hhs, including electrolytes, beta‐hydroxybuterate, urinalysis, venous ph, and electrocardiogram.
Recognize the indications for managing dka and hhs in an intensive care unit.
Select appropriate insulin therapies, initiate fluid resuscitation, and manage the electrolyte disturbances caused by dka and hhs.
Adjust medications to achieve optimal glycemic control and minimize side effects.
Assess caloric and nutritional needs and order appropriate diabetic diet.
Recognize and address neuropathic pain.
Anticipate and manage the presence of ongoing metabolic derangements associated with dka and hhs.
Develop an individualized diabetic regimen to achieve optimal glycemic control and prevent the development of complications from diabetes mellitus, including during the perioperative period.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the history and prognosis of diabetes mellitus.
Communicate with patients and families to explain potential long‐term complications of diabetes mellitus and prevention strategies, including foot and eye care.
Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from the hospital.
Communicate with patients and families to explain the importance of and factors affecting glycemic control, such as adherence to medical regimens and self‐monitoring, following dietary and exercise recommendations, and complying with routine follow‐up appointments.
Communicate with patients and families to explain the potential side effects or adverse interactions of diabetes medications, including hypoglycemia.
Recognize indications for early specialty consultation, which may include endocrinology and nutrition.
Employ a multidisciplinary approach, which may include nursing, nutrition and social services and a diabetes educator, to the care of patients with diabetes that begins at admission and continues through all care transitions.
Document treatment plan and discharge instructions, and communicate with the outpatient clinician responsible for follow‐up, including the need for continued nutrition and diabetic counseling.
Facilitate discharge planning early in the admission process.
Recommend appropriate post‐discharge care, which may include endocrinology, ophthalmology, and podiatry.
Utilize evidence based recommendation in the treatment of inpatients with diabetes mellitus.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Implement systems to ensure hospital‐wide adherence to national standards (american diabetes association and others), and document those measures as specified by recognized organizations.
Lead, coordinate or participate in efforts to develop guidelines and protocols that standardize assessment and aggressive treatment of dka and hhs.
Lead, coordinate or participate in efforts to develop guidelines and/or protocols to optimize glycemic control in hospitalized patients, including intensive regimens in critically ill medical and surgical patients.
Lead, coordinate or participate in multidisciplinary teams, which may include nursing, nutrition and endocrinology, to promote quality and cost‐effective diabetes management.
Diabetes mellitus is a disease characterized by abnormal insulin production or disordered glucose metabolism and is a co‐morbid condition of many hospitalized patients. diabetic ketoacidosis (dka) and hyperglycemia hyperosmolar state (hhs) are extreme presentations of diabetes mellitus that require hospitalization. there were 577,000 hospital discharges for diabetes mellitus in 2002, according to the american heart association. the prevalence of physician‐diagnosed diabetes mellitus was 13.9 million or 6.7 percent of the united states population. another 5.9 million americans are believed to have undiagnosed diabetes mellitus. the healthcare cost and utilization project (hcup) reports an average length‐of‐stay of 4.1 days and mean charges of $11,761 per patient for the diagnosis related group (drg) for diabetes mellitus. the estimated economic cost of diabetes in 2002 was $132 billion, of which $92 billion was direct medical costs. hospitalists care for diabetic patients and optimize glycemic control in the hospital setting. they stabilize and treat dka and hhs. the inpatient setting provides an opportunity to institute therapies to slow disease progression, prevent disease complications, and provide diabetic education to improve quality of life and limit complications leading to readmission. hospitalists use evidence based approaches to optimize care and lead multidisciplinary teams to develop institutional guidelines or care pathways to optimize glycemic control.
KNOWLEDGE
Hospitalists should be able to:
Define diabetes mellitus and explain the pathophysiologic processes that can lead to hyperglycemia, dka and hhs.
Describe the impact of hyperglycemia on immune function and wound healing.
Describe the effect of dka and hhs on intravascular volume status, electrolytes and acid‐base balance.
Describe the clinical presentation and laboratory findings of dka and hhs.
Describe the indicated tests to evaluate and diagnose dka and hhs.
Explain physiologic stressors and medications that adversely impact glycemic control.
Explain the precipitating factors of dka and hss.
Identify the goals of glycemic control in hospitalized patients in various settings, including critically ill and surgical patients, and cite supporting evidence.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat diabetes mellitus.
Explain the rationale of strict glycemic control and its effects on morbidity and mortality in hospitalized patients.
Recognize factors that indicate severity of disease in patients with dka or hhs.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a thorough and relevant history, and review the medical record to identify symptoms suggestive of acute co‐morbid illness that can impact glycemic control.
Estimate the level of outpatient glycemic control, adherence to medication regimen, and social influences that may impact glycemic control.
Perform a comprehensive physical examination to identify possible precipitants of hyperglycemia, dka or hhs.
Identify precipitating factors for dka and hhs, including infection, myocardial ischemia, and adherence to medication regimen.
Select and interpret indicated studies in patients suspected of having dka or hhs, including electrolytes, beta‐hydroxybuterate, urinalysis, venous ph, and electrocardiogram.
Recognize the indications for managing dka and hhs in an intensive care unit.
Select appropriate insulin therapies, initiate fluid resuscitation, and manage the electrolyte disturbances caused by dka and hhs.
Adjust medications to achieve optimal glycemic control and minimize side effects.
Assess caloric and nutritional needs and order appropriate diabetic diet.
Recognize and address neuropathic pain.
Anticipate and manage the presence of ongoing metabolic derangements associated with dka and hhs.
Develop an individualized diabetic regimen to achieve optimal glycemic control and prevent the development of complications from diabetes mellitus, including during the perioperative period.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the history and prognosis of diabetes mellitus.
Communicate with patients and families to explain potential long‐term complications of diabetes mellitus and prevention strategies, including foot and eye care.
Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from the hospital.
Communicate with patients and families to explain the importance of and factors affecting glycemic control, such as adherence to medical regimens and self‐monitoring, following dietary and exercise recommendations, and complying with routine follow‐up appointments.
Communicate with patients and families to explain the potential side effects or adverse interactions of diabetes medications, including hypoglycemia.
Recognize indications for early specialty consultation, which may include endocrinology and nutrition.
Employ a multidisciplinary approach, which may include nursing, nutrition and social services and a diabetes educator, to the care of patients with diabetes that begins at admission and continues through all care transitions.
Document treatment plan and discharge instructions, and communicate with the outpatient clinician responsible for follow‐up, including the need for continued nutrition and diabetic counseling.
Facilitate discharge planning early in the admission process.
Recommend appropriate post‐discharge care, which may include endocrinology, ophthalmology, and podiatry.
Utilize evidence based recommendation in the treatment of inpatients with diabetes mellitus.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Implement systems to ensure hospital‐wide adherence to national standards (american diabetes association and others), and document those measures as specified by recognized organizations.
Lead, coordinate or participate in efforts to develop guidelines and protocols that standardize assessment and aggressive treatment of dka and hhs.
Lead, coordinate or participate in efforts to develop guidelines and/or protocols to optimize glycemic control in hospitalized patients, including intensive regimens in critically ill medical and surgical patients.
Lead, coordinate or participate in multidisciplinary teams, which may include nursing, nutrition and endocrinology, to promote quality and cost‐effective diabetes management.
Diabetes mellitus is a disease characterized by abnormal insulin production or disordered glucose metabolism and is a co‐morbid condition of many hospitalized patients. diabetic ketoacidosis (dka) and hyperglycemia hyperosmolar state (hhs) are extreme presentations of diabetes mellitus that require hospitalization. there were 577,000 hospital discharges for diabetes mellitus in 2002, according to the american heart association. the prevalence of physician‐diagnosed diabetes mellitus was 13.9 million or 6.7 percent of the united states population. another 5.9 million americans are believed to have undiagnosed diabetes mellitus. the healthcare cost and utilization project (hcup) reports an average length‐of‐stay of 4.1 days and mean charges of $11,761 per patient for the diagnosis related group (drg) for diabetes mellitus. the estimated economic cost of diabetes in 2002 was $132 billion, of which $92 billion was direct medical costs. hospitalists care for diabetic patients and optimize glycemic control in the hospital setting. they stabilize and treat dka and hhs. the inpatient setting provides an opportunity to institute therapies to slow disease progression, prevent disease complications, and provide diabetic education to improve quality of life and limit complications leading to readmission. hospitalists use evidence based approaches to optimize care and lead multidisciplinary teams to develop institutional guidelines or care pathways to optimize glycemic control.
