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Patient safety
The National Patient Safety Foundation defines safety as the avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the processes of health care. Hospitalized patients are at risk for a variety of adverse events. Hospitalists anticipate complications from medical assessment and treatment, and take steps to reduce their incidence or severity. Application of individual and system failure analysis can improve patient safety. Hospitalists will increasingly lead and participate in multidisciplinary development of interventions to mitigate system and process failures. They will also need to assess the effects of recommended interventions across the continuum of care.
KNOWLEDGE
Hospitalists should be able to:
Identify the most common safety problems and their causes in different hospitalized patient populations.
Explain the role of human factors in device, procedure and technology‐related errors.
Specify clinical practices and interventions that improve the safe use of high‐alert medications.
Summarize methods of system and process evaluation of patient safety.
Describe the elements of well‐functioning teams.
Differentiate retrospective and prospective methods of evaluating medical errors.
Discuss the significance of sentinel events and near misses and their relationship to voluntary and mandatory reporting regulations.
Describe the components of Root Cause Analysis (RCA) and Failure Mode and Effects Analysis (FMEA).
SKILLS
Hospitalists should be able to:
Prevent iatrogenic complications and proactively reduce risks of hospitalization.
Formulate age‐ and disease‐specific safety practices, which may include reduction of incidence and severity of falls, decubitus ulcers, delirium, hospital‐acquired infections, venous thromboembolism, malnutrition, and medication adverse events.
Develop, implement and evaluate practice guidelines and care pathways as part of an interdisciplinary quality improvement initiative.
Gather, record and transfer patient information utilizing timely, accurate and confidential mechanisms.
Develop systems that promote patient safety and reduce the likelihood of adverse events.
Contribute to and interpret retrospective RCA and prospective Healthcare FMEA multidisciplinary risk evaluations.
Function as a member and/or leader of interdisciplinary safety teams.
Design evaluation methods and resources to define problems and recommend interventions.
ATTITUDES
Hospitalists should be able to:
Appreciate that adverse drug events must be monitored and steps taken to reduce their incidence.
Advocate and help foster a non‐punitive error‐reporting environment.
Exemplify safe medication prescribing and administration practices.
Facilitate practices that reduce the likelihood of hospital‐acquired infection.
Internalize and promote behaviors that minimize workforce fatigue, occupational illness and burnout.
Appreciate that redundant systems may reduce the likelihood of medical errors.
Understand the risk management issues of patient safety efforts.
Utilize evidence based evaluation methods and resources when defining problems and designing interventions.
Lead, coordinate or participate in multidisciplinary teams to improve the delivery of safe patient care.
Judge the effect of patient volume on the quality, efficiency and safety of healthcare services.
Prioritize patient safety evaluation and improvement efforts based on the impact, improvability and general applicability of proposed evaluations and interventions.
Employ continuous quality improvement techniques to identify, construct, implement and evaluate patient safety issues.
Lead, coordinate or participate in the development, use and dissemination of local, regional, or national clinical practice guidelines and patient safety alerts pertaining to the prevention of complications in hospitalized patients.
Lead, coordinate or participate in efforts to create a culture in which issues of patient safety and medical errors can be discussed openly, without fear of repercussion.
The National Patient Safety Foundation defines safety as the avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the processes of health care. Hospitalized patients are at risk for a variety of adverse events. Hospitalists anticipate complications from medical assessment and treatment, and take steps to reduce their incidence or severity. Application of individual and system failure analysis can improve patient safety. Hospitalists will increasingly lead and participate in multidisciplinary development of interventions to mitigate system and process failures. They will also need to assess the effects of recommended interventions across the continuum of care.
KNOWLEDGE
Hospitalists should be able to:
Identify the most common safety problems and their causes in different hospitalized patient populations.
Explain the role of human factors in device, procedure and technology‐related errors.
Specify clinical practices and interventions that improve the safe use of high‐alert medications.
Summarize methods of system and process evaluation of patient safety.
Describe the elements of well‐functioning teams.
Differentiate retrospective and prospective methods of evaluating medical errors.
Discuss the significance of sentinel events and near misses and their relationship to voluntary and mandatory reporting regulations.
Describe the components of Root Cause Analysis (RCA) and Failure Mode and Effects Analysis (FMEA).
SKILLS
Hospitalists should be able to:
Prevent iatrogenic complications and proactively reduce risks of hospitalization.
Formulate age‐ and disease‐specific safety practices, which may include reduction of incidence and severity of falls, decubitus ulcers, delirium, hospital‐acquired infections, venous thromboembolism, malnutrition, and medication adverse events.
Develop, implement and evaluate practice guidelines and care pathways as part of an interdisciplinary quality improvement initiative.
Gather, record and transfer patient information utilizing timely, accurate and confidential mechanisms.
Develop systems that promote patient safety and reduce the likelihood of adverse events.
Contribute to and interpret retrospective RCA and prospective Healthcare FMEA multidisciplinary risk evaluations.
Function as a member and/or leader of interdisciplinary safety teams.
Design evaluation methods and resources to define problems and recommend interventions.
ATTITUDES
Hospitalists should be able to:
Appreciate that adverse drug events must be monitored and steps taken to reduce their incidence.
Advocate and help foster a non‐punitive error‐reporting environment.
Exemplify safe medication prescribing and administration practices.
Facilitate practices that reduce the likelihood of hospital‐acquired infection.
Internalize and promote behaviors that minimize workforce fatigue, occupational illness and burnout.
Appreciate that redundant systems may reduce the likelihood of medical errors.
Understand the risk management issues of patient safety efforts.
Utilize evidence based evaluation methods and resources when defining problems and designing interventions.
Lead, coordinate or participate in multidisciplinary teams to improve the delivery of safe patient care.
Judge the effect of patient volume on the quality, efficiency and safety of healthcare services.
Prioritize patient safety evaluation and improvement efforts based on the impact, improvability and general applicability of proposed evaluations and interventions.
Employ continuous quality improvement techniques to identify, construct, implement and evaluate patient safety issues.
Lead, coordinate or participate in the development, use and dissemination of local, regional, or national clinical practice guidelines and patient safety alerts pertaining to the prevention of complications in hospitalized patients.
Lead, coordinate or participate in efforts to create a culture in which issues of patient safety and medical errors can be discussed openly, without fear of repercussion.
The National Patient Safety Foundation defines safety as the avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the processes of health care. Hospitalized patients are at risk for a variety of adverse events. Hospitalists anticipate complications from medical assessment and treatment, and take steps to reduce their incidence or severity. Application of individual and system failure analysis can improve patient safety. Hospitalists will increasingly lead and participate in multidisciplinary development of interventions to mitigate system and process failures. They will also need to assess the effects of recommended interventions across the continuum of care.
KNOWLEDGE
Hospitalists should be able to:
Identify the most common safety problems and their causes in different hospitalized patient populations.
Explain the role of human factors in device, procedure and technology‐related errors.
Specify clinical practices and interventions that improve the safe use of high‐alert medications.
Summarize methods of system and process evaluation of patient safety.
Describe the elements of well‐functioning teams.
Differentiate retrospective and prospective methods of evaluating medical errors.
Discuss the significance of sentinel events and near misses and their relationship to voluntary and mandatory reporting regulations.
Describe the components of Root Cause Analysis (RCA) and Failure Mode and Effects Analysis (FMEA).
SKILLS
Hospitalists should be able to:
Prevent iatrogenic complications and proactively reduce risks of hospitalization.
Formulate age‐ and disease‐specific safety practices, which may include reduction of incidence and severity of falls, decubitus ulcers, delirium, hospital‐acquired infections, venous thromboembolism, malnutrition, and medication adverse events.
Develop, implement and evaluate practice guidelines and care pathways as part of an interdisciplinary quality improvement initiative.
Gather, record and transfer patient information utilizing timely, accurate and confidential mechanisms.
Develop systems that promote patient safety and reduce the likelihood of adverse events.
Contribute to and interpret retrospective RCA and prospective Healthcare FMEA multidisciplinary risk evaluations.
Function as a member and/or leader of interdisciplinary safety teams.
Design evaluation methods and resources to define problems and recommend interventions.
ATTITUDES
Hospitalists should be able to:
Appreciate that adverse drug events must be monitored and steps taken to reduce their incidence.
Advocate and help foster a non‐punitive error‐reporting environment.
Exemplify safe medication prescribing and administration practices.
Facilitate practices that reduce the likelihood of hospital‐acquired infection.
Internalize and promote behaviors that minimize workforce fatigue, occupational illness and burnout.
Appreciate that redundant systems may reduce the likelihood of medical errors.
Understand the risk management issues of patient safety efforts.
Utilize evidence based evaluation methods and resources when defining problems and designing interventions.
Lead, coordinate or participate in multidisciplinary teams to improve the delivery of safe patient care.
Judge the effect of patient volume on the quality, efficiency and safety of healthcare services.
Prioritize patient safety evaluation and improvement efforts based on the impact, improvability and general applicability of proposed evaluations and interventions.
Employ continuous quality improvement techniques to identify, construct, implement and evaluate patient safety issues.
Lead, coordinate or participate in the development, use and dissemination of local, regional, or national clinical practice guidelines and patient safety alerts pertaining to the prevention of complications in hospitalized patients.
Lead, coordinate or participate in efforts to create a culture in which issues of patient safety and medical errors can be discussed openly, without fear of repercussion.
Copyright © 2006 Society of Hospital Medicine
Vascular access
Vascular access involves inserting a catheter into an appropriate blood vessel in order to measure useful diagnostic parameters, draw blood for diagnostic testing, and/or provide specific therapeutic interventions.
Vascular access procedures were performed in approximately 417,000 discharges in 2002, according to the Healthcare Cost and Utilization Project (HCUP). Many hospitalized patients require vascular access, and hospitalists will differentiate patients who simply need peripheral venous access from those who require more invasive types of arterial or central venous access. Complications of vascular catheters can cause prolonged hospital stays and increase morbidity and mortality. Hospitalists advocate for patients to determine the most appropriate type of vascular access based on the patient's diagnostic and therapeutic requirements and overall clinical condition.
KNOWLEDGE
Hospitalists should be able to:
Name the various locations for peripheral venous access and describe the normal vasculature and surrounding anatomy of the site chosen for access.
Name the various locations for arterial or central venous access and describe the normal vasculature and surrounding anatomy of the site chosen for vascular access.
Describe the collateral flow for arterial access procedures.
Describe the clinical findings or disease processes that require arterial or central venous access.
Explain the role of ultrasonography in vascular access placement.
Explain indications and contraindications of the various arterial or central venous access procedures.
Describe and differentiate the potential risks and complications of individual vascular access procedures based on the site chosen and other risk factors.
Select the necessary equipment to perform the indicated vascular access procedure at the bedside.
SKILLS
Hospitalists should be able to:
Elicit an accurate and thorough history to identify co‐morbid conditions and risk factors for complications related to arterial or central venous vascular access placement.
Identify absolute and relative contraindications to placement of arterial access or central venous access at specific sites.
Perform a directed physical examination of the site(s) intended for vascular access.
Perform specific maneuvers to evaluate for collateral flow for arterial access procedures.
Properly position the patient and identify anatomic landmarks to obtain vascular access.
Use sterile techniques during preparation for and performance of vascular access procedures.
Anticipate and manage complications from the vascular access procedure and in‐dwelling catheter.
