Cardiac arrhythmias are a group of conditions characterized by an abnormal heart rate or rhythm. These are common and affect approximately 5% of the population in the United States. More than 250,000 Americans die each year of sudden cardiac arrest, and most cases are thought to be due to ventricular fibrillation or ventricular tachycardia.¹ Several cardiac arrhythmias can cause instability, prompting hospitalization, or they may result from complications during hospitalization. Annually, more than 740,000 hospital discharges are associated with a primary diagnosis of cardiac arrhythmia.² Hospitalists identify and treat all types of arrhythmias, coordinate specialty and primary care resources, and transition patients safely and cost-effectively through the acute hospitalization and into the outpatient setting. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Identify and differentiate the common clinical presentations of both benign and pathologic arrhythmias.

• Explain the causes of atrial and ventricular arrhythmias.

• Describe the indicated tests required to evaluate arrhythmias.

• Explain how medications, metabolic abnormalities, and medical comorbidities may precipitate various arrhythmias.

• Explain indications, contraindications, and mechanisms of action of pharmacologic agents used to treat cardiac arrhythmias. Discuss the management options and goals for patients hospitalized with arrhythmias.

• Describe the patient characteristics and comorbid conditions that predict outcomes in patients with arrhythmias.

• Recognize indications for specialty consultation, which may include cardiology and cardiac electrophysiology.

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

• Recall appropriate indications for both initiation and discontinuation of continuous telemetry monitoring in the hospitalized patient.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history, including medications, family history, and social history.

• Perform a targeted physical examination with emphasis on identifying signs associated with hemodynamic instability, tissue perfusion, and occult cardiac and vascular disease.

• Identify common benign and pathologic arrhythmias on electrocardiography, rhythm strips, and continuous telemetry monitoring.

• Determine the appropriate level of care required based on risk stratification of patients with cardiac arrhythmias.

• Identify and prioritize high-risk arrhythmias that require urgent intervention and implement emergency protocols as indicated.

• Formulate patient-specific and evidence-based care plans incorporating diagnostic findings, prognosis, and patient characteristics.

• Develop patient-specific care plans that may include rate-controlling interventions, cardioversion, defibrillation, or implantable medical devices.

• Communicate with patients and families to explain the natural history and prognosis of cardiac arrhythmias.

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

• Communicate with patients and families to explain drug interactions for antiarrhythmic drugs and the importance of strict adherence to medication regimens and laboratory monitoring.

• Facilitate discharge planning early during hospitalization.

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians. 

Hospitalists should be able to:

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

• Follow evidence-based recommendations to guide diagnosis, monitoring, and treatment of cardiac arrhythmias.

• Acknowledge and ameliorate patient discomfort from uncontrolled arrhythmias and electrical cardioversion therapies. 

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

• Lead, coordinate, and/or participate in multidisciplinary teams to develop patient care guidelines and/or pathways on the basis of peer-reviewed outcomes research, patient and physician satisfaction, and cost.

• Implement systems to ensure hospital-wide adherence to national standards and document those measures as specified by recognized organizations (eg, The Joint Commission, American Heart Association, American College of Cardiology, Agency for Healthcare Research and Quality).

• Lead, coordinate, and/or participate in quality improvement initiatives to promote early identification of arrhythmias, reduce preventable complications, and promote appropriate use of telemetry resources.

Cardiac arrhythmias are a group of conditions characterized by an abnormal heart rate or rhythm. These are common and affect approximately 5% of the population in the United States. More than 250,000 Americans die each year of sudden cardiac arrest, and most cases are thought to be due to ventricular fibrillation or ventricular tachycardia.¹ Several cardiac arrhythmias can cause instability, prompting hospitalization, or they may result from complications during hospitalization. Annually, more than 740,000 hospital discharges are associated with a primary diagnosis of cardiac arrhythmia.² Hospitalists identify and treat all types of arrhythmias, coordinate specialty and primary care resources, and transition patients safely and cost-effectively through the acute hospitalization and into the outpatient setting. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Identify and differentiate the common clinical presentations of both benign and pathologic arrhythmias.

• Explain the causes of atrial and ventricular arrhythmias.

• Describe the indicated tests required to evaluate arrhythmias.

• Explain how medications, metabolic abnormalities, and medical comorbidities may precipitate various arrhythmias.

• Explain indications, contraindications, and mechanisms of action of pharmacologic agents used to treat cardiac arrhythmias. Discuss the management options and goals for patients hospitalized with arrhythmias.

• Describe the patient characteristics and comorbid conditions that predict outcomes in patients with arrhythmias.

• Recognize indications for specialty consultation, which may include cardiology and cardiac electrophysiology.

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

• Recall appropriate indications for both initiation and discontinuation of continuous telemetry monitoring in the hospitalized patient.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history, including medications, family history, and social history.

• Perform a targeted physical examination with emphasis on identifying signs associated with hemodynamic instability, tissue perfusion, and occult cardiac and vascular disease.

• Identify common benign and pathologic arrhythmias on electrocardiography, rhythm strips, and continuous telemetry monitoring.

• Determine the appropriate level of care required based on risk stratification of patients with cardiac arrhythmias.

• Identify and prioritize high-risk arrhythmias that require urgent intervention and implement emergency protocols as indicated.

• Formulate patient-specific and evidence-based care plans incorporating diagnostic findings, prognosis, and patient characteristics.

• Develop patient-specific care plans that may include rate-controlling interventions, cardioversion, defibrillation, or implantable medical devices.

• Communicate with patients and families to explain the natural history and prognosis of cardiac arrhythmias.

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

• Communicate with patients and families to explain drug interactions for antiarrhythmic drugs and the importance of strict adherence to medication regimens and laboratory monitoring.

• Facilitate discharge planning early during hospitalization.

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians. 

Hospitalists should be able to:

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

• Follow evidence-based recommendations to guide diagnosis, monitoring, and treatment of cardiac arrhythmias.

• Acknowledge and ameliorate patient discomfort from uncontrolled arrhythmias and electrical cardioversion therapies. 

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

• Lead, coordinate, and/or participate in multidisciplinary teams to develop patient care guidelines and/or pathways on the basis of peer-reviewed outcomes research, patient and physician satisfaction, and cost.

• Implement systems to ensure hospital-wide adherence to national standards and document those measures as specified by recognized organizations (eg, The Joint Commission, American Heart Association, American College of Cardiology, Agency for Healthcare Research and Quality).

• Lead, coordinate, and/or participate in quality improvement initiatives to promote early identification of arrhythmias, reduce preventable complications, and promote appropriate use of telemetry resources.

Cardiac arrhythmias are a group of conditions characterized by an abnormal heart rate or rhythm. These are common and affect approximately 5% of the population in the United States. More than 250,000 Americans die each year of sudden cardiac arrest, and most cases are thought to be due to ventricular fibrillation or ventricular tachycardia.¹ Several cardiac arrhythmias can cause instability, prompting hospitalization, or they may result from complications during hospitalization. Annually, more than 740,000 hospital discharges are associated with a primary diagnosis of cardiac arrhythmia.² Hospitalists identify and treat all types of arrhythmias, coordinate specialty and primary care resources, and transition patients safely and cost-effectively through the acute hospitalization and into the outpatient setting. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Identify and differentiate the common clinical presentations of both benign and pathologic arrhythmias.

• Explain the causes of atrial and ventricular arrhythmias.

• Describe the indicated tests required to evaluate arrhythmias.

• Explain how medications, metabolic abnormalities, and medical comorbidities may precipitate various arrhythmias.

• Explain indications, contraindications, and mechanisms of action of pharmacologic agents used to treat cardiac arrhythmias. Discuss the management options and goals for patients hospitalized with arrhythmias.

• Describe the patient characteristics and comorbid conditions that predict outcomes in patients with arrhythmias.

• Recognize indications for specialty consultation, which may include cardiology and cardiac electrophysiology.

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

• Recall appropriate indications for both initiation and discontinuation of continuous telemetry monitoring in the hospitalized patient.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history, including medications, family history, and social history.

• Perform a targeted physical examination with emphasis on identifying signs associated with hemodynamic instability, tissue perfusion, and occult cardiac and vascular disease.

• Identify common benign and pathologic arrhythmias on electrocardiography, rhythm strips, and continuous telemetry monitoring.

• Determine the appropriate level of care required based on risk stratification of patients with cardiac arrhythmias.

• Identify and prioritize high-risk arrhythmias that require urgent intervention and implement emergency protocols as indicated.

• Formulate patient-specific and evidence-based care plans incorporating diagnostic findings, prognosis, and patient characteristics.

• Develop patient-specific care plans that may include rate-controlling interventions, cardioversion, defibrillation, or implantable medical devices.

• Communicate with patients and families to explain the natural history and prognosis of cardiac arrhythmias.

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

• Communicate with patients and families to explain drug interactions for antiarrhythmic drugs and the importance of strict adherence to medication regimens and laboratory monitoring.

• Facilitate discharge planning early during hospitalization.

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians. 

Hospitalists should be able to:

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

• Follow evidence-based recommendations to guide diagnosis, monitoring, and treatment of cardiac arrhythmias.

• Acknowledge and ameliorate patient discomfort from uncontrolled arrhythmias and electrical cardioversion therapies. 

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

• Lead, coordinate, and/or participate in multidisciplinary teams to develop patient care guidelines and/or pathways on the basis of peer-reviewed outcomes research, patient and physician satisfaction, and cost.

• Implement systems to ensure hospital-wide adherence to national standards and document those measures as specified by recognized organizations (eg, The Joint Commission, American Heart Association, American College of Cardiology, Agency for Healthcare Research and Quality).

• Lead, coordinate, and/or participate in quality improvement initiatives to promote early identification of arrhythmias, reduce preventable complications, and promote appropriate use of telemetry resources.

Chronic obstructive pulmonary disease (COPD) is a heterogeneous group of respiratory conditions, predominantly composed of chronic bronchitis and emphysema. COPD is defined by airflow limitation that is not completely reversible, and it is associated with an abnormal airway inflammatory response. Exposure to tobacco smoke is the main risk factor. COPD affects more than 12 million Americans and is the third leading cause of death in the United States. A COPD exacerbation is defined as an increase in the usual symptoms of COPD that is beyond day-to-day variations and leads to a change in medication and often results in hospitalization. Annually, more than 670,000 hospital discharges occur with COPD as the primary diagnosis, and nearly 1 of every 5 hospitalized patients 40 years or older has COPD.^1,2The average length of stay is 4.3 days.¹ COPD is a substantial cause of disability and carries a large economic burden, accounting for almost $17 billion of total hospital charges billed to Medicare each year.³ The early detection and prompt treatment of exacerbations are essential to ensure optimal outcomes and to reduce the burden of COPD. Hospitalists use evidence-based approaches to optimize care, and they should strive to lead multidisciplinary teams to develop institutional guidelines and/or care pathways to reduce readmission rates and mortality from COPD exacerbations. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Define COPD and describe the pathophysiologic processes that lead to small airway obstruction and alveolar destruction.

• Describe potential precipitants of exacerbation, including both infectious and noninfectious etiologies.

• Differentiate the clinical presentation of a COPD exacerbation from asthma, heart failure, and other acute respiratory and nonrespiratory syndromes.

• List the indicators of disease severity.

• Describe the role of diagnostic testing used for the evaluation of COPD.

• Describe the role of pulmonary function tests in the treatment of a COPD exacerbation.

• Distinguish the medical management of patients with COPD exacerbations from that of patients with stable COPD.

• Recognize indications for specialty consultation, which may include pulmonary medicine.

• Describe the evidence-based therapies for treatment of COPD exacerbations, which may include bronchodilators, systemic corticosteroids, oxygen, and antibiotics.

• Identify the potential risks of supplemental oxygen therapy, including development of hypercarbia in patients with chronic respiratory acidosis.

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

• Describe and differentiate the means of ventilatory support, including the use of noninvasive positive pressure ventilation in COPD exacerbation.

• Recognize anxiety and depression as important comorbid conditions that negatively affect outcomes.

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

Hospitalists should be able to:

• Elicit a thorough and relevant medical history to identify symptoms consistent with a COPD exacerbation and etiologic precipitants.

• Perform a targeted physical examination to elicit signs consistent with a COPD exacerbation, differentiate findings from those of other mimicking conditions, and assess illness severity.

• Diagnose a COPD exacerbation on the basis of history, physical examination, and radiographic data.

• Select and interpret appropriate diagnostic studies to evaluate the severity of a COPD exacerbation.

• Recognize symptoms, signs, and severity of impending respiratory failure and select the indicated evidence-based ventilatory approach.

• Select patients with COPD exacerbation who would benefit from use of positive pressure ventilation and identify those in whom this intervention is contraindicated.

• Prescribe appropriate evidence-based pharmacologic therapies during COPD exacerbation, recommending the most appropriate drug route, dose, frequency, and duration of treatment.

• Address treatment preferences, including advance directives early during hospital stay; implement end-of-life decisions by patients and/or families when indicated or desired.

• Evaluate COPD in perioperative risk assessment, recommend measures to optimize perioperative management of COPD, and manage postoperative complications related to underlying COPD.

• Identify patients with COPD who may benefit from pulmonary rehabilitation.

• Communicate with patients and families to explain the natural history and prognosis of COPD.

• Facilitate discharge planning early during hospitalization.

• Communicate with patients and families to explain discharge medications, potential adverse effects, duration of therapy and dosing, and taper schedule.

• Ensure that patients receive training on proper inhaler techniques and use before hospital discharge.

• Communicate with patients and families to explain the goals of care (including clinical stability criteria, the importance of preventive measures), discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians.

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

Hospitalists should be able to:

• Employ a multidisciplinary approach, which may include pulmonary medicine, respiratory therapy, nursing, and social services, in the care of patients with a COPD exacerbation, beginning at admission and continuing through all care transitions.

• Engage in a collaborative way with primary care physicians and emergency physicians in making admission decisions.

• Promote and encourage preventive strategies, including smoking cessation, vaccinations, and venous thromboembolism prophylaxis.

• Establish and maintain an open dialogue with patients and/or families regarding goals and limitations of care, including palliative care and end-of-life wishes. 

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

• Lead, coordinate, and/or participate in multidisciplinary initiatives, which may include collaborative efforts with pulmonologists, to promote patient safety and optimize cost-effective diagnostic and management strategies for patients with COPD.

• Lead, coordinate, and/or participate in the development of educational modules, order sets, and/or pathways that facilitate use of evidence-based strategies for COPD exacerbation in the emergency department and the hospital, with goals of improving outcomes, decreasing length of stay, and reducing rehospitalization rates.

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

Chronic obstructive pulmonary disease (COPD) is a heterogeneous group of respiratory conditions, predominantly composed of chronic bronchitis and emphysema. COPD is defined by airflow limitation that is not completely reversible, and it is associated with an abnormal airway inflammatory response. Exposure to tobacco smoke is the main risk factor. COPD affects more than 12 million Americans and is the third leading cause of death in the United States. A COPD exacerbation is defined as an increase in the usual symptoms of COPD that is beyond day-to-day variations and leads to a change in medication and often results in hospitalization. Annually, more than 670,000 hospital discharges occur with COPD as the primary diagnosis, and nearly 1 of every 5 hospitalized patients 40 years or older has COPD.^1,2The average length of stay is 4.3 days.¹ COPD is a substantial cause of disability and carries a large economic burden, accounting for almost $17 billion of total hospital charges billed to Medicare each year.³ The early detection and prompt treatment of exacerbations are essential to ensure optimal outcomes and to reduce the burden of COPD. Hospitalists use evidence-based approaches to optimize care, and they should strive to lead multidisciplinary teams to develop institutional guidelines and/or care pathways to reduce readmission rates and mortality from COPD exacerbations. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Define COPD and describe the pathophysiologic processes that lead to small airway obstruction and alveolar destruction.

• Describe potential precipitants of exacerbation, including both infectious and noninfectious etiologies.

• Differentiate the clinical presentation of a COPD exacerbation from asthma, heart failure, and other acute respiratory and nonrespiratory syndromes.

• List the indicators of disease severity.

• Describe the role of diagnostic testing used for the evaluation of COPD.

• Describe the role of pulmonary function tests in the treatment of a COPD exacerbation.

• Distinguish the medical management of patients with COPD exacerbations from that of patients with stable COPD.

• Recognize indications for specialty consultation, which may include pulmonary medicine.