KNOWLEDGE
Hospitalists should be able to:
Define diabetes mellitus and explain the pathophysiologic processes that can lead to hyperglycemia, dka and hhs.
Describe the impact of hyperglycemia on immune function and wound healing.
Describe the effect of dka and hhs on intravascular volume status, electrolytes and acid‐base balance.
Describe the clinical presentation and laboratory findings of dka and hhs.
Describe the indicated tests to evaluate and diagnose dka and hhs.
Explain physiologic stressors and medications that adversely impact glycemic control.
Explain the precipitating factors of dka and hss.
Identify the goals of glycemic control in hospitalized patients in various settings, including critically ill and surgical patients, and cite supporting evidence.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat diabetes mellitus.
Explain the rationale of strict glycemic control and its effects on morbidity and mortality in hospitalized patients.
Recognize factors that indicate severity of disease in patients with dka or hhs.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a thorough and relevant history, and review the medical record to identify symptoms suggestive of acute co‐morbid illness that can impact glycemic control.
Estimate the level of outpatient glycemic control, adherence to medication regimen, and social influences that may impact glycemic control.
Perform a comprehensive physical examination to identify possible precipitants of hyperglycemia, dka or hhs.
Identify precipitating factors for dka and hhs, including infection, myocardial ischemia, and adherence to medication regimen.
Select and interpret indicated studies in patients suspected of having dka or hhs, including electrolytes, beta‐hydroxybuterate, urinalysis, venous ph, and electrocardiogram.
Recognize the indications for managing dka and hhs in an intensive care unit.
Select appropriate insulin therapies, initiate fluid resuscitation, and manage the electrolyte disturbances caused by dka and hhs.
Adjust medications to achieve optimal glycemic control and minimize side effects.
Assess caloric and nutritional needs and order appropriate diabetic diet.
Recognize and address neuropathic pain.
Anticipate and manage the presence of ongoing metabolic derangements associated with dka and hhs.
Develop an individualized diabetic regimen to achieve optimal glycemic control and prevent the development of complications from diabetes mellitus, including during the perioperative period.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the history and prognosis of diabetes mellitus.
Communicate with patients and families to explain potential long‐term complications of diabetes mellitus and prevention strategies, including foot and eye care.
Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from the hospital.
Communicate with patients and families to explain the importance of and factors affecting glycemic control, such as adherence to medical regimens and self‐monitoring, following dietary and exercise recommendations, and complying with routine follow‐up appointments.
Communicate with patients and families to explain the potential side effects or adverse interactions of diabetes medications, including hypoglycemia.
Recognize indications for early specialty consultation, which may include endocrinology and nutrition.
Employ a multidisciplinary approach, which may include nursing, nutrition and social services and a diabetes educator, to the care of patients with diabetes that begins at admission and continues through all care transitions.
Document treatment plan and discharge instructions, and communicate with the outpatient clinician responsible for follow‐up, including the need for continued nutrition and diabetic counseling.
Facilitate discharge planning early in the admission process.
Recommend appropriate post‐discharge care, which may include endocrinology, ophthalmology, and podiatry.
Utilize evidence based recommendation in the treatment of inpatients with diabetes mellitus.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Implement systems to ensure hospital‐wide adherence to national standards (american diabetes association and others), and document those measures as specified by recognized organizations.
Lead, coordinate or participate in efforts to develop guidelines and protocols that standardize assessment and aggressive treatment of dka and hhs.
Lead, coordinate or participate in efforts to develop guidelines and/or protocols to optimize glycemic control in hospitalized patients, including intensive regimens in critically ill medical and surgical patients.
Lead, coordinate or participate in multidisciplinary teams, which may include nursing, nutrition and endocrinology, to promote quality and cost‐effective diabetes management.
Copyright © 2006 Society of Hospital Medicine
Patient handoff
Patient handoff (or sign‐out) refers to the specific interaction, communication, and planning required to achieve seamless transitions of care from one clinician to another. Effective and timely sign‐outs are essential to maintain high quality medical care, reduce medical errors and redundancy, and prevent loss of information. Hospitalists are involved in the transfer of patient care on a daily basis and can lead institutional initiatives that promote optimal transfer of information between health care providers.
KNOWLEDGE
Hospitalists should be able to:
Describe key elements involved in signing out a patient.
Explain important information that should be communicated during patient sign‐out, which may include administrative details, updated clinical status, tasks to be completed and relative priority, severity of illness assessment, code status, and contingency planning.
Explain the components and strategies that are critical for successful communication during sign‐outs.
Explain how the components, strategies and specific information provided at sign‐out might vary depending on complexity of the patient, familiarity of provider with the patient and the care environment, and timing of sign‐out.
Explain the strengths and limitations of various sign‐out communication strategies and procedures.
SKILLS
Hospitalists should be able to:
Communicate effectively and efficiently during patient sign‐out.
Demonstrate the use of read back when communicating tasks.
Utilize the most efficient and effective verbal and written communication modalities.
Construct patient summaries for oral and written delivery, incorporating the unique characteristics of the patient, provider and timing of the sign‐out.
Evaluate all medications for indication, dosing, and planned duration at the time of sign‐out.
Document updated clinical status, recent and pending test and study results, a complete problem list, and plans for continued care.
Explain the importance of using if‐then statements for critical tasks to be completed.
Anticipate what may go wrong with a patient after a transition in care and communicate this clearly to the receiving clinician.
Synthesize medical information received from Hospitalists signing out patients into care plans
ATTITUDES
Hospitalists should be able to:
Inform patients and families in advance of sign‐out.
Recognize the impact of effective and ineffective sign‐outs on patient safety.
Appreciate the value of real time interactive dialogue between hospitalists during sign‐out.
Review received sign‐out summaries and communications information carefully and request clarification when needed.
Engage stakeholders in hospital initiatives to continuously assess the quality of sign‐outs.
Lead, coordinate or participate in initiatives to develop and implement new protocols to improve and optimize sign‐outs.
Lead, coordinate or participate in evaluation of new strategies or information systems designed to improve sign‐outs.
Promote availability after sign‐outs should questions arise.
Patient handoff (or sign‐out) refers to the specific interaction, communication, and planning required to achieve seamless transitions of care from one clinician to another. Effective and timely sign‐outs are essential to maintain high quality medical care, reduce medical errors and redundancy, and prevent loss of information. Hospitalists are involved in the transfer of patient care on a daily basis and can lead institutional initiatives that promote optimal transfer of information between health care providers.
KNOWLEDGE
Hospitalists should be able to:
Describe key elements involved in signing out a patient.
Explain important information that should be communicated during patient sign‐out, which may include administrative details, updated clinical status, tasks to be completed and relative priority, severity of illness assessment, code status, and contingency planning.
Explain the components and strategies that are critical for successful communication during sign‐outs.
Explain how the components, strategies and specific information provided at sign‐out might vary depending on complexity of the patient, familiarity of provider with the patient and the care environment, and timing of sign‐out.
Explain the strengths and limitations of various sign‐out communication strategies and procedures.
SKILLS
Hospitalists should be able to:
Communicate effectively and efficiently during patient sign‐out.
Demonstrate the use of read back when communicating tasks.
Utilize the most efficient and effective verbal and written communication modalities.
Construct patient summaries for oral and written delivery, incorporating the unique characteristics of the patient, provider and timing of the sign‐out.
Evaluate all medications for indication, dosing, and planned duration at the time of sign‐out.
Document updated clinical status, recent and pending test and study results, a complete problem list, and plans for continued care.
Explain the importance of using if‐then statements for critical tasks to be completed.
Anticipate what may go wrong with a patient after a transition in care and communicate this clearly to the receiving clinician.
Synthesize medical information received from Hospitalists signing out patients into care plans
ATTITUDES
Hospitalists should be able to:
Inform patients and families in advance of sign‐out.
Recognize the impact of effective and ineffective sign‐outs on patient safety.
Appreciate the value of real time interactive dialogue between hospitalists during sign‐out.
Review received sign‐out summaries and communications information carefully and request clarification when needed.
