In 2015, and in response to the Ebola virus outbreak in West Africa, the United States Department of Health and Human Services (HHS) designated 10 health departments and associated partner hospitals to become regional treatment centers for patients with highly infectious diseases, such as the Ebola virus and other highly infectious special pathogens (HISPs), and reinforce the nation’s infectious disease response capability. These efforts catalyzed the creation and/or expansion of a network of biocontainment units (BCUs) to safely care for patients diagnosed with highly infectious diseases. These units are designed as special care units with environmental/engineering controls, laboratory capabilities, simple imaging testing, and dedicated staff to allow for the uninterrupted care of patients.^1,2 The HHS approach closely resembled the tiered structure of trauma center levels familiar to the healthcare system. The regional framework identified four types of facilities (frontline healthcare facilities, assessment hospitals, treatment centers, and regional Ebola and other special pathogens treatment centers [RESPTCs]) with increasing levels of capabilities and responsibilities.

There are over 4,845 frontline healthcare facilities across the United States, which are able to identify and isolate a patient suspected of a HISP infection and inform local and state partners. The facility provides stabilizing treatment while coordinating the transport of the patient to a specialized center. An assessment hospital can identify and isolate a patient with a HISP, inform partnering agencies, and provide care at the facility for up to 96 hours. There are over 217 hospitals with this designation in the United States. Treatment centers are designated as state or jurisdiction treatment centers and have the capacity to care for HISP-infected patients for the entirety of their care plan, as well as serve as a partner in caring for a potential surge in high-risk patients if their partner RESPTC is unable to care for a patient because of capacity limits. Patients may receive care at a treatment center if and when it is determined to be more appropriate (eg, clinical purview, logistics, resources) than sending them to a RESPTC. There are currently 63 designated treatment centers in the United States.

As outlined by HHS, the RESPTCs³ must be ready to receive a HISP-infected patient within their HHS region, domestically, or internationally within 8 hours. RESPTCs provide care for the entirety of the patient care plan. The 10 regional Departments of Public Health representatives are: Massachusetts (Region 1); New York (Region 2); Maryland (Region 3); Georgia (Region 4); Minnesota (Region 5); Texas (Region 6); Nebraska (Region 7); Colorado in partnership with Denver Health Hospital Authority (DHHA; Region 8); California (Region 9); and Washington State (Region 10).

Most RESPCTs BCUs are staffed by a self-selected group of core providers with expertise in infectious diseases (ID) and critical care (CC). Teams are interdisciplinary and committed to a culture of safety.^4-7 ID physicians are experts in HISP disease processes and epidemiology, which enables expert guidance on patient care and infection control. CC physicians are trained to provide care to patients requiring life-saving interventions.

As specialized units are shifting to include high-risk infectious diseases beyond Ebola, hospitals are developing innovative ways to manage a potential surge of patients with respiratory pathogens, expanding care far beyond the biocontainment unit. With the potential for an influx of HISPs in the healthcare setting, identifying stakeholders uniquely equipped to provide care in all areas of the hospital is ideal. At DHHA, the BCU physician staffing model transitioned from ID and CC physicians to a selected group of ten hospitalists as the primary managing service in 2018.

When DHHA received the RESPTC nomination, it developed a fully voluntary multidisciplinary high-risk infection team (HITeam; Table) with specialized training in personal protective equipment (PPE) donning and doffing, as well as BCU protocols. Our HITeam members participate in every-6-weeks mandatory team drills that involve practicing team dynamics and dexterity while wearing PPE. Team members participate in regular hospital and/or BCU-focused exercises to simulate and practice real-world experiences. They also participate in HISP Journal Club, where members from different disciplines discuss pertinent articles in the field, as well as every-other-month team-building meetings. Our unit’s main challenges included maintaining competencies and staff retention. We developed a unique staffing model aimed at mitigating some of these challenges through a multidisciplinary team approach utilizing different levels of physician involvement. The first group comprises physicians providing primary, direct care to patients, which which consists our specially trained group of 10 hospitalists—including 2 pediatricians, as well as 3 CC and 4 ID consultants. The second group involves consultants from specialties such as nephrology, anesthesia, general surgery, radiology and gynecology; just–in-time training is available for them.

Hospitalists are uniquely positioned to care for this distinctive set of patients because they are comfortable with the care of acutely ill patients, many maintain bedside procedural skills, and many have acquired point-of-care-ultrasonography (POCUS) skills. Furthermore, hospitalists usually outnumber available specialists who may be needed to maintain consultative and critical care services for non-BCU patients. We were able to develop a feasible physician staffing model, as described below, and validate hospital medicine’s commitment in addressing institutional needs.

In order to provide ideal unit coverage, 2 hospitalists are scheduled daily and available to respond in case of unit activation. BCU hospitalists are scheduled to cover the BCU when already scheduled to work a clinical shift. In the very infrequent event of BCU activation, BCU hospitalists would move their clinical work to the BCU and a back-up hospitalist would be called in to cover the “other” clinical shift; by overlapping coverage, we ensure BCU hospitalists’ work-life balance and job satisfaction remain intact. Because of expected postexposure monitoring, individual physician’s planned international travel is considered while generating the call schedule. When the unit is activated, the hospital provides payment for extra hours worked by both the BCU hospitalist and the back-up hospitalist, with anticipated revenue recapture through critical care billing by the BCU hospitalist. There are 10 HITeam hospitalists, who are trained and credentialed in bedside procedures and with different levels of POCUS expertise (from literacy to expert level). Team members are expected to attend training in bedside procedures while in PPE 2 times a year. The hospital also provides financial support for hospitalists seeking to further their BCU-related skills and training. It is anticipated that hospitalists will require consultative services from CC and ID in some selected cases to provide a well-rounded care approach to the biocontained patient.

Eligibility criteria for HITeam hospitalists include complete initial and quarterly maintenance PPE training; possession of active bedside procedure credentials for at least central line, paracentesis, thoracentesis, and arterial line; demonstration of basic POCUS skills, such as having enough POCUS verbiage literacy to be able to follow a radiologist’s instructions on probe management (ie, a radiologist outside anteroom); and possibility of completing additional training and credentialing on conscious sedation and/or advanced airway management.

Similarly, hospitalists who join the team commit to attendance of at least one National Ebola Training and Education Center (NETEC) provider’s course, representing the Region 8 RESPTC for educational presentations and research at regional and national levels, participation in quarterly HISP multidisciplinary meetings, attendance at quarterly donning and doffing sessions, as well as HITeam training sessions and drills, and active participation in the every-other-month HISP Journal Club/Grand Rounds to maintain competence and knowledge on management of many different pathogens, including Ebola and other filoviruses, MERS-CoV, SARS-CoV, Arenaviruses causing hemorrhagic fevers, Hantavirus, and novel influenzas or coronaviruses.

All of these commitments provide HITeam hospitalists with multiple opportunities for professional growth and development, such as augmenting scholarship venues by participating in collaborative national research projects, participating in national topic networks discussion groups and committees, becoming topic experts, and engaging in diversified training such as advanced airway training and conscious sedation. A new bedside ultrasound machine was purchased for the unit and housed within the division of hospital medicine with the intent to provide hospitalists the means necessary to achieve POCUS proficiency. Above all, by fostering a highly motivated and collegial multidisciplinary team, our model helps develop lasting partnerships at an institutional, regional, and national level.

This multidisciplinary team—with its skillfully trained and engaged nurses, physicians, respiratory therapists, pharmacists, infection control and laboratory specialists—works, learns, trains, and thrives collectively with the aim of providing excellent clinical care to our patients while assuring the safety of the team. DHHA has pioneered a RESPTC physician staffing model led by hospitalists.

We live in an ever-changing landscape of emerging diseases with blurred borders of disease geography. Hospitalists are versatile, capable of managing patients of varying acuity, able to perform many bedside procedures and POCUS; they are champions of interdisciplinary and teamwork disposition. By utilizing the resourcefulness of hospital medicine while helping to ease some of the burden that might otherwise be placed on a smaller numbers of physician groups, this approach provides a unique, cost-effective, and viable physician staffing model, which could be implemented in other BCUs in the United States.

In 2015, and in response to the Ebola virus outbreak in West Africa, the United States Department of Health and Human Services (HHS) designated 10 health departments and associated partner hospitals to become regional treatment centers for patients with highly infectious diseases, such as the Ebola virus and other highly infectious special pathogens (HISPs), and reinforce the nation’s infectious disease response capability. These efforts catalyzed the creation and/or expansion of a network of biocontainment units (BCUs) to safely care for patients diagnosed with highly infectious diseases. These units are designed as special care units with environmental/engineering controls, laboratory capabilities, simple imaging testing, and dedicated staff to allow for the uninterrupted care of patients.^1,2 The HHS approach closely resembled the tiered structure of trauma center levels familiar to the healthcare system. The regional framework identified four types of facilities (frontline healthcare facilities, assessment hospitals, treatment centers, and regional Ebola and other special pathogens treatment centers [RESPTCs]) with increasing levels of capabilities and responsibilities.

There are over 4,845 frontline healthcare facilities across the United States, which are able to identify and isolate a patient suspected of a HISP infection and inform local and state partners. The facility provides stabilizing treatment while coordinating the transport of the patient to a specialized center. An assessment hospital can identify and isolate a patient with a HISP, inform partnering agencies, and provide care at the facility for up to 96 hours. There are over 217 hospitals with this designation in the United States. Treatment centers are designated as state or jurisdiction treatment centers and have the capacity to care for HISP-infected patients for the entirety of their care plan, as well as serve as a partner in caring for a potential surge in high-risk patients if their partner RESPTC is unable to care for a patient because of capacity limits. Patients may receive care at a treatment center if and when it is determined to be more appropriate (eg, clinical purview, logistics, resources) than sending them to a RESPTC. There are currently 63 designated treatment centers in the United States.

As outlined by HHS, the RESPTCs³ must be ready to receive a HISP-infected patient within their HHS region, domestically, or internationally within 8 hours. RESPTCs provide care for the entirety of the patient care plan. The 10 regional Departments of Public Health representatives are: Massachusetts (Region 1); New York (Region 2); Maryland (Region 3); Georgia (Region 4); Minnesota (Region 5); Texas (Region 6); Nebraska (Region 7); Colorado in partnership with Denver Health Hospital Authority (DHHA; Region 8); California (Region 9); and Washington State (Region 10).

Most RESPCTs BCUs are staffed by a self-selected group of core providers with expertise in infectious diseases (ID) and critical care (CC). Teams are interdisciplinary and committed to a culture of safety.^4-7 ID physicians are experts in HISP disease processes and epidemiology, which enables expert guidance on patient care and infection control. CC physicians are trained to provide care to patients requiring life-saving interventions.

As specialized units are shifting to include high-risk infectious diseases beyond Ebola, hospitals are developing innovative ways to manage a potential surge of patients with respiratory pathogens, expanding care far beyond the biocontainment unit. With the potential for an influx of HISPs in the healthcare setting, identifying stakeholders uniquely equipped to provide care in all areas of the hospital is ideal. At DHHA, the BCU physician staffing model transitioned from ID and CC physicians to a selected group of ten hospitalists as the primary managing service in 2018.

When DHHA received the RESPTC nomination, it developed a fully voluntary multidisciplinary high-risk infection team (HITeam; Table) with specialized training in personal protective equipment (PPE) donning and doffing, as well as BCU protocols. Our HITeam members participate in every-6-weeks mandatory team drills that involve practicing team dynamics and dexterity while wearing PPE. Team members participate in regular hospital and/or BCU-focused exercises to simulate and practice real-world experiences. They also participate in HISP Journal Club, where members from different disciplines discuss pertinent articles in the field, as well as every-other-month team-building meetings. Our unit’s main challenges included maintaining competencies and staff retention. We developed a unique staffing model aimed at mitigating some of these challenges through a multidisciplinary team approach utilizing different levels of physician involvement. The first group comprises physicians providing primary, direct care to patients, which which consists our specially trained group of 10 hospitalists—including 2 pediatricians, as well as 3 CC and 4 ID consultants. The second group involves consultants from specialties such as nephrology, anesthesia, general surgery, radiology and gynecology; just–in-time training is available for them.

Hospitalists are uniquely positioned to care for this distinctive set of patients because they are comfortable with the care of acutely ill patients, many maintain bedside procedural skills, and many have acquired point-of-care-ultrasonography (POCUS) skills. Furthermore, hospitalists usually outnumber available specialists who may be needed to maintain consultative and critical care services for non-BCU patients. We were able to develop a feasible physician staffing model, as described below, and validate hospital medicine’s commitment in addressing institutional needs.

In order to provide ideal unit coverage, 2 hospitalists are scheduled daily and available to respond in case of unit activation. BCU hospitalists are scheduled to cover the BCU when already scheduled to work a clinical shift. In the very infrequent event of BCU activation, BCU hospitalists would move their clinical work to the BCU and a back-up hospitalist would be called in to cover the “other” clinical shift; by overlapping coverage, we ensure BCU hospitalists’ work-life balance and job satisfaction remain intact. Because of expected postexposure monitoring, individual physician’s planned international travel is considered while generating the call schedule. When the unit is activated, the hospital provides payment for extra hours worked by both the BCU hospitalist and the back-up hospitalist, with anticipated revenue recapture through critical care billing by the BCU hospitalist. There are 10 HITeam hospitalists, who are trained and credentialed in bedside procedures and with different levels of POCUS expertise (from literacy to expert level). Team members are expected to attend training in bedside procedures while in PPE 2 times a year. The hospital also provides financial support for hospitalists seeking to further their BCU-related skills and training. It is anticipated that hospitalists will require consultative services from CC and ID in some selected cases to provide a well-rounded care approach to the biocontained patient.

Eligibility criteria for HITeam hospitalists include complete initial and quarterly maintenance PPE training; possession of active bedside procedure credentials for at least central line, paracentesis, thoracentesis, and arterial line; demonstration of basic POCUS skills, such as having enough POCUS verbiage literacy to be able to follow a radiologist’s instructions on probe management (ie, a radiologist outside anteroom); and possibility of completing additional training and credentialing on conscious sedation and/or advanced airway management.

Similarly, hospitalists who join the team commit to attendance of at least one National Ebola Training and Education Center (NETEC) provider’s course, representing the Region 8 RESPTC for educational presentations and research at regional and national levels, participation in quarterly HISP multidisciplinary meetings, attendance at quarterly donning and doffing sessions, as well as HITeam training sessions and drills, and active participation in the every-other-month HISP Journal Club/Grand Rounds to maintain competence and knowledge on management of many different pathogens, including Ebola and other filoviruses, MERS-CoV, SARS-CoV, Arenaviruses causing hemorrhagic fevers, Hantavirus, and novel influenzas or coronaviruses.

All of these commitments provide HITeam hospitalists with multiple opportunities for professional growth and development, such as augmenting scholarship venues by participating in collaborative national research projects, participating in national topic networks discussion groups and committees, becoming topic experts, and engaging in diversified training such as advanced airway training and conscious sedation. A new bedside ultrasound machine was purchased for the unit and housed within the division of hospital medicine with the intent to provide hospitalists the means necessary to achieve POCUS proficiency. Above all, by fostering a highly motivated and collegial multidisciplinary team, our model helps develop lasting partnerships at an institutional, regional, and national level.

This multidisciplinary team—with its skillfully trained and engaged nurses, physicians, respiratory therapists, pharmacists, infection control and laboratory specialists—works, learns, trains, and thrives collectively with the aim of providing excellent clinical care to our patients while assuring the safety of the team. DHHA has pioneered a RESPTC physician staffing model led by hospitalists.

We live in an ever-changing landscape of emerging diseases with blurred borders of disease geography. Hospitalists are versatile, capable of managing patients of varying acuity, able to perform many bedside procedures and POCUS; they are champions of interdisciplinary and teamwork disposition. By utilizing the resourcefulness of hospital medicine while helping to ease some of the burden that might otherwise be placed on a smaller numbers of physician groups, this approach provides a unique, cost-effective, and viable physician staffing model, which could be implemented in other BCUs in the United States.

In 2015, and in response to the Ebola virus outbreak in West Africa, the United States Department of Health and Human Services (HHS) designated 10 health departments and associated partner hospitals to become regional treatment centers for patients with highly infectious diseases, such as the Ebola virus and other highly infectious special pathogens (HISPs), and reinforce the nation’s infectious disease response capability. These efforts catalyzed the creation and/or expansion of a network of biocontainment units (BCUs) to safely care for patients diagnosed with highly infectious diseases. These units are designed as special care units with environmental/engineering controls, laboratory capabilities, simple imaging testing, and dedicated staff to allow for the uninterrupted care of patients.^1,2 The HHS approach closely resembled the tiered structure of trauma center levels familiar to the healthcare system. The regional framework identified four types of facilities (frontline healthcare facilities, assessment hospitals, treatment centers, and regional Ebola and other special pathogens treatment centers [RESPTCs]) with increasing levels of capabilities and responsibilities.

There are over 4,845 frontline healthcare facilities across the United States, which are able to identify and isolate a patient suspected of a HISP infection and inform local and state partners. The facility provides stabilizing treatment while coordinating the transport of the patient to a specialized center. An assessment hospital can identify and isolate a patient with a HISP, inform partnering agencies, and provide care at the facility for up to 96 hours. There are over 217 hospitals with this designation in the United States. Treatment centers are designated as state or jurisdiction treatment centers and have the capacity to care for HISP-infected patients for the entirety of their care plan, as well as serve as a partner in caring for a potential surge in high-risk patients if their partner RESPTC is unable to care for a patient because of capacity limits. Patients may receive care at a treatment center if and when it is determined to be more appropriate (eg, clinical purview, logistics, resources) than sending them to a RESPTC. There are currently 63 designated treatment centers in the United States.

As outlined by HHS, the RESPTCs³ must be ready to receive a HISP-infected patient within their HHS region, domestically, or internationally within 8 hours. RESPTCs provide care for the entirety of the patient care plan. The 10 regional Departments of Public Health representatives are: Massachusetts (Region 1); New York (Region 2); Maryland (Region 3); Georgia (Region 4); Minnesota (Region 5); Texas (Region 6); Nebraska (Region 7); Colorado in partnership with Denver Health Hospital Authority (DHHA; Region 8); California (Region 9); and Washington State (Region 10).

Most RESPCTs BCUs are staffed by a self-selected group of core providers with expertise in infectious diseases (ID) and critical care (CC). Teams are interdisciplinary and committed to a culture of safety.^4-7 ID physicians are experts in HISP disease processes and epidemiology, which enables expert guidance on patient care and infection control. CC physicians are trained to provide care to patients requiring life-saving interventions.

As specialized units are shifting to include high-risk infectious diseases beyond Ebola, hospitals are developing innovative ways to manage a potential surge of patients with respiratory pathogens, expanding care far beyond the biocontainment unit. With the potential for an influx of HISPs in the healthcare setting, identifying stakeholders uniquely equipped to provide care in all areas of the hospital is ideal. At DHHA, the BCU physician staffing model transitioned from ID and CC physicians to a selected group of ten hospitalists as the primary managing service in 2018.

