Acute coronary syndrome (ACS) defines a spectrum of ischemic heart disease that may include non‐ST‐segment elevation myocardial infarction (NSTEMI) and ST‐elevation myocardial infarction (STEMI). The American Heart Association (AHA) estimates that 942,000 people with ACS were discharged from acute care hospitals in 2002. This number increased to approximately 1.7 million when including secondary discharge diagnoses. According to the AHA, an estimated $142 billion will be spent on the treatment of heart disease in 2005. Hospitalists diagnose, risk stratify, and initiate early management of patients with ACS. Hospitalists provide leadership for multidisciplinary teams that optimize the quality of inpatient care, maximize opportunities for patient education, and efficiently utilize resources. In addition, hospitalists initiate secondary preventive measures, which increase compliance with outpatient medical regimens.

KNOWLEDGE

Hospitalists should be able to:

• Define and differentiate ACS without enzyme leak, NSTEMI and STEMI.

• Describe the variable clinical presentations of patients with unstable angina and acute myocardial infarction.

• Distinguish ACS from other cardiac and non‐cardiac conditions that may mimic this disease process.

• Describe how cardiac biomarkers are used in the diagnosis of ACS, including timing of testing, and the effects of renal disease and other co‐morbidities.

• Describe the role of noninvasive cardiac tests.

• Explain indications for and risks associated with cardiac catheterization.

• List the major and minor risk factors predisposing patients to coronary artery disease.

• Explain the value and use of validated risk stratification tools.

• Explain indications for hospitalization of patients with chest pain.

• Explain indications and contraindications for thrombolytic therapy.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat ACS.

• Describe factors that indicate the need for early invasive interventions, including angiography, stenting and/or coronary artery bypass grafting.

• 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 with emphasis on presenting symptoms and patient risk factors for coronary artery disease (cad).

• Conduct a physical examination with emphasis on the cardiovascular and pulmonary systems, and recognize clinical signs of acs and disease severity.

• Diagnose acs through interpretation of expedited testing including history, physical examination, electrocardiogram, chest radiograph, and biomarkers.

• Perform early risk stratification using validated risk stratification tools.

• Synthesize results of history, physical examination, ekg, laboratory and imaging studies, and risk stratification tools to determine therapeutic options, formulate an evidence‐based treatment plan, and determine level of care required.

• Identify patients who may benefit from thrombolytic therapy and/or early revascularization.

• Appreciate and treat patient chest pain, anxiety and other discomfort.

• Recognize symptoms and signs of decompensation and initiate immediate indicated therapies.

• Anticipate and address factors that may complicate acs or its management, which may include inadequate response to therapies, cardiopulmonary compromise, or bleeding.

• Assess patients with suspected acs in a timely manner, identify the level of care required, and manage or co‐manage the patient with the primary requesting service.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the history and prognosis of their cardiac disease.

• Communicate with patients and families to explain goals of care plan, discharge instructions, and management after release from the hospital.

• Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.

• Communicate with patients and families to explain tests and procedures and their indications, and to obtain informed consent.

• Recognize indications for early specialty consultation, which may include cardiology and cardiothoracic surgery.

• Initiate secondary prevention measures prior to discharge, which may include smoking cessation, dietary modification, and evidence based medical therapies.

• Employ a multidisciplinary approach, which may include nursing, nutrition, rehabilitation and social services in the care of patients with acs that begins at admission and continues through all care transitions.

• Communicate to outpatient providers the notable events of the hospitalization and post‐discharge needs, including outpatient cardiac rehabilitation.

• Provide and coordinate resources to patients to ensure safe transition from the hospital to arranged follow‐up care.

• Utilize evidence based recommendations and protocols and risk stratification tools for the treatment of acs.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate or participate in efforts to develop protocols to rapidly identify patients with acs and minimize time to intervention.

• Lead, coordinate or participate in efforts between institutions to develop protocols for the rapid identification and transfer of patients with acs to appropriate facilities.

• Implement systems to ensure hospital‐wide adherence to national standards, and document those measures as specified by recognized organizations (jcaho, aha/acc, ahrq or others).

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization, which may include acs and chest pain order sets.

• Lead efforts to educate staff on the importance of smoking cessation counseling and other prevention measures.

• Integrate outcomes research, institution‐specific laboratory policies, and hospital formulary to create indicated and cost‐effective diagnostic and management strategies for patients with acs.

Acute coronary syndrome (ACS) defines a spectrum of ischemic heart disease that may include non‐ST‐segment elevation myocardial infarction (NSTEMI) and ST‐elevation myocardial infarction (STEMI). The American Heart Association (AHA) estimates that 942,000 people with ACS were discharged from acute care hospitals in 2002. This number increased to approximately 1.7 million when including secondary discharge diagnoses. According to the AHA, an estimated $142 billion will be spent on the treatment of heart disease in 2005. Hospitalists diagnose, risk stratify, and initiate early management of patients with ACS. Hospitalists provide leadership for multidisciplinary teams that optimize the quality of inpatient care, maximize opportunities for patient education, and efficiently utilize resources. In addition, hospitalists initiate secondary preventive measures, which increase compliance with outpatient medical regimens.

KNOWLEDGE

Hospitalists should be able to:

• Define and differentiate ACS without enzyme leak, NSTEMI and STEMI.

• Describe the variable clinical presentations of patients with unstable angina and acute myocardial infarction.

• Distinguish ACS from other cardiac and non‐cardiac conditions that may mimic this disease process.

• Describe how cardiac biomarkers are used in the diagnosis of ACS, including timing of testing, and the effects of renal disease and other co‐morbidities.

• Describe the role of noninvasive cardiac tests.

• Explain indications for and risks associated with cardiac catheterization.

• List the major and minor risk factors predisposing patients to coronary artery disease.

• Explain the value and use of validated risk stratification tools.

• Explain indications for hospitalization of patients with chest pain.

• Explain indications and contraindications for thrombolytic therapy.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat ACS.

• Describe factors that indicate the need for early invasive interventions, including angiography, stenting and/or coronary artery bypass grafting.

• 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 with emphasis on presenting symptoms and patient risk factors for coronary artery disease (cad).

• Conduct a physical examination with emphasis on the cardiovascular and pulmonary systems, and recognize clinical signs of acs and disease severity.

• Diagnose acs through interpretation of expedited testing including history, physical examination, electrocardiogram, chest radiograph, and biomarkers.

• Perform early risk stratification using validated risk stratification tools.

• Synthesize results of history, physical examination, ekg, laboratory and imaging studies, and risk stratification tools to determine therapeutic options, formulate an evidence‐based treatment plan, and determine level of care required.

• Identify patients who may benefit from thrombolytic therapy and/or early revascularization.

• Appreciate and treat patient chest pain, anxiety and other discomfort.

• Recognize symptoms and signs of decompensation and initiate immediate indicated therapies.

• Anticipate and address factors that may complicate acs or its management, which may include inadequate response to therapies, cardiopulmonary compromise, or bleeding.

• Assess patients with suspected acs in a timely manner, identify the level of care required, and manage or co‐manage the patient with the primary requesting service.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the history and prognosis of their cardiac disease.

• Communicate with patients and families to explain goals of care plan, discharge instructions, and management after release from the hospital.

• Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.

• Communicate with patients and families to explain tests and procedures and their indications, and to obtain informed consent.

• Recognize indications for early specialty consultation, which may include cardiology and cardiothoracic surgery.

• Initiate secondary prevention measures prior to discharge, which may include smoking cessation, dietary modification, and evidence based medical therapies.

• Employ a multidisciplinary approach, which may include nursing, nutrition, rehabilitation and social services in the care of patients with acs that begins at admission and continues through all care transitions.

• Communicate to outpatient providers the notable events of the hospitalization and post‐discharge needs, including outpatient cardiac rehabilitation.

• Provide and coordinate resources to patients to ensure safe transition from the hospital to arranged follow‐up care.

• Utilize evidence based recommendations and protocols and risk stratification tools for the treatment of acs.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate or participate in efforts to develop protocols to rapidly identify patients with acs and minimize time to intervention.

• Lead, coordinate or participate in efforts between institutions to develop protocols for the rapid identification and transfer of patients with acs to appropriate facilities.

• Implement systems to ensure hospital‐wide adherence to national standards, and document those measures as specified by recognized organizations (jcaho, aha/acc, ahrq or others).

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization, which may include acs and chest pain order sets.

• Lead efforts to educate staff on the importance of smoking cessation counseling and other prevention measures.

• Integrate outcomes research, institution‐specific laboratory policies, and hospital formulary to create indicated and cost‐effective diagnostic and management strategies for patients with acs.

Acute coronary syndrome (ACS) defines a spectrum of ischemic heart disease that may include non‐ST‐segment elevation myocardial infarction (NSTEMI) and ST‐elevation myocardial infarction (STEMI). The American Heart Association (AHA) estimates that 942,000 people with ACS were discharged from acute care hospitals in 2002. This number increased to approximately 1.7 million when including secondary discharge diagnoses. According to the AHA, an estimated $142 billion will be spent on the treatment of heart disease in 2005. Hospitalists diagnose, risk stratify, and initiate early management of patients with ACS. Hospitalists provide leadership for multidisciplinary teams that optimize the quality of inpatient care, maximize opportunities for patient education, and efficiently utilize resources. In addition, hospitalists initiate secondary preventive measures, which increase compliance with outpatient medical regimens.

KNOWLEDGE

Hospitalists should be able to:

• Define and differentiate ACS without enzyme leak, NSTEMI and STEMI.

• Describe the variable clinical presentations of patients with unstable angina and acute myocardial infarction.

• Distinguish ACS from other cardiac and non‐cardiac conditions that may mimic this disease process.

• Describe how cardiac biomarkers are used in the diagnosis of ACS, including timing of testing, and the effects of renal disease and other co‐morbidities.

• Describe the role of noninvasive cardiac tests.

• Explain indications for and risks associated with cardiac catheterization.

• List the major and minor risk factors predisposing patients to coronary artery disease.

• Explain the value and use of validated risk stratification tools.

• Explain indications for hospitalization of patients with chest pain.

• Explain indications and contraindications for thrombolytic therapy.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat ACS.

• Describe factors that indicate the need for early invasive interventions, including angiography, stenting and/or coronary artery bypass grafting.

• 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 with emphasis on presenting symptoms and patient risk factors for coronary artery disease (cad).

• Conduct a physical examination with emphasis on the cardiovascular and pulmonary systems, and recognize clinical signs of acs and disease severity.

• Diagnose acs through interpretation of expedited testing including history, physical examination, electrocardiogram, chest radiograph, and biomarkers.

• Perform early risk stratification using validated risk stratification tools.

• Synthesize results of history, physical examination, ekg, laboratory and imaging studies, and risk stratification tools to determine therapeutic options, formulate an evidence‐based treatment plan, and determine level of care required.

• Identify patients who may benefit from thrombolytic therapy and/or early revascularization.

• Appreciate and treat patient chest pain, anxiety and other discomfort.

• Recognize symptoms and signs of decompensation and initiate immediate indicated therapies.

• Anticipate and address factors that may complicate acs or its management, which may include inadequate response to therapies, cardiopulmonary compromise, or bleeding.

