Introduction

Acute care pediatric services continue to be centralized, causing pediatric inter-facility transport programs to progress and evolve. Evidence has shown that specialty transport teams capable of delivering state of the art care improve patient outcomes. This has resulted in a paradigm shift in pediatric transport programs to emphasize delivery of definitive care both at the referring facility and throughout transport. Over the past years the number of institutionally sponsored hospital based pediatric specialty transport programs has increased in response to this need. Pediatric hospitalists may serve as the referring or accepting physician, transport physician, or medical control physician (transport coordinator) for these patients. Through each of these roles pediatric hospitalists fulfill an essential function in ensuring the safe and timely transport of ill children.

Pediatric hospitalists should be able to:

• Compare and contrast advantages and disadvantages between transport modalities including non-medical, Basic Life Support (BLS), Advanced Life Support (ALS), Critical Care Team (CCT), and specialized Neonatal/Pediatric Critical Care Transport service.
• Describe features of the medical history and physical examination that necessitate emergent or urgent patient transfer.
• Cite common transport team members and discuss the proficiency and expertise required to safely provide effective triage and stabilization for differing pediatric diseases and conditions, attending to the roles of physician, nurse, respiratory therapist, and others.
• Review the role of pediatric hospitalists serving as the referring and/or accepting physician, attending to communications with and documentation for the referring physician, accepting site, local healthcare team, and the family/caregivers.
• Discuss how pediatric hospitalists may serve as the physician on transport, attending to local context and scope of practice.
• Summarize the role of the Medical Control Officer and review the responsibilities related to triage, team management, and maintaining ongoing consistent care through assistance with treatment decisions and planning from referring to accepting sites.
• Explain how the selection of transport modality and team composition are influenced by the patient’s clinical status as well as environmental and logistical factors.
• Describe the benefits of various monitoring techniques commonly used on transport, including oximetry, capnography, venous and arterial pressure, electrocardiography (ECG), and others.
• Discuss the indications, benefits, and risks of various interventions commonly utilized during transport such as high flow oxygen delivery, non-invasive positive pressure ventilation systems, artificial airways, medications, and others.
• Describe the importance of collaboration between hospitalists, subspecialists, and intensivists in stabilization and management during transport and upon arrival to the destination facility.
• Describe the knowledge base and skill set of non-physician transport team members.
• Discuss the use of standardized protocols and procedures on transport, including how they are used by non-physician team members and the process for implementation and oversight.
• Review how technologies such as telemedicine or other devices can aid in communication, patient assessment, and care delivery.

Pediatric hospitalists should be able to:

• Efficiently obtain and communicate critical clinical information, placing emphasis on cardiac, pulmonary, and neurologic disease that could impact the transport process.
• Formulate accurate rapid assessments and provide recommendations regarding laboratory studies and imaging, as well as therapeutic interventions that are evidence based and in accordance with Pediatric Advanced Life Support/Neonatal Resuscitation Program guidelines.
• Select modality of transport and team composition based on patient acuity and potential for deterioration, in the context of local logistical and environmental factors, such as time of day, traffic, and weather conditions.
• Effectively communicate with the transport team members to anticipate possible complications during the transport and create action plans prior to transport.
• Provide ongoing recommendations for management throughout the transport process to ensure optimal patient outcomes and safety.
• Identify patients whose illness severity is outside of hospital medicine’s scope of practice and adjust transport plan appropriately, according to local context.
• Consult intensivists and subspecialists effectively and efficiently during the pre-transport, transport, and/or post-transport process as clinically indicated, whether serving as referring or accepting physician, transport physician, or Medical Control Officer.
• Ensure effective and efficient communication at each transition of care.
• Coordinate care between facilities that is timely yet also reduces unnecessary testing and/or radiation exposure through engagement of pediatric subspecialists and diagnostic testing equipment.
• Demonstrate skills in effective, efficient, and respectful phone communications.
• Identify patient-specific monitoring and immediate care needs, and secure best patient placement from the referring emergency department, such as to a pediatric emergency department, operating room, ward, or critical care unit within local context.
• Perform effective verbal handoffs and transfer of relevant written or electronically accessible patient information.
• Communicate effectively with patients and the family/caregivers regarding the transport process, adhering to the principles of patient and family centered care.

Pediatric hospitalists should be able to:

• Exemplify professionalism when responding to all calls and requests for transport.
• Realize the importance of educating and mentoring trainees and other healthcare providers regarding aspects of transport including clinical decision-making, risk management, customer service, and operational issues.
• Realize the importance of establishing and maintaining collegial relationships with referral sources and transport team members.
• Reflect on the importance of maintaining ongoing care for the child throughout the transport process.
• Recognize the added stress and fear felt by the family/caregivers when a child is being transported, including the fear of separation.

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

• Work with hospital administration, transport team members and transport program leadership to promote financially sound growth and development of pediatric transport services and corresponding policies, including those governing maintenance of competency and scope of practice.
• Lead, coordinate, or participate in ongoing educational and training opportunities to maintain the skill set of transport team members and medical control physicians.
• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways or protocols to standardize the management of common diagnoses for children transported between facilities.
• Lead, coordinate, or participate in multidisciplinary group forums of stakeholders involved in pediatric transport, to establish and/or track transport-specific benchmarks, ensure quality of care, and improve system-wide processes.
• Lead, coordinate, or participate in review of transport cases to promote improvement opportunities, identification of systems issues, and education.

Introduction

Acute care pediatric services continue to be centralized, causing pediatric inter-facility transport programs to progress and evolve. Evidence has shown that specialty transport teams capable of delivering state of the art care improve patient outcomes. This has resulted in a paradigm shift in pediatric transport programs to emphasize delivery of definitive care both at the referring facility and throughout transport. Over the past years the number of institutionally sponsored hospital based pediatric specialty transport programs has increased in response to this need. Pediatric hospitalists may serve as the referring or accepting physician, transport physician, or medical control physician (transport coordinator) for these patients. Through each of these roles pediatric hospitalists fulfill an essential function in ensuring the safe and timely transport of ill children.

Pediatric hospitalists should be able to:

• Compare and contrast advantages and disadvantages between transport modalities including non-medical, Basic Life Support (BLS), Advanced Life Support (ALS), Critical Care Team (CCT), and specialized Neonatal/Pediatric Critical Care Transport service.
• Describe features of the medical history and physical examination that necessitate emergent or urgent patient transfer.
• Cite common transport team members and discuss the proficiency and expertise required to safely provide effective triage and stabilization for differing pediatric diseases and conditions, attending to the roles of physician, nurse, respiratory therapist, and others.
• Review the role of pediatric hospitalists serving as the referring and/or accepting physician, attending to communications with and documentation for the referring physician, accepting site, local healthcare team, and the family/caregivers.
• Discuss how pediatric hospitalists may serve as the physician on transport, attending to local context and scope of practice.
• Summarize the role of the Medical Control Officer and review the responsibilities related to triage, team management, and maintaining ongoing consistent care through assistance with treatment decisions and planning from referring to accepting sites.
• Explain how the selection of transport modality and team composition are influenced by the patient’s clinical status as well as environmental and logistical factors.
• Describe the benefits of various monitoring techniques commonly used on transport, including oximetry, capnography, venous and arterial pressure, electrocardiography (ECG), and others.
• Discuss the indications, benefits, and risks of various interventions commonly utilized during transport such as high flow oxygen delivery, non-invasive positive pressure ventilation systems, artificial airways, medications, and others.
• Describe the importance of collaboration between hospitalists, subspecialists, and intensivists in stabilization and management during transport and upon arrival to the destination facility.
• Describe the knowledge base and skill set of non-physician transport team members.
• Discuss the use of standardized protocols and procedures on transport, including how they are used by non-physician team members and the process for implementation and oversight.
• Review how technologies such as telemedicine or other devices can aid in communication, patient assessment, and care delivery.

Pediatric hospitalists should be able to:

• Efficiently obtain and communicate critical clinical information, placing emphasis on cardiac, pulmonary, and neurologic disease that could impact the transport process.
• Formulate accurate rapid assessments and provide recommendations regarding laboratory studies and imaging, as well as therapeutic interventions that are evidence based and in accordance with Pediatric Advanced Life Support/Neonatal Resuscitation Program guidelines.
• Select modality of transport and team composition based on patient acuity and potential for deterioration, in the context of local logistical and environmental factors, such as time of day, traffic, and weather conditions.
• Effectively communicate with the transport team members to anticipate possible complications during the transport and create action plans prior to transport.
• Provide ongoing recommendations for management throughout the transport process to ensure optimal patient outcomes and safety.
• Identify patients whose illness severity is outside of hospital medicine’s scope of practice and adjust transport plan appropriately, according to local context.
• Consult intensivists and subspecialists effectively and efficiently during the pre-transport, transport, and/or post-transport process as clinically indicated, whether serving as referring or accepting physician, transport physician, or Medical Control Officer.
• Ensure effective and efficient communication at each transition of care.
• Coordinate care between facilities that is timely yet also reduces unnecessary testing and/or radiation exposure through engagement of pediatric subspecialists and diagnostic testing equipment.
• Demonstrate skills in effective, efficient, and respectful phone communications.
• Identify patient-specific monitoring and immediate care needs, and secure best patient placement from the referring emergency department, such as to a pediatric emergency department, operating room, ward, or critical care unit within local context.
• Perform effective verbal handoffs and transfer of relevant written or electronically accessible patient information.
• Communicate effectively with patients and the family/caregivers regarding the transport process, adhering to the principles of patient and family centered care.

Pediatric hospitalists should be able to:

• Exemplify professionalism when responding to all calls and requests for transport.
• Realize the importance of educating and mentoring trainees and other healthcare providers regarding aspects of transport including clinical decision-making, risk management, customer service, and operational issues.
• Realize the importance of establishing and maintaining collegial relationships with referral sources and transport team members.
• Reflect on the importance of maintaining ongoing care for the child throughout the transport process.
• Recognize the added stress and fear felt by the family/caregivers when a child is being transported, including the fear of separation.

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

• Work with hospital administration, transport team members and transport program leadership to promote financially sound growth and development of pediatric transport services and corresponding policies, including those governing maintenance of competency and scope of practice.
• Lead, coordinate, or participate in ongoing educational and training opportunities to maintain the skill set of transport team members and medical control physicians.
• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways or protocols to standardize the management of common diagnoses for children transported between facilities.
• Lead, coordinate, or participate in multidisciplinary group forums of stakeholders involved in pediatric transport, to establish and/or track transport-specific benchmarks, ensure quality of care, and improve system-wide processes.
• Lead, coordinate, or participate in review of transport cases to promote improvement opportunities, identification of systems issues, and education.

Introduction

Acute care pediatric services continue to be centralized, causing pediatric inter-facility transport programs to progress and evolve. Evidence has shown that specialty transport teams capable of delivering state of the art care improve patient outcomes. This has resulted in a paradigm shift in pediatric transport programs to emphasize delivery of definitive care both at the referring facility and throughout transport. Over the past years the number of institutionally sponsored hospital based pediatric specialty transport programs has increased in response to this need. Pediatric hospitalists may serve as the referring or accepting physician, transport physician, or medical control physician (transport coordinator) for these patients. Through each of these roles pediatric hospitalists fulfill an essential function in ensuring the safe and timely transport of ill children.

Pediatric hospitalists should be able to:

• Compare and contrast advantages and disadvantages between transport modalities including non-medical, Basic Life Support (BLS), Advanced Life Support (ALS), Critical Care Team (CCT), and specialized Neonatal/Pediatric Critical Care Transport service.
• Describe features of the medical history and physical examination that necessitate emergent or urgent patient transfer.
• Cite common transport team members and discuss the proficiency and expertise required to safely provide effective triage and stabilization for differing pediatric diseases and conditions, attending to the roles of physician, nurse, respiratory therapist, and others.
• Review the role of pediatric hospitalists serving as the referring and/or accepting physician, attending to communications with and documentation for the referring physician, accepting site, local healthcare team, and the family/caregivers.
• Discuss how pediatric hospitalists may serve as the physician on transport, attending to local context and scope of practice.
• Summarize the role of the Medical Control Officer and review the responsibilities related to triage, team management, and maintaining ongoing consistent care through assistance with treatment decisions and planning from referring to accepting sites.
• Explain how the selection of transport modality and team composition are influenced by the patient’s clinical status as well as environmental and logistical factors.
• Describe the benefits of various monitoring techniques commonly used on transport, including oximetry, capnography, venous and arterial pressure, electrocardiography (ECG), and others.
• Discuss the indications, benefits, and risks of various interventions commonly utilized during transport such as high flow oxygen delivery, non-invasive positive pressure ventilation systems, artificial airways, medications, and others.
• Describe the importance of collaboration between hospitalists, subspecialists, and intensivists in stabilization and management during transport and upon arrival to the destination facility.
• Describe the knowledge base and skill set of non-physician transport team members.
• Discuss the use of standardized protocols and procedures on transport, including how they are used by non-physician team members and the process for implementation and oversight.
• Review how technologies such as telemedicine or other devices can aid in communication, patient assessment, and care delivery.

Pediatric hospitalists should be able to:

• Efficiently obtain and communicate critical clinical information, placing emphasis on cardiac, pulmonary, and neurologic disease that could impact the transport process.
• Formulate accurate rapid assessments and provide recommendations regarding laboratory studies and imaging, as well as therapeutic interventions that are evidence based and in accordance with Pediatric Advanced Life Support/Neonatal Resuscitation Program guidelines.
• Select modality of transport and team composition based on patient acuity and potential for deterioration, in the context of local logistical and environmental factors, such as time of day, traffic, and weather conditions.
• Effectively communicate with the transport team members to anticipate possible complications during the transport and create action plans prior to transport.
• Provide ongoing recommendations for management throughout the transport process to ensure optimal patient outcomes and safety.
• Identify patients whose illness severity is outside of hospital medicine’s scope of practice and adjust transport plan appropriately, according to local context.
• Consult intensivists and subspecialists effectively and efficiently during the pre-transport, transport, and/or post-transport process as clinically indicated, whether serving as referring or accepting physician, transport physician, or Medical Control Officer.
• Ensure effective and efficient communication at each transition of care.
• Coordinate care between facilities that is timely yet also reduces unnecessary testing and/or radiation exposure through engagement of pediatric subspecialists and diagnostic testing equipment.
• Demonstrate skills in effective, efficient, and respectful phone communications.
• Identify patient-specific monitoring and immediate care needs, and secure best patient placement from the referring emergency department, such as to a pediatric emergency department, operating room, ward, or critical care unit within local context.
• Perform effective verbal handoffs and transfer of relevant written or electronically accessible patient information.
• Communicate effectively with patients and the family/caregivers regarding the transport process, adhering to the principles of patient and family centered care.

Pediatric hospitalists should be able to:

• Exemplify professionalism when responding to all calls and requests for transport.
• Realize the importance of educating and mentoring trainees and other healthcare providers regarding aspects of transport including clinical decision-making, risk management, customer service, and operational issues.
• Realize the importance of establishing and maintaining collegial relationships with referral sources and transport team members.
• Reflect on the importance of maintaining ongoing care for the child throughout the transport process.
• Recognize the added stress and fear felt by the family/caregivers when a child is being transported, including the fear of separation.

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

• Work with hospital administration, transport team members and transport program leadership to promote financially sound growth and development of pediatric transport services and corresponding policies, including those governing maintenance of competency and scope of practice.
• Lead, coordinate, or participate in ongoing educational and training opportunities to maintain the skill set of transport team members and medical control physicians.
• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways or protocols to standardize the management of common diagnoses for children transported between facilities.
• Lead, coordinate, or participate in multidisciplinary group forums of stakeholders involved in pediatric transport, to establish and/or track transport-specific benchmarks, ensure quality of care, and improve system-wide processes.
• Lead, coordinate, or participate in review of transport cases to promote improvement opportunities, identification of systems issues, and education.

Introduction

Pediatric palliative care (PPC) is comprehensive, specialized care for children facing serious or life-threatening illness, with the goal of improving quality of life for the child and the family/caregivers. Palliative care represents both a philosophy and an organized method for delivering care focused on addressing physical, psychosocial, and spiritual needs to prevent and relieve suffering. Pediatric hospice care (PHC) is a particular type of palliative care traditionally provided to patients with a more limited prognosis and carried out by licensed hospice agencies. Pediatric palliative care and PHC are delivered through interdisciplinary collaboration, across care settings, integrated throughout the course of the illness from diagnosis to bereavement, and provided alongside life-prolonging or curative interventions. Patients who may benefit from PPC or PHC are frequently hospitalized; however, PPC resources may be limited and may vary by geographic location. Pediatric hospitalists are often caring for these patients and well positioned to provide basic PPC needs and assist with accessing PPC resources.

Pediatric hospitalists should be able to:

• Compare and contrast between PPC and PHC, attending to scope, patient population, services, optimal timing, and goals of care, among other items.
• Cite key elements of PPC, including facilitation of informed decision-making; enhancing care coordination and communication among medical team members, the child, and family/caregivers; improving comfort through expert symptom management; and optimizing quality of life.
• Review the importance of appropriate timing of PHC referral when the child’s expected prognosis is 6 months or less, and list basic steps in the referral process.
• Summarize why PPC and PHC are optimally provided by an interdisciplinary team consisting of a pediatrician, pediatric nurse, social worker, chaplain, and others.
• Describe the value of conducting proactive discussions of goals of care (GOC), which may include forgoing or withdrawing life-sustaining treatment prior to a child becoming critically ill.
• Explain how PPC can be integrated with appropriate medical treatments, including curative and life-prolonging treatment, starting at diagnosis of serious illness.
• Discuss the benefits of items commonly included in a PPC treatment plan such as symptom management, spiritual counseling, and physical therapy, among others.
• Give examples of local, regional, and national resources for PPC and PHC that are accessible to patients, the family/caregivers, and healthcare providers.
• Describe ethical principles related to end-of-life (EOL) care and the role of the hospital ethics committee in these scenarios.
• Describe the processes for writing “allow natural death” (AND), orders, advanced directives, the “Physician Orders for Life-Sustaining Treatment” (POLST) form, pronouncement of death, and completion of a death certificate.

Pediatric hospitalists should be able to:

• Identify children who may benefit from complex decision-making, advanced symptom management, or higher level psychosocial and spiritual support and refer them to PPC or PHC services.
• Engage in difficult conversations, including communicating “bad news” with compassion.
• Describe and introduce PPC and PHC to patients, the family/caregivers, other subspecialists, and other healthcare providers.
• Lead a basic discussion of prognosis and GOC with patients, the family/caregivers, and the healthcare team.
• Manage ethical dilemmas encountered in the care of the dying patient in the hospital, in collaboration with other healthcare providers as appropriate.
• Provide care that respects the cultural, social, and spiritual preferences of patients and the family/caregivers.
• Screen and provide basic treatment for pain and other distressing symptoms experienced by seriously ill or dying patients, such as dyspnea, nausea, anxiety, delirium, and others.
• Prescribe indicated pharmacologic and non-pharmacologic therapies in collaboration with appropriate consultants, including pain specialists, PPC teams, child-life providers, and integrative therapies.
• Educate healthcare providers and the family/caregivers about symptoms related to active dying.
• Provide counseling regarding life-prolonging interventions, addition of medical technology, and code status.
• Refer patients to other available disciplines for psychosocial and spiritual support, such as pastoral care, social work, and child life, if local PPC and PHC resources are not immediately available.
• Collaborate with an interdisciplinary team including PPC, PHC, nursing, social work, pastoral care, case management, pharmacy, medical/surgical subspecialists, and primary care provider to ensure coordinated, longitudinal care consistent with GOC for this population.
• Manage care needs for this population across facilities where needed, including remotely accessing palliative specialists at tertiary care sites and organizing best plans for patients and the family/caregivers who wish to return for care to their local community center.
• Communicate autopsy and donor options for actively dying children and access immediate support for the family/caregivers and staff related to this decision-making process.

Pediatric hospitalists should be able to:

• Appreciate the key role hospitalists play in ensuring that PPC needs of seriously ill children are addressed.
• Recognize that PPC is appropriate throughout the course of serious illness and should be equitably provided to all children who may benefit from these services.
• Recognize the importance of empathetic, culturally sensitive communication.
• Acknowledge personal attitudes and biases and their influence on care of seriously ill or dying patients from a physical, psychosocial, and spiritual perspective.
• Exemplify ethical behavior in rendering care for these patients and their family/caregivers.
• Reflect on the value of and engage in self-care to cope with the stress of caring for seriously ill patients.
• Realize and address gaps in personal knowledge, skills, and attitudes regarding PPC through professional education.
• Recognize the importance of building therapeutic relationships with seriously ill children and the family/caregivers.
• Recognize that PPC is patient- and family-centered and that treatment plans should be aligned with GOC of patients and the family/caregivers.