Identify and manage the complications of vascular access procedures, which may include infection, thrombotic, and mechanical complications.
Order and interpret platelet and coagulation studies when indicated.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the indications and alternatives to vascular access.
Communicate with patients and families to explain the procedure, its expected therapeutic benefits and potential complications; and to obtain informed consent.
Provide education to patients and their families regarding the care of long‐term vascular access.
Recognize the importance of proper positioning during the procedure.
Remove all central venous catheters and arterial catheters as soon as they are no longer needed.
Promote the use of peripheral venous access over central venous access whenever possible.
Manage patient discomfort or pain during and after the procedure.
Recognize the indications for specialty consultation, which may include interventional radiology, surgery, or critical care medicine.
Arrange appropriate care for patients being discharged with long‐term vascular access.
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.
Lead, coordinate or participate in development of IV access teams to improve the placement and maintenance of IV catheters.
Lead, coordinator or participate in quality improvement programs to monitor hospitalists' performance and/or supervision of vascular access.
Lead, coordinate or participate in implementation of standard nursing protocols for catheter care.
Lead, coordinate or participate in efforts to organize and consolidate equipment in an identifiable location in the hospital that is easily accessible to clinicians who perform the procedure.
Vascular access involves inserting a catheter into an appropriate blood vessel in order to measure useful diagnostic parameters, draw blood for diagnostic testing, and/or provide specific therapeutic interventions.
Vascular access procedures were performed in approximately 417,000 discharges in 2002, according to the Healthcare Cost and Utilization Project (HCUP). Many hospitalized patients require vascular access, and hospitalists will differentiate patients who simply need peripheral venous access from those who require more invasive types of arterial or central venous access. Complications of vascular catheters can cause prolonged hospital stays and increase morbidity and mortality. Hospitalists advocate for patients to determine the most appropriate type of vascular access based on the patient's diagnostic and therapeutic requirements and overall clinical condition.
KNOWLEDGE
Hospitalists should be able to:
Name the various locations for peripheral venous access and describe the normal vasculature and surrounding anatomy of the site chosen for access.
Name the various locations for arterial or central venous access and describe the normal vasculature and surrounding anatomy of the site chosen for vascular access.
Describe the collateral flow for arterial access procedures.
Describe the clinical findings or disease processes that require arterial or central venous access.
Explain the role of ultrasonography in vascular access placement.
Explain indications and contraindications of the various arterial or central venous access procedures.
Describe and differentiate the potential risks and complications of individual vascular access procedures based on the site chosen and other risk factors.
Select the necessary equipment to perform the indicated vascular access procedure at the bedside.
SKILLS
Hospitalists should be able to:
Elicit an accurate and thorough history to identify co‐morbid conditions and risk factors for complications related to arterial or central venous vascular access placement.
Identify absolute and relative contraindications to placement of arterial access or central venous access at specific sites.
Perform a directed physical examination of the site(s) intended for vascular access.
Perform specific maneuvers to evaluate for collateral flow for arterial access procedures.
Properly position the patient and identify anatomic landmarks to obtain vascular access.
Use sterile techniques during preparation for and performance of vascular access procedures.
Anticipate and manage complications from the vascular access procedure and in‐dwelling catheter.
Identify and manage the complications of vascular access procedures, which may include infection, thrombotic, and mechanical complications.
Order and interpret platelet and coagulation studies when indicated.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the indications and alternatives to vascular access.
Communicate with patients and families to explain the procedure, its expected therapeutic benefits and potential complications; and to obtain informed consent.
Provide education to patients and their families regarding the care of long‐term vascular access.
Recognize the importance of proper positioning during the procedure.
Remove all central venous catheters and arterial catheters as soon as they are no longer needed.
Promote the use of peripheral venous access over central venous access whenever possible.
Manage patient discomfort or pain during and after the procedure.
Recognize the indications for specialty consultation, which may include interventional radiology, surgery, or critical care medicine.
Arrange appropriate care for patients being discharged with long‐term vascular access.
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.
Lead, coordinate or participate in development of IV access teams to improve the placement and maintenance of IV catheters.
Lead, coordinator or participate in quality improvement programs to monitor hospitalists' performance and/or supervision of vascular access.
Lead, coordinate or participate in implementation of standard nursing protocols for catheter care.
Lead, coordinate or participate in efforts to organize and consolidate equipment in an identifiable location in the hospital that is easily accessible to clinicians who perform the procedure.
Vascular access involves inserting a catheter into an appropriate blood vessel in order to measure useful diagnostic parameters, draw blood for diagnostic testing, and/or provide specific therapeutic interventions.
Vascular access procedures were performed in approximately 417,000 discharges in 2002, according to the Healthcare Cost and Utilization Project (HCUP). Many hospitalized patients require vascular access, and hospitalists will differentiate patients who simply need peripheral venous access from those who require more invasive types of arterial or central venous access. Complications of vascular catheters can cause prolonged hospital stays and increase morbidity and mortality. Hospitalists advocate for patients to determine the most appropriate type of vascular access based on the patient's diagnostic and therapeutic requirements and overall clinical condition.
KNOWLEDGE
Hospitalists should be able to:
Name the various locations for peripheral venous access and describe the normal vasculature and surrounding anatomy of the site chosen for access.
Name the various locations for arterial or central venous access and describe the normal vasculature and surrounding anatomy of the site chosen for vascular access.
Describe the collateral flow for arterial access procedures.
Describe the clinical findings or disease processes that require arterial or central venous access.
Explain the role of ultrasonography in vascular access placement.
Explain indications and contraindications of the various arterial or central venous access procedures.
Describe and differentiate the potential risks and complications of individual vascular access procedures based on the site chosen and other risk factors.
Select the necessary equipment to perform the indicated vascular access procedure at the bedside.
SKILLS
Hospitalists should be able to:
Elicit an accurate and thorough history to identify co‐morbid conditions and risk factors for complications related to arterial or central venous vascular access placement.
Identify absolute and relative contraindications to placement of arterial access or central venous access at specific sites.
Perform a directed physical examination of the site(s) intended for vascular access.
Perform specific maneuvers to evaluate for collateral flow for arterial access procedures.
Properly position the patient and identify anatomic landmarks to obtain vascular access.
Use sterile techniques during preparation for and performance of vascular access procedures.
Anticipate and manage complications from the vascular access procedure and in‐dwelling catheter.
Identify and manage the complications of vascular access procedures, which may include infection, thrombotic, and mechanical complications.
Order and interpret platelet and coagulation studies when indicated.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the indications and alternatives to vascular access.
Communicate with patients and families to explain the procedure, its expected therapeutic benefits and potential complications; and to obtain informed consent.
Provide education to patients and their families regarding the care of long‐term vascular access.
Recognize the importance of proper positioning during the procedure.
Remove all central venous catheters and arterial catheters as soon as they are no longer needed.
Promote the use of peripheral venous access over central venous access whenever possible.
Manage patient discomfort or pain during and after the procedure.
Recognize the indications for specialty consultation, which may include interventional radiology, surgery, or critical care medicine.
Arrange appropriate care for patients being discharged with long‐term vascular access.
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.
Lead, coordinate or participate in development of IV access teams to improve the placement and maintenance of IV catheters.
Lead, coordinator or participate in quality improvement programs to monitor hospitalists' performance and/or supervision of vascular access.
Lead, coordinate or participate in implementation of standard nursing protocols for catheter care.
Lead, coordinate or participate in efforts to organize and consolidate equipment in an identifiable location in the hospital that is easily accessible to clinicians who perform the procedure.
Copyright © 2006 Society of Hospital Medicine
Leadership
Hospitalists assume formal and informal leadership roles in the hospital system and community. In their individual institutions, hospitalists are responsible for the management and coordination of patient care. This role requires advocating for the patient, building consensus, and balancing the needs of individual patients with the resources available to the hospital. Hospitalists also lead efforts to assess, identify and improve patient outcomes, resource utilization, cost‐effectiveness, and quality of inpatient medical care. In the larger community, hospitalists lead innovations in hospital medicine research and education and the delivery of health care.
KNOWLEDGE
Hospitalists should be able to:
Differentiate management and leadership.
Describe hospitalist responsibilities and opportunities to provide active leadership.
Describe the key elements of a message.
Discuss how mentor relationships impact the development and advancement of the field of hospital medicine.
Explain the attributes and effects of modeling positive and negative behaviors.
Name the key elements of strategic planning processes.
Explain factors that predict the success or failure of strategic plans.
Describe styles of leadership.
Explain the attributes of effective leadership.
Articulate the business and financial motivators that impact decision making.
Explain the specific factors that affect positive change.
Explain effective negotiation and conflict resolution techniques.
SKILLS
Hospitalists should be able to:
Tailor messages to specific target audiences.
Develop effective communication skills using multiple modalities.
Plan and conduct an effective meeting.
Construct program mission and vision statements.
Develop personal, team and program goals, and identify indicators of achievement.
Establish, measure and report key performance metrics.
Utilize established metrics to assess progress and set new goals for performance and outcomes.
Analyze personal leadership style.
Demonstrate the ability to effectively work with various leadership styles.
Develop budgets to support goals using accepted financial principles.
Translate performance into measurable financial outcomes.
Assess the barriers and facilitating factors to effect change and incorporate those factors into a strategic approach.
Demonstrate effective and creative problem solving techniques.
Resolve conflicts using specific negotiation techniques.
ATTITUDES
Hospitalists should be able to:
Lead by example.
Practice active listening techniques.
Provide and seek timely, useful feedback.
Provide leadership in teaching, educational scholarship, quality improvement and other areas that serve to improve patient outcomes and advance the field of hospital medicine.
Explain the importance of finding mentor(s) and serving as a mentor.
Recognize the importance and influence of positive role modeling.
Assess and address personal leadership strengths and weaknesses.
Seek and participate in opportunities for professional development.
Advocate for financial and other resources needed to support goals and initiatives.
Exemplify professionalism.
Accept responsibility and accountability for management decisions.
Build consensus in support of key decisions.
Hospitalists assume formal and informal leadership roles in the hospital system and community. In their individual institutions, hospitalists are responsible for the management and coordination of patient care. This role requires advocating for the patient, building consensus, and balancing the needs of individual patients with the resources available to the hospital. Hospitalists also lead efforts to assess, identify and improve patient outcomes, resource utilization, cost‐effectiveness, and quality of inpatient medical care. In the larger community, hospitalists lead innovations in hospital medicine research and education and the delivery of health care.
KNOWLEDGE
Hospitalists should be able to:
Differentiate management and leadership.
Describe hospitalist responsibilities and opportunities to provide active leadership.
Describe the key elements of a message.
Discuss how mentor relationships impact the development and advancement of the field of hospital medicine.
Explain the attributes and effects of modeling positive and negative behaviors.
Name the key elements of strategic planning processes.
Explain factors that predict the success or failure of strategic plans.
Describe styles of leadership.
Explain the attributes of effective leadership.
Articulate the business and financial motivators that impact decision making.
Explain the specific factors that affect positive change.
Explain effective negotiation and conflict resolution techniques.
SKILLS
Hospitalists should be able to:
Tailor messages to specific target audiences.
Develop effective communication skills using multiple modalities.
Plan and conduct an effective meeting.
Construct program mission and vision statements.
Develop personal, team and program goals, and identify indicators of achievement.
Establish, measure and report key performance metrics.
Utilize established metrics to assess progress and set new goals for performance and outcomes.