• Assess patients with suspected acs in a timely manner, identify the level of care required, and manage or co‐manage the patient with the primary requesting service.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the history and prognosis of their cardiac disease.

• Communicate with patients and families to explain goals of care plan, discharge instructions, and management after release from the hospital.

• Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.

• Communicate with patients and families to explain tests and procedures and their indications, and to obtain informed consent.

• Recognize indications for early specialty consultation, which may include cardiology and cardiothoracic surgery.

• Initiate secondary prevention measures prior to discharge, which may include smoking cessation, dietary modification, and evidence based medical therapies.

• Employ a multidisciplinary approach, which may include nursing, nutrition, rehabilitation and social services in the care of patients with acs that begins at admission and continues through all care transitions.

• Communicate to outpatient providers the notable events of the hospitalization and post‐discharge needs, including outpatient cardiac rehabilitation.

• Provide and coordinate resources to patients to ensure safe transition from the hospital to arranged follow‐up care.

• Utilize evidence based recommendations and protocols and risk stratification tools for the treatment of acs.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, hospitalists should:

• Lead, coordinate or participate in efforts to develop protocols to rapidly identify patients with acs and minimize time to intervention.

• Lead, coordinate or participate in efforts between institutions to develop protocols for the rapid identification and transfer of patients with acs to appropriate facilities.

• Implement systems to ensure hospital‐wide adherence to national standards, and document those measures as specified by recognized organizations (jcaho, aha/acc, ahrq or others).

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization, which may include acs and chest pain order sets.

• Lead efforts to educate staff on the importance of smoking cessation counseling and other prevention measures.

• Integrate outcomes research, institution‐specific laboratory policies, and hospital formulary to create indicated and cost‐effective diagnostic and management strategies for patients with acs.

Hospitalist as teacher refers to specific interactions with members of the multidisciplinary care team to educate them about inpatient care plans, hospital protocols, patient safety, and evidence based clinical problem solving. As educators, hospitalists provide leadership in patient care, teach at multiple levels, and facilitate team building. Hospitalists serve as role models and teach the process of clinical decision making as a tool for future physician‐patient encounters. Hospitalists may review, modify, and promote new protocols and guidelines to implement across multiple services in the hospital. The hospitalist as teacher is a core competency essential to the process of effecting organizational change.

KNOWLEDGE

Hospitalists should be able to:

• Describe adult education principles.

• Explain the conditions that facilitate and inhibit learning.

• Define the concept of a teachable moment.

• Describe the process of developing a formal educational session, which may include needs assessment, determining goals and objectives, development of materials and teaching activities, and evaluation

• Describe practical steps that may be taken to deliver dynamic presentations for multiple venues, which may include bedside teaching to trainees, small group discussions with co‐workers or managers, academic detailing for new initiatives, and didactic lectures at national meetings.

• Describe teaching microskills, including obtaining a commitment, probing for supporting evidence, teaching general rules, reinforcing what was right, and correcting mistakes.

• Describe the benefits and limitations of various teaching modalities.

• Identify resources for training materials.

• Explain how the SHM Core Competencies can be applied to curricular development.

• Explain the role of the hospitalist as a teacher.

SKILLS

Hospitalists should be able to:

• Establish a comfortable and safe learning environment.

• Establish expectations for each teaching session and clearly articulate the objectives.

• Effectively communicate the goals of the learning session and assess progress towards those goals.

• Instruct at the level of learner experience and knowledge, and accommodate for learners at different levels.

• Determine the information needs of the intended recipient and evaluate performance.

• Tailor messages to the needs and abilities of intended recipient.

• Structure and organize the timing and delivery of information and learning experiences to maximize comprehension.

• Utilize adult learning principles in the development or selection of educational programs, methods and materials.

• Use explicit and relevant language to explain clinical reasoning process for the learner, who may include patients and families.

• Make the clinical reasoning process understandable, explicit, and relevant.

• Promote clinical problem solving during each patient encounter.

• Provide bedside teaching that is informative and comfortable for patients, trainees and members of the multidisciplinary care team.

• Demonstrate effective mentoring, which may include role modeling.

• Demonstrate procedures by explaining indications and contraindications, equipment, each sequential step in the procedure, and necessary follow‐up.

• Demonstrate an efficient and succinct approach to clinical care.

• Provide prompt, explicit, and action‐oriented feedback.

ATTITUDES

Hospitalists should be able to:

• Advocate the importance of lifelong learning and mentorship.

• Balance patient care and teaching.

• Demonstrate concern for the privacy and dignity of the patient.

• Adhere to time constraints.

• Establish a trusting relationship with patients and families, medical trainees, and the multidisciplinary team.

• Demonstrate respect for all learners at various knowledge and skill levels.

• Promote evaluation standards that are fair and prompt and facilitate career development.

• Appreciate the needs of the learner and the patient.

• Project enthusiasm for the teaching role.

• Admit the limitations of one's knowledge and respond appropriately to mistakes.

• Encourage and provide the tools for life‐long, self‐directed learning and clinical problem solving.

• Lead, coordinate or participate in efforts to formulate a needs assessment program for hospitalists' continued professional development.

• Lead, coordinate and participate in educational scholarship.

• Seek feedback on the effectiveness of instruction methods, modalities and materials.

• Reflect on teaching moments to identify opportunities for improvement.

• Promote evidence based information acquisition and clinical decision making.

• Utilize the role of the hospitalist as a clinician educator to lead, coordinate or participate in quality improvement initiatives.

Hospitalist as teacher refers to specific interactions with members of the multidisciplinary care team to educate them about inpatient care plans, hospital protocols, patient safety, and evidence based clinical problem solving. As educators, hospitalists provide leadership in patient care, teach at multiple levels, and facilitate team building. Hospitalists serve as role models and teach the process of clinical decision making as a tool for future physician‐patient encounters. Hospitalists may review, modify, and promote new protocols and guidelines to implement across multiple services in the hospital. The hospitalist as teacher is a core competency essential to the process of effecting organizational change.

KNOWLEDGE

Hospitalists should be able to:

• Describe adult education principles.

• Explain the conditions that facilitate and inhibit learning.

• Define the concept of a teachable moment.

• Describe the process of developing a formal educational session, which may include needs assessment, determining goals and objectives, development of materials and teaching activities, and evaluation

• Describe practical steps that may be taken to deliver dynamic presentations for multiple venues, which may include bedside teaching to trainees, small group discussions with co‐workers or managers, academic detailing for new initiatives, and didactic lectures at national meetings.

• Describe teaching microskills, including obtaining a commitment, probing for supporting evidence, teaching general rules, reinforcing what was right, and correcting mistakes.

• Describe the benefits and limitations of various teaching modalities.

• Identify resources for training materials.

• Explain how the SHM Core Competencies can be applied to curricular development.

• Explain the role of the hospitalist as a teacher.

SKILLS

Hospitalists should be able to:

• Establish a comfortable and safe learning environment.

• Establish expectations for each teaching session and clearly articulate the objectives.

• Effectively communicate the goals of the learning session and assess progress towards those goals.

• Instruct at the level of learner experience and knowledge, and accommodate for learners at different levels.

• Determine the information needs of the intended recipient and evaluate performance.

• Tailor messages to the needs and abilities of intended recipient.

• Structure and organize the timing and delivery of information and learning experiences to maximize comprehension.

• Utilize adult learning principles in the development or selection of educational programs, methods and materials.

• Use explicit and relevant language to explain clinical reasoning process for the learner, who may include patients and families.

• Make the clinical reasoning process understandable, explicit, and relevant.

• Promote clinical problem solving during each patient encounter.

• Provide bedside teaching that is informative and comfortable for patients, trainees and members of the multidisciplinary care team.

• Demonstrate effective mentoring, which may include role modeling.

• Demonstrate procedures by explaining indications and contraindications, equipment, each sequential step in the procedure, and necessary follow‐up.

• Demonstrate an efficient and succinct approach to clinical care.

• Provide prompt, explicit, and action‐oriented feedback.

ATTITUDES

Hospitalists should be able to:

• Advocate the importance of lifelong learning and mentorship.

• Balance patient care and teaching.

• Demonstrate concern for the privacy and dignity of the patient.

• Adhere to time constraints.

• Establish a trusting relationship with patients and families, medical trainees, and the multidisciplinary team.

• Demonstrate respect for all learners at various knowledge and skill levels.

• Promote evaluation standards that are fair and prompt and facilitate career development.

• Appreciate the needs of the learner and the patient.

• Project enthusiasm for the teaching role.

• Admit the limitations of one's knowledge and respond appropriately to mistakes.

• Encourage and provide the tools for life‐long, self‐directed learning and clinical problem solving.

• Lead, coordinate or participate in efforts to formulate a needs assessment program for hospitalists' continued professional development.

• Lead, coordinate and participate in educational scholarship.

• Seek feedback on the effectiveness of instruction methods, modalities and materials.

• Reflect on teaching moments to identify opportunities for improvement.

• Promote evidence based information acquisition and clinical decision making.

• Utilize the role of the hospitalist as a clinician educator to lead, coordinate or participate in quality improvement initiatives.

Hospitalist as teacher refers to specific interactions with members of the multidisciplinary care team to educate them about inpatient care plans, hospital protocols, patient safety, and evidence based clinical problem solving. As educators, hospitalists provide leadership in patient care, teach at multiple levels, and facilitate team building. Hospitalists serve as role models and teach the process of clinical decision making as a tool for future physician‐patient encounters. Hospitalists may review, modify, and promote new protocols and guidelines to implement across multiple services in the hospital. The hospitalist as teacher is a core competency essential to the process of effecting organizational change.

KNOWLEDGE

Hospitalists should be able to:

• Describe adult education principles.

• Explain the conditions that facilitate and inhibit learning.

• Define the concept of a teachable moment.

• Describe the process of developing a formal educational session, which may include needs assessment, determining goals and objectives, development of materials and teaching activities, and evaluation

• Describe practical steps that may be taken to deliver dynamic presentations for multiple venues, which may include bedside teaching to trainees, small group discussions with co‐workers or managers, academic detailing for new initiatives, and didactic lectures at national meetings.

• Describe teaching microskills, including obtaining a commitment, probing for supporting evidence, teaching general rules, reinforcing what was right, and correcting mistakes.

• Describe the benefits and limitations of various teaching modalities.

• Identify resources for training materials.

• Explain how the SHM Core Competencies can be applied to curricular development.

• Explain the role of the hospitalist as a teacher.

SKILLS

Hospitalists should be able to:

• Establish a comfortable and safe learning environment.

• Establish expectations for each teaching session and clearly articulate the objectives.

• Effectively communicate the goals of the learning session and assess progress towards those goals.

• Instruct at the level of learner experience and knowledge, and accommodate for learners at different levels.

• Determine the information needs of the intended recipient and evaluate performance.

• Tailor messages to the needs and abilities of intended recipient.

• Structure and organize the timing and delivery of information and learning experiences to maximize comprehension.

• Utilize adult learning principles in the development or selection of educational programs, methods and materials.

• Use explicit and relevant language to explain clinical reasoning process for the learner, who may include patients and families.

• Make the clinical reasoning process understandable, explicit, and relevant.

• Promote clinical problem solving during each patient encounter.