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

• Lead, coordinate, or participate in organizational efforts to provide PPC/PHC education.
• Collaborate with hospital administration and community partners to ensure efficient access to appropriate consultants necessary for success of these programs for children.
• Advocate for development of PPC and PHC resources within the institution and local community.
• Lead, coordinate, or participate in institutional initiatives aimed at improving care of seriously ill children, including improved advanced care planning or symptom management care pathways.

Introduction

Pediatric palliative care (PPC) is comprehensive, specialized care for children facing serious or life-threatening illness, with the goal of improving quality of life for the child and the family/caregivers. Palliative care represents both a philosophy and an organized method for delivering care focused on addressing physical, psychosocial, and spiritual needs to prevent and relieve suffering. Pediatric hospice care (PHC) is a particular type of palliative care traditionally provided to patients with a more limited prognosis and carried out by licensed hospice agencies. Pediatric palliative care and PHC are delivered through interdisciplinary collaboration, across care settings, integrated throughout the course of the illness from diagnosis to bereavement, and provided alongside life-prolonging or curative interventions. Patients who may benefit from PPC or PHC are frequently hospitalized; however, PPC resources may be limited and may vary by geographic location. Pediatric hospitalists are often caring for these patients and well positioned to provide basic PPC needs and assist with accessing PPC resources.

Pediatric hospitalists should be able to:

• Compare and contrast between PPC and PHC, attending to scope, patient population, services, optimal timing, and goals of care, among other items.
• Cite key elements of PPC, including facilitation of informed decision-making; enhancing care coordination and communication among medical team members, the child, and family/caregivers; improving comfort through expert symptom management; and optimizing quality of life.
• Review the importance of appropriate timing of PHC referral when the child’s expected prognosis is 6 months or less, and list basic steps in the referral process.
• Summarize why PPC and PHC are optimally provided by an interdisciplinary team consisting of a pediatrician, pediatric nurse, social worker, chaplain, and others.
• Describe the value of conducting proactive discussions of goals of care (GOC), which may include forgoing or withdrawing life-sustaining treatment prior to a child becoming critically ill.
• Explain how PPC can be integrated with appropriate medical treatments, including curative and life-prolonging treatment, starting at diagnosis of serious illness.
• Discuss the benefits of items commonly included in a PPC treatment plan such as symptom management, spiritual counseling, and physical therapy, among others.
• Give examples of local, regional, and national resources for PPC and PHC that are accessible to patients, the family/caregivers, and healthcare providers.
• Describe ethical principles related to end-of-life (EOL) care and the role of the hospital ethics committee in these scenarios.
• Describe the processes for writing “allow natural death” (AND), orders, advanced directives, the “Physician Orders for Life-Sustaining Treatment” (POLST) form, pronouncement of death, and completion of a death certificate.

Pediatric hospitalists should be able to:

• Identify children who may benefit from complex decision-making, advanced symptom management, or higher level psychosocial and spiritual support and refer them to PPC or PHC services.
• Engage in difficult conversations, including communicating “bad news” with compassion.
• Describe and introduce PPC and PHC to patients, the family/caregivers, other subspecialists, and other healthcare providers.
• Lead a basic discussion of prognosis and GOC with patients, the family/caregivers, and the healthcare team.
• Manage ethical dilemmas encountered in the care of the dying patient in the hospital, in collaboration with other healthcare providers as appropriate.
• Provide care that respects the cultural, social, and spiritual preferences of patients and the family/caregivers.
• Screen and provide basic treatment for pain and other distressing symptoms experienced by seriously ill or dying patients, such as dyspnea, nausea, anxiety, delirium, and others.
• Prescribe indicated pharmacologic and non-pharmacologic therapies in collaboration with appropriate consultants, including pain specialists, PPC teams, child-life providers, and integrative therapies.
• Educate healthcare providers and the family/caregivers about symptoms related to active dying.
• Provide counseling regarding life-prolonging interventions, addition of medical technology, and code status.
• Refer patients to other available disciplines for psychosocial and spiritual support, such as pastoral care, social work, and child life, if local PPC and PHC resources are not immediately available.
• Collaborate with an interdisciplinary team including PPC, PHC, nursing, social work, pastoral care, case management, pharmacy, medical/surgical subspecialists, and primary care provider to ensure coordinated, longitudinal care consistent with GOC for this population.
• Manage care needs for this population across facilities where needed, including remotely accessing palliative specialists at tertiary care sites and organizing best plans for patients and the family/caregivers who wish to return for care to their local community center.
• Communicate autopsy and donor options for actively dying children and access immediate support for the family/caregivers and staff related to this decision-making process.

Pediatric hospitalists should be able to:

• Appreciate the key role hospitalists play in ensuring that PPC needs of seriously ill children are addressed.
• Recognize that PPC is appropriate throughout the course of serious illness and should be equitably provided to all children who may benefit from these services.
• Recognize the importance of empathetic, culturally sensitive communication.
• Acknowledge personal attitudes and biases and their influence on care of seriously ill or dying patients from a physical, psychosocial, and spiritual perspective.
• Exemplify ethical behavior in rendering care for these patients and their family/caregivers.
• Reflect on the value of and engage in self-care to cope with the stress of caring for seriously ill patients.
• Realize and address gaps in personal knowledge, skills, and attitudes regarding PPC through professional education.
• Recognize the importance of building therapeutic relationships with seriously ill children and the family/caregivers.
• Recognize that PPC is patient- and family-centered and that treatment plans should be aligned with GOC of patients and the family/caregivers.

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

• Lead, coordinate, or participate in organizational efforts to provide PPC/PHC education.
• Collaborate with hospital administration and community partners to ensure efficient access to appropriate consultants necessary for success of these programs for children.
• Advocate for development of PPC and PHC resources within the institution and local community.
• Lead, coordinate, or participate in institutional initiatives aimed at improving care of seriously ill children, including improved advanced care planning or symptom management care pathways.

Introduction

Pediatric palliative care (PPC) is comprehensive, specialized care for children facing serious or life-threatening illness, with the goal of improving quality of life for the child and the family/caregivers. Palliative care represents both a philosophy and an organized method for delivering care focused on addressing physical, psychosocial, and spiritual needs to prevent and relieve suffering. Pediatric hospice care (PHC) is a particular type of palliative care traditionally provided to patients with a more limited prognosis and carried out by licensed hospice agencies. Pediatric palliative care and PHC are delivered through interdisciplinary collaboration, across care settings, integrated throughout the course of the illness from diagnosis to bereavement, and provided alongside life-prolonging or curative interventions. Patients who may benefit from PPC or PHC are frequently hospitalized; however, PPC resources may be limited and may vary by geographic location. Pediatric hospitalists are often caring for these patients and well positioned to provide basic PPC needs and assist with accessing PPC resources.

Pediatric hospitalists should be able to:

• Compare and contrast between PPC and PHC, attending to scope, patient population, services, optimal timing, and goals of care, among other items.
• Cite key elements of PPC, including facilitation of informed decision-making; enhancing care coordination and communication among medical team members, the child, and family/caregivers; improving comfort through expert symptom management; and optimizing quality of life.
• Review the importance of appropriate timing of PHC referral when the child’s expected prognosis is 6 months or less, and list basic steps in the referral process.
• Summarize why PPC and PHC are optimally provided by an interdisciplinary team consisting of a pediatrician, pediatric nurse, social worker, chaplain, and others.
• Describe the value of conducting proactive discussions of goals of care (GOC), which may include forgoing or withdrawing life-sustaining treatment prior to a child becoming critically ill.
• Explain how PPC can be integrated with appropriate medical treatments, including curative and life-prolonging treatment, starting at diagnosis of serious illness.
• Discuss the benefits of items commonly included in a PPC treatment plan such as symptom management, spiritual counseling, and physical therapy, among others.
• Give examples of local, regional, and national resources for PPC and PHC that are accessible to patients, the family/caregivers, and healthcare providers.
• Describe ethical principles related to end-of-life (EOL) care and the role of the hospital ethics committee in these scenarios.
• Describe the processes for writing “allow natural death” (AND), orders, advanced directives, the “Physician Orders for Life-Sustaining Treatment” (POLST) form, pronouncement of death, and completion of a death certificate.

Pediatric hospitalists should be able to:

• Identify children who may benefit from complex decision-making, advanced symptom management, or higher level psychosocial and spiritual support and refer them to PPC or PHC services.
• Engage in difficult conversations, including communicating “bad news” with compassion.
• Describe and introduce PPC and PHC to patients, the family/caregivers, other subspecialists, and other healthcare providers.
• Lead a basic discussion of prognosis and GOC with patients, the family/caregivers, and the healthcare team.
• Manage ethical dilemmas encountered in the care of the dying patient in the hospital, in collaboration with other healthcare providers as appropriate.
• Provide care that respects the cultural, social, and spiritual preferences of patients and the family/caregivers.
• Screen and provide basic treatment for pain and other distressing symptoms experienced by seriously ill or dying patients, such as dyspnea, nausea, anxiety, delirium, and others.
• Prescribe indicated pharmacologic and non-pharmacologic therapies in collaboration with appropriate consultants, including pain specialists, PPC teams, child-life providers, and integrative therapies.
• Educate healthcare providers and the family/caregivers about symptoms related to active dying.
• Provide counseling regarding life-prolonging interventions, addition of medical technology, and code status.
• Refer patients to other available disciplines for psychosocial and spiritual support, such as pastoral care, social work, and child life, if local PPC and PHC resources are not immediately available.
• Collaborate with an interdisciplinary team including PPC, PHC, nursing, social work, pastoral care, case management, pharmacy, medical/surgical subspecialists, and primary care provider to ensure coordinated, longitudinal care consistent with GOC for this population.
• Manage care needs for this population across facilities where needed, including remotely accessing palliative specialists at tertiary care sites and organizing best plans for patients and the family/caregivers who wish to return for care to their local community center.
• Communicate autopsy and donor options for actively dying children and access immediate support for the family/caregivers and staff related to this decision-making process.

Pediatric hospitalists should be able to:

• Appreciate the key role hospitalists play in ensuring that PPC needs of seriously ill children are addressed.
• Recognize that PPC is appropriate throughout the course of serious illness and should be equitably provided to all children who may benefit from these services.
• Recognize the importance of empathetic, culturally sensitive communication.
• Acknowledge personal attitudes and biases and their influence on care of seriously ill or dying patients from a physical, psychosocial, and spiritual perspective.
• Exemplify ethical behavior in rendering care for these patients and their family/caregivers.
• Reflect on the value of and engage in self-care to cope with the stress of caring for seriously ill patients.
• Realize and address gaps in personal knowledge, skills, and attitudes regarding PPC through professional education.
• Recognize the importance of building therapeutic relationships with seriously ill children and the family/caregivers.
• Recognize that PPC is patient- and family-centered and that treatment plans should be aligned with GOC of patients and the family/caregivers.

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

• Lead, coordinate, or participate in organizational efforts to provide PPC/PHC education.
• Collaborate with hospital administration and community partners to ensure efficient access to appropriate consultants necessary for success of these programs for children.
• Advocate for development of PPC and PHC resources within the institution and local community.
• Lead, coordinate, or participate in institutional initiatives aimed at improving care of seriously ill children, including improved advanced care planning or symptom management care pathways.

Introduction

Pediatric hospitalists are increasingly called upon to provide care for the immediate newborn. For those who provide these services, the components of this care vary and may include any combination of routine newborn care, level II and above neonatal intensive care, delivery room management, neonatal resuscitation and stabilization, or neonatal transport services. Rendering this care requires medical and procedural skills, as well as leadership and team skills while working with neonatologists, obstetricians, nurses, nurse midwives, advanced practice practitioners, primary care providers, and the family/caregivers. Pediatric hospitalists are well positioned to provide quality care for the newborn and to assure effective transition of care to home or to higher levels of support as needed.

Pediatric hospitalists should be able to:

• Describe the role of each team member commonly involved in newborn care, including the obstetricians, perinatologists, prenatal ultrasonographers/radiologists, nurses, advanced practice practitioners, lactation consultants, social workers, primary care providers, and others.
• Describe the skills needed to be an effective neonatal resuscitation team leader, including critical thinking, evidence-based decision-making, and effective communication.
• Define nursery care levels and the conditions that can be cared for at each level of acuity, while demonstrating knowledge and awareness of available resources.
• Describe the normal delivery process and the physiologic transitions of a newborn.
• Summarize the components of a complete newborn exam.
• Review the steps of neonatal resuscitation as recommended by the Neonatal Resuscitation Program (NRP).
• Describe the basic physiologic differences between preterm, late preterm, and term infants.
• Discuss common issues for preterm and late preterm infants including respiratory complications, temperature instability, feeding difficulties, hypoglycemia, infection, hyperbilirubinemia, and others.
• Discuss the impact of maternal factors and conditions on the fetus and newborn, including abnormal prenatal labs, diabetes, thyroid disorders, hypertension, and others.
• Discuss the impact of maternal use of prescription, non-prescription, and illicit drugs on the fetus and newborn.
• List symptoms of drug withdrawal and summarize the appropriate monitoring and management of the newborn at risk for neonatal abstinence syndrome (NAS).
• Compare and contrast the nutritional requirements of term versus preterm infants.
• Compare and contrast the benefits of breast milk, formulas, and supplements (Vitamin D, Iron) for term versus preterm infants.
• Cite examples where use of nutrition other than breast milk may be medically indicated.
• Identify when breastfeeding difficulties warrant additional support from lactation consultants.
• Review the components of common newborn screening tests, including state metabolic screening, hearing screening, critical congenital heart disease screening, car seat tolerance testing, and bilirubin screening.
• Review guidelines and recommendations for common newborn medications, such as immunizations for Hepatitis B, Vitamin K, and eye prophylaxis.
• Describe and differentiate between risk factors and pathophysiologic causes of hyperbilirubinemia requiring treatment for immediate newborns (first 1- 2 days of life) versus older infants.
• Discuss key elements in the assessment and management of newborns at risk for early onset sepsis, such as maternal antibiotic prophylaxis, presence of fever in the newborn, rupture of membranes, gestational age, and other factors.
• Describe the diagnostic and therapeutic approach toward newborns with common dysmorphisms including features associated with trisomies, ear pits, cleft-lip/palate, supernumerary digits, spinal dysraphisms, clubfoot, and others.
• Review risk factors for and pathophysiology of persistent fetal circulation/pulmonary hypertension of the newborn.
• Describe the diagnostic approach and differential diagnosis for a newborn with tachypnea, hypoxia, or cyanosis.
• Discuss the approach toward the newborn with hypoglycemia, including a summary of pathophysiology of glucose homeostasis, risk factors, diagnosis, and treatment.
• Discuss presentation and management of common birth traumas including clavicle fractures, brachial plexus injuries, and others.
• Describe the initial management and differential diagnosis for newborns with seizures.
• Review the role of prenatal ultrasound and describe appropriate post-birth follow-up of common findings including renal abnormalities, heart lesions, and others.
• List common clinical indications for an acute metabolic or endocrine work-up in newborns.
• Compare and contrast the characteristics of benign versus pathologic cardiac murmurs in this population, and give examples of indications for emergent echocardiogram and/or cardiology consultation.
• Describe the risk factors for developmental dysplasia of the hip, and the diagnostic and therapeutic approach to this condition.
• Explain specific goals that should be met to ensure safe transitions of care for this population, including recommendations for and timing of follow-up appointments.
• List commonly utilized resources to support the family/caregivers after hospital discharge, attending to global and potential special needs due to infant condition or the family/caregivers’ needs.

Pediatric hospitalists should be able to:

• Lead a team in an NRP-based resuscitation for term and preterm infants.
• Provide initial care and stabilization for newborns requiring a higher level of care.
• Perform a physician exam to elicit signs related to conditions requiring subspecialty consultation and counseling, including cardiac anomalies, ambiguous genitalia, dysmorphisms, and others.
• Identify and provide initial care and stabilization for newborns with surgical emergencies such as gastrointestinal obstruction, diaphragmatic hernia, cardiac anomalies, and others.
• Identify newborns with respiratory and cardiac instability and initiate appropriate cardiorespiratory support.
• Order and correctly interpret expanded newborn vital signs, including 4-extremity blood pressure and pre/post ductal oxygenation testing.
• Select appropriate diagnostic studies and therapeutics for common newborn conditions such as jaundice, tachypnea, hypoxia, altered mental status, hypoglycemia, neonatal sepsis, jitteriness, and others.
• Interpret basic studies (such as laboratory tests and radiographs) and identify abnormal finding that require further testing or consultation.
• Demonstrate basic competency in performing procedures on this population according to local context, including lumbar puncture, intravenous and intraosseous access, intubation, placement of enteral tubes, placement of umbilical catheters, frenotomy, needle thoracentesis, circumcision, and others.
• Order and manage enteral and parenteral nutrition for term and preterm infants.
• Demonstrate skills in counseling mothers and the family/caregivers, based on current evidence and recommendations, about common topics, such as immunizations, circumcision, breast-feeding, vitamin K administration, provision of erythromycin ophthalmic ointment, and others.
• Demonstrate skills in communicating with the family/caregivers to diffuse anxiety and provide support, particularly when discussing the need for consultation or emergency care.
• Coordinate care with the primary care provider and subspecialists as indicated to arrange for the referral, transfer or hospital discharge for this population.
• Identify when maternal, familial, and/or environmental factors warrant social work consultation or other support and initiate appropriate referrals.

Pediatric hospitalists should be able to:

• Role model a high level of commitment, responsibility, and accountability in rendering care for newborns.
• Exemplify professional and compassionate behavior towards the family/caregivers at all times while providing care and discussing care options, including during the delivery process and in the nursery.
• Reflect on the importance of and benefits from coordinating care with other multidisciplinary members of the health care team, including social workers, case managers, developmental specialists, and lactation consultants.
• Recognize the importance of utilizing shared decision-making with the family/caregivers when addressing care options for newborns with complex issues, such as extreme prematurity, congenital anomalies, and other conditions.

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

• Lead, coordinate, or participate in the development and implementation of cost-effective, evidence-based care pathways to standardize the evaluation, management, and discharge process for newborns.
• Work with hospital administration, hospital staff, subspecialists, and other services/consultants to provide appropriate newborn resuscitation services and newborn care at all levels of acuity according to local context.
• Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary care centers for newborns requiring higher levels of care.
• Promote or provide leadership for a newborn nursery or level II neonatal intensive care unit, in partnership with neonatologists and other subspecialists as indicated.
• Lead, coordinate, or participate in efforts to create and sustain in a process of continuous quality improvement in the nursery.

Introduction

Pediatric hospitalists are increasingly called upon to provide care for the immediate newborn. For those who provide these services, the components of this care vary and may include any combination of routine newborn care, level II and above neonatal intensive care, delivery room management, neonatal resuscitation and stabilization, or neonatal transport services. Rendering this care requires medical and procedural skills, as well as leadership and team skills while working with neonatologists, obstetricians, nurses, nurse midwives, advanced practice practitioners, primary care providers, and the family/caregivers. Pediatric hospitalists are well positioned to provide quality care for the newborn and to assure effective transition of care to home or to higher levels of support as needed.