• Describe the evidence-based therapies for treatment of COPD exacerbations, which may include bronchodilators, systemic corticosteroids, oxygen, and antibiotics.

• Identify the potential risks of supplemental oxygen therapy, including development of hypercarbia in patients with chronic respiratory acidosis.

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

• Describe and differentiate the means of ventilatory support, including the use of noninvasive positive pressure ventilation in COPD exacerbation.

• Recognize anxiety and depression as important comorbid conditions that negatively affect outcomes.

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

Hospitalists should be able to:

• Elicit a thorough and relevant medical history to identify symptoms consistent with a COPD exacerbation and etiologic precipitants.

• Perform a targeted physical examination to elicit signs consistent with a COPD exacerbation, differentiate findings from those of other mimicking conditions, and assess illness severity.

• Diagnose a COPD exacerbation on the basis of history, physical examination, and radiographic data.

• Select and interpret appropriate diagnostic studies to evaluate the severity of a COPD exacerbation.

• Recognize symptoms, signs, and severity of impending respiratory failure and select the indicated evidence-based ventilatory approach.

• Select patients with COPD exacerbation who would benefit from use of positive pressure ventilation and identify those in whom this intervention is contraindicated.

• Prescribe appropriate evidence-based pharmacologic therapies during COPD exacerbation, recommending the most appropriate drug route, dose, frequency, and duration of treatment.

• Address treatment preferences, including advance directives early during hospital stay; implement end-of-life decisions by patients and/or families when indicated or desired.

• Evaluate COPD in perioperative risk assessment, recommend measures to optimize perioperative management of COPD, and manage postoperative complications related to underlying COPD.

• Identify patients with COPD who may benefit from pulmonary rehabilitation.

• Communicate with patients and families to explain the natural history and prognosis of COPD.

• Facilitate discharge planning early during hospitalization.

• Communicate with patients and families to explain discharge medications, potential adverse effects, duration of therapy and dosing, and taper schedule.

• Ensure that patients receive training on proper inhaler techniques and use before hospital discharge.

• Communicate with patients and families to explain the goals of care (including clinical stability criteria, the importance of preventive measures), discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians.

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

Hospitalists should be able to:

• Employ a multidisciplinary approach, which may include pulmonary medicine, respiratory therapy, nursing, and social services, in the care of patients with a COPD exacerbation, beginning at admission and continuing through all care transitions.

• Engage in a collaborative way with primary care physicians and emergency physicians in making admission decisions.

• Promote and encourage preventive strategies, including smoking cessation, vaccinations, and venous thromboembolism prophylaxis.

• Establish and maintain an open dialogue with patients and/or families regarding goals and limitations of care, including palliative care and end-of-life wishes. 

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

• Lead, coordinate, and/or participate in multidisciplinary initiatives, which may include collaborative efforts with pulmonologists, to promote patient safety and optimize cost-effective diagnostic and management strategies for patients with COPD.

• Lead, coordinate, and/or participate in the development of educational modules, order sets, and/or pathways that facilitate use of evidence-based strategies for COPD exacerbation in the emergency department and the hospital, with goals of improving outcomes, decreasing length of stay, and reducing rehospitalization rates.

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

Chronic obstructive pulmonary disease (COPD) is a heterogeneous group of respiratory conditions, predominantly composed of chronic bronchitis and emphysema. COPD is defined by airflow limitation that is not completely reversible, and it is associated with an abnormal airway inflammatory response. Exposure to tobacco smoke is the main risk factor. COPD affects more than 12 million Americans and is the third leading cause of death in the United States. A COPD exacerbation is defined as an increase in the usual symptoms of COPD that is beyond day-to-day variations and leads to a change in medication and often results in hospitalization. Annually, more than 670,000 hospital discharges occur with COPD as the primary diagnosis, and nearly 1 of every 5 hospitalized patients 40 years or older has COPD.^1,2The average length of stay is 4.3 days.¹ COPD is a substantial cause of disability and carries a large economic burden, accounting for almost $17 billion of total hospital charges billed to Medicare each year.³ The early detection and prompt treatment of exacerbations are essential to ensure optimal outcomes and to reduce the burden of COPD. Hospitalists use evidence-based approaches to optimize care, and they should strive to lead multidisciplinary teams to develop institutional guidelines and/or care pathways to reduce readmission rates and mortality from COPD exacerbations. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Define COPD and describe the pathophysiologic processes that lead to small airway obstruction and alveolar destruction.

• Describe potential precipitants of exacerbation, including both infectious and noninfectious etiologies.

• Differentiate the clinical presentation of a COPD exacerbation from asthma, heart failure, and other acute respiratory and nonrespiratory syndromes.

• List the indicators of disease severity.

• Describe the role of diagnostic testing used for the evaluation of COPD.

• Describe the role of pulmonary function tests in the treatment of a COPD exacerbation.

• Distinguish the medical management of patients with COPD exacerbations from that of patients with stable COPD.

• Recognize indications for specialty consultation, which may include pulmonary medicine.

• Describe the evidence-based therapies for treatment of COPD exacerbations, which may include bronchodilators, systemic corticosteroids, oxygen, and antibiotics.

• Identify the potential risks of supplemental oxygen therapy, including development of hypercarbia in patients with chronic respiratory acidosis.

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

• Describe and differentiate the means of ventilatory support, including the use of noninvasive positive pressure ventilation in COPD exacerbation.

• Recognize anxiety and depression as important comorbid conditions that negatively affect outcomes.

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

Hospitalists should be able to:

• Elicit a thorough and relevant medical history to identify symptoms consistent with a COPD exacerbation and etiologic precipitants.

• Perform a targeted physical examination to elicit signs consistent with a COPD exacerbation, differentiate findings from those of other mimicking conditions, and assess illness severity.

• Diagnose a COPD exacerbation on the basis of history, physical examination, and radiographic data.

• Select and interpret appropriate diagnostic studies to evaluate the severity of a COPD exacerbation.

• Recognize symptoms, signs, and severity of impending respiratory failure and select the indicated evidence-based ventilatory approach.

• Select patients with COPD exacerbation who would benefit from use of positive pressure ventilation and identify those in whom this intervention is contraindicated.

• Prescribe appropriate evidence-based pharmacologic therapies during COPD exacerbation, recommending the most appropriate drug route, dose, frequency, and duration of treatment.

• Address treatment preferences, including advance directives early during hospital stay; implement end-of-life decisions by patients and/or families when indicated or desired.

• Evaluate COPD in perioperative risk assessment, recommend measures to optimize perioperative management of COPD, and manage postoperative complications related to underlying COPD.

• Identify patients with COPD who may benefit from pulmonary rehabilitation.

• Communicate with patients and families to explain the natural history and prognosis of COPD.

• Facilitate discharge planning early during hospitalization.

• Communicate with patients and families to explain discharge medications, potential adverse effects, duration of therapy and dosing, and taper schedule.

• Ensure that patients receive training on proper inhaler techniques and use before hospital discharge.

• Communicate with patients and families to explain the goals of care (including clinical stability criteria, the importance of preventive measures), discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians.

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

Hospitalists should be able to:

• Employ a multidisciplinary approach, which may include pulmonary medicine, respiratory therapy, nursing, and social services, in the care of patients with a COPD exacerbation, beginning at admission and continuing through all care transitions.

• Engage in a collaborative way with primary care physicians and emergency physicians in making admission decisions.

• Promote and encourage preventive strategies, including smoking cessation, vaccinations, and venous thromboembolism prophylaxis.

• Establish and maintain an open dialogue with patients and/or families regarding goals and limitations of care, including palliative care and end-of-life wishes. 

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

• Lead, coordinate, and/or participate in multidisciplinary initiatives, which may include collaborative efforts with pulmonologists, to promote patient safety and optimize cost-effective diagnostic and management strategies for patients with COPD.

• Lead, coordinate, and/or participate in the development of educational modules, order sets, and/or pathways that facilitate use of evidence-based strategies for COPD exacerbation in the emergency department and the hospital, with goals of improving outcomes, decreasing length of stay, and reducing rehospitalization rates.

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

Community-acquired pneumonia (CAP) is an infection of the lung parenchyma that occurs in the community or is diagnosed within 48 hours of hospital admission. CAP is a common and potentially life-threatening infection, and it is a leading cause of death from infectious diseases. Approximately 25% of persons with CAP require hospitalization, and 10% to 20% of these patients require admission to the intensive care unit.^1-3 The mortality rate ranges from about 13% in hospitalized patients to 36% in patients admitted to the intensive care unit.^1-3 CAP is a curable condition and an organized approach to management is likely to improve clinical results and reduce mortality. Pneumonia outcome measures are used to evaluate performance of healthcare providers and organizations. Hospitalists apply evidence-based guidelines to the management of patients hospitalized with pneumonia and lead initiatives to improve quality of care and reduce practice variability. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Define CAP, list the likely etiologies and the signs and symptoms, and distinguish CAP from hospital-acquired pneumonia and healthcare-associated pneumonia.

• Describe other causes of pulmonary infiltrates on radiographic studies.

• Describe the tests indicated to evaluate and treat CAP.

• Explain indications for respiratory isolation.

• Identify patients with comorbidities (such as immunocompromise, diabetes mellitus, and extremes of age) who are at high risk of a complicated course.

• Identify specific pathogens that predispose patients to a complicated course.

• Recognize indications for specialty consultation.

• Describe indicated therapeutic modalities for CAP, including oxygen therapy, respiratory care modalities, appropriate antimicrobial selection and duration, and other evidence-based treatments.

• Predict patient risk for morbidity and mortality from CAP using a validated risk score.

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

• Describe factors associated with a nonresponding pneumonia.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history to identify symptoms consistent with CAP and demographic factors that may predispose patients to CAP.

• Perform a targeted physical examination to elicit signs consistent with CAP and differentiate it from other mimicking conditions.

• Order and interpret laboratory, microbiologic, and radiologic studies to confirm the diagnosis of CAP and risk stratify patients.

• Apply evidence-based tools (such as the Pneumonia Severity Index) to triage decisions and identify factors that support the need for intensive care unit admission.

• Initiate empiric antimicrobials for CAP on the basis of illness severity and evidence-based national guidelines, incorporating local resistance patterns.

• Formulate a subsequent treatment plan that includes narrowing antimicrobial therapies on the basis of available culture data and patient response to treatment.

• Recognize the criteria for clinical stability, including the appropriate deescalation of treatment such as transitioning from parenteral to oral antimicrobials.

• Recognize and address complications of CAP and/or inadequate response to therapy, including respiratory failure and parapneumonic effusions.

• Communicate with patients and families to explain the pathophysiology and prognosis of CAP.

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

• Communicate with patients and families to explain the use and potential adverse effects of pharmacologic agents.

• Facilitate discharge planning early during hospitalization.

• Communicate with patients and families to explain the goals of care (including clinical stability criteria, the importance of preventive measures such as smoking cessation), discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

• Recognize and address barriers to follow-up care and anticipated postdischarge requirements.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians. 

Hospitalists should be able to:

• Employ a multidisciplinary approach, which may include nursing, respiratory therapy, nutrition, and pharmacy services, to the care of patients with CAP through all care transitions.

• Follow evidence-based recommendations for the treatment of patients with CAP.

• Work collaboratively with primary care physicians and emergency physicians in making admission decisions. 

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

• Lead, coordinate, and/or participate in multidisciplinary initiatives, which may include collaborative efforts with infectious disease and pulmonary specialists, to promote patient safety and cost-effective diagnostic and management strategies for patients with CAP.

• Lead, coordinate, and/or participate in efforts to identify, address, and monitor quality indicators for CAP.

• Implement systems to ensure hospital-wide adherence to national standards and document those measures as specified by recognized organizations (eg, Centers for Medicare & Medicaid Services, Infectious Diseases Society of America, American Thoracic Society).

• Integrate evidence-based clinical severity scores and clinical judgment into admission decisions.

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

Community-acquired pneumonia (CAP) is an infection of the lung parenchyma that occurs in the community or is diagnosed within 48 hours of hospital admission. CAP is a common and potentially life-threatening infection, and it is a leading cause of death from infectious diseases. Approximately 25% of persons with CAP require hospitalization, and 10% to 20% of these patients require admission to the intensive care unit.^1-3 The mortality rate ranges from about 13% in hospitalized patients to 36% in patients admitted to the intensive care unit.^1-3 CAP is a curable condition and an organized approach to management is likely to improve clinical results and reduce mortality. Pneumonia outcome measures are used to evaluate performance of healthcare providers and organizations. Hospitalists apply evidence-based guidelines to the management of patients hospitalized with pneumonia and lead initiatives to improve quality of care and reduce practice variability. 

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Hospitalists should be able to:

• Define CAP, list the likely etiologies and the signs and symptoms, and distinguish CAP from hospital-acquired pneumonia and healthcare-associated pneumonia.

• Describe other causes of pulmonary infiltrates on radiographic studies.

• Describe the tests indicated to evaluate and treat CAP.

• Explain indications for respiratory isolation.

• Identify patients with comorbidities (such as immunocompromise, diabetes mellitus, and extremes of age) who are at high risk of a complicated course.

• Identify specific pathogens that predispose patients to a complicated course.

• Recognize indications for specialty consultation.

• Describe indicated therapeutic modalities for CAP, including oxygen therapy, respiratory care modalities, appropriate antimicrobial selection and duration, and other evidence-based treatments.

• Predict patient risk for morbidity and mortality from CAP using a validated risk score.

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

• Describe factors associated with a nonresponding pneumonia.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history to identify symptoms consistent with CAP and demographic factors that may predispose patients to CAP.

• Perform a targeted physical examination to elicit signs consistent with CAP and differentiate it from other mimicking conditions.

• Order and interpret laboratory, microbiologic, and radiologic studies to confirm the diagnosis of CAP and risk stratify patients.

• Apply evidence-based tools (such as the Pneumonia Severity Index) to triage decisions and identify factors that support the need for intensive care unit admission.

• Initiate empiric antimicrobials for CAP on the basis of illness severity and evidence-based national guidelines, incorporating local resistance patterns.

• Formulate a subsequent treatment plan that includes narrowing antimicrobial therapies on the basis of available culture data and patient response to treatment.

• Recognize the criteria for clinical stability, including the appropriate deescalation of treatment such as transitioning from parenteral to oral antimicrobials.

• Recognize and address complications of CAP and/or inadequate response to therapy, including respiratory failure and parapneumonic effusions.

• Communicate with patients and families to explain the pathophysiology and prognosis of CAP.

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

• Communicate with patients and families to explain the use and potential adverse effects of pharmacologic agents.

• Facilitate discharge planning early during hospitalization.

• Communicate with patients and families to explain the goals of care (including clinical stability criteria, the importance of preventive measures such as smoking cessation), discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

• Recognize and address barriers to follow-up care and anticipated postdischarge requirements.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians. 

Hospitalists should be able to:

• Employ a multidisciplinary approach, which may include nursing, respiratory therapy, nutrition, and pharmacy services, to the care of patients with CAP through all care transitions.

• Follow evidence-based recommendations for the treatment of patients with CAP.

• Work collaboratively with primary care physicians and emergency physicians in making admission decisions. 

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

• Lead, coordinate, and/or participate in multidisciplinary initiatives, which may include collaborative efforts with infectious disease and pulmonary specialists, to promote patient safety and cost-effective diagnostic and management strategies for patients with CAP.

• Lead, coordinate, and/or participate in efforts to identify, address, and monitor quality indicators for CAP.

• Implement systems to ensure hospital-wide adherence to national standards and document those measures as specified by recognized organizations (eg, Centers for Medicare & Medicaid Services, Infectious Diseases Society of America, American Thoracic Society).

• Integrate evidence-based clinical severity scores and clinical judgment into admission decisions.

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

Community-acquired pneumonia (CAP) is an infection of the lung parenchyma that occurs in the community or is diagnosed within 48 hours of hospital admission. CAP is a common and potentially life-threatening infection, and it is a leading cause of death from infectious diseases. Approximately 25% of persons with CAP require hospitalization, and 10% to 20% of these patients require admission to the intensive care unit.^1-3 The mortality rate ranges from about 13% in hospitalized patients to 36% in patients admitted to the intensive care unit.^1-3 CAP is a curable condition and an organized approach to management is likely to improve clinical results and reduce mortality. Pneumonia outcome measures are used to evaluate performance of healthcare providers and organizations. Hospitalists apply evidence-based guidelines to the management of patients hospitalized with pneumonia and lead initiatives to improve quality of care and reduce practice variability. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Define CAP, list the likely etiologies and the signs and symptoms, and distinguish CAP from hospital-acquired pneumonia and healthcare-associated pneumonia.