• Provide bedside teaching that is informative and comfortable for patients, trainees and members of the multidisciplinary care team.

• Demonstrate effective mentoring, which may include role modeling.

• Demonstrate procedures by explaining indications and contraindications, equipment, each sequential step in the procedure, and necessary follow‐up.

• Demonstrate an efficient and succinct approach to clinical care.

• Provide prompt, explicit, and action‐oriented feedback.

ATTITUDES

Hospitalists should be able to:

• Advocate the importance of lifelong learning and mentorship.

• Balance patient care and teaching.

• Demonstrate concern for the privacy and dignity of the patient.

• Adhere to time constraints.

• Establish a trusting relationship with patients and families, medical trainees, and the multidisciplinary team.

• Demonstrate respect for all learners at various knowledge and skill levels.

• Promote evaluation standards that are fair and prompt and facilitate career development.

• Appreciate the needs of the learner and the patient.

• Project enthusiasm for the teaching role.

• Admit the limitations of one's knowledge and respond appropriately to mistakes.

• Encourage and provide the tools for life‐long, self‐directed learning and clinical problem solving.

• Lead, coordinate or participate in efforts to formulate a needs assessment program for hospitalists' continued professional development.

• Lead, coordinate and participate in educational scholarship.

• Seek feedback on the effectiveness of instruction methods, modalities and materials.

• Reflect on teaching moments to identify opportunities for improvement.

• Promote evidence based information acquisition and clinical decision making.

• Utilize the role of the hospitalist as a clinician educator to lead, coordinate or participate in quality improvement initiatives.

Stroke is defined as damage to brain tissue resulting from interruption in blood flow. The American Heart Association (AHA) reports 942,000 discharges for stroke in 2002. Stroke accounted for 1 in 15 deaths in the United States that same year. The average length of stay has been markedly decreasing, but is still almost six days. The estimated direct and indirect cost of stroke in 2005 is $56.8 billion. Stroke care is a rapidly evolving field in which expeditious and careful inpatient care significantly affects outcome. The hospitalist is frequently the primary provider of care for these inpatients. Therefore, it is incumbent on hospitalists to develop the knowledge and skills to identify and manage all types of strokes, coordinate specialty and primary care resources, and guide patients safely and cost‐effectively through the acute hospitalization and back into the outpatient setting.

KNOWLEDGE

Hospitalists should be able to:

• Describe the ischemic and hemorrhagic causes of stroke.

• Describe the relationship between the anatomic location of stroke and clinical presentation.

• Employ appropriate imaging and laboratory evaluation to exclude conditions that mimic stroke, guide therapy, and help determine etiology in patients with and without traditional risk factors.

• List risk factors for ischemic and hemorrhagic stroke.

• State indications and contraindications for thrombolytic therapy in the setting of acute stroke.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat stroke.

• Explain the optimal blood pressure control for individual patients presenting with different types of stroke.

• State indications for early surgical and endovascular interventions.

• Explain the spectrum of functional outcomes of different types of stroke and how these relate to the initial presentation.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

• Elicit pertinent details of clinical history and symptoms that are typical of stroke.

• Perform a directed physical examination with emphasis on thorough neurological examination to help guide further evaluation and treatment.

• Diagnose the etiology of stroke through interpretation of initial testing including history, physical examination, electrocardiogram, neurological imaging, and laboratory results.

• Initiate indicated acute therapies to improve the prognosis of stroke.

• Identify patients at risk for acute decompensation, which may include those with signs of increased intracranial pressure and posterior circulation disease, and initiate appropriate therapy.

• Identify patients at risk for aspiration and address nutritional issues.

• Manage the airway when indicated.

• Maintain temperature, blood pressure and glycemic control.

• Assess patients with stroke 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 history and prognosis of stroke.

• Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.

• Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.

• Communicate with patients and families to explain the tests and procedures and their indications, and to obtain informed consent.

• Recognize the indications for early specialty consultation, which may include neurology, neurosurgery and interventional radiology.

• Employ prophylaxis against common complications, which may include urinary tract infection, aspiration pneumonia, and venous thromboembolism.

• Initiate secondary stroke prevention.

• Employ an early and multidisciplinary approach to the care of stroke patients that begins at admission and continues through all care transitions.

• Address resuscitation status early during hospital stay; implement end‐of‐life decisions by patients and/or families when indicated or desired.

• Recognize barriers to follow‐up care of stroke patients and involve multidisciplinary hospital staff to accordingly tailor medications and transition of care plans.

• Communicate to outpatient providers the notable events of the hospitalization and post‐discharge needs, which may include outpatient cardiac rehabilitation.

• Utilize evidence based recommendations and protocols and risk stratification tools for the treatment of stroke.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, Hospitalists should:

• Lead, coordinate or participate in multidisciplinary teams, which may include neurology, rehabilitation medicine, nursing, physical and occupational therapy, speech pathology and other allied health professionals, early in the hospital course to reduce complications, facilitate patient education and discharge planning.

• Lead, coordinate or participate in multidisciplinary efforts to develop protocols to rapidly identify stroke patients with indications for acute interventions and minimize time to intervention.

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization, including aggressive treatment of risk factors and rehabilitation.

Stroke is defined as damage to brain tissue resulting from interruption in blood flow. The American Heart Association (AHA) reports 942,000 discharges for stroke in 2002. Stroke accounted for 1 in 15 deaths in the United States that same year. The average length of stay has been markedly decreasing, but is still almost six days. The estimated direct and indirect cost of stroke in 2005 is $56.8 billion. Stroke care is a rapidly evolving field in which expeditious and careful inpatient care significantly affects outcome. The hospitalist is frequently the primary provider of care for these inpatients. Therefore, it is incumbent on hospitalists to develop the knowledge and skills to identify and manage all types of strokes, coordinate specialty and primary care resources, and guide patients safely and cost‐effectively through the acute hospitalization and back into the outpatient setting.

KNOWLEDGE

Hospitalists should be able to:

• Describe the ischemic and hemorrhagic causes of stroke.

• Describe the relationship between the anatomic location of stroke and clinical presentation.

• Employ appropriate imaging and laboratory evaluation to exclude conditions that mimic stroke, guide therapy, and help determine etiology in patients with and without traditional risk factors.

• List risk factors for ischemic and hemorrhagic stroke.

• State indications and contraindications for thrombolytic therapy in the setting of acute stroke.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat stroke.

• Explain the optimal blood pressure control for individual patients presenting with different types of stroke.

• State indications for early surgical and endovascular interventions.

• Explain the spectrum of functional outcomes of different types of stroke and how these relate to the initial presentation.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

• Elicit pertinent details of clinical history and symptoms that are typical of stroke.

• Perform a directed physical examination with emphasis on thorough neurological examination to help guide further evaluation and treatment.

• Diagnose the etiology of stroke through interpretation of initial testing including history, physical examination, electrocardiogram, neurological imaging, and laboratory results.

• Initiate indicated acute therapies to improve the prognosis of stroke.

• Identify patients at risk for acute decompensation, which may include those with signs of increased intracranial pressure and posterior circulation disease, and initiate appropriate therapy.

• Identify patients at risk for aspiration and address nutritional issues.

• Manage the airway when indicated.

• Maintain temperature, blood pressure and glycemic control.

• Assess patients with stroke 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 history and prognosis of stroke.

• Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.

• Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.

• Communicate with patients and families to explain the tests and procedures and their indications, and to obtain informed consent.

• Recognize the indications for early specialty consultation, which may include neurology, neurosurgery and interventional radiology.

• Employ prophylaxis against common complications, which may include urinary tract infection, aspiration pneumonia, and venous thromboembolism.

• Initiate secondary stroke prevention.

• Employ an early and multidisciplinary approach to the care of stroke patients that begins at admission and continues through all care transitions.

• Address resuscitation status early during hospital stay; implement end‐of‐life decisions by patients and/or families when indicated or desired.

• Recognize barriers to follow‐up care of stroke patients and involve multidisciplinary hospital staff to accordingly tailor medications and transition of care plans.

• Communicate to outpatient providers the notable events of the hospitalization and post‐discharge needs, which may include outpatient cardiac rehabilitation.

• Utilize evidence based recommendations and protocols and risk stratification tools for the treatment of stroke.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, Hospitalists should:

• Lead, coordinate or participate in multidisciplinary teams, which may include neurology, rehabilitation medicine, nursing, physical and occupational therapy, speech pathology and other allied health professionals, early in the hospital course to reduce complications, facilitate patient education and discharge planning.

• Lead, coordinate or participate in multidisciplinary efforts to develop protocols to rapidly identify stroke patients with indications for acute interventions and minimize time to intervention.

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization, including aggressive treatment of risk factors and rehabilitation.

Stroke is defined as damage to brain tissue resulting from interruption in blood flow. The American Heart Association (AHA) reports 942,000 discharges for stroke in 2002. Stroke accounted for 1 in 15 deaths in the United States that same year. The average length of stay has been markedly decreasing, but is still almost six days. The estimated direct and indirect cost of stroke in 2005 is $56.8 billion. Stroke care is a rapidly evolving field in which expeditious and careful inpatient care significantly affects outcome. The hospitalist is frequently the primary provider of care for these inpatients. Therefore, it is incumbent on hospitalists to develop the knowledge and skills to identify and manage all types of strokes, coordinate specialty and primary care resources, and guide patients safely and cost‐effectively through the acute hospitalization and back into the outpatient setting.

KNOWLEDGE

Hospitalists should be able to:

• Describe the ischemic and hemorrhagic causes of stroke.

• Describe the relationship between the anatomic location of stroke and clinical presentation.

• Employ appropriate imaging and laboratory evaluation to exclude conditions that mimic stroke, guide therapy, and help determine etiology in patients with and without traditional risk factors.

• List risk factors for ischemic and hemorrhagic stroke.

• State indications and contraindications for thrombolytic therapy in the setting of acute stroke.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat stroke.

• Explain the optimal blood pressure control for individual patients presenting with different types of stroke.

• State indications for early surgical and endovascular interventions.

• Explain the spectrum of functional outcomes of different types of stroke and how these relate to the initial presentation.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

• Elicit pertinent details of clinical history and symptoms that are typical of stroke.

• Perform a directed physical examination with emphasis on thorough neurological examination to help guide further evaluation and treatment.

• Diagnose the etiology of stroke through interpretation of initial testing including history, physical examination, electrocardiogram, neurological imaging, and laboratory results.

• Initiate indicated acute therapies to improve the prognosis of stroke.

• Identify patients at risk for acute decompensation, which may include those with signs of increased intracranial pressure and posterior circulation disease, and initiate appropriate therapy.

• Identify patients at risk for aspiration and address nutritional issues.

• Manage the airway when indicated.

• Maintain temperature, blood pressure and glycemic control.

• Assess patients with stroke 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 history and prognosis of stroke.

• Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.

• Communicate with patients and families to explain tests and procedures, and the use and potential side effects of pharmacologic agents.

• Communicate with patients and families to explain the tests and procedures and their indications, and to obtain informed consent.

• Recognize the indications for early specialty consultation, which may include neurology, neurosurgery and interventional radiology.

• Employ prophylaxis against common complications, which may include urinary tract infection, aspiration pneumonia, and venous thromboembolism.