When DHHA received the RESPTC nomination, it developed a fully voluntary multidisciplinary high-risk infection team (HITeam; Table) with specialized training in personal protective equipment (PPE) donning and doffing, as well as BCU protocols. Our HITeam members participate in every-6-weeks mandatory team drills that involve practicing team dynamics and dexterity while wearing PPE. Team members participate in regular hospital and/or BCU-focused exercises to simulate and practice real-world experiences. They also participate in HISP Journal Club, where members from different disciplines discuss pertinent articles in the field, as well as every-other-month team-building meetings. Our unit’s main challenges included maintaining competencies and staff retention. We developed a unique staffing model aimed at mitigating some of these challenges through a multidisciplinary team approach utilizing different levels of physician involvement. The first group comprises physicians providing primary, direct care to patients, which which consists our specially trained group of 10 hospitalists—including 2 pediatricians, as well as 3 CC and 4 ID consultants. The second group involves consultants from specialties such as nephrology, anesthesia, general surgery, radiology and gynecology; just–in-time training is available for them.

Hospitalists are uniquely positioned to care for this distinctive set of patients because they are comfortable with the care of acutely ill patients, many maintain bedside procedural skills, and many have acquired point-of-care-ultrasonography (POCUS) skills. Furthermore, hospitalists usually outnumber available specialists who may be needed to maintain consultative and critical care services for non-BCU patients. We were able to develop a feasible physician staffing model, as described below, and validate hospital medicine’s commitment in addressing institutional needs.

In order to provide ideal unit coverage, 2 hospitalists are scheduled daily and available to respond in case of unit activation. BCU hospitalists are scheduled to cover the BCU when already scheduled to work a clinical shift. In the very infrequent event of BCU activation, BCU hospitalists would move their clinical work to the BCU and a back-up hospitalist would be called in to cover the “other” clinical shift; by overlapping coverage, we ensure BCU hospitalists’ work-life balance and job satisfaction remain intact. Because of expected postexposure monitoring, individual physician’s planned international travel is considered while generating the call schedule. When the unit is activated, the hospital provides payment for extra hours worked by both the BCU hospitalist and the back-up hospitalist, with anticipated revenue recapture through critical care billing by the BCU hospitalist. There are 10 HITeam hospitalists, who are trained and credentialed in bedside procedures and with different levels of POCUS expertise (from literacy to expert level). Team members are expected to attend training in bedside procedures while in PPE 2 times a year. The hospital also provides financial support for hospitalists seeking to further their BCU-related skills and training. It is anticipated that hospitalists will require consultative services from CC and ID in some selected cases to provide a well-rounded care approach to the biocontained patient.

Eligibility criteria for HITeam hospitalists include complete initial and quarterly maintenance PPE training; possession of active bedside procedure credentials for at least central line, paracentesis, thoracentesis, and arterial line; demonstration of basic POCUS skills, such as having enough POCUS verbiage literacy to be able to follow a radiologist’s instructions on probe management (ie, a radiologist outside anteroom); and possibility of completing additional training and credentialing on conscious sedation and/or advanced airway management.

Similarly, hospitalists who join the team commit to attendance of at least one National Ebola Training and Education Center (NETEC) provider’s course, representing the Region 8 RESPTC for educational presentations and research at regional and national levels, participation in quarterly HISP multidisciplinary meetings, attendance at quarterly donning and doffing sessions, as well as HITeam training sessions and drills, and active participation in the every-other-month HISP Journal Club/Grand Rounds to maintain competence and knowledge on management of many different pathogens, including Ebola and other filoviruses, MERS-CoV, SARS-CoV, Arenaviruses causing hemorrhagic fevers, Hantavirus, and novel influenzas or coronaviruses.

All of these commitments provide HITeam hospitalists with multiple opportunities for professional growth and development, such as augmenting scholarship venues by participating in collaborative national research projects, participating in national topic networks discussion groups and committees, becoming topic experts, and engaging in diversified training such as advanced airway training and conscious sedation. A new bedside ultrasound machine was purchased for the unit and housed within the division of hospital medicine with the intent to provide hospitalists the means necessary to achieve POCUS proficiency. Above all, by fostering a highly motivated and collegial multidisciplinary team, our model helps develop lasting partnerships at an institutional, regional, and national level.

This multidisciplinary team—with its skillfully trained and engaged nurses, physicians, respiratory therapists, pharmacists, infection control and laboratory specialists—works, learns, trains, and thrives collectively with the aim of providing excellent clinical care to our patients while assuring the safety of the team. DHHA has pioneered a RESPTC physician staffing model led by hospitalists.

We live in an ever-changing landscape of emerging diseases with blurred borders of disease geography. Hospitalists are versatile, capable of managing patients of varying acuity, able to perform many bedside procedures and POCUS; they are champions of interdisciplinary and teamwork disposition. By utilizing the resourcefulness of hospital medicine while helping to ease some of the burden that might otherwise be placed on a smaller numbers of physician groups, this approach provides a unique, cost-effective, and viable physician staffing model, which could be implemented in other BCUs in the United States.

Over the past two decades, physicians and nurses practicing in hospital settings have faced an onslaught of challenges in communication, an area frequently cited as critical to providing safe and effective care to patients.^1-3 Communication needs have increased significantly as hospitalized patients have become more acute, complex, and technology-dependent, requiring larger healthcare teams comprising subspecialists across multiple disciplines spread across increasingly larger inpatient facilities.⁴ During this same period, the evolution of mobile phones has led to dramatic shifts in personal communication patterns, with asynchronous text messaging replacing verbal communication.^5-7

In response to both the changing communication needs of clinicians and shifting cultural conventions, healthcare systems and providers alike have viewed text messaging as a solution to these growing communication problems. In fact, an entire industry has developed around “secure” and “Health Insurance Portability and Accountability Act (HIPAA)-compliant” text messaging platforms, which we will refer to below as secure text messaging systems (STMS). These systems offer benefits over carrier-based text messaging given their focus on the healthcare environment and HIPAA compliance. However, hospitals’ rapid adoption of these systems has outpaced our abilities to surveil, recognize, and understand the unintended consequences of transitioning to STMS communication in the hospital setting where failures in communication can be catastrophic. Below, we highlight three critical areas of concern encountered at our institutions and offer five potential mitigating strategies (Table).

Text Messaging is a Form of Alarm Fatigue

Text messaging renders clinicians vulnerable to a unique form of alarm fatigue. The burden of alarm fatigue has been well described in the literature and applies to interruptions to workflow in the electronic medical record and sensory alerts in clinical settings.^8,9 Text messaging serves as yet another interruption for healthcare providers. Without a framework to triage urgent versus nonurgent messages, a clinician can become inundated with information and miss critical messages. This can lead to delayed or incorrect responses and impede patient care. System design and implementation can also contribute to this phenomenon. For example, a text message analysis at one center identified how system and workflow design resulted in all messages to an intensive care unit team being routed to a single physician’s phone.¹⁰ This design left the singular physician at risk of information and task overload and at the mercy of endless interruptive alerts. Although this can occur with any communication system, it has been well demonstrated that adopting STMS correlates with an increased frequency of messaging, leading to an increase in interruptive alerts, which may have implications for patient safety.¹¹ This type of systems failure is silent unless proactively identified or revealed through a retrospective review of a resulting safety event.

Text Messaging Inappropriately Replaces Critical Communications that Should Happen in Person or by Phone

Text messaging has de-emphasized interpersonal communication skills and behaviors critical for quality and safety in hospital-based care. This concern emerges alongside evidence suggesting that new generations of physician trainees have profoundly different communication habits, preferences, and skillsets based on their experience in a text-heavy, asynchronous world of communication.¹² There is reason to worry that reliance on text messaging in healthcare leads to similar alterations in relationships and collaboration as it has in our broader cultural context.¹³ Academic medical centers in particular should attempt to mitigate the loss of profound and formative learning that occurs during face-to-face encounters between providers of different disciplines, experience levels, and specialties.

Text Messaging Increases the Risk of Communication Error

Finally, text messaging appears to be highly vulnerable to communication errors in the healthcare setting. Prior work emphasizes the importance of nonverbal communication in face-to-face and even voice-to-voice interactions, highlighting the loss of fidelity when using text-only methods to communicate.¹ Furthermore, the asynchronous nature of text messaging grants little room for clarification of minor misunderstandings that often arise in text-only communication through minor alterations in punctuation or automatic spelling corrections, a frequent occurrence when using medical terminology. Although a seasoned physician may be able to piece together the issues that deserve further clarification, young residents may be more hesitant to ask clarifying questions and determine the right course of action due to clinical inexperience.

Deliberate Design and Implementation

A recent systematic review identified a lack of high-quality evidence evaluating the impact of mobile technologies on communication and teamwork in hospital settings.¹⁴ This paucity of understanding renders communication via STMS in the healthcare setting uniquely vulnerable to latent safety threats unless the design and implementation of these systems are purposeful and proactive.

These concerns led us to postulate that deliberate and proactive implementation of these systems, rather than passive adoption, is needed in the healthcare environment. We propose a number of approaches and interventions that may guide institutions as they seek to implement STMS or redesign communication in the inpatient setting. At the core of these proposals lies an important tension: can implementation of STMS occur in isolation or should the arrival of these systems prompt an overhaul of an institution’s clinical communication system and culture?¹⁵

Proactive Surveillance

Surveillance is one proactive method for healthcare systems to understand where and how the implementation of STMS might lead to safety threats. From a quantitative standpoint, understanding the burden of messaging for each user across the system can reveal the clinical roles in the system that are particularly vulnerable to alert fatigue or information overload. Quality assurance monitoring of critical roles in the hospital (ie, airway emergency team, rapid response teams) could be conducted to ensure accurate directory listings at all times. Associating conversations with events, from serious safety events to near misses, could help leaders understand when and how text messaging contributes to safety events and create actionable learnings for safety learning systems.

Standardized Communication

A standardized language eliminates the burden of individuals to parse and translate each individual text message. A standardized algorithm for language, urgency, and expectations (ie, response before escalation) would help define the interaction in the clinical setting.¹⁶ Moving toward standardized, meaningful “quick messages,” one of our centers has implemented a campaign to “stick to the FACS,” where the following four standard quick messages are available for users: (1) “FYI no response needed,” (2) “ACTION needed within X min,” (3) “CONCERN can we talk or meet,” and (4) “STAT immediate response required.” These quick messages, developed with frontline stakeholders, represent the majority of requests exchanged by providers, and help standardize expectations and task prioritization.

Targeted Training

Targeted training and culture change efforts might help institutions counteract the broader impact of asynchronous messaging on communication skills and behaviors. Highlighting the contrast between clinical and casual communication with an emphasis on examples, scenarios, or role-playing has the potential to emphasize why and how clinical communication with STMS requires a careful, deliberate approach. For instance, safety culture training at one of our institutions features a scenario that illustrates the potential for miscommunication and missed connection between a nurse and a physician on the wards. The scenario gives way to discussion between participants about the shortcomings of text messaging and allows the facilitator to segue into the “dos and don’ts” of text messaging and when a phone call might be more appropriate.

Innovate

Finally, creatively harnessing the technology and data underlying these STMS may uncover methods to identify and mitigate communication errors in real time. For instance, using trigger methods to create a “ripple in the pond,” whereby a floor nurse reaching out with an urgent text automatically loops in the charge nurse of the unit. Building a chatbot or a virtual assistant functionality by leveraging user behavior patterns and natural language processing to provide text-based guidance to users might help busy clinicians connect to the key decision-makers on their team. For example, in response to an unanswered text, a virtual assistant might reach out to the waiting provider as follows: “you texted the resident 20 minutes ago and they haven’t replied, would you like to call the fellow instead?” The data-rich nature of these systems implies that they are ripe for automated solutions that can respond to behavioral- or text-based patterns to augment the existing operation and safety infrastructure.

The transition of healthcare communication systems toward STMS is already well underway. These systems, despite their flaws, are undoubtedly an improvement over legacy paging systems and, if properly implemented, offer several benefits to large healthcare systems. However, the communication needs in the healthcare setting are vastly different from the personal communication needs in everyday text messaging. As clinicians at the forefront of these transitions, we have the opportunity to critically assess the unique communication requirements in our hospital settings and help shape the way STMS are implemented in our hospitals. Pausing to deliberate about the limitations and the vulnerabilities of the current messaging systems for our acute clinical needs, including how they impact training and education, will allow us to proactively design and implement better communication systems that improve patient safety.

Over the past two decades, physicians and nurses practicing in hospital settings have faced an onslaught of challenges in communication, an area frequently cited as critical to providing safe and effective care to patients.^1-3 Communication needs have increased significantly as hospitalized patients have become more acute, complex, and technology-dependent, requiring larger healthcare teams comprising subspecialists across multiple disciplines spread across increasingly larger inpatient facilities.⁴ During this same period, the evolution of mobile phones has led to dramatic shifts in personal communication patterns, with asynchronous text messaging replacing verbal communication.^5-7

In response to both the changing communication needs of clinicians and shifting cultural conventions, healthcare systems and providers alike have viewed text messaging as a solution to these growing communication problems. In fact, an entire industry has developed around “secure” and “Health Insurance Portability and Accountability Act (HIPAA)-compliant” text messaging platforms, which we will refer to below as secure text messaging systems (STMS). These systems offer benefits over carrier-based text messaging given their focus on the healthcare environment and HIPAA compliance. However, hospitals’ rapid adoption of these systems has outpaced our abilities to surveil, recognize, and understand the unintended consequences of transitioning to STMS communication in the hospital setting where failures in communication can be catastrophic. Below, we highlight three critical areas of concern encountered at our institutions and offer five potential mitigating strategies (Table).

Text Messaging is a Form of Alarm Fatigue

Text messaging renders clinicians vulnerable to a unique form of alarm fatigue. The burden of alarm fatigue has been well described in the literature and applies to interruptions to workflow in the electronic medical record and sensory alerts in clinical settings.^8,9 Text messaging serves as yet another interruption for healthcare providers. Without a framework to triage urgent versus nonurgent messages, a clinician can become inundated with information and miss critical messages. This can lead to delayed or incorrect responses and impede patient care. System design and implementation can also contribute to this phenomenon. For example, a text message analysis at one center identified how system and workflow design resulted in all messages to an intensive care unit team being routed to a single physician’s phone.¹⁰ This design left the singular physician at risk of information and task overload and at the mercy of endless interruptive alerts. Although this can occur with any communication system, it has been well demonstrated that adopting STMS correlates with an increased frequency of messaging, leading to an increase in interruptive alerts, which may have implications for patient safety.¹¹ This type of systems failure is silent unless proactively identified or revealed through a retrospective review of a resulting safety event.

Text Messaging Inappropriately Replaces Critical Communications that Should Happen in Person or by Phone

Text messaging has de-emphasized interpersonal communication skills and behaviors critical for quality and safety in hospital-based care. This concern emerges alongside evidence suggesting that new generations of physician trainees have profoundly different communication habits, preferences, and skillsets based on their experience in a text-heavy, asynchronous world of communication.¹² There is reason to worry that reliance on text messaging in healthcare leads to similar alterations in relationships and collaboration as it has in our broader cultural context.¹³ Academic medical centers in particular should attempt to mitigate the loss of profound and formative learning that occurs during face-to-face encounters between providers of different disciplines, experience levels, and specialties.

Text Messaging Increases the Risk of Communication Error

Finally, text messaging appears to be highly vulnerable to communication errors in the healthcare setting. Prior work emphasizes the importance of nonverbal communication in face-to-face and even voice-to-voice interactions, highlighting the loss of fidelity when using text-only methods to communicate.¹ Furthermore, the asynchronous nature of text messaging grants little room for clarification of minor misunderstandings that often arise in text-only communication through minor alterations in punctuation or automatic spelling corrections, a frequent occurrence when using medical terminology. Although a seasoned physician may be able to piece together the issues that deserve further clarification, young residents may be more hesitant to ask clarifying questions and determine the right course of action due to clinical inexperience.

Deliberate Design and Implementation

A recent systematic review identified a lack of high-quality evidence evaluating the impact of mobile technologies on communication and teamwork in hospital settings.¹⁴ This paucity of understanding renders communication via STMS in the healthcare setting uniquely vulnerable to latent safety threats unless the design and implementation of these systems are purposeful and proactive.

These concerns led us to postulate that deliberate and proactive implementation of these systems, rather than passive adoption, is needed in the healthcare environment. We propose a number of approaches and interventions that may guide institutions as they seek to implement STMS or redesign communication in the inpatient setting. At the core of these proposals lies an important tension: can implementation of STMS occur in isolation or should the arrival of these systems prompt an overhaul of an institution’s clinical communication system and culture?¹⁵

Proactive Surveillance

Surveillance is one proactive method for healthcare systems to understand where and how the implementation of STMS might lead to safety threats. From a quantitative standpoint, understanding the burden of messaging for each user across the system can reveal the clinical roles in the system that are particularly vulnerable to alert fatigue or information overload. Quality assurance monitoring of critical roles in the hospital (ie, airway emergency team, rapid response teams) could be conducted to ensure accurate directory listings at all times. Associating conversations with events, from serious safety events to near misses, could help leaders understand when and how text messaging contributes to safety events and create actionable learnings for safety learning systems.

Standardized Communication

A standardized language eliminates the burden of individuals to parse and translate each individual text message. A standardized algorithm for language, urgency, and expectations (ie, response before escalation) would help define the interaction in the clinical setting.¹⁶ Moving toward standardized, meaningful “quick messages,” one of our centers has implemented a campaign to “stick to the FACS,” where the following four standard quick messages are available for users: (1) “FYI no response needed,” (2) “ACTION needed within X min,” (3) “CONCERN can we talk or meet,” and (4) “STAT immediate response required.” These quick messages, developed with frontline stakeholders, represent the majority of requests exchanged by providers, and help standardize expectations and task prioritization.

Targeted Training

Targeted training and culture change efforts might help institutions counteract the broader impact of asynchronous messaging on communication skills and behaviors. Highlighting the contrast between clinical and casual communication with an emphasis on examples, scenarios, or role-playing has the potential to emphasize why and how clinical communication with STMS requires a careful, deliberate approach. For instance, safety culture training at one of our institutions features a scenario that illustrates the potential for miscommunication and missed connection between a nurse and a physician on the wards. The scenario gives way to discussion between participants about the shortcomings of text messaging and allows the facilitator to segue into the “dos and don’ts” of text messaging and when a phone call might be more appropriate.

Innovate

Finally, creatively harnessing the technology and data underlying these STMS may uncover methods to identify and mitigate communication errors in real time. For instance, using trigger methods to create a “ripple in the pond,” whereby a floor nurse reaching out with an urgent text automatically loops in the charge nurse of the unit. Building a chatbot or a virtual assistant functionality by leveraging user behavior patterns and natural language processing to provide text-based guidance to users might help busy clinicians connect to the key decision-makers on their team. For example, in response to an unanswered text, a virtual assistant might reach out to the waiting provider as follows: “you texted the resident 20 minutes ago and they haven’t replied, would you like to call the fellow instead?” The data-rich nature of these systems implies that they are ripe for automated solutions that can respond to behavioral- or text-based patterns to augment the existing operation and safety infrastructure.

The transition of healthcare communication systems toward STMS is already well underway. These systems, despite their flaws, are undoubtedly an improvement over legacy paging systems and, if properly implemented, offer several benefits to large healthcare systems. However, the communication needs in the healthcare setting are vastly different from the personal communication needs in everyday text messaging. As clinicians at the forefront of these transitions, we have the opportunity to critically assess the unique communication requirements in our hospital settings and help shape the way STMS are implemented in our hospitals. Pausing to deliberate about the limitations and the vulnerabilities of the current messaging systems for our acute clinical needs, including how they impact training and education, will allow us to proactively design and implement better communication systems that improve patient safety.