• Describe other causes of pulmonary infiltrates on radiographic studies.

• Describe the tests indicated to evaluate and treat CAP.

• Explain indications for respiratory isolation.

• Identify patients with comorbidities (such as immunocompromise, diabetes mellitus, and extremes of age) who are at high risk of a complicated course.

• Identify specific pathogens that predispose patients to a complicated course.

• Recognize indications for specialty consultation.

• Describe indicated therapeutic modalities for CAP, including oxygen therapy, respiratory care modalities, appropriate antimicrobial selection and duration, and other evidence-based treatments.

• Predict patient risk for morbidity and mortality from CAP using a validated risk score.

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

• Describe factors associated with a nonresponding pneumonia.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history to identify symptoms consistent with CAP and demographic factors that may predispose patients to CAP.

• Perform a targeted physical examination to elicit signs consistent with CAP and differentiate it from other mimicking conditions.

• Order and interpret laboratory, microbiologic, and radiologic studies to confirm the diagnosis of CAP and risk stratify patients.

• Apply evidence-based tools (such as the Pneumonia Severity Index) to triage decisions and identify factors that support the need for intensive care unit admission.

• Initiate empiric antimicrobials for CAP on the basis of illness severity and evidence-based national guidelines, incorporating local resistance patterns.

• Formulate a subsequent treatment plan that includes narrowing antimicrobial therapies on the basis of available culture data and patient response to treatment.

• Recognize the criteria for clinical stability, including the appropriate deescalation of treatment such as transitioning from parenteral to oral antimicrobials.

• Recognize and address complications of CAP and/or inadequate response to therapy, including respiratory failure and parapneumonic effusions.

• Communicate with patients and families to explain the pathophysiology and prognosis of CAP.

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

• Communicate with patients and families to explain the use and potential adverse effects of pharmacologic agents.

• Facilitate discharge planning early during hospitalization.

• Communicate with patients and families to explain the goals of care (including clinical stability criteria, the importance of preventive measures such as smoking cessation), discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

• Recognize and address barriers to follow-up care and anticipated postdischarge requirements.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians. 

Hospitalists should be able to:

• Employ a multidisciplinary approach, which may include nursing, respiratory therapy, nutrition, and pharmacy services, to the care of patients with CAP through all care transitions.

• Follow evidence-based recommendations for the treatment of patients with CAP.

• Work collaboratively with primary care physicians and emergency physicians in making admission decisions. 

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

• Lead, coordinate, and/or participate in multidisciplinary initiatives, which may include collaborative efforts with infectious disease and pulmonary specialists, to promote patient safety and cost-effective diagnostic and management strategies for patients with CAP.

• Lead, coordinate, and/or participate in efforts to identify, address, and monitor quality indicators for CAP.

• Implement systems to ensure hospital-wide adherence to national standards and document those measures as specified by recognized organizations (eg, Centers for Medicare & Medicaid Services, Infectious Diseases Society of America, American Thoracic Society).

• Integrate evidence-based clinical severity scores and clinical judgment into admission decisions.

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

DELIRIUM
Delirium is defined as an acute, transient, global disorder of cognition. In two-thirds of cases, delirium occurs in patients with baseline vulnerability, including those with underlying dementia.¹ Although up to 30% of older medical patients experience delirium during hospitalization, this condition is unrecognized in nearly two-thirds of cases.^2-4 Patients with delirium experience an average increase in length of hospital stay of 8 days and mortality rates that are twice as high as those of patients without delirium.^5,6 In addition, delirium is associated with high rates of functional and cognitive decline and skilled nursing facility placement after hospitalization. The cost of caring for patients with delirium has a marked impact on individual patients, families, and hospital systems. Hospitalists lead their institutions in the development of screening and prevention protocols for patients at risk for delirium, as well as in the promotion of safe treatment approaches. Hospitalists also develop strategies to operationalize cost-effective delirium prevention programs that improve outcomes. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Define delirium and dementia and distinguish between them.

• Differentiate delirium from other causes of cognitive impairment, confusion, or psychosis.

• Describe the indicated tests required to evaluate delirium.

• Describe the causes of delirium in the hospital setting including environmental and iatrogenic risk factors.

• Identify medications known to precipitate delirium.

• Recognize the indications for specialty consultations.

• Describe methods for the prevention of delirium.

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

• Describe nonpharmacologic therapies to manage delirium.

• Describe the complications of delirium in the hospitalized patient.

• Discuss the multifaceted impact that delirium has on patients and their families.

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

Hospitalists should be able to:

• Predict a patient’s risk for the development of delirium on the basis of initial history and physical examination.

• Perform appropriate screening for delirium.

• Develop active strategies to reduce delirium in the hospital setting by identifying known patient risk factors that may precipitate delirium.

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

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

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

• Lead multidisciplinary teams to develop and implement care plans for patients with delirium.

• Develop an appropriate pharmacologic plan to manage delirium.

• Develop an appropriate nonpharmacologic plan to manage delirium.

• Develop an appropriate management plan for patients with delirium in the postoperative setting.

• Document an appropriate treatment plan to reduce mortality, limit the duration of delirium and the time required to control agitation, maintain adequate control of delirium, address complications, and manage cost of treatment.

• Use a patient- and family-centered approach in the care of older inpatients.

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

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

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

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care. 

Hospitalists should be able to:

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

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

• Value a patient- and family-centered approach in the care of older inpatients. 

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

• Lead, coordinate, and/or participate in multidisciplinary teams to develop early treatment protocols.

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

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

• Engage stakeholders in hospital initiatives to improve safety and quality in the care of patients with delirium.

DEMENTIA
Dementia is defined as a chronic, often progressive, decline in cognitive function, eventually limiting daily activities. Dementia is a common comorbidity in the hospitalized older patient. Alzheimer disease is the most prevalent form of dementia in older patients, and it accounts for up to 80% of cases.^7,8 More than 5 million persons older than 65 years have Alzheimer disease in the United States.^7,8 Patients with dementia are at increased risk for delirium, falls, and functional decline during hospitalization. Patients with baseline cognitive impairment have prolonged lengths of stay and complex needs after discharge. Agitation and behavioral symptoms of dementia can be exacerbated in the hospital setting and are often difficult to manage. Care of the patient with dementia requires that hospitalists engage in a multidisciplinary approach to inpatient and transitional care. Hospitalists may also become involved in hospital quality and safety initiatives that pertain to areas such as restraint use and fall prevention. 

Hospitalists should be able to:

• Define delirium and dementia and distinguish between them.

• Differentiate dementia from other causes of cognitive impairment, confusion, or psychosis.

• Describe the indicated tests required to evaluate dementia.

• Describe the causes of potentially reversible dementias or dementia-like conditions.

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

• Describe nonpharmacologic therapies to manage dementia symptoms.

• Recognize the indications for specialty consultations.

• Describe the complications of dementia in the hospitalized patient.

• Discuss the multifaceted impact that dementia has on patients and their families.

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

Hospitalists should be able to:

• Perform appropriate screening for dementia.

• Develop active strategies to reduce development of delirium in patients with dementia in the hospital setting by identifying known patient risk factors that may precipitate delirium.

• Assess patients with suspected dementia in a timely manner, identify the level of care required, and manage or comanage patients with the primary requesting service.

• Assess patients for potentially reversible causes of dementia or dementia-like conditions. Assess severity of cognitive impairment and perform a focused evaluation for the underlying etiology of dementia when appropriate.

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

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

• Develop an appropriate pharmacologic plan to manage dementia.

• Develop an appropriate nonpharmacologic plan to manage dementia.

• Use a patient- and family-centered approach in the care of older inpatients.

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

• Use evidence-based methods and tools to assess patients’ medical decision-making capacity.

• Defend patients’ right to autonomy when so qualified.

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

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care. 

Hospitalists should be able to:

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

• Follow evidence-based recommendations to guide diagnosis, monitoring, and treatment of dementia and its causes.

• Value a patient- and family-centered approach to educate and engage families and caregivers in the care of older inpatients.

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

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

• Lead, coordinate, and/or participate in multidisciplinary teams to develop early treatment protocols.

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

• Lead, coordinate, and/or participate in multidisciplinary initiatives, which may include collaboration withgeriatricians, to promote patient safety and cost-effective diagnostic and management strategies for older patients.

• Engage stakeholders in hospital initiatives to improve safety and quality in the care of patients with dementia.

DELIRIUM
Delirium is defined as an acute, transient, global disorder of cognition. In two-thirds of cases, delirium occurs in patients with baseline vulnerability, including those with underlying dementia.¹ Although up to 30% of older medical patients experience delirium during hospitalization, this condition is unrecognized in nearly two-thirds of cases.^2-4 Patients with delirium experience an average increase in length of hospital stay of 8 days and mortality rates that are twice as high as those of patients without delirium.^5,6 In addition, delirium is associated with high rates of functional and cognitive decline and skilled nursing facility placement after hospitalization. The cost of caring for patients with delirium has a marked impact on individual patients, families, and hospital systems. Hospitalists lead their institutions in the development of screening and prevention protocols for patients at risk for delirium, as well as in the promotion of safe treatment approaches. Hospitalists also develop strategies to operationalize cost-effective delirium prevention programs that improve outcomes. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Define delirium and dementia and distinguish between them.

• Differentiate delirium from other causes of cognitive impairment, confusion, or psychosis.

• Describe the indicated tests required to evaluate delirium.

• Describe the causes of delirium in the hospital setting including environmental and iatrogenic risk factors.

• Identify medications known to precipitate delirium.

• Recognize the indications for specialty consultations.

• Describe methods for the prevention of delirium.

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

• Describe nonpharmacologic therapies to manage delirium.

• Describe the complications of delirium in the hospitalized patient.

• Discuss the multifaceted impact that delirium has on patients and their families.

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

Hospitalists should be able to:

• Predict a patient’s risk for the development of delirium on the basis of initial history and physical examination.

• Perform appropriate screening for delirium.

• Develop active strategies to reduce delirium in the hospital setting by identifying known patient risk factors that may precipitate delirium.

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

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

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

• Lead multidisciplinary teams to develop and implement care plans for patients with delirium.

• Develop an appropriate pharmacologic plan to manage delirium.

• Develop an appropriate nonpharmacologic plan to manage delirium.

• Develop an appropriate management plan for patients with delirium in the postoperative setting.

• Document an appropriate treatment plan to reduce mortality, limit the duration of delirium and the time required to control agitation, maintain adequate control of delirium, address complications, and manage cost of treatment.

• Use a patient- and family-centered approach in the care of older inpatients.

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

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

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

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care. 

Hospitalists should be able to:

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

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

• Value a patient- and family-centered approach in the care of older inpatients. 

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

• Lead, coordinate, and/or participate in multidisciplinary teams to develop early treatment protocols.

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

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

• Engage stakeholders in hospital initiatives to improve safety and quality in the care of patients with delirium.

DEMENTIA
Dementia is defined as a chronic, often progressive, decline in cognitive function, eventually limiting daily activities. Dementia is a common comorbidity in the hospitalized older patient. Alzheimer disease is the most prevalent form of dementia in older patients, and it accounts for up to 80% of cases.^7,8 More than 5 million persons older than 65 years have Alzheimer disease in the United States.^7,8 Patients with dementia are at increased risk for delirium, falls, and functional decline during hospitalization. Patients with baseline cognitive impairment have prolonged lengths of stay and complex needs after discharge. Agitation and behavioral symptoms of dementia can be exacerbated in the hospital setting and are often difficult to manage. Care of the patient with dementia requires that hospitalists engage in a multidisciplinary approach to inpatient and transitional care. Hospitalists may also become involved in hospital quality and safety initiatives that pertain to areas such as restraint use and fall prevention. 

Hospitalists should be able to:

• Define delirium and dementia and distinguish between them.

• Differentiate dementia from other causes of cognitive impairment, confusion, or psychosis.

• Describe the indicated tests required to evaluate dementia.

• Describe the causes of potentially reversible dementias or dementia-like conditions.

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

• Describe nonpharmacologic therapies to manage dementia symptoms.

• Recognize the indications for specialty consultations.

• Describe the complications of dementia in the hospitalized patient.

• Discuss the multifaceted impact that dementia has on patients and their families.

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

Hospitalists should be able to:

• Perform appropriate screening for dementia.

• Develop active strategies to reduce development of delirium in patients with dementia in the hospital setting by identifying known patient risk factors that may precipitate delirium.

• Assess patients with suspected dementia in a timely manner, identify the level of care required, and manage or comanage patients with the primary requesting service.

• Assess patients for potentially reversible causes of dementia or dementia-like conditions. Assess severity of cognitive impairment and perform a focused evaluation for the underlying etiology of dementia when appropriate.

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

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

• Develop an appropriate pharmacologic plan to manage dementia.

• Develop an appropriate nonpharmacologic plan to manage dementia.

• Use a patient- and family-centered approach in the care of older inpatients.

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

• Use evidence-based methods and tools to assess patients’ medical decision-making capacity.

• Defend patients’ right to autonomy when so qualified.

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

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care. 

Hospitalists should be able to:

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

• Follow evidence-based recommendations to guide diagnosis, monitoring, and treatment of dementia and its causes.

• Value a patient- and family-centered approach to educate and engage families and caregivers in the care of older inpatients.

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

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

• Lead, coordinate, and/or participate in multidisciplinary teams to develop early treatment protocols.

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

• Lead, coordinate, and/or participate in multidisciplinary initiatives, which may include collaboration withgeriatricians, to promote patient safety and cost-effective diagnostic and management strategies for older patients.

• Engage stakeholders in hospital initiatives to improve safety and quality in the care of patients with dementia.

DELIRIUM
Delirium is defined as an acute, transient, global disorder of cognition. In two-thirds of cases, delirium occurs in patients with baseline vulnerability, including those with underlying dementia.¹ Although up to 30% of older medical patients experience delirium during hospitalization, this condition is unrecognized in nearly two-thirds of cases.^2-4 Patients with delirium experience an average increase in length of hospital stay of 8 days and mortality rates that are twice as high as those of patients without delirium.^5,6 In addition, delirium is associated with high rates of functional and cognitive decline and skilled nursing facility placement after hospitalization. The cost of caring for patients with delirium has a marked impact on individual patients, families, and hospital systems. Hospitalists lead their institutions in the development of screening and prevention protocols for patients at risk for delirium, as well as in the promotion of safe treatment approaches. Hospitalists also develop strategies to operationalize cost-effective delirium prevention programs that improve outcomes. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Define delirium and dementia and distinguish between them.

• Differentiate delirium from other causes of cognitive impairment, confusion, or psychosis.

• Describe the indicated tests required to evaluate delirium.

• Describe the causes of delirium in the hospital setting including environmental and iatrogenic risk factors.

• Identify medications known to precipitate delirium.

• Recognize the indications for specialty consultations.

• Describe methods for the prevention of delirium.

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

• Describe nonpharmacologic therapies to manage delirium.

• Describe the complications of delirium in the hospitalized patient.

• Discuss the multifaceted impact that delirium has on patients and their families.

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

Hospitalists should be able to:

• Predict a patient’s risk for the development of delirium on the basis of initial history and physical examination.

• Perform appropriate screening for delirium.

• Develop active strategies to reduce delirium in the hospital setting by identifying known patient risk factors that may precipitate delirium.

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

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

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

• Lead multidisciplinary teams to develop and implement care plans for patients with delirium.

• Develop an appropriate pharmacologic plan to manage delirium.

• Develop an appropriate nonpharmacologic plan to manage delirium.

• Develop an appropriate management plan for patients with delirium in the postoperative setting.

• Document an appropriate treatment plan to reduce mortality, limit the duration of delirium and the time required to control agitation, maintain adequate control of delirium, address complications, and manage cost of treatment.

• Use a patient- and family-centered approach in the care of older inpatients.

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

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

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

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care. 

Hospitalists should be able to:

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

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

• Value a patient- and family-centered approach in the care of older inpatients. 

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

• Lead, coordinate, and/or participate in multidisciplinary teams to develop early treatment protocols.

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

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

• Engage stakeholders in hospital initiatives to improve safety and quality in the care of patients with delirium.