• Initiate secondary stroke prevention.

• Employ an early and multidisciplinary approach to the care of stroke patients that begins at admission and continues through all care transitions.

• Address resuscitation status early during hospital stay; implement end‐of‐life decisions by patients and/or families when indicated or desired.

• Recognize barriers to follow‐up care of stroke patients and involve multidisciplinary hospital staff to accordingly tailor medications and transition of care plans.

• Communicate to outpatient providers the notable events of the hospitalization and post‐discharge needs, which may include outpatient cardiac rehabilitation.

• Utilize evidence based recommendations and protocols and risk stratification tools for the treatment of stroke.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, Hospitalists should:

• Lead, coordinate or participate in multidisciplinary teams, which may include neurology, rehabilitation medicine, nursing, physical and occupational therapy, speech pathology and other allied health professionals, early in the hospital course to reduce complications, facilitate patient education and discharge planning.

• Lead, coordinate or participate in multidisciplinary efforts to develop protocols to rapidly identify stroke patients with indications for acute interventions and minimize time to intervention.

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization, including aggressive treatment of risk factors and rehabilitation.

Paracentesis, the aspiration of fluid from the abdominal cavity, is a diagnostic and therapeutic procedure frequently performed in the hospital. Paracentesis was performed in almost 90,000 discharges in 2002, according to the Healthcare Cost and Utilization Project (HCUP). Hospitalists identify patients with suspected ascites on the basis of the clinical presentation, physical examination and/or ultrasonography. Utilizing evidence based decision making, hospitalists determine whether paracentesis is indicated in the diagnosis of disease or palliation of patient symptoms.

KNOWLEDGE

Hospitalists should be able to:

• Describe the normal anatomy of the abdomen and pelvis.

• Define and differentiate pathophysiologic processes that may lead to the development of ascites.

• Describe clinical presentations consistent with spontaneous bacterial peritonitis.

• Explain indications and contraindications for paracentesis, including potential risks and complications.

• Describe the physical examination maneuvers used in the evaluation of ascites and identify their sensitivity and specificity.

• Differentiate the indications for a diagnostic paracentesis versus a large‐volume paracentesis.

• Explain the appropriate diagnostic testing for ascitic fluid.

• Describe indications for use of ultrasonography to assess the quantity of ascitic fluid and/or to guide paracentesis.

• Select the necessary equipment to perform a paracentesis at the bedside, and differentiate what is needed for a diagnostic versus a large‐volume paracentesis.

• Define the serum‐ascites albumin gradient and its role in the evaluation of ascites.

• Identify the indications for administration of albumin in conjunction with paracentesis.

• Identify patients with ascites who may benefit from large‐volume paracentesis.

SKILLS

Hospitalists should be able to:

• Elicit a thorough and relevant history to identify co‐morbid conditions and risk factors for the development or complications of ascites.

• Perform a thorough physical examination, evaluating for signs associated with chronic liver disease or malignancy.

• Perform an abdominal examination, including specific maneuvers to assess for the presence of ascites.

• Properly position the patient and identify anatomic landmarks to perform a paracentesis.

• Use sterile techniques during preparation for and performance of paracentesis.

• Maintain clinician safety with appropriate protective wear.

• Manage the complications of paracentesis following the procedure, which ma include bleeding, persistent leak of ascitic fluid, and hemodynamic compromise.

• Order and interpret the results of ascitic fluid analysis, including cell count, differential, gram stain and culture, and serum‐ascites albumin gradient.

• Order and interpret platelet and coagulation studies when indicated.

• Synthesize a management plan based on history, physical examination, radiographic imaging and the results of fluid testing.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, and potential complications; and to obtain informed consent.

• Manage patient discomfort or pain during and after the procedure.

• Identify patients who may benefit from transfusion of fresh frozen plasma and/or platelets prior to paracentesis.

• Recognize the indications for specialty consultations, which may include interventional radiology or gastroenterology.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their institutions, Hospitalists should:

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.

• Lead, coordinate or participate in development of institutional guidelines for the pre‐procedure utilization of fresh frozen plasma and platelet transfusions in patients with coagulopathy or thrombocytopenia.

• Lead, coordinate or participate in development of institutional guidelines to identify patients who should receive albumin peri‐procedure.

• Collaborate with radiologists to standardize identification of patients who would benefit from ultrasound‐guided paracentesis.

• Lead, coordinate or participate in efforts to develop strategies to minimize institutional complication rates.

• Lead, coordinate or participate in quality improvement programs to monitor hospitalists' performance and/or supervision of paracentesis.

• Lead, coordinate, or participate in efforts to organize and consolidate paracentesis equipment in an identifiable location in the hospital, easily accessible to clinicians who perform the procedure.

Paracentesis, the aspiration of fluid from the abdominal cavity, is a diagnostic and therapeutic procedure frequently performed in the hospital. Paracentesis was performed in almost 90,000 discharges in 2002, according to the Healthcare Cost and Utilization Project (HCUP). Hospitalists identify patients with suspected ascites on the basis of the clinical presentation, physical examination and/or ultrasonography. Utilizing evidence based decision making, hospitalists determine whether paracentesis is indicated in the diagnosis of disease or palliation of patient symptoms.

KNOWLEDGE

Hospitalists should be able to:

• Describe the normal anatomy of the abdomen and pelvis.

• Define and differentiate pathophysiologic processes that may lead to the development of ascites.

• Describe clinical presentations consistent with spontaneous bacterial peritonitis.

• Explain indications and contraindications for paracentesis, including potential risks and complications.

• Describe the physical examination maneuvers used in the evaluation of ascites and identify their sensitivity and specificity.

• Differentiate the indications for a diagnostic paracentesis versus a large‐volume paracentesis.

• Explain the appropriate diagnostic testing for ascitic fluid.

• Describe indications for use of ultrasonography to assess the quantity of ascitic fluid and/or to guide paracentesis.

• Select the necessary equipment to perform a paracentesis at the bedside, and differentiate what is needed for a diagnostic versus a large‐volume paracentesis.

• Define the serum‐ascites albumin gradient and its role in the evaluation of ascites.

• Identify the indications for administration of albumin in conjunction with paracentesis.

• Identify patients with ascites who may benefit from large‐volume paracentesis.

SKILLS

Hospitalists should be able to:

• Elicit a thorough and relevant history to identify co‐morbid conditions and risk factors for the development or complications of ascites.

• Perform a thorough physical examination, evaluating for signs associated with chronic liver disease or malignancy.

• Perform an abdominal examination, including specific maneuvers to assess for the presence of ascites.

• Properly position the patient and identify anatomic landmarks to perform a paracentesis.

• Use sterile techniques during preparation for and performance of paracentesis.

• Maintain clinician safety with appropriate protective wear.

• Manage the complications of paracentesis following the procedure, which ma include bleeding, persistent leak of ascitic fluid, and hemodynamic compromise.

• Order and interpret the results of ascitic fluid analysis, including cell count, differential, gram stain and culture, and serum‐ascites albumin gradient.

• Order and interpret platelet and coagulation studies when indicated.

• Synthesize a management plan based on history, physical examination, radiographic imaging and the results of fluid testing.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, and potential complications; and to obtain informed consent.

• Manage patient discomfort or pain during and after the procedure.

• Identify patients who may benefit from transfusion of fresh frozen plasma and/or platelets prior to paracentesis.

• Recognize the indications for specialty consultations, which may include interventional radiology or gastroenterology.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their institutions, Hospitalists should:

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.

• Lead, coordinate or participate in development of institutional guidelines for the pre‐procedure utilization of fresh frozen plasma and platelet transfusions in patients with coagulopathy or thrombocytopenia.

• Lead, coordinate or participate in development of institutional guidelines to identify patients who should receive albumin peri‐procedure.

• Collaborate with radiologists to standardize identification of patients who would benefit from ultrasound‐guided paracentesis.

• Lead, coordinate or participate in efforts to develop strategies to minimize institutional complication rates.

• Lead, coordinate or participate in quality improvement programs to monitor hospitalists' performance and/or supervision of paracentesis.

• Lead, coordinate, or participate in efforts to organize and consolidate paracentesis equipment in an identifiable location in the hospital, easily accessible to clinicians who perform the procedure.

Paracentesis, the aspiration of fluid from the abdominal cavity, is a diagnostic and therapeutic procedure frequently performed in the hospital. Paracentesis was performed in almost 90,000 discharges in 2002, according to the Healthcare Cost and Utilization Project (HCUP). Hospitalists identify patients with suspected ascites on the basis of the clinical presentation, physical examination and/or ultrasonography. Utilizing evidence based decision making, hospitalists determine whether paracentesis is indicated in the diagnosis of disease or palliation of patient symptoms.

KNOWLEDGE

Hospitalists should be able to:

• Describe the normal anatomy of the abdomen and pelvis.

• Define and differentiate pathophysiologic processes that may lead to the development of ascites.

• Describe clinical presentations consistent with spontaneous bacterial peritonitis.

• Explain indications and contraindications for paracentesis, including potential risks and complications.

• Describe the physical examination maneuvers used in the evaluation of ascites and identify their sensitivity and specificity.

• Differentiate the indications for a diagnostic paracentesis versus a large‐volume paracentesis.

• Explain the appropriate diagnostic testing for ascitic fluid.

• Describe indications for use of ultrasonography to assess the quantity of ascitic fluid and/or to guide paracentesis.

• Select the necessary equipment to perform a paracentesis at the bedside, and differentiate what is needed for a diagnostic versus a large‐volume paracentesis.

• Define the serum‐ascites albumin gradient and its role in the evaluation of ascites.

• Identify the indications for administration of albumin in conjunction with paracentesis.

• Identify patients with ascites who may benefit from large‐volume paracentesis.

SKILLS

Hospitalists should be able to:

• Elicit a thorough and relevant history to identify co‐morbid conditions and risk factors for the development or complications of ascites.

• Perform a thorough physical examination, evaluating for signs associated with chronic liver disease or malignancy.

• Perform an abdominal examination, including specific maneuvers to assess for the presence of ascites.

• Properly position the patient and identify anatomic landmarks to perform a paracentesis.

• Use sterile techniques during preparation for and performance of paracentesis.

• Maintain clinician safety with appropriate protective wear.

• Manage the complications of paracentesis following the procedure, which ma include bleeding, persistent leak of ascitic fluid, and hemodynamic compromise.

• Order and interpret the results of ascitic fluid analysis, including cell count, differential, gram stain and culture, and serum‐ascites albumin gradient.

• Order and interpret platelet and coagulation studies when indicated.

• Synthesize a management plan based on history, physical examination, radiographic imaging and the results of fluid testing.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the procedure, its expected diagnostic or therapeutic benefits, and potential complications; and to obtain informed consent.

• Manage patient discomfort or pain during and after the procedure.

• Identify patients who may benefit from transfusion of fresh frozen plasma and/or platelets prior to paracentesis.

• Recognize the indications for specialty consultations, which may include interventional radiology or gastroenterology.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their institutions, Hospitalists should:

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize resource utilization.

• Lead, coordinate or participate in development of institutional guidelines for the pre‐procedure utilization of fresh frozen plasma and platelet transfusions in patients with coagulopathy or thrombocytopenia.