Pediatric hospitalists should be able to:

• Describe the role of each team member commonly involved in newborn care, including the obstetricians, perinatologists, prenatal ultrasonographers/radiologists, nurses, advanced practice practitioners, lactation consultants, social workers, primary care providers, and others.
• Describe the skills needed to be an effective neonatal resuscitation team leader, including critical thinking, evidence-based decision-making, and effective communication.
• Define nursery care levels and the conditions that can be cared for at each level of acuity, while demonstrating knowledge and awareness of available resources.
• Describe the normal delivery process and the physiologic transitions of a newborn.
• Summarize the components of a complete newborn exam.
• Review the steps of neonatal resuscitation as recommended by the Neonatal Resuscitation Program (NRP).
• Describe the basic physiologic differences between preterm, late preterm, and term infants.
• Discuss common issues for preterm and late preterm infants including respiratory complications, temperature instability, feeding difficulties, hypoglycemia, infection, hyperbilirubinemia, and others.
• Discuss the impact of maternal factors and conditions on the fetus and newborn, including abnormal prenatal labs, diabetes, thyroid disorders, hypertension, and others.
• Discuss the impact of maternal use of prescription, non-prescription, and illicit drugs on the fetus and newborn.
• List symptoms of drug withdrawal and summarize the appropriate monitoring and management of the newborn at risk for neonatal abstinence syndrome (NAS).
• Compare and contrast the nutritional requirements of term versus preterm infants.
• Compare and contrast the benefits of breast milk, formulas, and supplements (Vitamin D, Iron) for term versus preterm infants.
• Cite examples where use of nutrition other than breast milk may be medically indicated.
• Identify when breastfeeding difficulties warrant additional support from lactation consultants.
• Review the components of common newborn screening tests, including state metabolic screening, hearing screening, critical congenital heart disease screening, car seat tolerance testing, and bilirubin screening.
• Review guidelines and recommendations for common newborn medications, such as immunizations for Hepatitis B, Vitamin K, and eye prophylaxis.
• Describe and differentiate between risk factors and pathophysiologic causes of hyperbilirubinemia requiring treatment for immediate newborns (first 1- 2 days of life) versus older infants.
• Discuss key elements in the assessment and management of newborns at risk for early onset sepsis, such as maternal antibiotic prophylaxis, presence of fever in the newborn, rupture of membranes, gestational age, and other factors.
• Describe the diagnostic and therapeutic approach toward newborns with common dysmorphisms including features associated with trisomies, ear pits, cleft-lip/palate, supernumerary digits, spinal dysraphisms, clubfoot, and others.
• Review risk factors for and pathophysiology of persistent fetal circulation/pulmonary hypertension of the newborn.
• Describe the diagnostic approach and differential diagnosis for a newborn with tachypnea, hypoxia, or cyanosis.
• Discuss the approach toward the newborn with hypoglycemia, including a summary of pathophysiology of glucose homeostasis, risk factors, diagnosis, and treatment.
• Discuss presentation and management of common birth traumas including clavicle fractures, brachial plexus injuries, and others.
• Describe the initial management and differential diagnosis for newborns with seizures.
• Review the role of prenatal ultrasound and describe appropriate post-birth follow-up of common findings including renal abnormalities, heart lesions, and others.
• List common clinical indications for an acute metabolic or endocrine work-up in newborns.
• Compare and contrast the characteristics of benign versus pathologic cardiac murmurs in this population, and give examples of indications for emergent echocardiogram and/or cardiology consultation.
• Describe the risk factors for developmental dysplasia of the hip, and the diagnostic and therapeutic approach to this condition.
• Explain specific goals that should be met to ensure safe transitions of care for this population, including recommendations for and timing of follow-up appointments.
• List commonly utilized resources to support the family/caregivers after hospital discharge, attending to global and potential special needs due to infant condition or the family/caregivers’ needs.

Pediatric hospitalists should be able to:

• Lead a team in an NRP-based resuscitation for term and preterm infants.
• Provide initial care and stabilization for newborns requiring a higher level of care.
• Perform a physician exam to elicit signs related to conditions requiring subspecialty consultation and counseling, including cardiac anomalies, ambiguous genitalia, dysmorphisms, and others.
• Identify and provide initial care and stabilization for newborns with surgical emergencies such as gastrointestinal obstruction, diaphragmatic hernia, cardiac anomalies, and others.
• Identify newborns with respiratory and cardiac instability and initiate appropriate cardiorespiratory support.
• Order and correctly interpret expanded newborn vital signs, including 4-extremity blood pressure and pre/post ductal oxygenation testing.
• Select appropriate diagnostic studies and therapeutics for common newborn conditions such as jaundice, tachypnea, hypoxia, altered mental status, hypoglycemia, neonatal sepsis, jitteriness, and others.
• Interpret basic studies (such as laboratory tests and radiographs) and identify abnormal finding that require further testing or consultation.
• Demonstrate basic competency in performing procedures on this population according to local context, including lumbar puncture, intravenous and intraosseous access, intubation, placement of enteral tubes, placement of umbilical catheters, frenotomy, needle thoracentesis, circumcision, and others.
• Order and manage enteral and parenteral nutrition for term and preterm infants.
• Demonstrate skills in counseling mothers and the family/caregivers, based on current evidence and recommendations, about common topics, such as immunizations, circumcision, breast-feeding, vitamin K administration, provision of erythromycin ophthalmic ointment, and others.
• Demonstrate skills in communicating with the family/caregivers to diffuse anxiety and provide support, particularly when discussing the need for consultation or emergency care.
• Coordinate care with the primary care provider and subspecialists as indicated to arrange for the referral, transfer or hospital discharge for this population.
• Identify when maternal, familial, and/or environmental factors warrant social work consultation or other support and initiate appropriate referrals.

Pediatric hospitalists should be able to:

• Role model a high level of commitment, responsibility, and accountability in rendering care for newborns.
• Exemplify professional and compassionate behavior towards the family/caregivers at all times while providing care and discussing care options, including during the delivery process and in the nursery.
• Reflect on the importance of and benefits from coordinating care with other multidisciplinary members of the health care team, including social workers, case managers, developmental specialists, and lactation consultants.
• Recognize the importance of utilizing shared decision-making with the family/caregivers when addressing care options for newborns with complex issues, such as extreme prematurity, congenital anomalies, and other conditions.

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

• Lead, coordinate, or participate in the development and implementation of cost-effective, evidence-based care pathways to standardize the evaluation, management, and discharge process for newborns.
• Work with hospital administration, hospital staff, subspecialists, and other services/consultants to provide appropriate newborn resuscitation services and newborn care at all levels of acuity according to local context.
• Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary care centers for newborns requiring higher levels of care.
• Promote or provide leadership for a newborn nursery or level II neonatal intensive care unit, in partnership with neonatologists and other subspecialists as indicated.
• Lead, coordinate, or participate in efforts to create and sustain in a process of continuous quality improvement in the nursery.

Introduction

Pediatric hospitalists are increasingly called upon to provide care for the immediate newborn. For those who provide these services, the components of this care vary and may include any combination of routine newborn care, level II and above neonatal intensive care, delivery room management, neonatal resuscitation and stabilization, or neonatal transport services. Rendering this care requires medical and procedural skills, as well as leadership and team skills while working with neonatologists, obstetricians, nurses, nurse midwives, advanced practice practitioners, primary care providers, and the family/caregivers. Pediatric hospitalists are well positioned to provide quality care for the newborn and to assure effective transition of care to home or to higher levels of support as needed.

Pediatric hospitalists should be able to:

• Describe the role of each team member commonly involved in newborn care, including the obstetricians, perinatologists, prenatal ultrasonographers/radiologists, nurses, advanced practice practitioners, lactation consultants, social workers, primary care providers, and others.
• Describe the skills needed to be an effective neonatal resuscitation team leader, including critical thinking, evidence-based decision-making, and effective communication.
• Define nursery care levels and the conditions that can be cared for at each level of acuity, while demonstrating knowledge and awareness of available resources.
• Describe the normal delivery process and the physiologic transitions of a newborn.
• Summarize the components of a complete newborn exam.
• Review the steps of neonatal resuscitation as recommended by the Neonatal Resuscitation Program (NRP).
• Describe the basic physiologic differences between preterm, late preterm, and term infants.
• Discuss common issues for preterm and late preterm infants including respiratory complications, temperature instability, feeding difficulties, hypoglycemia, infection, hyperbilirubinemia, and others.
• Discuss the impact of maternal factors and conditions on the fetus and newborn, including abnormal prenatal labs, diabetes, thyroid disorders, hypertension, and others.
• Discuss the impact of maternal use of prescription, non-prescription, and illicit drugs on the fetus and newborn.
• List symptoms of drug withdrawal and summarize the appropriate monitoring and management of the newborn at risk for neonatal abstinence syndrome (NAS).
• Compare and contrast the nutritional requirements of term versus preterm infants.
• Compare and contrast the benefits of breast milk, formulas, and supplements (Vitamin D, Iron) for term versus preterm infants.
• Cite examples where use of nutrition other than breast milk may be medically indicated.
• Identify when breastfeeding difficulties warrant additional support from lactation consultants.
• Review the components of common newborn screening tests, including state metabolic screening, hearing screening, critical congenital heart disease screening, car seat tolerance testing, and bilirubin screening.
• Review guidelines and recommendations for common newborn medications, such as immunizations for Hepatitis B, Vitamin K, and eye prophylaxis.
• Describe and differentiate between risk factors and pathophysiologic causes of hyperbilirubinemia requiring treatment for immediate newborns (first 1- 2 days of life) versus older infants.
• Discuss key elements in the assessment and management of newborns at risk for early onset sepsis, such as maternal antibiotic prophylaxis, presence of fever in the newborn, rupture of membranes, gestational age, and other factors.
• Describe the diagnostic and therapeutic approach toward newborns with common dysmorphisms including features associated with trisomies, ear pits, cleft-lip/palate, supernumerary digits, spinal dysraphisms, clubfoot, and others.
• Review risk factors for and pathophysiology of persistent fetal circulation/pulmonary hypertension of the newborn.
• Describe the diagnostic approach and differential diagnosis for a newborn with tachypnea, hypoxia, or cyanosis.
• Discuss the approach toward the newborn with hypoglycemia, including a summary of pathophysiology of glucose homeostasis, risk factors, diagnosis, and treatment.
• Discuss presentation and management of common birth traumas including clavicle fractures, brachial plexus injuries, and others.
• Describe the initial management and differential diagnosis for newborns with seizures.
• Review the role of prenatal ultrasound and describe appropriate post-birth follow-up of common findings including renal abnormalities, heart lesions, and others.
• List common clinical indications for an acute metabolic or endocrine work-up in newborns.
• Compare and contrast the characteristics of benign versus pathologic cardiac murmurs in this population, and give examples of indications for emergent echocardiogram and/or cardiology consultation.
• Describe the risk factors for developmental dysplasia of the hip, and the diagnostic and therapeutic approach to this condition.
• Explain specific goals that should be met to ensure safe transitions of care for this population, including recommendations for and timing of follow-up appointments.
• List commonly utilized resources to support the family/caregivers after hospital discharge, attending to global and potential special needs due to infant condition or the family/caregivers’ needs.

Pediatric hospitalists should be able to:

• Lead a team in an NRP-based resuscitation for term and preterm infants.
• Provide initial care and stabilization for newborns requiring a higher level of care.
• Perform a physician exam to elicit signs related to conditions requiring subspecialty consultation and counseling, including cardiac anomalies, ambiguous genitalia, dysmorphisms, and others.
• Identify and provide initial care and stabilization for newborns with surgical emergencies such as gastrointestinal obstruction, diaphragmatic hernia, cardiac anomalies, and others.
• Identify newborns with respiratory and cardiac instability and initiate appropriate cardiorespiratory support.
• Order and correctly interpret expanded newborn vital signs, including 4-extremity blood pressure and pre/post ductal oxygenation testing.
• Select appropriate diagnostic studies and therapeutics for common newborn conditions such as jaundice, tachypnea, hypoxia, altered mental status, hypoglycemia, neonatal sepsis, jitteriness, and others.
• Interpret basic studies (such as laboratory tests and radiographs) and identify abnormal finding that require further testing or consultation.
• Demonstrate basic competency in performing procedures on this population according to local context, including lumbar puncture, intravenous and intraosseous access, intubation, placement of enteral tubes, placement of umbilical catheters, frenotomy, needle thoracentesis, circumcision, and others.
• Order and manage enteral and parenteral nutrition for term and preterm infants.
• Demonstrate skills in counseling mothers and the family/caregivers, based on current evidence and recommendations, about common topics, such as immunizations, circumcision, breast-feeding, vitamin K administration, provision of erythromycin ophthalmic ointment, and others.
• Demonstrate skills in communicating with the family/caregivers to diffuse anxiety and provide support, particularly when discussing the need for consultation or emergency care.
• Coordinate care with the primary care provider and subspecialists as indicated to arrange for the referral, transfer or hospital discharge for this population.
• Identify when maternal, familial, and/or environmental factors warrant social work consultation or other support and initiate appropriate referrals.

Pediatric hospitalists should be able to:

• Role model a high level of commitment, responsibility, and accountability in rendering care for newborns.
• Exemplify professional and compassionate behavior towards the family/caregivers at all times while providing care and discussing care options, including during the delivery process and in the nursery.
• Reflect on the importance of and benefits from coordinating care with other multidisciplinary members of the health care team, including social workers, case managers, developmental specialists, and lactation consultants.
• Recognize the importance of utilizing shared decision-making with the family/caregivers when addressing care options for newborns with complex issues, such as extreme prematurity, congenital anomalies, and other conditions.

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

• Lead, coordinate, or participate in the development and implementation of cost-effective, evidence-based care pathways to standardize the evaluation, management, and discharge process for newborns.
• Work with hospital administration, hospital staff, subspecialists, and other services/consultants to provide appropriate newborn resuscitation services and newborn care at all levels of acuity according to local context.
• Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary care centers for newborns requiring higher levels of care.
• Promote or provide leadership for a newborn nursery or level II neonatal intensive care unit, in partnership with neonatologists and other subspecialists as indicated.
• Lead, coordinate, or participate in efforts to create and sustain in a process of continuous quality improvement in the nursery.

Introduction

Behavioral issues are increasingly noted in hospitalized children, either as comorbidity or as the primary focus for admission. Yearly, 1 out of 5 children living in the United States experiences a mental disorder. Chronic mental health disorders can affect many children but may manifest differently when occurring in children with chronic medical conditions. Because of different etiologies and contexts, the approach toward inpatient care and treatment may also differ. Hospital systems vary in resources and, in particular, the availability of mental health units, including specialized units needed for children with eating disorders. Pediatric hospitalists often encounter children with behavioral needs and play a key role in the advocacy and care for these patients.

Pediatric hospitalists should be able to:

• List chronic neurodevelopmental disorders that may require acute behavioral and/or psychiatric management in the hospital setting, such as global developmental delay or intellectual disability due to varied etiologies, genetic disorders such as Rett syndrome or Down syndrome, neurodevelopmental conditions such as autism spectrum disorders, and others.
• Cite commonly encountered mood disorders (such as depression and anxiety) and chronic psychiatric conditions (such as conduct disorder, oppositional defiant disorder, attention deficit hyperactivity disorder (ADHD), eating disorders, and others).
• Summarize the relationship between mental health conditions (such as autism spectrum disorder, disruptive behavior disorder, anxiety, or depression) and common chronic medical conditions (such as diabetes, cystic fibrosis, sickle cell and others).
• Define disruptive behavior disorders and discuss strategies to mitigate the impact of these on care team members.
• Review the differences between “internalizing” and “externalizing” behaviors.
• Identify underlying triggers for escalating behavioral problems in these patients which are commonly encountered in the hospital setting, such as overstimulation from environmental cues, sleep loss, changes in routine and daily structure, fear of a new environment, and others.
• Describe safety precautions needed for the patient, staff, and the family/caregivers when a patient is agitated or emotionally dysregulated, including awareness of surroundings, objects that can be used for self-harm or harm to others, and others.
• Give examples of behaviors that may manifest from child abuse or neglect in this population, including aggression, withdrawal, and refusal of treatment or care.
• Identify some commonly used evidence-based treatments for different behavioral conditions, such as Applied Behavioral Analysis (behavior modification for autism spectrum disorder), Parent-Child Interaction Therapy (PCIT) (parenting skills training for behavior disorders and trauma), Cognitive Behavioral Therapy (CBT), Exposure therapy, and Dialectical Behavioral Therapy (DBT).
• List indications and possible side effects of medications commonly used in this population, including antidepressants, antipsychotics, psychostimulants, and others.
• Discuss basic characteristics of each of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM)-5 eating disorder diagnoses including anorexia nervosa - restricting type (AN-R), anorexia nervosa - binge-eating/purging type (AN-BP), bulimia nervosa (BN), Avoidant Restrictive Food Intake Disorder (ARFID), and Other Specified Feeding and Eating Disorder (OSFED).
• Cite examples of laboratory testing commonly used to identify organic causes of feeding intolerance, growth delay, and malnutrition.
• State the signs and symptoms of eating disorders that require hospitalization, including hemodynamic instability, bradycardia, and severe malnutrition.
• Give examples of potential maladaptive behaviors that may occur in family members of patients with chronic behavioral and psychiatric conditions, such as maternal or paternal psychopathology, poor parent relationships, and sibling conflicts.
• Review alternative communication modes that may be of value in this population such as drawing, use of symbols, sign language, photos, and computers.
• Identify examples of secondary gain underlying behavioral problems for some children, including school or home avoidance.
• Summarize medical and mental health care treatment needed for this population after hospital discharge, including access to mental health providers, residential or partial hospitalization programs, and coordination of care with the medical home.

Pediatric hospitalists should be able to:

• Utilize locally available screening tools to identify patients with potential for behavioral and psychiatric disorders.
• Identify adverse drug events related to medications used for behavioral health conditions.
• Order appropriate monitoring, medications, and treatments to prevent or manage escalation of chronic maladaptive behaviors.
• Coordinate care, with patients, the family/caregivers, and healthcare providers to ensure a safe environment for the child within the hospital setting, with attention to elective admission, procedures, and surgical events.
• Consult, collaborate with, and/or coordinate an interdisciplinary team in the management of this population, including child life, social work, psychology, psychiatry, rehabilitation medicine, physical therapy, occupational therapy, speech therapy, and others within local context.
• Diagnose conditions with both medical and behavioral/psychiatric components and create an effective, safe, and integrated management plan to address each.
• Consult other subspecialists and appropriately refer or coordinate transfer of patients.
• Identify patients who may benefit from evidence-based testing, such as imaging, genetic testing, hormonal testing, and others, and initiate orders as appropriate.
• Demonstrate the use of physical exam and communication skills that are appropriate for the patients’ cognitive and developmental abilities.
• Deliver care that is consistent and effective using behavioral and communication skills to support positive behavior choices.
• Identify the potential for and manage aggressive or maladaptive behavior using environmental, behavioral, and medication modalities as appropriate.
• Order and interpret common data including intake, output, vital signs, sleep habits, and nutritional needs for this population, and make care plan changes to address concerns.
• Create a comprehensive discharge plan in coordination with the patient, the family/caregivers, primary care provider, mental health providers, residential or partial hospitalization programs, and others.
• Provide support and empathy for health care providers and hospital staff facing challenging behaviors.

Pediatric hospitalists should be able to:

• Reflect on the importance of maintaining respect and compassion when speaking with and caring for this population.
• Role model professionalism by exemplifying patience and creating a positive therapeutic environment for patients, the family/caregivers, colleagues, and hospital staff.
• Recognize that care plans may need to be adapted to accommodate a child’s changing medical and behavioral needs.
• Realize that eating disorders occur in all genders, cultures, ethnicities, and socioeconomic classes.
• Reflect on the importance of education and advocacy for the population of patients with eating disorders, noting that eating disorders are mental health disorders with physiological manifestations.
• Recognize that children with neurodevelopmental disorders and disruptive behavioral disorders are at higher risk for abuse.
• Reflect on the value of acquiring and utilizing coping skills for patients, the family/caregivers, colleagues, hospital staff, and self.

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

• Work with hospital administration to develop and implement training for healthcare providers, hospital staff, and trainees around the approach toward care for this population.
• Work with hospital administration to develop and provide a safe and non-judgmental environment of care for this population.
• Collaborate with healthcare providers and hospital staff to determine roles and responsibilities that optimize each member’s strengths and training when managing patient behaviors.
• Collaborate with hospital administration and community partners to develop and sustain referral networks for family members to appropriate community resources, including respite care, social services, and therapy.
• Lead, coordinate, or participate in organizational efforts to educate community providers on recognition of and criteria for hospitalization for children with eating disorders.

Introduction

Behavioral issues are increasingly noted in hospitalized children, either as comorbidity or as the primary focus for admission. Yearly, 1 out of 5 children living in the United States experiences a mental disorder. Chronic mental health disorders can affect many children but may manifest differently when occurring in children with chronic medical conditions. Because of different etiologies and contexts, the approach toward inpatient care and treatment may also differ. Hospital systems vary in resources and, in particular, the availability of mental health units, including specialized units needed for children with eating disorders. Pediatric hospitalists often encounter children with behavioral needs and play a key role in the advocacy and care for these patients.