Over the past two decades, physicians and nurses practicing in hospital settings have faced an onslaught of challenges in communication, an area frequently cited as critical to providing safe and effective care to patients.^1-3 Communication needs have increased significantly as hospitalized patients have become more acute, complex, and technology-dependent, requiring larger healthcare teams comprising subspecialists across multiple disciplines spread across increasingly larger inpatient facilities.⁴ During this same period, the evolution of mobile phones has led to dramatic shifts in personal communication patterns, with asynchronous text messaging replacing verbal communication.^5-7

In response to both the changing communication needs of clinicians and shifting cultural conventions, healthcare systems and providers alike have viewed text messaging as a solution to these growing communication problems. In fact, an entire industry has developed around “secure” and “Health Insurance Portability and Accountability Act (HIPAA)-compliant” text messaging platforms, which we will refer to below as secure text messaging systems (STMS). These systems offer benefits over carrier-based text messaging given their focus on the healthcare environment and HIPAA compliance. However, hospitals’ rapid adoption of these systems has outpaced our abilities to surveil, recognize, and understand the unintended consequences of transitioning to STMS communication in the hospital setting where failures in communication can be catastrophic. Below, we highlight three critical areas of concern encountered at our institutions and offer five potential mitigating strategies (Table).

Text Messaging is a Form of Alarm Fatigue

Text messaging renders clinicians vulnerable to a unique form of alarm fatigue. The burden of alarm fatigue has been well described in the literature and applies to interruptions to workflow in the electronic medical record and sensory alerts in clinical settings.^8,9 Text messaging serves as yet another interruption for healthcare providers. Without a framework to triage urgent versus nonurgent messages, a clinician can become inundated with information and miss critical messages. This can lead to delayed or incorrect responses and impede patient care. System design and implementation can also contribute to this phenomenon. For example, a text message analysis at one center identified how system and workflow design resulted in all messages to an intensive care unit team being routed to a single physician’s phone.¹⁰ This design left the singular physician at risk of information and task overload and at the mercy of endless interruptive alerts. Although this can occur with any communication system, it has been well demonstrated that adopting STMS correlates with an increased frequency of messaging, leading to an increase in interruptive alerts, which may have implications for patient safety.¹¹ This type of systems failure is silent unless proactively identified or revealed through a retrospective review of a resulting safety event.

Text Messaging Inappropriately Replaces Critical Communications that Should Happen in Person or by Phone

Text messaging has de-emphasized interpersonal communication skills and behaviors critical for quality and safety in hospital-based care. This concern emerges alongside evidence suggesting that new generations of physician trainees have profoundly different communication habits, preferences, and skillsets based on their experience in a text-heavy, asynchronous world of communication.¹² There is reason to worry that reliance on text messaging in healthcare leads to similar alterations in relationships and collaboration as it has in our broader cultural context.¹³ Academic medical centers in particular should attempt to mitigate the loss of profound and formative learning that occurs during face-to-face encounters between providers of different disciplines, experience levels, and specialties.

Text Messaging Increases the Risk of Communication Error

Finally, text messaging appears to be highly vulnerable to communication errors in the healthcare setting. Prior work emphasizes the importance of nonverbal communication in face-to-face and even voice-to-voice interactions, highlighting the loss of fidelity when using text-only methods to communicate.¹ Furthermore, the asynchronous nature of text messaging grants little room for clarification of minor misunderstandings that often arise in text-only communication through minor alterations in punctuation or automatic spelling corrections, a frequent occurrence when using medical terminology. Although a seasoned physician may be able to piece together the issues that deserve further clarification, young residents may be more hesitant to ask clarifying questions and determine the right course of action due to clinical inexperience.

Deliberate Design and Implementation

A recent systematic review identified a lack of high-quality evidence evaluating the impact of mobile technologies on communication and teamwork in hospital settings.¹⁴ This paucity of understanding renders communication via STMS in the healthcare setting uniquely vulnerable to latent safety threats unless the design and implementation of these systems are purposeful and proactive.

These concerns led us to postulate that deliberate and proactive implementation of these systems, rather than passive adoption, is needed in the healthcare environment. We propose a number of approaches and interventions that may guide institutions as they seek to implement STMS or redesign communication in the inpatient setting. At the core of these proposals lies an important tension: can implementation of STMS occur in isolation or should the arrival of these systems prompt an overhaul of an institution’s clinical communication system and culture?¹⁵

Proactive Surveillance

Surveillance is one proactive method for healthcare systems to understand where and how the implementation of STMS might lead to safety threats. From a quantitative standpoint, understanding the burden of messaging for each user across the system can reveal the clinical roles in the system that are particularly vulnerable to alert fatigue or information overload. Quality assurance monitoring of critical roles in the hospital (ie, airway emergency team, rapid response teams) could be conducted to ensure accurate directory listings at all times. Associating conversations with events, from serious safety events to near misses, could help leaders understand when and how text messaging contributes to safety events and create actionable learnings for safety learning systems.

Standardized Communication

A standardized language eliminates the burden of individuals to parse and translate each individual text message. A standardized algorithm for language, urgency, and expectations (ie, response before escalation) would help define the interaction in the clinical setting.¹⁶ Moving toward standardized, meaningful “quick messages,” one of our centers has implemented a campaign to “stick to the FACS,” where the following four standard quick messages are available for users: (1) “FYI no response needed,” (2) “ACTION needed within X min,” (3) “CONCERN can we talk or meet,” and (4) “STAT immediate response required.” These quick messages, developed with frontline stakeholders, represent the majority of requests exchanged by providers, and help standardize expectations and task prioritization.

Targeted Training

Targeted training and culture change efforts might help institutions counteract the broader impact of asynchronous messaging on communication skills and behaviors. Highlighting the contrast between clinical and casual communication with an emphasis on examples, scenarios, or role-playing has the potential to emphasize why and how clinical communication with STMS requires a careful, deliberate approach. For instance, safety culture training at one of our institutions features a scenario that illustrates the potential for miscommunication and missed connection between a nurse and a physician on the wards. The scenario gives way to discussion between participants about the shortcomings of text messaging and allows the facilitator to segue into the “dos and don’ts” of text messaging and when a phone call might be more appropriate.

Innovate

Finally, creatively harnessing the technology and data underlying these STMS may uncover methods to identify and mitigate communication errors in real time. For instance, using trigger methods to create a “ripple in the pond,” whereby a floor nurse reaching out with an urgent text automatically loops in the charge nurse of the unit. Building a chatbot or a virtual assistant functionality by leveraging user behavior patterns and natural language processing to provide text-based guidance to users might help busy clinicians connect to the key decision-makers on their team. For example, in response to an unanswered text, a virtual assistant might reach out to the waiting provider as follows: “you texted the resident 20 minutes ago and they haven’t replied, would you like to call the fellow instead?” The data-rich nature of these systems implies that they are ripe for automated solutions that can respond to behavioral- or text-based patterns to augment the existing operation and safety infrastructure.

The transition of healthcare communication systems toward STMS is already well underway. These systems, despite their flaws, are undoubtedly an improvement over legacy paging systems and, if properly implemented, offer several benefits to large healthcare systems. However, the communication needs in the healthcare setting are vastly different from the personal communication needs in everyday text messaging. As clinicians at the forefront of these transitions, we have the opportunity to critically assess the unique communication requirements in our hospital settings and help shape the way STMS are implemented in our hospitals. Pausing to deliberate about the limitations and the vulnerabilities of the current messaging systems for our acute clinical needs, including how they impact training and education, will allow us to proactively design and implement better communication systems that improve patient safety.

As an appealing, physiologically plausible treatment, humidified oxygen delivery via high-flow nasal cannula (HFNC) has been rapidly adopted for the treatment of bronchiolitis despite weak evidence supporting its routine and early use in hypoxemic infants.¹ Although HFNC use has been associated with decreased work of breathing and lower rates of progression to invasive ventilation in some studies, the one large trial published on the topic found no difference between early HFNC and standard oxygen therapy on length of stay in hospital, duration of oxygen therapy, or rates of intubation.^2,3 No adequately powered studies have examined the effect of ward-based HFNC initiation on ICU transfer, an outcome that it is designed to prevent.

In this month’s issue of the Journal of Hospital Medicine, Coon et al examine the association between the implementation of ward-based HFNC initiation protocols and subsequent ICU transfer rates.⁴ Hospitals enrolled in the Pediatric Health Information System database were surveyed about their HFNC use and protocol implementation, with 41 (93% response rate) hospitals replying, 12 of which implemented ward-based HFNC initiation protocols during 2010 to 2016. Administrative data for bronchiolitis encounters were obtained with use of International Classification of Diseases, 9th and 10th Revisions, coding of children aged 3 to 24 months discharged during the respiratory seasons of the study period. The authors used an interrupted time series analysis to study the association between ward-based HFNC protocol initiation and several outcomes, revealing a small but significant increase in ICU transfers (absolute difference, 3.1%; 95% CI, 2.8%-3.4%) and ICU length of stay (absolute difference, 9.1 days per 100 patients; 95% CI 5.1-13.2), but not overall length of stay or use of mechanical ventilation. Modifications to the analysis that account for a learning period during the first season of implementation at each hospital, and for trends among nonadopting hospitals, did not substantially affect the findings.

The authors acknowledged many of the study’s limitations, including its retrospective design, presumption of bronchiolitis discharge code validity, restriction to tertiary care hospitals, and analysis of hospital-level rather than patient-level variables and outcomes. Because the data source does not capture patient-­level HFNC use, the number and characteristics of patients receiving HFNC at the centers are unknown. It is also important to note that the 12 included protocols are quite heterogeneous, with differing exclusion criteria, maximum flow rates, and indications for ICU transfer. Given the rapid evolution of ward-based HFNC use for bronchiolitis, these protocols from 2010 to 2016 are already out of date. All of the protocols allowed much lower maximum flow rates (4-10 L/min) than would typically be expected today (usually 2 L/kg per minute, which translates to 10 L/min of flow for a 5-kg child or 20 L/min for a 10-kg child). Many also had time-based criteria prompting ICU transfer (eg, 24 hours without improvement) that are not typically included in more recent protocols. Few had instructions for weaning or discontinuation of HFNC.

In spite of the above limitations, the results of this large, multicenter study advance our understanding of the consequences of ward-based protocols for HFNC initiation. However, it is important to contextualize this work as an examination of the implementation of a technology to a broad population in a specific era, not necessarily a study of the effectiveness of the technology itself.

The pediatric hospital medicine community has long recognized the need for more evidence regarding HFNC use.^5-7 Coon et al have highlighted possible unintended consequences, notably increased ICU use, that may be associated with ward-based HFNC implementation on a population basis. This finding mirrors evidence from a recent similarly designed study analyzing Canadian tertiary care centers implementing HFNC administration during 2009 to 2014, though not specifically limited to ward use.⁸

More recently there has been discussion of how we might deimplement ward-based HFNC protocols. Although it is increasingly clear that HFNC is not a panacea for bronchiolitis, there is not necessarily a problem with the technology; the problem that this study so clearly demonstrates is how we have applied it. We need pragmatic trials of HFNC protocols to understand what parameters should guide HFNC initiation as a rescue treatment; what oxygen and flow settings might prevent ICU transfer; how it should be used in populations that have been largely excluded from trials (ie, children with medical complexity); and how to optimally wean it. With that information we could construct evidence-based, utilitarian HFNC initiation and treatment protocols to maximize benefit and minimize harm and cost.

It is understandable that our desire to help patients has led us to hear the “siren’s call” for this therapy, and indeed we should work on putting some of the “horses back in the barn.”^5,6 Until new evidence guides how to best use this technology, institutional practice guidelines for HFNC initiation in ward settings should target children for whom ICU transfer seems very likely (eg, having oxygen saturations not maintained on maximum low-flow oxygen therapy) so that HFNC is not used routinely and that we maximize its cost to benefit ratio. It is important to approach this shift in a thoughtful manner to prevent a pendulum swing to premature universal deimplementation.

As an appealing, physiologically plausible treatment, humidified oxygen delivery via high-flow nasal cannula (HFNC) has been rapidly adopted for the treatment of bronchiolitis despite weak evidence supporting its routine and early use in hypoxemic infants.¹ Although HFNC use has been associated with decreased work of breathing and lower rates of progression to invasive ventilation in some studies, the one large trial published on the topic found no difference between early HFNC and standard oxygen therapy on length of stay in hospital, duration of oxygen therapy, or rates of intubation.^2,3 No adequately powered studies have examined the effect of ward-based HFNC initiation on ICU transfer, an outcome that it is designed to prevent.

In this month’s issue of the Journal of Hospital Medicine, Coon et al examine the association between the implementation of ward-based HFNC initiation protocols and subsequent ICU transfer rates.⁴ Hospitals enrolled in the Pediatric Health Information System database were surveyed about their HFNC use and protocol implementation, with 41 (93% response rate) hospitals replying, 12 of which implemented ward-based HFNC initiation protocols during 2010 to 2016. Administrative data for bronchiolitis encounters were obtained with use of International Classification of Diseases, 9th and 10th Revisions, coding of children aged 3 to 24 months discharged during the respiratory seasons of the study period. The authors used an interrupted time series analysis to study the association between ward-based HFNC protocol initiation and several outcomes, revealing a small but significant increase in ICU transfers (absolute difference, 3.1%; 95% CI, 2.8%-3.4%) and ICU length of stay (absolute difference, 9.1 days per 100 patients; 95% CI 5.1-13.2), but not overall length of stay or use of mechanical ventilation. Modifications to the analysis that account for a learning period during the first season of implementation at each hospital, and for trends among nonadopting hospitals, did not substantially affect the findings.

The authors acknowledged many of the study’s limitations, including its retrospective design, presumption of bronchiolitis discharge code validity, restriction to tertiary care hospitals, and analysis of hospital-level rather than patient-level variables and outcomes. Because the data source does not capture patient-­level HFNC use, the number and characteristics of patients receiving HFNC at the centers are unknown. It is also important to note that the 12 included protocols are quite heterogeneous, with differing exclusion criteria, maximum flow rates, and indications for ICU transfer. Given the rapid evolution of ward-based HFNC use for bronchiolitis, these protocols from 2010 to 2016 are already out of date. All of the protocols allowed much lower maximum flow rates (4-10 L/min) than would typically be expected today (usually 2 L/kg per minute, which translates to 10 L/min of flow for a 5-kg child or 20 L/min for a 10-kg child). Many also had time-based criteria prompting ICU transfer (eg, 24 hours without improvement) that are not typically included in more recent protocols. Few had instructions for weaning or discontinuation of HFNC.

In spite of the above limitations, the results of this large, multicenter study advance our understanding of the consequences of ward-based protocols for HFNC initiation. However, it is important to contextualize this work as an examination of the implementation of a technology to a broad population in a specific era, not necessarily a study of the effectiveness of the technology itself.

The pediatric hospital medicine community has long recognized the need for more evidence regarding HFNC use.^5-7 Coon et al have highlighted possible unintended consequences, notably increased ICU use, that may be associated with ward-based HFNC implementation on a population basis. This finding mirrors evidence from a recent similarly designed study analyzing Canadian tertiary care centers implementing HFNC administration during 2009 to 2014, though not specifically limited to ward use.⁸

More recently there has been discussion of how we might deimplement ward-based HFNC protocols. Although it is increasingly clear that HFNC is not a panacea for bronchiolitis, there is not necessarily a problem with the technology; the problem that this study so clearly demonstrates is how we have applied it. We need pragmatic trials of HFNC protocols to understand what parameters should guide HFNC initiation as a rescue treatment; what oxygen and flow settings might prevent ICU transfer; how it should be used in populations that have been largely excluded from trials (ie, children with medical complexity); and how to optimally wean it. With that information we could construct evidence-based, utilitarian HFNC initiation and treatment protocols to maximize benefit and minimize harm and cost.

It is understandable that our desire to help patients has led us to hear the “siren’s call” for this therapy, and indeed we should work on putting some of the “horses back in the barn.”^5,6 Until new evidence guides how to best use this technology, institutional practice guidelines for HFNC initiation in ward settings should target children for whom ICU transfer seems very likely (eg, having oxygen saturations not maintained on maximum low-flow oxygen therapy) so that HFNC is not used routinely and that we maximize its cost to benefit ratio. It is important to approach this shift in a thoughtful manner to prevent a pendulum swing to premature universal deimplementation.

As an appealing, physiologically plausible treatment, humidified oxygen delivery via high-flow nasal cannula (HFNC) has been rapidly adopted for the treatment of bronchiolitis despite weak evidence supporting its routine and early use in hypoxemic infants.¹ Although HFNC use has been associated with decreased work of breathing and lower rates of progression to invasive ventilation in some studies, the one large trial published on the topic found no difference between early HFNC and standard oxygen therapy on length of stay in hospital, duration of oxygen therapy, or rates of intubation.^2,3 No adequately powered studies have examined the effect of ward-based HFNC initiation on ICU transfer, an outcome that it is designed to prevent.

In this month’s issue of the Journal of Hospital Medicine, Coon et al examine the association between the implementation of ward-based HFNC initiation protocols and subsequent ICU transfer rates.⁴ Hospitals enrolled in the Pediatric Health Information System database were surveyed about their HFNC use and protocol implementation, with 41 (93% response rate) hospitals replying, 12 of which implemented ward-based HFNC initiation protocols during 2010 to 2016. Administrative data for bronchiolitis encounters were obtained with use of International Classification of Diseases, 9th and 10th Revisions, coding of children aged 3 to 24 months discharged during the respiratory seasons of the study period. The authors used an interrupted time series analysis to study the association between ward-based HFNC protocol initiation and several outcomes, revealing a small but significant increase in ICU transfers (absolute difference, 3.1%; 95% CI, 2.8%-3.4%) and ICU length of stay (absolute difference, 9.1 days per 100 patients; 95% CI 5.1-13.2), but not overall length of stay or use of mechanical ventilation. Modifications to the analysis that account for a learning period during the first season of implementation at each hospital, and for trends among nonadopting hospitals, did not substantially affect the findings.

The authors acknowledged many of the study’s limitations, including its retrospective design, presumption of bronchiolitis discharge code validity, restriction to tertiary care hospitals, and analysis of hospital-level rather than patient-level variables and outcomes. Because the data source does not capture patient-­level HFNC use, the number and characteristics of patients receiving HFNC at the centers are unknown. It is also important to note that the 12 included protocols are quite heterogeneous, with differing exclusion criteria, maximum flow rates, and indications for ICU transfer. Given the rapid evolution of ward-based HFNC use for bronchiolitis, these protocols from 2010 to 2016 are already out of date. All of the protocols allowed much lower maximum flow rates (4-10 L/min) than would typically be expected today (usually 2 L/kg per minute, which translates to 10 L/min of flow for a 5-kg child or 20 L/min for a 10-kg child). Many also had time-based criteria prompting ICU transfer (eg, 24 hours without improvement) that are not typically included in more recent protocols. Few had instructions for weaning or discontinuation of HFNC.

In spite of the above limitations, the results of this large, multicenter study advance our understanding of the consequences of ward-based protocols for HFNC initiation. However, it is important to contextualize this work as an examination of the implementation of a technology to a broad population in a specific era, not necessarily a study of the effectiveness of the technology itself.