• Lead, coordinate or participate in development of institutional guidelines to identify patients who should receive albumin peri‐procedure.

• Collaborate with radiologists to standardize identification of patients who would benefit from ultrasound‐guided paracentesis.

• Lead, coordinate or participate in efforts to develop strategies to minimize institutional complication rates.

• Lead, coordinate or participate in quality improvement programs to monitor hospitalists' performance and/or supervision of paracentesis.

• Lead, coordinate, or participate in efforts to organize and consolidate paracentesis equipment in an identifiable location in the hospital, easily accessible to clinicians who perform the procedure.

Perioperative medicine refers to the medical evaluation and management of patients before, during and after surgical intervention. In the United States, over 44 million patients undergo non‐cardiac surgery each year. The annual cost of perioperative cardiovascular morbidity is more than $20 billion. Hospitalists perform general medical consultation preoperatively and provide postoperative medical management. Optimal care for the surgical patient is realized with a team approach that coordinates the expertise of the hospitalist and the surgical team. Hospitalists apply practice guidelines to medical consultation and can lead initiatives to improve the quality of care and patient safety in the perioperative period.

KNOWLEDGE

Hospitalists should be able to:

• Explain the effect of anesthesia and surgical intervention on physiology.

• Explain the goals and components of preoperative risk assessment.

• Identify patients who require selective preoperative testing based on patient specific factors, type of surgery, and urgency of surgical procedure.

• Describe risk factors for perioperative complications.

• Explain risks for perioperative complications in specific patient populations.

• Explain pharmacologic therapies that should be modified or held prior to surgery.

• List widely accepted risk assessment tools and explain their value and limitations in patients undergoing nonvascular surgery.

• Describe the evidence supporting prophylactic perioperative ‐blockade.

SKILLS

Hospitalists should be able to:

• Elicit a thorough history, review the medical record and inquire about functional capacity in patients undergoing surgery.

• Perform a targeted physical examination, focused on the cardiovascular and pulmonary systems and other systems based on patient history.

• Perform a directed and cost effective diagnostic evaluation based on patient relevant history and physical examination findings.

• Employ published algorithms and validated clinical scoring systems, when available, to assess and risk stratify patients.

• Assess the urgency of the requested evaluation and provide feedback and evaluation in an appropriate timeframe.

• Recognize medical conditions that increase risk for perioperative complications and make specific evidence based recommendations to optimize outcomes in the perioperative period.

• Determine the perioperative medical management strategies required to address specific disease states.

• Reassess patients for postoperative complications and make medical recommendations as indicated.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the hospitalist's role in their perioperative medical care, any indicated preoperative testing related to their medical conditions or risk assessment, and any adjustment of pharmacologic therapies.

• Communicate with patients and families to explain any indicated perioperative prophylactic measures.

• Communicate with patients and families to explain the need for follow‐up medical care post‐discharge.

• Initiate indicated perioperative preventive strategies.

• Recommend specific prophylactic measures, which may include ‐blockade, VTE prophylaxis, or aspiration precautions, to avoid complications in the perioperative period.

• Serve as an advocate for patients.

• Promote a collaborative relationship with surgical services, which includes effective communication.

• Assess pain in perioperative patients and make recommendations for pain management when indicated.

• Facilitate discharge planning early in the hospitalization, including communicating with the primary care provider, and presenting the patient and family with contact information for follow‐up care.

• Utilize evidence based recommendations for the evaluation and treatment of patients in the perioperative period.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, Hospitalists should:

• Lead, coordinate or participate in multidisciplinary efforts to develop clinical guidelines, protocols and pathways to improve the timing and quality of perioperative care from initial preoperative evaluation through all care transitions.

• Lead, coordinate or participate in efforts to improve the efficiency and quality of care through innovative models, which may include co‐management of surgical patients in the perioperative period.

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize diagnostic and management strategies for surgical patients requiring medical evaluation.

• Lead, coordinate or participate in multidisciplinary protocols to promote the rapid identification, triage, and expeditious evaluation of patients requiring urgent operations.

Perioperative medicine refers to the medical evaluation and management of patients before, during and after surgical intervention. In the United States, over 44 million patients undergo non‐cardiac surgery each year. The annual cost of perioperative cardiovascular morbidity is more than $20 billion. Hospitalists perform general medical consultation preoperatively and provide postoperative medical management. Optimal care for the surgical patient is realized with a team approach that coordinates the expertise of the hospitalist and the surgical team. Hospitalists apply practice guidelines to medical consultation and can lead initiatives to improve the quality of care and patient safety in the perioperative period.

KNOWLEDGE

Hospitalists should be able to:

• Explain the effect of anesthesia and surgical intervention on physiology.

• Explain the goals and components of preoperative risk assessment.

• Identify patients who require selective preoperative testing based on patient specific factors, type of surgery, and urgency of surgical procedure.

• Describe risk factors for perioperative complications.

• Explain risks for perioperative complications in specific patient populations.

• Explain pharmacologic therapies that should be modified or held prior to surgery.

• List widely accepted risk assessment tools and explain their value and limitations in patients undergoing nonvascular surgery.

• Describe the evidence supporting prophylactic perioperative ‐blockade.

SKILLS

Hospitalists should be able to:

• Elicit a thorough history, review the medical record and inquire about functional capacity in patients undergoing surgery.

• Perform a targeted physical examination, focused on the cardiovascular and pulmonary systems and other systems based on patient history.

• Perform a directed and cost effective diagnostic evaluation based on patient relevant history and physical examination findings.

• Employ published algorithms and validated clinical scoring systems, when available, to assess and risk stratify patients.

• Assess the urgency of the requested evaluation and provide feedback and evaluation in an appropriate timeframe.

• Recognize medical conditions that increase risk for perioperative complications and make specific evidence based recommendations to optimize outcomes in the perioperative period.

• Determine the perioperative medical management strategies required to address specific disease states.

• Reassess patients for postoperative complications and make medical recommendations as indicated.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the hospitalist's role in their perioperative medical care, any indicated preoperative testing related to their medical conditions or risk assessment, and any adjustment of pharmacologic therapies.

• Communicate with patients and families to explain any indicated perioperative prophylactic measures.

• Communicate with patients and families to explain the need for follow‐up medical care post‐discharge.

• Initiate indicated perioperative preventive strategies.

• Recommend specific prophylactic measures, which may include ‐blockade, VTE prophylaxis, or aspiration precautions, to avoid complications in the perioperative period.

• Serve as an advocate for patients.

• Promote a collaborative relationship with surgical services, which includes effective communication.

• Assess pain in perioperative patients and make recommendations for pain management when indicated.

• Facilitate discharge planning early in the hospitalization, including communicating with the primary care provider, and presenting the patient and family with contact information for follow‐up care.

• Utilize evidence based recommendations for the evaluation and treatment of patients in the perioperative period.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, Hospitalists should:

• Lead, coordinate or participate in multidisciplinary efforts to develop clinical guidelines, protocols and pathways to improve the timing and quality of perioperative care from initial preoperative evaluation through all care transitions.

• Lead, coordinate or participate in efforts to improve the efficiency and quality of care through innovative models, which may include co‐management of surgical patients in the perioperative period.

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize diagnostic and management strategies for surgical patients requiring medical evaluation.

• Lead, coordinate or participate in multidisciplinary protocols to promote the rapid identification, triage, and expeditious evaluation of patients requiring urgent operations.

Perioperative medicine refers to the medical evaluation and management of patients before, during and after surgical intervention. In the United States, over 44 million patients undergo non‐cardiac surgery each year. The annual cost of perioperative cardiovascular morbidity is more than $20 billion. Hospitalists perform general medical consultation preoperatively and provide postoperative medical management. Optimal care for the surgical patient is realized with a team approach that coordinates the expertise of the hospitalist and the surgical team. Hospitalists apply practice guidelines to medical consultation and can lead initiatives to improve the quality of care and patient safety in the perioperative period.

KNOWLEDGE

Hospitalists should be able to:

• Explain the effect of anesthesia and surgical intervention on physiology.

• Explain the goals and components of preoperative risk assessment.

• Identify patients who require selective preoperative testing based on patient specific factors, type of surgery, and urgency of surgical procedure.

• Describe risk factors for perioperative complications.

• Explain risks for perioperative complications in specific patient populations.

• Explain pharmacologic therapies that should be modified or held prior to surgery.

• List widely accepted risk assessment tools and explain their value and limitations in patients undergoing nonvascular surgery.

• Describe the evidence supporting prophylactic perioperative ‐blockade.

SKILLS

Hospitalists should be able to:

• Elicit a thorough history, review the medical record and inquire about functional capacity in patients undergoing surgery.

• Perform a targeted physical examination, focused on the cardiovascular and pulmonary systems and other systems based on patient history.

• Perform a directed and cost effective diagnostic evaluation based on patient relevant history and physical examination findings.

• Employ published algorithms and validated clinical scoring systems, when available, to assess and risk stratify patients.

• Assess the urgency of the requested evaluation and provide feedback and evaluation in an appropriate timeframe.

• Recognize medical conditions that increase risk for perioperative complications and make specific evidence based recommendations to optimize outcomes in the perioperative period.

• Determine the perioperative medical management strategies required to address specific disease states.

• Reassess patients for postoperative complications and make medical recommendations as indicated.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the hospitalist's role in their perioperative medical care, any indicated preoperative testing related to their medical conditions or risk assessment, and any adjustment of pharmacologic therapies.

• Communicate with patients and families to explain any indicated perioperative prophylactic measures.

• Communicate with patients and families to explain the need for follow‐up medical care post‐discharge.

• Initiate indicated perioperative preventive strategies.

• Recommend specific prophylactic measures, which may include ‐blockade, VTE prophylaxis, or aspiration precautions, to avoid complications in the perioperative period.

• Serve as an advocate for patients.

• Promote a collaborative relationship with surgical services, which includes effective communication.

• Assess pain in perioperative patients and make recommendations for pain management when indicated.

• Facilitate discharge planning early in the hospitalization, including communicating with the primary care provider, and presenting the patient and family with contact information for follow‐up care.

• Utilize evidence based recommendations for the evaluation and treatment of patients in the perioperative period.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, Hospitalists should:

• Lead, coordinate or participate in multidisciplinary efforts to develop clinical guidelines, protocols and pathways to improve the timing and quality of perioperative care from initial preoperative evaluation through all care transitions.

• Lead, coordinate or participate in efforts to improve the efficiency and quality of care through innovative models, which may include co‐management of surgical patients in the perioperative period.

• Lead, coordinate or participate in multidisciplinary initiatives to promote patient safety and optimize diagnostic and management strategies for surgical patients requiring medical evaluation.

• Lead, coordinate or participate in multidisciplinary protocols to promote the rapid identification, triage, and expeditious evaluation of patients requiring urgent operations.

The development of The Core Competencies would not have been possible without the support and assistance of the Society of Hospital Medicine staff and countless practicing Hospitalists across the United States. The editors thank Parmanand Singh for research assistance, Lillian Higgins for project coordination, and Dr. Daniel Budnitz for assistance with medical editing and chapter formatting. Kathryn Alexander deserves special thanks for her medical editing and expertise and mix of patience and persistence that brought this project to completion. The editors also thank their families for all their patience and support throughout the development process.