Analyze personal leadership style.
Demonstrate the ability to effectively work with various leadership styles.
Develop budgets to support goals using accepted financial principles.
Translate performance into measurable financial outcomes.
Assess the barriers and facilitating factors to effect change and incorporate those factors into a strategic approach.
Demonstrate effective and creative problem solving techniques.
Resolve conflicts using specific negotiation techniques.
ATTITUDES
Hospitalists should be able to:
Lead by example.
Practice active listening techniques.
Provide and seek timely, useful feedback.
Provide leadership in teaching, educational scholarship, quality improvement and other areas that serve to improve patient outcomes and advance the field of hospital medicine.
Explain the importance of finding mentor(s) and serving as a mentor.
Recognize the importance and influence of positive role modeling.
Assess and address personal leadership strengths and weaknesses.
Seek and participate in opportunities for professional development.
Advocate for financial and other resources needed to support goals and initiatives.
Exemplify professionalism.
Accept responsibility and accountability for management decisions.
Build consensus in support of key decisions.
Hospitalists assume formal and informal leadership roles in the hospital system and community. In their individual institutions, hospitalists are responsible for the management and coordination of patient care. This role requires advocating for the patient, building consensus, and balancing the needs of individual patients with the resources available to the hospital. Hospitalists also lead efforts to assess, identify and improve patient outcomes, resource utilization, cost‐effectiveness, and quality of inpatient medical care. In the larger community, hospitalists lead innovations in hospital medicine research and education and the delivery of health care.
KNOWLEDGE
Hospitalists should be able to:
Differentiate management and leadership.
Describe hospitalist responsibilities and opportunities to provide active leadership.
Describe the key elements of a message.
Discuss how mentor relationships impact the development and advancement of the field of hospital medicine.
Explain the attributes and effects of modeling positive and negative behaviors.
Name the key elements of strategic planning processes.
Explain factors that predict the success or failure of strategic plans.
Describe styles of leadership.
Explain the attributes of effective leadership.
Articulate the business and financial motivators that impact decision making.
Explain the specific factors that affect positive change.
Explain effective negotiation and conflict resolution techniques.
SKILLS
Hospitalists should be able to:
Tailor messages to specific target audiences.
Develop effective communication skills using multiple modalities.
Plan and conduct an effective meeting.
Construct program mission and vision statements.
Develop personal, team and program goals, and identify indicators of achievement.
Establish, measure and report key performance metrics.
Utilize established metrics to assess progress and set new goals for performance and outcomes.
Analyze personal leadership style.
Demonstrate the ability to effectively work with various leadership styles.
Develop budgets to support goals using accepted financial principles.
Translate performance into measurable financial outcomes.
Assess the barriers and facilitating factors to effect change and incorporate those factors into a strategic approach.
Demonstrate effective and creative problem solving techniques.
Resolve conflicts using specific negotiation techniques.
ATTITUDES
Hospitalists should be able to:
Lead by example.
Practice active listening techniques.
Provide and seek timely, useful feedback.
Provide leadership in teaching, educational scholarship, quality improvement and other areas that serve to improve patient outcomes and advance the field of hospital medicine.
Explain the importance of finding mentor(s) and serving as a mentor.
Recognize the importance and influence of positive role modeling.
Assess and address personal leadership strengths and weaknesses.
Seek and participate in opportunities for professional development.
Advocate for financial and other resources needed to support goals and initiatives.
Exemplify professionalism.
Accept responsibility and accountability for management decisions.
Build consensus in support of key decisions.
Copyright © 2006 Society of Hospital Medicine
Drug safety, pharmacoeconomics and pharmacoepidemiology
The number of new therapeutic agents approved by the Food and Drug Administration (FDA) is rapidly increasing. With the availability of these new agents and the widening use of other agents, pharmaceutical costs have grown more than any other sector of healthcare, as have concerns about adverse drug events (ADEs) from these agents. Hospitalists who strive to prescribe evidence based therapies must understand how to evaluate the benefits, harms, and financial costs of drug therapy for individual patients. Hospitalists promote and lead multidisciplinary teams to implement protocols, guidelines and clinical pathways that recommend preferred drug therapies. Hospitalists should be able to interpret outcomes measurement (pharmacoepidemiology) and economic analyses (pharmacoeconomics).
KNOWLEDGE
Hospitalists should be able to:
Discuss principles of evaluating clinical efficacy, pharmacokinetics, dosing, drug and food interactions, and adverse effects that can affect the hospitalist's choice of agent, dosing frequency and route of administration.
Explain options for measuring medication benefit.
Explain the evidence based rationale for prophylactic drug therapies, comparing the costs, risks and benefits of competing strategies.
Explain how pharmacodynamics change with age, liver disease and renal insufficiency.
Describe the incidence of various types of ADEs in hospitalized patients, which may include adverse effects, interactions, and errors.
Explain the role of polypharmacy in the development of delirium, ADEs, and noncompliance.
Describe how the overuse of broad spectrum antibiotics promotes resistance.
Describe key principles for interpreting pharmacoeconomic analyses including inflation rate, discounting rate, incremental analysis, sensitivity analysis, and inherent bias.
Describe the clinical efficacy, safety profile, pharmacokinetics, dosing, drug and food interactions, and costs of commonly prescribed medications and biological agents (e.g., blood products).
SKILLS
Hospitalists should be able to:
Prescribe medications for elderly hospitalized patients based on altered pharmacokinetics and co‐morbid conditions.
Apply treatment guidelines to individual patients in the use of antibiotics to reduce cost and the emergence of resistance.
Minimize ADEs by using best practice models of medication ordering and administration.
Document medications accurately and legibly taking into account approved abbreviation, and indicate start and stop dates for short‐term medications.
Arrange adequate follow‐up for therapies that require outpatient monitoring, dosage adjustment, and education (e.g., anticoagulants, antibiotics).
Balance the benefits, risks, and cost of prophylactic therapies, which may include venous thromboembolism and stress ulcer prophylaxis
Convert intravenous medications to the oral route when indicated to promote patient safety, satisfaction, and reduce cost.
Standardize blood transfusion practices.
ATTITUDES
Hospitalists should be able to:
Educate patients and families about the importance of acquiring medication information and communicating medication history to clinicians at each transition of care.
Ensure patients and families comprehend medication instructions.
Recognize the benefits and hazards of drug therapy.
Recognize the risk of ADEs at the time of transfer of care.
Reconcile outpatient medications with inpatient medications at the time of admission and discharge.
Reconcile all documentation of medications at the time of discharge.
Integrate knowledge of benefits and risks of drug therapies into medical decision making for individual patients, and routinely reassess decisions.
Critically assess and apply results of new outcome studies to improve drug treatment and patient safety for individual patients.
Collaborate with pharmacists to improve drug safety for individual patients and reduce hospital costs.
Apply the principles of pharmacoepidemiology and drug safety to patient management.
Lead, coordinate and participate in the development, use, and dissemination of local, regional, and national practice guidelines and patient safety alerts pertaining to the prevention of complications.
Apply the principles of pharmacoepidemiology and pharmacoeconomics to implement practice guidelines and protocols for a hospital.
The number of new therapeutic agents approved by the Food and Drug Administration (FDA) is rapidly increasing. With the availability of these new agents and the widening use of other agents, pharmaceutical costs have grown more than any other sector of healthcare, as have concerns about adverse drug events (ADEs) from these agents. Hospitalists who strive to prescribe evidence based therapies must understand how to evaluate the benefits, harms, and financial costs of drug therapy for individual patients. Hospitalists promote and lead multidisciplinary teams to implement protocols, guidelines and clinical pathways that recommend preferred drug therapies. Hospitalists should be able to interpret outcomes measurement (pharmacoepidemiology) and economic analyses (pharmacoeconomics).
KNOWLEDGE
Hospitalists should be able to:
Discuss principles of evaluating clinical efficacy, pharmacokinetics, dosing, drug and food interactions, and adverse effects that can affect the hospitalist's choice of agent, dosing frequency and route of administration.
Explain options for measuring medication benefit.
Explain the evidence based rationale for prophylactic drug therapies, comparing the costs, risks and benefits of competing strategies.
Explain how pharmacodynamics change with age, liver disease and renal insufficiency.
Describe the incidence of various types of ADEs in hospitalized patients, which may include adverse effects, interactions, and errors.
Explain the role of polypharmacy in the development of delirium, ADEs, and noncompliance.
Describe how the overuse of broad spectrum antibiotics promotes resistance.
Describe key principles for interpreting pharmacoeconomic analyses including inflation rate, discounting rate, incremental analysis, sensitivity analysis, and inherent bias.
Describe the clinical efficacy, safety profile, pharmacokinetics, dosing, drug and food interactions, and costs of commonly prescribed medications and biological agents (e.g., blood products).
SKILLS
Hospitalists should be able to:
Prescribe medications for elderly hospitalized patients based on altered pharmacokinetics and co‐morbid conditions.
Apply treatment guidelines to individual patients in the use of antibiotics to reduce cost and the emergence of resistance.
Minimize ADEs by using best practice models of medication ordering and administration.
Document medications accurately and legibly taking into account approved abbreviation, and indicate start and stop dates for short‐term medications.
Arrange adequate follow‐up for therapies that require outpatient monitoring, dosage adjustment, and education (e.g., anticoagulants, antibiotics).
Balance the benefits, risks, and cost of prophylactic therapies, which may include venous thromboembolism and stress ulcer prophylaxis
Convert intravenous medications to the oral route when indicated to promote patient safety, satisfaction, and reduce cost.
Standardize blood transfusion practices.
ATTITUDES
Hospitalists should be able to:
Educate patients and families about the importance of acquiring medication information and communicating medication history to clinicians at each transition of care.
Ensure patients and families comprehend medication instructions.
Recognize the benefits and hazards of drug therapy.
Recognize the risk of ADEs at the time of transfer of care.
Reconcile outpatient medications with inpatient medications at the time of admission and discharge.
Reconcile all documentation of medications at the time of discharge.
Integrate knowledge of benefits and risks of drug therapies into medical decision making for individual patients, and routinely reassess decisions.
Critically assess and apply results of new outcome studies to improve drug treatment and patient safety for individual patients.
Collaborate with pharmacists to improve drug safety for individual patients and reduce hospital costs.
Apply the principles of pharmacoepidemiology and drug safety to patient management.
Lead, coordinate and participate in the development, use, and dissemination of local, regional, and national practice guidelines and patient safety alerts pertaining to the prevention of complications.
Apply the principles of pharmacoepidemiology and pharmacoeconomics to implement practice guidelines and protocols for a hospital.
The number of new therapeutic agents approved by the Food and Drug Administration (FDA) is rapidly increasing. With the availability of these new agents and the widening use of other agents, pharmaceutical costs have grown more than any other sector of healthcare, as have concerns about adverse drug events (ADEs) from these agents. Hospitalists who strive to prescribe evidence based therapies must understand how to evaluate the benefits, harms, and financial costs of drug therapy for individual patients. Hospitalists promote and lead multidisciplinary teams to implement protocols, guidelines and clinical pathways that recommend preferred drug therapies. Hospitalists should be able to interpret outcomes measurement (pharmacoepidemiology) and economic analyses (pharmacoeconomics).
KNOWLEDGE
Hospitalists should be able to:
Discuss principles of evaluating clinical efficacy, pharmacokinetics, dosing, drug and food interactions, and adverse effects that can affect the hospitalist's choice of agent, dosing frequency and route of administration.