Engage stakeholders in hospital initiatives to continuously assess the quality of sign‐outs.
Lead, coordinate or participate in initiatives to develop and implement new protocols to improve and optimize sign‐outs.
Lead, coordinate or participate in evaluation of new strategies or information systems designed to improve sign‐outs.
Promote availability after sign‐outs should questions arise.
Patient handoff (or sign‐out) refers to the specific interaction, communication, and planning required to achieve seamless transitions of care from one clinician to another. Effective and timely sign‐outs are essential to maintain high quality medical care, reduce medical errors and redundancy, and prevent loss of information. Hospitalists are involved in the transfer of patient care on a daily basis and can lead institutional initiatives that promote optimal transfer of information between health care providers.
KNOWLEDGE
Hospitalists should be able to:
Describe key elements involved in signing out a patient.
Explain important information that should be communicated during patient sign‐out, which may include administrative details, updated clinical status, tasks to be completed and relative priority, severity of illness assessment, code status, and contingency planning.
Explain the components and strategies that are critical for successful communication during sign‐outs.
Explain how the components, strategies and specific information provided at sign‐out might vary depending on complexity of the patient, familiarity of provider with the patient and the care environment, and timing of sign‐out.
Explain the strengths and limitations of various sign‐out communication strategies and procedures.
SKILLS
Hospitalists should be able to:
Communicate effectively and efficiently during patient sign‐out.
Demonstrate the use of read back when communicating tasks.
Utilize the most efficient and effective verbal and written communication modalities.
Construct patient summaries for oral and written delivery, incorporating the unique characteristics of the patient, provider and timing of the sign‐out.
Evaluate all medications for indication, dosing, and planned duration at the time of sign‐out.
Document updated clinical status, recent and pending test and study results, a complete problem list, and plans for continued care.
Explain the importance of using if‐then statements for critical tasks to be completed.
Anticipate what may go wrong with a patient after a transition in care and communicate this clearly to the receiving clinician.
Synthesize medical information received from Hospitalists signing out patients into care plans
ATTITUDES
Hospitalists should be able to:
Inform patients and families in advance of sign‐out.
Recognize the impact of effective and ineffective sign‐outs on patient safety.
Appreciate the value of real time interactive dialogue between hospitalists during sign‐out.
Review received sign‐out summaries and communications information carefully and request clarification when needed.
Engage stakeholders in hospital initiatives to continuously assess the quality of sign‐outs.
Lead, coordinate or participate in initiatives to develop and implement new protocols to improve and optimize sign‐outs.
Lead, coordinate or participate in evaluation of new strategies or information systems designed to improve sign‐outs.
Promote availability after sign‐outs should questions arise.
Copyright © 2006 Society of Hospital Medicine
Congestive heart failure syndrome
Congestive heart failure syndrome (chf) is characterized by impaired function of the heart resulting in a constellation of symptoms and signs, which may include fatigue, weakness and shortness of breath. the american heart association (aha) reports that chf affects nearly 5 million people in the united states. chf accounted for 970,000 hospital discharges in 2002. medicare paid $3.6 billion for the care of patients with chf in 1999, or $5,456 per discharge. the estimated direct and indirect cost of chf in 2005 is $27.9 billion. despite published guidelines for chf management, there is significant variation in treatment for hospitalized patients. this variability significantly impacts individual patients, families and hospital systems, and accounts for billions of dollars of the medicare budget. hospitalists can lead their institutions in early diagnosis, initiation of evidence based medical therapy, and incorporation of a multidisciplinary approach to heart failure. hospitalists can also develop strategies to operationalize cost‐effective interventions that reduce morbidity, mortality and readmission rates.
KNOWLEDGE
Hospitalists should be able to:
Explain underlying causes of chf and precipitating factors leading to exacerbation.
Differentiate features of systolic and diastolic dysfunction, and explain the common etiologies of each.
Describe the indicated tests required to evaluate chf, including assessment of left ventricular function.
Describe risk factors for the development of chf in the hospital setting.
Risk stratify patients admitted with chf and determine the appropriate level of care.
Describe goals of inpatient therapy for acute decompensated heart failure including pre‐load and after‐load reduction, hemodynamic stabilization, and optimization of volume status.
Describe the role of invasive and noninvasive ventilatory support.
Explain evidence based therapeutic options for management of acute and chronic chf and describe contraindications to these therapies.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat chf.
Identify medications and interventions contraindicated in chf.
Explain markers of severity of the disease and factors that influence prognosis.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a thorough and relevant history and review the medical record to identify symptoms, co‐morbidities, medications, and/or social influences contributing to chf or its exacerbation.
Review inpatient records to determine iatrogenic influences of chf.
Recognize the clinical presentation of heart failure, including features of exacerbation and reliability of signs and symptoms.
Identify physical findings consistent with chf.
Identify signs of low perfusion states and cardiogenic shock.
Order indicated diagnostic testing to identify precipitating factors of chf and assess cardiac function.
Formulate an evidence based treatment plan, tailored to the individual patient, which may include pharmacologic agents and dosing, nutritional recommendations, and patient compliance.
Recognize symptoms and signs of acute decompensation and initiate immediate indicated therapies.
Assess patients with suspected heart failure in a timely manner, identify the level of care required, and manage or co‐manage the patient with the primary requesting service.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the history and prognosis of chf.
Communicate with patients and families to explain the importance of home self‐monitoring and adherence to medication regimens, nutritional recommendations, and physical rehabilitation.
Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.
Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.
Recognize indications for early cardiology consultation.
Recognize indications and qualifications for cardiac transplant evaluation.
Advocate the importance of behavioral modification to delay the progression of disease and improve quality of life.
Employ a multidisciplinary approach to the care of patients with chf that begins at admission and continues through all care transitions.
Recognize the importance of palliative care in the treatment of patients with chronic chf.
Responsibly address and respect end of life care wishes for patients with end‐stage chf.
Communicate to outpatient providers the relevant events of the hospitalization and post‐discharge needs, including pending tests, and determine who is responsible for checking the results.
Document treatment plan and provide clear discharge instructions for receiving primary care physician.
Utilize evidence based recommendations to guide diagnosis, monitoring and treatment of chf.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Advocate to hospital administrators to establish and support outpatient chf teams, which have been shown to reduce readmission rates and possibly morbidity and mortality through outreach to chf patients.
Lead, coordinate or participate in multidisciplinary teams, which may include nursing and social services, nutrition, pharmacy, and physical therapy, early in the hospital course to facilitate patient education and discharge planning; improve patient function and outcomes; and advocate patient outreach post‐discharge.
Implement systems to ensure hospital wide adherence to national standards and document those measures as specified by recognized organizations (jcaho, aha, acc, ahrq or others).
Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.
Lead efforts to educate staff on the importance of smoking cessation counseling and other prevention measures.
Integrate outcomes research, institution‐specific laboratory policies, and hospital formulary to create indicated and cost‐effective diagnostic and management strategies for patients with chf.
Congestive heart failure syndrome (chf) is characterized by impaired function of the heart resulting in a constellation of symptoms and signs, which may include fatigue, weakness and shortness of breath. the american heart association (aha) reports that chf affects nearly 5 million people in the united states. chf accounted for 970,000 hospital discharges in 2002. medicare paid $3.6 billion for the care of patients with chf in 1999, or $5,456 per discharge. the estimated direct and indirect cost of chf in 2005 is $27.9 billion. despite published guidelines for chf management, there is significant variation in treatment for hospitalized patients. this variability significantly impacts individual patients, families and hospital systems, and accounts for billions of dollars of the medicare budget. hospitalists can lead their institutions in early diagnosis, initiation of evidence based medical therapy, and incorporation of a multidisciplinary approach to heart failure. hospitalists can also develop strategies to operationalize cost‐effective interventions that reduce morbidity, mortality and readmission rates.
KNOWLEDGE
Hospitalists should be able to:
Explain underlying causes of chf and precipitating factors leading to exacerbation.
Differentiate features of systolic and diastolic dysfunction, and explain the common etiologies of each.
Describe the indicated tests required to evaluate chf, including assessment of left ventricular function.
Describe risk factors for the development of chf in the hospital setting.
Risk stratify patients admitted with chf and determine the appropriate level of care.