Society of Hospital Medicine leadership and subject matter experts who provided content, review and guidance include:

Preetha Basaviah, MD

Jasminka Criley, MD

Douglas Cutler, MD

Steve Embry, MD

Christine Faulk, MD

Scott Flanders, MD

Jeffrey Genato, MD

Jeanne Huddleston, MD

Jennifer Kleinbart, MD

David Likosky, MD

Frank Michota, MD

Kevin O'Leary, MD

Michael Rovzar, MD

Winthrop Whitcomb, MD

Kevin Whitford, MD

Dorothea Wild, MD

Mitch Wilson, MD

SHM Benchmarks Committee

SHM Education Committee

SHM Geriatrics Task Force

SHM Health Quality Patient Safety Committee

SHM Non Physician Providers Task Force

SHM Pediatrics Committee

SHM Ethics Committee

SHM Executive Board of Directors

SHM Leadership Committee

SHM Palliative Care Task Force

SHM Pediatrics Core Curriculum Task Force

The development of The Core Competencies would not have been possible without the support and assistance of the Society of Hospital Medicine staff and countless practicing Hospitalists across the United States. The editors thank Parmanand Singh for research assistance, Lillian Higgins for project coordination, and Dr. Daniel Budnitz for assistance with medical editing and chapter formatting. Kathryn Alexander deserves special thanks for her medical editing and expertise and mix of patience and persistence that brought this project to completion. The editors also thank their families for all their patience and support throughout the development process.

Society of Hospital Medicine leadership and subject matter experts who provided content, review and guidance include:

Preetha Basaviah, MD

Jasminka Criley, MD

Douglas Cutler, MD

Steve Embry, MD

Christine Faulk, MD

Scott Flanders, MD

Jeffrey Genato, MD

Jeanne Huddleston, MD

Jennifer Kleinbart, MD

David Likosky, MD

Frank Michota, MD

Kevin O'Leary, MD

Michael Rovzar, MD

Winthrop Whitcomb, MD

Kevin Whitford, MD

Dorothea Wild, MD

Mitch Wilson, MD

SHM Benchmarks Committee

SHM Education Committee

SHM Geriatrics Task Force

SHM Health Quality Patient Safety Committee

SHM Non Physician Providers Task Force

SHM Pediatrics Committee

SHM Ethics Committee

SHM Executive Board of Directors

SHM Leadership Committee

SHM Palliative Care Task Force

SHM Pediatrics Core Curriculum Task Force

The development of The Core Competencies would not have been possible without the support and assistance of the Society of Hospital Medicine staff and countless practicing Hospitalists across the United States. The editors thank Parmanand Singh for research assistance, Lillian Higgins for project coordination, and Dr. Daniel Budnitz for assistance with medical editing and chapter formatting. Kathryn Alexander deserves special thanks for her medical editing and expertise and mix of patience and persistence that brought this project to completion. The editors also thank their families for all their patience and support throughout the development process.

Society of Hospital Medicine leadership and subject matter experts who provided content, review and guidance include:

Preetha Basaviah, MD

Jasminka Criley, MD

Douglas Cutler, MD

Steve Embry, MD

Christine Faulk, MD

Scott Flanders, MD

Jeffrey Genato, MD

Jeanne Huddleston, MD

Jennifer Kleinbart, MD

David Likosky, MD

Frank Michota, MD

Kevin O'Leary, MD

Michael Rovzar, MD

Winthrop Whitcomb, MD

Kevin Whitford, MD

Dorothea Wild, MD

Mitch Wilson, MD

SHM Benchmarks Committee

SHM Education Committee

SHM Geriatrics Task Force

SHM Health Quality Patient Safety Committee

SHM Non Physician Providers Task Force

SHM Pediatrics Committee

SHM Ethics Committee

SHM Executive Board of Directors

SHM Leadership Committee

SHM Palliative Care Task Force

SHM Pediatrics Core Curriculum Task Force

The term Transitions of Care refers to specific interactions, communication, and planning required for patients to safely move from one service or setting to another. These transitions traditionally apply to transfers between the inpatient and outpatient setting. Transitions also occur between or within acute care facilities, and to or from subacute and non‐acute facilities. Hospitalists provide leadership to promote efficient, safe transitions of care to ensure patient safety, reduce loss of information, and maintain the continuum of care.

KNOWLEDGE

Hospitalists should be able to:

• Define relevant information that should be retrieved and communicated during each care transition to ensure patient safety and maintain the continuum of care.

• Analyze potential strengths and limitations of patient transition processes.

• Describe the value of available ancillary services that can facilitate patient transitions.

• Distinguish available levels of care for patients and select the most appropriate option.

• Analyze strengths and limitations of different communication modalities utilized in patient transitions.

SKILLS

Hospitalists should be able to:

• Utilize the most efficient, effective, reliable and expeditious communication modalities for each care transition.

• Synthesize medical information received from referring physicians into care plan.

• Develop a care plan early during hospitalization that anticipates discharge or transfer needs.

• Organize and effectively communicate medical information in a succinct format for receiving clinicians.

ATTITUDES

Hospitalists should be able to:

• Appreciate the impact of care transitions on patient outcomes and satisfaction.

• Strive to utilize the best available communication modality in each care transition.

• Appreciate the value of real time interactive dialogue between clinicians during care transitions.

• Strive to personally communicate with every receiving or referring physician during care transitions.

• Appreciate the preferences of receiving physicians for transfer of information.

• Recognize the importance of a multidisciplinary approach to care transitions, including specifically nursing, rehabilitation, nutrition, pharmaceutical and social services.

• Expeditiously inform the primary care provider about significant changes in patient clinical status.

• Inform receiving physician of pending tests and determine who is responsible for checking results.

• Incorporate quality indicators for specific disease states and/or patient variables into discharge plans.

• Communicate with patients and families to explain their condition, ongoing medical regimens and therapies, follow‐up care and available support services.

• Communicate with patients and families to explain clinical symptomatology that may require medical attention prior to scheduled follow‐up.

• Anticipate and address language and/or literacy barriers to patient education.

• Prepare patients and families early in the hospitalization for anticipated care transitions.

• Review the discharge plans with patients, families, and healthcare team.

• Take responsibility to coordinate multidisciplinary teams early in the hospitalization course to facilitate patient education, optimize patient function, and improve discharge planning.

• Engage stakeholders in hospital initiatives to continuously assess the quality of care transitions.

• Lead, coordinate or participate in initiatives to develop and implement new protocols to improve or optimize transitions of care.

• Lead, coordinate or participate in evaluation of new strategies or information systems designed to improve care transitions.

• Maintain availability to discharged patients for questions during/between discharge and follow‐up visit with receiving physician.

The term Transitions of Care refers to specific interactions, communication, and planning required for patients to safely move from one service or setting to another. These transitions traditionally apply to transfers between the inpatient and outpatient setting. Transitions also occur between or within acute care facilities, and to or from subacute and non‐acute facilities. Hospitalists provide leadership to promote efficient, safe transitions of care to ensure patient safety, reduce loss of information, and maintain the continuum of care.

KNOWLEDGE

Hospitalists should be able to:

• Define relevant information that should be retrieved and communicated during each care transition to ensure patient safety and maintain the continuum of care.

• Analyze potential strengths and limitations of patient transition processes.

• Describe the value of available ancillary services that can facilitate patient transitions.

• Distinguish available levels of care for patients and select the most appropriate option.

• Analyze strengths and limitations of different communication modalities utilized in patient transitions.

SKILLS

Hospitalists should be able to:

• Utilize the most efficient, effective, reliable and expeditious communication modalities for each care transition.

• Synthesize medical information received from referring physicians into care plan.

• Develop a care plan early during hospitalization that anticipates discharge or transfer needs.

• Organize and effectively communicate medical information in a succinct format for receiving clinicians.

ATTITUDES

Hospitalists should be able to:

• Appreciate the impact of care transitions on patient outcomes and satisfaction.

• Strive to utilize the best available communication modality in each care transition.

• Appreciate the value of real time interactive dialogue between clinicians during care transitions.

• Strive to personally communicate with every receiving or referring physician during care transitions.

• Appreciate the preferences of receiving physicians for transfer of information.

• Recognize the importance of a multidisciplinary approach to care transitions, including specifically nursing, rehabilitation, nutrition, pharmaceutical and social services.

• Expeditiously inform the primary care provider about significant changes in patient clinical status.

• Inform receiving physician of pending tests and determine who is responsible for checking results.

• Incorporate quality indicators for specific disease states and/or patient variables into discharge plans.

• Communicate with patients and families to explain their condition, ongoing medical regimens and therapies, follow‐up care and available support services.

• Communicate with patients and families to explain clinical symptomatology that may require medical attention prior to scheduled follow‐up.

• Anticipate and address language and/or literacy barriers to patient education.

• Prepare patients and families early in the hospitalization for anticipated care transitions.

• Review the discharge plans with patients, families, and healthcare team.

• Take responsibility to coordinate multidisciplinary teams early in the hospitalization course to facilitate patient education, optimize patient function, and improve discharge planning.

• Engage stakeholders in hospital initiatives to continuously assess the quality of care transitions.

• Lead, coordinate or participate in initiatives to develop and implement new protocols to improve or optimize transitions of care.

• Lead, coordinate or participate in evaluation of new strategies or information systems designed to improve care transitions.

• Maintain availability to discharged patients for questions during/between discharge and follow‐up visit with receiving physician.

The term Transitions of Care refers to specific interactions, communication, and planning required for patients to safely move from one service or setting to another. These transitions traditionally apply to transfers between the inpatient and outpatient setting. Transitions also occur between or within acute care facilities, and to or from subacute and non‐acute facilities. Hospitalists provide leadership to promote efficient, safe transitions of care to ensure patient safety, reduce loss of information, and maintain the continuum of care.

KNOWLEDGE

Hospitalists should be able to:

• Define relevant information that should be retrieved and communicated during each care transition to ensure patient safety and maintain the continuum of care.

• Analyze potential strengths and limitations of patient transition processes.

• Describe the value of available ancillary services that can facilitate patient transitions.

• Distinguish available levels of care for patients and select the most appropriate option.

• Analyze strengths and limitations of different communication modalities utilized in patient transitions.

SKILLS

Hospitalists should be able to:

• Utilize the most efficient, effective, reliable and expeditious communication modalities for each care transition.

• Synthesize medical information received from referring physicians into care plan.

• Develop a care plan early during hospitalization that anticipates discharge or transfer needs.

• Organize and effectively communicate medical information in a succinct format for receiving clinicians.

ATTITUDES

Hospitalists should be able to:

• Appreciate the impact of care transitions on patient outcomes and satisfaction.

• Strive to utilize the best available communication modality in each care transition.

• Appreciate the value of real time interactive dialogue between clinicians during care transitions.

• Strive to personally communicate with every receiving or referring physician during care transitions.

• Appreciate the preferences of receiving physicians for transfer of information.

• Recognize the importance of a multidisciplinary approach to care transitions, including specifically nursing, rehabilitation, nutrition, pharmaceutical and social services.

• Expeditiously inform the primary care provider about significant changes in patient clinical status.