Explain options for measuring medication benefit.
Explain the evidence based rationale for prophylactic drug therapies, comparing the costs, risks and benefits of competing strategies.
Explain how pharmacodynamics change with age, liver disease and renal insufficiency.
Describe the incidence of various types of ADEs in hospitalized patients, which may include adverse effects, interactions, and errors.
Explain the role of polypharmacy in the development of delirium, ADEs, and noncompliance.
Describe how the overuse of broad spectrum antibiotics promotes resistance.
Describe key principles for interpreting pharmacoeconomic analyses including inflation rate, discounting rate, incremental analysis, sensitivity analysis, and inherent bias.
Describe the clinical efficacy, safety profile, pharmacokinetics, dosing, drug and food interactions, and costs of commonly prescribed medications and biological agents (e.g., blood products).
SKILLS
Hospitalists should be able to:
Prescribe medications for elderly hospitalized patients based on altered pharmacokinetics and co‐morbid conditions.
Apply treatment guidelines to individual patients in the use of antibiotics to reduce cost and the emergence of resistance.
Minimize ADEs by using best practice models of medication ordering and administration.
Document medications accurately and legibly taking into account approved abbreviation, and indicate start and stop dates for short‐term medications.
Arrange adequate follow‐up for therapies that require outpatient monitoring, dosage adjustment, and education (e.g., anticoagulants, antibiotics).
Balance the benefits, risks, and cost of prophylactic therapies, which may include venous thromboembolism and stress ulcer prophylaxis
Convert intravenous medications to the oral route when indicated to promote patient safety, satisfaction, and reduce cost.
Standardize blood transfusion practices.
ATTITUDES
Hospitalists should be able to:
Educate patients and families about the importance of acquiring medication information and communicating medication history to clinicians at each transition of care.
Ensure patients and families comprehend medication instructions.
Recognize the benefits and hazards of drug therapy.
Recognize the risk of ADEs at the time of transfer of care.
Reconcile outpatient medications with inpatient medications at the time of admission and discharge.
Reconcile all documentation of medications at the time of discharge.
Integrate knowledge of benefits and risks of drug therapies into medical decision making for individual patients, and routinely reassess decisions.
Critically assess and apply results of new outcome studies to improve drug treatment and patient safety for individual patients.
Collaborate with pharmacists to improve drug safety for individual patients and reduce hospital costs.
Apply the principles of pharmacoepidemiology and drug safety to patient management.
Lead, coordinate and participate in the development, use, and dissemination of local, regional, and national practice guidelines and patient safety alerts pertaining to the prevention of complications.
Apply the principles of pharmacoepidemiology and pharmacoeconomics to implement practice guidelines and protocols for a hospital.
Copyright © 2006 Society of Hospital Medicine
Lumbar puncture
Lumbar puncture is a procedure during which a needle is inserted into the subarachnoid space to obtain cerebrospinal fluid (CSF) for laboratory analysis. CSF is formed within the ventricular choroid plexus and distributed in the ventricular system, basal cisterns and the subarachnoid space. The Healthcare Cost and Utilization Project (HCUP) estimates over 240,000 lumbar punctures were performed in hospitalized patients in 2002. Hospitalists identify patients who require lumbar puncture to assess acute or chronic central nervous system (CNS) disease processes. Early diagnosis and therapy of acute CNS infections or subarachnoid hemorrhage is essential to lower morbidity and mortality.
KNOWLEDGE
Hospitalists should be able to:
Describe the anatomy of the spinal column and the spinal cord.
Describe the signs and symptoms that require lumbar puncture.
Describe disease processes that require frequent therapeutic lumbar puncture.
Explain the indications and contraindications for lumbar puncture, including potential risks and complications.
Describe the physical examination maneuvers used in the evaluation of suspected CNS infections and identify their sensitivity and specificity.
List the indications for brain imaging prior to lumbar puncture.
Explain the diagnostic testing indicated for CSF based on the clinical presentation.
Describe indications for the use of interventional radiology in performing lumber puncture.
Select the necessary equipment to perform a lumbar puncture at the bedside.
SKILLS
Hospitalists should be able to:
Elicit a thorough history and review medical records to identify indications and potential contraindications for lumbar puncture.
Perform a thorough physical examination, including neurologic and fundoscopic examination.
Properly position the patient for lumbar puncture and identify major anatomic landmarks.
Use sterile techniques during preparation for and performance of lumbar puncture.
Obtain an accurate measurement of and interpret the opening pressure.
Maintain clinician safety with appropriate protective wear.
Manage the complications of lumbar puncture, particularly post‐lumbar puncture headache.
Order and interpret indicated diagnostic tests for CSF fluid.
Order and interpret platelet and coagulation studies when indicated.
Synthesize data obtained from history, physical examination, radiographic imaging, and CSF analysis to develop an evidence based treatment plan.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the procedure, its expected diagnostic benefits, and potential complications; and to obtain informed consent.
Discuss with patients and families pain management strategies for discomfort during and after lumbar puncture.
Recognize the importance of proper positioning following the procedure.
Identify patients who require isolation precautions.
Manage patient discomfort or pain during and after the procedure.
Recognize the indications for specialty consultation, which may include interventional radiology, infectious disease or neurology.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
Collaborate with emergency physicians to develop protocols for rapid identification and evaluation of patients with suspected CNS infections.
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 lumbar puncture.
Lead, coordinate or participate in efforts to organize and consolidate lumbar puncture equipment in an identifiable location in the hospital, easily accessible to clinicians who perform the procedure.
Lumbar puncture is a procedure during which a needle is inserted into the subarachnoid space to obtain cerebrospinal fluid (CSF) for laboratory analysis. CSF is formed within the ventricular choroid plexus and distributed in the ventricular system, basal cisterns and the subarachnoid space. The Healthcare Cost and Utilization Project (HCUP) estimates over 240,000 lumbar punctures were performed in hospitalized patients in 2002. Hospitalists identify patients who require lumbar puncture to assess acute or chronic central nervous system (CNS) disease processes. Early diagnosis and therapy of acute CNS infections or subarachnoid hemorrhage is essential to lower morbidity and mortality.
KNOWLEDGE
Hospitalists should be able to:
Describe the anatomy of the spinal column and the spinal cord.
Describe the signs and symptoms that require lumbar puncture.
Describe disease processes that require frequent therapeutic lumbar puncture.
Explain the indications and contraindications for lumbar puncture, including potential risks and complications.
Describe the physical examination maneuvers used in the evaluation of suspected CNS infections and identify their sensitivity and specificity.
List the indications for brain imaging prior to lumbar puncture.
Explain the diagnostic testing indicated for CSF based on the clinical presentation.
Describe indications for the use of interventional radiology in performing lumber puncture.
Select the necessary equipment to perform a lumbar puncture at the bedside.
SKILLS
Hospitalists should be able to:
Elicit a thorough history and review medical records to identify indications and potential contraindications for lumbar puncture.
Perform a thorough physical examination, including neurologic and fundoscopic examination.
Properly position the patient for lumbar puncture and identify major anatomic landmarks.
Use sterile techniques during preparation for and performance of lumbar puncture.
Obtain an accurate measurement of and interpret the opening pressure.
Maintain clinician safety with appropriate protective wear.
Manage the complications of lumbar puncture, particularly post‐lumbar puncture headache.
Order and interpret indicated diagnostic tests for CSF fluid.
Order and interpret platelet and coagulation studies when indicated.
Synthesize data obtained from history, physical examination, radiographic imaging, and CSF analysis to develop an evidence based treatment plan.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the procedure, its expected diagnostic benefits, and potential complications; and to obtain informed consent.
Discuss with patients and families pain management strategies for discomfort during and after lumbar puncture.
Recognize the importance of proper positioning following the procedure.
Identify patients who require isolation precautions.
Manage patient discomfort or pain during and after the procedure.
Recognize the indications for specialty consultation, which may include interventional radiology, infectious disease or neurology.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
Collaborate with emergency physicians to develop protocols for rapid identification and evaluation of patients with suspected CNS infections.
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 lumbar puncture.
Lead, coordinate or participate in efforts to organize and consolidate lumbar puncture equipment in an identifiable location in the hospital, easily accessible to clinicians who perform the procedure.
Lumbar puncture is a procedure during which a needle is inserted into the subarachnoid space to obtain cerebrospinal fluid (CSF) for laboratory analysis. CSF is formed within the ventricular choroid plexus and distributed in the ventricular system, basal cisterns and the subarachnoid space. The Healthcare Cost and Utilization Project (HCUP) estimates over 240,000 lumbar punctures were performed in hospitalized patients in 2002. Hospitalists identify patients who require lumbar puncture to assess acute or chronic central nervous system (CNS) disease processes. Early diagnosis and therapy of acute CNS infections or subarachnoid hemorrhage is essential to lower morbidity and mortality.
KNOWLEDGE
Hospitalists should be able to:
Describe the anatomy of the spinal column and the spinal cord.
Describe the signs and symptoms that require lumbar puncture.
Describe disease processes that require frequent therapeutic lumbar puncture.
Explain the indications and contraindications for lumbar puncture, including potential risks and complications.
Describe the physical examination maneuvers used in the evaluation of suspected CNS infections and identify their sensitivity and specificity.
List the indications for brain imaging prior to lumbar puncture.
Explain the diagnostic testing indicated for CSF based on the clinical presentation.
Describe indications for the use of interventional radiology in performing lumber puncture.
Select the necessary equipment to perform a lumbar puncture at the bedside.
SKILLS
Hospitalists should be able to:
Elicit a thorough history and review medical records to identify indications and potential contraindications for lumbar puncture.
Perform a thorough physical examination, including neurologic and fundoscopic examination.
Properly position the patient for lumbar puncture and identify major anatomic landmarks.
Use sterile techniques during preparation for and performance of lumbar puncture.
Obtain an accurate measurement of and interpret the opening pressure.
Maintain clinician safety with appropriate protective wear.
Manage the complications of lumbar puncture, particularly post‐lumbar puncture headache.
Order and interpret indicated diagnostic tests for CSF fluid.
Order and interpret platelet and coagulation studies when indicated.
Synthesize data obtained from history, physical examination, radiographic imaging, and CSF analysis to develop an evidence based treatment plan.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the procedure, its expected diagnostic benefits, and potential complications; and to obtain informed consent.
Discuss with patients and families pain management strategies for discomfort during and after lumbar puncture.
Recognize the importance of proper positioning following the procedure.
Identify patients who require isolation precautions.
Manage patient discomfort or pain during and after the procedure.
Recognize the indications for specialty consultation, which may include interventional radiology, infectious disease or neurology.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
Collaborate with emergency physicians to develop protocols for rapid identification and evaluation of patients with suspected CNS infections.
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 lumbar puncture.
Lead, coordinate or participate in efforts to organize and consolidate lumbar puncture equipment in an identifiable location in the hospital, easily accessible to clinicians who perform the procedure.
Copyright © 2006 Society of Hospital Medicine
Communication
Communication refers the transfer of information between individuals, groups, or organizations. Hospitalists communicate in multiple modalities with patients, families, other health care providers and administrators. Patient‐centered care requires that physicians and members of multidisciplinary teams effectively inform, educate, reassure, and empower patients and families to participate in the creation of a care plan. Effective communication is central to the role of the hospitalist to promote efficient, safe, and high quality care and to reduce discontinuity of care. Hospitalists can lead initiatives to improve communication amongst team members, patients, families, primary care physicians and receiving physicians within the hospital and at extended care facilities beginning with admission and through all care transitions.