Describe goals of inpatient therapy for acute decompensated heart failure including pre‐load and after‐load reduction, hemodynamic stabilization, and optimization of volume status.
Describe the role of invasive and noninvasive ventilatory support.
Explain evidence based therapeutic options for management of acute and chronic chf and describe contraindications to these therapies.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat chf.
Identify medications and interventions contraindicated in chf.
Explain markers of severity of the disease and factors that influence prognosis.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a thorough and relevant history and review the medical record to identify symptoms, co‐morbidities, medications, and/or social influences contributing to chf or its exacerbation.
Review inpatient records to determine iatrogenic influences of chf.
Recognize the clinical presentation of heart failure, including features of exacerbation and reliability of signs and symptoms.
Identify physical findings consistent with chf.
Identify signs of low perfusion states and cardiogenic shock.
Order indicated diagnostic testing to identify precipitating factors of chf and assess cardiac function.
Formulate an evidence based treatment plan, tailored to the individual patient, which may include pharmacologic agents and dosing, nutritional recommendations, and patient compliance.
Recognize symptoms and signs of acute decompensation and initiate immediate indicated therapies.
Assess patients with suspected heart failure in a timely manner, identify the level of care required, and manage or co‐manage the patient with the primary requesting service.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the history and prognosis of chf.
Communicate with patients and families to explain the importance of home self‐monitoring and adherence to medication regimens, nutritional recommendations, and physical rehabilitation.
Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.
Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.
Recognize indications for early cardiology consultation.
Recognize indications and qualifications for cardiac transplant evaluation.
Advocate the importance of behavioral modification to delay the progression of disease and improve quality of life.
Employ a multidisciplinary approach to the care of patients with chf that begins at admission and continues through all care transitions.
Recognize the importance of palliative care in the treatment of patients with chronic chf.
Responsibly address and respect end of life care wishes for patients with end‐stage chf.
Communicate to outpatient providers the relevant events of the hospitalization and post‐discharge needs, including pending tests, and determine who is responsible for checking the results.
Document treatment plan and provide clear discharge instructions for receiving primary care physician.
Utilize evidence based recommendations to guide diagnosis, monitoring and treatment of chf.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Advocate to hospital administrators to establish and support outpatient chf teams, which have been shown to reduce readmission rates and possibly morbidity and mortality through outreach to chf patients.
Lead, coordinate or participate in multidisciplinary teams, which may include nursing and social services, nutrition, pharmacy, and physical therapy, early in the hospital course to facilitate patient education and discharge planning; improve patient function and outcomes; and advocate patient outreach post‐discharge.
Implement systems to ensure hospital wide adherence to national standards and document those measures as specified by recognized organizations (jcaho, aha, acc, ahrq or others).
Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.
Lead efforts to educate staff on the importance of smoking cessation counseling and other prevention measures.
Integrate outcomes research, institution‐specific laboratory policies, and hospital formulary to create indicated and cost‐effective diagnostic and management strategies for patients with chf.
Congestive heart failure syndrome (chf) is characterized by impaired function of the heart resulting in a constellation of symptoms and signs, which may include fatigue, weakness and shortness of breath. the american heart association (aha) reports that chf affects nearly 5 million people in the united states. chf accounted for 970,000 hospital discharges in 2002. medicare paid $3.6 billion for the care of patients with chf in 1999, or $5,456 per discharge. the estimated direct and indirect cost of chf in 2005 is $27.9 billion. despite published guidelines for chf management, there is significant variation in treatment for hospitalized patients. this variability significantly impacts individual patients, families and hospital systems, and accounts for billions of dollars of the medicare budget. hospitalists can lead their institutions in early diagnosis, initiation of evidence based medical therapy, and incorporation of a multidisciplinary approach to heart failure. hospitalists can also develop strategies to operationalize cost‐effective interventions that reduce morbidity, mortality and readmission rates.
KNOWLEDGE
Hospitalists should be able to:
Explain underlying causes of chf and precipitating factors leading to exacerbation.
Differentiate features of systolic and diastolic dysfunction, and explain the common etiologies of each.
Describe the indicated tests required to evaluate chf, including assessment of left ventricular function.
Describe risk factors for the development of chf in the hospital setting.
Risk stratify patients admitted with chf and determine the appropriate level of care.
Describe goals of inpatient therapy for acute decompensated heart failure including pre‐load and after‐load reduction, hemodynamic stabilization, and optimization of volume status.
Describe the role of invasive and noninvasive ventilatory support.
Explain evidence based therapeutic options for management of acute and chronic chf and describe contraindications to these therapies.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat chf.
Identify medications and interventions contraindicated in chf.
Explain markers of severity of the disease and factors that influence prognosis.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a thorough and relevant history and review the medical record to identify symptoms, co‐morbidities, medications, and/or social influences contributing to chf or its exacerbation.
Review inpatient records to determine iatrogenic influences of chf.
Recognize the clinical presentation of heart failure, including features of exacerbation and reliability of signs and symptoms.
Identify physical findings consistent with chf.
Identify signs of low perfusion states and cardiogenic shock.
Order indicated diagnostic testing to identify precipitating factors of chf and assess cardiac function.
Formulate an evidence based treatment plan, tailored to the individual patient, which may include pharmacologic agents and dosing, nutritional recommendations, and patient compliance.
Recognize symptoms and signs of acute decompensation and initiate immediate indicated therapies.
Assess patients with suspected heart failure in a timely manner, identify the level of care required, and manage or co‐manage the patient with the primary requesting service.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the history and prognosis of chf.
Communicate with patients and families to explain the importance of home self‐monitoring and adherence to medication regimens, nutritional recommendations, and physical rehabilitation.
Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.
Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.
Recognize indications for early cardiology consultation.
Recognize indications and qualifications for cardiac transplant evaluation.
Advocate the importance of behavioral modification to delay the progression of disease and improve quality of life.
Employ a multidisciplinary approach to the care of patients with chf that begins at admission and continues through all care transitions.
Recognize the importance of palliative care in the treatment of patients with chronic chf.
Responsibly address and respect end of life care wishes for patients with end‐stage chf.
Communicate to outpatient providers the relevant events of the hospitalization and post‐discharge needs, including pending tests, and determine who is responsible for checking the results.
Document treatment plan and provide clear discharge instructions for receiving primary care physician.
Utilize evidence based recommendations to guide diagnosis, monitoring and treatment of chf.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Advocate to hospital administrators to establish and support outpatient chf teams, which have been shown to reduce readmission rates and possibly morbidity and mortality through outreach to chf patients.
Lead, coordinate or participate in multidisciplinary teams, which may include nursing and social services, nutrition, pharmacy, and physical therapy, early in the hospital course to facilitate patient education and discharge planning; improve patient function and outcomes; and advocate patient outreach post‐discharge.
Implement systems to ensure hospital wide adherence to national standards and document those measures as specified by recognized organizations (jcaho, aha, acc, ahrq or others).
Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.
Lead efforts to educate staff on the importance of smoking cessation counseling and other prevention measures.
Integrate outcomes research, institution‐specific laboratory policies, and hospital formulary to create indicated and cost‐effective diagnostic and management strategies for patients with chf.
Copyright © 2006 Society of Hospital Medicine
Thoracentesis
Thoracentesis is a bedside procedure involving the withdrawal of fluid from the pleural cavity. Pleural effusions are associated with several disease processes in hospitalized patients and may be evaluated using thoracentesis. The Healthcare Cost and Utilization Project (HCUP) estimates almost 189,000 thoracenteses were performed in hospitalized patients in 2002, although this total includes chest tube placement as well. Using the history, physical examination and radiographic findings, hospitalists identify those patients who would benefit from diagnostic or therapeutic thoracentesis.
KNOWLEDGE
Hospitalists should be able to:
Describe the normal anatomy of the chest wall, thorax and lung.
Define and differentiate the disease processes that may lead to the development of pleural effusion.
Define and differentiate transudative and exudative pleural effusions and their causes.
Explain indications and contraindications of thoracentesis and its potential risks and complications.
Explain the role of chest imaging in the evaluation of pleural effusion.
Explain the appropriate diagnostic testing for pleural fluid.
Describe indications for use of ultrasonography or computed tomography to assess the quantity of pleural fluid and/or guide thoracentesis.