DEMENTIA
Dementia is defined as a chronic, often progressive, decline in cognitive function, eventually limiting daily activities. Dementia is a common comorbidity in the hospitalized older patient. Alzheimer disease is the most prevalent form of dementia in older patients, and it accounts for up to 80% of cases.^7,8 More than 5 million persons older than 65 years have Alzheimer disease in the United States.^7,8 Patients with dementia are at increased risk for delirium, falls, and functional decline during hospitalization. Patients with baseline cognitive impairment have prolonged lengths of stay and complex needs after discharge. Agitation and behavioral symptoms of dementia can be exacerbated in the hospital setting and are often difficult to manage. Care of the patient with dementia requires that hospitalists engage in a multidisciplinary approach to inpatient and transitional care. Hospitalists may also become involved in hospital quality and safety initiatives that pertain to areas such as restraint use and fall prevention. 

Hospitalists should be able to:

• Define delirium and dementia and distinguish between them.

• Differentiate dementia from other causes of cognitive impairment, confusion, or psychosis.

• Describe the indicated tests required to evaluate dementia.

• Describe the causes of potentially reversible dementias or dementia-like conditions.

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

• Describe nonpharmacologic therapies to manage dementia symptoms.

• Recognize the indications for specialty consultations.

• Describe the complications of dementia in the hospitalized patient.

• Discuss the multifaceted impact that dementia has on patients and their families.

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

Hospitalists should be able to:

• Perform appropriate screening for dementia.

• Develop active strategies to reduce development of delirium in patients with dementia in the hospital setting by identifying known patient risk factors that may precipitate delirium.

• Assess patients with suspected dementia in a timely manner, identify the level of care required, and manage or comanage patients with the primary requesting service.

• Assess patients for potentially reversible causes of dementia or dementia-like conditions. Assess severity of cognitive impairment and perform a focused evaluation for the underlying etiology of dementia when appropriate.

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

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

• Develop an appropriate pharmacologic plan to manage dementia.

• Develop an appropriate nonpharmacologic plan to manage dementia.

• Use a patient- and family-centered approach in the care of older inpatients.

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

• Use evidence-based methods and tools to assess patients’ medical decision-making capacity.

• Defend patients’ right to autonomy when so qualified.

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

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care. 

Hospitalists should be able to:

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

• Follow evidence-based recommendations to guide diagnosis, monitoring, and treatment of dementia and its causes.

• Value a patient- and family-centered approach to educate and engage families and caregivers in the care of older inpatients.

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

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

• Lead, coordinate, and/or participate in multidisciplinary teams to develop early treatment protocols.

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

• Lead, coordinate, and/or participate in multidisciplinary initiatives, which may include collaboration withgeriatricians, to promote patient safety and cost-effective diagnostic and management strategies for older patients.

• Engage stakeholders in hospital initiatives to improve safety and quality in the care of patients with dementia.

Diabetes mellitus is a disease characterized by abnormal insulin production or disordered glucose metabolism and is a comorbid condition of many hospitalized patients. Diabetic ketoacidosis (DKA) and hyperglycemia hyperosmolar state (HHS) are extreme presentations of diabetes mellitus that require hospitalization. Diabetes mellitus is present in nearly 10% of the US population, and it is more common in older adults, affecting at least 25% of persons older than 65 years.¹ Type 2 diabetes mellitus accounts for 90% to 95% of all diagnosed cases of diabetes in adults.¹ Annually, more than 700,000 hospital discharges occur with diabetes mellitus or DKA as the primary diagnosis.² Hospitalists care for diabetic patients and optimize glycemic control in the hospital setting. They stabilize and treat DKA and HHS. The inpatient setting provides an opportunity to institute therapies to slow disease progression, prevent disease complications, and provide diabetes education to improve quality of life and limit complications leading to readmission. Hospitalists use evidence-based approaches to optimize care and lead multidisciplinary teams to develop institutional guidelines or care pathways to optimize glycemic control. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Define diabetes mellitus and explain the pathophysiologic processes that lead to hyperglycemia, DKA, and HHS.

• Describe the impact of hyperglycemia on immune function and wound healing.

• Describe the effect of DKA and HHS on intravascular volume status, electrolytes, and acid–base balance.

• Describe the clinical presentation and laboratory findings of DKA and HHS.

• Describe the indicated tests to evaluate and diagnose DKA and HHS.

• Explain the physiologic stressors and medications that adversely affect glycemic control.

• Explain the precipitating factors of DKA and HSS.

• Identify the goals of glycemic control in hospitalized patients in various settings, including critically ill and surgical patients.

• Recognize the indications for managing DKA and HHS in an intensive care unit.

• Recognize indications for early specialty consultation, which may include endocrinology and nutrition.

• Summarize the indications, contraindications, and mechanisms of action of pharmacologic agents used to treat diabetes mellitus.

• Recognize features that indicate disease severity.

• Recognize the impact of suboptimal glycemic control on other concurrent medical conditions and illness.

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

Hospitalists should be able to:

• Elicit a thorough and relevant medical history and review the medical record to identify factors that can affect glycemic control.

• Estimate the level of previous glycemic control, adherence to medication regimen, and social influences that may affect the quality of glycemic control in hospitalized patients.

• Perform a comprehensive physical examination to identify possible precipitants of hyperglycemia, DKA, or HHS.

• Select and interpret indicated studies in patients suspected of having DKA or HHS, including relevant metabolic and acid–base measurements.

• Develop an individualized management plan for patients with controlled and uncontrolled diabetes mellitus, DKA, HHS, and any associated complications.

• Adjust medications and dosages to achieve optimal glycemic control and minimize adverse effects.

• Evaluate and treat the signs and symptoms of hypoglycemia (especially neuroglycopenia).

• Direct the perioperative management of the diabetic patient, and when necessary, manage or comanage the patient with the primary requesting service.

• Assess caloric and nutritional needs and recommend a suitable diet.

• Assess hospitalized patients for undiagnosed diabetes mellitus.

• Recognize and address the effects of various diabetic complications such as neuropathic pain.

• Communicate with patients and families to explain the natural history and prognosis of diabetes mellitus.

• Communicate with patients and families to explain potential long-term complications of diabetes mellitus and preventive strategies, including foot and eye care.

• Communicate with patients and families to explain the importance of glycemic control and factors that affect it such as adhering to medication regimens and self-monitoring, following dietary and exercise recommendations, and attending routine follow-up appointments.

• Communicate with patients and families to explain the potential adverse effects or adverse interactions of diabetes medications, including hypoglycemia.

• Facilitate discharge planning early in the admission process.

• Recommend appropriate postdischarge care, which may include endocrinology, ophthalmology, and podiatry.

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians, including the need for continued nutrition and diabetic counseling. 

Hospitalists should be able to:

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

• Follow evidence-based recommendations in the treatment of inpatients with diabetes mellitus. 

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

• Lead, coordinate, and/or participate in multidisciplinary teams, which may include nursing, nutrition, and endocrinology, to promote quality and cost-effective diabetes management.

• Lead, coordinate, and/or participate in efforts to develop guidelines and protocols that standardize the assessment and management of uncontrolled diabetes mellitus, DKA, and HHS.

• Lead, coordinate, and/or participate in initiatives to standardize hospital formulary-based diabetes therapies to reduce the likelihood of an adverse drug event.

• Lead, coordinate, and/or participate in efforts to develop guidelines and/or protocols to optimize glycemic control in hospitalized patients including suitable regimens in critically ill medical and surgical patients.

• Implement systems to ensure hospital-wide adherence to national standards and document those measures as specified by recognized organizations.

Diabetes mellitus is a disease characterized by abnormal insulin production or disordered glucose metabolism and is a comorbid condition of many hospitalized patients. Diabetic ketoacidosis (DKA) and hyperglycemia hyperosmolar state (HHS) are extreme presentations of diabetes mellitus that require hospitalization. Diabetes mellitus is present in nearly 10% of the US population, and it is more common in older adults, affecting at least 25% of persons older than 65 years.¹ Type 2 diabetes mellitus accounts for 90% to 95% of all diagnosed cases of diabetes in adults.¹ Annually, more than 700,000 hospital discharges occur with diabetes mellitus or DKA as the primary diagnosis.² Hospitalists care for diabetic patients and optimize glycemic control in the hospital setting. They stabilize and treat DKA and HHS. The inpatient setting provides an opportunity to institute therapies to slow disease progression, prevent disease complications, and provide diabetes education to improve quality of life and limit complications leading to readmission. Hospitalists use evidence-based approaches to optimize care and lead multidisciplinary teams to develop institutional guidelines or care pathways to optimize glycemic control. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Define diabetes mellitus and explain the pathophysiologic processes that lead to hyperglycemia, DKA, and HHS.

• Describe the impact of hyperglycemia on immune function and wound healing.

• Describe the effect of DKA and HHS on intravascular volume status, electrolytes, and acid–base balance.

• Describe the clinical presentation and laboratory findings of DKA and HHS.

• Describe the indicated tests to evaluate and diagnose DKA and HHS.

• Explain the physiologic stressors and medications that adversely affect glycemic control.

• Explain the precipitating factors of DKA and HSS.

• Identify the goals of glycemic control in hospitalized patients in various settings, including critically ill and surgical patients.

• Recognize the indications for managing DKA and HHS in an intensive care unit.

• Recognize indications for early specialty consultation, which may include endocrinology and nutrition.

• Summarize the indications, contraindications, and mechanisms of action of pharmacologic agents used to treat diabetes mellitus.

• Recognize features that indicate disease severity.

• Recognize the impact of suboptimal glycemic control on other concurrent medical conditions and illness.

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

Hospitalists should be able to:

• Elicit a thorough and relevant medical history and review the medical record to identify factors that can affect glycemic control.

• Estimate the level of previous glycemic control, adherence to medication regimen, and social influences that may affect the quality of glycemic control in hospitalized patients.

• Perform a comprehensive physical examination to identify possible precipitants of hyperglycemia, DKA, or HHS.

• Select and interpret indicated studies in patients suspected of having DKA or HHS, including relevant metabolic and acid–base measurements.

• Develop an individualized management plan for patients with controlled and uncontrolled diabetes mellitus, DKA, HHS, and any associated complications.

• Adjust medications and dosages to achieve optimal glycemic control and minimize adverse effects.

• Evaluate and treat the signs and symptoms of hypoglycemia (especially neuroglycopenia).

• Direct the perioperative management of the diabetic patient, and when necessary, manage or comanage the patient with the primary requesting service.

• Assess caloric and nutritional needs and recommend a suitable diet.

• Assess hospitalized patients for undiagnosed diabetes mellitus.

• Recognize and address the effects of various diabetic complications such as neuropathic pain.

• Communicate with patients and families to explain the natural history and prognosis of diabetes mellitus.

• Communicate with patients and families to explain potential long-term complications of diabetes mellitus and preventive strategies, including foot and eye care.

• Communicate with patients and families to explain the importance of glycemic control and factors that affect it such as adhering to medication regimens and self-monitoring, following dietary and exercise recommendations, and attending routine follow-up appointments.

• Communicate with patients and families to explain the potential adverse effects or adverse interactions of diabetes medications, including hypoglycemia.

• Facilitate discharge planning early in the admission process.

• Recommend appropriate postdischarge care, which may include endocrinology, ophthalmology, and podiatry.

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians, including the need for continued nutrition and diabetic counseling. 

Hospitalists should be able to:

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

• Follow evidence-based recommendations in the treatment of inpatients with diabetes mellitus. 

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

• Lead, coordinate, and/or participate in multidisciplinary teams, which may include nursing, nutrition, and endocrinology, to promote quality and cost-effective diabetes management.

• Lead, coordinate, and/or participate in efforts to develop guidelines and protocols that standardize the assessment and management of uncontrolled diabetes mellitus, DKA, and HHS.

• Lead, coordinate, and/or participate in initiatives to standardize hospital formulary-based diabetes therapies to reduce the likelihood of an adverse drug event.

• Lead, coordinate, and/or participate in efforts to develop guidelines and/or protocols to optimize glycemic control in hospitalized patients including suitable regimens in critically ill medical and surgical patients.

• Implement systems to ensure hospital-wide adherence to national standards and document those measures as specified by recognized organizations.

Diabetes mellitus is a disease characterized by abnormal insulin production or disordered glucose metabolism and is a comorbid condition of many hospitalized patients. Diabetic ketoacidosis (DKA) and hyperglycemia hyperosmolar state (HHS) are extreme presentations of diabetes mellitus that require hospitalization. Diabetes mellitus is present in nearly 10% of the US population, and it is more common in older adults, affecting at least 25% of persons older than 65 years.¹ Type 2 diabetes mellitus accounts for 90% to 95% of all diagnosed cases of diabetes in adults.¹ Annually, more than 700,000 hospital discharges occur with diabetes mellitus or DKA as the primary diagnosis.² Hospitalists care for diabetic patients and optimize glycemic control in the hospital setting. They stabilize and treat DKA and HHS. The inpatient setting provides an opportunity to institute therapies to slow disease progression, prevent disease complications, and provide diabetes education to improve quality of life and limit complications leading to readmission. Hospitalists use evidence-based approaches to optimize care and lead multidisciplinary teams to develop institutional guidelines or care pathways to optimize glycemic control. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Define diabetes mellitus and explain the pathophysiologic processes that lead to hyperglycemia, DKA, and HHS.

• Describe the impact of hyperglycemia on immune function and wound healing.

• Describe the effect of DKA and HHS on intravascular volume status, electrolytes, and acid–base balance.

• Describe the clinical presentation and laboratory findings of DKA and HHS.

• Describe the indicated tests to evaluate and diagnose DKA and HHS.

• Explain the physiologic stressors and medications that adversely affect glycemic control.

• Explain the precipitating factors of DKA and HSS.

• Identify the goals of glycemic control in hospitalized patients in various settings, including critically ill and surgical patients.

• Recognize the indications for managing DKA and HHS in an intensive care unit.

• Recognize indications for early specialty consultation, which may include endocrinology and nutrition.

• Summarize the indications, contraindications, and mechanisms of action of pharmacologic agents used to treat diabetes mellitus.

• Recognize features that indicate disease severity.

• Recognize the impact of suboptimal glycemic control on other concurrent medical conditions and illness.

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

Hospitalists should be able to:

• Elicit a thorough and relevant medical history and review the medical record to identify factors that can affect glycemic control.

• Estimate the level of previous glycemic control, adherence to medication regimen, and social influences that may affect the quality of glycemic control in hospitalized patients.

• Perform a comprehensive physical examination to identify possible precipitants of hyperglycemia, DKA, or HHS.

• Select and interpret indicated studies in patients suspected of having DKA or HHS, including relevant metabolic and acid–base measurements.

• Develop an individualized management plan for patients with controlled and uncontrolled diabetes mellitus, DKA, HHS, and any associated complications.

• Adjust medications and dosages to achieve optimal glycemic control and minimize adverse effects.

• Evaluate and treat the signs and symptoms of hypoglycemia (especially neuroglycopenia).

• Direct the perioperative management of the diabetic patient, and when necessary, manage or comanage the patient with the primary requesting service.

• Assess caloric and nutritional needs and recommend a suitable diet.

• Assess hospitalized patients for undiagnosed diabetes mellitus.

• Recognize and address the effects of various diabetic complications such as neuropathic pain.

• Communicate with patients and families to explain the natural history and prognosis of diabetes mellitus.

• Communicate with patients and families to explain potential long-term complications of diabetes mellitus and preventive strategies, including foot and eye care.

• Communicate with patients and families to explain the importance of glycemic control and factors that affect it such as adhering to medication regimens and self-monitoring, following dietary and exercise recommendations, and attending routine follow-up appointments.

• Communicate with patients and families to explain the potential adverse effects or adverse interactions of diabetes medications, including hypoglycemia.

• Facilitate discharge planning early in the admission process.

• Recommend appropriate postdischarge care, which may include endocrinology, ophthalmology, and podiatry.

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians, including the need for continued nutrition and diabetic counseling. 

Hospitalists should be able to:

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

• Follow evidence-based recommendations in the treatment of inpatients with diabetes mellitus. 

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

• Lead, coordinate, and/or participate in multidisciplinary teams, which may include nursing, nutrition, and endocrinology, to promote quality and cost-effective diabetes management.

• Lead, coordinate, and/or participate in efforts to develop guidelines and protocols that standardize the assessment and management of uncontrolled diabetes mellitus, DKA, and HHS.

• Lead, coordinate, and/or participate in initiatives to standardize hospital formulary-based diabetes therapies to reduce the likelihood of an adverse drug event.