• Inform receiving physician of pending tests and determine who is responsible for checking results.

• Incorporate quality indicators for specific disease states and/or patient variables into discharge plans.

• Communicate with patients and families to explain their condition, ongoing medical regimens and therapies, follow‐up care and available support services.

• Communicate with patients and families to explain clinical symptomatology that may require medical attention prior to scheduled follow‐up.

• Anticipate and address language and/or literacy barriers to patient education.

• Prepare patients and families early in the hospitalization for anticipated care transitions.

• Review the discharge plans with patients, families, and healthcare team.

• Take responsibility to coordinate multidisciplinary teams early in the hospitalization course to facilitate patient education, optimize patient function, and improve discharge planning.

• Engage stakeholders in hospital initiatives to continuously assess the quality of care transitions.

• Lead, coordinate or participate in initiatives to develop and implement new protocols to improve or optimize transitions of care.

• Lead, coordinate or participate in evaluation of new strategies or information systems designed to improve care transitions.

• Maintain availability to discharged patients for questions during/between discharge and follow‐up visit with receiving physician.

Delirium is defined as a transient global disorder of cognition. many factors lead to delirium including baseline vulnerability interacting with precipitants during hospitalization. delirium affects an estimated 2.3 million hospitalized elders annually, accounting for 17.5 million inpatient days, and leading to more than $4 billion in medicare costs. it is associated with increased mortality, high rates of functional and cognitive decline, prolonged lengths of stay and high rates of skilled nursing facility placement. the cost of caring for patients with delirium significantly impacts individual patients, families and hospital systems, and accounts for billions of the medicare budget. hospitalists lead their institutions in the development of screening and prevention protocols for patients at risk for delirium, and in the promotion of safe approaches to treatment. hospitalists also develop strategies to operationalize cost‐effective delirium prevention programs that will improve outcomes.

Dementia is defined as a progressive decline in cognitive function, eventually limiting daily activities. dementia is a common co‐morbidity in the hospitalized elder. patients with dementia are at increased risk for delirium, falls, and functional decline during hospitalization. patients with baseline cognitive impairment have prolonged lengths of stay and complex needs after discharge. agitation and behavioral symptoms of dementia can exacerbate and be difficult to manage in the hospital setting. care of the patient with dementia requires that hospitalists engage in a multidisciplinary approach to inpatient and transitional care. hospitalists may also become involved in hospital quality and safety initiatives that pertain to areas such as restraint use and fall prevention.

KNOWLEDGE

Hospitalists should be able to:

• Define delirium and dementia.

• Distinguish the causes of delirium.

• Describe the indicated tests required to evaluate delirium and dementia.

• Recognize innate and environmental/ematrogenic risk factors for the development of delirium in the hospitalized patient.

• Identify medications known to precipitate delirium.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat delirium and dementia.

• Determine the best setting within the hospital to initiate, monitor, evaluate and treat patients with delirium.

• Describe the poor outcomes related to delirium and dementia in the hospitalized patient.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

• Distinguish delirium and dementia from other causes of cognitive impairment, confusion or psychosis.

• Predict a patient's risk for the development of delirium or poor outcomes related to dementia based on initial history and physical examination.

• Screen for delirium using appropriate testing early and repeatedly during the patient's hospital course.

• Perform a screen for dementia using the appropriate testing.

• Apply known patient risk factors to create a care plan for reducing delirium.

• Perform a focused evaluation for the underlying etiology of delirium and institute prompt treatment to lessen the severity of delirium.

• Formulate and lead multidisciplinary teams to develop and implement care plans for patients with delirium or dementia.

• Prescribe appropriate medications and dosing regimens for patients with delirium or dementia.

• Repeatedly assess the need for additional interventions.

• Assess patients with suspected delirium in a timely manner, identify the level of care required, and manage or co‐manage the patient with the primary requesting service.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the history and prognosis of delirium or dementia.

• Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.

• Educate and engage families in the care of elder inpatients.

• Establish goals and boundaries of care with patients and their family.

• Communicate with the families and others with durable powers of attorney to explain tests and procedures and their indications, and to obtain informed consent.

• Recognize the indications for specialty consultations.

• Describe methods for the prevention of delirium.

• Employ a multidisciplinary approach to the care of patients with delirium or dementia that begins at admission and continues through all care transitions.

• Responsibly address and respect end of life care wishes for patients with advanced dementia.

• Realize the multi‐faceted impact of delirium or dementia on patients and their families.

• Appreciate and document the value of appropriate treatment in reducing mortality, duration of delirium, time required to control agitation, adequate control of delirium, treatment of complications, and cost.

• Facilitate discharge planning early in the hospitalization, including communicating with the primary care provider, and presenting the patient and family with contact information for follow‐up care, support and rehabilitation.

• Utilize evidence based recommendations to guide diagnosis, monitoring and treatment of delirium and its causes.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, hospitalists should:

• Lead multidisciplinary teams to develop early treatment protocols.

• Lead, coordinate or participate in multidisciplinary initiatives to implement screening and prevention protocols for patients at risk for delirium or poor outcomes related to dementia.

• Engage stakeholders in hospital initiatives to improve safety and quality in the care of delirious and demented patients (e.g. provide diversion activities rather than using restraints).

• Lead, coordinate or participate in multidisciplinary initiatives, which may include collaboration with geriatricians, to promote patient safety and cost‐effective diagnostic and management strategies for elderly patients.

Delirium is defined as a transient global disorder of cognition. many factors lead to delirium including baseline vulnerability interacting with precipitants during hospitalization. delirium affects an estimated 2.3 million hospitalized elders annually, accounting for 17.5 million inpatient days, and leading to more than $4 billion in medicare costs. it is associated with increased mortality, high rates of functional and cognitive decline, prolonged lengths of stay and high rates of skilled nursing facility placement. the cost of caring for patients with delirium significantly impacts individual patients, families and hospital systems, and accounts for billions of the medicare budget. hospitalists lead their institutions in the development of screening and prevention protocols for patients at risk for delirium, and in the promotion of safe approaches to treatment. hospitalists also develop strategies to operationalize cost‐effective delirium prevention programs that will improve outcomes.

Dementia is defined as a progressive decline in cognitive function, eventually limiting daily activities. dementia is a common co‐morbidity in the hospitalized elder. patients with dementia are at increased risk for delirium, falls, and functional decline during hospitalization. patients with baseline cognitive impairment have prolonged lengths of stay and complex needs after discharge. agitation and behavioral symptoms of dementia can exacerbate and be difficult to manage in the hospital setting. care of the patient with dementia requires that hospitalists engage in a multidisciplinary approach to inpatient and transitional care. hospitalists may also become involved in hospital quality and safety initiatives that pertain to areas such as restraint use and fall prevention.

KNOWLEDGE

Hospitalists should be able to:

• Define delirium and dementia.

• Distinguish the causes of delirium.

• Describe the indicated tests required to evaluate delirium and dementia.

• Recognize innate and environmental/ematrogenic risk factors for the development of delirium in the hospitalized patient.

• Identify medications known to precipitate delirium.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat delirium and dementia.

• Determine the best setting within the hospital to initiate, monitor, evaluate and treat patients with delirium.

• Describe the poor outcomes related to delirium and dementia in the hospitalized patient.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

• Distinguish delirium and dementia from other causes of cognitive impairment, confusion or psychosis.

• Predict a patient's risk for the development of delirium or poor outcomes related to dementia based on initial history and physical examination.

• Screen for delirium using appropriate testing early and repeatedly during the patient's hospital course.

• Perform a screen for dementia using the appropriate testing.

• Apply known patient risk factors to create a care plan for reducing delirium.

• Perform a focused evaluation for the underlying etiology of delirium and institute prompt treatment to lessen the severity of delirium.

• Formulate and lead multidisciplinary teams to develop and implement care plans for patients with delirium or dementia.

• Prescribe appropriate medications and dosing regimens for patients with delirium or dementia.

• Repeatedly assess the need for additional interventions.

• Assess patients with suspected delirium in a timely manner, identify the level of care required, and manage or co‐manage the patient with the primary requesting service.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the history and prognosis of delirium or dementia.

• Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.

• Educate and engage families in the care of elder inpatients.

• Establish goals and boundaries of care with patients and their family.

• Communicate with the families and others with durable powers of attorney to explain tests and procedures and their indications, and to obtain informed consent.

• Recognize the indications for specialty consultations.

• Describe methods for the prevention of delirium.

• Employ a multidisciplinary approach to the care of patients with delirium or dementia that begins at admission and continues through all care transitions.

• Responsibly address and respect end of life care wishes for patients with advanced dementia.

• Realize the multi‐faceted impact of delirium or dementia on patients and their families.

• Appreciate and document the value of appropriate treatment in reducing mortality, duration of delirium, time required to control agitation, adequate control of delirium, treatment of complications, and cost.

• Facilitate discharge planning early in the hospitalization, including communicating with the primary care provider, and presenting the patient and family with contact information for follow‐up care, support and rehabilitation.

• Utilize evidence based recommendations to guide diagnosis, monitoring and treatment of delirium and its causes.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, hospitalists should:

• Lead multidisciplinary teams to develop early treatment protocols.

• Lead, coordinate or participate in multidisciplinary initiatives to implement screening and prevention protocols for patients at risk for delirium or poor outcomes related to dementia.

• Engage stakeholders in hospital initiatives to improve safety and quality in the care of delirious and demented patients (e.g. provide diversion activities rather than using restraints).

• Lead, coordinate or participate in multidisciplinary initiatives, which may include collaboration with geriatricians, to promote patient safety and cost‐effective diagnostic and management strategies for elderly patients.

Delirium is defined as a transient global disorder of cognition. many factors lead to delirium including baseline vulnerability interacting with precipitants during hospitalization. delirium affects an estimated 2.3 million hospitalized elders annually, accounting for 17.5 million inpatient days, and leading to more than $4 billion in medicare costs. it is associated with increased mortality, high rates of functional and cognitive decline, prolonged lengths of stay and high rates of skilled nursing facility placement. the cost of caring for patients with delirium significantly impacts individual patients, families and hospital systems, and accounts for billions of the medicare budget. hospitalists lead their institutions in the development of screening and prevention protocols for patients at risk for delirium, and in the promotion of safe approaches to treatment. hospitalists also develop strategies to operationalize cost‐effective delirium prevention programs that will improve outcomes.

Dementia is defined as a progressive decline in cognitive function, eventually limiting daily activities. dementia is a common co‐morbidity in the hospitalized elder. patients with dementia are at increased risk for delirium, falls, and functional decline during hospitalization. patients with baseline cognitive impairment have prolonged lengths of stay and complex needs after discharge. agitation and behavioral symptoms of dementia can exacerbate and be difficult to manage in the hospital setting. care of the patient with dementia requires that hospitalists engage in a multidisciplinary approach to inpatient and transitional care. hospitalists may also become involved in hospital quality and safety initiatives that pertain to areas such as restraint use and fall prevention.

KNOWLEDGE

Hospitalists should be able to:

• Define delirium and dementia.

• Distinguish the causes of delirium.

• Describe the indicated tests required to evaluate delirium and dementia.