Select the necessary equipment to perform a thoracentesis at the bedside, and differentiate what is needed for diagnostic versus therapeutic thoracentesis.
Define the criteria that distinguish transudative and exudative effusions.
Describe the effects of various disease processes on pleural fluid results.
SKILLS
Hospitalists should be able to:
Elicit a thorough history, identifying potential disease processes and risk factors for the development of pleural effusions.
Perform a chest examination, including specific maneuvers to assess for the presence of pleural effusion.
Properly position the patient and identify anatomic landmarks to perform a thoracentesis.
Use sterile techniques during preparation for and performance of thoracentesis.
Maintain clinician safety with appropriate protective wear.
Recognize and manage complications associated with thoracentesis, especially pneumothorax and re‐expansion pulmonary edema.
Order and interpret the results of pleural fluid analysis.
Order and interpret platelet and coagulation studies when indicated.
Determine need for chest tube placement based on thoracentesis results.
Synthesize a management plan based on history, physical examination, radiographic imaging and results of pleural fluid analysis.
Identify patients with pleural effusions who may benefit from therapeutic thoracentesis, chest tube placement and/or pleurodesis.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, and potential complications; and to obtain informed consent.
Order and promptly review the results of routine post‐procedure chest radiographs.
Manage patient discomfort or pain during and after the procedure.
Recognize indications for specialty consultations, which may include interventional radiology, pulmonary medicine, infectious disease, or cardiothoracic surgery.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.
Collaborate with radiologists to standardize identification of patients who would benefit from ultrasound‐guided thoracentesis.
Lead, coordinate or participate in efforts to develop strategies to minimize institution complication rates.
Lead, coordinate or participate in quality improvement programs to monitor hospitalists' performance and/or supervision of thoracentesis.
Lead, coordinate or participate in efforts to organize and consolidate thoracentesis equipment in an identifiable location in the hospital, easily accessible to clinicians who perform the procedure.
Thoracentesis is a bedside procedure involving the withdrawal of fluid from the pleural cavity. Pleural effusions are associated with several disease processes in hospitalized patients and may be evaluated using thoracentesis. The Healthcare Cost and Utilization Project (HCUP) estimates almost 189,000 thoracenteses were performed in hospitalized patients in 2002, although this total includes chest tube placement as well. Using the history, physical examination and radiographic findings, hospitalists identify those patients who would benefit from diagnostic or therapeutic thoracentesis.
KNOWLEDGE
Hospitalists should be able to:
Describe the normal anatomy of the chest wall, thorax and lung.
Define and differentiate the disease processes that may lead to the development of pleural effusion.
Define and differentiate transudative and exudative pleural effusions and their causes.
Explain indications and contraindications of thoracentesis and its potential risks and complications.
Explain the role of chest imaging in the evaluation of pleural effusion.
Explain the appropriate diagnostic testing for pleural fluid.
Describe indications for use of ultrasonography or computed tomography to assess the quantity of pleural fluid and/or guide thoracentesis.
Select the necessary equipment to perform a thoracentesis at the bedside, and differentiate what is needed for diagnostic versus therapeutic thoracentesis.
Define the criteria that distinguish transudative and exudative effusions.
Describe the effects of various disease processes on pleural fluid results.
SKILLS
Hospitalists should be able to:
Elicit a thorough history, identifying potential disease processes and risk factors for the development of pleural effusions.
Perform a chest examination, including specific maneuvers to assess for the presence of pleural effusion.
Properly position the patient and identify anatomic landmarks to perform a thoracentesis.
Use sterile techniques during preparation for and performance of thoracentesis.
Maintain clinician safety with appropriate protective wear.
Recognize and manage complications associated with thoracentesis, especially pneumothorax and re‐expansion pulmonary edema.
Order and interpret the results of pleural fluid analysis.
Order and interpret platelet and coagulation studies when indicated.
Determine need for chest tube placement based on thoracentesis results.
Synthesize a management plan based on history, physical examination, radiographic imaging and results of pleural fluid analysis.
Identify patients with pleural effusions who may benefit from therapeutic thoracentesis, chest tube placement and/or pleurodesis.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, and potential complications; and to obtain informed consent.
Order and promptly review the results of routine post‐procedure chest radiographs.
Manage patient discomfort or pain during and after the procedure.
Recognize indications for specialty consultations, which may include interventional radiology, pulmonary medicine, infectious disease, or cardiothoracic surgery.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.
Collaborate with radiologists to standardize identification of patients who would benefit from ultrasound‐guided thoracentesis.
Lead, coordinate or participate in efforts to develop strategies to minimize institution complication rates.
Lead, coordinate or participate in quality improvement programs to monitor hospitalists' performance and/or supervision of thoracentesis.
Lead, coordinate or participate in efforts to organize and consolidate thoracentesis equipment in an identifiable location in the hospital, easily accessible to clinicians who perform the procedure.
Thoracentesis is a bedside procedure involving the withdrawal of fluid from the pleural cavity. Pleural effusions are associated with several disease processes in hospitalized patients and may be evaluated using thoracentesis. The Healthcare Cost and Utilization Project (HCUP) estimates almost 189,000 thoracenteses were performed in hospitalized patients in 2002, although this total includes chest tube placement as well. Using the history, physical examination and radiographic findings, hospitalists identify those patients who would benefit from diagnostic or therapeutic thoracentesis.
KNOWLEDGE
Hospitalists should be able to:
Describe the normal anatomy of the chest wall, thorax and lung.
Define and differentiate the disease processes that may lead to the development of pleural effusion.
Define and differentiate transudative and exudative pleural effusions and their causes.
Explain indications and contraindications of thoracentesis and its potential risks and complications.
Explain the role of chest imaging in the evaluation of pleural effusion.
Explain the appropriate diagnostic testing for pleural fluid.
Describe indications for use of ultrasonography or computed tomography to assess the quantity of pleural fluid and/or guide thoracentesis.
Select the necessary equipment to perform a thoracentesis at the bedside, and differentiate what is needed for diagnostic versus therapeutic thoracentesis.
Define the criteria that distinguish transudative and exudative effusions.
Describe the effects of various disease processes on pleural fluid results.
SKILLS
Hospitalists should be able to:
Elicit a thorough history, identifying potential disease processes and risk factors for the development of pleural effusions.
Perform a chest examination, including specific maneuvers to assess for the presence of pleural effusion.
Properly position the patient and identify anatomic landmarks to perform a thoracentesis.
Use sterile techniques during preparation for and performance of thoracentesis.
Maintain clinician safety with appropriate protective wear.
Recognize and manage complications associated with thoracentesis, especially pneumothorax and re‐expansion pulmonary edema.
Order and interpret the results of pleural fluid analysis.
Order and interpret platelet and coagulation studies when indicated.
Determine need for chest tube placement based on thoracentesis results.
Synthesize a management plan based on history, physical examination, radiographic imaging and results of pleural fluid analysis.
Identify patients with pleural effusions who may benefit from therapeutic thoracentesis, chest tube placement and/or pleurodesis.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, and potential complications; and to obtain informed consent.
Order and promptly review the results of routine post‐procedure chest radiographs.
Manage patient discomfort or pain during and after the procedure.
Recognize indications for specialty consultations, which may include interventional radiology, pulmonary medicine, infectious disease, or cardiothoracic surgery.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.
Collaborate with radiologists to standardize identification of patients who would benefit from ultrasound‐guided thoracentesis.
Lead, coordinate or participate in efforts to develop strategies to minimize institution complication rates.
Lead, coordinate or participate in quality improvement programs to monitor hospitalists' performance and/or supervision of thoracentesis.
Lead, coordinate or participate in efforts to organize and consolidate thoracentesis equipment in an identifiable location in the hospital, easily accessible to clinicians who perform the procedure.
Copyright © 2006 Society of Hospital Medicine
Cardiac arrhythmia
Cardiac arrhythmias are an abnormal heart rate or rhythm. the american heart association (aha) states that in 2002, cardiac arrhythmias were associated with 480,400 deaths and 858,000 hospital discharges. medical reimbursements for arrhythmia‐related diagnoses were $2.2 billion or $6,041 per discharge in 2003. many arrhythmias may lead to hospitalization or may result as a complication during hospitalization. hospitalists identify and treat all types of arrhythmias, coordinate specialty and primary care resources, and guide patients safely and cost effectively through the acute hospitalization and back into the outpatient setting.