Pediatric hospitalists should be able to:

• List chronic neurodevelopmental disorders that may require acute behavioral and/or psychiatric management in the hospital setting, such as global developmental delay or intellectual disability due to varied etiologies, genetic disorders such as Rett syndrome or Down syndrome, neurodevelopmental conditions such as autism spectrum disorders, and others.
• Cite commonly encountered mood disorders (such as depression and anxiety) and chronic psychiatric conditions (such as conduct disorder, oppositional defiant disorder, attention deficit hyperactivity disorder (ADHD), eating disorders, and others).
• Summarize the relationship between mental health conditions (such as autism spectrum disorder, disruptive behavior disorder, anxiety, or depression) and common chronic medical conditions (such as diabetes, cystic fibrosis, sickle cell and others).
• Define disruptive behavior disorders and discuss strategies to mitigate the impact of these on care team members.
• Review the differences between “internalizing” and “externalizing” behaviors.
• Identify underlying triggers for escalating behavioral problems in these patients which are commonly encountered in the hospital setting, such as overstimulation from environmental cues, sleep loss, changes in routine and daily structure, fear of a new environment, and others.
• Describe safety precautions needed for the patient, staff, and the family/caregivers when a patient is agitated or emotionally dysregulated, including awareness of surroundings, objects that can be used for self-harm or harm to others, and others.
• Give examples of behaviors that may manifest from child abuse or neglect in this population, including aggression, withdrawal, and refusal of treatment or care.
• Identify some commonly used evidence-based treatments for different behavioral conditions, such as Applied Behavioral Analysis (behavior modification for autism spectrum disorder), Parent-Child Interaction Therapy (PCIT) (parenting skills training for behavior disorders and trauma), Cognitive Behavioral Therapy (CBT), Exposure therapy, and Dialectical Behavioral Therapy (DBT).
• List indications and possible side effects of medications commonly used in this population, including antidepressants, antipsychotics, psychostimulants, and others.
• Discuss basic characteristics of each of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM)-5 eating disorder diagnoses including anorexia nervosa - restricting type (AN-R), anorexia nervosa - binge-eating/purging type (AN-BP), bulimia nervosa (BN), Avoidant Restrictive Food Intake Disorder (ARFID), and Other Specified Feeding and Eating Disorder (OSFED).
• Cite examples of laboratory testing commonly used to identify organic causes of feeding intolerance, growth delay, and malnutrition.
• State the signs and symptoms of eating disorders that require hospitalization, including hemodynamic instability, bradycardia, and severe malnutrition.
• Give examples of potential maladaptive behaviors that may occur in family members of patients with chronic behavioral and psychiatric conditions, such as maternal or paternal psychopathology, poor parent relationships, and sibling conflicts.
• Review alternative communication modes that may be of value in this population such as drawing, use of symbols, sign language, photos, and computers.
• Identify examples of secondary gain underlying behavioral problems for some children, including school or home avoidance.
• Summarize medical and mental health care treatment needed for this population after hospital discharge, including access to mental health providers, residential or partial hospitalization programs, and coordination of care with the medical home.

Pediatric hospitalists should be able to:

• Utilize locally available screening tools to identify patients with potential for behavioral and psychiatric disorders.
• Identify adverse drug events related to medications used for behavioral health conditions.
• Order appropriate monitoring, medications, and treatments to prevent or manage escalation of chronic maladaptive behaviors.
• Coordinate care, with patients, the family/caregivers, and healthcare providers to ensure a safe environment for the child within the hospital setting, with attention to elective admission, procedures, and surgical events.
• Consult, collaborate with, and/or coordinate an interdisciplinary team in the management of this population, including child life, social work, psychology, psychiatry, rehabilitation medicine, physical therapy, occupational therapy, speech therapy, and others within local context.
• Diagnose conditions with both medical and behavioral/psychiatric components and create an effective, safe, and integrated management plan to address each.
• Consult other subspecialists and appropriately refer or coordinate transfer of patients.
• Identify patients who may benefit from evidence-based testing, such as imaging, genetic testing, hormonal testing, and others, and initiate orders as appropriate.
• Demonstrate the use of physical exam and communication skills that are appropriate for the patients’ cognitive and developmental abilities.
• Deliver care that is consistent and effective using behavioral and communication skills to support positive behavior choices.
• Identify the potential for and manage aggressive or maladaptive behavior using environmental, behavioral, and medication modalities as appropriate.
• Order and interpret common data including intake, output, vital signs, sleep habits, and nutritional needs for this population, and make care plan changes to address concerns.
• Create a comprehensive discharge plan in coordination with the patient, the family/caregivers, primary care provider, mental health providers, residential or partial hospitalization programs, and others.
• Provide support and empathy for health care providers and hospital staff facing challenging behaviors.

Pediatric hospitalists should be able to:

• Reflect on the importance of maintaining respect and compassion when speaking with and caring for this population.
• Role model professionalism by exemplifying patience and creating a positive therapeutic environment for patients, the family/caregivers, colleagues, and hospital staff.
• Recognize that care plans may need to be adapted to accommodate a child’s changing medical and behavioral needs.
• Realize that eating disorders occur in all genders, cultures, ethnicities, and socioeconomic classes.
• Reflect on the importance of education and advocacy for the population of patients with eating disorders, noting that eating disorders are mental health disorders with physiological manifestations.
• Recognize that children with neurodevelopmental disorders and disruptive behavioral disorders are at higher risk for abuse.
• Reflect on the value of acquiring and utilizing coping skills for patients, the family/caregivers, colleagues, hospital staff, and self.

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

• Work with hospital administration to develop and implement training for healthcare providers, hospital staff, and trainees around the approach toward care for this population.
• Work with hospital administration to develop and provide a safe and non-judgmental environment of care for this population.
• Collaborate with healthcare providers and hospital staff to determine roles and responsibilities that optimize each member’s strengths and training when managing patient behaviors.
• Collaborate with hospital administration and community partners to develop and sustain referral networks for family members to appropriate community resources, including respite care, social services, and therapy.
• Lead, coordinate, or participate in organizational efforts to educate community providers on recognition of and criteria for hospitalization for children with eating disorders.

Introduction

Behavioral issues are increasingly noted in hospitalized children, either as comorbidity or as the primary focus for admission. Yearly, 1 out of 5 children living in the United States experiences a mental disorder. Chronic mental health disorders can affect many children but may manifest differently when occurring in children with chronic medical conditions. Because of different etiologies and contexts, the approach toward inpatient care and treatment may also differ. Hospital systems vary in resources and, in particular, the availability of mental health units, including specialized units needed for children with eating disorders. Pediatric hospitalists often encounter children with behavioral needs and play a key role in the advocacy and care for these patients.

Pediatric hospitalists should be able to:

• List chronic neurodevelopmental disorders that may require acute behavioral and/or psychiatric management in the hospital setting, such as global developmental delay or intellectual disability due to varied etiologies, genetic disorders such as Rett syndrome or Down syndrome, neurodevelopmental conditions such as autism spectrum disorders, and others.
• Cite commonly encountered mood disorders (such as depression and anxiety) and chronic psychiatric conditions (such as conduct disorder, oppositional defiant disorder, attention deficit hyperactivity disorder (ADHD), eating disorders, and others).
• Summarize the relationship between mental health conditions (such as autism spectrum disorder, disruptive behavior disorder, anxiety, or depression) and common chronic medical conditions (such as diabetes, cystic fibrosis, sickle cell and others).
• Define disruptive behavior disorders and discuss strategies to mitigate the impact of these on care team members.
• Review the differences between “internalizing” and “externalizing” behaviors.
• Identify underlying triggers for escalating behavioral problems in these patients which are commonly encountered in the hospital setting, such as overstimulation from environmental cues, sleep loss, changes in routine and daily structure, fear of a new environment, and others.
• Describe safety precautions needed for the patient, staff, and the family/caregivers when a patient is agitated or emotionally dysregulated, including awareness of surroundings, objects that can be used for self-harm or harm to others, and others.
• Give examples of behaviors that may manifest from child abuse or neglect in this population, including aggression, withdrawal, and refusal of treatment or care.
• Identify some commonly used evidence-based treatments for different behavioral conditions, such as Applied Behavioral Analysis (behavior modification for autism spectrum disorder), Parent-Child Interaction Therapy (PCIT) (parenting skills training for behavior disorders and trauma), Cognitive Behavioral Therapy (CBT), Exposure therapy, and Dialectical Behavioral Therapy (DBT).
• List indications and possible side effects of medications commonly used in this population, including antidepressants, antipsychotics, psychostimulants, and others.
• Discuss basic characteristics of each of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM)-5 eating disorder diagnoses including anorexia nervosa - restricting type (AN-R), anorexia nervosa - binge-eating/purging type (AN-BP), bulimia nervosa (BN), Avoidant Restrictive Food Intake Disorder (ARFID), and Other Specified Feeding and Eating Disorder (OSFED).
• Cite examples of laboratory testing commonly used to identify organic causes of feeding intolerance, growth delay, and malnutrition.
• State the signs and symptoms of eating disorders that require hospitalization, including hemodynamic instability, bradycardia, and severe malnutrition.
• Give examples of potential maladaptive behaviors that may occur in family members of patients with chronic behavioral and psychiatric conditions, such as maternal or paternal psychopathology, poor parent relationships, and sibling conflicts.
• Review alternative communication modes that may be of value in this population such as drawing, use of symbols, sign language, photos, and computers.
• Identify examples of secondary gain underlying behavioral problems for some children, including school or home avoidance.
• Summarize medical and mental health care treatment needed for this population after hospital discharge, including access to mental health providers, residential or partial hospitalization programs, and coordination of care with the medical home.

Pediatric hospitalists should be able to:

• Utilize locally available screening tools to identify patients with potential for behavioral and psychiatric disorders.
• Identify adverse drug events related to medications used for behavioral health conditions.
• Order appropriate monitoring, medications, and treatments to prevent or manage escalation of chronic maladaptive behaviors.
• Coordinate care, with patients, the family/caregivers, and healthcare providers to ensure a safe environment for the child within the hospital setting, with attention to elective admission, procedures, and surgical events.
• Consult, collaborate with, and/or coordinate an interdisciplinary team in the management of this population, including child life, social work, psychology, psychiatry, rehabilitation medicine, physical therapy, occupational therapy, speech therapy, and others within local context.
• Diagnose conditions with both medical and behavioral/psychiatric components and create an effective, safe, and integrated management plan to address each.
• Consult other subspecialists and appropriately refer or coordinate transfer of patients.
• Identify patients who may benefit from evidence-based testing, such as imaging, genetic testing, hormonal testing, and others, and initiate orders as appropriate.
• Demonstrate the use of physical exam and communication skills that are appropriate for the patients’ cognitive and developmental abilities.
• Deliver care that is consistent and effective using behavioral and communication skills to support positive behavior choices.
• Identify the potential for and manage aggressive or maladaptive behavior using environmental, behavioral, and medication modalities as appropriate.
• Order and interpret common data including intake, output, vital signs, sleep habits, and nutritional needs for this population, and make care plan changes to address concerns.
• Create a comprehensive discharge plan in coordination with the patient, the family/caregivers, primary care provider, mental health providers, residential or partial hospitalization programs, and others.
• Provide support and empathy for health care providers and hospital staff facing challenging behaviors.

Pediatric hospitalists should be able to:

• Reflect on the importance of maintaining respect and compassion when speaking with and caring for this population.
• Role model professionalism by exemplifying patience and creating a positive therapeutic environment for patients, the family/caregivers, colleagues, and hospital staff.
• Recognize that care plans may need to be adapted to accommodate a child’s changing medical and behavioral needs.
• Realize that eating disorders occur in all genders, cultures, ethnicities, and socioeconomic classes.
• Reflect on the importance of education and advocacy for the population of patients with eating disorders, noting that eating disorders are mental health disorders with physiological manifestations.
• Recognize that children with neurodevelopmental disorders and disruptive behavioral disorders are at higher risk for abuse.
• Reflect on the value of acquiring and utilizing coping skills for patients, the family/caregivers, colleagues, hospital staff, and self.

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

• Work with hospital administration to develop and implement training for healthcare providers, hospital staff, and trainees around the approach toward care for this population.
• Work with hospital administration to develop and provide a safe and non-judgmental environment of care for this population.
• Collaborate with healthcare providers and hospital staff to determine roles and responsibilities that optimize each member’s strengths and training when managing patient behaviors.
• Collaborate with hospital administration and community partners to develop and sustain referral networks for family members to appropriate community resources, including respite care, social services, and therapy.
• Lead, coordinate, or participate in organizational efforts to educate community providers on recognition of and criteria for hospitalization for children with eating disorders.

Introduction

Children with complicated special health care needs, termed children with medical complexity, currently accountfor 10% of pediatric admissions and 40% of all pediatric inpatientexpenditures. Advances in intensive care practices, technological devices, and improved survival continue to increase the number and complexity of these children cared for both in the hospital and at home. Many of these children require some form of technological device to compensate for loss or impairment of one or more vital functions and to improve or sustain life. Commonly used devices include gastrostomy and jejunostomy tubes with and without fundoplication, ventricular shunts, baclofen pumps, indwelling central venous catheters, tracheostomies, and various forms of non-invasive and invasive ventilation. When these children are hospitalized, they require acute stabilization, long term care planning, and care coordination in the hospital and for transitions of care to home. Theimportance of these issues is reflected in the work of national agencies and advocacy groups such as the NationalCenter of Medical Home Initiatives for Children with SpecialNeeds and the American Academy of Pediatrics. Pediatric hospitalists frequently encounter these children with medical complexity and therefore must be able to address and help coordinate their acute and chronic needs across the continuum of care.

Pediatric hospitalists should be able to:

• Discuss the impact of the increasing prevalence of children with medical complexity in the inpatient setting, including hospital and post-hospital care resource needs, access to care, and burden to patients and the family/caregivers.
• Summarize how common acute systemic illnesses affect the child with medical complexity from both short- and long-term perspectives.
• Give examples of possible social, emotional, and fiscal impacts of assessment, initiation, or removal of medical devices on patients and the family/caregivers.
• Discuss the indications for and risks and benefits of initiation and removal of chronic respiratory support, including interventions such as bilevel positive airway pressure, continuous positive airway pressure, tracheostomy, chronic positive pressure ventilation, and others.
• Review the importance of shared decision-making and assessing the values and beliefs of patients and the family/caregivers, including those regarding goals of care and quality of life, prior to placement of any device intended for long term use, especially chronic respiratory support devices.
• Discuss the indications for and risks and benefits of placement and removal of common enteral feeding devices, such as nasogastric feeding tubes, nasojejunal feeding tubes, percutaneous gastrostomy tubes, surgically performed gastrostomy tubes with and without fundoplication, and gastro-jejunal tubes.
• Discuss the goals and utility of differing evaluations for feeding disorders, including occupational and/or speech therapist assessment, developmental assessment, radiographic evaluations, and others, and review the importance of timing of these related to placement or removal of enteral feeding devices.
• Describe the indications for and risks and benefits of placement and removal of common modes of long-term intravenous access, including externally implanted, totally implanted, and percutaneously implanted catheters and ports.
• List the indications for and risks and benefits of placement and removal of common modes of cerebrospinal fluid shunting (such as ventriculoperitoneal shunts and others).
• Discuss the benefits of use of short term enteral, vascular, or respiratory devices during acute episodes of clinical decompensation, including the importance of communicating the goals of these interventions to patients, the family/caregivers, and the healthcare team.
• Cite the common acute problems related to specific medical devices, such as enteral feeding tube dysfunction, central venous catheter infection, ventilator-associated pneumonia, and others, including the diagnostic evaluation and treatment for each.
• Compare and contrast nosocomial infection risk in patients chronically dependent on technology from those with acute, limited technology device use.
• Discuss the increased risks for non-ambulatory patients, such as skin ulceration, deep venous thrombosis, osteopenia, sarcopenia, and others.
• List the indications for and common side effects of commonly used medications for this population, including those for spasticity, anti-epileptics, sialorrhea aides, and others.
• Compare and contrast the utility of commonly used assessment tools for pain, anxiety, fear, and depression for this population with other hospitalized children.
• Discuss the benefits and limitations of providing homecare for this population, attending to access, care networks, home environment, availability of the family/caregivers in the home, and other issues.
• Review commonly encountered issues that may prompt an ethics referral, attending to disagreements with the plan of care between and among the family/caregivers and healthcare team.
• Summarize the benefits of early referral to palliative care services and list indications for hospice referral.
• List the community and educational resources for children with medical complexity within the local context.
• State the importance of creating and maintaining the Medical Home for this population.

Introduction

Children with complicated special health care needs, termed children with medical complexity, currently accountfor 10% of pediatric admissions and 40% of all pediatric inpatientexpenditures. Advances in intensive care practices, technological devices, and improved survival continue to increase the number and complexity of these children cared for both in the hospital and at home. Many of these children require some form of technological device to compensate for loss or impairment of one or more vital functions and to improve or sustain life. Commonly used devices include gastrostomy and jejunostomy tubes with and without fundoplication, ventricular shunts, baclofen pumps, indwelling central venous catheters, tracheostomies, and various forms of non-invasive and invasive ventilation. When these children are hospitalized, they require acute stabilization, long term care planning, and care coordination in the hospital and for transitions of care to home. Theimportance of these issues is reflected in the work of national agencies and advocacy groups such as the NationalCenter of Medical Home Initiatives for Children with SpecialNeeds and the American Academy of Pediatrics. Pediatric hospitalists frequently encounter these children with medical complexity and therefore must be able to address and help coordinate their acute and chronic needs across the continuum of care.

Pediatric hospitalists should be able to:

• Discuss the impact of the increasing prevalence of children with medical complexity in the inpatient setting, including hospital and post-hospital care resource needs, access to care, and burden to patients and the family/caregivers.
• Summarize how common acute systemic illnesses affect the child with medical complexity from both short- and long-term perspectives.
• Give examples of possible social, emotional, and fiscal impacts of assessment, initiation, or removal of medical devices on patients and the family/caregivers.
• Discuss the indications for and risks and benefits of initiation and removal of chronic respiratory support, including interventions such as bilevel positive airway pressure, continuous positive airway pressure, tracheostomy, chronic positive pressure ventilation, and others.
• Review the importance of shared decision-making and assessing the values and beliefs of patients and the family/caregivers, including those regarding goals of care and quality of life, prior to placement of any device intended for long term use, especially chronic respiratory support devices.
• Discuss the indications for and risks and benefits of placement and removal of common enteral feeding devices, such as nasogastric feeding tubes, nasojejunal feeding tubes, percutaneous gastrostomy tubes, surgically performed gastrostomy tubes with and without fundoplication, and gastro-jejunal tubes.
• Discuss the goals and utility of differing evaluations for feeding disorders, including occupational and/or speech therapist assessment, developmental assessment, radiographic evaluations, and others, and review the importance of timing of these related to placement or removal of enteral feeding devices.
• Describe the indications for and risks and benefits of placement and removal of common modes of long-term intravenous access, including externally implanted, totally implanted, and percutaneously implanted catheters and ports.
• List the indications for and risks and benefits of placement and removal of common modes of cerebrospinal fluid shunting (such as ventriculoperitoneal shunts and others).
• Discuss the benefits of use of short term enteral, vascular, or respiratory devices during acute episodes of clinical decompensation, including the importance of communicating the goals of these interventions to patients, the family/caregivers, and the healthcare team.
• Cite the common acute problems related to specific medical devices, such as enteral feeding tube dysfunction, central venous catheter infection, ventilator-associated pneumonia, and others, including the diagnostic evaluation and treatment for each.
• Compare and contrast nosocomial infection risk in patients chronically dependent on technology from those with acute, limited technology device use.
• Discuss the increased risks for non-ambulatory patients, such as skin ulceration, deep venous thrombosis, osteopenia, sarcopenia, and others.
• List the indications for and common side effects of commonly used medications for this population, including those for spasticity, anti-epileptics, sialorrhea aides, and others.
• Compare and contrast the utility of commonly used assessment tools for pain, anxiety, fear, and depression for this population with other hospitalized children.
• Discuss the benefits and limitations of providing homecare for this population, attending to access, care networks, home environment, availability of the family/caregivers in the home, and other issues.
• Review commonly encountered issues that may prompt an ethics referral, attending to disagreements with the plan of care between and among the family/caregivers and healthcare team.
• Summarize the benefits of early referral to palliative care services and list indications for hospice referral.
• List the community and educational resources for children with medical complexity within the local context.
• State the importance of creating and maintaining the Medical Home for this population.

Introduction

Children with complicated special health care needs, termed children with medical complexity, currently accountfor 10% of pediatric admissions and 40% of all pediatric inpatientexpenditures. Advances in intensive care practices, technological devices, and improved survival continue to increase the number and complexity of these children cared for both in the hospital and at home. Many of these children require some form of technological device to compensate for loss or impairment of one or more vital functions and to improve or sustain life. Commonly used devices include gastrostomy and jejunostomy tubes with and without fundoplication, ventricular shunts, baclofen pumps, indwelling central venous catheters, tracheostomies, and various forms of non-invasive and invasive ventilation. When these children are hospitalized, they require acute stabilization, long term care planning, and care coordination in the hospital and for transitions of care to home. Theimportance of these issues is reflected in the work of national agencies and advocacy groups such as the NationalCenter of Medical Home Initiatives for Children with SpecialNeeds and the American Academy of Pediatrics. Pediatric hospitalists frequently encounter these children with medical complexity and therefore must be able to address and help coordinate their acute and chronic needs across the continuum of care.