The pediatric hospital medicine community has long recognized the need for more evidence regarding HFNC use.^5-7 Coon et al have highlighted possible unintended consequences, notably increased ICU use, that may be associated with ward-based HFNC implementation on a population basis. This finding mirrors evidence from a recent similarly designed study analyzing Canadian tertiary care centers implementing HFNC administration during 2009 to 2014, though not specifically limited to ward use.⁸

More recently there has been discussion of how we might deimplement ward-based HFNC protocols. Although it is increasingly clear that HFNC is not a panacea for bronchiolitis, there is not necessarily a problem with the technology; the problem that this study so clearly demonstrates is how we have applied it. We need pragmatic trials of HFNC protocols to understand what parameters should guide HFNC initiation as a rescue treatment; what oxygen and flow settings might prevent ICU transfer; how it should be used in populations that have been largely excluded from trials (ie, children with medical complexity); and how to optimally wean it. With that information we could construct evidence-based, utilitarian HFNC initiation and treatment protocols to maximize benefit and minimize harm and cost.

It is understandable that our desire to help patients has led us to hear the “siren’s call” for this therapy, and indeed we should work on putting some of the “horses back in the barn.”^5,6 Until new evidence guides how to best use this technology, institutional practice guidelines for HFNC initiation in ward settings should target children for whom ICU transfer seems very likely (eg, having oxygen saturations not maintained on maximum low-flow oxygen therapy) so that HFNC is not used routinely and that we maximize its cost to benefit ratio. It is important to approach this shift in a thoughtful manner to prevent a pendulum swing to premature universal deimplementation.

Unlike other service industries, US healthcare has been slower to adopt an approach of asking users (patients) how to make things better. However, patient engagement in systems of healthcare (eg, Patient and Family Advisory Councils [PFAC]) and health system-­based research (eg, Patient Centered Outcomes Research Institute [PCORI]) are gaining currency in the United States.^1,2

Increasing patient/family involvement in health systems research design, especially in terms of setting research priorities, may lead to improved patient outcomes and experience. Patients and investigators have coproduced research agendas,¹ typically for specific diagnoses or with a focus on ambulatory care.³ To date, few efforts have actively engaged patients/families as true partners in identifying research gaps in the inpatient setting.^3,4

In their prospective study, Harrison et al⁵ used a systematic approach and methods established by PCORI and the James Lind Alliance to establish a patient-centered research agenda for improving care of hospitalized adult patients. They formed a national steering committee of clinical researchers, patients and caregivers, administrators, and stakeholder organizations. A survey was distributed to about 500 similar stakeholders to generate a list of potential research questions, which were sorted, analyzed, ranked, and prioritized based on frequency. The steering committee ultimately identified an agenda of 11 system of care–related research questions. The highest priority questions focused on ensuring shared decision making (SDM) and transitions of care.

This study has several strengths. Patients served as coleads on the steering committee and were engaged early and often throughout the process, considered a Tier 1, or deliberative, engagement approach.¹ This is in contrast to a consultative, or Tier 2, approach in which patients serve as consultants and comment later in the process.¹ As Harrison et al. demonstrate, including patients impacted the breadth and depth of results. An emphasis on patient perspectives seems to have led to recognition of topics that clinical researchers did not develop a priori. Some patient-proposed research topics, such as best modes to navigate the hospital and visiting hours, suggest a bigger question beyond patient experience: How might attention to details minimize disorientation, which likely detracts from ability to engage in care?

The most highly ranked research question regarded study of interventions that would ensure SDM among patients and physicians. SDM-based interventions in pediatrics have led to significantly improved knowledge and lower decisional conflict.⁶Many SDM-based interventions use decisional aids, which are tools that facilitate patient/family involvement in decision making for specific clinical situations (eg, end of life care, oral vs. intravenous antibiotics). Future work can focus on designing interventions that further enable SDM regardless of the scenario, such as enhancing provider training.⁶

More than half of the research questions ranked by the investigators related to transitions of care, including ensuring proper comprehension of and adherence to postdischarge care plans, medical provider handoffs, and mechanisms for communication after discharge. Interventions that promote inpatient physician and nurse use of health literacy–informed communication strategies, such as teach back, providing instructions using plain language or enhanced with graphics, or providing opportunities to practice follow-up care prior to discharge, may be beneficial.⁷

Moving from understanding to execution is another gap recognized in this study. Improving resources and care in the home after discharge also would likely improve outcomes. Industry, with use of rapid-cycle improvement methods, has already implemented comprehensive, home-based approaches focusing on enhanced presence of care team members (including physicians, nurses, and social workers) in the home. Team tasks include verifying that prescriptions are filled and medications are taken properly and ensuring that social needs are met, which could possibly lead to decreased healthcare utilization.⁸ Additional innovative strategies that leverage technology to optimize information exchange and facilitate postdischarge communication when questions arise (eg, telemedicine as suggested by stakeholders in this study) may also be beneficial. Such strategies, as well as models established by industry, should be further studied as part of interventions that also incorporate the perspective of patients, caregivers, and other stakeholders.

The study had a few limitations. This study, while national in scope, did not provide patient/caregiver demographics or preferred language, so it is unclear if participation was inclusive of all populations. Use of qualitative methods, including this study’s apparently modified Delphi approach, is important to ensuring equal consideration is given to all suggestions—but this only works if the stakeholders are representative. Patients and caregivers were primarily recruited from PFAC, which represent a more activated constituency and often lacks demographic diversity.⁹ Given that “care of vulnerable populations” was an infrequently proposed question category, future work would benefit from oversampling from marginalized, underrepresented groups.

While the study’s aim was development of a research agenda for adult patients, children, especially those who are medically complex, and their caregivers may experience similar issues. There may be barriers related to hospitalizations and transitions unique to children given their inherent dependent status. Future work could incorporate similar methods and engage children and their caregivers in setting a pediatric hospital medicine research agenda.

Unlike other service industries, US healthcare has been slower to adopt an approach of asking users (patients) how to make things better. However, patient engagement in systems of healthcare (eg, Patient and Family Advisory Councils [PFAC]) and health system-­based research (eg, Patient Centered Outcomes Research Institute [PCORI]) are gaining currency in the United States.^1,2

Increasing patient/family involvement in health systems research design, especially in terms of setting research priorities, may lead to improved patient outcomes and experience. Patients and investigators have coproduced research agendas,¹ typically for specific diagnoses or with a focus on ambulatory care.³ To date, few efforts have actively engaged patients/families as true partners in identifying research gaps in the inpatient setting.^3,4

In their prospective study, Harrison et al⁵ used a systematic approach and methods established by PCORI and the James Lind Alliance to establish a patient-centered research agenda for improving care of hospitalized adult patients. They formed a national steering committee of clinical researchers, patients and caregivers, administrators, and stakeholder organizations. A survey was distributed to about 500 similar stakeholders to generate a list of potential research questions, which were sorted, analyzed, ranked, and prioritized based on frequency. The steering committee ultimately identified an agenda of 11 system of care–related research questions. The highest priority questions focused on ensuring shared decision making (SDM) and transitions of care.

This study has several strengths. Patients served as coleads on the steering committee and were engaged early and often throughout the process, considered a Tier 1, or deliberative, engagement approach.¹ This is in contrast to a consultative, or Tier 2, approach in which patients serve as consultants and comment later in the process.¹ As Harrison et al. demonstrate, including patients impacted the breadth and depth of results. An emphasis on patient perspectives seems to have led to recognition of topics that clinical researchers did not develop a priori. Some patient-proposed research topics, such as best modes to navigate the hospital and visiting hours, suggest a bigger question beyond patient experience: How might attention to details minimize disorientation, which likely detracts from ability to engage in care?

The most highly ranked research question regarded study of interventions that would ensure SDM among patients and physicians. SDM-based interventions in pediatrics have led to significantly improved knowledge and lower decisional conflict.⁶Many SDM-based interventions use decisional aids, which are tools that facilitate patient/family involvement in decision making for specific clinical situations (eg, end of life care, oral vs. intravenous antibiotics). Future work can focus on designing interventions that further enable SDM regardless of the scenario, such as enhancing provider training.⁶

More than half of the research questions ranked by the investigators related to transitions of care, including ensuring proper comprehension of and adherence to postdischarge care plans, medical provider handoffs, and mechanisms for communication after discharge. Interventions that promote inpatient physician and nurse use of health literacy–informed communication strategies, such as teach back, providing instructions using plain language or enhanced with graphics, or providing opportunities to practice follow-up care prior to discharge, may be beneficial.⁷

Moving from understanding to execution is another gap recognized in this study. Improving resources and care in the home after discharge also would likely improve outcomes. Industry, with use of rapid-cycle improvement methods, has already implemented comprehensive, home-based approaches focusing on enhanced presence of care team members (including physicians, nurses, and social workers) in the home. Team tasks include verifying that prescriptions are filled and medications are taken properly and ensuring that social needs are met, which could possibly lead to decreased healthcare utilization.⁸ Additional innovative strategies that leverage technology to optimize information exchange and facilitate postdischarge communication when questions arise (eg, telemedicine as suggested by stakeholders in this study) may also be beneficial. Such strategies, as well as models established by industry, should be further studied as part of interventions that also incorporate the perspective of patients, caregivers, and other stakeholders.

The study had a few limitations. This study, while national in scope, did not provide patient/caregiver demographics or preferred language, so it is unclear if participation was inclusive of all populations. Use of qualitative methods, including this study’s apparently modified Delphi approach, is important to ensuring equal consideration is given to all suggestions—but this only works if the stakeholders are representative. Patients and caregivers were primarily recruited from PFAC, which represent a more activated constituency and often lacks demographic diversity.⁹ Given that “care of vulnerable populations” was an infrequently proposed question category, future work would benefit from oversampling from marginalized, underrepresented groups.

While the study’s aim was development of a research agenda for adult patients, children, especially those who are medically complex, and their caregivers may experience similar issues. There may be barriers related to hospitalizations and transitions unique to children given their inherent dependent status. Future work could incorporate similar methods and engage children and their caregivers in setting a pediatric hospital medicine research agenda.

Unlike other service industries, US healthcare has been slower to adopt an approach of asking users (patients) how to make things better. However, patient engagement in systems of healthcare (eg, Patient and Family Advisory Councils [PFAC]) and health system-­based research (eg, Patient Centered Outcomes Research Institute [PCORI]) are gaining currency in the United States.^1,2

Increasing patient/family involvement in health systems research design, especially in terms of setting research priorities, may lead to improved patient outcomes and experience. Patients and investigators have coproduced research agendas,¹ typically for specific diagnoses or with a focus on ambulatory care.³ To date, few efforts have actively engaged patients/families as true partners in identifying research gaps in the inpatient setting.^3,4

In their prospective study, Harrison et al⁵ used a systematic approach and methods established by PCORI and the James Lind Alliance to establish a patient-centered research agenda for improving care of hospitalized adult patients. They formed a national steering committee of clinical researchers, patients and caregivers, administrators, and stakeholder organizations. A survey was distributed to about 500 similar stakeholders to generate a list of potential research questions, which were sorted, analyzed, ranked, and prioritized based on frequency. The steering committee ultimately identified an agenda of 11 system of care–related research questions. The highest priority questions focused on ensuring shared decision making (SDM) and transitions of care.

This study has several strengths. Patients served as coleads on the steering committee and were engaged early and often throughout the process, considered a Tier 1, or deliberative, engagement approach.¹ This is in contrast to a consultative, or Tier 2, approach in which patients serve as consultants and comment later in the process.¹ As Harrison et al. demonstrate, including patients impacted the breadth and depth of results. An emphasis on patient perspectives seems to have led to recognition of topics that clinical researchers did not develop a priori. Some patient-proposed research topics, such as best modes to navigate the hospital and visiting hours, suggest a bigger question beyond patient experience: How might attention to details minimize disorientation, which likely detracts from ability to engage in care?

The most highly ranked research question regarded study of interventions that would ensure SDM among patients and physicians. SDM-based interventions in pediatrics have led to significantly improved knowledge and lower decisional conflict.⁶Many SDM-based interventions use decisional aids, which are tools that facilitate patient/family involvement in decision making for specific clinical situations (eg, end of life care, oral vs. intravenous antibiotics). Future work can focus on designing interventions that further enable SDM regardless of the scenario, such as enhancing provider training.⁶

More than half of the research questions ranked by the investigators related to transitions of care, including ensuring proper comprehension of and adherence to postdischarge care plans, medical provider handoffs, and mechanisms for communication after discharge. Interventions that promote inpatient physician and nurse use of health literacy–informed communication strategies, such as teach back, providing instructions using plain language or enhanced with graphics, or providing opportunities to practice follow-up care prior to discharge, may be beneficial.⁷

Moving from understanding to execution is another gap recognized in this study. Improving resources and care in the home after discharge also would likely improve outcomes. Industry, with use of rapid-cycle improvement methods, has already implemented comprehensive, home-based approaches focusing on enhanced presence of care team members (including physicians, nurses, and social workers) in the home. Team tasks include verifying that prescriptions are filled and medications are taken properly and ensuring that social needs are met, which could possibly lead to decreased healthcare utilization.⁸ Additional innovative strategies that leverage technology to optimize information exchange and facilitate postdischarge communication when questions arise (eg, telemedicine as suggested by stakeholders in this study) may also be beneficial. Such strategies, as well as models established by industry, should be further studied as part of interventions that also incorporate the perspective of patients, caregivers, and other stakeholders.

The study had a few limitations. This study, while national in scope, did not provide patient/caregiver demographics or preferred language, so it is unclear if participation was inclusive of all populations. Use of qualitative methods, including this study’s apparently modified Delphi approach, is important to ensuring equal consideration is given to all suggestions—but this only works if the stakeholders are representative. Patients and caregivers were primarily recruited from PFAC, which represent a more activated constituency and often lacks demographic diversity.⁹ Given that “care of vulnerable populations” was an infrequently proposed question category, future work would benefit from oversampling from marginalized, underrepresented groups.

While the study’s aim was development of a research agenda for adult patients, children, especially those who are medically complex, and their caregivers may experience similar issues. There may be barriers related to hospitalizations and transitions unique to children given their inherent dependent status. Future work could incorporate similar methods and engage children and their caregivers in setting a pediatric hospital medicine research agenda.

Introduction

Research is a rapidly growing aspect of inpatient medicine. The practice of evidence-based medicine and the acute need for more evidence on inpatient conditions require that pediatric hospitalists understand and participate in research related activities. Pediatric hospitalists’ role in research will vary depending on their setting and job description. This role may include many facets, from reviewing relevant patient-based articles, to participating in multi-institutional studies requiring enrollment of patients, to leading local or national studies. Pediatric hospitalists should have a basic understanding of research methods and processes in order to participate in and benefit from research. Pediatric hospitalists are well positioned to promote research to patients, the family/caregivers, colleagues, and other healthcare providers and through this, to contribute to the effective care of hospitalized patients.

Pediatric hospitalists should be able to:

• Compare and contrast the advantages and disadvantages of experimental (such as randomized control trials) and observational (such as descriptive, cohort, or case control) study designs, including meta-analyses and systematic reviews.
• Define common sources of bias, including information bias, selection bias, and uncontrolled confounding, and describe how each may impact a study.
• Define basic statistical terms such as sample, discrete and continuous data variables, measures of central tendency (mean, median, and mode), and variability (variance, standard deviation, range).
• List resources available to access current or proposed studies including The Pediatric Health Information System (PHIS), the Healthcare Cost and Utilization Project (HCUP), the Kids’ Inpatient Database (KID), clinicaltrials.gov, and others.
• Name potential research funding sources, such as the Agency for Healthcare Research and Quality (AHRQ), the National Institutes of Health (NIH), the Patient-Centered Outcomes Research Institute (PCORI), the Robert Wood Johnson Foundation, local and state funding sources, and others.
• Summarize the goals of pediatric hospital medicine-specific research networks, including the Pediatric Research in the Inpatient Setting (PRIS) network and the Value in Pediatrics (VIP) network.
• Discuss the basic resources commonly required to support research components, including data collection, data analysis, abstract and manuscript preparation, grant funding, and others.
• Review the aspects of the research process that relate to protection of participants, including informed consent and/or assent, the institutional review boards (IRB) review, and HIPAA (Health Insurance Portability and Accountability Act) forms.
• Discuss special protections needed when conducting research with vulnerable populations.
• Define “minimal risk” for a healthy child and for a child with an illness.
• Discuss why common training that addresses ethics, vulnerable populations, consenting, data safety, and other items is required prior to participating as a research team member for a research study.
• Compare and contrast the goals, intent, study focus, and IRB requirements for quality improvement studies from those of traditional clinical research.
• Cite the steps needed to obtain approval for a QI study within the local context.
• Compare and contrast the goals, intent, study focus, and IRB requirements for education studies to those of traditional clinical research.
• Cite the steps needed to obtain approval for a study focused on educational outcomes.
• List common barriers to implementation of clinical studies and describe the pediatric hospitalist’s role in overcoming these barriers.

Pediatric hospitalists should be able to:

• Utilize a format such as PICO (Population, Intervention, Comparison, Outcome) to generate an answerable patient-centered clinical question that is relevant to improving patient care.
• Demonstrate proficiency in systematic searching of the primary medical literature using online search engines.
• Perform critical appraisal of the literature, including identifying threats to study validity, determining if study subjects were similar to local patients, and determining if all clinically important outcomes were considered.
• Apply and integrate the results of studies to clinical practice.
• Determine if the likely benefits noted in a treatment study are worth the potential harm and cost.
• Determine whether a test noted in a diagnostic study is available, affordable, accurate, and precise in the present clinical setting and determine whether the results of the test will change the management of patients being treated.
• Determine if the magnitude of risk warrants an attempt to stop the exposure for a given study on harm.
• Identify if the results of a given study on disease prognosis will lead directly to selecting therapy and/or are useful for counseling patients.
• Participate in educating learners and junior faculty about research and research methodologies, within the local context.
• Determine the relevance of potential research studies with regards to impact on patient care.
• Perform effective informed consent or assent for patients participating in research studies, as appropriate.
• Identify and resolve conflict of interest or potential conflict of interest when participating in research studies.
• Demonstrate basic skills in acquiring, managing, and sharing data collected for research purposes in a responsible and professional manner.
• Adhere to standards for protecting confidentiality, avoiding unjustified exclusions, sharing data, and adhering to copyright law.
• Perform peer-review of a manuscript, abstract, or other research-based work, in collaboration with colleagues as appropriate.
• Demonstrate basic skills in communicating about research opportunities with patients and the family/caregivers within the local context.

Pediatric hospitalists should be able to:

• Recognize the value of seeking the research that supports clinical care decisions and how research fills knowledge gaps and challenges the field to advance.
• Realize the importance of informed consent for patient participation in clinical research.
• Reflect on the importance of patient assent, even in the presence of legal guardian informed consent, when involving children in clinical research.
• Exemplify highly ethical behaviors when promoting or participating in research studies.
• Realize the value of and exemplify a willingness to perform journal-requested peer review of manuscripts, conference abstracts, or other research-based work.
• Reflect on and provide support and education for patients and the family/caregivers on the benefits of research for hospitalized children.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in interdisciplinary initiatives to develop and sustain participation of interdisciplinary teams in performance of research.
• Collaborate with colleagues, hospital administration, and community leaders for thoughtful application of research findings to improve systems of healthcare delivery.
• Lead, coordinate, or participate in national multi-center research efforts that improve the evidence base in inpatient pediatrics, within local context.
• Collaborate with leaders in the university department of pediatrics and school of medicine, hospital administration, and medical staff to encourage local hospital participation in national multi-center research efforts.
• Collaborate with research team members to educate colleagues, hospital staff, and others on the importance of research in improving child health outcomes.