KNOWLEDGE
Hospitalists should be able to:
Identify and differentiate the clinical presentation of common arrhythmias.
Distinguish the causes of atrial and ventricular arrhythmias.
Describe the indicated tests required to evaluate arrhythmias.
Explain how medications, metabolic abnormalities and medical co‐morbidities may precipitate various arrhythmias.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat cardiac arrhythmia.
Risk stratify patients with arrhythmias and determine the level of care required.
Describe the management goals and options for patients hospitalized with arrhythmia.
Identify the patient characteristics and co‐morbid conditions that predict outcome.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a thorough history, including medication, family and social history.
Perform a directed physical examination with special emphasis on identifying signs associated with hemodynamic stability, tissue perfusion, and occult cardiac and vascular disease.
Order and interpret ekgs, rhythm monitoring, and telemetry to determine indicated management plan.
Identify specific arrhythmias by utilizing 12‐lead electrocardiogram (ekg) and rhythm strip, and continuous telemetry monitoring.
Formulate patient‐specific, evidence based care plans incorporating diagnostic findings, prognosis and patient characteristics.
Develop patient‐specific care plans that may include rate controlling interventions, cardioversion, defibrillation, or implantable medical devices.
Utilize telemetry resources for identification of malignant rhythms in patients who require potentially arrhythmegenic interventions or patients who are otherwise at high risk for malignant arrhythmias.
Limit the use of telemetry resources in patients with chronic stable arrhythmias.
Quickly recognize high‐risk arrhythmias that require urgent intervention, and implement emergency protocols as indicated.
Assess patients with arrhythmias in a timely manner, identify the level of care required, and manage or co‐manage the patient with the primary requesting service.
ATTITUDE
Hospitalists should be able to:
Communicate with patients and families to explain the history and prognosis of cardiac arrhythmia.
Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.
Communicate with patients and families to explain drug interactions for anti‐arrhythmic drugs, and the importance of strict adherence to medication regimens and laboratory monitoring.
Communicate with patients and families to explain tests and procedures and their indications, and to obtain informed consent.
Recognize specific arrhythmias or effects of arrhythmias that require early specialty consultation and procedural interventions.
Employ a multidisciplinary approach, which may include primary care, cardiology, nursing and social services, to develop a care plan for patients with cardiac arrhythmias that begins at admission and continues through all care transitions.
Acknowledge and ameliorate patient discomfort from uncontrolled arrhythmias and electrical cardioversion therapies.
Inform receiving physician of pending tests and determine who is responsible for checking results.
Employ multidisciplinary teams to facilitate discharge planning and communicate to outpatient providers the diagnosis of the arrhythmia, the care plan that occurred in the hospital, and post‐discharge needs.
Utilize evidence based recommendations to guide diagnosis, monitoring and treatment of cardiac arrhythmias.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Lead, coordinate or participate in multidisciplinary teams to develop patient care guidelines and/or pathways based on peer reviewed outcomes research, patient/physician satisfaction, and cost.
Implement systems to ensure hospital‐wide adherence to national standards and document those measures as specified by recognized organizations (jcaho, aha, acc, ahrq or others).
Lead, coordinate or participate in quality improvement initiates to promote early identification of arrhythmias, reduce preventable complications, and promote appropriate use of telemetry resources.
Cardiac arrhythmias are an abnormal heart rate or rhythm. the american heart association (aha) states that in 2002, cardiac arrhythmias were associated with 480,400 deaths and 858,000 hospital discharges. medical reimbursements for arrhythmia‐related diagnoses were $2.2 billion or $6,041 per discharge in 2003. many arrhythmias may lead to hospitalization or may result as a complication during hospitalization. hospitalists identify and treat all types of arrhythmias, coordinate specialty and primary care resources, and guide patients safely and cost effectively through the acute hospitalization and back into the outpatient setting.
KNOWLEDGE
Hospitalists should be able to:
Identify and differentiate the clinical presentation of common arrhythmias.
Distinguish the causes of atrial and ventricular arrhythmias.
Describe the indicated tests required to evaluate arrhythmias.
Explain how medications, metabolic abnormalities and medical co‐morbidities may precipitate various arrhythmias.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat cardiac arrhythmia.
Risk stratify patients with arrhythmias and determine the level of care required.
Describe the management goals and options for patients hospitalized with arrhythmia.
Identify the patient characteristics and co‐morbid conditions that predict outcome.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a thorough history, including medication, family and social history.
Perform a directed physical examination with special emphasis on identifying signs associated with hemodynamic stability, tissue perfusion, and occult cardiac and vascular disease.
Order and interpret ekgs, rhythm monitoring, and telemetry to determine indicated management plan.
Identify specific arrhythmias by utilizing 12‐lead electrocardiogram (ekg) and rhythm strip, and continuous telemetry monitoring.
Formulate patient‐specific, evidence based care plans incorporating diagnostic findings, prognosis and patient characteristics.
Develop patient‐specific care plans that may include rate controlling interventions, cardioversion, defibrillation, or implantable medical devices.
Utilize telemetry resources for identification of malignant rhythms in patients who require potentially arrhythmegenic interventions or patients who are otherwise at high risk for malignant arrhythmias.
Limit the use of telemetry resources in patients with chronic stable arrhythmias.
Quickly recognize high‐risk arrhythmias that require urgent intervention, and implement emergency protocols as indicated.
Assess patients with arrhythmias in a timely manner, identify the level of care required, and manage or co‐manage the patient with the primary requesting service.
ATTITUDE
Hospitalists should be able to:
Communicate with patients and families to explain the history and prognosis of cardiac arrhythmia.
Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.
Communicate with patients and families to explain drug interactions for anti‐arrhythmic drugs, and the importance of strict adherence to medication regimens and laboratory monitoring.
Communicate with patients and families to explain tests and procedures and their indications, and to obtain informed consent.
Recognize specific arrhythmias or effects of arrhythmias that require early specialty consultation and procedural interventions.
Employ a multidisciplinary approach, which may include primary care, cardiology, nursing and social services, to develop a care plan for patients with cardiac arrhythmias that begins at admission and continues through all care transitions.
Acknowledge and ameliorate patient discomfort from uncontrolled arrhythmias and electrical cardioversion therapies.
Inform receiving physician of pending tests and determine who is responsible for checking results.
Employ multidisciplinary teams to facilitate discharge planning and communicate to outpatient providers the diagnosis of the arrhythmia, the care plan that occurred in the hospital, and post‐discharge needs.
Utilize evidence based recommendations to guide diagnosis, monitoring and treatment of cardiac arrhythmias.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Lead, coordinate or participate in multidisciplinary teams to develop patient care guidelines and/or pathways based on peer reviewed outcomes research, patient/physician satisfaction, and cost.
Implement systems to ensure hospital‐wide adherence to national standards and document those measures as specified by recognized organizations (jcaho, aha, acc, ahrq or others).
Lead, coordinate or participate in quality improvement initiates to promote early identification of arrhythmias, reduce preventable complications, and promote appropriate use of telemetry resources.
Cardiac arrhythmias are an abnormal heart rate or rhythm. the american heart association (aha) states that in 2002, cardiac arrhythmias were associated with 480,400 deaths and 858,000 hospital discharges. medical reimbursements for arrhythmia‐related diagnoses were $2.2 billion or $6,041 per discharge in 2003. many arrhythmias may lead to hospitalization or may result as a complication during hospitalization. hospitalists identify and treat all types of arrhythmias, coordinate specialty and primary care resources, and guide patients safely and cost effectively through the acute hospitalization and back into the outpatient setting.
KNOWLEDGE
Hospitalists should be able to:
Identify and differentiate the clinical presentation of common arrhythmias.
Distinguish the causes of atrial and ventricular arrhythmias.
Describe the indicated tests required to evaluate arrhythmias.
Explain how medications, metabolic abnormalities and medical co‐morbidities may precipitate various arrhythmias.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat cardiac arrhythmia.
Risk stratify patients with arrhythmias and determine the level of care required.
Describe the management goals and options for patients hospitalized with arrhythmia.
Identify the patient characteristics and co‐morbid conditions that predict outcome.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a thorough history, including medication, family and social history.