Pediatric hospitalists should be able to:

• Discuss the impact of the increasing prevalence of children with medical complexity in the inpatient setting, including hospital and post-hospital care resource needs, access to care, and burden to patients and the family/caregivers.
• Summarize how common acute systemic illnesses affect the child with medical complexity from both short- and long-term perspectives.
• Give examples of possible social, emotional, and fiscal impacts of assessment, initiation, or removal of medical devices on patients and the family/caregivers.
• Discuss the indications for and risks and benefits of initiation and removal of chronic respiratory support, including interventions such as bilevel positive airway pressure, continuous positive airway pressure, tracheostomy, chronic positive pressure ventilation, and others.
• Review the importance of shared decision-making and assessing the values and beliefs of patients and the family/caregivers, including those regarding goals of care and quality of life, prior to placement of any device intended for long term use, especially chronic respiratory support devices.
• Discuss the indications for and risks and benefits of placement and removal of common enteral feeding devices, such as nasogastric feeding tubes, nasojejunal feeding tubes, percutaneous gastrostomy tubes, surgically performed gastrostomy tubes with and without fundoplication, and gastro-jejunal tubes.
• Discuss the goals and utility of differing evaluations for feeding disorders, including occupational and/or speech therapist assessment, developmental assessment, radiographic evaluations, and others, and review the importance of timing of these related to placement or removal of enteral feeding devices.
• Describe the indications for and risks and benefits of placement and removal of common modes of long-term intravenous access, including externally implanted, totally implanted, and percutaneously implanted catheters and ports.
• List the indications for and risks and benefits of placement and removal of common modes of cerebrospinal fluid shunting (such as ventriculoperitoneal shunts and others).
• Discuss the benefits of use of short term enteral, vascular, or respiratory devices during acute episodes of clinical decompensation, including the importance of communicating the goals of these interventions to patients, the family/caregivers, and the healthcare team.
• Cite the common acute problems related to specific medical devices, such as enteral feeding tube dysfunction, central venous catheter infection, ventilator-associated pneumonia, and others, including the diagnostic evaluation and treatment for each.
• Compare and contrast nosocomial infection risk in patients chronically dependent on technology from those with acute, limited technology device use.
• Discuss the increased risks for non-ambulatory patients, such as skin ulceration, deep venous thrombosis, osteopenia, sarcopenia, and others.
• List the indications for and common side effects of commonly used medications for this population, including those for spasticity, anti-epileptics, sialorrhea aides, and others.
• Compare and contrast the utility of commonly used assessment tools for pain, anxiety, fear, and depression for this population with other hospitalized children.
• Discuss the benefits and limitations of providing homecare for this population, attending to access, care networks, home environment, availability of the family/caregivers in the home, and other issues.
• Review commonly encountered issues that may prompt an ethics referral, attending to disagreements with the plan of care between and among the family/caregivers and healthcare team.
• Summarize the benefits of early referral to palliative care services and list indications for hospice referral.
• List the community and educational resources for children with medical complexity within the local context.
• State the importance of creating and maintaining the Medical Home for this population.

Introduction

Child abuse and neglect (hereafter described using the single term “maltreatment”) refer to the physical, sexual or psychological maltreatment of children by a caregiver or other adult. Maltreatment results in harm and/or risk of harm that may impact a child’s mental and physical health outcomes into adulthood. Annually, child protective services agencies investigate more than 3 million reports of suspected child maltreatment; approximately 1 million children per year are victims of maltreatment, resulting in nearly 2000 fatalities per year. Children may require hospitalization to manage problems directly related to potential maltreatment or discovery of an abusive or high-risk situation may occur when they are hospitalized for another reason. Pediatric hospitalists are in a unique position to identify and/or prevent and participate in treatment plans for these victims of child maltreatment.

Pediatric Hospitalists should be able to:

• Discuss the role of pediatric hospitalists in recognition/detection of maltreatment, evaluation and treatment of maltreatment-related injuries or medical conditions, coordination of subspecialty care, and reporting to child welfare authorities in centers with and without child maltreatment pediatric experts.
• Describe the role of consultants who may be involved in evaluation of suspected maltreatment, including hospital child protection team, trauma/surgical team, radiology, neurosurgery, ophthalmology, orthopedics, social work, child protective services/social services, law enforcement, psychiatry/psychology, forensic nursing/sexual assault examiners, and others.
• Describe the aspects of the history that raise concern for abusive trauma, including either no or vague explanation for a significant injury; explanation inconsistent with the pattern, age, or severity of injury; explanation inconsistent with the child’s physical and/or developmental capabilities; unexplained/unexpected notable delay in seeking medical care; or other.
• Describe circumstances, characteristics, and risk factors that may be associated with child maltreatment, including child-related factors (physical or developmental disabilities, prematurity, chronic illness, and others), caregiver-related factors (substance abuse, mental illness, unrealistic expectations of child development, and others), and environmental factors (poverty, unemployment, intimate partner violence, and others).
• Discuss how developmental status impacts the likelihood of accidental injury.
• Describe aspects of the physical examination that should prompt an evaluation for abusive trauma, such as patterned injuries, injuries to non-bony or other unusual locations (torso, ear, head, face, neck, or genitals), bruises and unusual bruising patterns, fractures, intraoral injuries, any injury to young, pre-ambulatory infants, and others.
• Compare and contrast key history and exam features that may discriminate between a victim of child maltreatment and other diagnoses for infants presenting with conditions such as failure to thrive or BRUE (Brief Resolved Unexplained Event), attending to both medical and behavioral features.
• Compare and contrast key history and exam feature that may discriminate between a victim of child maltreatment and other diagnoses for children and adolescents presenting with conditions such as abdominal pain or genital complaints, attending to both medical and behavioral features.
• Review common factors found in association with caregiver medical child abuse (formerly Munchausen Syndrome by Proxy), such as inexplicable findings or treatment failures, pursuit of unnecessary medical care or procedures, use of varied providers and/or provider networks, and others.
• Discuss the utility, risks, and benefits of radiologic and laboratory studies in the evaluation of suspected child maltreatment, including non-contrast head CT, MRI, skeletal survey (initial and repeat), coagulation studies, liver function tests, and others.
• List examples of culturally appropriate behaviors, such as coining or cupping, that may result in unusual physical examination findings which may lead to erroneous concern for physical child maltreatment.
• Cite the steps required for reporting of suspected child maltreatment to local child welfare agencies/child protective services and law enforcement.
• Discuss the importance of objective, unbiased, thorough written documentation of findings in the medical record.
• Compare and contrast the role of pediatric hospitalists with expert witnesses in providing court testimony for suspected maltreatment cases.
• List common community resources for caregivers and maltreated children, such as support groups, domestic violence resources, safe houses, parenting classes, foster care, and others.

Pediatric Hospitalists should be able to:

• Elicit a thorough medical history to identify signs consistent with child maltreatment.
• Perform a physical exam to elicit signs consistent with child maltreatment, differentiating it from findings with mimicking conditions.
• Identify genital abnormalities suggestive of sexual trauma.
• Discriminate between physical examination findings such as bruises, burns, and cutaneous findings that may be suggestive of maltreatment from those related to medical conditions, accidental trauma, or cultural healing practices.
• Initiate with efficiency the local processes for suspected maltreatment case evaluation.
• Report suspected maltreatment promptly and communicate concerns for maltreatment to investigative authorities clearly and effectively.
• Communicate concerns about maltreatment to the family/caregivers at the bedside, including discussion regarding reports of suspected maltreatment made to investigative authorities.
• Coordinate care with child maltreatment experts to ensure timely and accurate collection of forensic evidence as appropriate for the local context.
• Select and correctly interpret appropriate diagnostic testing based on risk/benefit assessment to evaluate child maltreatment in collaboration with other subspecialists.
• Engage consultants efficiently and appropriately when indicated.
• Coordinate care with the primary care provider, subspecialists, and child protective services to arrange an appropriate multidisciplinary transition plan for hospital discharge, including determination of the location and responsible party to whom the child will be discharged.
• Educate learners and other healthcare providers on child maltreatment and the role of pediatric hospitalists in early maltreatment detection and intervention.
• Provide accurate court testimony where indicated and within local context.

Pediatric hospitalists should be able to:

• Recognize that child maltreatment and neglect affect all cultures, ethnicities/races, and socioeconomic classes.
• Reflect on the importance of and provide support and education for the family/caregivers of child maltreatment victims.
• Exemplify behaviors that espouse sensitivity, lack of bias, and empathy.
• Communicate effectively with patients, the family/caregivers, other subspecialists, social services, and investigative authorities regarding diagnosis, relevant medical findings, and care plans.
• Realize the importance of post-hospital care and support for victims of child maltreatment and their family/caregivers.

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

• Collaborate with hospital administration and community leaders to advocate for policies/programs that support the family/caregivers and protect children from maltreatment.
• Lead, coordinate, or participate in the development and implementation of evidence-based care pathways to standardize the evaluation and management of hospitalized children with suspected maltreatment concerns.
• Collaborate with hospital administration, community partners, social work, and subspecialty care providers to develop and sustain referral networks for suspected victims of maltreatment that address both immediate and long-term care needs.

Introduction

Child abuse and neglect (hereafter described using the single term “maltreatment”) refer to the physical, sexual or psychological maltreatment of children by a caregiver or other adult. Maltreatment results in harm and/or risk of harm that may impact a child’s mental and physical health outcomes into adulthood. Annually, child protective services agencies investigate more than 3 million reports of suspected child maltreatment; approximately 1 million children per year are victims of maltreatment, resulting in nearly 2000 fatalities per year. Children may require hospitalization to manage problems directly related to potential maltreatment or discovery of an abusive or high-risk situation may occur when they are hospitalized for another reason. Pediatric hospitalists are in a unique position to identify and/or prevent and participate in treatment plans for these victims of child maltreatment.

Pediatric Hospitalists should be able to:

• Discuss the role of pediatric hospitalists in recognition/detection of maltreatment, evaluation and treatment of maltreatment-related injuries or medical conditions, coordination of subspecialty care, and reporting to child welfare authorities in centers with and without child maltreatment pediatric experts.
• Describe the role of consultants who may be involved in evaluation of suspected maltreatment, including hospital child protection team, trauma/surgical team, radiology, neurosurgery, ophthalmology, orthopedics, social work, child protective services/social services, law enforcement, psychiatry/psychology, forensic nursing/sexual assault examiners, and others.
• Describe the aspects of the history that raise concern for abusive trauma, including either no or vague explanation for a significant injury; explanation inconsistent with the pattern, age, or severity of injury; explanation inconsistent with the child’s physical and/or developmental capabilities; unexplained/unexpected notable delay in seeking medical care; or other.
• Describe circumstances, characteristics, and risk factors that may be associated with child maltreatment, including child-related factors (physical or developmental disabilities, prematurity, chronic illness, and others), caregiver-related factors (substance abuse, mental illness, unrealistic expectations of child development, and others), and environmental factors (poverty, unemployment, intimate partner violence, and others).
• Discuss how developmental status impacts the likelihood of accidental injury.
• Describe aspects of the physical examination that should prompt an evaluation for abusive trauma, such as patterned injuries, injuries to non-bony or other unusual locations (torso, ear, head, face, neck, or genitals), bruises and unusual bruising patterns, fractures, intraoral injuries, any injury to young, pre-ambulatory infants, and others.
• Compare and contrast key history and exam features that may discriminate between a victim of child maltreatment and other diagnoses for infants presenting with conditions such as failure to thrive or BRUE (Brief Resolved Unexplained Event), attending to both medical and behavioral features.
• Compare and contrast key history and exam feature that may discriminate between a victim of child maltreatment and other diagnoses for children and adolescents presenting with conditions such as abdominal pain or genital complaints, attending to both medical and behavioral features.
• Review common factors found in association with caregiver medical child abuse (formerly Munchausen Syndrome by Proxy), such as inexplicable findings or treatment failures, pursuit of unnecessary medical care or procedures, use of varied providers and/or provider networks, and others.
• Discuss the utility, risks, and benefits of radiologic and laboratory studies in the evaluation of suspected child maltreatment, including non-contrast head CT, MRI, skeletal survey (initial and repeat), coagulation studies, liver function tests, and others.
• List examples of culturally appropriate behaviors, such as coining or cupping, that may result in unusual physical examination findings which may lead to erroneous concern for physical child maltreatment.
• Cite the steps required for reporting of suspected child maltreatment to local child welfare agencies/child protective services and law enforcement.
• Discuss the importance of objective, unbiased, thorough written documentation of findings in the medical record.
• Compare and contrast the role of pediatric hospitalists with expert witnesses in providing court testimony for suspected maltreatment cases.
• List common community resources for caregivers and maltreated children, such as support groups, domestic violence resources, safe houses, parenting classes, foster care, and others.

Pediatric Hospitalists should be able to:

• Elicit a thorough medical history to identify signs consistent with child maltreatment.
• Perform a physical exam to elicit signs consistent with child maltreatment, differentiating it from findings with mimicking conditions.
• Identify genital abnormalities suggestive of sexual trauma.
• Discriminate between physical examination findings such as bruises, burns, and cutaneous findings that may be suggestive of maltreatment from those related to medical conditions, accidental trauma, or cultural healing practices.
• Initiate with efficiency the local processes for suspected maltreatment case evaluation.
• Report suspected maltreatment promptly and communicate concerns for maltreatment to investigative authorities clearly and effectively.
• Communicate concerns about maltreatment to the family/caregivers at the bedside, including discussion regarding reports of suspected maltreatment made to investigative authorities.
• Coordinate care with child maltreatment experts to ensure timely and accurate collection of forensic evidence as appropriate for the local context.
• Select and correctly interpret appropriate diagnostic testing based on risk/benefit assessment to evaluate child maltreatment in collaboration with other subspecialists.
• Engage consultants efficiently and appropriately when indicated.
• Coordinate care with the primary care provider, subspecialists, and child protective services to arrange an appropriate multidisciplinary transition plan for hospital discharge, including determination of the location and responsible party to whom the child will be discharged.
• Educate learners and other healthcare providers on child maltreatment and the role of pediatric hospitalists in early maltreatment detection and intervention.
• Provide accurate court testimony where indicated and within local context.

Pediatric hospitalists should be able to:

• Recognize that child maltreatment and neglect affect all cultures, ethnicities/races, and socioeconomic classes.
• Reflect on the importance of and provide support and education for the family/caregivers of child maltreatment victims.
• Exemplify behaviors that espouse sensitivity, lack of bias, and empathy.
• Communicate effectively with patients, the family/caregivers, other subspecialists, social services, and investigative authorities regarding diagnosis, relevant medical findings, and care plans.
• Realize the importance of post-hospital care and support for victims of child maltreatment and their family/caregivers.

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

• Collaborate with hospital administration and community leaders to advocate for policies/programs that support the family/caregivers and protect children from maltreatment.
• Lead, coordinate, or participate in the development and implementation of evidence-based care pathways to standardize the evaluation and management of hospitalized children with suspected maltreatment concerns.
• Collaborate with hospital administration, community partners, social work, and subspecialty care providers to develop and sustain referral networks for suspected victims of maltreatment that address both immediate and long-term care needs.

Introduction

Child abuse and neglect (hereafter described using the single term “maltreatment”) refer to the physical, sexual or psychological maltreatment of children by a caregiver or other adult. Maltreatment results in harm and/or risk of harm that may impact a child’s mental and physical health outcomes into adulthood. Annually, child protective services agencies investigate more than 3 million reports of suspected child maltreatment; approximately 1 million children per year are victims of maltreatment, resulting in nearly 2000 fatalities per year. Children may require hospitalization to manage problems directly related to potential maltreatment or discovery of an abusive or high-risk situation may occur when they are hospitalized for another reason. Pediatric hospitalists are in a unique position to identify and/or prevent and participate in treatment plans for these victims of child maltreatment.

Pediatric Hospitalists should be able to:

• Discuss the role of pediatric hospitalists in recognition/detection of maltreatment, evaluation and treatment of maltreatment-related injuries or medical conditions, coordination of subspecialty care, and reporting to child welfare authorities in centers with and without child maltreatment pediatric experts.
• Describe the role of consultants who may be involved in evaluation of suspected maltreatment, including hospital child protection team, trauma/surgical team, radiology, neurosurgery, ophthalmology, orthopedics, social work, child protective services/social services, law enforcement, psychiatry/psychology, forensic nursing/sexual assault examiners, and others.
• Describe the aspects of the history that raise concern for abusive trauma, including either no or vague explanation for a significant injury; explanation inconsistent with the pattern, age, or severity of injury; explanation inconsistent with the child’s physical and/or developmental capabilities; unexplained/unexpected notable delay in seeking medical care; or other.
• Describe circumstances, characteristics, and risk factors that may be associated with child maltreatment, including child-related factors (physical or developmental disabilities, prematurity, chronic illness, and others), caregiver-related factors (substance abuse, mental illness, unrealistic expectations of child development, and others), and environmental factors (poverty, unemployment, intimate partner violence, and others).
• Discuss how developmental status impacts the likelihood of accidental injury.
• Describe aspects of the physical examination that should prompt an evaluation for abusive trauma, such as patterned injuries, injuries to non-bony or other unusual locations (torso, ear, head, face, neck, or genitals), bruises and unusual bruising patterns, fractures, intraoral injuries, any injury to young, pre-ambulatory infants, and others.
• Compare and contrast key history and exam features that may discriminate between a victim of child maltreatment and other diagnoses for infants presenting with conditions such as failure to thrive or BRUE (Brief Resolved Unexplained Event), attending to both medical and behavioral features.
• Compare and contrast key history and exam feature that may discriminate between a victim of child maltreatment and other diagnoses for children and adolescents presenting with conditions such as abdominal pain or genital complaints, attending to both medical and behavioral features.
• Review common factors found in association with caregiver medical child abuse (formerly Munchausen Syndrome by Proxy), such as inexplicable findings or treatment failures, pursuit of unnecessary medical care or procedures, use of varied providers and/or provider networks, and others.
• Discuss the utility, risks, and benefits of radiologic and laboratory studies in the evaluation of suspected child maltreatment, including non-contrast head CT, MRI, skeletal survey (initial and repeat), coagulation studies, liver function tests, and others.
• List examples of culturally appropriate behaviors, such as coining or cupping, that may result in unusual physical examination findings which may lead to erroneous concern for physical child maltreatment.
• Cite the steps required for reporting of suspected child maltreatment to local child welfare agencies/child protective services and law enforcement.
• Discuss the importance of objective, unbiased, thorough written documentation of findings in the medical record.
• Compare and contrast the role of pediatric hospitalists with expert witnesses in providing court testimony for suspected maltreatment cases.
• List common community resources for caregivers and maltreated children, such as support groups, domestic violence resources, safe houses, parenting classes, foster care, and others.

Pediatric Hospitalists should be able to:

• Elicit a thorough medical history to identify signs consistent with child maltreatment.
• Perform a physical exam to elicit signs consistent with child maltreatment, differentiating it from findings with mimicking conditions.
• Identify genital abnormalities suggestive of sexual trauma.
• Discriminate between physical examination findings such as bruises, burns, and cutaneous findings that may be suggestive of maltreatment from those related to medical conditions, accidental trauma, or cultural healing practices.
• Initiate with efficiency the local processes for suspected maltreatment case evaluation.
• Report suspected maltreatment promptly and communicate concerns for maltreatment to investigative authorities clearly and effectively.
• Communicate concerns about maltreatment to the family/caregivers at the bedside, including discussion regarding reports of suspected maltreatment made to investigative authorities.
• Coordinate care with child maltreatment experts to ensure timely and accurate collection of forensic evidence as appropriate for the local context.
• Select and correctly interpret appropriate diagnostic testing based on risk/benefit assessment to evaluate child maltreatment in collaboration with other subspecialists.
• Engage consultants efficiently and appropriately when indicated.
• Coordinate care with the primary care provider, subspecialists, and child protective services to arrange an appropriate multidisciplinary transition plan for hospital discharge, including determination of the location and responsible party to whom the child will be discharged.
• Educate learners and other healthcare providers on child maltreatment and the role of pediatric hospitalists in early maltreatment detection and intervention.
• Provide accurate court testimony where indicated and within local context.