KNOWLEDGE
Hospitalists should be able to:
Describe key elements in a message.
Describe various modalities used to communicate, including advantages and disadvantages of each.
Describe techniques of providing and eliciting feedback, and differentiate formative and summative feedback.
Define the role of effective communication in risk management.
SKILLS
Hospitalists should be able to:
Explain issues of pathophysiology, treatment options, and prognosis using language understandable to patients, family members, and other care providers.
Listen without interruption to the questions and concerns of patients, family members and other care providers, and promptly address any issues.
Identify potentially problematic family and team dynamics and explore their effects on the patient.
Identify a family spokesperson.
Facilitate family meetings when necessary, collaborating with nurses and other team members to identify goals for the meeting, summarize conclusions reached, and utilize support staff as needed.
Effectively utilize a translator when communicating with patients and families speaking a different language.
ATTITUDES
Hospitalists should be able to:
Appreciate the positive impact that subtle changes in body language, such as sitting and appropriate touching, have on patient and family perceptions of an interaction.
Demonstrate empathy for patient and family concerns.
Recognize the importance of allowing patients and families to have questions answered in a straightforward and timely manner.
Demonstrate cultural sensitivity in all interactions with patients and families.
Appreciate the importance of active listening.
Counsel patients and families objectively when considering various treatment options.
Acknowledge and remain comfortable with uncertainty in issues of prognosis.
Provide a quiet and comfortable setting for family meetings.
Discuss the patient's illness realistically without negating hope.
Ensure that input from surrogate decision makers accurately reflects the patient's interests, with a minimum of personal bias.
Communicate with nursing staff and consultants on a regular basis to convey critical information.
Remain available to the patient and family for follow‐up questions through all care transitions.
Lead, coordinate or participate in hospital initiatives to assure adequate translator services and cross cultural sensitivities.
Communication refers the transfer of information between individuals, groups, or organizations. Hospitalists communicate in multiple modalities with patients, families, other health care providers and administrators. Patient‐centered care requires that physicians and members of multidisciplinary teams effectively inform, educate, reassure, and empower patients and families to participate in the creation of a care plan. Effective communication is central to the role of the hospitalist to promote efficient, safe, and high quality care and to reduce discontinuity of care. Hospitalists can lead initiatives to improve communication amongst team members, patients, families, primary care physicians and receiving physicians within the hospital and at extended care facilities beginning with admission and through all care transitions.
KNOWLEDGE
Hospitalists should be able to:
Describe key elements in a message.
Describe various modalities used to communicate, including advantages and disadvantages of each.
Describe techniques of providing and eliciting feedback, and differentiate formative and summative feedback.
Define the role of effective communication in risk management.
SKILLS
Hospitalists should be able to:
Explain issues of pathophysiology, treatment options, and prognosis using language understandable to patients, family members, and other care providers.
Listen without interruption to the questions and concerns of patients, family members and other care providers, and promptly address any issues.
Identify potentially problematic family and team dynamics and explore their effects on the patient.
Identify a family spokesperson.
Facilitate family meetings when necessary, collaborating with nurses and other team members to identify goals for the meeting, summarize conclusions reached, and utilize support staff as needed.
Effectively utilize a translator when communicating with patients and families speaking a different language.
ATTITUDES
Hospitalists should be able to:
Appreciate the positive impact that subtle changes in body language, such as sitting and appropriate touching, have on patient and family perceptions of an interaction.
Demonstrate empathy for patient and family concerns.
Recognize the importance of allowing patients and families to have questions answered in a straightforward and timely manner.
Demonstrate cultural sensitivity in all interactions with patients and families.
Appreciate the importance of active listening.
Counsel patients and families objectively when considering various treatment options.
Acknowledge and remain comfortable with uncertainty in issues of prognosis.
Provide a quiet and comfortable setting for family meetings.
Discuss the patient's illness realistically without negating hope.
Ensure that input from surrogate decision makers accurately reflects the patient's interests, with a minimum of personal bias.
Communicate with nursing staff and consultants on a regular basis to convey critical information.
Remain available to the patient and family for follow‐up questions through all care transitions.
Lead, coordinate or participate in hospital initiatives to assure adequate translator services and cross cultural sensitivities.
Communication refers the transfer of information between individuals, groups, or organizations. Hospitalists communicate in multiple modalities with patients, families, other health care providers and administrators. Patient‐centered care requires that physicians and members of multidisciplinary teams effectively inform, educate, reassure, and empower patients and families to participate in the creation of a care plan. Effective communication is central to the role of the hospitalist to promote efficient, safe, and high quality care and to reduce discontinuity of care. Hospitalists can lead initiatives to improve communication amongst team members, patients, families, primary care physicians and receiving physicians within the hospital and at extended care facilities beginning with admission and through all care transitions.
KNOWLEDGE
Hospitalists should be able to:
Describe key elements in a message.
Describe various modalities used to communicate, including advantages and disadvantages of each.
Describe techniques of providing and eliciting feedback, and differentiate formative and summative feedback.
Define the role of effective communication in risk management.
SKILLS
Hospitalists should be able to:
Explain issues of pathophysiology, treatment options, and prognosis using language understandable to patients, family members, and other care providers.
Listen without interruption to the questions and concerns of patients, family members and other care providers, and promptly address any issues.
Identify potentially problematic family and team dynamics and explore their effects on the patient.
Identify a family spokesperson.
Facilitate family meetings when necessary, collaborating with nurses and other team members to identify goals for the meeting, summarize conclusions reached, and utilize support staff as needed.
Effectively utilize a translator when communicating with patients and families speaking a different language.
ATTITUDES
Hospitalists should be able to:
Appreciate the positive impact that subtle changes in body language, such as sitting and appropriate touching, have on patient and family perceptions of an interaction.
Demonstrate empathy for patient and family concerns.
Recognize the importance of allowing patients and families to have questions answered in a straightforward and timely manner.
Demonstrate cultural sensitivity in all interactions with patients and families.
Appreciate the importance of active listening.
Counsel patients and families objectively when considering various treatment options.
Acknowledge and remain comfortable with uncertainty in issues of prognosis.
Provide a quiet and comfortable setting for family meetings.
Discuss the patient's illness realistically without negating hope.
Ensure that input from surrogate decision makers accurately reflects the patient's interests, with a minimum of personal bias.
Communicate with nursing staff and consultants on a regular basis to convey critical information.
Remain available to the patient and family for follow‐up questions through all care transitions.
Lead, coordinate or participate in hospital initiatives to assure adequate translator services and cross cultural sensitivities.
Copyright © 2006 Society of Hospital Medicine
Urinary tract infection
Urinary tract infection (UTI) refers to a spectrum of clinical presentations ranging from asymptomatic urinary infection to acute pyelonephritis with septicemia. UTI is a common infection diagnosed at the time of admission or acquired during hospitalization. According to the Healthcare Cost and Utilization Project (HCUP), the Diagnosis Related Group for UTI with complications or co‐morbidities accounted for almost 302,000 hospital discharges in 2002. The mean length‐of‐stay was 4.9 days with mean charges of $13,000 per patient. In‐hospital mortality was 2.2% for this group. Hospitalists diagnose, treat and identify complications of UTI. Hospitalists can lead hospital‐wide patient safety initiatives to reduce the incidence of hospital‐acquired infection and emerging antibiotic resistance.
KNOWLEDGE
Hospitalists should be able to:
Define UTI and describe the pathophysiology that leads to complicated UTI.
Describe common symptoms and signs of UTI.
Explain the clinical spectrum of UTI including patient populations that may present with atypical symptoms.
Name common community‐acquired and hospital‐acquired urinary pathogens.
Explain how local and national resistance patterns impact the selection of initial antibiotics.
Distinguish UTI from sterile pyuria and from colonization.
Explain the indications and limitations of specific tests used to diagnose UTI, its underlying causes and complicating conditions.
Define risk factors for UTI.
Name specific patient populations at increased risk for development of hospital acquired or other complicated UTIs.
Distinguish the specific clinical management, including antibiotic selection for different patient populations, including patients with community‐acquired UTI, hospital‐acquired UTI, chronic indwelling catheters, pregnancy, immunosuppression and incidentally recognized UTI.
Explain the indications for hospitalization.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a targeted history to identify risk factors and symptoms for UTI and its known complications.
Perform a focused physical examination looking for signs of complicated UTI, prostatitis and other co‐morbid conditions.
Order and interpret urinalysis and urine culture.
Order and interpret the results of imaging studies when indicated.
Formulate an initial care plan based on patient risk factors, acute medical illness, co‐morbid disease, and local and national antibiotic resistance patterns.
Adjust antibiotic therapy based on subsequent culture results and determine appropriate duration of treatment.
Recognize and address complications of UTI and/or inadequate response to therapy.
Evaluate and treat patients for UTI in the perioperative setting when indicated.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the 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 specialty consultation, which may include urology or infectious disease services.
Promote and employ prevention measures, which may include early removal of urinary catheters and other interventions to prevent recurrent UTI.
Apply judicious antibiotic selection to help reduce antibiotic resistance.
Employ a multidisciplinary approach to the care of patients with complicated UTI that begins on admission and continues through all care transitions.
Appreciate and treat patient's pain.
Document treatment plan, and provide clear discharge instructions for the receiving primary care physician, including duration of antibiotic treatment and need for follow‐up testing.
Provide and coordinate resources to patients to ensure safe transition from the hospital to arranged follow‐up care.
Coordinate discharge plans when patients will require ongoing skilled nursing care.
Utilize evidence based recommendations for the diagnosis and treatment of UTI.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
Implement systems to ensure hospital‐wide adherence to national standards, and document those measures as specified by recognized organizations.
Collaborate with local infection control practitioners to reduce the spread of resistant organisms within the institution.
Lead, coordinate or participate in multidisciplinary initiatives to minimize use and duration of urinary catheters and reduce incidence of hospital‐acquired UTI.
Urinary tract infection (UTI) refers to a spectrum of clinical presentations ranging from asymptomatic urinary infection to acute pyelonephritis with septicemia. UTI is a common infection diagnosed at the time of admission or acquired during hospitalization. According to the Healthcare Cost and Utilization Project (HCUP), the Diagnosis Related Group for UTI with complications or co‐morbidities accounted for almost 302,000 hospital discharges in 2002. The mean length‐of‐stay was 4.9 days with mean charges of $13,000 per patient. In‐hospital mortality was 2.2% for this group. Hospitalists diagnose, treat and identify complications of UTI. Hospitalists can lead hospital‐wide patient safety initiatives to reduce the incidence of hospital‐acquired infection and emerging antibiotic resistance.
KNOWLEDGE
Hospitalists should be able to:
Define UTI and describe the pathophysiology that leads to complicated UTI.
Describe common symptoms and signs of UTI.
Explain the clinical spectrum of UTI including patient populations that may present with atypical symptoms.
Name common community‐acquired and hospital‐acquired urinary pathogens.
Explain how local and national resistance patterns impact the selection of initial antibiotics.
Distinguish UTI from sterile pyuria and from colonization.
Explain the indications and limitations of specific tests used to diagnose UTI, its underlying causes and complicating conditions.