Perform a directed physical examination with special emphasis on identifying signs associated with hemodynamic stability, tissue perfusion, and occult cardiac and vascular disease.
Order and interpret ekgs, rhythm monitoring, and telemetry to determine indicated management plan.
Identify specific arrhythmias by utilizing 12‐lead electrocardiogram (ekg) and rhythm strip, and continuous telemetry monitoring.
Formulate patient‐specific, evidence based care plans incorporating diagnostic findings, prognosis and patient characteristics.
Develop patient‐specific care plans that may include rate controlling interventions, cardioversion, defibrillation, or implantable medical devices.
Utilize telemetry resources for identification of malignant rhythms in patients who require potentially arrhythmegenic interventions or patients who are otherwise at high risk for malignant arrhythmias.
Limit the use of telemetry resources in patients with chronic stable arrhythmias.
Quickly recognize high‐risk arrhythmias that require urgent intervention, and implement emergency protocols as indicated.
Assess patients with arrhythmias in a timely manner, identify the level of care required, and manage or co‐manage the patient with the primary requesting service.
ATTITUDE
Hospitalists should be able to:
Communicate with patients and families to explain the history and prognosis of cardiac arrhythmia.
Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.
Communicate with patients and families to explain drug interactions for anti‐arrhythmic drugs, and the importance of strict adherence to medication regimens and laboratory monitoring.
Communicate with patients and families to explain tests and procedures and their indications, and to obtain informed consent.
Recognize specific arrhythmias or effects of arrhythmias that require early specialty consultation and procedural interventions.
Employ a multidisciplinary approach, which may include primary care, cardiology, nursing and social services, to develop a care plan for patients with cardiac arrhythmias that begins at admission and continues through all care transitions.
Acknowledge and ameliorate patient discomfort from uncontrolled arrhythmias and electrical cardioversion therapies.
Inform receiving physician of pending tests and determine who is responsible for checking results.
Employ multidisciplinary teams to facilitate discharge planning and communicate to outpatient providers the diagnosis of the arrhythmia, the care plan that occurred in the hospital, and post‐discharge needs.
Utilize evidence based recommendations to guide diagnosis, monitoring and treatment of cardiac arrhythmias.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, hospitalists should:
Lead, coordinate or participate in multidisciplinary teams to develop patient care guidelines and/or pathways based on peer reviewed outcomes research, patient/physician satisfaction, and cost.
Implement systems to ensure hospital‐wide adherence to national standards and document those measures as specified by recognized organizations (jcaho, aha, acc, ahrq or others).
Lead, coordinate or participate in quality improvement initiates to promote early identification of arrhythmias, reduce preventable complications, and promote appropriate use of telemetry resources.
Copyright © 2006 Society of Hospital Medicine
Risk management
Risk management seeks to reduce hazards to patients through a process identification, evaluation, and analysis of potential or actual adverse events. Hazard involves that harm that may occur as a result of healthcare delivery, which may be heightened in the hospital setting due to the higher acuity of patient illness, time pressures, and presence of trainees. Hospitalists should strive to comply with the letter and spirit of all applicable laws and regulations, avoid conflicts of interest, and conduct hospital business with integrity and ethical fervor. Hospitalists should also take a collaborative and proactive role with various services that may include risk management to help reduce risk in the hospital setting.
KNOWLEDGE
Hospitalists should be able to:
Explain the legal definition of negligence and the concept of standard of care.
Describe the effective components of informed consent.
Explain the circumstances requiring informed consent.
Describe HIPAA regulations related to patient confidentiality.
Explain requirements for billing compliance.
Describe other laws and regulations to the extent they are relevant to the practice of hospital medicine, including the Emergency Medical Treatment and Active Labor Act (EMTALA), the Patient Safety and Quality Improvement Act, and credentialing and licensing.
Explain how ethical principles can be applied to risk management.
SKILLS
Hospitalists should be able to:
Elicit informed consent from patients or surrogates for treatment plans and procedures when indicated.
Provide adequate supervision of members of the patient care team, which may include physician assistants, fellows, residents or medical students.
Apply guidelines of clinical ethics to patient care and risk management.
Compare and minimize hazards of diagnostic and treatment management strategies for the individual patient.
Ensure patient confidentiality.
Comply with HIPAA regulations.
Conduct medical practice and complete chart documentation to meet care needs and billing compliance, and reduce risks through effective communication.
Conduct medical practice without violating any relevant laws or regulations.
ATTITUDES
Hospitalists should be able to:
Apply ethical principles, which may include autonomy, beneficence, nonmaleficence, and justice, to promote patient centered care.
Practice Hospital Medicine to meet or exceed accepted standards of care and reduce risk.
Appreciate the importance of prompt, honest, and open discussions with patients and families regarding medical errors or harm.
Respect patient wishes for treatment decisions and plans.
Respect patient confidentiality.
Collaborate with risk management in the required reporting and addressing of sentinel events or other medical errors.
Lead, coordinate or participate in initiatives to improve and maintain HIPAA and billing compliance standards
Lead, coordinate or participate in initiatives that result in processes of care that minimize risk.
Risk management seeks to reduce hazards to patients through a process identification, evaluation, and analysis of potential or actual adverse events. Hazard involves that harm that may occur as a result of healthcare delivery, which may be heightened in the hospital setting due to the higher acuity of patient illness, time pressures, and presence of trainees. Hospitalists should strive to comply with the letter and spirit of all applicable laws and regulations, avoid conflicts of interest, and conduct hospital business with integrity and ethical fervor. Hospitalists should also take a collaborative and proactive role with various services that may include risk management to help reduce risk in the hospital setting.
KNOWLEDGE
Hospitalists should be able to:
Explain the legal definition of negligence and the concept of standard of care.
Describe the effective components of informed consent.
Explain the circumstances requiring informed consent.
Describe HIPAA regulations related to patient confidentiality.
Explain requirements for billing compliance.
Describe other laws and regulations to the extent they are relevant to the practice of hospital medicine, including the Emergency Medical Treatment and Active Labor Act (EMTALA), the Patient Safety and Quality Improvement Act, and credentialing and licensing.
Explain how ethical principles can be applied to risk management.
SKILLS
Hospitalists should be able to:
Elicit informed consent from patients or surrogates for treatment plans and procedures when indicated.
Provide adequate supervision of members of the patient care team, which may include physician assistants, fellows, residents or medical students.
Apply guidelines of clinical ethics to patient care and risk management.
Compare and minimize hazards of diagnostic and treatment management strategies for the individual patient.
Ensure patient confidentiality.
Comply with HIPAA regulations.
Conduct medical practice and complete chart documentation to meet care needs and billing compliance, and reduce risks through effective communication.
Conduct medical practice without violating any relevant laws or regulations.
ATTITUDES
Hospitalists should be able to:
Apply ethical principles, which may include autonomy, beneficence, nonmaleficence, and justice, to promote patient centered care.
Practice Hospital Medicine to meet or exceed accepted standards of care and reduce risk.
Appreciate the importance of prompt, honest, and open discussions with patients and families regarding medical errors or harm.
Respect patient wishes for treatment decisions and plans.
Respect patient confidentiality.
Collaborate with risk management in the required reporting and addressing of sentinel events or other medical errors.
Lead, coordinate or participate in initiatives to improve and maintain HIPAA and billing compliance standards
Lead, coordinate or participate in initiatives that result in processes of care that minimize risk.
Risk management seeks to reduce hazards to patients through a process identification, evaluation, and analysis of potential or actual adverse events. Hazard involves that harm that may occur as a result of healthcare delivery, which may be heightened in the hospital setting due to the higher acuity of patient illness, time pressures, and presence of trainees. Hospitalists should strive to comply with the letter and spirit of all applicable laws and regulations, avoid conflicts of interest, and conduct hospital business with integrity and ethical fervor. Hospitalists should also take a collaborative and proactive role with various services that may include risk management to help reduce risk in the hospital setting.
KNOWLEDGE
Hospitalists should be able to:
Explain the legal definition of negligence and the concept of standard of care.
Describe the effective components of informed consent.
Explain the circumstances requiring informed consent.
Describe HIPAA regulations related to patient confidentiality.
Explain requirements for billing compliance.
Describe other laws and regulations to the extent they are relevant to the practice of hospital medicine, including the Emergency Medical Treatment and Active Labor Act (EMTALA), the Patient Safety and Quality Improvement Act, and credentialing and licensing.