Pediatric hospitalists should be able to:

• Recognize that child maltreatment and neglect affect all cultures, ethnicities/races, and socioeconomic classes.
• Reflect on the importance of and provide support and education for the family/caregivers of child maltreatment victims.
• Exemplify behaviors that espouse sensitivity, lack of bias, and empathy.
• Communicate effectively with patients, the family/caregivers, other subspecialists, social services, and investigative authorities regarding diagnosis, relevant medical findings, and care plans.
• Realize the importance of post-hospital care and support for victims of child maltreatment and their family/caregivers.

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

• Collaborate with hospital administration and community leaders to advocate for policies/programs that support the family/caregivers and protect children from maltreatment.
• Lead, coordinate, or participate in the development and implementation of evidence-based care pathways to standardize the evaluation and management of hospitalized children with suspected maltreatment concerns.
• Collaborate with hospital administration, community partners, social work, and subspecialty care providers to develop and sustain referral networks for suspected victims of maltreatment that address both immediate and long-term care needs.

Introduction

Adolescents and young adults represent a unique population of patients cared for by pediatric hospitalists with a distinct set of medical conditions, ethical dilemmas, and legal considerations due to multiple factors beyond age alone. Puberty and sexual exploration put adolescents at risk for conditions related to abnormal uterine bleeding, acute ovarian and testicular issues, and complications from sexually transmitted infections which may require hospitalization for evaluation and management. This period of life is also associated with the deeper evolution of sexuality and gender identity. Pediatric hospitalists need to be skilled at caring for patients and advocating for a safe, sensitive, non-judgmental environment in the hospital. In addition, pediatric hospitalists must be competent in managing children with conditions typically first diagnosed in adulthood, as well as conditions diagnosed in childhood for which new therapies are supporting longer lifespans. These patients often continue to seek care from specialists at university/children’s hospitals well into adulthood. Pediatric hospitalists are well positioned to address the medical, social, and legal needs of these patients, including transition of care to adult healthcare systems where appropriate.

Pediatric hospitalists should be able to:

• Identify common diseases of adulthood that have an increasing incidence in adolescents and young adults (including type II diabetes mellitus, hypertension, obesity and others), and list resources to guide the care of these diseases.
• Identify healthcare disparities facing lesbian, gay, bisexual, transgendered, queer, or questioning (LGBTQQ) adolescents and young adults, including access to medical and psychiatric care, social determinants of health, screening and preventable illnesses, and domestic violence.
• Identify risk factors associated with sexual violence, trafficking, and abuse in the adolescent and young adult population.
• State interventions that can be applied for this population to identify and abate commonly encountered problems, such as prescription or street drug abuse, mental health disorders, school failures, and bullying.
• Summarize the common sexually transmitted infections often seen in adolescents and young adults based upon local epidemiology.
• Identify indications for hospitalization when a patient has a sexually transmitted infection.
• Review common conditions resulting in hospitalization of this population, including toxic ingestion, suicide attempts, abdominal pain, eating disorder sequelae, trauma, and others.
• Describe the treatment of various sexually transmitted infections, including pelvic inflammatory disease and tubo-ovarian abscess.
• Compare and contrast typical menstrual patterns in adolescents and young adults with abnormal uterine bleeding.
• Identify indications for hospitalization in a patient with abnormal uterine bleeding.
• Discuss risk factors, epidemiology, clinical presentation, evaluation and management of emergent ovarian and testicular conditions (such as ovarian and testicular torsion).
• Compare and contrast procedures for privacy, confidentiality, consent, and assent for this population.
• Review standards around shared medical records as they apply to this population, including local state law.
• Summarize the long-term complications and prognosis for children with chronic illnesses of childhood (such as cystic fibrosis, sickle cell, childhood cancers, asthma, and others).
• Cite the benefits and limitations of adult versus pediatric hospital care for this population with chronic care needs, attending to access to specialists, equipment, support for the family/caregivers, neurodevelopmental needs, and other issues.
• Describe the core elements necessary for transition to adult health care providers (such as a transition policy, assessment of transition readiness, transition tracking and monitoring, transition planning, successful transfer of care to completion, and others).

Pediatric hospitalists should be able to:

• Diagnose and manage common diseases of adulthood that have an increasing incidence in young adults, including but not limited to type II diabetes mellitus, hypertension, and obesity.
• Triage patient admissions accurately ensuring care needed is within the scope and skill set of local hospital and healthcare providers.
• Consult other subspecialists and coordinate care efficiently and effectively.
• Act as consultant or provide appropriate medical or surgical co-management for this population.
• Provide a safe and sensitive clinical environment attending to special social, developmental, sexual identity, or other needs, for patients including LGBTQQ and others.
• Document in the medical record in appropriate locations, using correct terms that meet requirements for confidentiality for this population.
• Screen and provide care for sexually transmitted infections in hospitalized adolescents and young adults according to established guidelines based upon behavioral risk factors, signs, and symptoms.
• Screen and provide medical resources for sexual violence and abuse in this population, and refer for legal and social resources as indicated.
• Screen and provide resources for depression and other mental health disorders as available within the local context.
• Diagnose abnormal uterine bleeding, perform a cost-effective evaluation, and institute a management plan.
• Provide basic triage care for patients with complications of abnormal uterine bleeding and other common gynecologic and testicular conditions.
• Initiate a cost-effective and timely evaluation of common ovarian and testicular conditions, in collaboration with other subspecialists as appropriate.
• Counsel patients, the family/caregivers, and other healthcare providers about risk factors, etiologies, treatments, prognoses, and potential social and medical complications of identified conditions such as sexually transmitted infections, abnormal uterine bleeding, and emergent ovarian and testicular conditions.
• Obtain informed consent from the patient or the family/caregivers, consistently adhering to legal guidelines and ethical principles and utilizing shared decision-making skills.
• Demonstrate skills in providing safe transitions of care, using respectful and effective written and verbal communication with patients, the family/caregivers, and healthcare providers.
• Counsel patients, the family/caregivers, and other healthcare providers about the importance of transition of young adults to adult providers and healthcare institutions.

Pediatric hospitalists should be able to:

• Reflect on the importance of collaboration with subspecialists and adult hospitalists to build partnerships that facilitate transitions of care of these patients where appropriate.
• Appreciate the value of a multi-disciplinary approach in the prevention, diagnosis, and treatment of common diseases of adulthood that have an increasing incidence in young adults.
• Exemplify competent and non-judgmental care for this population, including those with special social, developmental, sexual identity, or other needs such as LGBTQQ adolescents and young adults.
• Reflect on the importance of shared decision-making for this population.
• Realize the importance of institutional policies that address self-advocacy, autonomy, and the ethical approach toward care for this population.
• Recognize the complexity of how an individual develops sexuality and gender identity throughout childhood, adolescence, and young adulthood.

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

• Collaborate with hospital administration and other healthcare providers to develop institutional policies, educational tools, and individual plans for safe transition of care from pediatric to adult healthcare systems for this population.
• Lead, coordinate, or participate in institutional efforts to improve the care provided for common diseases of adulthood that have an increasing incidence in young adults.
• Advocate for institutional policies that promote and ensure a safe, sensitive, and non-judgmental environment for LGBTQQ adolescents and young adults.
• Lead, coordinate, or participate in institutional efforts to improve screening and care for sexually transmitted infections and mental health.
• Collaborate with other subspecialists to develop cost-effective, evidence-based care pathways to manage emergent ovarian and testicular conditions.

Introduction

Adolescents and young adults represent a unique population of patients cared for by pediatric hospitalists with a distinct set of medical conditions, ethical dilemmas, and legal considerations due to multiple factors beyond age alone. Puberty and sexual exploration put adolescents at risk for conditions related to abnormal uterine bleeding, acute ovarian and testicular issues, and complications from sexually transmitted infections which may require hospitalization for evaluation and management. This period of life is also associated with the deeper evolution of sexuality and gender identity. Pediatric hospitalists need to be skilled at caring for patients and advocating for a safe, sensitive, non-judgmental environment in the hospital. In addition, pediatric hospitalists must be competent in managing children with conditions typically first diagnosed in adulthood, as well as conditions diagnosed in childhood for which new therapies are supporting longer lifespans. These patients often continue to seek care from specialists at university/children’s hospitals well into adulthood. Pediatric hospitalists are well positioned to address the medical, social, and legal needs of these patients, including transition of care to adult healthcare systems where appropriate.

Pediatric hospitalists should be able to:

• Identify common diseases of adulthood that have an increasing incidence in adolescents and young adults (including type II diabetes mellitus, hypertension, obesity and others), and list resources to guide the care of these diseases.
• Identify healthcare disparities facing lesbian, gay, bisexual, transgendered, queer, or questioning (LGBTQQ) adolescents and young adults, including access to medical and psychiatric care, social determinants of health, screening and preventable illnesses, and domestic violence.
• Identify risk factors associated with sexual violence, trafficking, and abuse in the adolescent and young adult population.
• State interventions that can be applied for this population to identify and abate commonly encountered problems, such as prescription or street drug abuse, mental health disorders, school failures, and bullying.
• Summarize the common sexually transmitted infections often seen in adolescents and young adults based upon local epidemiology.
• Identify indications for hospitalization when a patient has a sexually transmitted infection.
• Review common conditions resulting in hospitalization of this population, including toxic ingestion, suicide attempts, abdominal pain, eating disorder sequelae, trauma, and others.
• Describe the treatment of various sexually transmitted infections, including pelvic inflammatory disease and tubo-ovarian abscess.
• Compare and contrast typical menstrual patterns in adolescents and young adults with abnormal uterine bleeding.
• Identify indications for hospitalization in a patient with abnormal uterine bleeding.
• Discuss risk factors, epidemiology, clinical presentation, evaluation and management of emergent ovarian and testicular conditions (such as ovarian and testicular torsion).
• Compare and contrast procedures for privacy, confidentiality, consent, and assent for this population.
• Review standards around shared medical records as they apply to this population, including local state law.
• Summarize the long-term complications and prognosis for children with chronic illnesses of childhood (such as cystic fibrosis, sickle cell, childhood cancers, asthma, and others).
• Cite the benefits and limitations of adult versus pediatric hospital care for this population with chronic care needs, attending to access to specialists, equipment, support for the family/caregivers, neurodevelopmental needs, and other issues.
• Describe the core elements necessary for transition to adult health care providers (such as a transition policy, assessment of transition readiness, transition tracking and monitoring, transition planning, successful transfer of care to completion, and others).

Pediatric hospitalists should be able to:

• Diagnose and manage common diseases of adulthood that have an increasing incidence in young adults, including but not limited to type II diabetes mellitus, hypertension, and obesity.
• Triage patient admissions accurately ensuring care needed is within the scope and skill set of local hospital and healthcare providers.
• Consult other subspecialists and coordinate care efficiently and effectively.
• Act as consultant or provide appropriate medical or surgical co-management for this population.
• Provide a safe and sensitive clinical environment attending to special social, developmental, sexual identity, or other needs, for patients including LGBTQQ and others.
• Document in the medical record in appropriate locations, using correct terms that meet requirements for confidentiality for this population.
• Screen and provide care for sexually transmitted infections in hospitalized adolescents and young adults according to established guidelines based upon behavioral risk factors, signs, and symptoms.
• Screen and provide medical resources for sexual violence and abuse in this population, and refer for legal and social resources as indicated.
• Screen and provide resources for depression and other mental health disorders as available within the local context.
• Diagnose abnormal uterine bleeding, perform a cost-effective evaluation, and institute a management plan.
• Provide basic triage care for patients with complications of abnormal uterine bleeding and other common gynecologic and testicular conditions.
• Initiate a cost-effective and timely evaluation of common ovarian and testicular conditions, in collaboration with other subspecialists as appropriate.
• Counsel patients, the family/caregivers, and other healthcare providers about risk factors, etiologies, treatments, prognoses, and potential social and medical complications of identified conditions such as sexually transmitted infections, abnormal uterine bleeding, and emergent ovarian and testicular conditions.
• Obtain informed consent from the patient or the family/caregivers, consistently adhering to legal guidelines and ethical principles and utilizing shared decision-making skills.
• Demonstrate skills in providing safe transitions of care, using respectful and effective written and verbal communication with patients, the family/caregivers, and healthcare providers.
• Counsel patients, the family/caregivers, and other healthcare providers about the importance of transition of young adults to adult providers and healthcare institutions.

Pediatric hospitalists should be able to:

• Reflect on the importance of collaboration with subspecialists and adult hospitalists to build partnerships that facilitate transitions of care of these patients where appropriate.
• Appreciate the value of a multi-disciplinary approach in the prevention, diagnosis, and treatment of common diseases of adulthood that have an increasing incidence in young adults.
• Exemplify competent and non-judgmental care for this population, including those with special social, developmental, sexual identity, or other needs such as LGBTQQ adolescents and young adults.
• Reflect on the importance of shared decision-making for this population.
• Realize the importance of institutional policies that address self-advocacy, autonomy, and the ethical approach toward care for this population.
• Recognize the complexity of how an individual develops sexuality and gender identity throughout childhood, adolescence, and young adulthood.

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

• Collaborate with hospital administration and other healthcare providers to develop institutional policies, educational tools, and individual plans for safe transition of care from pediatric to adult healthcare systems for this population.
• Lead, coordinate, or participate in institutional efforts to improve the care provided for common diseases of adulthood that have an increasing incidence in young adults.
• Advocate for institutional policies that promote and ensure a safe, sensitive, and non-judgmental environment for LGBTQQ adolescents and young adults.
• Lead, coordinate, or participate in institutional efforts to improve screening and care for sexually transmitted infections and mental health.
• Collaborate with other subspecialists to develop cost-effective, evidence-based care pathways to manage emergent ovarian and testicular conditions.

Introduction

Adolescents and young adults represent a unique population of patients cared for by pediatric hospitalists with a distinct set of medical conditions, ethical dilemmas, and legal considerations due to multiple factors beyond age alone. Puberty and sexual exploration put adolescents at risk for conditions related to abnormal uterine bleeding, acute ovarian and testicular issues, and complications from sexually transmitted infections which may require hospitalization for evaluation and management. This period of life is also associated with the deeper evolution of sexuality and gender identity. Pediatric hospitalists need to be skilled at caring for patients and advocating for a safe, sensitive, non-judgmental environment in the hospital. In addition, pediatric hospitalists must be competent in managing children with conditions typically first diagnosed in adulthood, as well as conditions diagnosed in childhood for which new therapies are supporting longer lifespans. These patients often continue to seek care from specialists at university/children’s hospitals well into adulthood. Pediatric hospitalists are well positioned to address the medical, social, and legal needs of these patients, including transition of care to adult healthcare systems where appropriate.

Pediatric hospitalists should be able to:

• Identify common diseases of adulthood that have an increasing incidence in adolescents and young adults (including type II diabetes mellitus, hypertension, obesity and others), and list resources to guide the care of these diseases.
• Identify healthcare disparities facing lesbian, gay, bisexual, transgendered, queer, or questioning (LGBTQQ) adolescents and young adults, including access to medical and psychiatric care, social determinants of health, screening and preventable illnesses, and domestic violence.
• Identify risk factors associated with sexual violence, trafficking, and abuse in the adolescent and young adult population.
• State interventions that can be applied for this population to identify and abate commonly encountered problems, such as prescription or street drug abuse, mental health disorders, school failures, and bullying.
• Summarize the common sexually transmitted infections often seen in adolescents and young adults based upon local epidemiology.
• Identify indications for hospitalization when a patient has a sexually transmitted infection.
• Review common conditions resulting in hospitalization of this population, including toxic ingestion, suicide attempts, abdominal pain, eating disorder sequelae, trauma, and others.
• Describe the treatment of various sexually transmitted infections, including pelvic inflammatory disease and tubo-ovarian abscess.
• Compare and contrast typical menstrual patterns in adolescents and young adults with abnormal uterine bleeding.
• Identify indications for hospitalization in a patient with abnormal uterine bleeding.
• Discuss risk factors, epidemiology, clinical presentation, evaluation and management of emergent ovarian and testicular conditions (such as ovarian and testicular torsion).
• Compare and contrast procedures for privacy, confidentiality, consent, and assent for this population.
• Review standards around shared medical records as they apply to this population, including local state law.
• Summarize the long-term complications and prognosis for children with chronic illnesses of childhood (such as cystic fibrosis, sickle cell, childhood cancers, asthma, and others).
• Cite the benefits and limitations of adult versus pediatric hospital care for this population with chronic care needs, attending to access to specialists, equipment, support for the family/caregivers, neurodevelopmental needs, and other issues.
• Describe the core elements necessary for transition to adult health care providers (such as a transition policy, assessment of transition readiness, transition tracking and monitoring, transition planning, successful transfer of care to completion, and others).

Pediatric hospitalists should be able to:

• Diagnose and manage common diseases of adulthood that have an increasing incidence in young adults, including but not limited to type II diabetes mellitus, hypertension, and obesity.
• Triage patient admissions accurately ensuring care needed is within the scope and skill set of local hospital and healthcare providers.
• Consult other subspecialists and coordinate care efficiently and effectively.
• Act as consultant or provide appropriate medical or surgical co-management for this population.
• Provide a safe and sensitive clinical environment attending to special social, developmental, sexual identity, or other needs, for patients including LGBTQQ and others.
• Document in the medical record in appropriate locations, using correct terms that meet requirements for confidentiality for this population.
• Screen and provide care for sexually transmitted infections in hospitalized adolescents and young adults according to established guidelines based upon behavioral risk factors, signs, and symptoms.
• Screen and provide medical resources for sexual violence and abuse in this population, and refer for legal and social resources as indicated.
• Screen and provide resources for depression and other mental health disorders as available within the local context.
• Diagnose abnormal uterine bleeding, perform a cost-effective evaluation, and institute a management plan.
• Provide basic triage care for patients with complications of abnormal uterine bleeding and other common gynecologic and testicular conditions.
• Initiate a cost-effective and timely evaluation of common ovarian and testicular conditions, in collaboration with other subspecialists as appropriate.
• Counsel patients, the family/caregivers, and other healthcare providers about risk factors, etiologies, treatments, prognoses, and potential social and medical complications of identified conditions such as sexually transmitted infections, abnormal uterine bleeding, and emergent ovarian and testicular conditions.
• Obtain informed consent from the patient or the family/caregivers, consistently adhering to legal guidelines and ethical principles and utilizing shared decision-making skills.
• Demonstrate skills in providing safe transitions of care, using respectful and effective written and verbal communication with patients, the family/caregivers, and healthcare providers.
• Counsel patients, the family/caregivers, and other healthcare providers about the importance of transition of young adults to adult providers and healthcare institutions.

Pediatric hospitalists should be able to:

• Reflect on the importance of collaboration with subspecialists and adult hospitalists to build partnerships that facilitate transitions of care of these patients where appropriate.
• Appreciate the value of a multi-disciplinary approach in the prevention, diagnosis, and treatment of common diseases of adulthood that have an increasing incidence in young adults.
• Exemplify competent and non-judgmental care for this population, including those with special social, developmental, sexual identity, or other needs such as LGBTQQ adolescents and young adults.
• Reflect on the importance of shared decision-making for this population.
• Realize the importance of institutional policies that address self-advocacy, autonomy, and the ethical approach toward care for this population.
• Recognize the complexity of how an individual develops sexuality and gender identity throughout childhood, adolescence, and young adulthood.

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

• Collaborate with hospital administration and other healthcare providers to develop institutional policies, educational tools, and individual plans for safe transition of care from pediatric to adult healthcare systems for this population.
• Lead, coordinate, or participate in institutional efforts to improve the care provided for common diseases of adulthood that have an increasing incidence in young adults.
• Advocate for institutional policies that promote and ensure a safe, sensitive, and non-judgmental environment for LGBTQQ adolescents and young adults.
• Lead, coordinate, or participate in institutional efforts to improve screening and care for sexually transmitted infections and mental health.
• Collaborate with other subspecialists to develop cost-effective, evidence-based care pathways to manage emergent ovarian and testicular conditions.

Introduction

Over the past several years, the number of children with acute behavioral and psychiatric conditions who require admission to the hospital has grown. Over the past decade, due to reductions in available psychiatric beds nationally, coupled with increases in children and young adults seeking and referred for acute mental health issues, the numbers of patients who require care by pediatric hospitalists while awaiting psychiatric disposition has risen dramatically. Pediatric hospitalists working in both university/children’s and community hospitals often encounter patients with acute behavioral or psychiatric illnesses. Patients may present with acute behavioral or psychiatric issues due to acute effects such as intoxication, medical illness, or suicide attempt, or for an acute change in an underlying behavioral, developmental, or psychiatric disorder. Pediatric patients with aggressive or agitated presentations are particularly challenging to care for in the hospital setting. In collaboration with mental health specialists, the hospitalist should know how to approach the diagnosis and initiate best treatment for these patients, while optimizing safety for the patients, the family/caregivers, and hospital staff.