Introduction

Research is a rapidly growing aspect of inpatient medicine. The practice of evidence-based medicine and the acute need for more evidence on inpatient conditions require that pediatric hospitalists understand and participate in research related activities. Pediatric hospitalists’ role in research will vary depending on their setting and job description. This role may include many facets, from reviewing relevant patient-based articles, to participating in multi-institutional studies requiring enrollment of patients, to leading local or national studies. Pediatric hospitalists should have a basic understanding of research methods and processes in order to participate in and benefit from research. Pediatric hospitalists are well positioned to promote research to patients, the family/caregivers, colleagues, and other healthcare providers and through this, to contribute to the effective care of hospitalized patients.

Pediatric hospitalists should be able to:

• Compare and contrast the advantages and disadvantages of experimental (such as randomized control trials) and observational (such as descriptive, cohort, or case control) study designs, including meta-analyses and systematic reviews.
• Define common sources of bias, including information bias, selection bias, and uncontrolled confounding, and describe how each may impact a study.
• Define basic statistical terms such as sample, discrete and continuous data variables, measures of central tendency (mean, median, and mode), and variability (variance, standard deviation, range).
• List resources available to access current or proposed studies including The Pediatric Health Information System (PHIS), the Healthcare Cost and Utilization Project (HCUP), the Kids’ Inpatient Database (KID), clinicaltrials.gov, and others.
• Name potential research funding sources, such as the Agency for Healthcare Research and Quality (AHRQ), the National Institutes of Health (NIH), the Patient-Centered Outcomes Research Institute (PCORI), the Robert Wood Johnson Foundation, local and state funding sources, and others.
• Summarize the goals of pediatric hospital medicine-specific research networks, including the Pediatric Research in the Inpatient Setting (PRIS) network and the Value in Pediatrics (VIP) network.
• Discuss the basic resources commonly required to support research components, including data collection, data analysis, abstract and manuscript preparation, grant funding, and others.
• Review the aspects of the research process that relate to protection of participants, including informed consent and/or assent, the institutional review boards (IRB) review, and HIPAA (Health Insurance Portability and Accountability Act) forms.
• Discuss special protections needed when conducting research with vulnerable populations.
• Define “minimal risk” for a healthy child and for a child with an illness.
• Discuss why common training that addresses ethics, vulnerable populations, consenting, data safety, and other items is required prior to participating as a research team member for a research study.
• Compare and contrast the goals, intent, study focus, and IRB requirements for quality improvement studies from those of traditional clinical research.
• Cite the steps needed to obtain approval for a QI study within the local context.
• Compare and contrast the goals, intent, study focus, and IRB requirements for education studies to those of traditional clinical research.
• Cite the steps needed to obtain approval for a study focused on educational outcomes.
• List common barriers to implementation of clinical studies and describe the pediatric hospitalist’s role in overcoming these barriers.

Pediatric hospitalists should be able to:

• Utilize a format such as PICO (Population, Intervention, Comparison, Outcome) to generate an answerable patient-centered clinical question that is relevant to improving patient care.
• Demonstrate proficiency in systematic searching of the primary medical literature using online search engines.
• Perform critical appraisal of the literature, including identifying threats to study validity, determining if study subjects were similar to local patients, and determining if all clinically important outcomes were considered.
• Apply and integrate the results of studies to clinical practice.
• Determine if the likely benefits noted in a treatment study are worth the potential harm and cost.
• Determine whether a test noted in a diagnostic study is available, affordable, accurate, and precise in the present clinical setting and determine whether the results of the test will change the management of patients being treated.
• Determine if the magnitude of risk warrants an attempt to stop the exposure for a given study on harm.
• Identify if the results of a given study on disease prognosis will lead directly to selecting therapy and/or are useful for counseling patients.
• Participate in educating learners and junior faculty about research and research methodologies, within the local context.
• Determine the relevance of potential research studies with regards to impact on patient care.
• Perform effective informed consent or assent for patients participating in research studies, as appropriate.
• Identify and resolve conflict of interest or potential conflict of interest when participating in research studies.
• Demonstrate basic skills in acquiring, managing, and sharing data collected for research purposes in a responsible and professional manner.
• Adhere to standards for protecting confidentiality, avoiding unjustified exclusions, sharing data, and adhering to copyright law.
• Perform peer-review of a manuscript, abstract, or other research-based work, in collaboration with colleagues as appropriate.
• Demonstrate basic skills in communicating about research opportunities with patients and the family/caregivers within the local context.

Pediatric hospitalists should be able to:

• Recognize the value of seeking the research that supports clinical care decisions and how research fills knowledge gaps and challenges the field to advance.
• Realize the importance of informed consent for patient participation in clinical research.
• Reflect on the importance of patient assent, even in the presence of legal guardian informed consent, when involving children in clinical research.
• Exemplify highly ethical behaviors when promoting or participating in research studies.
• Realize the value of and exemplify a willingness to perform journal-requested peer review of manuscripts, conference abstracts, or other research-based work.
• Reflect on and provide support and education for patients and the family/caregivers on the benefits of research for hospitalized children.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in interdisciplinary initiatives to develop and sustain participation of interdisciplinary teams in performance of research.
• Collaborate with colleagues, hospital administration, and community leaders for thoughtful application of research findings to improve systems of healthcare delivery.
• Lead, coordinate, or participate in national multi-center research efforts that improve the evidence base in inpatient pediatrics, within local context.
• Collaborate with leaders in the university department of pediatrics and school of medicine, hospital administration, and medical staff to encourage local hospital participation in national multi-center research efforts.
• Collaborate with research team members to educate colleagues, hospital staff, and others on the importance of research in improving child health outcomes.

Introduction

Research is a rapidly growing aspect of inpatient medicine. The practice of evidence-based medicine and the acute need for more evidence on inpatient conditions require that pediatric hospitalists understand and participate in research related activities. Pediatric hospitalists’ role in research will vary depending on their setting and job description. This role may include many facets, from reviewing relevant patient-based articles, to participating in multi-institutional studies requiring enrollment of patients, to leading local or national studies. Pediatric hospitalists should have a basic understanding of research methods and processes in order to participate in and benefit from research. Pediatric hospitalists are well positioned to promote research to patients, the family/caregivers, colleagues, and other healthcare providers and through this, to contribute to the effective care of hospitalized patients.

Pediatric hospitalists should be able to:

• Compare and contrast the advantages and disadvantages of experimental (such as randomized control trials) and observational (such as descriptive, cohort, or case control) study designs, including meta-analyses and systematic reviews.
• Define common sources of bias, including information bias, selection bias, and uncontrolled confounding, and describe how each may impact a study.
• Define basic statistical terms such as sample, discrete and continuous data variables, measures of central tendency (mean, median, and mode), and variability (variance, standard deviation, range).
• List resources available to access current or proposed studies including The Pediatric Health Information System (PHIS), the Healthcare Cost and Utilization Project (HCUP), the Kids’ Inpatient Database (KID), clinicaltrials.gov, and others.
• Name potential research funding sources, such as the Agency for Healthcare Research and Quality (AHRQ), the National Institutes of Health (NIH), the Patient-Centered Outcomes Research Institute (PCORI), the Robert Wood Johnson Foundation, local and state funding sources, and others.
• Summarize the goals of pediatric hospital medicine-specific research networks, including the Pediatric Research in the Inpatient Setting (PRIS) network and the Value in Pediatrics (VIP) network.
• Discuss the basic resources commonly required to support research components, including data collection, data analysis, abstract and manuscript preparation, grant funding, and others.
• Review the aspects of the research process that relate to protection of participants, including informed consent and/or assent, the institutional review boards (IRB) review, and HIPAA (Health Insurance Portability and Accountability Act) forms.
• Discuss special protections needed when conducting research with vulnerable populations.
• Define “minimal risk” for a healthy child and for a child with an illness.
• Discuss why common training that addresses ethics, vulnerable populations, consenting, data safety, and other items is required prior to participating as a research team member for a research study.
• Compare and contrast the goals, intent, study focus, and IRB requirements for quality improvement studies from those of traditional clinical research.
• Cite the steps needed to obtain approval for a QI study within the local context.
• Compare and contrast the goals, intent, study focus, and IRB requirements for education studies to those of traditional clinical research.
• Cite the steps needed to obtain approval for a study focused on educational outcomes.
• List common barriers to implementation of clinical studies and describe the pediatric hospitalist’s role in overcoming these barriers.

Pediatric hospitalists should be able to:

• Utilize a format such as PICO (Population, Intervention, Comparison, Outcome) to generate an answerable patient-centered clinical question that is relevant to improving patient care.
• Demonstrate proficiency in systematic searching of the primary medical literature using online search engines.
• Perform critical appraisal of the literature, including identifying threats to study validity, determining if study subjects were similar to local patients, and determining if all clinically important outcomes were considered.
• Apply and integrate the results of studies to clinical practice.
• Determine if the likely benefits noted in a treatment study are worth the potential harm and cost.
• Determine whether a test noted in a diagnostic study is available, affordable, accurate, and precise in the present clinical setting and determine whether the results of the test will change the management of patients being treated.
• Determine if the magnitude of risk warrants an attempt to stop the exposure for a given study on harm.
• Identify if the results of a given study on disease prognosis will lead directly to selecting therapy and/or are useful for counseling patients.
• Participate in educating learners and junior faculty about research and research methodologies, within the local context.
• Determine the relevance of potential research studies with regards to impact on patient care.
• Perform effective informed consent or assent for patients participating in research studies, as appropriate.
• Identify and resolve conflict of interest or potential conflict of interest when participating in research studies.
• Demonstrate basic skills in acquiring, managing, and sharing data collected for research purposes in a responsible and professional manner.
• Adhere to standards for protecting confidentiality, avoiding unjustified exclusions, sharing data, and adhering to copyright law.
• Perform peer-review of a manuscript, abstract, or other research-based work, in collaboration with colleagues as appropriate.
• Demonstrate basic skills in communicating about research opportunities with patients and the family/caregivers within the local context.

Pediatric hospitalists should be able to:

• Recognize the value of seeking the research that supports clinical care decisions and how research fills knowledge gaps and challenges the field to advance.
• Realize the importance of informed consent for patient participation in clinical research.
• Reflect on the importance of patient assent, even in the presence of legal guardian informed consent, when involving children in clinical research.
• Exemplify highly ethical behaviors when promoting or participating in research studies.
• Realize the value of and exemplify a willingness to perform journal-requested peer review of manuscripts, conference abstracts, or other research-based work.
• Reflect on and provide support and education for patients and the family/caregivers on the benefits of research for hospitalized children.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in interdisciplinary initiatives to develop and sustain participation of interdisciplinary teams in performance of research.
• Collaborate with colleagues, hospital administration, and community leaders for thoughtful application of research findings to improve systems of healthcare delivery.
• Lead, coordinate, or participate in national multi-center research efforts that improve the evidence base in inpatient pediatrics, within local context.
• Collaborate with leaders in the university department of pediatrics and school of medicine, hospital administration, and medical staff to encourage local hospital participation in national multi-center research efforts.
• Collaborate with research team members to educate colleagues, hospital staff, and others on the importance of research in improving child health outcomes.

Introduction

Quality Improvement (QI) in healthcare involves planning, implementation, and ongoing assessment of care to proactively improve healthcare outcomes. Hospitals use QI programs to optimize care, streamline systems operations, meet regulatory requirements, and enhance customer service quality. Since the publication of Crossing the Quality Chasm decades ago by the Institutes of Medicine (now the National Academies of Medicine), even greater attention has been focused on improving use and assessing outcomes of evidence-based practices. Proving that “quality of care” and healthcare “value” (quality achieved relative to cost) has been achieved is critical for individual hospitals as well as the national healthcare system. The challenge is to maintain fiscal viability while delivering appropriate healthcare. Healthcare leaders therefore consider QI programs integral to system operations as a means to assure that resources are used wisely and delivery of consistent outcomes that improve the health of the populations served occurs. Pediatric hospitalists work on the front lines of clinical care and are aware of opportunities to improve acute care management, address gaps in chronic care needs, and identify opportunities for system-wide enhancements. Pediatric hospitalists are well positioned to act as influential change agents to promote, champion, and lead QI projects to ensure the highest value of healthcare for hospitalized children.

Pediatric hospitalists should be able to:

• Compare and contrast between Quality Assurance (focus on individual compliance with standards) and Quality Improvement (proactive systems improvement via integration of best practices).
• Define the “Model for Improvement.”
• Summarize the steps of the Shewart-Deming Plan Do Study Act (PDSA) cycle of improvement.
• Explain the value of demonstrating small gains and identifying failures for correction through rapid cycle improvement.
• Describe how lean methodology attempts to eliminate waste and Six Sigma attempts to reduce variation and defects within a process.
• Define commonly used QI tools and terms such as common cause and special cause variation, run charts, cumulative proportion charts, process map, and others.
• Cite examples of structure, process, outcome, and balancing metrics, attending to areas such as clinical, financial, resource use, and perceptions of care improvement.
• Summarize how QI supports effective development of care standardization, best practices, and practice guidelines in order to improve clinical outcomes.
• Discuss the importance of integrating evidence-based medicine into the planning stage of QI projects affecting patient care.
• Explain how QI can be effectively used for both clinical and system operations improvements using examples such as clinical care guidelines and hospital procedures.
• Describe the business case for quality and review why quality should drive cost and resource allocation.
• Define the role of the patient and family in QI and illustrate how their involvement or perspectives are central to QI project success.
• Discuss how interprofessional teams and a culture of commitment to QI impact the success of QI Programs.
• Explain the role of human factors in implementing healthcare improvements.
• List the attributes necessary to moderate, facilitate, and lead QI initiatives and discuss the importance of team building methods.
• Summarize how regulatory, accrediting, advocacy, research funders, and insurers impact QI initiatives and outcomes reporting for hospitalized children, attending to the Centers for Medicare and Medicaid, The Joint Commission, Agency for Healthcare Research and Quality, Leapfrog, and the National Quality Forum.
• Discuss the value of national, state, and local comparative quality data reporting and the clinical, educational, and research utility of national sources such as the Pediatric Health Information Dataset (PHIS).
• Review how reporting quality outcomes to external sources and posting on local hospital websites can affect the patient experience and community trust.
• Summarize the value of continuous participation in QI activities, noting the expectations from medical school through American Board of Pediatrics initial and ongoing certification.

Pediatric hospitalists should be able to:

• Identify processes in need of improvement and engage the appropriate personnel to gain approval for a QI project.
• Demonstrate proficiency in performing each step in a basic QI project.
• Demonstrate proficiency in utilizing basic QI tools such as a process map, key driver diagram, and fishbone diagram.
• Perform review of quality data, including basic data analysis, interpretation, and development of recommendations from the data.
• Serve as a liaison between physician staff and hospital administrative staff when interpreting physician-specific information and clinical care outliers.
• Utilize communication and leadership skills to participate effectively on an interdisciplinary team.
• Educate trainees, nursing staff, ancillary staff, and peers on the basic principles of QI.
• Assist with development of practice guidelines to assure delivery of standardized high value care in the hospital setting.
• Use best practice guidelines effectively and consistently.
• Demonstrate facility with the use of common computer applications, including spreadsheet and database management for information retrieval and analysis.

Pediatric hospitalists should be able to:

• Realize the value of leading as an “early adopter” and “change agent” by building an awareness of and consensus for changes needed to make patient care quality a high priority.
• Recognize the importance of team building, leadership, and family centeredness in performing effective QI.
• Acknowledge the importance of collaboration with healthcare providers critical to QI efforts, such as clinical team members, information technology staff, data analysts, and others.
• Seek opportunities to initiate or actively participate in QI projects.
• Work collaboratively to help create and maintain a QI culture within the institution.
• Exemplify professional behavior when reviewing and interpreting data.
• Recognize how value is defined by the patient and family/caregivers and support QI efforts to increase this value.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Engage hospital, medical group, and medical staff leadership in creating, implementing, and sustaining short- and long-term QI goals that add value for all customers.
• Participate on QI committees and seek opportunities to serve as QI officers or consultants.
• Advocate for the necessary information systems and other infrastructure to secure accurate data and assure success in the QI process.

Introduction

Quality Improvement (QI) in healthcare involves planning, implementation, and ongoing assessment of care to proactively improve healthcare outcomes. Hospitals use QI programs to optimize care, streamline systems operations, meet regulatory requirements, and enhance customer service quality. Since the publication of Crossing the Quality Chasm decades ago by the Institutes of Medicine (now the National Academies of Medicine), even greater attention has been focused on improving use and assessing outcomes of evidence-based practices. Proving that “quality of care” and healthcare “value” (quality achieved relative to cost) has been achieved is critical for individual hospitals as well as the national healthcare system. The challenge is to maintain fiscal viability while delivering appropriate healthcare. Healthcare leaders therefore consider QI programs integral to system operations as a means to assure that resources are used wisely and delivery of consistent outcomes that improve the health of the populations served occurs. Pediatric hospitalists work on the front lines of clinical care and are aware of opportunities to improve acute care management, address gaps in chronic care needs, and identify opportunities for system-wide enhancements. Pediatric hospitalists are well positioned to act as influential change agents to promote, champion, and lead QI projects to ensure the highest value of healthcare for hospitalized children.

Pediatric hospitalists should be able to:

• Compare and contrast between Quality Assurance (focus on individual compliance with standards) and Quality Improvement (proactive systems improvement via integration of best practices).
• Define the “Model for Improvement.”
• Summarize the steps of the Shewart-Deming Plan Do Study Act (PDSA) cycle of improvement.
• Explain the value of demonstrating small gains and identifying failures for correction through rapid cycle improvement.
• Describe how lean methodology attempts to eliminate waste and Six Sigma attempts to reduce variation and defects within a process.
• Define commonly used QI tools and terms such as common cause and special cause variation, run charts, cumulative proportion charts, process map, and others.
• Cite examples of structure, process, outcome, and balancing metrics, attending to areas such as clinical, financial, resource use, and perceptions of care improvement.
• Summarize how QI supports effective development of care standardization, best practices, and practice guidelines in order to improve clinical outcomes.
• Discuss the importance of integrating evidence-based medicine into the planning stage of QI projects affecting patient care.
• Explain how QI can be effectively used for both clinical and system operations improvements using examples such as clinical care guidelines and hospital procedures.
• Describe the business case for quality and review why quality should drive cost and resource allocation.
• Define the role of the patient and family in QI and illustrate how their involvement or perspectives are central to QI project success.
• Discuss how interprofessional teams and a culture of commitment to QI impact the success of QI Programs.
• Explain the role of human factors in implementing healthcare improvements.
• List the attributes necessary to moderate, facilitate, and lead QI initiatives and discuss the importance of team building methods.
• Summarize how regulatory, accrediting, advocacy, research funders, and insurers impact QI initiatives and outcomes reporting for hospitalized children, attending to the Centers for Medicare and Medicaid, The Joint Commission, Agency for Healthcare Research and Quality, Leapfrog, and the National Quality Forum.
• Discuss the value of national, state, and local comparative quality data reporting and the clinical, educational, and research utility of national sources such as the Pediatric Health Information Dataset (PHIS).
• Review how reporting quality outcomes to external sources and posting on local hospital websites can affect the patient experience and community trust.
• Summarize the value of continuous participation in QI activities, noting the expectations from medical school through American Board of Pediatrics initial and ongoing certification.