Define risk factors for UTI.
Name specific patient populations at increased risk for development of hospital acquired or other complicated UTIs.
Distinguish the specific clinical management, including antibiotic selection for different patient populations, including patients with community‐acquired UTI, hospital‐acquired UTI, chronic indwelling catheters, pregnancy, immunosuppression and incidentally recognized UTI.
Explain the indications for hospitalization.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a targeted history to identify risk factors and symptoms for UTI and its known complications.
Perform a focused physical examination looking for signs of complicated UTI, prostatitis and other co‐morbid conditions.
Order and interpret urinalysis and urine culture.
Order and interpret the results of imaging studies when indicated.
Formulate an initial care plan based on patient risk factors, acute medical illness, co‐morbid disease, and local and national antibiotic resistance patterns.
Adjust antibiotic therapy based on subsequent culture results and determine appropriate duration of treatment.
Recognize and address complications of UTI and/or inadequate response to therapy.
Evaluate and treat patients for UTI in the perioperative setting when indicated.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the 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 specialty consultation, which may include urology or infectious disease services.
Promote and employ prevention measures, which may include early removal of urinary catheters and other interventions to prevent recurrent UTI.
Apply judicious antibiotic selection to help reduce antibiotic resistance.
Employ a multidisciplinary approach to the care of patients with complicated UTI that begins on admission and continues through all care transitions.
Appreciate and treat patient's pain.
Document treatment plan, and provide clear discharge instructions for the receiving primary care physician, including duration of antibiotic treatment and need for follow‐up testing.
Provide and coordinate resources to patients to ensure safe transition from the hospital to arranged follow‐up care.
Coordinate discharge plans when patients will require ongoing skilled nursing care.
Utilize evidence based recommendations for the diagnosis and treatment of UTI.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
Implement systems to ensure hospital‐wide adherence to national standards, and document those measures as specified by recognized organizations.
Collaborate with local infection control practitioners to reduce the spread of resistant organisms within the institution.
Lead, coordinate or participate in multidisciplinary initiatives to minimize use and duration of urinary catheters and reduce incidence of hospital‐acquired UTI.
Urinary tract infection (UTI) refers to a spectrum of clinical presentations ranging from asymptomatic urinary infection to acute pyelonephritis with septicemia. UTI is a common infection diagnosed at the time of admission or acquired during hospitalization. According to the Healthcare Cost and Utilization Project (HCUP), the Diagnosis Related Group for UTI with complications or co‐morbidities accounted for almost 302,000 hospital discharges in 2002. The mean length‐of‐stay was 4.9 days with mean charges of $13,000 per patient. In‐hospital mortality was 2.2% for this group. Hospitalists diagnose, treat and identify complications of UTI. Hospitalists can lead hospital‐wide patient safety initiatives to reduce the incidence of hospital‐acquired infection and emerging antibiotic resistance.
KNOWLEDGE
Hospitalists should be able to:
Define UTI and describe the pathophysiology that leads to complicated UTI.
Describe common symptoms and signs of UTI.
Explain the clinical spectrum of UTI including patient populations that may present with atypical symptoms.
Name common community‐acquired and hospital‐acquired urinary pathogens.
Explain how local and national resistance patterns impact the selection of initial antibiotics.
Distinguish UTI from sterile pyuria and from colonization.
Explain the indications and limitations of specific tests used to diagnose UTI, its underlying causes and complicating conditions.
Define risk factors for UTI.
Name specific patient populations at increased risk for development of hospital acquired or other complicated UTIs.
Distinguish the specific clinical management, including antibiotic selection for different patient populations, including patients with community‐acquired UTI, hospital‐acquired UTI, chronic indwelling catheters, pregnancy, immunosuppression and incidentally recognized UTI.
Explain the indications for hospitalization.
Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.
SKILLS
Hospitalists should be able to:
Elicit a targeted history to identify risk factors and symptoms for UTI and its known complications.
Perform a focused physical examination looking for signs of complicated UTI, prostatitis and other co‐morbid conditions.
Order and interpret urinalysis and urine culture.
Order and interpret the results of imaging studies when indicated.
Formulate an initial care plan based on patient risk factors, acute medical illness, co‐morbid disease, and local and national antibiotic resistance patterns.
Adjust antibiotic therapy based on subsequent culture results and determine appropriate duration of treatment.
Recognize and address complications of UTI and/or inadequate response to therapy.
Evaluate and treat patients for UTI in the perioperative setting when indicated.
ATTITUDES
Hospitalists should be able to:
Communicate with patients and families to explain the 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 specialty consultation, which may include urology or infectious disease services.
Promote and employ prevention measures, which may include early removal of urinary catheters and other interventions to prevent recurrent UTI.
Apply judicious antibiotic selection to help reduce antibiotic resistance.
Employ a multidisciplinary approach to the care of patients with complicated UTI that begins on admission and continues through all care transitions.
Appreciate and treat patient's pain.
Document treatment plan, and provide clear discharge instructions for the receiving primary care physician, including duration of antibiotic treatment and need for follow‐up testing.
Provide and coordinate resources to patients to ensure safe transition from the hospital to arranged follow‐up care.
Coordinate discharge plans when patients will require ongoing skilled nursing care.
Utilize evidence based recommendations for the diagnosis and treatment of UTI.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
Implement systems to ensure hospital‐wide adherence to national standards, and document those measures as specified by recognized organizations.
Collaborate with local infection control practitioners to reduce the spread of resistant organisms within the institution.
Lead, coordinate or participate in multidisciplinary initiatives to minimize use and duration of urinary catheters and reduce incidence of hospital‐acquired UTI.
Copyright © 2006 Society of Hospital Medicine
Patient education
The Institute of Medicine has defined patient centered care as one of the six aims for healthcare improvements in the 21st century. Patient centered care requires that physicians and members of multidisciplinary teams effectively inform, educate, reassure and empower patients and families to participate in the creation and implementation of a care plan. Patient safety initiatives focus on the role of patient education in improving the quality of care from the perspective of both patients and clinicians. Hospitalists can develop and promote strategies to improve patient education initiatives and foster greater patient and family involvement in health care decisions and management.
KNOWLEDGE
Hospitalists should be able to:
Describe the guiding principles for patient education.
Explain the factors that impact the success or failure of behavior change strategies.
Identify institutional resources for patient education materials and programs.
Summarize the evidence for the primacy of patient education as a means to improve the quality of health care.
Discuss the contextual factors that influence a patient's readiness to learn new information.
Describe the role of patient education in the management of chronic diseases, which may include diabetes, congestive heart failure, and asthma.
Explain how each patient's socio‐cultural background affects his or her health beliefs and behavior.
Identify barriers to implementation of patient education, including literacy levels and language fluency.
Determine the utility and appropriateness of patient education materials based on specific patient characteristics, which may include culture, literacy, cognitive ability, age, native language, and visual or other sensory impairments.
SKILLS
Hospitalists should be able to:
Identify and assist patients and families who require additional education about their medical illnesses.
Communicate effectively with patients from diverse backgrounds.
Formulate specific patient centered care plans that may include pain management; integration of psychiatric, social, and other support services; and discharge planning.
Describe different methods of delivering patient education and effectively apply this knowledge to the care of individual patients.
Utilize and/or develop methods and materials to fully inform patients and families.
Determine patient and family understanding of severity of illness, prognosis, and their role in determining the goals of care.
Provide patients with safety tips at the time of transfer of care, which may include instructions about medications, tests, procedures, alert symptoms to initiate a physician call, and follow‐up.
ATTITUDES
Hospitalists should be able to:
Recognize the potential for patient education to improve the quality of health care.
Encourage patients to ask questions, keep accurate medication lists and obtain test results.
Ensure that patients understand anticipated therapies, procedures and/or surgery.
Convey diagnosis, prognosis, treatment and support options available for patients and families in a clear, concise, compassionate, culturally sensitive and timely manner.
Provide or arrange for patient education materials and programs for patients with chronic diseases.
Advocate incorporation of patient wishes into care plans.
Appreciate patient education as a tool to improve the experience of clinical care for both patients and families.
Lead, coordinate or participate in the development of team‐based approaches to patient education.
Lead, coordinate or participate in the development of effective quality measures sensitive to the effects of patient education.
The Institute of Medicine has defined patient centered care as one of the six aims for healthcare improvements in the 21st century. Patient centered care requires that physicians and members of multidisciplinary teams effectively inform, educate, reassure and empower patients and families to participate in the creation and implementation of a care plan. Patient safety initiatives focus on the role of patient education in improving the quality of care from the perspective of both patients and clinicians. Hospitalists can develop and promote strategies to improve patient education initiatives and foster greater patient and family involvement in health care decisions and management.
KNOWLEDGE
Hospitalists should be able to:
Describe the guiding principles for patient education.
Explain the factors that impact the success or failure of behavior change strategies.
Identify institutional resources for patient education materials and programs.
Summarize the evidence for the primacy of patient education as a means to improve the quality of health care.
Discuss the contextual factors that influence a patient's readiness to learn new information.
Describe the role of patient education in the management of chronic diseases, which may include diabetes, congestive heart failure, and asthma.
Explain how each patient's socio‐cultural background affects his or her health beliefs and behavior.
Identify barriers to implementation of patient education, including literacy levels and language fluency.
Determine the utility and appropriateness of patient education materials based on specific patient characteristics, which may include culture, literacy, cognitive ability, age, native language, and visual or other sensory impairments.
SKILLS
Hospitalists should be able to:
Identify and assist patients and families who require additional education about their medical illnesses.
Communicate effectively with patients from diverse backgrounds.
Formulate specific patient centered care plans that may include pain management; integration of psychiatric, social, and other support services; and discharge planning.
Describe different methods of delivering patient education and effectively apply this knowledge to the care of individual patients.
Utilize and/or develop methods and materials to fully inform patients and families.
Determine patient and family understanding of severity of illness, prognosis, and their role in determining the goals of care.
Provide patients with safety tips at the time of transfer of care, which may include instructions about medications, tests, procedures, alert symptoms to initiate a physician call, and follow‐up.
ATTITUDES
Hospitalists should be able to:
Recognize the potential for patient education to improve the quality of health care.
Encourage patients to ask questions, keep accurate medication lists and obtain test results.
Ensure that patients understand anticipated therapies, procedures and/or surgery.
Convey diagnosis, prognosis, treatment and support options available for patients and families in a clear, concise, compassionate, culturally sensitive and timely manner.
Provide or arrange for patient education materials and programs for patients with chronic diseases.
Advocate incorporation of patient wishes into care plans.
Appreciate patient education as a tool to improve the experience of clinical care for both patients and families.
Lead, coordinate or participate in the development of team‐based approaches to patient education.
Lead, coordinate or participate in the development of effective quality measures sensitive to the effects of patient education.
The Institute of Medicine has defined patient centered care as one of the six aims for healthcare improvements in the 21st century. Patient centered care requires that physicians and members of multidisciplinary teams effectively inform, educate, reassure and empower patients and families to participate in the creation and implementation of a care plan. Patient safety initiatives focus on the role of patient education in improving the quality of care from the perspective of both patients and clinicians. Hospitalists can develop and promote strategies to improve patient education initiatives and foster greater patient and family involvement in health care decisions and management.
KNOWLEDGE
Hospitalists should be able to:
Describe the guiding principles for patient education.
Explain the factors that impact the success or failure of behavior change strategies.