• Lead, coordinate, and/or participate in efforts to develop guidelines and/or protocols to optimize glycemic control in hospitalized patients including suitable regimens in critically ill medical and surgical patients.

• Implement systems to ensure hospital-wide adherence to national standards and document those measures as specified by recognized organizations.

Gastrointestinal (GI) bleed refers to any bleeding that originates in the GI tract. Bleeding is generally defined as upper (between the mouth and the ligament of Treitz) or lower (from the ligament of Treitz to the anus). Acute GI bleeding complicates about 7% of all hospital stays in the United States and has an approximate 3% in-hospital mortality rate. Annually, more than 245,000, 130,000, and 165,000 hospital discharges occur with upper GI bleed, lower GI bleed, and unspecified GI bleed as the primary diagnosis, respectively.¹ The degree of blood loss can vary from microscopic amounts to noticeable or massive volumes that can cause hemodynamic instability. Between 19% and 28% of patients with GI bleeding have complications that require intensive care unit admission.^2-5 A well-orchestrated approach that includes prompt assessment for risk stratification, evaluation for early endoscopy, initiation of pharmacotherapy, and treatment of comorbid diseases is necessary for a favorable outcome. Hospitalists provide immediate care for patients presenting with GI bleeding while coordinating care across multiple specialties. Hospitalists lead quality improvement initiatives that optimize the efficiency and quality of care for patients with GI bleeding. 

Hospitalists should be able to:

• Explain the etiologies and pathophysiologic processes that lead to GI bleeds.

• Describe and differentiate the clinical features and presentations of upper and lower GI bleeds.

• Describe the tests required to evaluate GI bleeds.

• Explain the risk factors for upper and lower GI bleeds and clinical indicators of patients at high risk for complications.

• List the indications for early specialty consultation, which may include interventional radiology, gastroenterology, and surgery.

• Describe the approach to transfusion therapy in GI bleeds.

• Describe the treatment for concomitant coagulopathy in patients with GI bleeds.

• Compare the advantages and disadvantages of medical, endoscopic, and surgical treatments for patients with GI bleeds.

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

• Identify clinical, laboratory, and imaging studies that indicate disease severity.

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

Hospitalists should be able to:

• Elicit a thorough and relevant history, including a directed medication, family, and social history.

• Perform a physical examination to identify the likely source of bleeding, presence of comorbid conditions (such as liver disease), and signs of clinical instability (such as organ hypoperfusion) or complications (such as intestinal perforation).

• Order and interpret results of appropriate laboratory, imaging, and endoscopic tests.

• Synthesize results of physical examination, laboratory testing, and imaging studies to determine the best management and care plan for the patient.

• Assess patients with GI bleeds for the purpose of risk stratification and determine the corresponding level of care required.

• Initiate preventive measures including avoidance of nonsteroidal anti-inflammatory agents, stress ulcer prophylaxis in critically ill patients, dietary modification, and evidence-based medical therapies.

• Formulate an evidence-based treatment plan, including nutritional recommendations, pharmacologic agents and dosing, and coordination of endoscopic and surgical interventions tailored to the individual patient.

• Determine frequency for laboratory monitoring and transfusion during hospitalization.

• Ensure adequate intravenous access to allow rapid volume and blood product resuscitation.

• Perform rapid hemodynamic resuscitation.

• Recognize and treat signs of clinical decompensation and recurrent bleeding.

• Assess patients with suspected GI bleeds in a timely manner and manage or comanage the patient with the primary requesting service.

• Communicate with patients and families to explain the disease etiology, prognosis, risk reduction strategies, and symptoms of recurrent GI bleed.

• Communicate with patients and families to explain risks, benefits, and alternatives to transfusion therapy.

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care. 

Hospitalists should be able to:

• Employ a multidisciplinary approach, which may include nursing, pharmacy and nutrition services, and specialty and referring physicians, in the care of patients with GI bleeds that begins at admission and continues through all care transitions.

• Establish and maintain an open dialogue with patients and/or families regarding goals and limitations of care, including palliative care and end-of-life wishes. 

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

• Lead, coordinate, and/or participate in the development and promotion of evidence-based guidelines and/or pathways for treatment of patients with GI bleeds.

• Lead, coordinate, and/or participate in multidisciplinary teams to develop quality improvement initiatives that promote early identification of GI bleeds and reduce preventable complications.

• Develop systems that provide timely reports of pending study results to outpatient providers.

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

Gastrointestinal (GI) bleed refers to any bleeding that originates in the GI tract. Bleeding is generally defined as upper (between the mouth and the ligament of Treitz) or lower (from the ligament of Treitz to the anus). Acute GI bleeding complicates about 7% of all hospital stays in the United States and has an approximate 3% in-hospital mortality rate. Annually, more than 245,000, 130,000, and 165,000 hospital discharges occur with upper GI bleed, lower GI bleed, and unspecified GI bleed as the primary diagnosis, respectively.¹ The degree of blood loss can vary from microscopic amounts to noticeable or massive volumes that can cause hemodynamic instability. Between 19% and 28% of patients with GI bleeding have complications that require intensive care unit admission.^2-5 A well-orchestrated approach that includes prompt assessment for risk stratification, evaluation for early endoscopy, initiation of pharmacotherapy, and treatment of comorbid diseases is necessary for a favorable outcome. Hospitalists provide immediate care for patients presenting with GI bleeding while coordinating care across multiple specialties. Hospitalists lead quality improvement initiatives that optimize the efficiency and quality of care for patients with GI bleeding. 

Hospitalists should be able to:

• Explain the etiologies and pathophysiologic processes that lead to GI bleeds.

• Describe and differentiate the clinical features and presentations of upper and lower GI bleeds.

• Describe the tests required to evaluate GI bleeds.

• Explain the risk factors for upper and lower GI bleeds and clinical indicators of patients at high risk for complications.

• List the indications for early specialty consultation, which may include interventional radiology, gastroenterology, and surgery.

• Describe the approach to transfusion therapy in GI bleeds.

• Describe the treatment for concomitant coagulopathy in patients with GI bleeds.

• Compare the advantages and disadvantages of medical, endoscopic, and surgical treatments for patients with GI bleeds.

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

• Identify clinical, laboratory, and imaging studies that indicate disease severity.

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

Hospitalists should be able to:

• Elicit a thorough and relevant history, including a directed medication, family, and social history.

• Perform a physical examination to identify the likely source of bleeding, presence of comorbid conditions (such as liver disease), and signs of clinical instability (such as organ hypoperfusion) or complications (such as intestinal perforation).

• Order and interpret results of appropriate laboratory, imaging, and endoscopic tests.

• Synthesize results of physical examination, laboratory testing, and imaging studies to determine the best management and care plan for the patient.

• Assess patients with GI bleeds for the purpose of risk stratification and determine the corresponding level of care required.

• Initiate preventive measures including avoidance of nonsteroidal anti-inflammatory agents, stress ulcer prophylaxis in critically ill patients, dietary modification, and evidence-based medical therapies.

• Formulate an evidence-based treatment plan, including nutritional recommendations, pharmacologic agents and dosing, and coordination of endoscopic and surgical interventions tailored to the individual patient.

• Determine frequency for laboratory monitoring and transfusion during hospitalization.

• Ensure adequate intravenous access to allow rapid volume and blood product resuscitation.

• Perform rapid hemodynamic resuscitation.

• Recognize and treat signs of clinical decompensation and recurrent bleeding.

• Assess patients with suspected GI bleeds in a timely manner and manage or comanage the patient with the primary requesting service.

• Communicate with patients and families to explain the disease etiology, prognosis, risk reduction strategies, and symptoms of recurrent GI bleed.

• Communicate with patients and families to explain risks, benefits, and alternatives to transfusion therapy.

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care. 

Hospitalists should be able to:

• Employ a multidisciplinary approach, which may include nursing, pharmacy and nutrition services, and specialty and referring physicians, in the care of patients with GI bleeds that begins at admission and continues through all care transitions.

• Establish and maintain an open dialogue with patients and/or families regarding goals and limitations of care, including palliative care and end-of-life wishes. 

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

• Lead, coordinate, and/or participate in the development and promotion of evidence-based guidelines and/or pathways for treatment of patients with GI bleeds.

• Lead, coordinate, and/or participate in multidisciplinary teams to develop quality improvement initiatives that promote early identification of GI bleeds and reduce preventable complications.

• Develop systems that provide timely reports of pending study results to outpatient providers.

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

Gastrointestinal (GI) bleed refers to any bleeding that originates in the GI tract. Bleeding is generally defined as upper (between the mouth and the ligament of Treitz) or lower (from the ligament of Treitz to the anus). Acute GI bleeding complicates about 7% of all hospital stays in the United States and has an approximate 3% in-hospital mortality rate. Annually, more than 245,000, 130,000, and 165,000 hospital discharges occur with upper GI bleed, lower GI bleed, and unspecified GI bleed as the primary diagnosis, respectively.¹ The degree of blood loss can vary from microscopic amounts to noticeable or massive volumes that can cause hemodynamic instability. Between 19% and 28% of patients with GI bleeding have complications that require intensive care unit admission.^2-5 A well-orchestrated approach that includes prompt assessment for risk stratification, evaluation for early endoscopy, initiation of pharmacotherapy, and treatment of comorbid diseases is necessary for a favorable outcome. Hospitalists provide immediate care for patients presenting with GI bleeding while coordinating care across multiple specialties. Hospitalists lead quality improvement initiatives that optimize the efficiency and quality of care for patients with GI bleeding. 

Hospitalists should be able to:

• Explain the etiologies and pathophysiologic processes that lead to GI bleeds.

• Describe and differentiate the clinical features and presentations of upper and lower GI bleeds.

• Describe the tests required to evaluate GI bleeds.

• Explain the risk factors for upper and lower GI bleeds and clinical indicators of patients at high risk for complications.

• List the indications for early specialty consultation, which may include interventional radiology, gastroenterology, and surgery.

• Describe the approach to transfusion therapy in GI bleeds.

• Describe the treatment for concomitant coagulopathy in patients with GI bleeds.

• Compare the advantages and disadvantages of medical, endoscopic, and surgical treatments for patients with GI bleeds.

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

• Identify clinical, laboratory, and imaging studies that indicate disease severity.

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

Hospitalists should be able to:

• Elicit a thorough and relevant history, including a directed medication, family, and social history.

• Perform a physical examination to identify the likely source of bleeding, presence of comorbid conditions (such as liver disease), and signs of clinical instability (such as organ hypoperfusion) or complications (such as intestinal perforation).

• Order and interpret results of appropriate laboratory, imaging, and endoscopic tests.

• Synthesize results of physical examination, laboratory testing, and imaging studies to determine the best management and care plan for the patient.

• Assess patients with GI bleeds for the purpose of risk stratification and determine the corresponding level of care required.

• Initiate preventive measures including avoidance of nonsteroidal anti-inflammatory agents, stress ulcer prophylaxis in critically ill patients, dietary modification, and evidence-based medical therapies.

• Formulate an evidence-based treatment plan, including nutritional recommendations, pharmacologic agents and dosing, and coordination of endoscopic and surgical interventions tailored to the individual patient.

• Determine frequency for laboratory monitoring and transfusion during hospitalization.

• Ensure adequate intravenous access to allow rapid volume and blood product resuscitation.

• Perform rapid hemodynamic resuscitation.

• Recognize and treat signs of clinical decompensation and recurrent bleeding.

• Assess patients with suspected GI bleeds in a timely manner and manage or comanage the patient with the primary requesting service.

• Communicate with patients and families to explain the disease etiology, prognosis, risk reduction strategies, and symptoms of recurrent GI bleed.

• Communicate with patients and families to explain risks, benefits, and alternatives to transfusion therapy.

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care. 

Hospitalists should be able to:

• Employ a multidisciplinary approach, which may include nursing, pharmacy and nutrition services, and specialty and referring physicians, in the care of patients with GI bleeds that begins at admission and continues through all care transitions.

• Establish and maintain an open dialogue with patients and/or families regarding goals and limitations of care, including palliative care and end-of-life wishes. 

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

• Lead, coordinate, and/or participate in the development and promotion of evidence-based guidelines and/or pathways for treatment of patients with GI bleeds.

• Lead, coordinate, and/or participate in multidisciplinary teams to develop quality improvement initiatives that promote early identification of GI bleeds and reduce preventable complications.

• Develop systems that provide timely reports of pending study results to outpatient providers.

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

Heart failure (HF) is characterized by impaired cardiac function resulting in a constellation of symptoms that includes fatigue, weakness, and shortness of breath. In North America, the lifetime risk of developing HF is 20% for all persons older than 40 years; more than 5 million persons have HF in the United States.^1,2 Roughly half of those who develop HF die within 5 years of diagnosis.¹ HF exacerbation is one of the most common diagnoses leading to hospital admission, and annually more than 1 million hospital discharges occur with HF as the primary diagnosis. The average length of stay is 5.2 days.³ Direct medical costs for HF total more than $20 billion each year.⁴ Despite published guidelines for HF management, treatment of hospitalized patients varies markedly. Hospitalists can lead their institutions in the prompt diagnosis of HF, initiation of evidence-based medical therapy, and incorporation of a multidisciplinary approach to management. Hospitalists can also develop strategies to operationalize cost-effective interventions that reduce morbidity, mortality, and readmissions. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Explain underlying causes of HF and precipitating factors leading to exacerbation.

• Differentiate features of systolic and diastolic dysfunction and explain the common etiologies of each.

• Identify the clinical indications for hospitalization for acute decompensated HF.

• Describe the indicated tests required to evaluate HF including assessment of both left and right ventricular function.

• Explain when reassessment of left ventricular function is indicated.

• Explain the utility and limitations of cardiac biomarkers (eg, age adjusted).

• Explain markers of disease severity and factors that influence prognosis.

• Describe risk factors for the development of HF in the hospital setting.

• Recognize indications for early cardiology consultation.

• Describe the goals of inpatient therapy for acute decompensated HF, including pre-load and after-load reduction, hemodynamic stabilization, and optimization of volume status.

• Describe the role of invasive and noninvasive ventilatory support.

• Explain evidence-based therapeutic options for management of both acute and chronic HF and list contraindications to these therapies.

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

• Identify medications and interventions contraindicated in HF.

• Recognize indications for device therapy (such as implanted cardioverter defibrillator, cardiac resynchronization therapy, and left ventricular assist devices).

• Recognize indications and qualifications for cardiac transplant evaluation.

• Explain the importance of palliative care in the treatment of patients with chronic HF.

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

Hospitalists should be able to:

• Elicit a thorough and relevant medical history and review the medical record to identify symptoms, comorbidities, medications, and/or social influences contributing to HF or its exacerbation.

• Recognize the clinical presentation of HF including features of exacerbation and reliability of signs and symptoms.

• Identify physical findings consistent with HF.

• Identify symptoms and signs of low perfusion states and cardiogenic shock.

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

• Order indicated diagnostic testing to identify precipitating factors of HF and assess cardiac function.

• Risk stratify patients admitted with HF and determine the appropriate level of care.

• Formulate an evidence-based treatment plan tailored to the individual patient, which may include pharmacologic agents, device implantation, nutritional recommendations, and patient adherence.

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

• Communicate with patients and families to explain the history and prognosis of HF.

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

• Communicate with patients and families to explain the use and potential adverse effects of pharmacologic agents.

• Communicate with patients and families to explain the importance of home self-monitoring, adherence to medication regimens, nutritional recommendations, and physical rehabilitation.

• Facilitate discharge planning early during hospitalization.

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

• Communicate to outpatient providers the relevant events of the hospitalization and postdischarge needs, including pending tests, and determine who is responsible for checking the results.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians. 

Hospitalists should be able to:

• Employ a multidisciplinary approach in the care of patients with HF that begins at admission and continues through all care transitions.

• Follow evidence-based recommendations to guide diagnosis, monitoring, and treatment of HF.

• Advocate the importance of behavioral modification to delay the progression of disease and improve quality of life.

• Responsibly address and respect end-of-life care wishes for patients with end-stage HF. 

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

• Lead, coordinate, and/or participate in multidisciplinary teams, which may include nursing and social services, nutrition, pharmacy, and physical therapy, early in the hospital course to facilitate patient education and discharge planning, improve patient function and outcomes, and advocate for patient outreach after discharge.