• Recognize innate and environmental/ematrogenic risk factors for the development of delirium in the hospitalized patient.

• Identify medications known to precipitate delirium.

• Explain indications, contraindications and mechanisms of action of pharmacologic agents used to treat delirium and dementia.

• Determine the best setting within the hospital to initiate, monitor, evaluate and treat patients with delirium.

• Describe the poor outcomes related to delirium and dementia in the hospitalized patient.

• Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition.

SKILLS

Hospitalists should be able to:

• Distinguish delirium and dementia from other causes of cognitive impairment, confusion or psychosis.

• Predict a patient's risk for the development of delirium or poor outcomes related to dementia based on initial history and physical examination.

• Screen for delirium using appropriate testing early and repeatedly during the patient's hospital course.

• Perform a screen for dementia using the appropriate testing.

• Apply known patient risk factors to create a care plan for reducing delirium.

• Perform a focused evaluation for the underlying etiology of delirium and institute prompt treatment to lessen the severity of delirium.

• Formulate and lead multidisciplinary teams to develop and implement care plans for patients with delirium or dementia.

• Prescribe appropriate medications and dosing regimens for patients with delirium or dementia.

• Repeatedly assess the need for additional interventions.

• Assess patients with suspected delirium in a timely manner, identify the level of care required, and manage or co‐manage the patient with the primary requesting service.

ATTITUDES

Hospitalists should be able to:

• Communicate with patients and families to explain the history and prognosis of delirium or dementia.

• Communicate with patients and families to explain goals of care plan, discharge instructions and management after release from hospital.

• Educate and engage families in the care of elder inpatients.

• Establish goals and boundaries of care with patients and their family.

• Communicate with the families and others with durable powers of attorney to explain tests and procedures and their indications, and to obtain informed consent.

• Recognize the indications for specialty consultations.

• Describe methods for the prevention of delirium.

• Employ a multidisciplinary approach to the care of patients with delirium or dementia that begins at admission and continues through all care transitions.

• Responsibly address and respect end of life care wishes for patients with advanced dementia.

• Realize the multi‐faceted impact of delirium or dementia on patients and their families.

• Appreciate and document the value of appropriate treatment in reducing mortality, duration of delirium, time required to control agitation, adequate control of delirium, treatment of complications, and cost.

• Facilitate discharge planning early in the hospitalization, including communicating with the primary care provider, and presenting the patient and family with contact information for follow‐up care, support and rehabilitation.

• Utilize evidence based recommendations to guide diagnosis, monitoring and treatment of delirium and its causes.

SYSTEM ORGANIZATION AND IMPROVEMENT

To improve efficiency and quality within their organizations, hospitalists should:

• Lead multidisciplinary teams to develop early treatment protocols.

• Lead, coordinate or participate in multidisciplinary initiatives to implement screening and prevention protocols for patients at risk for delirium or poor outcomes related to dementia.

• Engage stakeholders in hospital initiatives to improve safety and quality in the care of delirious and demented patients (e.g. provide diversion activities rather than using restraints).

• Lead, coordinate or participate in multidisciplinary initiatives, which may include collaboration with geriatricians, to promote patient safety and cost‐effective diagnostic and management strategies for elderly patients.

0

0

0

0

APPENDICES

• I

  Abbreviations

• II

  Organizations Cited in Text

• III

  Core Competencies in Hospital Medicine: Development and Methodology Daniel D. Dressler, Michael J. Pistoria, Tina L. Budnitz, Sylvia C. W. McKean, and Alpesh N. Amin Reprinted from Journal of Hospital Medicine, Volume 1, Number 1, 2006, Pages 48‐56

• IV

  How to Use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development Sylvia C. W. McKean, Tina L. Budnitz, Daniel D. Dressler, Alpesh N. Amin, and Michael J. Pistoria Reprinted from Journal of Hospital Medicine, Volume 1, Number 1, 2006, Pages 57‐67

0

0

0

0

APPENDICES

• I

  Abbreviations

• II

  Organizations Cited in Text

• III

  Core Competencies in Hospital Medicine: Development and Methodology Daniel D. Dressler, Michael J. Pistoria, Tina L. Budnitz, Sylvia C. W. McKean, and Alpesh N. Amin Reprinted from Journal of Hospital Medicine, Volume 1, Number 1, 2006, Pages 48‐56

• IV

  How to Use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development Sylvia C. W. McKean, Tina L. Budnitz, Daniel D. Dressler, Alpesh N. Amin, and Michael J. Pistoria Reprinted from Journal of Hospital Medicine, Volume 1, Number 1, 2006, Pages 57‐67

0

0

0

0

APPENDICES

• I

  Abbreviations

• II

  Organizations Cited in Text

• III

  Core Competencies in Hospital Medicine: Development and Methodology Daniel D. Dressler, Michael J. Pistoria, Tina L. Budnitz, Sylvia C. W. McKean, and Alpesh N. Amin Reprinted from Journal of Hospital Medicine, Volume 1, Number 1, 2006, Pages 48‐56

• IV

  How to Use The Core Competencies in Hospital Medicine: A Framework for Curriculum Development Sylvia C. W. McKean, Tina L. Budnitz, Daniel D. Dressler, Alpesh N. Amin, and Michael J. Pistoria Reprinted from Journal of Hospital Medicine, Volume 1, Number 1, 2006, Pages 57‐67

Practice Based Learning and Improvement (PBLI) is a means of evaluating individual and system practice patterns and incorporating the best available evidence to improve patient care. PBLI is recognized as a critical skill for all clinicians by the Accreditation Council for Graduate Medical Education (ACGME), the American Board of Internal Medicine (ABIM), and the American Board of Pediatrics (ABP). As the practice of Hospital Medicine rapidly evolves, hospitalists apply the most up‐to‐date knowledge to their care of inpatients. Hospitalists use a PBLI approach to lead, coordinate and participate in initiatives to improve hospital processes and clinical care.

KNOWLEDGE

Hospitalists should be able to:

• Describe systematic methods of analyzing practice experience.

• Explain key concepts of practice based improvement methodology, which include the Plan Do Study Act (PDSA) model.

• Define the role of multidisciplinary teams and team leaders in improving patient care.

• Describe how critical appraisal skills, including study design, statistical methods and clinical relevance apply to PBLI.

• Describe how information technology can be used to identify opportunities to improve patient care.

SKILLS

Hospitalists should be able to:

• Translate information about a general population into management of subpopulations or individual patients.

• Critically assess individual and system practice patterns and experience to identify areas for improvement and minimize heterogeneity of practice.

• Design practice interventions to improve quality, efficiency, and consistency of patient care using standard PBLI methodology and tools.

• Assess medical information to support self‐directed learning.

• Establish and maintain an open dialogue with patients and families regarding care goals and limitations, palliative care, and end of life issues.

• Critically appraise and apply the reports of new medical evidence.

• Use health information systems efficiently to manage and improve care at the individual and system levels.

• Utilize evidence based information resources to inform clinical decisions.

ATTITUDES

Hospitalists should be able to:

• Advocate for the use of PBLI in clinical practice and in system improvement projects.

• Create an environment conducive to self‐evaluation and improvement.

• Advocate for investment in information technology.

• Facilitate and encourage self‐directed learning among health care professionals and trainees.

• Promote self improvement and care standardization, utilizing best evidence and practice.

Practice Based Learning and Improvement (PBLI) is a means of evaluating individual and system practice patterns and incorporating the best available evidence to improve patient care. PBLI is recognized as a critical skill for all clinicians by the Accreditation Council for Graduate Medical Education (ACGME), the American Board of Internal Medicine (ABIM), and the American Board of Pediatrics (ABP). As the practice of Hospital Medicine rapidly evolves, hospitalists apply the most up‐to‐date knowledge to their care of inpatients. Hospitalists use a PBLI approach to lead, coordinate and participate in initiatives to improve hospital processes and clinical care.

KNOWLEDGE

Hospitalists should be able to:

• Describe systematic methods of analyzing practice experience.

• Explain key concepts of practice based improvement methodology, which include the Plan Do Study Act (PDSA) model.

• Define the role of multidisciplinary teams and team leaders in improving patient care.

• Describe how critical appraisal skills, including study design, statistical methods and clinical relevance apply to PBLI.

• Describe how information technology can be used to identify opportunities to improve patient care.

SKILLS

Hospitalists should be able to:

• Translate information about a general population into management of subpopulations or individual patients.

• Critically assess individual and system practice patterns and experience to identify areas for improvement and minimize heterogeneity of practice.

• Design practice interventions to improve quality, efficiency, and consistency of patient care using standard PBLI methodology and tools.

• Assess medical information to support self‐directed learning.

• Establish and maintain an open dialogue with patients and families regarding care goals and limitations, palliative care, and end of life issues.

• Critically appraise and apply the reports of new medical evidence.

• Use health information systems efficiently to manage and improve care at the individual and system levels.

• Utilize evidence based information resources to inform clinical decisions.

ATTITUDES

Hospitalists should be able to:

• Advocate for the use of PBLI in clinical practice and in system improvement projects.

• Create an environment conducive to self‐evaluation and improvement.

• Advocate for investment in information technology.

• Facilitate and encourage self‐directed learning among health care professionals and trainees.

• Promote self improvement and care standardization, utilizing best evidence and practice.

Practice Based Learning and Improvement (PBLI) is a means of evaluating individual and system practice patterns and incorporating the best available evidence to improve patient care. PBLI is recognized as a critical skill for all clinicians by the Accreditation Council for Graduate Medical Education (ACGME), the American Board of Internal Medicine (ABIM), and the American Board of Pediatrics (ABP). As the practice of Hospital Medicine rapidly evolves, hospitalists apply the most up‐to‐date knowledge to their care of inpatients. Hospitalists use a PBLI approach to lead, coordinate and participate in initiatives to improve hospital processes and clinical care.

KNOWLEDGE

Hospitalists should be able to:

• Describe systematic methods of analyzing practice experience.

• Explain key concepts of practice based improvement methodology, which include the Plan Do Study Act (PDSA) model.

• Define the role of multidisciplinary teams and team leaders in improving patient care.

• Describe how critical appraisal skills, including study design, statistical methods and clinical relevance apply to PBLI.

• Describe how information technology can be used to identify opportunities to improve patient care.

SKILLS

Hospitalists should be able to:

• Translate information about a general population into management of subpopulations or individual patients.

• Critically assess individual and system practice patterns and experience to identify areas for improvement and minimize heterogeneity of practice.

• Design practice interventions to improve quality, efficiency, and consistency of patient care using standard PBLI methodology and tools.

• Assess medical information to support self‐directed learning.

• Establish and maintain an open dialogue with patients and families regarding care goals and limitations, palliative care, and end of life issues.

• Critically appraise and apply the reports of new medical evidence.

• Use health information systems efficiently to manage and improve care at the individual and system levels.

• Utilize evidence based information resources to inform clinical decisions.

ATTITUDES

Hospitalists should be able to:

• Advocate for the use of PBLI in clinical practice and in system improvement projects.

• Create an environment conducive to self‐evaluation and improvement.

• Advocate for investment in information technology.

• Facilitate and encourage self‐directed learning among health care professionals and trainees.

• Promote self improvement and care standardization, utilizing best evidence and practice.