Pediatric hospitalists should be able to:

• State the most common groups of underlying conditions that occur in children that manifest with acute behavioral concerns, attending to medication effects (accidental or intentional misuse or withdrawal from prescription or non-prescription drugs), abuse, endocrine/metabolic/rheumatologic disorders, encephalitidies, primary central nervous system disorders, new onset psychiatric disorders, and others.
• Compare and contrast the role of pediatric hospitalists with other subspecialists in management of these patients as it relates to diagnosis and treatment.
• Discuss the role of diagnostic testing for patient presenting with acute behavioral concerns.
• State indications for intra- or interfacility transfer, attending to local context and resource needs.
• Summarize potentially dangerous environmental hazards in the acute care hospital setting and cite methods that can be used to safeguard the patient, family, and healthcare providers.
• Define somatoform and conversion disorders and describe the relationship between somatic symptoms and depression or other mental illness.
• Define delirium and list examples of potential causes in the pediatric population for patients newly admitted and those developing delirium during the hospital stay.
• Distinguish agitation from aggression and review how patients may be acutely agitated secondary to an underlying medical condition, psychiatric illness, developmental disorder, change in environment, or loss of sensory abilities such as hearing or sight.
• Review common acute behavioral concerns that may occur in children with autism or developmental delays.
• Describe the approach toward an aggressive patient, including environmental changes, use of sitters, use of medications, and application of restraints.
• Summarize the Joint Commission requirements for patients placed in Violent Restraints (previously called Behavioral Restraints).
• List medications commonly used to stabilize pediatric patients with acute behavioral or psychiatric crises, and discuss associated adverse effects, overdose effects, potential drug-drug interactions, contraindications, and potential risks of repeated use.
• Review the use and value of commonly used screening tools for suicide and depression and describe use in local context.
• Explain the approach toward management of the acutely suicidal patient in the hospital environment, attending to issues such as safe eating utensils, room choice, and engagement of appropriate psychiatric consultants.
• Discuss the approach toward a successful interdisciplinary family meeting for this population.

Pediatric hospitalists should be able to:

• Diagnose the source of an acute behavioral condition by performing a history and physical exam, determining if key features of varied etiologies are present.
• Order appropriate studies and arrange needed consultation to further assess and address the underlying medical, psychiatric, or environmental/social problem resulting in the altered behavior.
• Order monitoring and environmental safeguards appropriate for the witnessed behavior and potential etiology.
• Prescribe appropriate, evidence-based medications indicated for acute behavioral or psychiatric crises using the safest route, dosing, frequency, and duration of treatment to stabilize the patient.
• Engage consultants such as Poison Control Center staff or toxicology experts to help manage patients with acute intoxication.
• Consult and engage psychiatric specialists and associated medical and mental health professionals (including developmental pediatricians, neurologists, therapists, and others) in ongoing care of hospitalized patients with acute behavior issues, within local context.
• Demonstrate basic skills in de-escalating aggression in patients.
• Document according to Joint Commission requirements for patients placed in Violent Restraints (previously called Behavioral Restraints).
• Demonstrate communication skills that diffuse anxiety and fears for patients, the family/caregivers, and healthcare providers.
• Demonstrate skills in maintaining confidentiality, empathy, and respect for the patient, family/caregivers, and staff.
• Coordinate the timing and frequency of care delivery with other healthcare providers in order to reduce unnecessary stimulation for patients with acute behavioral and psychiatric conditions.
• Create a comprehensive discharge plan that is interdisciplinary, engaging patients and the family/caregivers in shared decision-making for next steps in care.

Pediatric hospitalists should be able to:

• Recognize the need for empathy and sensitivity in the care of these patients, including awareness of the potential negative effects of varied treatment modalities.
• Reflect on the importance of maintaining a calm focus while leading the healthcare team caring for these patients with challenging needs.
• Appreciate the significant role that communication with the family/caregivers plays in allaying fears and reducing anxiety associated with the child’s illness.
• Realize that anxiety and other stress behaviors demonstrated by the family/caregivers may contribute to the child’s symptoms.

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

• Work with hospital administration and medical staff leaders to ensure access to experts in behavioral and psychiatric medicine within referral networks.
• Lead, coordinate, or participate in development of education and training of teams regarding safe response to patients who exhibit aggressive behaviors.
• Promote an environment that embraces the importance of confidentiality in evaluating and treating patients with behavioral or psychiatric illness.
• Collaborate with an interdisciplinary team to develop and sustain a system of review of events that resulted in physical restraint or medication usage to control aggressive behavior.
• Collaborate with or lead an interdisciplinary team ensuring the security and safety of patients with aggressive or self-injurious behaviors.

Introduction

Over the past several years, the number of children with acute behavioral and psychiatric conditions who require admission to the hospital has grown. Over the past decade, due to reductions in available psychiatric beds nationally, coupled with increases in children and young adults seeking and referred for acute mental health issues, the numbers of patients who require care by pediatric hospitalists while awaiting psychiatric disposition has risen dramatically. Pediatric hospitalists working in both university/children’s and community hospitals often encounter patients with acute behavioral or psychiatric illnesses. Patients may present with acute behavioral or psychiatric issues due to acute effects such as intoxication, medical illness, or suicide attempt, or for an acute change in an underlying behavioral, developmental, or psychiatric disorder. Pediatric patients with aggressive or agitated presentations are particularly challenging to care for in the hospital setting. In collaboration with mental health specialists, the hospitalist should know how to approach the diagnosis and initiate best treatment for these patients, while optimizing safety for the patients, the family/caregivers, and hospital staff.

Pediatric hospitalists should be able to:

• State the most common groups of underlying conditions that occur in children that manifest with acute behavioral concerns, attending to medication effects (accidental or intentional misuse or withdrawal from prescription or non-prescription drugs), abuse, endocrine/metabolic/rheumatologic disorders, encephalitidies, primary central nervous system disorders, new onset psychiatric disorders, and others.
• Compare and contrast the role of pediatric hospitalists with other subspecialists in management of these patients as it relates to diagnosis and treatment.
• Discuss the role of diagnostic testing for patient presenting with acute behavioral concerns.
• State indications for intra- or interfacility transfer, attending to local context and resource needs.
• Summarize potentially dangerous environmental hazards in the acute care hospital setting and cite methods that can be used to safeguard the patient, family, and healthcare providers.
• Define somatoform and conversion disorders and describe the relationship between somatic symptoms and depression or other mental illness.
• Define delirium and list examples of potential causes in the pediatric population for patients newly admitted and those developing delirium during the hospital stay.
• Distinguish agitation from aggression and review how patients may be acutely agitated secondary to an underlying medical condition, psychiatric illness, developmental disorder, change in environment, or loss of sensory abilities such as hearing or sight.
• Review common acute behavioral concerns that may occur in children with autism or developmental delays.
• Describe the approach toward an aggressive patient, including environmental changes, use of sitters, use of medications, and application of restraints.
• Summarize the Joint Commission requirements for patients placed in Violent Restraints (previously called Behavioral Restraints).
• List medications commonly used to stabilize pediatric patients with acute behavioral or psychiatric crises, and discuss associated adverse effects, overdose effects, potential drug-drug interactions, contraindications, and potential risks of repeated use.
• Review the use and value of commonly used screening tools for suicide and depression and describe use in local context.
• Explain the approach toward management of the acutely suicidal patient in the hospital environment, attending to issues such as safe eating utensils, room choice, and engagement of appropriate psychiatric consultants.
• Discuss the approach toward a successful interdisciplinary family meeting for this population.

Pediatric hospitalists should be able to:

• Diagnose the source of an acute behavioral condition by performing a history and physical exam, determining if key features of varied etiologies are present.
• Order appropriate studies and arrange needed consultation to further assess and address the underlying medical, psychiatric, or environmental/social problem resulting in the altered behavior.
• Order monitoring and environmental safeguards appropriate for the witnessed behavior and potential etiology.
• Prescribe appropriate, evidence-based medications indicated for acute behavioral or psychiatric crises using the safest route, dosing, frequency, and duration of treatment to stabilize the patient.
• Engage consultants such as Poison Control Center staff or toxicology experts to help manage patients with acute intoxication.
• Consult and engage psychiatric specialists and associated medical and mental health professionals (including developmental pediatricians, neurologists, therapists, and others) in ongoing care of hospitalized patients with acute behavior issues, within local context.
• Demonstrate basic skills in de-escalating aggression in patients.
• Document according to Joint Commission requirements for patients placed in Violent Restraints (previously called Behavioral Restraints).
• Demonstrate communication skills that diffuse anxiety and fears for patients, the family/caregivers, and healthcare providers.
• Demonstrate skills in maintaining confidentiality, empathy, and respect for the patient, family/caregivers, and staff.
• Coordinate the timing and frequency of care delivery with other healthcare providers in order to reduce unnecessary stimulation for patients with acute behavioral and psychiatric conditions.
• Create a comprehensive discharge plan that is interdisciplinary, engaging patients and the family/caregivers in shared decision-making for next steps in care.

Pediatric hospitalists should be able to:

• Recognize the need for empathy and sensitivity in the care of these patients, including awareness of the potential negative effects of varied treatment modalities.
• Reflect on the importance of maintaining a calm focus while leading the healthcare team caring for these patients with challenging needs.
• Appreciate the significant role that communication with the family/caregivers plays in allaying fears and reducing anxiety associated with the child’s illness.
• Realize that anxiety and other stress behaviors demonstrated by the family/caregivers may contribute to the child’s symptoms.

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

• Work with hospital administration and medical staff leaders to ensure access to experts in behavioral and psychiatric medicine within referral networks.
• Lead, coordinate, or participate in development of education and training of teams regarding safe response to patients who exhibit aggressive behaviors.
• Promote an environment that embraces the importance of confidentiality in evaluating and treating patients with behavioral or psychiatric illness.
• Collaborate with an interdisciplinary team to develop and sustain a system of review of events that resulted in physical restraint or medication usage to control aggressive behavior.
• Collaborate with or lead an interdisciplinary team ensuring the security and safety of patients with aggressive or self-injurious behaviors.

Introduction

Over the past several years, the number of children with acute behavioral and psychiatric conditions who require admission to the hospital has grown. Over the past decade, due to reductions in available psychiatric beds nationally, coupled with increases in children and young adults seeking and referred for acute mental health issues, the numbers of patients who require care by pediatric hospitalists while awaiting psychiatric disposition has risen dramatically. Pediatric hospitalists working in both university/children’s and community hospitals often encounter patients with acute behavioral or psychiatric illnesses. Patients may present with acute behavioral or psychiatric issues due to acute effects such as intoxication, medical illness, or suicide attempt, or for an acute change in an underlying behavioral, developmental, or psychiatric disorder. Pediatric patients with aggressive or agitated presentations are particularly challenging to care for in the hospital setting. In collaboration with mental health specialists, the hospitalist should know how to approach the diagnosis and initiate best treatment for these patients, while optimizing safety for the patients, the family/caregivers, and hospital staff.

Pediatric hospitalists should be able to:

• State the most common groups of underlying conditions that occur in children that manifest with acute behavioral concerns, attending to medication effects (accidental or intentional misuse or withdrawal from prescription or non-prescription drugs), abuse, endocrine/metabolic/rheumatologic disorders, encephalitidies, primary central nervous system disorders, new onset psychiatric disorders, and others.
• Compare and contrast the role of pediatric hospitalists with other subspecialists in management of these patients as it relates to diagnosis and treatment.
• Discuss the role of diagnostic testing for patient presenting with acute behavioral concerns.
• State indications for intra- or interfacility transfer, attending to local context and resource needs.
• Summarize potentially dangerous environmental hazards in the acute care hospital setting and cite methods that can be used to safeguard the patient, family, and healthcare providers.
• Define somatoform and conversion disorders and describe the relationship between somatic symptoms and depression or other mental illness.
• Define delirium and list examples of potential causes in the pediatric population for patients newly admitted and those developing delirium during the hospital stay.
• Distinguish agitation from aggression and review how patients may be acutely agitated secondary to an underlying medical condition, psychiatric illness, developmental disorder, change in environment, or loss of sensory abilities such as hearing or sight.
• Review common acute behavioral concerns that may occur in children with autism or developmental delays.
• Describe the approach toward an aggressive patient, including environmental changes, use of sitters, use of medications, and application of restraints.
• Summarize the Joint Commission requirements for patients placed in Violent Restraints (previously called Behavioral Restraints).
• List medications commonly used to stabilize pediatric patients with acute behavioral or psychiatric crises, and discuss associated adverse effects, overdose effects, potential drug-drug interactions, contraindications, and potential risks of repeated use.
• Review the use and value of commonly used screening tools for suicide and depression and describe use in local context.
• Explain the approach toward management of the acutely suicidal patient in the hospital environment, attending to issues such as safe eating utensils, room choice, and engagement of appropriate psychiatric consultants.
• Discuss the approach toward a successful interdisciplinary family meeting for this population.

Pediatric hospitalists should be able to:

• Diagnose the source of an acute behavioral condition by performing a history and physical exam, determining if key features of varied etiologies are present.
• Order appropriate studies and arrange needed consultation to further assess and address the underlying medical, psychiatric, or environmental/social problem resulting in the altered behavior.
• Order monitoring and environmental safeguards appropriate for the witnessed behavior and potential etiology.
• Prescribe appropriate, evidence-based medications indicated for acute behavioral or psychiatric crises using the safest route, dosing, frequency, and duration of treatment to stabilize the patient.
• Engage consultants such as Poison Control Center staff or toxicology experts to help manage patients with acute intoxication.
• Consult and engage psychiatric specialists and associated medical and mental health professionals (including developmental pediatricians, neurologists, therapists, and others) in ongoing care of hospitalized patients with acute behavior issues, within local context.
• Demonstrate basic skills in de-escalating aggression in patients.
• Document according to Joint Commission requirements for patients placed in Violent Restraints (previously called Behavioral Restraints).
• Demonstrate communication skills that diffuse anxiety and fears for patients, the family/caregivers, and healthcare providers.
• Demonstrate skills in maintaining confidentiality, empathy, and respect for the patient, family/caregivers, and staff.
• Coordinate the timing and frequency of care delivery with other healthcare providers in order to reduce unnecessary stimulation for patients with acute behavioral and psychiatric conditions.
• Create a comprehensive discharge plan that is interdisciplinary, engaging patients and the family/caregivers in shared decision-making for next steps in care.

Pediatric hospitalists should be able to:

• Recognize the need for empathy and sensitivity in the care of these patients, including awareness of the potential negative effects of varied treatment modalities.
• Reflect on the importance of maintaining a calm focus while leading the healthcare team caring for these patients with challenging needs.
• Appreciate the significant role that communication with the family/caregivers plays in allaying fears and reducing anxiety associated with the child’s illness.
• Realize that anxiety and other stress behaviors demonstrated by the family/caregivers may contribute to the child’s symptoms.

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

• Work with hospital administration and medical staff leaders to ensure access to experts in behavioral and psychiatric medicine within referral networks.
• Lead, coordinate, or participate in development of education and training of teams regarding safe response to patients who exhibit aggressive behaviors.
• Promote an environment that embraces the importance of confidentiality in evaluating and treating patients with behavioral or psychiatric illness.
• Collaborate with an interdisciplinary team to develop and sustain a system of review of events that resulted in physical restraint or medication usage to control aggressive behavior.
• Collaborate with or lead an interdisciplinary team ensuring the security and safety of patients with aggressive or self-injurious behaviors.

Introduction

Sedation is used in conjunction with nonpharmacological interventions to minimize procedural pain and to provide decreased motion for successful completion of studies and interventions. Control of pain, anxiety, and memory can minimize negative psychological responses to treatment and lead to a higher success rate for diagnostic testing or therapy administration. Safe attainment of these goals requires careful preparation and clinical decision-making prior to the procedure, meticulous monitoring during the procedure, and skillful application of techniques to avoid or treat the complications of sedation. This may include the need to rescue patients from a deeper level of sedation than intended. While not all pediatric hospitalists will need to perform procedural sedation in their daily work, those who do must adhere to high standards of quality. With appropriate training and experience, pediatric hospitalists can safely provide a range of sedation services for pediatric patients.

Pediatric hospitalists should be able to:

• Discuss the goals of sedation, such as pain control, anxiolysis, amnesia, and motion control.
• Compare and contrast the definitions of minimal, moderate, and deep sedation, and general anesthesia, as established by the American Society of Anesthesiologists (ASA), American Academy of Pediatrics (AAP), and The Joint Commission (TJC).
• Define the ASA Physical Status Classification System and the Mallampati score to predict ease of endotracheal intubation.
• Discuss the pharmacology and effects of commonly used sedation medications (such as propofol, ketamine, midazolam, fentanyl, dexmedetomidine, nitrous oxide, and others), including planned effects and potential side effects.
• List commonly used single or combination medications and describe how each achieves the desired goal while minimizing the risk of complications and side effects.
• Discuss the establishment of a safe sedation plan that is developmentally tailored for children and adolescents of various ages.
• Discuss the proper level of monitoring and personnel needed to maximize the likelihood of a safe sedation outcome.
• Describe the use of nonpharmacologic interventions (such as bundling, glucose water pacifiers, presence of the family/caregivers, visual imagery, deep breathing, music, and others) as adjuncts to medications, to mitigate the perception of pain and anxiety.
• Discuss the inherent risks of administering sedating medications and apply the proper monitoring necessary to avoid and promptly recognize instability.
• Describe how age, disease process, and anatomy may increase the risk of sedation complications.
• Review indications for use of common reversal drugs, including anticipated results and duration of rescue effects.
• Identify the indications for consultation with subspecialists, such as anesthesiologists, intensivists, child life specialists, and others, when appropriate.

Pediatric hospitalists should be able to:

• Perform a pre-sedation evaluation, appropriately assigning ASA physical classification and Mallampati score, identifying anatomical risk factors, and delineating other patient-specific risks.
• Identify patients at higher risk for complications and efficiently refer to an anesthesiologist as appropriate.
• Review home medications and anticipate impact of these on the sedation plan.
• Communicate effectively with patients and the family/caregivers regarding the indications for, risks, benefits, and steps of sedation.
• Obtain informed consent from the family/caregivers prior to the sedation.
• Develop a sedation plan that is based on the pre-sedation evaluation and incorporates goals for the sedation and any patient-specific risks.
• Communicate effectively with the healthcare team before, during, and after the sedation to ensure accurate handoffs and safe, efficient care.
• Obtain intravenous access according to patient needs.
• Manage the airway at all levels of sedation, whether the level of sedation achieved was intended or unintended.
• Perform airway interventions and pediatric advanced life support as needed, in case of sedation complications.
• Identify side effects and complications of sedation and respond with appropriate actions.
• Select appropriate monitoring and correctly interpret monitor data.
• Identify when recovery criteria are met and initiate an appropriate discharge/transfer plan.

Pediatric hospitalists should be able to:

• Recognize the importance of effective collaboration with hospital staff and subspecialists to ensure coordinated planning and performance of sedation.
• Role model effective communication with patients and the family/caregivers about sedation indications, risks, benefits, and steps.

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

• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based procedures and policies for performance of sedation for children.
• Lead, coordinate, or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction with sedation services.
• Collaborate with hospital staff and subspecialists to develop and implement management strategies for sedation.
• Lead, coordinate or participate in the establishment and maintenance of a process for obtaining sedation privileges, including demonstration of adequate knowledge and skill.
• Lead, coordinate or participate in the development and implementation of a system for review of the efficacy, efficiency and outcomes of procedures involving sedation.

Introduction

Sedation is used in conjunction with nonpharmacological interventions to minimize procedural pain and to provide decreased motion for successful completion of studies and interventions. Control of pain, anxiety, and memory can minimize negative psychological responses to treatment and lead to a higher success rate for diagnostic testing or therapy administration. Safe attainment of these goals requires careful preparation and clinical decision-making prior to the procedure, meticulous monitoring during the procedure, and skillful application of techniques to avoid or treat the complications of sedation. This may include the need to rescue patients from a deeper level of sedation than intended. While not all pediatric hospitalists will need to perform procedural sedation in their daily work, those who do must adhere to high standards of quality. With appropriate training and experience, pediatric hospitalists can safely provide a range of sedation services for pediatric patients.