• Implement systems to ensure hospital-wide adherence to national standards and document those measures as specified by recognized organizations (eg, Joint Commission on Accreditation of Healthcare Organizations, American Heart Association, American College of Cardiology, Agency for Healthcare Research and Quality).

• Integrate outcomes research, institution-specific laboratory policies, and hospital formulary to create guideline-driven and cost-effective diagnostic and management strategies for patients with HF.

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

• Advocate to hospital administrators to establish and support outpatient programs that have been shown to reduce readmissions and other unfavorable patient outcomes through outreach to patients with HF.

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

• Lead, coordinate, and/or participate in initiatives to increase awareness and improve documentation efforts that appropriately categorize patients with HF and the impact this may have on risk-adjusted mortality and value-based purchasing.

Heart failure (HF) is characterized by impaired cardiac function resulting in a constellation of symptoms that includes fatigue, weakness, and shortness of breath. In North America, the lifetime risk of developing HF is 20% for all persons older than 40 years; more than 5 million persons have HF in the United States.^1,2 Roughly half of those who develop HF die within 5 years of diagnosis.¹ HF exacerbation is one of the most common diagnoses leading to hospital admission, and annually more than 1 million hospital discharges occur with HF as the primary diagnosis. The average length of stay is 5.2 days.³ Direct medical costs for HF total more than $20 billion each year.⁴ Despite published guidelines for HF management, treatment of hospitalized patients varies markedly. Hospitalists can lead their institutions in the prompt diagnosis of HF, initiation of evidence-based medical therapy, and incorporation of a multidisciplinary approach to management. Hospitalists can also develop strategies to operationalize cost-effective interventions that reduce morbidity, mortality, and readmissions. 

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Hospitalists should be able to:

• Explain underlying causes of HF and precipitating factors leading to exacerbation.

• Differentiate features of systolic and diastolic dysfunction and explain the common etiologies of each.

• Identify the clinical indications for hospitalization for acute decompensated HF.

• Describe the indicated tests required to evaluate HF including assessment of both left and right ventricular function.

• Explain when reassessment of left ventricular function is indicated.

• Explain the utility and limitations of cardiac biomarkers (eg, age adjusted).

• Explain markers of disease severity and factors that influence prognosis.

• Describe risk factors for the development of HF in the hospital setting.

• Recognize indications for early cardiology consultation.

• Describe the goals of inpatient therapy for acute decompensated HF, including pre-load and after-load reduction, hemodynamic stabilization, and optimization of volume status.

• Describe the role of invasive and noninvasive ventilatory support.

• Explain evidence-based therapeutic options for management of both acute and chronic HF and list contraindications to these therapies.

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

• Identify medications and interventions contraindicated in HF.

• Recognize indications for device therapy (such as implanted cardioverter defibrillator, cardiac resynchronization therapy, and left ventricular assist devices).

• Recognize indications and qualifications for cardiac transplant evaluation.

• Explain the importance of palliative care in the treatment of patients with chronic HF.

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

Hospitalists should be able to:

• Elicit a thorough and relevant medical history and review the medical record to identify symptoms, comorbidities, medications, and/or social influences contributing to HF or its exacerbation.

• Recognize the clinical presentation of HF including features of exacerbation and reliability of signs and symptoms.

• Identify physical findings consistent with HF.

• Identify symptoms and signs of low perfusion states and cardiogenic shock.

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

• Order indicated diagnostic testing to identify precipitating factors of HF and assess cardiac function.

• Risk stratify patients admitted with HF and determine the appropriate level of care.

• Formulate an evidence-based treatment plan tailored to the individual patient, which may include pharmacologic agents, device implantation, nutritional recommendations, and patient adherence.

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

• Communicate with patients and families to explain the history and prognosis of HF.

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

• Communicate with patients and families to explain the use and potential adverse effects of pharmacologic agents.

• Communicate with patients and families to explain the importance of home self-monitoring, adherence to medication regimens, nutritional recommendations, and physical rehabilitation.

• Facilitate discharge planning early during hospitalization.

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

• Communicate to outpatient providers the relevant events of the hospitalization and postdischarge needs, including pending tests, and determine who is responsible for checking the results.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians. 

Hospitalists should be able to:

• Employ a multidisciplinary approach in the care of patients with HF that begins at admission and continues through all care transitions.

• Follow evidence-based recommendations to guide diagnosis, monitoring, and treatment of HF.

• Advocate the importance of behavioral modification to delay the progression of disease and improve quality of life.

• Responsibly address and respect end-of-life care wishes for patients with end-stage HF. 

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

• Lead, coordinate, and/or participate in multidisciplinary teams, which may include nursing and social services, nutrition, pharmacy, and physical therapy, early in the hospital course to facilitate patient education and discharge planning, improve patient function and outcomes, and advocate for patient outreach after discharge.

• Implement systems to ensure hospital-wide adherence to national standards and document those measures as specified by recognized organizations (eg, Joint Commission on Accreditation of Healthcare Organizations, American Heart Association, American College of Cardiology, Agency for Healthcare Research and Quality).

• Integrate outcomes research, institution-specific laboratory policies, and hospital formulary to create guideline-driven and cost-effective diagnostic and management strategies for patients with HF.

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

• Advocate to hospital administrators to establish and support outpatient programs that have been shown to reduce readmissions and other unfavorable patient outcomes through outreach to patients with HF.

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

• Lead, coordinate, and/or participate in initiatives to increase awareness and improve documentation efforts that appropriately categorize patients with HF and the impact this may have on risk-adjusted mortality and value-based purchasing.

Heart failure (HF) is characterized by impaired cardiac function resulting in a constellation of symptoms that includes fatigue, weakness, and shortness of breath. In North America, the lifetime risk of developing HF is 20% for all persons older than 40 years; more than 5 million persons have HF in the United States.^1,2 Roughly half of those who develop HF die within 5 years of diagnosis.¹ HF exacerbation is one of the most common diagnoses leading to hospital admission, and annually more than 1 million hospital discharges occur with HF as the primary diagnosis. The average length of stay is 5.2 days.³ Direct medical costs for HF total more than $20 billion each year.⁴ Despite published guidelines for HF management, treatment of hospitalized patients varies markedly. Hospitalists can lead their institutions in the prompt diagnosis of HF, initiation of evidence-based medical therapy, and incorporation of a multidisciplinary approach to management. Hospitalists can also develop strategies to operationalize cost-effective interventions that reduce morbidity, mortality, and readmissions. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Explain underlying causes of HF and precipitating factors leading to exacerbation.

• Differentiate features of systolic and diastolic dysfunction and explain the common etiologies of each.

• Identify the clinical indications for hospitalization for acute decompensated HF.

• Describe the indicated tests required to evaluate HF including assessment of both left and right ventricular function.

• Explain when reassessment of left ventricular function is indicated.

• Explain the utility and limitations of cardiac biomarkers (eg, age adjusted).

• Explain markers of disease severity and factors that influence prognosis.

• Describe risk factors for the development of HF in the hospital setting.

• Recognize indications for early cardiology consultation.

• Describe the goals of inpatient therapy for acute decompensated HF, including pre-load and after-load reduction, hemodynamic stabilization, and optimization of volume status.

• Describe the role of invasive and noninvasive ventilatory support.

• Explain evidence-based therapeutic options for management of both acute and chronic HF and list contraindications to these therapies.

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

• Identify medications and interventions contraindicated in HF.

• Recognize indications for device therapy (such as implanted cardioverter defibrillator, cardiac resynchronization therapy, and left ventricular assist devices).

• Recognize indications and qualifications for cardiac transplant evaluation.

• Explain the importance of palliative care in the treatment of patients with chronic HF.

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

Hospitalists should be able to:

• Elicit a thorough and relevant medical history and review the medical record to identify symptoms, comorbidities, medications, and/or social influences contributing to HF or its exacerbation.

• Recognize the clinical presentation of HF including features of exacerbation and reliability of signs and symptoms.

• Identify physical findings consistent with HF.

• Identify symptoms and signs of low perfusion states and cardiogenic shock.

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

• Order indicated diagnostic testing to identify precipitating factors of HF and assess cardiac function.

• Risk stratify patients admitted with HF and determine the appropriate level of care.

• Formulate an evidence-based treatment plan tailored to the individual patient, which may include pharmacologic agents, device implantation, nutritional recommendations, and patient adherence.

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

• Communicate with patients and families to explain the history and prognosis of HF.

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

• Communicate with patients and families to explain the use and potential adverse effects of pharmacologic agents.

• Communicate with patients and families to explain the importance of home self-monitoring, adherence to medication regimens, nutritional recommendations, and physical rehabilitation.

• Facilitate discharge planning early during hospitalization.

• Communicate with patients and families to explain the goals of care, discharge instructions, and management after hospital discharge to ensure safe follow-up and transitions of care.

• Communicate to outpatient providers the relevant events of the hospitalization and postdischarge needs, including pending tests, and determine who is responsible for checking the results.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians. 

Hospitalists should be able to:

• Employ a multidisciplinary approach in the care of patients with HF that begins at admission and continues through all care transitions.

• Follow evidence-based recommendations to guide diagnosis, monitoring, and treatment of HF.

• Advocate the importance of behavioral modification to delay the progression of disease and improve quality of life.

• Responsibly address and respect end-of-life care wishes for patients with end-stage HF. 

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

• Lead, coordinate, and/or participate in multidisciplinary teams, which may include nursing and social services, nutrition, pharmacy, and physical therapy, early in the hospital course to facilitate patient education and discharge planning, improve patient function and outcomes, and advocate for patient outreach after discharge.

• Implement systems to ensure hospital-wide adherence to national standards and document those measures as specified by recognized organizations (eg, Joint Commission on Accreditation of Healthcare Organizations, American Heart Association, American College of Cardiology, Agency for Healthcare Research and Quality).

• Integrate outcomes research, institution-specific laboratory policies, and hospital formulary to create guideline-driven and cost-effective diagnostic and management strategies for patients with HF.

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

• Advocate to hospital administrators to establish and support outpatient programs that have been shown to reduce readmissions and other unfavorable patient outcomes through outreach to patients with HF.

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

• Lead, coordinate, and/or participate in initiatives to increase awareness and improve documentation efforts that appropriately categorize patients with HF and the impact this may have on risk-adjusted mortality and value-based purchasing.

Hospital-acquired pneumonia (HAP) is an infection of the lung parenchyma that occurs during the course of hospitalization. HAP is a significant source of morbidity, mortality, and increased resource expenditures, including prolonged hospital length of stay by an average of 7 to 9 days.^1-3 HAP accounts for approximately 15% of all hospital-acquired infections, and the associated mortality rate ranges from 20% to 50%.^1-4 The primary risk factor for the development of HAP is mechanical ventilation, and HAP occurs in 9% to 27% of all intubated patients.^1,3 Hospitalists manage patients with HAP either as an attending physician or as a consultant to patients admitted to other services. Healthcare-associated pneumonia (HCAP) was added as a category of pneumonia in the 2005 American Thoracic Society/Infectious Diseases Society of America guidelines to identify patients at increased risk for multidrug-resistant pathogens coming from community settings. HCAP is defined as pneumonia acquired in healthcare environments outside of the traditional hospital setting and is distinct from community-acquired pneumonia (CAP), HAP, or ventilator-acquired pneumonia. HCAP more closely resembles HAP with respect to pathogens and prognosis. Quality indicators have been created around the key processes of care for patients with pneumonia, and these indicators are used to evaluate performance of states, healthcare organizations, physician groups, and individual physicians. Hospitalists apply evidence-based practice guidelines to the management of patients hospitalized with pneumonia and lead initiatives to improve quality of care and reduce practice variability. 

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Hospitalists should be able to:

• Define HAP and HCAP and differentiate them from CAP.

• List common organisms associated with HAP and HCAP.

• Describe local and national resistance patterns for HAP and HCAP.

• Identify important historical elements, medical record data, and physical examination findings consistent with HAP and HCAP.

• Differentiate the infectious causes of HAP and HCAP from those of CAP.

• Describe the tests required to evaluate HAP and HCAP.

• Identify risk factors for developing HAP and HCAP.

• Describe the role of mechanical ventilation as a risk factor for the development of HAP.

• Explain the prophylactic measures commonly used to lower the risk of HAP.

• Describe steps that can be used to limit the emergence of antibiotic resistance.

• Recognize indications for specialty consultation, which may include infectious disease and/or pulmonary services.

• Describe the role of mechanical ventilation as a potential treatment option.

• Describe infection control practices to prevent the spread of resistant organisms within the hospital.

• Describe potential complications of HAP and HCAP.

• Explain goals for hospital discharge including evidence-based measures of clinical stability for safe care transition.

• Explain implications of HAP and HCAP on discharge planning.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history to identify symptoms consistent with HAP and HCAP.

• Perform a targeted physical examination to elicit signs consistent with HAP and HCAP.

• Assess patients with suspected HAP in a timely manner and manage or comanage the patient with the primary requesting service.

• Order and interpret laboratory, microbiologic, and radiologic studies to confirm the diagnosis of HAP and HCAP and determine the etiologic agent.

• Initiate an empiric antibiotic regimen on the basis of patient history, underlying comorbid conditions, likely organisms, and local resistance patterns.

• Tailor antibiotic regimens on the basis of microbiologic culture and sensitivity data as soon as available.

• Manage complications of HAP and HCAP, which may include respiratory failure, pleural effusions, and empyema.

• Coordinate care for patients requiring mechanical ventilation.

• Identify patients who require thoracentesis, perform or coordinate the procedure, and interpret the results.

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

• Communicate with patients and families to explain the etiology, management plan, and potential outcomes of HAP and HCAP.

• Facilitate discharge planning early during hospitalization.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians. 

Hospitalists should be able to:

• Employ a multidisciplinary approach, which may include nursing, respiratory therapy, nutrition, and pharmacy services, to the care of patients with HAP and HCAP through all care transitions.

• Follow evidence-based recommendations, protocols, and risk stratification tools for the treatment of HAP.

• Work collaboratively with primary care physicians and emergency physicians in making admission decisions. 

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

• Collaborate with local infection control practitioners to reduce the spread of resistant organisms within the institution.

• Lead, coordinate, and/or participate in multidisciplinary initiatives, which may include collaboration with critical care specialists and pulmonologists, to reduce the incidence of HAP in ventilated patients.

• Lead, coordinate, and/or participate in quality improvement initiatives to reduce ventilator days, rates of HAP, and variance in antibiotic use.

• Implement systems to ensure hospital-wide adherence to national standards for empiric antibiotic use and document those measures as specified by recognized organizations.

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

Hospital-acquired pneumonia (HAP) is an infection of the lung parenchyma that occurs during the course of hospitalization. HAP is a significant source of morbidity, mortality, and increased resource expenditures, including prolonged hospital length of stay by an average of 7 to 9 days.^1-3 HAP accounts for approximately 15% of all hospital-acquired infections, and the associated mortality rate ranges from 20% to 50%.^1-4 The primary risk factor for the development of HAP is mechanical ventilation, and HAP occurs in 9% to 27% of all intubated patients.^1,3 Hospitalists manage patients with HAP either as an attending physician or as a consultant to patients admitted to other services. Healthcare-associated pneumonia (HCAP) was added as a category of pneumonia in the 2005 American Thoracic Society/Infectious Diseases Society of America guidelines to identify patients at increased risk for multidrug-resistant pathogens coming from community settings. HCAP is defined as pneumonia acquired in healthcare environments outside of the traditional hospital setting and is distinct from community-acquired pneumonia (CAP), HAP, or ventilator-acquired pneumonia. HCAP more closely resembles HAP with respect to pathogens and prognosis. Quality indicators have been created around the key processes of care for patients with pneumonia, and these indicators are used to evaluate performance of states, healthcare organizations, physician groups, and individual physicians. Hospitalists apply evidence-based practice guidelines to the management of patients hospitalized with pneumonia and lead initiatives to improve quality of care and reduce practice variability. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Define HAP and HCAP and differentiate them from CAP.

• List common organisms associated with HAP and HCAP.

• Describe local and national resistance patterns for HAP and HCAP.

• Identify important historical elements, medical record data, and physical examination findings consistent with HAP and HCAP.

• Differentiate the infectious causes of HAP and HCAP from those of CAP.

• Describe the tests required to evaluate HAP and HCAP.

• Identify risk factors for developing HAP and HCAP.

• Describe the role of mechanical ventilation as a risk factor for the development of HAP.

• Explain the prophylactic measures commonly used to lower the risk of HAP.