Identify institutional resources for patient education materials and programs.
Summarize the evidence for the primacy of patient education as a means to improve the quality of health care.
Discuss the contextual factors that influence a patient's readiness to learn new information.
Describe the role of patient education in the management of chronic diseases, which may include diabetes, congestive heart failure, and asthma.
Explain how each patient's socio‐cultural background affects his or her health beliefs and behavior.
Identify barriers to implementation of patient education, including literacy levels and language fluency.
Determine the utility and appropriateness of patient education materials based on specific patient characteristics, which may include culture, literacy, cognitive ability, age, native language, and visual or other sensory impairments.
SKILLS
Hospitalists should be able to:
Identify and assist patients and families who require additional education about their medical illnesses.
Communicate effectively with patients from diverse backgrounds.
Formulate specific patient centered care plans that may include pain management; integration of psychiatric, social, and other support services; and discharge planning.
Describe different methods of delivering patient education and effectively apply this knowledge to the care of individual patients.
Utilize and/or develop methods and materials to fully inform patients and families.
Determine patient and family understanding of severity of illness, prognosis, and their role in determining the goals of care.
Provide patients with safety tips at the time of transfer of care, which may include instructions about medications, tests, procedures, alert symptoms to initiate a physician call, and follow‐up.
ATTITUDES
Hospitalists should be able to:
Recognize the potential for patient education to improve the quality of health care.
Encourage patients to ask questions, keep accurate medication lists and obtain test results.
Ensure that patients understand anticipated therapies, procedures and/or surgery.
Convey diagnosis, prognosis, treatment and support options available for patients and families in a clear, concise, compassionate, culturally sensitive and timely manner.
Provide or arrange for patient education materials and programs for patients with chronic diseases.
Advocate incorporation of patient wishes into care plans.
Appreciate patient education as a tool to improve the experience of clinical care for both patients and families.
Lead, coordinate or participate in the development of team‐based approaches to patient education.
Lead, coordinate or participate in the development of effective quality measures sensitive to the effects of patient education.
Copyright © 2006 Society of Hospital Medicine
Gastrointestinal bleed
Gastrointestinal (GI) bleed refers to any bleeding that originates in the GI tract. Bleeding is generally defined as upper (between the mouth and ligament of Treitz) or lower (from the ligament of Treitz to the anus). Healthcare Cost and Utilization Project (HCUP) 2002 data for the Diagnosis Related Group (DRG) for GI bleed with complications or co‐morbidities reveals approximately 409,000 discharges with an in‐hospital mortality of 3.0%. The mean length‐of‐stay for these patients was 4.4 days, with mean charges of $15,000. Hospitalists provide immediate care for these patients, who often require coordination of care across multiple specialties. Hospitalists lead quality improvement initiatives that optimize the efficiency and quality of care for these patients.
KNOWLEDGE
Hospitalists should be able to:
Explain the multiple potential etiologies or pathophysiologic processes that lead to GI bleeds.
Describe and differentiate the clinical features and presentations of upper and lower GI bleeds.
Explain the differential diagnosis for the most common causes of upper and lower GI bleeds.
Describe the indicated tests required to evaluate GI bleeds.
Explain the risk factors for upper and lower GI bleeds, and clinical indicators of patients at high risk for complications.
Explain the factors that may require early aggressive interventions or increase patient risk for recurrent bleeds.
Risk stratify patients with GI bleeds and determine the level of care required.
Describe the indications for transfusion therapy in GI bleeds, and explain the various methods of treatment for coagulopathy.
Compare the advantages and disadvantages of medical, endoscopic, and surgical treatments for patients with upper and lower GI bleeds.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat GI bleeds.
Explain patient characteristics that on admission portend poor prognosis.
Identify clinical, laboratory and imaging studies that indicate severity of disease.
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, including a directed medication, family and social history.
Perform a physical examination and identify clinical indicators of upper and lower GI bleeds, and evidence of underlying states, which may include liver disease.
Recognize physical findings that indicate clinical instability due to acute blood loss, including digital rectal examination, and interpretation of orthostatic blood pressure and pulse measurements.
Insert a nasogastric tube, perform a gastric lavage, and interpret the results.
Order and interpret results of appropriate laboratory, imaging, and endoscopic testing.
Synthesize results of physical examination, laboratory and imaging studies to determine the best management and care plan for the patient.
Formulate an evidence based treatment plan including nutritional recommendations, pharmacologic agents and dosing, and coordination of endoscopic and surgical interventions tailored to the individual patient.
Determine frequency for laboratory monitoring and transfusion during hospitalization.
Assure adequate intravenous access to allow rapid volume and blood product resuscitation.
Perform rapid hemodynamic resuscitation.
Recognize and treat signs of clinical decompensation and recurrent bleeding.
Assess patients with suspected GI bleeds in a timely manner, 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 disease etiology, prognosis, risk reduction strategies, and symptoms of recurrent GI bleed.
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 risks, benefits, and alternatives to transfusion therapy.
Communicate with patients and families to explain tests and procedures and their indications, and to obtain informed consent.
Recognize the indications for early specialty consultation, which may include interventional radiology, gastroenterology and surgery.
Initiate prevention measures including avoidance of NSAIDs, stress ulcer prophylaxis in critically ill patients, dietary modification, and evidence based medical therapies.
Employ a multidisciplinary approach, which may include nursing, pharmacy and nutrition services, and specialty and referring physicians, to the care of patients with GI bleeds.
Employ a multidisciplinary approach to the care of patients with GI bleed that begins at admission and continues through all care transitions.
Establish and maintain an open dialogue with patients and families regarding care goals and limitations, including palliative care and end‐of‐life wishes.
Address resuscitation status early during hospital stay; discuss and implement end‐of‐life decisions by patient or family when indicated or desired.
Inform receiving physician of pending study results.
Employ multidisciplinary teams to facilitate discharge planning and communicate to outpatient providers the notable events of the hospitalization and anticipated post‐discharge needs.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
Lead, coordinate or participate in the development and promotion of guidelines and/or pathways that facilitate efficient and timely evaluation and treatment of patients with GI bleeds.
Lead, coordinate or participate in multidisciplinary teams, which may include emergency medicine physicians, gastroenterologists and nurses, to develop quality improvement initiatives that promote early identification of GI bleeds and reduce preventable complications.
Develop systems that provide timely reports of pending study results to outpatient providers.
Integrate outcomes research, institution‐specific laboratory policies, and hospital formulary to create indicated and cost‐effective diagnostic and management strategies for patients with GI bleeds.
Gastrointestinal (GI) bleed refers to any bleeding that originates in the GI tract. Bleeding is generally defined as upper (between the mouth and ligament of Treitz) or lower (from the ligament of Treitz to the anus). Healthcare Cost and Utilization Project (HCUP) 2002 data for the Diagnosis Related Group (DRG) for GI bleed with complications or co‐morbidities reveals approximately 409,000 discharges with an in‐hospital mortality of 3.0%. The mean length‐of‐stay for these patients was 4.4 days, with mean charges of $15,000. Hospitalists provide immediate care for these patients, who often require coordination of care across multiple specialties. Hospitalists lead quality improvement initiatives that optimize the efficiency and quality of care for these patients.
KNOWLEDGE
Hospitalists should be able to:
Explain the multiple potential etiologies or pathophysiologic processes that lead to GI bleeds.
Describe and differentiate the clinical features and presentations of upper and lower GI bleeds.
Explain the differential diagnosis for the most common causes of upper and lower GI bleeds.
Describe the indicated tests required to evaluate GI bleeds.
Explain the risk factors for upper and lower GI bleeds, and clinical indicators of patients at high risk for complications.
Explain the factors that may require early aggressive interventions or increase patient risk for recurrent bleeds.
Risk stratify patients with GI bleeds and determine the level of care required.
Describe the indications for transfusion therapy in GI bleeds, and explain the various methods of treatment for coagulopathy.
Compare the advantages and disadvantages of medical, endoscopic, and surgical treatments for patients with upper and lower GI bleeds.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat GI bleeds.
Explain patient characteristics that on admission portend poor prognosis.
Identify clinical, laboratory and imaging studies that indicate severity of disease.
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, including a directed medication, family and social history.
Perform a physical examination and identify clinical indicators of upper and lower GI bleeds, and evidence of underlying states, which may include liver disease.
Recognize physical findings that indicate clinical instability due to acute blood loss, including digital rectal examination, and interpretation of orthostatic blood pressure and pulse measurements.
Insert a nasogastric tube, perform a gastric lavage, and interpret the results.
Order and interpret results of appropriate laboratory, imaging, and endoscopic testing.
Synthesize results of physical examination, laboratory and imaging studies to determine the best management and care plan for the patient.
Formulate an evidence based treatment plan including nutritional recommendations, pharmacologic agents and dosing, and coordination of endoscopic and surgical interventions tailored to the individual patient.
Determine frequency for laboratory monitoring and transfusion during hospitalization.
Assure adequate intravenous access to allow rapid volume and blood product resuscitation.
Perform rapid hemodynamic resuscitation.
Recognize and treat signs of clinical decompensation and recurrent bleeding.
Assess patients with suspected GI bleeds in a timely manner, 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 disease etiology, prognosis, risk reduction strategies, and symptoms of recurrent GI bleed.
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 risks, benefits, and alternatives to transfusion therapy.
Communicate with patients and families to explain tests and procedures and their indications, and to obtain informed consent.
Recognize the indications for early specialty consultation, which may include interventional radiology, gastroenterology and surgery.
Initiate prevention measures including avoidance of NSAIDs, stress ulcer prophylaxis in critically ill patients, dietary modification, and evidence based medical therapies.
Employ a multidisciplinary approach, which may include nursing, pharmacy and nutrition services, and specialty and referring physicians, to the care of patients with GI bleeds.
Employ a multidisciplinary approach to the care of patients with GI bleed that begins at admission and continues through all care transitions.
Establish and maintain an open dialogue with patients and families regarding care goals and limitations, including palliative care and end‐of‐life wishes.
Address resuscitation status early during hospital stay; discuss and implement end‐of‐life decisions by patient or family when indicated or desired.
Inform receiving physician of pending study results.
Employ multidisciplinary teams to facilitate discharge planning and communicate to outpatient providers the notable events of the hospitalization and anticipated post‐discharge needs.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
Lead, coordinate or participate in the development and promotion of guidelines and/or pathways that facilitate efficient and timely evaluation and treatment of patients with GI bleeds.
Lead, coordinate or participate in multidisciplinary teams, which may include emergency medicine physicians, gastroenterologists and nurses, to develop quality improvement initiatives that promote early identification of GI bleeds and reduce preventable complications.
Develop systems that provide timely reports of pending study results to outpatient providers.
Integrate outcomes research, institution‐specific laboratory policies, and hospital formulary to create indicated and cost‐effective diagnostic and management strategies for patients with GI bleeds.
Gastrointestinal (GI) bleed refers to any bleeding that originates in the GI tract. Bleeding is generally defined as upper (between the mouth and ligament of Treitz) or lower (from the ligament of Treitz to the anus). Healthcare Cost and Utilization Project (HCUP) 2002 data for the Diagnosis Related Group (DRG) for GI bleed with complications or co‐morbidities reveals approximately 409,000 discharges with an in‐hospital mortality of 3.0%. The mean length‐of‐stay for these patients was 4.4 days, with mean charges of $15,000. Hospitalists provide immediate care for these patients, who often require coordination of care across multiple specialties. Hospitalists lead quality improvement initiatives that optimize the efficiency and quality of care for these patients.