Explain how ethical principles can be applied to risk management.
SKILLS
Hospitalists should be able to:
Elicit informed consent from patients or surrogates for treatment plans and procedures when indicated.
Provide adequate supervision of members of the patient care team, which may include physician assistants, fellows, residents or medical students.
Apply guidelines of clinical ethics to patient care and risk management.
Compare and minimize hazards of diagnostic and treatment management strategies for the individual patient.
Ensure patient confidentiality.
Comply with HIPAA regulations.
Conduct medical practice and complete chart documentation to meet care needs and billing compliance, and reduce risks through effective communication.
Conduct medical practice without violating any relevant laws or regulations.
ATTITUDES
Hospitalists should be able to:
Apply ethical principles, which may include autonomy, beneficence, nonmaleficence, and justice, to promote patient centered care.
Practice Hospital Medicine to meet or exceed accepted standards of care and reduce risk.
Appreciate the importance of prompt, honest, and open discussions with patients and families regarding medical errors or harm.
Respect patient wishes for treatment decisions and plans.
Respect patient confidentiality.
Collaborate with risk management in the required reporting and addressing of sentinel events or other medical errors.
Lead, coordinate or participate in initiatives to improve and maintain HIPAA and billing compliance standards
Lead, coordinate or participate in initiatives that result in processes of care that minimize risk.
Copyright © 2006 Society of Hospital Medicine
Quality improvement
Quality improvement (QI) is the process of continually evaluating existing processes of care and developing new standards of practice. QI is influenced by objective data and focuses on systems change, rather than individual performance, in order to optimize performance and appropriate resource utilization. Hospitalists may lead or participate in QI teams to optimize management of common inpatient conditions and improve clinical outcomes based on standardized evidence based practices. Hospitalists should use evidence based outcomes data whenever available to support their inpatient practices and QI initiatives.
KNOWLEDGE
Hospitalists should be able to:
Identify and categorize adverse outcomes that may include sentinel events, near misses, or other adverse events.
Describe QI requirements for hospital accreditation that are supported by regulatory organizations.
Describe outcome measurements currently studied by major payers and regulatory agencies.
Identify guidelines and protocols supported by outcomes data to shape and standardize clinical practice.
Describe and differentiate Root Cause Analysis (RCA) and Healthcare Failure Mode Effects Analysis (HFMEA) and their utility in quality improvement in the hospital setting.
Describe the differences between outcome and process measures.
List the characteristics of high‐reliability organizations.
Describe the elements of effective teams and teamwork.
SKILLS
Hospitalists should be able to:
Apply current outcomes data and evidence based literature to individual hospitalist practice and systems improvements.
Utilize quality data to define hospitalist practice.
Express the relationship between value, quality and cost, and incorporate patient desires and satisfaction into the optimization of health care quality.
Assess and incorporate new technology for systems improvement in hospital practice.
Differentiate outcome measurements from process measurements.
Interpret patient satisfaction metrics.
ATTITUDES
Hospitalists should be able to:
Practice patient centered care and appreciate its value in improving patient safety and satisfaction.
Apply the results of validated outcome studies to inpatient practice.
Promote the adoption of new practices, guidelines and technology as supported by best available evidence.
Structure QI initiatives that reflect evidence based literature and high quality outcomes data.
Lead, coordinate or participate in the design and implementation of QI initiatives at individual, practice, and system levels, using a collaborative multidisciplinary team approach.
Lead, coordinate or participate in Root Cause Analyses (RCA) and/or Healthcare Failure Mode Effects Analyses (HFMEA).
Lead, coordinate or participate in outcomes monitoring at the institutional, regional and national levels, with an emphasis on development of standards and benchmarks.
Quality improvement (QI) is the process of continually evaluating existing processes of care and developing new standards of practice. QI is influenced by objective data and focuses on systems change, rather than individual performance, in order to optimize performance and appropriate resource utilization. Hospitalists may lead or participate in QI teams to optimize management of common inpatient conditions and improve clinical outcomes based on standardized evidence based practices. Hospitalists should use evidence based outcomes data whenever available to support their inpatient practices and QI initiatives.
KNOWLEDGE
Hospitalists should be able to:
Identify and categorize adverse outcomes that may include sentinel events, near misses, or other adverse events.
Describe QI requirements for hospital accreditation that are supported by regulatory organizations.
Describe outcome measurements currently studied by major payers and regulatory agencies.
Identify guidelines and protocols supported by outcomes data to shape and standardize clinical practice.
Describe and differentiate Root Cause Analysis (RCA) and Healthcare Failure Mode Effects Analysis (HFMEA) and their utility in quality improvement in the hospital setting.
Describe the differences between outcome and process measures.
List the characteristics of high‐reliability organizations.
Describe the elements of effective teams and teamwork.
SKILLS
Hospitalists should be able to:
Apply current outcomes data and evidence based literature to individual hospitalist practice and systems improvements.
Utilize quality data to define hospitalist practice.
Express the relationship between value, quality and cost, and incorporate patient desires and satisfaction into the optimization of health care quality.
Assess and incorporate new technology for systems improvement in hospital practice.
Differentiate outcome measurements from process measurements.
Interpret patient satisfaction metrics.
ATTITUDES
Hospitalists should be able to:
Practice patient centered care and appreciate its value in improving patient safety and satisfaction.
Apply the results of validated outcome studies to inpatient practice.
Promote the adoption of new practices, guidelines and technology as supported by best available evidence.
Structure QI initiatives that reflect evidence based literature and high quality outcomes data.
Lead, coordinate or participate in the design and implementation of QI initiatives at individual, practice, and system levels, using a collaborative multidisciplinary team approach.
Lead, coordinate or participate in Root Cause Analyses (RCA) and/or Healthcare Failure Mode Effects Analyses (HFMEA).
Lead, coordinate or participate in outcomes monitoring at the institutional, regional and national levels, with an emphasis on development of standards and benchmarks.
Quality improvement (QI) is the process of continually evaluating existing processes of care and developing new standards of practice. QI is influenced by objective data and focuses on systems change, rather than individual performance, in order to optimize performance and appropriate resource utilization. Hospitalists may lead or participate in QI teams to optimize management of common inpatient conditions and improve clinical outcomes based on standardized evidence based practices. Hospitalists should use evidence based outcomes data whenever available to support their inpatient practices and QI initiatives.
KNOWLEDGE
Hospitalists should be able to:
Identify and categorize adverse outcomes that may include sentinel events, near misses, or other adverse events.
Describe QI requirements for hospital accreditation that are supported by regulatory organizations.
Describe outcome measurements currently studied by major payers and regulatory agencies.
Identify guidelines and protocols supported by outcomes data to shape and standardize clinical practice.
Describe and differentiate Root Cause Analysis (RCA) and Healthcare Failure Mode Effects Analysis (HFMEA) and their utility in quality improvement in the hospital setting.
Describe the differences between outcome and process measures.
List the characteristics of high‐reliability organizations.
Describe the elements of effective teams and teamwork.
SKILLS
Hospitalists should be able to:
Apply current outcomes data and evidence based literature to individual hospitalist practice and systems improvements.
Utilize quality data to define hospitalist practice.
Express the relationship between value, quality and cost, and incorporate patient desires and satisfaction into the optimization of health care quality.
Assess and incorporate new technology for systems improvement in hospital practice.
Differentiate outcome measurements from process measurements.
Interpret patient satisfaction metrics.
ATTITUDES
Hospitalists should be able to:
Practice patient centered care and appreciate its value in improving patient safety and satisfaction.
Apply the results of validated outcome studies to inpatient practice.
Promote the adoption of new practices, guidelines and technology as supported by best available evidence.
Structure QI initiatives that reflect evidence based literature and high quality outcomes data.
Lead, coordinate or participate in the design and implementation of QI initiatives at individual, practice, and system levels, using a collaborative multidisciplinary team approach.
Lead, coordinate or participate in Root Cause Analyses (RCA) and/or Healthcare Failure Mode Effects Analyses (HFMEA).
Lead, coordinate or participate in outcomes monitoring at the institutional, regional and national levels, with an emphasis on development of standards and benchmarks.
Copyright © 2006 Society of Hospital Medicine