Pediatric hospitalists should be able to:

• Discuss the goals of sedation, such as pain control, anxiolysis, amnesia, and motion control.
• Compare and contrast the definitions of minimal, moderate, and deep sedation, and general anesthesia, as established by the American Society of Anesthesiologists (ASA), American Academy of Pediatrics (AAP), and The Joint Commission (TJC).
• Define the ASA Physical Status Classification System and the Mallampati score to predict ease of endotracheal intubation.
• Discuss the pharmacology and effects of commonly used sedation medications (such as propofol, ketamine, midazolam, fentanyl, dexmedetomidine, nitrous oxide, and others), including planned effects and potential side effects.
• List commonly used single or combination medications and describe how each achieves the desired goal while minimizing the risk of complications and side effects.
• Discuss the establishment of a safe sedation plan that is developmentally tailored for children and adolescents of various ages.
• Discuss the proper level of monitoring and personnel needed to maximize the likelihood of a safe sedation outcome.
• Describe the use of nonpharmacologic interventions (such as bundling, glucose water pacifiers, presence of the family/caregivers, visual imagery, deep breathing, music, and others) as adjuncts to medications, to mitigate the perception of pain and anxiety.
• Discuss the inherent risks of administering sedating medications and apply the proper monitoring necessary to avoid and promptly recognize instability.
• Describe how age, disease process, and anatomy may increase the risk of sedation complications.
• Review indications for use of common reversal drugs, including anticipated results and duration of rescue effects.
• Identify the indications for consultation with subspecialists, such as anesthesiologists, intensivists, child life specialists, and others, when appropriate.

Pediatric hospitalists should be able to:

• Perform a pre-sedation evaluation, appropriately assigning ASA physical classification and Mallampati score, identifying anatomical risk factors, and delineating other patient-specific risks.
• Identify patients at higher risk for complications and efficiently refer to an anesthesiologist as appropriate.
• Review home medications and anticipate impact of these on the sedation plan.
• Communicate effectively with patients and the family/caregivers regarding the indications for, risks, benefits, and steps of sedation.
• Obtain informed consent from the family/caregivers prior to the sedation.
• Develop a sedation plan that is based on the pre-sedation evaluation and incorporates goals for the sedation and any patient-specific risks.
• Communicate effectively with the healthcare team before, during, and after the sedation to ensure accurate handoffs and safe, efficient care.
• Obtain intravenous access according to patient needs.
• Manage the airway at all levels of sedation, whether the level of sedation achieved was intended or unintended.
• Perform airway interventions and pediatric advanced life support as needed, in case of sedation complications.
• Identify side effects and complications of sedation and respond with appropriate actions.
• Select appropriate monitoring and correctly interpret monitor data.
• Identify when recovery criteria are met and initiate an appropriate discharge/transfer plan.

Pediatric hospitalists should be able to:

• Recognize the importance of effective collaboration with hospital staff and subspecialists to ensure coordinated planning and performance of sedation.
• Role model effective communication with patients and the family/caregivers about sedation indications, risks, benefits, and steps.

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

• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based procedures and policies for performance of sedation for children.
• Lead, coordinate, or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction with sedation services.
• Collaborate with hospital staff and subspecialists to develop and implement management strategies for sedation.
• Lead, coordinate or participate in the establishment and maintenance of a process for obtaining sedation privileges, including demonstration of adequate knowledge and skill.
• Lead, coordinate or participate in the development and implementation of a system for review of the efficacy, efficiency and outcomes of procedures involving sedation.

Introduction

Sedation is used in conjunction with nonpharmacological interventions to minimize procedural pain and to provide decreased motion for successful completion of studies and interventions. Control of pain, anxiety, and memory can minimize negative psychological responses to treatment and lead to a higher success rate for diagnostic testing or therapy administration. Safe attainment of these goals requires careful preparation and clinical decision-making prior to the procedure, meticulous monitoring during the procedure, and skillful application of techniques to avoid or treat the complications of sedation. This may include the need to rescue patients from a deeper level of sedation than intended. While not all pediatric hospitalists will need to perform procedural sedation in their daily work, those who do must adhere to high standards of quality. With appropriate training and experience, pediatric hospitalists can safely provide a range of sedation services for pediatric patients.

Pediatric hospitalists should be able to:

• Discuss the goals of sedation, such as pain control, anxiolysis, amnesia, and motion control.
• Compare and contrast the definitions of minimal, moderate, and deep sedation, and general anesthesia, as established by the American Society of Anesthesiologists (ASA), American Academy of Pediatrics (AAP), and The Joint Commission (TJC).
• Define the ASA Physical Status Classification System and the Mallampati score to predict ease of endotracheal intubation.
• Discuss the pharmacology and effects of commonly used sedation medications (such as propofol, ketamine, midazolam, fentanyl, dexmedetomidine, nitrous oxide, and others), including planned effects and potential side effects.
• List commonly used single or combination medications and describe how each achieves the desired goal while minimizing the risk of complications and side effects.
• Discuss the establishment of a safe sedation plan that is developmentally tailored for children and adolescents of various ages.
• Discuss the proper level of monitoring and personnel needed to maximize the likelihood of a safe sedation outcome.
• Describe the use of nonpharmacologic interventions (such as bundling, glucose water pacifiers, presence of the family/caregivers, visual imagery, deep breathing, music, and others) as adjuncts to medications, to mitigate the perception of pain and anxiety.
• Discuss the inherent risks of administering sedating medications and apply the proper monitoring necessary to avoid and promptly recognize instability.
• Describe how age, disease process, and anatomy may increase the risk of sedation complications.
• Review indications for use of common reversal drugs, including anticipated results and duration of rescue effects.
• Identify the indications for consultation with subspecialists, such as anesthesiologists, intensivists, child life specialists, and others, when appropriate.

Pediatric hospitalists should be able to:

• Perform a pre-sedation evaluation, appropriately assigning ASA physical classification and Mallampati score, identifying anatomical risk factors, and delineating other patient-specific risks.
• Identify patients at higher risk for complications and efficiently refer to an anesthesiologist as appropriate.
• Review home medications and anticipate impact of these on the sedation plan.
• Communicate effectively with patients and the family/caregivers regarding the indications for, risks, benefits, and steps of sedation.
• Obtain informed consent from the family/caregivers prior to the sedation.
• Develop a sedation plan that is based on the pre-sedation evaluation and incorporates goals for the sedation and any patient-specific risks.
• Communicate effectively with the healthcare team before, during, and after the sedation to ensure accurate handoffs and safe, efficient care.
• Obtain intravenous access according to patient needs.
• Manage the airway at all levels of sedation, whether the level of sedation achieved was intended or unintended.
• Perform airway interventions and pediatric advanced life support as needed, in case of sedation complications.
• Identify side effects and complications of sedation and respond with appropriate actions.
• Select appropriate monitoring and correctly interpret monitor data.
• Identify when recovery criteria are met and initiate an appropriate discharge/transfer plan.

Pediatric hospitalists should be able to:

• Recognize the importance of effective collaboration with hospital staff and subspecialists to ensure coordinated planning and performance of sedation.
• Role model effective communication with patients and the family/caregivers about sedation indications, risks, benefits, and steps.

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

• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based procedures and policies for performance of sedation for children.
• Lead, coordinate, or participate in the development and implementation of a system for review of family/caregiver and healthcare provider satisfaction with sedation services.
• Collaborate with hospital staff and subspecialists to develop and implement management strategies for sedation.
• Lead, coordinate or participate in the establishment and maintenance of a process for obtaining sedation privileges, including demonstration of adequate knowledge and skill.
• Lead, coordinate or participate in the development and implementation of a system for review of the efficacy, efficiency and outcomes of procedures involving sedation.

Introduction

Pediatric hospitalists take a generalist and preventive care approach to patient care in the inpatient setting, focusing on the provision of routine health care maintenance and the prevention of hospital-acquired conditions (HACs). Hospitalized children, particularly those with barriers to consistent access to health care, deserve a thorough review of items related to general well-child and preventive care, regardless of the reason for admission. Furthermore, safety research in pediatrics has consistently shown that hospitalized children, especially those with high medical complexity, are at great risk for adverse events. In this context, pediatric hospitalists in all practice settings must make efforts to eliminate unnecessary exposures and monitor for and prevent HACs.

Pediatric hospitalists should be able to:

• Summarize the current recommended vaccine schedules for pediatric patients, the indications, contraindications, and side effects for each vaccine.
• Explain typical patterns for growth and development of secondary sex characteristics and describe how to utilize growth charts and the sexual maturity rating scale to assess age-appropriate changes.
• List the developmental milestones for children of different ages and describe the components of commonly utilized developmental screening tools.
• List the elements of the HEADDS exam for adolescents.
• Explain the value of assessing for preventive health needs during the hospital encounter, attending to socioeconomic factors that may limit opportunities for these assessments in the ambulatory setting, such as access to healthcare.
• Discuss the impact of oral health on children with and without chronic medical conditions.
• Define the phrase hospital-acquired condition (HAC).
• List the common HACs affecting hospitalized children, such as central line associated bloodstream infections, catheter associated urinary tract infections, pressure injuries and wound infections, and surgical site infections.
• Describe proven methods to prevent HACs, with emphasis on the need for multiple grouped interventions (such as bundled care, clinical pathways, checklists, and others) to produce more complete and sustained change.
• Identify the HACs routinely monitored by their hospital safety teams.

Pediatric hospitalists should be able to:

• Complete a comprehensive physical exam, including anthropometrics, breast exam if applicable, and a genitourinary exam, to assess for appropriate growth and development of secondary sex characteristics.
• Perform and respond to needs identified by preventive care assessments, including:

–Immunization history, accessing immunization registries if available local records are incomplete

–HEADSS exam for adolescents

–Screening for: Developmental and behavioral needs; oral health; toxic exposure; growth including inadequate or excessive weight and obesity.

• Coordinate care with an interdisciplinary team to identify and address needs of patients with depression and/or suicidality.
• Coordinate care with an interdisciplinary team to identify and address needs of patients and the family/caregivers with at risk social determinants of health, such as food insecurity, homelessness, and others.
• Refer patients and the family/caregivers to appropriate institutional and community resources to address identified gaps in health care maintenance.
• Identify patients at risk for HACs upon initial assessment, taking the clinical presentation and level of medical complexity into account.
• Use evidence-based, bundled care practices to reduce or prevent HACs.
• Order appropriate interventions for the prevention of HACs and other clinical conditions, including:

–Central line infections

–Skin breakdown and pressure injuries

–Deep venous thromboses

–Gastritis, esophagitis, and related gastrointestinal conditions

–Deconditioning

• Order appropriate interventions to support oral hygiene and ocular health.
• Assess the ongoing need for intravenous access, urinary catheters, and other tubes and lines when applicable, promoting removal as soon as they are no longer medically necessary.
• Evaluate the necessity of commonly ordered interventions in order to decrease or eliminate unnecessary exposures and risks for patients.
• Order vaccinations for patients where appropriate, indicated, and available, including annual flu vaccine.

Pediatric hospitalists should be able to:

• Appreciate the importance of reviewing the general heath care of a child during hospitalization.
• Realize the value of communicating directly with a patient’s primary care provider regarding healthcare maintenance concerns found and/or addressed during hospitalization.
• Maintain awareness of the risks of hospitalization, as well as risk management strategies, for pediatric patients.
• Recognize the importance of participating in care collaboratives to reduce harm beyond the immediate care setting.
• Appreciate the value of submitting patient safety data to appropriate sources for benchmarking in order to support overall preventive care strategies.

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

• Collaborate with hospital information systems to ensure accurate representation of relevant healthcare maintenance data in the electronic health record, such as immunization records, growth charts, and contact information for primary care providers.
• Advocate for access to primary care providers and community resources for children with health care maintenance gaps and social determinants of health risks identified during hospitalization.
• Collaborate with hospital administrators to ensure existence of referral processes for local and national developmental services resources.
• Lead, coordinate, or participate in the development of effective surveillance tools and other quality improvement efforts to identify, prevent, or reduce the occurrence of HACs.
• Collaborate with hospital quality and safety teams to collect and share institutional data on HACs.

Introduction

Pediatric hospitalists take a generalist and preventive care approach to patient care in the inpatient setting, focusing on the provision of routine health care maintenance and the prevention of hospital-acquired conditions (HACs). Hospitalized children, particularly those with barriers to consistent access to health care, deserve a thorough review of items related to general well-child and preventive care, regardless of the reason for admission. Furthermore, safety research in pediatrics has consistently shown that hospitalized children, especially those with high medical complexity, are at great risk for adverse events. In this context, pediatric hospitalists in all practice settings must make efforts to eliminate unnecessary exposures and monitor for and prevent HACs.

Pediatric hospitalists should be able to:

• Summarize the current recommended vaccine schedules for pediatric patients, the indications, contraindications, and side effects for each vaccine.
• Explain typical patterns for growth and development of secondary sex characteristics and describe how to utilize growth charts and the sexual maturity rating scale to assess age-appropriate changes.
• List the developmental milestones for children of different ages and describe the components of commonly utilized developmental screening tools.
• List the elements of the HEADDS exam for adolescents.
• Explain the value of assessing for preventive health needs during the hospital encounter, attending to socioeconomic factors that may limit opportunities for these assessments in the ambulatory setting, such as access to healthcare.
• Discuss the impact of oral health on children with and without chronic medical conditions.
• Define the phrase hospital-acquired condition (HAC).
• List the common HACs affecting hospitalized children, such as central line associated bloodstream infections, catheter associated urinary tract infections, pressure injuries and wound infections, and surgical site infections.
• Describe proven methods to prevent HACs, with emphasis on the need for multiple grouped interventions (such as bundled care, clinical pathways, checklists, and others) to produce more complete and sustained change.
• Identify the HACs routinely monitored by their hospital safety teams.

Pediatric hospitalists should be able to:

• Complete a comprehensive physical exam, including anthropometrics, breast exam if applicable, and a genitourinary exam, to assess for appropriate growth and development of secondary sex characteristics.
• Perform and respond to needs identified by preventive care assessments, including:

–Immunization history, accessing immunization registries if available local records are incomplete

–HEADSS exam for adolescents

–Screening for: Developmental and behavioral needs; oral health; toxic exposure; growth including inadequate or excessive weight and obesity.

• Coordinate care with an interdisciplinary team to identify and address needs of patients with depression and/or suicidality.
• Coordinate care with an interdisciplinary team to identify and address needs of patients and the family/caregivers with at risk social determinants of health, such as food insecurity, homelessness, and others.
• Refer patients and the family/caregivers to appropriate institutional and community resources to address identified gaps in health care maintenance.
• Identify patients at risk for HACs upon initial assessment, taking the clinical presentation and level of medical complexity into account.
• Use evidence-based, bundled care practices to reduce or prevent HACs.
• Order appropriate interventions for the prevention of HACs and other clinical conditions, including:

–Central line infections

–Skin breakdown and pressure injuries

–Deep venous thromboses

–Gastritis, esophagitis, and related gastrointestinal conditions

–Deconditioning

• Order appropriate interventions to support oral hygiene and ocular health.
• Assess the ongoing need for intravenous access, urinary catheters, and other tubes and lines when applicable, promoting removal as soon as they are no longer medically necessary.
• Evaluate the necessity of commonly ordered interventions in order to decrease or eliminate unnecessary exposures and risks for patients.
• Order vaccinations for patients where appropriate, indicated, and available, including annual flu vaccine.

Pediatric hospitalists should be able to:

• Appreciate the importance of reviewing the general heath care of a child during hospitalization.
• Realize the value of communicating directly with a patient’s primary care provider regarding healthcare maintenance concerns found and/or addressed during hospitalization.
• Maintain awareness of the risks of hospitalization, as well as risk management strategies, for pediatric patients.
• Recognize the importance of participating in care collaboratives to reduce harm beyond the immediate care setting.
• Appreciate the value of submitting patient safety data to appropriate sources for benchmarking in order to support overall preventive care strategies.

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

• Collaborate with hospital information systems to ensure accurate representation of relevant healthcare maintenance data in the electronic health record, such as immunization records, growth charts, and contact information for primary care providers.
• Advocate for access to primary care providers and community resources for children with health care maintenance gaps and social determinants of health risks identified during hospitalization.
• Collaborate with hospital administrators to ensure existence of referral processes for local and national developmental services resources.
• Lead, coordinate, or participate in the development of effective surveillance tools and other quality improvement efforts to identify, prevent, or reduce the occurrence of HACs.
• Collaborate with hospital quality and safety teams to collect and share institutional data on HACs.

Introduction

Pediatric hospitalists take a generalist and preventive care approach to patient care in the inpatient setting, focusing on the provision of routine health care maintenance and the prevention of hospital-acquired conditions (HACs). Hospitalized children, particularly those with barriers to consistent access to health care, deserve a thorough review of items related to general well-child and preventive care, regardless of the reason for admission. Furthermore, safety research in pediatrics has consistently shown that hospitalized children, especially those with high medical complexity, are at great risk for adverse events. In this context, pediatric hospitalists in all practice settings must make efforts to eliminate unnecessary exposures and monitor for and prevent HACs.

Pediatric hospitalists should be able to:

• Summarize the current recommended vaccine schedules for pediatric patients, the indications, contraindications, and side effects for each vaccine.
• Explain typical patterns for growth and development of secondary sex characteristics and describe how to utilize growth charts and the sexual maturity rating scale to assess age-appropriate changes.
• List the developmental milestones for children of different ages and describe the components of commonly utilized developmental screening tools.
• List the elements of the HEADDS exam for adolescents.
• Explain the value of assessing for preventive health needs during the hospital encounter, attending to socioeconomic factors that may limit opportunities for these assessments in the ambulatory setting, such as access to healthcare.
• Discuss the impact of oral health on children with and without chronic medical conditions.
• Define the phrase hospital-acquired condition (HAC).
• List the common HACs affecting hospitalized children, such as central line associated bloodstream infections, catheter associated urinary tract infections, pressure injuries and wound infections, and surgical site infections.
• Describe proven methods to prevent HACs, with emphasis on the need for multiple grouped interventions (such as bundled care, clinical pathways, checklists, and others) to produce more complete and sustained change.
• Identify the HACs routinely monitored by their hospital safety teams.

Pediatric hospitalists should be able to:

• Complete a comprehensive physical exam, including anthropometrics, breast exam if applicable, and a genitourinary exam, to assess for appropriate growth and development of secondary sex characteristics.
• Perform and respond to needs identified by preventive care assessments, including:

–Immunization history, accessing immunization registries if available local records are incomplete

–HEADSS exam for adolescents

–Screening for: Developmental and behavioral needs; oral health; toxic exposure; growth including inadequate or excessive weight and obesity.

• Coordinate care with an interdisciplinary team to identify and address needs of patients with depression and/or suicidality.
• Coordinate care with an interdisciplinary team to identify and address needs of patients and the family/caregivers with at risk social determinants of health, such as food insecurity, homelessness, and others.
• Refer patients and the family/caregivers to appropriate institutional and community resources to address identified gaps in health care maintenance.
• Identify patients at risk for HACs upon initial assessment, taking the clinical presentation and level of medical complexity into account.
• Use evidence-based, bundled care practices to reduce or prevent HACs.
• Order appropriate interventions for the prevention of HACs and other clinical conditions, including:

–Central line infections

–Skin breakdown and pressure injuries

–Deep venous thromboses

–Gastritis, esophagitis, and related gastrointestinal conditions

–Deconditioning

• Order appropriate interventions to support oral hygiene and ocular health.
• Assess the ongoing need for intravenous access, urinary catheters, and other tubes and lines when applicable, promoting removal as soon as they are no longer medically necessary.
• Evaluate the necessity of commonly ordered interventions in order to decrease or eliminate unnecessary exposures and risks for patients.
• Order vaccinations for patients where appropriate, indicated, and available, including annual flu vaccine.

Pediatric hospitalists should be able to:

• Appreciate the importance of reviewing the general heath care of a child during hospitalization.
• Realize the value of communicating directly with a patient’s primary care provider regarding healthcare maintenance concerns found and/or addressed during hospitalization.
• Maintain awareness of the risks of hospitalization, as well as risk management strategies, for pediatric patients.
• Recognize the importance of participating in care collaboratives to reduce harm beyond the immediate care setting.
• Appreciate the value of submitting patient safety data to appropriate sources for benchmarking in order to support overall preventive care strategies.

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

• Collaborate with hospital information systems to ensure accurate representation of relevant healthcare maintenance data in the electronic health record, such as immunization records, growth charts, and contact information for primary care providers.
• Advocate for access to primary care providers and community resources for children with health care maintenance gaps and social determinants of health risks identified during hospitalization.
• Collaborate with hospital administrators to ensure existence of referral processes for local and national developmental services resources.
• Lead, coordinate, or participate in the development of effective surveillance tools and other quality improvement efforts to identify, prevent, or reduce the occurrence of HACs.
• Collaborate with hospital quality and safety teams to collect and share institutional data on HACs.