Pediatric hospitalists should be able to:

• Identify processes in need of improvement and engage the appropriate personnel to gain approval for a QI project.
• Demonstrate proficiency in performing each step in a basic QI project.
• Demonstrate proficiency in utilizing basic QI tools such as a process map, key driver diagram, and fishbone diagram.
• Perform review of quality data, including basic data analysis, interpretation, and development of recommendations from the data.
• Serve as a liaison between physician staff and hospital administrative staff when interpreting physician-specific information and clinical care outliers.
• Utilize communication and leadership skills to participate effectively on an interdisciplinary team.
• Educate trainees, nursing staff, ancillary staff, and peers on the basic principles of QI.
• Assist with development of practice guidelines to assure delivery of standardized high value care in the hospital setting.
• Use best practice guidelines effectively and consistently.
• Demonstrate facility with the use of common computer applications, including spreadsheet and database management for information retrieval and analysis.

Pediatric hospitalists should be able to:

• Realize the value of leading as an “early adopter” and “change agent” by building an awareness of and consensus for changes needed to make patient care quality a high priority.
• Recognize the importance of team building, leadership, and family centeredness in performing effective QI.
• Acknowledge the importance of collaboration with healthcare providers critical to QI efforts, such as clinical team members, information technology staff, data analysts, and others.
• Seek opportunities to initiate or actively participate in QI projects.
• Work collaboratively to help create and maintain a QI culture within the institution.
• Exemplify professional behavior when reviewing and interpreting data.
• Recognize how value is defined by the patient and family/caregivers and support QI efforts to increase this value.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Engage hospital, medical group, and medical staff leadership in creating, implementing, and sustaining short- and long-term QI goals that add value for all customers.
• Participate on QI committees and seek opportunities to serve as QI officers or consultants.
• Advocate for the necessary information systems and other infrastructure to secure accurate data and assure success in the QI process.

Introduction

Quality Improvement (QI) in healthcare involves planning, implementation, and ongoing assessment of care to proactively improve healthcare outcomes. Hospitals use QI programs to optimize care, streamline systems operations, meet regulatory requirements, and enhance customer service quality. Since the publication of Crossing the Quality Chasm decades ago by the Institutes of Medicine (now the National Academies of Medicine), even greater attention has been focused on improving use and assessing outcomes of evidence-based practices. Proving that “quality of care” and healthcare “value” (quality achieved relative to cost) has been achieved is critical for individual hospitals as well as the national healthcare system. The challenge is to maintain fiscal viability while delivering appropriate healthcare. Healthcare leaders therefore consider QI programs integral to system operations as a means to assure that resources are used wisely and delivery of consistent outcomes that improve the health of the populations served occurs. Pediatric hospitalists work on the front lines of clinical care and are aware of opportunities to improve acute care management, address gaps in chronic care needs, and identify opportunities for system-wide enhancements. Pediatric hospitalists are well positioned to act as influential change agents to promote, champion, and lead QI projects to ensure the highest value of healthcare for hospitalized children.

Pediatric hospitalists should be able to:

• Compare and contrast between Quality Assurance (focus on individual compliance with standards) and Quality Improvement (proactive systems improvement via integration of best practices).
• Define the “Model for Improvement.”
• Summarize the steps of the Shewart-Deming Plan Do Study Act (PDSA) cycle of improvement.
• Explain the value of demonstrating small gains and identifying failures for correction through rapid cycle improvement.
• Describe how lean methodology attempts to eliminate waste and Six Sigma attempts to reduce variation and defects within a process.
• Define commonly used QI tools and terms such as common cause and special cause variation, run charts, cumulative proportion charts, process map, and others.
• Cite examples of structure, process, outcome, and balancing metrics, attending to areas such as clinical, financial, resource use, and perceptions of care improvement.
• Summarize how QI supports effective development of care standardization, best practices, and practice guidelines in order to improve clinical outcomes.
• Discuss the importance of integrating evidence-based medicine into the planning stage of QI projects affecting patient care.
• Explain how QI can be effectively used for both clinical and system operations improvements using examples such as clinical care guidelines and hospital procedures.
• Describe the business case for quality and review why quality should drive cost and resource allocation.
• Define the role of the patient and family in QI and illustrate how their involvement or perspectives are central to QI project success.
• Discuss how interprofessional teams and a culture of commitment to QI impact the success of QI Programs.
• Explain the role of human factors in implementing healthcare improvements.
• List the attributes necessary to moderate, facilitate, and lead QI initiatives and discuss the importance of team building methods.
• Summarize how regulatory, accrediting, advocacy, research funders, and insurers impact QI initiatives and outcomes reporting for hospitalized children, attending to the Centers for Medicare and Medicaid, The Joint Commission, Agency for Healthcare Research and Quality, Leapfrog, and the National Quality Forum.
• Discuss the value of national, state, and local comparative quality data reporting and the clinical, educational, and research utility of national sources such as the Pediatric Health Information Dataset (PHIS).
• Review how reporting quality outcomes to external sources and posting on local hospital websites can affect the patient experience and community trust.
• Summarize the value of continuous participation in QI activities, noting the expectations from medical school through American Board of Pediatrics initial and ongoing certification.

Pediatric hospitalists should be able to:

• Identify processes in need of improvement and engage the appropriate personnel to gain approval for a QI project.
• Demonstrate proficiency in performing each step in a basic QI project.
• Demonstrate proficiency in utilizing basic QI tools such as a process map, key driver diagram, and fishbone diagram.
• Perform review of quality data, including basic data analysis, interpretation, and development of recommendations from the data.
• Serve as a liaison between physician staff and hospital administrative staff when interpreting physician-specific information and clinical care outliers.
• Utilize communication and leadership skills to participate effectively on an interdisciplinary team.
• Educate trainees, nursing staff, ancillary staff, and peers on the basic principles of QI.
• Assist with development of practice guidelines to assure delivery of standardized high value care in the hospital setting.
• Use best practice guidelines effectively and consistently.
• Demonstrate facility with the use of common computer applications, including spreadsheet and database management for information retrieval and analysis.

Pediatric hospitalists should be able to:

• Realize the value of leading as an “early adopter” and “change agent” by building an awareness of and consensus for changes needed to make patient care quality a high priority.
• Recognize the importance of team building, leadership, and family centeredness in performing effective QI.
• Acknowledge the importance of collaboration with healthcare providers critical to QI efforts, such as clinical team members, information technology staff, data analysts, and others.
• Seek opportunities to initiate or actively participate in QI projects.
• Work collaboratively to help create and maintain a QI culture within the institution.
• Exemplify professional behavior when reviewing and interpreting data.
• Recognize how value is defined by the patient and family/caregivers and support QI efforts to increase this value.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Engage hospital, medical group, and medical staff leadership in creating, implementing, and sustaining short- and long-term QI goals that add value for all customers.
• Participate on QI committees and seek opportunities to serve as QI officers or consultants.
• Advocate for the necessary information systems and other infrastructure to secure accurate data and assure success in the QI process.

Introduction

Patient safety is defined as freedom from accidental injury caused by medical care, such as harm or death attributable to adverse drug events, patient misidentifications, or health care-acquired infections. In 1999 the Institute of Medicine (IOM; now the National Academy of Medicine) published the “To Err is Human” report, which challenged United States healthcare systems and providers to recognize, report, and mitigate error and harm to patients. Children, as a vulnerable population, are at particular risk for medical errors and specifically medication errors. Pediatric hospitalists work in the acute care hospital setting where high-risk diagnostic decision-making, transitions of care, medication safety, and handoffs are commonly performed. Pediatric hospitalists therefore have a duty to promote patient safety and help develop and implement systems to reduce both error and harm to hospitalized children.

Pediatric hospitalists should be able to:

• Review the basic principles of patient safety, including systems redesign and the prevention, identification, and mitigation of preventable adverse events.
• Review the difference between error and harm including different types of errors.
• Cite the key components of a culture of safety.
• Review the fundamental components of a “Just Culture” and describe how organizations can achieve them.
• Discuss why errors are multifactorial and more often the result of systems failures rather than individual failures.
• Define the concept of “second victim” and review steps to support colleagues, trainees, and other providers when they become a second victim.
• Define common features of a “High Reliability Organization” and explain how high reliability principles apply to clinical care and work on patient safety initiatives.
• Review common patient safety interventions to reduce errors, including electronic order sets, practice guidelines, checklists, clinical decision support, double checks, bar coding, lock-out drawers, and others.
• Discuss factors unique to children that lead to increased risk for medication errors.
• Describe how using structured communication techniques, such as standardized handoffs, closed loop communication, active listening, and critical language are critical to safety.
• Describe the role of patient/family engagement in patient safety.
• Describe the safety components of hospital accreditation and how pediatric hospitalists can help ensure these standards are met.
• Describe common types of cognitive biases, such as premature closure, anchoring, and others, and review how they contribute to diagnostic error.
• Discuss the goals of national safety collaboratives, such as Solutions for Patient Safety (SPS) and describe safety bundles for common hospital-acquired conditions (HACs).
• Review the role of pediatric hospitalists in maintaining national safety goals required by common key accrediting organizations, such as The Joint Commission (TJC) and others.

Pediatric hospitalists should be able to:

• Demonstrate skill in creating an environment that reflects a high reliability organization.
• Facilitate safe and efficient hospital admissions and discharges.
• Identify and order the level of nursing care needed for safe patient care.
• Engage and educate patients and the family/caregivers on their role in ensuring patient safety.
• Utilize and participate in optimizing patient safety features of health information technology.
• Educate trainees, colleagues, and other healthcare providers on basic safety principles.
• Demonstrate proficiency in reporting errors using safety reporting systems.
• Work effectively and collaboratively with patient safety teams.
• Engage in patient safety event reviews, including (root) causal analyses, Morbidity and Mortality committees, and sentinel event reviews.
• Disclose medical errors clearly, concisely, and completely to patients and the family/caregivers.
• Participate in continuous readiness for accreditation agencies by consistently adhering to patient safety practices.

Pediatric hospitalists should be able to:

• Reflect on the importance of creating and sustaining a culture of patient safety.
• Role model behaviors that exemplify a “Just Culture,” accountability, and learning from failure.
• Recognize that patient safety improvements come from consistently reporting near misses as well as medical errors.
• Promote an awareness of the need for and will for change to make patient safety a high and consistent priority.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in multidisciplinary broad strategies to positively impact patient safety in the organization.
• Collaborate with hospital administration and community leaders for the necessary information systems and other infrastructure to ensure success with pediatric patient safety initiatives.
• Lead, coordinate, or participate in multidisciplinary initiatives to develop and implement patient safety interventions where possible.

• Actively participate in hospital-wide safety committees and seek to become leaders in pediatric patient safety in their institutions.

Introduction

Patient safety is defined as freedom from accidental injury caused by medical care, such as harm or death attributable to adverse drug events, patient misidentifications, or health care-acquired infections. In 1999 the Institute of Medicine (IOM; now the National Academy of Medicine) published the “To Err is Human” report, which challenged United States healthcare systems and providers to recognize, report, and mitigate error and harm to patients. Children, as a vulnerable population, are at particular risk for medical errors and specifically medication errors. Pediatric hospitalists work in the acute care hospital setting where high-risk diagnostic decision-making, transitions of care, medication safety, and handoffs are commonly performed. Pediatric hospitalists therefore have a duty to promote patient safety and help develop and implement systems to reduce both error and harm to hospitalized children.

Pediatric hospitalists should be able to:

• Review the basic principles of patient safety, including systems redesign and the prevention, identification, and mitigation of preventable adverse events.
• Review the difference between error and harm including different types of errors.
• Cite the key components of a culture of safety.
• Review the fundamental components of a “Just Culture” and describe how organizations can achieve them.
• Discuss why errors are multifactorial and more often the result of systems failures rather than individual failures.
• Define the concept of “second victim” and review steps to support colleagues, trainees, and other providers when they become a second victim.
• Define common features of a “High Reliability Organization” and explain how high reliability principles apply to clinical care and work on patient safety initiatives.
• Review common patient safety interventions to reduce errors, including electronic order sets, practice guidelines, checklists, clinical decision support, double checks, bar coding, lock-out drawers, and others.
• Discuss factors unique to children that lead to increased risk for medication errors.
• Describe how using structured communication techniques, such as standardized handoffs, closed loop communication, active listening, and critical language are critical to safety.
• Describe the role of patient/family engagement in patient safety.
• Describe the safety components of hospital accreditation and how pediatric hospitalists can help ensure these standards are met.
• Describe common types of cognitive biases, such as premature closure, anchoring, and others, and review how they contribute to diagnostic error.
• Discuss the goals of national safety collaboratives, such as Solutions for Patient Safety (SPS) and describe safety bundles for common hospital-acquired conditions (HACs).
• Review the role of pediatric hospitalists in maintaining national safety goals required by common key accrediting organizations, such as The Joint Commission (TJC) and others.

Pediatric hospitalists should be able to:

• Demonstrate skill in creating an environment that reflects a high reliability organization.
• Facilitate safe and efficient hospital admissions and discharges.
• Identify and order the level of nursing care needed for safe patient care.
• Engage and educate patients and the family/caregivers on their role in ensuring patient safety.
• Utilize and participate in optimizing patient safety features of health information technology.
• Educate trainees, colleagues, and other healthcare providers on basic safety principles.
• Demonstrate proficiency in reporting errors using safety reporting systems.
• Work effectively and collaboratively with patient safety teams.
• Engage in patient safety event reviews, including (root) causal analyses, Morbidity and Mortality committees, and sentinel event reviews.
• Disclose medical errors clearly, concisely, and completely to patients and the family/caregivers.
• Participate in continuous readiness for accreditation agencies by consistently adhering to patient safety practices.

Pediatric hospitalists should be able to:

• Reflect on the importance of creating and sustaining a culture of patient safety.
• Role model behaviors that exemplify a “Just Culture,” accountability, and learning from failure.
• Recognize that patient safety improvements come from consistently reporting near misses as well as medical errors.
• Promote an awareness of the need for and will for change to make patient safety a high and consistent priority.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in multidisciplinary broad strategies to positively impact patient safety in the organization.
• Collaborate with hospital administration and community leaders for the necessary information systems and other infrastructure to ensure success with pediatric patient safety initiatives.
• Lead, coordinate, or participate in multidisciplinary initiatives to develop and implement patient safety interventions where possible.

• Actively participate in hospital-wide safety committees and seek to become leaders in pediatric patient safety in their institutions.

Introduction

Patient safety is defined as freedom from accidental injury caused by medical care, such as harm or death attributable to adverse drug events, patient misidentifications, or health care-acquired infections. In 1999 the Institute of Medicine (IOM; now the National Academy of Medicine) published the “To Err is Human” report, which challenged United States healthcare systems and providers to recognize, report, and mitigate error and harm to patients. Children, as a vulnerable population, are at particular risk for medical errors and specifically medication errors. Pediatric hospitalists work in the acute care hospital setting where high-risk diagnostic decision-making, transitions of care, medication safety, and handoffs are commonly performed. Pediatric hospitalists therefore have a duty to promote patient safety and help develop and implement systems to reduce both error and harm to hospitalized children.

Pediatric hospitalists should be able to:

• Review the basic principles of patient safety, including systems redesign and the prevention, identification, and mitigation of preventable adverse events.
• Review the difference between error and harm including different types of errors.
• Cite the key components of a culture of safety.
• Review the fundamental components of a “Just Culture” and describe how organizations can achieve them.
• Discuss why errors are multifactorial and more often the result of systems failures rather than individual failures.
• Define the concept of “second victim” and review steps to support colleagues, trainees, and other providers when they become a second victim.
• Define common features of a “High Reliability Organization” and explain how high reliability principles apply to clinical care and work on patient safety initiatives.
• Review common patient safety interventions to reduce errors, including electronic order sets, practice guidelines, checklists, clinical decision support, double checks, bar coding, lock-out drawers, and others.
• Discuss factors unique to children that lead to increased risk for medication errors.
• Describe how using structured communication techniques, such as standardized handoffs, closed loop communication, active listening, and critical language are critical to safety.
• Describe the role of patient/family engagement in patient safety.
• Describe the safety components of hospital accreditation and how pediatric hospitalists can help ensure these standards are met.
• Describe common types of cognitive biases, such as premature closure, anchoring, and others, and review how they contribute to diagnostic error.
• Discuss the goals of national safety collaboratives, such as Solutions for Patient Safety (SPS) and describe safety bundles for common hospital-acquired conditions (HACs).
• Review the role of pediatric hospitalists in maintaining national safety goals required by common key accrediting organizations, such as The Joint Commission (TJC) and others.

Pediatric hospitalists should be able to:

• Demonstrate skill in creating an environment that reflects a high reliability organization.
• Facilitate safe and efficient hospital admissions and discharges.
• Identify and order the level of nursing care needed for safe patient care.
• Engage and educate patients and the family/caregivers on their role in ensuring patient safety.
• Utilize and participate in optimizing patient safety features of health information technology.
• Educate trainees, colleagues, and other healthcare providers on basic safety principles.
• Demonstrate proficiency in reporting errors using safety reporting systems.
• Work effectively and collaboratively with patient safety teams.
• Engage in patient safety event reviews, including (root) causal analyses, Morbidity and Mortality committees, and sentinel event reviews.
• Disclose medical errors clearly, concisely, and completely to patients and the family/caregivers.
• Participate in continuous readiness for accreditation agencies by consistently adhering to patient safety practices.

Pediatric hospitalists should be able to:

• Reflect on the importance of creating and sustaining a culture of patient safety.
• Role model behaviors that exemplify a “Just Culture,” accountability, and learning from failure.
• Recognize that patient safety improvements come from consistently reporting near misses as well as medical errors.
• Promote an awareness of the need for and will for change to make patient safety a high and consistent priority.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in multidisciplinary broad strategies to positively impact patient safety in the organization.
• Collaborate with hospital administration and community leaders for the necessary information systems and other infrastructure to ensure success with pediatric patient safety initiatives.
• Lead, coordinate, or participate in multidisciplinary initiatives to develop and implement patient safety interventions where possible.

• Actively participate in hospital-wide safety committees and seek to become leaders in pediatric patient safety in their institutions.

Introduction

Risk Management is a discipline commonly perceived to be the domain of institutional personnel and committees who are called upon to address adverse events that have already occurred. However, consequence management is far from the most effective utilization of such resources, as they are most efficiently and ethically deployed in preventive programs. Risk management therefore prospectively draws upon the disciplines of patient safety, performance improvement, systems management (including engineering and technology), ethics, and human factors in addition to medicine, in an effort to eliminate or ameliorate the undesirable consequences of delivering healthcare services. Hospitalized children are a highly vulnerable population due to social dependencies and developmental needs and have unique legal regulations that may impact care delivery. Pediatric hospitalists deliver care in this acute, high-risk healthcare environment and should be knowledgeable about legal and regulatory requirements, prevention strategies, and ways in which to collaborate with other professionals in management of hospitalized children.