• Describe steps that can be used to limit the emergence of antibiotic resistance.

• Recognize indications for specialty consultation, which may include infectious disease and/or pulmonary services.

• Describe the role of mechanical ventilation as a potential treatment option.

• Describe infection control practices to prevent the spread of resistant organisms within the hospital.

• Describe potential complications of HAP and HCAP.

• Explain goals for hospital discharge including evidence-based measures of clinical stability for safe care transition.

• Explain implications of HAP and HCAP on discharge planning.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history to identify symptoms consistent with HAP and HCAP.

• Perform a targeted physical examination to elicit signs consistent with HAP and HCAP.

• Assess patients with suspected HAP in a timely manner and manage or comanage the patient with the primary requesting service.

• Order and interpret laboratory, microbiologic, and radiologic studies to confirm the diagnosis of HAP and HCAP and determine the etiologic agent.

• Initiate an empiric antibiotic regimen on the basis of patient history, underlying comorbid conditions, likely organisms, and local resistance patterns.

• Tailor antibiotic regimens on the basis of microbiologic culture and sensitivity data as soon as available.

• Manage complications of HAP and HCAP, which may include respiratory failure, pleural effusions, and empyema.

• Coordinate care for patients requiring mechanical ventilation.

• Identify patients who require thoracentesis, perform or coordinate the procedure, and interpret the results.

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

• Communicate with patients and families to explain the etiology, management plan, and potential outcomes of HAP and HCAP.

• Facilitate discharge planning early during hospitalization.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians. 

Hospitalists should be able to:

• Employ a multidisciplinary approach, which may include nursing, respiratory therapy, nutrition, and pharmacy services, to the care of patients with HAP and HCAP through all care transitions.

• Follow evidence-based recommendations, protocols, and risk stratification tools for the treatment of HAP.

• Work collaboratively with primary care physicians and emergency physicians in making admission decisions. 

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

• Collaborate with local infection control practitioners to reduce the spread of resistant organisms within the institution.

• Lead, coordinate, and/or participate in multidisciplinary initiatives, which may include collaboration with critical care specialists and pulmonologists, to reduce the incidence of HAP in ventilated patients.

• Lead, coordinate, and/or participate in quality improvement initiatives to reduce ventilator days, rates of HAP, and variance in antibiotic use.

• Implement systems to ensure hospital-wide adherence to national standards for empiric antibiotic use and document those measures as specified by recognized organizations.

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

Hospital-acquired pneumonia (HAP) is an infection of the lung parenchyma that occurs during the course of hospitalization. HAP is a significant source of morbidity, mortality, and increased resource expenditures, including prolonged hospital length of stay by an average of 7 to 9 days.^1-3 HAP accounts for approximately 15% of all hospital-acquired infections, and the associated mortality rate ranges from 20% to 50%.^1-4 The primary risk factor for the development of HAP is mechanical ventilation, and HAP occurs in 9% to 27% of all intubated patients.^1,3 Hospitalists manage patients with HAP either as an attending physician or as a consultant to patients admitted to other services. Healthcare-associated pneumonia (HCAP) was added as a category of pneumonia in the 2005 American Thoracic Society/Infectious Diseases Society of America guidelines to identify patients at increased risk for multidrug-resistant pathogens coming from community settings. HCAP is defined as pneumonia acquired in healthcare environments outside of the traditional hospital setting and is distinct from community-acquired pneumonia (CAP), HAP, or ventilator-acquired pneumonia. HCAP more closely resembles HAP with respect to pathogens and prognosis. Quality indicators have been created around the key processes of care for patients with pneumonia, and these indicators are used to evaluate performance of states, healthcare organizations, physician groups, and individual physicians. Hospitalists apply evidence-based practice guidelines to the management of patients hospitalized with pneumonia and lead initiatives to improve quality of care and reduce practice variability. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Define HAP and HCAP and differentiate them from CAP.

• List common organisms associated with HAP and HCAP.

• Describe local and national resistance patterns for HAP and HCAP.

• Identify important historical elements, medical record data, and physical examination findings consistent with HAP and HCAP.

• Differentiate the infectious causes of HAP and HCAP from those of CAP.

• Describe the tests required to evaluate HAP and HCAP.

• Identify risk factors for developing HAP and HCAP.

• Describe the role of mechanical ventilation as a risk factor for the development of HAP.

• Explain the prophylactic measures commonly used to lower the risk of HAP.

• Describe steps that can be used to limit the emergence of antibiotic resistance.

• Recognize indications for specialty consultation, which may include infectious disease and/or pulmonary services.

• Describe the role of mechanical ventilation as a potential treatment option.

• Describe infection control practices to prevent the spread of resistant organisms within the hospital.

• Describe potential complications of HAP and HCAP.

• Explain goals for hospital discharge including evidence-based measures of clinical stability for safe care transition.

• Explain implications of HAP and HCAP on discharge planning.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history to identify symptoms consistent with HAP and HCAP.

• Perform a targeted physical examination to elicit signs consistent with HAP and HCAP.

• Assess patients with suspected HAP in a timely manner and manage or comanage the patient with the primary requesting service.

• Order and interpret laboratory, microbiologic, and radiologic studies to confirm the diagnosis of HAP and HCAP and determine the etiologic agent.

• Initiate an empiric antibiotic regimen on the basis of patient history, underlying comorbid conditions, likely organisms, and local resistance patterns.

• Tailor antibiotic regimens on the basis of microbiologic culture and sensitivity data as soon as available.

• Manage complications of HAP and HCAP, which may include respiratory failure, pleural effusions, and empyema.

• Coordinate care for patients requiring mechanical ventilation.

• Identify patients who require thoracentesis, perform or coordinate the procedure, and interpret the results.

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

• Communicate with patients and families to explain the etiology, management plan, and potential outcomes of HAP and HCAP.

• Facilitate discharge planning early during hospitalization.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians. 

Hospitalists should be able to:

• Employ a multidisciplinary approach, which may include nursing, respiratory therapy, nutrition, and pharmacy services, to the care of patients with HAP and HCAP through all care transitions.

• Follow evidence-based recommendations, protocols, and risk stratification tools for the treatment of HAP.

• Work collaboratively with primary care physicians and emergency physicians in making admission decisions. 

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

• Collaborate with local infection control practitioners to reduce the spread of resistant organisms within the institution.

• Lead, coordinate, and/or participate in multidisciplinary initiatives, which may include collaboration with critical care specialists and pulmonologists, to reduce the incidence of HAP in ventilated patients.

• Lead, coordinate, and/or participate in quality improvement initiatives to reduce ventilator days, rates of HAP, and variance in antibiotic use.

• Implement systems to ensure hospital-wide adherence to national standards for empiric antibiotic use and document those measures as specified by recognized organizations.

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

Hyponatremia, defined as a serum sodium value less than 135 mEq/L, is the most common electrolyte disorder observed in hospitalized patients in the United States, occurring in up to 60% of patients.¹ The disorder may develop within 48 hours of, or during, hospitalization (acute), or may be subacute or chronic. When it develops in the hospital, hyponatremia is associated with increased length of stay, increased cost of hospitalization, increased in-hospital mortality, and increased postdischarge mortality. Even chronic hyponatremia present at hospital admission adversely affects outcomes—such patients have a 30% higher risk of mortality and are hospitalized 14% longer than patients without hyponatremia at admission.^2,3Hospitalists can facilitate the evaluation and management of hyponatremia to improve patient outcomes, as well as decrease healthcare costs and length of stay. 

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Hospitalists should be able to:

• Distinguish acute from chronic hyponatremia.

• Identify hospitalized patients at risk of developing hyponatremia and institute monitoring measures to increase early recognition.

• Describe the symptoms of mild and severe hyponatremia.

• Describe the indicated serum and urine laboratory tests used to evaluate the causes of hyponatremia.

• Differentiate among hypertonic, isotonic, and hypotonic forms of hyponatremia.

• Identify the likely pathophysiologic process underlying a patient’s hyponatremia on the basis of urine osmolality and electrolyte concentrations.

• Identify the likely pathophysiologic process underlying a patient’s hyponatremia on the basis of the clinical volume status and urine sodium value.

• Explain how concurrent fluid administration or diuresis may affect urinary tests used in the evaluation of hyponatremia.

• Explain the physiology leading to development of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and describe how it is diagnosed.

• Recognize indications for specialty consultation, such as endocrinology or nephrology.

• Describe an appropriate treatment strategy for patients with asymptomatic, mildly symptomatic, and severely symptomatic hyponatremia, including the risks of treatment.

• Explain the appropriate rate of correction for acute or chronic hyponatremia, adjusted to the needs of the individual patient.

• Explain the indications for water restriction in hyponatremia.

• Explain the indications of isotonic sodium chloride fluid administration in hyponatremia.

• Explain the indications for hypertonic sodium chloride fluid administration in hyponatremia.

• Explain the role, limitations, risks, and contraindications of vasopressin receptor agonists in the treatment of hyponatremia.

• Predict how concurrent correction of other electrolyte disorders (eg, hypokalemia) may affect sodium correction.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history, perform a physical examination, and review the medical record for factors contributing to the development of hyponatremia.

• Accurately assess the relevant volume status and neurologic examination findings of a patient with hyponatremia.

• Order and interpret indicated diagnostic studies that may include serum electrolytes, serum and urine osmolality, serum blood urea nitrogen, creatinine, uric acid, urine sodium, thyrotropin, and early-morning cortisol.

• Formulate and implement the most appropriate intervention tailored to the individual patient’s etiology of hyponatremia while minimizing potential complications from overcorrection or undercorrection.

• Identify the most appropriate care setting to monitor patients with hyponatremia, including indications to transfer to the intensive care unit.

• Recognize symptoms and signs of severe hyponatremia and osmotic demyelination syndrome.

• Communicate with patients and families to explain the significance, etiology, and importance of recognizing and treating hyponatremia.

• Communicate with patients and families to explain the risks, monitoring, and appropriate management of hyponatremia.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians.

• Facilitate coordination of transitional monitoring of recurrent hyponatremia after hospital discharge. 

Hospitalists should be able to:

• Follow evidence-based recommendations when managing hospitalized patients with hyponatremia.

• Acknowledge the opportunity to decrease mortality, length of stay, and healthcare costs by addressing hyponatremia, even when asymptomatic. 

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

• Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize management strategies for hyponatremia.

• Participate in initiatives to articulate, manage, or restrict the use of high-risk therapies, such as hypertonic saline.

Hyponatremia, defined as a serum sodium value less than 135 mEq/L, is the most common electrolyte disorder observed in hospitalized patients in the United States, occurring in up to 60% of patients.¹ The disorder may develop within 48 hours of, or during, hospitalization (acute), or may be subacute or chronic. When it develops in the hospital, hyponatremia is associated with increased length of stay, increased cost of hospitalization, increased in-hospital mortality, and increased postdischarge mortality. Even chronic hyponatremia present at hospital admission adversely affects outcomes—such patients have a 30% higher risk of mortality and are hospitalized 14% longer than patients without hyponatremia at admission.^2,3Hospitalists can facilitate the evaluation and management of hyponatremia to improve patient outcomes, as well as decrease healthcare costs and length of stay. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Distinguish acute from chronic hyponatremia.

• Identify hospitalized patients at risk of developing hyponatremia and institute monitoring measures to increase early recognition.

• Describe the symptoms of mild and severe hyponatremia.

• Describe the indicated serum and urine laboratory tests used to evaluate the causes of hyponatremia.

• Differentiate among hypertonic, isotonic, and hypotonic forms of hyponatremia.

• Identify the likely pathophysiologic process underlying a patient’s hyponatremia on the basis of urine osmolality and electrolyte concentrations.

• Identify the likely pathophysiologic process underlying a patient’s hyponatremia on the basis of the clinical volume status and urine sodium value.

• Explain how concurrent fluid administration or diuresis may affect urinary tests used in the evaluation of hyponatremia.

• Explain the physiology leading to development of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and describe how it is diagnosed.

• Recognize indications for specialty consultation, such as endocrinology or nephrology.

• Describe an appropriate treatment strategy for patients with asymptomatic, mildly symptomatic, and severely symptomatic hyponatremia, including the risks of treatment.

• Explain the appropriate rate of correction for acute or chronic hyponatremia, adjusted to the needs of the individual patient.

• Explain the indications for water restriction in hyponatremia.

• Explain the indications of isotonic sodium chloride fluid administration in hyponatremia.

• Explain the indications for hypertonic sodium chloride fluid administration in hyponatremia.

• Explain the role, limitations, risks, and contraindications of vasopressin receptor agonists in the treatment of hyponatremia.

• Predict how concurrent correction of other electrolyte disorders (eg, hypokalemia) may affect sodium correction.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history, perform a physical examination, and review the medical record for factors contributing to the development of hyponatremia.

• Accurately assess the relevant volume status and neurologic examination findings of a patient with hyponatremia.

• Order and interpret indicated diagnostic studies that may include serum electrolytes, serum and urine osmolality, serum blood urea nitrogen, creatinine, uric acid, urine sodium, thyrotropin, and early-morning cortisol.

• Formulate and implement the most appropriate intervention tailored to the individual patient’s etiology of hyponatremia while minimizing potential complications from overcorrection or undercorrection.

• Identify the most appropriate care setting to monitor patients with hyponatremia, including indications to transfer to the intensive care unit.

• Recognize symptoms and signs of severe hyponatremia and osmotic demyelination syndrome.

• Communicate with patients and families to explain the significance, etiology, and importance of recognizing and treating hyponatremia.

• Communicate with patients and families to explain the risks, monitoring, and appropriate management of hyponatremia.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians.

• Facilitate coordination of transitional monitoring of recurrent hyponatremia after hospital discharge. 

Hospitalists should be able to:

• Follow evidence-based recommendations when managing hospitalized patients with hyponatremia.

• Acknowledge the opportunity to decrease mortality, length of stay, and healthcare costs by addressing hyponatremia, even when asymptomatic. 

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

• Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize management strategies for hyponatremia.

• Participate in initiatives to articulate, manage, or restrict the use of high-risk therapies, such as hypertonic saline.

Hyponatremia, defined as a serum sodium value less than 135 mEq/L, is the most common electrolyte disorder observed in hospitalized patients in the United States, occurring in up to 60% of patients.¹ The disorder may develop within 48 hours of, or during, hospitalization (acute), or may be subacute or chronic. When it develops in the hospital, hyponatremia is associated with increased length of stay, increased cost of hospitalization, increased in-hospital mortality, and increased postdischarge mortality. Even chronic hyponatremia present at hospital admission adversely affects outcomes—such patients have a 30% higher risk of mortality and are hospitalized 14% longer than patients without hyponatremia at admission.^2,3Hospitalists can facilitate the evaluation and management of hyponatremia to improve patient outcomes, as well as decrease healthcare costs and length of stay. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Distinguish acute from chronic hyponatremia.

• Identify hospitalized patients at risk of developing hyponatremia and institute monitoring measures to increase early recognition.

• Describe the symptoms of mild and severe hyponatremia.

• Describe the indicated serum and urine laboratory tests used to evaluate the causes of hyponatremia.

• Differentiate among hypertonic, isotonic, and hypotonic forms of hyponatremia.

• Identify the likely pathophysiologic process underlying a patient’s hyponatremia on the basis of urine osmolality and electrolyte concentrations.

• Identify the likely pathophysiologic process underlying a patient’s hyponatremia on the basis of the clinical volume status and urine sodium value.

• Explain how concurrent fluid administration or diuresis may affect urinary tests used in the evaluation of hyponatremia.

• Explain the physiology leading to development of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and describe how it is diagnosed.

• Recognize indications for specialty consultation, such as endocrinology or nephrology.

• Describe an appropriate treatment strategy for patients with asymptomatic, mildly symptomatic, and severely symptomatic hyponatremia, including the risks of treatment.

• Explain the appropriate rate of correction for acute or chronic hyponatremia, adjusted to the needs of the individual patient.

• Explain the indications for water restriction in hyponatremia.

• Explain the indications of isotonic sodium chloride fluid administration in hyponatremia.

• Explain the indications for hypertonic sodium chloride fluid administration in hyponatremia.

• Explain the role, limitations, risks, and contraindications of vasopressin receptor agonists in the treatment of hyponatremia.

• Predict how concurrent correction of other electrolyte disorders (eg, hypokalemia) may affect sodium correction.