KNOWLEDGE
Hospitalists should be able to:
Explain the multiple potential etiologies or pathophysiologic processes that lead to GI bleeds.
Describe and differentiate the clinical features and presentations of upper and lower GI bleeds.
Explain the differential diagnosis for the most common causes of upper and lower GI bleeds.
Describe the indicated tests required to evaluate GI bleeds.
Explain the risk factors for upper and lower GI bleeds, and clinical indicators of patients at high risk for complications.
Explain the factors that may require early aggressive interventions or increase patient risk for recurrent bleeds.
Risk stratify patients with GI bleeds and determine the level of care required.
Describe the indications for transfusion therapy in GI bleeds, and explain the various methods of treatment for coagulopathy.
Compare the advantages and disadvantages of medical, endoscopic, and surgical treatments for patients with upper and lower GI bleeds.
Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat GI bleeds.
Explain patient characteristics that on admission portend poor prognosis.
Identify clinical, laboratory and imaging studies that indicate severity of disease.
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, including a directed medication, family and social history.
Perform a physical examination and identify clinical indicators of upper and lower GI bleeds, and evidence of underlying states, which may include liver disease.
Recognize physical findings that indicate clinical instability due to acute blood loss, including digital rectal examination, and interpretation of orthostatic blood pressure and pulse measurements.
Insert a nasogastric tube, perform a gastric lavage, and interpret the results.
Order and interpret results of appropriate laboratory, imaging, and endoscopic testing.
Synthesize results of physical examination, laboratory and imaging studies to determine the best management and care plan for the patient.
Formulate an evidence based treatment plan including nutritional recommendations, pharmacologic agents and dosing, and coordination of endoscopic and surgical interventions tailored to the individual patient.
Determine frequency for laboratory monitoring and transfusion during hospitalization.
Assure adequate intravenous access to allow rapid volume and blood product resuscitation.
Perform rapid hemodynamic resuscitation.
Recognize and treat signs of clinical decompensation and recurrent bleeding.
Assess patients with suspected GI bleeds in a timely manner, 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 disease etiology, prognosis, risk reduction strategies, and symptoms of recurrent GI bleed.
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 risks, benefits, and alternatives to transfusion therapy.
Communicate with patients and families to explain tests and procedures and their indications, and to obtain informed consent.
Recognize the indications for early specialty consultation, which may include interventional radiology, gastroenterology and surgery.
Initiate prevention measures including avoidance of NSAIDs, stress ulcer prophylaxis in critically ill patients, dietary modification, and evidence based medical therapies.
Employ a multidisciplinary approach, which may include nursing, pharmacy and nutrition services, and specialty and referring physicians, to the care of patients with GI bleeds.
Employ a multidisciplinary approach to the care of patients with GI bleed that begins at admission and continues through all care transitions.
Establish and maintain an open dialogue with patients and families regarding care goals and limitations, including palliative care and end‐of‐life wishes.
Address resuscitation status early during hospital stay; discuss and implement end‐of‐life decisions by patient or family when indicated or desired.
Inform receiving physician of pending study results.
Employ multidisciplinary teams to facilitate discharge planning and communicate to outpatient providers the notable events of the hospitalization and anticipated post‐discharge needs.
SYSTEM ORGANIZATION AND IMPROVEMENT
To improve efficiency and quality within their organizations, Hospitalists should:
Lead, coordinate or participate in the development and promotion of guidelines and/or pathways that facilitate efficient and timely evaluation and treatment of patients with GI bleeds.
Lead, coordinate or participate in multidisciplinary teams, which may include emergency medicine physicians, gastroenterologists and nurses, to develop quality improvement initiatives that promote early identification of GI bleeds and reduce preventable complications.
Develop systems that provide timely reports of pending study results to outpatient providers.
Integrate outcomes research, institution‐specific laboratory policies, and hospital formulary to create indicated and cost‐effective diagnostic and management strategies for patients with GI bleeds.
Copyright © 2006 Society of Hospital Medicine
Nutrition and the hospitalized patient
Optimal nutrition in the hospital can facilitate better patient outcomes. Malnutrition in hospitalized patients can lead to poor wound healing, impaired immune function resulting in infectious complications, increased hospital length of stay, and overall increased morbidity and mortality. The prevalence of malnutrition has been reported in up to 50% of hospitalized patients. Early screening for nutritional risk allows for appropriate intervention in the hospital setting, as well as planning for appropriate home services and follow‐up for outpatient nutritional care. Hospitalists use a multidisciplinary approach to evaluate and address the nutritional needs of hospitalized patients. Hospitalists lead, coordinate or participate in multidisciplinary initiatives to improve the nutritional status of hospitalized patients.
KNOWLEDGE
Hospitalists should be able to:
Describe methods of screening for malnutrition.
Identify when a nutrition evaluation by a registered dietitian is required.
Differentiate between basic modified diets and explain the indications for each (sodium, diabetic, renal, and different dietary consistencies).
Explain the indications and contraindications for enteral nutrition.
Describe the indications for parenteral nutrition.
Describe potential complications associated with enteral and parenteral nutrition.
Explain risk factors for the re‐feeding syndrome.
SKILLS
Hospitalists should be able to:
Use objective criteria to determine if a patient is malnourished.
Determine appropriate laboratory measures to ascertain presence of malnutrition.
Utilize individualized modified diets and/or nutritional supplements, which may include total parenteral nutrition, based on the patient's medical condition.
Choose an appropriate enteral nutrition formula when indicated.
Treat for electrolyte abnormalities associated with the re‐feeding syndrome.
Monitor electrolytes as indicated in the setting of enteral and/or parenteral nutritional support.
ATTITUDES
Hospitalists should be able to:
Recognize the importance of adequate nutrition in hospitalized patients.
Recognize when a nutrition evaluation by a registered dietitian is required.
Consult a nutrition specialist for a comprehensive nutritional evaluation when indicated.
Collaborate with clinical nutrition staff to implement the nutrition care plan.
Utilize a team approach for early discharge planning for patients requiring home parenteral or enteral nutrition.
Recognize that specialized nutritional supplementation may be required in certain patient populations, which may include patients with extensive wounds or increased catabolic needs.
Implement routine nutrition screening to identify malnourished patients early in admission.
Lead, coordinate or participate in the development of care pathways for patients requiring enteral or parenteral nutrition.
Coordinate follow‐up nutrition care as part of discharge plans for those patients requiring nutritional support.
Optimal nutrition in the hospital can facilitate better patient outcomes. Malnutrition in hospitalized patients can lead to poor wound healing, impaired immune function resulting in infectious complications, increased hospital length of stay, and overall increased morbidity and mortality. The prevalence of malnutrition has been reported in up to 50% of hospitalized patients. Early screening for nutritional risk allows for appropriate intervention in the hospital setting, as well as planning for appropriate home services and follow‐up for outpatient nutritional care. Hospitalists use a multidisciplinary approach to evaluate and address the nutritional needs of hospitalized patients. Hospitalists lead, coordinate or participate in multidisciplinary initiatives to improve the nutritional status of hospitalized patients.
KNOWLEDGE
Hospitalists should be able to:
Describe methods of screening for malnutrition.
Identify when a nutrition evaluation by a registered dietitian is required.
Differentiate between basic modified diets and explain the indications for each (sodium, diabetic, renal, and different dietary consistencies).
Explain the indications and contraindications for enteral nutrition.
Describe the indications for parenteral nutrition.
Describe potential complications associated with enteral and parenteral nutrition.
Explain risk factors for the re‐feeding syndrome.
SKILLS
Hospitalists should be able to:
Use objective criteria to determine if a patient is malnourished.
Determine appropriate laboratory measures to ascertain presence of malnutrition.
Utilize individualized modified diets and/or nutritional supplements, which may include total parenteral nutrition, based on the patient's medical condition.
Choose an appropriate enteral nutrition formula when indicated.
Treat for electrolyte abnormalities associated with the re‐feeding syndrome.
Monitor electrolytes as indicated in the setting of enteral and/or parenteral nutritional support.
ATTITUDES
Hospitalists should be able to:
Recognize the importance of adequate nutrition in hospitalized patients.
Recognize when a nutrition evaluation by a registered dietitian is required.
Consult a nutrition specialist for a comprehensive nutritional evaluation when indicated.
Collaborate with clinical nutrition staff to implement the nutrition care plan.
Utilize a team approach for early discharge planning for patients requiring home parenteral or enteral nutrition.
Recognize that specialized nutritional supplementation may be required in certain patient populations, which may include patients with extensive wounds or increased catabolic needs.
Implement routine nutrition screening to identify malnourished patients early in admission.
Lead, coordinate or participate in the development of care pathways for patients requiring enteral or parenteral nutrition.
Coordinate follow‐up nutrition care as part of discharge plans for those patients requiring nutritional support.
Optimal nutrition in the hospital can facilitate better patient outcomes. Malnutrition in hospitalized patients can lead to poor wound healing, impaired immune function resulting in infectious complications, increased hospital length of stay, and overall increased morbidity and mortality. The prevalence of malnutrition has been reported in up to 50% of hospitalized patients. Early screening for nutritional risk allows for appropriate intervention in the hospital setting, as well as planning for appropriate home services and follow‐up for outpatient nutritional care. Hospitalists use a multidisciplinary approach to evaluate and address the nutritional needs of hospitalized patients. Hospitalists lead, coordinate or participate in multidisciplinary initiatives to improve the nutritional status of hospitalized patients.
KNOWLEDGE
Hospitalists should be able to:
Describe methods of screening for malnutrition.
Identify when a nutrition evaluation by a registered dietitian is required.
Differentiate between basic modified diets and explain the indications for each (sodium, diabetic, renal, and different dietary consistencies).
Explain the indications and contraindications for enteral nutrition.
Describe the indications for parenteral nutrition.
Describe potential complications associated with enteral and parenteral nutrition.
Explain risk factors for the re‐feeding syndrome.
SKILLS
Hospitalists should be able to:
Use objective criteria to determine if a patient is malnourished.
Determine appropriate laboratory measures to ascertain presence of malnutrition.
Utilize individualized modified diets and/or nutritional supplements, which may include total parenteral nutrition, based on the patient's medical condition.
Choose an appropriate enteral nutrition formula when indicated.
Treat for electrolyte abnormalities associated with the re‐feeding syndrome.
Monitor electrolytes as indicated in the setting of enteral and/or parenteral nutritional support.
ATTITUDES
Hospitalists should be able to:
Recognize the importance of adequate nutrition in hospitalized patients.
Recognize when a nutrition evaluation by a registered dietitian is required.
Consult a nutrition specialist for a comprehensive nutritional evaluation when indicated.
Collaborate with clinical nutrition staff to implement the nutrition care plan.
Utilize a team approach for early discharge planning for patients requiring home parenteral or enteral nutrition.
Recognize that specialized nutritional supplementation may be required in certain patient populations, which may include patients with extensive wounds or increased catabolic needs.
Implement routine nutrition screening to identify malnourished patients early in admission.
Lead, coordinate or participate in the development of care pathways for patients requiring enteral or parenteral nutrition.
Coordinate follow‐up nutrition care as part of discharge plans for those patients requiring nutritional support.
Copyright © 2006 Society of Hospital Medicine