Pediatric hospitalists should be able to:

• Summarize the role of common entities that accredit and license organizations, including The Joint Commission (TJC), the Centers for Medicare and Medicaid Services (CMS), and state health departments.
• Cite examples of how interfacility transfer of patients may be affected by the Emergency Medical Treatment and Active Labor Act (EMTALA).
• Summarize the basic regulatory and legal stipulations that may impact pediatric hospitalist contracting and practice, as noted in the anti-kickback regulations (Stark Rules) and anti-trust regulations (Sherman Act).
• Discuss the importance of fraud and abuse regulations for billing, coding, documentation, collections, utilization review, and managed care operations.
• Describe the common features of privacy regulations, such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
• Review the role of physician licensing and oversight agencies such as the state Medical Board, National Practitioner Data Bank, and Drug Enforcement Agency.
• Define “medical liability,” “standard of practice,” and “negligence” and discuss the role of state malpractice statutes of limitation for children.
• Discuss the role of behavior and attitudes in generating patient and family/caregiver complaints.
• Describe the behavioral and physical characteristics of the impaired practitioner, including fatigue, substance abuse, and disruptive behavior.
• Summarize the role of the hospital medical staff in granting clinical privileges and initiating disciplinary actions through peer review process.
• List responsibilities associated with maintaining malpractice insurance, including documentation and disclosure requirements.
• Define the terms “assent” and “consent” and describe the circumstances in which informed assent or consent is needed.
• Give an example of legal issues that can arise in various clinical scenarios, such as end of life care, “no code” discussions (do-not-resuscitate or allow-natural-death), organ donation, guardianship, and newborn resuscitation.
• Describe the role of pediatric hospitalists in appropriate and timely notification to risk management or hospital counsel when medical errors or preventable events occur.
• Describe the role of pediatric hospitalists in recognizing and reporting family violence for the child, spouse, or elder.
• Provide examples of potential errors related to devices and technology, including Electronic Health Record (EHR) data entry, use, and documentation, privacy, device alert fatigue, and others.
• Review the relationship between human factors, design factors, risk management, patient safety, and quality improvement.

Pediatric hospitalists should be able to:

• Obtain informed assent and/or consent from patients and/or the family/caregivers.
• Disclose medical errors clearly, concisely, and completely to patients and the family/caregivers.
• Communicate in difficult situations and when delivering sensitive information, with compassion and a professional attitude.
• Support and communicate end-of-life decisions and planning.
• Transfer patient information concisely and precisely to other healthcare providers during all transitions of care.
• Prescribe treatments using safe medication prescribing practices.
• Document in the medical record with accuracy and appropriate detail.
• Identify when legal and risk management notification and/or expert consultation is indicated and initiate the escalation process.
• Demonstrate basic skills in utilizing risk reduction strategies, in partnership with local legal and risk management experts.

Pediatric hospitalists should be able to:

• Role model professional behavior.
• Recognize the importance of responding to complaints in a compassionate and sensitive manner.
• Reflect on the importance of collaborating with legal and risk management experts to learn and practice risk reduction strategies, such as failure modes and effects analysis (FMEA) and others.
• Reflect on and provide support and education for trainees in discussions on the importance of communication and documentation from the legal and risk management perspective.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in organizational risk management efforts and promote risk prevention by active participation in appropriate hospital committees.
• Collaborate with hospital administration and other colleagues to advocate for and modify systems and processes that help risk reduction.
• Lead, coordinate, or participate in healthcare information systems related initiatives that enhance the ease and accuracy of documentation and prescribing.
• Lead, coordinate, or participate in efforts to create a comprehensive risk reduction program encompassing education for hospital staff, medical staff, and trainees.

Introduction

Risk Management is a discipline commonly perceived to be the domain of institutional personnel and committees who are called upon to address adverse events that have already occurred. However, consequence management is far from the most effective utilization of such resources, as they are most efficiently and ethically deployed in preventive programs. Risk management therefore prospectively draws upon the disciplines of patient safety, performance improvement, systems management (including engineering and technology), ethics, and human factors in addition to medicine, in an effort to eliminate or ameliorate the undesirable consequences of delivering healthcare services. Hospitalized children are a highly vulnerable population due to social dependencies and developmental needs and have unique legal regulations that may impact care delivery. Pediatric hospitalists deliver care in this acute, high-risk healthcare environment and should be knowledgeable about legal and regulatory requirements, prevention strategies, and ways in which to collaborate with other professionals in management of hospitalized children.

Pediatric hospitalists should be able to:

• Summarize the role of common entities that accredit and license organizations, including The Joint Commission (TJC), the Centers for Medicare and Medicaid Services (CMS), and state health departments.
• Cite examples of how interfacility transfer of patients may be affected by the Emergency Medical Treatment and Active Labor Act (EMTALA).
• Summarize the basic regulatory and legal stipulations that may impact pediatric hospitalist contracting and practice, as noted in the anti-kickback regulations (Stark Rules) and anti-trust regulations (Sherman Act).
• Discuss the importance of fraud and abuse regulations for billing, coding, documentation, collections, utilization review, and managed care operations.
• Describe the common features of privacy regulations, such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
• Review the role of physician licensing and oversight agencies such as the state Medical Board, National Practitioner Data Bank, and Drug Enforcement Agency.
• Define “medical liability,” “standard of practice,” and “negligence” and discuss the role of state malpractice statutes of limitation for children.
• Discuss the role of behavior and attitudes in generating patient and family/caregiver complaints.
• Describe the behavioral and physical characteristics of the impaired practitioner, including fatigue, substance abuse, and disruptive behavior.
• Summarize the role of the hospital medical staff in granting clinical privileges and initiating disciplinary actions through peer review process.
• List responsibilities associated with maintaining malpractice insurance, including documentation and disclosure requirements.
• Define the terms “assent” and “consent” and describe the circumstances in which informed assent or consent is needed.
• Give an example of legal issues that can arise in various clinical scenarios, such as end of life care, “no code” discussions (do-not-resuscitate or allow-natural-death), organ donation, guardianship, and newborn resuscitation.
• Describe the role of pediatric hospitalists in appropriate and timely notification to risk management or hospital counsel when medical errors or preventable events occur.
• Describe the role of pediatric hospitalists in recognizing and reporting family violence for the child, spouse, or elder.
• Provide examples of potential errors related to devices and technology, including Electronic Health Record (EHR) data entry, use, and documentation, privacy, device alert fatigue, and others.
• Review the relationship between human factors, design factors, risk management, patient safety, and quality improvement.

Pediatric hospitalists should be able to:

• Obtain informed assent and/or consent from patients and/or the family/caregivers.
• Disclose medical errors clearly, concisely, and completely to patients and the family/caregivers.
• Communicate in difficult situations and when delivering sensitive information, with compassion and a professional attitude.
• Support and communicate end-of-life decisions and planning.
• Transfer patient information concisely and precisely to other healthcare providers during all transitions of care.
• Prescribe treatments using safe medication prescribing practices.
• Document in the medical record with accuracy and appropriate detail.
• Identify when legal and risk management notification and/or expert consultation is indicated and initiate the escalation process.
• Demonstrate basic skills in utilizing risk reduction strategies, in partnership with local legal and risk management experts.

Pediatric hospitalists should be able to:

• Role model professional behavior.
• Recognize the importance of responding to complaints in a compassionate and sensitive manner.
• Reflect on the importance of collaborating with legal and risk management experts to learn and practice risk reduction strategies, such as failure modes and effects analysis (FMEA) and others.
• Reflect on and provide support and education for trainees in discussions on the importance of communication and documentation from the legal and risk management perspective.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in organizational risk management efforts and promote risk prevention by active participation in appropriate hospital committees.
• Collaborate with hospital administration and other colleagues to advocate for and modify systems and processes that help risk reduction.
• Lead, coordinate, or participate in healthcare information systems related initiatives that enhance the ease and accuracy of documentation and prescribing.
• Lead, coordinate, or participate in efforts to create a comprehensive risk reduction program encompassing education for hospital staff, medical staff, and trainees.

Introduction

Risk Management is a discipline commonly perceived to be the domain of institutional personnel and committees who are called upon to address adverse events that have already occurred. However, consequence management is far from the most effective utilization of such resources, as they are most efficiently and ethically deployed in preventive programs. Risk management therefore prospectively draws upon the disciplines of patient safety, performance improvement, systems management (including engineering and technology), ethics, and human factors in addition to medicine, in an effort to eliminate or ameliorate the undesirable consequences of delivering healthcare services. Hospitalized children are a highly vulnerable population due to social dependencies and developmental needs and have unique legal regulations that may impact care delivery. Pediatric hospitalists deliver care in this acute, high-risk healthcare environment and should be knowledgeable about legal and regulatory requirements, prevention strategies, and ways in which to collaborate with other professionals in management of hospitalized children.

Pediatric hospitalists should be able to:

• Summarize the role of common entities that accredit and license organizations, including The Joint Commission (TJC), the Centers for Medicare and Medicaid Services (CMS), and state health departments.
• Cite examples of how interfacility transfer of patients may be affected by the Emergency Medical Treatment and Active Labor Act (EMTALA).
• Summarize the basic regulatory and legal stipulations that may impact pediatric hospitalist contracting and practice, as noted in the anti-kickback regulations (Stark Rules) and anti-trust regulations (Sherman Act).
• Discuss the importance of fraud and abuse regulations for billing, coding, documentation, collections, utilization review, and managed care operations.
• Describe the common features of privacy regulations, such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
• Review the role of physician licensing and oversight agencies such as the state Medical Board, National Practitioner Data Bank, and Drug Enforcement Agency.
• Define “medical liability,” “standard of practice,” and “negligence” and discuss the role of state malpractice statutes of limitation for children.
• Discuss the role of behavior and attitudes in generating patient and family/caregiver complaints.
• Describe the behavioral and physical characteristics of the impaired practitioner, including fatigue, substance abuse, and disruptive behavior.
• Summarize the role of the hospital medical staff in granting clinical privileges and initiating disciplinary actions through peer review process.
• List responsibilities associated with maintaining malpractice insurance, including documentation and disclosure requirements.
• Define the terms “assent” and “consent” and describe the circumstances in which informed assent or consent is needed.
• Give an example of legal issues that can arise in various clinical scenarios, such as end of life care, “no code” discussions (do-not-resuscitate or allow-natural-death), organ donation, guardianship, and newborn resuscitation.
• Describe the role of pediatric hospitalists in appropriate and timely notification to risk management or hospital counsel when medical errors or preventable events occur.
• Describe the role of pediatric hospitalists in recognizing and reporting family violence for the child, spouse, or elder.
• Provide examples of potential errors related to devices and technology, including Electronic Health Record (EHR) data entry, use, and documentation, privacy, device alert fatigue, and others.
• Review the relationship between human factors, design factors, risk management, patient safety, and quality improvement.

Pediatric hospitalists should be able to:

• Obtain informed assent and/or consent from patients and/or the family/caregivers.
• Disclose medical errors clearly, concisely, and completely to patients and the family/caregivers.
• Communicate in difficult situations and when delivering sensitive information, with compassion and a professional attitude.
• Support and communicate end-of-life decisions and planning.
• Transfer patient information concisely and precisely to other healthcare providers during all transitions of care.
• Prescribe treatments using safe medication prescribing practices.
• Document in the medical record with accuracy and appropriate detail.
• Identify when legal and risk management notification and/or expert consultation is indicated and initiate the escalation process.
• Demonstrate basic skills in utilizing risk reduction strategies, in partnership with local legal and risk management experts.

Pediatric hospitalists should be able to:

• Role model professional behavior.
• Recognize the importance of responding to complaints in a compassionate and sensitive manner.
• Reflect on the importance of collaborating with legal and risk management experts to learn and practice risk reduction strategies, such as failure modes and effects analysis (FMEA) and others.
• Reflect on and provide support and education for trainees in discussions on the importance of communication and documentation from the legal and risk management perspective.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in organizational risk management efforts and promote risk prevention by active participation in appropriate hospital committees.
• Collaborate with hospital administration and other colleagues to advocate for and modify systems and processes that help risk reduction.
• Lead, coordinate, or participate in healthcare information systems related initiatives that enhance the ease and accuracy of documentation and prescribing.
• Lead, coordinate, or participate in efforts to create a comprehensive risk reduction program encompassing education for hospital staff, medical staff, and trainees.

Introduction

Healthcare is complex and dynamic. As such, it requires leaders who understand its multiple components, including highly technical professions, longstanding institutions of care and education, third-party payers, and large supporting industries. Regulatory frameworks, fragmented incentives, and multidimensional determinants of health serve to further complicate healthcare processes. Leadership is a broad construct that involves individuals, interactions, and change. Leaders motivate and influence others using a combination of virtuous behavior and process-oriented management of change. Pediatric hospitalists are required to be leaders on a daily basis, in communication, interprofessional practice, high-performing teams, operational efficiency, quality improvement efforts, and family centered care. They often are involved in administration, where additional competencies in business and strategy are also useful. Pediatric hospitalists work in the most complex and expensive part of the healthcare system and are therefore well positioned to lead at the bedside, in programs, and in the larger healthcare system.

Pediatric hospitalists should be able to:

• Identify some common models or styles of leadership, such as transformational, transactional, autocratic, laissez-faire, task-oriented, and relationship-oriented leadership.
• Review the impact that differing leadership styles may have on quality improvement and patient safety efforts.
• Compare and contrast leadership styles with communication styles.
• Illustrate how utilizing leadership skills enhances performance when working clinically at the bedside, as well as when leading projects, programs, or other larger efforts.
• Identify the key aspects of a high-performing healthcare system, attending to continuous learning, equity, cost, patient experience, access, clinical quality, and patient safety.
• Identify the key aspects of a high-performing team, attending to mutual respect, recognition, communication, cohesion, mutual support, and situational awareness.
• Describe the importance of task and role clarity in team performance.
• List factors that impact team dynamics.
• Explain how respecting dignity and embracing cultural diversity in the context of family centered and interprofessional health care is central to effective leadership.
• Compare and contrast between leadership and management.
• Explain the importance of setting vision and strategy in leadership.
• List examples of commonly used group decision-making techniques, such as brainstorming, nominal group, Delphi, and dialectical inquiry.
• Define “change management” and review the role of leaders as change agents for projects and quality improvement processes.
• Discuss the impact of effective leadership of interprofessional teams on hospital daily operational efficiency and throughput.
• Describe the impact of effective leadership on quality improvement efforts, patient safety, high value care, hospital business, and population health outcomes.

Pediatric hospitalists should be able to:

• Demonstrate effective leadership skills in communication, de-escalation and conflict resolution and management of team dynamic problems.
• Lead family centered rounds with an interprofessional team.
• Execute efficient operations, such as hospital throughput, in collaboration with hospital administrative initiatives.
• Collaborate in interprofessional improvement initiatives.
• Demonstrate basic skills in leading an effective meeting that results in a specific outcome, decision, or action.

Pediatric hospitalists should be able to:

• Realize the value of cultural and professional diversity in interprofessional practice and family centered care.
• Model self-awareness, ethical behavior, integrity, and inclusiveness.
• Reflect on the importance of leadership as a journey of self-development.
• Exemplify effective delivery and receipt of constructive feedback.
• Recognize the interaction between business performance, healthcare delivery, and clinical outcomes in an evolving health care landscape.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate or participate in efforts to expand education and mentorship in leadership skills in pediatric hospital medicine.
• Participate and lead where appropriate in division, department or group, and hospital level committees to advocate for care of hospitalized children.
• Collaborate with and actively participate and lead where appropriate in medical staff related activities.

Introduction

Healthcare is complex and dynamic. As such, it requires leaders who understand its multiple components, including highly technical professions, longstanding institutions of care and education, third-party payers, and large supporting industries. Regulatory frameworks, fragmented incentives, and multidimensional determinants of health serve to further complicate healthcare processes. Leadership is a broad construct that involves individuals, interactions, and change. Leaders motivate and influence others using a combination of virtuous behavior and process-oriented management of change. Pediatric hospitalists are required to be leaders on a daily basis, in communication, interprofessional practice, high-performing teams, operational efficiency, quality improvement efforts, and family centered care. They often are involved in administration, where additional competencies in business and strategy are also useful. Pediatric hospitalists work in the most complex and expensive part of the healthcare system and are therefore well positioned to lead at the bedside, in programs, and in the larger healthcare system.

Pediatric hospitalists should be able to:

• Identify some common models or styles of leadership, such as transformational, transactional, autocratic, laissez-faire, task-oriented, and relationship-oriented leadership.
• Review the impact that differing leadership styles may have on quality improvement and patient safety efforts.
• Compare and contrast leadership styles with communication styles.
• Illustrate how utilizing leadership skills enhances performance when working clinically at the bedside, as well as when leading projects, programs, or other larger efforts.
• Identify the key aspects of a high-performing healthcare system, attending to continuous learning, equity, cost, patient experience, access, clinical quality, and patient safety.
• Identify the key aspects of a high-performing team, attending to mutual respect, recognition, communication, cohesion, mutual support, and situational awareness.
• Describe the importance of task and role clarity in team performance.
• List factors that impact team dynamics.
• Explain how respecting dignity and embracing cultural diversity in the context of family centered and interprofessional health care is central to effective leadership.
• Compare and contrast between leadership and management.
• Explain the importance of setting vision and strategy in leadership.
• List examples of commonly used group decision-making techniques, such as brainstorming, nominal group, Delphi, and dialectical inquiry.
• Define “change management” and review the role of leaders as change agents for projects and quality improvement processes.
• Discuss the impact of effective leadership of interprofessional teams on hospital daily operational efficiency and throughput.
• Describe the impact of effective leadership on quality improvement efforts, patient safety, high value care, hospital business, and population health outcomes.

Pediatric hospitalists should be able to:

• Demonstrate effective leadership skills in communication, de-escalation and conflict resolution and management of team dynamic problems.
• Lead family centered rounds with an interprofessional team.
• Execute efficient operations, such as hospital throughput, in collaboration with hospital administrative initiatives.
• Collaborate in interprofessional improvement initiatives.
• Demonstrate basic skills in leading an effective meeting that results in a specific outcome, decision, or action.

Pediatric hospitalists should be able to:

• Realize the value of cultural and professional diversity in interprofessional practice and family centered care.
• Model self-awareness, ethical behavior, integrity, and inclusiveness.
• Reflect on the importance of leadership as a journey of self-development.
• Exemplify effective delivery and receipt of constructive feedback.
• Recognize the interaction between business performance, healthcare delivery, and clinical outcomes in an evolving health care landscape.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate or participate in efforts to expand education and mentorship in leadership skills in pediatric hospital medicine.
• Participate and lead where appropriate in division, department or group, and hospital level committees to advocate for care of hospitalized children.
• Collaborate with and actively participate and lead where appropriate in medical staff related activities.

Introduction

Healthcare is complex and dynamic. As such, it requires leaders who understand its multiple components, including highly technical professions, longstanding institutions of care and education, third-party payers, and large supporting industries. Regulatory frameworks, fragmented incentives, and multidimensional determinants of health serve to further complicate healthcare processes. Leadership is a broad construct that involves individuals, interactions, and change. Leaders motivate and influence others using a combination of virtuous behavior and process-oriented management of change. Pediatric hospitalists are required to be leaders on a daily basis, in communication, interprofessional practice, high-performing teams, operational efficiency, quality improvement efforts, and family centered care. They often are involved in administration, where additional competencies in business and strategy are also useful. Pediatric hospitalists work in the most complex and expensive part of the healthcare system and are therefore well positioned to lead at the bedside, in programs, and in the larger healthcare system.

Pediatric hospitalists should be able to:

• Identify some common models or styles of leadership, such as transformational, transactional, autocratic, laissez-faire, task-oriented, and relationship-oriented leadership.
• Review the impact that differing leadership styles may have on quality improvement and patient safety efforts.
• Compare and contrast leadership styles with communication styles.
• Illustrate how utilizing leadership skills enhances performance when working clinically at the bedside, as well as when leading projects, programs, or other larger efforts.
• Identify the key aspects of a high-performing healthcare system, attending to continuous learning, equity, cost, patient experience, access, clinical quality, and patient safety.
• Identify the key aspects of a high-performing team, attending to mutual respect, recognition, communication, cohesion, mutual support, and situational awareness.
• Describe the importance of task and role clarity in team performance.
• List factors that impact team dynamics.
• Explain how respecting dignity and embracing cultural diversity in the context of family centered and interprofessional health care is central to effective leadership.
• Compare and contrast between leadership and management.
• Explain the importance of setting vision and strategy in leadership.
• List examples of commonly used group decision-making techniques, such as brainstorming, nominal group, Delphi, and dialectical inquiry.
• Define “change management” and review the role of leaders as change agents for projects and quality improvement processes.
• Discuss the impact of effective leadership of interprofessional teams on hospital daily operational efficiency and throughput.
• Describe the impact of effective leadership on quality improvement efforts, patient safety, high value care, hospital business, and population health outcomes.