Hospitalists should be able to:

• Elicit a thorough and relevant medical history, perform a physical examination, and review the medical record for factors contributing to the development of hyponatremia.

• Accurately assess the relevant volume status and neurologic examination findings of a patient with hyponatremia.

• Order and interpret indicated diagnostic studies that may include serum electrolytes, serum and urine osmolality, serum blood urea nitrogen, creatinine, uric acid, urine sodium, thyrotropin, and early-morning cortisol.

• Formulate and implement the most appropriate intervention tailored to the individual patient’s etiology of hyponatremia while minimizing potential complications from overcorrection or undercorrection.

• Identify the most appropriate care setting to monitor patients with hyponatremia, including indications to transfer to the intensive care unit.

• Recognize symptoms and signs of severe hyponatremia and osmotic demyelination syndrome.

• Communicate with patients and families to explain the significance, etiology, and importance of recognizing and treating hyponatremia.

• Communicate with patients and families to explain the risks, monitoring, and appropriate management of hyponatremia.

• Document the treatment plan and provide clear discharge instructions for postdischarge clinicians.

• Facilitate coordination of transitional monitoring of recurrent hyponatremia after hospital discharge. 

Hospitalists should be able to:

• Follow evidence-based recommendations when managing hospitalized patients with hyponatremia.

• Acknowledge the opportunity to decrease mortality, length of stay, and healthcare costs by addressing hyponatremia, even when asymptomatic. 

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

• Lead, coordinate, and/or participate in multidisciplinary initiatives to promote patient safety and optimize management strategies for hyponatremia.

• Participate in initiatives to articulate, manage, or restrict the use of high-risk therapies, such as hypertonic saline.

Pain is a very common presenting or accompanying symptom in hospitalized patients. Pain management relies on the use of various modalities to alleviate suffering and restore patient function. Proper assessment and treatment of pain can improve clinical outcomes, discharge planning, and patient and family satisfaction. Managing pain in inpatients necessitates understanding the various mechanisms that cause pain, properties of analgesic pharmacologic and nonpharmacologic modalities, and accurate assessment of severity and treatment response. Hospitalists assess and manage patients experiencing pain. This role requires that hospitalists be aware of current issues and controversies in pain management. Opioid therapy, for example, is a well-established approach for treating severe acute pain and cancer-related pain, and opioids are the most commonly prescribed drug class in the United States.¹ However, the continued increase in opioid prescription coincides with an increased number of poisoning deaths. Poisoning deaths involving opioid analgesics have more than tripled since 1999.^2,3 To best manage patients’ pain, hospitalists must demonstrate empathy, clinical excellence, and an understanding of the myriad obstacles, cautions, specific knowledge, skills, and attitudes necessary for appropriate pain management. Hospitalists serve as leaders of multidisciplinary teams to develop policies and protocols to improve pain management in their healthcare system. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Describe the mechanisms that cause pain.

• Describe the symptoms and signs of pain.

• Differentiate acute, chronic, somatic, neuropathic, referred, and visceral pain syndromes.

• Differentiate tolerance, dependence, addiction, and pseudoaddiction.

• Describe the value and limitations of the physical examination and various validated pain intensity assessment scales.

• Recognize indications for specialty consultation, which may include pain service, anesthesiology, and physical and rehabilitation medicine.

• Explain the relationship among physical, cultural, and psychological factors and pain and pain thresholds.

• Describe the indications and limitations of opioid pharmacotherapy.

• Discuss the genetic, social, and psychological factors that may contribute to opioid addiction.

• Describe the indications and limitations of other analgesics including tramadol, tricyclic agents, and anticonvulsant medications in the treatment of various pain syndromes.

• Describe the indications and limitations of nonopioids including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and topical agents.

• Describe specific factors that affect dosing regimens such as drug half-life, renal function, and hepatic function.

• Describe the indications and limitations of nonpharmacologic methods of pain control available in the inpatient setting.

• Establish functional criteria for discharge.

Hospitalists should be able to:

• Elicit a thorough and relevant history and description of pain and review the medical record to determine the likely source and acuity of pain.

• Review patient pharmacologic and psychosocial history and identify factors contributing to pain or factors that might affect its management.

• Perform a physical examination to determine the likely source of pain.

• Order and interpret diagnostic studies to determine the source of pain when underlying acute illness is suspected.

• Assess pain severity using validated measurement tools.

• Formulate an initial pain management plan.

• Determine the appropriate route, dosage, and frequency of dosing for pharmacologic agents on the basis of patient-specific factors.

• Reassess pain severity and determine the need for escalating therapy and/or adjuvant therapies.

• Determine equianalgesic dosing for pharmacologic therapy when needed.

• Titrate short- and long-acting opioids to desired effect.

• Predict and counteract as needed expected analgesic adverse effects, including use of reversal and specific agents, especially in older patients.

• Anticipate and manage adverse effects of pain medications including respiratory depression and sedation, nausea, vomiting, and pruritis.

• Initiate appropriate therapies to prevent and treat constipation when a patient is taking opioid analgesics.

• Assess and communicate the need for pain management during medical consultation.

• Recognize the signs and symptoms of addiction and assess patients for prescription drug abuse when appropriate.

• Educate patients on the adverse effects of prescription drug abuse.

• Educate patients and physicians on the importance of appropriate use of opioids in pain management and explain the rarity of opioid addiction in the setting of appropriate pain management.

• Establish and maintain an open dialogue with patients and families regarding care goals and limitations, which may include palliative care and end-of-life wishes.

• Document treatment plans, provide clear discharge instructions, and communicate with the outpatient clinician responsible for follow-up to ensure a safe transition. 

Hospitalists should be able to:

• Employ a multidisciplinary approach to the assessment and management of patients with pain that begins at admission and continues through all care transitions.

• Follow evidence-based recommendations, including the World Health Organization (WHO) step approach to pain management.

• Promote the ethical imperative of frequent pain assessment and adequate control.

• Appreciate that all pain is subjective and acknowledge patients’ self-reports of pain.

• Appreciate the value of patient-controlled analgesia.

• Appreciate the importance of a patient/family-centered approach for establishing the goals for pain management strategies and setting targets for pain control. 

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

• Lead, coordinate, and/or participate in efforts to develop educational modules, order sets, and/or pathways that facilitate effective pain management in the hospital setting, with goals of improving outcomes and patient satisfaction, decreasing length of stay, and reducing rehospitalization rates.

• Lead, coordinate, and/or participate in efforts to measure quality of inpatient pain control, operationalize system improvements, and reduce barriers to adequate pain control.

• Lead, coordinate, and/or participate in efforts to establish or support existing multidisciplinary pain control teams.

Pain is a very common presenting or accompanying symptom in hospitalized patients. Pain management relies on the use of various modalities to alleviate suffering and restore patient function. Proper assessment and treatment of pain can improve clinical outcomes, discharge planning, and patient and family satisfaction. Managing pain in inpatients necessitates understanding the various mechanisms that cause pain, properties of analgesic pharmacologic and nonpharmacologic modalities, and accurate assessment of severity and treatment response. Hospitalists assess and manage patients experiencing pain. This role requires that hospitalists be aware of current issues and controversies in pain management. Opioid therapy, for example, is a well-established approach for treating severe acute pain and cancer-related pain, and opioids are the most commonly prescribed drug class in the United States.¹ However, the continued increase in opioid prescription coincides with an increased number of poisoning deaths. Poisoning deaths involving opioid analgesics have more than tripled since 1999.^2,3 To best manage patients’ pain, hospitalists must demonstrate empathy, clinical excellence, and an understanding of the myriad obstacles, cautions, specific knowledge, skills, and attitudes necessary for appropriate pain management. Hospitalists serve as leaders of multidisciplinary teams to develop policies and protocols to improve pain management in their healthcare system. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Describe the mechanisms that cause pain.

• Describe the symptoms and signs of pain.

• Differentiate acute, chronic, somatic, neuropathic, referred, and visceral pain syndromes.

• Differentiate tolerance, dependence, addiction, and pseudoaddiction.

• Describe the value and limitations of the physical examination and various validated pain intensity assessment scales.

• Recognize indications for specialty consultation, which may include pain service, anesthesiology, and physical and rehabilitation medicine.

• Explain the relationship among physical, cultural, and psychological factors and pain and pain thresholds.

• Describe the indications and limitations of opioid pharmacotherapy.

• Discuss the genetic, social, and psychological factors that may contribute to opioid addiction.

• Describe the indications and limitations of other analgesics including tramadol, tricyclic agents, and anticonvulsant medications in the treatment of various pain syndromes.

• Describe the indications and limitations of nonopioids including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and topical agents.

• Describe specific factors that affect dosing regimens such as drug half-life, renal function, and hepatic function.

• Describe the indications and limitations of nonpharmacologic methods of pain control available in the inpatient setting.

• Establish functional criteria for discharge.

Hospitalists should be able to:

• Elicit a thorough and relevant history and description of pain and review the medical record to determine the likely source and acuity of pain.

• Review patient pharmacologic and psychosocial history and identify factors contributing to pain or factors that might affect its management.

• Perform a physical examination to determine the likely source of pain.

• Order and interpret diagnostic studies to determine the source of pain when underlying acute illness is suspected.

• Assess pain severity using validated measurement tools.

• Formulate an initial pain management plan.

• Determine the appropriate route, dosage, and frequency of dosing for pharmacologic agents on the basis of patient-specific factors.

• Reassess pain severity and determine the need for escalating therapy and/or adjuvant therapies.

• Determine equianalgesic dosing for pharmacologic therapy when needed.

• Titrate short- and long-acting opioids to desired effect.

• Predict and counteract as needed expected analgesic adverse effects, including use of reversal and specific agents, especially in older patients.

• Anticipate and manage adverse effects of pain medications including respiratory depression and sedation, nausea, vomiting, and pruritis.

• Initiate appropriate therapies to prevent and treat constipation when a patient is taking opioid analgesics.

• Assess and communicate the need for pain management during medical consultation.

• Recognize the signs and symptoms of addiction and assess patients for prescription drug abuse when appropriate.

• Educate patients on the adverse effects of prescription drug abuse.

• Educate patients and physicians on the importance of appropriate use of opioids in pain management and explain the rarity of opioid addiction in the setting of appropriate pain management.

• Establish and maintain an open dialogue with patients and families regarding care goals and limitations, which may include palliative care and end-of-life wishes.

• Document treatment plans, provide clear discharge instructions, and communicate with the outpatient clinician responsible for follow-up to ensure a safe transition. 

Hospitalists should be able to:

• Employ a multidisciplinary approach to the assessment and management of patients with pain that begins at admission and continues through all care transitions.

• Follow evidence-based recommendations, including the World Health Organization (WHO) step approach to pain management.

• Promote the ethical imperative of frequent pain assessment and adequate control.

• Appreciate that all pain is subjective and acknowledge patients’ self-reports of pain.

• Appreciate the value of patient-controlled analgesia.

• Appreciate the importance of a patient/family-centered approach for establishing the goals for pain management strategies and setting targets for pain control. 

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

• Lead, coordinate, and/or participate in efforts to develop educational modules, order sets, and/or pathways that facilitate effective pain management in the hospital setting, with goals of improving outcomes and patient satisfaction, decreasing length of stay, and reducing rehospitalization rates.

• Lead, coordinate, and/or participate in efforts to measure quality of inpatient pain control, operationalize system improvements, and reduce barriers to adequate pain control.

• Lead, coordinate, and/or participate in efforts to establish or support existing multidisciplinary pain control teams.

Pain is a very common presenting or accompanying symptom in hospitalized patients. Pain management relies on the use of various modalities to alleviate suffering and restore patient function. Proper assessment and treatment of pain can improve clinical outcomes, discharge planning, and patient and family satisfaction. Managing pain in inpatients necessitates understanding the various mechanisms that cause pain, properties of analgesic pharmacologic and nonpharmacologic modalities, and accurate assessment of severity and treatment response. Hospitalists assess and manage patients experiencing pain. This role requires that hospitalists be aware of current issues and controversies in pain management. Opioid therapy, for example, is a well-established approach for treating severe acute pain and cancer-related pain, and opioids are the most commonly prescribed drug class in the United States.¹ However, the continued increase in opioid prescription coincides with an increased number of poisoning deaths. Poisoning deaths involving opioid analgesics have more than tripled since 1999.^2,3 To best manage patients’ pain, hospitalists must demonstrate empathy, clinical excellence, and an understanding of the myriad obstacles, cautions, specific knowledge, skills, and attitudes necessary for appropriate pain management. Hospitalists serve as leaders of multidisciplinary teams to develop policies and protocols to improve pain management in their healthcare system. 

Want all 52 JHM Core Competency articles in an easy-to-read compendium? Order your copy now from Amazon.com.

Hospitalists should be able to:

• Describe the mechanisms that cause pain.

• Describe the symptoms and signs of pain.

• Differentiate acute, chronic, somatic, neuropathic, referred, and visceral pain syndromes.

• Differentiate tolerance, dependence, addiction, and pseudoaddiction.

• Describe the value and limitations of the physical examination and various validated pain intensity assessment scales.

• Recognize indications for specialty consultation, which may include pain service, anesthesiology, and physical and rehabilitation medicine.

• Explain the relationship among physical, cultural, and psychological factors and pain and pain thresholds.

• Describe the indications and limitations of opioid pharmacotherapy.

• Discuss the genetic, social, and psychological factors that may contribute to opioid addiction.

• Describe the indications and limitations of other analgesics including tramadol, tricyclic agents, and anticonvulsant medications in the treatment of various pain syndromes.

• Describe the indications and limitations of nonopioids including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and topical agents.

• Describe specific factors that affect dosing regimens such as drug half-life, renal function, and hepatic function.

• Describe the indications and limitations of nonpharmacologic methods of pain control available in the inpatient setting.

• Establish functional criteria for discharge.

Hospitalists should be able to:

• Elicit a thorough and relevant history and description of pain and review the medical record to determine the likely source and acuity of pain.

• Review patient pharmacologic and psychosocial history and identify factors contributing to pain or factors that might affect its management.

• Perform a physical examination to determine the likely source of pain.

• Order and interpret diagnostic studies to determine the source of pain when underlying acute illness is suspected.

• Assess pain severity using validated measurement tools.

• Formulate an initial pain management plan.

• Determine the appropriate route, dosage, and frequency of dosing for pharmacologic agents on the basis of patient-specific factors.

• Reassess pain severity and determine the need for escalating therapy and/or adjuvant therapies.

• Determine equianalgesic dosing for pharmacologic therapy when needed.

• Titrate short- and long-acting opioids to desired effect.

• Predict and counteract as needed expected analgesic adverse effects, including use of reversal and specific agents, especially in older patients.

• Anticipate and manage adverse effects of pain medications including respiratory depression and sedation, nausea, vomiting, and pruritis.

• Initiate appropriate therapies to prevent and treat constipation when a patient is taking opioid analgesics.

• Assess and communicate the need for pain management during medical consultation.

• Recognize the signs and symptoms of addiction and assess patients for prescription drug abuse when appropriate.

• Educate patients on the adverse effects of prescription drug abuse.

• Educate patients and physicians on the importance of appropriate use of opioids in pain management and explain the rarity of opioid addiction in the setting of appropriate pain management.

• Establish and maintain an open dialogue with patients and families regarding care goals and limitations, which may include palliative care and end-of-life wishes.

• Document treatment plans, provide clear discharge instructions, and communicate with the outpatient clinician responsible for follow-up to ensure a safe transition. 

Hospitalists should be able to:

• Employ a multidisciplinary approach to the assessment and management of patients with pain that begins at admission and continues through all care transitions.

• Follow evidence-based recommendations, including the World Health Organization (WHO) step approach to pain management.

• Promote the ethical imperative of frequent pain assessment and adequate control.

• Appreciate that all pain is subjective and acknowledge patients’ self-reports of pain.

• Appreciate the value of patient-controlled analgesia.

• Appreciate the importance of a patient/family-centered approach for establishing the goals for pain management strategies and setting targets for pain control. 

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

• Lead, coordinate, and/or participate in efforts to develop educational modules, order sets, and/or pathways that facilitate effective pain management in the hospital setting, with goals of improving outcomes and patient satisfaction, decreasing length of stay, and reducing rehospitalization rates.

• Lead, coordinate, and/or participate in efforts to measure quality of inpatient pain control, operationalize system improvements, and reduce barriers to adequate pain control.

• Lead, coordinate, and/or participate in efforts to establish or support existing multidisciplinary pain control teams.