Pediatric hospitalists should be able to:

• Demonstrate effective leadership skills in communication, de-escalation and conflict resolution and management of team dynamic problems.
• Lead family centered rounds with an interprofessional team.
• Execute efficient operations, such as hospital throughput, in collaboration with hospital administrative initiatives.
• Collaborate in interprofessional improvement initiatives.
• Demonstrate basic skills in leading an effective meeting that results in a specific outcome, decision, or action.

Pediatric hospitalists should be able to:

• Realize the value of cultural and professional diversity in interprofessional practice and family centered care.
• Model self-awareness, ethical behavior, integrity, and inclusiveness.
• Reflect on the importance of leadership as a journey of self-development.
• Exemplify effective delivery and receipt of constructive feedback.
• Recognize the interaction between business performance, healthcare delivery, and clinical outcomes in an evolving health care landscape.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate or participate in efforts to expand education and mentorship in leadership skills in pediatric hospital medicine.
• Participate and lead where appropriate in division, department or group, and hospital level committees to advocate for care of hospitalized children.
• Collaborate with and actively participate and lead where appropriate in medical staff related activities.

Introduction

Infections are one of the most common causes of hospitalization, morbidity, and mortality among children. Infections due to antibiotic resistant bacteria are an increasing burden on public health. Antibiotic exposure in both the ambulatory and hospital settings is a prime driver for development of antibiotic resistance and is a risk factor for developing infections which are increasingly due to multi-drug resistant organisms (MDROs). As the number of children surviving with significant medical complexity grows, the incidence of device-associated infections and of hospital-acquired (nosocomial) infections (HAI) is also rising. In addition, children are often more severely impacted when community outbreaks of infectious diseases occur, requiring rapid identification, containment, and treatment while limiting unnecessary antibiotic exposure. Pediatric hospitalists play a vital role in minimizing antimicrobial treatment risks to children through the judicious use of antimicrobials and participation in antimicrobial stewardship programs and practices.

Pediatric hospitalists should be able to:

• Describe common infection prevention measures used to reduce the spread of infection, including vaccinations, hand hygiene, and the use of personal protective equipment (PPE).
• Define commonly used infection control terms for precautions, such as standard, contact, droplet, airborne, protective (reverse) isolation, and transmission-based, and give an example of each.
• Explain the difference between community-acquired and hospital-acquired infections.
• Explain why antibiotic exposure is a prime driver of antibiotic resistance.
• Cite examples of commonly used daily practices that are integral to antimicrobial stewardship, such as judicious initiation of antimicrobials, appropriate use and interpretation of diagnostic microbiology, and narrowing the spectrum or discontinuation of antimicrobials.
• Delineate the risk for and types of infections associated with commonly used temporary medical devices, such as urinary catheters, intravenous access lines, chest tubes, nasogastric tubes, and others.
• Delineate the risk for and types of infections associated with common chronic medical devices, such as tracheostomy tubes, ventriculoperitoneal shunts, and others.
• Distinguish between empirical and definitive antimicrobial prescribing.
• Review the risks of repeated antimicrobial empiric therapy use for children with chronic medical complexity, attending to antimicrobial resistance for the host and community, antimicrobial side effects, and drug-drug interactions that may limit antimicrobial effectiveness.
• List common adverse effects of frequently prescribed antibiotics and antivirals for children hospitalized with routine infections, such as pneumonia, cellulitis, and fever in the infant, and discuss how antimicrobial stewardship and infection control practices may minimize these risks.
• List common strategies used by antimicrobial stewardship programs to optimize appropriate antimicrobial use, including prospective audit and feedback, formulary restrictions, automated stop dates for prescribed antibiotics, and 48-hour timeouts.
• Summarize common infection control practices used to minimize the risk of HAIs, including catheter-related bloodstream infections, urinary catheter infections, and others.
• List common multiple-drug resistant organisms (MDROs) and distinguish between infection control practices for these organisms compared to other infectious organisms.
• Review the clinical presentation of Clostridium difficile infection in children and discuss risk factors for it, including antibiotic exposure.
• Describe the relationship between antimicrobial stewardship, patient safety, and quality improvement, including clinical practice guidelines.
• Discuss how the hospital may be a potential venue for initial recognition of a community infectious disease outbreak and review the role that pediatric hospitalists can play in patient triage, admission decision-making, management, and hospital flow, attending to local context and resources.
• Review the relationship between community infection outbreaks and vaccination rates and discuss the role pediatric hospitalists can play in vaccination of hospitalized children.
• List which communicable diseases are mandatory to report to the local or state Department of Health.

Pediatric hospitalists should be able to:

• Demonstrate skills in recognizing the need for and ordering appropriate isolation precautions for children hospitalized with acute infection symptoms.
• Determine the need for and order appropriate contact precautions for children hospitalized with a history of MDRO infection, including methicillin-resistant Staphylococcus aureus (MRSA) and multi-drug resistant gram-negative bacteria.
• Select and order appropriate diagnostic studies for commonly encountered infections, including serologies, polymerase chain reaction (PCR) tests, cultures and sensitivities for varied organisms (including bacterial, viral, and fungal), and other rapid diagnostic testing for pathogens as available in the local context.
• Interpret diagnostic testing results efficiently and initiate appropriate treatment based on the results.
• Interpret diagnostic testing performed related to medical devices, distinguishing between infection and colonization, and initiate or change treatment based on the results.
• Participate actively in infection prevention and control programs.
• Utilize antimicrobial best practices that are embedded in local clinical pathways.
• Identify common signs and symptoms of possible device-associated infection.
• Interpret a hospital antibiogram to guide selection of antibiotic therapy.
• Identify opportunities to limit antimicrobial exposure among hospitalized children receiving empirical antibiotic therapy and initiate action for a given patient or population of patients.
• Develop and execute antibiotic treatment plans that maximize the safety of antibiotic use, including transitions to oral antibiotics when appropriate, limiting treatment duration, and discontinuing antibiotics.
• Communicate and educate patient and the family/caregivers regarding the risks and benefits of antimicrobial treatment and the importance of adhering to infection control practices, including rules regarding visitation during infectious seasons or outbreaks.

Pediatric hospitalists should be able to:

• Recognize that infection control practices are a primary means of reducing the risk of harm to hospitalized children.
• Reflect on the importance of collaboration with infectious diseases specialists and pharmacists to improve the judicious use of antibiotics.
• Role model infection control practices at the bedside including appropriate empirical and definitive antibiotic therapy practices.
• Reflect on the impact that infection control practices may have on patients and the family/caregivers.
• Recognize how adhering to infection control practices and antimicrobial stewardship for a given patient influences risks for the patient and the larger community.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Collaborate with hospital staff, infection prevention specialists, hospital epidemiologists, microbiology laboratory, and others in multidisciplinary initiatives to monitor and prevent community-acquired and nosocomial infections.
• Coordinate or participate in the local antimicrobial stewardship program to develop and implement evidence-based guidelines for antimicrobial use.
• Lead, coordinate, or participate in the local program to reduce the incidence of hospital-acquired infections.
• Lead, coordinate, or participate in efforts to educate staff, trainees, patients, and the family/caregivers on the importance of infection control and antimicrobial stewardship.

Introduction

Infections are one of the most common causes of hospitalization, morbidity, and mortality among children. Infections due to antibiotic resistant bacteria are an increasing burden on public health. Antibiotic exposure in both the ambulatory and hospital settings is a prime driver for development of antibiotic resistance and is a risk factor for developing infections which are increasingly due to multi-drug resistant organisms (MDROs). As the number of children surviving with significant medical complexity grows, the incidence of device-associated infections and of hospital-acquired (nosocomial) infections (HAI) is also rising. In addition, children are often more severely impacted when community outbreaks of infectious diseases occur, requiring rapid identification, containment, and treatment while limiting unnecessary antibiotic exposure. Pediatric hospitalists play a vital role in minimizing antimicrobial treatment risks to children through the judicious use of antimicrobials and participation in antimicrobial stewardship programs and practices.

Pediatric hospitalists should be able to:

• Describe common infection prevention measures used to reduce the spread of infection, including vaccinations, hand hygiene, and the use of personal protective equipment (PPE).
• Define commonly used infection control terms for precautions, such as standard, contact, droplet, airborne, protective (reverse) isolation, and transmission-based, and give an example of each.
• Explain the difference between community-acquired and hospital-acquired infections.
• Explain why antibiotic exposure is a prime driver of antibiotic resistance.
• Cite examples of commonly used daily practices that are integral to antimicrobial stewardship, such as judicious initiation of antimicrobials, appropriate use and interpretation of diagnostic microbiology, and narrowing the spectrum or discontinuation of antimicrobials.
• Delineate the risk for and types of infections associated with commonly used temporary medical devices, such as urinary catheters, intravenous access lines, chest tubes, nasogastric tubes, and others.
• Delineate the risk for and types of infections associated with common chronic medical devices, such as tracheostomy tubes, ventriculoperitoneal shunts, and others.
• Distinguish between empirical and definitive antimicrobial prescribing.
• Review the risks of repeated antimicrobial empiric therapy use for children with chronic medical complexity, attending to antimicrobial resistance for the host and community, antimicrobial side effects, and drug-drug interactions that may limit antimicrobial effectiveness.
• List common adverse effects of frequently prescribed antibiotics and antivirals for children hospitalized with routine infections, such as pneumonia, cellulitis, and fever in the infant, and discuss how antimicrobial stewardship and infection control practices may minimize these risks.
• List common strategies used by antimicrobial stewardship programs to optimize appropriate antimicrobial use, including prospective audit and feedback, formulary restrictions, automated stop dates for prescribed antibiotics, and 48-hour timeouts.
• Summarize common infection control practices used to minimize the risk of HAIs, including catheter-related bloodstream infections, urinary catheter infections, and others.
• List common multiple-drug resistant organisms (MDROs) and distinguish between infection control practices for these organisms compared to other infectious organisms.
• Review the clinical presentation of Clostridium difficile infection in children and discuss risk factors for it, including antibiotic exposure.
• Describe the relationship between antimicrobial stewardship, patient safety, and quality improvement, including clinical practice guidelines.
• Discuss how the hospital may be a potential venue for initial recognition of a community infectious disease outbreak and review the role that pediatric hospitalists can play in patient triage, admission decision-making, management, and hospital flow, attending to local context and resources.
• Review the relationship between community infection outbreaks and vaccination rates and discuss the role pediatric hospitalists can play in vaccination of hospitalized children.
• List which communicable diseases are mandatory to report to the local or state Department of Health.

Pediatric hospitalists should be able to:

• Demonstrate skills in recognizing the need for and ordering appropriate isolation precautions for children hospitalized with acute infection symptoms.
• Determine the need for and order appropriate contact precautions for children hospitalized with a history of MDRO infection, including methicillin-resistant Staphylococcus aureus (MRSA) and multi-drug resistant gram-negative bacteria.
• Select and order appropriate diagnostic studies for commonly encountered infections, including serologies, polymerase chain reaction (PCR) tests, cultures and sensitivities for varied organisms (including bacterial, viral, and fungal), and other rapid diagnostic testing for pathogens as available in the local context.
• Interpret diagnostic testing results efficiently and initiate appropriate treatment based on the results.
• Interpret diagnostic testing performed related to medical devices, distinguishing between infection and colonization, and initiate or change treatment based on the results.
• Participate actively in infection prevention and control programs.
• Utilize antimicrobial best practices that are embedded in local clinical pathways.
• Identify common signs and symptoms of possible device-associated infection.
• Interpret a hospital antibiogram to guide selection of antibiotic therapy.
• Identify opportunities to limit antimicrobial exposure among hospitalized children receiving empirical antibiotic therapy and initiate action for a given patient or population of patients.
• Develop and execute antibiotic treatment plans that maximize the safety of antibiotic use, including transitions to oral antibiotics when appropriate, limiting treatment duration, and discontinuing antibiotics.
• Communicate and educate patient and the family/caregivers regarding the risks and benefits of antimicrobial treatment and the importance of adhering to infection control practices, including rules regarding visitation during infectious seasons or outbreaks.

Pediatric hospitalists should be able to:

• Recognize that infection control practices are a primary means of reducing the risk of harm to hospitalized children.
• Reflect on the importance of collaboration with infectious diseases specialists and pharmacists to improve the judicious use of antibiotics.
• Role model infection control practices at the bedside including appropriate empirical and definitive antibiotic therapy practices.
• Reflect on the impact that infection control practices may have on patients and the family/caregivers.
• Recognize how adhering to infection control practices and antimicrobial stewardship for a given patient influences risks for the patient and the larger community.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Collaborate with hospital staff, infection prevention specialists, hospital epidemiologists, microbiology laboratory, and others in multidisciplinary initiatives to monitor and prevent community-acquired and nosocomial infections.
• Coordinate or participate in the local antimicrobial stewardship program to develop and implement evidence-based guidelines for antimicrobial use.
• Lead, coordinate, or participate in the local program to reduce the incidence of hospital-acquired infections.
• Lead, coordinate, or participate in efforts to educate staff, trainees, patients, and the family/caregivers on the importance of infection control and antimicrobial stewardship.

Introduction

Infections are one of the most common causes of hospitalization, morbidity, and mortality among children. Infections due to antibiotic resistant bacteria are an increasing burden on public health. Antibiotic exposure in both the ambulatory and hospital settings is a prime driver for development of antibiotic resistance and is a risk factor for developing infections which are increasingly due to multi-drug resistant organisms (MDROs). As the number of children surviving with significant medical complexity grows, the incidence of device-associated infections and of hospital-acquired (nosocomial) infections (HAI) is also rising. In addition, children are often more severely impacted when community outbreaks of infectious diseases occur, requiring rapid identification, containment, and treatment while limiting unnecessary antibiotic exposure. Pediatric hospitalists play a vital role in minimizing antimicrobial treatment risks to children through the judicious use of antimicrobials and participation in antimicrobial stewardship programs and practices.

Pediatric hospitalists should be able to:

• Describe common infection prevention measures used to reduce the spread of infection, including vaccinations, hand hygiene, and the use of personal protective equipment (PPE).
• Define commonly used infection control terms for precautions, such as standard, contact, droplet, airborne, protective (reverse) isolation, and transmission-based, and give an example of each.
• Explain the difference between community-acquired and hospital-acquired infections.
• Explain why antibiotic exposure is a prime driver of antibiotic resistance.
• Cite examples of commonly used daily practices that are integral to antimicrobial stewardship, such as judicious initiation of antimicrobials, appropriate use and interpretation of diagnostic microbiology, and narrowing the spectrum or discontinuation of antimicrobials.
• Delineate the risk for and types of infections associated with commonly used temporary medical devices, such as urinary catheters, intravenous access lines, chest tubes, nasogastric tubes, and others.
• Delineate the risk for and types of infections associated with common chronic medical devices, such as tracheostomy tubes, ventriculoperitoneal shunts, and others.
• Distinguish between empirical and definitive antimicrobial prescribing.
• Review the risks of repeated antimicrobial empiric therapy use for children with chronic medical complexity, attending to antimicrobial resistance for the host and community, antimicrobial side effects, and drug-drug interactions that may limit antimicrobial effectiveness.
• List common adverse effects of frequently prescribed antibiotics and antivirals for children hospitalized with routine infections, such as pneumonia, cellulitis, and fever in the infant, and discuss how antimicrobial stewardship and infection control practices may minimize these risks.
• List common strategies used by antimicrobial stewardship programs to optimize appropriate antimicrobial use, including prospective audit and feedback, formulary restrictions, automated stop dates for prescribed antibiotics, and 48-hour timeouts.
• Summarize common infection control practices used to minimize the risk of HAIs, including catheter-related bloodstream infections, urinary catheter infections, and others.
• List common multiple-drug resistant organisms (MDROs) and distinguish between infection control practices for these organisms compared to other infectious organisms.
• Review the clinical presentation of Clostridium difficile infection in children and discuss risk factors for it, including antibiotic exposure.
• Describe the relationship between antimicrobial stewardship, patient safety, and quality improvement, including clinical practice guidelines.
• Discuss how the hospital may be a potential venue for initial recognition of a community infectious disease outbreak and review the role that pediatric hospitalists can play in patient triage, admission decision-making, management, and hospital flow, attending to local context and resources.
• Review the relationship between community infection outbreaks and vaccination rates and discuss the role pediatric hospitalists can play in vaccination of hospitalized children.
• List which communicable diseases are mandatory to report to the local or state Department of Health.

Pediatric hospitalists should be able to:

• Demonstrate skills in recognizing the need for and ordering appropriate isolation precautions for children hospitalized with acute infection symptoms.
• Determine the need for and order appropriate contact precautions for children hospitalized with a history of MDRO infection, including methicillin-resistant Staphylococcus aureus (MRSA) and multi-drug resistant gram-negative bacteria.
• Select and order appropriate diagnostic studies for commonly encountered infections, including serologies, polymerase chain reaction (PCR) tests, cultures and sensitivities for varied organisms (including bacterial, viral, and fungal), and other rapid diagnostic testing for pathogens as available in the local context.
• Interpret diagnostic testing results efficiently and initiate appropriate treatment based on the results.
• Interpret diagnostic testing performed related to medical devices, distinguishing between infection and colonization, and initiate or change treatment based on the results.
• Participate actively in infection prevention and control programs.
• Utilize antimicrobial best practices that are embedded in local clinical pathways.
• Identify common signs and symptoms of possible device-associated infection.
• Interpret a hospital antibiogram to guide selection of antibiotic therapy.
• Identify opportunities to limit antimicrobial exposure among hospitalized children receiving empirical antibiotic therapy and initiate action for a given patient or population of patients.
• Develop and execute antibiotic treatment plans that maximize the safety of antibiotic use, including transitions to oral antibiotics when appropriate, limiting treatment duration, and discontinuing antibiotics.
• Communicate and educate patient and the family/caregivers regarding the risks and benefits of antimicrobial treatment and the importance of adhering to infection control practices, including rules regarding visitation during infectious seasons or outbreaks.

Pediatric hospitalists should be able to:

• Recognize that infection control practices are a primary means of reducing the risk of harm to hospitalized children.
• Reflect on the importance of collaboration with infectious diseases specialists and pharmacists to improve the judicious use of antibiotics.
• Role model infection control practices at the bedside including appropriate empirical and definitive antibiotic therapy practices.
• Reflect on the impact that infection control practices may have on patients and the family/caregivers.
• Recognize how adhering to infection control practices and antimicrobial stewardship for a given patient influences risks for the patient and the larger community.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Collaborate with hospital staff, infection prevention specialists, hospital epidemiologists, microbiology laboratory, and others in multidisciplinary initiatives to monitor and prevent community-acquired and nosocomial infections.
• Coordinate or participate in the local antimicrobial stewardship program to develop and implement evidence-based guidelines for antimicrobial use.
• Lead, coordinate, or participate in the local program to reduce the incidence of hospital-acquired infections.
• Lead, coordinate, or participate in efforts to educate staff, trainees, patients, and the family/caregivers on the importance of infection control and antimicrobial stewardship.